Slah Bouchoucha

Serotherapy in scorpion envenomation: a randomised controlled trial

BACKGROUND Evidence for the benefit of scorpion antivenom, the only specific treatment for scorpion envenomation, is scarce, despite its common use. We did a prospective, randomised, controlled trial to assess the efficacy of routine administration of scorpion antivenom to scorpion-stung patients, irrespective of clinical severity. METHODS We included 825 consecutive patients older than 10 years, who presented to the accident and emergency department of the hospital in Tozeur, Tunisia. We graded severity by absence (grade I) or presence (grade II) of systemic manifestations of scorpion envenomation. Patients were randomly assigned placebo (n=413) or 20 mL bivalent intraveneous scorpion antivenom (n=412). All patients were observed for 4 h. Patients who developed life-threatening symptoms were admitted to the intensive-care unit. At the end of 4 h observation we reassessed grade and discharged grade II patients and admitted grade II patients. We assessed the preventive and curative effects of scorpion antivenom by prevention of worsening grade or by improvement from grade II to grade I. FINDINGS Distribution of severity grades was similar in the two groups at baseline, as were the cure rates (55% scorpion antivenom, 66% placebo, absolute difference, 11% [95% CI -4.8 to 26.8]; p=0.234). Preventive effects were seen in 94% and 96% of patients in the scorpion antivenom and placebo groups, respectively, who were initially grade I and who remained symptom-free (absolute difference, 2% [-1.27 to 5.27]; p=0.377). Time from scorpion sting to administration of scorpion antivenom did not affect curative and preventive effects. INTERPRETATION We found no benefit in routine administration of scorpion antivenom after scorpion sting, irrespective of clinical severity. Future studies should focus on patients with the most severe symptoms and signs.

Predictive value of severity scoring systems : Comparison of four models in Tunisian adult intensive care units

OBJECTIVES To compare the performance of four severity scoring systems: the Acute Physiology and Chronic Health Evaluation (APACHE) II, the new versions of the Mortality Prediction Model (MPM0 and MPM24), and the Simplified Acute Physiology Score (SAPS) II. DESIGN A prospective cohort study. SETTING Three Tunisian intensive care units (ICUs). PATIENTS Consecutive, unselected adult patients (n = 1325). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Overall, observed death rates were higher than predicted by all models except MPM0. All the evaluated scoring systems had good discrimination power as expressed by area under the receiver operating characteristics curve, but their calibration was less perfect when compared with original validation reports. There were no major differences between the models with regard either to discrimination or calibration performance. CONCLUSION Despite an overall good discrimination, APACHE II, MPM0, MPM24, and SAPS II showed a less satisfactory calibration in our Tunisian sample of ICU patients. Part of the models inaccuracy could be related to quality of care problems in our ICUs, but this issue needs further analysis.

Assessment of left ventricular function in severe scorpion envenomation: Combined hemodynamic and echo-Doppler study

ObjectiveTo assess left ventricular function in patients presenting with pulmonary edema following scorpion envenomation.DesignCohort study.Setting: Medical intensive care unit of a teaching hospital.Patients: Nine consecutive adult patients stung byAndroctonus australis and presenting with pulmonary edema entered the study. Fourteen normal volunteers comprised the control group.InterventionsUpon admission, all patients had right heart catheterization and, within the first 8 h, a Doppler echocardiographic study. Results of Doppler echocardiographic studies were compared to those of controls.Measurements and resultsUsual hemodynamic information (heart and vascular pressures, derived data and tissue oxygenation parameters), left ventricular dimensions and indicators of systolic function, and Doppler-derived parameters of left ventricular filling and diastolic function were obtained upon admission. Serial echocardiographic measurements were repeated daily until full clinical recovery (eight patients) or death (one patient). All patients had a hemodynamic profile of acute congestive heart failure (mean PAOP=24±2 mmHg; mean SVI=22±7 ml/m2; mean CI=2.5±0.5 l/min/m2). However, SVR were not increased (mean=22±3 U/m2). Left ventricle was hypokinetic in all patients with transient mitral regurgitation present in five patients. Left ventricular systolic function was markedly depressed (FS=12±6%; EF=26±12%). An associated diastolic dysfunction is suggested by Doppler records of mitral inflow. Left ventricular systolic function evolved toward normalization within 6±2 days preceded by full clinical recovery.ConclusionsThese data suggest that pulmonary edema in scorpion envenomation is of hemodynamic origin and is related to a severe and prominent impairment of left ventricular systolic function.

Hellp syndrome: Incidence and maternal-fetal outcome—a prospective study

Objective: to determine the incidence of Hellp syndrome (HS) and the maternal fetal outcome associated with its occurrence.Design: a prospective study during a 6-month period.Setting: the department of obstetrics and gynecology and the Intensive Care Unit of a 700 bed teaching hospital.Patients: Sixty-two consecutive preeclamptic and eclamptic women.Measurements and results: all patients were systematically investigated for the biological markers of HS. The effects of the occurrence of HS on maternal and fetal prognosis were evaluated by comparing for prognosis indicators usually assessed in gravidic hypertension, pre-eclamptic and eclamptic women who exhibited HS (HS+subgroup) with HS free patients (HS-subgroup). HS was found in 12 out of the 62 pre-eclamptic and eclamptic women (19.3%). Its occurrence was associated with higher maternal mortality (16.7% vs 0%;p=0.03), a greater incidence of eclamptic crisis (50% vs 20%;p=0.03), severe hypertension (33% vs 8%;p=0.03) and episodes of acute renal failure (66% vs 30%;p=0.02). Mean proteinuria was also higher in HS+patients (4.6±3.3 vs 2.2±2.5 g/day;p=0.001). However, fetal outcome was not significantly altered.Conclusion: Pre-eclampsia and elampsia may be more severe in the presence of HS with a worsening of maternal prognosis while fetal outcome seems not altered.

Efficacy of serotherapy in scorpion sting: a matched-pair study.

BACKGROUND/OBJECTIVE Although evidence of scorpion antivenin effectiveness in the clinical setting is lacking, scorpion antivenin is generally considered the only specific treatment for scorpion sting irrespective of its clinical severity. We conducted a matched-pair study to assess the efficacy of systematic administration of scorpion antivenin. METHODS Among 600 stung patients who participated in a study on the efficacy of high-dose hydrocortisone after scorpion sting, 135 (cases) had been treated with 10 to 20 mL intravenous scorpion antivenin (neutralizing 10 LD50 venom/mL). Controls were matched on disease severity on arrival to the emergency department. The severity of envenomation was graded I or II according to the absence (grade I) or the presence (grade II) of systemic manifestations of scorpion envenomation. Assessment of scorpion antivenin efficacy was based on the rate of changing severity grade in both groups (clinical improvement or worsening during an observation period of at least 4 hours). RESULTS Both groups were similar with respect to clinical severity (36 patients were graded II in each group), age, sex, time-lapse between scorpion sting and ED arrival, and the administration of adjunctive therapy such as hydrocortisone. By the 4-hour evaluation, 50% and 64% of patients initially graded II exhibited a substantial clinical improvement in cases and controls, respectively, suggesting similar effects in cases and controls. There was no difference in preventive effects: 13% and 10% of cases and controls developed systemic manifestations of scorpion envenomation during the 4-hour observation period; 23% of cases and 17% controls were hospitalized by this time. There was no difference in the duration of hospitalization. Three cases developed anaphylactic shock as a consequence of scorpion antivenin administration, while 1 scorpion antivenin-untreated patient died from refractory shock. CONCLUSION Systematic administration of scorpion antivenin irrespective of clinical severity did not alter the clinical course of scorpion sting. A prospective study is needed concerning the response of the more severe scorpion envenomations.

A controlled trial of nebulized salbutamol and adrenaline in acute severe asthma

ObjectiveTo compare efficacy and safety of nebulisation of adrenaline (2 mg over 10 min) and salbutamol (5 mg over 10 min) in acute severe asthma.DesignProspective randomized and double blind study.SettingIntensive care unit of a University teaching hospital.Patients and participants22 asthmatic patients presenting to the emergency room with acute severe asthma.InterventionsPatients were randomly assigned to receive either adrenaline (n=11) or salbutamol (n=11) via a nebulizer. Additional treatment comprised hydrocortisone hemisuccinate (100 mg) and supplemental oxygen (7l/min). The efficacy and safety of both drugs were evaluated at 20 and 40 min.ResultsA statistically significant increase in the Peak Expiratory Flow (PEF) was achieved at the 20th min in both groups (from 85±38 l/min to 120±45 l/min;p<0.001; and from 107±28 l/min to 145±19 l/min;p<0.001; in adrenaline group and salbutamol group respectively). With both drugs, PEF further increased at 40 min to a level that was statistically significant when compared to the 20 min evaluation. The magnitude of the absolute variation in PEF was similar with both drugs. Both drugs induced a significant decrease in heart rate, respiratory frequency and PaCO2 while the increase of PaO2/FIO2 ratio was not significant. The decrease of respiratory frequency at 40 min was more important with salbutamol (p=0.03). No side effects were recorded in both groups.ConclusionAfter a single dose, nebulized adrenaline (2 mg) proved as effective and safe as salbutamol (5 mg) in acute severe asthma.

High-Dose Hydrocortisone Hemisuccinate in Scorpion Envenomation

STUDY OBJECTIVE Scorpion envenomation is a common life-threatening hazard in tropical and subtropical countries. Standard treatment is not clearly defined. Many therapies, such as steroids, are prescribed without experimental justification. We sought to assess the efficacy of systematic administration of intravenous hydrocortisone hemisuccinate (50 mg/kg) in scorpion envenomation. METHODS Six hundred consecutive envenomated patients older than 10 years who presented to the ED of a nonteaching secondary hospital in an area of Tunisia endemic for scorpion envenomation were randomly assigned to receive hydrocortisone hemisuccinate 50 mg/kg (n = 305) or placebo (n = 295) in addition to standard medical care. Patients in the two groups had similar clinical characteristics on initial clinical evaluation. Each was categorized as grade 1 (absence of systemic symptoms) or grade 2 (systemic symptoms of scorpion envenomation). Patients were treated in the ED for up to 4 hours or in the ICU, depending on clinical severity. Steroid and placebo groups were compared according to mortality rate, change of severity grade 4 hours after presentation and treatment, and duration of hospital stay. RESULTS Distribution of patients with respect to severity grade was similar in the two groups at the 4-hour clinical evaluation. We detected no significant difference at the time of discharge between steroid-and placebo-treated patients with respect to mortality (one patient in each group) or duration of hospital stay. Extra costs incurred through steroid administration totaled US

Scorpion envenomation: from a neglected to a helpful disease?

989,000. CONCLUSION Our findings do not support the use of intravenous high-dose steroids in scorpion-envenomated patients. The discontinuation of this practice would reduce costs substantially.

Prognostic value of serum cholinesterase in organophosphate poisoning.

Scorpion envenomation is a life-threatening accident encountered in tropical and subtropical areas. It remains an under-reported disease but around 1.2 million stings are yearly recorded around the world, ensuing in 3250 deaths as a consequence of acute heart and respiratory failure) [1]. The great majority (> 90%) of stings by the Old World scorpions (North Africa, India, and the Middle East) are so-called dry stings, resulting in localized discomfort. When systemic envenomation occurs, several systems may be affected, including the gastrointestinal, neurological, inflammatory systems, etc. [2]. Life-threatening presentations with acute heart failure features occur in less than 1% of cases. In what follows, we will strive to show how the little research dedicated to this neglected disease has led to significant scientific advances both through the derived experimental model of the widespread Takotsubo syndrome and by the proliferation of venom-derived drugs. In 1995, we published a study in Intensive Care Medecine which included 9 consecutive young patients admitted to the ICU for pulmonary edema consecutive to severe scorpion envenomation [3]. Early upon ICU admission, all patients where equipped with a pulmonary artery catheter, and had serial echo-doppler examinations in order to assess left ventricular function in comparison to 14 matched controls. This report confirmed the findings of a previous study which was one of the first to unveil the hemodynamic nature of the scorpion envenomation-related pulmonary edema [4]. In addition, the study highlighted two of the peculiar features of scorpion-induced LV dysfunction: the marked and reversible (in days) depression in LV systolic function. The next study has brought together arguments in favor of the third characteristic of the scorpion-related cardiomyopathy: the right ventricle may also be involved and to the same extent as the LV making unlikely the ischemic hypothesis of scorpion-related cardiomyopathy, especially since the majority of victims are young with healthy coronary circulation [5]. Subsequent studies have tried to unravel the mechanisms involved in scorpion-related cardiomyopathy where a scorpion-specific, ischemic, or catecholaminergic cardiomyopathy were also advocated [6].