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Warren JD, Hughes KM. Pharmacologic Management of Pediatric Burns. J Burn Care Res 2024; 45:277-291. [PMID: 37948608 DOI: 10.1093/jbcr/irad177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Indexed: 11/12/2023]
Abstract
Many pediatric patients with burn injuries may be initially treated in a hospital where pediatric specialized care, including resources and trained personnel may be limited. This includes resuscitation in adult emergency departments and inpatient care in mixed adult-pediatric burn units. The intent of this review is to provide a compilation of topics for the adult trained pharmacist or another healthcare practitioner on the management of pediatric patients with burn injuries. This article focuses on several key areas of pharmacologic burn management in the pediatric patient that may differ from the adult patient, including pain and sedation, fluid resuscitation, nutrition support, antimicrobial selection, anticoagulation, and inhalation injury. It is important that all clinicians have resources to help optimize the management of burn injuries in the pediatric population as, in addition to burn injury itself, pediatric patients have different pharmacokinetics and pharmacodynamics affecting which medications are used and how they are dosed. This article highlights several key differences between pediatric and adult patients, providing an additional resource to assist adult-trained pharmacists or other healthcare practitioners with making clinical decisions in the pediatric burn population.
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Affiliation(s)
- Jontae D Warren
- Ochsner Baptist-A Campus of Ochsner Medical Center, Pharmacy Department, New Orleans, LA, 70115, USA
| | - Kaitlin M Hughes
- Riley Hospital for Children, Pharmacy Department, Indianapolis, IN, 46202, USA
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2
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Freytag DL, Schiefer JL, Beier JP, Grieb G. Hyperbaric oxygen treatment in carbon monoxide poisoning - Does it really matter? Burns 2023; 49:1783-1787. [PMID: 37821285 DOI: 10.1016/j.burns.2023.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 03/10/2023] [Accepted: 06/12/2023] [Indexed: 10/13/2023]
Abstract
Carbon monoxide (CO) is an odorless and colorless gas that can lead to fulminant and life-threatening intoxications. Besides an early diagnosis, an appropriate treatment of the intoxication is important. In this context the reduction of CO concentration in blood and tissues is crucial revealing hyperbaric oxygen treatment (HBO) as a highly promising tool. However, the benefit of HBO in CO intoxications is still considered controversial. In this review, we discuss the evidence of the role of HBO treatment in isolated CO intoxication.
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Affiliation(s)
- David Lysander Freytag
- Department of Plastic Surgery and Hand Surgery, Gemeinschaftskrankenhaus Havelhoehe, Kladower Damm 221, 14089 Berlin, Germany
| | - Jennifer Lynn Schiefer
- Department of Plastic, Reconstructive, Hand and Burn Surgery, Hospital Cologne Mehrheim, University of Witten, Herdecke, Germany
| | - Justus P Beier
- Department of Plastic Surgery and Hand Surgery - Burn Center, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074 Aachen, Germany
| | - Gerrit Grieb
- Department of Plastic Surgery and Hand Surgery, Gemeinschaftskrankenhaus Havelhoehe, Kladower Damm 221, 14089 Berlin, Germany; Department of Plastic Surgery and Hand Surgery - Burn Center, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074 Aachen, Germany.
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Barrios EL, Polcz VE, Moldawer LL, Rincon JC, Efron PA, Larson SD. VARIABLES INFLUENCING THE DIFFERENTIAL HOST RESPONSE TO BURNS IN PEDIATRIC AND ADULT PATIENTS. Shock 2023; 59:145-154. [PMID: 36730790 PMCID: PMC9957807 DOI: 10.1097/shk.0000000000002042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
ABSTRACT Burn injury is a significant source of morbidity and mortality in the pediatric population. Although 40,000 pediatric patients in the United States are admitted to the hospital with burn wounds annually, significant differences exist in the management and treatment of these patients, even among highly specialized burn centers. Some aspects of pediatric burn research, such as metabolic changes and nutritional support after burn injury, have been studied extensively; however, in many aspects of burn care, pediatric research lags behind the study of adult populations. This review compares and contrasts a wide array of physiologic and immune responses between children and adults after burn injury. Such a review elucidates where robust research has been conducted, where adult research is applicable to pediatric patients, and where additional pediatric burn research needs to be conducted.
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Affiliation(s)
- Evan L Barrios
- Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
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Muacevic A, Adler JR, Singh Y, Thakur D, Koushal V, Kumar A. A Fire Incident Case at a Radiodiagnostic Center of a Tertiary Care Hospital: Methods for Reduction in Fatality by Smoke Evacuation. Cureus 2022; 14:e31873. [PMID: 36579269 PMCID: PMC9790076 DOI: 10.7759/cureus.31873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/24/2022] [Indexed: 11/26/2022] Open
Abstract
For the general public, healthcare facilities are always a safe and secure place for treatment. Generally, healthcare institutions are equipped to deal with exterior interruptions, but circumstances brought on by internal risks are more serious and frequently require an emergency evacuation of the facility. An incident happened at the radiodiagnostic setup of a tertiary care institute in North India. This fire incident created panic among staff and patients. At the place of casualty, there were around 150 persons, including staff, patients, and their attendants. Immediately after the confirmation of the fire incident, the fire department and security department took action in the form of fire control and smoke evacuation. Though six fire handling staff required minor emergency services for asphyxia due to smoke inhalation and were cured by oxygen support only, none of the patients was affected due to timely smoke evacuation. Most often, smoke management techniques implemented are compartmentation, pressurization, dilution, ventilation, buoyancy, and airflow. So, we concluded that the step of timely smoke evacuation and preventing the spread of smoke by various methods help to reduce fatality due to smoke. The training programs and mock drills give stakeholders the needed knowledge, skills, and practice they need to safeguard patients and employees.
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Ferrés-Padró V, Solà-Muñoz S, Jimenez-Fàbrega FX. Evaluation of prehospital hydroxocobalamin use in the setting of smoke inhalation. Am J Emerg Med 2022; 54:297-298. [DOI: 10.1016/j.ajem.2022.01.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 01/24/2022] [Indexed: 10/19/2022] Open
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6
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Lemoine S, Grognard G, Chabernaud JL, Jost D, Travers S, Prunet B. Pediatric victims involved in urban fires in Paris and its suburbs: Epidemiology, prehospital care, and lessons learned. Arch Pediatr 2020; 27:196-201. [PMID: 32331913 DOI: 10.1016/j.arcped.2020.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 12/18/2019] [Accepted: 03/28/2020] [Indexed: 10/24/2022]
Abstract
AIM The literature includes few reports on the prehospital care of pediatric casualties of urban house fires. Here we aimed to describe the epidemiology of pediatric fire victims, focusing on their injuries, prehospital care, and survival. METHODS This retrospective study included children under 15 years of age who were victims of urban house fires and who received care from prehospital medical teams. The variables analyzed included epidemiology, specific care provided by prehospital emergency services, the number of cardiac arrests, and survival rates. RESULTS Over the 15-month study period, 365 house fires required the presence of at least one prehospital medical team. Casualties of these fires included 121 pediatric victims (median age, 4 years [interquartile range: 2-9 years]). All children were initially treated by a prehospital medical team that was not specialized in pediatrics. Six children (4.9%) received secondary treatment from a pediatric support team. Of the 121 children, 114 (94.2%) suffered from smoke inhalation and seven (5.8%) from burns. Two patients who were in cardiac arrest at their initial medical care did not survive. CONCLUSION Pediatric fire casualties were initially managed by prehospital medical teams that were not specialized in pediatrics. As in adults, the main injuries were secondary to smoke inhalation, but this has increased toxicity in children. Prehospital teams not specialized in pediatrics can optimize their practice via the sharing of experiences, team training, and cognitive aid checklist for pediatric fire victims.
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Affiliation(s)
- S Lemoine
- Paris fire brigade medical emergency department, 1, place Jules-Renard 75017 Paris, France.
| | - G Grognard
- SMUR pédiatrique (SAMU 75), hôpital Necker, 149, rue de Sèvres, 75015 Paris, France
| | - J-L Chabernaud
- SMUR pédiatrique (SAMU 92), hôpital Antoine-Béclère, 157, rue porte de Trivaux, 92140 Clamart, France
| | - D Jost
- Paris fire brigade medical emergency department, 1, place Jules-Renard 75017 Paris, France
| | - S Travers
- Paris fire brigade medical emergency department, 1, place Jules-Renard 75017 Paris, France
| | - B Prunet
- Paris fire brigade medical emergency department, 1, place Jules-Renard 75017 Paris, France
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Geslain G, Tilea B, Heraut F, Rubinsztajn R. Smoke inhalation injury in a 2-year-old domestic fire victim. Arch Pediatr 2020; 27:223-226. [PMID: 32192813 DOI: 10.1016/j.arcped.2020.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 11/06/2019] [Accepted: 01/25/2020] [Indexed: 11/15/2022]
Abstract
Smoke inhalation injury is common in victims of domestic fires, among whom children are the most vulnerable. Cyanide poisoning may occur in addition to carbon monoxide poisoning and is challenging to diagnose. In France, the recommended antidotes are hydroxocobalamin for cyanide and hyperbaric oxygen for carbon monoxide. We managed a 26-month-old girl who sustained smoke inhalation injury with both carbon monoxide and cyanide poisoning during a house fire. Despite hydroxocobalamin and sodium thiosulfate therapy combined with hyperbaric oxygen, she had residual neurological impairments 3 months after the injury. The treatment challenges and detailed neurological follow-up data are described.
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Affiliation(s)
- G Geslain
- Pediatric Intensive Care Unit, Raymond-Poincaré Hospital, AP-HP, 92380 Garches, France.
| | - B Tilea
- Radiology, Robert-Debré Hospital, AP-HP, 75019 Paris, France
| | - F Heraut
- Physiological Explorations, Raymond-Poincaré Hospital, AP-HP, 92380 Garches, France
| | - R Rubinsztajn
- Pediatric Intensive Care Unit, Raymond-Poincaré Hospital, AP-HP, 92380 Garches, France
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8
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Legrand M, Barraud D, Constant I, Devauchelle P, Donat N, Fontaine M, Goffinet L, Hoffmann C, Jeanne M, Jonqueres J, Leclerc T, Lefort H, Louvet N, Losser MR, Lucas C, Pantet O, Roquilly A, Rousseau AF, Soussi S, Wiramus S, Gayat E, Blet A. Management of severe thermal burns in the acute phase in adults and children. Anaesth Crit Care Pain Med 2020; 39:253-267. [PMID: 32147581 DOI: 10.1016/j.accpm.2020.03.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVES To provide recommendations to facilitate the management of severe thermal burns during the acute phase in adults and children. DESIGN A committee of 20 experts was asked to produce recommendations in six fields of burn management, namely, (1) assessment, admission to specialised burns centres, and telemedicine; (2) haemodynamic management; (3) airway management and smoke inhalation; (4) anaesthesia and analgesia; (5) burn wound treatments; and (6) other treatments. At the start of the recommendation-formulation process, a formal conflict-of-interest policy was developed and enforced throughout the process. The entire process was conducted independently of any industry funding. The experts drew up a list of questions that were formulated according to the PICO model (Population, Intervention, Comparison, and Outcomes). Two bibliography experts per field analysed the literature published from January 2000 onwards using predefined keywords according to PRISMA recommendations. The quality of data from the selected literature was assessed using GRADE® methodology. Due to the current paucity of sufficiently powered studies regarding hard outcomes (i.e. mortality), the recommendations are based on expert opinion. RESULTS The SFAR guidelines panel generated 24 statements regarding the management of acute burn injuries in adults and children. After two scoring rounds and one amendment, strong agreement was reached for all recommendations. CONCLUSION Substantial agreement was reached among a large cohort of experts regarding numerous strong recommendations to optimise the management of acute burn injuries in adults and children.
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Affiliation(s)
- Matthieu Legrand
- Department of Anaesthesia and Perioperative Care, University of California, San Francisco, United States.
| | - Damien Barraud
- Hôpital de Mercy, Intensive Care Medicine and Burn Centre, CHR Metz-Thionville, Ars-Laquenexy, France
| | - Isabelle Constant
- Anaesthesiology Department, Hôpital Armand-Trousseau, Sorbonne Université, Assistance publique-Hôpitaux de Paris, Paris, France
| | | | - Nicolas Donat
- Burn Centre, Percy Military Teaching Hospital, Clamart, France
| | - Mathieu Fontaine
- Burn Intensive Care Unit, Saint-Joseph Saint-Luc Hospital, 20, quai Claude-Bernard, 69007 Lyon, France
| | - Laetitia Goffinet
- Paediatric Burn Centre, University Hospital of Nancy, 54511 Vandœuvre-Lès-Nancy, France
| | | | - Mathieu Jeanne
- CHU Lille, Anaesthesia and Critical Care, Burn Centre, 59000 Lille, France; University of Lille, Inserm, CHU Lille, CIC 1403, 59000 Lille, France; University of Lille, EA 7365 - GRITA, 59000 Lille, France
| | - Jeanne Jonqueres
- Burn Intensive Care Unit, Saint-Joseph Saint-Luc Hospital, 20, quai Claude-Bernard, 69007 Lyon, France
| | - Thomas Leclerc
- Burn Centre, Percy Military Teaching Hospital, Clamart, France
| | - Hugues Lefort
- Department of emergency medicine, Legouest Military Teaching Hospital, Metz, France
| | - Nicolas Louvet
- Anaesthesiology Department, Hôpital Armand-Trousseau, Sorbonne Université, Assistance publique-Hôpitaux de Paris, Paris, France
| | - Marie-Reine Losser
- Hôpital de Mercy, Intensive Care Medicine and Burn Centre, CHR Metz-Thionville, Ars-Laquenexy, France; Paediatric Burn Centre, University Hospital of Nancy, 54511 Vandœuvre-Lès-Nancy, France; Inserm UMR 1116, Team 2, 54000 Nancy, France; University of Lorraine, 54000 Nancy, France
| | - Célia Lucas
- Department of Anaesthesiology, Critical Care and Burn Centre, Lariboisière-Saint-Louis Hospitals, DMU Parabol, AP-HP Nord, University of Paris, Paris, France
| | - Olivier Pantet
- Service of Adult Intensive Care Medicine and Burns, Lausanne University Hospital (CHUV), BH 08-651, Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Antoine Roquilly
- Department of Anaesthesia and Critical Care, Hôtel-Dieu, University Hospital of Nantes, Nantes, France; Laboratoire UPRES EA 3826 "Thérapeutiques cliniques et expérimentales des infections", University of Nantes, Nantes, France
| | | | - Sabri Soussi
- Department of Anaesthesiology, Critical Care and Burn Centre, Lariboisière-Saint-Louis Hospitals, DMU Parabol, AP-HP Nord, University of Paris, Paris, France; Interdepartmental Division of Critical Care, Keenan Research Centre for Biomedical Science and Institute of Medical Sciences, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Sandrine Wiramus
- Department of Anaesthesia and Intensive Care Medicine and Burn Centre, University Hospital of Marseille, La Timone Hospital, Marseille, France
| | - Etienne Gayat
- Department of Anaesthesiology, Critical Care and Burn Centre, Lariboisière-Saint-Louis Hospitals, DMU Parabol, AP-HP Nord, University of Paris, Paris, France; Inserm UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), University of Paris, Paris, France
| | - Alice Blet
- Department of Anaesthesiology, Critical Care and Burn Centre, Lariboisière-Saint-Louis Hospitals, DMU Parabol, AP-HP Nord, University of Paris, Paris, France; Inserm UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), University of Paris, Paris, France; Department of Research, University of Ottawa Heart Institute, Ottawa, ON, Canada
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Martínez-Sánchez L, Ferrés-Padró V, Martínez-Millán D, Fernández-Calabria C, Amigó-Tadín M, Jiménez-Fàbrega FX, Nogué-Xarau S. Prehospital emergency care of patients exposed to poisoning: Assessment of epidemiological, clinical characteristics and quality of care. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2020. [DOI: 10.1016/j.anpede.2019.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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10
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Eichhorn L, Thudium M, Jüttner B. The Diagnosis and Treatment of Carbon Monoxide Poisoning. DEUTSCHES ARZTEBLATT INTERNATIONAL 2019; 115:863-870. [PMID: 30765023 DOI: 10.3238/arztebl.2018.0863] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 06/04/2018] [Accepted: 09/24/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND The symptoms of carbon monoxide (CO) poisoning are nonspecific, ranging from dizziness and headache to unconsciousness and death. A German national guideline on the diagnosis and treatment of this condition is lacking at present. METHODS This review is based on a selective literature search in the PubMed and Cochrane databases, as well as on existing guidelines from abroad and expert recommendations on diagnosis and treatment. RESULTS The initiation of 100% oxygen breathing as early as possible is the most important treatment for carbon monoxide poisoning. In case of CO poisoning, the reduced oxygen-carrying capacity of the blood, impairment of the cellular respiratory chain, and immune-modulating processes can lead to tissue injury in the myocardium and brain even after lowering of the carboxyhemoglobin (COHb) concentration. In patients with severe carbon monoxide poisoning, an ECG should be obtained and biomarkers for cardiac ischemia should be measured. Hyperbaric oxygen therapy (HBOT) should be critically considered and initiated within six hours in patients with neurologic deficits, unconsciousness, cardiac ischemia, pregnancy, and/or a very high COHb concentration. At present, there is no general recommendation for HBOT, in view of the heterogeneous state of the evidence from multiple trials. Therapeutic decision-making is directed toward the avoidance of sequelae such as cognitive dysfunction and cardiac complications, and the reduction of mortality. Smoke intoxication must be considered in the differential diagnosis. The state of the evidence on the diagnosis and treatment of this condition is not entirely clear. Alternative or supplementary pharmacological treatments now exist only on an experimental basis. CONCLUSION High-quality, prospective, randomized trials that would enable a definitive judgment of the efficacy of HBOT are currently lacking.
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Affiliation(s)
- Lars Eichhorn
- Department of Anaesthesiology and Intensive Care University Hospital Bonn (UKB), Bonn Clinic for Anesthesiology and Intensive Care Medicine, Hannover Medical School
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11
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Thompson A, Dunn M, Jefferson RD, Dissanayake K, Reed F, Gregson R, Greenhalgh S, Clutton RE, Blain PG, Thomas SH, Eddleston M. Modest and variable efficacy of pre-exposure hydroxocobalamin and dicobalt edetate in a porcine model of acute cyanide salt poisoning. Clin Toxicol (Phila) 2019; 58:190-200. [PMID: 31389254 PMCID: PMC7034532 DOI: 10.1080/15563650.2019.1628969] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Background: Dicobalt edetate and hydroxocobalamin are widely used to treat hydrogen cyanide poisoning. However, comparative and quantitative efficacy data are lacking. Although post-exposure treatment is typical, it may be possible to administer these antidotes before exposure to first attenders entering a known site of cyanide release, as supplementary protection to their personal protective equipment.Methods: We established an anaesthetised Gottingen minipig model of lethal bolus potassium cyanide (KCN) injection to simulate high dose hydrogen cyanide inhalation. Doses were similar to human lethal doses of KCN. Dicobalt edetate and hydroxocobalamin were administered shortly before KCN and their effect on metabolic and cardiovascular variables and survival time were measured.Results: Increases in arterial lactate were similar after 0.08 and 0.12 mmol/kg KCN. KCN 0.08 mmol/kg was survived by 4/4 animals with moderate cardiovascular effects, while the 0.12 mmol/kg dose was lethal in 4/4 animals, with a mean time to euthanasia of 28.3 (SEM: 13.9) min. Administration of dicobalt edetate (0.021 mmol/kg, 8.6 mg/kg) or hydroxocobalamin (0.054 mmol/kg, 75 mg/kg) at clinically licenced doses had modest effect on lactate concentrations but increased survival after administration of KCN 0.12 mmol/kg (survival: dicobalt edetate 4/4, hydroxocobalamin 2/4) but not 0.15 mmol/kg (0/4 and 0/4, respectively). In a subsequent larger study, doubling the dose of hydroxocobalamin (0.108 mmol/kg, 150 mg/kg) was associated with a modest but inconsistent increased survival after 0.15 mmol/kg KCN (survival: control 0/8, 75 mg/kg 1/10, 150 mg/kg 3/10) likely due to variable pharmacokinetics.Conclusions: In this porcine study of cyanide exposure, with pre-exposure antidote administration, licenced doses of dicobalt edetate and hydroxocobalamin were effective at just lethal doses but ineffective at less than twice the estimated LD50. The efficacy of a rapidly-administered double-dose of hydroxocobalamin was limited by variable pharmacokinetics. In clinical poisoning scenarios, with delayed administration, the antidotes are likely to be even less effective. New antidotes are required for treatment of cyanide exposures appreciably above the minimum lethal dose.
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Affiliation(s)
- Adrian Thompson
- Department of Pharmacology, Toxicology, & Therapeutics, University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Michael Dunn
- Medical Toxicology Centre, University of Newcastle, Newcastle upon Tyne, UK
| | - Robert D Jefferson
- Medical Toxicology Centre, University of Newcastle, Newcastle upon Tyne, UK
| | - Kosala Dissanayake
- Department of Pharmacology, Toxicology, & Therapeutics, University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Frances Reed
- Wellcome Critical Care Laboratory for Large Animals, Roslin Institute, Royal (Dick) School of Veterinary Studies, University of Edinburgh, Edinburgh, UK
| | - Rachael Gregson
- Wellcome Critical Care Laboratory for Large Animals, Roslin Institute, Royal (Dick) School of Veterinary Studies, University of Edinburgh, Edinburgh, UK
| | - Stephen Greenhalgh
- Wellcome Critical Care Laboratory for Large Animals, Roslin Institute, Royal (Dick) School of Veterinary Studies, University of Edinburgh, Edinburgh, UK
| | - R Eddie Clutton
- Wellcome Critical Care Laboratory for Large Animals, Roslin Institute, Royal (Dick) School of Veterinary Studies, University of Edinburgh, Edinburgh, UK
| | - Peter G Blain
- Medical Toxicology Centre, University of Newcastle, Newcastle upon Tyne, UK
| | - Simon Hl Thomas
- Medical Toxicology Centre, University of Newcastle, Newcastle upon Tyne, UK
| | - Michael Eddleston
- Department of Pharmacology, Toxicology, & Therapeutics, University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
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12
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[Prehospital emergency care of patients exposed to poisoning: Assessment of epidemiological, clinical characteristics and quality of care]. An Pediatr (Barc) 2019; 92:37-45. [PMID: 31129026 DOI: 10.1016/j.anpedi.2019.03.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 03/09/2019] [Accepted: 03/20/2019] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE To describe the characteristics of paediatric patients with suspected poisoning treated by advanced life support (ALS) units, and to evaluate quality indicators (QI) for the prehospital emergency care of these patients. METHOD A one-year observational study of patients under 18 years of age exposed to poisoning and treated by an ALS unit of the Medical Emergency System in Catalonia. Severe clinical criteria were defined, with 8 QI being evaluated for prehospital emergency care of poisoned paediatric patients. RESULTS The study included a total of 254 patients, with a median age of 14 years-old (p25-75 = 7-16), with intentional poisoning in 50.8% of cases. The most frequently involved toxic agent was carbon monoxide (CO) (33.8%). Poisoning was found in 48.8% of those patients, being serious in 16.5%. Intentionally (OR 5.1; 95% CI: 1.9-13.8) and knowledge of the time of exposure (OD 3.1; 95% CI: 1.3-7.3) were independent risk factors associated with the appearance of severe clinical symptoms. Five QI did not reach the quality standard and included, availability of specific clinical guidelines, activated charcoal administration in selected patients, oxygen therapy administration at maximum possible concentration in carbon monoxide poisoning, electrocardiographic assessment in patients exposed to cardiotoxic substances, and recording of the minimum data set. CONCLUSIONS Paediatric patients attended by ALS units showed specific characteristics, highlighting the involvement of CO and adolescents with voluntary poisoning. The QI assessment was useful to detect weak points in the quality of care of these patients and to develop strategies for improvement.
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Affiliation(s)
- Fred M Henretig
- From the Division of Emergency Medicine and Poison Control Center, Children's Hospital of Philadelphia, and the Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia (F.M.H.); the Department of Homeland Security, Washington, DC (M.A.K.); and the Division of Medical Toxicology, Department of Emergency Medicine, University of Connecticut Health Center and Hartford Hospital, Hartford (C.A.M.)
| | - Mark A Kirk
- From the Division of Emergency Medicine and Poison Control Center, Children's Hospital of Philadelphia, and the Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia (F.M.H.); the Department of Homeland Security, Washington, DC (M.A.K.); and the Division of Medical Toxicology, Department of Emergency Medicine, University of Connecticut Health Center and Hartford Hospital, Hartford (C.A.M.)
| | - Charles A McKay
- From the Division of Emergency Medicine and Poison Control Center, Children's Hospital of Philadelphia, and the Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia (F.M.H.); the Department of Homeland Security, Washington, DC (M.A.K.); and the Division of Medical Toxicology, Department of Emergency Medicine, University of Connecticut Health Center and Hartford Hospital, Hartford (C.A.M.)
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14
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Jüttner M, Körner-Göbel H, Starke H, Enax S, Eismann H, Göbel V, Eichhorn L, Jüttner B. [Evaluation and assessment of the health care process in patients with carbon monoxide poisoning in Germany]. ZEITSCHRIFT FUR EVIDENZ, FORTBILDUNG UND QUALITAT IM GESUNDHEITSWESEN 2019; 140:1-13. [PMID: 30598287 DOI: 10.1016/j.zefq.2018.12.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 12/03/2018] [Accepted: 12/04/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Carbon monoxide poisoning (COP) is the most common cause for poisoning by inhalation in Germany. In the past 8 years, a marked increase in the number of COP-related deaths has been registered nationwide. A national German guideline is missing. METHODS The national and international literature was screened systematically. Existing international guidelines and expert recommendations for the diagnosis and treatment of COP were compared and evaluated. Furthermore, quality of health care was analyzed by a prospective preclinical dataset of emergency rescue services and retrospective analysis of routine data from 2014 to 2016 in Germany. RESULTS There is not a single evidence-based guideline worldwide. We determined 8 key performance indicators based on the five recommendations available for treatment of COP. These indices were subdivided into prehospital terms, hospital facilities, and diagnostic and therapeutic measures performed; they act as indicators for quality of care. In particular, the key figure "start oxygen" revealed that up to 41 % of the patients had not been treated with inhaled oxygen. In summary, data capture showed considerable incompleteness that is mainly due to missing time stamps. CONCLUSION In order to achieve a consistent treatment of patients with COP which meets the standard of recommended care, there is an urgent need for a consented national guideline. Another objective is to establish a nationwide prospective registry evaluating the treatment of carbon monoxide poisoning.
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Affiliation(s)
- Marieke Jüttner
- Klinik für Anästhesiologie und Intensivmedizin, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - Hella Körner-Göbel
- HELIOS Universitätsklinikum Wuppertal, Institut für Notfallmedizin, Wuppertal, Deutschland
| | - Henning Starke
- Klinik für Anästhesiologie und Intensivmedizin, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - Sascha Enax
- Klinik für Anästhesiologie und Intensivmedizin, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - Hendrik Eismann
- Klinik für Anästhesiologie und Intensivmedizin, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - Volker Göbel
- Berufsfeuerwehr Wuppertal, Wuppertal, Deutschland
| | - Lars Eichhorn
- Klinik und Poliklinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Bonn, Bonn, Deutschland
| | - Björn Jüttner
- Klinik für Anästhesiologie und Intensivmedizin, Medizinische Hochschule Hannover, Hannover, Deutschland.
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15
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Abstract
Smoke inhalation injury can cause severe physiologic perturbations. In pediatric patients, these perturbations cause profound changes in cardiac and pulmonary physiology. In this review, we examine the pathology, early management options, ventilator strategy, and long-term outcomes in pediatric patients who have suffered a smoke inhalation injury.
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Affiliation(s)
- Soman Sen
- Division of Burn Surgery, Department of Surgery, University of California Davis, Shriners Hospital for Children Northern California, Sacramento, USA
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16
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Sabourin PJ, Kobs CL, Gibbs ST, Hong P, Matthews CM, Patton KM, Sabourin CL, Wakayama EJ. Characterization of a Mouse Model of Oral Potassium Cyanide Intoxication. Int J Toxicol 2016; 35:584-603. [PMID: 27170682 DOI: 10.1177/1091581816646973] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Potassium cyanide (KCN) is an inhibitor of cytochrome C oxidase causing rapid death due to hypoxia. A well-characterized model of oral KCN intoxication is needed to test new therapeutics under the Food and Drug Administration Animal Rule. Clinical signs, plasma pH and lactate concentrations, biomarkers, histopathology, and cyanide and thiocyanate toxicokinetics were used to characterize the pathology of KCN intoxication in adult and juvenile mice. The acute oral LD50s were determined to be 11.8, 11.0, 10.9, and 9.9 mg/kg in water for adult male, adult female, juvenile male, and juvenile female mice, respectively. The time to death was rapid and dose dependent; juvenile mice had a shorter mean time to death. Juvenile mice displayed a more rapid onset and higher incidence of seizures. The time to observance of respiratory signs and prostration was rapid, but mice surviving beyond 2 hours generally recovered fully within 8 hours. At doses up to the LD50, there were no gross necropsy or microscopic findings clearly attributed to administration of KCN in juvenile or adult CD-1 mice from 24 hours to 28 days post-KCN challenge. Toxicokinetic analysis indicated rapid uptake, metabolism, and clearance of plasma cyanide. Potassium cyanide caused a rapid, dose-related decrease in blood pH and increase in serum lactate concentration. An increase in fatty acid-binding protein 3 was observed at 11.5 mg/kg KCN in adult but not in juvenile mice. These studies provide a characterization of KCN intoxication in adult and juvenile mice that can be used to screen or conduct preclinical efficacy studies of potential countermeasures.
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17
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Hawk MA, Ritchie GD, Henderson KA, Knostman KAB, Roche BM, Ma ZJ, Matthews CM, Sabourin CL, Wakayama EJ, Sabourin PJ. Neurobehavioral and Cardiovascular Effects of Potassium Cyanide Administered Orally to Mice. Int J Toxicol 2016; 35:604-15. [PMID: 27170681 DOI: 10.1177/1091581816646974] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The Food and Drug Administration Animal Rule requires evaluation of cardiovascular and central nervous system (CNS) effects of new therapeutics. To characterize an adult and juvenile mouse model, neurobehavioral and cardiovascular effects and pathology of a single sublethal but toxic, 8 mg/kg, oral dose of potassium cyanide (KCN) for up to 41 days postdosing were investigated. This study describes the short- and long-term sensory, motor, cognitive, and behavioral changes associated with oral dosing of a sublethal but toxic dose of KCN utilizing functional observation battery and Tier II CNS testing in adult and juvenile mice of both sexes. Selected tissues (histopathology) were evaluated for changes associated with KCN exposure with special attention to brain regions. Telemetry (adult mice only) was used to evaluate cardiovascular and temperature changes. Neurobehavioral capacity, sensorimotor responsivity or spontaneous locomotor activity, and rectal temperature were significantly reduced in adult and juvenile mice at 30 minutes post-8 mg/kg KCN dose. Immediate effects of cyanide included bradycardia, adverse electrocardiogram arrhythmic events, hypotension, and hypothermia with recovery by approximately 1 hour for blood pressure and heart rate effects and by 2 hours for body temperature. Lesions consistent with hypoxia, such as mild acute tubular necrosis in the kidneys corticomedullary junction, were the only histopathological findings and occurred at a very low incidence. The mouse KCN intoxication model indicates rapid and completely reversible effects in adult and juvenile mice following a single oral 8 mg/kg dose. Neurobehavioral and cardiovascular measurements can be used in this animal model as a trigger for treatment.
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Affiliation(s)
| | | | | | | | | | | | | | - Carol L Sabourin
- Department of Health and Human Services (HHS), Office of the Assistant Secretary for Preparedness and Response (ASPR), The Biomedical Advanced Research and Development Authority (BARDA), Washington, DC, USA
| | - Edward J Wakayama
- Department of Health and Human Services (HHS), Office of the Assistant Secretary for Preparedness and Response (ASPR), The Biomedical Advanced Research and Development Authority (BARDA), Washington, DC, USA
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18
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XXXV International Congress of the European Association of Poisons Centres and Clinical Toxicologists (EAPCCT) 26–29 May 2015, St Julian's, Malta. Clin Toxicol (Phila) 2015. [DOI: 10.3109/15563650.2015.1024953] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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19
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Febrile young infants with altered urinalysis at low risk for invasive bacterial infection. a Spanish Pediatric Emergency Research Network's Study. Pediatr Infect Dis J 2015; 34:17-21. [PMID: 25036049 DOI: 10.1097/inf.0000000000000482] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Urinary tract infection (UTI) is the most common serious bacterial infection (SBI) in infants younger than 90 days of age. Many physicians admit infants younger than 90 days old because of their greater risk of developing invasive bacterial infections (IBIs), secondary to UTI. The primary objective of this study was to design a prediction model to identify febrile infants younger than 90 days old with an altered urinalysis who were at low risk for IBI and suitable for outpatient management METHODS : Prospective multicenter study included 19 hospitals that are members of the Spanish Pediatric Emergency Research Group of the Spanish Society of Pediatric Emergencies. Febrile infants younger than 90 days old with altered urinalysis were included. RESULTS A total of 766 (22.5%) infants with altered urine dipstick were analyzed. Fifty (6.5%) of them developed IBI, 39 (78.0%) secondary to UTI. Patients were at low risk for IBI if they were well appearing at arrival to the emergency department, were older than 21 days and had procalcitonin and C-reactive protein (CRP) blood values lower than 0.5 ng/mL and 20 mg/L, respectively. These factors were used to create a prediction model for IBI secondary to UTI, with a sensitivity of 100% (95% CI: 89.3-100) and a negative predictive value of 100% (95% CI: 97.5-100). CONCLUSIONS We have derived a highly accurate prediction model for IBI in febrile infants with altered urinalysis. Given these results, outpatient management might be suitable for 1 of each 4 infants diagnosed, with a considerable improvement in resource utilization.
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