Cuma Yildirim

Characteristics of Acute Adult Poisoning in Gaziantep, Turkey

Background:The objective of this prospective hospital-based study was to evaluate the rate and characteristics of acute human poisoning in our province (Gaziantep City, Turkey). Methods: All cases of acute human poisonings admitted to the emergency department of the Gaziantep University Hospital, Gaziantep, Turkey, between January 2000 and December 2001, were included in the study. The rate and causes of mortality from poisoning as well as demographic data of the patients were investigated. Results: There were 179 (0.7%) poisoning cases among 25,605 patients who admitted to the emergency department. Of the poisoning cases, 64.3% were female and 35.6% were male patients. The poisoning made a peak between the ages of 16 and 25. The majority of poisonings resulted from oral ingestion with deliberate intake accounting for 78.7% of the cases. Most of the suicide attempt cases were also females. Analgesics were the most common agents (42.4%) among the drugs incriminated in poisoning. Twenty-four patients (13.7%) were admitted to intensive care unit, of whom 42% were female and 58% were male patients. Drugs for suicide attempts were the main cause of poisoning in the patients who admitted to intensive care unit. Five patients (2.8% of all cases) died in the intensive care unit. Conclusions: These data provide important preliminary information on the pattern of symptomatic poisonings in this south-east part of our country.

Role of inferior vena cava and right ventricular diameter in assessment of volume status: a comparative study: ultrasound and hypovolemia.

OBJECTIVE Ultrasonography has been suggested as a useful noninvasive tool for the detection and follow-up for hypovolemia. Two possible sonographic markers as a surrogate for hypovolemia are the diameters of the inferior vena cava (dIVC) and the right ventricle (dRV). The goal of this study was to evaluate IVC and RV diameters and diameter changes in patients treated for hypovolemia and compare these findings with healthy volunteers. METHODS Fifty healthy volunteers and 50 consecutive hypovolemic patients were enrolled in the study. The dIVC, both during inspiration (IVCi) and expiration (IVCe), was measured in hypovolemic patients both before and after fluid resuscitation, and they were also measured in healthy volunteers during the time they participated in the study. The dIVC, in hypovolemic patients both before and after fluid resuscitation, was measured ultrasonographically by M-mode in the subxiphoid area. The dRV was measured ultrasonographically by B-mode in the third and fourth intercostals spaces. RESULTS The average diameters of the IVCe, IVCi, and dRV in hypovolemic patients upon arrival were significantly lower compared with healthy volunteers (P = .001). After fluid resuscitation, there was a significant increase in the mean diameters of the IVCe, IVCi, and RV in hypovolemic patients (P = .001). CONCLUSIONS The results indicate that the dIVC and dRV are consistently low in hypovolemic subjects when compared with euvolemic subjects. Bedside serial measurements of dIVC and dRV could be a useful noninvasive tool for the detection and follow-up of patients with hypovolemia and evaluation of the response to the treatment.

Serum Levels of NT-ProBNP as an Early Cardiac Marker of Carbon Monoxide Poisoning

Acute carbon monoxide (CO) poisoning may cause cardiotoxicity. The natriuretic peptides, including atrial natriuretic peptide, brain natriuretic peptide (BNP), N-BNP, and NT-proBNP (N-terminal pro brain natriuretic peptide), are endogenous cardiac hormones that may be secreted upon myocardial stress. The aim of this study was to assess the plasma NT-proBNP level in acute CO poisoning and to compare it with healthy control. After approval by the ethical committee, 15 healthy controls and 15 patients admitted to the Gaziantep University Hospital (Gaziantep, Turkey) between January 2005 and July 2005 with the diagnosis of carbon monoxide poisoning were studied. Echocardiography was performed to all patients. Serum NT-proBNP, creatine kinase (CK), creatine kinase-MB (CK-MB), and troponin-T were also analyzed, along with the carboxyhemoglobin (COHb) level. The correlation between serum NT-proBNP and COHb level was investigated. Electrocardiography (ECG) was performed to all patients and healthy controls, and the results were compared. Differences in troponin, CK, and CK-MB levels were not statistically significant between groups (p > 0.05). The level of NT-proBNP and COHb were found to be increased in the study group. There was a positive correlation between the COHb and the NT-proBNP (r = 0.829, p < 0.01), and between the COHb and the CK (r = 0.394, p < 0.01). There was no difference between groups in other parameters, all of which were within normal range. Thus, in this sudy we showed that the plasma NT-proBNP level may contribute to the early diagnosis of cardiotoxicity in patients with carbon monoxide poisoning.

Effects of music therapy on pain and anxiety in patients undergoing port catheter placement procedure

BACKGROUND Patients scheduled to invasive medical procedures experience high levels of anxiety, which may lead to increased perceptions of pain and vital sign instability throughout. AIMS To examine the effect of a music intervention (MI) on stress hormones, physiologic parameters, pain, and anxiety state before and during port catheter placement procedures (PCPPs). METHODS We conducted a prospective, randomized, controlled study in 100 oncology patients, who were randomly assigned to an MI group (n=50) or a control group (n=50). The effects of music were assessed by determination of serum cortisol and adrenocorticotropic hormone (ACTH) levels, heart and respiratory rate (HR, RR) and systolic and diastolic blood pressure (SBP, DBP), on arrival in the surgical intervention room, as well as immediately prior to and immediately after the PCPP, in both groups. Furthermore, pain and anxiety levels were identified using visual analogue scale and state-trait anxiety inventory scales. RESULTS On arrival, there were no differences between the patients in terms of serum cortisol and ACTH levels, HR, RR, SBP, DBP and anxiety levels. There were significant reductions in hormone levels (p<0.05 for all), HR (p<0.001), RR (p<0.001), SBP (p<0.05) and DBP (p<0.05), immediately prior to and immediately after the PCPP in participants in the MI group compared to those in the control group. Furthermore, music led to a significant reduction in pain (p<0.05) and anxiety scores (p<0.05) in the MI group compared to control group. CONCLUSION During invasive medical procedures, MI significantly decreases stress hormone levels, physiological parameters, acute procedural pain and anxiety.

Chronic Carbon Monoxide Exposure Increases Electrocardiographic P-wave and QT Dispersion

We investigated the association between chronic carbon monoxide (CO) exposure and electrocardiographic maximum/minimum P-wave duration (Pmax/Pmin), P-wave dispersion (Pd), maximum/minimum QT interval (QTmax/QTmin), and QT and corrected QT dispersion (QTd/cQTd), which are known as predictors of atrial fibrillation, ventricular arrhythmias, and sudden death. We obtained electrocardiograms of 48 apparently healthy male indoor barbecue workers (age mean ± SD; 33.6 ± 9.4) who were working in various restaurants for at least 3 yr and 51 age-matched healthy men (age mean ± SD; 35.1 ± 6.7). Average working time of the indoor barbecue workers in their jobs was 15.6 ± 7.1 yr. P-wave parameters were analyzable in 39 barbecue workers and 40 control subjects and QT intervals were analyzable in 44 barbecue workers and 47 control subjects. Clinical characteristics of indoor barbecue workers and the control group were comparable in terms of age, sex, body mass index, blood pressure, heart rate, Pmin, and QTmin. However, COHb levels, Pmax, Pd, QTmax, QTd, and cQTd measurements were higher in indoor barbecue workers than in the control group (6.48 ± 1.43 vs. 2.19 ± 1.30, p < .001; 106.15 ± 7.47 vs. 101.50 ± 6.62, p < .005; 30.51 ± 7.59 vs. 24.50 ± 6.77, p < .001; 406.59 ± 17.64 vs. 390.85 ± 13.15, P < .001; 48.40 ± 8.87 vs. 34.89 ± 5.85, P < .001; 53.64 ± 9.14 vs. 37.77 ± 6.71, P < .001, respectively). In Pearson correlation analysis there were significant correlations between COHb level and Pd, QTmax, QTd, and cQTd (r = .315 P < .005; r = .402, P < .001, r = .573, P < .001, r = .615, P < .001, respectively). In conclusion, the present study is the first to assess and find an association between chronic CO exposure and electrocardiographic Pd and QTd/cQTd.

Myocarditis after black widow spider envenomation

The black widow spider (BWS), which is a member of the arthropod family, is widely distributed on earth. Black widow spider bites can cause a wide variety of signs or symptoms in humans, but the cardiovascular manifestations are relatively rare except hypertension/hypotension and bradycardia/tachycardia. We report on a 65-year-old man who experienced myocarditis after BWS envenomation, which is extremely rare. He complained of chest pain after the BWS bite, and electrocardiography (ECG) was consistent with a 0.5-mm ST-segment elevation in leads II, aVF, and V3 through V6 and accompanying augmentation in T-wave amplitude in leads V3 through V6 without reciprocal changes. Creatine kinase-MB, troponin-I, and aspartate aminotransferase levels peaked at 98 IU/L, 6.1 ng/mL, and 62 U/L, respectively. His ECG readings and cardiac enzymes returned to normal with supportive treatment, and he was discharged with complete recovery. To the best of our knowledge, the present case is the third in the literature reporting myocarditis and the first reporting ST-segment elevation and accompanying augmentation in T-wave amplitude after BWS envenomation. In addition to usual measures, we recommend ECG and cardiac-specific enzyme followup for every patient envenomated by BWS for potentially fatal cardiac involvement.

Leech bites: massive bleeding, coagulation profile disorders, and severe anemia

Leeches have been in use for centuries, especially in plastic and reconstructive surgery wound and flap healing, in venous insufficiencies, and in the treatment of many disorders such as hemorrhoids and varicosity. With this study, we aimed to discuss coagulation disorder due to uncontrolled leech bites, consequent excessive skin hemorrhage, and anemia requiring blood transfusion. A 65-year-old male patient was referred to the emergency department because of excessive intractable bleeding that had occurred after leech bites. On physical examination, a total of 130 bites were detected on various regions of the body. In the laboratory findings of the patient, hemoglobin and hematocrit levels were extremely low, and prothrombin time, international normalized ratio, and partial thromboplastin time were markedly increased. The patient received a total of 8 units of fresh frozen plasma and 6 units of erythrocyte suspension. Bleeding stopped by decreasing after the transfusion of fresh frozen plasma. Although the complications due to leech injuries are rare, they may be an important cause of morbidity and mortality when an injury or prolonged bleeding in an internal region occurs. Prolonged skin hemorrhages rarely cause anemia, and deaths are caused by intractable hemorrhages. However, a coagulation disorder and consequent intractable hemorrhage have not been reported previously in the literature. In conclusion, it should be known that uncontrolled, blind, and excessive leech use causes severe hemorrhage and excessive blood loss, causing significant morbidity and mortality. Therefore, the awareness of either physicians or people using or recommending alternative medicine should be raised on this subject.

Patient satisfaction in a university hospital emergency department in Turkey.

OBJECTIVE Patient satisfaction, an indicator of the quality of care provided by emergency department (ED) personnel, is a significant issue for EDs. The purpose of this study was to identify factors associated with patient satisfaction and dissatisfaction, and to describe demographic characteristics of those surveyed in a university hospital ED. METHODS All adult patients who consecutively presented to the ED between 8:00 a.m. and 5:00 p.m. on weekdays were included in the study. Patients were asked to complete a questionnaire prior to discharge. The questionnaire asked about the attitude, politeness, and efficiency of the medical and ancillary staff, the reason for preferring our centre and reasons for dissatisfaction. RESULTS Two-hundred and forty-five adult patients presenting to our ED were included in this study. Forty-five percent of patients preferred our ED because of the previous perception of higher quality of care, informed by other people previously treated in this ED unit, and 35% because of restrictions by their health insurance carrier. The main causes of patient dissatisfaction were lengthy waiting times (27%). CONCLUSION As a result, lengthy waiting time was the major reason for patient dissatisfaction, and high quality care together with insurance restrictions were the main reasons for preference of this university hospital ED.

Cardiac damage in acute organophosphate poisoning in rats: effects of atropine and pralidoxime.

Anticholinesterase poisoning is an important health problem in our country, and a complete understanding of its underlying mechanisms is essential for the emergency physician. Thus, we aimed to investigate the cardiac biochemical parameters and mortality in dichlorvos-induced poisoning in rats. Rats were randomly divided into 5 groups as control (corn oil), dichlorvos, atropine, pralidoxime, and atropine+pralidoxime groups. Immunohistochemical analyses of apoptosis and inducible nitric oxide synthase showed no change in cardiac tissue for all of the groups. Serum cholinesterase levels were suppressed with dichlorvos, and these reductions were inhibited with atropine and/or pralidoxime pretreatment. Serum levels of creatine kinase, creatine kinase-MB, cardiac troponin I, myoglobin, and N-terminal probrain natriuretic peptide were not affected with poisoning. Malondialdehyde and glutathione levels were not statistically significant between the groups. Although serum nitric oxide levels in the dichlorvos group were lower than those in the control group, cardiac nitric oxide levels in the atropine+pralidoxime group were markedly higher than those in the dichlorvos group. Atropine, pralidoxime, and atropine+pralidoxime pretreatments markedly reduced the mortality. In conclusion, our results implied that measured cardiac markers especially N-terminal probrain natriuretic peptide may not contribute to the early (first 6 hours) diagnosis of cardiotoxicity in dichlorvos-induced poisoning in rats. These results also showed that acute dichlorvos administration did not cause significant cardiac damage, and oxidative stress does not play a marked role in dichlorvos-induced poisoning. Besides, cardiac nitric oxide may produce protective effect on myocardium with atropine+pralidoxime therapy in rats.

Long-term pulmonary histopathologic changes in rats following acute experimental exposure to chlorine gas

In this study, we aimed to investigate the long-term histopathologic changes in the lungs of rats exposed to a high concentration of chlorine gas. Twenty-four Sprague-Dawley rats were divided into three groups: the control group (group I) (n = 8), early-examined group (group II) (n = 8), and late-examined group (group III) (n = 8). In group II the lungs of rats were taken out just after the exposure, whereas in group III the lungs were taken out 45 days after the exposure. Eosinophilic liquid accumulation in alveoli and bronchi, diffuse intraalveolar edema, vascular congestion, severe perivascular edema, and free bleeding in intraalveolar and interstitial area were observed in the lungs of rats in group II. Interstitial fibrosis and thickening of the alveolar septa were observed in group III. These findings suggest that the people using these cleaning agents are at risk of harming themselves, and the victims of chlorine gas injury should be reexamined at a later period since they may have pulmonary damage even after 45 days of exposure.