Poisoning due to consumption of horse chestnut seed

Horse chestnut (Aesculus hippocastanum) is a common tree found on roads and parks. The shape of the fruit is very similar to that of the edible Korean chestnut (Castanea crenata); thus, people can eat it by mistake. However, reports of the side effects and toxicity from ingestion are very rare. A 46-year-old male who had no unusual findings in the past had eaten horse chestnut seed which he had mistaken to be Korean chestnut. He visited the emergency department (ED) with complaints of epigastric pain, nausea, and sweating. Blood tests showed a slight increase in the levels of liver enzymes, serum amylase, and pancreatic amylase. During the monitoring, he complained of palpitations, and electrocardiogram showed atrial fibrillation. On the following day after conservative treatment, blood testing and electrocardiogram showed normal findings. He was discharged from the ED as he did not complain of any further symptoms. When a patient who has eaten horse chestnut visits the ED, blood examination and electrocardiogram monitoring are needed, and conservative treatment is required.

The Effect of Video-assisted Informed Consent for Central Venous Catheterization in the Emergency Department

PURPOSE: Informed consent is a basic right of patients undergoing medical procedures, but the effect of the type of consent form on the risk of invasive procedures is controversial, and the recall of information by patients has been poor. This trial was designed to assess the effect of video-assisted information on verbal informed consent to allow central venous catheter (CVC) insertion in the emergency department. METHODS: A prospective, randomized controlled trial was done on adult emergency department patients undergoing CVC insertion. Patients were randomized to the intervention or the control group. The intervention group had consent obtained with the assistance of video information (video group). The control group received a conventional education process that was conducted by the physician (verbal group) regarding indications, risks, and treatment of complications due to the procedure. Outcome variables consisted of an anxiety score, heart rate, and systolic and diastolic blood pressure at baseline and immediately after informed consent. All participants completed a 5-question knowledge measurement and graded their satisfaction level after the explanation. RESULTS: Of 208 patients enrolled, nine withdrew, leaving 199 for analysis (video n=99; verbal n=100). The two groups were similar with regard to their baseline characteristics. The video group was significantly less anxious after informed consent (4.5+/-0.8 vs 5.8+/-1.0, p=0.029) and had a significantly lower heart rate (64+/-12 vs 73+/-10, p=0.027). Mean knowledge scores were higher in the video group (3.82+/-0.55) compared to the verbal group (2.94+/- 0.75) (p=0.01). Satisfaction regarding the information received was higher in the video group (4.09+/-1.08) than in the verbal group (3.15+/-1.04) (p=0.00). CONCLUSION: Video-assisted informed consent decreases anxiety and improves satisfaction scales in patients undergoing CVC insertion. The Video group showed better recall of information compared with the verbal group.

The Utility of Bispectral Index Scores for Sedative Intoxication in the Emergency Department

PURPOSE: This study was designed to determine the utility of bispectral index scores (BIS) compared to Glasgow coma scale (GCS) or Observer's Assessment of Alertness/Sedation Scale (OAA/S), in measuring changes in consciousness, prognosis and management of sedative-intoxication patients. METHODS: Sedative intoxication patients, who came to the emergency department with a severe deficit in consciousness, or a GCS less than 12, were analyzed. Patients' consciousness states were evaluated using OAA/S and GCS and compared with BIS scores. Patients' consciousness recovery time and hospitalization were recorded to see if these could be predicted by BIS using regression analysis. BIS, OAS/S and GCS were compared with regard to intubation, admission and ICU admission. Furthermore, usefulness and cut-off values of BIS were evaluated for those intubated. RESULTS: Of 128 sedative intoxication patients, 32 were enrolled for this study. Mean age was 50.94+/-18.01. They took 20.76+/-16.95 times over the average recommended dose. OAA/S and GCS ranged between 1~4 and 4~12, respectively; BIS was 39~88. The Spearman bivariate correlation coefficient was 0.619 between OAA/S and BIS and 0.651 between GCS and BIS, both showing a positive correlation (p0.05). BIS was an effective index for intubation (p=0.012) showing a sensitivity of 91% and a specificity of 50% when the boundary value was set to 65.5. When set to 77.5, sensitivity and specificity were 59%, 100%, respectively. CONCLUSION: In sedative intoxication patients, BIS is useful in determining the degree of sedation, predicting time to recovery of consciousness and as an objective index of intubation.

Insulin Treatment of Shock Induced by Acute Propafenone Toxicity Refractory to Sodium Bicarbonate Administration

Propafenone is a Class Ic antidysrhythmic agent, used in the management of atrial fibrillation. This is also a calcium channel and a weak beta blocker. The conventional therapy of hypotension induced by propafenone overdose includes fluid resuscitation followed by inotropic support. NaHCO3 is considered to be the treatment of choice. We report a case of successful insulin therapy for propafenone-induced hypotension unresponsive to NaHCO3. A 41-year-old woman with a prior medical history of atrial fibrillation presented to the ED after ingesting 4500 mg of propafenone, prescribed for her atrial fibrillation treatment. On initial examination, she was alert with O2 saturation of 96% and normal vital sign. Fifteen minutes later, her electrocardiogram revealed polymorphic ventricular tachycardia and then changed to ventricular fibrillation. When CPR was stopped, her BP was 70/40 mmHg, HR was 68 beats/min with wide QRS complex. Normal saline and inotropics were administered rapidly to improve hypotension. And we injected NaHCO3. Her blood pH was kept between 7.45 and 7.55. But, BP was not improved. Refractory to the conventional therapy for sodium channel blocker toxicity, we decided to try insulin treatment, considering properties of propafenonen having beta and calcium channel blocking effect. We administered short-acting insulin. Her blood glucose level was kept euglycemia by continuous 5% dextrose infusions and tried to keep serum potassium normal range. Thirty minutes after adminstering insulin, her SBP was checked at 100 mmHg. She was discharged 8 days post-ingestion without further complications. Insulin must be considered in severe hypotension induced by propafenone overdose unresponsive to other conventional therapy.

The Usefulness of Ultrasound-assisted Lumbar Puncture on Adult Patients in the Emergency Center: Comparison with Classic Lumbar Puncture

PURPOSE: To evaluate the utility of ultrasound-assisted lumbar puncture in the emergency department. METHODS: This was a prospective randomized controlled trial. We enrolled patients who were 18 years of age or older from May to August 2007. Patients were divided into a classic lumbar puncture group (group A) and an ultrasoundassisted lumbar puncture group (group B). We compared the frequency of attempting the procedure, the procedure time, the failure rate of lumbar puncture, and the traumatic lumbar puncture between groups. RESULTS: Sixty-one patients were enrolled in the study. Thirty-two patients were in group A and 29 patients were in group B. There were 6 cases of failed lumbar puncture in group A and one case in group B (p=0.07), and there were 3 cases of traumatic lumbar puncture in group A, and one case in group B (p=0.35). It took 8.6+/-8.4 minutes to accomplish lumbar puncture in group A compared to 8.2+/-6.4 minutes in group B (p=0.85). Overall, the frequency of attempting the procedure was 2.3+/-1.8 in group A and, 1.6 +/-1.1 in group B (p=0.66). In elderly patients (age> or =60 years) the frequency of attempting the procedure was 4.0+/-2.5 in group A and 1.6+/-0.5 in group B (p=0.03). There were 4 cases of failed lumbar puncture in group A but none in group B. CONCLUSION: Emergency physicians did not generally attempt ultrasound-assisted lumbar puncture in the emergency department. For elderly patients(> or =60 years), however, it was an available tool for emergency physicians and employed more frequently.

The Usefulness of Serum S-100 beta Levels as a Screening Test for Pediatric Minor Head Trauma

PURPOSE: It is well known that serum S-100 beta protein levels increased in adults after brain injury. However, there is no definite clinical data in children with isolated minor head trauma. The present study was conducted to validate S-100 beta protein levels as a screening test for brain damage in children with minor head trauma. METHODS: Serum S-100 beta protein levels were measured in 48 pediatric patients with minor head trauma. All patients had brain computed tomography (CT) scan to confirm brain injury. Data were analyzed using a contingency table and a receiver operating characteristic (ROC) curve to determine the diagnostic value of S-100 beta protein levels. RESULTS: Twelve (25%) patients had abnormal brain CT findings. Using a concentration cutoff value of 0.12 ug/L, patients with abnormal brain CT findings were identified by S-100 beta protein levels measurement with a sensitivity level of 100% and a specificity 38.9%. The area under the ROC curve for S-100 beta protein levels was 0.758 (95% CI, 0.606- 0.910). The number of high risk factors were 2.35+/-1.23 in the positive group and 1.53+/-0.76 in the negative group (p=0.011). CONCLUSION: Serum S-100 beta protein levels in children with minor head trauma were similar to those of adults. Our study supports the contention that rapid assessment of serum S-100 beta protein levels may reduce the use of brain CT in children with minor head trauma.

The Usefulness of Visual Aids assisted Informed Consent for Central Venous Catheter Insertion with Subclavian Vein

PURPOSE: Informed consent is a basic standard of care for all patients undergoing invasive procedures, but the effectiveness of consent form describing risks of procedures in a way that minimizes anxiety and maximizes recall of information is often poor. This study was designed to compare level of understanding and recall of information between patients receiving visual aid assisted informed consent and those administered written consent only. METHODS: A sample population was randomized into two groups to receive one of two information delivery methods. The intervention group was presented visual aids explaining the procedure. The control group received information from physicians with written consent in the traditional manner. After the education sessions, all participants completed a questionnaire including a 9-question knowledge measurement section and were asked to grade there satisfaction level on 4-point scale. Mean scores, agreement and satisfaction levels were compared to assess whether the informed consent with visual aids was superior to standard written consent. Statistical analysis employed Student's ttest, and the chi-square test with significance levels at a pvalue of <0.05. RESULTS: Of the 100 individuals enrolled, 50 were randomized to the visual aids group. Mean knowledge scores were higher in the visual aids group (76.4+/-11.1) than in the written consent group (50.9+/-15.1, p=0.00), and the visual aid group expressed greater satisfaction with their education than did the written consent group (74.5+/-14.7 versus 49.0+/-20.8, p=0.00). The proportion of agreement was also higher in the visual aid group than in the written consent group (p=0.00). CONCLUSION: The use of visual aids in explaining central venous catheterization yielded higher knowledge scores and satisfaction levels than did traditional written informed consent.

A case of Hyperornithinemia-Hyperam monemia-Homocitrullinuria Syndrome: a Patient Who Visited the Emergency Center with Mental Change

Rapid ammonia elevation in blood with accompanying mental change should be considered as a true medical emergency. In such a case, action leading to immediate diagnosis and the earliest possible treatment must occur in order to minimize permanent brain damage. Hyperornithinemia- Hyperammonemia-Homocitrullinuria (HHH) syndrome is a rare inborn errors of metabolism and autosomal recessive metabolic disorder caused by a deficiency of the mitochondrial ornithine transporter at the cellular level. Emergency physicians should take account of the possibility of HHH syndrome in patients with unreasonable hyperammonemia coupled with altered mental status. We report a case of a 59-year old man who presented with headache, nausea, vomiting and altered mental status. His serologic test showed hyperornithinemia, hyperammomemia, and homocitrullinuria. He was treated with fluid therapy and hemodialysis. His clinical manifestation improved and he was discharged after hemodialysis

A Case of Churg-Strauss Syndrome

Churg-Strauss syndrome is a rare syndrome that affects small to medium sized arteries and veins. The American College of Rheumatology has proposed six criteria for the diagnosis of Churg-Strauss syndrome. These criteria are asthma, eosinophilia 10% in peripheral blood, paranasal sinusitis, pulmonary infiltrates, histological proof of vasculitis with extravascular eosinophils, mononeuritis multiplex or polyneuropathy. If at least 4 of these 6 criteria are positive, a patient shall be said to have Churg-Strauss syndrome. We report a case of a 70-year-old woman who had presented with polyneuropathy, hemorrhagic bullae and petechiae on both the legs and the arms. Previously, she had been diagnosed with asthma. Laboratory studies revealed peripheral blood eosinophilia. Water's view showed mucoperiosteal thickening and hazziness in both of the maxillary sinus. A skin biopsy revealed perivascular leukocytoclastic infiltration with marked eosinophilic infiltration. The patient was treated with prednisolone and a skin graft. Within a few days of prednisolone treatment, the clinical presentation improved with the exception of peripheral polyneuropathy.

The Comparison of Sedative Efficacy and Safety of Oral Chloral Hydrate and Intramuscular Ketamine in Children for Primary Repair in Emergency Department

PURPOSE: To compare the sedation quality of oral chloral hydrate against intramuscular ketamine in children requiring primary repair in the emergency department. METHODS: Patients needing primary repair of lacerations (range 1.6 years of age) were blindly randomized to either chloral hydrate or ketamine groups. One group received intramuscular ketamine at 4 mg/kg and the other group received oral chloral hydrate at 50 mg/kg. Both groups received lidocaine for local anesthesia. Physiologic parameters (heart rate, blood pressure and respiratory rate), the time from sedation to recovery, and the degree of sedation as measured by the Ramsay sedation score and the Modified Aldrete recovery score were recorded during the treatment. Overall behavior and complication were assessed both at baseline and at the end of the treatment. RESULTS: Data are mean+/-SD. We enrolled 80 consecutive patients into the study; 39 received intramuscular ketamine and 41 were administered oral chloral hydrate. The two groups were similar with regard to age, sex, and body weights. No patient had a clinically significant change in vital signs and the time from sedation to recovery. Changes in the Modified Aldrete recovery score after sedation were not statistically significant. However, statistically significant differences were observed for the Ramsay sedation score at 15 minutes after sedation (4.89+/-0.32 versus 4.23+/-0.48; p=0.024). No differences at other time points achieved statistical significance in the Ramsay sedation score. CONCLUSION: Both oral chloral hydrate and intramuscular ketamine are safe and effective for the sedation of children requiring laceration repair in the emergency department.

A case of Visceral Larva Migrans Due to Toxocara Carni in the Emergency Department

Toxocariasis is a zoonotic infection seen all over the world that is caused by the parasitic roundworm Toxocara canis. Toxocariasis is transmitted to humans by oral ingestion of infectious eggs from Toxocara canis. In most cases, Toxocara infection is asymptomatic and self-limited. However, we report a case of severe manifestations of visceral larva involving the liver, the respiratory tract. The case involved a man with Toxocara canis infection who presented with diarrhea, abdominal pain, dyspnea and hepatomegaly. Blood tests revealed a leucocytosis with prominent eosinophilia. The patient's chest X-ray showed ground glass opacity in both lung fields. The diagnosis was confirmed by an ELISA (Enzyme-Linked Immunospecific Assay) for Toxocara canis. He was treated with albendazole and prednisolone medication and was discharged without complication.