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

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.

Do mnemonics help healthcare professionals learn and recall cholinergic toxidromes?

BACKGROUND: The U.S. National Library of Medicine and Department of Homeland Security assembled subject matter experts (SMEs) for the Toxic Chemical Syndrome Definitions and Nomenclature Workshop. The SMEs at this meeting identified a lack of research evaluating the effectiveness of field recognition of toxidromes to guide treatment. They suggested that mnemonics may be helpful for remembering and recognizing toxidromes and further, that rapid toxidrome recognition, through use of a mnemonic or otherwise, leads to rapid action and urgent intervention. OBJECTIVES: (1) Determine if published studies demonstrate HPs can learn and recall hazardous materials (hazmat) toxidromes. (2) Determine if Healthcare Professionals (HPs) can learn mnemonics for muscarinic and nicotinic toxidromes during the Advanced Hazmat Life Support (AHLS) Provider Course (PC) and recall these cholinergic mnemonics when retested years later. Our hypothesis is HPs can learn these mnemonics and recall them up to four years later. METHODS: We analyzed results of HPs who completed AHLS PC pre-tests and post-tests during their initial AHLS PC between March 1, 2007 and March 1, 2010, and then, within four years, took either an online retest or a pre-test for a second AHLS PC. We compared pre- and post-test answers for questions regarding muscarinic and nicotinic mnemonics to assess if HPs can learn these mnemonics during an initial AHLS PC and then recall these mnemonics later, during retesting. We compared the percentage of HPs who correctly identified each cholinergic mnemonic on the pre-test, post-test, and retest using McNemar's test for paired, nominal data. We searched six literature databases to see if there were any previous similar studies. RESULTS: Our literature search found no similar published studies. The mean time to re-testing was 3.6 years (SD 0.8 year). The percentage of respondents correctly answering the question for the muscarinic toxidrome was 53% on the pre-test, 100% on the post-test, and 75% on the retest. The percentage of respondents correctly answering the nicotinic toxidrome question was 52% on the pre-test, 100% on the post-test, and 77% on the retest. CONCLUSION: All studied healthcare professionals learned the cholinergic toxidrome mnemonics during their initial AHLS PC. Mnemonic recall declined somewhat on retesting; however, recall was evident in 75-77% of retest takers compared to their pre-test results up to four years earlier, a statistically significant difference (p < .001) for both mnemonics. This supports our study hypothesis that HPs can learn these mnemonics and recall them up to 4 years later.

Availability and use of medications by prehospital providers trained to manage medical complications of patients in hazardous materials incidents.

INTRODUCTION: Little is known about prehospital availability and use of medications to treat patients from hazardous materials (hazmat) medical emergencies. The aim of this study was to identify the availability and frequency of use of medications for patients in hazmat incidents by paramedics with advanced training to care for these patients. METHODS: A prospectively validated survey was distributed to United States paramedics with advanced training in the medical management of patients from hazmat incidents who successfully completed a 16-hour Advanced Hazmat Life Support (AHLS) Provider Course from 1999 to 2017. The survey questioned hazmat medication availability, storage, and frequency of use. Hazmat medications were considered to have been used if administered anytime within the past 5 years. For analyses, medications were grouped into those with hazmat indications only and those with multiple indications. RESULTS: The survey email was opened by 911 course participants and 784 of these completed the survey (86.1 percent). Of these 784 respondents, 279 (35.6 percent) reported carrying dedicated hazmat medication kits, ie, tox-boxes, and 505 (64.4 percent) did not carry tox-boxes. For those medications specifically for hazmat use, hydroxocobalamin was most commonly available, either within or not within a dedicated tox-box. Of the 784 respondents, 313 (39.9 percent) reported carrying hydroxocobalamin and 69 (8.8 percent) reported administering it within the past 5 years. For medications with multiple indications, availability and use varied: for example, of the 784 respondents, albuterol was available to 699 (89.2 percent) and used by 572 (73.0 percent), while calcium gluconate was available to 247 (31.5 percent) and used by 80 (10.2 percent) within the last 5 years. CONCLUSION: Paramedics with advanced training in the medical management of patients in hazmat incidents reported limited availability and use of medications to treat patients in hazmat incidents.

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

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.

Heavy metal contaminants in yerberia shop products.

Complementary and alternative medications, including the use of herbal medications, have become quite popular in the USA. Yerberias are found throughout the southwest and specialize in selling Hispanic herbal products. The products sold in these stores are not regulated by any governmental agency. Previous reports have found Ayurvedic medications contain high levels of lead, mercury, and arsenic. The primary purpose of this study is to examine the prevalence of heavy metal contaminants sold at Yerberia stores in the southwest. Yerberias in the Phoenix, Arizona area were identified via search of an on-line search engine using the words "Yerberia Phoenix." Every second store was selected, and products were purchased using a standard script. The products were subsequently analyzed for mercury, lead, and arsenic. The main outcome is the prevalence of heavy metal content in over-the-counter "cold" medications purchased at a Yerberia. Twenty-two samples were purchased. One product contained pure camphor (2-camphone) and was subsequently not further analyzed. Of the 21 samples analyzed, lead was found in 4/21 (19.4 %). Arsenic and mercury were in 1/21 (4.8 %) each. Because two samples contained two heavy metals, the total prevalence of heavy metals was 4/21 (19.4). Heavy metal contaminants are commonly encountered in over-the-counter herbal "cold" medications purchased at Yerberias in the southwest.

Gila monster bite.

A 29-year-old man was bitten on the forearm by a wild Gila monster. Radiographs demonstrated subcutaneous air. During a period of observation, erythema and edema progressed from the forearm to the axilla and he developed a significant leukocytosis. No purulence was found upon surgical evaluation. We hypothesize that air was introduced into the wound by the "pulsing," chewing-like action that the Gila monster made while it was attached to the man's forearm.

Toxicology in the ICU: Part 2: specific toxins.

This is the second of a three-part series that reviews the generalized care of poisoned patients in the ICU. This article focuses on specific agents grouped into categories, including analgesics, anticoagulants, cardiovascular drugs, dissociative agents, carbon monoxide, cyanide, methemoglobinemia, cholinergic agents, psychoactive medications, sedative-hypnotics, amphetamine-like drugs, toxic alcohols, and withdrawal states. The first article discussed the general approach to the toxicology patient, including laboratory testing; the third article will cover natural toxins.