Fatal hydrogen sulphide poisoning in unconfined spaces.

Fatal hydrogen sulphide poisoning usually occurs in confined spaces. We report two fatal accidents in unconfined spaces. The first accident caused the death of three workers who entered an unconfined room in a silo of sludge at the same time that a truck dumped several tons of sludge from water purification stations. The hydrogen sulphide that had accumulated inside the silo spilled out into the interior of the room due to a 'splashing effect' caused by the impact of the dumped sludge. The second accident occurred when the foreman of a wastewater treatment plant entered one of the substations to perform routine checks and suddenly lost consciousness. Although he was rapidly transferred to an intensive care unit, death occurred a few hours later. Hydrogen sulphide production was, in this case, due to an 'embolism effect' produced by the displacement of wastewater when the substation pumps were activated. We suggest ways in which accidents such as these caused by sudden release of hydrogen sulphide can be prevented.

[Visits to the emergency department due to ecstasy (MDMA) and amphetamine derivative consumption: Epidemiological, clinical and evolutional profile]. / Consultas urgentes derivadas del consumo de éxtasis (3,4-metilenodioximetanfetamina) y derivados anfetamínicos: perfil epidemiológico, clínico y evolutivo.

OBJECTIVES: To describe clinical and epidemiologic characteristics of emergency department visits related with ecstasy usage, determine the rate of re-visits of the patients and their related factors. MATERIAL AND METHODS: The clinical histories of the patients coming to the Emergency Department for ecstasy-related problems were reviewed during 89 consecutive months in order to define the epidemiological and clinical profile. The computerized system of admission was used to study re-visits to the emergency department, reviewing the clinical history of the re-visits to see if they were related with drug consumption. RESULTS: The study included 498 cases (71% male, mean age 26.5 years). The majority of the patients were attended on the weekend (66.6%) and at night (57%). Main complaints were anxiety or altered thoughts (32.8%), agitation (17.2%), impaired awareness level (7.2%) and convulsions or abnormal movements (5.6%). A total of 81% of the patients had consumed other substances besides ecstasy, mainly ethanol (53%), cocaine (36%) and gammahydroxibutirate (liquid ecstasy, 25%). Twenty six patients (5%) required admission to hospital (6 in the intensive care unit) and 4 died (0.8%). Fifteen percent of the patients were re-attended in the same ED for drug-related problems after a mean follow-up of 3 years, the new visit being more frequent during the first months. The need for an urgent psychiatric visit (OR: 6.3; 95% CI: 2.9-12.8) and hospital admission (OR: 3.5; 95% CI: 1.5-8.4) during their first ED attendance were independently associated with a greater risk of re-attendance. CONCLUSIONS: Ecstasy consumption frequently leads to an ED visit, sometimes due to severe medical complications, and at least 15% of patients will need urgent care again for drug-related problems within the next 3 years. This likelihood increases along with increased severity of the index episode (need of psychiatric consultation or hospital admission).

[Sodium intoxication with fatal outcome caused by peritoneal lavage with hypertonic solution of NaCl].

We report a case of fatal sodium poisoning due to the unintentional use of 20% hypertonic saline serum during peritoneal lavage after intestinal resection. The patient presented with unconsciousness, metabolic acidosis, and plasma sodium concentration of 193 mE/l. After 3 hours, he developed paroxysmal supraventricular tachycardia, hyperthermia, generalized tonic-clonic convulsions, disseminated intravascular coagulation, and adult respiratory distress syndrome. The patient died 15 hours after the operation. Pathological examination revealed cerebral and lung oedema, pericentral hepatic necrosis, and fibrin thrombi in the lungs, stomach, and kidneys. We review, in addition, other reported cases of sodium poisoning.

Severe acute poisoning due to a glufosinate containing preparation without mitochondrial involvement.

Glufosinate is a non-selective herbicide widely used in domestic gardens and agriculture. Few cases of glufosinate poisoning have been reported although there has been an increase in recent years, particularly in Japan. Glufosinate toxicity is related to its capacity to inhibit glutamine synthetase and glutamate decarboxylase, which may lead to a potentially fatal multiorgan failure. We report the case of a 41-year-old woman who ingested between 30 and 50 mL of a herbicide (Finale) containing glufosinate (14%) in a suicide attempt. One hour after ingestion, the patient attended the Emergency Department of her own volition. Her overall status was good, and the physical examination was unremarkable. Gastric lavage was carried out, 25 g of activated charcoal was administered, and the patient was admitted for observation. Seventeen hours later, the patient presented drowsiness and a sinus bradycardia of 40 bpm. Thirty-two hours after ingestion, the Glasgow Coma Score was 8, and orotracheal intubation and mechanical ventilation were begun. At 3 days, the patient presented a self-limiting episode of ventricular tachycardia. She recovered consciousness progressively and was extubated without complications. The evolution was favorable, but the sinus bradycardia persisted up to 8 days after the ingestion. A study of lymphocyte mitochondrial function showed no alteration in mitochondrial oxidative capacity or the enzymatic activity of the complexes of the electron transport chain. A small ingestion of glufosinate can cause severe poisoning, whose manifestations predominantly involve the central nervous system and heart rhythm. Signs and symptoms may not appear for several hours and may persist for several days. In spite of these multi-organ manifestations, no alteration in lymphocyte mitochondrial function has been reported.

Progressive supranuclear palsy-like parkinsonism resulting from occupational exposure to lead sulphate batteries.

A 53-year-old man who had worked for 17 years manufacturing car batteries, with overt exposure to lead, developed a clinical picture initially characterized by signs of parkinsonism, followed by atypical signs such as loss of memory, reduction of eye movement, dysarthria, chorea-like dyskinesia and sexual impotence. The diagnosis of atypical parkinsonism was eventually changed to progressive supranuclear palsy-like parkinsonism. The patient was treated with various anti-Parkinson's disease drugs, including levodopa, with modest improvement. The symptoms deteriorated progressively, leading to permanent occupational disability with noticeable limitation of daily activities. Toxicological studies revealed abnormally high blood levels of lead. Discontinuation of lead exposure was followed first by clinical stabilization and then steady improvement. This case confirms recent reports that link exposure to lead and its compounds with degenerative diseases of the central nervous system, such as Parkinson's disease.

Metabolic acidosis and coma due to an overdose of nalidixic acid.

A case of severe metabolic acidosis and coma after taking 28 g of nalidixic acid is described. After administration of 600 mEq of sodium bicarbonate the patient developed a respiratory alkalosis with secondary tetany. She recovered her state of consciousness nine hours later and the acid-base disturbance resolved after sixty hours.

Acute scopolamine poisoning after sniffing adulterated cocaine.

Five cases of acute poisoning by scopolamine bought as cocaine, are reported. All the cases presented a serious anticholinergic syndrome which needed physostigmine administration. The presence of scopolamine in urine and the specimen sniffed was demonstrated in all the cases.

The profile evolution of acute severe poisoning in Spain.

About 5% of the patients admitted to emergency departments with poisonings are seriously ill and need admission to intensive care units (ICUs). This paper presents the result of three multicentric studies carried out in Spain during the last ten years. A study was made of 6 ICUs in 1980, 41 in 1987 and 15 in 1990 with a total of 596 patients. The average age (36) remained stable throughout, but the number of female cases decreased each time. The most frequent cause (79%) was attempted suicide. The products used most frequently were therapeutic drugs (82, 71 and 58%) followed by drugs of abuse, and then agricultural, household and industrial products. We observed a progressive decrease in barbiturates (54, 15 and 2%) and an increase in benzodiazepines and cyclic antidepressants. Therapeutic methods used were mostly gastric lavage (64%), activated charcoal (35%), forced diuresis (43%), extracorporeal therapy (11%) and antidotes. The mortality rate fluctuated between 6.4 and 9.1%, being significantly higher with poisoning by non-therapeutic drugs. In conclusion, the most common poisoning admitted to our ICUs was by psychoactive drugs in suicide attempts. We observed the under-use of activated charcoal and an excessive usage of kidney and extracorporeal methods. The prognosis was worse for poisonings with non-therapeutic drugs.

Acute renal failure in a patient treated by continuous povidone-iodine mediastinal irrigation.

Polyvinylpyrrolidone-iodine (PI) is a widely used antiseptic agent, safe and effective, in the treatment and prophylaxis of wound sepsis. By continuous irrigation it is frequently used to treat suppurative mediastinitis after median sternotomy. We describe a 63 year old woman with a suppurative mediastinitis, treated with continuous PI irrigation who developed an acute oliguric renal failure. The withdrawal of PI was followed by a complete improvement of renal function. Herein we present our case and a review of the literature about the systemic toxicity of PI.

Pneumonia in ventilated head trauma patients: the role of thiopental therapy.

The role of barbiturate therapy in the development of pneumonia in head trauma patients in the intensive care unit of a university hospital was studied retrospectively. A total of 151 ventilated head trauma patients were included in the study. Intravenous thiopentone was administered to 75 patients (Group A), and 76 patients were managed without thiopentone therapy (Group B). Pneumonia was diagnosed when a new persistent pulmonary infiltrate appeared, with at least two of the following: (a) fever greater than 38 degrees C, (b) a white blood cell count greater than 15,000/mm3, or (c) the presence of purulent bronchial secretions. On admission, there were no differences in the acute physiology and chronic health evaluation 2 revision (APACHE II) and Glasgow Coma Score between Groups A and B. Fifty-three per cent of the patients treated with thiopentone (Group A) developed pneumonia compared with 35% in Group B (odds ratio 1.85, 95% confidence interval 0.97-3.51). Gram-negative and Staphylococcus aureus organisms were the most frequently isolated in all cases. No differences in age, sex, APACHE II, Glasgow Coma Score, nutritional status or dexamethasone treatment were observed between the groups with and without pulmonary infection. In the multivariate analysis, prolonged mechanical ventilation before pneumonia and thiopentone treatment remained as the only independent risk factors for the appearance of pneumonia in head trauma patients (p = 0.001 for both). Nevertheless, thiopentone did not increase the rate of mortality in patients with pneumonia. In conclusion, head trauma victims treated with thiopentone have a greater risk for the development of nosocomial pneumonia independent of mechanical ventilation.

Acute overdose due to benzydamine.

Benzydamine is a nonsteroidal anti-inflammatory drug, currently available as mouthwash, aerosol, dermal cream, vaginal douche preparation, pills and otic drops. Up to now no cases of poisoning due to this drug have been reported. A 6-year-old girl with an accidental poisoning with benzydamine is described. The episode consisted of hallucinosis without other symptoms and resolved spontaneously in 17 h.

Fatal weeverfish sting.

We report a case of fatal weeverfish sting. An 18-year-old man was stung on the left leg by a weeverfish, which he was attempting to capture while snorkelling off the coast of Majorca (Spain). The man felt intense pain, but managed to swim to his boat where he lost consciousness after boarding rapidly. An hour later, when examined by a doctor, the subject was found to be in cardiorespiratory arrest. Reanimation manoeuvres were unsuccessful. The most import post-mortem findings were in the skin and lungs. A puncture wound, which traversed the greater saphenous vein and was covered by an intense haemorrhagic infiltrate, was observed in the skin. The lungs showed haemorrhagic alveolar oedema.

Datura stramonium poisoning. Identification of tropane alkaloids in urine by gas chromatography-mass spectrometry.

A case of acute poisoning by ingestion of Datura stramonium infusion is reported. The patient presented with a typical anticholinergic syndrome (dryness of mouth, mydriasis, flushing, tachycardia, agitation, hallucinations) and was treated with symptomatic and supportive measures. The presence of tropane belladona alkaloids in a urine sample was demonstrated by gas chromatography-mass spectrometry.

Gamma hydroxybutirate use for sexual assault.

The use of gamma hydroxybutyrate (GHB) as a recreational drug has quickly spread among European young people during the past decade. Although it has been claimed that GHB can be potentially used to facilitate sexual assault, no case reports have been previously described. A case is described in which GHB was used with that criminal purpose and a review of previous literature is undertaken.

[Availability, use and cost of antidotes in Catalonia]. / Disponibilidad, utilización y coste de los antídotos en Cataluña.

BACKGROUND: To know the availability of antidotes in hospital and extra-hospital emergency services in Catalonia (Spain), their real use, and the cost. PATIENTS AND METHODS: Availability was studied by means of a transversal questionnaire carried out in 24 hospitals and 3 extra-hospital emergency services in Catalonia; the real use of antidotes was investigated using a prospective study carried out for one year in the same 24 hospitals, and the cost was determined using the data obtained over 12 months in one large hospital. RESULTS: Average availability was 35 antidotes in hospital and 13 in extra-hospital emergency services. In no service did the availability coincide exactly with that of another service, nor with the recommendations made by international institutions (World Health Organization and International Programme for Chemical Safety) or the Government of Catalonia. The low incidence of availability of antidotes to cyanide was notable. Antidotes were used in 12.9% of acute intoxications. In 167 cases treated with these drugs, only 9 different antidotes were used. The consumption of these antidotes represents 0.1% of the budget of a pharmacy service in one large hospital. CONCLUSIONS: The availability of antidotes in Catalonia is heterogeneous and some services lack antidotes whose use is considered essential. Antidotes are scarcely used in acute intoxications and their economic cost is low.

[Failure of a cyclophosphamide-dexamethasone combination in paraquat poisoning]. / Fracaso de la combinación ciclofosfamida-dexametasona en la intoxicación por paracuat.

A 37-year-old female deliberately ingested a 20% solution of paraquat in water. One hour later gastric lavage was carried out and bentonite was administered. Five hours later cyclophosphamide (5 mg/kg/day) and dexamethasone (24 mg/day) were started and a continuous intestinal lavage was carried out; four hours later, hemodialysis was begun. After 36 hours, features of renal and respiratory failure developed, with a rapid progress to respiratory distress. The patient died 94 hours after the ingestion of the poison. Despite early therapy with dexamethasone and cyclophosphamide, this patient's evolution does not support the presumed effectiveness of this drug association for paraquat poisoning.

[Oliguric and non-oliguric renal failure in high risk patient in intensive care units (author's transl)]. / Insuficiencia renal aguda oligúrica y no oligúrica en enfermos de alto riesgo ingresados en unidades de cuidados intensivos.

Oliguric and non-oliguric acute renal failure was studied in a group of 28 high risk patients in an intensive care unit. Of these, 15 (53.5%) presented oliguric and 13 (46.4%) non oliguric acute renal failure. Causal agents of the renal failure were postoperative in 14 cases, mainly peritonitis; medical in 10 and posttraumatic in 4. Oliguric renal failure was most commonly medical, while non-oliguric renal failure was predominantly postoperative in origin (p less than 0.05). Results of urinalysis indicative of renal failure were similar in both groups: NAO, osmolarity, FeNa, BUN o/p and creatinine o/p, as were degree and course of renal failure, and the appearance of complications and indications for dialysis. There was no significant difference in mortality rate between oliguric (93%) and non-oliguric (85%) patients; total mortality was 89%. The results of this study clearly show that non-oliguric acute renal failure carries the same poor prognosis in high risk patients in intensive care units as do the oliguric forms of the entity.

[Liquid ecstasy poisoning: study of 22 cases]. / Intoxicación por éxtasis líquido: estudio de 22 casos.

BACKGROUND: To describe characteristics of acute poisoning with liquid ecstasy (gammahydroxybutyrate, GHB). PATIENTS AND METHOD: Epidemiological and clinical data of patients with acute GHB poisoning seen at emergency department (ED) along one year were collected. RESULTS: 22 patients were included. Typical profile corresponds to a young male, who consults on weekend, at night, complaining of a marked decreased level of consciousness. Patients refer coingestion of other drugs and typically regain consciousness spontaneously in a short time. CONCLUSION: The frequency of GHB poisoning has increased notably in our environment. GHB poisoning must be considered on the differential diagnostic of coma of unknown origin in young patients attended in ED.

[The gastrointestinal concealment of illegal drugs]. / Ocultación gastrointestinal de drogas ilegales.

The clinical, radiological and analytical aspects, and the complications observed in 16 cases of swallowing or insertion into the rectum of illicit drugs ("body-packing") are described. The drugs detected were heroin (6 cases), cocaine (5 cases) and cannabis (5 cases). In 15 cases abdominal plain X-rays were useful in the detection of the drug packages, their position and progression in the gastrointestinal tract and the presence of complications. The most valuable finding for radiologic diagnosis was the presence of a radiolucent halo surrounding the drug packages, or "double condom" sign, which was observed in 13/15 cases (87%). Urine analysis was positive for opiates or metabolites of cocaine in 7/9 cases (78%). One case presented acute heroin intoxication and three subjects gastric or intestinal obstruction requiring surgical treatment. In another case a packet, which had been retained in the stomach for five days, was extracted by upper gastrointestinal endoscopy using a Dormia basket with no complications.

[The radiological findings in poisonings by metals]. / Hallazgos radiológicos en intoxicaciones por metales.

We present four cases of heavy metal poisoning (mercury, lead, bismuth and arsenic) in which plain chest and/or abdominal assisted in the differential diagnosis of the clinical picture manifested upon admission at our Emergency Department. The patients suffering from mercury, lead, and bismuth poisoning recovered some weeks after treatment was started. However, the patient with arsenic trioxide poisoning developed cardio-circulatory collapse leading to death three days after admission.