Salim Satar

Abdominal Compartment Syndrome: Current Problems and New Strategies

BackgroundAbdominal compartment syndrome (ACS) is a diffucult entity with two main problems during its course: (1) survival of the patient during the early period and (2) closure of the open wounds during the late period. In this study we evaluated the decision to decompress according to the level of intraabdominal pressure (IAP) and analysis of any recurrent or persistent increase in IAP.MethodsA prospective study was undertaken on 119 patients with increased IAP. The IAP was measured daily by obtaining the bladder pressure. Patients were monitored via a central venous line; and vital signs, arterial blood gases, the Acute Physiology, Age, and Chronic Health Evaluation II (APACHE II) score, and abbreviated mental tests were recorded. The suggestions of Meldrum et al. were taken as a guideline during the treatment. The sensitivity and specifity of IAP and APACHE II scores for different cutoff values were calculated using the receiver operating characteristic curve.ResultsHospital mortality was 33.6%, which increased with co-morbidities (p = 0.03). A cutoff value for IAP of 23 mmHg was considered an optimal point predicting mortality. The IAP within the first 3 days for patients who died was higher than the cutoff value. For patients with IAP of 15 to 25 mmHg, nonsurgical therapy increased the rate of mortality (odds ratio 5.2, 95% confidence interval 1.0–27.7; p = 0.03).ConclusionsIn patients with ACS emergency, it is recommended that decompressive laparotomy to be performed even if the IAP falls below 25 mmHg. For patients with IAP levels higher than 25 mmHg, the IAP should be meticolusly brought below the cutoff level during the postoperative period.

Ingestion of Caustic Substances by Adults

Caustic products are responsible for the most serious cases of poisoning, which are always emergency cases. In this paper, we review demographic features and endoscopic results of the patients admitted to a university emergency department with a history of caustic substance ingestion between January 2000 and June 2003. Thirty-seven patients were included in this study. Twenty-one of the patients were female and 16 were male. The mean age of the patients was 30.9 ± 14.7 years. The agents included sodium hypochlorite in 24 patients and hydrochloric acid in 13 patients. All the patients ingested these agents orally. The mean interval time of admission to emergency department after ingestion of caustic agent was 5.4 ± 5.6 hours. Endoscopy was attempted in 37 patients. Endoscopic results were as follows: grade 0 in 8 (21.6%) patients, grade 1 in 17 (45.9%) patients, grade 2a in 5 (13.5%) patients, and grade 2b in 7 (18.9%) patients. We believe that early signs and symptoms after caustic substance ingestion are not consistent with the extent of damage, and endoscopy is the only reliable method to assess injury. It is important that efforts should be made to educate the public about the dangers of caustic substances so that their threat may be diminished.

The prevalance, epidemiology and risk factors for onychomycosis in hemodialysis patients

BackgroundOnychomycosis has a high prevalance among immunocompromised patients such as diabetics and hemodialysis patients. In the present study, we aimed to investigate the prevalence of onychomycosis among hemodialysis patients with and without diabetes mellitus, and to find out the factors likely to be associated with the development of onychomycosis among hemodialysis patients.MethodsOne hundred and nine hemodialysis patients were enrolled. Fifty-seven of hemodialysis patients had the diagnosis of diabetes mellitus. Nail scrapings were obtained from 76 patients who had dystrophic nail changes. Samples were examined with 20% potassium hydroxide solution and all of the samples were inoculated on Saborauds dextrose agar, potateus dextrose agar and mycobiotic agar. Diagnosis of onychomycosis was based on the presence of both positive clinical signs and positive potassium hydroxide test.ResultsOnychomycosis was diagnosed in 26.6% of hemodialysis patients. Diabetes mellitus was present in 68.9% of patients with onychomycosis. Toenail scraping cultures were reported to be positive in 19.7% of patients with dystrophic nail changes. Logistic regression analysis revealed that the presence of diabetes mellitus and the mean duration of hemodialysis were the significant predictors associated with the development of onychomycosis.ConclusionThe prevalence of dystrophic nail changes and onychomycosis is increased among hemodialysis patients. The dialysis duration and the presence of diabetes mellitus are the independent risk factors associated with the development of onychomycosis in uraemic patients.

The efficacy of low-dose antivenom therapy on morbidity and mortality in snakebite cases

UNLABELLED Similar to the cases seen around the world, snakebite causes mortality and morbidity in Turkey. The venom of different types of snake in the region of Cukurova causes serious systemic and local tissue damage. METHODS We performed this prospective study on 45 patients who complained of snakebite. We grouped the patients according to their clinical presentations to facilitate treatment and follow-up period procedures. RESULTS Whereas the patients with grade 1 envenomation did not receive any antivenom, grades 2 and 3 patients received 2.70 +/- 0.77 and 4.88 +/- 1.65 vials of antivenom, respectively. One of our patients had to undergo finger amputation but there were no deaths. Allergic reactions developed after antivenom therapy in 8 patients (17.8%). CONCLUSIONS When we considered the cost and complications of the antivenom treatment, it was seen that low-dose antivenom treatment effectively treated the patients with venomous snakebite injuries in our region.

Analysis of acute adult poisoning in a 6-year period and factors affecting the hospital stay

Case management of adult patients with acute poisoning in a university-based emergency department to determine the factors that affect duration of hospital stay was assessed. In this survey, data were obtained for the period between January 1, 1997 and December 31, 2002 at the emergency department (ED). Case analyses of 2229 patients older than 14 years of age were reviewed. Of all patients, 725 (32.5%) were male, 801 (35.9%) were younger than 20, and 540 (24.2%) were older than 30 years. Mean ages of patients were 29.3±13.2 for the males and 23.8±9.6 for the females (P< .001). During the study, the greatest number of patients were admitted in May (11.0%). Suicidal poisoning was the observed etiology in the majority of cases (76.4%). Moreover, the mortality rate due to poisoning was 3.9%. Drug ingestion was the most frequent means of poisoning (59.0%), followed by pesticides (19.0%). The rate of poisoning with multiple drugs has declined over time, whereas the rate owing to psychoactive drugs has increased markedly. The mean length of hospital stay was 2.9±1.8 days and the proportion of patients who stayed for longer than 2 days was 44.3%. The mean length of hospital stay was longer for males, those older than 30 years, those who had been poisoned unintentionally, and for confused and unconscious patients and those who had arrived to ED more than 2 hours after the event. This study suggests that morbidity for adult patients with poisoning varied by sex, age, and season. Length of hospital stay was affected by sex, age, arrival time to ED, mode of transport, severity of poisoning, and type of agent.

Snakebite during pregnancy

Little is known about snakebites during pregnancy and only a few cases have been reported in the literature. The fact that venomous snakebites during pregnancy result in high fetal wastage and may cause maternal mortality makes this an important, albeit, uncommonly encountered entity in emergency medicine. In this paper, we report on the successful treatment of three cases of snakebite in pregnancy.

QTc intervals in drug poisoning patients with tricyclic antidepressants and selective serotonin reuptake inhibitors.

Commonly used agents of drug poisoning among patients who come to the emergency services are tricyclic antidepressants (TCAs). These drugs may cause defect in cardiac conduction due to the slowdown in the cardiac depolarization and expansions in the QT interval. Selective serotonin reuptake inhibitors (SSRIs) are less expansion of the QT period and lower cardio toxic side effects. The aim of this study was to investigate QTc intervals and prognosis of the patients who come to the emergency service due to TCA and SSRI group antidepressant drug poisoning. In a study of 96 patients, 75 of whom were diagnosed to be poisoned by TCAs (TCA group) and 21 by SSRIs (SSRI group) were examined. Electrocardiographic alterations and QTc intervals all of patients were evaluated. QTc intervals of patients in TCA group were determined to be slightly more than those in SSRI group and it was not statistically significant. In the SSRI group, only one patient had QTc period more than 500 milliseconds (520 milliseconds); however, TCA overdose showed 9 (12%) patients with QTc interval over 500 milliseconds, and QTc values of 2 patients were over 600 milliseconds. In our study, it was determined that SSRI group drugs caused similar expansion of the QTc period as TCA drugs but they did not reach high values like TCA drugs, and their OTc intervals stayed in more innocent levels.

Effectiveness of Treatment to Prevent Adhesions After Abdominal Surgery: An Experimental Evaluation in Rats

This study was conducted to determine the probability of adhesion formation with certain materials after abdominopelvic surgery, and to assess the effectiveness of adhesion-preventing agents. The study included 2 phases. In the first phase of the study, 50 rats that had been divided into 5 groups were examined. Group 1 served as the control group. In group 2,2 mL blood was taken from the femoral vein of the rat; in group 3,0.0625 g talcum powder was mixed with 2 mL saline; in group 4, 2 mL ileal content was identified; and in group 5, 2 mL cecal content had spilled into the peritoneum. In the second phase of the study, 50 rats that had been divided into 5 groups were examined. Ileal content was the leading cause of intraperitoneal adhesions in the first phase; in the second phase, in group 1, 2 mL ileal content and 5 mL povidone-iodine (10%) were used; in group 2,2 mL ileal content and 5000 units aprotinin were mixed with 5 mL saline; in group 3, 2 mL ileal content and 25 IU heparin (5000 IU/L) were mixed with 5 mL saline; in group 4,2 mL ileal content and 5 mL 32% dextran 70 were combined; and in group 5, 2 mL ileal content was used together with 5 mL Ringer’s lactate. On postoperative day 14, the rats were killed with the use of high-dose intramuscular ketamine, and necropsies were performed on all rats. Adhesions were most often established because of ileal and cecal contents. Blood and talcum powder produced less adhesion formation. Heparin and 32% dextran 70 were significantly more effective at preventing adhesion formation due to ileal contents. Intraperitoneal heparin and 32% dextran 70 may be particularly valuable for the prevention of adhesions due to intestinal content in cases with no contraindications.

Effectiveness of therapeutic plasma exchange in patients with intermediate syndrome due to organophosphate intoxication

OBJECTIVE We aimed to determine effectiveness of therapeutic plasma exchange (TPE) in patients with intermediate syndrome (IMS) due to organophosphate (OP) intoxication. METHODS Patients diagnosed with IMS due to OP intoxication were included in this prospective study. Therapeutic plasma exchange procedure was performed with fresh frozen plasma as a replacement fluid via Fresenius-AS-TEC 204 device by Therapeutic Apheresis Unit to patients who developed IMS during follow-up. Samples were taken from patients blood and waste plasma collected in the device before and after TPE procedure to be studied in laboratory for detection of organic phosphate and pseudocholinesterase (PChE) levels. In this study, SPSS 18.0 software package was used for statistical analysis of the data obtained. Level of statistical significance was taken as P < .05 for all tests. RESULTS Of all 17 patients, 4 (23.5%) were female, and 13 (76.5%) were male. A statistically significant decrease was detected in organic phosphate levels in the plasma of patients after TPE procedure (P = .012). A statistically significant increase was detected in PChE levels in the plasma of patients after TPE procedure (P = .014). Of 17 patients included in the study, 13 patients showed clinical improvement and were discharged after the TPE process. CONCLUSION In our study, it was observed that a significant decrease in the level of blood plasma OP and a significant increase in the level of PChE were achieved with TPE process in the early period of IMS due to OP poisoning. This study indicates that TPE is one of the effective treatment options for IMS due to OP intoxication.

Unusual presentations of scorpion envenomation

Scorpions are nocturnal arthropods that inject their venom through the victims’ skin by stingers. By the envenomation, clinical manifestations in a wide spectrum may occur, including pain at one side and death because of severe cardiopulmonary or neurological abnormalities. Sometimes the victim cannot describe the insect or does not remember even being stung after the event. We present two cases of scorpion envenomation with different and rare clinical situations with a short review of the literature.