The Clinical Feature and Prognostic Factor of Glyphosate Intoxication Patients

PURPOSE: Glyphosate is widely used and its toxic exposures are not rare. Occasionally, glyphosate intoxication can lead to death. The aim of this study is to analyze clinical findings and fatality in glyphosate intoxication. METHODS: Clinical data on acute glyphosate intoxication were prospectively collected at 28 hospitals nationwide between August 2005 and July 2006. The patients' clinical symptoms and characteristics of fatalities were investigated and statistical analysis was performed. RESULTS: Among 105 patients who were finally included, gastrointestinal symptoms(59%) were the most common. A significant difference in the amount ingested was observed between patients with higher systolic blood pressure and those with systolic blood pressure less than or equal to 80 mmHg (p<0.001). The more the patients ingested, the more aggravated their mental status became (p=0.004). Seven patients(6.7%) died, and all of them had ingested greater than or equal to 200 ml. Patients who died had ingested greater amounts than the survivors (p<0.001), and their mental status was worse (p<0.001), and systolic blood pressure was lower (p<0.001). According to the result of logistic regression analysis, relative risk was 24.1-fold higher in the 'poor' mental status group compared with 'good'. CONCLUSION: Patients who ingested large amounts of glyphosate showed poor mental status and lower blood pressure. Statistical difference in amount ingested, mental status, and systolic blood pressure was observed between survivors and patients who died. Ingested amounts and mental status were the most important factor of the prognosis of glyphosate intoxication.

Clinical Characteristics of Acute Zolpidem Intoxication

PURPOSE: The hypnotic effect of zolpidem is comparable to benzodiazepines, but has less abuse and addiction potential than benzodiazepines, so is one of the most commonly prescribed hypnotics. The frequency of acute zolpidem overdose has increased, but clinical analysis and severity predictors are not known in Korea. METHODS: A retrospective evaluation of histories, clinical courses, and laboratory findings of each patient treated from June, 2000, to May, 2006, in a university hospital for acute zolpidem intoxication. RESULTS: We evaluated 30 patients, including 16 co-intoxication cases. Twenty-five patients presented mental alterations but became alert within 2 days. All patients recovered completely. The median zolpidem concentration was 0.9 mg/L (range: 0.2~7.4 mg/L). There was a weak correlation between the amount ingested and zolpidem concentration (r=0.25). None of them presented severe laboratory abnormalities, and these abnormalities did not relate to zolpidem concentration. CONCLUSION: The clinical progress of acute zolpidem intoxication is mild. We could not predict zolpidem concentration or clinical severity from the amount ingested and could not predict the clinical course from laboratory findings in the emergency department.

Clinical Characteristics of Acute Dichlorvos Poisoning in Korea

Purpose: Dichlorvos has been in widespread use as an organophosphate (OP) insecticide compound. The purpose of this study was to access the epidemiology and clinical features of dichlorvos in Korea. Methods: This was a 38 multi-center prospective study of dichlorvos poisoning using surveys, a structural reporting system and review of hospital records from August 2005 to July 2006. A total of 54 patients with acute dichlorvos poisoning on a national basis were enrolled. We analyzed the epidemiologic characteristics and clinical manifestations of dichlorvos poisoning. In addition, the clinical features of dichlorvos poisoning were compared with others OP compounds. Results: During the study period, compounds involving pure OP poisoning were dichlorvos (22.7%), methidathion (8.4%), and phosphamidon (6.7%). In acute dichlorvos poisoning, all ingestion routes were oral. Intentional poisoning involved 74.1% of cases. The common initial complaints involved gastrointestinal (64.8%), systemic (61.1%), central or peripheral nervous system (53.7%), and respiratory symptoms (50.0%). The median arrival time to hospital after dichlorvos poisoning was 2.6 hours and mean hospitalization duration was 7.1 days. 2-PAM was administered in 35 patients in mean doses of 6.3 g/day intravenously. Atropine was administered in 30 patients with a mean dose of 62.8 mg/day (maximal 240 mg/day). Overall mortality rate for dichlorvos poisonings were 14.8% (8/54). Immediate causes for death included sudden cardiac arrest or ventricular dysrhythmias (50%), multi-organ failure (25%), acute renal failure (12.5%), and unknown causes (12.5%). Conclusion: When compared to previous reports, dichlorvos poisoning displayed relatively moderate severity. The presence of a lower GCS score, altered mental status, serious dysrhythmias, systemic shock, acute renal failure, and respiratory complications upon presentation were associated with a more serious and fatal poisoning.

Clinical Implication of Acetylcholinesterase in Acute Organophosphate Poisoning

Purpose: Acute organophosphate (OP) poisoning may be monitored by measuring the acetylcholinesterase (AChE). It is important to assess severity and establish prognostic tests in the early stage of OP poisoning. The aim of this study was to look at the relationship between various clinical aspects of the OP poisoning, prognostic indicators of OP poisoning including Simplified Acute Physiology Score (SAPS) 3, and the associated changes in AChE levels. Methods: Clinical data and initial AChE levels from thirty-seven patients with OP poisoning were prospectively reviewed from 12 teaching hospitals in South Korea from August 2005 to July 2006. Clinical manifestations at the time of arrival such as miosis, respiratory abnormality, salivation, urinary incontinence, GCS score, AVPU scale, need for intubation, and mechanical ventilation requirements were recorded. SAPS 3 was calculated using clinical data and laboratory results. Results: The median level of AChE was 9.8 (1.3-53.6) U/gHb. There was no significant difference in AChE levels between the groups with and without cholinergic symptoms. The median level of AChE of the patients who required intubation and those who did not were 3.5 U/gHb and it 19.7 U/gHb respectively (Mann-Whitney test; p<0.001). The AChE levels were also significantly different (p=0.007) in patients who needed mechanical ventilation compared to those who did not with AChE levels found to be 3.1 U/gHb and it was 14.8 U/gHb, respectively. Level of consciousness assessed using the AVPU scale was correlated with AChE levels (Kruskal-Wallis test; p=0.013). GCS score were correlated with AChE levels (p=0.007, Spearman's rho = 0.454). In addition, the lower the level of initial AChE, the longer the ICU stay (p=0.029, Spearman's rho=-0.380). SAPS 3 was inversely correlated with the initial AChE (p<0.001, Spearman's rho=-0.633). Conclusion: In the acute OP poisoning, low AChE levels appear to help indicate the severity of poisoning. The initial AChE level may be a useful prognostic parameter for acute OP poisoning.

A Case of Amitraz Insecticide Intoxication after Ingestion of Large Amount

Amitraz is used as farm-animal insecticide. Its side effects in humans are related to its pharmacological activity on alpha 2-adrenergic receptors. The case describes a previously healthy 46-year-old woman who intentionally ingested approximately 250mL of liquid amitraz. She presented with vomiting, altered mental status, miosis, dry mouth, hypopnea, metabolic and respiratory acidosis, hypotension, hypothermia, polyuria, metabolic acidosis, elevated serum aminotransferase and abdominal distension. Supportive treatments including mechanical ventilation, hydration, dopamine infusion, bicarbonate infusion and gastric decompression resulted in improvement. By hospital day 3, she recovered with resolution of abdominal distension. It is paramount to recognize amitraz poisoning when apesticide-intoxicated patient presets with signs and symptoms consistent with organophosphate intoxicated patients but with greater alpha 2-adrenergic related symptoms such as decreased bowel motility and xerostomia.

Rational Use of Antimicrobial Agents in Traumatic Simple Wounds

PURPOSE: The primary goal of wound management is to avoid infection. Wounds in all patients presenting to the Emergency Department are contaminated with bacteria. Despite this, there is a low incidence of infection. Unfortunately, physicians continue to use antimicrobial agents indiscriminately. The authors intended to determine the effect of selective antimicrobial agents and the indications for appropriate antimicrobial agent use in traumatic simple wounds. METHODS: This prospective study was performed from Jul. 2005 to Aug. 2005. A pilot study had been performed from Nov. 2003 to Jul. 2004 at the Ewha Woman's University Mokdong Hospital. Structured data sheets were completed at the times of the patient's visits to the Emergency Department and to the Outpatient Department for follow-up. Infection was determined at the time of follow-up. The indications of antimicrobial agent use are immunocompromised patients, wounds contaminated for 3 hours or longer, devitalized tissue, and extremity wounds except hand wounds caused by sharp objects. RESULTS: The study enrolled 216 injured patients. The general characteristics of patients and wounds between the two groups were not significantly different. The antimicrobial agent use and infection rate of the pilot study were 227 cases (90.4%) and 10 cases (4.0%), and those of this study were 100 cases (46.3%) and 9 cases (4.1%). In this study, antibiotic use was reduced to almost half compared with the previous study, but the infection rate was similar (p<0.001). CONCLUSION: Rational use of antimicrobial agents in simple wounds reduced the use of antimicrobial agents in the Emergency Department without increasing the infection rate.

Ondine's Curse in a Patient with Right Medullary and Bilateral Cerebellar Infarctions: A Case Report

Failure of automatic control of ventilation (Ondine's curse syndrome) is a rare syndrome that sometimes occurs following localized brainstem dysfunction. In this report, we present a case of a 52-year-old male who was admitted to the hospital with sudden-onset nausea. On examination, no lateralization signs were presented. After one hour, his consciousness was altered and he became apneic. After endotracheal intubation and mechanical ventilation, his mentality improved and he was able to ventilate spontaneously. Cranial magnetic resonance imaging demonstrated acute infarction in both cerebellar inferior aspects involving the right side of the medulla. Eleven hours later, the patient's consciousness altered again. Computed tomography demonstrated newly developed hydrocephalus and emergent craniotomy, and extraventricular drainage were performed. The patient improved in both consciousness and respiratory status but complained of mild ataxia and left arm weakness. We recommend cautious examination and early diagnosis and therapeutic decisions in cases of patients with atypical presentation of stroke.