Coral snake bites (Micrurus spp.) in Brazil: a review of literature reports.

CONTEXT: In the Americas, the main representatives of the family Elapidae are coral snakes of the genus Micrurus, of which 33 species are in Brazil. They are the smallest cause of venomous snakebite in Brazil. We analyzed literature reports of coral snake bites in Brazil from 1867 to 2014, and provide a brief review of case series and reports of coral snake bites in the Americas in general. METHODS: Only reports with clinical descriptions of envenomation were included. The variables recorded included identification of the offending snake, patient's age, sex, bite site, clinical manifestations, treatment, including antivenom and anticholinesterase drugs, and general evolution of the cases. 30 published reports describing bites caused by Micrurus spp. in Brazil were identified and involved 194 distinct cases. Since no information on the clinical manifestations was available in 44 cases, the analysis was restricted to 25 reports (150 cases). RESULTS: Most patients were from southern (61.3%; primarily Santa Catarina state, 60%) and southeastern (20%) Brazil and were male (70.7%), with a median age of 27 years (interquartile interval = 18 to 40 years). The offending snakes were described in 59 cases (M. corallinus 36, M. frontalis 12, M. lemniscatus 5, M. hemprichi 2, M. filiformis 1, M. ibiboboca 1, M. spixii 1 and M. surinamensis 1); in 22 cases only the genus (Micrurus spp.) was reported. Of the 143 cases in which the bite site was recorded, most involved the hands (46.2%) and feet (26.6%). The main clinical features were local numbness/paresthesia (52.7%), local pain (48%), palpebral ptosis (33.3%), dizziness (26.7%), blurred vision (20.7%), weakness (20%), slight local edema (16%), erythema (16%), dysphagia (14.7%), dyspnea (11.3%), inability to walk (10.7%), myalgia (9.3%), salivation (8%) and respiratory failure (4.3%). Fang marks were described in 47.3% of cases and 14% of bites were classified as asymptomatic. A slight increase in total blood creatine kinase was reported in 3 children, suggesting mild myotoxicity. Therapeutic procedures included coral snake antivenom (77.3%), anticholinesterase drugs (6%), and mechanical ventilation (3.3%). Two patients reported in 1933 developed paralysis/respiratory failure and died 6 h and 17 h post-bite. Four more deaths probably caused by coral snakes were reported (2 in 1867, 1 in 1959, 1 in 1962), but no clinical information was available. DISCUSSION: Neuromuscular blockade was the hallmark of systemic envenomation by Micrurus spp., with signs of myasthenia such as weakness and ptosis that may evolve to paralysis and respiratory failure. Local features, mainly numbness/paresthesia and pain, were frequently reported, with the pain being intense in some cases. Although myotoxicity has been detected in experimental studies with Micrurus spp. venoms, few human reports described laboratory findings compatible with myotoxicity. CONCLUSION: Most coral snake bites reported in Brazil were caused by M. corallinus and M. frontalis, with several patients showing signs of acute myasthenia. Serious complications such as paralysis with respiratory failure were observed but comparatively rare. The deaths occurred where respiratory support (mechanical ventilation) was unavailable when needed.

Poisoning by illegal rodenticides containing acetylcholinesterase inhibitors (chumbinho): a prospective case series.

OBJECTIVE: To describe a prospective case series of poisonings caused by ingestion of illegal rodenticides containing acetylcholinesterase inhibitors, mainly "chumbinho," followed-up by the Campinas PCC for a period of 1 year. CASE SERIES: Seventy-six cases were included, of which 53.9% were males. Age ranged from 2 to 74 years (median = 36 years). The main circumstances leading to poisoning were intentional (suicide attempts 92.1%; homicide attempts 5.3%), and 65.8% were admitted less than 2 hours after ingestion. Most of the patients (96.1%) showed cholinergic muscarinic manifestations, particularly salivation (86.8%), myosis (77.6%), sweating (50%), and bronchorrhea (35.5%). Atropine was used in 82.9% of patients (median = 2 days), intubation and mechanical ventilation in 46.1% (median = 3 days), and the median length of the hospital stay was 4 days. Plasma samples obtained upon admission in 59 cases revealed (LC-MS/MS): aldicarb (55), carbofuran (2), aldicarb and carbofuran (1), no active component (1). In most of the plasma and urine samples collected upon admission, the highest concentrations (ng/mL) obtained were for the active metabolite aldicarb sulphoxide (plasma, median = 831, IIQ = 99.2-2885; urine, median = 9800, IIQ = 2000-15000) than aldicarb (plasma, median = 237, IIQ = 35.7-851; urine, median = 584, IIQ = 166-1230), indicating rapid metabolism. The excretion of aldicarb and its metabolites was rapid since these compounds were rarely detected in plasma samples 48 hours after admission. Sequential cholinesterase analysis in 14 patients revealed almost complete reactivation in the first 48 hours post-admission, compatible for poisoning by carbamates. Based on the Poisoning Severity Score, the cases were classified as asymptomatic (5.3%), minor (11.8%), moderate (35.5%), severe (43.4%), and fatal (3.9%). CONCLUSIONS: Most poisonings involved aldicarb and resulted from suicide attempts; the poisonings were generally severe, with a mortality of 3.9%. Aldicarb was rapidly absorbed, metabolized, and excreted.

Human accidents involving Rhinocricus spp., a common millipede genus observed in urban areas of Brazil.

OBJECTIVE: The most important millipede species causing accidents in Brazil is Rhinocricus padbergi (order Spirobolida, family Rhinocricidae), a vegetarian scavenger distributed from Central to South America. Eleven clinical cases of dermal and oral accidental exposures to secretions from Rhinocricus spp. milipedes are described. CASE SERIES: Eleven cases of skin and oral involvement after accidental contact with the secretions of Rhinocricus spp. in patients from 1to 46 years are detailed. Ten of the 11 accidents involved the feet and in 1 child the mouth. Mild pain was reported in two of the cases, and a transient local burning sensation was described by most of the patients. Three reported no pain or any sensation at all. What was observed in all patients was a dark reddish or blackish staining of the skin simulating inflammatory or even necrotic lesions, which resolved naturally after some weeks. CONCLUSION: Despite the necrotic appearance of Rhinocricus spp. skin lesions, only a very mild inflammation and no necrosis occur. Analysis of the content of 50 glands of these animals captured in the southeast region of Brazil identified 2-methil-1,4-benzoquinone and 3,3a,4,5-tetrahydro-1H-pyrrolo-[2,3-b] pyridine-2,6-dione as the substances responsible for the lesions. Benzoquinones are strongly irritant and persistent compounds, working very well as insect repellents and are toxic to a great variety of other parasites and pathogens. They also have tanning properties. No systemic toxic effects have been described so far after skin contact with benzoquinones or Rhinocricus species.

Finger burns caused by concentrated hydrofluoric acid, treated with intra-arterial calcium gluconate infusion: case report / Queimadura digital por ácido fluorídrico concentrado tratada com infusão intra-arterial de gluconato de cálcio: relato de caso

CONTEXT: Hydrofluoric acid (HF) is widely used in industry and at home. Severe lesions can occur after contact with highly concentrated solutions, leading to tissue necrosis and bone destruction. Specific treatment is based on neutralization of fluoride ions with calcium or magnesium solutions. CASE REPORT: A 41-year-old male was seen at the emergency department 35 minutes after skin contact with 70 percent HF, showing whitened swollen lesions on the middle and fourth fingers of his right hand with severe pain starting immediately after contact. 2.5 percent calcium gluconate ointment was applied. Twenty-four hours later, the patient was still in severe pain and the lesions had worsened. Considering the high concentration of the solution, early start of severe pain, lesion characteristics and impossibility of administering calcium gluconate subcutaneously because of the lesion location, the radial artery was catheterized and 2 percent calcium gluconate was administered via infusion pump for 36 hours, until the pain subsided. No adverse effects were seen during the procedure. Ten days later, the lesions were stable, without bone abnormalities on X-rays. Six months later, a complete recovery was seen. CONCLUSIONS: Intra-arterial calcium gluconate might be considered for finger burns caused by concentrated HF. Complete recovery of wounded fingers can be achieved with this technique even if started 24 hours after the exposure. However, controlled clinical trials are needed to confirm the effectiveness and safety of this intervention.

CONTEXTO: Ácido fluorídrico é largamente usado na indústria e no ambiente doméstico. Lesões graves podem ocorrer depois de contato com soluções altamente concentradas levando a necrose tecidual e destruição óssea. O tratamento específico é baseado na neutralização dos íons de flúor com soluções de cálcio ou magnésio. RELATO DE CASO: Homem de 41 anos foi atendido na sala de urgência 35 minutos depois de contato da pele com ácido fluorídrico a 70 por cento, apresentando lesões esbranquiçadas e edemaciadas nos dedos médio e quarto da mão direita com dor intensa que iniciou logo após o contato. Pomada de gluconato de cálcio a 2,5 por cento foi aplicada. Depois de 24 horas, o paciente continuava com dor mais intensa e as lesões haviam piorado. Considerando a concentração da solução, o início precoce da dor intensa, as características das lesões e a impossibilidade de administrar gluconato de cálcio no subcutâneo devido ao local da lesão, foi inserido cateter na artéria radial para infusão de gluconato de cálcio a 2 por cento com bomba de infusão por 36 horas até melhora da dor. Nenhum efeito adverso foi observado durante o procedimento. Dez dias depois as lesões encontravam-se estáveis, sem alterações dos ossos vistas nos raios-X. Seis meses depois houve recuperação completa. CONCLUSÃO: Gluconato de cálcio intra-arterial pode ser considerado em queimaduras digitais por ácido fluorídrico. Recuperação completa dos dedos acometidos pode ser obtida com essa técnica mesmo que iniciada 24 horas após a exposição. Porém, ensaios clínicos controlados são necessários para confirmar a efetividade e a segurança desta intervenção.

Suicide attempt using pure methanol with hospitalization of the patient soon after ingestion: case report.

CONTEXT: Most patients with methanol poisoning typically show up one to several days after ingestion, presenting severe acidosis, visual disorders, or both. Reports of hospitalization less than 6 h after exposure are unusual. We describe a case of attempted suicide using methanol admitted 3 h after ingestion. CASE REPORT: A 52-year-old male was hospitalized 3 h after intentional ingestion of 150 ml of 99.9% methanol with no co-ingestion of ethanol. He was alert and cooperative, presenting nausea and vertigo, and reporting six episodes of vomiting. Physical examination showed no remarkable features. A blood sample for methanol and ethanol determination was obtained 4 h after ingestion. The result (available 10 h after ingestion) showed 70 mg/dl of methanol, without detectable ethanol. He was treated with a loading dose of 10% ethanol solution (7 ml/kg, intravenously), followed by a maintenance dose of 0.9-1.0 ml/kg/h intravenously (10 to 51 h); hemodialysis (19 to 27 h, together with 2.1 ml/kg/h of 10% ethanol intravenously); and folinic acid intravenously (50 mg every 6 h, from 4 to 51 h). He developed mild/moderate metabolic acidosis without acidemia and was discharged on day four after ophthalmological evaluation and cerebral computed tomography scan, without abnormalities. Follow-up revealed no sequelae. CONCLUSION: This could be classified as a potentially severe case of methanol poisoning, according to the amount and concentration of methanol ingested, and blood methanol concentration at 4 h. The good outcome was attributable to early hospitalization and early antidotal therapy with hemodialysis, starting at 10 and 19 h, respectively.

Lead poisoning due to gunshot bullet in contact with cerebrospinal fluid: case report.

CONTEXT: Lead poisoning due to retained gunshot bullets is a well-known clinical problem that is fairly frequently described in the literature. The risk factors for this occurrence relate mainly to whether the lead bullet is in contact with the joint fluid or cerebrospinal fluid (CSF). The treatment for these cases entails chelation therapy while symptoms are shown and definitive surgical removal of the bullet as a potential source of lead. The aim of this paper is to describe a clinical case of lead poisoning due to a retained gunshot bullet in contact with CSF. CASE REPORT: A 42-year-old male was hit by gunshot bullets during a holdup, and one of them was retained in the spinal cord. Six years later, he developed intense low back pain and underwent laminectomy. Nine years later, he then underwent arthrodesis on L5-S1, but he developed intense abdominal pain after the surgical procedure. For five years, he was treated with calcium versenate in five-day cycles, with a good response. The chelation therapy cycles showed great efficacy during symptomatic periods, thus reducing the symptoms and signs of poisoning and promoting great amounts of lead excretion, thereby reducing the total lead burden responsible for the symptoms. Fortunately, over the last four years, the symptoms have improved and the urine levels of aminolevulinic acid (ALA) have declined, to reach complete normalization. This shows that a healing process is probably taking place on the spinal wound, thereby isolating the bullet fragments from CSF contact.

Suicide attempt using pure methanol with hospitalization of the patient soon after ingestion: case report / Tentativa de suicídio com metanol puro em paciente admitido precocemente após a ingestão: relato de caso

CONTEXT: Most patients with methanol poisoning typically show up one to several days after ingestion, presenting severe acidosis, visual disorders, or both. Reports of hospitalization less than 6 h after exposure are unusual. We describe a case of attempted suicide using methanol admitted 3 h after ingestion. CASE REPORT: A 52-year-old male was hospitalized 3 h after intentional ingestion of 150 ml of 99.9 percent methanol with no co-ingestion of ethanol. He was alert and cooperative, presenting nausea and vertigo, and reporting six episodes of vomiting. Physical examination showed no remarkable features. A blood sample for methanol and ethanol determination was obtained 4 h after ingestion. The result (available 10 h after ingestion) showed 70 mg/dl of methanol, without detectable ethanol. He was treated with a loading dose of 10 percent ethanol solution (7 ml/kg, intravenously), followed by a maintenance dose of 0.9-1.0 ml/kg/h intravenously (10 to 51 h); hemodialysis (19 to 27 h, together with 2.1 ml/kg/h of 10 percent ethanol intravenously); and folinic acid intravenously (50 mg every 6 h, from 4 to 51 h). He developed mild/moderate metabolic acidosis without acidemia and was discharged on day four after ophthalmological evaluation and cerebral computed tomography scan, without abnormalities. Follow-up revealed no sequelae. CONCLUSION: This could be classified as a potentially severe case of methanol poisoning, according to the amount and concentration of methanol ingested, and blood methanol concentration at 4 h. The good outcome was attributable to early hospitalization and early antidotal therapy with hemodialysis, starting at 10 and 19 h, respectively.

CONTEXTO: A maioria dos pacientes intoxicados por metanol se apresenta um a vários dias após a ingestão, com acidose grave e/ou alterações visuais, sendo rara a admissão com menos de seis horas da exposição. Descrevemos uma tentativa de suicídio com metanol puro admitido três horas após a ingestão. RELATO DE CASO: Homem de 52 anos, admitido três horas após ingestão intencional de 150 ml de metanol 99,9 por cento sem co-ingestão de etanol. Ele estava alerta e cooperativo, apresentando náuseas, vertigem e relatando seis episódios de vômitos. Sem achados relevantes no exame físico. Foi coletada amostra sanguínea para determinação dos níveis séricos de metanol e etanol em quatro horas, com resultado liberado em 10 horas, mostrando metanol = 70 mg/dl e etanol não detectável. O paciente foi tratado com uma dose de ataque intravenosa (IV) de etanol 10 por cento de 7 ml/kg, seguida por uma dose de manutenção de 0,9-1,0 ml/kg/h IV de 10 a 51 horas; hemodiálise (19 a 27 horas), recebendo, nesse período, 2,1 ml/kg/h de etanol 10 por cento IV e oito doses de ácido folínico IV (50 mg cada 6 horas, de 4 a 51 horas). Desenvolveu acidose metabólica leve/moderada, sem acidemia, sendo liberado no quarto dia de internação após avaliação oftalmológica e realização de tomografia computadorizada cerebral, sem alterações. Acompanhamento não revelou sequelas. CONCLUSÃO: O presente caso pode ser classificado como uma intoxicação potencialmente grave por metanol, considerando a quantidade e a concentração ingerida e o nível sérico de metanol obtido em quatro horas. A boa evolução pode ser atribuída ao intervalo entre a exposição e a admissão hospitalar, e o tratamento específico com o antídoto e a hemodiálise, respectivamente iniciados em 10 e 19 horas.

Comparison of the FiO2 delivered by seven models of the self-inflating bag-mask system.

BACKGROUND AND OBJECTIVES: Since resuscitators with self-inflating bag-mask systems manufactured and/or commercialized in Brazil are widely available and used in health services, both out- and intra-hospitals, the objective of this study was to determine the O2 fractions delivered by seven resuscitators receiving different O2 flows. METHODS: Seven resuscitators with self-inflating bag-mask systems were tested at the Respiratory Unit of the HC/UNICAMP. A wall O2 flowmeter was connected to the resuscitator that received an O2 flow of 1, 5, 10, and 15 L min(-1) and those were connected to a test lung. Resuscitators capable of being connected to an O2 reservoir were tested with and without this accessory Twenty consecutive measurements were performed and the mean determined. RESULTS: Only one resuscitator delivered an O2 fraction slightly below the accepted limit (0.80) when used with the O2 reservoir. Without this device, all resuscitators achieved the minimal limit of O2 fraction (0.40). Resuscitators not capable of being connected to an O2 reservoir delivered a higher O2. CONCLUSIONS: All resuscitators capable of being connected to an O2 reservoir delivered a higher O2 concentration when connected to this device. Resuscitators that do not have this capability delivered a higher O2 concentration than the ones that could be connected to this device but are used without it.

[Contact dermatitis to elemental mercury with distant lesion].

A clinical case of contact dermatitis following direct skin contact with elemental mercury is presented. Patient had metal mercury in contact with extensive part of his leg and foot skin resulting in erythematous, edematous, and vesicular dermatitis. Lesions evolved to erythematous plaques with small scattered areas of necrosis and drying vesicle lesions. Distant lesions appeared in the right forearm, chest and abdomen. Urinary mercury 36h after contact was 5.9 microg/L, and one week later 19.6 microg/L, indicating dermal absorption. dermal absorption. Dermal effects due to elemental mercury must be expected after direct skin contact.

Dermatite de contato por mercúrio elementar com reação a distância / Contact dermatitis to elemental mercury with distant lesion

Apresenta-se caso clínico de dermatite de contato e reação a distância por contato com mercúrio elementar. Paciente apresentou eritema, edema e vesículas após contato dérmico com mercúrio. Lesões evoluíram para placas eritematosas com pequenas áreas enegrecidas sugerindo necrose e vesículas secas. Ocorreram lesões eritematosas a distância no tórax, abdômen e face flexora do cotovelo. Dosagem de Hg na urina 36 horas após início do contato foi de 5,9µg/L, e no sétimo dia 19,6µg/L, indicando absorção através da pele inflamada. Lesões dermatológicas por contato direto por mercúrio metálico elementar devem ser esperadas em casos acidentais.

A clinical case of contact dermatitis following direct skin contact with elemental mercury is presented. Patient had metal mercury in contact with extensive part of his leg and foot skin resulting in erythematous, edematous, and vesicular dermatitis. Lesions evolved to erythematous plaques with small scattered areas of necrosis and drying vesicle lesions. Distant lesions appeared in the right forearm, chest and abdomen. Urinary mercury 36h after contact was 5.9 µg/L, and one week later 19.6 µg/L, indicating dermal absorption. dermal absorption. Dermal effects due to elemental mercury must be expected after direct skin contact.

Comparação da FiO2 fornecida por sete modelos de sistema balão-máscara auto-inflável / Comparación de la FiO2 suministrada por siete modelos de sistema balón-máscara autoinflable / Comparison of the FiO2 delivered by seven models of the self-inflating bag-mask system

JUSTIFICATIVA E OBJETIVOS: Devido ao fato dos reanimadores com sistema balão-máscara auto-infláveis fabricados e/ou comercializados no Brasil serem amplamente disponíveis e utilizados em serviços de saúde extra e intra-hospitalares, este estudo teve o objetivo de determinar as frações de O2 ofertadas por sete reanimadores recebendo diferentes fluxo de O2. MÉTODO: Sete reanimadores com sistema balão-máscara auto-infláveis foram testados na Unidade Respiratória do HC/UNICAMP. Um fluxômetro de O2 de parede foi conectado ao reanimador que recebia fluxo de O2 de 1, 5, 10 e 15 L.min-1, sendo estes conectados a um pulmão-teste. Os reanimadores que têm a capacidade de se conectar um reservatório de O2 foram testados com e sem esse acessório. Foram efetuadas 20 medidas consecutivas e determinada a média. RESULTADOS: Apenas um reanimador apresentou oferta de fração de O2 pouco abaixo do limite mínimo preconizado (0,80), quando utilizado com o reservatório de O2. Sem esse dispositivo acoplado todos os reanimadores atingiram o limite mínimo de fração de O2 preconizada (0,40). Os reanimadores que não apresentam a possibilidade de acoplar o reservatório de O2 apresentaram maior oferta de O2 em relação aos outros reanimadores. CONCLUSÕES: Todos os reanimadores que possuem a opção de acoplagem do reservatório de O2 forneceram maior concentração de O2 com esse acessório. Os reanimadores que não têm possibilidade de acoplar o reservatório de O2 apresentaram maior oferta de O2 em relação aos outros que podem ser acoplados ao reservatório quando usados sem esse acessório.

JUSTIFICATIVA Y OBJETIVOS: Debido al hecho de que los reanimadores con sistema balón -máscara autoinflables fabricados y/o comercializados en Brasil están ampliamente al alcance y que son utilizados en servicios de salud extra e intrahospitalarios, este estudio tuvo el objetivo de determinar las fracciones de O2 ofertadas por siete reanimadores recibiendo diferentes flujos de O2. MÉTODO: Siete reanimadores con sistema balón-máscara autoinflables fueron probados en la Unidad Respiratoria del HC/UNICAMP. Un fluxómetro de O2 de pared fue conectado al reanimador que recibía flujo de O2 de 1, 5, 10 y 15 L.min-1, siendo que ellos se conectaron a un pulmón test. Los reanimadores que poseen la capacidad de conectarse a un reservorio de O2 se probaron con y sin ese accesorio. Se efectuaron 20 medidas consecutivas y se determinó el promedio. RESULTADOS: Apenas un reanimador presentó oferta de fracción de O2 poco por debajo del límite mínimo preconizado (0,80), cuando se usó con el reservorio de O2. Sin ese dispositivo acoplado, todos los reanimadores alcanzaron el límite mínimo de fracción de O2 preconizada (0,40). Los reanimadores que no presentaron la posibilidad de acoplar el reservorio de O2 presentaron una mayor oferta de O2 con relación a los otros reanimadores. CONCLUSIONES: Todos los reanimadores que poseen la opción de acoplamiento del reservorio de O2, suministraron una mayor concentración de O2 con ese accesorio. Los reanimadores que no tienen la posibilidad de acoplar el reservorio de O2 presentaron una mayor oferta de O2 con relación a los otros que sí pueden ser acoplados al reservorio cuando se usan sin ese accesorio.

BACKGROUND AND OBJECTIVES: Since resuscitators with self-inflating bag-mask systems manufactured and/or commercialized in Brazil are widely available and used in health services, both out- and intra-hospitals, the objective of this study was to determine the O2 fractions delivered by seven resuscitators receiving different O2 flows. METHODS: Seven resuscitators with self-inflating bag-mask systems were tested at the Respiratory Unit of the HC/UNICAMP. A wall O2 flowmeter was connected to the resuscitator that received an O2 flow of 1, 5, 10, and 15 L.min-1 and those were connected to a test lung. Resuscitators capable of being connected to an O2 reservoir were tested with and without this accessory. Twenty consecutive measurements were performed and the mean determined. RESULTS: Only one resuscitator delivered and O2 fraction slightly below the accepted limit (0.80) when used with the O2 reservoir. Without this device, all resuscitators achieved the minimal limit of O2 fraction (0.40). Resuscitators not capable of being connected to an O2 reservoir delivered a higher O2. CONCLUSIONS: All resuscitators capable of being connected to an O2 reservoir delivered a higher O2 concentration when connected to this device. Resuscitators that do not have this capability delivered a higher O2 concentration than the ones that could be connected to this device but are used without it.

Lead poisoning due to gunshot bullet in contact with cerebrospinal fluid: case report / Intoxicação por chumbo devida a projétil de arma de fogo em contato com o líquido cefalorraquidiano: relato de caso

CONTEXT: Lead poisoning due to retained gunshot bullets is a well-known clinical problem that is fairly frequently described in the literature. The risk factors for this occurrence relate mainly to whether the lead bullet is in contact with the joint fluid or cerebrospinal fluid (CSF). The treatment for these cases entails chelation therapy while symptoms are shown and definitive surgical removal of the bullet as a potential source of lead. The aim of this paper is to describe a clinical case of lead poisoning due to a retained gunshot bullet in contact with CSF. CASE REPORT: A 42-year-old male was hit by gunshot bullets during a holdup, and one of them was retained in the spinal cord. Six years later, he developed intense low back pain and underwent laminectomy. Nine years later, he then underwent arthrodesis on L5-S1, but he developed intense abdominal pain after the surgical procedure. For five years, he was treated with calcium versenate in five-day cycles, with a good response. The chelation therapy cycles showed great efficacy during symptomatic periods, thus reducing the symptoms and signs of poisoning and promoting great amounts of lead excretion, thereby reducing the total lead burden responsible for the symptoms. Fortunately, over the last four years, the symptoms have improved and the urine levels of aminolevulinic acid (ALA) have declined, to reach complete normalization. This shows that a healing process is probably taking place on the spinal wound, thereby isolating the bullet fragments from CSF contact.

CONTEXTO: A intoxicação por chumbo devida a projétil retido em ferimento por arma de fogo é uma complicação já conhecida e descrita na literatura. O risco de intoxicação endógena por chumbo está associado ao contato do projétil com o líquido sinovial ou líquido o cefalorraquidiano. O tratamento requer terapia de quelação e retirada cirúrgica do projétil como tratamento definitivo. Este artigo descreve caso clínico de paciente que desenvolveu intoxicação por chumbo devida a projétil retido em contato com líquido cefalorraquidiano. RELATO DE CASO: Paciente masculino, 42 anos, foi baleado durante assalto e teve projéteis que se alojaram no abdômen, perna direita e coluna lombo-sacra. Seis anos depois, desenvolveu intensa lombociatalgia e foi submetido a laminectomia. Nove anos após o acidente, foi submetido a artrodese de L5-S1, quando foi tentada a retirada do projétil, sem sucesso, desenvolvendo no pós-operatório intensa dor abdominal. Foi então feito diagnóstico de intoxicação por chumbo, que foi tratada com gluconato de cálcio, com boa resposta. Durante os cinco anos seguintes, fez ciclos de quelação com ácido etilenodiaminotetracético (EDTA) cálcico, com boa evolução. Os ciclos de quelação mostraram grande eficácia na redução dos sinais e sintomas da intoxicação, promovendo um grande aumento da excreção de chumbo e reduzindo a carga corpórea total de chumbo responsável pelos sintomas. Nos últimos quatro anos, apresentou melhora dos sintomas de intoxicação, com diminuição dos níveis de ALA urinário até a normalização, mostrando que provavelmente houve um processo de cicatrização da lesão, isolando os fragmentos de chumbo do contato com o líquor.

Finger burns caused by concentrated hydrofluoric acid, treated with intra-arterial calcium gluconate infusion: case report.

CONTEXT: Hydrofluoric acid (HF) is widely used in industry and at home. Severe lesions can occur after contact with highly concentrated solutions, leading to tissue necrosis and bone destruction. Specific treatment is based on neutralization of fluoride ions with calcium or magnesium solutions. CASE REPORT: A 41-year-old male was seen at the emergency department 35 minutes after skin contact with 70% HF, showing whitened swollen lesions on the middle and fourth fingers of his right hand with severe pain starting immediately after contact. 2.5% calcium gluconate ointment was applied. Twenty-four hours later, the patient was still in severe pain and the lesions had worsened. Considering the high concentration of the solution, early start of severe pain, lesion characteristics and impossibility of administering calcium gluconate subcutaneously because of the lesion location, the radial artery was catheterized and 2% calcium gluconate was administered via infusion pump for 36 hours, until the pain subsided. No adverse effects were seen during the procedure. Ten days later, the lesions were stable, without bone abnormalities on X-rays. Six months later, a complete recovery was seen. CONCLUSIONS: Intra-arterial calcium gluconate might be considered for finger burns caused by concentrated HF. Complete recovery of wounded fingers can be achieved with this technique even if started 24 hours after the exposure. However, controlled clinical trials are needed to confirm the effectiveness and safety of this intervention.

Alterations in peak inspiratory pressure and tidal volume delivered by manually operated self-inflating resuscitation bags as a function of the oxygen supply rate.

OBJECTIVE: To assess possible alterations in the tidal volume and peak inspiratory pressure delivered by seven models of manually operated self-inflating resuscitation bags as a function of the oxygen supply rate used. METHODS: The resuscitation bags tested were the following: Oxigel, models A and B; CE Reanimadores; ProtecSolutions; Missouri; Axmed; and Narcosul. For the measurements, a wall oxygen flow meter, a flow meter/respirometer, a resuscitation bag, a sensor (Tracer 5 unit), and a test lung were connected. In addition, the Tracer 5 unit was connected to a notebook computer. Oxygen supply rates of 1, 5, 10, and 15 L/min were used. RESULTS: The tidal volume delivered by the Oxigel model A resuscitation bag when receiving oxygen at a rate of 15 L/min was approximately 99% greater than that delivered when receiving oxygen at a rate of 1 L/min. Similarly, peak inspiratory pressure was approximately 155% greater. Under the same conditions, the tidal volume delivered by the Narcosul resuscitation bag was 48% greater, and peak inspiratory pressure was 105% greater. The remaining resuscitation bags tested showed no significant alterations in the tidal volume or peak inspiratory pressure delivered. CONCLUSIONS: Under the resistance and compliance conditions used, the resuscitation bags in which the oxygen inflow is directly to the interior of the bag had the patient valve stuck at the inspiratory position when receiving oxygen at a rate >or= 5 L/min, significantly increasing the tidal volume and peak inspiratory pressure delivered. This did not occur with the resuscitation bags in which the oxygen inflow is directed to the exterior of the bag.

Alterações da pressão de pico inspiratório e do volume corrente fornecidos por reanimadores manuais com balão auto-inflável em função do fluxo de entrada de oxigênio utilizado / Alterations in peak inspiratory pressure and tidal volume delivered by manually operated self-inflating resuscitation bags as a function of the oxygen supply rate

OBJETIVO: Determinar possíveis alterações do volume corrente e da pressão de pico inspiratório fornecidos por sete modelos de reanimador manual com balão auto-inflável em função do fluxo de entrada de oxigênio utilizado. MÉTODOS: Os reanimadores testados foram: Oxigel, modelos A e B; CE Reanimadores; ProtecSolutions; Missouri; Axmed; e Narcosul. Para as aferições, acoplaram-se um fluxômetro de oxigênio de parede, um fluxômetro/respirômetro, um reanimador, um sensor (aparelho Tracer 5) e um pulmão-teste. Além disso, acoplou-se o aparelho Tracer 5 a um notebook. Utilizaram-se fluxos de entrada de oxigênio de 1, 5, 10 e 15 L/min. RESULTADOS: O volume corrente fornecido pelo reanimador Oxigel modelo A ao receber 15 L/min de oxigênio foi aproximadamente 99 por cento maior que o fornecido ao receber 1 L/min de oxigênio. Da mesma forma, a pressão de pico inspiratório foi 155 por cento maior. Nas mesmas condições, o volume corrente fornecido pelo reanimador Narcosul foi 48 por cento maior, e a pressão de pico inspiratório foi 105 por cento maior. Os demais reanimadores testados não apresentaram alterações significativas do volume corrente e da pressão de pico inspiratório fornecidos. CONCLUSÕES: Nas condições de resistência e complacência utilizadas, os reanimadores em que o fluxo de entrada de oxigênio é direcionado diretamente ao interior do balão tiveram a válvula do paciente presa em posição de inspiração ao receberem um fluxo > 5 L/min, aumentando significativamente o volume corrente e a pressão de pico inspiratório fornecidos. Isso não ocorreu nos reanimadores em que o fluxo de entrada de oxigênio é direcionado ao exterior do balão.

OBJECTIVE: To assess possible alterations in the tidal volume and peak inspiratory pressure delivered by seven models of manually operated self-inflating resuscitation bags as a function of the oxygen supply rate used. METHODS: The resuscitation bags tested were the following: Oxigel, models A and B; CE Reanimadores; ProtecSolutions; Missouri; Axmed; and Narcosul. For the measurements, a wall oxygen flow meter, a flow meter/respirometer, a resuscitation bag, a sensor (Tracer 5 unit), and a test lung were connected. In addition, the Tracer 5 unit was connected to a notebook computer. Oxygen supply rates of 1, 5, 10, and 15 L/min were used. RESULTS: The tidal volume delivered by the Oxigel model A resuscitation bag when receiving oxygen at a rate of 15 L/min was approximately 99 percent greater than that delivered when receiving oxygen at a rate of 1 L/min. Similarly, peak inspiratory pressure was approximately 155 percent greater. Under the same conditions, the tidal volume delivered by the Narcosul resuscitation bag was 48 percent greater, and peak inspiratory pressure was 105 percent greater. The remaining resuscitation bags tested showed no significant alterations in the tidal volume or peak inspiratory pressure delivered. CONCLUSIONS: Under the resistance and compliance conditions used, the resuscitation bags in which the oxygen inflow is directly to the interior of the bag had the patient valve stuck at the inspiratory position when receiving oxygen at a rate > 5 L/min, significantly increasing the tidal volume and peak inspiratory pressure delivered. This did not occur with the resuscitation bags in which the oxygen inflow is directed to the exterior of the bag.

Systemic envenomation caused by the wandering spider Phoneutria nigriventer, with quantification of circulating venom.

INTRODUCTION: Bites by Phoneutria spp. spiders are common in Brazil, although only 0.5-1% result in severe envenomation, with most of these occurring in children. Cases of systemic envenomation in adults are very unusual, and no serum venom levels have been previously quantified in these cases. CASE REPORT: A 52-year-old man was bitten on the neck by an adult female Phoneutria nigriventer. Immediately after the bite, there was intense local pain followed by blurred vision, profuse sweating, tremors, and an episode of vomiting; 1-2 h post bite the patient showed agitation and a blood pressure of 200/130 mmHg, and was given captopril and meperidine. Upon admission to our service 4 h post bite (time zero - T0), his blood pressure was 130/80 mmHg with a heart rate of 150 beats/min, mild tachypnea, agitation, cold extremities, profuse sweating, generalized tremors, and priapism. The patient was treated with antivenom, local anesthetic, and fluid replacement. Most of the systemic manifestations disappeared within 1 h after antivenom. Laboratory blood analyses at T0, T1, T6, T24, and T48 detected circulating venom by ELISA only at T0, before antivenom infusion (47.5 ng/mL; cut-off, 17.1 ng/mL); his serum blood sugar was 163 mg/dL at T0. The patient was discharged on the second day with a normal arterial blood pressure and a follow-up evaluation revealed no sequelae. CONCLUSION: This is the first report of confirmed moderate/severe envenoming in an adult caused by P. nigriventer with the quantification of circulating venom.

Endotracheal tube cuff pressure alteration after changes in position in patients under mechanical ventilation.

OBJECTIVE: The purpose of this study was to investigate endotracheal tube cuff pressure (Pcuff) alteration in patients under mechanical ventilation after changes in position. METHODS: All selected patients were initially placed in the 35 degrees semi-Fowler position, with Pcuff adjusted to 20 mmHg, and randomly divided into two groups. Group A, in which patients were moved to the lateral decubitus position, facing away from the ventilator (measurement designated Pcuff A1), returned to the initial position (measurement designated Pcuff A2), moved to a lateral decubitus position, facing the ventilator (measurement designated Pcuff A3) and then returned to the initial position (measurement designated Pcuff A4); and Group B, in which patients were moved to the lateral decubitus position, facing the ventilator (measurement designated Pcuff B1), returned to the initial position (measurement designated Pcuff B2), moved to the lateral decubitus position; facing away from the ventilator (measurement designated Pcuff B3) and then returned to the initial position (measurement designated Pcuff B4). RESULTS: The study comprised 70 patients, 31 allocated to group A and 39 allocated to group B. Values >22 mmHg were observed in 142(50.7%) of the 280 Pcuff measurements taken, and values <18 mmHg were observed in 14 (5%). When moved from the 35 degrees semi-Fowler position to the lateral decubitus position, facing away from the ventilator, 58 (82.2%) of the patients presented mean Pcuff values in the higher range (>22 mmHg). CONCLUSIONS: Changes in body position can cause significant Pcuff variations in patients under mechanical ventilation.

Alteração da pressão intra-cuff do tubo endotraqueal após mudança da posição em pacientes sob ventilação mecânica / Endotracheal tube cuff pressure alteration after changes in position in patients under mechanical ventilation

OBJETIVO: O objetivo deste trabalho foi investigar a alteração da pressão intra-cuff (Pcuff) do tubo endotraqueal em pacientes sob ventilação mecânica, após alteração de sua posição corporal. MÉTODOS: Todos os pacientes selecionados eram inicialmente colocados em posição de semi-Fowler (35º), Pcuff em 20 mmHg, e divididos aleatoriamente em dois grupos. No Grupo A: a Pcuff era medida após mover-se o paciente para decúbito lateral, costas voltadas para o ventilador (denominada Pcuff A1); após retornar o paciente à posição inicial (denominada Pcuff A2); após mover-se o paciente para decúbito lateral, de frente para o ventilador (denominada Pcuff A3); e após retornar o paciente, novamente, à posição inicial (denominada Pcuff A4). No Grupo B: a Pcuff era medida após mover-se o paciente para decúbito lateral, de frente para o ventilador (denominada Pcuff B1); após retornar o paciente à posição inicial (denominada Pcuff B2); após mover-se o paciente para decúbito lateral, costas voltadas para o ventilador (denominada Pcuff B3); e após retornar o paciente, novamente, à posição inicial (denominada Pcuff B4). RESULTADOS: Foram incluídos 70 pacientes no estudo, 31 no grupo A e 39 no grupo B. Valores >22 mmHg foram observados em 142 (50,7 por cento) das 280 medidas de Pcuff realizadas, e valores <18 mmHg, em 14 (5 por cento). Quando movidos da posição de semi-Fowler (35º) para decúbito lateral, costas voltadas para o ventilador, 58 (82,2 por cento) dos pacientes apresentaram valores médios de Pcuff mais altos, >22 mmHg. CONCLUSÕES: Mudanças na posição corporal dos pacientes sob ventilação mecânica podem alterar significativamente a Pcuff.

OBJECTIVE: The purpose of this study was to investigate endotracheal tube cuff pressure (Pcuff) alteration in patients under mechanical ventilation after changes in position. METHODS: All selected patients were initially placed in the 35º semi-Fowler position, with Pcuff adjusted to 20 mmHg, and randomly divided into two groups. Group A, in which patients were moved to the lateral decubitus position, facing away from the ventilator (measurement designated Pcuff A1), returned to the initial position (measurement designated Pcuff A2), moved to a lateral decubitus position, facing the ventilator (measurement designated Pcuff A3) and then returned to the initial position (measurement designated Pcuff A4); and Group B, in which patients were moved to the lateral decubitus position, facing the ventilator (measurement designated Pcuff B1), returned to the initial position (measurement designated Pcuff B2), moved to the lateral decubitus position; facing away from the ventilator (measurement designated Pcuff B3) and then returned to the initial position (measurement designated Pcuff B4). RESULTS: The study comprised 70 patients, 31 allocated to group A and 39 allocated to group B. Values >22 mmHg were observed in 142(50.7 percent) of the 280 Pcuff measurements taken, and values <18 mmHg were observed in 14 (5 percent). When moved from the 35º semi-Fowler position to the lateral decubitus position, facing away from the ventilator, 58 (82.2 percent) of the patients presented mean Pcuff values in the higher range (>22 mmHg). CONCLUSIONS: Changes in body position can cause significant Pcuff variations in patients under mechanical ventilation.

Oxygen outflow delivered by manually operated self-inflating resuscitation bags in patients breathing spontaneously.

OBJECTIVE: To determine the oxygen outflow delivered by seven different models of manually operated self-inflating resuscitation bags (with and without an oxygen reservoir connected), which were tested using different oxygen supply rates without manipulating the bag, by simulating their use in patients breathing spontaneously. METHODS: The oxygen outflow was measured using a wall oxygen flow meter and a flow meter/respirometer attached to the bag, together with another flow meter/respirometer attached to the patient connection port. The resuscitation bags that allow the connection of an oxygen reservoir were tested with and without this device. All resuscitation bags were tested using oxygen supply rates of 1, 5, 10, and 15 L/min. Statistical analyses were performed using analysis of variance and t-tests. RESULTS: The resuscitation bags that allow the connection of an oxygen reservoir presented a greater oxygen outflow when this device was connected. All resuscitation bags delivered a greater oxygen outflow when receiving oxygen at a rate of 15 L/min. However, not all models delivered a sufficient oxygen outflow even when the two previous conditions were satisfied. CONCLUSIONS: Of the resuscitation bags studied, those that allow the connection of an oxygen reservoir must have this reservoir connected to the bag when used as a source of oxygen in nonintubated spontaneously breathing patients. All of the models studied should receive oxygen at a rate > 15 L/min. It is not safe to use manually operated self-inflating resuscitation bags for this purpose without knowing their characteristics.

Fluxo de saída de oxigênio fornecido por reanimadores manuais com balão auto-inflável em pacientes com ventilação espontânea / Oxygen outflow delivered by manually operated self-inflating resuscitation bags in patients breathing spontaneously

OBJETIVO: Determinar o fluxo de saída de oxigênio fornecido por sete modelos diferentes de reanimadores manuais com balão auto-inflável (com e sem reservatório de oxigênio acoplado), que foram testados utilizando-se diferentes fluxos de entrada de oxigênio sem manipular o balão, simulando o uso em pacientes com respiração espontânea. MÉTODOS: O fluxo de saída de oxigênio foi medido utilizando-se um fluxômetro de oxigênio de parede e um fluxômetro/respirômetro conectados ao balão e outro fluxômetro/respirômetro conectado à porta de conexão do paciente. Os reanimadores que permitem o acoplamento de um reservatório de oxigênio foram testados com e sem esse reservatório. Todos os reanimadores foram testados utilizando-se fluxos de entrada de oxigênio de 1, 5, 10 e 15 L/min. Para a análise estatística utilizaram-se análise de variância e o teste t. RESULTADOS: Os reanimadores que permitem o acoplamento de um reservatório de oxigênio apresentaram maior fluxo de saída de oxigênio quando esse dispositivo estava acoplado. Todos os reanimadores forneceram maior fluxo de saída de oxigênio quando receberam 15 L/min de oxigênio. Entretanto, nem todos os modelos testados forneceram fluxo de saída de oxigênio suficiente mesmo quando as duas condições anteriores foram atendidas. CONCLUSÕES: Dos reanimadores estudados, os que permitem o acoplamento de um reservatório de oxigênio devem obrigatoriamente estar com esse reservatório acoplado ao balão quando utilizados como fonte de oxigênio em pacientes não intubados com respiração espontânea. Todos os modelos estudados devem receber um fluxo de oxigênio > 15 L/min. Não é seguro utilizar reanimadores manuais com balão auto-inflável para esse propósito sem conhecer suas características.

OBJECTIVE: To determine the oxygen outflow delivered by seven different models of manually operated self-inflating resuscitation bags (with and without an oxygen reservoir connected), which were tested using different oxygen supply rates without manipulating the bag, by simulating their use in patients breathing spontaneously. METHODS: The oxygen outflow was measured using a wall oxygen flow meter and a flow meter/respirometer attached to the bag, together with another flow meter/respirometer attached to the patient connection port. The resuscitation bags that allow the connection of an oxygen reservoir were tested with and without this device. All resuscitation bags were tested using oxygen supply rates of 1, 5, 10, and 15 L/min. Statistical analyses were performed using analysis of variance and t-tests. RESULTS: The resuscitation bags that allow the connection of an oxygen reservoir presented a greater oxygen outflow when this device was connected. All resuscitation bags delivered a greater oxygen outflow when receiving oxygen at a rate of 15 L/min. However, not all models delivered a sufficient oxygen outflow even when the two previous conditions were satisfied. CONCLUSIONS: Of the resuscitation bags studied, those that allow the connection of an oxygen reservoir must have this reservoir connected to the bag when used as a source of oxygen in nonintubated spontaneously breathing patients. All of the models studied should receive oxygen at a rate > 15 L/min. It is not safe to use manually operated self-inflating resuscitation bags for this purpose without knowing their characteristics.