Ali Yurtseven

A `glue sniffer` teenager with anuric renal failure and hepatitis

Yurtseven A, Türksoylu M, Yazıcı P, Karapınar B, Saz EU. A `glue sniffer` teenager with anuric renal failure and hepatitis. Turk J Pediatr 2018; 60: 206-209. `Inhalant abuse` is a common form of volatile drug abuse throughout the world especially in developing countries. This substance mainly contains toluene. Acute toluene inhalation produces a biphasic response with an initial central nervous system (CNS) excitation followed by CNS depression as well as various metabolic alterations. Chronic inhalational abuse is associated with muscular weakness, gastrointestinal symptoms, renal and hepatic injury. In this report, a 16-year-old boy presented with jaundice, nausea, vomiting and reduced urine output. He developed severe acute renal/hepatic damage due to abuse of gas products. Since toluene is the main toxic agent involved in glue sniffing which is metabolized to hippuric acid, the present case was treated with continuous hemodiafiltration, plasma exchange and conservative therapy to eliminate hippuric acid. The jaundice gradually disappeared, he had complete recovery of renal/hepatic functions in ten days. We aimed to increase the awareness among emergency physicians that ``glue sniffing` should be considered in the differential diagnosis of unexplained reversible acute renal/hepatic damage.

Integration of radiology and clinical score in pediatric appendicitis

The efficacy of ultrasonography (US) and abdominal X‐ray in combination with Pediatric Appendicitis Score (PAS) is complicated in the diagnosis of acute appendicitis. Abdominal X‐ray is as useful as US with clinical assessment when evaluated by experienced pediatric radiologist in acute appendicitis. The aim of this study was to determine the value of US and abdominal X‐ray for appendicitis in children when combined with clinical assessment based on PAS, and to establish a practical pathway for acute appendicitis in childhood.

Infantil delirium induced by cycloplegic eye drops

Cyclopentolate 1% and tropicamide 1% eye drops are considered to be safe in the pediatric population for the fundus examination and treatment of ocular diseases. Although adverse reactions rarely occur, some of them can be life-threatening such as seizure, delirium, coma, arrhythmia, acute life-threatening event, and death. Here we report 15 months old boy who developed delirium after administration of ocular cyclopentolate 1% drops in both eyes during a routine examination for retinopathy of prematurity. Cyclopentolate is a parasympatholytic drug with actions similar to atropine. With ophthalmic administration of cyclopentolate, severe central nervous system effects and systemic reactions may occur. In order to minimize absorption following instill one or two drops of 1% solution, applying pressure to nasolacrimal sac for 2 to 3 min should be considered. In mild to moderate toxicity, benzodiazepines may be used to control central nervous system findings secondary to anticholinergic effects.

Red flag; wheezing with neck pain may be a clue to the early diagnosis of spontaneous pneumomediastinum

Spontaneous pneumomediastinum is an uncommon clinical condition in pediatric field. We report two pediatric cases with first time wheezing episode complicated by pneumomediastinum. Investigations failed to reveal any underlying cause for secondary pneumomediastinum. Pneumomediastinum most commonly occurs in asthmatic children. It can be explained by increased pressure gradient between the intraalveolar and interstitial spaces. We conclude that high prevalence of respiratory infections in children predisposes for spontaneous pneumomediastinum due to increased pressure within obstructed airways, or by tissue necrosis from parenchymal infection.

Frequency and outcomes of endotracheal intubation in the pediatric emergency department

Intubation is a core airway skill in Pediatric Emergency Medicine (PEM). The data on pediatric endotracheal intubation in the emergency department, especially in developing countries, is currently very limited. This study was designed to describe the frequency, clinical features and outcomes of pediatric intubation in a large children`s hospital. We performed a retrospective analysis of PEM medical records between January 2014 and December 2015 that involved any attempted intubations of children younger than 18 years. The medical records were reviewed to describe the intubation process, demographics, clinical features and outcomes. A total of 110,000 patients visited our emergency department during the study period. Ninety-one of them (1/1300) were intubated. The median age was 2 years, (F/M: 1) and 25 patients were younger than 12 months. Respiratory failure was the most common indication for intubation (42%), followed by status epilepticus (26%) and sepsis-shock (16%). Mortality was associated with prolonged chest compression (more than 10 minute). A poor outcome was associated with sepsis-shock and cardiac diseases; however, better outcomes were associated with status epilepticus (p < 0.001). The first attempt success (FAS) was achieved in 60/91 (66 %) patients and the FAS rate was also higher in younger patients (p=0.002). The discharge rate of all intubated patients in our study was sixty-four percent. Pediatric residents performed the majority of intubations. A higher FAS rate was associated with younger patients. Favorable outcomes were directly related to duration of cardiopulmonary resuscitation and main diagnosis.

The First Use of Pralidoxime in a Child With Rivastigmine Poisoning.

The aim of this report is to describe the successful use of pralidoxime in a pediatric patient who accidentally ingested 12 mg of rivastigmine and presented to the emergency department with weakness, drowsiness, hyporeactivity to environmental stimuli, and full cholinergic syndrome. Case The patient presented to the emergency department 2 hours after a suspected ingestion of rivastigmine. He was sleepy but oriented and cooperative, hypotonic, and hyporeflexic and has a Glasgow Coma Scale score of 13 (E3M6V4). Laboratory tests showed a low plasma cholinesterase levels of 2141 U/L (reference range, 5300–12 900 U/L), hyperglycemia (251 mg/dL), and leukocytosis with neutrophilia (21 900/mL, 75.2% neutrophils). Conclusions Only 2 pediatric cases of rivastigmine poisoning have been reported in the literature, and there are no previous reports of using pralidoxime in the management of this poisoning. In the present case, intravenous pralidoxime (30 mg/kg) was administered twice at the fifth and sixth hours of ingestion for nicotinic and central effects. There is reasonable theoretical science to suggest pralidoxime in case of acetylcholinesterase inhibitor toxicity. We conclude that observed clinical improvement in weakness temporally associated with pralidoxime administration. Increased plasma cholinesterase activity after pralidoxime administration also makes it useful in this type of poisoning.

Metheboglobinemia Developing in Four Infants after Local Anesthesia

Eritrosit yapısında bulunan hemoglobin, normal şartlarda ferro (Fe+2) formunda demir içeren ve dokulara oksijen taşınmasını sağlayan bir moleküldür. Hemoglobinin çeşitli oksidatif streslerle oksitlenmesi sonucu, içeriğindeki demirin, üç değerli ferrik (Fe+3) haline dönüşmesi ve dokulara oksijen taşınmasının bozulması sonucu hipoksi oluşmasına methemoglobinemi (MH) denir (1). MH patofizyolojisi Şekil 1’de belirtilmektdir. MH’nin kesin tanısı kan methemoglobin (MetHb) düzeyinin ölçülmesi ile konur (1,2). Normal fizyolojik durumda eritrosit enzim sistemleri olan NADH-MetHbredüktaz ve NADPH-MetHb-redüktaz enzimleri, MetHb değerini, hemoglobin değerinin %1’den daha az olacak şekilde tutar. MetHb konsantrasyonu %15’i geçtiğinde siyanoz, %30’u geçtiğinde taşikardi, halsizlik, bulantı, kusma, solunum sıkıntısı, %55’in üzerinde letarji, stupor ve senkop görülürken, %70’in üzerindeki değerlerde ise mortal seyredebilir (2,3). MH konjenital ve edinsel nedenlere bağlı olarak gelişebilir (1-3). Edinsel MH yaptığı belirlenen birçok kimyasal madde ve ilaç tanımlanmıştır. Çocukluk yaş grubunda özellikle lokal anestezikler MH gelişiminde en çok suçlanan ilaçlardır (4,5). Bu yazıda hastane ortamında, çocuk cerrahisi uzmanı tarafından yapılan sünnet öncesi prilokain uygulanan, sonrasında MH gelişen, yaşları 1-1,5 ay arasında değişen 4 olgu, sözel onam alınarak sunulmuştur.