1/19. Sevoflurane mask anesthesia for urgent tracheostomy in an uncooperative trauma patient with a difficult airway.PURPOSE: Proper care of the trauma patient often includes tracheal intubation to insure adequate ventilation and oxygenation, protect the airway from aspiration, and facilitate surgery. airway management can be particularly complex when there are facial bone fractures, head injury and cervical spine instability. CLINICAL FEATURES: A 29-yr-old intoxicated woman suffered a motor vehicle accident. Injuries consisted of multiple abrasions to her head, forehead, and face, right temporal lobe hemorrhage, and complex mandibular fractures with displacement. mouth opening was <10 mm. blood pressure was 106/71 mm Hg, pulse 109, respirations 18, temperature 37.3 degrees C, SpO2 100%. Chest and pelvic radiographs were normal and the there was increased anterior angulation of C4-C5 on the cervical spine film. Drug screen was positive for cocaine and alcohol. The initial plan was to perform awake tracheostomy with local anesthesia. However, the patient was uncooperative despite sedation and infiltration of local anesthesia. Sevoflurane, 1%, inspired in oxygen 100%, was administered via face mask. The concentration of sevoflurane was gradually increased to 4%, and loss of consciousness occurred within one minute. The patient breathed spontaneously and required gentle chin lift and jaw thrust. A cuffed tracheostomy tube was surgically inserted without complication. Blood gas showed pH 7.40, PCO2 35 mm Hg, PO2 396 mm Hg, hematocrit 33.6%. Diagnostic peritoneal lavage was negative. Pulmonary aspiration did not occur. Oxygenation and ventilation were maintained throughout the procedure. CONCLUSION: Continuous mask ventilation with sevoflurane is an appropriate technique when confronted with an uncooperative trauma patient with a difficult airway.- - - - - - - - - - ranking = 1keywords = gas (Clic here for more details about this article) |
2/19. Fatal acute alcohol intoxication in an ALDH2 heterozygote: a case report.On an evening in November, a 25-year-old man was found dead in his bedroom. There were many empty snap-out sheets for flunitrazepam tablets in the trash at his bedside. He had been beaten by a gang of young people earlier in the morning of the same day. At the medico-legal autopsy, although there were many bruises and/or abrasions on the whole body, only slight subdural hemorrhage was observed, and none of them was thought to be the cause of death. flunitrazepam and its metabolites were not detected in his body fluid by gas chromatography-mass spectrometry (GC-MS). Marked lung edema and a severe congestion of organs were observed. His blood alcohol concentration from the femoral vein was 2.00 mg/ml. Fatal cases of acute alcohol intoxication usually have shown higher alcohol concentration (2.25-6.23 mg/ml). Although the genotype of aldehyde dehydrogenase 2 (ALDH2) has not previously been mentioned as a contributing factor in determining the cause of death, in this case the genotype of ALDH2 was ALDH2*1/2 and thus is important. Those who possess the ALDH2*2 gene show high concentrations of acetaldehyde (AcH) at even comparatively lower alcohol levels. Consequently, the cause of death was considered to be acute alcohol intoxication including AcH poisoning.- - - - - - - - - - ranking = 1keywords = gas (Clic here for more details about this article) |
3/19. Acute carbon monoxide poisoning and alcohol intoxication: a rare condition that is complex to manage.Since the changeover in the gas used in domestic appliances, the prevalence of acute carbon monoxide (CO) poisoning has been dramatically reduced. In suicide attempts with car exhaust fumes lies the most common cause of the disorder. As a consequence, patients are more complex to manage as they often have other associated diagnoses such as substance use disorder, depressive disorder, or long-standing personality disorder. This report details such a case. The medical treatment was based on the carboxyhemoglobin (COHgb) levels at the time of admission. The patient developed permanent cognitive and functional deficits consistent with the observed brain scan changes. The author discusses the importance of an appropriate early diagnosis of the condition, the difficulties associated with it, and the validity of using the carboxyhemoglobin levels as a guide to treatment.- - - - - - - - - - ranking = 1keywords = gas (Clic here for more details about this article) |
4/19. Bialaphos poisoning with apnea and metabolic acidosis.A 64-year-old man with ethanol intoxication, ingested a bottle of Herbiace (100 ml, 32 w/v% of bialaphos, CAS #35597-43-4, Meiji Seika Kaisha, tokyo, japan). He had severe metabolic acidosis and was treated with infusions of sodium bicarbonate and furosemide, plus gastric lavage and enema. The metabolic acidosis improved 15 hours after treatment but nystagmus, apnea and convulsions were progressive. Although his sensorium was clear, spontaneous respirations were not observed for 64 hours. The electroencephalographic findings of atypical triphasic waves and slow waves suggest a unique response to bialaphos poisoning. His clinical course indicates that the management of apnea is critically important to recovery from bialaphos poisoning.- - - - - - - - - - ranking = 1keywords = gas (Clic here for more details about this article) |
5/19. Clinical experience with the benzodiazepine antagonist flumazenil in suspected benzodiazepine or ethanol poisoning.The clinical efficacy of different doses of the specific benzodiazepine antagonist flumazenil was studied in a total of 72 patients with benzodiazepine or ethanol overdose. In a randomized double-blind study, 18 patients (group 1) and eight patients (group 2) with suspected benzodiazepine overdose received 5 mg (group 1) or 1 mg (group 2) flumazenil or placebo, respectively. The stage of coma, heart rate, blood pressure and respiratory rate were monitored within the following 15 min. If no change in the stage of coma was observed, 5 mg (group 1) or 1 mg (group 2) flumazenil were given, and the stage of coma, heart rate and blood pressure were again monitored. In a similar way, the effect of 5 and 1 mg flumazenil was investigated in 13 patients (group 3) and four patients (group 4) with ethanol intoxication. In an open trial, the clinical efficacy of flumazenil for the diagnosis of benzodiazepine or ethanol overdose was studied in 29 patients (group 5). In all patients, a toxicological screening confirmed benzodiazepine or ethanol overdose. None of the patients receiving placebo showed effects on stage of coma, heart rate, blood pressure or respiratory rate. patients with benzodiazepine overdose who received 5 mg flumazenil regained consciousness about 1-2 min after the end of injection. The effect of 1 mg flumazenil (group 2) on benzodiazepine-induced coma was less pronounced. In patients with ethanol overdose (group 3), ethanol-induced coma was reversed after 5 mg flumazenil more slowly than in patients of group 1. No effect of flumazenil on ethanol-induced coma was observed in group 4. In group 5, flumazenil proved to be useful for diagnosing benzodiazepine or ethanol intoxication. In one patient with coma due to carbamazepine overdose, flumazenil was also found to be effective. Additionally, a possible analytical interference of flumazenil and its metabolites with the identification of other benzodiazepines by a toxicological screening procedure was studied. Even after an oral dose of 200 mg flumazenil, no interference with immunological benzodiazepine assays (EMIT, TDX, and RIA) was found. A metabolite and an artifact of flumazenil could be identified in urine by gas chromatography/mass spectrometry.- - - - - - - - - - ranking = 1keywords = gas (Clic here for more details about this article) |
6/19. Differences between multisite postmortem ethanol concentrations as related to agonal events.In a study of postmortem ethanol concentrations, blood was withdrawn from the right atrium, ascending aorta, and inferior vena cava. These samples, vitreous humor, and gastric fluid were analyzed in 307 autopsies, where a minimum blood ethanol concentration of 0.05% weight/volume (w/v) was present. Premortem, agonal, and postmortem events were reviewed in an attempt to account for differences in blood ethanol concentrations between sites. The agonal aspiration of vomitus having at least 0.80% w/v ethanol appears to be associated with an increase in aortic ethanol concentrations. We conclude that valid interpretation of postmortem ethanol concentrations must take into consideration the possible entry of ethanol into the pulmonary venous circulation via the respiratory system.- - - - - - - - - - ranking = 1keywords = gas (Clic here for more details about this article) |
7/19. A fatal interaction of methocarbamol and ethanol in an accidental poisoning.A case is presented of a fatal drug interaction caused by ingestion of methocarbamol (Robaxin) and ethanol. methocarbamol is a carbamate derivative used as a muscle relaxant with sedative effects. Therapeutic concentrations of methocarbamol are reported to be 24 to 41 micrograms/mL. Biological fluids were screened for ethanol using the Abbott TDx system and quantitated by gas-liquid chromatography (GLC). Determination of methocarbamol concentrations in biological tissue homogenates and fluids were obtained by colorimetric analysis of diazotized methocarbamol. Blood ethanol concentration was 135 mg/dL (0.135% w/v) and urine ethanol was 249 mg/dL (0.249% w/v). methocarbamol concentrations were: blood, 257 micrograms/mL; bile, 927 micrograms/L; urine, 255 micrograms/L; gastric, 3.7 g; liver, 459 micrograms/g; and kidney, 83 micrograms/g. The combination of ethanol and carbamates is contraindicated since acute alcohol intoxication combined with carbamate usage can lead to combined central nervous system depression as a result of the interactive sedative-hypnotic properties of the compounds.- - - - - - - - - - ranking = 2keywords = gas (Clic here for more details about this article) |
8/19. Sleeping beauty: a case of pickwickian syndrome.The patient arriving at the emergency department with somnolence must be evaluated quickly, efficiently, and with a definite goal in mind. Head and neck trauma should always be suspected and protective steps taken in the unconscious patient. The coma mnemonic, AEIOU TIPS, (alcohol, epilepsy, insulin, overdose, uremia, trauma, infection, psychiatric, stroke) provides an excellent memory tool for the evaluation of decreased level of consciousness in the emergency setting. Interventions that provide diagnostic and therapeutic results (naloxone and 50% dextrose) should be initiated immediately while blood samples are drawn for pretreatment documentation. Each of the possible causes of lethargy or somnolence needs to be evaluated with the understanding that a multitude of factors may be present in the patient whose condition precludes a thorough history; the depressed diabetic may have taken an overdose of medications in addition to his insulin. Social preconceptions may also effect the outcome. The intoxicated patient described herein was allowed to "sleep it off" in the emergency department under the watchful eyes (and ears) of a nursing staff who faithfully recorded vital signs and pupil reactivity as the patient's blood gas values deteriorated.- - - - - - - - - - ranking = 1keywords = gas (Clic here for more details about this article) |
9/19. fluoxetine overdose: a case report.A fatality due to the ingestion of fluoxetine and ethanol is reported. Quantitation of the drug and its active normetabolite was accomplished by gas chromatography with a flame ionization detector. Identification of the compounds was performed by gas chromatography/mass spectrometry. tissue distribution of fluoxetine and norfluoxetine, as well as analytical details, is presented.- - - - - - - - - - ranking = 2keywords = gas (Clic here for more details about this article) |
10/19. survival of a child despite unusually high blood ethanol levels.A 30-month-old, 13-kg child reportedly ingested up to 16 ounces of a wine containing 20% ethanol. The child was brought into the emergency department by paramedics, and upon arrival was found to be comatose and unresponsive to deep stimuli but breathing spontaneously. The patient remained unconscious and unresponsive for three hours after admission. Despite an initial blood ethanol level of 98.78 mmol/L (455 mg/dL), recovery was complete without sequelae. Treatment consisted of prompt gastric decontamination and maintenance of adequate hydration and euglycemia. Elimination of ethanol was rapid in this child and appeared to follow first-order kinetics instead of the zero-order kinetics usually observed. To our knowledge, this is the highest initial blood ethanol level reported in a child with survival. Additionally, no significant metabolic or cardiorespiratory derangement occurred. ethanol toxicity, elimination kinetics, and treatment are discussed.- - - - - - - - - - ranking = 1keywords = gas (Clic here for more details about this article) |
| | Next -> |