[Brugada syndrome and other cardiovascular abnormalities related to tricyclic antidepressants ans related drugs intoxication]. / Syndrome de Brugada et autres anomalies cardiovasculaires associées à l'intoxication par les antidépresseurs tricycliques et apparentés.

UNLABELLED: The aim of this paper is to report major cardiovascular complications related to intoxication due to tricyclic antidepressants (TCA) and related drugs, especially the stabilizing membrane effect (SME) and Brugada syndrome, and identify risk factors related to cardiac toxicity. POPULATION AND METHODS: A retrospective study (35 months), including all adult patients admitted for an isolated intoxication by a TCA or a related drug. The statistical analysis of clinical signs and history as well as ECG abnormalities included parameters recorded in emergency rooms. RESULTS: 65 patients without underlying cardiovascular history were retrieved (mean age 30 + 12 years). The intoxication was intentional in all cases, and the mean estimated taken dosage (ETD) was at 749 + 436 mg. Amitriptyline was the most common drug (66%) followed by clomipramine (29%). The cardiovascular examination noted a tachycardia in 63% of cases (mean HR - 108 + 13 bpm), followed by hypotension (SBP = 80 + 40 mmHg) in 11% of cases. The ECG showed a sinus tachycardia (63%), a PR prolongation (>200 ms) in 28% of cases, a MSE (15.4%) and a type-I aspect of Brugada syndrome (15.4%). The analysis of influence of ETD on HR showed a linear relationship, with the equation HR = 82.276 + 0.039 EDT (mg) (R2=0.138, p=0.001). Analyzing the influence of type of drug on ECG abnormalities revealed a more tachycardia effect of amitryptiline vs. clomipramine (p=0.047). CONCLUSION: Tachycardia is a frequent sign of intoxication, which can be expressed by a linear function depending on ETD. The MSE is more frequently noted with amitriptyline. The clinical aspect of type-I Brugada syndrome is as frequent as the MSE but does not seem prognostic. It is unclear whether it is related to an isolated electrical aspect or it hides a genetic mutation.

[Impact of antibiotic use and prescribing policy in a Tunisian intensive care unit]. / Impact d'une politique de prescription d'antibiotiques dans un service de réanimation Tunisien.

OBJECTIVE: The aim of this study was to assess the efficacy of local antibiotic policy in a Tunisian ICU. The predefined primary efficacy objectives were the decrease of antibiotic consumption, reduction of inappropriate antibiotic (ATB) use and antimicrobial resistance. DESIGN: This prospective intervention study lasted from January 2002 to December 2004. In the first study period or the baseline phase (from January to December 2002) we focused on physician education for ATB prescription practice. The second period concerned intervention (control of all ATB use). RESULTS: The number of infection episodes significantly decreased from 2002 to 2004; 198 infection episodes in 2002 (1.63+/-1.15 episodes/patient) versus 124 in 2003 (1.22+/-0.93) (P<0.0008) versus 121 in 2004 (1.23+/-0.8) (P1<0.0008). The number of ATB/prescription also significantly decreased from 1.85+/-1.3 in 2002 to 1.5+/-0.9 in 2003 (P=0.02) and 1.5+/-1.4 in 2004 (P1=0.05). Appropriateness of antibiotherapy improved during the intervention period: 65% in 2002 versus 86% in 2003 (P=0.0003) and 81% in 2004 (P1=0.02). The length of antibiotherapy in survivors was considerably reduced: 14.1+/-2.9 days in 2002 versus 11.9+/-1.2 days in 2003 (P<10(-5)) and 10.9+/-2.5 days in 2004 (P1<10(-5)) with a significant reduction of antibiotherapy cost and length of stay (20.4+/-9 days in 2002 versus 18.3+/-6 days in 2003 and 16.9+/-8 days in 2004; P=0.05; P1=0.02). There was a significant decrease of carbapenem resistant Enterobacteriaceae esbeta, Pseudomonas aeruginosa and Acinetobacter baumannii.

[Septic shock complicating amniocentesis]. / Choc septique compliquant une amniocentèse.

Amniocentesis is a routine technique for prenatal diagnosis. The incidence of severe intra-amniotic infection is very low. We report a case of septic shock following an amniocentesis in a 34-year-old women. Patient admitted in intensive care unit and need mechanical ventilation and vasoactives drugs to control hemodynamic pertubation. Bacteriological data showed positive polymicrobial blood cultures to Klebsiella pneumoniae and Enterobacter. The patient gradually improved, however her renal function was still impaired and she was discharged three months after admission.

[Acute self-induced poisoning with carbamazepine]. / Intoxication aiguë volontaire par la carbamazépine.

OBJECTIVE: We report the epidemiological, clinical, toxicological and therapeutic aspects of acute voluntary intoxication with carbamazepine. PATIENTS AND METHODS: The study included 17 cases of acute carbamazepine intoxication in patients hospitalized in our toxicology unit. RESULTS: Neurological signs predominated at admission, mainly agitation or coma associated with seizures. Mydriasis and cardiovascular signs were frequent. Blood chemistry most frequently showed hyponatremia. Mean serum carbamazepine level admission was 24 mg/l (range 4 ñ 12 mg/l). Ten patient required respiratory assistance for 28 +/- 17 hours. Symptomatic treatment and gastric lavage (+activated carbon) provided favorable outcome. CONCLUSION: Acute carbamazepine intoxication is seen with increasing frequency. Severity is related to the degree and duration of the coma, respiratory depression, seizures, cardiovascular disorders, and metabolic abnormalities. Symptomatic and specific treatment with activated carbon are required.

[Graded classification of acute chloralose poisoning. 509 cases]. / Classification en grades des intoxications aiguës par le chloralose. 509 cas.

OBJECTIVE: The annual incidence of chloralose poisoning has exceeded 3 cases per 100,000 inhabitants in Tunisia since 1997. The purpose of this study was to analyze clinical features of chloralose poisoning. METHODS: We reviewed patients admitted to the intensive care unit during the last 5 years to search for chloralose poisoning. The identified cases were classed into 5 grades by clinical features: depth of coma, characteristics of the myoclonia, and cerebral trunk reflex response. RESULTS: We identified 509 cases of chloralose poisoning over the last 5 years. Seventy-five patients (14.7%) were in grade 1: drowsiness alone. Four hundred ten patients (80.8%) were in grades 2 and 3: hypertonic coma and myoclonus. The clinical course was favorable after sedation, tracheal intubation and mechanical ventilation. Twenty-three patients (4.6%) were in grades 4 and 5: hypertonic coma (Glasgow coma score = 3). Three of them died. CONCLUSION: The clinical features of chloralose poisoning depend on the ingested dose. Despite the gravity of the initial clinical presentation, prognosis is excellent if symptomatic treatment is given early, even in grade 5 cases which simulate brain death.

[Eikenella corrodens pleuro-pulmonary infection. Apropos of a case]. / Infection pleuro-pulmonaire à Eikenella corrodens. A propos d'une observation.

A case of single bacteria pleuropulmonary infection was observed in a 21-year-old patient with heterozygous sicle-cell amenia. The role of this bacteria in pleuropulmonary suppuration, the pathophysiology and secondary lesions are discussed together with therapeutic modalities.

[Artificial enteral nutrition. Overview of the technics and their applications]. / La nutrition entérale artificielle. Vue d'ensemble des techniques et des applications.

In intensive care it is usual to give from between 3000 and 4500 calories. It seems that an intake of 1 gram of nitrogen for 150 to 200 calories from a non-protein source allows the optimal utilization of nitrogen. The advances made in the manufacture of nutritional mixtures and the techniques of administration often allow high calorie/protein intakes by the oral route alone. Small calibre silicone tubes which are perfectly tolerated are now available. They avoid naso-pharyngeal, oesophageal and pulmonary complications, and there is no reflux. Continuous oral feeding usually given by a pump improves gastric tolerance, reduces the digestive secretions, and slows down the intestinal transit. Digestion and absorption are improved. This technique, as well as the new tubes, allows comatose patients to be fed without any risk. The use of refrigerated nutripompes avoids bacterial proliferation in the nutritional liquid, which can affect digestion. Furthermore these pumps reduce the work of the nurse. Various nutritional mixtures allow a high calorie intake despite the abnormal digestion in the patient. Complications of oral feeding are rare. Reactions of intolerance and the respiratory risks have been considerably reduced. Metabolic disorders can be easily avoided. Diarrhoea is the result either of bacterial proliferation or an error in administration. These complications are definitely less frequent and less serious than those of feeding by the intravenous route, and the precautions to be taken are much simpler. The method is also cheaper.

Metformin associated acute pancreatitis.

Metformin poisoning is not common and is usually associated with lactic acidosis and acute hepatitis. A case of metformin-poisoning associated with acute pancreatitis is reported here for the first time.

Extrapyramidal syndrome as a delayed and reversible complication of acute dichlorvos organophosphate poisoning.

We describe 4 cases of delayed extrapyramidal disorder following acute dichlorvos poisonings. All patients were seriously poisoned since all exhibited profound coma and respiratory failure, and they were all tracheally intubated and mechanically ventilated. On admission, plasma cholinesterase activity was greaty decreased, < 10 micromol/ml/h at 37 C in all patients (< 10% of normal for our laboratory). Extrapyramidal symptoms occurred between 5 and 15 d and were characterized by dystonia of arms and legs, resting tremor, cogwheel rigidity, and hypereflexia. With bromocriptine therapy the features of extrapyramidal syndrome disappeared progressively with complete recovery in all patients. Our observations suggest a delayed extrapyramidal syndrome should be taken into account during the course of acute dichlorvos organophosphate poisonings.

A review of acute poisoning from Atractylis gummifera L.

Atractylis gummifera is a poisonous plant widely found in North Africa. The thistle grows commonly in dry areas, and the juice of the rhizome is poisonous. It provokes frequent poisoning, especially of children. Toxic glucosides have been isolated and their identified as atractyloside and carboxyatractyloside. Tissues of high metabolic activity are the main target organs. Atractylis gummifera glucosides cause a severe hepatitis with fatal liver failure common. The plant's poisonous compounds interact with detoxication and/or transformation systems in the liver even at doses not likely to induce cytolysis by blocking ADP-ATP conversion through inhibition of P450 cytochrome. Clinical manifestations are related to an induced hypoglycemia and neurovegetative disorders or subsequent renal failure. Liver transplantation or immunotherapy may improve the often fatal prognosis.

Datura stramonium poisonings in humans.

Datura stramonium is a hallucinogenic plant which causes serious poisoning. Clinical symptoms are those of atropinic intoxication with psychiatric manifestations of dryness of mouth, mydriasis, tachycardia and hallucinations. Diagnosis is essentially clinical. Treatment is symptomatic and suppurative; prognosis is usually favorable.

Use of plants to induce chemical submission in Tunisia.

Induced chemical submission is the administration or instigation of consumption of one or more substances to an individual without their knowledge to alter attentiveness and make the person vulnerable to abuse. Specific experiences in managing victims of induced submission from plant materials at a poison control center are presented.

Acute iron poisoning.

Intoxications with ferrous compounds are uncommon but ferrous sulphate is most frequently involved. Ferrous fumarate is less toxic than ferrous sulphate. Two cases of ferrous fumarate poisoning that resulted in digestive mucosal lesions are reported.