PURPOSE: Ingestion of puffer fish can be poisonous due to the presence of potent neurotoxins such as tetrodotoxin (TTX) found in its tissues. There are few clinical reports related to TTX. We performed this study to evaluate the clinical characteristics of TTX poisoning. METHODS: We conducted a retrospective study of the 41 patients diagnosed with TTX poisoning who visited the Seoul Asan medical center from July 2004 and December 2010. A review of patients'electronic medical records and patient telephone interviews were conducted. Diagnosis of TTX poisoning was confirmed by observing the casual link between puffer fish consumption and the development of typical TTX intoxication symptoms. RESULTS: The mean age of the patients included in the study was 46.6 years. The highest incidence of intoxication was observed in patients in their 50s (10 patients). Seasonal distribution of intoxication events included 10 in spring, 7 in summer, 10 in fall, and 14 in winter. In most cases, symptoms occurred within 1 hour of ingestion. A wide range of symptoms were associated with puffer fish ingestion affecting multiple body systems including neuromuscular (27 patients), gastrointestinal (19 patients), and cardiopulmonary/vascular (19 patients). All patients were treated with symptomatic and supportive therapy and recovered completely, without sequelae, within 48 hours. In three cases, ventilator support was required. CONCLUSION: TTX poisoning is not seasonally related, and patients admitted to the emergency room were observed with a wide range of symptoms. Where TTX poisoning is diagnosed, supportive therapy should be performed. Early intubation and ventilation is important, especially is cases of respiratory failure.
Aluminum Hydroxide ; Carbonates ; Eating ; Emergencies ; Humans ; Incidence ; Interviews as Topic ; Intubation ; Medical Records ; Neurotoxins ; Respiratory Insufficiency ; Retrospective Studies ; Seasons ; Tetraodontiformes ; Tetrodotoxin ; Ventilation ; Ventilators, Mechanical

We report two cases of toxic methemoglobinemia caused by an inert ingredient in pesticide product after intentional ingestion of pesticide. First, 51-year-old male visited to the emergency department (ED) after the ingestion of pesticide in a suicide attempt. Initial methemoglobin (MetHb) level was 25.6%. We did not know the cause of methemoglobinemia at that time. Second, 56-year-old female visited to the ED after the ingestion of the same pesticide in a suicide attempt. MetHb level after 30 minutes was 16.1%. The patients were treated with methylene blue. We contacted to the Korean Rural Development Administration and estimated that magnesium nitrate was more likely to cause methemoglobinemia. This report highlights the importance of considering the possibility of methemoglobinemia caused by inert ingredient in pesticide and early antidotal therapy.
Eating* ; Emergency Service, Hospital ; Female ; Humans ; Magnesium ; Male ; Methemoglobin ; Methemoglobinemia* ; Methylene Blue ; Middle Aged ; Pesticides ; Social Planning ; Suicide

BACKGROUND: The prevalence and prognostic value of overt disseminated intravascular coagulation (DIC) in patients with septic shock presenting to emergency departments (EDs) is poorly understood, particularly following the release of a new definition of septic shock. The purpose of this study was to investigate the prevalence and prognostic value of DIC in septic shock. METHODS: We performed retrospective review of 391 consecutive patients with septic shock admitting to the ED of tertiary care, university-affiliated hospital during a 16-month. Septic shock was defined as fluid-unresponsive hypotension requiring vasopressor to maintain a mean arterial pressure of 65 mmHg or greater, and serum lactate level ≥ 2 mmol/L. Overt DIC was defined as an International Society on Thrombosis and Hemostasis (ISTH) score ≥ 5 points. The primary endpoint was 28-day mortality. RESULTS: Of 391 patients with septic shock, 290 were included in the present study. The mean age was 65.6 years, the 28-day mortality rate was 26.9%, and the prevalence of overt DIC was 17.6% (n = 51) according to the ISTH score. The median DIC score was higher in non-survivors than in survivors (5.0 vs. 2.0, p = 0.001). Significant higher risk of mortality was observed in overt DIC patients compared to those without (28.2% vs. 13.7%, p = 0.005). Multivariable logistic regression analysis identified DIC to be independently associated with 28-day mortality (odds ratio, 2.689 [95% confidence interval, 1.390-5.201]). CONCLUSIONS: Using the ISTH criteria of DIC, overt DIC in septic shock was found to be common among patients admitting to the ED and to be associated with higher mortality when it is accompanied with septic shock. Efforts are required to identify presence of overt DIC during the initial treatment of septic shock in patients presenting the the ED.
Arterial Pressure ; Consensus* ; Dacarbazine ; Disseminated Intravascular Coagulation* ; Emergencies* ; Emergency Service, Hospital* ; Hemostasis ; Humans ; Hypotension ; Lactic Acid ; Logistic Models ; Mortality ; Prevalence* ; Retrospective Studies ; Shock, Septic* ; Survivors ; Tertiary Healthcare ; Thrombosis

Aconitine is an anti-inflammatory agent with therapeutic uses in oriental medicine as an analgesic and for treatment of stroke. Because of its sodium channel effect, aconitine can promote undesirable, wide complex tachyarrhythmia. If tachycardia develops during use of aconitine, class Ia and class III anti arrhythmic drugs can be utilized for treatment. However there are no single anti-arrhythmia agents which are uniformly effective. We report a case, characterized by wide complex tachyarrhythmia and severe hypotension, which was successfully treated by simultaneous injections of amiodarone and lidocaine. A 59-year-old woman exhibiting clinical signs of drowsiness as a result of ingesting 6 g of aconitine, was admitted to the emergency department. Initially, wide complex tachyarrhythmia (ventricular tachycardia and pulse rate of 180 beats/min) and severe hypotension (blood pressure of 53/26 mmHg) was observed. After simultaneous injection of amiodarone and lidocaine, the patient's rhythm pattern changed to an accelerated junctional rhythm with ventricular premature complex. Two hours later, the patient's heart pattern became a sinus rhythm. As demonstrated by this case, simultaneous injections of amiodarone and lidocaine can be useful in treating ventricular arrhythmia induced by aconitine.
Aconitine ; Amiodarone ; Anti-Arrhythmia Agents ; Arrhythmias, Cardiac ; Emergencies ; Female ; Heart ; Heart Rate ; Humans ; Hypotension ; Lidocaine ; Medicine, East Asian Traditional ; Middle Aged ; Sleep Stages ; Sodium Channels ; Stroke ; Tachycardia ; Tachycardia, Ventricular ; Therapeutic Uses ; Ventricular Premature Complexes

BACKGROUND/AIMS: Esophageal perforation is a rare but often a life-threatening condition. However, the incidence and clinical features of esophageal perforation caused by ingested foreign body are unknown. This study investigated the incidence of esophageal perforation caused by ingested foreign body and evaluated the clinical features and outcome of patients with esophageal perforation. METHODS: Among a total of 196 adult patients with confirmed esophageal foreign body and complained of at least one of the related symptoms at the emergency department between January 2000 and July 2008, 18 patients with esophageal perforation due to esophageal foreign body ingestion were included in the study. Data were collected by retrospectively reviewing the electric medical records. RESULTS: The incidence of esophageal foreign body and esophageal perforation in adults was 19.4% (196/1,009) and 1.8% (18/1,009), respectively. Chest pain was the most common symptom and fishbone was the most common foreign body causing esophageal perforation. Mediastinitis or mediastinal abscess occurred in 13 patients (13/18, 72.2%). About half (8/18) of the patients were admitted to the intensive care unit but there was no in-hospital mortality. CONCLUSIONS: The incidence of esophageal perforation in patients with foreign body ingestion was low but it increased up to 9.2% in patients with esophageal foreign body. However, prognosis was favorable with timely proper treatment. Chest pain can be an ominous sign indicating the presence of esophageal perforation in patients with esophageal foreign body.
Aged ; Chest Pain/etiology ; Emergency Medical Services ; Esophageal Perforation/*diagnosis/epidemiology/etiology ; Female ; Foreign Bodies/*complications ; Humans ; Incidence ; Intensive Care Units ; Male ; Middle Aged ; Prognosis ; Retrospective Studies

PURPOSE: The aim of this study was to evaluate the clinical characteristics and outcome of patients who presented to the emergency department (ED) with cardiotoxicity caused by ingestion of Himalayan mad honey. METHODS: Medical records of 12 patients who presented to the ED from January 1, 2005 to December 31, 2012 with cardiotoxicity caused by ingestion of Himalayan mad honey were retrospectively reviewed. RESULTS: The mean age of patients was 54.5 years and 58.3% were men. The median amount of mad honey ingested was 30.0 cc, and the mean time from ingestion to onset of symptoms was 39.4 minutes. All patients had hypotension and bradycardia upon arrival in the ED. The initial electrocardiogram showed sinus bradycardia in seven patients, junctional bradycardia in four patients, and atrial fibrillation with slow ventricular response in one patient. Four patients were treated with intravenous normal saline solution only. Eight patients were treated with intravenous normal saline solution and atropine sulfate in a dose ranging from 0.5 to 2.0 mg. Blood pressure and pulse rate returned to normal limits within 24 hours in all patients. CONCLUSION: Our study showed that all patients with cardiotoxicity caused by ingestion of Himalayan mad honey had severe hypotension, bradycardia, and bradyarrythmias, including sinus bradycardia and junctional bradycardia and all patients responded well to conservative treatment, including intravenous normal saline solution and intravenous atropine sulfate.
Atrial Fibrillation ; Atropine ; Blood Pressure ; Bradycardia ; Eating ; Electrocardiography ; Emergencies ; Heart Rate ; Honey* ; Humans ; Hypotension ; Male ; Medical Records ; Poisoning ; Retrospective Studies ; Sodium Chloride

PURPOSE: Acute cardiac dysfunction is a well recognized manifestation of organ failure in severe sepsis and septic shock. Although echocardiography is the golden standard for the evaluation of cardiac dysfunction, it is difficult to use in the emergency department (ED). The purpose of this study was to determine the availability of cardiac biomarkers for the estimation of cardiac dysfunction in septic shock patients. METHODS: All study subjects included consecutive patients with septic shock diagnosed in the ED and treated with an algorithm of early goal-directed therapy between January 2011 and June 2012. We enrolled patients measured for cardiac biomarkers and performed echocardiography within 24 hours. We divided patients into two groups based on the occurrence of left ventricular dysfunction (defined as an ejection fraction< or =40%) and compared serum levels of troponin-I (TnI) and B-type natriuretic peptide (BNP) between the two groups. The area under the receiver operating characteristic (ROC) curve was used to compare the diagnostic ability of TnI and BNP. RESULTS: A total of 127 patients with septic shock and evaluated for cardiac dysfunction were enrolled in this study. TnI and BNP were significantly higher in the left ventricular dysfunction group group (4.2+/-9.0 vs. 0.6+/-1.8 ng/mL, respectively, p<0.05) compared with the non-dysfunction group (1087.6+/-680.1 vs. 633.2+/-859.1 pg/mL, respectively, p<0.05). However, in the ROC curve for predicting left ventricular dysfunction, the area under the curves of TnI and BNP, respectively, were 0.631(95% CI 0.473-0.788, p=0.103) and 0.704 (95% CI 0.552-0.856, p=0.011). TnI and BNP showed a 84.6% negative predictive value. CONCLUSION: Although TnI and BNP were significantly higher in septic shock patients with cardiac dysfunction but demonstrated limited accuracy compared to echocardiography. However, TnI and BNP have high negative predictive value in septic shock patients for the evaluation of cardiac dysfunction. Therefore they could serve as a valuable supplement for the detection of cardiac dysfunction.
Biomarkers ; Echocardiography ; Emergencies ; Humans ; Natriuretic Peptide, Brain ; ROC Curve ; Sepsis ; Shock, Septic ; Troponin I ; Ventricular Dysfunction, Left

Antidotes for toxicological emergencies can be life-saving. However, there is no nationwide estimation of the antidotes stocking amount in Korea. This study tried to estimate the quantities of stocking antidotes at emergency department (ED). An expert panel of clinical toxicologists made a list of 18 emergency antidotes. The quantity was estimated by comparing the antidote utilization frequency in a multicenter epidemiological study and the nation-wide EDs' data of National Emergency Department Information System (NEDIS). In an epidemiological study of 11 nationwide EDs from January 2009 to December 2010, only 92 (1.9%) patients had been administered emergency antidotes except activated charcoal among 4,870 cases of acute adult poisoning patients. Comparing with NEDIS data, about 1,400,000 patients visited the 124 EDs nationwide due to acute poisoning and about 103,348 adult doses of the 18 emergency antidotes may be required considering poisoning severity score. Of these, 13,224 (1.9%) adult doses of emergency antidotes (575 of atropine, 144 of calcium gluconate or other calcium salts, 2,587 of flumazenil, 3,450 of N-acetylcysteine, 5,893 of pralidoxime, 287 of hydroxocobalamin, 144 of sodium nitrite, and 144 of sodium thiosulfate) would be needed for maintaining the present level of initial treatment with emergency antidotes at EDs in Korea.
Acute Disease ; Antidotes/*supply & distribution/therapeutic use ; Databases, Factual ; Emergency Service, Hospital ; Humans ; Poisoning/*drug therapy ; Republic of Korea

PURPOSE: The aim of this study was to describe the epidemiologic characteristics of adult patients with carbon monoxide poisoning who presented to the emergency department in recent years. METHODS: This was a retrospective cohort study on adult consecutive patients with carbon monoxide (CO) poisoning who presented to the emergency department of a tertiary care university-affiliated hospital from January 1, 2008 to December 31, 2011. RESULTS: A total of 91 patients were included in this study; there were 56(61.5%) unintentional and 35(38.5%) intentional poisonings. For the unintentional CO poisonings, the principal sources of exposure to CO were fire (39.3%), charcoal (17.9%), briquette charcoal (7.1%), wood burning boiler (7.1%), gas boiler (5.4%), automobile heater (3.6%), briquette boiler (3.6%), firewood (3.6%), and other items (12.5%). For the intentional CO poisonings, the sources were ignition charcoal (60.0%), briquette (31.4%), charcoal (5.7%) and butane gas (2.9%). For the unintentional CO poisonings, the places of poisoning were the home (58.9%), workplace (10.7%), public accommodation (8.9%), tent (8.9%), automobile (3.6%) and parking place (1.8%). For the intentional CO poisonings, the places of poisoning were the home (77.1%), public accommodation (11.4%) and automobile (11.4%). The proportion of intentional CO poisonings among total poisonings has increased significantly in recent years; 0.0% in 2008, 3.3% in 2009, 5.5% in 2010, and 29.7% in 2011. CONCLUSION: This study showed that in recent years in Korea, the source of CO has diversified broadly and intentional CO poisonings from burning ignition charcoal or briquettes has increased. Prevention efforts should consider these factors.
Adult ; Automobiles ; Burns ; Butanes ; Carbon ; Carbon Monoxide ; Carbon Monoxide Poisoning ; Charcoal ; Cohort Studies ; Emergencies ; Fires ; Humans ; Hypogonadism ; Korea ; Mitochondrial Diseases ; Ophthalmoplegia ; Retrospective Studies ; Tertiary Healthcare ; Wood

PURPOSE: Spontaneous intestinal intramural hematoma (SIMH) is a very rare complication of anticoagulation. Most reports on SIMH have been case reports and case series, not well-established clinical studies. Therefore, the aim of this study was to evaluate the clinical characteristics and outcomes from SIMH. METHODS: A retrospective review of the records of 48 patients with non-traumatic SIMH was performed at an urban academic tertiary hospital between January 2001 and December 2012. These patients were diagnosed with SIMH by computed tomography and confirmed by a radiology specialist. Their clinical characteristics and outcomes from SIMH were determined. RESULTS: Among all SIMH cases, the percentage of warfarin users was 70.8%. The median age at presentation was 66.5 years, whereas warfarin users were older (68.0 years) than non-users (55.0 years) (p<0.01). SIMH patients had abdominal pain (81.3%), nausea and vomiting (50.0%) and 62.5% of them had abdominal tenderness. The most frequently involved site was the small bowel (85.4%) and there was only one patient with bowel obstruction from SIMH. A total of 33(68.6%) patients were admitted for 9.3 days for conservative treatment, including transfusion. On the other hand, two patients had surgical intervention. There were no mortality cases from SIMH during the study period. CONCLUSION: SIMH is rare disease which can treated with supportive care. However, it can cause severe complications, such as bowel obstruction and perforation, requiring surgical intervention. Therefore, emergency physicians have to consider SIMH carefully, especially in patients treated with an anticoagulation agent.
Abdominal Pain ; Emergencies ; Hand ; Hematoma* ; Humans ; Intestines ; Mortality ; Nausea ; Rare Diseases ; Retrospective Studies ; Specialization ; Tertiary Care Centers ; Vomiting ; Warfarin