Adrenaline is effective in reversing the inadequate heart rate response in atropine treated organophosphorus and carbamate poisoning.

BACKGROUND: In acute organophosphorus (OP) or carbamate poisoning, some patients require high dose atropine to counteract the effects on heart rate (HR) and blood pressure (BP). This study describes the factors associated with high dose atropine therapy and the use of adrenaline to reverse the inadequate HR response to atropine. METHODS: Consecutive patients admitted to the intensive care unit (ICU) were prospectively recruited. Demographic data, treatment and outcomes of patients who failed to achieve target HR (100/min) or systolic BP >90 mm Hg with either a cumulative atropine dose of 100-mg within 6-h following admission or an infusion of 30 mg/h for at least 3-h were compared with patients who achieved the targets. Factors associated with high dose atropine therapy were explored using logistic regression analysis and expressed as odds ratio (OR) with 95% confidence intervals (CIs). RESULTS: Of the 181 patients admitted with OP or carbamate poisoning, 155 patients fulfilled inclusion criteria. The mean (SD) age was 35.7 (15.8) years; admission APACHE-II score was 14.6 (7.5). Heart rate and/or BP target was not achieved in 13.6%. In these patients, target HR was achieved after adding adrenaline infusion at 2-4 µg/min. Ventilation duration (11.6 ± 6.3 vs. 8.4 ± 6.9 days, p = 0.05) and ICU stay (12.3 ± 5.8 vs. 8.9 ± 5.8 days, p = 0.01) were longer in patients requiring high dose atropine when compared with others. On multivariate logistic regression analysis, shorter time to presentation to hospital (p = 0.04) was associated with need for high dose atropine. Overall mortality was 9% and similar in both groups (p = 0.41). CONCLUSIONS: High dose atropine therapy is required in a subset of patients with OP and carbamate poisoning and was associated with longer ventilation duration and ICU stay. Adrenaline infusion improved hemodynamics in these patients.

Study of the factors at admission predicting the outcome in patients with attempted suicidal hanging.

Our study sought to identify factors at presentation which can predict the outcome after an attempted hanging. A retrospective analysis of patients over a 12-year period was carried out. A poor outcome was found in 17.8% and this could be predicted by the presence of myoclonus, a Glasgow coma motor score of ≤3 or an abnormal chest radiograph.

Intra-aortic balloon pump (IABP) rescue therapy for refractory cardiogenic shock due to scorpion sting envenomation.

BACKGROUND: Cardiomyopathy, cardiogenic shock or acute pulmonary oedema are well recognised complications of scorpion sting envenomation occurring in about 1-3% of patients. Current treatment recommendations include afterload reduction using prazosin and improving cardiac contractility with inotropes like dobutamine. We report the use of intra-aortic balloon pump (IABP) as rescue therapy in a patient with refractory cardiogenic shock due to Mesobuthus tamulus (Indian red scorpion) envenomation. CASE: A 32-year-old woman was referred 24 h after a scorpion sting. At presentation she was ventilated and in circulatory shock (systolic blood pressure < 50 mmHg). After admission, the patient had four cardiac arrests (three episodes of pulseless ventricular tachycardia/ventricular fibrillation and one episode of asystole) over the next few hours. Following resuscitation, despite a combination of dobutamine, noradrenaline, and adrenaline, blood pressure did not improve significantly. In view of persistent tachycardia (heart rate 160/min), catecholamine storm was suspected and prazosin was added. However, shock was refractory. Hence, IABP was considered as rescue therapy. Following initiation of IABP, there was improvement in cardiac function (improved ejection fraction) which translated to weaning of inotropes over 48 h and improved organ function (renal, respiratory) in the next 2-3 d. However, following extubation, on Day 8, she was noted to have features of hypoxic brain injury. This improved gradually. At discharge (Day 30) she was independent for activities of daily living and was able to mobilise without support. CONCLUSION: IABP could be generally considered as a rescue therapy in refractory cardiogenic shock in envenomations.

Case report of Aspergillus osteomyelitis of the ribs in an immunocompetent patient.

Aspergillus is a saprophytic fungus which is universally found in the environment. Most people breathe in the spores of Aspergillus every day without development of disease. It commonly affects immunocompromised hosts. There are only few reported cases in an immunocompetent host. It most commonly affects the respiratory system, causing superficial or invasive disease. It also affects the skin, brain and eye in severely immunocompromised patients. Aspergillosis of the bone is extremely rare. Amongst all the reported cases of invasive aspergillosis the incidence of osteomyelitis is less than three percent. In these cases commonly of the spine is reported. We present a case of Aspergillus osteomyelitis of the ribs in an immunocompetent host.