Foxglove poisoning: diagnostic and therapeutic differences with medicinal digitalis glycosides overdose

We report a case of a 19-year-old woman who ingested Digitalis purpurea leaves as a suicide attempt. She developed gastro-intestinal symptoms, loss of colour vision, cardiac conduction disturbances as well as an elevated serum potassium. Treatment was initiated in analogy to medicinal digoxin poisoning by means of digoxin-specific Fab-fragments with a good effect. However during the further course we faced difficulties of prolonged intestinal absorption and inability to estimate the ingested dose or half-life of the vegetal cardiac glycoside compounds. To prevent further absorption and interrupt enterohepatic recycling, multi-dose activated charcoal was administered. Because of a relapse of cardiac conduction disturbances and hyperkalemia, two supplementary doses of Fab-fragments were given, up to a total dose of nineteen vials (one vial containing 40 mg). The important diagnostic and therapeutic differences of vegetal digitalis intoxication as compared to medicinal intoxication and the applicability of existing guidelines on medicinal digitalis intoxication in the light of these differences will be discussed here.

Implementation of a protocol using ketamine-propofol ('ketofol') in a 1 to 4 ratio for procedural sedation in adults at a university hospital emergency department - report on safety and effectiveness

Objectives: To test the feasibility of an evidence-based protocol for procedural sedation in adults at our emergency department, using a mixture of ketamine and propofol ('ketofol') in a 1 to 4 ratio. We hypothesize that the protocol is safe and effective and can facilitate procedural sedation.Methods: During 14 months, adults in need of procedural sedation at our university hospital emergency department were included in a prospective convenience sample study. Patients with important comorbidity were discussed with the anaesthesiology department for feasibility of sedation in the emergency department setting. Outcome measures were procedural success, respiratory and hemodynamic events, vomiting, agitation or hallucinations, recall and physician's satisfaction.Results: Sixty-one patients between 18 and 89 years were included. All but one procedure were successful. Six respiratory events were registered in 6 patients (9.8%). These consisted of airway obstruction alleviated by airway repositioning and without influence on vital signs except for one brief episode of desaturation. Neither hemodynamic events nor vomiting were reported. Five patients (8.2%) experienced pleasant hallucinations and one patient (1.6%) became agitated upon awakening but recovered rapidly without medication. Three patients (4.9%) had recall and physician satisfaction rate was 93.4%.Conclusion: A feasibility trial of an implemented protocol for ketofol procedural sedation in adults showed only minor respiratory events, a low incidence of agitation or hallucinations, minimal recall and a high success and physician satisfaction rate. Despite a non-consecutive and limited sample used, ketofol in a 1 to 4 ratio appears safe and effective for use in the emergency department.

Recognition of a disulfiram ethanol reaction in the emergency department is not always straightforward

OBJECTIVES

Disulfiram is an adjunct in the treatment of alcohol use disorders, but case reports indicate that disulfiram ethanol reactions are not always recognized in the emergency department. Our first aim is to remind of this risk with two case reports of life-threatening reactions not immediately considered by the emergency physician. The second aim is to estimate the probability that a disulfiram reaction goes unrecognized with the use of a retrospective study of patients admitted to the emergency department.

METHODS

Clinical files of patients admitted between October 1, 2010 and September 30, 2014 to the emergency department were retrospectively screened for the key words "ethanol use" and "disulfiram". Their diagnoses were then scored by a panel regarding the probability of an interaction.

RESULTS

Seventy-nine patients were included, and a disulfiram-ethanol reaction was scored as either 'highly likely', 'likely' or 'possible' in 54.4% and as 'doubtful' or 'certainly not present' in 45.6% of the patients. The interrater agreement was 0.71 (95% CI: 0.64-0.79). The diagnosis was not considered or only after a delay in 44.2% of the patients with a 'possible' to 'highly likely' disulfiram interaction. One patient with a disulfiram overdose died and was considered as a 'possible' interaction.

DISCUSSION AND CONCLUSIONS

A disulfiram ethanol interaction can be life threatening and failure to consider the diagnosis in the emergency department seems frequent. Prospective studies with documentation of the intake of disulfiram and evaluation of the value of acetaldehyde as a biomarker are needed to determine the precise incidence. Improving knowledge of disulfiram interactions and adequate history taking of disulfiram intake may improve the care for patients.

Hospital referrals of patients with acute poisoning by the Belgian Poison Centre: analysis of characteristics, associated factors, compliance and costs

OBJECTIVE

Aims were (1) to assess the characteristics, associated factors and compliance of patients with acute poisoning advised by the Belgian Poison Centre (BPC) to go (conditionally) to the hospital, (2) to assess the compliance and potential health-economic impact.

METHODS

Three types of referrals to the hospital of patients who called the BPC between 1 January and 30 June 2018 were analysed: referrals in case of deterioration in the patient's condition (Hosp-watchful-wait), referrals (Hosp-referral) or urgent referrals (Hosp-urgent-referral). Factors associated with type of recommendation were registered. A survey was conducted on a second dataset of patients who called the BPC between 1 March and 15 May 2019 and referred (conditionally) to the hospital.

RESULTS

5476 referrals were included: 72.4% accidental poisoning, 25.3% intentional self-harm, 1.2% substance abuse and 1.1% unclear intentionality. There were 2368 (43.2%) Hosp-watchful-wait cases, 2677 (48.9%) Hosp-referrals and 431 (7.9%) Hosp-urgent-referrals. In Hosp-watchful-wait cases, soaps and detergents were represented most (20.5%). In Hosp-referrals and Hosp-urgent-referrals, benzodiazepines (12.7% and 15.1%, respectively) predominated. Factors associated with hospitalisation type were number of symptoms, intentionality, type of agent(s) involved and advising antidotes. The survey showed that 7.8% of Hosp-watchful-wait patients went to the hospital versus 57.3% of Hosp-referrals and 59.6% of Hosp-urgent-referrals. The mean cost for Hosp-watchful-wait patients, Hosp-referrals and Hosp-urgent-referrals was estimated at €127, €767 and €796, respectively.

CONCLUSION

Only a small proportion of patients followed the advice of the BPC to go (conditionally) to the hospital. A systematic follow-up of cases is warranted to examine the appropriateness of referrals and the compliance of patients.

Adults with acute poisoning admitted to a university hospital in Belgium in 2017: cost analysis benchmarked with national data

Objective: Aims were to (1) analyse the direct cost charged by a university hospital to the government and the patient in case of an admission for acute poisoning, (2) identify the factors associated with the cost, and (3) compare the cost in the hospital studied with national data from the government.Methods: Patient records and invoices of all poisoning-related episodes of patients 14 years or older admitted to the Emergency Department (ED) of Ghent University Hospital (GUH) in 2017 were analysed. A generalised linear model with gamma loglink was applied to assess the variables associated with the cost. Our GUH data collected in 2017 were compared with national data 2016 for all Belgian hospitals on the one hand, and for the subgroup of GUH 2016 data on the other hand. To do this, we used data provided by the Technical Unit of the Federal Public Service Health, containing All Patient Refined Diagnosis Related Groups 812 (poisoning by medicinal agents) and 816 (toxic effects by non-medicinal substances).Results: The total direct cost for the treatment of 1,175 poisoned patients amounted to $1,830,870. Median direct cost per patient was $512 per episode, with $199 for ambulatory patients, $1,575 for patients admitted to the ED-observation-unit, $3,398 for hospitalised patients and $4,859 for patients treated in the intensive care unit. Factors associated with the cost were gender, degree of severity, type of hospitalisation, intentionality, and involvement of ethanol, paracetamol, antidepressants or amphetamines. Median hospitalisation cost per admission in GUH for medicinal agents was 70.5% higher than the cost reported in national hospitalisation data. Median cost per admission in case of non-medicinal agents was 54.5% higher than the national median 2016.Conclusion: The type of hospitalisation has a high impact on the cost, a.o. primarily due to the length of hospital stay, with accommodation accounting for a large proportion of the costs. It is important to benchmark individual hospital data with (inter)national data to evaluate its own cost management in the context of continuous improvement.

Ingestion of white spirit resulting in perineal skin burns: a case report and review of the literature

In the literature, possible systemic effects on health of inhalation or ingestion of white spirit are well described. Only a few case reports discuss the toxic skin effects that can occur following massive ingestion. Ingestion of large amounts of white spirit produces a watery diarrhoea with a high concentration of white spirit, resulting in perineal skin burns when there is prolonged contact. We describe a patient who developed partial thickness perineal skin burns after ingestion of white spirit and review the literature. The present data indicate that conservative therapy of the skin burns is recommended.

Combined acute inhalation of hydrofluoric acid and nitric acid: a case report and literature review

We describe a nonlethal, delayed onset case of combined acute inhalation of hydrofluoric acid (HFA) and nitric acid (NA) together with a review of the literature. Our patient was exposed to fumes of a 12% HFA and 22% NA solution in a closed environment and suffered during several months after the incident from exertional dyspnoea but recovered completely. Since HFA and NA are dangerous and widely used substances, preparedness for exposure is mandatory. After inhalational exposure, the principles of decontamination with attention to treatment of the skin for HFA burns together with general medical incident management should be applied. The severity of combined NA and HFA intoxication depends on the concentration, the nature of the contact and the duration of exposure but other factors may also be involved. Therapy resistant hypoxia and death have been reported in the literature. Inhalation injury from HFA alone is rare but systemic toxicity should be anticipated. Calcium is advocated as the cornerstone of local and systemic therapy. NA inhalation alone is very rare and causes heavy pulmonary irritation. Massive pulmonary secretions seem a sign of very severe intoxication and treatment appears to be mainly supportive.

Biomarkers in patients admitted to the emergency department after exposure to acrylonitrile in a major railway incident involving bulk chemical material

BACKGROUND

A railway incident with victims of exposure to the cyanogenic substance acrylonitrile (ACN).

AIMS

We retrospectively (i)built an inventory of the clinical characteristics of individuals admitted to surrounding emergency departments (ED's) and (ii)studied the correlation between N-2-cyanoethylvaline (CEV), a biomarker used in a population study for evaluating exposure to ACN, with lactate and thiocyanate (SCN), biomarkers determined during emergency care.

RESULTS

438 patients from 11 ED's were included and presented with known symptoms of ACN poisoning but also with concern about the risks. A comparison of CEV with lactate or SCN was possible in 108 and 73 patients respectively. CEV was very high in a critically ill patient with a high lactate. There was no correlation with CEV in the patients with normal or slightly elevated lactate concentrations. A correlation of CEV with SCN was only observed in smokers.

LIMITATIONS

First there is a lack of data in some clinical files concerning the time and duration of exposure and the smoking-status. A second limitation is that blood samples for biomarkers were not taken systematically in all patients, which may have induced bias. A third limitation is that blood sampling was possibly done outside the correct time window related to the delayed toxicity of ACN. Finally the number of severely-intoxicated patients was low and ACN exposure may not have taken place e.g. in individuals consulting with psychological symptoms. These aspects may have contributed to the below detection limits' analyses of biomarkers.

CONCLUSIONS

CEV was markedly elevated in a severely-intoxicated patient with high lactate, a sensitive marker for CN intoxication. We found no correlation of CEV with normal or slightly elevated lactate concentrations but clinicians should consider the possibility of subsequent rises due to the delay in ACN toxicity. CEV correlated with SCN in smokers, which may be explained by ACN in tobacco smoke and deserves further exploration. Further studies are necessary to evaluate the correlation between biomarkers in acute chemical exposures to ACN and these should be carried out prospectively using a preplanned template.

Spontaneous tension pneumoperitoneum presenting as an out of hospital cardiac arrest: A case report and review of the literature

OBJECTIVES

It is known that tension pneumoperitoneum (TPP) can lead to cardiopulmonary arrest but it does not figure in the advanced life support algorithms. Therefore we discuss a case of TPP together with the literature review of its aetiology and treatment.

PATIENT

We describe an out of hospital cardiac arrest due to a spontaneous TPP secondary to a perforated duodenal ulcer.

CONCLUSION

Emergency personnel should consider the possibility of TPP in a patient with a distended abdomen and a cardiac arrest, even in the absence of known traumatic and iatrogenic causes for TPP. We believe that TPP should be added as a reversible cause for pulseless electrical activity in the resuscitation guidelines.

Communication in healthcare: a narrative review of the literature and practical recommendations

OBJECTIVES

Effective and efficient communication is crucial in healthcare. Written communication remains the most prevalent form of communication between specialised and primary care. We aimed at reviewing the literature on the quality of written communication, the impact of communication inefficiencies and recommendations to improve written communication in healthcare.

DESIGN

Narrative literature review.

METHODS

A search was carried out on the databases PubMed, Web of Science and The Cochrane Library by means of the (MeSH)terms 'communication', 'primary health care', 'correspondence', 'patient safety', 'patient handoff' and 'continuity of patient care'. Reviewers screened 4609 records and 462 full texts were checked according following inclusion criteria: (1) publication between January 1985 and March 2014, (2) availability as full text in English, (3) categorisation as original research, reviews, meta-analyses or letters to the editor.

RESULTS

A total of 69 articles were included in this review. It was found that poor communication can lead to various negative outcomes: discontinuity of care, compromise of patient safety, patient dissatisfaction and inefficient use of valuable resources, both in unnecessary investigations and physician worktime as well as economic consequences.

CONCLUSION

There is room for improvement of both content and timeliness of written communication. The delineation of ownership of the communication process should be clear. Peer review, process indicators and follow-up tools are required to measure the impact of quality improvement initiatives. Communication between caregivers should feature more prominently in graduate and postgraduate training, to become engraved as an essential skill and quality characteristic of each caregiver.

The impact of neighborhood deprivation on patients' unscheduled out-of-hours healthcare seeking behavior: a cross-sectional study

BACKGROUND

The use of unscheduled out of hours medical care is related to the social status of the patient. However, the social variance in the patient's preference for a hospital based versus a primary care based facility, and the impact of specific patient characteristics such as the travel distance to both types of facilities is unclear. This study aims to determine the social gradient in emergency care seeking behavior (consulting the emergency department (ED) in a hospital or the community-based Primary Care Center (PCC)) taking into account patient characteristics including the geographical distance from the patient's home to both services.

METHODS

A cross-sectional study, including 7,723 patients seeking out-of-hours care during 16 weekends and 2 public holidays was set up in all EDs and PCCs in Ghent, Belgium. Information on the consulted type of service, and neighborhood deprivation level was collected, but also the exact geographical distance from the patient's home to both types of services, and if the patient has a regular GP.

RESULTS

Patients living in a socially deprived area have a higher propensity to choose a hospital-based ED than their counterparts living in more affluent neighborhoods. This social difference persists when taking into account distance to both services, having a regular GP, and being hospitalized or not. The impact of the distance between the patient's home address and the location of both types of services on the patient's choice of service is rather small.

CONCLUSIONS

Initiatives aiming to lead patients more to PCC by penalizing inappropriate ED use might increase health inequity when they are not twinned with interventions improving the access to primary care services and tackling the underlying mechanisms of patients' emergency care seeking behavior. Further research exploring the impact of out-of-hours care organization (gatekeeping, payment systems, …) and the patient's perspectives on out-of-hours care services is needed.

Drug interactions and adverse drug reactions in the older patients admitted to the emergency department

PURPOSE

The aim of this study was to prospectively evaluate drug interactions and adverse drug reactions (ADRs) in the older patients admitted to the emergency department (ED) and to characterize risk factors.

METHODS

In 80 patients aged 65 years and older medication history and ED drug administration were analysed. Medical records were analysed for ADRs by an expert panel which also evaluated their avoidability and causality. An interaction program was used to search for potential drug interactions followed by assessment for clinical significance. Data were analysed using a logistic regression model. The significance level was set at alpha=0.05.

RESULTS

Eighty seven ADRs were identified in 37 patients; 18 were the result of an interaction (15 patients). Causality was assessed as definite (n=11), probable (n=62) and possible (n=24). The reason for admission was definitely and probably related to an ADR in 6 and 18 patients respectively. Only 17 (20%) of the ADRs were assessed as unavoidable, while 23 (26%) and 47 (54%) were classified as definitely and possibly avoidable, respectively. ADRs were related with female gender (p=0.023) and number of drugs (p=0.004), but not with high age (p=0.151). Clinically relevant interactions were related with older age (p=0.032) and number of drugs (p=0.003), but not with gender (p=0.380). None of the interactions with ED initiated medications were considered unjustified.

CONCLUSIONS

ADRs frequently occur in the older patients admitted to the ED and are an important cause of hospital admissions with a substantial contribution of adverse drug interactions.

Use of out-of-hours services: the patient's point of view on co-payment a mixed methods approach

INTRODUCTION

In many countries out of hours (OOH) care is offered by different health care services. General practitioners (GP) tend to offer services in competition with emergency departments (ED). Patients behaviour depends on a number of factors. In this study, we highlight the knowledge and ideas of patients concerning the co-payment system.

METHODS

We used a mixed methods design, combining quantitative and qualitative research. During two weekends in January 2005, all patients using the ED or the GP OOH service, were invited for an interview with a structured questionnaire. A stratified random sample of patients participated in a semi-structured interview. Both methods add complementary data to answer the research questions.

RESULTS

Most mentioned reasons for seeking help at the ED are: accessibility (15.0%), proximity (6.4%) and competence of the staff (5.6%). Reasons for choosing the GP are: GP is easy to find, minor medical problem or anxiety and confidence in the GP. The odds of not knowing the co-payment system are significantly higher in patients visiting the ED (OR 1.783; 95% CI: 1.493-2.129). Mostly GP users recognize the problem of ED overuse. They suggested especially to provide clear information about the tasks of the different services and about the payment system, to reduce ED overuse.

CONCLUSION AND DISCUSSION

When intending to shift from ED to GP services for minor medical problems, aiming at just one measure is no option. Information campaigns aiming to address the entire population, can clarify the role of each player in out-of-hours care.

Presence of psychoactive substances in injured Belgian drivers

OBJECTIVE

To estimate the percentage of drivers involved in a traffic crash in Belgium who have alcohol and drugs in their blood.

METHODS

Blood samples of the drivers injured in a traffic crash and admitted to the emergency departments of 5 hospitals in Belgium between January 2008 and May 2010 were analyzed for ethanol (with an enzymatic method) and 22 other psychoactive substances (with ultra-performance liquid chromatography with tandem mass spectrometry or gas chromatography-mass spectrometry).

RESULTS

One thousand seventy-eight drivers were included in the study. Alcohol (≥0.1 g/L) was the most common substance (26.2%). A large majority of the drivers (64%) who were positive for alcohol had a blood alcohol concentration (BAC) ≥1.3 g/L (legal limit in Belgium: 0.5 g/L). These high BACs were most frequent among male injured drivers. Cannabis was the most prevalent illicit drug (5.3%) and benzodiazepines (5.3%) were the most prevalent medicinal drugs. Approximately 1 percent of the drivers were positive for cocaine and amphetamines. No drivers tested positive for illicit opioids. Medicinal drugs were more likely to be found among female drivers and drivers older than 35 years, and alcohol and illicit drugs were more likely to be found among male drivers and drivers younger than 35 years.

CONCLUSION

A high percentage of the injured drivers were positive for a psychoactive substance at the time of injury. Alcohol was the most common substance, with 80 percent of the positive drivers having a BAC ≥0.5 g/L. Compared to a roadside survey in the same area, drivers/riders with high BACs and combinations of drugs were overrepresented. Efforts should be made to increase alcohol and drug enforcement. The introduction of a categorization and labeling system might reduce driving under the influence of medicinal drugs by informing health care professionals and patients.

An inquiry on pain management in the emergency department of training hospitals

INTRODUCTION

Improving pain management in the ED might be attained by adequate teaching of medical students. We assessed the skills in pain treatment of ED physicians who teach the students.

METHODS

All physicians working in an ED who provide elective training to undergraduate medical students from the Ghent University were asked to complete a questionnaire consisting of vignette patient cases concerning acute pain management of abdominal colic pain, and non-traumatic abdominal pain.

RESULTS

Thirty two physicians completed the cases. In the renal colic case 91% of the respondents proposed a NSAID as first line treatment. Butylhyoscine was still suggested by 18%. After initial failure of analgesia 31% administered a strong opioid. In biliary colic pain NSAIDs and butylhyoscine were proposed as first line analgesics by 59% and 31% respectively. In second line, butylhyoscine would be given by 22%. The patient case with right fossa abdominal pain would initially be treated with acetaminophen by 81%. Thirteen % of the respondents would not give further analgesia if the first line treatment was insufficient.

CONCLUSION

Our results indicate that adherence by teachers to evidence based guidelines of acute pain management is insufficient. Therefore improving knowledge and skills in pain management of the teachers should receive more attention.

Perceptions, needs and mourning reactions of bereaved relatives confronted with a sudden unexpected death

Many individuals die suddenly and unexpectedly outside the hospital or in the emergency department (ED). The aim of this study was to determine the perceptions, needs and mourning reactions of their bereaved relatives and to assess the relationship with the cause of death. Data were collected prospectively in the emergency department of a university hospital by means of an interview and a standardised questionnaire. We registered 339 deaths over a period of 10 months, of which 110 met the inclusion criteria for sudden and unexpected death. The study group included 74 relatives of 53 deceased individuals. The majority of relatives were confronted with a traumatic death outside the hospital. Most frequently reported complaints concerned a lack of information and being left with unanswered questions. Psychological problems related to mourning were mainly associated with a traumatic cause of death. The results of this study highlight the specific needs of relatives in case of a sudden death either outside the hospital or in the ED and may serve as a basis for recommendations for improvement of psychological care of individuals who are suddenly bereaved.

Collisions involving mobile intensive care unit vehicles in Flanders, Belgium

In order to evaluate the risk of collision during emergency responses of mobile intensive care units (MICUs) in Flanders, Belgium, a questionnaire was sent to 37 MICU services. The response rate was 84%. During the study period (1992-96) the incident rates for collision, collision with significant physical harm, and collision leading to a wrecked MICU vehicle were 1 per 52,000 km, 1 per 214,000 km and 1 per 250,000 km, respectively. Most collisions occurred during use of 'lights and siren' (66%), and involved other motor vehicles (72%). About 50% occurred during daylight with clear weather conditions and on dry roadways. Drivers had attended a course for safe and defensive driving in only four services (13%). The use of seat belts was imposed by the hospital authorities in 21 services (72%). Vehicles equipped with airbags and an ABS-braking system were used in eight (28%) and 13 (45%) services, respectively. Our data confirm that the collision rate for MICUs is high and that measures to reduce the risk of collisions and resulting injuries and damage are at present not optimal.

When an AED meets an ICD... Automated external defibrillator. Implantable cardioverter defibrillator

The chances of prehospital care providers being confronted with a patient with an implantable cardioverter defibrillator (ICD) are increasing and so care providers must receive proper training. Based on observations made during the resuscitation of a patient with an ICD using an automated external defibrillator (AED) some technical features and possible interactions of ICDs and AEDs are highlighted. Furthermore, we discuss the key points of basic knowledge, safety, and treatment protocols for cardiac arrest and other situations required for practical training in the ICD for prehospital care providers.

ECG changes and plasma concentrations of propafenone and its metabolites in a case of severe poisoning

CASE REPORT

Propafenone is a class IC antiarrhythmic agent metabolized into two major metabolites, 5-hydroxypropafenone and N-depropylpropafenone. The potency of 5-hydroxypropafenone to block fast sodium channels is comparable to that of its parent. We report the positive correlation between plasma concentrations and electrocardiographic changes in a patient with severe oral self-poisoning. Serial ECG changes were measured and plasma concentrations were determined by high-performance liquid chromatography. The initial plasma concentrations of propafenone were in the toxic range and correlated with the widening of the QRS-complex. The slow decline in concentration during this first phase might relate to saturation of the isoenzyme CYP2D6. The half-life of propafenone, calculated from the second phase, was approximately 3 hours, defining the patient as a fast metabolizer. The initial concentrations of the metabolite N-depropylpropafenone were surprisingly higher than those of 5-hydroxypropafenone which may also be due to saturation of CYP2D6.

The effect of semi-automatic external defibrillation by emergency medical technicians on survival after out-of-hospital cardiac arrest: an observational study in urban and rural areas in Belgium

The introduction of semi-automatic external defibrillators (SAEDs) allowed emergency medical technicians (EMTs) to deliver electroshocks in cases of out-of-hospital ventricular fibrillation (VF) or ventricular tachycardia (VT), often many minutes before the arrival of the mobile intensive care unit (MICU) team. In this observational study we report on the results obtained by the EMTs from the fire departments of Gent, Aalter and Brugge. In Gent, an SAED project started in May 1991. By December 1995, the SAED's electrodes had been attached in 367 cardiac arrest patients. The first rhythm detected by the device was asystole or electromechanical dissociation (EMD) in 241 patients (66%): only 5 of these patients survived to hospital discharge (2%). In the remaining 126 VF/VT cases (34%) the survival rate was 21% (26/126). In 14 of these 26 patients the shock(s) delivered by the EMTs restored spontaneous circulation before the arrival of the MICU team, with only venous cannulation and/or intubation being performed by the MICU team. In 4 other VF patients, the shock(s) delivered by EMTs converted the VF, with the MICU team successfully taking care of VF/VT relapses or postcountershock EMD. In the remaining 8 VF/VT cases, only the MICU attempts could resuscitate the patient. The SAED project in Aalter was set up in April 1993. By December 1995, care was taken for only 21 patients. None of the 4 VF/VT patients and the 17 asystole/EMD patients survived. In Brugge, there were 240 cardiac arrest cases treated with SAED between January 1991 and December 1995. Among the 89 VF/VT cases, there were 20 survivors (22%): 8 cases survived thanks to SAED shock(s) delivered by EMTs, in 3 cases survival was due to the combination of SAED shock(s) by EMTs and extensive ALS treatment by the MICU team, and in 9 cases restoration of spontaneous circulation was only obtained after application of ALS techniques by the MICU team. This observational study seems to show a beneficial effect of the introduction of SAED in Gent and Brugge. In Aalter the number of treated cases is tool low to draw conclusions. Anyhow, the global survival rate in the three areas remains low. Therefore, more efforts are needed to strengthen the other links of the chain of survival (early access to the emergency medical services-system, early basic cardiopulmonary resuscitation and early advanced life support.

Hepatotoxicity of N, N-dimethylformamide (DMF) in acute poisoning with the veterinary euthanasia drug T-61

1. We report on a patient who was resuscitated after a suicide attempt with the veterinary euthanasia product T-61 and treated with N-acetylcysteine (NAC) to prevent hepatotoxicity from N,N-dimethylformamide (DMF), the solvent of T-61. 2. Serum concentrations of DMF were high as compared with values published on occupational exposure. 3. The patient showed only a transient increase in liver enzymes with eventually a full recovery. 4. The hepatoprotective effect of NAC was studied in a rat model using the rise in serum sorbitol dehydrogenase (SDH) as a marker for DMF-induced hepatotoxicity. 5. Four series of randomized, controlled and double-blind experiments were carried out and consistently showed a lower increase in SDH in NAC-treated animals in each series. The difference was statistically significant only when the data of the 4 series were pooled. This is probably due to the large interindividual variations in the effect of DMF. 6. We hypothesize that in the rat NAC may have a protective effect. Whether NAC is also protective in patients, in which it is administered after exposure to DMF, cannot be concluded from the present experiments.

Patients with psychiatric emergencies transported by an ambulance in an urban region

This paper studies the use of an ambulance service in the case of psychiatric emergency referrals. A cross-sectional design was used to compare the patients brought in by an ambulance with all other psychiatric emergency referrals. The sociodemographic and clinical characteristics as well as the referral pattern of both groups of patients are compared. Results show that an important proportion of patients brought in by an ambulance can be described as high risk referrals. However, for another group of referrals the ambulance is used for other reasons. The possibility of using alternative social services in these cases are discussed.

The management of non-compliance with referral to out-patient after-care among attempted suicide patients: a controlled intervention study

The failure to comply with referral for out-patient after-care is a well-documented problem among attempted suicide patients. The present study aimed at the investigation of an experimental referral procedure by means of a randomized controlled study. Non-compliant patients in the experimental group were visited in their homes by a community nurse in order to assess reasons for non-compliance and to motivate patients to comply with referral. One year after their suicide attempt patients were visited in their homes in order to assess repetition of suicidal behaviour. Uni- and multi-variate analyses showed a significant beneficial effect of the experimental procedure on compliance with referral. A near-significant effect of the experimental procedure on the rate of repetition of suicidal behaviour was found.

How to evaluate an emergency medical dispatch system: a Belgian perspective

In order to evaluate the local emergency medical dispatch centre, 4601 calls were analysed. Information was obtained from the tape recordings of the dispatch centre and standardized reports from the basic life support (BLS) teams, advanced life support (ALS) teams and the emergency departments of all receiving hospitals in the study area. The need for prehospital ALS care was assessed 'post hoc', based on the clinical findings at the scene and in the emergency department. The accuracy of the medical dispatch was evaluated by comparing the level of care actually sent with the real medical needs of the patient. The 4601 medical problems reported led to 4446 interventions: a BLS team only in 82% (n = 3627), an ALS team and BLS team simultaneously in 14% (n = 623), and a BLS team followed somewhat later by an ALS team in 4% (n = 196). In the 633 cases judged 'post hoc' to require prehospital ALS care, an ALS team was not sent in 260 (41%) or sent with some delay in 112 (18%). Of the 819 interventions of the ALS teams, 446 (54%) dealt with cases not requiring that level of care. With regard to the role of the dispatchers in the mismatches between the medical needs of the patients and the level of care sent, underestimation and overestimation of the severity of the emergency by the dispatchers was found in 31% and 22% cases respectively.

The 'early access' link in the chain of survival for cardiac arrest victims in Ghent, Belgium

Without early access to the emergency medical services (EMS) system, the chances of surviving an out-of-hospital cardiopulmonary arrest (CPA) are poor. The aim of this study was to evaluate this first link in the chain of survival in Ghent. Therefore, we reviewed the data from the registry on all CPA cases treated by our mobile intensive care unit (MICU) and the tape recordings from the local EMS dispatch centre of 100 consecutive non-traumatic CPA cases that occurred after January 1, 1993. Alarm signs before the collapse were recorded in 39 cases. In only 54% (21 out of 39) a pre-arrest call to the EMS system was made. In only four cases (10%) was the MICU at the patient's side when the collapse occurred. The delay between collapse and call in the 79 cases in which no call to the EMS system was made before the collapse was estimated to be 3 min or less for only 49% (39 out of 79). To evaluate the processing of the call in the EMS dispatch centre, we examined all 100 cases with regard to whether or not the first tier (emergency medical technicians) and the second tier (MICU) were dispatched simultaneously upon the first call. We found that in 41 cases the MICU was not sent immediately. The most important reasons were minimal information available for the EMS system (n = 8), underestimation of the emergency of the call by the dispatcher (n = 10) and underestimation of the pre-alarm signs by a general practitioner (n = 7). This analysis shows that all aspects of the first link of the chain of survival need improvement.

Metabolism and hepatotoxicity of N,N-dimethylformamide, N-hydroxymethyl-N-methylformamide, and N-methylformamide in the rat

The metabolism and hepatotoxicity of N,N-dimethylformamide (DMF) and two of its metabolites, N-hydroxymethyl-N-methylformamide (HMMF) and N-methylformamide (NMF) were evaluated over a 4-day period in rats. DMF toxicity was dose dependent and delayed toxicity after the administration of a high DMF dose (13.7 mmol/kg) in comparison to a lower dose (4.1 mmol/kg) was observed. Treatment of rats with 13.7 mmol/kg DMF, HMMF, or NMF showed i) that DMF is more toxic than HMMF or NMF, and ii) that hepatotoxicity occurs later for DMF than for HMMF or NMF. Analysis of serum and urine samples demonstrated that DMF is first metabolized to HMMF, which is then partially converted to NMF. After HMMF administration, NMF was found both in serum and in urine. The time course of DMF and HMMF toxicity in relation to NMF formation fitted the hypothesis that the hepatotoxicity of DMF and HMMF is mediated via NMF. The degree of hepatotoxicity after HMMF and NMF treatment is similar. However, the degree of DMF hepatotoxicity is much higher than in the case of NMF or HMMF. The role of NMF as an obligatory intermediate in DMF and HMMF hepatotoxicity is discussed.

[Resuscitation in heart arrest due to severe hypothermia]

Two patients were resuscitated after cardiopulmonary arrest due to severe hypothermia. The first patient, a 76-year-old man, had ventricular fibrillation resistant to conventional therapy; he was rapidly rewarmed by means of cardiopulmonary bypass. In the second patient, a 77-year-old woman, classical resuscitation led to restoration of spontaneous circulation. The patient was subsequently rapidly rewarmed with hemodialysis with fluid of 40 degrees C. We conclude that rapid rewarming with cardiopulmonary bypass is the treatment of choice in severely hypothermic patients presenting with cardiac arrest that is resistant to conventional therapy. Hemodialysis seems a suitable technique in patients who remain deeply hypothermic after resuscitation. However, it is difficult to assess its value because of the lack of clinical studies comparing this technique with other procedures.

A positron emission tomography study of patients with acute carbon monoxide poisoning treated by hyperbaric oxygen

Seven patients with an acute and severe carbon monoxide intoxication were treated with hyperbaric oxygen and underwent a positron emission tomographic examination 2-5 days after the acute event. Although the final clinical outcome was good in all patients, ischaemic changes were observed. Three patients with temporary sequelae after hyperbaric oxygen treatment showed the most severe changes, mainly in striatum and thalamus. Although positron emission tomographic examination cannot predict the final outcome, it can show the regions at risk for development of late complications following carbon monoxide poisoning.

Should semi-automatic defibrillators be used by emergency medical technicians in Belgium? The Belgian Cerebral Resuscitation Study Group

Early external defibrillation is the single most effective intervention in patients with out-of-hospital cardiac arrest. Literature data indicate that instructing emergency medical technicians (EMTs) to use defibrillators is beneficial, provided the local emergency medical system is well organized. We tried to estimate the potential benefit of early defibrillation in some centres in Belgium by retrospectively analyzing the data from the Belgian Cardio-Pulmonary-Cerebral Resuscitation Registry collected between 1983 and 1987 in Belgian centres with a Mobile Intensive Care Unit (MICU). The data show that 2310 out of 3371 patients (69%) were first attended by the EMTs; on subsequent arrival of the MICU-teams, 584 of these 2310 patients i.e. 17% of the whole study population, presented with ventricular fibrillation. Analysis of estimated time factors in these 2310 patients revealed that the median time interval between collapse and start of resuscitation by EMTs was 8 min; the median time interval between collapse and start of MICU-resuscitation attempts was 16 min. The duration of EMT-resuscitation before MICU-arrival was probably more than 5 min and 10 min in 58% and 23% of the cases respectively. It is concluded that EMTs can be expected to reach a substantial number of ventricular fibrillation victims within a few minutes after the collapse and many minutes before arrival of the MICU. Therefore, training of EMTs in the use of semi-automatic defibrillators seems worthwhile in MICU-served regions in Belgium.

Early prediction of non-survival for patients suffering cardiac arrest--a word of caution. The Belgian Cerebral Resuscitation Study Group

A total of 6178 persons with out-of-hospital (70%) and in hospital (30%) cardiac arrests from the first of January 1982 until the end of 1989 were reviewed retrospectively with respect to 4 variables, contributing to a score for specific prediction of poor prognosis (cut-off point: greater than 3 points). These included age, initial ECG, type of respiratory arrest and bystander resuscitation. Presence of ventricular fibrillation, gasping and bystander resuscitation contributes nothing to the score, while presence of asystole or EMD (electromechanical dissociation), apnoea and absence of bystander resuscitation adds one point to it. Of patients scoring 4 or 5 points 44 were awake 14 days post CPR (Class 3). The positive predictive value of the score was 97% (95% CI 96-98%) for the out-of-hospital group and 92.2% (95% CI 88-95%) for the in-hospital group. The specificity was respectively 92.3% (95% CI 89-95%) and 94.2% (95% CI 91-96%). Although the score can weigh the likelihood of no success against that of success, we cannot recommend it for decision making as far as abandoning or continuing cardiopulmonary resuscitation efforts.

Acute cholinesterase inhibitor poisoning mimicking pulmonary oedema

In patients poisoned with a cholinesterase inhibitor, the diagnosis may initially be missed especially when no history is available from the patient or his relatives. The predominant respiratory symptoms may suggest pulmonary oedema as illustrated by the two case reports presented here. A high degree of suspicion and a careful clinical examination are necessary to make the correct diagnosis, which eventually can be confirmed by measurement of red cell and serum cholinesterase activity.

[Analysis of severely injured patients admitted via an emergency service]

Data about the number and treatment of trauma-patients are, certainly in our country, very rare. In this study we showed that such a registration with grading of the severity of the injuries following the ISS-Score is feasible and useful. Further and more extensive registration seems necessary in order to obtain a better insight in epidemiology and treatment of trauma patients in our country.