Paracetamol (acetaminophen) poisoning.

INTRODUCTION: Paracetamol directly causes around 150 deaths per year in UK. METHODS AND OUTCOMES: We conducted a systematic overview, aiming to answer the following clinical question: What are the effects of treatments for acute paracetamol poisoning? We searched: Medline, Embase, The Cochrane Library, and other important databases up to October 2014 (Clinical Evidence overviews are updated periodically; please check our website for the most up-to-date version of this overview). RESULTS: At this update, searching of electronic databases retrieved 127 studies. After deduplication and removal of conference abstracts, 64 records were screened for inclusion in the overview. Appraisal of titles and abstracts led to the exclusion of 46 studies and the further review of 18 full publications. Of the 18 full articles evaluated, one systematic review was updated and one RCT was added at this update. In addition, two systematic reviews and three RCTs not meeting our inclusion criteria were added to the Comment sections. We performed a GRADE evaluation for three PICO combinations. CONCLUSIONS: In this systematic overview we categorised the efficacy for six interventions, based on information about the effectiveness and safety of activated charcoal (single or multiple dose), gastric lavage, haemodialysis, liver transplant, methionine, and acetylcysteine.

The result of revision total hip arthroplasty in patients with metallosis following a catastrophic failure of a polyethylene liner.

BACKGROUND: Wear cannot be completely prevented after total hip arthroplasty. If severe polyethylene (PE) liner wear develops, the so-called catastrophic failure occurs and metallosis develops. We postulated that longevity of the new implant may be affected after revision surgery for metallosis following a catastrophic failure of a PE liner due to the substantial amount of PE wear particles and infiltration of the metal particles in this catastrophic condition. METHODS: Twenty-three hips of 23 patients were identified because they showed metallosis during revision total hip arthroplasties performed in Seoul National University Hospital between January 1996 and August 2004. They were followed for at least 6.5 years after the index revision total hip arthroplasty. The clinical and radiological results of revision total hip arthroplasties in these patients were evaluated. RESULTS: The median Harris hip score increased from 60 points before revision total hip arthroplasties to 90 points at the final follow-up. Osteolysis was detected at an average of 9.3 years after revision total hip arthroplasties in 13 hips and acetabular cup loosening at average 9.8 years after revision total hip arthroplasties in 9 hips. With radiographic evidence of osteolysis and loosening as the end points, the 15-year survival rates were 28.2% and 56.0%, respectively. CONCLUSIONS: The survival rate of revision total hip arthroplasty in patients with metallosis following a catastrophic failure of a PE liner was low.

[SURGICAL COMPLICATIONS IN ACUTE POISONING AND PROTEIN--ENERGY DYSFUNCTION].

The article presents a review of acute surgical pathology and the frequency of its occurrence, complicating alcohol poisoning, cauterizing liquids, narcotic and psychotropic drugs and acute emerging metabolic (protein-energy). The development of surgical complications in poisoning was observed in patients in severe and very severe condition and is accompanied by a sharp increase in mortality (75%) and severe energy dysfunction. The most diverse and difficult flowing surgical complications were encountered in alcohol poisoning and cauterizing liquids.

Severe metallosis following total knee arthroplasty: a case report and review of radiographic signs.

Metallosis is an uncommon complication following total knee arthroplasty that leads to osteolysis and implant loosening due to chronic inflammatory reaction. Abrasion between the metallic surfaces of the implant releases metallic debris that interacts with the periprosthetic soft tissues and causes chronic synovitis. Here we present a case of a 65-year-old man who had undergone total knee arthroplasty 10 years ago and developed implant loosening associated with severe metallosis and varus instability. Radiographs show the three typical signs of metallosis: metal-line sign, bubble sign, and cloud sign. This patient was subjected to revision surgery consisting of debridement and primary implant replacement by a hinged endoprosthesis. Knowledge of the typical radiographic and clinical findings of metallosis is important to rapidly diagnose this complication and avoid progressive joint destruction.

Liver transplantation for acute liver failure: a Spanish perspective.

The Spanish characteristics of organ donation (high accessibility to a transplant) and the different proportion in the etiologies of acute liver failure (ALF), namely, the very low incidence of paracetamol overdose causing this syndrome in contrast with other Western countries, are the causes of some specific features of emergency liver transplantation for ALF. The most relevant are the short time between the need for a graft and effective urgent liver transplant, and the high proportion of patients who undergo this therapy. This paper analyzes these characteristics and provides information about the use of biological and nonbiological extracorporeal liver support devices in acute liver failure, suggesting that these systems should be tested in countries with a long waiting times for urgent liver transplantation, or in patients with ALF and contraindications for transplantation.

Systematic review of controlled clinical trials of gastric lavage in acute organophosphorus pesticide poisoning.

BACKGROUND: Organophosphorus pesticide (OP) self-poisoning is a major problem in the developing rural world. There is little clinical trial data to guide therapy, hindering the identification of best therapy. Despite the recognition of adverse effects, gastric lavage is commonly done in Asia. We aimed to identify studies assessing its effectiveness. METHOD: We systematically searched the literature for controlled clinical studies that assessed the effect of gastric lavage in OP pesticide self-poisoning. RESULTS: All 56 studies identified were Chinese and reported benefit from the intervention studied, including multiple gastric lavages, use of norepinephrine or pralidoxime in the lavage fluid, concurrent treatment with naloxone or scopolamine, insertion of the gastric tube via a laparotomy incision, and lavage later than 12 h post-ingestion. However, only 23 were RCTs and none presented adequate methodology for their quality to be assessed. The patient population and study treatment protocol were not defined - large variation in case fatality in the control arm of the studies (from 4.5 to 93%) suggests marked variation between studies and likely between study arms. No study compared an intervention against a control group receiving no gastric lavage or provided any data to indicate whether a significant quantity of poison was removed. CONCLUSION: Despite widespread use of multiple gastric lavages for OP pesticide poisoning across Asia, there is currently no high-quality evidence to support its clinical effectiveness. There is a need for studies to identify in which patients and for what duration gastric lavage is able to remove significant quantities of poison. Following these studies, large clinical trials will be required to address the effectiveness and safety of gastric lavage (either single or multiple) in acute OP pesticide poisoning.

Severe cobalt intoxication due to prosthesis wear in repeated total hip arthroplasty.

Our study describes a 55-year-old man with a total hip prosthesis (ceramic femoral head and polyethylene [PE] inlay). After a fall, the ceramic head broke into several pieces, and a subsequent revision surgery with metal femoral head and PE inlay was performed. Three months later, the so far healthy patient complained of multiorgan symptoms. The subsequent clinical examinations revealed hypothyroidism, peripheral neuropathy, and cardiomyopathy for the first time. In a second revision surgery, a massive deterioration of the metal femoral head by overlooked particles of the broken ceramic head was found. The cobalt concentration in blood exceeded a never before observed level. After replacement of the scraped femoral head, the cobalt concentration decreased considerably, and most of the symptoms disappeared.

Zinc intoxication in dogs: 19 cases (1991-2003).

OBJECTIVE: To determine physical examination findings, clinicopathologic changes, and prognosis in dogs with zinc toxicosis. DESIGN: Retrospective case series. ANIMALS: 19 dogs with zinc toxicosis. PROCEDURES: Medical records from 1991 through 2003 were searched for animals with a diagnosis of zinc toxicosis. Information concerning signalment, body weight, historical findings, initial owner complaints, physical examination findings, clinicopathologic findings, blood zinc concentrations, source of zinc, treatments given, duration of hospital stay, and outcome was collected. RESULTS: Records of 19 dogs with zinc toxicosis were reviewed. The most common historical findings were vomiting (n = 14) and pigmenturia (12). The most common clinicopathologic findings were anemia (n = 19) and hyperbilirubinemia (12). Median age was 1.3 years, and median weight was 5.6 kg (12.3 lb). The prognosis was favorable, with 17 dogs surviving after a median hospital stay of 2 days. CONCLUSIONS AND CLINICAL RELEVANCE: Hemolytic anemia as a result of zinc toxicosis appeared to affect young small-breed dogs more frequently than older large-breed dogs. The prognosis with treatment is good, and most affected dogs had a short hospital stay.

Renal and liver transplantation for toxin-induced organ failure.

OBJECTIVE: Determine the number and outcome of renal (January 1987-June 2001, inclusive) and liver transplants (January 1993-June 2001) performed in Ireland for drug or toxin-induced organ failure and identify the toxins involved. METHODS: Retrospective review of national transplant coordinators' records and patient charts. RESULTS: Fourteen patients received renal transplants for nephropathy secondary to drugs or toxins. In 12 of these cases, renal failure was attributed to chronic toxicity, principally cyclosporin A therapy (seven cases). One-year patient and graft survival were 100%. Twenty-nine liver transplants were for toxin-induced organ failure, and 20 of these were for chronic ethanol induced liver disease. One-year patient and graft survival rates were 77% and 73%, respectively. CONCLUSIONS: Kidney and liver transplants were needed more often because of chronic toxicity than acute poisoning. Both groups had good outcomes at one year post-transplantation.

[Surgery to save body-packers]. / La chirurgie au secours des body-packers.

Cocaine body packing may expose to the risk of intestinal obstruction or acute cocaine poisoning. During the last five years (1998-2002), 17 symptomatic body-packers were admitted to our intensive care unit, for a closed monitoring. Clinical evolution of three patients required a surgical intervention. The first patient had a laparotomy, in the presence of an occlusive syndrome, to recover the packets of cocaine. The second patient presented peritonitis, in relation to an ileal perforation, treated with an intestinal segment resection followed by a double ileostomy. The third patient presented severe ventricular dysrhythmia, due to cocaine toxicity, after a bullet disruption in the stomach. Adrenaline and labetalol-combined therapy as well as gastric incision to recover the bullets were needed to allow cardiovascular stabilization. In these three cases, the surgical treatment allowed patient survival.

Methyl ethyl ketone peroxide ingestion: toxicity and outcome in a 6-year-old child.

A 6-year-old boy developed respiratory distress, metabolic acidosis, severe esophageal and gastric burns, and a coagulopathy after ingestion of an unknown volume of methyl ethyl ketone peroxide (MEKP) in dimethyl phthalate. He was discharged from the pediatric intensive care unit 19 days postingestion but subsequently developed a stricture of the gastroesophageal junction and complete fibrosis of the middle third of the stomach, necessitating gastric resection and reconstruction. He was discharged 93 days postingestion on a program of dilation for the residual esophageal stricture. MEKP acts by initiating lipid peroxidation via free radical production that results in cellular dysfunction and death. Acetylcysteine, a glutathione precursor and possible free radical scavenger, may be of use in severe MEKP poisoning. This case demonstrates the severe effects that some industrial chemicals can have both systemically and locally at the point of contact with the gastrointestinal tract, as well as the long-term management required to ensure good quality of life.

Urgencias quirúrgicas en el niño / Surgical emergencies in the child

Presentamos en este trabajo las urgencias quirúrgicas más frecuentes en pediatría, exceptuando las debidas a traumatismos. El dolor abdominal, apendicitis, invaginación intestinal, hernia inguinal incarcerada, estenosis hipertrófica de píloro, aspiración o ingestión de cuerpos extraños, causticaciones y la torsión testicular, son descritas con un enfoque eminentemente práctico dirigido al pediatra de Atención Primaria. Se exponen de forma resumida, datos epidemiológicos, la clínica más habitual, los métodos diagnósticos más utilizados, las medidas iniciales y el tratamiento sin profundizar en las técnicas quirúrgicas. El adecuado conocimiento de estos padecimientos permitirán al pediatra y al cirujano pediátrico cumplir con el objetivo de ofrecer la mejor asistencia sanitaria a los niños (AU)

Anesthesia for victims of nerve agents undergoing surgery: establishment of a management protocol.

Awareness of the effects of nerve agents still being stocked around the world has led to the establishment of protocols for rapid evacuation and decontamination of large civilian areas. Perioperative care protocol and procedures for the administration of anesthesia in lifesaving surgical intervention for combined multiple trauma and intoxicated casualties have not been established. There are also no guidelines for anesthetizing those casualties who had already been medicated on site. The only exception to anecdotal reports and isolated communications on these issues is the organophosphate poisoning database of substances which act similarly to the nerve agents or their antagonists. We gathered the few reports existing on the subjects in the literature and extrapolated the knowledge of the nature and action of various anesthetic drugs. We applied it to biological and physiological conditions that exist in combined chemical and multiple trauma casualties and consolidated the data into two charts that may serve as guidelines for preventing the avoidable hazardous outcomes.

David R. Boyd lecture in trauma care and emergency medical systems: "The surgical complications of toxins.".

Toxins have had major roles in our societies for thousands of years. Interactions between surgeons, both generalists and subspecialists, and those caring for poisoned patients have been extensive throughout history. The advancement of the science of toxicology, the development of regional poison control centers, the development of emergency medicine, and the development of the subspecialty of medical toxicology have led to more appropriate and creative interactions between medical toxicologists, emergency physicians, and surgeons. This article will review the diverse interfaces between the medical toxicologist and the surgeon.

[Surgical diseases in acute poisonings]. / Khirurgicheskie zabolevaniia pri ostrykh otravleniiakh.

Under analysis there were 104 case histories of patients with surgical diseases diagnosed in a toxicological center. In 34 patients the surgical diseases or mechanical traumas were combined with poisoning, in 106 patients they appeared due to acute poisoning. In the first group most frequent were closed craniocerebral injuries and acute destructive pancreatitis. In the second group prevailing were gastroesophageal bleedings.

Transportador gastrointestinal de cocaína intoxicado / Gastrointestinal intoxication of a cocaine carrier

Se analiza el caso de un paciente varón de 44 años procedente de Colombia y que transportaba 48 paquetes de cocaína en su tubo digestivo. A raíz de la ruptura de uno de estos envoltorios ingresó al Servicio de Urgencia por compromiso metabólico grave. Fue operado extrayéndole los cuerpos extraños a través de múltiples enterotomías