Epidemiological features of stress hyperglycemia in elderly at emergency department.

UNLABELLED: Background : Stress hyperglycemia among patients having an acute pathology is frequently described in recent studies. AIMS: The objectives of this work were to describe epidemiologic features of elderly patients hospitalized in the emergency department and having a hyperglycemia due to stress. METHODS: A retrospective chart review identified patients older than 65 years with obtained serum glucose levels. Patients with diabetes were excluded. Two levels of serum glucose were considered (>6,9 mmol/l and ≤ 6,9 mmol/l).   RESULTS: We included 165.  There were 94 patients with high level of serum glucose level (56,9%). Multivariate analysis found that only cardio-vascular pathologies were more predictive of having stress hyperglycemia (p=0,014, odds-ratio=2,8, IC=1,2-6,4). There were no correlation between serum glucose levels and mortality. CONCLUSION: Stress hyperglycemia is a fairly common disorder but underestimated in emergency department. Its impact on the prognosis of elderly patients remains to be studied.

Clinical features, complications and mortality in critically ill patients with 2009 influenza A(H1N1) in Sfax,Tunisia.

PURPOSE: Africa, as the rest of the world, was touched by the 2009 pandemic influenza A(H1N1). In the literature, a few publications covering this subject emerged from this continent. We prospectively describe baseline characteristics, treatment and outcomes of consecutive critically ill patients with confirmed 2009 influenza A(H1N1) in the intensive care unit (ICU) of Sfax hospital. METHODS: From 29 November 2009 through 21 January 2010, 32 patients with confirmed 2009 influenza A(H1N1) were admitted to our ICU. We prospectively analysed data and outcomes of these patients and compared survivors and dead patients to identify any predictors of death. RESULTS: Patients were young (mean, 36·1 [SD], 20·7 years) and 21 (65·6%) of whom had co-morbidities. During ICU care, 29 (90·6%) patients had respiratory failure; among these, 15 (46·9%) patients required invasive ventilation with a median duration of 9 (IQR 3-12) days. In our experience, respiratory dysfunction can remain isolated but may also be associated with other dysfunctions or complications, such as, septic shock, seizures, myasthenia gravis exacerbation, Guillan-Barre syndrome, acute renal failure, nosocomial infections and biological disturbances. The nine patients (28·1%) who died had greater initial severity of illness (SAPS II and sequential organ failure assessment (SOFA) scores) but also a higher SOFA score and increasing severity of organ dysfunction during their ICU evolution. CONCLUSION: Critical illness from the 2009 influenza A(H1N1) in Sfax occurred in young individuals and was associated with severe acute respiratory and additional organ system failure. SAPS II and SOFA scores at ICU admission, and also during evolution, constitute a good predictor of death.

Severe head injury among children: prognostic factors and outcome.

AIM: To determine predictive factors of mortality among children after traumatic brain injury. METHODS: A retrospective study over 8 years of 222 children with severe head injury (Glasgow Coma Scale score < or = 8) admitted to a university hospital (Sfax, Tunisia). Basic demographic, clinical, biological and radiological data were recorded on admission and during intensive care unit stay. RESULTS: The study included 163 boys (73.4%) and 59 girls, with mean age 7.54+/-3.8 years. The main cause of trauma was road traffic accident (75.7%). Mean Glasgow Coma Scale score was 6+/-1.5, mean Injury Severity Score (ISS) was 28.2+/-6.9, mean Paediatric Trauma Score (PTS) was 3.7+/-2.1 and mean Paediatric Risk of Mortality (PRISM) was 14.3+/-8.5; 54 children (24.3%) died. Univariate analysis showed that low PTS on admission, high ISS or PRISM, presence of shock or meningeal haemorrhage or bilateral mydriasis, and serum glucose > 10 mmol l(-1) were associated with mortality rate. Multivariate analysis showed that factors associated with a poor prognosis were PRISM > 20 and bilateral mydriasis on admission. CONCLUSIONS: In Tunisia, head injury is a frequent cause of hospital admission and is most often due to road traffic accidents. Short-term prognosis is poor, with a high mortality rate (24.3%), and is influenced by demographic, clinical, radiological and biological factors.

Curious fatal intentional poisoning case with organophosphate pesticide.

BACKGROUND: A case of organophosphorus intoxication with rebounding symptoms is reported. CASE REPORT: Case report of a 24-year-old man who poisoned himself with organophosphorus pesticide and was hospitalized in a 22-bed adult medical surgical intensive care unit at a tertiary care hospital. The patient had ingested organophosphorus pesticide after an argument and fight with his family and had presented typical clinical and biological manifestations of intoxication by this chemical. He was treated by mechanical ventilation, large fluid infusion, gastric lavage, as well as atropine and pralidoxime. After 48 hours of intensive care, the patient improved considerably, but shortly after this improvement, mental, hemodynamic, and respiratory status altered again. Gastric fibroscopy showed a small plastic bag containing powder in the stomach which was responsible for the rebounding symptoms of the intoxication. CONCLUSIONS: Gastric fibroscopy can be helpful in case of organophosphorus intoxication with persistent or rebounding symptoms.

Neurogenic pulmonary edema due to traumatic brain injury: evidence of cardiac dysfunction.

BACKGROUND: Acute neurogenic pulmonary edema, a common and underdiagnosed clinical entity, can occur after virtually any form of injury of the central nervous system and is a potential early contributor to pulmonary dysfunction in patients with head injuries. OBJECTIVE: To explore myocardial function in patients with evident neurogenic pulmonary edema after traumatic head injury. METHODS: During a 1-year period in a university hospital in Sfax, Tunisia, information was collected prospectively on patients admitted to the 22-bed intensive care unit because of isolated traumatic head injury who had neurogenic pulmonary edema. Data included demographic information, vital signs, neurological status, physiological status, and laboratory findings. All of the patients had computed tomography and plain radiography of the neck and determination of cardiac function. RESULTS: All 7 patients in the sample had cardiac dysfunction. Evidence of myocardial damage was confirmed by echocardiography in 3 patients, pulmonary artery catheterization in 3 patients, and/or postmortem myocardial biopsy in 4 patients. Echocardiography studies, repeated 7 days after the initial study in one patient and 90 days afterward in another, showed complete improvement in wall motion, with a left ventricular ejection fraction of 0.65. CONCLUSION: All patients who had neurogenic pulmonary edema due to traumatic head injury had myocardial dysfunction. The mechanisms of the dysfunction were multiple. The great improvement in wall motion seen in 2 patients indicated the presence of a stunned myocardium. Further studies are needed to understand the mechanisms of this cardiac dysfunction.

Factors associated with pulmonary edema in severe scorpion sting patients--a multivariate analysis of 428 cases.

OBJECTIVE: To determine clinical and routine laboratory factors associated with pulmonary edema secondary to scorpion envenomation. DESIGN AND SETTING: Retrospective study covering 13 years (1990-2002) in the medical Intensive Care Unit of a university hospital (Sfax-Tunisia). PATIENTS: 428 patients older than 3 years who were admitted to the intensive care unit for scorpion envenomation were included in this study. Patients were stratified into two groups according to the presence or absence of pulmonary edema as assessed by a medical committee. MEASUREMENTS AND RESULTS: The mean (+/- SD) age was 17.5 +/- 17.7 years, ranging from 3 to 76 years. The pulmonary edema group included 294 patients (68.7%). A multivariate analysis found the following factors to be correlated with a pulmonary edema: age less than 5 years (p = 0.04), sweating (p = 0.004), agitation (p = 0.01), leukocytes of 25000 cells/mm3 or more (p = 0.02), and a plasma protein concentration of 72 g/L or more (p < 0.0001). In addition, a plasma protein concentration of 72 g/L or more predicted the presence of pulmonary edema with a sensitivity of 78% a specificity of 88%, a positive predictive value of 93%, and negative predictive value of 64%. Almost 84% of patients having a respiratory rate of > or = 30 breaths/minute associated with agitation and sweating were classified in the pulmonary edema group. This clinical association indicates the presence of pulmonary edema with a specificity of 84.3% and a positive predictive value of 87.5%. CONCLUSION: In scorpion envenomation patients older than 3 years, the association of a respiratory rate of > or = 30 breaths/minute, agitation, sweating, or the presence of high plasma protein concentrations suggest the presence of pulmonary edema.

The effect of ventilator-associated pneumonia on the prognosis of head trauma patients.

BACKGROUND: To investigate the effect of ventilator-associated pneumonia (VAP) on the prognosis of head trauma patients. METHODS: We performed a retrospective case-control study in which 57 head trauma patients with VAP were matched to 57 head trauma patients without VAP. Matching criteria were age (+/-5 years), Glasgow Coma Scale score (+/-2), Injury Severity Score (+/-5), Simplified Acute Physiology Score II (+/-5), and duration of exposure to mechanical ventilation. RESULTS: The most causative organisms of VAP were Pseudomonas aeruginosa, and Acinetobactor baumannii (36.8% and 33.8% of isolated organisms, respectively). The duration of mechanical ventilation, intensive care unit stay, and hospital stay were significantly increased in case patients (13 +/- 8.4, 24.5 +/- 18, and 30.8 +/- 18.6 days, respectively) compared with control patients (8.3 +/- 4.3, 12.3 +/- 8, and 20.3 +/- 18.7 days, respectively). Mortality rate was also higher in case (29.8%) than in control (12.3%) patients (p = 0.02). CONCLUSION: We conclude that the occurrence of VAP caused by high-risk organisms in cranial trauma patients may increase the risk of death, the mechanical ventilation duration, the intensive care unit stay, and the hospital stay.

Clinical manifestations of systemic paraphenylene diamine intoxication.

BACKGROUND: To report clinical symptoms and outcome of systemic paraphenylene diamine (PPD) intoxication. METHODS: Our study was retrospective. It was conducted over 6 yrs (1994-2000) in the medical intensive care unit (ICU) of a university hospital and it concerned 19 patients hospitalized for systemic PPD intoxication. RESULTS: The mean age (+/- SD) was 27.9 +/- 16.8 yrs, the sex ratio was about 0.58 and the Simplified Acute Physiology Score (SAPS II) was 30 +/- 27. At admission, clinical symptoms were dominated by cervicofacial edema (79%), chocolate brown colored urine (74%), upper airway tract edema (68.4%), oliguria (36.8%), muscular edema (26.3%) and shock (26.3%). The biological results were dominated by rhabdomyolysis (100%), metabolic acidosis (100%), acute renal failure (ARF) (47.4%) and hyperkalemia (26.3%) (biological disturbances were more pronounced in patients with ARF). The therapies used were gastric lavage (100%), fluid infusion (100%), mechanical ventilation (84.2%), alcalinization (80%), corticosteroids (84.2%), vasopressors (26.3%) and renal replacement therapy (26.3%). The intoxication evolution was marked by the death of six patients (31.6%); five of them had developed ARF. The mechanical ventilation duration and the ICU stay were both more prolonged in patients who developed ARF. CONCLUSIONS: Clinical manifestations of systemic PPD intoxication were associated with respiratory, muscular, renal and hemodynamic syndromes. ARF occurrence testifies to the severity of the intoxication.

Neurological complications secondary to severe scorpion envenomation.

BACKGROUND: The aim was to study the incidence, clinical manifestations, and prognosis of neurological complications secondary to scorpion envenomation. MATERIAL/METHODS: A retrospective study over a 13-year period including all patients admitted to our ICU for scorpion envenomation. RESULTS: During the period of study, 951 patients were admitted due to scorpion envenomation. Mean age was 14.7+/-17.4 years, ranging from 0.5 to 90 years. Neuromuscular signs were observed in 739 patients (78%), coma (Glasgow Coma Score 12) in 15.4% of cases, and convulsions in 6%. The other neurological signs observed were: agitation in 709 patients (74.6%), squint in 119 patients (12.5%), bilateral miosis in 43 patients (5%), and a bilateral mydriasis in 16 patients (1.7%). Brain CT was performed in 10 patients, these being abnormal in 90% of cases. In our study the presence of coma (p<0.001), convulsions (p<0.001), bilateral miosis (P<0.001), and the presence of bilateral mydriasis (P<0.001) correlated with poor outcome. CONCLUSIONS: Neurological manifestations were often observed in severe scorpion-envenomed patients and they correlated with poor outcome. Their mechanisms are complex. Prevention is highly warranted.

Gastrointestinal manifestations in severe scorpion envenomation.

OBJECTIVES: To evaluate the type and incidence of gastrointestinal manifestations secondary to scorpion envenomation and their prognostic significance. PATIENTS AND METHODS: All patients admitted to our ICU for scorpion envenomation were included in this retrospective chart review of a 13-year period (1990 - 2002). RESULTS: During the study period, 951 patients were admitted for scorpion envenomation and 72 (7.6%) died. Ages ranged from 0.5 to 90 years with a mean of 14.7 +/- 17.4 years. Gastrointestinal symptoms were present in 700 patients (73.6%): nausea in 24 (2.5%), vomiting in 687 (72.2%) and diarrhea in 41 patients (4.3%). At univariate analysis, the presence of diarrhea was associated with a fatal outcome (P < 0.05). Diarrhea was also correlated with other indicators of severe envenomation and poor prognosis: respiratory failure (P = 0.01), neurological failure (P < 0.0001), liver failure (P < 0.0001) and low blood pressure requiring catecholamine support (P = 0.02). The multivariate analysis showed that young age (age less than 5 years), fever > 38.5 degrees C, neurological failure and pulmonary edema were independent factors of severity. Digestive disorders were more frequent in children and in this subgroup diarrhea appeared to be associated with poor outcome. In a subset of patients for whom data were available, fatal cases demonstrated significantly higher liver enzymes levels on admission. CONCLUSION: In Tunisia, gastrointestinal symptoms are often observed in severe scorpion envenomations, especially in young patients. In children, diarrhea and elevated liver enzymes are associated with poor prognosis.

Prognosis of traumatic head injury in South Tunisia: a multivariate analysis of 437 cases.

BACKGROUND: This study aimed to determine predictive factors of mortality after posttraumatic brain injury. METHODS: A retrospective study conducted over a 3-year period (1997-1999) involved 437 adult patients with head injury admitted to the intensive care unit of a university hospital in Sfax, Tunisia. Basic demographic, clinical, biologic, and radiologic data were recorded at admission and during the intensive care unit stay. RESULTS: This study included 393 men (90%) and 44 women with a mean age of 36 +/- 17 years. Traffic accidents were the main cause of trauma (85.6%). In 58% of the cases, the injury was serious (Glasgow Coma Score, <8). The mean simplified acute physiology score was 39 +/- 15, and the mean Injury Severity Score was 34.5 +/- 17. Of the 437 patients, 127 (29.1%) died. According to multivariate analysis, the factors that correlated with a poor prognosis were age older than 40 years (p < 0.01), simplified acute physiology score exceeding 40 (p < 0.001), Glasgow Coma Score lower than 7 (p = 0.03), intracranial mass lesion (p = 0.02), a cerebral herniation (p < 0.001), diabetes insipidus (p < 0.001), and blood sugar level higher than 10 mmol/L (p < 0. 001). CONCLUSIONS: In Tunisia, head injury is a frequent cause of hospitalization, comprising 14.4% of all adult admissions. It is observed most often among young patients involved in traffic accidents. The short-term prognosis is poor, with a high (29%) mortality rate, and determined by demographic, clinical, radiologic, and biologic factors. Prevention is highly advised.

Evidence of myocardial ischaemia in severe scorpion envenomation. Myocardial perfusion scintigraphy study.

OBJECTIVE: To explore the myocardial perfusion by thallium-201 scintigraphy for patients with evidence of myocardial damage after scorpion envenomation. DESIGN: Prospective study over 1-year period. SETTING: Medical intensive care unit of a university hospital (Sfax, Tunisia). PATIENTS: We have prospectively included six patients admitted for scorpion envenomation over a period of 1 year in the 22-bed intensive care unit (ICU) of our university hospital. The evidence of myocardial damage was confirmed by electrocardiography and echocardiography in all patients. Myocardial perfusion scintigraphy ((201)Tl scintigraphy) coupled with radionuclide ventriculography ((99m)Tc) was performed for all patients, occurring 32 h on average (range 12-72 h) after the sting. RESULTS: Radionuclide ventriculography was abnormal in all cases; the abnormalities observed were similar to those observed by echocardiography. Moreover (201)Tl scintigraphy showed evidence of myocardial hypoperfusion in all cases. The myocardial hypoperfusion grade and localisation were more marked in the abnormal localisation shown by echocardiography and electrocardiography, compared to the normal wall. Repeated studies, obtained only in two patients within 6 and 15 days, respectively, showed considerable, but not complete, improvement of wall motion and myocardial perfusion. Segments with improved perfusion showed greatly improved regional wall motion. CONCLUSION: This study confirms the evidence of myocardial hypoperfusion after severe scorpion envenomation.