Fikret Bildik

Basic toxicological approach has been effective in two poisoned patients with amitraz ingestion: case reports

Amitraz, a formamidine insecticide and acaricide used in veterinary practice, presents side effects in humans related to its pharmacological activity on alpha 2-adrenergic receptors. There is little information available in the literature about the toxicology of the product in man and the treatment of this poisoning. In this report, the clinical and laboratory features of amitraz poisoning in two patients by a veterinary formulation also containing xylene are presented. The major clinical findings were unconsciousness, drowsiness, respiratory failure requiring mechanical ventilation, miosis, hypothermia and brady cardia. The laboratory findings were hyperglycemia, hypertransaminasemia and increased urinary output. Supportive management of this poisoning in humans is suggested in only a few articles and there is no specific antidote for the subsequent possible pharmacological effects of amitraz. In our two cases, we performed supportive treatment such as mechanical ventilation, atropine, gastric lavage, active carbon, oxygen and fluid administration. We concluded that the basic approach to the patient with amitraz poisoning, including initial stabilization to correct immediate life-threatening problems, treatment to reduce absorption and measures to improve elimination of the toxin, is effective.

Acute aortic dissection provoked by sneeze: a case report

The response of the abdominal viscera and the contraction of the intercostal muscles during the respiratory phase of sneezing increases intrathoracic pressure, which may lead to several complications. However, there are no reports in the literature concerning aortic dissection after sneezing. We report a patient in whom the development of dissection was secondary to sneezing, although hypertension was present as a risk factor, and we discuss the relationship between sneezing and aortic dissection. To our knowledge, this is the first report of aortic dissection provoked by sneezing in the literature.

Pulmonary embolism presenting as syncope: a case report.

IntroductionDespite the high incidence of pulmonary embolism its diagnosis continues to be difficult, primarily because of the vagaries of symptoms and signs in presentation. Conversely, syncope is a relatively easy clinical symptom to detect, but has varied etiologies that lead to a documented cause in only 58% of syncopal events. Syncope as the presenting symptom of pulmonary embolism has proven to be a difficult clinical correlation to make.Case presentationWe present the case of a 26-year-old Caucasian man with pulmonary embolism induced-syncope and review the pathophysiology and diagnostic considerations.ConclusionsPulmonary embolism should be considered in the differential diagnosis of every syncopal event that presents at an emergency department.

Clinical warning criteria in evaluation by computed tomography the secondary neurological headaches in adults.

Our aims were to investigate the frequency of intracranial lesions detected by cranial computed tomography (CT‐scan) amongst adult patients who had clinical warning criteria (CWC) for secondary neurological headaches and to determine the importance of CWC in predicting a possible lesion on CT‐scan. Seventy consecutive patients with headache exhibiting CWC were included in this prospective study. The CWC included: (i) increase in the intensity and frequency of headache; (ii) abrupt onset of headache; (iii) persistence of headache despite analgesics; (iv) alteration of the characteristics of headache; and (v) presence of focal neurological symptoms or findings. The mean age of the patients was 46.5 years; the female‐to‐male ratio was 1.5. Of the patients, 35.7% had a neurological cause identified by CT‐scan, and 64.3% had normal CT‐scan. In the patients without lesion, of headaches, 64.4% were primary, and 35.6% were from undefined headache group. Although, of the above criteria, only the 5th was different markedly in the patients with lesion than the patients without lesion, in evaluation by CT‐scan the secondary neurological headaches in adults, all CWC should look for absolutely in their history and physical examination.

Efficacy of Triage by Paramedics: A Real-Time Comparison Study

OBJECTIVES Triage has evolved as an effective method of separating patients who require immediate medical attention from patients with non-urgent problems. The aim of this study was to assess the agreement between paramedics and emergency residents about triage decisions using the 3-level triage (3L) system and the 5-level (5L) Australian triage scale in real time. METHODS All patients who presented to a central triage area during a 1-week period were triaged by paramedics and emergency residents. The chance-adjusted measure of agreement kappa (κ) was calculated to evaluate the agreement between triage decisions made by paramedics and by emergency residents. RESULTS A total of 731 patients were included in the final data analysis. Admitting time and waiting time were significantly consistent in the triage area. Agreement between the triage decisions made by paramedics and by emergency residents was 47% (κ = 0.47) when using the 3L triage scale and 45% (κ = 0.45) when using the 5L triage scale across all cases. A strong correlation existed among the general conditions of the patients, the 3L triage scale, and the 5L triage scale. DISCUSSION Triaging is commonly performed by nurses in the American emergency system, and triage by paramedics is not common. Few studies are available about triage by paramedics, and more studies are necessary. A new triage scale may be necessary for untrained personnel so that all emergency departments can conduct simple triage.

The Need for First Aid Awareness among Candidate Teachers

SUMMARY Objectives Students at schools may require first aid due to illness, deterioration in their condition, or accidents. Therefore, educators should know first aid procedures and be able to put them into practice. In this study, the objective was to determine the level of first aid knowledge among students at a Faculty of Education and evaluate the efficacy of the first aid training (FAT) provided to them. Methods This study included 88 students at Gazi University, Faculty of Education (Ankara). All students were provided 20 hours of FAT over a period of three months. Participants completed pre- and post-FAT questionnaires and a final examination. Results Sixty-one percent of participants (n=54) had attended FAT within the previous five years. Average pre- and and post-test scores were 47.89±11.29 and 75.28±12.62, respectively. There was a significant increase between the average scores (p<0.001). The proportion of correct responses on basic life support issues was also significantly higher after the training. Significantly more participants felt they had sufficient first aid knowledge and skills after the training (58%) compared to pre-training (8%) levels (p<0.001). Conclusions First aid knowledge among students at a Faculty of Education was considered to be insufficient. FAT should be standard in educational programs at all teacher training schools and the results show such training needs to be updated regularly.

Contact with wet cement: report of a case

Contact dermatitis ranks high in occupational disease statistics in many countries. Its aetiology may be allergic or irritant, sometimes combined, and often aggravated because of constitutional factors. A very high proportion of men and a relatively high proportion of patients with occupational skin disease and with hand dermatitis, respectively, are evident among construction workers. The prevalence of work-related hand dermatitis (allergic or irritant) was found to be 6.8% among construction workers and 8.9% among concrete element prefabrication workers according to a Finnish cross-sectional study performed in 1987 (1). A review of the available literature suggests that cement has constituents that produce irritant contact dermatitis and corrosive effects (from alkaline ingredients such as lime) as well as sensitization leading to allergic contact dermatitis (from chromate) (2). Chemical burns from cement produce erythema, oedema, vesicles, bullae, and weeping and can be considered to be a more severe form of acute irritant reaction; they have been described as acute ulcerative dermatitis. Chemical burns caused by cement are associated with the amateur user working in a short ready-mix timeframe with poor protective measures. These burns can result in significant morbidity and often require skin grafting but can initially be associated with minimal discomfort (3). Here, we report a case presented to our ED with acute ulcerative dermatitis related to working with wet cement without protection. This case also illustrates the potential hazards as a result of working with cement.

Delay in Diagnosis of Pulmonary Thromboembolism in Emergency Department Is it Still a Problem

Background and Aim: Pulmonary embolism (PE) is a common and serious disease that can result in death unless emergent diagnosis is made and treatment is initiated. In this study, we aimed to identify whether there is still a delay in the diagnosis of PE and to identify the time to delay in diagnosis and factors leading to this delay. Methods: This is a prospective observational cohort study performed in an emergency department (ED) of a tertiary care university hospital between September 2008 and September 2010. The rate and cause of delay in diagnosis were analyzed among patients with PE. The “delay” was defined as diagnosing after first 24 hours of symptom onset. Results: Among the 53 patients who were diagnosed with PE, a delay in diagnosis was present in 49 (93%) of them. Total delay time was 6.8 ± 7.7 days. In 33 (62%) patients, there was a delay of 4.6 ± 6.5 days due to patient-related factors. Delay in diagnosis after admission to hospital was 2.2 ± 2.9 days in 40 (75%) patients. In multivariate regression analysis, being female and having chest pain and cough were identified as significant factors causing patient-related delay. Unilateral leg edema, recent operation, and previous venous thromboembolism (VTE) history were the significant factors causing PE diagnosis without a delay. On the other hand, systemic hypertension as comorbidity was the only factor leading to physician-related delay. Conclusion: The delay in diagnosis of PE in EDs still remains as an important problem. While being female and having chest pain and cough are significantly and independently associated with patient delay in diagnosis, the unilateral leg edema, recent operation, and previous VTE history cause physicians to diagnose on time. On the other hand, having hypertension as comorbidity may lead to physician delay. In order to prevent the delay in diagnosis, hospital-associated factors must be elucidated totally and more interventions must be made to increase public and professional awareness of the disease.

Serum tau protein level for neurological injuries in carbon monoxide poisoning

Abstract Introduction. Carbon monoxide (CO) poisoning causes hypoxia that results tissue injury, especially in the brain and heart. Delayed neurologic sequela is one of the most serious complications that may occur up to 40% of severe CO poisoning cases. Objective. The aim of the study was to determine an association between the serum tau protein and severe neurologic symptoms/signs upon presentation. Methods. Seventy-eight patients with CO poisoning were evaluated in this cross-sectional study. The patients were divided into two groups, Group 1: those with loss of consciousness (LOC)/syncope, seizure, coma, altered mental status (n = 19), and Group 2; without LOC (n = 59). Serum tau protein levels were studied on admission. Results. Mean age of the patients was 37.3 ± 15.4 and 53.6% were male. Headache was the most common presenting symptom observed among 67 patients (86%). The median serum tau protein level was 76.54 pg/mL (35.56–152.65) within group 1, 64.04 pg/mL (23.85–193.64) in patients within group 2 (p = 0.039), respectively. The median serum tau protein levels were 79.80 pg/mL (35.56–193.64) in patients who received HBO therapy and 65.79 pg/mL (23.85–167.29) in patients who did not receive HBO therapy (p = 0.032). The value of area under the curve was 0.642 for detecting CO poisoning with severe neurological symptoms. Conclusion. Although tau protein levels were significantly higher in patients with severe neurological symptoms; the difference did not reach a clinical significance. Further studies are needed in order to reveal the validity of tau protein for detecting neurological injuries in patients with CO toxicity.

Endogenous carboxyhemoglobin concentrations in the assessment of severity in patients with community-acquired pneumonia☆ , ☆☆

INTRODUCTION Previous studies have shown that carbon monoxide, which is endogenously produced, is increased in community-acquired pneumonia (CAP). However, it has not been studied enough whether severity of pneumonia is correlated with increased carboxyhemoglobin (COHb) concentrations in CAP. The aim of this study was to determine whether endogenous carbon monoxide levels in patients with CAP were higher compared with the control group and, if so, to determine whether COHb concentrations could predict severity in CAP. MATERIALS AND METHODS Eighty-two patients with CAP were evaluated in this cross-sectional study during a 10-month period. Demographic data, pneumonia severity index and confusion, uremia, rate respiratory, pressure blood, age>65 (CURB-65) scores, hospital admission or discharge decisions, and 30-day hospital mortality rate were recorded. In addition, 83 control subjects were included to study. The COHb concentration was measured in arterial blood sample. RESULTS The levels of COHb in patients with CAP were 1.70% (minimum-maximum, 0.8-3.2), whereas those in control subjects, 1.40% (minimum-maximum, 0.8-2.9). The higher COHb concentrations in patients with CAP were statistically significant (P < .05). Concentration of COHb correlated with pneumonia severity index (P = .04, r = 0.187); however, it did not correlate with CURB-65 (P = .218, r = 0.112). CONCLUSION Although COHb concentrations show an increase in patients with pneumonia, it was concluded that this increase did not act as an indicator in diagnosis process or prediction of clinical severity for the physicians.