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Greek School of Agia Marina

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Naum Aksenov
Naum Aksenov

Numero De Serie Antidote 8

Vasoplegic syndrome, a form of vasodilatory shock following cardiopulmonary bypass (CPB), may affect up to half of all patients undergoing major cardiovascular surgery [1,2,3,4,5,6]. The pathophysiology of vasoplegic syndrome is similar to that of sepsis. A large number of patients require vasopressors post-operatively to maintain adequate tissue perfusion. The need for escalating vasopressors is associated with a higher incidence of morbidity and mortality. Research describing the use of agents in refractory vasoplegic syndrome is limited primarily to case series and case reports. The present review discusses the pathophysiology of vasoplegic syndrome and evaluates the various treatment options with insight from personal experience with novel non-catecholamine therapies.

Numero de serie antidote 8

No antidote has been developed and approved for human use, but a primary research report (preliminary result) indicates that a monoclonal antibody specific to tetrodotoxin is in development by USAMRIID that was effective, in the one study, for reducing toxin lethality in tests on mice.[52]

If you had to pick one reason for patients ending up in the ICU for Acute Liver Failure (ALF), it would be acute acetaminophen (APAP) overdose. While the differential diagnosis for ALF includes many entities, APAP overdose constitutes more than 50% of cases of acute liver failure in the developed world and remains one of the leading causes of liver failure that needs acute transplantation (1). The burden of disease is severe, but fortunately many patients can recover with timely critical care support as well as early administration of antidote.

Without fail, the most important part of ALF management in APAP overdose is early antidote. NAC acts to replete glutathione reserves and is most efficacious when used as early as possible (1, 3) For this reason, ANYONE who comes in as with suicide attempt/ ideation as well as ANY overdose patient MUST be screened with a Tylenol level. APAP is in basically every over-the-counter remedy, and most overdose cases involve 2 or more substances (5). It is also important to remember that the number 1 cause of most toxicity deaths is opiate toxicity (6). One of the most widely available and most often implicated prescription narcotic is Percocet (oxycodone PLUS APAP).

N-acetylcysteine (NAC or Mucomyst) is the specific antidote for acetaminophentoxicity. NAC given before 8 hours post-ingestion eliminates mortality andbrings morbidity to a few percent (the 8-hr window). Its efficacy diminishesbeyond 8 hours, and diminished further beyond 16 hours post-ingestion. Failureto recognize and treat acetaminophen toxicity within 16 hours results insignificant morbidity and mortality. NAC can be withheld pending a drug level ifthe results will be available within this 8-hour period. It should be given onspec if the ingestion occurred between 8 - 16 hours and then continued if thelevel is within toxic range.

N-acetylcysteine (NAC) is a dietary supplement derived from the amino acid L-cysteine. It is used as an antidote for acetaminophen overdose. As an antioxidant, it is thought to reduce DNA damage. NAC is also marketed for its liver-protective properties and to support healthy immune functioning.

NAC is a precursor to glutathione (GSH). It is used as both an antidote for acetaminophen-induced hepatotoxicity, and as a mucolytic agent for respiratory diseases. NAC reduces disulphide bonds to sulfhydryl bonds to reduce mucus formation (20). Its hepatoprotective action may occur by cytokine-mediated mechanisms as well as GSH replenishment (21). NAC crosses the blood-brain barrier, increases brain GSH levels, and acts as a glutamine modulator (11).

Dembe is revealed to have an adult daughter, Isabella, whose infant daughter, Elle, was kidnapped by Matias Solomon for blackmail to get to him. Solomon threatens Elle's life by suggesting he gave her a poisonous nerve agent and Dembe will not get the antidote unless he wears a chemical mask and inhales. Without hesitation, Dembe takes the mask and takes several slow breaths, his eyes fluttering shut. In the mask appears to be a sleeping gas.

Two general and important conclusions will become obvious to the reader as he or she proceeds through this chapter. The first is that with a few exceptions, drugs, antitoxins, and supportive medical equipment are generally available in small quantities (although two recent surveys [Dart et al., 1996; Skolfield, 1997] by poison control centers report that very few hospitals in their service areas carried sufficient amounts of all recommended antidotes). Proper planning and coordination among area medical and veterinary facilities might yield sufficient quantities of these drugs and other supplies for a multiple-victim incident, but few locales will have adequate supplies for a true mass-casualty event.

Discussion of chemical agents is based upon an approach that integrates local, state, and federal systems for the delivery and stockpiling of antidotes for mass casualty events. This approach emphasizes which agents must be available locally, how much and under whose jurisdiction. The principle being that a plan should be developed to deliver large quantities of antidotes to any part of our country in a rapid organized fashion. Research and development should focus on models of storage and methods for deployment and delivery in a timely fashion. First responders from Emergency Medical Services and Hazmat Services cannot be expected to make definitive decisions and in general will not be stocked for population antidotal care, although they should have access to personal antidotal material for high-risk toxins so as to effectively complete scene assessment and victim rescue.

Appropriate adult doses of atropine sulfate, 2-PAM, and diazepam are packaged in autoinjectors issued to U.S. military personnel for self- or buddy-aid. A metered dose atropine methonitrate inhaler called the medical aerosolized nerve agent antidote (MANAA) has been approved by FDA and is being produced for DoD by 3M/Riker. However, it is intended for use, under medical supervision, as a supplement to injectable atropine, not as self/buddy aid. Except under special circumstances, utilization of these prepackaged autoinjectors should be limited to Hazmat and prehospital EMS staff for their own personal care and that of their coworkers. Consideration for use of these antidotes for the general public should be restricted to exceptional circumstances when patients cannot be expeditiously removed from the environment, decontaminated, and brought to an emergency department. None of these antidotes is ideally delivered intramuscularly, in the absence of intravenous fluids and control of the airway, or during a convulsion. If these are considered essential products for civilian care, the hospital emergency department is the ideal site for their use.

An alternative to extensive field treatment by Hazmat, EMS, and MMST teams in a particular region might utilize Hazmat and MMST teams as a mobile stockpile system delivering large quantities of antidotes to the EMS teams/ambulances (and individual hospitals as patients move there). This approach will ensure that patient load at a given hospital will be matched by antidote supply, thus expediting therapy and avoiding delays in delivery from a single central stockpile. Decisions on antidote stockpiling and control will involve geographic (rural vs. urban), financial, and other legitimate but nonscientific determinations, but in the proposed procedure, first responders would draw on established supplies of antidotes prepared for disaster management to ensure that patients transported to local emergency departments arrived with sufficient antidotes to begin treatment. Simultaneous communication with Regional Poison Control Centers and Poison Control Center-Emergency Department linkages to local and state health departments would track stockpile usage and allow for coordination with more distant sources, such as the Centers for Disease Control and Prevention.

soman (GD). Soman is an exception, because 2-PAM acts by competitively binding to the organophosphate agent and thereby "reactivating" the acetylcholinesterase enzyme the agent had tied up. However, once the enzyme-agent complex has undergone an irreversible "aging" process, 2-PAM is unable to reactivate the enzyme. The aging process takes hours for VX and most of the G agents, but only minutes in the case of soman (GD). In most cases of domestic civilian terrorism involving soman intoxication, it will not be possible to administer 2-PAM this quickly. Additional limitations in the use of 2-PAM as an antidote in nerve agent toxicity include the fact that large doses may be necessary for protection and survival, but in such large doses 2-PAM itself can lead to significant side effects, most notably hypertension. In addition, because it does not readily cross the blood-brain barrier, 2-PAM is thought to have little action against the central nervous system effects of nerve-agent poisoning.

Needle, intravenous, and/or intravenous bag adapters should be designed to facilitate the intravenous delivery of antidotes currently prepared solely for intramuscular use. The prepackaged systems designed for intramuscular use can only be used intravenously with risk to the health professional giving the injections.

Lewisite (ß-chlorovinyldichloroarsine) was synthesized in 1918 for use as a weapon, and its clinical effects are similar to those of mustard in many respects, although the cellular mechanisms are believed to differ. However, unlike mustard, Lewisite liquid or vapor produces irritation and pain seconds to minutes after contact. Immediate decontamination may limit damage to skin or eyes, and intramuscular injections of a specific antidote, dimercaprol, or British antiLewisite (BAL) will reduce the severity of systemic effects. BAL has toxic effects of its own, however, and must be used with care.

Phosgene oxime (dichloroformoxime) is a colorless crystalline solid with a melting point of approximately 37.7C (100F). In liquid or vapor form it is highly corrosive, and it penetrates clothing and rubber readily. The mechanism by which it damages tissue is unknown, but its effects are almost instantaneous and produce severe pain. Skin lesions are like those caused by a strong acid. There is no antidote; treatment will be similar to that for mustard. 350c69d7ab


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