- Acute Organophosphorus Pesticide Poisoning
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Mi-Jin Lee, Joon-Seok Park, Tai-Yong Hong, Sung-Soo Park, Yeon-Ho You
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J Korean Soc Clin Toxicol. 2008;6(2):83-90. Published online December 31, 2008
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- Organophosphate (OP) pesticides are the most common source of human toxicity globally, causing high mortality and morbidity despite the availability of atropine as a specific antidote and oximes to reactivate acetylcholinesterase. The primary toxicity mechanism is inhibition of acetylcholinesterase (AchE), resulting in accumulation of the neurotransmitter, acetylcholine, and abnormal stimulation of acetylcholine receptors. Thus, the symptoms (muscarinic, nicotinic, and central nervous system) result from cholinergic overactivity because of AchE inhibition. OP can also cause rhabdomyolysis, pancreatitis, parotitis, and hepatitis. OP therapy includes decontamination, supportive therapy, and the use of specific antidotes such as atropine and oximes. However, there has been a paucity of controlled trials in humans. Here we evaluated the literature for advances in therapeutic strategies for acute OP poisoning over the last 10 years.
- Clinical Implication of Acetylcholinesterase in Acute Organophosphate Poisoning
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Hoon Kim, Seung-Baik Han, Jun-Sig Kim, Mi-Jin Lee, Joon-Seok Park, Woon-Yong Kwon, Eun-Kyung Eo, Bum-Jin Oh, Sung-Woo Lee, Joo-Hyun Suh, Hyung-Keun Roh
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J Korean Soc Clin Toxicol. 2008;6(1):25-31. Published online June 30, 2008
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- Purpose: Acute organophosphate (OP) poisoning may be monitored by measuring the acetylcholinesterase (AChE). It is important to assess severity and establish prognostic tests in the early stage of OP poisoning. The aim of this study was to look at the relationship between various clinical aspects of the OP poisoning, prognostic indicators of OP poisoning including Simplified Acute Physiology Score (SAPS) 3, and the associated changes in AChE levels. Methods: Clinical data and initial AChE levels from thirty-seven patients with OP poisoning were prospectively reviewed from 12 teaching hospitals in South Korea from August 2005 to July 2006. Clinical manifestations at the time of arrival such as miosis, respiratory abnormality, salivation, urinary incontinence, GCS score, AVPU scale, need for intubation, and mechanical ventilation requirements were recorded. SAPS 3 was calculated using clinical data and laboratory results. Results: The median level of AChE was 9.8 (1.3-53.6) U/gHb. There was no significant difference in AChE levels between the groups with and without cholinergic symptoms. The median level of AChE of the patients who required intubation and those who did not were 3.5 U/gHb and it 19.7 U/gHb respectively (Mann-Whitney test; p<0.001). The AChE levels were also significantly different (p=0.007) in patients who needed mechanical ventilation compared to those who did not with AChE levels found to be 3.1 U/gHb and it was 14.8 U/gHb, respectively. Level of consciousness assessed using the AVPU scale was correlated with AChE levels (Kruskal-Wallis test; p=0.013). GCS score were correlated with AChE levels (p=0.007, Spearman's rho = 0.454). In addition, the lower the level of initial AChE, the longer the ICU stay (p=0.029, Spearman's rho=-0.380). SAPS 3 was inversely correlated with the initial AChE (p<0.001, Spearman's rho=-0.633). Conclusion: In the acute OP poisoning, low AChE levels appear to help indicate the severity of poisoning. The initial AChE level may be a useful prognostic parameter for acute OP poisoning.
- Clinical Characteristics of Patients with Acute Organophosphate Poisoning Requiring Prolonged Mechanical Ventilation
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Hwang-Jin Shin, Mi-Jin Lee, Kyu-Nam Park, Joon-Seok Park, Seong-Soo Park
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J Korean Soc Clin Toxicol. 2008;6(1):32-36. Published online June 30, 2008
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- Purpose: The major complication of acute organophosphate (OP) poisoning is respiratory failure as a result of cholinergic toxicity. Many clinicians find it difficult to predict the optimal time to initiate mechanical ventilation (MV) weaning, and as a result have tended to provide a prolonged ventilator support period. The purpose of this study is to determine any clinical predictors based on patients characteristics and laboratory findings to assist in the optimal timing of mechanical ventilator weaning. Methods: We reviewed medical and intensive care records of 44 patients with acute OP poisoning who required mechanical ventilation admitted to medical intensive care unit between July 1998 and June 2007. Patient information regarding the poisoning, clinical data and demographic features, APACHE II score, laboratory data, and serial cholinesterase (chE) levels were collected. Base on the time period of MV, the patients were divided into two groups: early group (wean time < 7 days, n = 28) and delayed group (${geq}$ 7 days, n = 16). Patients were assessed for any clinical characteristics and predictors associated with the MV weaning period. Results: During the study period, 44 patients were enrolled in this study. We obtained the sensitivity and specificity values of predictors in the late weaning group. APACHE II score and a reciprocal convert of hypoxic index but specificity (83.8%) is only APACHE II score. Also, the chE concentration (rho = -0.517, p = 0.026) and APACHE II score (rho = 0.827, p < 0.001) correlated with a longer mechanical ventilation duration. Conclusion: In patients with acute OP poisoning who required mechanical ventilation, the APACHE II scoring system on a point scale of less than 17 and decrements in cholinesterase levels on 1-3 days were good predictors of delayed MV weaning.
- Clinical Characteristics of Acute Dichlorvos Poisoning in Korea
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Mi-Jin Lee, Joon-Seok Park, Woon-Yong Kwon, Eun-Kyung Eo, Bum-Jin Oh, Sung-Woo Lee, Joo-Hyun Suh, Hyung-Keun Roh
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J Korean Soc Clin Toxicol. 2008;6(1):9-15. Published online June 30, 2008
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- Purpose: Dichlorvos has been in widespread use as an organophosphate (OP) insecticide compound. The purpose of this study was to access the epidemiology and clinical features of dichlorvos in Korea. Methods: This was a 38 multi-center prospective study of dichlorvos poisoning using surveys, a structural reporting system and review of hospital records from August 2005 to July 2006. A total of 54 patients with acute dichlorvos poisoning on a national basis were enrolled. We analyzed the epidemiologic characteristics and clinical manifestations of dichlorvos poisoning. In addition, the clinical features of dichlorvos poisoning were compared with others OP compounds. Results: During the study period, compounds involving pure OP poisoning were dichlorvos (22.7%), methidathion (8.4%), and phosphamidon (6.7%). In acute dichlorvos poisoning, all ingestion routes were oral. Intentional poisoning involved 74.1% of cases. The common initial complaints involved gastrointestinal (64.8%), systemic (61.1%), central or peripheral nervous system (53.7%), and respiratory symptoms (50.0%). The median arrival time to hospital after dichlorvos poisoning was 2.6 hours and mean hospitalization duration was 7.1 days. 2-PAM was administered in 35 patients in mean doses of 6.3 g/day intravenously. Atropine was administered in 30 patients with a mean dose of 62.8 mg/day (maximal 240 mg/day). Overall mortality rate for dichlorvos poisonings were 14.8% (8/54). Immediate causes for death included sudden cardiac arrest or ventricular dysrhythmias (50%), multi-organ failure (25%), acute renal failure (12.5%), and unknown causes (12.5%). Conclusion: When compared to previous reports, dichlorvos poisoning displayed relatively moderate severity. The presence of a lower GCS score, altered mental status, serious dysrhythmias, systemic shock, acute renal failure, and respiratory complications upon presentation were associated with a more serious and fatal poisoning.
- Clinical Aspects of the Chlorophenoxy Herbicide Intoxicated Patients
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Young-Soon Cho, Ho-Jung Kim, Bum-Jin Oh, Joo-Hyun Suh, Woon-Yong Kwon, Joon-Seok Park, Eun-Kyung Eo, Mi-Jin Lee, Sung-Woo Lee, Hyung-Keun Roh, Hoon Lim
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J Korean Soc Clin Toxicol. 2007;5(2):112-118. Published online December 31, 2007
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- Purpose: There have been relatively few reports of chlorophenoxy herbicide poisoning. The purpose of this study is to analyze the general characteristics and clinical aspects of the chlorophenoxy herbicide intoxicated patients in Korea. Methods: We prospectively evaluated the chlorophenoxy herbicide intoxicated patients visiting to the 38 emergency medical centers in Korea from the 1 August 2005 to the 31 July 2006. Results: 24 patients were enrolled during the study periods. Their mean age was 55.7 years old. The median amount of the chlorophenoxy herbicide intoxicated is 150 mL. The most frequent location where the patients obtained and took the chlorophenoxy herbicide was their home. Frequent compounds involving chlorophenoxy herbicide poisoning were dicamba(66.7%), MCPP(16.7%), and 2,4-D(12.5%). The most common symptom of the patients was confusion and vomiting. 16 patients(66.7%) intended to suicide. 3 patients out of 24 patients(13.0%) were died. Conclusion: There were 24 patients intoxicated by the chlorophenoxy herbicide during the study periods. The mortality rate was 13.0%. The suicidal attempts and the numbers of death involving chlorophenoxy herbicide were high in Korea.
- The Study of Pyrethroid Intoxication: The basis of Agrichemical Intoxication Survey in 2005
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Ah-Jin Kim, Kyung-Hwan Kim, Joon-Seok Park, Eun-Kyung Eo, Bum-Jin Oh, Mi-Jin Lee, Sung-Woo Lee, Joo-Hyun Suh, Hyung-Keun Roh
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J Korean Soc Clin Toxicol. 2007;5(2):99-105. Published online December 31, 2007
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- Purpose: Pyrethroid is an insecticide that produces moderate intoxication in mammals, with neither exposure to skin nor inhalation resulting in severe systemic manifestations. In 2005 we made a nationwide survey of agrichemical human intoxication. The object of this study is to analyze pyrethroid intoxications based on the 2005 survey. Methods: We prospectively collected data from 1 August 2005 to 31 July 2006 by a standard investigation protocol. We analyzed demographic data, exposure data (cause, amount, ingredients), clinical features, and courses. Results: A total of 125 cases of pyrethroid intoxication were surveyed. The mean patient age was $56.78{pm}16.158$ years old, and the mean amount ingested was $121.85{pm}110.732ml$. Patients were classified into four severity groups according to symptoms and mental status: the asymptomatic group (27 patients, 21.6%), the mild symptom group (48, 38.4%), the moderate symptom group (21, 16.8%), and the severe symptom group (7, 5.6%). There were statistically significant differences in mental status, severity, and mean ICU days between two groups. Admission days by severity grade for the asymptomatic, mild, moderate, and severe symptom groups were $5.49{pm}16.051,;3.65{pm}4.143,;4.59{pm}3.335,;and;8.14{pm}7.199days$, respectively (p=0.047). Conclusion: Nationwide surveillance was extremely telling in uncovering a high frequency of agrichemical intoxication in Korea. In pyrethroid intoxication, severity grading can be a useful prognostic tool.
- Characteristics and Prognostic Factors of Carbamate Poisoning in Korea
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Woon-Yong Kwon, Joon-Seok Park, Eun-Kyung Eo, Bum-Jin Oh, Mi-Jin Lee, Sung-Woo Lee, Joo-Hyun Suh, Hyung-Keun Roh, Gil-Joon Suh
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J Korean Soc Clin Toxicol. 2007;5(1):1-7. Published online June 30, 2007
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- Purpose: The aim of this study was to evaluate the characteristics and the prognostic factors of carbamate poisoned patients who visited emergency departments. Methods: From August 2005 to July 2006, we investigated the demographic feature, dose of exposure, time of exposure, alcohol intake, route of exposure, reason of exposure, site of exposure, pre-existing medical condition, time from exposure to emergency department (ED), transfer from other hospitals, vital sign at ED arrival, symptom or sign at ED arrival, and result of care of the patients who visited the ED of thirty-eight hospitals in Korea. According to the result of care, we divided the patients into two groups, the survival and the dead. To evaluated the prognostic factors, we calculated the odds ratio of each factor for the survival. Results: Among the sixty-eight patients, fifty-five patients (80.9%) were survival and thirteen patients (19.1%) were dead. The patients in the dead were older than the patients in the survival. The Glasgow coma scale (GCS) of the patients in the dead was lower than the GCS in the survival. The odds ratio of the GCS at ED arrival for the survival was 1.58 (95% CI; 1.23-2.05). Other factors showed no statistical significances. Conclusion: The GCS at emergency department arrival was the prognosis factor of the carbamate poisoned patients who visited emergency departments. If the carbamate poisoned patients showed altered mentalities, they should be provided intensive care, immediately.
- Clinical Aspects of the Organochlorine Intoxicated Patients
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Jun-Ho Cho, Bum-Jin Oh, Joo-Hyun Suh, Woon-Yong Kwon, Joon-Seok Park, Eun-Kyung Eo, Mi-Jin Lee, Sung-Woo Lee, Hyung-Keun Roh, In-Cheol Park
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J Korean Soc Clin Toxicol. 2007;5(1):15-20. Published online June 30, 2007
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- Purpose: To analyze the general characteristics and clinical aspects of the organochlorine intoxicated patients in Korea. Methods: We prospectively evaluated the organochlorine intoxicated patients visiting to the 38 emergency medical centers in Korea from the 1, Aug. 2005 to the 31, Jul. 2006. Results: There were 38 patients intoxicated by the organochlorine during the study periods. The mean age of patients was 55.1 years old. The mean amount of the organochlorine intoxicated is 246.1 mL. The most frequent place where the patients got and took the organochlorine was their home. Twenty eight patients(73.7%) intended to suicide. Nine patients out of 38 patients(23.7%) were died and they all intended to suicide. Conclusion: There were 38 patients intoxicated by the organochlorine during the study periods. The suicidal attempts and the number of the dead were higher in Korea than the developed countries.
- Organophosphate-Pyrethroid Mixtures Poisoning
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Dae-Young Hong, Kwang-Je Baek, Kyeong-Ryong Lee, Woon-Yong Kwon, Joon-Seok Park, Eun-Kyung Eo, Bum-Jin Oh, Mi-Jin Lee, Sung-Woo Lee, Joo-Hyun Suh, Hyung-Keun Roh, Jun-Sig Kim
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J Korean Soc Clin Toxicol. 2007;5(1):21-26. Published online June 30, 2007
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- Purpose: Owing to organophosphate-pyrethroid mixtures are widely used, suicidal or unintentional poisoning is common. But there have been relatively few reports of poisoning. The purpose of this study is to evaluate the difference of the severity and toxicity between organophosphate-pyrethroid mixtures poisoning and single organophosphate poisoning. Methods: From August 2005 to July 2006, 65 patients presented with organophosphate-pyrethroid mixtures poisoning to emergency medical center. Date were gathered by report form it was drawn up. Results: 65 patients were enrolled in 28 hospitals and their mean age was $56.5{pm}16.2$ years old. The most common cause of poisoning was suicide, in 52 cases(80%). Chlorpyrifos-cypermethrin, malathion-esfenvalerate were the most frequent chemicals involved, and the mean ingestion amount was 135.4ml. The most common symptom of the patients was nausea/vomiting, in 16 patients. The average GCS score was 13. The mean ICU stay was $4.4{pm}5.2$ days, and mortality was 3.1%. Conclusion: The severity and toxicity of organophosphate-pyrethroid mixture poisoning were lower than that of single organophosphate poisoning.
- Clinical Characteristics of Acute Pure Organophosphate Compounds Poisoning - 38 Multi-centers Survey in South Korea -
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Mi-Jin Lee, Woon-Yong Kwon, Joon-Seok Park, Eun-Kyung Eo, Bum-Jin Oh, Sung-Woo Lee, Joo-Hyun Suh, Hyung-Keun Roh
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J Korean Soc Clin Toxicol. 2007;5(1):27-35. Published online June 30, 2007
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- Purpose: Organophosphate (OP) compounds insecticides are the most commonly associated with serious human toxicity all over the world. The aim of this study was to identify sociocultural factors that contribute to high incidence of pure OP poisoning and prevent OP poisoning in order to reduce the factors responsible for deaths in South Korea. Methods: This is the 38 multi-centers survey and prospective study of pure OP poisoning by structural reporting system and hospital records from August 2005 to July 2006. 238 patients with acute pure OP poisoning were enrolled. We collected patient information regarding poisoning, clinical, and demographic features. Results: The mean age was $55.32{pm}17.3$ years old. The most frequent site of exposure was their own residence(85.7%). Frequent compounds involving pure OP poisoning were dichlorvos(22.7%), methidathion(8.4%), and phosphamidon(6.7%). Intentional poisoning was 77.9%. The most frequently route of exposure was ingestion(94.5%). The mean arrival time to hospital after poisoning was 12.7 hours and mean hospitalization duration was 12.9 days. 2-PAM was administered to 101 patients in mean doses of 6.3 g/day intravenously. Atropine was administered to 81 patients in mean doses of 74.6 mg/day (maximal 910 mg/day). The presence of lower level of GCS score, respiratory complications, hypotension, acute renal failure, and serious dysrhythmia was associated with serious and fatal poisoning. Overall final mortality in pure OP poisoning was 9.7%(23/238). Conclusion: This study highlights the problem of pure OP poisoning in South Korea as a basic national survey. Futhermore this might help the establishment of strict policies availability of OP and the statistics of OP poison exposure in South Korea.
- Epidemiology and Clinical Analysis of Poisoning of Glufosinate Herbicide - Multicenter Study -
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Sung-Woo Lee, Yun-Sik Hong, Woon-Yong Kwon, Joon-Seok Park, Eun-Kyung Eo, Bum-Jin Oh, Mi-Jin Lee, Joo-Hyun Suh, Hyung-Keun Roh
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J Korean Soc Clin Toxicol. 2007;5(1):36-42. Published online June 30, 2007
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- Purpose: To assess the epidemiology and the clinical features of Glufosinate herbicide in Korea. Methods: Data was prospectively collected during 1 year since August 2005 from 38 hospital in Korea. We analyzed the epidemiologic characters and clinical manifestations of Glufosinate poisoning. In addition, the characteristics of patients with severe central nervous system toxicity were separately analyzed to find poor prognosis relating factors. Results: During study periods, there were 715 persons of poisoning of herbicides and insecticides. 6.3% (45 persons) of the agricultural chemicals poisoning had Glufosinate poisoning. There were 36 cases of suicide attempts and 7 cases of accidental exposure, The major of poisoning route was oral ingestion (44 cases). 28.9 % of the study patients had not toxic symptoms. The most common symptoms were gastrointestinal symptoms relating surfactant irritation. 67.7% of central nervous symptoms occurred lately. 10 persons showed severe central nervous system toxicity. 4 persons of them showed poor outcomes (1 death, 3 hopeless discharged). Complications of respiratory failure and renal failure related with poor outcome. Conclusion: Majority of patients ingested Glufosinate for suicide attempt. 22.2% of patients with Glufosinate poisoning showed delayed serious central nervous system toxicity. Early supportive care of altered mentality may prevent late respiratory complications and improve the outcomes.
- A Case of Myoclonus Presenting as a Side Effect of Amitriptyline
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Jong-Pil Choi, Seong-Soo Park, Joon-Seok Park, Sang-Jun Na
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J Korean Soc Clin Toxicol. 2006;4(2):155-157. Published online December 31, 2006
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- Myoclonus is manifested in a variety of situations including metabolic derangements, brain lesions, epilepsy, and drugs toxicity. We reported a rare case of amitriptyline-induced myoclonus. A 64-year-old man with a tension-type headache was administered amitriptyline at 15 mg/day. Eight days after initiation of amitriptyline, multifocal myoclonus developed, involving the face and upper extremities. Two hours after the administration of clonazepam at 1 mg, myoclonus resolved completely.
- Indoxacarb Pesticide Poisoning with Methemoglobinemia
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Jae-Hoon Shin, Jae-Kwang Lee, Seong-Soo Park, Sang-Jun Na, Joon-Seok Park
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J Korean Soc Clin Toxicol. 2006;4(2):158-160. Published online December 31, 2006
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- Acute methemoglobinemia is induced by various causes, especially ingestion of oxidizing agents such as phenazopyridine, dapsone, and nitrite. Indoxacarb is an oxadiazine insecticide with high insecticidal activity and low mammalian toxicity. It is known to block voltage-gated Na+ channels in insects and mammals, but the mechanism is not yet well understood. We describe a case of a 41-year-old woman with methemoglobinemia that developed following Indoxacarb ingestion, which improved after intravenous injection of methylene blue. This is the first known such case. If signs and symptoms of methemoglobinemia occur after Indoxacarb ingestion, antidotal therapy with methylene blue should be considered as a necessary treatment.
- Reactive Airways Dysfunction Syndrome (RADS) from Chlorine Gas Releasing Cleaning Agents
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Kwang-Hyun Cho, Seung-Hwan Kim, Young-Soon Cho, Hahn-Shick Lee, Joon-Seok Park
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J Korean Soc Clin Toxicol. 2005;3(1):60-62. Published online June 30, 2005
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- A previously healthy 57-year-old woman with dyspnea and wheezing presented to the emergency department a few minutes after exposure to unknown gas from mixing bleach (sodium hypochlorite) and cleaning agent (hydrochloric acid) at work place. Initial physical examination revealed severe wheezing on both whole lung fields, but the chest radiograph was normal. Arterial blood gas analysis showed only moderate hypoxemia. The patient was treated with oxygen, $eta$adrenergic bronchodilators, antihistamines and corticosteroids, after then symptoms were improved. And the patient discharged against medical advice. We report a rare case of reactive airways dysfuntion syndrome from chlorine gas exposure.
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KSCT
Korean Society of Clinical Toxicology