A Case of Saponated Cresol Ingestion which Led to Altered Mentality, Chemical Dermal Burn, and Liver Toxicity

Saponated cresol solutions are common household disinfectants worldwide. Their main component, concentrated cresol, is extremely toxic and fatal; however, precise information on the clinical manifestations of cresol intoxication is not available. We report on a case of suicidal poisoning by ingestion of saponated cresol. A 63-year-old male presented with unconsciousness and brownish discoloration on the neck and anterior chest wall after ingesting 100 ml of 50% saponated cresol solution with suicidal attempt. The patient showed a wide range of clinical features of cresol intoxication, including decreased consciousness, respiratory distress, strong carbolic acid odor, dark brown urine, and chemical dermal burns on multiple areas. General treatment of cresol intoxication is intensive supportive care. In addition, reducing systemic absorption is most important in patients with cresol intoxication who present with cresol burns. Because the rate of cresol absorption through the skin is proportional to the size of the area involved and the duration of contact of the chemical with the skin rather than to the concentration of the cresol solution, gross decontamination, including removal of contaminated clothing and vigorous flushing with water, is very important. Quantitative assays for cresol and its metabolites in blood or urine are needed in order to confirm the diagnosis. However, because these analytical methods are time consuming and are not routinely available in most emergency departments, the clinical manifestations of this case may be useful in early diagnosis and treatment.

A Case of Saponated Cresol Ingestion which Led to Altered Mentality, Chemical Dermal Burn, and Liver Toxicity

Saponated cresol solutions are common household disinfectants worldwide. Their main component, concentrated cresol, is extremely toxic and fatal; however, precise information on the clinical manifestations of cresol intoxication is not available. We report on a case of suicidal poisoning by ingestion of saponated cresol. A 63-year-old male presented with unconsciousness and brownish discoloration on the neck and anterior chest wall after ingesting 100 ml of 50% saponated cresol solution with suicidal attempt. The patient showed a wide range of clinical features of cresol intoxication, including decreased consciousness, respiratory distress, strong carbolic acid odor, dark brown urine, and chemical dermal burns on multiple areas. General treatment of cresol intoxication is intensive supportive care. In addition, reducing systemic absorption is most important in patients with cresol intoxication who present with cresol burns. Because the rate of cresol absorption through the skin is proportional to the size of the area involved and the duration of contact of the chemical with the skin rather than to the concentration of the cresol solution, gross decontamination, including removal of contaminated clothing and vigorous flushing with water, is very important. Quantitative assays for cresol and its metabolites in blood or urine are needed in order to confirm the diagnosis. However, because these analytical methods are time consuming and are not routinely available in most emergency departments, the clinical manifestations of this case may be useful in early diagnosis and treatment.

Serotonin Syndrome After an Overdose of Dextromethorphan and Chlorpeniramine: Two Case Reports

Dextromethorphan and chlorpeniramine are common ingredients of over-the-counter (OTC) cough pills. They are known to be safe when used alone, however, combination with other serotonergic drugs or use of an overdose can cause serotonergic toxicity. We report on a 43-year-old male and a 57-year-old female who ingested an overdose of antitussive drugs containing dextromethorphan and chlorpeniramine. They commonly presented with altered mentality and hyperreflexia on both upper and lower extremities. After conservative therapies, they were discharged with alert mentality. These cases are meaningful in that there are few cases of serotonin syndrome with an overdose of a combination of dextromethorphan and chlorpeniramine. Careful use with medication counseling for OTC cough pills is needed in order to prevent overdose of these ingredients.

A Case of Central Nervous System (CNS) Toxicity in Acute Organophosphate Intoxication

Acute organophosphate intoxication is important because of its high morbidity and mortality. The mortality is still high despite the use of atropine as specific antidotal therapy and oximes for reactivation of acetylcholinesterase. Inhibition of acetylcholinesterase by organophosphate can cause acute parasympathetic system dysfunction, muscle weakness, seizure, coma, and respiratory failure. Acute alteration in conscious state or a coma, which may occur following organophosphate intoxication, is an indication of severe intoxication and poorer prognosis. This acute decline in conscious state often reverses when the cholinergic crisis settles; however, it may be prolonged in some patients. We report on a case of a 60-year-old male who showed prolonged decline in conscious state due to of Central Nervous System (CNS) toxicity after a suicide attempt with organophosphate.

Two Cases of Ethylene Glycol Poisoning

Ethylene glycol poisoning is treated mainly by alcohol dehydrogenase inhibition therapy and hemodialysis. Early recognition and initiation of treatment is important because toxic metabolites increase over time by hepatic metabolism; however, there is no confirmative diagnostic tool in our clinical setting. Therefore, diagnosis is dependent on history, high anion gap acidosis, high osmolal gap, etc.. Diagnosis and treatment are delayed in cases where history taking is not possible, such as a mental changed patient. Authors report on two cases of ethylene glycol poisoning by contrasting clinical outcomes, demonstrating the importance of early diagnosis and treatment for achievement of a good outcome.

A Case of Delayed Carbon Monoxide Encephalopathy

Following are brief statements about the delayed encephalopathy of a patient who recovered without disturbance of consciousness after acute carbon monoxide poisoning. A 72-year-old male was found without consciousness at home and then visited the ER center. Later we learned that the patient was using briquettes as a household heating source. Blood carbon monoxide hemoglobin level was 17.5%. As carbon monoxide poisoning was uncertain after the first interview with the patient, hyperbaric oxygen therapy was not administered at the early stage. After supplying 100% oxygen, the patient recovered consciousness, however, the strength of the lower limb muscle had decreased to class II. The patient showed continued weakening of the lower limb muscle and an increase of CPK; therefore, he was diagnosed as carbon monoxide intoxication and rhabdomyolysis and then admitted to the intensive care unit (ICU) for conservative treatment. During the hospitalization period, continued weakening of the lower limb muscle was observed and he was diagnosed as myopathy after EMG/MCV. However, he suddenly showed altered mentality on the 20th day of hospitalization, and underwent brain MRI. T2 weighted MRI showed typically high signal intensity of both globus pallidus and periventricular white matter; therefore, he was diagnosed as delayed carbon monoxide encephalopathy. This case showed delayed encephalopathy accompanied by rhabdomyolysis and myopathy of a patient who recovered without disturbance of consciousness.

A Case of Fentanyl Toxicity with Misused Durogesic Transdermal Patch

Fentanyl, a synthetic, highly selective opioid micro-receptor agonist, is 50 to 100 times more potent than morphine. The low molecular weight, high potency, great transdermal permeation rate and lipid solubility of fentanyl make it very suitable for transdermal administration. Durogesic is a novel matrix transdermal system providing continuous systemic delivery of fentanyl. In recently, there are many reports that misused or overused fentanyl transdermal patches result in severe intoxication of fentanyl. We present a case of fentanyl toxicity with misused durogesic transdermal patch and discuss the safe and appropriate application of the patches. In conclusion, fentanyl patches should be used in opioid tolerant patients and prescribed at the lowest possible dose and titrated upward as needed. All patients and their caregivers should be educated safe application of fentanyl patches and advised to avoid exposing the patches application site to direct external heat sources, such as heating pads, or electric blankets, heat lamps, sauna, hot tubs, and others. In addition, concomittant medications that affect fentanyl's metabolism should be avoided.

An Evaluation of the Disaster Medical System after an Accident which Occurred after a Bus fell off the Incheon Bridge

PURPOSE: Field triage, medical care, and transportation are important and life-saving medical tasks performed at the site of a mass-casualty incident (MCI). We experienced a mass-casualty incident when an express bus fell off the Incheon bridge and conducted an evaluation of problems. We are willing to provide information for equipping an local disaster planning. METHODS: We surveyed the local emergency medical system response time, transportation time, and patients' clinical data using paramedics' records and medical records. We evaluated the adequacy of the order of priority of transportation by field triage used using the simple triage and rapid treatment (START) method. We evaluated field medical care, as well preponderance of transportation. RESULTS: Twenty four people who were on the bus were evacuated, and 2 persons were dead on the scene. Two persons died within one week. There was a transport delay for patients who would benefit significantly from medical intervention because dead persons were transported early. Neither advanced airway nor fluid resuscitation was provided. Sixteen patients (66.7%) were transported to one hospital. CONCLUSION: When we reviewed this mass-casualty incident, there was no appropriate medical control, such as triage, field medical care, and transportation. In construction of the emergency medical service system for preparation for MCI or disasters, we suggest integration and unification of 119 rescue services and emergency medical information centers for effective medical control. Disaster drills should be performed according to guidelines for local emergency medical services.

A Case of Multi-organ Failure due to Acute Chromic Acid Poisoning

Chromic acid is a strong metal acid and acute poisoning is very rare. However, chromic acid causes serious complications, such as skin injuries, as well as renal and hepatic failure. We report on a case of a 47-year-old male who accidentally had chromic acid spilled over his nose and face. For the first few days, he was treated with ascorbic acid and massive hydration. However, after three days, his condition began to worsen. He was treated with hemodialysis for anuria and acute renal failure, and antibiotics for pneumonia. On day 10 of hospitalization, he expired of multi-organ failure. We suggest firm control and close supervision of chromic acid in the work place, and, considering severe complications of chromic acid, we propose a nearly and aggressive treatment.

The Clinical Relationship between Intraocular Pressure and Brain Hemorrhage

PURPOSE: Rapid and noninvasive detection of increased intracranial pressure (IICP) is important in evaluating a clinically unstable, unconscious patient. The purpose of this study was to measure the mean intraocular pressure (IOP) of patients with intracranial hemorrhage and correlate the results to the variable clinical features associated with intracranial hemorrhage. METHODS: Patients admitted to the emergency department were sorted into two groups based on their IOP results as measured using a Tono-Pen. The hemorrhage group consisted of patients suffering with intracranial hemorrhage and the normal group consisted of patients without intracranial hemorrhage. Patients with glaucoma or trauma of the ocular or facial area were excluded from this study. RESULTS: Mean IOP (30.45+/-9.13 mmHg) of the hemorrhage group (52 patients, 34 male, 18 female, mean age 58.28+/-14.39 years) was higher than the mean IOP (16.14+/-2.24 mmHg) of the normal group (39 patients, 23 male, 16 female, mean age 52.69+/-17.79 years) (p<0.001). Whether or not the intracranial hemorrhage was traumatic or nontraumatic, severe, or mild to moderate, accompanied with IICP or non-IICP, requiring an emergency or non-emergency operation, the IOP measured did not show any statistical significance. CONCLUSION: The IOP of the hemorrhage group was higher than the IOP of the normal group, but to determine the clinical usefulness of this measurement when accompanying presentation of headache or traumatic brain injury in the emergency department will require further investigation.

The Clinical Relationship between Intraocular Pressure and Brain Hemorrhage

PURPOSE: Rapid and noninvasive detection of increased intracranial pressure (IICP) is important in evaluating a clinically unstable, unconscious patient. The purpose of this study was to measure the mean intraocular pressure (IOP) of patients with intracranial hemorrhage and correlate the results to the variable clinical features associated with intracranial hemorrhage. METHODS: Patients admitted to the emergency department were sorted into two groups based on their IOP results as measured using a Tono-Pen. The hemorrhage group consisted of patients suffering with intracranial hemorrhage and the normal group consisted of patients without intracranial hemorrhage. Patients with glaucoma or trauma of the ocular or facial area were excluded from this study. RESULTS: Mean IOP (30.45+/-9.13 mmHg) of the hemorrhage group (52 patients, 34 male, 18 female, mean age 58.28+/-14.39 years) was higher than the mean IOP (16.14+/-2.24 mmHg) of the normal group (39 patients, 23 male, 16 female, mean age 52.69+/-17.79 years) (p<0.001). Whether or not the intracranial hemorrhage was traumatic or nontraumatic, severe, or mild to moderate, accompanied with IICP or non-IICP, requiring an emergency or non-emergency operation, the IOP measured did not show any statistical significance. CONCLUSION: The IOP of the hemorrhage group was higher than the IOP of the normal group, but to determine the clinical usefulness of this measurement when accompanying presentation of headache or traumatic brain injury in the emergency department will require further investigation.

A Case of Aluminum Phosphide Poisoning

Aluminum phosphide is commonly used as a rodenticidal agent in agricultural workplaces. However, reported cases of aluminum phosphide poisoning in Korea are rare. Upon contact with moisture in the air, aluminum phosphide releases highly toxic phosphine gas (PH3). PH3 is readily absorbed through lung epithelium and into the bloodstream. Phosphine may cause denaturing of oxyhemoglobin and enzymes important to respiration and metabolism, and also may effect cellular membranes. There are numerous complications associated with acute aluminum phosphide poisoning including gastrointestinal, respiratory, and cardiac toxicities. We report the case of a 46-year-old man who suffered from respiratory and cardiac toxicities after unintentional aluminum phosphide exposure. More intensive education for prevention is recommended.

Prognostic Factors of Acute Poisoning in Elderly Patients

PURPOSE: Incidents of suicide attempt and acute poisoning in the elderly population is rising. This study investigated the clinical nature of acute poisoning and differences between the survival and mortality groups in the elderly. METHODS: We retrospectively investigated 325 patients with acute poisoning who visited the emergency department. Patients were divided into two groups, one survival and one death group. Information regarding patient sex, age, root cause of poisoning, time of year of poisoning, type of intoxicant, duration of time between intoxicant ingestion and arrival at the emergency department, total length of hospital stay, and any previous suicide attempts and subsequent hospitalization were collected. An initial Glasgow Coma Scale (GCS) and an initial and final Poison Severity Score (PSS) for each patient was calculated. RESULTS: The survival rate for men was higher than for women in this study. The most common reason of drug intoxication was suicide, with accidental ingestion and substance abuse occurring in descending frequency. Seasonal factors were reflected in the data with the highest number of incidents occurring in spring and the lowest number in winter. Compared with the mortality group, the survival group had a lower initial PSS with a higher GCS. CONCLUSION: We conclude that being female, having suicide as a root cause, agrochemicals as an intoxicant, low initial Glasgow Coma Scale and high initial Poisoning Severity Score, are all associated with poor prognosis.

A Case of Bentazone Poisoning Mimicking Organophosphate Intoxication

Basagran(R) is a herbicide that is widely used in the field and it acts by interfering with photosynthesis in plants. It consists of bentazone, 2-methyl-4-chloro phenoxyacetic acid (MCPA) and surfactants. Bentazone is commonly used, but poisoning due to Bentazone has not been previously reported in Korea. The patients with toxic effects of bentazone show mild to severe symptoms and various complications. We report here on a case of a woman who intentionally ingested 500 ml of Basagran(R) and she was discharged without complication. As soon as the patient visited the emergency department, we started to treat her as if she had organophosphate intoxication because of the cholinergic symptoms. We could not detect the bentazone in her serum and urine, and we could confirm Basagran(R) ingestion only after getting information from her husband. Bentazone poisoning may induce harmful complications like muscle rigidity, rhabdomyolysis, respiratory failure and cardiac arrest. A detailed history taking, an accurate analysis method and early conservative management will be helpful for patients with acute bentazone poisoning.

The Relationship of Plasma Concentration of Doxylamine and Rhabdomyolysis in Doxylamine Overdose

PURPOSE: The relationship between plasma concentration of doxylamine and rhabdomyolysis in doxylamine overdose has not yet been reported. The aim of this study was to determine if the plasma concentration of doxylamine can predict the occurrence of rhabdomyolysis. METHODS: We reviewed the medical records of patients whose plasma concentration of doxylamine were checked during a state of doxylamine overdose. Variables, including the measured concentration (Ct) of drug, were compared between the rhabdomyolysis and the non-rhabdomyolysis group. We calculated the hypothetical initial concentration (C0) based on first order pharmacokinetics and measurement of each patient's plasma concentration of doxylamine (Ct). C0 values were compared based on the occurrence of rhabdomyolysis. RESULTS: A total of 41 blood samples were taken; all were taken more than two hours after the ingestion of doxylamine. Of the 41, 14 of the subjects showed rhabdomyolysis and 15 of the subjects did not. The rest were excluded from the study. Average values of Ct and C0 in the rhabdomyolysis and non-rhabdomyolysis groups were, respectively, 4.18+/-5.17 mg/L Vs 4.18+/-2.23 mg/L, for Ct; 6.21+/-7.92 mg/L Vs 15.53+/-17.97 mg/L for C0. Ct levels between the two groups were not different (p=1.00), but the difference in C0 was marginally significant (p=0.08). Blood sampling time showed a significant difference between the two groups (p=0.03). CONCLUSION: We can not confirm a relationship of plasma doxylamine concentration and rhabdomyolysis but it appears that the development of rhabdomyolysis in doxylamine overdose has a tendency to increase at high plasma concentration.

Outcome after Admission to Intensive Care Unit Following Out-of-Hospital Cardiac Arrest: Comparison between Cardiac Etiology and Non-Cardiac Etiology / 대한구급학회지

BACKGROUND: To evaluate the post-resuscitation intensive care unit outcome of patients who initially survived out-of-hospital cardiac arrest (OHCA). METHODS: We retrospectively analyzed patients who were admitted to the ICU after OHCA in a tertiary hospital between January, 2005 and December, 2009. We compared the patients' clinical data, the factors associated with admission and the prognosis of patients in cardiac and non-cardiac groups. RESULTS: Sixty-four patients were included in this study. Thirty-four patients were in the cardiac group and thirty patients were in the non-cardiac group. The mean age was 57.3 +/- 15.1 years of age in the cardiac group and 61.9 +/- 15.7 years of age in the non-cardiac group (p = 0.235). The collapse-to-start of the CPR interval was 5.9 +/- 3.8 min in the cardiac group and 6.0 +/- 3.2 min in the non-cardiac group (p = 0.851). The complaint of chest pain occurred in 12 patients (35.3%) in the cardiac group and 1 patient (3.3%) in the non-cardiac group (p = 0.011). The time duration for making a decision for admission was 285.2 +/- 202.2 min in the cardiac group and 327.7 +/- 264.1 min in the non-cardiac group (p = 0.471). The regional wall motion abnormality and ejection fraction decrease were significant in the cardiac group (p = 0.002, 0.030). Grade 5 CPC was present in 8 patients (23.5%) in the cardiac group and 14 patients (46.7%) in the non-cardiac group. CONCLUSIONS: The key symptom that could initially differentiate the two groups was chest pain. The time duration for making an admission decision was long in both groups. The CPC score of the cardiac group was lower than that for the non-cardiac group.

Clinical Characteristics of Patients who Suffered an Injury Associated with A Maritime Accidents

PURPOSE: This study was designed to determine the characteristics of patients who suffered from an injury associated with a maritime accident. METHODS: Using reviews of medical records, we retrospectively investigated the characteristics of maritime accident related injured patients that visited the emergency center of Inha University hospital. Variables analyzed were age, sex, sailor or passenger, type of accident, time required to arrive at the hospital, type of injury, site of injury, submersion or not, level of submersion, severity of injury, disposition of injury, type of ship, gross tonnage of ship, and distance from shore. RESULTS: Between January 1999 and December 2009, a total of 85 patients who were injured because of a maritime accident visited the emergency center of InHa Univ. hospital. The mean age of patients was 45.7+/-15.1 years old. Fifty four were male and 31 were female. The most common types of injury were submersion (40.0%) and contusion (38.8%). Submersed patients as a group had a higher injury severity and higher mortality than those not submersed. The most frequent sites of injury were the extremities (62.9%) and the head and neck (35.5%). The mean injury severity scale were 4.63+/-13.05 units?. Almost all patients (85.9%) had a mild degree of injury. The mortality rate was 10.6%; the most common cause of death was drowning. CONCLUSION: Submerged patients have a higher injury severity and mortality than non-submerged patients. Capsizing and sinking is associated with a higher severity of injury and mortality according to the type of accident, because submersion confers high risk for injury and mortality. Prevention of submersion is important for reducing injury severity and mortality in patients who have maritime accidents.

Anticholinergic Toxicity Following Ingestion of Angel's Trumpet: A Case Report

Angel's trumpet is a poisonous shrub recently imported to Korea for ornamental PURPOSE. It contains tropane alkaloids and the ingestion of any part of the plant can cause serious anticholinergic toxicity. Not only accidental ingestion, intentional intake as hallucinogen is not uncommon in the United States and Europe. We report a woman who ingested angel's trumpet by mistake and showed anticholinergic syndrome. The potential public medical harm of this widespread plant should be reported in the media, along with the associated dangers from misuse as a hallucinogen.

Pulsatility Index Detected by Carotid Ultrasonography Can Predict Increased Intracranial Pressure

PURPOSE: A rapid, portable, and noninvasive means of detecting increased intracranial pressure (IICP) is required when conventional imaging methods are unavailable. The purpose of this study is to show the predictive value of IICP using ultrasonographic measurement of pulsatility index (PI), through the common carotid artery. METHODS: We performed a prospective study of emergency department patients who have hemorrhage finding on brain conputed tomography (hemorrhage group) and normal group for 9 months prospectively. Hemorrhage group was divided into IICP group and non IICP group by brain CT findings. The PI was calculated using systolic flow velocity and diastolic flow velocity acquired from common carotid ultrasonography. For each patient, brain computed tomography (CT) was also evaluated for signs of IICP. RESULTS: 140 patients were enrolled; 70 patients were normal group and hemorrhage group included 70 patients; 38 had IICP (IICP group) and 32 had no signs of IICP on CT (non IICP group). Mean PI of normal group was 1.46+/- 0.30, non IICP group was 1.40+/-0.31 and mean PI value of IICP group was 2.39+/-0.78. Cutoff value was 1.69, sensitivity was 81.6% and specificity was 81.4%. CONCLUSION: The PI from common carotid artery is a simple, fast, and noninvasive procedure. The PI is a potentially useful tool the assessment of and themonitoring of patients suspected of having IICP.

Epidemiologic Study of Systemic Inflammatory Response Syndrome in Emergency Department

PURPOSE: Epidemiologic data on emergency department (ED) patients with systemic inflammatory response syndrome (SIRS) are limited. We examined the prevalence, risk factors, etiologies and outcomes for the various forms of the SIRS, as well as their relationships with infection in ED. METHODS: The subjects were 16,718 non-trauma adult patients who visited a 900- bed university hospital ED between November 2006 and October 2007. ED records were reviewed, and all patients meeting the criteria for SIRS were enrolled retrospectively. SIRS patients were further subdivided into four groups (non-infectious SIRS, sepsis, severe sepsis, septic shock). Baseline characteristics, ED dispositions, and prognoses of patients in each group were analyzed. RESULTS: Among 16,718 patients, there were 2,790 SIRS patients (16.7%). The SIRS patient group was composed of 1,546 non-infectious SIRS patients (55.4%), 1,078 sepsis patients (38.6%), 119 severe sepsis patients (4.3%), and 47 septic shock patients (1.7%). ED patients with SIRS were older on average than non-SIRS patients (52 versus 48, p<0.001). The most common sources of SIRS was the gastrointestinal system (28.3%), followed by the respiratory system (22.9%) and the genitourinary system (11.8%). Pneumonia (18.9%) was the single most common cause of infectious SIRS. The admission rate was higher for SIRS patients than for non-SIRS patients (44% versus 21%). The 28-day mortality rate for non-infectious SIRS, sepsis, severe sepsis, and septic shock patients were 4.5%, 1.3%, 25.2%, and 63.8%. Sepsis severity was correlated with increased rates of both hospital admission and mortality (p<0.001). CONCLUSION: 55% of SIRS patients who visited the ED had a non-infectious cause. SIRS patients were older than non-SIRS patients, and hospital and ICU admission rates were also higher. Sepsis severity was correlated with older age, increased hospital admission rate, increased ICU admission rate, and increased mortality rate.