ICEM 2014

ICEM 2014

Tintinalli Headlines & Holliman Assumes Presidency

On June 11, EPM Editor-in- Chief and renowned educator Judith Tintinalli took to the stage in Hong Kong to address…

The Medical Malpractice Rundown: A State-by-State Report Card

The Medical Malpractice Rundown: A State-by-State Report Card

When it comes to medical liability laws and culture, where you live matters.

Find out how your state stacks up against the other 49.

CT – Lowering Cost and Radiation

CT – Lowering Cost and Radiation

Medicare pays only about 20% of typical charges and radiation can be reduced by 90%.

The cost of a CT is actually quite nominal – the charge, however, is an entirely different matter. 

 Aftermath: The Night Shift Season 1 Finale Review

Aftermath: The Night Shift Season 1 Finale Review

At Loose Ends

It’s strange calling this a season finale, because it’s only been an 8-episode summer run, and nearly every episode has…

Doximity’s Next Trick: Connectivity at the Point of Care

Doximity’s Next Trick: Connectivity at the Point of Care

You’ve raised $81 million in investments and your physician membership now exceeds that of the AMA. What’s next?

If you're Doximity, it's time to dream big. 

Subcutaneous Insulin in DKA: Safe — But Not Better

Subcutaneous Insulin in DKA: Safe — But Not Better

Newer Isn't Always Better

Studies show that the benefits of subcutaneous insulin over old fashioned IV insulin are marginal at best.

A Return to (Lousy) Form: Episode 7 of The Night Shift

A Return to (Lousy) Form: Episode 7 of The Night Shift

Forks! Strippers! Guns!

Once again, our characters are responding to the (frankly unbelievable) events unfolding around them, rather than driving the action.

Oxygen is a Drug— Act Accordingly

Oxygen is a Drug— Act Accordingly

Understanding the dangers of indiscriminate oxygenation in the ED setting

As with many things in medicine, dogma seems to overpower the evidence in this arena. 

Oh Henry: A Sucker is Born Every Minute

Oh Henry: A Sucker is Born Every Minute

Pharmaceutical Ads, Government, and the Physician-Patient Relationship

Though it pains me to say it, this is one time where caveat emptor doesn’t apply. 


A Ray of Hope

A Ray of Hope

The Night Shift, episode 6

This was the first episode where it felt like the characters were driving the plot.

The Downside of the Upswing

The Downside of the Upswing

You should have cashed in big-time. 
But did you?

The last several years of returns have been among the best ever.

5 Things Your Patients Might Think After Watching ‘Code Black’

5 Things Your Patients Might Think After Watching ‘Code Black’

An inside view of the ED

Code Black provides a harrowing and enlightening window into the front lines of healthcare. 

Talking Points

Talking Points

Link your vision to action

As an ED leader, you must not only have a vision and plan, but you must communicate that vision effectively…

Toxic Liquid Nicotine

Toxic Liquid Nicotine

New FDA regulations proposed for E-cigs

Highly unregulated, the sale of toxic nicotine concoctions for e-cigarette refills pose a serious threat to children.

All Choked Up

All Choked Up

Best Practices for Battery Ingestion

A two-year-old presents at a clinic with persistent cough and neck discomfort and winds up in the ED.

Gag Order

Gag Order

New ruling prohibits would-be ACEP leaders from answering questions from non-ACEP publications.

Greg Henry seldom fails to deliver on a promise. But this time, it looks like it’s out of his control.

Lock the Gates!

Lock the Gates!

Board certification is vital in EM

Last month, Rick Bukata suggested that ACEP open its gates to non-boarded EPs. 
This would be an insult to EM…

AMA Meeting Highlights

AMA Meeting Highlights

Association Gives Nod to First EP President-elect

This June’s AMA Annual Meeting proved as eventful as ever, with one exciting twist that has the potential to impact…

The Storm Episode!

The Storm Episode!

Episode 5 of NBC's "The Night Shift"

It’s time for the passion that’s been building up between the two lead ED doctors for … the past few…

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This article reviews the health effects most commonly associated with the release of industrial and environmental substances. The classes of substances are divided into asphyxiants, cholinesterase inhibitors, respiratory tract irritants, and vesicants. Each class of substance has a corresponding clinical syndrome, or “toxidrome”, that can guide the healthcare professional in providing the appropriate therapy.
   
Asphyxiants are substances that cause tissue hypoxia and have prominent neurologic and cardiovascular signs. Asphyxiants are divided into simple asphyxiants, which physically displace oxygen in inspired air, and chemical asphyxiants, which interfere with oxygen transport and cellular respiration. Simple asphyxiants (methane, propane, nitrogen, carbon dioxide) and chemical asphyxiants (carbon monoxide, cyanide, and hydrogen sulfide) are treated with 100% oxygen therapy. Cyanide poisoning should be treated with sodium nitrite and thiosulfate. Sodium nitrite induces the formation of methhemoglobin, which binds to cyanide. The thiosulfate acts synergistically to accelerate the detoxification of cyanide to thiocyanate. It should be suspected when a laboratory or industrial worker suddenly collapses. The treatment of victims of house fires is more complex as they may be suffering from carbon monoxide poisoning as well as cyanide poisoning. Some advocate using thiosulfate and only adding nitrites to those patients that are unstable. Hydrogen sulfide poisoning should also be treated with sodium nitrite, but there is no role for thiosulfate. Hyperbaric oxygen therapy is also indicated in the treatment of carbon monoxide and hydrogen sulfide poisoning.
   
Cholinesterase inhibitors include organic phosphorus pesticides, carbamate pesticides, and organophosphorus compounds known as “nerve agents” (e.g. sarin, soman, tabun, and VX). These compounds result in cholingeric overstimulation with both muscarinic and nicotinic effects. Muscarinic symptoms include profuse exocrine secretions such as tearing, rhinorrhea, salivation, bronchorrhea, and sweating. A useful mnemonic is SLUDGE and the killer B’s: salvation, lacrimation, urination, defecation, GI, emesis and bradycardia, bronchorrhea, bronchospasm.  Nicotinic symptoms include weakness of the skeletal muscles, fasciculations, and paralysis. Treatment of cholinesterase inhibitors includes atropine, pralidoxime, and benzodiazepines. Atropine works primarily at the muscarinic sites, and should be administered in doses of 2 mg every 5 to 10 minutes, with adjustments in the dose to minimize dyspnea, airway resistance, and respiratory secretions. Pralidoxime reactivates acetylcholinesterase and can be given at doses of 1 g intravenously every 20 to 30 minutes. Benzodiazepines should be administered for seizures from cholinesterase inhibitors, and are the only effective therapy in this instance. In an instance of terrorism attack in which people suddenly collapse, cyanide poisoning should also be suspected. This can be differentiated by the bitter almond smell, lack of sludge symptoms, and absence of fasiculations.
   
In general there are differences between the different types of cholinesterase inhibitors. The organophasphosphorus insecticides are oily and less volatile liquids. They have a slower onset but have longer lasting effects and can require larger doses of atropine. The nerve agents are watery, very volatile, with rapid effects that last for a shorter amount of time. Thus they are better for a weapon but will require less atropine. Another difference between the groups is due to aging. Organophosphates bind irreversibly to acetylcholinesterase. However this reaction that takes time and if pralidoxime is delivered early in the course, this reaction can be reversed. Carbamates bind reversibly so pralidoxime is generally not needed in these poisonings unless they are severe.
   
Respiratory tract irritants are typically hazardous materials released in industrial accidents, or tear gas and choking agents released in warfare, which can result in laryngeal edema and acute lung injury. Usually respiratory tract symptoms predominate as compared to irritation of the eyes or skin. The clinical effects of these substances are determined by the direct tissue reactivity, reflex stimulation, water solubility, and dose. Tear gas or other substances for riot control usually cause a very limited, but intense reaction to exposed body surfaces only. Highly soluble agents such as ammonia, hydrocholoric acid, and sulfuric acid are absorbed in the upper respiratory system where symptoms of early toxicity can develop. Less soluble irritants such as phosgene or nitrogen dioxide (silo-filler’s disease) penetrate more deeply and can cause acute lung injury with only delayed onset of symptoms. Of course if the exposure is intense or prolonged, even highly soluble agents can cause an acute lung injury. Phosgene is the prototypical low-solubility agent. It can have an odor of new-mown hay and people can develop an injury as late as 15 to 48 hours after exposure. Dyspnea or x-rays consistent with pulmonary edema within 4 hours require ICU observation. If patients are not exhibiting any signs of injury and have clear chest x-rays at 8 hours, they are unlikely to develop an acute lung injury.

The treatment of respiratory irritants begins with life support, the administration of high flow oxygen, and decontamination. Patients with impending respiratory failure (hoarseness, stridor, upper-airway burns, wheezing) may require endotracheal intubation. Bronchodilators and corticosteroid may be an additional therapy for severe airway reactivity. Nebulized bicarbonate can be used to neutralize chlorine derivatives but there is no definitive evidence to prove that it helps. In patients whom have sustained acute lung injury, the treatment remains supportive.
   
Vesicants are blistering agents that are extremely irritating to the eye, skin, and airway. The agent, which remains the most important in the class, is mustard, a radiomimetic alkylating agent that affects DNA chains and acts as an inflammatory activator. The ophthalmic effects range from conjunctivitis to corneal damage, with temporary or permanent loss of vision. Dermatologic lesions have a predilection for forming in intertriginous areas and progress from erythema to vesicles and bullae. The most common cause of death results from pulmonary complications. Airway involvement can range from pharyngitis, laryngitis, dyspnea, sputum production, to hemorrhagic edema and mucosal sloughing with possible airway obstruction. Indicators of a fatal exposure include symptoms related to the victim’s airway within 6 hours, burns over 25% of body surface area, and a WBC less than 200 per cubic millimeter. Treatment begins with immediate decontamination and eye irrigation. Ophthalmic treatment consists of topical anticholinergic agents, antibiotics, and petrolatum to prevent eyelid adherence. Dermatologic care involves debridement, application of topical antibiotics, and liberal administration of analgesics. While these patients can have large areas of burns, they do not require the same amount of hydration as in true burn victims. Although no antidote to mustard exists, emerging evidence suggest treatment with nonsteroidal anti-inflammatory drugs may be beneficial. Treatment with thiosulfate has shown to decrease systemic effects and reduce morality in animal studies, though human studies are lacking. Most chemical burns of the skin only require skin washing and are not true vesicants. Hydrofluoric acid is different. Exposure can be incredibly painful and lead to life-threatening hypocalcemia and hypomamagnesemia. Treatment is through the timely administration of calcium preparations.
   
The successful outcome in all cases of serious exposure depends upon the immediate provision of basic life support, decontamination, and excellent supportive care. Community preparedness, a well-organized emergency-medical-response system, and trained clinicians and hospitals, are necessary to care for both accident and deliberate chemical releases.

For the full article please go to http://pmid.us/14973213
 
 

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