Noureddine Rekik

Scorpion Envenomation Among Children: Clinical Manifestations and Outcome (Analysis of 685 Cases)

Our objective was to characterize both epidemiologically and clinically manifestations after severe scorpion envenomation and to define simple factors indicative of poor prognosis in children. We performed a retrospective study over 13 years (1990-2002) in the medical intensive care unit (ICU) of a university hospital (Sfax-Tunisia). The diagnosis of scorpion envenomation was based on a history of scorpion sting. The medical records of 685 children aged less than 16 years who were admitted for a scorpion sting were analyzed. There were 558 patients (81.5%) in the grade III group (with cardiogenic shock and/or pulmonary edema or severe neurological manifestation [coma and/or convulsion]) and 127 patients (18.5%) in the grade II group (with systemic manifestations). In this study, 434 patients (63.4%) had a pulmonary edema, and 80 patients had a cardiogenic shock; neurological manifestations were observed in 580 patients (84.7%), 555 patients (81%) developed systemic inflammatory response syndrome (SIRS), and 552 patients (80.6%) developed multi-organ failure. By the end of the stay in the ICU, evolution was marked by the death in 61 patients (8.9%). A multivariate analysis found the following factors to be correlated with a poor outcome: coma with Glasgow coma score ≤ 8/15 (odds ratio [OR] = 1.3), pulmonary edema (OR = 2.3), and cardiogenic shock (OR = 1.7). In addition, a significant association was found between the development of SIRS and heart failure. Moreover, a temperature > 39°C was associated with the presence of pulmonary edema, with a sensitivity at 20.6%, a specificity at 94.4%, and a positive predictive value at 91.7%. Finally, blood sugar levels above 15 mmol/L were significantly associated with a heart failure. In children admitted for severe scorpion envenomation, coma with Glasgow coma score ≤ 8/15, pulmonary edema, and cardiogenic shock were associated with a poor outcome. The presence of SIRS, a temperature > 39°C, and blood sugar levels above 15 mmol/L were associated with heart failure.

Prediction value of the Canadian CT head rule and the New Orleans criteria for positive head CT scan and acute neurosurgical procedures in minor head trauma: a multicenter external validation study.

STUDY OBJECTIVE The New Orleans Criteria and the Canadian CT Head Rule have been developed to decrease the number of normal computed tomography (CT) results in mild head injury. We compare the performance of both decision rules for identifying patients with intracranial traumatic lesions and those who require an urgent neurosurgical intervention after mild head injury. METHODS This was an observational cohort study performed between 2008 and 2011 on patients with mild head injury who were aged 10 years or older. We collected prospectively clinical head CT scan findings and outcome. Primary outcome was need for neurosurgical intervention, defined as either death or craniotomy, or the need of intubation within 15 days of the traumatic event. Secondary outcome was the presence of traumatic lesions on head CT scan. New Orleans Criteria and Canadian CT Head Rule decision rules were compared by using sensitivity specifications and positive and negative predictive value. RESULTS We enrolled 1,582 patients. Neurosurgical intervention was performed in 34 patients (2.1%) and positive CT findings were demonstrated in 218 patients (13.8%). Sensitivity and specificity for need for neurosurgical intervention were 100% (95% confidence interval [CI] 90% to 100%) and 60% (95% CI 44% to 76%) for the Canadian CT Head Rule and 82% (95% CI 69% to 95%) and 26% (95% CI 24% to 28%) for the New Orleans Criteria. Negative predictive values for the above-mentioned clinical decision rules were 100% and 99% and positive values were 5% and 2%, respectively, for the Canadian CT Head Rule and New Orleans Criteria. Sensitivity and specificity for clinical significant head CT findings were 95% (95% CI 92% to 98%) and 65% (95% CI 62% to 68%) for the Canadian CT Head Rule and 86% (95% CI 81% to 91%) and 28% (95% CI 26% to 30%) for the New Orleans Criteria. A similar trend of results was found in the subgroup of patients with a Glasgow Coma Scale score of 15. CONCLUSION For patients with mild head injury, the Canadian CT Head Rule had higher sensitivity than the New Orleans Criteria, with higher negative predictive value. The question of whether the use of the Canadian CT Head Rule would have a greater influence on head CT scan reduction requires confirmation in real clinical practice.

Atteinte cardiovasculaire lors d'envenimation scorpionique grave : Mécanismes et physiopathologie

Points essentials • La gravite de l’envenimation scorpionique resulte essentiellement de la dysfonction cardiaque gauche avec oedeme pulmonaire et/ou etat de choc. • La myocardite adrenergique, la myocardite toxique et l’ischemie myocardique sont les 3 mecanismes expliquant cette dysfunction cardiaque. • L’ischemie myocardique est due non seulement a la decharge des catecholamines mais aussi a l’action des cytokines et/ou du neuropeptide Y sur les vaisseaux coronaires. • L’atteinte cardiaque peut etre due ou aggravee par l’action depressive des cytokines sur les cellules myocardiques. • L’hyperglycemie frequemment observee ne fait qu’aggraver l’etat du myocarde deja lese.The seriousness of scorpion envenomation results essentially from left cardiac function with pulmonary oedema and/or a state of shock. Adrenergic myocarditis, toxic myocarditis and myocardial ischemia are the 3 mechanisms that explain the cardiac dysfunction. Myocardial ischemia is not only due to the release of catecolamines but also the effect of the cytokines and/or neuropeptide Y on the coronary vessels. The cardiac damage can be due or enhanced by the depressive effect of the cytokines on the myocardial cells. The frequently observed hyperglycaemia only enhances the state of the already damaged myocardium.

Pulmonary embolism in intensive care unit: Predictive factors, clinical manifestations and outcome

OBJECTIVE: To determine predictive factors, clinical and demographics characteristics of patients with pulmonary embolism (PE) in ICU, and to identify factors associated with poor outcome in the hospital and in the ICU. METHODS: During a four-year prospective study, a medical committee of six ICU physicians prospectively examined all available data for each patient in order to classify patients according to the level of clinical suspicion of pulmonary thromboembolism. During the study periods, all patients admitted to our ICU were classified into four groups. The first group includes all patients with confirmed PE; the second group includes some patients without clinical manifestations of PE; the third group includes patients with suspected and not confirmed PE and the fourth group includes all patients with only deep vein thromboses (DVTs) without suspicion of PE. The diagnosis of PE was confirmed either by a high-probability ventilation/perfusion (V/Q) scan or by a spiral computed tomography (CT) scan showing one or more filling defects in the pulmonary artery or in its branches. The diagnosis was also confirmed by echocardiography when a thrombus in the pulmonary artery was observed. RESULTS: During the study periods, 4408 patients were admitted in our ICU. The diagnosis of PE was confirmed in 87 patients (1.9%). The mean delay of development of PE was 7.8 ± 9.5 days. On the day of PE diagnosis, clinical examination showed that 50 patients (57.5%) were hypotensive, 63 (72.4%) have SIRS, 15 (17.2%) have clinical manifestations of DVT and 71 (81.6%) have respiratory distress requiring mechanical ventilation. In our study, intravenous unfractionated heparin was used in 81 cases (93.1%) and low molecular weight heparins were used in 4 cases (4.6%). The mean ICU stay was 20.2 ± 25.3 days and the mean hospital stay was 25.5 ± 25 days. The mortality rate in ICU was 47.1% and the in-hospital mortality rate was 52.9%. Multivariate analysis showed that factors associated with a poor prognosis in ICU are the use of norepinephrine and epinephrine. Furthermore, factors associated with in-hospital poor outcome in multivariate analysis were a number of organ failure associated with PE ≥ 3. Moreover, comparison between patients with and without pe showed that predictive factors of pe are: acute medical illness, the presence of meningeal hemorrhage, the presence of spine fracture, hypoxemia with PaO2/FiO2 ratio <300 and the absence of pharmacological prevention of venous thromboembolism. CONCLUSION: Despite the high frequency of DVT in critically ill patients, symptomatic PE remains not frequently observed, because systematic screening is not performed. Pulmonary embolism is associated with a high ICU and in-hospital mortality rate. Predictive factors of PE are acute medical illness, the presence of meningeal hemorrhage, the presence of spine fracture, hypoxemia with PaO2/FiO2 < 300 and the absence of pharmacological prevention of venous thromboembolism.

Factors Associated with Pulmonary Edema in Severe Scorpion Sting Patients – A Multivariate Analysis of 428 Cases

Objective. To determine clinical and routine laboratory factors associated with pulmonary edema secondary to scorpion envenomation. Design and Setting. Retrospective study covering 13 years (1990–2002) in the medical Intensive Care Unit of a university hospital (Sfax-Tunisia). Patients. 428 patients older than 3 years who were admitted to the intensive care unit for scorpion envenomation were included in this study. Patients were stratified into two groups according to the presence or absence of pulmonary edema as assessed by a medical committee. Measurements and Results. The mean (± SD) age was 17.5 ± 17.7 years, ranging from 3 to 76 years. The pulmonary edema group included 294 patients (68.7%). A multivariate analysis found the following factors to be correlated with a pulmonary edema: age less than 5 years (p = 0.04), sweating (p = 0.004), agitation (p = 0.01), leukocytes of 25000 cells/mm3 or more (p = 0.02), and a plasma protein concentration of 72 g/L or more (p < 0.0001). In addition, a plasma protein concentration of 72 g/L or more predicted the presence of pulmonary edema with a sensitivity of 78% a specificity of 88%, a positive predictive value of 93%, and negative predictive value of 64%. Almost 84% of patients having a respiratory rate of ≥30 breaths/minute associated with agitation and sweating were classified in the pulmonary edema group. This clinical association indicates the presence of pulmonary edema with a specificity of 84.3% and a positive predictive value of 87.5%. Conclusion. In scorpion envenomation patients older than 3 years, the association of a respiratory rate of ≥30 breaths/minute, agitation, sweating, or the presence of high plasma protein concentrations suggest the presence of pulmonary edema.

Gastrointestinal manifestations in severe scorpion envenomation

OBJECTIVES To evaluate the type and incidence of gastrointestinal manifestations secondary to scorpion envenomation and their prognostic significance. PATIENTS AND METHODS All patients admitted to our ICU for scorpion envenomation were included in this retrospective chart review of a 13-year period (1990 - 2002). RESULTS During the study period, 951 patients were admitted for scorpion envenomation and 72 (7.6%) died. Ages ranged from 0.5 to 90 years with a mean of 14.7 +/- 17.4 years. Gastrointestinal symptoms were present in 700 patients (73.6%): nausea in 24 (2.5%), vomiting in 687 (72.2%) and diarrhea in 41 patients (4.3%). At univariate analysis, the presence of diarrhea was associated with a fatal outcome (P < 0.05). Diarrhea was also correlated with other indicators of severe envenomation and poor prognosis: respiratory failure (P = 0.01), neurological failure (P < 0.0001), liver failure (P < 0.0001) and low blood pressure requiring catecholamine support (P = 0.02). The multivariate analysis showed that young age (age less than 5 years), fever > 38.5 degrees C, neurological failure and pulmonary edema were independent factors of severity. Digestive disorders were more frequent in children and in this subgroup diarrhea appeared to be associated with poor outcome. In a subset of patients for whom data were available, fatal cases demonstrated significantly higher liver enzymes levels on admission. CONCLUSION In Tunisia, gastrointestinal symptoms are often observed in severe scorpion envenomations, especially in young patients. In children, diarrhea and elevated liver enzymes are associated with poor prognosis.

Severe head injury among children: Prognostic factors and outcome

AIM To determine predictive factors of mortality among children after traumatic brain injury. METHODS A retrospective study over 8 years of 222 children with severe head injury (Glasgow Coma Scale score < or = 8) admitted to a university hospital (Sfax, Tunisia). Basic demographic, clinical, biological and radiological data were recorded on admission and during intensive care unit stay. RESULTS The study included 163 boys (73.4%) and 59 girls, with mean age 7.54+/-3.8 years. The main cause of trauma was road traffic accident (75.7%). Mean Glasgow Coma Scale score was 6+/-1.5, mean Injury Severity Score (ISS) was 28.2+/-6.9, mean Paediatric Trauma Score (PTS) was 3.7+/-2.1 and mean Paediatric Risk of Mortality (PRISM) was 14.3+/-8.5; 54 children (24.3%) died. Univariate analysis showed that low PTS on admission, high ISS or PRISM, presence of shock or meningeal haemorrhage or bilateral mydriasis, and serum glucose > 10 mmol l(-1) were associated with mortality rate. Multivariate analysis showed that factors associated with a poor prognosis were PRISM > 20 and bilateral mydriasis on admission. CONCLUSIONS In Tunisia, head injury is a frequent cause of hospital admission and is most often due to road traffic accidents. Short-term prognosis is poor, with a high mortality rate (24.3%), and is influenced by demographic, clinical, radiological and biological factors.

Maladie cœliaque, thrombose veineuse cérébrale et déficit en protéine S, Une association fortuite ?

Resume Introduction La maladie cœliaque est une pathologie qui s’associe rarement a des complications thrombo-emboliques. La thrombose veineuse cerebrale n’a jamais ete decrite chez des patients ayant une maladie cœliaque. Observation Nous rapportons une observation d’une fille âgee de 21 ans ayant des antecedents de maladie cœliaque sous regime sans gluten, hospitalisee en reanimation pour etat de mal convulsif en rapport avec un ramollissement cerebral secondaire a une thrombose veineuse cerebrale. L’enquete etiologique de cette complication thrombo-embolique revele un deficit en proteine S. Commentaire Cette observation originale permet de discuter l’association fortuite de la maladie cœliaque et de la thrombose veineuse cerebrale. (J Mal Vasc 2005 ; 30 : 228-230).

Guillain–Barré syndrome related to pandemic influenza A (H1N1) infection

Dear Editor, Since April 2009, the world has been experiencing a pandemic influenza caused by the reasserting virus A (H1N1). Little information about neurological complications induced by this virus is available in the literature. We report the case of a 37-year-old woman who was admitted to our intensive care unit for respiratory distress associated with flaccid tetraplegia. Two weeks ago, she had fever, asthenia, and cough. A nasopharyngeal swab was performed, and reverse-transcription polymerase chain reaction (RT-PCR) confirmed infection with pandemic flu virus A (H1N1). Ten days later, she suffered muscular weakness of the lower limb, then the upper limb. At admission, she had normal consciousness, flaccid tetraplegia with complete areflexia, and symmetric paresthesia of the lower limb. A few hours later, she developed severe dyspnea with impaired coughing, accumulation of airway secretions, nasal voice, swallowing difficulties, and severe hypoxemia (SpO2 at 85% under 10 l oxygen/min) requiring mechanical ventilation. During the first 2 days, episodes of bradycardia and hypertension were recorded on hemodynamic monitoring. Diagnosis of Guillain–Barre syndrome was considered and confirmed by electromyography showing reduction in motor conduction velocity and prolonged distal latencies, which were more severe in the lower limb. On analysis of cerebrospinal fluid, there was no albuminocytologic dissociation. Investigations performed in order to identify another triggering factor were negative. Five consecutive plasma exchanges were performed, and the patient improved progressively. Repeated and prolonged weaning tests were successful, and the patient had a vigorous cough. She was free from mechanical ventilation within 2 weeks, and neither swallowing problems nor dysautonomia abnormalities were reported. The patient was discharged from our intensive care unit within 45 days. Guillain–Barre syndrome is an acute, immune-mediated polyradiculoneuropathy. In 66% of patients, history of respiratory or gastrointestinal infection within 6 weeks preceding onset of the disease is found [1]. Some infectious agents are particularly known as triggering factors of Guillain–Barre syndrome [2]. Sivadon-Tardy et al. [3] reported that influenza virus can also induce Guillain–Barre syndrome, but the majority of infections were due to virus A (H3N2), and clinical course was less severe compared with other infectious agents. For our patient, acute respiratory failure and bulbar dysfunction were the main causes leading to intensive care admission. Bulbar dysfunction can be responsible for autonomic instability and aspiration that worsens respiratory distress [4]. Determining the best time for mechanical ventilation is crucial, and up to 25% of patients with Guillain–Barre syndrome may need mechanical ventilation [1]. Delayed intubation, especially when bulbar dysfunction is considered, may increase the risk of early-onset pneumonia related to aspiration [4]. In adults, plasmapheresis is considered the gold standard for treatment of the most severe cases of Guillain– Barre syndrome. In five randomized trials, plasma exchange reduced the need for prolonged ventilation from 27% to 4% [2]. To the best of our knowledge, there are no available data concerning clinical severity and prognosis of Guillain–Barre syndrome related to pandemic flu virus A (H1N1). Further studies are needed to clarify the incidence of this complication and its prognostic impact.

Clinical features, complications and mortality in critically ill patients with 2009 influenza A(H1N1) in Sfax,Tunisia

Please cite this paper as: Damak et al.(2011) Clinical features, complications and mortality in critically ill patients with 2009 influenza A(H1N1) in Sfax,Tunisia. Influenza and Other Respiratory Viruses 5(4), 230–240