Report on a study of fires with smoke gas development : determination of blood cyanide levels, clinical signs and laboratory values in victims.

BACKGROUND: This is a report on an international non-interventional study of patients exposed to fires with smoke development in closed rooms. The objective of the study was to document clinical symptoms, relevant laboratory values and blood cyanide concentrations from fire victims in order to confirm or rule out presumptive correlations between the individual parameters. MATERIALS AND METHODS: The study was conducted in five European countries with patients being included if they presented with the characteristic clinical signs, such as soot deposits and altered neurological status. Venous blood samples were taken from victims prior to administration of an antidote in all cases and determination of cyanide concentration was performed in a central laboratory using high performance liquid chromatography. RESULTS: Data from 102 patients (62 % male, average age 49 years) were included in the evaluation with no blood samples being available for analysis from 2 patients. In 25 patients the blood cyanide concentration was below the limit of detection of 1.2 µmol/l. Cyanide levels between 1.2 and 10 µmol/l were measured in 54 patients, 7 patients had values between 10 and 20 µmol/l, 4 patients between 20 and 40 µmol/l while levels above 40 µmol/l were determined in 10 patients. The results of the study could not demonstrate that the cyanide level was influenced either by the interval between smoke exposure and blood sampling or the duration presence at the fire scene. The following clinical signs or laboratory values were recorded as relevant for increased and possibly toxic cyanide levels: respiratory arrest, dyspnea, resuscitation requirement, tracheal intubation, respiratory support measures, low Glasgow coma scale (GCS) score and respiratory frequency. A correlation between cyanide concentration and the total amount of soot deposits on the face and neck, in the oral cavity and in expectoration was confirmed. A correlation between cyanide and carboxyhemoglobin (COHb) levels in the blood of fire victims was also confirmed. CONCLUSIONS: As long as it is not possible to immediately determine the blood cyanide concentration in patients exposed to fire with smoke development, a decreased GCS score, soot deposits particularly in expectoration, dyspnea and convulsions are to be regarded as risk markers for intoxication. In their presence immediate administration of hydroxocobalamin as an antidote is recommended.

An easier method for percutaneous endoscopic gastrojejunostomy tube placement.

BACKGROUND: The current procedures for percutaneous endoscopic gastrojejunostomy (PEG-J) tube placement require fluoroscopy and are time consuming. We describe a new, simple method. METHODS: Ten patients had a PEG-J tube placed by the new method. After placement of a percutaneous endoscopic gastrostomy (PEG) tube using standard technique, the PEG tube was pushed up to the pylorus to make it easier to place the jejunal tube into the duodenum without looping in the stomach. Fluoroscopy was not used. The position of the tube was confirmed by a plain x-ray film of the abdomen. RESULTS: The mean time required for PEG placement and jejunal tube placement was 9.0 and 8.2 minutes, respectively. In all patients the tip of the jejunal tube was at the ligament of Treitz. In one patient the jejunal tube formed a loop in the duodenum, but this was reduced by spontaneous forward migration. In another patient, the tube migrated back into the stomach after 1 week. CONCLUSION: The method described allows easier PEG-J placement without fluoroscopy.

Paraquat poisoning. "State of the art".

The authors describe the main features of acute paraquat poisoning. The clinical picture together with severity grading is presented. The pathophysiological mechanisms responsible for multiple organ dysfunction are discussed. Despite a better understanding of pathophysiological pathways and numerous experimental data, the treatment of the most severe forms of poisoning remains limited. The efficacy of more recently developed therapeutic approaches is still to be evaluated.

Severe diltiazem poisoning with intestinal pseudo-obstruction: case report and toxicological data.

This case report concerns a 30-year-old man who survived a 4.2 g diltiazem overdose. He sustained vasoplegic shock with a junctional escape rhythm which required high doses of norepinephrine and epinephrine. Among other complications, ileus with paralytic intestinal pseudo-obstruction developed on day three. Cecal distention was demonstrated by abdomen computed tomodensitometry. The ileus resolved on day seven following the poisoning. Diltiazem plasma concentrations were determined during the first three days. The possible role of other medications, activated charcoal and sufentanil, is noted.