Prognostic Factors Determining Morbidity and Mortality in Organophosphate Poisoning.

OBJECTIVE: Our aim in this retrospective study was to determine the factors affecting poor prognosis and mortality of organophosphate (OP) poisoning by reviewing patient data. We also reviewed present knowledge to make conclusions on certain longstanding debates in light of the literature. METHODS: In this retrospective descriptive study, patients who were admitted to and hospitalized in the emergency department (ED) or intensive care unit (ICU) of a university hospital with the diagnosis of OP poisoning between December 2010 and December 2015 were evaluated. All the data were obtained from electronic and manual patient files. A total of 80 patients were included in the study. RESULTS: The mean age of the study patients was 32.4±15.0 (13-94). Forty-nine (61.2%) patients were female. Twenty-two (27.5%) patients were seriously poisoned and needed mechanical ventilation (MV) support. Low pseudocholinesterase (PChE), high creatinine (Cr), low Glasgow Coma Scale (GCS) scores and long hospitalization durations were all found to be poor prognostics in MV patients. Low PChE and high Cr levels were found to be independent predictors of the hospitalization duration and high Cr was found to be an independent predictor of the intubation duration of MV patients in regression analyses. Ten (45.5%) of the MV patients were unresponsive to medical treatment and Therapeutic plasma exchange (TPE) was performed. Seven patients were discharged healthy. Three patients with low PChE levels and comorbidities died. CONCLUSIONS: Prolongation of respiratory depression necessitating MV support, comorbidities, long hospital stay, elevated creatinine, low GCS scores and low PcHE levels without regeneration in the first 48 hours of admission are all found to be poor prognostic factors for organophosphate (OP) poisoning.

Levofloxacin-induced hepatotoxicity and death.

Drug-induced hepatotoxicity is a major cause of hepatocellular injury in patients admitting to emergency services with acute liver failure. Hepatic necrosis may be at varying degrees from mild elevations in transaminases to fulminant hepatitis, and even death. The case of a 53-year-old female patient with toxic hepatitis due to levofloxacin and multiple organ failure secondary to toxic hepatitis is presented. Patient suffered itching, redness, and rash after receiving a single dose of 750 mg of levofloxacin tablets for pulmonary infection 10 days ago. Skin lesions had regressed within 3 days, but desquamation formed all over the body. After the fifth day of drug intake, complaints of abdominal pain, vomiting, and yellowing in skin color had started. The patient was referred to our emergency department with these complaints 10 days after drug intake. Patient was thought as a candidate for liver transplant, but cardiopulmonary arrest occurred, and the patient died before she could be referred to a transplant center. This case is important because hepatotoxicity and death due to levofloxacin is uncommon in the literature.

Comparison of the analgesic efficacy of dexketoprofen trometamol and meperidine HCl in the relief of renal colic.

In this study, the analgesic effects of dexketoprofen trometamol and meperidine hydrochloride were compared in patients diagnosed with renal colic. This study was a prospective, randomized, double-blind study. Fifty-two patients, between the ages of 18 and 70 years who were diagnosed with renal colic, were enrolled in the study after obtaining ethics committee approval. Before drug injection, dexketoprofen trometamol and meperidine hydrochloride were placed in closed envelopes, and the patients were randomly given a single dose of intravenous infusion for 20 minutes. Severity of pain and symptoms was evaluated with the numerical rating scale and renal colic symptom score for each patient immediately before administration of drugs and 30 minutes after the end of the application. At the same time, systolic arterial blood pressure, diastolic arterial pressure, respiratory rate, heart rate, nausea, vomiting, and reactions due to drug administration were recorded before and after drug administration. In statistical methods, t test, analysis of variance, and repeated measure analysis were used for the analysis of normally distributed continuous variables and the Mann-Whitney U, Kruskal-Wallis and Friedman tests were used for analysis of not-normally distributed continuous variables. In the analysis of discrete variables, the χ test was used. In both groups, a significant decrease was found in numerical rating scale values measured 30 minutes after drug administration, but the decline in dexketoprofen trometamol group (P = 0.02) was found to be more. Although a significant decrease was found in the renal colic symptom score (P < 0.001) values measured after drug administration in the dexketoprofen trometamol group, no significant decrease was found in the meperidine HCl (P = 0.058) group. After drug administration, a statistically significant decrease was found in the systolic arterial blood pressure, heart rate, and respiratory rate in both groups. Also, a statistically significant decrease was found in the diastolic arterial pressure in the meperidine group. But these changes in vital findings were not serious enough to disrupt patients' clinical status. With this study, we concluded that dexketoprofen trometamol, from the nonsteroidal anti-inflammatory drug group, can be within the primary treatment options for renal colic because of better analgesic efficacy, being well tolerated by patients compared with meperidine hydrochloride.

ST elevation in inferior derivation, coronary ectasia, and slow coronary flow following ceftriaxone use.

A 24-year-old male patient presented with acute coronary syndrome with ST elevation following an allergic reaction to ceftriaxone. A coronary angiogram revealed ectasia and slow coronary flow in the right coronary artery, whereas the left coronary system was found to be normal. The patient was transferred to the coronary intensive care unit and given steroids, antihistamines, acetylsalicylic acid, clopidogrel, low­molecular weight heparin, and diltiazem. In this case study, we presented acute coronary events following an allergic reaction to ceftriaxone.

Serum IL-6, TNFα levels in snakebite cases occurring in Southern Turkey.

OBJECTIVE: The snake species Vipera ammodytes meridionalis and Vipera lebetina obtuse are often seen in Southern Turkey and have venom that causes serious systemic and tissue damage. The aim of our study is to assess the relationship between tumour necrosis factor α (TNFα) and interleukin 6 (IL-6) serum levels, and clinical and laboratory findings in the snakebite patients. METHODS: 26 patients who had received snakebites were included in a prospective study. Patients were grouped according to their clinical presentations in order to plan treatment. RESULTS: TNFα serum levels of most patients who went to the emergency room to receive treatment for snakebite were high. This increase was most likely to be related to the clinical severity of the snakebite and the length of time between the snakebite and their arrival at the hospital. In contrast to TNFα, there was no relationship between serum IL-6 levels and clinical and laboratory parameters. CONCLUSIONS: Snakebites from Vipera ammodytes meridionalis and Vipera lebetina obtuse lead to increased levels of serum TNFα. However, serum TNFα and IL-6 levels depend on various factors such as the kind of snake, the area the venom was injected into, the amount of venom and the body size of the patients.

QTc intervals in drug poisoning patients with tricyclic antidepressants and selective serotonin reuptake inhibitors.

Commonly used agents of drug poisoning among patients who come to the emergency services are tricyclic antidepressants (TCAs). These drugs may cause defect in cardiac conduction due to the slowdown in the cardiac depolarization and expansions in the QT interval. Selective serotonin reuptake inhibitors (SSRIs) are less expansion of the QT period and lower cardio toxic side effects. The aim of this study was to investigate QTc intervals and prognosis of the patients who come to the emergency service due to TCA and SSRI group antidepressant drug poisoning. In a study of 96 patients, 75 of whom were diagnosed to be poisoned by TCAs (TCA group) and 21 by SSRIs (SSRI group) were examined. Electrocardiographic alterations and QTc intervals all of patients were evaluated. QTc intervals of patients in TCA group were determined to be slightly more than those in SSRI group and it was not statistically significant. In the SSRI group, only one patient had QTc period more than 500 milliseconds (520 milliseconds); however, TCA overdose showed 9 (12%) patients with QTc interval over 500 milliseconds, and QTc values of 2 patients were over 600 milliseconds. In our study, it was determined that SSRI group drugs caused similar expansion of the QTc period as TCA drugs but they did not reach high values like TCA drugs, and their OTc intervals stayed in more innocent levels.

Myocardial infarction, acute ischemic stroke, and hyperglycemia triggered by acute chlorine gas inhalation.

Chlorine is one of the most common substances involved in toxic inhalation. Until now, several accidental exposures have been reported. The damage to the respiratory tract in the immediate phase after exposure to chlorine is well defined. Death occurs particularly due to pulmonary edema with respiratory failure and circulatory collapse. On the other hand, no association with myocardial infarction, acute stroke, severe hyperglycemia, and acute chlorine inhalation has been reported in literature. In the present study, an elderly (74-year-old) and diabetic case with myocardial infarction, acute stroke, hyperglycemia, and respiratory failure associated with acute chlorine intoxication after a diagnosis of acute chlorine poisoning and treatment in the emergency department is reported and the literature is revisited. Physicians should know that in elderly patients with a systemic disease who apply with chlorine gas inhalation, more serious complications along with damage in respiratory tract might be observed.

[Evaluation of the process and effectiveness of consultation system in the Department of Emergency Medicine]. / Acil Tip Anabilim Dali'nda konsültasyon sisteminin isleyisi ve etkinliginin degerlendirilmesi.

BACKGROUND: Triage, consultations, and radiological and laboratory test processes have different effects on the total waiting time in the emergency department (ED). Under these circumstances, the importance of the consultation system process and effectiveness of consultation becomes very clear. Our aim in this study was to verify the process of the consultation system. METHODS: This prospective and defining study was performed with 276 patients admitted to the ED. A total of 342 consultations were requested. These patients were classified as very urgent, urgent and non-urgent according to their problems, and a survey form was completed by the ED resident. RESULTS: The most frequently requested consultation was to the Department of Internal Medicine (72%). Mean time for reply to the consultation was 29+/-43 minutes. The earliest reply to the consultation was from Cardiology while the latest responders were the general surgeons. Timeline for replying to the consultation was shorter depending on the urgency of the case. CONCLUSION: In our study, we determined that the most important factor for the effectiveness of consultation was the definition of the urgency of the patients by the residents in the ED. Since the number of patients admitting to the ED will continue to increase in the future, more detailed prospective studies are needed about the efficiency of consultation in the ED.

Add oleander to your list of corrosives.

INTRODUCTION: Nerium oleander is a toxic ornamental plant which usually grows in the Mediterranean area. In the past it was used to produce cardiotonic medicine and there are studies on using this plant as an anti-cancer medicine and on its use in alternative medicine for many causes. CASE PRESENTATION: Our case was of a 36 years old male who came to the emergency department with sore throat and burning feel in the throat following his curious bite of the oleander leaf. He had no trouble of breathing. The physical examination of the mouth showed burn-like lesions and edema of the uvula, oropharyngeal hyperemia, congestion and on the second day; necrosis. The edema and necrosis were later reduced with the treatment. We discharged the patient after observing for three following days without any complications or side effects. CONCLUSION: Besides the systemic effects of the oleander plant, this case demonstrates that it could cause serious tissue necrosis when applied locally and corrosive esophagitis when taken by oral way. Patients must be examined and followed also for local toxic effects.

The efficacy of low-dose antivenom therapy on morbidity and mortality in snakebite cases.

UNLABELLED: Similar to the cases seen around the world, snakebite causes mortality and morbidity in Turkey. The venom of different types of snake in the region of Cukurova causes serious systemic and local tissue damage. METHODS: We performed this prospective study on 45 patients who complained of snakebite. We grouped the patients according to their clinical presentations to facilitate treatment and follow-up period procedures. RESULTS: Whereas the patients with grade 1 envenomation did not receive any antivenom, grades 2 and 3 patients received 2.70 +/- 0.77 and 4.88 +/- 1.65 vials of antivenom, respectively. One of our patients had to undergo finger amputation but there were no deaths. Allergic reactions developed after antivenom therapy in 8 patients (17.8%). CONCLUSIONS: When we considered the cost and complications of the antivenom treatment, it was seen that low-dose antivenom treatment effectively treated the patients with venomous snakebite injuries in our region.

Utilization of plasmapheresis in the management of bismuth intoxication with acute renal failure.

A 34-year-old female patient who ingested 2400 mg bismuth subcitrate in a suicide attempt was brought to the emergency department. She had mild encephalopathy and acute renal failure on admission. One session of plasmapheresis was performed to remove bismuth, and needed three sessions of hemodialysis and was discharged on the 24th day of hospitalization with the recovery of the renal function.

Utilization of plasmapheresis for organophosphate intoxication: A case report.

Organophosphate (OP) compounds are extremely toxic chemicals that may be absorbed via skin, conjunctiva, gastrointestinal and respiratory systems. Treatment of OP poisoning is a critical and aggressive process which includes decontamination, antidote administration (atropin and oximes), mechanical ventilation support and extracorporeal elimination procedures if needed. Here we present a young female patient who was unintentionally poisoned by an OP (trichlorfon) after using it to moisture her skin. The importance of this patient is the dermal disease that makes her unprotective to dermal exposure of chemicals and application of plasmapheresis to treat her poisoning.

Anticholinergic syndrome and supraventricular tachycardia caused by lavender tea toxicity.

Lavender plants have been used for their cosmetic and biologic benefits for many centries. Extracts from Lavandula plants have been found to cause antimuscarinic effects by blocking sodium and calcium ion channels in in vitro and in vivo studies. We present a case of poisoning by ingestion of tea made from Lavender stoechas ( grass). The patient was admitted to our emergency department with supraventricular tachycardia due to anticholinergic syndrome triggered by drinking lavender tea. On electrocardiography, a narrow QRS complex tachycardia was evident. After carotid sinus massage, the patient immediately returned to sinus rhythm. There are no reported data about the toxicity of Lavender stoechas plants with respect to supraventricular tachycardia, anticholinergic syndrome or sympathetic nerve activity.

H-FABP in cases of carbon monoxide intoxication admitted to the emergency room.

INTRODUCTION: Carbon monoxide (CO) intoxication causes cardiovascular problems as a result of diffuse tissue hypoxia. Cardiac biochemical markers and electrocardiographic changes have been reported in CO intoxications. Human fatty acid-binding protein (H-FABP) has been recently used as a reliable marker in identifying early cardiac damage. In this prospective study, we aimed to investigate the advantages of the use of H-FABP, in evaluating the findings of myocardial ischemia in patients with CO intoxication in our region. METHODS: Twenty four successive patients admitted to the emergency department with acute CO intoxication were included in our study. Serum traditional markers and H-FABP were also taken in the earliest period for evaluation of cardiac damage. RESULTS: The creatinine kinase MB (CKMB) levels were positive in 11 of the patients; however, H-FABP and troponin T levels were positive in only 3 of them. One of these subjects had elevated level of H-FABP in the short-term and increasing troponin T level increasing level of troponin T during the follow-up period. CONCLUSION: The obtained data supports the use of H-FABP, a specific indicator in identifying the cardiotoxicity of CO intoxications at an early phase.

Unusual electrocardiographic changes with propranolol and diltiazem overdosage: a case report.

The therapeutic efficacy and safety of beta-adrenoreceptor-blocking drugs has been well established in patients with angina pectoris, cardiac arrhythmias, and hypertension and reducing the risk of mortality and nonfatal reinfarction on survival of acute myocardial infarction. The calcium antagonists are used for the treatment of patients with angina pectoris, long-term systemic hypertension, and the management of hypertensive emergencies and also for a multitude of other cardiovascular and noncardiovascular conditions. Because adverse cardiovascular effects can occur, however, patients being considered for combination treatment with propranolol and diltiazem must be selected carefully and observed closely. In this article, we present a suicidal case of drug overdose with propranolol and diltiazem with unusual electrocardiographic changes.

Parotitis due to organophosphate intoxication.

Acute pancreatitis due to pancreatic exocrine over-secretion induced by organophosphate poisoning has been previously reported but parotid gland involvement has not. This paper describes a case of acute organophosphate-induced parotitis in a patient with pre-existing sialolithiasis. The patient developed bilateral facial swelling in the pre-auricular area extending to the angle of the jaw and also developed elevated serum amylase on the second day of the poisoning. Serum lipase remained normal. Autopsy confirmed parotid gland inflammation and pre-existing ductal lithiasis. This case illustrates that organophosphate-induced parotitis can occur and should be considered in patients with organophosphate poisoning who have hyperamylasemia without elevation in serum lipase.

High-dose verapamil + trandolapril-induced thrombotic microangiopathy.

Thrombotic microangiopathy (TMA) is a syndrome characterized by microangiopathic haemolytic anaemia, thrombocytopenia, and several variable signs of organ damage due to the platelet thrombi in the microcirculation. This article reports a case with TMA which developed after ingestion of a high-dose combination of verapamil and trandolapril. To the authors' knowledge, no prior cases of TMA induced by trandolapril (an angiotensin-converting enzyme inhibitor) and verapamil (a calcium channel blocker) have been reported in the literature.