Encounters with Venomous Sea-Life

Background: Sea-life with envenomation capabilities are quite abundant and diverse worldwide, being predominantly found in tropical waters. Most envenomations occur not as an attack, but as a result of self defense when the animal perceives danger; and often when locals or tourists are engaged in recreational activities. Most of these cases have only minor injuries, and few are fatal. Objectives: To describe the impact, clinical features, and management of life-threatening marine envenomations. Discussion: Recognition of the injury and identification of the responsible animal is crucial for quick and successful management. Medical professionals should be cognizant of presenting symptoms such as respiratory distress, muscle paralysis, or cardiovascular decompensation. For these patients, antivenom should be given immediately if available, followed by pharmacological and physical therapy to relieve symptoms and pain. If any foreign bodies are left at the site of the injury, they must be removed. Tetanus prophylaxis should also be considered in case of puncture, and if signs of early infection are present, broad-spectrum antibiotics should be administered. Conclusion: Management of envenomations from marine animals should be emphasized not only to health centers, but also to the general population, so that initial treatment can be started as soon as possible. Educational programs regarding risks and initial management for these incidents are also recommended to reduce the incidence and associated morbidity and mortality of the encounters.     

Tracheal intubation prevented with administration of Fab antivenom after severe crotaline envenomation

Background: Crotaline snake envenomations are common, but severe crotaline envenomations are infrequent. Death from severe envenomation is usually from upper airway edema and respiratory failure. Published reports of severe respiratory compromise and anaphylactoid reactions are rare. Currently, FabAV (Crotalidae polyvalent immune Fab [Ovine] [CroFab]) is the mainstay of crotaline envenomation treatment; however, FabAV has been approved for only mild and moderate envenomations. Case report: We describe a case of a male with severe systemic effects and airway compromise after crotaline envenomation. The patient's systemic effects and upper airway edema substantially improved after antivenom infusion and before epinephrine administration. Endotracheal intubation was averted, clinical deterioration was avoided, and improvement occurred after prompt FabAV use. Conclusion: Fab antivenom likely prevented endotracheal intubation in our case of severe crotaline envenomation.     

Ion Channels, the QT Interval, and Arrhythmias

Aberrations in genes encoding for ion channels have been shown to underlie a number of cardiac arrhythmia syndromes, hitherto classified as idiopathic. These aberrations, inherited and congenital, may lead to dysfunction of channels with resultant abnormal current characteristics. In addition, a variety of stimuli may cause altered expression of these genes. Because prolongation of the action potential (and the QT-interval) is often the result, patients are at risk for the occurrence of arrhythmias based on reentry and the development of abnormal impulse initiation. Molecular dissection of the inherited syndromes hus led to rapid progress in our understanding of basic knowledge about ion channel function and its relation to channel structure. This progress is undoubtly of benefit for the understanding of the repolarization changes in more common conditions and will become of benefit to many more patients who suffer from therapy resistant arrhythmias.     

Spinal pain syndromes: nociceptive, neuropathic, and psychologic mechanisms.

BACKGROUND: Pain continues to be the main symptom reported by patients. Frequently, clinicians incorrectly diagnose patients and resulting treatments are ineffective, which may promote the development of chronic pain. This situation may arise as a result of a lack of clarity in the literature regarding pain syndromes. OBJECTIVE: To discuss the differences between nociceptive, neuropathic, and psychologic induction of pain and provide important clinical correlates to aid in diagnosis and treatment. DATA SOURCES: The data were accumulated over a period of years by reviewing contemporary articles and books and subsequently retrieving relevant papers. Articles also were selected from MEDLINE searches and from manual library searches. DATA SYNTHESIS: Nociceptive pain syndromes are responsible for the majority of pain complaints in clinical practice. Care must be taken to avoid the common mistake of the diagnosis of neuropathic pain, which can lead to inappropriate treatments. CONCLUSION: Although the treatment of neuropathic pain is difficult, sufficient evidence in the literature demonstrates that the treatment of nociceptive pain should be multimodal and involve spinal manipulation, muscle lengthening/stretching, trigger point therapy, rehabilitation exercises, electrical modalities, a variety of nutritional factors, and mental/emotional support.     

Inotropic agents. Catecholamines, digoxin, amrinone

Three broad categories of pharmacologic support that enhance myocardial contractility and modify organ blood flow are reviewed. Appropriate selection among these compounds will minimize the occurrence of adverse effects. The catecholamines increase cardiac work and myocardial oxygen demand. In the setting of a failing ventricle, the increase in oxygen requirement may be balanced by improved coronary blood flow. Problems associated with catecholamines include tachycardia, induction of dysrhythmias, and unsuitable vasoconstriction. Epinephrine and isoproterenol are most likely to increase heart rate excessively. Norepinephrine is most likely to be associated with poor tissue perfusion. Amrinone, a bipyridine, has a favorable effect on oxygen balance in the failing ventricle and is unlikely to produce tachycardia or dysrhythmias. Principal concerns are the potential for accumulation in the patient with multiple organ system failure and the lack of pharmacokinetic information in critically ill patients, including children. Thrombocytopenia may be a problem as well. Digitalis glycosides are venerable drugs. Acute and chronic toxicity are problems that the intensivist is called on to treat frequently. Therapy with digitalis Fab fragments is now routine for severe intoxications and should improve outcome.     

Pathophysiology of inflammatory,degenerative, and compressive radiculopathies

In answering the patient's question regarding how treatments are likely to "help [her] herniated disc," the mechanical and chemical components of radiculopathy should be addressed. Focal disc abnormalities often can be observed in those without pain, and symptomatic discs can become asymptomatic. Disc lesions can resolve radiologically with time, and patients' symptoms can improve before their radiographs. The literature reviewed in this article suggests that the best opportunity to offer therapies that address the chemical component of injury might be in those patients with acute disc pathology. In the case of degenerative stenosis, gradually evolving mechanical stressors may comprise the primary component of injury. In other instances, patients with radiographic evidence of neural foraminal or lumbar central stenosis may become symptomatic secondary to a superimposed mechanochemical injury. Such stressors can include a focal disc protrusion, leaking nuclear material from an annular tear, or synovial fluid from an adjacent arthrotic zygapophyseal joint. In these patients, the successful treatment of the acute injury process might allow the affected neural elements to return to their state of accommodation in an environment of gradually evolving mechanical compromise. A growing body of literature has helped clinicians to better understand the mechanisms behind radicular disorders. As spine clinicians, we should strive to educate our patients so that they may become more knowledgeable consumers of spine care. As the components of radicular pathology are elucidated further, new biochemical therapies will likely evolve. Similarly, there will probably always be a subset of patients who will require mechanical decompression, and some of these individuals should be offered such treatment without delay. There may a time in the radicular injury process at which a window of opportunity for treatment begins to close. After this point, any therapy offered will not be as likely to result in a more complete symptomatic response. Patients with chronic radicular pain may have neural structural insults and an increased sensitivity of the somatosensory system. Clinicians should strive to avoid this end stage of neural injury, which is less reversible from a chemical or mechanical standpoint and may respond only to chronic pain management modalities.     

Assessment of health-related quality of life.

In addition to mortality, morbidity, and patient satisfaction, health-related quality of life (HRQOL) is an outcome of health care as well as a consequence of illness or injury. Consequently, instruments to assess HRQOL have become important outcome measures for the evaluation of health care. The last 2 decades have seen the development of hundreds of HRQOL instruments, which are increasingly being incorporated in clinical trials. However, for HRQOL instruments to be valid outcome measures, a variety of factors must be addressed, including conceptual and methodological issues. In addition, there must be careful selection and thoughtful administration. The present report discusses these issues in addition to the scoring and interpretation considerations for the valid assessment of HRQOL. We provide an overview of generic, disease-specific, and utility measures. Using disease-specific instruments pertinent to respiratory care, we discuss their validity, reliability, responsiveness, and minimum clinically important difference. We conclude with recommendations regarding which HRQOL tools have documented evidence that they are psychometrically sound for application to research and clinical practice in respiratory care.     

Role of anti-C1q autoantibodies in the pathogenesis of lupus nephritis

Anti-C1q autoantibodies can be found in the sera of patients with several autoimmune diseases, but also in healthy individuals. Although these anti-C1q autoantibodies were already identified several decades ago, they still puzzle both immunologists and nephrologists. The main reason for this puzzling effect are observations that seemed to indicate quite clearly that anti-C1q should be pathogenic to the kidney and the observation on the other hand that anti-C1q autoantibodies can be found in several disease conditions, as well as in healthy individuals, and are then unrelated to overt renal inflammation. This puzzle is the focus of the current review, which will provide an overview of the historical data, define the clinical interests and, importantly, will try to put several aspects in perspective based on recent observations in patients and in murine models. In addition, the paper will discuss therapeutic intervention possibilities regarding anti-C1q-mediated damage in systemic lupus erythematosus, as well as the therapeutic potential of anti-C1q antibodies in other conditions.     

Criminal clozapine intoxications

The paper deals with the topical problem--study criminal clozapine intoxications that have recently ranked first in the total structure of criminal intoxications, by ousting poisoning by clofelin. Thus, in 2004 to 2006, the number of victims taken to the Prof. A. A. Ostroumov Moscow City Hospital No. 33 increased by 1.9 times, by amounting to 1120 cases in 2006. At the same time, its correct prehospital diagnosis was made only in 1.76% of the victims. Abundant clinical material (2720 cases) has been analyzed, by using the currently performed studies. The specific features of the development and clinical manifestations of these intoxications, including those concurrent with alcoholic intoxication, are described in detail. The characteristic manifestations of impaired consciousness, hypersalivation, and myosis in the absence of generally, respiratory failure and hemodynamic disorders, as well as altered clinical and biochemical blood parameters are shown. At the same time there were elevated ammonia levels within the first hours after intoxication, which, in the authors' opinion, may suggest the development of hepatic dysfunction. Emphasis is laid on the fact that the leading component in the complex of medical measures is the administration of central anticholinesterase agents (aminostigmine and galantamine hydrobromide) that may be used as an antidote and for the differential diagnosis of these intoxications.     

Biological Evaluation of Hemoperfusion in Acute Poisoning

Abstract

Hemoperfusion with cartridges of coated activated charcoal or resins in acute intoxications has several theoretical indications that have been established by previous studies [1-5]: intoxication must be massive, the extracellular distribution of the drug must be high, the intoxicants must be measurable, and hemoperfusion should take place when the plasma level is maximum. For the physician working in intensive care units, complications do not appear as an additive indication: respiratory depression and cardiac failure or convulsions require immediate aggressive supportive treatment.     

Nonsteroidal anti-inflammatory drug-induced acute respiratory distress syndrome

Drug induced acute respiratory distress syndrome (ARDS) is a common clinical condition. Patients typically present with noncardiogenic pulmonary edema. Large number of ARDS cases reported induced by antineoplastic drugs and other drug intoxications. The pathophysiologic mechanisms of drug induced ARDS remains unknown. One of the postulated mechanisms of drug induced ARDS is anaphylaxis. We present a case of acute respiratory distress syndrome complicated by anaphylactic shock after use of two different nonsteroidal antiinflammatory drugs (NSAID). To the best of our knowledge, ARDS following normal doses of NSAID ingestion has not been reported previously. The case showed that ARDS may occur after ingestion of therapeutic doses of NSAID. NSAID ingestion should be considered in the differential diagnosis of patients with non-cardiogenic pulmonary edema.     

Multimodal analgesia in crotalid snakebite envenomation: A novel use of femoral nerve block

Snakebite envenomations occur throughout the United States, with most envenomations resulting from Crotalid bites. These envenomations can result in severe pain despite aggressive analgesia due to effects of venom toxins. We report a case in which we treated a 44- year-old man who sustained a Copperhead (Agkistrodon contortrix) bite to his left hallux with progressive local toxicity, including severe pain radiating into his upper leg, without evidence of compartment syndrome or coagulopathy. His pain was unresponsive to multiple doses of opioids.We performed a fascia iliaca compartment femoral nerve block under dynamic ultrasound guidance with 20?mL of 0.25% bupivacaine, which provided substantial pain relief in his upper leg. To our knowledge, this is a novel application of regional anesthesia with peripheral nerve block. We demonstrate fascia iliaca compartment femoral nerve block may be a safe, beneficial technique for emergency physicians to utilize in providing multimodal analgesia in Crotalid envenomation.     

Requirements for infection control during surgery

Infections of the surgical site following surgery may compromise the outcome of surgery and may under certain circumstances even endanger the life of the patient. Therefore, hospital epidemiology plays an important role in various surgical fields of medicine by developing guidelines and recommendations for the prevention of surgical site infections. In addition, surveillance of patients regarding the development of surgical site infections should be another important component of infection control activities in all hospitals. In order to develop appropriate guidelines and to perform surveillance in surgery, it is important to utilize uniform definitions of surgical site infections and to know the pathogenesis and risk factors of surgical site infections. Knowledge in this field has increased dramatically over the course of the last several decades and has resulted in the creation of guidelines for prevention, their implementation, and revision. The current review will summarize the state-of-the-art of the requirements for infection control. The recommendations will be grouped according to their respective timing during the course of a surgical procedure, which includes a pre- as well as a postoperative phase in addition to the intraoperative phase. Despite the significant progress that has been achieved in this field, some issues remain unresolved. Among these, the practical implementations of nasal decolonization regarding S. aureus prior to surgery and improvement of glucose control during surgery in patients with diabetes are mentioned as examples for unfinished work, which awaits further research.     

Nucleic acid amplification-based diagnosis of respiratory virus infections

The appearance of eight new respiratory viruses in the human population in the past 9 years, including two new pandemics (SARS coronavirus in 2003 and swine-origin influenza A/H1N1 in 2009), has tested the ability of virology laboratories to develop diagnostic tests to identify these viruses. Nucleic acid amplification tests (NATs) that first appeared two decades ago have been developed for both conventional and emerging viruses and now form the backbone of the clincical laboratory. NATs provide fast, accurate and sensitive detection of respiratory viruses and have significantly increased our understanding of the epidemiology of these viruses. Multiplex PCR assays have been introduced recently and several commercial tests are now available. The final chapter in the evolution of respiratory virus diagnostics will be the addition of allelic discrimination and detection of single nucleotide polymorphisms associated with antiviral resistance to multiplex assays. These resistance assays together with new viral load tests will enable clinical laboratories to provide physicians with important information for optimal treatment of patients.     

Nucleic acid amplification-based diagnosis of respiratory virus infections

The appearance of eight new respiratory viruses in the human population in the past 9 years, including two new pandemics (SARS coronavirus in 2003 and swine-origin influenza A/H1N1 in 2009), has tested the ability of virology laboratories to develop diagnostic tests to identify these viruses. Nucleic acid amplification tests (NATs) that first appeared two decades ago have been developed for both conventional and emerging viruses and now form the backbone of the clinical laboratory. NATs provide fast, accurate and sensitive detection of respiratory viruses and have significantly increased our understanding of the epidemiology of these viruses. Multiplex PCR assays have been introduced recently and several commercial tests are now available. The final chapter in the evolution of respiratory virus diagnostics will be the addition of allelic discrimination and detection of single nucleotide polymorphisms associated with antiviral resistance to multiplex assays. These resistance assays together with new viral load tests will enable clinical laboratories to provide physicians with important information for optimal treatment of patients.     

Diffuse alveolar hemorrhage

Diffuse alveolar hemorrhage (DAH) is a life-threatening disorder characterized clinically by the presence of hemoptysis, falling hematocrit, diffuse pulmonary infiltrates and hypoxemic respiratory failure. It refers to bleeding that originates in the pulmonary microvasculature instead of the parenchyma or bronchial circulation. DAH should be considered a medical emergency due to the morbidity and mortality associated with failure to treat the disorder promptly. Pulmonary renal syndromes, connective tissue disorders and drugs make up the majority of the cases of DAH. The treatment of DAH ranges from supportive care and withdrawal of offending drugs to high-dose steroids, immunosuppresents and plasmapharesis. The following review will discuss the clinical, radiographic and pathologic findings in a variety of disorders that cause DAH. Standard treatment options, as well as new treatment options will also be discussed.     

The Role of Complement in Transfusion-Related Acute Lung Injury

Transfusion-related acute lung injury (TRALI) is a life-threatening complication of acute respiratory distress occurring within 6 hours of blood transfusion. TRALI is one of the leading causes of transfusion-related fatalities and specific therapies are unavailable. Neutrophils are recognized as the major pathogenic cells, whereas T regulatory cells and dendritic cells appear to be important for protection against TRALI. The pathogenesis, however, is complex and incompletely understood. It is frequently postulated that the complement system plays an important role in the TRALI pathogenesis. In this article, we assess the evidence regarding the involvement of complement in TRALI from both human and animal studies. We hypothesize about the potential connection between the complement system and neutrophils in TRALI. Additionally, we draw parallels between TRALI and other acute pulmonary disorders of acute lung injury and acute respiratory distress syndrome regarding the involvement of complement. We conclude that, even though a role for complement in the TRALI pathogenesis seems plausible, studies investigating the role of complement in TRALI are remarkably limited in number and also present conflicting findings. Different types of TRALI animal models, diverse experimental conditions, and the composition of the gastrointestinal microbiota may perhaps all be factors which contribute to these discrepancies. More systematic studies are warranted to shed light on the contribution of the complement cascade in TRALI. The underlying clinical condition of the patient, which influences the susceptibility to TRALI, as well as the transfusion factor (antibody-mediated vs non–antibody-mediated), will be important to take into consideration when researching the contribution of complement. This should significantly increase our understanding of the role of complement in TRALI and may potentially result in promising new treatment strategies.     

Surge capacity mechanical ventilation

Mechanical ventilation in a situation of mass casualty respiratory failure will require a substantial increase in the capacity for mechanical ventilation, to prevent unnecessary mortality. Concern over the difficulties of treating large numbers of patients with respiratory failure is exceeded only by our lack of experience on which to base decisions. This review evaluates the likely scenarios that could lead to mass casualty respiratory failure and the types of respiratory failure anticipated. A literature review was conducted, using the National Library of Medicine Medical Subject Headings terms "mass casualty respiratory failure," "pandemic flu," "disaster preparedness," and "mass casualty care." Papers were reviewed for relevance to the topic. There is little historical or empirical evidence upon which to base decisions regarding mass casualty respiratory failure and augmenting positive-pressure ventilation capacity. Matching the degree of respiratory impairment anticipated from the most likely mass casualty scenarios allows conclusions to be drawn regarding the performance characteristics of ventilators required for these situations. Little is known about the success of mechanical-ventilator stockpiling for mass casualty respiratory failure. Careful planning with an emphasis on matching ventilator performance to patient need and caregiver skill is critical to appropriate stockpile choices.     

Envenomations

Numerous types of envenomations may be encountered by health care workers depending on where in North America they work. Clinicians should be familiar with the animals in their region that may lead to envenomation.A rational approach with use of poison center or medical toxicology consultation services ensures that cases are managed appropriately.