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.

Therapeutic plasma exchange in poisoning: 8 years' experience of a university hospital.

INTRODUCTION AND AIM: This study examined the extracorporeal methods for the elimination of toxic substances in poisoned patients that are used by clinicians taking care of such patients. Here we present our experience in the use of therapeutic plasma exchange (TPE). To the best of our knowledge, this is the largest number of poisoning cases ever reported in a study. PATIENTS AND METHODS: This is a retrospective study conducted at the Çukurova University Faculty of Medicine, Department of Emergency Medicine, with the permission of the ethical committee of the medical faculty. The study includes patients who had undergone TPE because of poisoning between January 2007 and May 2015. We summarize the clinical data and outcomes of the patients with available files. RESULTS: A total of 36 cases among the 42 patients who underwent TPE in this 8-year period were included in the study. More than 20 identified toxic substances, most of which were pesticides, were found to be the causes of poisoning. Twenty-three healthy discharges and 12 deaths are discussed in the study. CONCLUSION: We believe that our study reports the largest ever number of poisoning cases treated with TPE in the literature. When applicable, TPE may be a promising extracorporeal elimination and treatment technique in poisoned patients when performed in selected cases.

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.

The relationship between inferior vena cava diameter measured by bedside ultrasonography and central venous pressure value.

OBJECTIVE: We aimed to present inferior vena cava (IVC) diameter as a guiding method for detection of relationship between IVC diameter measured noninvasively with the help of ultrasonography (USG) and central venous pressure (CVP) and evaluation of patient's intravascular volume status. METHODS: Patients over the age of 18, to whom a central venous catheter was inserted to their subclavian vein or internal jugular vein were included in our study. IVC diameter measurements were recorded in millimeters following measurement by the same clinician with the help of USG both at the end-inspiratory and end-expiratory phase. CVP measurements were viewed on the monitor by means of piezoelectric transducer and recorded in mmHg. SPSS 18.0 package program was used for statistical analysis of data. RESULTS: Forty five patients were included in the study. The patients had the diagnosis of malignancy (35.6%), sepsis (13.3%), pneumonia, asthma, chronic obstructive pulmonary disease (11.1%). 11 patients (24.4%) required mechanical ventilation while 34 (75.6%) patients had spontaneous respiration. In patients with spontaneous respiration, a significant relationship was found between IVC diameters measured by ultrasonography at the end of expiratory and inspiratory phases and measured CVP values at the same phases (for expiratory p = 0.002, for inspiratory p= 0.001). There was no statistically significant association between IVC diameters measured by ultrasonography at the end of expiration and inspiration and measured CVP values at the same phases in mechanically ventilated patients. CONCLUSIONS: IVC diameter measured by bedside ultrasonography can be used for determination of the intravascular volume status of the patients with spontaneous respiration.

Effectiveness of therapeutic plasma exchange in patients with intermediate syndrome due to organophosphate intoxication.

OBJECTIVE: We aimed to determine effectiveness of therapeutic plasma exchange (TPE) in patients with intermediate syndrome (IMS) due to organophosphate (OP) intoxication. METHODS: Patients diagnosed with IMS due to OP intoxication were included in this prospective study. Therapeutic plasma exchange procedure was performed with fresh frozen plasma as a replacement fluid via Fresenius-AS-TEC 204 device by Therapeutic Apheresis Unit to patients who developed IMS during follow-up. Samples were taken from patient's blood and waste plasma collected in the device before and after TPE procedure to be studied in laboratory for detection of organic phosphate and pseudocholinesterase (PChE) levels. In this study, SPSS 18.0 software package was used for statistical analysis of the data obtained. Level of statistical significance was taken as P < .05 for all tests. RESULTS: Of all 17 patients, 4 (23.5%) were female, and 13 (76.5%) were male. A statistically significant decrease was detected in organic phosphate levels in the plasma of patients after TPE procedure (P = .012). A statistically significant increase was detected in PChE levels in the plasma of patients after TPE procedure (P = .014). Of 17 patients included in the study, 13 patients showed clinical improvement and were discharged after the TPE process. CONCLUSION: In our study, it was observed that a significant decrease in the level of blood plasma OP and a significant increase in the level of PChE were achieved with TPE process in the early period of IMS due to OP poisoning. This study indicates that TPE is one of the effective treatment options for IMS due to OP intoxication.

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.

Unintentional endosulfan poisoning.

Endosulfan is an organochloride insecticide, widely used in insect control. It is responsible for many severe intoxication and several deaths. We present a case series of endosulfan poisoning, admitted to our emergency department with different clinical courses. Two patients presented with status epilepticus and were successfully treated with thiopental sodium to control seizures. One patient required also hemodialysis. All patients were discharged following a complete recovery of their health. Endosulfan is a highly toxic insecticide that produces tonic-clonic convulsions, headache, dizziness and ataxia. It can cause also life threatening metabolic disturbances. Treatment is symptomatic and supportive (Tab. 2, Ref. 11). Full Text (Free, PDF) www.bmj.sk.

Trends in acute adult poisoning in a ten-year period in Turkey: factors affecting the hazardous outcome.

AIM: The aim of this study was to evaluate the trends in acute adult poisoning data during ten years in university emergency department and determine the factors of hazardous outcome such as severe clinical status, prolonged hospital stay and mortality. MATERIAL AND METHODS: Medical records of 4569 poisoned patients admitted to Emergency Department (ED) of Qukurova University, School of Medicine in Adana. RESULTS: The mean age of 2988 females (65.4% of the patients) was 24.5+/-10.1 years, whilst the mean age of 1581 male patients (34.6%) was 29.5+/-13.2 years (p=0.001). Of the poisonings 80.0% were suicidal; 69.4% of the women and 30.6% of the men committed suicide. The most common types of poisonings were ingestion of drugs (58.4%), organophosphates (23.9%) corrosives (3.4%), mushrooms (1.7%), methanol (2.4%), carbon monoxide (2.1%) and unknown (8.1%). Of the total 96.0% were discharged from emergency department, 1.4% transferred to IC and 2.6% died. CONCLUSIONS: Young people and women are high-risk groups for acute poisoning and drug poisoning was found to be the most common type of poisoning. The poisoning by psychoactive drugs is increasinging in the recent years and organophosphates poisoning seems to be still a serious problem in such an agricultural area. However, while the ratios of prolonged hospitalization and mortality are decreasing, suicidal poisoning is seriously increasing (Tab. 4, Fig. 2, Ref. 34). Full Text (Free, PDF) www.bmj.sk.

The genotoxicity and cytotoxicity among patients diagnosed with organophosphate poisoning.

The genotoxicity and cytotoxicity were investigated in 40 patients (20 females aged 21.57 +/- 1.42 and 20 males aged 29.35 +/- 3.59) diagnosed at the Emergency Department with organophosphate poisoning. Chromosome aberrations (CAs), sister chromatid exchanges (SCEs), micronucleus (MN), mitotic index (MI), replication index (RI) and nuclear division index (NDI) were evaluated in peripheral bloods of patients. The blood samples were collected from the patients on admission to the emergency department before treatment and after treatment before being discharged from the intensive care unit. The CA, MI and NDI values were increased before the discharge when compared to the levels measured on admission. However, there are no differences in mean SCE, frequency of MN and RI (Tab. 2, Ref. 42).

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.

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.

Intracranial hemorrhage associated with methanol intoxication.

Methanol is a common component of gasoline, antifreeze, washer fluid, perfume, household cleaners and various other industrial products. Acute methanol poisoning produces severe metabolic acidosis, serious neurologic sequelae and rarely imaging findings. In this paper, we describe a 35-year-old man with methanol intoxication who was in a comatose stage. Computed tomography (CT) showed widespread brain edema and hemorrhages localized in the supratentorial region of the temporal lobe, nearly 3 x 1 cm in a crescent shape, in the white matter surrounding the capsula externa and extending to the periventricular white matter and occipital lobes. Temporal lobe hemorrhage in our patient might also have been due to the effect of heparinization during hemodialysis, metabolic and lactic acidosis, or formate.

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.

An unusual localization of snakebite treated without antivenin: case report.

Snakebite is one of the commonest causes of morbidity and mortality in tropical regions. This paper focuses on the medical treatment of a patient who had been bitten by a snake on the vertex of his head. It was a severe envenomation with ensuing marked edema associated with coagulation abnormalities. Although the antivenin was extensively sought in various medical centers, it was unavailable. We observed and treated the patient, with special regard to his hematological findings and potential complications. Specifically, tetanus prophylaxis and intravenous fluids were administered, and the wound was cleaned and dressed. Fresh frozen plasma was also administered. The patient responded well, and was discharged on the fourth day of his admission, without any sequelae.

Carbofuran poisoning among farm workers.

Accidental or intentional ingestion of carbofuran can produce a life-threatening syndrome that requires prompt diagnosis and treatment. This paper investigates unintentional carbofuran poisoning in farm workers. Thirteen patients were admitted to the emergency department with carbofuran poisoning between January 2002 and August 2004 (2 female, 11 male). The patients had been poisoned while mixing the liquid form of carbofuran with seeds. Their hands were red on admission. Complaints most commonly reported by the patients on admission were nausea, vomiting, headache, weakness, dizziness and blurred vision. The most commonly observed signs were tachycardia, tachypnea, salivation, miosis, elevated blood pressure, and fasciculation. Three patients were agitated and one was lethargic on admission. We reviewed the patients' medical charts retrospectively, as well as the demographic data, intoxication route, clinical and laboratory presentations, and outcomes. We made the diagnosis according to a compatible exposure history and clinical findings. The most commonly observed laboratory finding was hyperglycemia, which was found in 6 patients. Serum pseudocholinesterase level was low in only one patient. All the patients were cured and discharged from the hospital in good physical condition. Rapid onset, mild illness and quick recovery are typical characteristics of acute occupational carbofuran poisoning. We conclude that public health efforts should educate farm workers about the dangers of pesticide application so that its threat can be diminished.

Organophosphate poisoning associated with fetal death: a case study.

The increasing use of organophosphorus insecticides in agriculture and inside homes and schools, as well as its widespread existence in the environment, poses a potential health hazard. As the use of these agents increases, acute and chronic exposure has become more common. As with other organophosphates, chlorpyrifos kills insects and other animals, including human beings, because of its toxicity to the nervous system. Exposure of pregnant women to organophosphates is an important clinical entity because of its effects on two organisms--mother and fetus. There are few reports about fetal toxicity of organophosphates in the literature because of the relatively few cases reported. In this paper we report a case of intoxication from chlorpyrifos, an organophosphorus compound, during pregnancy, causing fetal death.

Acute intoxication with doxazosin.

Experience with overdosage and toxicity with the alpha-adrenoreceptor antagonists remains very limited in the literature. In this paper, the second case in the literature with doxazosin overdosage is reported. Supportive treatment was given to the patient and the patient was discharged 48 hours after admission to the emergency department.

Role of intravenous lipid emulsions in the management of calcium channel blocker and ß-blocker overdose: 3 years experience of a university hospital.

OBJECTIVES: The objective of this study was to assess the efficacy of lipid emulsion as antidotal therapy in severe calcium channel blocker (CCB) and ß-blocker (BB) intoxications. PATIENTS AND METHODS: This is a retrospective study in which we have summarized data of patients who were admitted to a university-based emergency department in a period of 3 years and were given intravenous lipid emulsion (ILE) to manage cardiogenic shock due to CCB and BB overdose. RESULTS: We identified 15 patients who received ILE therapy for CCB and BB toxicity. Hospitalization durations variated between 3 and 33 days (mean 7.46 ± 7.41 days). Drug exposures included CCBs (n = 8, 53.3%), CCBs and paracetamol (n = 1, 6.6%), and BBs (n = 6, 40%). ILE therapy was effective in 12 patients (80%). Three patients (20%) had resistant hypotension, one of whom progressed to pulmonary edema. Adverse effects of ILE therapy were seen in three patients (20%). Two patients underwent mechanical ventilation. Two patients developed hypoxic ischemic encephalopathy, one patient died, and 14 patients (93.3%) were discharged from hospital. CONCLUSION: There was 93.3% survival in patients receiving ILE for drug-induced cardiovascular collapse. Clinically significant adverse effects were uncommon. We suggest ILE administration for the treatment of cardiogenic shock due to CCB and BB overdose.

Thyroid storm induced by aspirin intoxication and the effect of hemodialysis: a case report.

Thyroid dysfunction is one of the serious consequences of an overdose of acetaminophen, aspirin, or nonsteroidal antiinflammatory drugs. The management of such consequences remains a medical challenge. A variety of thyroid abnormalities are common in clinical practice and can, in many cases, be accurately diagnosed and managed by the primary care physician. This case study covers an aspirin overdose causing thyroid storm that was treated successfully with hemodialysis.