Ibrahim Ikizceli

Acute amitraz poisoning in adults : Clinical features, laboratory findings, and management

Background. Amitraz is a formamidine pesticide widely used in agriculture and veterinary medicine as an insecticide and acaricide. Reports on amitraz poisoning in humans are not as prevalent as those in animals. Of human intoxications in the medical literature, the majority of intoxications are in children. The number of adult intoxications with amitraz is limited. Methods. In this study, we discuss the clinical features, laboratory findings, and management of 23 adults with amitraz poisoning cared for in our center. Data were extracted from the charts retrospectively, and included age, gender, mode of poisoning, initial symptoms, time to appearance of initial symptoms, clinical and laboratory findings, management, and prognosis. Results. Fourteen of 23 patients were female (61%). Ages ranged from 16 and 78 years (mean 38.6 ± 19.8 years). Twenty-one patients ingested amitraz orally while one was exposed through skin contact and one probably through skin contact and/or inhalation. Seven patients ingested amitraz with intent to commit suicide and 11 patients accidentally. Vomiting, altered consciousness, and drowsiness were the predominant initial symptoms. Initially, hypotension was present in seven patients (30%), bradycardia in two (8.7%), myosis in six (26%), and mydriasis (without atropine administration) in three (13%). Time to appearance of the initial symptoms ranged from 5 to 120 minutes. Laboratory findings included an initial blood glucose level higher than 120 mg/dL in 62% of patients (mean 191 ± 70 mg/dL) and elevations in AST levels in four patients (81 ± 28 U/L) and ALT levels in three (60 ± 14 U/L). Ten patients had central nervous system depression, which resolved spontaneously. Five patients required mechanical ventilation for respiratory depression (mean duration of mechanical ventilatory support: 50 ± 16 hours). Six patients were thought to have been poisoned with an organophosphate and three with a carbamate pesticide due to confusing clinical picture; four of these nine patients received pralidoxim. Conclusions. In spite of a rapidly progressing and life-threatening clinical picture, amitraz intoxication in humans carries a low morbidity and mortality when appropriate supportive treatment is given. No antidote has been developed for use in more serious cases. To prevent accidental ingestions, prominent and clear warning labels should be placed on its containers.

Poisoning severity score, Glasgow coma scale, corrected QT interval in acute organophosphate poisoning

The aim of this study was to investigate effectiveness of the poisoning severity score (PSS), Glasgow coma scale (GCS), and corrected QT (QTc) interval in predicting outcomes in acute organophosphates (OP) poisoning. Over a period of 2 years, 62 patients with OP poisoning were admitted to emergency department (ED) of Erciyes University Medical School Hospital. The age, sex, cause of contact, compound involved, time elapsed between exposure and admission to the ED, duration of hospital stay, and cardiac manifestations at the time of presentation were recorded. GCS and poisoning severity score (PSS) was calculated for each patient. Electrocardiogram (ECG) analysis included the rate, rhythm, ST-T abnormalities, conduction defects, and measurement of PR and QT intervals. Sixty-two patients with OP poisoning presented to our ED from January 2007 to December 2008 from which 54 patients were included in the study. The mean age was 34.1 ± 14.8 years. Of the cases, 53.7% were female. Twenty-six patients had a prolonged QTc interval. Mean PSS of men and women was 1.8 ± 1.0. No statistically significant correlation was found between the PSS and QTc intervals of the cases. A significant correlation was determined between the GCS and PSS of grade 3 and grade 4 cases. GCS is a parameter that helps clinician to identify advanced grade OP poisoning patients in the initial assessment in the ED. However, ECG findings, such as prolonged QTc interval, are not effective in determination of short-term prognosis and show no relationship with PSS.

Bleeding due to a medicinal leech bite

This paper reports a case of prolonged bleeding following application of leeches to treat chronic pain. The paper discusses the characteristics of the wounds and possible complication of prolonged bleeding following medicinal leech application. The principles of treatment are also described.

Adult burn injuries in an Emergency Department in Central Anatolia, Turkey: a 5-year analysis

PURPOSE Burn injuries require a multidisciplinary approach. Emergency Departments can play vital roles in the treatment of burns. The purpose of this study is to investigate the epidemiological and clinical characteristics of the adult burn patients admitted to our Emergency Department and to determine the frequency of the patients who were treated on an outpatient basis and discharged from the Emergency Department. PROCEDURE A retrospective review of 314 adult burn patients who presented to the Emergency Medicine Department of Erciyes University Hospital from January 1996 to December 2000. FINDINGS Sixty-four percent of the patients were male. Mean age was 32.9+/-14.7. Ninety-nine patients (32%) had moderate to major burns. The highest numbers of patients were in the 21-30 age group. Flame burns comprised the majority of presentations and admissions (48 and 69%, respectively). Thirteen patients had associated injuries (4%). Eighty-seven patients (28%) were hospitalized, 21 of these died. Death occurred mostly from respiratory failure and sepsis. Domestic accidents were the leading mechanism (63%). CONCLUSION Burns were mostly due to accidents arising from carelessness, ignorance, hazardous traditions and improperly manufactured products. These can be prevented through mass education programs countrywide. Because almost all burn patients present to Emergency Departments first and not all hospitals can employ burn specialists, the patients with minor burns can be treated on an outpatient basis and the treatment of severe burns can be effectively initiated by emergency physicians.

Ocular trauma in Turkey: a 2-year prospective study

This 2-year prospective study was conducted to identify those at risk for ophthalmologic emergencies, to define the risk factors and reasons for eye injuries, to analyze treatment options, and to compare findings with those of previous studies. A total of 203 patients (74% male, mean age 27.3±13.9 y, 51% right eye injuries, 44% left eye injuries, 5% bilateral injuries) with injury to 208 eyes who presented to the emergency department for treatment were included in this study. All patients were evaluated by an ophthalmologist, who completed a formal questionnaire. Information recorded included demographic data, details of the eye injury, whether eye protection was used, and the type, location, and mechanism of injury to the eye. Mechanism of injury was categorized as blunt, sharp, or a combination. The ophthalmologist reported the time that had passed between occurrence of injury and presentation for treatment. Each patient was examined by the ophthalmologist, and findings, diagnosis, and treatment were documented. Of treated patients, 93% were hospitalized, most of whom required surgical treatment. One hundred (48%) injuries were related to blunt trauma and 86 (41%) to sharp device trauma. Only 10 (4%) patients were wearing protective eyewear when injured. Ruptured globe was the most common diagnosis of hospitalized patients and the most frequent cause of this was corneal lesions; subconjunctival hemorrhage was the most common diagnosis among nonhospitalized patients. In this study, the leading cause of eye injury was workplace accidents, probably attributable to growing industrialization in the region. Ocular trauma continues to be an important health problem in Turkey. Investigators believe that with education about and use of proper eye protection, 90% of eye injuries could be prevented.

Poisoning from wild mushrooms in Eastern Anatolia region: analyses of 5 years

The objective of this study was to describe the demographic and clinical features of patients who were admitted to the emergency department (ED) due to wild mushroom poisoning and to point the importance of mushroom poisonings in our area. This study was performed by examining the files of wild mushroom poisoning patients who were admitted to the ED of Firat University, Faculty of Medicine, between January 2000 and June 2004, retrospectively. Patients ≥16 years of age were included in the study. The frequency of wild mushroom poisoning, age and sex of the patients, season, place of the residence, laboratory findings, treatment and outcome of the patients were investigated. During the study period, 64 patients with wild mushroom poisoning were admitted to the ED. From 64 overall patients, 25 (39.1%) were males. The most common complaints during the admission were nausea, vomiting and abdominal discomfort. The duration of hospitalization was two (range 1—4 days) days. No death was observed. Severity of mushroom poisoning depends on the type of mushroom eaten, the time lag between the poisoning and admission to the hospital, and the rapid and correct treatment given to the patient either in the ambulance or at health centre. Human & Experimental Toxicology (2007) 26: 579—582.

Experiences with endosulfan mass poisoning in rural areas.

This paper describes very rare chemical poisoning and characteristics of patients with acute endosulfan mass poisoning in a rural area of Turkey and our experiences of these patients. We included 41 patients who were treated in our hospital with the diagnosis of endosulfan poisoning. After the first vital intervention they were examined in terms of age, sex, symptoms and physical examination findings, laboratory results, treatment and outcome. Forty-one patients were admitted to the emergency department (ED) after triage. Nineteen (46.3%) of the patients were female, 22 (53.7%) were male. The mean age was 27.9±16.0 years (1–67 years). The mean time to the ED was 4.1±0.9 h (3–6.5 h). The most common symptoms were anxiety (97.6%), nausea (56.1%) and vomiting (48.8%). Tests of the blood samples obtained at the ED revealed leucocytosis (11 070.6±4302.5/μl), increased blood glucose, LDH, CK and CK-MB levels. Toxicological analysis of blood and urine samples revealed endosulfan as the causative agent. Especially in the rural areas, cases with acute repetitive seizures should suggest endosulfan intoxication when the aetiology is uncertain even in the absence of any signs of intoxication. Health care professionals should understand the hazards associated with the pesticide use as well as diagnosis and treatment of these types of poisonings.

Experimental Inhalation of Chlorine Gas Produced with a Different Method; Effects of N-Acetyl Cysteine on Acute Pulmonary Damage

ABSTRACT The two most common gas inhalation injuries encountered in emergency departments are carbon monoxide and chlorine inhalations. In this study, chlorine was produced through a method different to the previous experimental models. Rats were subjected to inhale chlorine, after which the effects of N-acetylcysteine on pulmonary damage were evaluated. A total of 50 rats were equally divided into five groups. Group 1 received nothing. Groups 2 and 3 were taken as 6 h, groups 4 and 5 as 24 h control and N-acetylcysteine groups, respectively. Firstly, 200 ppm chlorine gas was given for 20 min. Then, 40 mg/kg N-acetylcysteine was given intraperitoneally. The same procedure with the same dose was repeated 3 h later. The same procedures were applied to the control group but this time saline was used. Tissue samples of lungs were taken. Glutathione levels of the rats in the N-acetylcysteine group sacrificed at 24 h were significantly higher than those of the control group. Histopathological evaluation of the pulmonary tissues of the rats sacrificed at 6 and 24 h revealed mild-to-moderate degrees of tissue damage. The degree of tissue damage at 6 h and 24 h N-acetylcysteine group rats was lower than that in the control group. As a result, tissue damage resulting from experimental chlorine inhalation can be alleviated by N-acetylcysteine. This is mainly the result of the antioxidant effects of the N-acetylcysteine.

The effect of rapid blood pressure control on P-wave dispersion in hypertensive urgency

IntroductionA sharp increase in blood pressure, increase in atrial pressure and atrial strain, left ventricular diastolic dysfunction, and left ventricular hypertrophy (LVH) lead to heterogeneity and instability in atrial conduction. The resulting physiopathological situation may elevate maximum Pwave duration (Pmax) and P-wave dispersion (PWD) in electrocardiography. The objective of our study was to explore the effect of the sudden change in atrial hemodynamics on Pmax and PWD, which may indicate the risk of atrial fibrillation (AF) development in hypertensive urgency.MethodsThe study included patients diagnosed as hypertensive urgency (systolic blood pressure ≥180 mmHg, diastolic blood pressure ≥110 mmHg). Nitroprusside was started at a dose of 0.2 μg/kg/min, and the ensuing dose was arranged according to blood pressure. Echocardiography and electrocardiography were used to noninvasively measure changes in diastolic function and PWD and Pmax, respectively.ResultsThe study enrolled 102 patients (mean age 57.9±11.6 years; 32 [31.4%] males, and 70 [68.6%] females). Pmax decreased from 99.9±11.1 msec (95% confidence intervals [CI] 97.7, 102) to 88.5±9.3 msec (95% CI 86.6, 90.3) (P<0.001), while PWD decreased from 60.1±7.4 msec (95% CI 58.7, 61.6) to 43.9±6.7 msec (95% CI 42.5, 45.2) (P<0.001). In addition, most patients had LVH and diastolic dysfunction. After nitroprusside treatment improvements in indicators of diastolic functions such as E/A ratio, deceleration time, and isovolumetric relaxation time were observed.ConclusionThe change observed in Pmax and PWD in hypertensive urgency may be associated with the rapid change in blood pressure and atrial strain, sympathetic nervous system activation, relative myocardial ischemia, and left ventricular diastolic dysfunction. Rapid regulation of blood pressure with nitroprusside brought about a marked decrease in Pmax and PWD in our patients. This improvement was interpreted as atrial conduction acquiring a stable and homogeneous character, which may reduce the risk of AF development in hypertensive urgency.

Contrast-induced nephropathy risk due to emergency contrast-enhanced computed tomography.

Objective In this study, we aimed to compare serum creatinine, blood urea, and glomerular filtration rate (GFR) levels of patients at baseline and 48 h after the administration of radiocontrast agent in the emergency department. Method We prospectively enrolled 114 patients who underwent contrast-enhanced computed tomography scan and had a baseline creatinine level of 1.5 mg/dl or less. Serum creatinine and blood urea levels were measured at baseline and 48 h after the administration of radiocontrast agent. GFR and Mehran risk score were calculated at baseline and 48 h after the administration of radiocontrast agent. Results Baseline mean serum creatinine was 1.03±0.25 mg/dl. Forty-eight hours after the administration of radiocontrast agent, mean serum creatinine was 1.04±0.31 mg/dl, baseline mean blood urea was 8.14±4.04 mmol/l, mean blood urea was 8.42±4.42 mmol/l, baseline mean GFR was 76.74±27.08 ml/min, and mean GFR was 77.21±27.92 ml/min. There were no significant differences between baseline and 48 h after the administration of radiocontrast agent serum creatinine, blood urea levels, and GFR (P>0.05). Conclusion There was no statistically significant difference between basal and 48 h after the administration of radiocontrast agent serum creatinine and GFR levels of patients who were enrolled in this study. Results had shown that administration of intravenous radiocontrast agent (⩽100 ml) for emergency imaging in the emergency department did not produce a risk for contrast-induced nephropathy in patients with serum creatinine levels of 1.5 mg/dl or less.