Assessment of the knowledge of basic first aid of acute poisoning among medical students at Imam Abdulrahman bin Faisal University, KSA

ABSTRACT Background In a poison emergency, responders should assess the condition and begin treatment immediately. Training general practitioners in clinical toxicology can help manage patients with acute poisoning cost-effectively. Aim Assessment of Imam Abdulrahman bin Faisal University (IAU) medical students’ knowledge of dealing with toxicological emergencies. Methods This is a cross-sectional study carried out from December 2022 to February 2023 at IAU, KSA. Results 201 undergraduate medical students participated: 20.4% fourth graders, 30.8% fifth graders, 32.3% sixth graders, and 16.4% interns. 79.1% attended a first aid training program, and 19.9% received emergency department (ED) training in managing acute poisoning. Most students have moderate knowledge of risk assessment (70.6%), as indicated by correct answers about importance of patient characteristics, type of poison, psychological background, time, and type of exposure. Incorrectly answering about source of information and reliance on drug-level screening. Participants demonstrated moderate knowledge (53.7%) of the initial management of poisoned patients, which is recognized by correct answers about maintaining an adequate airway, breathing, and circulation, meaning and mechanism of decontamination, indication and time of gastric lavage, and action of activated charcoal. Correctly disagree with the priority of induction of vomiting and offering gastric lavage to all patients. Recognize the meaning of corrosive poisoning but incorrectly respond to methods of its treatment while correctly agreeing about the appropriateness of oral liquid administration. Incorrectly respond to the availability of an antidote for every toxicity. Advancements in student education, first aid training, and ED training insignificantly impacted knowledge of risk assessment while significantly improving knowledge of the initial management of acute poisoning. Conclusion Most participating students had suboptimal knowledge of risk assessment and management of toxicological emergencies. Education levels, first aid training, and ED training, while improved knowledge of initial management, have a low impact on knowledge of risk assessment of acutely poisoned cases.


Introduction
Poisoning is exposure to substances that can harm, kill or impair normal physiological functions in humans and that, through their chemical activity, can cause general or local damage or impairment of the body functions [1].
Almost all substances known today can harm humans, but only the dosage plays a pivotal role.The critical question is not whether the drug is toxic but whether there are risks associated with the exposure [2].Acute poisoning is a common cause of emergency department visits and hospitalizations worldwide and a significant cause of morbidity and mortality [3,4].
Over 340,000 accidental deaths are estimated to be due to poisoning [5].In addition to unintentional accidents, the estimated number of intentional poisonings is about 2 million cases annually, resulting in about 200,000 deaths [6].
Nevertheless, few researchers have addressed the problem of poisoning, and as a result, epidemiological data are scarce, especially in developing countries, including Saudi Arabia [7].The exact extent and complications of poisoning in Saudi Arabia are not known.However, Alghafees et al. [8] reported that the ICU admission and mortality rates due to acute poisoning in King Abdulaziz Medical City (KAMC), a tertiary care facility in Riyadh, was 6.7% in adult samples and 4.8% in pediatric samples, with a mortality rate of 0.8% and 0.3%, respectively.Between 1983 and 1987, there were 7,142 accidental poisonings among children admitted to all Riyadh government hospitals [9].Moreover, a review of published studies from 1998 to 2021 by Almutairi et al. [10] revealed 39 childhood poisoning deaths in Saudi Arabia during that period.However, the increased availability and use of disinfectants and sanitizers during the coronavirus 2 (SARS-CoV-2) pandemic significantly increased the risk of poisoning, especially among preschool children [11].
Western studies report an annual rate of approximately 0.3% for poisoning-related emergency department (ED) visits [12,13].Poisoningrelated visits were recorded as urgent in 75% of cases and were more likely to lead to hospitalization in 22% of cases [13].
In a poison emergency, saving lives is the top priority.Because the patient may be close to death or unconscious, emergency responders should assess the condition and begin treatment immediately [14].Acute poisoning is a dynamic medical situation in which the patient's condition changes rapidly.These rapid changes require the attending emergency physician's prompt and continuous observation of these patients.
Most medical professionals, especially those inadequately trained, need to become more familiar with properly managing acute poisoning incidents.Data show that physicians trained in toxicology can cost-effectively treat patients with acute poisoning [15].Medical students in training hospitals should also know how to act in such situations early in their training courses.
Studies evaluating the knowledge of KSA Eastern Province medical students of the first aid of acute emergency poisoning are still lacking.As the College of Medical at Imam Abdulrahman bin Faisal University (IAU) does not offer a specialized clinical toxicology training course, this study is designed to assess students' knowledge of dealing with toxicological emergencies.

Study design
The present study is a cross-sectional study carried out in December 2022 at Imam Abdulrahman Bin Faisal University (IAU), KSA.

Study setting: Participants, recruitment, and sampling procedure
A randomized sample of IAU medical students at levels 4, 5, 6, and internship were included in the study.

Inclusion and exclusion criteria
Saudi medical students from different levels of clinical education, specifically fourth grade to internship levels, were surveyed.Those who did not meet the previous criteria or students who refused to participate were excluded from the study.

Sample size
The sample size calculator "Raosoft" [16] was used to set the sample size with 85% confidence intervals and a 5% error margin.For an expected response rate of 50% and a population size of 975 medical students in the fourth, fifth, sixth, and internship levels of the IAU, the minimum sample size required for this study was 172 responders to determine the statistical differences in the results based on participants' characteristics.Data collection Technique and tools: Surveys were created after performing systematic searches using Scopus, Pubmed, Google Scholar, and other available search engines.Two experts reviewed the domains of the questionnaire.The questionnaire achieved satisfactory content adequacy in terms of relevance and clarity.A self-administered QuestionPro online questionnaire was distributed to a suitable sample of participants via social media, specifically Twitter and WhatsApp.The survey was designed to take 5-7 minutes to complete.Eligible participants will receive a Participant Information Sheet outlining the purpose of the study and ensuring data confidentiality and anonymity of responses.Participants do not receive any compensation or incentives for their participation.

Questionnaire
The research instrument was a structured questionnaire developed in English.The questionnaire consisted of 25 questions in three domains.The first domain (four questions) asked participants to indicate their characteristics, education level, gender, participation in first aid training, and emergency room training on patients with acute poisoning.In the second domain (7 questions), participants were asked to consider their knowledge of risk assessment of patients with acute poisoning.A third domain (14 questions) asked participants about their knowledge of initial care for poisoned patients.The resulting survey included multiple-choice close-ended questions in which participants were asked to select only one option.
Respondents were asked to indicate their level of knowledge, ranging from agreeing, no idea, and disagreeing.
A scoring system was introduced to assess the level of knowledge, giving "1" points for correct answers, "0" points for no idea answers, and "−1" points for incorrect answers.For each participant, the scores of responses in the second domain and the third domain were summed separately.Percentages of total scores of examined samples related to knowledge of risk assessment or initial treatment of poisoned patients were calculated and were classified as low (<60%), medium (60-80%), and high (>80).

Data analysis
Data were entered into a computer and analyzed using the IBM SPSS software package version 20.0.(Armonk, NY: IBM Corp).Categorical data were presented as numbers and percentages.A chi-square test was applied to examine associations between categorical variables.Alternatively, a Monte Carlo correction test was applied when 20% or more of the cells had an expected value less than 5.For continuous data, Kolmogorov-Smirnov was used to test normality.Quantitative data were expressed as a range (minimum and maximum), mean, standard deviation, and median.Student's t-test was used to compare two categories of normally distributed quantitative variables, and ANOVA was used to compare between different categories.Pearson's coefficient for the correlation between two normally distributed quantitative variables.The significance of the results obtained was judged at the 5% level.

Results
A total of 201 undergraduate medical students participated in this study: 41 (20.4%) fourth graders, 62 (30.8%) fifth graders, 65 (32.3%)sixth graders, and 33 (16.4%) interns.One hundred eight female students (53.7%) and 93 male students (46.3%) participated.159 (79.1%) attended a first-aid training program, and 40 (19.9%)attended emergency department (ED) training in the management of acute poisoning.(Table 1) Table 2 shows only 7.0% correct answers for inadequate dependency on patients' families as the most important source of information in poisoning situations.94.0% of the students correctly indicated that patient characteristics were important in managing poisoned patients, and 75.1% said knowing the type of poison was necessary when deciding to treat acutely poisoned patients.Most students recognized the impact of the patient's psychological background (82.6%) and time since exposure to the poison (74.1%) in the assessment of poisoned patients.Only 9.5% correctly disagree with the statement indicating reliance on screening of drug level in risk assessment to the poisoned patients.However, a 92.0%accuracy rate was obtained for the importance of the type of exposure to the toxicant in the assessment of acute poisoning.
Using the response rating scheme, Table 3 shows the mean (±SD) total scores for knowledge of risk assessment of poisoned patients at all levels of student education ranged from 2.39 (±1.66) to 2.91 (±1.33), with insignificant differences between them (p = 0.491).The overall score means (± SD) for those who participated in the first aid training program was 2.41 (±1.73) compared with 2.81 (±1.49) for those who did not participate in the program, with an insignificant difference between them (p = 0.171).The mean (± SD) of the total scores for students trained in ED on poisoned patients was 2.43 (±1.55), whereas, for students who were not trained, it was 2.51 (±1.72), and a significant difference was not found (p = 0.778).
As shown in Table 4, 56.7% of participants agreed that maintaining an adequate airway, breathing, and circulation during acute intoxication is a priority.Most participants recognized the meaning (69.7%) and mechanism (67.7%) of the decontamination of poisoned patients.Most students (63.2%) correctly stated that the induction of vomiting is not a priority in treating patients with acute poisoning.Most students (81.6%) correctly disagree with the gastric lavage indication in all patients with acute poisoning, and 59.2% correctly reported that the maximum benefit of lavage is 2 hours after ingestion.68.7% of participants were aware of the mechanism of action of activated charcoal in treating acute poisoning patients.
Regarding corrosive poisoning, 68.7% of students recognized its direct damaging effects.Only 14.4% of participants correctly responded to the potential benefits of oral administration of a milk as first aid to caustic ingestion.Most participants (62.2%) erroneously agreed on the appropriateness of neutralizing ingested corrosive agents as firstaid treatment.While most participants (91.0%) incorrectly consented to administer oral liquids as first aid after corrosive ingestion.Moreover, 87.6% of the students incorrectly agreed with the existence of specific antidotes for all toxic substances.
Table 5 shows the relationship between the total score of knowledge of primary care of poisoned patients and student characteristics.Total scores (Mean ± SD) for knowledge of initial care of poisoned patients significantly increased as students progressed from education level 4, 5, and 6 to internship level (2.54 ± 3.45), (4.37 ± 3.73), (4.86 ± 3.60), and (5.03 ± 3.69) (p = 0.007).Students who participated in the first aid training program showed a significantly higher knowledge of

Discussion
Emergency department teams must adopt an approach that ensures immediate decision-making regarding individualizing critical interventions and management according to the patient's medical condition.Early risk assessment is paramount to determining an appropriate plan for tailoring management on a patient-by-patient basis.These are the pillars of the "Risk-assessment-based approach to managing acute poisoning" strategy.Ideally, this approach should include optimizing poisoned patients' medical and psychosocial care [17].Healthcare professionals taking care of patients with acute poisoning and medical students of varying levels of education should be well-informed and trained in the emergency management of these patients.
The present study aims to assess Imam Abdulrahman bin Faisal University (IAU) medical students' knowledge of dealing with toxicological emergencies.The knowledge assessment is the first step to determine the need for a clinical toxicology course in the teaching program of medical students in the college of medicine at IAU.
Regarding risk assessment, this study demonstrated that participating students had moderate knowledge of risk assessment for patients with acute poisoning.The moderate level of most students about the basics of risk assessment was found regardless of the advancement of education levels or previous first-aid training.Even emergency room training on patients with acute poisoning could not improve risk assessment knowledge to higher levels.A literature search found no study addressing the risk assessment of acute toxicological cases as a separate entity.The present study may be the first to investigate medical students' knowledge of risk assessment in acute toxicological emergencies.
The present study also indicated a marginally moderate overall knowledge level concerning the initial management of acute toxicity.However, as the level of education increased, knowledge improved.The results of the present study demonstrated that medical students have moderate knowledge of the theoretical aspects of clinical toxicology but lesser knowledge of the basic first aid requirements.Increasing levels of student medical education, first aid training, and emergency department patient care somewhat improved knowledge about the initial management of acute poisoning but did not improve students' risk-assessment skills.

Participation in a first aid training program
The results of this study are generally consistent with a study conducted by Hakami et al. [18] in Riyadh city, where most of the medical students who participated had an adequate level of knowledge about the initial management of acute poisoning, which was related to their training program and experience in the emergency department.However, the present study focused on knowledge of the initial management of acute toxicity and the fundamentals of risk assessment, which is very important for management planning.Also, the questionnaire used to assess the knowledge level differs in many aspects from the one used in our study.Another study conducted in Istanbul by Goktas S et al. [19] found that medical undergraduates had more first-aid knowledge of poisoning than non-medical students.Unlike the current study, the sample participating in the study was different from ours, and some survey questions were nonspecific regarding management of poisoning.
A suboptimal level of information of the medical students on risk assessment may complicate the assessment of surveillance and disposal requirements, increase the risk of complications in patients with acute poisoning, and may provide opportunities for patient deterioration [20].Improving medical students' knowledge can improve the management of patients with acute poisoning.Moreover, given the widespread ignorance of the proper dealing with toxic xenobiotics, improving medical students' knowledge could help transfer knowledge that improves the public's ability to understand the risk of poisoning [21].
Considering that the initial evaluation and clinical management of patients with acute poisoning in the emergency department are performed by young  physicians with no formal training in clinical toxicology [22].Clinical care for patients with acute poisoning can be improved through targeted educational measures [23].The present study highlights the importance of providing medical students with training programs for immediate risk assessment in acute poisoning situations and early training to improve their field competencies in managing acute poisoning [21].Many medical schools offer undergraduate courses in clinical toxicology.In the United States, toxicology training is part of the curriculum of emergency medical programs [24,25].Established poison control centers also provide consultations, undergraduate and graduate training, and community awareness and education [24,26].Moreover, some Arabic medical schools offer undergraduate students specialized clinical toxicology training courses [27,28].
Medical college in Imam Abdulrahman bin Faisal University does not offer a professional clinical toxicology training course for undergraduates.The forensic curriculum includes a few clinical toxicology lectures.Moreover, the clinical exposure is delayed to the internship training.
Although the Eastern Province of Saudi Arabia has a regional toxicology control center, its training facilities are limited, and clinical experience in toxicity management is lacking.Generally, many toxicology centers offer telephone consultations and do not include on-site clinical services.The provision of "onsite" training by medical toxicologists makes emergency department training more clinically applicable [24].

Conclusion
Given the moderate knowledge of the students about the first aid management of acutely poisoned patients, the incorporation of a clinical toxicology course into the undergraduate medical students' educational program is necessary to reduce morbidity and mortality resulting from delayed or ineffective management of acutely poisoned patients.
A specific toxicology syllabus should be established to provide the main principles of assessment of the level of risk to the poisoned patients and the conventional and new management modalities.
It should also focus on clinical applications by providing students with real-world examples of toxicological situations relevant to clinical practice.
In addition, the construction of a specialized clinical toxicology center is necessary to improve students' clinical skills in dealing with acutely poisoned patients at an early stage.

Table 1 .
Distribution of the studied sample according to students' characteristics (n = 201).

Table 2 .
Responses of the tested sample according to the level of knowledge of risk assessment of poisoned patients (n = 201).

Table 3 .
Relation between total score of overall knowledge of risk assessment of poisoned patients and students' characteristics (n = 201).
SD: Standard deviation t: Student t-test F: F for One way ANOVA test p: p-value for comparing the studied categories

Table 4 .
Responses of the tested sample according to the knowledge of initial management of the poisoned patient (n = 201).

Table 5 .
Relation between the total score of knowledge about the initial management of poisoned patients and the students' characteristics (n = 201).
SD: Standard deviation t: Student t-test F: F for One way ANOVA test.p: p-value for comparing the studied categories.*Statistically significant at p≤0.05.
Zuhur Jafar Al-qteeb is a student, College of Clinical Pharmacy, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia.Md.Ashraful Islam is an Assistant Professor, Department of Pharmacy Practice, College of Clinical Pharmacy, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia ORCID