Two Cases of Comatose Patients Presenting after Exposure to Hydrogen Sulfide Gas

Hydrogen sulfide is a by-product of decayed organic material and is ubiquitously found as an ingredient of manufacturing reagents or as an undesirable by-product of the manufacturing or industrial processing. Hydrogen sulfide is a chemical asphyxiant and interferes with cytochrome oxidase and aerobic metabolism. It has thus been deemed an important cause of work-related sudden death. This gas is particularly insidious due to the unpredictability of its presence and concentration and its neurotoxicity at relatively low concentrations, causing olfactory nerve paralysis and loss of the warning odor. Here, we report two cases of comatose patients presenting after accidental exposure to hydrogen sulfide gas.

A Clinical Analysis of Hiccup Patients who Visited the Emergency Department

PURPOSE: There have been few studies concerned with the hiccup patients who visit the emergency department. The purpose of this study is to investigate the epidemiology and clinical characteristics of hiccup patients. METHODS: We retrospectively reviewed 60 hiccup patients who visited the emergency departments of Chungbuk National University Hospitals, Chungnam National University Hospital and Chonnam National University Hospital in Korea from January 2005 to December 2007. We categorized the patients into 2 groups of the discharged and the admitted and also into groups of patients who had different types of treatments. We compared clinical outcomes and characteristics of the groups. RESULTS: A total of 60 cases of hiccup patients visited the emergency department from January 2005 to December 2007. There was a significant difference in the recovery rate from hiccups between the discharged group and the admission group (72.4% & 100.0%, p=0.04). The 3 major drugs used for treatment were metoclopramide, chlorpromazine, and benzodiazepine. The patients showed a broad spectrum for the final diagnosis, from the benign hiccups to ischemic stroke in the pons area. CONCLUSION: In this study, the hiccup patients who visited the ED showed simple temporal signs to various severe diseases such as the ischemic stroke in the pons. These findings can be useful reference for the decision making at admission or discharge and for predicting the prognosis of the hiccup patients who visit the emergency department.

Plasma Paraquat Concentration and the Severity Index of Paraquat Poisoning (SIPP) at Presentation in Paraquat Intoxication

PURPOSE: Paraquat is a chemical which causes death in 30~80% of patients even after ingestion of small quantities. In spite of much studies, there are no successful treatment modalities or predictive parameters for determining the prognosis of the poisoning. The aims of this study were to evaluate plasma-paraquat concentration and initial laboratory and clinical data as prognostic parameters in patients with paraquat poisoning. METHODS: A retrospective analysis by chart review was done on 168 patients over three years who had ingested paraquat. The patients were divided into two subgroups based on survival and evaluated for ingested amounts of paraquat, the time between ingestion and treatment, urine dithionite test, and plasma paraquat concentration at the time of emergency department (ED) visit. Other clinical and laboratory factors such as age, sex, serum biochemical parameters, and severity index of paraquat poisoning (SIPP) were also analyzed. RESULTS: The plasma paraquat concentrations in the mortality group were higher than in the survival group (51.59+/-55.07 vs. 1.09+/-3.09 microgram/mL, p<0.001). The SIPP was higher in the mortality group as well (173.87+/-219.67 vs. 5.18+/-13.51 microgram/mL/hour). Among the laboratory data obtained in the ED, s-Potassium, s-Protein, arterial pH, PaCO2, bicarbonate, s-Albumin, s-Amylase, AST, BUN, s-Creatinine, and s-Glucose were significant factors which could affect the prognosis for paraquat poisoning. A Cox regression analysis revealed that plasma paraquat concentration, SIPP, s-Creatinine, s-Protein, s-Potassium and bicarbonate were associated with mortality. In addition, SIPP was more significantly correlated with mortality than plasma paraquat concentration (OR 1.362 vs. 1.011, p<0.001 vs. 0.019). CONCLUSION: Initial laboratory parameters including s-creatinine, s-protein, s-potassium, bicarbonate, plasma Paraquat concentration, and SIPP were significant prognostic factors. In addition, the author suggests that SIPP is a better index than plasma paraquat concentration for predicting the outcome of patients admitted for ingestion of paraquat.

Clinical Manifestations and Prognostic Factors for Tetanus in the Emergency Department

PURPOSE: Tetanus is difficult for emergency physician to diagnosis at an early stage because of its low incidence and atypical initial clinical features. Therefore, we reviewed the clinical features of 54 tetanus cases and attempted to identify factors associated with prognosis in order to improve early diagnosis and treatment. METHODS: We carried out a retrospective chart review of 54 adult tetanus patients who presented to the ED of Chonnam National University Hospital between January 1996 and December 2005. We collected information on demographics, SAPS II score, clinical feature, course of infection and prognosis. We divided the patients to two groups according to the survival and compared their data statistically. RESULTS: Fifty four patients, 33 men and 21 women, were included in the study. The mean age was 50.97+/-15.95. The most common initial diagnosis in ED were electrolyte imbalance (n=15), neck and facial dystonia (n=9). The mean incubation period was 10.27+/-6.47 days. The initial SPAS II score 17.29+/-8.45 and the Wood score was 3.12 +/-1.47. Most commonly symptom was dyspnea and dysarthria. Twenty one patients were supported by mechanical ventilation, and the duration of mechanical ventilation was 5.92+/-4.52 days. On multivariate logistic regression analysis, four variables were found to be associated with the prognosis: incubation period, Wood score, Time interval from initial symptom to mechanical ventilation, initial SAPS II. CONCLUSION: Four variables correlated well with the prognosis: Incubation period, Wood score, Time interval from initial symptom to mechanical ventilation, initial SAPS II score.

The Analysis of the Clinical Characteristics and Prognosis of Vibrio Vulnificus Septicemia

PURPOSE: Vibrio vulnificus, one of the most invasive and rapidly fatal human pathogens known is a free-living inhabitant of estuarine and marine environments throughout the world. Vibrio septicemia usually present with a sudden onset of fever, chills, vomiting, diarrhea, abdominal pain, pain in the extremities, and cutaneous lesions. There are many microbiologic studies of V. vulnificus, but few clinical and prognostic studies are reported. We performed a study in 81 clinically suspected V. vulnificus cases to analyze the clinical characteristics of and the prognosis for V. vulnificus septicemia. METHODS: The study included 81 clinically suspected cases V. vulnificus septicemia at the emergency department from 1997 to 2003. We retrospectively analyzed the clinical features and the laboratory data, and measured the simplified acute physiologic score (SAPS II). RESULTS: The overall fatality was 39.5%. The monthly incidence was high in July and August. Almost all cases were primary septicemia (92.6%). Many patients had underlying disease; such as liver disease (66.6%), and diabetes mellitus (18.5%). Alcohol drinking habits were observed in 61.7% of the cases. There were significant difference between non-survivors and survivors in the extent of skin manifestations, respiration rate, leukocyte count, platelet count, albumin, PT, PTT, creatinine, pH, HCO(3-), and SAPS II. CONCLUSION: The platelet count, PT, PTT, creatinine, pH, H CO3-, the leukocyte count, albumin, SAPS II, and the extent of skin manifestations can be used as severity indicators in V. vulnificus septicemia. Especially, the SAPS II on hospital day 2 and the extent of skin manifestations can be used as prognostic factors.

Effect of High-dose Pralidoxime in Organophosphate Intoxication

PURPOSE: Pralidoxime(2-PAM) is the mainstay of organophosphate intoxication management as an antidote. We investigated the usefulness of high-dose pralidoxime therapy. METHODS: From January 2000 to July 2003, 86 patients presented with organophosphate insecticide intoxication to the emergency medical center of Chonnam National University Hospital. They were randomized into two groups: Group I was given continuous IV infusion of pralidoxime in dose of 500 mg/hr after an initial bolus dose of 2 g and Group II was given continuous IV infusion of pralidoxime in dose of 1000 mg/hr after an initial bolus dose of 2 g. Both groups were given same therapeutic interventions, including the duration of atropine administration. The plasma cholinesterase activites were monitored at admission and at 24 hr and 48 hr after infusion of pralidoxime. The effectiveness of the two treatment modalities were gauged by comparing the durations of mechanical ventilation and intensive care unit (ICU) stay. RESULTS: The mean durations of mechanical ventilation were 9.82+/-6.45 days in group I and 6.51+/-4.50 days in group II. The mean durations of ICU stay were 12.82+/- 7.69 days in group I and 9.15+/-5.38 days in group II. group I showed that longer durations of mechanical ventilation (p=0.03) and ICU stay( p<0.001). The plasma cholinesterase reactivation rate were higher in group II than in group I. CONCLUSION: The results suggest that continuous high-dose pralidoxime therapy may be helpful in the treatment of organophosphate intoxication.

Clinical Analysis of Hyponatremia in Emergency Patients

PURPOSE: Hyponatremia is the most common electrolyte imbalance encountered in the hospital, there have been few studies about the clinical characteristics of hyponatremia in emergency patients. This study was performed to evaluate the causes and the initial symptoms of hyponatremia in emergency patients, the relationship between their ages and their initial symptoms and the relationship between the causes and the recovery time. METHODS: A total of 42 patients with hyponatremia, who were treated in the Emergency Department of Chonnam National University Hospital from 2000 to 2001, were studied by chart review. RESULTS: The initial symptoms were generalized weakness (33.3%), seizure (28.6%), mental change (21.6%), confusion (9.5%), dizziness (4.8%), and non-specific (2.4%). There was a significant difference in the initial symptoms between children and older. The initial symptom for younger patients was usually seizure. The most common causes of hyponatremia were dehydration and sodium loss (52.4%), other causes were hypothyroidism (11.9%), SIADH (7.1%), heart failure (7.1%), adrenal insufficiency (4.8%), polydypsia (4.8%), CRF (2.4%), nephrotic syndrome (2.4%) and unidentified causes (7.1%). There were significant differences in the recovery times among the causes of hyponatremia. CONCLUSION: The initial symptoms of hyponatremia in emergency patients were usually generalized weakness in older patients and seizure in the young. There were significant differences in the recovery times among the causes of hyponatremia. There were many more incidences of hypovolemic hyponatremia of emergency patients than normovolemic hyponatremia.