BackgroundEarly and adequate atropine administration in organophosphorus (OP) or carbamate insecticide poisoning improves outcome. However, some authors advise that oxygen must be given before atropine due to the risk of inducing ventricular dysrhythmias in hypoxic patients. Because oxygen is frequently unavailable in district hospitals of rural Asia, where the majority of patients with insecticide poisoning present, this guidance has significant implications for patient care. The published evidence for this advice is weak. We therefore performed a patient cohort analysis to look for early cardiac deaths in patients poisoned by anticholinesterase pesticides.MethodsWe analysed a prospective Sri Lankan cohort of OP or carbamate-poisoned patients treated with early atropine without the benefit of oxygen for evidence of early deaths. The incidence of fatal primary cardiac arrests within 3 h of admission was used as a sensitive (but non-specific) marker of possible ventricular dysrhythmias.ResultsThe cohort consisted of 1957 patients. The incidence of a primary cardiac death within 3 h of atropine administration was 4 (0.2%) of 1957 patients. The majority of deaths occurred at a later time point from respiratory complications of poisoning.ConclusionWe found no evidence of a high number of early deaths in an observational study of 1957 patients routinely given atropine before oxygen that might support guidance that oxygen must be given before atropine. The published literature indicates that early and rapid administration of atropine during resuscitation is life-saving. Therefore, whether oxygen is available or not, early atropinisation of OP- and carbamate-poisoned patients should be performed.
No abstract
The presence in wartime day nurseries of groups of young children provided an opportunity for investigating anaemia in children under five years of age. There are, however, considerable drawbacks to such investigations in day nurseries. Chief among these are the high rate of cross-infections, the unstable population, and the investigator's ignorance, from lack of contact with the mothers, of the children's life outside the nursery.
Goldsmith and associates (1944), that when liver 'extract is given to rats simultaneously with thiourea it protected them from neutropenia. Three patients had operations of partial thyroidectomy before they came under the present review. No. 6, operated on 18 years before, had a nodular goitre, and a recurrence of symptoms 9 years after operation. About 12 months before coming to hospital she becanie short of breath, experienced nausea and vomiting, and when admitted her heart showed marked enlargement to the left and a systolic murmur at the apex. She showed no appreciable response after 4 weeks' treatment, and, unfortunately, although she was urged to stay, insisted on going home. It was reported later that she had died suddenly 3 weeks after leaving hospital. In No. 8, in which partial thyroidectomy failed to cure the condition, 5 months' treatment with thiouracil appeared to complete what surgery had left undone. Another milder recurrence, 8 years after partial thyroidectomy-No. 15-did equally well. No. 17, radium treatment of which 10 years before had been a complete failure, responded satisfactorily to thiouracil. Conclusion We have now in thiouracil a potent weapon for overcoming thyrotoxicosis. The drug, although not entirely devoid of risks, is much safer than operation. All patients suffering from thyrotoxicosis should therefore be given'thiouracil. At some future date it may be possible to assess the initial and maintenance dosages on a more scientific basis, but at present, in the light of experience, a satisfactory working rule is to give 0.2 g. of thiouracil thrice daily for the first 3 to 5 weeks, after which the dose should be gradually reduced, and kept at the lowest possible level compatible with the patient's well-being. Slow response to treatment calls for patience, and not for increasing the dose beyond a safe limit. Leucopenia before the treatment should not be taken as a contraindication to the use of thiouracil. All patients treated with thiouracil should be kept under adequate supervision. Only more prolonged observations will tell whether thiouracil is capable of effecting a permanent cure within a measurable period. Summary A series of 27 unselected cases of thyrotoxicosis treated' with thiouracil for periods varying from 3 weeks to 12 months are described. Good response, with the exception of one long-standing instance, was noted in all. The importance of continued supervision of the treatment is stressed. It is submitted that the hitherto almost unrivalled surgical treatment of thyrotoxicosis may, in the light of further experience, have to give way to medical treatment. Grateful thanks are due to both my medical and my surgical colleagues, who kindly passed on to me their patients with thyrotoxicosis, and thus made this series much larger than it would otherwise have been. Our biochemist, F. Morton, M.Sc., F.R.I.C., carried out the B.M.R. estimations, and Messrs. British Drug Houses generously supplied, free of charge, most of the thiouracil used in this investigation.
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