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.

Diagnostic role of thoracic ultrasound in patients with acute respiratory failure at emergency service.

BACKGROUND AND AIM: This study aimed to elucidate the effectiveness of bedside thoracic ultrasound according to BLUE protocol and to investigate its superiority over other imaging methods in the emergency service. METHODS: A total of 120 patients admitted to our institution's emergency care department due to respiratory distress have been enrolled in this prospective research. Thorax USG has been performed in the right and left hemithorax at the points specified in the BLUE protocol for each patient. Pleural sliding motion, A-lines, B-lines, consolidation, effusion, and the presence of barcode signs were evaluated individually. Age, sex, comorbid diseases, other radiological examination findings, laboratory findings, final clinical diagnosis, and hospitalization-discharge status of the patients were recorded. RESULTS: When a correct diagnosis of pneumonia has been analyzed for imaging techniques, the diagnostic rate of chest radiography was 83.3%, CT was 100.0%, and USG was 66.6%. The correct diagnostic rate of chest radiography was 94.5%; CT and USG were 100.0%. The correct diagnosis of pulmonary edema on chest radiography was 94.5%; CT and USG were 100.0%. While the correct diagnosis of pleural effusion on chest radiography and CT was 100.0%, it was 92.3% in USG imaging. Finally, CT and USG imaging performed better than chest radiography in patients with pneumothorax (chest radiography 80.0%, CT and USG 100%). CONCLUSION: USG imaging could be preferred in the diagnosis of pneumonia, pulmonary edema, pleural effusion, pneumothorax, pulmonary embolism, and differential diagnosis at the emergency service.

Determination of phosphatidyl ethanol (PEth) 16:0/18:1 in dried blood samples of drivers involved in traffic accidents: A pilot study.

In routine forensic toxicology practices, blood alcohol concentration (BAC) levels are measured in traffic accidents that ended up in emergency departments. Nevertheless, since the elimination of ethanol from the blood is fast and the detection time is short, BAC cannot indicate the occurrence of chronic excessive alcohol consumption. Phosphatidylethanol (PEth) is a unique ethanol direct biomarker that occurs only in the presence of phospholipase D enzyme in erythrocyte membranes during alcohol intake, and it indicates alcohol intake. In this study, both whole blood and dried blood samples were collected from 50 patients who were admitted to Cukurova University Hospital Emergency Department due to a traffic accident. While studying BAC in whole blood samples, PEth 16:0/18:1 analysis was performed on dried blood samples by LC-MS/MS. According to the BAC (50 mg/dL) value, the legal limit in Turkey, the optimal threshold PEth 16:0/18:1 value was set as 160 ng/mL and over. This study determined that 15 people with above PEth 16:0/18:1 concentrations above 160 ng/mL were classified as excessive alcohol consumption. The data obtained in this study showed a positive correlation between BAC and PEth concentration when driving under the influence of ethanol.

Efficacy of tramadol vs meperidine in vasoocclusive sickle cell crisis.

Despite progress in management, patients with sickle cell disease who are experiencing acute painful episode are often incompletely treated. We compared meperidine and tramadol with respect to their effects on the hemodynamics and pain relief in patients with sickle cell disease who were admitted to the emergency department with painful crisis. A total of 68 patients with sickle cell disease were randomly assigned to receive either tramadol 1.5 mg/kg (n = 34) or meperidine 1 mg/kg (n = 34). Hemodynamic parameters were recorded at regular intervals after analgesic infusions. Pain intensity and relief were documented by visual analog and pain relief scale, respectively. Sedation level was defined according to Ramsay sedation scale. Both meperidine and tramadol administration resulted in a significant reduction in systolic and diastolic blood pressure after 2 hours (P < .05). Efficacy in pain relief between the analgesics was more rapid and better in the meperidine group, although the degree of relief were significantly improved compared to baseline levels in both groups (P < .05). Sedation was more commonly seen in the meperidine arm. None of the patients had experienced neurotoxicity. In summary, both agents had proven safe and effective for emergent use in patients with sickle cell disease. Avoiding meperidine injections as recommended with previous guidelines needs to be carefully reconsidered especially when low doses are mentioned.

The effect of antioxidants (N-acetylcysteine and melatonin) on hypoxia due to carbonmonoxide poisoning.

We aimed to determine the effect NAC (N-acetylcysteine) and melatonin on the histopathological and biochemical paramethers in the rats poisoned with CO (Carbon monoxide) experimentally. Winster albino female rats were placed in a plexiglass chamber and they were poisoned with CO. After the poisoning, rats were randomly divided into 3 groups. The group given only normal saline, was used as a control group (n = 9). The second group was given 30 mg/kg intraperitonally NAC (n = 10). And the third group was treated with 10 mg/kg of melatonin intramuscularly (n = 9). It is determined that some biochemical values affected by NAC but not by melatonin. CK, ALT, Lactate, MDA levels were significantly higher in NAC group than control and Melatonin group (p < 0.01 for all comparisons). Thiol level was lower in NAC group than control group and Melatonin group (p < 0.01 and p < 0.001, respectively). There were no statistical significant differences between the melatonin and control group. There were statistically significant difference between control, NAC and Melatonin groups according to brain and lung tissue damage. It is shown that both NAC and Melatonin are reducing the brain and lung tissue damage of CO poisoning but due to biochemical results worsened by NAC, Melatonin may recommend for CO poisoning (Tab. 3, Ref. 21).

Oral deltamethrin ingestion due in a suicide attempt.

Deltamethrin intoxication is uncommon throughout the world. The toxicity of insecticides containing pyrethroids is considered relatively lower than that of other insecticides such as compounds containing organophosphate. Acute deltamethrin poisoning due to oral ingestions is relatively rare. This report describes a case of a 32-year-old woman admitted to the emergency department (ED) with irritability, muscle cramps, discomfort, sensation of burning, loss of sensation in her feet and arms and dyspnea due to deltamethrin ingestion. Deltamethrin intoxication should be considered as a differential diagnosis in patients presented to ED with nonspecific neurological symptoms. The supportive treatment in acute phase of intoxication is critical in the management of these patients since higher doses of deltamethrin ingestion may cause severe symptoms (Tab. 2, Ref. 16). Full Text (Free, PDF) www.bmj.sk.

Myeloneuritis due to acute organophosphate (DDVP) intoxication.

Given the importance of agriculture and widespread use of pesticides, intoxication due to organophosphate insecticides is common in Turkey. Organophosphorus compounds may cause late-onset distal polyneuropathy occurring 2 or more weeks after the acute exposure. An 18-year-old woman and a 22-year-old man were admitted to the hospital with weakness, paresthesia, and gait disturbances at 35 and 22 days, respectively, after ingesting dimethyl-2,2-dichloro vinyl phosphate (DDVP). Neurological examination revealed weakness, vibration sense loss, bilateral dropped foot, brisk deep tendon reflexes, and bilaterally positive Babinski sign. Electroneurography demonstrated distal motor polyneuropathy with segmental demyelination associated with axonal degeneration prominent in the distal parts of both lower extremities.

Evaluation of the necessity of whole-body scan tomography in cases with head trauma.

BACKGROUND: In our study, we have tried to find out how necessary whole-body computed tomography (WBCT) is to detect other body injuries that may accompany the patients, evaluating head trauma cases with WBCT. METHODS: In our study, we included 198 patients, who were referred to our hospital's emergency service after head trauma, had brain lesions detected in brain tomography (BT), had no additional examination findings and who underwent WBCT. In this retrospective study, patients' age, gender, type of lesion in brain CT, Glasgow Coma Scale (GCS) values and WBCT findings were examined. RESULTS: In this study, 85.4% of the patients were male and the average age was 25.7 years. The most common cranial CT findings were fracture, followed by parenchymal bleeding. 67% of the patients' GCS were below 8. Additional trauma was detected in 78 of the patients (39.4%). The most common additional lesion was the thoracic contusion. The mean age of the patients with cervical injuries determined in CT was significantly high (p<0.05). Statistical significance was determined between cranial fracture, foreign body incidence and thoracic injuries (p<0.05). The incidence of cervical injuries was significantly higher in patients with brain contusion detected in CT (p<0.05). Fracture frequency and presence of additional lesions in WBCT were significantly high (p<0.05). There was no correlation between other cranial lesions and additional injury areas (p>0.05). CONCLUSION: The number of studies evaluating WBCT is high in the literature. However, our study is important concerning that to our knowledge this study is the first study to evaluate the WBCT findings in the head trauma cases without the additional lesions on their bodies. WBCT scan should be recommended in patients whose clinical evaluation could not be completed. WBCT is an important diagnostic tool for the diagnosis of many pathologies, especially for intrathoracic lesions.

Ocular trauma in Turkey: a 2-year prospective study.

This 2-year prospective study was conducted to identify those at risk for ophthalmologic emergencies, to define the risk factors and reasons for eye injuries, to analyze treatment options, and to compare findings with those of previous studies. A total of 203 patients (74% male, mean age 27.3+/-13.9 y, 51% right eye injuries, 44% left eye injuries, 5% bilateral injuries) with injury to 208 eyes who presented to the emergency department for treatment were included in this study. All patients were evaluated by an ophthalmologist, who completed a formal questionnaire. Information recorded included demographic data, details of the eye injury, whether eye protection was used, and the type, location, and mechanism of injury to the eye. Mechanism of injury was categorized as blunt, sharp, or a combination. The ophthalmologist reported the time that had passed between occurrence of injury and presentation for treatment. Each patient was examined by the ophthalmologist, and findings, diagnosis, and treatment were documented. Of treated patients, 93% were hospitalized, most of whom required surgical treatment. One hundred (48%) injuries were related to blunt trauma and 86 (41%) to sharp device trauma. Only 10 (4%) patients were wearing protective eyewear when injured. Ruptured globe was the most common diagnosis of hospitalized patients and the most frequent cause of this was corneal lesions; subconjunctival hemorrhage was the most common diagnosis among nonhospitalized patients. In this study, the leading cause of eye injury was workplace accidents, probably attributable to growing industrialization in the region. Ocular trauma continues to be an important health problem in Turkey. Investigators believe that with education about and use of proper eye protection, 90% of eye injuries could be prevented.

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.

The role of patient-controlled apparatus for sedation in the emergency department.

AIM: Hand trauma is a fairly common cause of emergency unit admissions. Various analgesic and sedative agents are used to decrease pain and anxiety during minor surgical procedures for hand trauma patients and provide more comfortable conditions for the surgeon. The aim of this study was to investigate the potential role of patient-controlled sedation (PCS) during surgical procedures done under local anesthesia for hand trauma in the emergency department. MATERIALS AND METHODS: Forty ASA I-II (Assignment of the American Society of Anesthesiologists) patients who visited the emergency unit with hand trauma were randomized to 2 groups of 20 patients each. The control group received 1 microg/kg of fentanyl (i.v.) and 0.028 mg/kg of midazolam (i.v.). Additional 1 mg doses of midazolam were given by the anesthesiologist to keep the sedation level between 3 and 4. In the PCS group, the midazolam was administered after programming the apparatus. The settings were as follows: loading dose: 0.028 mg/kg, bolus dose 1 mg, lock-out period: 5 min and basal infusion rate: 0. The loading dose was given before local anesthesia. All patients received prilocaine hydrochloride (Citanest 2%, 10 mL) for local anesthesia. The systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), oxygen saturation (SpO2) and respiration rate (RR) were measured before intervention and at 2, 3, 5, 10, 15, 20 and 30 minutes. RESULTS: There were no differences in the demographic characteristics, operation and discharge times in the two groups (p>0.05). No cardiovascular or respiratory instability was observed in any patient, and SpO2 remained over 95% for all. The SBP, DBP, HR and SpO2 did not differ significantly (p>0.05). Although the sedation levels of all patients were satisfactory, the sedation levels of the control group were significantly lower at 5 and 15 minutes (p<0.05). The total midazolam dose was 4.3+1.1 in the control group and 4.0+0.8 in the PCS group. The patient satisfaction rate was 95% in the PCS group and 80% in the control group (p>0.05). CONCLUSIONS: The two regimens did not differ with respect to hemodynamic changes, sedation levels and patient satisfaction. Therefore, PCS may be an acceptable alternative for surgical procedures performed using local anesthesia.

Poisoned after Dinner: Dolma with Datura Stramonium.

Datura stramonium, which is also known as Thorn Apple or Jimson Weed, is an alkaloid containing plant that is entirely toxic. The active toxic constituents of the plant are atropine, scopolamine and hyoscyamine. It has been abused worldwide for hundreds of years because of its hallucinogenic properties. Previous reports have shown that herbal medication overdose and accidental food contamination are ways it can cause poisoning. Herein we present a family that had three of its members poisoned after eating a traditional meal "dolma" made of datura flowers. None had fatal complications and all were discharged healthy. Datura stromonium may be used accidentally as a food ingredient. Since its poisonous effects are not known, people should be informed and warned about the effects of this plant.

Adult burn injuries in an Emergency Department in Central Anatolia, Turkey: a 5-year analysis.

PURPOSE: Burn injuries require a multidisciplinary approach. Emergency Departments can play vital roles in the treatment of burns. The purpose of this study is to investigate the epidemiological and clinical characteristics of the adult burn patients admitted to our Emergency Department and to determine the frequency of the patients who were treated on an outpatient basis and discharged from the Emergency Department. PROCEDURE: A retrospective review of 314 adult burn patients who presented to the Emergency Medicine Department of Erciyes University Hospital from January 1996 to December 2000. FINDINGS: Sixty-four percent of the patients were male. Mean age was 32.9+/-14.7. Ninety-nine patients (32%) had moderate to major burns. The highest numbers of patients were in the 21-30 age group. Flame burns comprised the majority of presentations and admissions (48 and 69%, respectively). Thirteen patients had associated injuries (4%). Eighty-seven patients (28%) were hospitalized, 21 of these died. Death occurred mostly from respiratory failure and sepsis. Domestic accidents were the leading mechanism (63%). CONCLUSION: Burns were mostly due to accidents arising from carelessness, ignorance, hazardous traditions and improperly manufactured products. These can be prevented through mass education programs countrywide. Because almost all burn patients present to Emergency Departments first and not all hospitals can employ burn specialists, the patients with minor burns can be treated on an outpatient basis and the treatment of severe burns can be effectively initiated by emergency physicians.

Blood levels of acute phase reactants with traffic accidents.

Emergency departments are generally the first treatment places for the trauma victims. Evaluating the traumatised patients by objective criteria are of great importance in diagnosis, treatment and prognosis. This prospective study was conducted at the Medical School of Erciyes University. Blood levels of Ceruloplasmin, Haptoglobulin and Transferrin, which are known as acute phase reactants, were obtained. 60 trauma patients were included in this study. 19 (31.6%) females and 41 (68.4%) males. 15 patients were operated. 4 (26%) patients died during the postoperative follow-up period. When compared with ceruloplasmin values obtained on all of the groups this they were statistically significant except that two day-control group. All of the haptoglobulin groups were statistically significant. When compared with transferin values obtained on first-two day, first-seven day and two-seven day, they were statistically significant (P < 0.05). As a results, We might say that the changes in the blood levels of all three biochemical parameters are related to the severity of the trauma. Taking advantage of all such changes we might predict both the severity of the trauma and the prognosis of traumatic episodes. This gives us an opportunity to define better strategies for the follow-up and treatment of our trauma patients.

The relationship of trauma severity and mortality with cardiac enzymes and cytokines at multiple trauma patients.

BACKGROUND: In this study, we aimed to determine the effects of trauma severity on cardiac involvement through evaluating the trauma severity score together with diagnostic tests in multiple trauma patients. A trauma score was determined using various trauma severity scales. METHODS: After obtaining the approval of the ethics committee of the faculty, this prospective study was performed through evaluating 100 multiple trauma patients, aged over 15 years, who applied to our Emergency Department (ED). After determining the trauma severity score using instruments such as the Injury Severity Score (ISS), Glasgow Coma Scale (GCS), and Revised Trauma Score (RTS), the cardiac condition was evaluated using biochemical and radiological diagnostic tests. RESULTS: During the study period, 100 patients were evaluated (78 male, 22 female; mean age: 33.2±15.4; range 15 to 70 years). It was determined that 92 (92%) were blunt trauma cases, and 77 (77%) of them were due to traffic accidents. The majority of cases showed electrocardiogram (ECG) abnormalities (63%) and sinus tachycardia (36%). Abnormal echocardiogram (ECHO) findings, mostly accompanied by ventricular defects (n=24), were determined in 31 of the cases. Nineteen cases with high trauma severity score resulted in death, and 14 of all deaths were secondary to traffic accidents. Trauma scores were found to show a significant difference between the two groups. CONCLUSION: The ISS trauma scale was determined to be the most effective in terms of indicating heart involvement in patients with multiple traumas. Close follow-up and cardiac monitoring should be applied to patients with high trauma severity scores considering possible cardiac rhythm changes and hemodynamic disturbances due to cardiac involvement.

Association of chronic pesticide exposure with serum cholinesterase levels and pulmonary functions.

The present study focused on the analysis of serum cholinesterase levels and the pulmonary function tests in seasonal farm workers who were chronically exposed to pesticides, mostly organophosphorus, in comparison with non-farm workers in the farming areas of Cukurova region, Turkey. Serum cholinesterase levels and pulmonary function tests using spyrometer in 50 male seasonal farm workers (study group) were compared to 50 male non-farm workers (control group) in this cross-sectional study. The mean serum cholinesterase enzyme level in the farm worker group (7095.5 ± 1699.4 U/L) was significantly lower than those of the control group (9716.4 ± 1484.4 U/L) (p < .001). There was no significant difference between pulmonary function tests of 2 groups (p > .05). These results show that chronic environmental organophosphorus exposure caused a decrease in the serum cholinesterase enzyme levels in farm workers, emphasizing the importance of primary prevention.

Cardiac effects of magnesium sulfate pretreatment on acute dichlorvos-induced organophosphate poisoning: an experimental study in rats.

Although atropine and oximes are traditionally used in the management of organophosphate poisoning, investigations have been directed to finding additional therapeutic approaches. Thus, the aim of this study was to evaluate the cardiac effects of magnesium sulfate pretreatment on dichlorvos intoxication in rats. Rats were randomly divided into three groups as control, dichlorvos, and magnesium sulfate groups. After 6 h of dichlorvos or corn oil (as a vehicle) injection, venous blood samples were collected, and cardiac tissue samples were obtained. Biochemical analyses were performed to measure some parameters on serum and cardiac tissue. Immunohistochemical analyses of apoptosis and inducible nitric oxide (NO) synthase showed no change in cardiac tissue. Serum cholinesterase levels were markedly depressed with dichlorvos, and further suppressed markedly with magnesium sulfate pretreatment. Although we have demonstrated that serum NO levels in dichlorvos and magnesium sulfate groups were lower than the control group, cardiac tissue NO levels in magnesium sulfate group were higher than the other two groups. Mortality was not significantly affected with magnesium sulfate pretreatment. Uncertainty still persists on the right strategies for the treatment of organophosphate acute poisoning; however, it was concluded that our results do not suggest that magnesium sulfate therapy is beneficial in the management of acute dichlorvos-induced organophosphate poisoning, and also further studies are required.

Analysis of altered mental status in Turkey.

The aim of this study was to determine the frequency and etiology of altered mental status in adults at an Emergency Department. Medical records of 790 patients with altered mental status were reviewed. Out of 790 patients, 414 (52.3%) were male, 376 (47.7%) were female. Mean age was 45.65 +/- 15.5 years. Etiologic factors were neurological (n = 566; 71.6%), head trauma (n = 82; 10.4%), endocrine/metabolic (n = 48; 6.1%), cardiovascular/pulmonary (n = 49; 6.2%), infectious (n = 30; 3.8%), gynecologic and obstetric (n = 2; 0. 4%), toxicologic (n = 12; 1.5%). Of patients, 40% were in deep coma, 11% were confused, 20% were in agitated confusion, 15% were lethargic, and 14% were in stupor. Eighteen percent of were hypertensive. Total mortality rate was 20.1% (n = 159). Common causes of death were cerebrovascular disease and trauma. Most patients presenting with altered mental status seem to be elderly with the most frequent cause being cerebrovascular accidents. Fatality rate is very high.

Bilateral luxatio erecta humeri.

BACKGROUND: Inferior dislocation of the glenohumeral joint or luxatio erecta humeri is a rare form of injury, accounting for only 0.5% of all shoulder dislocations. Bilateral cases are even less frequent, with only eight cases reported in the literature. METHOD AND RESULT: We report one case of bilateral inferior dislocation of the shoulder. The patient made a complete functional recovery within 2 years after treatment by closed reduction and rehabilitation. CONCLUSION: Based on this case and the pertinent literature, the pathophysiology, diagnosis, and treatment of this rare injury are discussed.

An analysis of 682 adult poisonings in Central Anatolia of Turkey.

We defined patient demographics, type of the poisoning, distribution according to month, route and reason for exposure, mortality causes and rates from 682 poisonings admitted to University Hospital in Kayseri, Turkey to evaluate whether they follow the pattern of other countries. Poisoning were drugs (54.5%), inhalational poisonings including carbon monoxide (13.7%), food (12.4%), alcohol (7%), pesticides (5.4%) and corrosives (2.1%). In drug ingestions, psychoactive drugs most common; psychoactive, analgesic, and anti-inflammatory drugs were most frequent agents in multiple drug poisonings. Drugs were the most used poison while pesticides, mushrooms, methanol and carbon monoxide caused more deaths. The mortality rate was 2%.