Ozlem Guneysel

Intralipid emulsion treatment as an antidote in lipophilic drug intoxications

Intravenous lipid emulsion (ILE) is a lifesaving treatment of lipophilic drug intoxications. Not only does ILE have demonstrable efficacy as an antidote to local anesthetic toxicity, it is also effective in lipophilic drug intoxications. Our case series involved 10 patients with ingestion of different types of lipophilic drugs. Intravenous lipid emulsion treatment improved Glasgow Coma Scale or blood pressure and pulse rate or both according to the drug type. Complications were observed in 2 patients (minimal change pancreatitis and probable ILE treatment-related fat infiltration in lungs). In our case series, ILE was used for different lipophilic drug intoxications to improve cardiovascular and neurologic symptoms. According to the results, it was found that ILE treatment is a lifesaving agent in lipophilic drug intoxications and it can be used in unconscious patients who have cardiac and/or neurologic symptoms but no history of a specific drug ingestion.

Parkinson's disease and the frequent reasons for emergency admission

Introduction Available data suggest that Parkinson’s disease (PD) patients have a significant socioeconomic impact owing partly to increased hospital and drug utilization. The aims of this study were to provide a profile of patients with PD who required admission to hospital and to determine the reasons for emergency admission. Patients and methods Between September 1st, 2004 and August 31st, 2006, patients with PD who were admitted to our emergency department (ED) were included in the study. Patients with PD who were diagnosed by a neurologist formerly, and admitted to the ED with any reason constituted the study population. Demographical data, reasons for admission, years exposed to PD, number of admissions to the emergency department in the past 12 months, prior Hoehn and Yahr (H&Y) scores were recorded. H&Y was performed again for all patients 4 weeks after discharge. Results Seventy-six patients with PD were included in the study. Reasons for admission to hospital were infectious diseases (31.6%), trauma (27.6%), cardiovascular emergencies (14.5%), cerebrovascular emergencies (11.8%), gastrointestinal emergencies (7.9%), and electrolyte disturbances (6.6%), respectively. There was no dependence between the time of exposure to PD and H&Y score. Number of emergency admittance in the last 12 months was independent from the last H&Y score (p = 0.297). However, there was a dependency between the reasons for emergency admittance and the H&Y scores (p = 0.023). Discussion H&Y score is not dependent on the emergency admittance or on the outcome after discharge from the emergency department. The motor disability by itself cannot predict the whole picture of PD and the systemic complications leading to emergency admittance.

Determination of the appropriate catheter length and place for needle thoracostomy by using computed tomography scans of pneumothorax patients

INTRODUCTION The primary goal of this study was to compare the chest wall thicknesses (CWT) at the 2nd intercostal space (ICS) at the mid-clavicular line (MCL) and 5th ICS at the mid-axillary line (MAL) in a population of patients with a CT confirmed pneumothorax (PTX). This result will help physicians to determine the optimum needle thoracostomy (NT) puncture site in patients with a PTX. MATERIALS AND METHODS All trauma patients who presented consecutively to A&E over a 12-month period were included. Among all the trauma patients with a chest CT (4204 patients), 160 were included in the final analysis. CWTs were measured at both sides and were compared in all subgroup of patients. RESULTS The average CWT for men on the 2nd ICS-MCL was 38mm and for women was 52mm; on the other hand, on the 5th ICS-MAL was 33mm for men and 38mm for women. On the 2nd ICS-MCL 17% of men and 48% of women; on the 5th ICS-MAL 13% of men and 33% of women would be inaccessible with a routine 5-cm catheter. Patients with trauma, subcutaneous emphysema and multiple rib fractures would have thicker CWT on the 2nd ICS-MCL. Patients with trauma, lung contusion, sternum fracture, subcutaneous emphysema and multiple rib fractures would have thicker CWT on the 5th ICS-MAL. CONCLUSIONS This study confirms that a 5.0-cm catheter would be unlikely to access the pleural space in at least 1/3 of female and 1/10 of male Turkish trauma patients, regardless of the puncture site. If NT is needed, the 5th ICS-MAL is a better option for a puncture site with thinner CWT.

Adrenomedullin reduces the severity of cerulein-induced acute pancreatitis.

We investigated the effect of Adrenomedullin (AM) on cerulein-induced acute pancreatitis in rats. AM treatment (100 ng/kg per rat, subcutaneous) after one hour of cerulein injection reduced the plasma amylase levels, pancreatic weight, pancreatic malondialdehyde (MDA) levels, and the severity of the lesions microscopically. These data suggest that AM has a protective effect on cerulein-induced acute pancreatitis. These could be due to anti-inflammatory properties of AM, inhibition of proinflammatory cytokine secretion, reducing the endothelial permeability increased by reactive oxygen species, endotoxins or cytokines.

Utility of cervical spinal and abdominal computed tomography in diagnosing occult pneumothorax in patients with blunt trauma: Computed tomographic imaging protocol matters.

BACKGROUND Small pneumothoraces (PXs), which are not initially recognized with a chest x-ray film and diagnosed by a thoracic computed tomography (CT), are described as occult PX (OCPX). The objective of this study was to evaluate cervival spine (C-spine) and abdominal CT (ACT) for diagnosing OCPX and overt PX (OVPX). METHODS All patients with blunt trauma who presented consecutively to the emergency department during a 26-months period were included. Among all the chest CTs (CCTs) (6,155 patients) conducted during that period, 254 scans were confirmed to have a true PX. The findings in their C-spine CT and ACT were compared with the findings in CCTs. RESULTS Among these patients, 254 had a diagnosis of PX confirmed with CCT. OCPXs were identified on the chest computed tomographic scan of 128 patients (70.3%), whereas OVPXs were evident in 54 patients (29.7%). Computed tomographic imaging of the C-spine was performed in 74% of patients with OCPX and 66.7% of patients with OVPX trauma. Only 45 (35.2%) cases of OCPX and 42 (77.8%) cases of OVPX were detected by C-spine CT. ACT was performed in almost all patients, and 121 (95.3%) of 127 of these correctly identified an existing OCPX. Sensitivity of C-spine CT and ACT was 35.1% and 96.5%, respectively; specificity was 100% and 100%, respectively. CONCLUSION Almost all OCPXs, regardless of intrathoracic location, could be detected by ACT or by combining C-spine and abdominal computed tomographic screening for patients. If the junction of the first and second vertebra is used as the caudad extent, C-spine CT does not have sufficient power to diagnose more than a third of the cases. LEVEL OF EVIDENCE Diagnostic study, level III.

Oral, axillary, and tympanic temperature measurements in older and younger adults with or without fever.

Objectives The purpose of this study was to compare the results of body temperature obtained by a nurse with standard mercury thermometers from axillary and oral regions with the results of infrared tympanic thermometer in febrile and afebrile patients/in older and younger adults with or without fever, and to determine whether tympanic measures are suitable for use in the elderly population. Methods This study comprises a single-center, randomized, prospective comparison trial. Patients were allocated according to the Australasian National Triage Scale. Patients in triage categories 1 and 2 were excluded from this study. Only individuals aged 18 years and above were included in this study. Each patient was exposed to a constant environmental temperature for 10 min before the administration of simultaneous temperature measurements, which were performed via mouth, right axilla, and tympanic membranes. A record of readings and descriptive informations was made. Results No statistical significance in readings according to the type or place of thermometers according to the age groups (<65 years/≥65 years) or according to fever were observed. Tympanic temperature sensitivity and specificity were high. Conclusion Tympanic thermometers seem to be optimal for use with the elderly population. Owing to the ease of application, safety, and tolerability in the elderly; their use in routine practice seems to be advantageous. Higher reading of tympanic measurements may lead to a suspicion of infection, especially in the elderly, which may be helpful in clinical treatment in this age group.

Insulin glargine overdose

Insulin glargine is a long acting novel recombinant human insulin analogue indicated to improve glycemic control, in adults and children with type 1 diabetes mellitus and in adults with type 2 diabetes mellitus. The time course of action of insulins including insulin glargine may vary between individuals and/or within the same individual. Insulin glargine is given as a 24-h dosing regimen and has no documented half-life or peak effect. Hypoglycemia is the most common adverse effect of insulin, including insulin glargine. As with all insulins, the timing of hypoglycemia may differ among various insulin formulations. We present a case of a 76-year-old male insulin-dependent diabetic patient with refractory hypoglycemia secondary to an intentional overdose of insulin glargine. We would like to highlight the necessity of prolonging IV glucose infusion, for a much longer period than expected from pharmacokinetic properties of these insulin analogues after intentional massive overdose.

Effects of recombinant human granulocyte colony-stimulating factor (filgrastim) on ECG parameters in neutropenic patients: a single-centre, prospective study.

AbstractBackground and objective: Human granulocyte colony-stimulating factor (G-CSF) is a haematopoietic hormone that promotes the growth, proliferation, differentiation and maturation of neutrophil precursors. Filgrastim is a recombinant human G-CSF. Myocardial infarction, atrial fibrillation and arrhythmia have been reported in several patients with malignancy receiving filgrastim, but a causal relationship with the drug has not been established. The purpose of this study was to investigate the changes in ECG parameters in neutropenic patients during treatment with filgrastim. Methods: This was a single-centre, prospective study carried out in a hospital emergency room. Patients with neutropenia and malignancy who were required to receive filgrastim were eligible for the study. After a reference ECG had been obtained, filgrastim was administered to all patients at a dose of 5 µg/kg/day subcutaneously for 2 days. Follow-up ECGs were then obtained at 12-hourly intervals. Continuous telemetric monitoring was conducted throughout hospitalization. Results: Serial ECG parameters were compared in 102 patients. There were no statistically significant differences between baseline and follow-up ECG measurements of rhythm, P-wave duration, PR interval, QRS-wave duration, corrected QT (QTc) interval, ECG axis, premature supraventricular events, ventricular arrhythmia, R-wave progression, right bundle branch block or left bundle branch block. There was a significant reduction in mean heart rate in subsequent ECGs compared with baseline (p≪0.05). Conclusion: This study did not demonstrate any ECG changes other than a significant reduction in mean heart rate in this selected population of neutropenic patients given 2 days’ treatment with subcutaneous 5 µg/kg/day of filgrastim.

Rising Threat; Bonsai

SUMMARY Objectives In recent years, and especially in the past few months, the number of synthetic cannabinoid (bonsai) users has increased in our country. The aim of this study was to draw attention to the consumption of bonsai among young people and reveal the demographic and basic clinical characteristics of these users. Methods This was a retrospective study conducted at the Ümraniye Training and Research Hospital. All of the adult patients (≥18 year old) with synthetic cannabinoid intoxication who presented to the Emergency Department throughout the two years of the study (July 1st 2012–June 30th 2014) were enrolled. The frequencies were given as the median and inter-quartile range). Results 197 patients were included in this study, with 190 male patients (96.4%) and 7 (3.6%) female patients. Two of the four hospitalized patients were exitus, 52 left on their own will and a total of 141 patients were discharged after 6-12 hours of observation in the ED. Conclusions The use of synthetic cannabinoids (bonsai) in the recent years, especially in the summer months of 2014 was investigated in this study. Although these patients can have a benign clinical course, the process can also be fatal. It should especially be noted that patients with depressed respiration, low GCS scores and high PaCO2 values are at higher risk for mortality and the necessity of early intubation should be kept in mind.

Intravenous Lipid Emulsion Therapy for Acute Synthetic Cannabinoid Intoxication: Clinical Experience in Four Cases

There is no specific antidote for intoxication with synthetic cannabinoids. In this case series, we considered the efficiency of intravenous lipid emulsion therapy in four cases, who presented to emergency department with synthetic cannabinoid (bonzai) intoxication. The first patient had a GCS of 3 and a left bundle branch block on electrocardiography. The electrocardiography revealed sinus rhythm with normal QRS width after the treatment. The second patient had bradycardia, hypotension, and a GCS of 14. After intravenous lipid emulsion therapy, the bradycardia resolved, and the patients GCS improved to 15. The third patient presented with a GCS of 8, and had hypotension and bradycardia. After the treatment, not only did the bradycardia resolve, but also the GCS improved to 15. The fourth patient, whose electrocardiography revealed accelerated junctional rhythm, had a GCS of 13. The patients rhythm was sinus after the treatment. Cardiovascular recovery was seen in all four cases, and neurological recovery was also seen in three of them. Based on the fact that intravenous lipid emulsion is beneficial in patients intoxicated with lipophilic drugs, unstable patients presenting to the emergency department with acute synthetic cannabinoid intoxication may be candidates for intravenous lipid emulsion treatment.