Abstracts of the Middle East and North Africa clinical Toxicology Association Meeting, January 11–14, 2023, Abu Dhabi, UAE

Background: Kuwait, like all GCC countries, has warning label requirements for energy drinks. To protect vulnerable groups, including children, pregnant women, breastfeeding women, and others, warning labels are intended to caution these groups against using energy drinks. We conducted cross-sectional sampling in 2022 to determine if energy drinks sold in Kuwait carry the required warning labels. Methods: Fifteen vendors, including the 5 largest supermarkets and 10 smaller non-franchise supermarkets were sampled and all available energy drinks were included. Variables were recorded: brand, product name, and warning label components including for pregnant women, breastfeeding women, children <16 years, cardiac patients, exercising persons, and persons with caffeine allergy/sensitivity. The null hypothesis that >10% of products do not have a warning label was tested. Summary descriptive results of other analyses were also compiled. Results: Every vendor that was visited sold energy drinks. 43 products were available, and all had a warning label. Of these, 19/43 (44.2%) carried all warnings correctly in Arabic (Ar) and English (En). To a statistically significant degree ( p = 0.0023), products do contain some warning labels, but also to a statistically significant degree ( p = 0.0001), they do not contain all warnings in both Arabic and English. Conclusion: Energy drinks are sold widely throughout Kuwait and are available at every retail grocery supplier sampled. All products (100%) had some warning label. Most did not contain warnings for all required conditions in both Arabic and English. For individual warning label components, many products failed to provide a warning to all required groups of vulnerable consumers.

clinical-biological collaboration are the conditions for highlighting this form of delinquency, the consequences of which are both medical and legal.
The toxicological analyzes carried out at the level of the Algerian National Center of Toxicology (CNT) detected a psychotropic drug (benzodiazepine) in the urine of a married couple and in a mixture of water and honey which was administered to them in a context of "Ruqya" home.These victims of aggression (robbery) consulted in the emergency room, with symptoms suggestive of chemical submission (amnesia, impaired vigilance).The toxicological analyzes were carried out by chromatographic techniques (HPLC-UV/DAD) on blood, urine, water, and the mixture (water-honey).
The diagnosis of chemical submission is difficult to establish formally.Often, the products used have short half-lives, the circulating concentrations are low, and the samples are taken late.Hence the importance of discussing this diagnostic hypothesis and taking plasma and urine samples early, which should be sent to a specialized laboratory.This will be the first step in the always essential forensic investigation.

Deadly toilet seat: fatal bite in an unusual location-case series
Musa Alfaifi a and Bader Alyahya b a Armed Forces Hospitals Southern Region, Abha, Saudi Arabia; b King Saud University, Riyadh, Saudi Arabia ABSTRACT Background: According to the world health organization, people are bitten ubiquitously they go, even just walking to an outdoor toilet.We are reporting three cases who were bitten in an indoor toilet by an Arabian cobra.Method: This is a case series of three patients who were bitten by an Arabian Cobra on the indoor toilet on ground floor.Case 1: A Five-year-old female was bit in the left buttock multiple times while she was sitting on the indoor toilet seat on the ground floor.The snake was identified as an Arabia cobra.She had a cardiac arrest at a primary health clinic after 90 min of envenomation.Resuscitation was started, ROSC was achieved, and she was transported to the hospital where she died after two days.She received 110 vials of antivenom, 200 ml of PRBCs, 400 ml of FFP, 400 ml of platelets, and a total of 15 mg of intravenous vitamin K.She developed multiorgan failure and passed away on the fifth day of admission.Case 2: A 25-year-old male was bit by a snake on his left big toe while stepping in the indoor toilet.The snake attacked him abruptly from the toilet seat before he sat on it.The patient picked up a brief clip from his mobile camera, which revealed a two-meter-tall Arabian cobra.The patient presented to the emergency within 30 mins complaining of intense pain with local oozing.He received 50 micrograms of intravenous fentanyl, and 10 vials of snake antivenom, with a maintenance dose of 2 vials every 6 h for three doses.The patient had a mild local edema on physical exam with no neurological or systematic manifestations.His labs were within reasonable limits.He was discharged home after 3 days of admission.Case 3: A 55-year-old male was bit by a snake multiple times on his left small and ring finger while he was sitting on the toilet seat.He arrived at the emergency 30 mins post envenomation complaining of difficulty to stand and walk and with ptosis.No ophthalmoplegia or neck weakness was present.The provisional diagnosis was a neurogenic snake bite, and he received 10 vials of anti-venom immediately.On the second day, the patient's friends opened the toilet and killed around one-half-meter tall Arabian cobra.An additional 5 vials of antivenom were given, two hours post the initial dose as the improvement was mild.There was a complete recovery after six hours, and the patient was started on a maintenance dose.His left hand was noticeably swollen, which improved by pillow elevation and antivenom administration.The patient was discharged after five days of admission.Conclusion: Though the Arabian cobra bite is lethal, immediately seeking medical care can be lifesaving, especially in pediatric patients with small body weight.It is obvious that the Arabian cobra can access the ground floor toilet seats through sewages pipe, especially near agricultural areas.Thus, community education in terms of using a one-way valve in the toilet seat as a preventive technique and early medical care are crucial to avert such life-threatening rare scenarios.

Manifestations and management of black widow spider (Latrodectus renivulatus) bite in pediatrics in Saudi Arabia: a case series and call for antivenom availability
Musa Alfaifi a , Bader Alyahya b , Ibrahim Alhelali c , Lujaine Al-Murayeh c , Mohamed Elbarbary c , Ibrahim AL-Benhassan c and Hesham Gamal c a Armed Forces Hospitals Southern Region, Abha, Saudi Arabia; b king Saud University, Riyadh, Saudi Arabia; c MOH, Abha, Saudi Arabia ABSTRACT Introduction: Black widow spider (Latrodectus renivulatus) envenomation is a unique toxicological emergency affecting Middle Eastern countries.Although the mortality risk of black widow spider envenomation is low, bites pose a considerable morbidity risk to victims and have a substantial economic impact on health care systems.The severity of clinical manifestations depends on the amount of venom delivered in the bite and the age of the victim.Here, we report four pediatric cases of severe black widow spider envenomation in Saudi Arabia.Discussion: This is the first case series reported in on pediatric black widow spider envenomation in Saudi Arabia.The neurological manifestations of envenomation in these patients were predominant, and all patients required morphine for pain relief.All patients required admission to the pediatric intensive care unit (PICU).The duration of PICU stay and total hospital stay was 1-3 days and 2-5 days, respectively.Conclusion: Previous reports have shown that Latrodectus antivenom is safe and effective, and we believe that it should be considered in cases of severe envenomation in Saudi Arabia to rapidly relieve symptoms and reduce the duration of hospitalization.However, patients did not receive the Latrodectus antivenom in this study owing to unavailability.

Sound tasty but toxic, cantharidin poisoning due to Spanish fly ingestion in children: case series
Musa Alfaifi a , Rawan Alshahrani a and Daad ElGari b a Armed Forces Hospitals Southern Region, Abha, Saudi Arabia; b National Poison Center, Riyadh, Saudi Arabia ABSTRACT Introduction: Cantharidin is a known toxin and vesicant in the ovaries, blood, and soft tissue of blister beetle (known as Spanish fly).Hycleus maculiventris, subspecies of Meloidae family, is a recognized species in the southern region of Saudi Arabia.We are describing two cases of cantharidin poisoning after ingestion of blister beetle.Case 1: A 9-month-old boy appeared unwell after a Spanish fly was found in his mouth Even though the beetle was removed intact before being chewed, the baby had persisting vomiting for 15 episodes.He had a gross hematuria after 20 h of ingestion.He was dehydrated, lethargic, tachycardiac, febrile, and hyperglycemic, and he required admission to the intensive care unit.His laboratory results revealed mild metabolic acidosis, renal impairment, hyperkalemia, leukocytosis, hematuria (4× blood), and proteinuria (2× protein) in the urine dipstick.The main step of management was conservative through hydration, pain control, and antiemetics.His clinical condition improved, and he was discharged after 6 days of hospitalization.Case 2: A 2 years 9-month-old boy appeared intoxicated after ingestion of a beetle blister.He developed repeated vomiting for 12 h, followed by gross hematuria, and urine clots, with 4× blood and 2× protein in his urine dipstick.The patient required admission to the intensive care unit for monitoring and supportive care.His laboratory studies were within normal range except for leukocytosis.His hematuria resolved after three days of hospitalization, and he was discharged after 5 days of hospital stay.Discussion: The onset of symptoms of cantharidin intoxication occurred shortly after ingestion, secondary to its irritant effect on the mucous membrane of the esophagus and stomach.Absorption of cantharidin is associated with systematic manifestations, particularly hematuria, proteinuria, and leukocytosis.The key management of cantharidin poisoning is supportive care with painkillers, hydration, and antiemetics.Though there are case reports of renal failure and shock, most of the incidental cantharidin poisoning cases completely recovered.

Therapeutic baclofen induced neurotoxicity in patient on renal dialysis, a case report and literature review
Nejah Ellouze a and Suad Al Abri a,b a Sultan Qaboos University Hospital, Muscat, Oman; b Toxicology Club, Oman Society of Emergency Medicine, Muscat Oman ABSTRACT Background: Baclofen is a centrally acting GABA receptor agonist, and it is used widely for the treatment of spasticity, persistent hiccups, and multiple sclerosis.It is mainly eliminated by the kidneys.Thus, it is accumulated in patients with renal insufficiency leading to central nervous system toxicity.Methods: This is a case report and a literature review of therapeutic baclofen-induced toxicity in patients with renal hemodialysis.Case summary: A 74-year-old female with a known history of hypertension on medications, was brought to the Emergency Department with a decreased level of consciousness that started after taking two tablets of baclofen for low back pain.The patient was lying in bed, sleepy, but not in distress.Her initial vital signs were normal apart from a mild tachycardia 111.Her GCS was 9/15.She had no focal neurological deficit.Her pupils were normally dilated, equal, and reactive to light.The Computed tomography scan of the Brain and her laboratory tests findings did not explain her decreased level of consciousness.In view of the recent use and the known neurotoxic side effect, the patient was diagnosed with baclofen toxicity after alternative causes for altered mental status were ruled out.She received two sessions of intermittent hemodialysis with no significant improvement in her GCS.Therefore, continuous venovenous hemodialysis was performed, after which her condition improved, and her GCS became 15/15.She was discharged the following day with her regular medications.She was advised to continue her regular dialysis sessions as planned before and to avoid baclofen and nephrotoxic medications.Conclusion: Baclofen neurotoxicity is not very common in the general population and is mainly seen in patients with ESRD.In this group of patients, it can be serious and life-threatening.We recommend that Baclofen should not be used in patients with end-stage renal disease and that healthcare providers should be educated about its toxicity.

Prevalence and outcome of phenytoin toxicity in patients presenting to a Tertiary Care Hospital Emergency Department
Nejah Ellouze a , Munira Al Rumhi a , Huda Al Ruqaishi a and Suad Al Abri a,b a Emergency MedicineDepartment at Sultan, Qaboos University Hospital, Muscat, Oman; b Toxicology Club, Oman Society of Emergency Medicine, Muscat Oman ABSTRACT Background: The overdose of oral phenytoin causes mainly neurotoxicity and rarely causes cardiovascular toxicity.The neurological clinical features depending on the serum phenytoin level ranged from nystagmus to seizure, and coma.Objectives: This study aimed to describe the prevalence of phenytoin toxicity, the most common presenting symptoms, clinical manifestations, and outcomes in patients presented to Sultan Qaboos University Hospital (SQUH) Emergency Department (ED) over 10 years.Methods: It was a cross-sectional retrospective study that included all patients who presented to the SQUH ED from January 2012 to January 2022 who had high phenytoin levels.Data were collected using electronic patients' medical records.Results: The total number of patients was 2245.The sample included 24 patients who met the study inclusion criteria.17 (70.8%)were males and all were Omani.The age ranged between 6-77 years old with a median age of 35.5 years.Acute overdose was seen in one patient only (4.2%) and chronic overdose was present in 23 (95.8%) patients.20 (83.3%) presented with neurological symptoms.Drug levels ranged from 82.7-259 μmol/l (median134.8).20 (83.3%) had abnormal neurological examinations including seizures.ECG was normal in all patients.14 patients (58.3%) were discharged from the ED and 10 patients (41.7%) were admitted to the hospital.Conclusion: Chronic toxicity was observed more commonly than acute toxicity.Neurological symptoms and signs were most common.The results of this study showed that more than half of the patients were discharged from ED.

Paracetamol overdose and poisoning enquiries received by the Khartoum Medicines Information Centre (KhMIC) in 2022
Tayseer Mohammed a , Sawsan Mohamed a , Hisham Abdelrahim a and Muhammad Elamin b a Khartoum Medicines Information Centre, Khartoum, Sudan; b National Poisons Information Service (Birmingham Unit), Birmingham, UK ABSTRACT Introduction: Paracetamol (acetaminophen) is a commonly and widely used over-thecounter analgesic worldwide.It is also commonly involved in overdoses and poisoning worldwide.Though safe in therapeutic use, overdose and poisoning may lead to severe liver toxicity.Paracetamol overdose and poisoning are well recognized and documented worldwide, however, the extent of this, has not been previously examined in the Sudan.The Khartoum Medicines Information Centre (KhMIC) receives telephone enquiries from both the public and health professionals related to medication use and pharmaceutical exposures including paracetamol poisoning.
This study was carried out to evaluate the volume of telephone enquiries received related to paracetamol overdose and poisoning and to determine the patterns of paracetamol overdose and poisoning reported to the center.Objectives: Identify the volume of paracetamol overdose/poisoning enquiries received by KhMIC in 2022.Identify patterns of paracetamol overdose/poisoning enquiries reported to KhMIC Methodology: A retrospective review of telephone enquires received by KhMIC between January and November 2022 was conducted.All paracetamol poisoning enquires received were reviewed.Results: During the study period, a total of 1,163 telephone enquiries were received by KhMIC.Of these, the total number of paracetamol overdose and poisoning enquires received was 48 (4.1%) enquiries.Age distribution: The largest number of enquiries received, 27 enquiries (56.2%), involved children between the ages of 1-12 years.Of these, 13 enquiries (27.1%) involved preschool children between ages of 4-6 years old, 4 enquiries (8.3%) of school children (ages 7-12 years), and 10 enquiries (20.8%) of children between ages of 1-3 years old.Enquiries involving adolescents (12-18 years old) made up 8 enquiries (16.7%).Infants (1 month-1 year old) were involved in 5 enquiries (10.4%), and neonates (0-28 days old) in only 2 enquiries (4.2%).Enquiries relating to adults (above 18 years) were 6 enquiries (12.5%).

Circumstances of enquiry:
The main cause of overdose or poisoning was accidental in 18 enquiries (37.5%).Medication errors accounted for 17 enquiries (35.5%), and suicidal attempts were documented in 11 enquiries (23%).In 2 enquiries (4%) an adverse drug reaction was noted/suspected.Paracetamol tablets were the most common formulation reported, with 21 enquiries (44%).16enquiries (33%) involved intravenous paracetamol infusions.Paracetamol syrup ingestion was reported in 9 enquiries (19%), paracetamol suspension ingestion and suppository vaginal insertion in 1 enquiry each (2%).Most medication errors were due to incorrect infusion doses and errors related to infusion administration (14 out of 17 enquiries).Toxicity: A toxic dose of paracetamol was reported in 16 enquiries (33%).However, features of poisoning severity with signs of liver injury were reported in 20 enquiries (42%).17 enquiries (35%) received the antidote N-acetylcysteine.Conclusion: Though widely available over the counter, our findings suggest that paracetamol overdose and poisoning are not as common in the Sudan compared to other countries.Accidental overdose was the most common cause of overdose reported, though there were reports of use with suicidal intent.Our small study has identified areas of required improvement in prescribing and administration of intravenous paracetamol infusions to prevent and reduce medication errors.

Group vesicant exposure in the Republic of Georgia
Otari Dikhaminjia a , Teimuraz Kobidze b , Lorraine Vitek c and Ziad Kazzi c a Caucasus Medical Center, Tbilisi, Georgia; b Tbilisi State Medical University, Tbilisi, Georgia; c Emory University, Atlanta, GA, USA

Introduction:
The differential diagnosis for a vesicular rash is broad and encapsulates multiple infectious and noninfectious etiologies.Considering potential toxic exposures can be crucial for correct diagnosis, treatment, identification of a toxic exposure, and appropriate preparation for additional exposed patients.
In July 2018, an employee in a public location in Georgia discovered a yellow liquid on a surface with a strong smell of mustard and burnt wires; she assumed a malfunctioning air conditioner and summoned maintenance.All twelve individuals who spent time in the room experienced dizziness, burning in the eyes and throat, and a cough shortly after the exposure.One maintenance worker had direct hand contact with the substance and developed widespread vesicles of varying sizes in multiple body sites over the next 48 h.The patient was hospitalized for three days and received supportive treatment.Three other workers presented with conjunctivitis and were treated with antibiotics and steroid eye drops.The remaining eight patients were asymptomatic upon evaluation at the hospital.No patients presented to the hospital with respiratory complaints, although all patients reported transient respiratory symptoms after exposure prior to their evaluation at the hospital.None of the symptomatic patients had neutropenia upon evaluation or follow-up testing.
The liquid was identified to be the vesicle-causing alkylating agent sulfur mustard, which is consistent with the liquid's description and patient presentations.Exposure to sulfur mustard liquid or gas causes burns to the eyes, skin, and respiratory tract that usually manifest after several hours or up to 48 h for skin lesions; the clinical manifestations include vesicular blisters, burning, and pain in the eyes.Systemic absorption of large or repeated doses of sulfur mustard can be immunosuppressive.Conclusion: Toxic exposures should be considered in the evaluation of an index patient with a new onset vesicular rash.Rapid identification of toxic exposure can aid in the appropriate treatment of the index patient as well as in better identification and care of other potentially exposed persons.

Mohamed Elgassim and Waleed Salem
Hamad Medical Corporation, Doha, Qatar

ABSTRACT
We are reporting the case of a 39-year-old woman with a known history of hypertension who deliberately ingested large unidentified amounts of amlodipine (calcium channel blocker) in a suicidal attempt as well as smaller unidentified amounts of perindopril, (angiotensin-converting enzyme inhibitors) and hydrochlorothiazide (a thiazide diuretic).She was initially found to be obtunded and in severe hypotension with a blood pressure of 57/29 mmHg by the ambulance crew, and her hemodynamic instability persisted despite aggressive fluid resuscitation, multiple inotropic agents for vasopressor support, intravenous calcium infusion, and ultra-high-dose insulin therapy.Her initial gases showed metabolic acidosis with a pH of 7.01 and HCO3-of 11, potassium of 2.0, and initial hemoglobin of 10 g/dl, which rapidly dropped to 6 g/dl over an hour of her presentation.Her initial resuscitative measures were not showing signs of improvement, and the patient went into pulseless electrical activity cardiac arrest; however, return of spontaneous circulation was achieved after ten minutes of cardiopulmonary resuscitation.In lifesaving efforts, she underwent organ support through veno-arterial extracorporeal membrane oxygenation (VA ECMO), sustained low-efficiency dialysis (SLED), was sedated, and intubated, and had blood transfusions commenced.The patient gradually improved over the next six days, all organ support measures were stopped, and the patient regained consciousness with no long-term complications of the previous events throughout her follow-ups.The current literature on the management of calcium channel blockers toxicity shows varied results, with patients showing significant improvement in their overall status versus other patients with poor efficacy.In our case, the patient showed complete recovery despite the severe progression.

Tizanidine: the lethal withdrawal
Sarah Ahmed a , Elmunzer Ibrahim a , Moayad Elgassim b , Asma Jamil a , Mohamed Elgassim a and Waleed Salem a a Hamad Medical Corporation, Doha, Qatar; b Taylors University Lakeside Campus, Subang Jaya, Malaysia ABSTRACT Introduction: We report the case of a 41-year-old male who presented to the Emergency Department with insomnia, vomiting, diaphoresis, and visible signs of autonomic disturbances.Initially, a differential diagnosis of withdrawal syndrome was made; however, it was also accompanied by several others, including the acute abdomen, acute cholecystitis, and other possible underlying infections.Other causes were ruled out, and extensive, detailed history revealed the patient's long history of substance abuse, psychiatric history, and a previous diagnosis of Tizanidine withdrawal that presented similarly two years prior to this incident, that a diagnosis of Tizanidine withdrawal was made.Tizanidine is a muscle relaxant that acts by exerting an agonistic effect on noradrenergic alpha-2 receptors, increasing presynaptic inhibition.
Therefore, its abrupt cessation results in a withdrawal syndrome that is due to an adrenergic surge.The issue with Tizanidine withdrawal is that there are not many reported cases, and as such, its diagnosis can easily be missed, which can eventually lead to catastrophic consequences.Our patient was managed and stabilized in the ED with rate-controlling medication, antiemetics, an alpha-2 adrenergic agonist, and a benzodiazepine, after which he was admitted to the medical intensive care unit for follow-up after no further management could be sought in his current location.Tizanidine withdrawal diagnosis is a difficult one to make and requires elaborate medical history taking and should be suspected in patients with symptoms suspicious of withdrawal syndrome.It should be prescribed with care, especially to psychiatric patients, and side effects, including those of abrupt cessation, should be explained in detail prior to prescription.

A rare, late complication of digoxin overdose: myocardial injury
Rıza Cete, İbrahim Altundag, İbrahim Halil Toksul and Aynur Sahin Department of Emergency Medicine Medical Toxicology Intensive Care Unit, Başakşehir Çam and Sakura City Hospital, İstanbul, Turkey ABSTRACT Introduction: Digoxin is a cardiac glycoside used for the treatment of heart failure and certain arrythmias.Digoxin poisoning can develop due to its narrow therapeutic to toxic dose range (0.6-1.2 ng/mL).A range of arrythmias can be seen in poisoning including AV block, premature ventricular contractions, bradycardia, and even ventricular tachycardia.Review of literature however showed no report of elevated troponin in the setting of digoxin toxicity.Case report: A 28-year-old male patient was brought to the emergency department due to a drug overdose.Approximately three hours before admission to the emergency department, the patient had taken 40 tablets of 0.25 mg digoxin (Digoxin-Assos®, Assos Pharmaceuticals), with the intention of committing suicide.Upon arrival, the glasgow coma scale (GCS) was 15.He was oriented and cooperative.His vital signs showed a blood pressure of155/55 mmHg, heart rate of60/min, temperature of 36.4 °C, and pulse oximetry of98%.His ECG showed a normal sinus rhythm at a rate of 67 beats/minute.The patient was admitted to the toxicology intensive care unit (ICU) for close monitoring and treatment.The serum digoxin level was 4.43 ng/ml.The other laboratory results were normal.Upon further follow-up, no hypotension or arrhythmia developed and his EKG showed a normal sinus rhythm.The patient was cleared to the psychiatry unit after three days of hospitalization in the ICU ward.On Day 4 of hospitalization in the psychiatry ward, he started developing hypotension and bradycardia.His EKG was remarkable for a rate of 53 beats/minute and downsloping ST segment depression in the inferolateral leads.His troponin levels increased progressively (30,485,538ng/l) and he was readmitted back to the toxicology intensive care unit.Left ventricular ejection fraction was 55% and there was not any abnormality on echocardiography.D-dimer level was 790 ng/mL (normal range 0-500 ng/mL).Ct thoracic and abdominal angiography was negative for pulmonary embolism.The patient underwent a diagnostic coronary angiography that was found normal, and no thrombus found.In the follow-ups, after an increase in blood pressure and heart rate, norepinephrine infusion dose was reduced and stopped.Troponin levels gradually decreased (426, 300, 181, 67, 12.6 ng/l).Discussion: Digoxin toxicity may develop by increasing the frequency of administration or gradually increasing the dose due to its therapeutic window.Although patients with heart failure and renal disease are required to follow up closely on the drug level, they are at increased risk for developing toxicity, especially when digoxin is combined with diuretics that cause electrolyte imbalance including hypokalemia or hypercalcemia.There are no published reports on myocardial injury related to digoxin overdose.There was no clear explanation for the increase in troponin level and myocardial injury.This suggests that myocardial damage may be a late complication due to digoxin poisoning.The follow-up period should be extended due to the delayed presentation of hypotension, bradycardia, and myocardial damage which can develop in patients with digoxin poisoning.In the light of this case, we suggest that patients presenting with digoxin overdose may develop late complications and the follow-up period should be extended.

A rare case of botulism due to gastric injection of Botox(R)®
İbrahim Halil Toksul a , İbrahim Altundag a , Rıza Cete a , Aynur Sahin a , Burcu Genc yavuz b and Berna Atli b a Department of Emergency Medicine Medical Toxicology Intensive Care Unit, Başakşehir Çam and Sakura City Hospital, İstanbul, Turkey; b Department Of Emergency Medicine, Haydarpaşa Training and Research Hospital, İstanbul, Turkey ABSTRACT Introduction: Obesity is a serious public health problem that is rapidly increasing in the world and in our country.According to the latest data from the Turkish Ministry of Health, more than 30% of the adult population is obese in Turkey.Diet and exercise are the first approaches in the treatment of obesity.The search for an effective non-surgical method continues for individuals who cannot be successful with diet and exercise.Endoscopic applications are a constant research topic.The possible risks of surgical methods and problems such as nutritional deficiency in the long term attract the attention of patients and practitioners to endoscopic methods.Gastric botulinum toxin (BTx) is one of the most widely used endoscopic applications in our country recently.In this case report, we aim to present a case with neuropathy findings after stomach Botox(R) injection.Case report: A 44-year-old female patient was admitted to the emergency department with complaints of weakness, shortness of breath, and blurred double vision.The patient started to complain of weakness, shortness of breath, and blurred vision immediately after stomach Botox(R) injection.Her double vision started 3 days following the Botox (R) injection.Her symptoms worsened on the fourth day for which she presented to the emergency department.
Antitoxin was given to the patient in the emergency department, considering the effect of botulinum toxin.The patient's complaints of blurred and double vision persisted for which she got admitted to the toxicology intensive care unit.Her Glasgow coma score was 15 and she was complaining of generalized weakness, malaise, dysphagia, and dyspnea.Her laboratory tests and chest, neuroimaging was normal.Her electromyography (EMG) test was normal.The patient was followed up closely for 4 days.There were not any additional symptoms or pathology in her neurological evaluations including eye exam.She did not develop any respiratory distress, nor did she require mechanical ventilatory support.Her complaints regressed gradually, and she was discharged home fully recovered at Day 8 post Botox ® injection.Discussion: The development of neuropathy after botulinum toxin injection for cosmetic or medical treatment is a very rare condition.In our case, there were signs of cranial nerve involvement and proximal neuropathy, which developed after botulinum toxin-A was injected in the stomach for weight loss.In addition, BTx-A is also used in the treatment of achalasia, which is a motility disorder of the gastrointestinal tract.BTx-A prevents the contraction of smooth and skeletal muscles by inhibiting the release of acetylcholine at the neuromuscular junction.The injection of BTx-A into the stomach delays gastric emptying by preventing gastric motility, which enables weight loss by maintaining satiety for a longer period.Unexpected findings that develop after botulinum toxin applications for cosmetic and medical treatment are generally short-lived and temporary and resolve without sequelae.The literature on this subject is at the level of case reports.

Successful management of carbamazepine overdose with hemodialysis
İbrahim Altundag, İbrahim Halil Toksul, Rıza Çete and Aynur Şahin Department of Emergency Medicine Medical Toxicology Intensive Care Unit, Başakşehir Çam and Sakura City Hospital, İstanbul, Turkey ABSTRACT Introduction: Carbamazepine is a medication used to treat epilepsy and trigeminal neuralgia and as a mood stabilizer in bipolar disorder.Due to high lipid solubility, it quickly passes into the brain after oral administration.Both the carbamazepine itself and its active epoxide metabolite are responsible for toxic effects.Despite its high affinity for plasma proteins and its lipophilic nature, which gives it a wide distribution volume, studies are showing that it can be successfully treated with hemodialysis.In this article, we aim to present a case of carbamazepine poisoning successfully treated with hemodialysis.Case report: A 23-year-old male patient with epilepsy was brought to the emergency department due to a drug overdose.Approximately three hours before admission to the emergency department, the patient had taken 20 tablets of his own medication, carbamazepine (Tegretol® CR, Novartis), with the intention of committing suicide.He was brought to the emergency department after his family noticed vomiting and confusion.Upon arrival, his Glasgow coma scale was 13, and he was drowsy.His vital signs showed a blood pressure of 105/55 mmHg, heart rate of80/min, temperature of 36.4 °C, and pulse oximetry of98%.His ekg showed a normal sinus rhythm at 82 beats/minute.The patient was lethargic, had poor cooperation, and agitated.His eye exam was remarkable for mydriasis.Activated charcoal was not given due to altered mental status.The patient was admitted to the toxicology intensive care unit for close monitoring and treatment.The serum carbamazepine level was 39.4 μg/ml.A hemodialysis catheter was immediately inserted, and hemodialysis was performed for four hours.After hemodialysis, the serum carbamazepine level was 18.8 μg/ml.The following day, the patient's consciousness improved, but the agitation continued.The control serum carbamazepine level was 10.2 μg/ml.On the fourth day, the patient was referred to the psychiatry clinic since he had active thoughts of suicide.Discussion: Carbamazepine is one of the drugs whose toxicity can be monitored by serum level.Serum carbamazepine level should be checked every 4 h in overdose.Normal serum level is 4-12 μg/ml, serum toxic level is >20 μg/ml, and toxicity-related symptoms are seen at a level of >40 μg/ml.In acute intoxications, coma, seizures, agitation, hallucination, ataxia, dizziness, mydriasis, nystagmus, respiratory depression, apnea, or pulmonary edema can be seen.In patients whose serum carbamazepine level cannot be detected, the diagnosis of severe toxicity is made with the presence of recurrent seizures, life-threatening arrhythmias, and severe respiratory distress requiring mechanical ventilation.MDAC is recommended for carbamazepine poisoning.However, repetitive administration of activated charcoal could not be performed due to unconsciousness and risk of aspiration in our case.The main treatment for severe poisoning is intermittent hemodialysis.Extracorporeal methods are strongly recommended by ExTRIP in the presence of life-threatening arrhythmias and resistant seizures; It has also been stated that hemodialysis can be terminated when the serum carbamazepine level is <10 μg/ml or in the presence of clinical improvement.As a matter of fact, re-hemodialysis was not considered in our case since the clinical improvement was observed in the follow-ups and the serum carbamazepine level was in a decreasing trend.period of May 24 and June 14, 2022.In addition to demographics, the survey explored attitude, knowledge, and knowledge level regarding radiation emergencies.Descriptive statistics were used to analyze the results.Results: The survey response rate was 62.7% (N = 69/110).Sixty Two percent of the total responders (N = 43/69) had not attended any training in radiological emergencies.Most of the responders had never used nor attended training on operating radiation detection devices.Self-reported knowledge differences were assessed using 10 knowledge questions.Knowledge gaps were identified as the median score of self-reported knowledge was 50/100.Fifty-nine percent 59% (N = 41/69) of the participants felt that they needed educational programs and materials.Education courses followed by lectures were the preferred method of education by participants.Discussion and conclusion: Our results suggest a need for additional radiological incident preparedness training for emergency medicine residents and physicians in Oman.Training should include a performance of a radiation detection survey, decontamination, and management of radiation injuries.

Exotic snake species envenomation drill by an urban zoo, a regional poison center, and an academic medical center (on behalf of the Zoo Atlanta Practice Exercise Planning Group)
Afra Alsuwaidi a,b , Connor Walsh b , Debbie Forde c , Robert Hill c , Stephanie Hon b , Gaylord Lopez b , Robert Geller b , Brent Morgan a,b and Ziad Kazzi a,b a Department of Emergency Medicine, Emory University, Atlanta, GA, USA; b Grady Health System-Georgia Poison Center, Atlanta, GA, USA; c Zoo Atlanta, Atlanta, GA, USA ABSTRACT Introduction: Many zoos house venomous species that pose an occupational risk of envenomation to staff.These zoos maintain policies and procedures for urgent envenomation medical care and antivenom administration and keep on-site or have access to appropriate antivenoms.The study's purpose is to evaluate the current exotic envenomation guidelines through a simulated snake bite.Methods: The drill was a collaboration between the zoo, emergency medical service, the hospital's emergency department and pharmacy department, and the regional poison center.Checklists were created to document the required actions for each part of the process.The drill date and time were communicated to involved parties and consisted of four phases: the bite response at the zoo, the EMS response, the RPC consultation, and medical and antivenom management by the hospital's ED and toxicology teams.Results: During the zoo phase, the zoo dispatch center mistakenly reported a king cobra instead of a cape cobra snakebite to RPC and EMS.Despite that, the zoo still provided the appropriate antivenom due to an internal process that links the snake's identity to a numeric system.With the assistance of the zoo, EMS located the patient for transportation with the antivenom and a zoo staff member to the hospital.The RPC notified the ED communications center, provided verbal instructions, and faxed guidelines.However, the materials were not received by the physician because the number that was provided sent the material to an unreachable electronic inbox.The preparation of antivenom was completed at the bedside by a clinical pharmacist which decreased admixture time by 13 min compared to admixture by the inpatient pharmacy (previously reported).The toxicologists arrived in a timely manner and recommended administering the antivenom.The antivenom did not have a pre-built order within the electronic medical record (EMR) but was entered with pharmacy assistance.No test dose was administered, however, there was a discussion regarding its initial dose and infusion rate.The time from the bite to initiation of the antivenom administration was 74 min.The FDA was contacted when the patient arrived at the hospital through the emergency hotline and approval was obtained verbally.Hospital IRB approval was not requested due to the life-threatening nature of the situation and because the notification process was not available at the time of the drill.Discussion: The procedures set in place by the zoo and RPC were clearly documented, however, were met with a few problems and delays upon practice.Communication issues included the misidentification of the snake species to the RPC (later rectified).Envenomation incidents should be reported by herpetology staff instead of the zoo dispatch center.Pre-position guidelines in the ED or send them with the antivenom brought by the zoo staff.An orderset should be built in the hospital's EMR and should include the antivenom dose, lab and adjunct medications.We suggest conducting an unannounced drill to allow a more realistic assessment of the process.

Conclusion:
The drill has identified several items to improve the process of responding to a snakebite at the zoo.

Comparison of whole blood clotting time, INR, and Sonoclotactivated clotting time in management of hemotoxic snake envenomation in a Tertiary Care Hospital in North India
Introduction: N-acetylcysteine (NAC) is the specific antidote treatment of paracetamol intoxication, which aims to prevent the complications related to them.The objective is to highlight the economic impact of the introduction of the antidote N-Acetylcysteine in the therapeutic protocol of paracetamol intoxications in Algeria.Materials and methods: A local simulation was carried out to estimate the financial impact related to the introduction of the IV form in the Algerian market for the management of acute paracetamol poisoning (APP).An estimation of the global expenses of the management of APP cases recorded at the level of the poison control center (PCC) between 2017-2021 with the Oral NAC according to the 72h protocol was carried out.To compare the costs of APP management if the use of the IV form during the same period and on the same patients.The results were expressed in Algerian Dinar (DZD).Results: The use of IV NAC resulted in a saving of 12700.22DZD per patient per incident, reducing the length of stay from 72 to 21 h.In the end, a 20,2% reduction (18636498.59