Kouichiro Suzuki

A New Method for Predicting the Outcome and Survival Period in Paraquat Poisoning

1 To elucidate the importance of lung damage in the prognosis of paraquat poisoning, the respiratory index (RI: A-aDO2/PO2) was analysed in 51 patients with paraquat poisoning. 2 Progressive deterioration of the RI was observed in 43 non-survivors, but not in 8 survivors. In addition, the RI of non-survivors became greater than 1.5 in the course of their poisoning, while that of the survivors remained less than 1.5. 3 The level of the RI (i.e. whether it became greater than 1.5 or not) was found to be a good indicator for the prognosis for life. 4 The RI-time, defined as the time taken from ingestion for the RI to be greater than 1.5, was found to be a good indicator for predicting the survival period in fatal cases. 5 As a result, we conclude that it is important and useful to examine a series of RI and the RI-time in poisoned patients not only to provide proper respiratory care, but also to predict outcome and survival period.

Effects of Hypertonic Saline and Dextran 70 on Cardiac Contractility after Hemorrhagic Shock

OBJECTIVE The effects of a bolus of 7.5% NaCl-6% dextran 70 (HSD) on cardiac contractility were evaluated in anesthetized sheep with hemorrhagic shock. BACKGROUND HSD has been shown to be effective at resuscitation in cases of hypovolemia caused by hemorrhage. Common hemodynamic findings after the injection of HSD in hemorrhagic shock are the restoration of cardiac output, increased blood pressure, and improvement of peripheral circulation. Some mechanisms by which HSD maintains circulation in hemorrhagic shock have been proposed: rapid shift of fluid from intracellular to extracellular space, improved peripheral perfusion, and increased cardiac contractility. Conflicting data exist, however, regarding the positive effect of HSD on cardiac contractility after hemorrhagic shock. METHODS Hemorrhagic shock was induced by shedding mean blood volume of 31.4 mL/kg, and mean blood pressure was maintained at 50 mm Hg for 30 minutes. The HSD group (n = 6) received HSD (4 mL/kg), and the saline group (n = 6) received normal saline (40 mL/kg) after shock. Cardiac functions were measured in both groups using the left ventricular end-systolic pressure-volume relationship and preload recruitable stroke work during the experimental period: before shock, immediately after the resuscitation, and 2 hours after resuscitation. RESULTS Hemodynamic parameters in both groups demonstrated similar changes throughout the experimental period without significant difference between the two groups. Not only the slopes of end-systolic pressure-volume relationship and preload recruitable stroke work but also their placements did not result in any significant differences between the groups. CONCLUSION HSD seems to be an effective resuscitation fluid after hemorrhagic shock because the volume required to maintain circulation is smaller than that of normal saline. Our data, however, show that HSD does not enhance cardiac contractility after hemorrhagic shock.

Evaluation of Severity Indexes of Patients with Paraquat Poisoning

1 Three indexes for evaluating the severity of paraquat poisoning based on plasma-paraquat concentration are presently in use; the curves of Proudfood et al. and Scherrmann et al. and the SIPP. Their effectiveness in determining the prognosis of patients with paraquat poisoning was evaluated. 2 To determine which index was more accurate, contingency tables of the three indexes were obtained and compared; Proudfoots curve vs the SIPP Scherrmanns curve vs the SIPP. Proudfoots curve and the SIPP were applied to patients admitted within 24 h after intoxication. Scherrmanns curve and the SIPP were applied to patients admitted more than 24 h after intoxication. The proportions of patients with true positive and true negative results to total patients were compared by a ratio test. 3 Proudfoots curve was found to be more accurate than the SIPP for predicting the prognosis of patients admitted within 24 h (P < 0.05). No significant difference, however, was noted between Scherrmanns curve and the SIPP in determining the prognosis of patients admitted after more than 24 h. 4 In conclusion, Proudfoots curve proved a better index for predicting the outcome of patients who were admitted within 24 h. However, for the prognosis of patients admitted more than 24 h after the ingestion of paraquat, further study is required.

Acute and chronic effects of sarin exposure from the Tokyo subway incident

The Tokyo subway sarin attack was the second documented incident of nerve gas poisoning in Japan. The St. Lukes International Hospital received 640 patients on the day of the attack. Reduction in plasma cholinesterase (ChE) activity was generally associated with the severity of acute signs of toxicity. With time and treatment, the value rose quickly. To evaluate possible residual signs of symptoms 1 year after the attack, we sent questionnaires to the victims; of 303 respondents, 45% still had some symptoms including eye problems, easy fatigability, headache, and fear. Therefore, we conducted a study in collaboration with investigators at the Tokyo University Department of Public Health to evaluate possible long-term neuropsychological sequelae. The findings suggest the need to closely follow such patients for possible persistent functional changes.

Intravenous detergent poisoning

Case Report: In the literature regarding surfactant poisoning, the route of exposure has almost always been oral. We report a case in which about 40 mL of bath detergent for home use was self-injected. The primary pathophysiologic effects were relative hypovolemia and cardiac dysfunction. The patient experienced frequent ventricular tachycardia, acute renal failure, rhabdomyolysis, hemolysis, and coagulation dysfunction. Intensive care included the administration of antiarrythmial agents and hemodialysis. The patient survived and was discharged from our hospital without sequelae.

The Tokyo Subway Sarin Attack: Toxicological Whole Truth

Publisher Summary This chapter discusses sarin toxicity based on experiences of the attacks in Matsumoto and the Tokyo subway, and also the Iran–Iraq war. The chapter provides some conclusions drawn from the toxicological issues related to sarin. Given the low concentration and means of dispersal, the Tokyo subway sarin attack can be referred to as a ‘‘passive’’ attack. The implication of such an assumption is therefore that mankind has not yet witnessed a ‘‘full-scale’’ sarin attack in any major city. While valuable information can certainly be gained from the Tokyo subway sarin attack; the experience obtained from the more aggressive Matsumoto sarin attack, and the Iran–Iraq war should also be considered when developing initiatives directed at dealing with a potential ‘‘full-scale’’ attack in the future, where the effects will be more serious. Importantly, reliable epidemiologic data is lacking regarding the long-term effects of sarin toxicity, whether low dose exposure to sarin has any long-term effects, and specific effects on children, pregnant women, and fetuses. The sporadic and limited epidemiologic surveys undertaken to date suggest that some long-term effects are present. Thus, well-designed international epidemiologic studies should be conducted in victims exposed to sarin in Japan, Iran, and during the Persian Gulf War.Publisher Summary This chapter discusses sarin toxicity based on experiences of the attacks in Matsumoto and the Tokyo subway, and also the Iran–Iraq war. The chapter provides some conclusions drawn from the toxicological issues related to sarin. Given the low concentration and means of dispersal, the Tokyo subway sarin attack can be referred to as a ‘‘passive’’ attack. The implication of such an assumption is therefore that mankind has not yet witnessed a ‘‘full-scale’’ sarin attack in any major city. While valuable information can certainly be gained from the Tokyo subway sarin attack; the experience obtained from the more aggressive Matsumoto sarin attack, and the Iran–Iraq war should also be considered when developing initiatives directed at dealing with a potential ‘‘full-scale’’ attack in the future, where the effects will be more serious. Importantly, reliable epidemiologic data is lacking regarding the long-term effects of sarin toxicity, whether low dose exposure to sarin has any long-term effects, and specific effects on children, pregnant women, and fetuses. The sporadic and limited epidemiologic surveys undertaken to date suggest that some long-term effects are present. Thus, well-designed international epidemiologic studies should be conducted in victims exposed to sarin in Japan, Iran, and during the Persian Gulf War.

Lessons Learned from the Tokyo Subway Sarin Attack

On the morning of 20 March 1995, sarin was released in the Tokyo Subway System. There had never been such a large scale act of urban terrorism using a nerve gas. There are many lessons to be learned from Tokyo Subway Sarin Attack. Two major lessons can be cited in summary: 1) Absence of decontamination — In total, 1,364 EMTs were dispatched, and among them, 135 were secondarily affected. At St. Lukes hospital, 23% of the medical staff complained of symptoms and signs of secondary exposure. Fortunately, nobody died from the secondary exposure. The religious cult used a 30% sarin solution. If they had used a 100% sarin solution, the outcome would have been much more tragic — secondarily exposed prehospital and medical staff would have been killed. This is the reason for the development of decontamination facilities and the use of personal protective equipment (PPE) in the prehospital and hospital settings; and 2) Confusion of information and lack of coordination among related organizations — Japan is a highly vertically structured society. Fire departments, police, metropolitan governments, and hospitals acted independently without coordination. After the attack, the Japanese government developed the Severe Chemical Hazard Response Team. The Prime Ministers office created a National Security and Crisis Management Office that calls realistic desktop hazmat drills involving the concerned organizations and specialists.

The Tokyo Subway Sarin Attack

Publisher Summary This chapter discusses sarin toxicity based on experiences of the attacks in Matsumoto and the Tokyo subway, and also the Iran–Iraq war. The chapter provides some conclusions drawn from the toxicological issues related to sarin. Given the low concentration and means of dispersal, the Tokyo subway sarin attack can be referred to as a ‘‘passive’’ attack. The implication of such an assumption is therefore that mankind has not yet witnessed a ‘‘full-scale’’ sarin attack in any major city. While valuable information can certainly be gained from the Tokyo subway sarin attack; the experience obtained from the more aggressive Matsumoto sarin attack, and the Iran–Iraq war should also be considered when developing initiatives directed at dealing with a potential ‘‘full-scale’’ attack in the future, where the effects will be more serious. Importantly, reliable epidemiologic data is lacking regarding the long-term effects of sarin toxicity, whether low dose exposure to sarin has any long-term effects, and specific effects on children, pregnant women, and fetuses. The sporadic and limited epidemiologic surveys undertaken to date suggest that some long-term effects are present. Thus, well-designed international epidemiologic studies should be conducted in victims exposed to sarin in Japan, Iran, and during the Persian Gulf War.Publisher Summary This chapter discusses sarin toxicity based on experiences of the attacks in Matsumoto and the Tokyo subway, and also the Iran–Iraq war. The chapter provides some conclusions drawn from the toxicological issues related to sarin. Given the low concentration and means of dispersal, the Tokyo subway sarin attack can be referred to as a ‘‘passive’’ attack. The implication of such an assumption is therefore that mankind has not yet witnessed a ‘‘full-scale’’ sarin attack in any major city. While valuable information can certainly be gained from the Tokyo subway sarin attack; the experience obtained from the more aggressive Matsumoto sarin attack, and the Iran–Iraq war should also be considered when developing initiatives directed at dealing with a potential ‘‘full-scale’’ attack in the future, where the effects will be more serious. Importantly, reliable epidemiologic data is lacking regarding the long-term effects of sarin toxicity, whether low dose exposure to sarin has any long-term effects, and specific effects on children, pregnant women, and fetuses. The sporadic and limited epidemiologic surveys undertaken to date suggest that some long-term effects are present. Thus, well-designed international epidemiologic studies should be conducted in victims exposed to sarin in Japan, Iran, and during the Persian Gulf War.

Severe respiratory distress following sodium oleate ingestion.

CASE REPORT Oleic acid and oleate are pulmonary toxins used to create laboratory models of acute respiratory distress syndrome, but there is little information on human toxicity. We report the intentional ingestion of 50 mL sodium oleate 20% by a 22-year-old woman with no symptoms for the first 2 days after ingestion. Her respiratory status deteriorated rapidly on day 3 progressing to acute respiratory distress syndrome (PaO2/FIO2 < 100 mm Hg) on day 4. Treatment with high-dose steroids and intensive respiratory support including high-frequency jet ventilation were associated with gradual but complete recovery by day 39. The delayed onset of symptoms suggested that the lung injury was due to the systemic circulation of oleate to the lungs rather than to direct aspiration. In oral poisoning by sodium oleate, the lung is the first and most lethally affected target organ in humans. This case demonstrates that ingestion of a relatively small amount of sodium oleate can cause delayed, progressively severe, lung injury.

The Tokyo Subway Sarin Attack: Acute and Delayed Health Effects in Survivors

On the morning of March 20, 1995, 15 stations in the Tokyo subway system were filled with a noxious substance that later was identified as a diluted form of sarin. A total of five subway commuter cars were affected during the Monday morning rush hour. Fortunately, only a relatively small number of victims died, but the details of the incident suggest that it was not a full-scale attack. What this means is that humanity has not yet experienced a full-scale sarin attack in a modern major city. This chapter describes the emergency treatment, signs and symptoms, and laboratory findings connected with this and similar incidents. The medical treatment required for responding to a chemical terrorist attack on the general public will require a different strategy to that employed for such attacks in a military setting. From the standpoint of international security, collaborative research on drugs for treating chemical terrorism and a global agreement on standard treatment is needed.