Toxicoepidemiology of Phosphide Poisoning in the Central Part of Iran.

Objective: Aluminum phosphide (ALP) and zinc phosphide (ZnP) are toxic agrochemical pesticides, which are commonly used as an agent of self-harm in developing countries. Because of high toxicity of phosphides, we evaluated toxico-epidemiology ALP and ZnP poisoning in with respect to outcome. Methods: We performed a cross-sectional study with retrospective chart review including the records for patients admitted due to phosphide poisoning (ALP, ZnP) in a poisoning referral center in Khorshid Hospital, affiliated with Isfahan University of Medial Sciences, Isfahan, Iran. Demographic characteristics, clinical manifestations, outcome (survived or death), and length of hospital stay for the patients were recorded in a data collecting form. Binary backward stepwise logistic regression was used for outcome prediction. Findings: Sixty patients were evaluated in the study. The mean age of patients was 27.61. Thirty-nine patients were men. 96.7% of the patients ingested it intentionally. Most of the patients on admission were conscious (66.7%). Abnormality of EKG was noted in 8.3%. The mortality in ALP and ZnP poisoning was 39.2% and 22.2%, respectively. Serum bicarbonate and base excess in the venous blood gas analysis, systolic blood pressure, and serum sodium level were significantly different between patients with ALP and ZnP poisoning on admission time (P < 0.05). On admission, systolic blood pressure was an important predictive factor for mortality (odds ratio 4.87; 95% confidence interval: 1.5-15.45; P = 0.007). Conclusion: The rate of mortality in phosphide poisoning is high. Knowing predictive factors for mortality help physicians for selecting patients in intensive care unit admission and aggressive treatment.

Common Opioids Involved in Drug Poisoning Presenting to the Emergency Department: A Cross-sectional Study.

OBJECTIVE: Opioids poisoning is of the most important cause of mortality. The objective of the study was to compare the demographic factors, clinical manifestations, and outcomes of the most common opioids involved in drug overdose presenting to the Emergency Department. METHODS: This cross-sectional study was conducted from October 2016 to March 2017 in the Clinical Toxicology Department of the main referral center of the university. All poisoning cases with common opioids were included in the study. Demographic factors, clinical manifestations, and outcome were recorded in a check list. ANOVA, Chi-square or Fisher's exact test, and binary logistic regression analysis were used for outcome prediction. FINDINGS: Two hundred and thirty six patients with opioids poisoning were evaluated during the study period. The most common opioids involved in poisoning were methadone (47.9%), tramadol (24.2%), and opium (21.6%). Patients with opium poisoning were older than others (P < 0.0001). The rate of suicide was more in the tramadol group, while the past history of psychological problems was more observed in the methadone group (P < 0.0001). Increasing age (odds ratio [OR], 1.05; 95% confidence interval [CI]: 1.02-1.09; P = 0.05) and addiction (P = 0.01; OR, 7; 95% CI: 1.55-31.52) was associated with an increased complications or death. Also patients with somatic disease had more chance of complications/death (P = 0.04; OR, 3.71; 95% CI: 1.06-12.97). Kind of opioids was not a predictive factor in the outcome of the patients with acute poisoning. CONCLUSION: Age, addiction, and somatic disease should be considered as more important factors in outcome prediction with opioids poisoning, including opium, tramadol, and methadone.

What are the Predictive Factors for the Treatment Outcomes in Multi Drug Poisoning Including Antidepressants/Antipsychotic Drugs?

BACKGROUND: There have been studies on the outcome of acute intoxication with antidepressants or antipsychotics. We performed outcome prediction analysis in acute poisoning patients with antidepressants/antipsychotics with or without combination with other drugs. MATERIALS AND METHODS: A cross-sectional study was performed in Khorshid (PBUH) University Hospital affiliated with Isfahan University of Medical Sciences from March 2016 to May 2017. Patients with acute poisoning ingested antidepressants and antipsychotics with or without other drugs were included in the study. The outcome was categorized as survived without complications and complications/death. Binary regression analysis was performed for outcome prediction. RESULTS: The data from 239 patients were analyzed. Most of the patients were female (68.2%), 5.9% of patients admitted to the Intensive Care Unit. About 94.99% of patients survived without complications. There was a significant difference between patients with and without complications with respect to the level of consciousness, hypotension, seizure, electrocardiography findings, pulse rate after 24 hours (h) of admission, and need to endotracheal intubation (P < 0.0001). Binary logistic regression analysis showed admission level of consciousness (stupor/coma) (odds ratio [OR] =8.07; P = 0,005), hypotension (OR = 12.16; P = 0.001), seizure (OR = 11.15; P = 0.009), tachycardia after 24 h of admission (OR = 22.50; P = 0.003), and need for endotracheal intubation (OR = 10.47; P = 0.002) were determinant factors in outcome prediction. CONCLUSIONS: Stupor/coma and hypotension were the predictive factors for outcome. Patients with seizure and tachycardia after 24 h of admission; and those intubated and received mechanical ventilation had a higher chance of complications.

Anemia, Depression, and Suicidal Attempts in Women: Is There a Relationship?

OBJECTIVE: Suicide is a social health problem worldwide. Anemia has been associated with depression. Since it remains debated whether anemia is associated with suicide independently of depression, we evaluate this probable association in women who attempted suicide through acute poisoning. METHODS: The study design was cross-sectional and performed on women who attempted suicide through intentional poisoning with age more than 18 years old. Different variables were evaluated and compared in patients with respect to anemia, depression, other psychiatric diseases and history of suicide. Independent t-tests and binary logistic regression were used for statistical analysis. FINDINGS: Nearly 26.2% of the women had anemia (n = 55). Most women with anemia were in the age group of 20-40 years (68.8%). 52.2% of the women were married. Mixed-drug poisoning was the most common (60.1%) followed by pesticide (8.9%), and antipsychiatric medications (8.4%). There was a significant difference in duration of hospitalization between anemic and nonanemic patients. Nearly 72.7% of the patients survived without complications. Anemia and depression were not significant predictive factors for depression and suicide. However, in our patients, the presence of other underlaying psychiatric disorders was a risk factor for suicidal attempt through acute poisoning. CONCLUSION: In women who attempted suicide through acute poisoning, anemia and depression were not predicting factors for suicide. However, the presence of other underlying psychiatric psychiatric disorders had a predictive value for the outcome of treatment. Length of hospital stay was also correlated with anemia.

Bispectral Index in Poisoning Cases with Multi-drug Ingestion: A Predictable Role for Early Endotracheal Intubation.

OBJECTIVE: Bispectral index (BIS) is one of the several methods used to monitor the depth of anesthesia. Poisoning with ingestion of different drugs is one of the most common poisonings that have different clinical signs from drowsiness to coma. This study was performed to compare the BIS index number in poisoned patients with multi drugs ingestion with or without the need for endotracheal intubation. METHODS: This cross-sectional study was performed on poisoned patients with ingestion of different drugs referring to Clinical Toxicology Department of Noor University Hospital, Isfahan, Iran. The clinical signs and symptoms and the vital signs at the admission time were measured, and the required therapies were given. The endotracheal intubation was done for patients who had the indication of intubation. BIS was monitored and compared for all patients with or without a need for intubation on the admission time and time of endotracheal intubation. Obtained data were analyzed by SPSS software. FINDINGS: At the admission time, the mean (standard error [SE]) BIS index value for poisoned patients who needed endotracheal intubation was 66.47 ± 2.57 in comparison with 85.21 ± 1.47 for patients who did not need intubation (P < 0.001). The results of receiver operating characteristic curve (mean ± SE) showed the discrimination was excellent for BIS (0.899 ± 0.04; 95% confidence interval: 0.81-0.98) (P < 0.0001). BIS <79.5 had the sensitivity 88% and specificity 87% for endotracheal intubation. CONCLUSION: BIS is an appropriate index for prediction of the need to intubation in poisoned patients with ingestion of different drugs.

Acid-base and hemodynamic status of patients with intraoperative hemorrhage using two solution types: Crystalloid Ringer lactate and 1.3% sodium bicarbonate in half-normal saline solution.

BACKGROUND: Intraoperative hemorrhage is one of the problems during surgery and, if it happens in a high volume without an immediate action to control, it can be fatal. Nowadays, various injectable solutions are used. The aim of this study was to compare the acid-base and hemodynamic status of the patient using two solutions, Ringer lactate and 1.3% sodium bicarbonate, in half saline solution. MATERIALS AND METHODS: This clinical trial was performed at the Al-Zahra Hospital in 2013 on 66 patients who were randomly selected and put in two studied groups at the onset of hemorrhage. For the first group, crystalloid Ringer lactate solution and for the second group, 1.3% sodium bicarbonate in half-normal saline solution was used. Electrocardiogram, heart rate, O2 saturation non-invasive blood pressure and end-tidal CO2 were monitored. The arterial blood gas, blood electrolytes, glucose and blood urea nitrogen were measured before serum and blood injection. After the infusion of solutions and before blood transfusions, another sample was sent for measurement of blood parameters. Data were analyzed using SPSS software. RESULTS: The mean arterial pressure was significantly higher in the second group than in the first group at some times after the infusion of solutions. pHh levels, base excess, bicarbonate, sodium, strong ion differences and osmolarity were significantly greater and potassium and chloride were significantly lower in the second group than in the first group after the infusion of solutions. CONCLUSION: 1.3% sodium bicarbonate in half-normal saline solution can lead to a proper correction of hemodynamic instability. By maintaining hemodynamic status, osmolarity and electrolytes as well as better balance of acid-base, 1.3% sodium bicarbonate solution in half-normal saline solution can be more effective than Ringer lactate solution during intraoperative bleeding.

Comparison of capillary and venous blood glucose levels using glucometer and laboratory blood glucose level in poisoned patients being in coma.

BACKGROUND: Poisoning is one of the most common medical presentations in a hospital. Hypoglycemic patients are at increased risk of toxicity. The purpose of this study was to compare capillary blood glucose and venous blood glucose measurements using glucometer against laboratory blood glucose in case of poisoned patients being in coma. MATERIALS AND METHODS: During the 6-month study period, a random sample of 98 patients was admitted in the Department of Poisoning Emergency and Clinical Toxicology of Noor Hospital, Isfahan University of Medical Sciences, Iran from May 2010. Data collected included age, gender, poisoning reason, vital signs, and Glasgow Coma Scale. Capillary blood samples were obtained from the fourth fingertip of the non-dominant hand. t-Test, paired t-test, Pearson's correlation analysis, and one-way analysis of variance (ANOVA) were used for analysis. RESULTS: The mean of capillary blood glucose was 115.7 ± 50.2, of venous blood glucose measured by glucose meter was 117.8 ± 47.3, and of glucose measured in vitro was 115.8 ± 55.1. Mean of blood glucose showed no significant difference with the three mentioned methods. The correlation between capillary and intravenous blood glucose samples measured by glucometer was 0.93, between capillary blood glucose and in vitro measured venous blood glucose was 0.78, and between venous blood glucose measured by glucose meter and in vitro measured sample was 0.81. The mean of capillary and venous blood glucose levels measured by glucose meter, capillary and venous blood glucose levels measured in vitro, and venous blood glucose levels measured by glucose meter had no significant differences. CONCLUSION: Using venous blood sample and measuring the glucose level in it by glucometer is an acceptable and advisable method, and capillary blood glucose measurement by using glucometer is not recommended for patients in coma.

Is Admission Serum Sodium Concentration a Clinical Predictor for the Outcome of Therapy in Critically Ill Poisoned Patients?

BACKGROUND: Disorders of serum sodium concentration are some of the most electrolyte abnormalities in the intensive care unit (ICU) patients. These disorders adversely affect the function of vital organs and are associated with increased hospital mortality. PURPOSE: In the present study we aimed to evaluate the effects of serum sodium concentration abnormalities at the time of hospital admission on the clinical outcome of therapy in a cohort of critically ill poisoned patients. METHODS: In this cross-sectional study, 184 critically ill poisoned patients aged >18 years and in the first 8 hours of their poisoning, hospitalized in the ICU of a tertiary care university hospital (Isfahan, Iran) between 2010-2012, were evaluated at the admission time and 24 hours later for serum sodium concentration abnormalities and its relationship with age, gender, consciousness status, ingested drugs and clinical outcome of therapy. The clinical outcome was considered as recovery and mortality. Logistic Regression analysis was performed for predictive variables including serum sodium concentration abnormalities in patients' clinical outcome. FINDINGS: On admission, 152 patients (82.6%) were eunatremic, 21 patients (11.4%) were hyponatremic and 11 patients (6%) were hypernatremic. In the second day eunatremia, hyponatremia and hypernatremia was observed in 84.4%, 13% and 2.2% respectively. Age (OR=1.92; CI=1.18-3.12) and severity of toxicity (OR=1.32; CI=1.12-2.41) were predicting factors of mortality in ICU poisoning patients. CONCLUSIONS: Serum sodium concentration abnormalities are prevalent in critically ill poisoned patient but do not seem to have a predictive value for the clinical outcome of therapy.

Clinical Presentation and the Outcome of Therapy in a Cohort of Patients with Methadone Toxicity in Iran.

BACKGROUND: Agonist maintenance therapy with methadone is amongst the preferred remedies for treating opioid dependence and is increasingly supported by the regional governments in this part of the world. In this study we have investigated the clinical manifestations and factors affecting the outcome of therapy in patients with methadone poisoning in a Middle-Eastern (Iranian) referral tertiary care University hospital. METHODS: In this prospective and descriptive-analytic study which was done in a tertiary care and referral University hospital in Iran (2012-2013) all of the admitted patients with a clear and reliable history of methadone poisoning (n=433) were included and demographic data, Clinical status on admission including Glasgow Coma Scale (GCS) score, time elapsed from ingestion to hospital admission, average dose of naloxone used, any history of psychiatric disorder, type of toxic exposure, co ingestion of other medication, hospitalization time and the outcome were recorded and statistically analyzed. RESULTS: The average length of hospital stay was 33 ± 26 hours. 80.1% of patients had ingested methadone alone, and 90.3% survived. Complications were pulmonary edema (7%), aspiration pneumonia (1.4%), generalized tonic colonic seizure (0.9%), and renal failure (0.5%). GCS, systolic blood pressure and respiratory rate were lower in fatal cases and GCS had prognostic value for the outcome of therapy in methadone intoxicated patients. Patients with higher GCS on admission had better outcome [OR =0.47 (95% CI: 0.38-0.580); P value< 0.0001]. CONCLUSION: Admission time GCS score maybe considered as an important predictor for the outcome of therapy in methadone poisoning.

Comparison of five methods in predicting difficult laryngoscopy: Neck circumference, neck circumference to thyromental distance ratio, the ratio of height to thyromental distance, upper lip bite test and Mallampati test.

BACKGROUND: Preoperative airway assessment tests have been presented to help in anticipating a difficult airway. We conducted this study to compare five methods in prediction of difficult laryngoscopy: Neck circumference (NC), NC to thyromental distance ratio (NC/TMD), the ratio of height to thyromental distance (RHTMD), upper lip bite test (ULBT) and Mallampati test (MMT). These five methods are the most commonly used ones and have different powers for it. It was not clear which of these methods predicts difficult laryngoscopy better. MATERIALS AND METHODS: Six hundred consecutive patients participated in this study. NC, NC/TMD and RHTMD were measured, and ULBT and MMT were performed and recorded. The laryngoscopy view was graded according to Cormack and Lehane's scale (CLS) and difficult laryngoscopy was defined as CLS grades 3 and 4. Accuracy of tests in predicting difficult laryngoscopy was assessed using the area under a receiver-operating characteristic curve. RESULTS: The area under the curve in ULBT and RHTMD were significantly larger than that in TMD, NC and MMT. No statistically significant differences were noted between TMD, NC and MMT (all P > 0.05) (ULBT = RHTMD > NC/TMD > TMD = NC = MMT). RHTMD (>22.7 cm) exhibited the highest sensitivity (sensitivity = 64.77, 95% confidence interval [CI]: 53.9-74.7) and the most specific test was ULBT (specificity = 99.41%, 95% CI: 98.3-99.9). CONCLUSION: RHTMD and ULBT as simple preoperative bedside tests have a higher level of accuracy compared to NC/TMD, TMD, NC, MMT in predicting a difficult airway.

Memory Impairment following Acute Tricyclic Antidepressants Overdose.

Background. Psychiatric consultation is necessary for all patients with intentional poisoning and its reliability depends on the proper function of patients' memory performance. This study aimed to determine the possible memory impairment following acute TCAs' poisoning. Materials and Methods. In this cross-sectional study, patients with acute TCAs poisoning were allocated to two groups of severe poisoning (with coma, seizures, cardiac arrhythmias, hypotension, and a wide QRS complex) and mild-to-moderate poisoning according to their clinical presentation at the time of hospital admission. All patients underwent memory performance test both immediately and 24 hours after their initial consciousness after admission, using Wechsler Memory Scale (WMS-IV). Results. During the study period, 67 TCA-poisoned patients (aged, 20-64 years) were evaluated, of which 67.2% were female. The mean memory scores of patients immediately and 24 hours after the initial consciousness were 31.43 ± 9.02 and 50.62 ± 9.12, respectively (P < 0.001). Twenty-four hours after the initial consciousness, memory score was statistically correlated with the amount of ingested drug and the intoxication severity. Conclusion. Following the recovery from somatic symptoms of acute TCA poisoning, patients may still suffer from memory impairment and it seems that this time is not suitable for performing a reliable psychiatric consultation.

Arterial blood gas analysis and the outcome of treatment in tricyclic antidepressants poisoned patients with benzodiazepine coingestion.

Background. Poisoning with tricyclic antidepressants (TCAs) is still a major concern for emergency physicians and intensivists. Concomitant ingestion of other psychoactive drugs especially benzodiazepines with TCAs may make this clinical situation more complex. This study aimed to compare the arterial blood gas (ABG) values and the outcome of treatment in patients with coingestion of TCA and benzodiazepine (TCA + BZD) poisoning and TCA poisoning alone. Methods. In this cross-sectional study which was carried out in a tertiary care university hospital in Iran, clinical and paraclinical characteristics of one hundred forty TCA only or TCA + BZD poisoned patients (aged 18-40 years) were evaluated. ABG analysis was done on admission in both groups. Outcomes were considered as survival with or without complication (e.g., intubation) and the frequency of TCA poisoning complications. Results. Arterial pH was significantly lower in TCA + BZD poisoning group compared with TCA only poisoning group (7.34 ± 0.08 and 7.38 ± 0.08, resp.; P = 0.02). However, other complications such as seizure, and the need for the endotracheal intubation were not significantly different. All patients in both groups survived. Conclusions. Concomitant TCA plus BZD poisoning may make the poisoned patients prone to a lower arterial pH level on hospital admission which may potentially increases the risk of cardiovascular complications in TCA poisoning.

Risk factors and the outcome of therapy in patients with seizure after Carbamazepine poisoning: A two-year cross-sectional study.

OBJECTIVE: We aimed to investigate the frequency of seizure after acute carbamazepine poisoning and the important risk factors related to the outcomes of therapy. METHODS: In this two-year cross-sectional study conducted in a University Hospital in Iran, 114 patients with acute carbamazepine poisoning were divided into two groups of with seizure (n = 8) and without seizure (n = 106) after intoxication. Demographic data, average amount of drug ingestion, time elapsed from ingestion to hospital admission, history of seizure before poisoning, mental status, visual disturbances and nystagmus, duration of hospitalization, the outcomes of therapy, arterial blood gas values and serum biochemical indices were compared between the two groups. FINDINGS: Patients with seizure had an estimated (Mean ± SD) ingestion of 14,300 ± 570 mg carbamazepine, which was significantly higher (P < 0.0001) than the seizure-free group (4600 ± 420 mg). The estimated average time between drug ingestion and hospital admission in patients with seizure and the seizure-free group were 515 ± 275 and 370 ± 46 minutes, respectively (P < 0.0001). In this study, 104 out of the total number of patients had recovered without any complication. Need for respiratory support, including airway support or intubation were the most recorded complication. One patient died after status epilepticus and aspiration pneumonia. CONCLUSION: The ingested amount of carbamazepine and the time elapsed from the ingestion of drug to hospital admission may influence the occurrence of seizure after acute carbamazepine poisoning; however, the outcome of supportive care in these patients seems to be positive.

The outcome of agitation in poisoned patients in an Iranian tertiary care university hospital.

Introduction. This study was conducted to evaluate and document the frequency and causes of agitation, the symptoms accompanying this condition in intoxications, relationship between agitation score on admission and different variables, and the outcome of therapy in a tertiary care referral poisoning center in Iran. Methods. In this prospective observational study which was done in 2012, 3010 patients were screened for agitation at the time of admission using the Richmond Agitation Sedation Scale. Demographic data including age, gender, and the drug ingested were also recorded. The patients' outcome was categorized as recovery without complications, recovery with complications (hyperthermia, renal failure, and other causes), and death. Results. Agitation was observed in 56 patients (males, n = 41), mostly aged 19-40 years (n = 38) and more frequently in illegal substance (stimulants, opioids and also alcohol) abusers. Agitation score was not significantly related to the age, gender, and previous history of psychiatric disorders. Forty nine patients had recovery without any complication. The need for mechanical ventilation was the most frequent complication. None of the patients died. Conclusion. Drug abuse seems to be a must-to-consider etiology for patients presenting with acute agitation and its morbidity and mortality could be low in agitated poisoning cases if prompt supportive care is performed.

Naloxone therapy in opioid overdose patients: intranasal or intravenous? A randomized clinical trial.

INTRODUCTION: This study was designed to compare the effects of intranasal (IN) and intravenous (IV) administration of naloxone in patients who had overdosed on opioids. MATERIAL AND METHODS: This randomized clinical trial study was conducted in the Department of Poisoning Emergencies at Noor and Ali Asghar (PBUH) University Hospital. One hundred opioid overdose patients were assigned by random allocation software into two study groups (n = 50). Both groups received 0.4 mg naloxone: one group IN and the other IV. Outcomes included change in the level of consciousness (measured using a descriptive scale and the Glasgow Coma Scale (GCS)), time to response, vital signs (blood pressure, heart rate and respiratory rate), arterial blood O2 saturation before and after naloxone administration, side-effects (agitation) and length of hospital stay. RESULTS: Patients who had been administered IN naloxone demonstrated significantly higher levels of consciousness than those in the IV group using both descriptive and GCS scales (p < 0.001). There was a significant difference in the heart rate between IN and IV groups (p = 0.003). However, blood pressure, respiratory rate and arterial O2 saturation were not significantly different between the two groups after naloxone administration (p = 0.18, p = 0.17, p = 0.32). There was also no significant difference in the length of hospital stay between the two groups (p = 0.14). CONCLUSIONS: Intranasal naloxone is as effective as IV naloxone in reversing both respiratory depression and depressive effects on the central nervous system caused by opioid overdose.

Comparative evaluation of hemodynamic and respiratory parameters during mechanical ventilation with two tidal volumes calculated by demi-span based height and measured height in normal lungs.

BACKGROUND: Appropriate determination of tidal volume (VT) is important for preventing ventilation induced lung injury. We compared hemodynamic and respiratory parameters in two conditions of receiving VTs calculated by using body weight (BW), which was estimated by measured height (HBW) or demi-span based body weight (DBW). MATERIALS AND METHODS: This controlled-trial was conducted in St. Alzahra Hospital in 2009 on American Society of Anesthesiologists (ASA) I and II, 18-65-years-old patients. Standing height and weight were measured and then height was calculated using demi-span method. BW and VT were calculated with acute respiratory distress syndrome-net formula. Patients were randomized and then crossed to receive ventilation with both calculated VTs for 20 min. Hemodynamic and respiratory parameters were analyzed with SPSS version 20.0 using univariate and multivariate analyses. RESULTS: Forty nine patients were studied. Demi-span based body weight and thus VT (DTV) were lower than Height based body weight and VT (HTV) (P = 0.028), in male patients (P = 0.005). Difference was observed in peak airway pressure (PAP) and airway resistance (AR) changes with higher PAP and AR at 20 min after receiving HTV compared with DTV. CONCLUSIONS: Estimated VT based on measured height is higher than that based on demi-span and this difference exists only in females, and this higher VT results higher airway pressures during mechanical ventilation.

The frequency of agitation due to inappropriate use of naltrexone in addicts.

BACKGROUND: There is a high tendency among specialists to treat the addicts with naltrexone; withdrawal symptoms are frequent after taking naltrexone along with opioids. This study investigated the frequency of agitation due to inappropriate use of naltrexone in addicts. MATERIALS AND METHODS: This was a cross-sectional study, conducted in Noor and Aliasghar hospitals in Isfahan city. The study population included the addicts who were agitated as a result of naltrexone abuse. Scores of patients with agitation were measured with Richmond Agitation Sedation Scale (RASS). Patient outcomes including recovery without complications, recovery with complications (rhabdomyolysis), and mortality were recorded. RESULTS: All the patients with agitation caused by naltrexone abuse during 1 year were 40 people, of whom nine were excluded due to their comorbid diseases (diabetes or cardiovascular disease). Among the remaining 31 patients, 30 were male. The patients' mean age was 29.93 (5.24) years. The most common symptoms observed besides agitation was midriasis (41.9%), and vomiting (41.9%), A 38.8% of the patients scored 3 or 4, and, 61.2% scored 1 or 2 for agitation. The mean time for patients' restlessness scores to reach zero was 9.30 (3.71) h (min: 3 h, max: 18 h). All the patients in both groups were discharged with recovery without complication. CONCLUSION: Considering the high prevalence of agitation in the poisoning emergency department due to inappropriate use of naltrexone, more accurate planning for administration of naltrexone in addicts seems necessary.

Prediction of endotracheal intubation outcome in opioid-poisoned patients: A clinical approach to bispectral monitoring.

BACKGROUND: Some opioid-poisoned patients do not respond appropriately to naloxone; consequently, intubation is required. Although various measures have been used to evaluate the level of consciousness of poisoned patients, no study has assessed the role of the bispectral index (BIS) to ascertain the depth of anesthesia in opioid-poisoned patients who require endotracheal intubation. OBJECTIVE: To compare BIS scores between opioid-poisoned patients with and without intubation, and to determine the BIS cut-off point for endotracheal intubation in these patients. METHODS: In the present cross-sectional study, conducted in an Iranian university referral hospital for poisoning emergencies between 2012 and 2013, opioid-poisoned patients (n=41) were divided into two groups according to their requirement for endotracheal intubation. BIS analyses were performed at the time of admission and at the time of intubation for those who required it. In addition, electromyography and signal quality index were evaluated for all patients at the time of admission, and cardiorespiratory monitoring was performed during the hospitalization period. Using ROC curves, and sensitivity and specificity analyses, the optimal BIS cut-off point for prediction of intubation of these patients was determined. RESULTS: The optimal cut-off point for prediction of intubation was BIS ≤78, which had a sensitivity of 86.7% (95% CI 66.1 to 98.8) and specificity of 88.5% (95% CI 73.9% to 98.8%); the positive and negative predictive values were 81.2 % and 92%, respectively. CONCLUSIONS: BIS may be considered an acceptable index to determine the need for intubation in opioid-poisoned patients whose response to naloxone is inadequate.

HISTORIQUE: Certains patients empoisonnés par des opioïdes ne répondent pas bien au naloxone et doivent être intubés. Diverses mesures sont utilisées pour évaluer le niveau de conscience des patients empoisonnés, mais aucune étude n'a porté sur le rôle de l'index bispectral (IBS) pour déterminer la profondeur de l'anesthésie chez les patients empoisonnés par des opioïdes qui doivent subir une intubation trachéale. OBJECTIF: Comparer les indices de l'IBS entre les patients empoisonnés par des opioïdes intubés ou non et déterminer le seuil d'IBS pour l'intubation trachéale de ces patients. MÉTHODOLOGIE: Dans la présente étude transversale menée entre 2012 et 2013 dans un hôpital universitaire iranien spécialisé dans les urgences causées par des empoisonnements, les patients empoisonnés par des opioïdes (n=41) ont été divisés en deux groupes, en fonction de la nécessité qu'ils subissent une intubation trachéale. Les chercheurs ont analysé l'IBS au moment de l'admission et de l'intubation des patients qui devaient la subir. Ils ont aussi évalué l'électromyographie et l'indice de qualité du signal chez tous les patients au moment de l'admission et assuré un monitorage cardiorespiratoire pendant la période d'hospitalisation. À l'aide des courbes ROC et des analyses de sensibilité et de spécificité, ils ont déterminé le seuil d'IBS optimal pour prédire l'intubation de ces patients. RÉSULTATS: Un IBS de 78 ou moins, d'une sensibilité de 86,7 % (95 % IC 66,1 à 98,8) et d'une spécificité de 88,5 % (95 % IC 73,9 % à 98,8 %), était le seuil optimal pour prédire l'intubation. Les valeurs prédictives positives et négatives s'établissaient à 81,2 % et 92 %, respectivement. CONCLUSIONS: L'IBS peut être considéré comme un index acceptable pour déterminer la nécessité d'intuber les patients empoisonnés par des opioïdes qui répondent peu au naloxone.

Efficacy of Yamamoto new scalp acupuncture versus Traditional Chinese acupuncture for migraine treatment.

BACKGROUND: Traditional Chinese acupuncture (TCA) is an effective alternative treatment in migraine headache. The aim of this study was to compare the therapeutic effect of Yamamoto new scalp acupuncture (YNSA), a recently developed microcupuncture system, with TCA for the prophylaxis and treatment of migraine headache. METHODS: In a randomized clinical trial, 80 patients with migraine headache were assigned to receive YNSA or TCA. A pain visual analogue scale (VAS) and migraine therapy assessment questionnaire (MTAQ) were completed before treatment, after 6 and 18 sections of treatment, and 1 month after completion of therapy. RESULTS: All the recruited patients completed the study. Baseline characteristics were similar between the two groups. Frequency and severity of migraine attacks, nausea, the need for rescue treatment, and work absence rate decreased similarly in both groups. Recovery from headache and ability to continue daily activities 2 hours after medical treatment showed similar improvement in both groups (p>0.05). CONCLUSION: Classic acupuncture and YNSA are similarly effective in the prophylaxis and treatment of migraine headache and may be considered as alternatives to pharmacotherapy.

Hypercapnic hyperventilation shortens emergence time from Propofol and Isoflurane anesthesia.

OBJECTIVE: The aim of this study is to compare the effects of hypercapnic hyperventilation and normocapnic normoventilation on emergence time from propofol and isoflurane anesthesia. METHODS: In this clinical trial, the differences in emergence time were evaluated in 80 patients undergoing elective abdominal surgery in Alzahra University hospital, Isfahan, Iran, in 2011-2012. Patients were randomly divided into four groups (groups 1-4) receiving isoflurane hypercapnic hyperventilation, isoflurane normocapnic normoventilation, propofol hypercapnic hyperventilation, and propofol normocapnic normoventilation, respectively. Hypercapnia was maintained by adding CO2 to the patient's inspired gas during hyperventilation. The emergence time and the duration of stay in recovery room in the four groups were measured and compared by one-way analysis of variance (ANOVA) and least significant difference tests. FINDINGS: The average emergence time in groups 1, 2, 3, and 4 were (11.3 ± 3.2), (15.2 ± 3.8), (9 ± 4.2) and (11.8 ± 5.3) min, respectively. These differences were significant (P = 0.001). In patients receiving propofol hypercapnic hyperventilation, the emergence time was faster than in other groups. There was also a significant difference in duration of stay in recovery room between the groups (P = 0.004). Patients who received isoflurane hypercapnic hyperventilation had a shortest length of stay in the recovery room. CONCLUSION: The emergence time after intravenous anesthesia with propofol can be shortened significantly by using hyperventilation and hypercapnia, without any side effects.