Publications by authors named "Frank G Walter"

21 Publications

  • Page 1 of 1

Fatal abrin poisoning by injection.

Clin Toxicol (Phila) 2021 Feb 1;59(2):169-171. Epub 2020 Jun 1.

Arizona Poison and Drug Information Center, University of Arizona Arizona Health Sciences Center, Tucson, AZ, USA.

Abrin is a toxin of public health concern due to its lethality, lack of antidote, and potential for use as a bioterrorism agent. Possible routes of exposure include ingestion, inhalation, and injection. Onset of symptoms is often delayed, even in severe cases. In fatal cases, death occurs from multi-organ failure. We describe the clinical course, laboratory, and pathologic findings in a case of fatal human poisoning associated with abrin injection. The seeds in this case were obtained the internet. The Centers for Disease Control and Prevention's Laboratory Response Network detected abrine in the urine confirming abrin exposure in this fatal poisoning.
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http://dx.doi.org/10.1080/15563650.2020.1771360DOI Listing
February 2021

Differential physiological and behavioral cues observed in individuals smoking botanical marijuana versus synthetic cannabinoid drugs.

Clin Toxicol (Phila) 2016 ;54(1):14-9

a Arizona Poison and Drug Information Center, The University of Arizona College of Pharmacy , Tucson , AZ , USA ;

Context: Synthetic cannabinoid use has increased in many states, and medicinal and/or recreational marijuana use has been legalized in some states. These changes present challenges to law enforcement drug recognition experts (DREs) who determine whether drivers are impaired by synthetic cannabinoids or marijuana, as well as to clinical toxicologists who care for patients with complications from synthetic cannabinoids and marijuana. Our goal was to compare what effects synthetic cannabinoids and marijuana had on performance and behavior, including driving impairment, by reviewing records generated by law enforcement DREs who evaluated motorists arrested for impaired driving.

Methods: Data were from a retrospective, convenience sample of de-identified arrest reports from impaired drivers suspected of using synthetic cannabinoids (n = 100) or marijuana (n = 33). Inclusion criteria were arrested drivers who admitted to using either synthetic cannabinoids or marijuana, or who possessed either synthetic cannabinoids or marijuana; who also had a DRE evaluation at the scene; and whose blood screens were negative for alcohol and other drugs. Exclusion criteria were impaired drivers arrested with other intoxicants found in their drug or alcohol blood screens. Blood samples were analyzed for 20 popular synthetic cannabinoids by using liquid chromatography-tandem mass spectrometry. Delta-9-tetrahydrocannabinol (THC) and THC-COOH were quantified by gas chromatography-mass spectrometry. Statistical significance was determined by using Fisher's exact test or Student's t-test, where appropriate, to compare the frequency of characteristics of those in the synthetic cannabinoid group versus those in the marijuana group.

Results: 16 synthetic cannabinoid and 25 marijuana records met selection criteria; the drivers of these records were arrested for moving violations. Median age for the synthetic cannabinoid group (n = 16, 15 males) was 20 years (IQR 19-23 years). Median age for the marijuana group (n = 25, 21 males) was 20 years (IQR 19-24 years) (p = 0.46). In the synthetic cannabinoid group, 94% (15/16) admitted to using synthetic cannabinoids. In the marijuana group, 96% (24/25) admitted to using marijuana. Blood was available for testing in 96% (24/25) of the marijuana group; 21 of these 24 had quantitative levels of THC (mean + SD = 10.7 + 5 ng/mL) and THC-COOH (mean + SD = 57.8 + 3 ng/mL). Blood was available for testing in 63% (10/16) of the synthetic cannabinoid group, with 80% (8/10) of these positive for synthetic cannabinoids. Those in the synthetic cannabinoid group were more frequently confused (7/16 [44%] vs. 0/25 [0%], p ≤ 0.003) and disoriented (5/16 [31%] vs. 0/25 [0%], p ≤ 0.003), and more frequently had incoherent, slurred speech (10/16 [63%] vs. 3/25 [12%], p = 0.0014) and horizontal gaze nystagmus (8/16 [50%] vs. 3/25 [12%], p = 0.01) than those in the marijuana group.

Conclusion: Drivers under the influence of synthetic cannabinoids were more frequently impaired with confusion, disorientation, and incoherent, slurred speech than drivers under the influence of marijuana in this population evaluated by DREs.
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http://dx.doi.org/10.3109/15563650.2015.1101769DOI Listing
April 2016

Toxic industrial chemicals and chemical weapons: exposure, identification, and management by syndrome.

Emerg Med Clin North Am 2015 Feb 15;33(1):13-36. Epub 2014 Nov 15.

College of Medicine, College of Pharmacy, The University of Arizona, 1501 North Campbell Avenue, Tucson, AZ 85724, USA.

Toxidromes aid emergency care providers in the context of the patient presenting with suspected poisoning, unexplained altered mental status, unknown hazardous materials or chemical weapons exposure, or the unknown overdose. The ability to capture an adequate chemical exposure history and to recognize toxidromes may reduce dependence on laboratory tests, speed time to delivery of specific antidote therapy, and improve selection of supportive care practices tailored to the etiologic agent. This article highlights elements of the exposure history and presents selected toxidromes that may be caused by toxic industrial chemicals and chemical weapons. Specific antidotes for toxidromes and points regarding their use, and special supportive measures, are presented.
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http://dx.doi.org/10.1016/j.emc.2014.09.004DOI Listing
February 2015

Multiple vantage points on the mental health effects of mass shootings.

Curr Psychiatry Rep 2014 Sep;16(9):469

Center for Disaster & Extreme Event Preparedness (DEEP Center), University of Miami Miller School of Medicine, Miami, FL, 33136, USA,

The phenomenon of mass shootings has emerged over the past 50 years. A high proportion of rampage shootings have occurred in the United States, and secondarily, in European nations with otherwise low firearm homicide rates; yet, paradoxically, shooting massacres are not prominent in the Latin American nations with the highest firearm homicide rates in the world. A review of the scientific literature from 2010 to early 2014 reveals that, at the individual level, mental health effects include psychological distress and clinically significant elevations in posttraumatic stress, depression, and anxiety symptoms in relation to the degree of physical exposure and social proximity to the shooting incident. Psychological repercussions extend to the surrounding affected community. In the aftermath of the deadliest mass shooting on record, Norway has been in the vanguard of intervention research focusing on rapid delivery of psychological support and services to survivors of the "Oslo Terror." Grounded on a detailed review of the clinical literature on the mental health effects of mass shootings, this paper also incorporates wide-ranging co-author expertise to delineate: 1) the patterning of mass shootings within the international context of firearm homicides, 2) the effects of shooting rampages on children and adolescents, 3) the psychological effects for wounded victims and the emergency healthcare personnel who care for them, 4) the disaster behavioral health considerations for preparedness and response, and 5) the media "framing" of mass shooting incidents in relation to the portrayal of mental health themes.
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http://dx.doi.org/10.1007/s11920-014-0469-5DOI Listing
September 2014

Epidemiology of the reported severity of cottonmouth (Agkistrodon piscivorus) snakebite.

South Med J 2014 Mar;107(3):150-6

From the Department of Emergency Medicine, Section of Medical Toxicology, College of Medicine, the Arizona Emergency Medicine Research Center, College of Medicine, University of Arizona, and Rare Disease Therapeutics, Tucson.

Objective: The goal of this study was to analyze trends in the annual rates of reported medical outcomes of cottonmouth (Agkistrodon piscivorus) snakebites in the United States, published in the annual reports of the American Association of Poison Control Centers in the course of 29 years.

Methods: This was a retrospective analysis of medical outcomes for cottonmouth snakebite victims who developed fatal, major, moderate, minor, or no effects. The annual rates for these medical outcomes were calculated by dividing the annual number of patients in each outcome category by the total annual number of people reported as being bitten by cottonmouths. Negative binomial regression was used to examine trends in annual rates.

Results: From 1985 through 2011, after controlling for the availability of CroFab, the annual incidence rate of cottonmouth snakebites causing no effect decreased significantly by 7.3%/year (incidence rate ratio [IRR] 0.927, 95% confidence interval [CI] 0.885-0.970), the incidence rate of minor outcomes did not change significantly (IRR 0.989, CI 0.974-1.006), the incidence rate of moderate outcomes increased significantly by 2.3%/year (IRR 1.023, CI 1.004-1.042), and the incidence rate of major outcomes did not change significantly (IRR 0.987, CI 0.935-1.041). One fatality was reported in 2011.

Conclusions: Annual rates of cottonmouth snakebites producing no effects decreased significantly, those producing minor outcomes did not change significantly, those producing moderate outcomes increased significantly, and those producing major outcomes did not change significantly, from 1985 through 2011.
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http://dx.doi.org/10.1097/SMJ.0000000000000067DOI Listing
March 2014

Epidemiology of the reported severity of copperhead (Agkistrodon contortrix) snakebite.

South Med J 2012 Jun;105(6):313-20

Section of Medical Toxicology, Department of Emergency Medicine,College of Medicine, University of Arizona, Tucson, AZ 85724-5057, USA.

Objective: The goal of this study was to analyze trends in the annual rates of reported medical outcomes of US copperhead (Agkistrodon contortrix) snakebites published in the annual reports of the American Association of Poison Control Centers in the course of 26 years.

Methods: This was a retrospective analysis of medical outcomes for copperhead snakebite victims who developed fatal, major, moderate, minor, or no effects. The annual rates for these medical outcomes were calculated by dividing the annual number of patients in each outcome category by the total annual number of people reported as being bitten by copperheads. Poisson and negative binomial regression were used to examine trends in annual rates.

Results: From 1983 through 2008, the incidence rate of copperhead snakebites causing no effect significantly decreased by 12.1%/year (incidence rate ratio [IRR] 0.879; 95% confidence interval [CI] 0.848-0.911]. From 1985 through 2008, the incidence rate of minor outcomes significantly decreased by 2.3%/year (IRR 0.977; 95% CI 0.972-0.981), whereas the rate of moderate outcomes significantly increased by 2.8%/year (IRR 1.028; 95% CI 1.024-1.033). The rate of major outcomes did not significantly change. One fatality was reported in 2001.

Conclusions: Annual rates of copperhead snakebites producing no effects and minor outcomes significantly decreased, those producing moderate outcomes significantly increased, and those producing major outcomes did not significantly change in a 26-year period.
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http://dx.doi.org/10.1097/SMJ.0b013e318257c2d5DOI Listing
June 2012

Radiological preparedness-awareness and attitudes: a cross-sectional survey of emergency medicine residents and physicians at three academic institutions in the United States.

Clin Toxicol (Phila) 2012 Jan 19;50(1):34-8. Epub 2011 Dec 19.

Emory University, Atlanta, USA.

Context: Emergency preparedness has been increasingly recognized as important. Research shows many medical personnel feel unprepared to respond to radiation incidents. Knowledge and attitudes of emergency medicine residents and faculty are largely unstudied, regarding their abilities to provide care for radiation disaster victims. It is unknown whether receiving training in radiological emergency preparedness improves knowledge and attitudes.

Objectives: (1) Assess the attitudes of emergency medicine residents and faculty toward a radiological disaster; (2) Assess knowledge gaps of emergency medicine residents and faculty regarding radiological emergency preparedness; (3) Assess the attitudes of emergency medicine residents and faculty toward different educational strategies.

Methods: An electronic survey was sent to 309 emergency medicine residents and faculty at three U.S. academic institutions. Analyses were performed using SAS 9.0 software.

Results: The survey response rate was 36.6%. Only 37% and 28% of respondents had attended radiological preparedness training in the preceding 5 years or any training in radiation detection, respectively. Higher proportions of trained physicians were: (1) more familiar with DTPA and Prussian blue; (2) more comfortable assessing, decontaminating, and managing victims of radiation incidents; and (3) more comfortable using radiation detectors than their untrained counterparts. Many respondents were unable to differentiate between contamination with and exposure to radiological material. Classroom teaching at the workplace and prepackaged educational materials were most frequently rated as the preferred educational method for radiation preparedness training.

Discussion And Conclusion: Our results suggest a need for additional radiological-nuclear preparedness training for emergency medicine residents and faculty. Training should include radiation detection, decontamination, explaining differences between radiation exposure and contamination, and teaching patient management, including DTPA and Prussian blue.
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http://dx.doi.org/10.3109/15563650.2011.637047DOI Listing
January 2012

Disaster preparedness education and a Midwest Regional Poison Center.

Am J Disaster Med 2010 Jul-Aug;5(4):229-36

Pediatric Emergency Medicine, Saint Louis University, Missouri, USA.

Objective: To assess knowledge and comfort related to disaster preparedness and response gained and retained from a disaster medicine workshop given to Certified Specialists in Poison Information (CSPI).

Design: A pilot study with a pre-post intervention design.

Setting: A Midwest Regional Poison Center.

Participants: All CSPIs employed at the participating Poison Center (N = 27) were recruited. Participation ranged from 44 percent (n = 12) for the 4-month postworkshop knowledge quiz to 78 percent (n = 21) for the preworkshop survey.

Intervention: A disaster medicine workshop was given to the CSPIs. Quizzes and surveys were done preworkshop and then repeated at 1 week, 4 months, and 14 months postworkshop.

Main Outcome Measures: CSPI knowledge and comfort pertaining to disaster-related calls.

Results: CSPIs' comfort levels with calls regarding major chemical or nuclear/radiation disasters significantly increased and stayed elevated during all follow-up periods [Kruskal-Wallis chi2 (3) = 13.1, p = 0.01]. The average preworkshop quiz score was 58.2 percent. A statistically significant increase in mean quiz score was demonstrated amongst preworkshop and postworkshop scores at all tested time intervals (F = 18.8, p < 0.001).

Conclusions: CSPIs' knowledge regarding disaster management significantly increased after a disaster medicine workshop, and this knowledge was significantly retained for the 14-month duration of this study. Currently, there are no uniform guidelines for Poison Centers regarding disaster response training. Studies targeted at the development of educational competencies for CSPIs and disaster response would help to standardize this much needed education.
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October 2010

Temporal analyses of coral snakebite severity published in the American Association of Poison Control Centers' Annual Reports from 1983 through 2007.

Clin Toxicol (Phila) 2010 Jan;48(1):72-8

Department of Emergency Medicine, College of Medicine, University of Arizona, Tucson, AZ, USA.

Introduction: The only U.S. Food and Drug Administration-approved coral snake antivenom was officially discontinued in 2007, causing ever-diminishing supplies. This study describes the severity of U.S. coral snakebites during the last 25 years to determine trends in annual rates of these bites' medical outcomes.

Methods: This study retrospectively analyzed all human coral snakebites voluntarily reported by the public and/or health care professionals to poison centers that were subsequently published in the Annual Reports of the American Association of Poison Control Centers (AAPCC) from 1983 through 2007. Annual rates of medical outcomes from coral snakebites were calculated by dividing the annual number of people bitten by coral snakes who developed fatal, major, moderate, minor, or no effect outcomes by the total annual number of people bitten by coral snakes. Negative binomial regression was used to examine trends in annual rates.

Results: From 1983 through 2007, the incidence rate of coral snakebites producing no effects significantly decreased by 4.7% per year [incidence rate ratio (IRR) = 0.953; 95% confidence interval (CI) = 0.920-0.987]. From 1985 through 2007, the incidence rates of minor and major outcomes did not significantly change; however, moderate outcomes significantly increased by 3.4% per year (IRR = 1.034; 95% CI = 1.004-1.064). No fatalities were reported from 1983 through 2007.

Conclusion: Annual rates of coral snakebites producing no effects significantly decreased and those producing moderate outcomes significantly increased in our analyses of data from the last 25 years of published AAPCC Annual Reports. This study has important limitations that must be considered when interpreting these conclusions.
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http://dx.doi.org/10.3109/15563650903430944DOI Listing
January 2010

Epidemiology of severe and fatal rattlesnake bites published in the American Association of Poison Control Centers' Annual Reports.

Clin Toxicol (Phila) 2009 Aug;47(7):663-9

Section of Medical Toxicology, Department of Emergency Medicine, College of Medicine, University of Arizona, Tucson, AZ 85724-5057, USA.

Introduction: No study has focused on the nationwide epidemiology of severe and fatal rattlesnake bites during the last 25 years. We examined rates and temporal trends of severe and fatal rattlesnake bites across the United States. Our hypothesis was that nationwide annual rates of both severe and fatal outcomes from rattlesnake bites have remained unchanged over time.

Methods: This study retrospectively analyzed all human rattlesnake bites published in the Annual Reports of the American Association of Poison Control Centers from 1983 through 2007. Annual rates of severe (major) and fatal rattlesnake bites were calculated using the annual number of major outcomes and fatalities as respective numerators and the total annual number of single rattlesnake bites (exposures) as denominators. Negative binomial and Poisson regressions were used to examine trends of severe and fatal rattlesnake bites over time.

Results: Annually, from 1985 to 2007, the incidence rate of major outcomes decreased by 2% per year (incidence rate ratio = 0.980; CI = 0.967-0.993), corresponding to an absolute annual rate decrease of two major outcomes per 1,000 bites per year. Annual rates of fatalities showed no statistically significant change from 1983 through 2007.

Conclusion: This is the first study to examine rates and trends of published severe and fatal rattlesnake bites across the United States over the past 25 years. Annual rates of severe rattlesnake bites, derived from the published Annual Reports of the American Association of Poison Control Centers, have significantly decreased over time, whereas rates of fatal rattlesnake bites have remained unchanged.
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http://dx.doi.org/10.1080/15563650903113701DOI Listing
August 2009

Establishing causality of CNS depression in breastfed infants following maternal codeine use.

Paediatr Drugs 2008 ;10(6):399-404

Department of Physiology and Pharmacology, The University of Western Ontario, London, Ontario, Canada.

Background: We recently reported on a breastfed infant who succumbed to opioid toxicity following exposure to morphine, the active metabolite of codeine, which was prescribed to his mother who was a cytochrome P450 2D6 (CYP2D6) ultrarapid metabolizer. This report is believed to be the first case of neonatal fatality as a direct result of maternal drug excretion into breast milk and, therefore, it is critical to corroborate the causative relationship between maternal codeine use during breastfeeding and neonatal opioid toxicity with other existing evidence.

Objective: To establish whether maternal use of codeine can be a cause of CNS depression in breastfed infants.

Study Design: A systematic review of the medical literature using several databases was conducted. The Naranjo Adverse Drug Reaction Probability Scale (NADRPS) was used to examine causality.

Results: In addition to our case report, three abstracts and two full-length studies reported adverse drug reactions (ADRs) in infants exposed to codeine in breast milk. In total, 35 infants were identified. Specifically, ADRs were described as unexplained episodes of drowsiness, apnea, bradycardia, and cyanosis in suckling infants. Using the NADRPS, codeine was found to be a definite cause of CNS depression in breastfed infants.

Conclusion: The use of codeine by breastfeeding mothers can cause adverse CNS events in breastfed infants. Physicians should recognize codeine use during breastfeeding as a cause of CNS depression in infants, and breastfeeding mothers should be educated on these adverse events before receiving codeine.
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http://dx.doi.org/10.2165/0148581-200810060-00007DOI Listing
February 2009

Hazmat disaster preparedness in Hong Kong: what are the hazardous materials on Lantau, Lamma, and Hong Kong Islands?

Am J Disaster Med 2008 Jul-Aug;3(4):213-33

Bureau of Emergency Preparedness and Response, Arizona Department of Health Services, Tucson, USA.

Objective: Hazmat disaster preparedness is critical, especially as Hong Kong prepares for major international events, such as the 2008 Olympic Equestrian Games. No published medical study describes the identities and quantities of hazardous materials (HMs) in Hong Kong and lists what antidotes are needed for these dangerous goods (DGs). This study describes what HMs are most common in Hong Kong to prioritize disaster preparedness and training.

Design: A descriptive, cross-sectional study.

Setting: The Hong Kong Special Administrative Region, specifically Lantau, Lamma, and Hong Kong Islands.

Sample: The Hong Kong Fire Services Department (HKFSD) Dangerous Goods Database (DGD).

Interventions: Descriptive statistical analyses with Stata 9.2.

Main Outcome Measures: Identifying and quantifying HMs in the HKFSD DGD.

Results: Most HMs do not have antidotes. The most common HMs with recognized antidotes are carbon monoxide, methylene chloride, fluorides, cyanides, nitriles, hydrazine, methanol, and nitrates. The most common categories of DGs are substances giving off inflammable vapors, compressed gases, and corrosive and poisonous substances.

Conclusions: Hazmat disaster preparedness and training should emphasize these most common categories of DGs. Disaster planning should ensure adequate antidotes for HMs with recognized antidotes, ie, oxygen for carbon monoxide and methylene chloride; calcium gluconate and calcium chloride for fluorides; hydroxocobalamin or amyl nitrite, sodium nitrite, and sodium thiosulfate for cyanides and nitriles; pyridoxine for hydrazine; fomepizole or ethanol for methanol; and methylene blue for methemoglobinemia produced by nitrates. Supportive care is essential for patients exposed to HMs because most DGs do not have antidotes.
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October 2008

Radiation emergencies: a primer to nuclear incidents.

JEMS 2007 Mar;32(3):122-4, 126, 128-32, passim; quiz 138

Medical Toxicology, Evanston Northwestern Healthcare-OMEGA, Glenbrook Hospital, Glenview, IL, USA.

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http://dx.doi.org/10.1016/S0197-2510(07)70092-XDOI Listing
March 2007

Pyridoxine does not prevent hyperbaric oxygen-induced seizures in rats.

J Emerg Med 2006 Aug;31(2):135-8

Division of Medical Toxicology, Department of Emergency Medicine, University of Arizona, College of Medicine, Tucson, Arizona, 85724-5057, USA.

Normobaric supplemental oxygen can prolong seizures not caused by hyperbaric oxygen therapy. In addition, hyperbaric oxygen therapy can cause seizures. The mechanism of hyperbaric oxygen-induced seizures is unknown. We hypothesized that pretreatment with pyridoxine may delay the onset of hyperbaric oxygen-induced seizures, recognizing that pyridoxine is already an antidote for some epileptogenic poisons such as isoniazid and monomethylhydrazine. Therefore, rats were pretreated with intraperitoneal injections of pyridoxine at 48, 24, and 2 h before undergoing hyperbaric oxygen (HBO) treatment at 3 atmospheres absolute with 100% oxygen and were compared to a control group of HBO-treated rats for time to onset of seizures. There was no difference in onset of seizure time between the pyridoxine-treated group of rats and the control rats. Supplemental pyridoxine pretreatment did not alter the time to onset of seizures during HBO treatment in this study.
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http://dx.doi.org/10.1016/j.jemermed.2005.09.011DOI Listing
August 2006

Reimbursement profile of a private toxicology practice.

Clin Toxicol (Phila) 2006 ;44(3):261-5

Evanston Northwestern Health Care, OMEGA, Glenbrook Hospital, Glenview, IL 60026, USA.

This article presents two years of billing and collection data for a bedside toxicology consultation service. The collections rate was 34% or dollars 26.19 per hour of consultative time. There was an inverse correlation between collection rates and patient acuity.
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http://dx.doi.org/10.1080/15563650600584402DOI Listing
June 2006

International report: current state and development of health insurance and emergency medicine in Germany. The influence of health insurance laws on the practice of emergency medicine in a European country.

J Emerg Med 2003 Aug;25(2):203-10

Department of Internal Medicine, Kantonsspital Luzern, Luzern, Switzerland.

Germany has a comprehensive health insurance system, with only 0.183% of the population being uninsured. Access to office-based medicine and to hospitals is easy and convenient. Due to enormous financial pressures, Germany is currently decreasing the number of beds in hospitals, introducing the Diagnosis Related Groups (DRG), and restricting accessibility to specialists. In contrast to Anglo-American countries, Germany follows the concept of bringing the physician to the patient in the prehospital setting, with Emergency Medical Services (EMS) physicians responding to all Advanced Life Support (ALS) calls. Despite a mature EMS system with sophisticated medical equipment and technology, both in the prehospital and hospital setting, logistical issues such as a single emergency telephone number or multidisciplinary Emergency Departments have yet to be established. Within the hospital, this "Franco-German model" considers Emergency Medicine a practice model that does not merit specialty status. Spending restrictions in the health care system, with less access to hospital beds and office-based physicians, will increase the demand for hospital-based emergency care when patients experience problems accessing the medical system. Currently, the German hospital system is unprepared to care for greater numbers of emergency patients. This may call for changes in the German health care system as well as the medical education system, with the introduction of hospital-based Emergency Medicine as its own specialty, similar to Anglo-American countries.
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http://dx.doi.org/10.1016/s0736-4679(03)00173-2DOI Listing
August 2003

A primer for nuclear terrorism.

Dis Mon 2003 Aug;49(8):485-516

Department of Medical Toxicology, Evanston Northwestern Healthcare--OMEGA, Glenbrook Hospital, Glenview, Illinois, USA.

Mass exposure to radiologic substances presents a unique challenge to the entire response effort, which includes health care professionals, law enforcement personnel, and other first responders. Recognition of signs and symptoms of exposure, and focus on removal and decontamination are priorities of management. Radiation injuries require specialized equipment and access to experts. Patients can have complex patterns of injury, ranging from trauma and the immediate results of an explosion or exposure, to progressive damage associated with radiation sickness. Both conventional injury and radiation illness may require critical care management. Remembering the essentials of first response, that is, treat the patient, not the poison, by addressing the ABCs of airway, breathing, and circulation, is critical to appropriate treatment of radiation exposure. Understanding the basic science of radiologic agents will aid the provider in managing affected patients and preventing further casualties.
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http://dx.doi.org/10.1016/s0011-5029(03)00100-7DOI Listing
August 2003

Hazardous materials responses in a mid-sized metropolitan area.

Prehosp Emerg Care 2003 Apr-Jun;7(2):214-8

Arizona Emergency Medicine Research Center, Division of Medical Toxicology, Medical Toxicology Fellowship, Department of Emergency Medicine, College of Medicine, University of Arizona, Tucson, Arizona 85724-5057, USA.

Objective: To determine the chemicals involved in fire department hazardous materials (hazmat) responses and analyze the concomitant emergency medical services' patient care needs.

Methods: The setting was a mid-sized metropolitan area in the southwestern United States with a population base of 400,000 and an incorporated area of 165 square miles. The authors conducted a retrospective evaluation of all fire department hazmat reports, with associated emergency medical services patient encounter forms, and in-patient hospital records from January 1, 1992, through December 31, 1994.

Results: The fire department hazardous materials control team responded to 468 hazmat incidents, involving 62 chemicals. The majority of incidents occurred on city streets, with a mean incident duration of 46 minutes. More than 70% of the responses involved flammable gases or liquids. A total of 32 incidents generated 85 patients, 53% of whom required transport for further evaluation and care. Most patients were exposed to airborne toxicants. Only two patients required hospital admission for carbon monoxide poisoning.

Conclusion: Most hazmat incidents result in few exposed patients who require emergency medical services care. Most patients were exposed to airborne toxicants and very few required hospitalization. Routine data analysis such as this provides emergency response personnel with the opportunity to evaluate current emergency plans and identify areas where additional training may be necessary.
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http://dx.doi.org/10.1080/10903120390936806DOI Listing
June 2003

A review of nerve agent exposure for the critical care physician.

Crit Care Med 2002 Oct;30(10):2346-54

Evanston Northwestern Healthare OMEGA, Glenbrook Hospital, Glenview, IL, USA.

Nerve agents are discussed. The article discusses their properties, routes of exposure, toxicodynamics, targets of toxicity, and treatment. It is concluded that a focused organized approach to the treatment of nerve agents is key to its successful management.
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http://dx.doi.org/10.1097/00003246-200210000-00026DOI Listing
October 2002

Survival after ethylene glycol poisoning in a patient with an arterial pH of 6.58.

Vet Hum Toxicol 2002 Jun;44(3):167-8

Department of Emergency Medicine, University of California, UCI Medical Center, Orange 92868, USA.

This ethylene glycol poisoning case had a blood pH of 6.58 and severe hypothermia (30.9 C). The patient received supportive care with dialysis and ethanol therapy. He survived in his premorbid state after 23 days in the hospital. A similar case survived ethylene glycol poisoning neurologicaly intact with an initial pH of 6.46. Although severe acidosis in the presence of serious illness is usually associated with a poor prognosis, our case emphasized the importance of aggressive supportive care and antidotal therapy for ethylene glycol poisoning even when there is a low pH.
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June 2002

Immediate and delayed allergic reactions to Crotalidae polyvalent immune Fab (ovine) antivenom.

Ann Emerg Med 2002 Jun;39(6):671-6

Division of Medical Toxicology, Department of Emergency Medicine, University of California San Diego Medical Center, and the California Poison Control System, San Diego Division, San Diego, CA, USA.

Allergic reactions are the most commonly reported adverse events after administration of antivenoms. Conventional horse serum-based crotalid antivenom used in the United States (Antivenin [Crotalidae] polyvalent) can lead to both immediate and delayed hypersensitivity reactions. Crotalidae polyvalent immune Fab (ovine) (CroFab; FabAV) has recently been approved for use in the United States. Experience from premarketing trials of this product and in the administration of other types of Fab, such as in digoxin poisoning, has demonstrated these fragments to be safe and effective, with a low incidence of sequella; however, allergic reactions can occur when any animal-protein derivatives are administered to human subjects. We report in detail the nature and course of allergic reactions that occurred in 4 patients treated with FabAV. Cases of anaphylaxis, acute urticaria, angioedema, and delayed serum sickness are described. All reactions were easily treated with some combination of antihistamines, epinephrine, and steroids, with prompt resolution of signs and symptoms enabling further dosing of antivenom as required. Several of these cases may have resulted from batches of antivenom contaminated with Fc fragments. The overall incidence of immediate and delayed allergic reactions to this product appears so far to be lower than that reported with conventional whole-immunoglobulin G (IgG) antivenom, but postmarketing surveillance is warranted.
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http://dx.doi.org/10.1067/mem.2002.123134DOI Listing
June 2002
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