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LETTERS TO THE EDITOR

Why should be concerned sis and alternatives and asked about ad - ment and care towards the end of life: good vance directives, including organ dona - practice in decision making. Reino Unido: about organ donation in the tion. Guidance for doctors; 2010. emergency department? All the families confirmed the will to 5 Domínguez-Gil B, Delmonico Fl, Shaheen FAM, Matesanz R, O’Connor K, Minina M, et The patient's right to donate; this implied the need to establish al. The critical pathway for deceased dona - become a donor (or maintain) tracheal intubation and the tion: reportable uniformity in the approach donation protocol. All 7 died of fatal BD to deceased donation. Transplant Internatio - and 6 became organ donors. The new nal (ESOT). 2011;24:373-8. Sir, procedure increased the diagnosis of BD 6 NHS Guidelines: The Role of Emergency Me - dicine in Organ Donation. Oct 2010. NHS The limitation of therapeutic ef - by 28% and the number of donors by 24% . Blood and Transplant, The College of Emer - fort (LTE), as part of end-of-life care, gency Medicine, BTS. is sometimes indicated in emergency The aim of the EPs 10 was not to 7 George M. Abouna. Ethical Issues in Organ department (ED) patients with fatal solicit donations, but to establish the Transplantation. Med Princ Pract. 1-3 2003;12:54-69. brain damage . In this context, the patient's desire and initiate the neces - 8 Truog RD, Miller FG, Halpern S. The Dead- objectives are to ensure wellbeing sary measures to make the donation Donor Rule and the Future of Organ Dona - measures, lack of pain, family sup - possible. It may be unusual to consi - tion. NEJM. 2013;369:1287-90. port and to preserve the dignity of der organ donation in the context of 9 Hemphill III C, Bonovich DC, Besmertis L, 4 Manely GT, Johnston SC. The ICH Score: A patient . LTE or prolonged cardiopulmonary Simple, Reliable Grading Scale for Intracere - But to provide care according to resuscitation after cardiac arrest (un - bral Hemorrhage. Stroke. 2001;32:891-7. the wishes of the patient, we should controlled asystole donation, 10 Matesanz R. Papel de los Servicios de y also consider their will to become an DANC 11 ,12 ). But considering the possi - Emergencias en la donación de órganos. 5-8 Emergencias. 2010;22:68-71. organ transplant donor . Thus, not bility of organ donation in end-of-life 11 Carmona F, Ruiz A, Palma P, Soto A, Alberola only is their desire respected but but, care, after making every diagnostic M, Saavedra S. Utilización de un compresor secondarily, we can increase the and therapeutic effort, conforms to torácico mecánico (LUCAS ®) en un progra - number of organ donors. the principles of medical ethics go - ma de donación en asistolia: efecto sobre la perfusión de los órganos y la tasa de tras - Introducing this consideration in verning the doctor-patient relations - plante. Emergencias 2012;266-371. urgent care is fraught with difficulties: hip (beneficence, maleficence) and 12 Matesanz R, Toranzo T, Cuñat J. Donación the desire to be a donor must be in - organ donation (dead donor rule) 7 en asistolia no controlada: salvamos vidas y corporated in the first decisions, con - and protects the patient's right to be donamos vida. Emergencias. 2013;25:150. 2,4,6,10 sensus protocols ensuring reliability, a donor . Mireia PUIG , transparency and safety are required, Furthermore, this approach, in se - Francisco CABALLERO , and finally training and the conviction lected cases, is the only opportunity Josep RIS , of emergency physicians (EPs) . To this to satisfy the will of the patient in Jesús LEAL end, in the last quarter of 2013, we this regard. Pre-hospital emergency Servicio de Urgencias y Coordinación de evaluated the opinion and the attitu - medical services and EDs have played Trasplante, Hospital de la Santa Creu i Sant Pau, de of our emergency physicians as a an important role in DANC. Thus, in Barcelona, Spain. first step in designing an intervention patients with fatal brain damage and plan that included discussion of ethi - LTE, the emergency physician should cal issues and training in donor pre- know and take into account the pa - evaluation, contraindications and risk tient's wishes regarding organ dona - Triaje and urgenciólogo: two quantification of brain death (BD) 9. tion, whenever possible. words knocking at the doors Finally, we adapted the protocol of of the Spanish Royal end-of-life care in the ED and obtained Academy support from the transplant coordinator. The following semester, assessed the im - References plementation of the new consensus, the I cannot miss the magnificent cases and the resulting number of organ 1 Michael GE, Jesus JE. Treatment of Potential opportunity offered me by the two Organ Donors in the Emergency Depart - donations. ment: a Review. Ann Emerg Med. reputed authors of articles published Our ED is a hierarchical service with 2012;60:480-91. in the latest issue of EMERGEN - its own expert staff, part of a tertiary 2 Miller LD, Gardiner SK, Gubler KD. Emer - CIAS 1,2 to ask your opinion about the 530-bed hospital (42 critical care beds). gency department referral for organ dona - two words triaje and urgenciólogo tion: more organ donors and more organs In the period under review, 22 of the 25 (triage and emergency physician), hospital cases of BD were diagnosed in per donor. Am J Surg. 2014;207:728-34. the ED; in 7 of the 22 cases, fatal BD was 3 Michael GE, O’Connor RE. The importance whose use has long been establis - diagnosed in the first period: 2 arrived in - of emergency medicine in organ donation: hed in Spanish. And not only by he - successful donation is more likely when po - alth professionals working in the tubated and 5 were not. In these seven tential donors are referred from the emer - cases, the ED physician agreed on the ap - gency department. Acad Emerg Med. field of Accident and Emergency plication of LTE with at least one consul - 2009;16:850-8. Medicine (EM) but also by other tant, presented to the family the progno - 4 General Medical Council Guidelines: Treat - professional colleagues and even by

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many non-medical members of the Latin word emergens 14 , but this gencias. 2014;26:35-46. general Spanish population. These term appears to be no better than 14 Real Academia Española. Diccionario de la lengua española. (Consultado 7 Noviembre words are currently absent from the urgenciólogo . 2014). Disponible en: http://lema.rae.es/drae/ dictionary of the Royal Spanish Aca - In any case, leaving aside these 15 Universidad de Salamanca. Diccionario mé - demy (RAE). However, they are re - and other linguistic technicalities, it dico-biológico, histórico y etimológico. gularly used in the journal Emergen - seems to me that both words (Consultado 7 Noviembre 2014). Disponible en: http://dicciomed.eusal.es/lexema/ cias, specialized in the field of EM, should be evaluated for inclusion in albeit italicized, as evidenced by future editions of the RAE dictionary Òscar Miró multiple recently published titles on grounds of general use, without Editor, EMERGENCIAS, Spain. and relevant articles 3-10 . prejudice to other alternatives that Alternatives for triaje may be may be currently available. found in Spanish (in fact it is men - tioned in the Royal National Aca - Author’s reply demy of Medicine dictionary as a References synonym for priorization 11 ), but the - se alternatives will not replace the 1 Sánchez Ron JM. Ciencia, medicina y len - Sir, widespread use of triaje since it was guaje. Emergencias. 2014;26:400-3. In response to your letter con - first introduced to designate "classi - 2 Poch Broto J. Español y Medicina. Emergen - cerning the terms triaje and urgen - fication of ill or injured people ac - cias. 2014;404-6. ciólogo (triage and emergency 3 Sánchez Bermejo R, Cortés Fadrique C, Rin - cording to severity of injuries or cón Fraile B, Fernández Centeno E, Peña physician), I first wish to express my condition, in order to prioritize their Cueva S, De las Heras Castro EM. El triaje en thanks for raising this terminological attention with the care resources urgencias en los hospitales españoles. Emer - debate; analysis and reflection on available" by Dr. Larrey in France gencias. 2013;25:66-70. the proper use of medical terms is 4 Castro González E, Vázquez Lima M, Dorribo during the Napoleonic wars, which Masid M, Abellás Álvarez C, Santos Guerra F. always necessary and it is enriching probably has its Latin roots in ano - Validez del Sistema de Triaje Manchester en to have a framework to present our ther word striare meaning "separa - la predicción del volumen de transportes e studies and reflections on these is - ted by a groove." 12 . This term and ingresos en un servicio de urgencias de sues. un hospital comarcal. Emergencias. this meaning has been recognized 2013;25:191-5. The term triage is already inclu - in Catalan, English and possibly in 5 Ávila Naranjo MM, García Pérez D, Contre - ded in our Dictionary of Medical many other languages unknown to ras Lovera JI, Zaglul Ruiz J, Escale Blesa A, Terms (DTM) as a synonym for prio - the editor, as words borrowed from Obiols Torrebadella M. La puntuación MEDS ritization 1, correct and established in y el lactato como factores pronóstico de French. mortalidad y de ingreso en una unidad de the medical field. Italics are not re - Regarding the word urgenciólo - cuidados intensivos en los pacientes activa - commended since it is not an En - go, the lack of recognition of the dos desde el triaje con código de sepsis gra - glish term, as its spelling and pro - specialty of emergency medicine in ve. Emergencias. 2013;25:330-1. nunciation are fully adapted to 6 Burbano P, Martín-Sánchez FJ, Burillo-Putze Spain has possibly impeded its offi - G, Fernández Pérez C, Del Prado González Castilian Spanish. cial recognition, despite the fact N, Miró O. Producción y repercusión científi - In the case of urgenciólogo , that a growing number of physi - ca de un grupo de urgenciólogos españoles whose use is indeed recent, the cians devote all their working life seleccionados por su trayectoria investigado - term is not currently included in the ra. Emergencias. 2013;25:245-54. to the practice of this specialty. 7 Aleixandre-Benavent R. Modelo de valora - DTM, although it is under study for Obviously, many are specialists of ción de la evolución de la producción y la inclusion in the terminology databa - other medical disciplines 13 , but repercusión científica de los urgenciólogos es - se of the Royal Academy of Medici - cannot use the word urgenciólogo pañoles. Emergencias. 2013;25:243-4. ne (ANPR), along with its equivalent 8 Castanyer Puig B, Puiguriguer Ferrando J, to denominate their true professio - Barceló Martín B, Nogué Xarau S. Encuesta emergency physician. The terms nal role. In Spanish, médico de ur - a urgenciólogos sobre el papel del laboratorio emergenciólogo and emergencista gencias y emergencias could be an en el manejo de las intoxicaciones agudas. have also been documented but re - option, but the reality is that the Emergencias. 2012;24:447-53. jected because they considered to 9 Miró O, Valcárcel De La Iglesia MA, Crema - word urgenciólogo has already be - des Pallas RM, Burillo-Putze G, Julián Jiménez be excessively based on the English en established in Spain. While re - A, Martín-Sánchez FJ. Producción científica equivalent. Regarding this term, ple - cognizing that the word is of de los urgenciólogos españoles durante el ase see “urgencia” 1 in the DTM. hybrid origin whose composition quinquenio 2005-2009 y comparación con OBS .: Due to the influence of the el quinquenio 2000-2004. Emergencias. involves two lexemes from diffe - 2012;24:164-74. English term emergency, in Spanish rent languages (Latin urgentia, 10 González Cabrera J, Fernández Prada M, we increasingly see the anglicized meaning "imperative need" and Molina Ruano R, Blázquez A, Guillén Solvas "emergency" used in the sense of Greek - λόγος – which means "de - J, Peinado JM. Riesgo psicosocial en el traba - "urgency" which has met with 14,15 jo, estrés autopercibido y cortisol en saliva dicated to") , denoting that it en una muestra de urgenciólogos de Grana - strong opposition among some doc - was created by a group with little da. Emergencias. 2012;24:101-6. tors. Also due to the influence of linguistic competence, it is now 11 Real Academia Nacional de Medicina. Dic - English, we have begun to see a part of the usual vocabulary used cionario de términos médicos. Madrid: Edi - distinction between "urgencia" in torial Panamericana; 2014. in and outside the field of medici - 12 Enciclopedia catalana. Diccionari.cat. (Con - the sense of "mild urgency" and ne. The word emergenciólogo is al - sultado 7 Noviembre 2014). Disponible en: "emergencia" in the sense of "vital so used in many Spanish-speaking http://www.diccionari.cat/lexicx.jsp?GE - emergency”. countries, possibly favored by con - CART=0137262 This is, in short, the information 13 Miró O, Escalada X, Boqué C, Gené E, Jimé - tamination from the English term nez Fábrega FX, Netto C, et al. Estudio SUH - gathered by the RANM Unit of Me - (emergency physician) and the CAT (2): mapa funcional de los servicios de dical Terminology regarding these hybrid term is also traceable to the urgencias hospitalarios de Cataluña. Emer - terms and it is beyond our scope to

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judge their inclusion in the dictio - instances were published in 25 pa - ments with basal hyperkinesis and de - nary of the Royal Spanish Academy, pers (first documented in 2004); for pressed systolic function. The findings as that is a dictionary of general use example: "The material for care of were confirmed by echocardiography. and does not include the entire lexi - victims includes a classification or The patient had elevated biomarkers of con of the specialty, and the RAE triage station,...... " P. Arcos González, myocardial injury (troponin T: 383 ng / L, average: 0-14 ng / L) while other la - will decide on the criteria for inclu - La ayuda sanitaria en desastres (Fun - boratory parameters were normal. An sion or not of such technical terms. dación Carlos III, Madrid 2006)). Fur - electrophysiological study was perfor - thermore, the dictionary of medical med without arrhythmia induction. At terms (DTM) of the Royal Academy discharge she was prescribed treatment References of Medicine and dictionaries of other with beta-blockers and angiotensin-con - languages (Oxford Dictionary -OED- verting enzyme inhibitors (ACEI). 1 Real Academia Nacional de Medicina. Dic - Inglés and Lo Zingarelli already inclu - Takotsubo syndrome is an acute cionario de términos médicos. Madrid: Edi - ded it). It is hoped, therefore, that it torial Panamericana, 2012. Disponible en: cardiomyopathy precipitated by a http://dtme.ranm.es/terminos/triaje.html?id= will soon be included in DRAE. stressful situation that mimics acute 89 Regarding urgenciólogo (emer - coronary syndrome. It is characteri - 2 Real Academia Nacional de Medicina. Dic - gency physician) at the moment the - zed by electrocardiographic changes cionario de términos médicos. Madrid: Edi - re is less documentation. In the torial Panamericana, 2012. Disponible en: compatible with ischemia, minimum http://dtme.ranm.es/terminos/urgencia.html CREA, 2 cases occur in 1 document elevation of markers of myocardial ?id=31 (and quotes): "Any of us who have damage with impaired contractility spent some time practicing as an ' ur - Joaquín POCH BROTO with apical dyskinesia on ventriculo - genciólogo ', has ample experience to graphy and coronary arteries without Presidente de la Real Academia Nacional de build a volume of short stories 3.4 Medicina, Spain. injury . In a series of 60 patients ....."(Jimenez de Diego, L. (2002): newly published by Nogales-Asensio Memoirs of an emergency physi - et al. the authors highlight the high cians). In CORPES, there are 3 cases incidence of heart failure (40%) and Author’s reply in 6 documents. However, this term cardiogenic shock (18%) and the fact is not recorded in the dictionaries that dyspnea was the most prevalent mentioned above (DTM, OED, Lo 1.4 Sir, symptom . Ventricular arrhythmia Zingarelli). The hybrid origin of the may be the start in 9% of cases 5. Indeed, the term triaje is not re - term would not be an obstacle for corded in the dictionary of the Royal Most (90%) cases occur in pos - inclusion as there are words in Spa - tmenopausal women in relation to Spanish Academy (DRAE), twenty- nish that have this double morpholo - third edition (2014), with a specifi - emotional stress while in men a gical origin (criminología, glaciolo - 2,7 cally medical meaning (it is listed as physical trigger is predominant . gía, herbología), but rather the lack The most plausible etiological hypo - "action and effect of triar", where of documented use at this time.. "triar" is "choose, separate," and the thesis is based on myocardial toxicity dictionary provides various non-me - José Manuel S ÁNCHEZ RON by elevated circulating catecholami - nes 2,8 . Segmental contractility chan - dical examples of use. It is true, ho - Académico, Real Academia Española, Spain. wever, that existing documentation ges are explained by a greater num - ber of betadrenergic receptors in the at this time in the databases of the 2 Academy would allow its inclusion - cardiac apex . The prognosis is generally favora - regardless of its medical meaning re - Ventricular fibrillation in the lated to the first meaning of "triar" - ble, with recovery of ventricular as it is well documented in the cor - presentation of Takotsubo function, and low hospital mortality cardiomyopathy of 3.3% (8.3% in those who develop pus. In the Reference Corpus of Cu - 1,6,8 rrent Spanish (CREA, made up of a heart failure ). The treatment is wide variety of written and oral texts Sir, that employed in systolic dysfunc - produced in all Spanish-speaking Takotsubo syndrome was first tion: ACE inhibitors, beta blockers described by Sato et al. in Japan in and diuretics5. Antiplatelet therapy countries from 1975-2004), 9 cases 8 appear in one document: "Triaje is a 19901. Since then the number of re - with aspirin is also used . In conclu - process of preliminary clinical evalua - ported cases has increased due to sion, we describe a case of Takotsu - tion that classifies patients by urgent widespread echocardiography and bo syndrome debuting as ventricular need to be subject to complete diag - coronary angiography. Also, new va - fibrillation. The condition was attri - nostic and therapeutic evaluation in riants have been described according buted to pain and the stress of hos - these emergency services. to the affected segment 1,2 . pitalization. Triage assesses symptoms and A 69 year-old woman with hyperten - signs and the presence of a structu - sion was admitted for elective hip fractu - red triage system is an indicator of re repair. Analgesic perfusion for pain quality in risk-efficiency that protects began. Within 24 hours of admission, References the most serious patients, optimizes before surgery, she presented dyspnea, resources, decongests the ED and hypertension and ventricular fibrillation 1 Nogales-Asensio JM, González-Fernández MR, López-Mínguez JR, Merchán-Herrera A, improves patient care in these de - which subsequently reverted to sinus rhythm after shock therapy at 200 J. Ur - Martínez-Cáceres G, Aranda-López C. Síndro - partments" ( Diario Málaga-Costa del gent coronary angiography revealed no me de Tako-tsubo: análisis de una serie de 60 casos. Med Clin (Barc). 2014;143:255-60. Sol, 22/01/2004).). In the Corpus of significant lesions. Ventriculography sho - Spanish in XXI (CORPES, texts com - 2 Rueda F. Aturdimiento miocárdico, miocar - wed left ventricular dilation, akinesia of diopatías de estrés y síndrome de takotsubo. posed between 2001 and 2012) 68 the anterolateral, apical and inferior seg - Med Clin (Barc). 2014;143:252-4.

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3 Akashi YJ, Goldstein DS, Barbaro G, Ueyama ble en: http://circ.ahajournals.org/con - T. Takotsubo cardiomyopathy: a new form of tent/112/24_suppl/IV-126.full.pdf+html acute, reversible heart failure. Circulation. 2008;118:2754-62. Julia MEZQUIDA ARNÓ 1, 4 Parodi G, Bellandi B, del Pace S, Barchielli A, Teresa ESCOLAR MARTÍNEZ-BERGANZA 2, Zampini L, Velluzzi S, et al. Natural history María del Carmen LAHOZA PÉREZ 1 of tako-tsubo cardiomyopathy. Chest. 1 2011;139:887-92. Medicina Familiar y Comunitaria del Área 3 de 2 5 Ferrer Gracia MC. Dolor torácico y fibrilación Zaragoza, España. Servicio de Urgencias, Hospital ventricular con coronarias sanas y abalona - Clínico Universitario Lozano Blesa, Zaragoza, miento apical izquierdo transitorio. Med Clin Spain. (Barc). 2004;123:38-9. 6 Núñez-Gil IJ, Molina M, Bernardo E, Ibáñez B, Ruiz-Mateos B, García-Rubira JC, et al. Ta - ko-tsubo syndrome and heart failure: Long- term follow-up. Rev Esp Cardiol. 2012;65:996-1002. Levamisole: a dangerous 7 Kurisu S, Inoue I, Kawagoe T, Ishihara M, cocaine additive widely used Shimatani Y, Nakama Y, et al. Presentation of Tako-tsubo cardiomyopathy in men and wo - in Spain men. Clin Cardiol. 2010;33:42-5. 8 Guzón Illescas O, Alonso Blas C. Miocardio - patía inducida por estrés o síndrome de ta - Sir, kotsubo. Emergencias. 2013;25:292-300. Levamisole is an antiparasitic José GÓMEZ RUBIO 1, drug marketed from 1966, which in Ana Belén BÁRCENA ATALAYA 2 Figure 1. Angioedema of the uvula. most Western countries was banned 1Servicio de Medicina Interna, 2Servicio de for human use from the 1980s be - Cuidados Críticos y Urgencias, Hospital tory difficulty, without further incidents. cause of the risk of agranulocytosis Universitario de Valme, Sevilla, España. The patient improved after 6 hours of arri - and necrotizing vasculitis, although val and was discharged after 24 hours un - it is authorized for veterinary use, der observation. primarily as a nematicide 1. From Since the most common cause of 2008 cocaine adulterated with this angioedema includes type I1 hyper - chemical was detected, probably Angioedema caused by use: sensitivity reactions and a history of due to its organoleptic characteris - a rare complication in the cocaine use, it was suspected that tics which are similar to those of co - emergency department the patient had an allergic reaction caine, coupled with its low cost and secondary to cocaine use or any of its availability for veterinary use, in ad - Sir, multiple chemical and / or pollutant dition to its psychostimulant proper - In the last decade there has been excipients, although the effects may ties. In the USA, up to 80% of co - 2 a progressive increase in cocaine use, only appear 24 hours after consump - caine seized contained levamisole . and consequently, increased demand tion, since the allergic reaction may In Spain we have found only three for care in the emergency depart - originate from the early hours of con - reported cases of adverse reaction ment for complications related to sumption up to 48 hours later 1-3 . In to cocaine / levamisole detected in such use. This drug can be adminis - this situation, it is essential for the hospital departments of dermato - tered by various routes, and the most emergency physician to ensure pa - logy, nephrology and internal medi - 3-5 common is intranasal. tency of the airway 4 by administering cine , so it seemed to us important adrenaline and to perform patient to present this series of patients se - A 45 year-old male sporadic consumer en in the emergency department. of and inhaled cocaine visited the monitoring. The use of adrenaline is ED for a sensation of a foreign body sen - controversial in the literature revie - In a period of 15 months (May sation in the oral cavity during 4 hours, wed, as it was administered only in 2013-July 2014) we treated in the emer - without dyspnea, sore throat or laryngeal one case 3, because it is a sympatho - gency department of our hospital 6 pa - stridor. He reported using cocaine 24 mimetic drug that can worsen the tients with acute adverse reaction after hours before the onset of these clinical symptoms reported. consuming, among other substances, symptoms. He reported no previous food cocaine adulterated with levamisole. intake and no known drug allergies. Upon Identification of cocaine or its metaboli - arrival, he was hemodynamically stable tes and / or levamisole is by gas chro - but with psychomotor, eupneic agitation, References matography coupled to a mass spectro - oxygen saturation of 97% and in the oral meter. The characteristics of these cavity an edematous uvula (1.5 cm dia - 1 Hidalgo Mora JJ, Giménez de Llano E, Sem - patients are shown in Table 1. pere Verdú E, Feliú Sagalá M. Uvular angioe - meter) was observed without erythema or In the first case we would highlight dema after intranasal cocaine consumption. the occurrence of painful purple retiform exudate (Figure 1). The rest of the exami - Med Clin (Barc). 2002;119:438-9. nation was normal. Complementary tests 2 Welling A. Enlarged uvula (Quincke ’s Oede - skin lesions with areas of necrosis in the showed no significant alterations, except ma)- A side effect of inhaled cocaine?- A ca - center (Figure 1) and located on the ab - positive blood ethanol (0.3 g / L) and co - se study and review of the literature. Int domen, arms and thighs. Skin biopsy caine in urine (> 900 ng / mL). With the Emerg Nurs. 2008;16:207-210. showed small vessel vasculitis with clinical suspicion that it was angioedema 3 Kestler A, Keyes L. Images in clinical medici - thrombotic phenomena. This was ac - ’ 9 secondary to cocaine or excipients, he ne. Uvular Angioedema (Quincke s Disease). companied by leukopenia (3.4 x 10 / L N Engl J Med. 2003;349:867. 9 was administered antihistamines (dexclor - total leukocytes with 1.1 x 10 / L neu - 4 American Heart Association. 2005 American trophils). The exact mechanism of these feniramine 5 mg) and intravenous corti - Heart Association Guidelines for Cardiopul - costeroids (methylprednisolone 40 mg). monary Resuscitation and Emergency Cardio - effects is unknown, but most authors He required intramuscular adrenaline after vascular Care. Part 10.2: Toxicology in ECC. agree on an immune hypothesis as sug - 30 minutes due to sudden onset respira - Circulation. 2005;112:IV-126-IV-132. Disponi - gested by the presence of positive anti-

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vamisole could have been enhanced the 9 Muñoz R, Borobia AM, Quintana M, Martí - cardio-toxicity of cocaine. nez-Virto AM, Frías J, Carcas AJ. Desarrollo y validación de un programa de toxicovigilan - cia con detección automatizada de casos en Cases of drug abuse are on the un hopital terciario (SAT-HULP). Emergen - 8,9 rise in the ED , but changes in the cias. 2013;25:423-9. qualitative and quantitative compo - 10 Caudevilla Gálligo F, Quintana Mathé P, For - sition of these substances represents nís Espinosa I, Ventura Vilamala M. Metanfe - tamina vendida como MDMA (3,4- metilen - an added challenge to clinicians ca - dioximetanfetamina, éxtasis). Emergencias. ring for these patients and laborato - 2013;25:154-5. ries trying to identify them to im - 11 Castanyer Puig B, Puiguriguer Ferrando J, Figure 1. Purple retiform skin lesions with prove the quality of care 10,11 . Barceló Martín B, Nogué Xarau S. Encuesta a urgenciólogos sobre el papel del laborato - central necrosis, located in the abdomen of rio en el manejo de las intoxicaciones agu - case 1. Skin biopsy showed small vessel vascu - das. Emergencias. 2012;24:447-53. litis. References Santiago NOGUÉ XARAU 1, Jordi TO-FIGUERAS 2, elastase antibodies (ANCA) found in the 1 Wolford A, McDonald TS, Eng H, Hansel S, Gregori CASALS 2, case presented and others in the litera - Chen Y, Bauman J, et al. Immune-mediated José MANUEL MASCARÓ 3 agranulocytosis caused by the cocaine adul - ture, as well as the detection of other 1 terant levamisole. A case for reactive metabo - Sección de Toxicología Clínica, Área de Urgencias, antibodies (phospholipid, cardiolipin, an - 2 3 lite(s) involvement. DMD. 2012;40:1067-75. Laboratorio de Toxicología, Servicio de ticoagulants and others) 6. The same 2 Tallarida CS, Egan E, Alejo GD, Raffa R, Talla - Dermatología, Hospital Clínic, Barcelona, España. hypothesis would explain the retiform rida RJ, Rawls SM. Levamisole and cocaine purple characteristics, due to thrombo - synergism: a prevalent adulterant enhaces sing vasculitis, which may lead to tissue cocaine’s action in vivo. Neuropharmaco - ischemia and even the risk of limb am - logy. 2014;79:590-5. putation. 3 Álvarez H, Mariño AI, García JF, Rodríguez L, Severe sepsis in a man with Cases 2, 3 and 4 presented clinical Gómez I, Bermejo AM. ANCA-positive vascu - events (coma, agitation) which may be litis induced by levamisole-adulterated cocai - colonized elephantiasis explained by the combination of cocaine ne and nephphrotic syndrome: The kidney as an unusual target. Am J Case Rep. nostra verrucosa and other drugs (MDMA or ecstasy, GHB 2013;14:557-61. or liquid ecstasy, ethyl alcohol), and is 4 Riveros A, Martínez-Morillo M, Tejera B, Oli - Sir, not likely that levamisole played a signi - vé A. Cocaína y levamisol: una combinación The presence of predisposing fac - ficant role here but it is known that this ilícita. Emergencias. 2013;25:153-4. tors such as obesity, diabetes melli - substance is deliberately added to cocai - 5 De la Hera I, Sanz V, Cullen D, Chico R, Peti - ne to enhance its euphoric effects and ti G, Villar M, et al. Necrosis of ears after use tus, disabilities, , poor thus may have contributed to the agita - of cocaine probably adulterated with levima - hygiene and self-care and / or asso - tion. sole. Dermatology. 2011;223:25-8. ciated psychiatric conditions means 6 Buchanan JA, Oyer RJ, Patel NR, Jacquet GA, In cases 5 and 6 we would highlight Bornikova L, Thienelt C, et al. A confirmed that verrucous elephantiasis nostra the presentation of asystole; in one of case of agranulocytosis after use of cocaine (EVN) constitutes the ideal breeding them, there was no recovery. It is true contaminated with levamisole. J Med Toxi - ground for superinfection and skin that cocaine, per se, has been described col. 2010;6:160-4. parasitism 1, implying very unfavorable as a cause of sudden death and, in the 7 Hoskins JD. Arrhytmia associated with leva - misole heartworm therapy in a dog. J Am prognosis in these patients. We re - latter case presented, heroin and its me - port the case of a patient treated in tabolites were also detected. Therefore, Vet Med Assoc. 1983;183:330-1. these drugs alone could explain the as - 8 Azkunaga B, Mintegi S, Del Arco Arco L, Biz - the emergency department who pre - karra I. Cambios epidemiológicos en las in - sented serious sepsis with superinfec - ystole. But experimentally, it is known toxicaciones atendidas en los servicios de ur - 7 that levamisole is arrhythmogenic and gencias pediátricos españoles entre 2001 y ted and colonized skin lesions on has sympathomimetic effects similar to 2010: incremento de las intoxicaciones etíli - both legs, compatible with a diagno - cocaine or amphetamines. Therefore, le - cas. Emergencias. 2012;24:376-9. sis of EVN.

Table 1. Epidemiological, clinical and toxicological characteristics and outcomes of patients treated in emergency departments after cocaine / levamisole use Case Sex Age Reason for Co-ingestion Leukopenia Other notable Main therapeutic Outcome (years) consultation of other (<4.5 10 9/L) clinical measures drugs* measures 1M36 Purple retiform Cannabis YES NO Symptomatic Recovery 2M33 Coma GHB NO NO IIntubation and Recovery mechanical ventilation.

3M34 Agitation GHB, poppers NO NO Sedation with benzodiazepines. Recovery Mechanical restraint. Symptomatic measures. 4M26 Agitation Ethanol (2.83, NO NO Sedation with benzodiazepines. Recovery g/L), MDMA Symptomatic measures. 5M32 Decreased Ethanol (1.38 g/L), NO Asystole recovered External cardiac massage. Recovery consciousness agitation GHB, poppers Atropine. Symptomatic measures 6M41 Cardiorespirator Ethanol (1.35 g/L), NO Asystole CPR. Death y arrest MDMA, heroin unrecovered ed *Detected or reported. M = male; GHB = gamma-hydroxybutyrate (liquid ecstasy); MDMA = methylene-dioximetanfetamina (ecstasy); Poppers = drug of abuse usually composed of amyl nitrite or isobutyl.

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This case involved a 4-month old in - fant, operated at 7 days for type B aortic arch interruption and ostium secundum atrial septal defect. The visit was occasio - ned by catarrh of 4 days duration, asso - ciated with high fever (39°C) during two days, and recurrent vomiting and drowsi - ness in the past 12 hours. Physical exami - nation revealed hypotension (50/30 mmHg), poor peripheral perfusion, tachypnea and costal retractions, crackles at the base of the left lung, a stuporous state of consciousness and bulging ante - rior fontanelle. Laboratory tests showed leukopenia, PCR of 187 mg / L and coa - gulopathy. Chest radiography showed Figure 1. Bilateral increase of lower limb perimeters and associated deformity secondary condensation in the left lower lobe. Cere - to chronic lymphedema, with warty lesions and signs of superinfection and colonization. brospinal fluid (CSF) was purulent with B) Detail showing characteristic lesions and multiple colonization by house fly larvae 190 cells (90% PMN), proteins 182.1 mg (arrow). / dl and glucose 5 mg / dl. Computed tomography (CT) scan was normal. Given A 51 year-old man visited the emer - References the hemodynamic instability, echocardio - gency department for significant deterio - graphy was performed, revealing an 8 x ration of general condition during a few 4 mm wart in the atrial septum (Figure 1 Rubio C, Ladrón de Guevara C, Martín MA, 1). was isolated hours. Previous history included important Campos L, Quesada A, Casado M. Cutane - alcoholism, ischemic heart disease and ous myiasis over tumor-lesions: presentation in blood and CSF samples. Treatment was metabolic syndrome without medical su - of three cases. Actas Dermosifiliogr. started with cefotaxime, gentamicin and pervision, in the context of poor personal 2006;97:39-42. vancomycin, mechanical ventilation, do - hygiene and extreme self-neglect. On arri - 2 Simón Llanes J, Coll Vilar I, Tamarit Francés pamine, crystalloid and plasma. No sur - C, Niubó de Castro I. Elephantiasis nostras val the patient presented poor general gery was performed given the presence verrucosa in a patient with major depressive of coagulopathy and hemodynamic insta - condition and hemodynamic instability disorder. Semergen. 2012;38:526-9. (hypotension, tachycardia and signs of bility secondary to sepsis. The patient 3 Gutiérrez-González E, Peteiro C, Toribio J. evolved favorably with complete resolu - distal hypo-perfusion). The anamnesis was Elephantiasis nostras verrucosa. Med Clin very difficult, and he only reported excru - (Barc). 2013;140:288. tion in nine days without sequelae. He ciating pain in both legs. After removal of 4 Ferreira-González L, Vázquez Vázquez B, then completed 6 weeks of intravenous self-prepared malodorous bandages, we García Alén D, Gómez Gigirey A. Elefantiasis antibiotic therapy. observed increased perimeter of both lo - verrucosa nostra colonizada. Galicia Clin. 2012;73:173-4. In pneumococcal endocarditis wer extremities associated with significant early diagnosis is critical. Therefore, deformity (Figure 1A) and many warty le - José Aurelio NAVAS CUÉLLAR , echocardiography was performed for sions, nodules and papules with abundant Julio REGUERA ROSAL , greenish exudate and intense larval colo - active search in patients with pneu - Verónica PINO DÍAZ mococcal associated with nization (Figure 1B). Samples for micro - Javier PADILLO RUIZ biological and parasitic study were taken, hemodynamic instability or other and the patient received resuscitative me - Unidad de Gestión Clínica de Cirugía General, Hospital Universitario Virgen del Rocío, Sevilla, signs suggesting endocarditis (emer - asures, broad-spectrum intravenous anti - Spain. ging murmur, etc.) as well as in pa - biotics and urgent admission to the criti - tients with pneumococcal 4 pneumo - cal care unit. Despite a favorable initial nia and . Although cases response, the patient died after 48 hours. have been reported in patients wi - The culture was positive for Pseudomonas aeruginosa, and the larvae were housefly. EVN is a rare entity in our setting Austrian syndrome in and that arises from chronic obstructive infant with pneumococcal lymphedema, of multiple etiology septic shock (congenital, infectious, neoplastic etc.), characterized by severe defor - Sir, mity and cutaneous features such as Pneumococcal endocarditis is a dermal fibrosis, verrucous lesions and rare complication (incidence 0.4%) papillomatosis 2. Diagnosis at an early of pneumococcal bacteremia in chil - stage allows treating the cause of dren 1,2 . The association of pneumo - lymphatic obstruction, and measures nia, meningitis and pneumococcal to prevent superinfection of skin le - endocarditis is known as Austrian 3 sions should be administered 3. In an syndrome. In this picture, endocardi - unfavorable socio-cultural context, tis is caused by hematogenous spre - the lack of personal and hygienic ca - ad from a primary pneumonic focus re is a predisposing factor for supe - and preferentially affects the aortic 3.4 rinfection of such injury, with very valve . Meningitis is secondary to Figure 1. Subcostal longitudinal plane echo - poor prognosis in some cases. Pre - septic emboli. Its importance lies in cardiography showing a triangular mass in ventive measures are vital in these being an infection with high morta - the mid-zone of the inter-atrial septum patients, as is very thorough hygiene lity (50%), unless early diagnosis and (arrow) at the level of the surgical suture, or even the use of insect repellent 4. treatment are performed 4. which protrudes towards the right atrium.

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thout underlying heart disease, echo - intention 1. ses para el tratamiento en un servicio de ur - cardiography is indicated especially gencias (Consultado 24 Septiembre 2014). A 25 year-old man with unremarkable Disponible en http://www.fetoc.es/asisten - in patients with structural heart dise - medical history was brought to the emer - cia/Intoxicaciones%20Agudas%20Protoco - ase 2, focusing the study on cavities gency department 30 minutes after an al - los%202010.pdf and left ventricular valves or implan - tercation in the street, where he volunta - 2 Barceloux DG, Krenzelok EP, Olson K, Wat - ted prosthetic material, as in our ca - rily swallowed the contents of a fire son W. American Academy of Clinical Toxi - extinguisher. Upon arrival, he was he - cology Practice Guidelines on the Treatment se. Antibiotic therapy was administe - of Ethylene Glycol Poisoning. Ad Hoc Com - red early and combined with modynamically stable, afebrile, with inco - mittee. J Toxicol Clin Toxicol. 1999;37:537- third-generation cephalosporin, herent and disorganized speech. The rest 60. of the physical examination was normal. glycopeptide and an aminoglycoside 3 Bayliss G. Dialysis in the poisoned patient. Arterial blood gases showed metabolic Hemodial Int. 2010;14:158-67. (completed 4-6 weeks of intravenous acidosis with increased anion gap (pH 4 Kruse JA. Methanol and ethylene glycol into - treatment) 5. Surgery is reserved for xication. Crit Care Clin. 2012;28:661-711. 7.08, bicarbonate 8 mEq / l, pCO 2 27 cases where medical treatment alone mmHg, anion gap 37 mEq / l). Other 5 Jammalamadaka D, Raissi S. Ethylene glycol, appears unlikely to be effective 5,6 . causes of metabolic acidosis were ruled methanol and isopropyl . Am J Med Sci. 2010;339:276-81. out (negative ketonuria and etanolemia, 6 Senthilkumaran S, Meenakshisundaram R, Ba - lactic acid was normal and there was lamurgan N, SathyaPrabhu K, Karthikeyan V, References mild acute renal failure), and the osmolar Thirumalaikolundusubramanian P. Fire extin - gap was calculated: 21.08 mOsm / L guisher: an imminent threat or an eminent 1 Givner LB, Mason EO, Tan TQ, Barson WJ, (normal <10 mOsm / l). danger? Am J Emerg Med. 2012;30:515.e3-5. The Poison Information Centre confir - Schutze GE, Wald ER, et al. Pneumococcal 1 endocarditis in children. Clin Infect Dis. med that the fire extinguisher involved Isabel GALÁN CARRILLO , 2 2004;38:1273-8. contained ethylene glycol. Although blo - Pablo DEMELO-RODRÍGUEZ , 2 Choi M, Mailman TL. Pneumococcal endo - od levels of ethylene glycol were not de - Juan Carlos CANO BALLESTEROS 2, carditis in infants and children. Pediatr Infect termined, due to interference of renal re - Úrsula VERDALLES GUZMÁN 1 Dis J. 2004;23:166-71. placement therapy, the final diagnosis 1Servicio de Nefrología, 2Servicio de Medicina 3 Austrian R. Pneumococcal endocarditis, me - was secondary metabolic acidosis due to Interna, Hospital General Universitario Gregorio ningitis, and rupture of the aortic valve. Marañón, Madrid, Spain. AMA Arch Intern Med. 1957;99:539-44. ingestion of ethylene glycol. In the ED, 4 Rammeloo L, Hruda J, Sobotka-Plojhar M, gastric lavage was performed with activa - Avis W, Schoof P. Austrian syndrome in a ted carbon, and because of the severity child-aortic valve endocarditis following of metabolic acidosis urgent hemodialysis pneumococcal meningitis. Int J Cardiol. was performed. The session was unevent - Subcutaneous emphysema in 2004;94:321-2. ful and at first control pH was 7.3, HCO 3 a boy with multiple injuries: 5 Habib G, Hoen B, Tornos P, Thuny F, Pren - 17 mEq / l, anion gap 17 mEq / l, osmo - dergast B, Vilacosta I, et al. Guidelines on lar gap 12 mOsmol / l. At no time did he tracheal rupture the prevention, diagnosis, and treatment of infective endocarditis (new version 2009): present respiratory or visual disturbances. the Task Force on the Prevention, Diagnosis, The patient was discharged after seven Sir, and Treatment of Infective Endocarditis of days with a diagnosis of acute psychotic Tracheal rupture is a rare injury, the European Society of Cardiology (ESC). episode. especially in children. It happens af - Endorsed by the European Society of Clinical Early diagnosis and treatment of ter high-energy trauma, and can Microbiology and Infectious Diseases (ES - 1-4 CMID) and the International Society of Che - ethylene glycol poisoning are essen - cause death in situ . motherapy (ISC) for Infection and Cancer. tial for short and long term progno - This case was a 6 year-old boy crus - Eur Heart J. 2009;30:2369-413. sis. Ingestion can cause metabolic 6 Byrne JG, Rezai K, Sanchez JA, Bernstein RA, hed by a metal door with direct trauma Okum E, Leacche M, et al. Surgical manage - acidosis, renal failure, retinal toxicity of the head and chest. Upon ED arrival ment of endocarditis: the society of thoracic and brain damage. Besides treatment about 20 minutes later, Glasgow Coma surgeons clinical practice guideline. Ann with intravenous bicarbonate and al - Scale score was 15, and he showed epis - Thorac Surg. 2011;6:2012-9. cohol dehydrogenase inhibitors, he - taxis, otorrhagia, dental avulsion injuries and discrete frontoparietal subcutaneous Moisés RODRÍGUEZ-GONZÁLEZ , modialysis is the best method for the rapid removal of both ethylene emphysema. After endotracheal intuba - Miguel Ángel MATAMALA-MORILLO tion, mechanical ventilation was started Sección de Cardiología Pediátrica, Pediatría, glycol and its metabolites. It is indi - Hospital Universitario Puerta del Mar, cated in metabolic acidosis with Cádiz, Spain. anion gap > 30 meq / l and osmolar gap> 20 mosmol / l, as in our case 2,3 . Early treatment is crucial to avoid the high lethality of untreated or chronic Ethylene glycol poisoning effects in survivors 4, so it should be after ingestion of the started without confirming the va - 5 contents of a fire lues of ethylene glycol in blood . Al - though there have been cases in the extinguisher literature of poisoning related to in - halation of the contents of fire extin - Sir, guishers 6, poisoning by ingestion has Ethylene glycol poisoning is com - not been previously described. mon in our setting. This alcohol, odorless and colorless, is present in Figure 1. Chest CT scan showing the presen - many industrial and household pro - ce of bilateral pneumothorax and subcutane - ous emphysema with chest drainage tubes. ducts. Poisonings have been repor - References Deviation of the endotracheal tube relative to ted as a substitute intake of ethyl al - the tracheal route towards the posterior me - cohol and, exceptionally, suicidal 1 Nogué Xarau S. Intoxicaciones agudas. Ba - diastinum.

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with positive pressure. At that time incre - copy / bronchoscopy. Intubation 2 Gorosh LR, Ingaramo O, Nelson D, Vohra M, ased subcutaneous emphysema was ob - should be guided by bronchoscopy, Ciccolo ML. Spontaneous tracheal rupture: a served. Computed tomography (CT) scan and the end of the ETT must be dis - case report. J Emerg Med. 2014;46:31-3. showed a massive bilateral pneumotho - 3,8 3 Barrett E. Management of a traumatic tracheal tal to the lesion . In this case, on tear: a case report. AANA J. 2011;79:468-70. rax, so two chest tubes were placed in moving the ETT, it was introduced in - continuous aspiration. Control CT sho - 4 Akyol A, Cay A, Imamoglu M, Ulusoy H, wed better lung expansion, and the en - to the mediastinal area, so it was re - Ozen I. Conservative treatment of spontane - dotracheal tube (ETT) in infracarinal posi - moved, and the distal end was loca - ous tracheal rupture. Pediatr Pulmonol. 2006;41:690-3. tion in the posterior mediastinum (Figure ted proximal to the lesion. We consider the case relevant for the pe - 5 Prokakis C, Koletsis EN, Dedeilias P, Fligow F, 1). With the suspicion of tracheal rupture, Filos K, Dougenis D. Airway trauma: a re - he was transferred to a referral hospital, culiarity of the injury and its severity. view on epidemiology, mechanisms of in - where 3-dimensional CT and bronchos - The presence of subcutaneous jury, diagnosis and treatment. J Cardiothorac copy confirmed a membranous tracheal emphysema should alert us to the Surg. 2014;9:117. rupture with ETT located distally in the possibility of tracheobronchial injury 6 Boubia S, Fouraiji K, Elkari A, Sibai H, Chlilek posterior mediastinum. The ETT above and it is recommended that it should M, Ridai M. Une rupture trachéobronchique the lesion was withdrawn, and the lesion be guided by fiberoptic intubation af - chez l ’enfant. Arch Pediatr. 2010;17:1059-61. closed spontaneously. Currently the pa - ter locating the lesion. In our case, 7 Lapuerta Irigoyen L, Sánchez Benítez M, Be - tient is asymptomatic. larra Gorrochategui JE, Martínez Flórez J, Pé - tracheal injury was probably caused rez Homs M. Rotura traumática parcial de The clinical manifestations of tra - by the accident as subcutaneous tráquea. Emergencias. 2006;18:254-5. cheobronchial injury depend on the emphysema was observed before in - 8 American Society of Anesthesiologists. ASA location and severity 5; chest pain and tubation. Endotracheal intubation wi - difficult airway algorithm modified for trau - dyspnea are common symptoms, thout bronchoscopy could in fact ma. ASA Newslett. 2005;69:14. while subcutaneous emphysema and worsen the injury. Isabel SAN MARTÍN GARCÍA 1, pneumothorax indicate an air leak 2.4-6 . Nuria CLERIGUÉ ARRIETA 1, The presence of cervical pain, 1 References Jorge RODRÍGUEZ OZCOIDI , dysphagia, hemoptitis or dysphonia Laura MORENO GALARRAGA 2

may also be indicative of tracheal in - 1 7 1 Hwang JJ, Kim YJ, Cho HM, Lee TY. Trauma - Unidad de Cuidados Intensivos Pediátricos, jury . It is recommended to keep the 2 tic tracheobronchial injury: delayed diagno - Servicio de Pediatría. Unidad de Neumología patient on spontaneous ventilation sis and treatment outcome. Korean J Thorac Infantil, Servicio de Pediatría, Complejo until locating the lesion by laryngos - Cardiovasc Surg. 2013;46:197-201. Hospitalario de Navarra B, Pamplona, Spain.

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