Hydrogen sulfide gas poisoning in fish garbage room: A report of a fisherman

We report the case of a fisherman who was exposed to high concentrations of hydrogen sulfide (H2S) gas from the fish garbage room. The patient survived and was discharged with full recovery from the hospital. H2S is a colourless, foul smelling and highly toxic gas next to carbon monoxide, which causes inhalation death. It is a by-product of various industrial processes particularly involves exposure from agriculture, petrochemical industry and organic matter decomposition from sewage processing. It is a by-product of H2S has been referred as the knock down gas because inhalation of high concentrations can cause immediate loss of consciousness and death. Although early use of amyl nitrate and hyperbaric oxygen shows some benefit in literature, supportive care remains the mainstay of treatment. Emergency physicians and pre-hospital care personnel are not very familiar with such exposure due to its rarity. This becomes more relevant in the developing world settings where there are rising concerns about the unsafe exposure to hazardous chemicals and its impact on human health. Emergency physicians working in Pakistan should be aware of this entity especially in regard to fishermen presenting to the Emergency Department with such a clinical presentation and its toxic manifestations. This incident also illustrates the need of enforcement of health and safety regulations in the fishing industry

Non-traumatic aortic emergencies--experience from a tertiary care centre in Karachi, Pakistan

Objective: To review the incidence, clinical presentation and outcome of Non traumatic Aortic emergencies in a tertiary care hospital and its evaluation in the Emergency department (ED).Methods: We conducted a retrospective review of cases presented to the ED at Aga Khan University Hospital during 15 year period (1988 - 2002) who had final diagnosis of Aortic Dissection or Ruptured Aortic Aneurysm. Patients without confirmatory investigations were excluded. We aimed at looking for the incidence, clinical presentation, evaluation in the ED and final outcome.Results: Of the 12 cases, 7 had aortic dissection while the remaining 5 had ruptured aortic aneurysm. For Aortic dissection, mean age of presentation was 53 years with male predominance. Most of these patients had chest pain. Most common comorbid condition was hypertension. Pulse deficit was found in 2 cases, murmur in 4 cases, and focal neurologic deficit in 2 cases. Electrocardiogram revealed ischemic changes in 3 cases. Widened mediastinum on chest x-ray was present in all cases. The only initial misdiagnosis was cardiac ischemia. One patient survived to discharge. For patients presenting with ruptured aortic aneurysm, mean age of presentation was 52 yrs with a male predominance. The associated comorbid condition was hypertension. Almost all patients presented classically with abdominal pain, hypotension and palpable mass. No patient survived to discharge.CONCLUSION: Aortic emergencies although rare, are associated with significant mortality. High index of suspicion and prompt recognition by the emergency physician is of key importance

Clinical decision making in acutely sick patients

This workshop approaches medical errors from a new and challenging viewpoint by examining the thought processes that influence medical decision making. The “failure to diagnose” accounts for the majority of malpractice suits, and most failures are the result of cognitive errors. Concepts including “heuristics and “Cognitive Disposition to Respond” are employed. Several case scenarios of adverse patient outcomes will be reviewed. All physicians involved in managing acutely sick patient should understand this important new insight into medical decision making and its impact on patient care

The current state of poison control center in Pakistan and the need of capacity building

Context Poison control center plays a leading role both in developed and developing countries in the prevention and control of poisonous exposure. In a developing country, the poison control center may be the only source of information and advice on toxic chemicals because of unavailability of resources such as occupational, food and drug regulatory bodies. Objective In this study, we aim to assess the current state of poison control centers of Pakistan and to highlight gaps in their capacity building needs. Methods Cross-sectional survey of two poison control centers was done during August – December 2011 with the help of standardized tool. Results Both poison control centers were affiliated with tertiary care hospital involved in undergraduate and post graduate teaching. Clinical services were available 24/ 7. Information on common local product was available to poison center staff. Common antidotes were available. Telephonic poison information service to the public was currently not available. There was a limited capacity for qualitative and analytical toxicology. There were limited surveillance activities to capture toxic risk existing in the community and also deficiency was observed in chemical disaster planning. Conclusion Poison control centers in Pakistan need capacity building for specialized training in toxicology. Keywords: toxicology, Emergency, Karachi, Pakista

Poisoning in children: 22 years’ experience from a tertiary care center in Karachi, Pakistan

Objective: To determine the nature of agents involved in poisoning in pediatric patients \u3c 16 years; its clinical presentation and outcome, over a period of 22 years in an emergency department (ED) of tertiary care hospital of Karachi, Pakistan. Methods: This retrospective cross-sectional study was conducted over a time period of 22 years from January 1989 to December 2010 and included all pediatric (\u3c 16 years) poisoning cases presenting to the Emergency Department of the Aga Khan University Hospital. Data collection from patient files was carried out using the case record forms. The charts of all pediatric patients who were admitted with a diagnosis of any poisoning during the study period of 22 years (1989-2010) were reviewed retrospectively. Results: A total of 243 pediatric cases were admitted during the study period. Fifty six percent (136) males and forty four percent (107) were females. The time taken by patients from incidence to presentation was \u3c one hour in (73) 30% and \u3e one hour in 170 (70%). Most common substance involved was prescription medicine 64 (26.3%), hydrocarbons 56 (23%) and pesticides in 33 (13.6%) of the cases. Moreover, fluid and tablets were the most commonly used substances 127 (52.3%) and 96 (39.5) respectively. While out of the total pediatric poisoning cases 205 (84.4%) were unintended. Conclusion: Prescription medications, hydrocarbons and pesticides are the most common agents used by pediatrics for poisoning in Pakistan, requiring ED supervision and subsequent admissions Keywords: toxicology, Emergency, Karachi, Pakista

APACHE II scores as predictors of cardio pulmonary resuscitation outcome: Evidence from a tertiary care institute in a low-income country.

Aim: The aim of this study was to demonstrate that APACHE II scores can be used as a predictor of the cardio-pulmonary resuscitation (CPR) outcome in hospitalized Patients. Methods: A retrospective chart review of Patients admitted, from 2002 to 2007, at the Aga Khan University Hospital, Karachi, was done for this study. Information was collected on 738 Patients, constituting all adults admitted in general ward, ICU, CICU and SCU during this time, and who had under-went cardiac arrest and received cardiopulmonary resuscitation during their stay at the hospital. Patient characteristics, intra-arrest variables such as event-witnessed, initial cardiac rhythm, pre arrest need for intubation and vasoactive drugs, duration of CPR and survival details were extracted from Patient records. The APACHE II score was calculated for each Patient and a descriptive analysis was done for demographic and clinical features. The primary outcome of successful CPR was categorized as survival \u3e24 h after CPR versus survival Results: Patients with APACHE II scores less than 20 had 4.6 times higher odds of survival compared to Patients with a score of \u3e35 (AOR: 4.6, 95% CI: 2.4-9.0). Also, shorter duration of CPR (AOR: 2.9, 95% CI: 1.9-4.4), evening shift (AOR: 2.1, 95% CI: 1.3-3.5) and Male Patients (AOR: 0.6, 95% CI: (0.4-0.9) compared to females were other significant predictors of CPR outcome. Conclusion: APACHE II score, along with other Patient characteristics, should be considered in clinical decisions related to CPR administration