Delayed life-threatening reaction to anthrax vaccine.

BACKGROUND: Anthrax is an acute infectious disease caused by the spore-forming bacterium Bacillus anthracis. Due to the current world threat of unpredictable biological terrorism, the Department of Defense has mandated the systematic vaccination of all US military personnel against this warfare agent. Many may experience al mild flu-like illness and soreness at the injection site, but systemic reactions are rare. CASE REPORT: We report a delayed and potentially serious life-threatening adverse reaction to anthrax vaccine. A previously healthy 34-year-old male was transported to the emergency department with dyspnea, diaphoresis, pallor, and urticarial wheals on his face, arms, and torso after the administration of the third dose of anthrax vaccine. All symptoms resolved after pharmacological intervention and the patient was discharged. Pharmaco-epidemiological data indicate that 30% of anthrax vaccine recipients experience mild local reactions. With large numbers of military personnel being vaccinated, emergency physicians may encounter more vaccine-related adverse reactions.

Nystagmus secondary to fomepizole administration in a pediatric patient.

BACKGROUND: Fomepizole is an alcohol dehydrogenase inhibitor used to treat ethylene glycol poisoning in adults, with only one report describing the use of fomepizole in the pediatric population. We report a case of nystagmus associated with fomepizole treatment of a 6-year-old female who ingested ethylene glycol 15 hours prior to admission. CASE REPORT: A previously healthy 6-year-old presented to the emergency department mottled, comatose, and with Kussmaul respirations. Initial arterial blood gases: pH 7.11, PO2 200, HCO3 2, base excess -29, and within 20 minutes her pH dropped to 7.03. The patient was responsive to pain only. Initially, crystalluria without fluorescence was observed in the emergency department; 2 hours after admission, the urine fluoresced under Wood's light. Laboratory data were significant for increased anion and osmolar gaps. She was fluid-resuscitated, NaHCO3, thiamine, and pyridoxine were administered, and she was admitted to the pediatric intensive care unit. Within 4 hours of admission, a loading dose of fomepizole (15 mg/kg) was infused due to the severity of the patient's clinical status. Hemodialysis was initiated but discontinued temporarily due to catheter thrombus formation. The initial (3-hour postadmission) ethylene glycol concentration was 13 mg/dL. She developed coarse vertical nystagmus within 2 hours of fomepizole infusion. The ethylene glycol concentration was 5 mg/dL 3 hours after hemodialysis which then was discontinued. No further fomepizole was administered and the child recovered uneventfully. CONCLUSION: There was no evidence of the more frequently cited adverse events, such as headache, nausea, and dizziness. Fomepizole has been incompletely evaluated in the pediatric population, and the nature and occurrence of adverse events have not been described adequately. The use of fomepizole appeared safe in this patient although she developed transient nystagmus.

Air bags: lifesaving with toxic potential?

Federal Motor Vehicle Safety Standard No. 208, "Occupant Crash Protection", requires that all passenger cars manufactured after September 1, 1989 be equipped with automatic crash protection. Car manufacturers met this requirement by installing automatic safety belts or air bags. No chemical injuries have been reported as a result of air bag deployment in motor vehicle accidents (MVA). A 6-month retrospective study was conducted to evaluate the toxic effects of the white powdery residue from air bags, a combination of talc and sodium hydroxide, found in the driver compartment after an MVA. The study reviewed time to onset of symptoms, symptomatology, and treatment. The study included seven patients exposed to deployed air bags after an MVA. Four cases resulted in dermal burns and three patients were diagnosed with unrelated injuries. Three patients presented to an emergency department within 48 hours of the exposure complaining of burns to the skin. Two patients attempted home therapy but became concerned when the symptoms did not subside. One patient was discharged with the diagnosis of first degree burns of the chin and left hand. Another patient experienced bilateral hand erythema and blisters. Standard burn therapy was instituted in both instances. A third patient arrived 1 hour post-exposure to the emergency department complaining of a burning sensation to the hands, but the skin appeared normal. Thorough irrigation was initiated and Silvadene (Marion, Kansas City, MO) applied. One patient notified the poison center 1 hour post-exposure complaining of erythema and burning to his hands after an MVA.(ABSTRACT TRUNCATED AT 250 WORDS)

Successful donation and transplantation of multiple organs from a victim of cyanide poisoning.

Demand for viable human organs for transplantation continues to exceed the supply. To expand supply, the criteria for identification and management of suitable donors must continue to evolve. Poisoned patients are often excluded as potential organ donors due to perceived risks of transmittable agents and/or physiologically compromised organs. In this report, a patient succumbed after an intentional ingestion of cyanide and multiple pharmaceuticals. Donor organ viability was determined by lack of significant injury beyond the central nervous system. Following standard procurement procedures, the heart, liver, corneas, 16 skin grafts and 16 bone grafts were deemed suitable and successfully transplanted. All organ recipients were doing well eight months post transplantation. The focus of procurement personnel should be on tissue injury and not on the mere presence of clinical effect of a toxic agent. With the paucity of organs available, poison centers need to be cognizant of this dilemma when faced with a toxicologically compromised potential organ donor.

Contaminant identification: the importance of thorough interviewing techniques.

The exact name of a contaminant is of extreme importance to the poison information specialist (SPI) in order to make a correct assessment of the poisoning exposure and to recommend proper treatment modalities. Incorrect contaminant information could lead to a serious and possibly fatal mistake on the part of the SPI. Thorough and effective interviewing techniques must be employed to avoid errors. We conducted a prospective study to determine how often misinformation is provided to the SPI at the time of the initial contact with the poison center. Over a 6-mo period 159 calls were identified in which the original caller mistakenly identified the contaminant. Fifty-two (33%) of these calls were received from health care professionals and 107 (67%) were from the lay public. Drug names were improperly reported in 80 cases, cleaning products in 26, cosmetics 14 times, general products 19, chemicals 7, rodenticides 8, and plants were incorrectly identified in 5 cases. In 110 of these cases, proper identification of the contaminant changed the assessment and also the treatment recommendations made by the SPI. Errors in contaminant identification occurs more frequently than is realized by poison center professionals. It is imperative to have the caller clarify the contaminant name by checking the container, when available, and supplying the SPI with as much information as possible. It is equally important that the SPI employ precise interviewing techniques to obtain information to avoid a serious error in assessment and treatment of the poisoned victim.

Acute phenolphthalein ingestion in children. A retrospective review.

The Patient Management Exchange for this edition of the Journal features a research study on phenolphthalein ingestion done at the Pittsburgh Poison Center. The purpose of selecting this article was twofold. First, the material presented about the management of phenolphthalein ingestion in children is valuable information for health care practitioners working in ambulatory settings. Second, this work is an excellent illustration of how research can be incorporated into one's clinical practice. This study also demonstrates that research does not always involve a long and cumbersome process. Instead, research can evolve from the need of health care professionals to answer a simple question that is raised about a particular aspect of their patient practice.

The effects of penicillin and cephalosporin ingestions in children less than six years of age.

Oral antibiotic ingestions account for 1-2% of all pediatric exposures reported to regional poison information centers. The majority of these pediatric exposures involve the ingestion of penicillin or cephalosporin derivatives. How much can be ingested before gastric emptying is necessary is a controversial issue in the management of these cases. A study was designed to determine if children less than 6 years of age could safely ingest a maximum of 250 mg/kg of a penicillin or cephalosporin derivative without significant adverse effects. Sixty-one cases were prospectively collected. The average antibiotic amount ingested was 113.3 mg/kg (17.8-250.0 mg/kg). Each patient was evaluated for symptoms at the time of the initial call and at 6-12 degrees, 24 degrees, 48 degrees, and 72 degrees. Eighty-four percent of the children remained asymptomatic during the evaluation period. Eight of 13 symptomatic patients developed 1 or 2 episodes of diarrhea; 2 developed a rash. Amoxicillin suspension was involved in 70% of the cases, followed by cefachlor suspension 11%, and amoxicillin tablets 5%. Liquid preparations accounted for 90% of the cases and solid dosage forms, the remainder. The data strongly suggests that ingestions of less than 250 mg/kg of these products are not associated with significant outcomes and do not require gastric emptying.