IX Symposium of Macedonian association of toxicologists

IX Symposium of ZTM with international participation

IX Симпозиум на Здружението на токсиколози на Македонија со меѓународно учество

IX Symposium of the Macedonian Association of Toxicologists with International participation

Kniga so prezentacii

Book with presentations

Centre for education ALKALOID

Dojran, 18-20 November 2011


Центар за едукација АЛКАЛОИД ДОЈРАН 18-20 Ноември 2011 2

Organizing committee of the Symposium

Nestor Popovski

Niko Bekjarovski

Zhanina Pereska

Natasha Simonovska

Irena Jurukov

Isa Mucha

Symposium is accredited by the Medical Chamber of Macedonia (LKM)

and the Macedonian Medical Association (MLD)

GENERAL SPONSOR OF THE SYMPOSIUM

AD Alkaloid Skopje



Macedonian guidance for the Use of Lipid Resuscitation Therapy

in acute poisonings Niko Bekjarovski, Irena Jurukov, Aleksandra Babulovska, Fani Lichoska

University Clinic for Toxicology Skopje, Macedonia

Abstract: LipidRescue resuscitation refers to the use of an intravascular infusion of a

lipid emulsion to treat severe, systemic drug toxicity or poisoning. In the last four-five

years, LipidRescue has been proposed as a treatment modality for poisoning or overdose

by lipophilic agents in general.

Aim of the study is to present interim guidance for the use of intralipid emulsion as an

antidote in acute poisonings in the Republic of Macedonia.

Our guidance is based upon the ones posted on the LipidRescue.org, the UK

Resuscitation Council, the Association of Anaesthetists of Great Britain and Ireland and

American College of Medical Toxicology.

Key words: LRT, guidance, poisosnings

Introduction: LipidRescue resuscitation refers to the use of an intravascular infusion of a

lipid emulsion to treat severe, systemic drug toxicity or poisoning.

It was originally developed to treat local anesthetic toxicity, a potentially fatal

complication of regional anesthesia that can also occur in other situations where patients

receive local anesthetic injections.

In the last four-five years, LipidRescue has been proposed as a treatment

modality for poisoning or overdose by lipophilic agents in general. The predominant theory for its mechanism of action is that by creating an

expanded, intravascular lipid phase, equilibria are established that drive the offending

drug from target tissues into the newly formed 'lipid sink'. Based on this hypothesis, lipid

emulsion has been considered a candidate for generic reversal of toxicity caused by

overdose of any lipophilic drug.

The first effectiveness of lipid emulsion in resuscitation from local anaesthetic

overdose appeared in 1998, reporting its successful use in rats [1]. A similar paper

reporting successful results in dogs appeared in 2003 [2]. This was followed in 2004 by

publication of a suggested treatment regimen for local anaesthetic-induced cardiac arrest

in humans using lipid emulsion, dubbed „lipid rescue‟ [3]. An editorial in “Anesthesia”

journal in 2006 highlighted its probable efficacy in humans and pointed out that ethically

acceptable, randomised, controlled trials of lipid rescue in humans would be impossible

[4]. In the same year, the first peer-reviewed accounts of lipid rescue‟s effectiveness in

local anaesthetic-induced cardiac arrest in humans appeared [5, 6]. In each of the two

cases, administration of lipid rescue was associated with restoration of effective cardiac

output.

The first systematic review of effectiveness of lipid emulsion in treatment of acute

poisonings was published in Clinical Toxicology on January 2010 [7]. All analyzed case

and human trials (less than 50) suggest some benefits of lipid emulsion in bupivacaine,

verapamil, chlorpromazine, and some tricyclic antidepressants and beta-blockers

toxicity, but without any trial that assessed the safety of Lipid emulsion in the treatment

of acute poisoning. Ten months later the range of effectiveness was extended with cases

of acute poisoning with parasiticides, herbicides and several varieties of psychotropic

agents [8].



In April 2011, Journal of Emergency Medicine Australasia published the

summary study of all acute poisonings treated with intralipid emulsion (ILE). Forty-two

cases of ILE use (19 local-anaesthetic, 23 non-local-anaesthetic) were identified, with

anecdotal reports of successful resuscitation from cardiovascular collapse and central

nervous system depression associated with ILE administration in lipophilic toxin

overdose. Although significant heterogeneity was observed in both agents of intoxication,

and reported outcomes; case report data suggest a possible benefit of ILE in potentially

life-threatening cardio-toxicity from bupivacaine, mepivacaine, ropivacaine, haloperidol,

tricyclic antidepressants, lipophilic beta blockers and calcium channel blockers [9].

Aim of the study is to present interim guidance for the use of intralipid emulsion as an

antidote in acute poisonings in the Republic of Macedonia.

Our guidance is based upon the ones posted on the LipidRescue.org [10], the UK

Resuscitation Council [11], the Association of Anaesthetists of Great Britain and Ireland

[12] and American College of Medical Toxicology [13].

INTERIM GUIDANCE FOR USE OF LIPID RESCUE THERAPY IN MACEDONIA

Use of LRT is to be based on the clinical judgment of the treating physician.

Use of LRT could be helpful in severe poisonings with local anesthetics,

poisonings with Ca antagonist, β blockers, tricycles antidepresives and other

lipophilic drugs and substances.

Think for LRT if one of these signs are noted:

Cardiovascular collapse: sinus bradycardia, conduction blocks,

asystole and ventricular tachyarrhythmias

Cardiac arrest

Sudden loss of consciousness, with or without tonic-clonic

convulsions (GCS < 6)

Protocol for treatment

Give an intravenous bolus injection of Intralipid®/Lipofundin® 20% for 1 min

o Give a bolus of 60-120 ml ( 60 ml for patients with < 30kg, 80 ml patients between 30-

60kg, 100ml for patients between 60-90kg and 120 ml for patients over 90kg.) Use

syringes of 50 or 20 ml.

• Continue CPR

• Start the rest of Intralipid®/Lipofundin® (380-440ml).

o Give at a rate of 400 ml over 20 min

• Repeat the bolus injection twice at 5 min intervals if an adequate circulation has not

been restored

o Give two further boluses of 100 ml at 5 min intervals

o Give the rest of 20% lipid infusion over 10 min

References:

1. Weinberg GL, VadeBoncouer T, Ramaraju GA, Garcia-Amaro MF, Cwik MJ.

Pretreatment or resuscitation with a lipid infusion shifts the dose-response to

bupivacaine induced asystole in rats. Anesthesiology 1998; 88: 1071–5.



2. Weinberg G, Ripper R, Feinstein DL, Hoffman W. Lipid emulsion infusion

rescues dogs from bupivacaine-induced cardiac toxicity. Regional Anesthesia and

Pain Medicine 2003; 28: 198–202.

3. Weinberg G. Reply to Drs Goor, Groban and Butterworthlipid rescue:caveats

and recommendations for the „„Silver Bullet‟‟. Regional Anesthesia and Pain

Medicine 2004; 29: 74–5.

4. Picard J, Meek T. Lipid emulsion to treat overdose oflocal anaesthetic: the gift of

the glob. Anaesthesia 2006; 61:107–9.

5. Litz RJ, Popp M, Stehr SN, Koch T. Successful resuscitation of a patient with

ropivacaine-induced asystole after axillary plexus block using lipid infusion.

Anaesthesia 2006; 61: 800–1.

6. Rosenblatt MA, Abel M, Fischer GW, Itzkovich CJ, Eisenkraft JB. Successful use

of a 20% lipid emulsion to resuscitate a patient after a presumed bupivacaine-

related cardiac arrest. Anesthesiology 2006; 105: 217–8.

7. Jamaty C, Bailey B, Larocque A, Notebaert E, Sanogo K, Chauny JM.Lipid

emulsions in the treatment of acute poisoning: a systematic review of human and

animal studies. Clin Toxicol (Phila). 2010 Jan;48(1):1-27.

8. Rothschild L, Bern S, Oswald S, Weinberg G.Intravenous lipid emulsion in

clinical toxicology. Scand J Trauma Resusc Emerg Med. 2010 Oct 5;18:51.

9. Cave G, Harvey M, Graudins A. Intravenous lipid emulsion as antidote: a

summary of published human experience. Emerg Med Australas.

2011 Apr;23(2):123-41

10. Weinberg G (2007) LipidRescue: resuscitation for cardiac toxicity

http://www.lipidrescue.org/

11. Resuscitation Council (UK) (2010) Resuscitation Council (UK).

http://www.resus.org.uk/

12. AAGBI (2010) The Association of Anaesthetists of Great Britain and Ireland.

http://www.aagbi.org/

13. ACMT Position Statement: Interim Guidance for the Use of Lipid Resuscitation

Therapy American College of Medical Toxicology; J. Med. Toxicol. (2011) 7:81–

82

http://www.ncbi.nlm.nih.gov/pubmed/20095812?itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum&ordinalpos=1



http://www.ncbi.nlm.nih.gov/pubmed/20923546





http://www.lipidrescue.org/

http://www.resus.org.uk/

http://www.aagbi.org/



NOVEL RECREATIONAL DRUGS OF ABUSE – AN

OVERVIEW

Hultén Peter, Swedish Poisons Information Centre, Stockholm, Sweden

Objective: In recent years a large number of these new synthetic psychoactive substances

(»legal highs«) have appeared as alternatives to illegal drugs. These novel recreational

drugs are often synthetic research chemicals or herbal materials containing psychoactive

natural substances sometimes adulterated with synthetic compounds. The novel drugs of

abuse are often available for purchase over the Internet and are commonly legal to use,

possess, and supply. In several countries different control measures have been put into

force. Some main groups are cannabinoid receptor agonists (»Spice«), piperazines,

phenethylamines (including amphetamines, cathinones, ring substituted

phenethylamines), tryptamines, and ketamine and phencyclidine derivatives.

Discussion: The overall population prevalence of use of novel recreational drugs is

difficult to assess since most reports, e.g. the UN World Drug Report and the European

Monitoring Centre for Drugs and Drug Addiction (EMCDDA), do not enquire about

novel compounds since the focus is on “classical” substances. The source is the drug

dealers on the street market, but also the Internet and street “head shops”, particularly

when the drugs first become available. These drugs are frequently sold as “bath salt”,

“fertilizer”, “plant food” and/or labeled as “not for human consumption” or “research

chemical” to elude the legislation. Most of these substances are produced in China or

India and shipped into Europe and North America in bulk quantities where they are

packaged into dose quantities before being sold to the user. The content of the products

often changes, sometimes including illegal substances, leading to increased risk of toxicity

and risk of criminal conviction. Over 40 new substances were reported in 2010 to the

EMCDDA via the EU early-warning system. The challenges are to identify the

compounds and determine their acute toxicity. To identify the acute toxicity of these

compounds poisons centre data, admissions to hospital and death case statistics could be

used. This information is difficult to assess and may lack analytical confirmation.

Common clinical features seen in individuals include wide pupils, agitation, tachycardia,

hypertension and seizures. Most poisonings are benign and symptomatic treatment is

normally sufficient.

Conclusion: Risks new psychoactive substances are not fully documented and serious

clinical symptoms have occurred, even fatalities. Therefore it is of great importance that

clinicians are informed about the risks associated with the use of novel recreational

drugs.

Key words: recreational drugs, abuse



The effects of Poisonings Information Centre‟s (PIC) activities - an

Estonian example

Mare Oder MSc RN

Estonian Poisoning Information Centre (EPIC), Heath Board, Ministry of Social Affairs

Objective: To describe the PIC´s role in a community and the effects of active poison

information education on the awareness of public about PIC.

Introduction: EPICs mission is to provide adequate advice quickly so as to reduce the

incidence of illness, damage to health and death as a result of severe cases of poisoning.

In October, 2008 EPIC‟s phone line 16662 became active on business days from 09.00–

17.00; since January 2011 24h/5. No expensive media campaign was launched.

EPIC has continually two educational activities – primary(PP) and secondary

prevention(SP). The goal of PP is to avoid poisonings; SP is defined as reducing

morbidity and mortality by creating PIC awareness. Additionally is public´s and

healthcare providers‟ education, awareness of the PIC‟s phone number associated in

turn with a positive impact on call volume in PIC.

Method: All calls answered in the EPIC, activities, published articles and lectures about

poisonings and their prevention were analysed via a time-line from the 1st of October

2008 to the 30th of September 2011. All calls concerning general information about

health, diseases and other questions were classified as general questions (GQ). Only calls

concerning acute exposure to poisons were defined as poisoning questions (PQ). The

annual number of calls, lectures and articles was compared.

Results: In order to achieve the goal EPIC launched a presentation‟s programme about

poisonings, their treatment and prevention for healthcare providers and general

population as well as started participating in health promotional fair. EPIC has

developed the expert-status for healthcare providers, population, media, authorities.

During the analysed period in total 1620 calls were answered. The structure of the calls

was as follows: 2008: 90 calls: 37 (41.1%) GQ, 53 (58.9%) PQ; 2009: 331 calls: 127

(38.4%) GQ, 204 (61.6%) PQ; 2010: 450 calls: 112 (24,9%) GQ, 338 (75,1%) PQ; 2011:

761 calls: 184(24,2%) GQ, 577(75,8%) PQ.

Structure of lectures/published articles (and reflections in media publications) was as

follows: 2008: 3/2 (50); 2009: 9/8 (9); 2010: 12/15 (19); 2011: 20/12 (96).

A total annual number of deaths from poisoning decreased from 410 (in 2007) to 300 (in

2010).

Conclusion: Active, systematic poisonings information activity, education increases the

awareness, confidence of the population to the PIC and has a positive impact on the

volume of poisoning calls handled by the centre. The educational programmes did not

have an immediate effect but had a positive effect from a longer perspective. As earlier

published articles described, combining PP and SP in one initiative may have a positive

impact on PIC‟s call volume and might influence number of deaths from poisonings.

Key words: role, Poisoning center, Estonia



NUMBER OF DEATHS BECAUSE OF ETHANOL INCREASES

IN SLOVENIA

Marija Jamsek, Milos Kravanja, Lucija Sarc

Poison Control Centre, University Medical Centre, Ljubljana, Slovenia

Introduction. Ethanol – a legal drug is the most commonly used psychoactive substance.

Ethanol abuse represents a large social and health burden. Ethanol abuse causes many

chronic diseases and is involved in complications by management of many other diseases

due to withdrawal. There is an increase in mortality because of ethanol in Slovenia.

Aim. In this study we analyse national epidemiological data about deaths caused by

ethanol in the last ten years period.

Methods. The epidemiological data for the dead because of ethanol in years 2000 and

2009 were obtained from The Institute for Public Health of Republic of Slovenia (IPH

RS). Their national statistical data are based on “The International Statistical

Classification of Diseases” (ICD-10). 25 Codes related to ethanol were divided in 5

groups: T51.0, F10.0 and F10.1 acute ethanol poisoning; F10.2, F10.3 and F10.4 ethanol

withdrawal; K70.0, K70.1, K70.2, K70.3, K70.4 and K70.9 ethanol hepatopathy; I42.6

ethanol cardiomyopathy; F10.5 F10.6, F10.7, F10.8, F10.9, E24.4, E51.2, G31.2, G62.1,

G72.1, K29.2 and K86.0 others. We compared the number of dead in both years in each

code group in relation to gender and age group.

Results. A total number of the dead in year 2000 is 475 and 840 in year 2009, what

represent an increase by 77%. Gender distribution is in average in both periods similar;

75% of the total dead because of ethanol belong to males and 25% to females. In the both

periods is the leading cause for the mortality of alcoholics ethanol hepatopathy, followed

by ethanol withdrawal, acute ethanol poisoning and ethanol cardiomyopathy.

Comparison of the code group distribution shows in year 2009 an increase of

hepatopathy share by 25%, a decrease of ethanol withdrawal share and acute poisoning

share by 30% and 43% respectively in comparison to year 2000. Peak of age group

distribution is in an age group 50-64 years for males and in age group above 65 years for

females in both periods

(Figure1).

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Conclusions. The mortality increase because of consequences of ethanol abuse almost

redoubled in the last ten years. Three fourth of the dead because of ethanol belong to a

male population. Leading cause of mortality among chronic alcoholics is ethanol

hepatopathy for both genders. We estimate that absolute number of the deaths because

of ethanol is underestimated; some deaths because of ethanol do not get one of the above

mentioned codes thus they are hidden behind pneumonia, sepsis, trauma or

haemorrhage.

Key words: ethanol. deaths, Slovenia



Benzodiazepines–Drugs or poison? Irena Ignjatović,

Emergency medicine ward, General Hospital in Leskovac, Serbia

Introduction: In many countries around the world the most frequent case of poisoning is

acute drug poisoning. Epidemiological data concerning poisoning cases in Belgrade, the

capital of Serbia, for the period from 1995 until 1998 shows precisely that the most

frequent and effective causers of acute poisoning with chemical substances are drugs.

Among them benzodiazepine medicals (taken with or without other chemical substances)

take part with 50% of all cases; moreover, benzodiazepines have become the most

frequent causer of poisonings, often deliberately ones, due to their wide availability.

Toxicity of benzodiazepines is very small; that is the main reason why the poisoning

cases are not so severe. In the majority of cases they are combined with alcohol and

opiates. Even though the clinical image has a difficult course, these poisonings can

sometimes be severe if the patients who took the drugs were elderly persons or in case of

so called „combined‟ poisonings.

Aim of the paper: The aim of this paper is to show the frequency and modes of treating

the patients with acute, benzodiazepine drug poisoning in the Emergency Room (ER) of

the Hospital in Leskovac. The author‟s intention was also to show the importance and

the role of an ER specialist in reception and emergency hospital treatment of the patients

with acute drug poisoning.

Methods: The research was conducted as a retrospective, nine-year observational study,

analyzing the data from the admission and triage protocol of the department of the ER,

where patients are received and treated according to the protocol for the patients with

acute poisoning, as well as the data from the stationary department, the Toxicology Unit,

in the period from the beginning of 2002 to the end of 2010. The method of quantitative

analysis of the total number of the patients with poisoning and the number of patients

with benzodiazepine drug poisoning was used, accompanied with graph, percentage and

table overviews.

Results: In the period from the beginning of 2002 till the end of 2010, 297 737 patients

were admitted in Emergency ward, 1.08% of whom with acute poisoning, were examined

in the Emergency Room of the hospital in Leskovac. The largest number poisoning is

drug poisoning with 34.82%. There was an increase from 62 drug poisoning in 2002. To

216 cases in 2010. From the total number of drug poisoning, 72% of cases were

intoxications with benzodiazepine drugs; poisoning cases with diazepam were observed

in 43.12% of all cases. The data analysis of acutely poisoned patients showed a greater

number of acute poisoning with benzodiazepines among female population (87.13%),

94.46% of which was suicidal. In the majority of cases (39.56%) the PSS level 1

poisoning were recorded. Acute poisoning of patients from the age of 30 to 40 happened

in 36.98% of all poisoning cases.

Conclusion: Benzodiazepines as medications of wide application area and they have a

greater toxicological significance, due to the high increase of suicidal cases in Jablanica

district. These drugs mainly cause light poisonings what was recorded in 45% of all

admitted patients in Emergency ward of General Hospital in Leskovac. Dominate signs

of poisoning were noted by examining patients central nervous system and



cardiovascular system. Most patients, 84% of them, after being treated in the ER, were

discharged home in good general condition. During the research there were not any cases

with fatal outcome.

The best advice for a therapeutic protocol in benzodiazepine poisoning is the application

of general measures of treatment and resuscitation according to the protocol ABC,

gastric lavage and medicine coal application with infusions. Poisoning facilitations at a

basic level require the application of supportive therapy, stabilization of the circulatory

and respiratory function, gastrointestinal decontamination and general care of patients.

In the case of serious poisoning the application of basic supportive therapy and specific

therapy antidote (flumazenil which is applied intravenously at a dose of 0.3 mg at the

very beginning) is required. If the desired level of awareness is not reached after 60

seconds, repeated doses to a total dose of 2 mg are applied to the patient until the waking

up. In the case sleepiness the readmission of intravenous infusion of 0,1-0,4 mg/h is

required. In order to prevent benzodiazepine poisoning, it is necessary to reduce the free

sale of these products.

Key words: BNZD, poisoning, ABC protocol



ACUTE SALICYLATE POISONING TREATED IN THE NATIONAL POISON

CONTROL CENTRE: RETROSPECTIVE STUDY

Đorđević D, Režić T, Jović-Stošić J, Bokonjić D, Kilibarda V, Vučinić S

Clinic of Emergency and Clinical Toxicology, National Poison Control Centre, Military

Medical Academy, Crnotravska 17, Belgrade, Serbia

American Association of Poison Control Centers (AAPCT) has reported the increase of

salicylate exposure in a five years period, 1998-2003, and emphasized that 12,6% of all

fatal analgesics poisonings have been caused by salicylates.

OBJECTIVE: The aim of this study was to analyze the frequency, the most frequent

features and severity of acute salicylate poisoning treated in the National Poison Control

Centre (NPCC).

MATERIALS AND METHODS: The restrospective study was performed in the Clinic

of Emergency and Clinical Toxicology, NPCC, Military Medical Academy, Belgrade.

RESULTS: During the five years period (2005-2009), 5463 patients with acute poisoning

were hospitalized and 30 (0,549%) of them had acute salicylate poisoning. Poisoning was

deliberate in all the cases, and the most of the patients were women - 26 (86,6%). The

severity of poisoning was determined according to the Poisoning Severity Score: 12

(40%) patients had no clinical signs of poisoning (PSS 0), but salicylates were detected in

blood with the levels above the therapeutic; 13(43,3%) patients had mild poisoning (PSS

1), and in 5 (16,6%) patients the poisoning was moderate (PSS 2). The most frequent

signs of poisoning were nausea, vertigo, tinnitus, epigastric pain, vomiting, somnolence,

electrolyte disorders, while one patient had metabolic acidosis of moderate degree. The

highest detected salicylate concentration was 520 mg/L. The therapy consisted of

rehidration, correction of electrolyte disorders, H2 antagonists or inhibitors of proton

pump, and sodium bicarbonate infusion (for alkaline diuresis and correction of

metabolic disorders).

CONCLUSION: Acute salicylate poisoning, although not so frequent could be a clinical

problem, and it is necessary to provide prompt diagnosis, supportive and symptomatic

treatment. Alkaline diuresis is indicated for patients with any sign of poisoning and

should not be delayed untill salicylate levels are determined. However, serum levels are

helpful in confirming the diagnosis and may help guide therapy, but levels may also be

misleading and should be clinically correlated.

Key Words: acidosis, salicylates, poisonings



СТИМУЛАТИВНА (МОДЕЛ) ПСИХОЗА ВЕРСУС

ШИЗОФРЕНИЈА

Дарко Костовски, Оливера Суботин

Психијатриска болница Скопје

Психозите предизвикани од амфетамини се експериментален модел на

параноидна шизофренија. Овие психоактивни супстанции употребувани како

дроги се неврохемиски медијатори на ЦНС кои предизвикуваат синдром на

параноидна состојба. Тоа е ткн. Модел психоза кај која се целосно изразени

аудитивните и /или визуелните перцептивни измами. Овие состојби се јавуваат по

интоксикација, долготрајна употреба или во рамките на апстиненцијата.

Најголемиот број на истражувања на веројатните невроанатомски

структури одговорни за појавата на на шизофренијата, се фокусирани на

субкортикалните јадра. Постојат и докази за промени предизвикани од употребата

на амфетамини и во префронталниот кортекс.

Од особена важност за секојдневната клиничка пракса во психијатриските

и другите медицински институции е диференцијацијата на оваа состојба во однос

на параноидната шизофренија. Акцентот на овој клинички ентитет се дава поради

голем број на млади лица кои употребуваат рекреативни стимулативни

супстанции или во случаите на комбинирана зависност. Дополнително, лицата

што користат исклучиво амфетамини, најчесто бараат медицинска помош само во

случај на психотична декомпензација.

Сцената на корисниците на стимулативни дроги е стабилна, но не е толку

достапна за службите и невладините организации, компарирана со сцената на

корисниците на опијати.

Key Words: psychosis, schizophrenia, psychoactive drugs;



Metabolic acidosis caused by corrosive agent ingestion – main

characteristics and specific therapeutic approach

Režić T, Vučinić S, Babić G, Potrebić O, Đorđević D, Perković-Vukčević N, Vuković-

Ercegović G, Bokonjić D, Jović-Stošić J

Clinic of Emergency and Clinical Toxicology, National Poison Control Center (NPCC),

Military Medical Academy Belgrade, Crnotravska 17, Serbia

Acute poisoning with corrosive agents treated in NPCC, make 15% to 20% of all

hospitalizations, and also the main cause of a fatal outcome. Metabolic acidosis is one of

the most important systemic disturbance which may be caused by this kind of poisoning.

OBJECTIVE: The two main goals of this study were to determine the frequency, type

and severity of metabolic acidosis as well as the efficacy of sodium bicarbonate therapy

during the corrosive agents poisoning.

MATERIAL AND METHODS: The retrospective study included 112 patients, 83 (74%)

were female, 29 (26%) male, hospitalized in our facility throughout two years period

(from 2008. to 2009.). Patients were categorized by two major criteria: Poisoning severity

score (PSS 1-4) and by the type of corrosive substance (six groups). Parameters of blood

acid-base status are determined by the ABL 735 analyzer-Radiometer.

RESULTS: Acid-base profile was determined initially in 73 out of 112 patients (65%).

Metabolic acidosis (Standard Base Excess or SBE< -2,5 mmol/l) was proven in 56

samples (77% of analyzed). All of them were a high anion gap acidosis (AG>11mmol/l).

In etiological group 1 (acetic acid) 32 (76%) acidosis was confirmed with an average of

SBE = -10,7 mmol/l, and in group 2 (hydrochloric acid) 17 (89%) , average SBE= -12,8

mmol/l. These two groups have also shown good correlation between PSS and the

severity of acidosis, with statistical importance of subgroups PSS4 (lethal poisonings)

compared to groups PSS1, 2 and 3: in group 1 (p<0,001), in group 2 (p<0,05).

Intoxication with sodium hydroxide (group 3) caused moderate acidosis (SBE= -6,1

mmol/l) in four cases (57%). Thirty three patients were treated with sodium bicarbonate

(4,2% or 8,4% infusion), during an average period of 24 hours from time of admission.

Initial mean values of blood bicarbonate concentration or cHCO3 (16 mmol/l) and SBE (-

11,1mmol/l), were significantly improved at the end of the therapy (cHCO3 22 mmol/l,

SBE= -3,1 mmol/l respectively; p<0,001).

CONCLUSION: initial assessment and follow up of metabolic acidosis is an obligatory

diagnostic procedure to determine the severity of the poisoning, prognosis and

therapeutic efficacy in cases of corrosive chemical poisoning.

Key words: acidosis, corrosive ingestion,



PLASMAPHERESIS APPLIED AT ACUTE SUICIDAL

POISONING BY CARBAMAZEPINE (EPITOL, TEGRETOL,

ATRETOL) AND BENZODIAZEPINE-DIAZEPAM

B.Pavlovski, A.Cibisev, G. Spasovski, V.Nikolov, N.Popovski, L.Trencevska, L.

Milosevska

University Clinics for Toxicology and Nephrology, Skopje, R. Macedonia

Background: Clinical applications of plasmapheresis are rapidly increasing as a method

of detoxification in the field of clinical toxicology. Carbamazepine in blood is 76% bound

to plasma proteins. Initial half-life values range from 25-65 hours, decreasing to 12-17

hours on repeated doses. Carbamazepine is metabolized in the liver. Cytochrome P450

3A4 was identified as the major isoform responsible for the formation of carbamazepine-

10,11-epoxide from carbamazepine. Peak plasma levels occur 4-8hours after

administration… Most of the toxicity is due to the CNS depression and anticholinergic

effects. Diazepam and its metabolites are highly bound to plasma proteins (diazepam

98%).

The aim of this case report was to demonstrate successfully treatment using

plasmapheresis by evidence of effective clearance of remedies and change comatose

status to full consciousness. The patient N.N 29 old man, prisoner, was admit at our clinic

on 02.10 .2011 in the evening hours, 24 hours after suicidal ingestion of unknown

remedies. He was in comatose status, with tachycardia, mydriasis, and dry mucous

membranes.

Following routine biochemical blood and urine tests were made: SE,ER , Hm,

Pl,Le,Glicemia. Enzymatic status: ALP, AST, ALT, LDH, GGT..degradationes

products: Urea, Kreatinine-serum.Total bilirubine , Dir bil,Ind bil,. .Electrolytes status:

Na, Ka, Ca..Lipoproteins status: Total lipids, Trigl,Total Hol, Hol-est, HDL, LDL.Urine:

PH, Prot, Glicemia, Le. ECG and blood pressure were continually monitoring, and

specially QRS and QT prolongation.

Toxicological substances were determined using TLC ( Thin Lower Chromatography).

Using this method we detected presence of Carbamazepine and Benzodiazepines in the

urine. Plasma concentration of Carbamazepine and urine concentration of

Benzodiazepine we measured using Fluorescence Polarization immunoassay (FPIA)

technique on Abbott TDx FLx instrument.

Result: Two consecutive plasmapheresis were made. We measured the plasma

concentrations of Carbamazepine before the treatment and after to the each

plasmapheresis.These are plasma concentration of Carbamazepine: Before the first

treatment -275mmol/L, after the first treatment-140mmol/l, after the second treatment -

54mmol/L. (Ref. values 17- 50mmol/L,for the patients who take therapeutic doses of

Carbamazepine.Urine concentration of BZD before the treatment were: 862,29ng/ml.

Resume: We measured the plasma concentrations of Carbamazepine at this intoxication

and we found clinically significant clearance with plasmapheresis. Because of a lack of

large controlled series, the rationale for using plasmapheresis must be confirmed in each

type of intoxication by evidence of effective clearance, as well as by high plasma protein

binding and a low volume of distribution of the toxic substances.

Key words: Plasmapheresis, acute suicidal poisonings, Carbamazepine, Diazepam.



ALCOHOLIC CARDIOMYOPATHY in 33 year old male patient

A.Stevchevska, A.Chibichev, B.Pavlovski

University Clinic for Toxicology, Skopje

Introduction: Alcoholic cardiomyopathy is a type of dilated cardiomyopathy which represents

3,8% of all cases of CMP in general.

It is concidered that the duration of alcohol consumption(over 5 years) and the amount of daily

alcohol ingestion (over 90g per day), have important role in the apeareance of the alcoholic

cardiomyopathy.

Case report: We present a case of 33 year old patient admited to our clinic during two weeks,

in march 2009', because of dyspnea, bilateral leg swelling,progresive abdominal swelling,

nausea, intense fetigue-reduced effort tolerance, especially the last two weeks before

admission.

The patient was without positive hystory of hospital admissions or health issues of any kind

before , with anamnestic data of 1/2 litar of daily alcohol uptake last ten years.

On examination the patient had bilateral basal crepitations and systolic murmur over mitral

and tricuspidal valve.Also the abdomen was meteoristic with positive sign of

fluctuation,congestive hepatomegaly and bilateral pitting crural oedema.

During hospitalisation following examination were made: ECG; biochemical labaratory

analysis, echocardyography, abdominal echosonography, chest x-ray.

Since the given anamnestic information, also absence of precipitating moments in patient's

hystory ,and according to the performed tests and analysis , a diagnosis of alcoholic

cardiomyopathy was made.

Conclusion: Long term heavy alcohol abuse is second leading cause of dilated CMP. Since

there are no specific criteria for diagnosis of ACM , the key factor in rulling is long term

hystory of alcohol consumption. It has been shown that alcohol abstinence besides hearth

failer therapy is nessecery in the treatment of this patients.

Key words: alcohol abuse, dilated cardiomyopathy, echocardiography

IX Symposium of Macedonian association of toxicologists

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Transcript of IX Symposium of Macedonian association of toxicologists