Prognostic Factors of Patients with Paraquat Poisoning

PURPOSE: Paraquat is a lethal herbicide and induces acute renal failure, hepatic dysfunction, and progressive respiratory failure. The purpose of this study was to investigate in cases of paraquat poisoning, the correlation between the serum concentration of paraquat and the ingested amount and between the prognostic factors. METHODS: In 53 patients who had ingested a 24.5% paraquat solution, we evaluated the significance of plasma paraquat concentrations and ingested amounts of paraquat. Prognostic factors such as age, sex, hypoxia, serum total CO2, and serum creatinine were also analyzed. RESULTS: The plasma paraquat concentration related to time after ingestion could definitely be used to predict the probability of the patient's survival. The mortality rate was significantly higher in the patients who had hypoxia, serum total CO2 below 18 mEq/L, serum creatinine above 2.0mg/dL, and an ingested amount of 2 mouthfuls (=40 cc) or more, but not in old patients or in patients with positive uroparaquat tests. CONCLUSION: The initial plasma paraquat concentration was the most important prognostic factor, but it had close relation with the ingested amount of paraquat.

The Clinical Investigation of Acute Diarrheal Disease by Seafood in Autumn at a Seacoast Communities of Korea

PURPOSE: The purpose of this study was to investigate the relationship between acute diarrheal disease and causative seafood. METHODS: This study was done retrospectively by investigating age, sex, symptoms, and causative seafoods in 140 patients. Correlating symptoms were vomiting, abdominal pain, fever, and bloody diarrhea. Causative seafood were crab, spiny lobster, pickles, sliced raw fish, and shellfish. All patients was seen at our hospital between September and November in two consecutive years, 2000 and 2001. RESULTS: An characteristic of seafood related food poisoning was an age of 30 or older. The major cause of seafood related food poisoning was crab. The most common symptom of seafood related food poisoning was abdominal pain. Symptom of crab relate food poisoning was most severe. CONCLUSION: Further studies are recommended to document an epidemiology and bacteriologic analysis of seafood related food poisoning in Chungnam-Taeangun.

How is the Clinical Efficacy of Extracorporeal Extraction Treatment Especially, Focused on the Hemodiafiltration, for Removal of Paraquat? / 대한신장학회잡지

PURPOSE: We tried to estimate the clinical efficacy of hemodiafiltration in the paraquat poisoning, as compared with that of other various extracorporeal extraction treatment. METHODS: We prepared the fresh frozen plasma mixed with paraquat concentrated up to 30 mg/L. The experiment was designed to remove paraquat by use of various extracorporeal treatment, such as hemodialysis (HD), hemoperfusion (HP), hemofiltration (HF), hemodia-filtration (HDF), hemodiafiltration & hemoperfusion (HDFP), respectively. The efficacy was analyzed on the basis of counting extraction ratio, observing the decreasing concentration of paraquat with the lapse of time. Four pigs (Yorkshire) were prepared and poisoned by paraquat (40 mg/kg) intramuscularly. Two poisoned animals were assigned for hemoperfusion and hemodiafiltration respectively and other two were assigned for the control. We observed extraction ratio, decreasing concentration of paraquat in blood, remained amount of paraquat in major organs, in addition to pathologic change of major organs after sacrifying the animals. RESULTS: The mean of extraction ratio is 0.84+/-0.27 in case of HP, 0.81+/-0.21 in HD, 0.74+/-0.40 in HDFP, 0.53+/-0.24 in HDF, 0.5+/-0.14 in HF. The extraction ratio of HP & HD & HDFP was significantly higher than that of HDF & HF (p<0.01). The extraction ratio was counted as the difference between the paraquat concentration of inlet and outlet was divided by the concentration of inlet. The slope of paraquat concentration undergoing extracorporeal treatment was the most acutely decreased in the case of HDFP, the less decreased in HP, and sequentially in HD, HDF and HF (the least) in the order of the decrease. The more decreased paraquat concentration in plasma was observed, the higher flow rate of dialysate of HDF was conducted. The mean of extraction ratio in animal study was 0.61 in HP and 0.36 in HDF. The blood concentration of paraquat was observed to be much lower in case of HP & HDF, as compared with the control animals. The remained concentration of paraquat in major organs, 7 hours later after being poisoned, was observed to be higher in the vascular structure like kidney and heart. However, it was observed to be lower in kidney, lung & muscle, when either of HDF and HP was conducted, than control. Especially, it was much lower in HP and much less pathologic change in HP. HDF is the less effective measure than HP, but is effective as a continuous treatment to make paraquat concentration to be lower as much as it possible. CONCLUSION: The HDF is the effective measure to keep the blood paraquat level low, even though it is behind the HP in effectiveness.

How is the Clinical Efficacy of Extracorporeal Extraction Treatment Especially, Focused on the Hemodiafiltration, for Removal of Paraquat? / 대한신장학회잡지

PURPOSE: We tried to estimate the clinical efficacy of hemodiafiltration in the paraquat poisoning, as compared with that of other various extracorporeal extraction treatment. METHODS: We prepared the fresh frozen plasma mixed with paraquat concentrated up to 30 mg/L. The experiment was designed to remove paraquat by use of various extracorporeal treatment, such as hemodialysis (HD), hemoperfusion (HP), hemofiltration (HF), hemodia-filtration (HDF), hemodiafiltration & hemoperfusion (HDFP), respectively. The efficacy was analyzed on the basis of counting extraction ratio, observing the decreasing concentration of paraquat with the lapse of time. Four pigs (Yorkshire) were prepared and poisoned by paraquat (40 mg/kg) intramuscularly. Two poisoned animals were assigned for hemoperfusion and hemodiafiltration respectively and other two were assigned for the control. We observed extraction ratio, decreasing concentration of paraquat in blood, remained amount of paraquat in major organs, in addition to pathologic change of major organs after sacrifying the animals. RESULTS: The mean of extraction ratio is 0.84+/-0.27 in case of HP, 0.81+/-0.21 in HD, 0.74+/-0.40 in HDFP, 0.53+/-0.24 in HDF, 0.5+/-0.14 in HF. The extraction ratio of HP & HD & HDFP was significantly higher than that of HDF & HF (p<0.01). The extraction ratio was counted as the difference between the paraquat concentration of inlet and outlet was divided by the concentration of inlet. The slope of paraquat concentration undergoing extracorporeal treatment was the most acutely decreased in the case of HDFP, the less decreased in HP, and sequentially in HD, HDF and HF (the least) in the order of the decrease. The more decreased paraquat concentration in plasma was observed, the higher flow rate of dialysate of HDF was conducted. The mean of extraction ratio in animal study was 0.61 in HP and 0.36 in HDF. The blood concentration of paraquat was observed to be much lower in case of HP & HDF, as compared with the control animals. The remained concentration of paraquat in major organs, 7 hours later after being poisoned, was observed to be higher in the vascular structure like kidney and heart. However, it was observed to be lower in kidney, lung & muscle, when either of HDF and HP was conducted, than control. Especially, it was much lower in HP and much less pathologic change in HP. HDF is the less effective measure than HP, but is effective as a continuous treatment to make paraquat concentration to be lower as much as it possible. CONCLUSION: The HDF is the effective measure to keep the blood paraquat level low, even though it is behind the HP in effectiveness.

Risk assessment of Rebleeding and Mortality after Acute Upper Gastrointestinal Bleeding through Clinical Manifestations

PURPOSE: Upper gastrointestinal bleeding (UGIB) is an urgent medical condition that emergency medicine doctors commonly encounter in the emergency room (ER). Initial management and triage of UGIB patients depend on nonendoscopic findings, so we sought risk factors for UGIB patients by using only the initial clinical data and the patient's condition in the ER. METHODS: By reviewing the data of 302 patients with the impression of UGIB between January of 1998 and December of 2000, the authors attempted to predict risk factors related to rebleeding, mortality, and need for surgical treatment. Based on blood analysis, physical exam, and history taking performed at the ER, the authors conducted a retrospective study in order to determine factors which influence rebleeding and overall mortality. RESULTS: From the blood pressure, pulse rate, and blood analysis taken at the time of admission, the levels of hemoglobin and hematocrits were shown to be related to rebleeding (p<0.05). If there was on-going bleeding, the relative risk of rebleeding was 2.314 times (p=0.023), and if the hemoglobin value was under 8 gm/dL, relative risk of rebleeding was 6.809 times (p=0.000). The factors which influenced the overall mortality rate were the blood pressure measured at the time of admission (p=0.001), the presence of on-going bleeding and rebleeding (p=0.000), and the level of hemoglobin, hematocrits and creatinine (p=0.001). A logistic regression analysis showed that when there was on-going bleeding, the relative risk of the mortality was 10.4 times (p=0.000) and when there was a high creatinine level, it was 7.8 times (p=0.001) CONCLUSION: When a patient with UGIB reports to the ER and shows unstable vital signs, a low hemoglobin level, and evidence of on-going bleeding, one should perform gastroendoscopy as soon as possible, and a need exists for aggressive treatment, even after admission.

The Investigation of Epidemiological and Clinical, Laboratory Characteristics of Acute Febrile Illness of Autumn-Winter Type in Rural Communities of Korea

BACKGROUND: Tsutsugamushi disease, Leptospirosis, and Hemorrhagic fever with renal syndrome(HFRS) are an acute febrile illness of autumn-winter type which are characterized by fever, headache, myalgia in acute stage. We reported the clinical and laboratory characteristics of 49 cases under investigation far febrile illness in rural communities of Korea in order to differentiate the diagnosis among Tsutsugamushi disease, Leptospirosis, and HFRS. METHODS: This study was done retrospectively by investigation of patient's age, occupation, symptom, laboratory findings and chest X-ray findings of Tsutsugamushi disease, Leptospirosis, and HFRS. All patients was seen in our hospital between September and November in 1997 and 1998 consecutive year. RESULTS: The most characteristic symptoms and signs of Tsutsugamushi disease were eschar(90.1%), and skin rash(70%). The epidemiological and laboratory characteristics of Tsutsugamushi disease were age 40 or more, farmer(90.1%), s-GOT(serum glutamic oxaloacetic transaminase) and s-GPT(serum glutamic pyruvic transaminase) elevation. The most characteristic symptoms and signs of Leptospirosis were sputum and cough(75%). The epidemiological and laboratory characteristics of Leptospirosis were all farmers(100%), hyperbilirubinemia(1.67 mg/dl). The most characteristic symptoms and signs of HFRS were gastrointestinal disturbance(100%), flank pain(66.7%). The epidemiological and laboratory characteristics of HFRS were leukocytosis, thrombocytopenia, azotemia, proteinuria (91.6%), and hematuria (83.3%). CONCLUSION: As the clinical feature, presence of eschar and skin rash were suggestive of Tsutsugamushi disease. As the clinical feature, presence of cough and sputum and laboratory finding such as elevation of bilirubin level were suggestive of Leptospirosis. As the clinical feature, presence of gastrointestinal disturbance, flank pain and laboratory finding of thrombocytopenia, and renal dysfunction were suggestive of HFRS.

Mild Head Injury: CT scanning and Discharge at Emergency Room

We studied retrospectively 1,112 mild head injury patients visited during a 2-year period to Dankuk University Medical Center to determine the clinical value of routine computerized tomography(CT) of the head and the indication of early discharge in patients with mild head injury(Glasgow coma scale score>or=13) at emergency room. Routine urgent cranial CT scans were obtained on all patients. Variables reviewed were mental status, symptom & sign of head trauma(brief loss of consciousness(LOC), amnesia, nausea and vomiting, headache). skull fracture on skull radiology, intracranial lesions, and operation. Patients with 13-14 Glasgow coma scale(GCS) or skull fracture have a significantly higher incidence of intracranial lesions and operation. Thus we suggest classifing patients with a GCS of 13-14 or skull fracture into "moderate" rather than "mild" in severity and recommend performing CT in all those patients. The patients with normal mental status(GCS score of 15) and no skull fracture have a rate of abnormal CT finding of 8.5% in the subgroup with history of LOC/amnesia and symptoms of head injury, but no patient in the subgroup without LOC/amnesia and symptoms of head injury. There was a few occurrence of delayed intracranial hematoma in normal mental status, but no patient required surgical intervention. We conclude that routine CT of the head in patients with GCS score of 13-14, skull fracture, and history of LOC/amnesia or symptoms of head injury in clear mental status is indicated. If the results of CT scan are normal, these patients may be safely discharged. But if there is no history of LOC/amnesia or symtoms of head injury in normal mental status, an immediate CT scan is not indicated and these patients may also be safely discharged.

Clinical Analysis of Delayed Intracranial Hemorrhage in Head Injury

Experinece in the management of 74 patients with delayed traumatic intracranial hemorrhage(DTICH) of 474 head injury from January 1996 to December 1996 is poresented with emphasis on the incidence, occurring time, risk factors and outcome. The incidence of DTICH was 15.6% of all hospitalized head-injury patients. After an injury, every patient had an immediate computerized tomography(CT) scan to diagnose intracranial pathology and then CT follow-up was carried out according to intial CT finding and reurological deficit. The lesion was almost occurred in patients with initial abnormal CT finding(85.1%). 82.4% of DTICH were noted within 72 hours after injury. The delayed epidural hematoma and intracerebral hemorrhage were almost noted in first 72 hours(>90%), but the delayed subdural hemorrhage was found after a time interval varying from 6 hours to 10 days. So we strongly recommend CT follow-up in 4-8hour, 24-72hour, and then 7th day after head injury, especially in patients with initial abnormal CT findings. The risk factor of the delayed lesion was not hypotension, hypoxia, and consciousness level, but age of patients and the initial CT finding. The development of DTICH was not heralded by neurological deterioration. The prognosis of DTICH was not worse than non-DTICH. The patient with delayed subdural hemorrhage was better than the patient with non-delayed lesion(including hemorrhage and normal CT finding).

EFFECTS OF HYPOXIA IN HEAD INJURY

To evaluate the effects of hypoxia to the outcome of patients with head injury, we analyzed 223 patients prospectively. We divided patients into two groups; without hypoxia and with hypoxia. Hypoxia was defined as PaO29)(8.9%). Hypoxic insult to the already-injured brain was closely associated with increased mortality and morbidity. Of the 37 patients with hypoxic insult, 23(62.2%) showed poor outcome (vegetative state & dead); only 48 patients(25.8%) without hypoxia showed poor outcome(p<0.001). Among hypoxic group, the incidence of poor outcome was especially high in patients injured in vehicular accidents(55.6%), in low consciousness level(GCS<8) on admission(80.7%), and in intracranial mass lesions(67.9%). Care for the patient with head injuries should start at the scene of injury. 100% oxygen should be administered via a suitable airway during transportation to the hospital, and early positive-pressure ventilation may be necessary.