• Exposure to organophosphates can lead to “intermediate syndrome.”

• It is a syndrome characterized by weakness of neck flexors and proximal limbs, cranial nerve palsies, and respiratory muscle weakness, which can lead to respiratory paralysis.

• It follows acute cholinergic syndrome and precedes a delayed neuropathy, thus it is an “intermediate syndrome,” typically developing 24-96 hours post exposure.

• The pathophysiology of IMS remains unclear.

• Serum cholinesterase levels and electrophysiological studies are helpful in confirming the diagnosis.

• With supportive therapy, including artificial ventilation, complete recovery occurs within 5-18 days.

Acute, uncomplicated cystitis (in the non-pregnant female):

·      The drug of choice is SMX/TMP (provided the resistance rate is <20%) X 3 days.

·      An alternative is nitrofurantoin X 5 days.

Acute, uncomplicated pyleonephritis (in the non-pregnanct female) may be treated with:

·      Levofloxacin X 5 days, or ciprofloxacin X 7 days (provided resistance rate is <10%).

·      Alternatively, SMX/TMP may be used X 14 days.

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No one treatment has demonstrated consistency of pain relief from jellyfish stings over all species; conversely, a treatment for one species may worsen an envenomation from another.

Deionized water, seawater, meat tenderizer, and urea treatment do not appear to produce any improvement in pain sensation.

Ammonia, acetic acid, and ethanol may cause an increased stinging sensation, and in most species vinegar may cause nematocyst discharge.

Application of topical lidocaine reduced the local sensation of pain (10% and 15% produced immediate pain relief), and hot water results in pain relief in the majority of patients tested.

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It may not be necessary to give oral vitamin K to patients that are not bleeding that have INRs between 4.5 and 10.

Patients who were supratherapeutic on warfarin were randomized to vitamin K 1.25 mg (n=355) versus placebo (n=369).

In the 90 days after enrollment, 15.8% of patients allocated to vitamin K and 16.3% allocated to placebo had a bleeding event. Major bleeding events occurred in 9 patients in the vitamin K group and 4 in the placebo.

Thromboembolic events occurred in 1.1% of patients in the vitamin K group, compared to 0.8% of patients in the placebo group. An equal number of patients died in each group (n=7).

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If vancomycin resistance is suspected with MRSA infections, there are several other antibiotic choices. They are all extremely expensive.

Skin and soft tissue infection (SSTI); ventilator acquired pneumonia (VAP)

Protamine for enoxaparin overdose

• Protamine may be used to treat severe cases of hemorrhage in enoxaparin overdose
• Protamine reverses the prolonged aPTT, but fails to completely reverse the anti-Xa effect (reverses about 60%)
• Administer protamine by slow IV to equal the dose of enoxaparin injected: (1:1 ratio) 
• if < 8 hours after last dose enoxaparin, give 1 mg protamine per 1 mg enoxaparin;
• if 8-12 hours after last dose enoxaparin, give 0.5 mg protamine per 1 mg enoxaparin;
• if >12 hours after last dose of enoxaparin,  protamine is not required

• Sulfonyurea overdose is associated with hypoglycemia, which may be delayed and prolonged.
• Treatment with dextrose results in hyperglycemia, which potentiates insulin release from the pancreas, resulting in recurrent hypoglycemia.
• Octreotide mimics somatostatin, which suppresses the secretion of glucagon and insulin, among others.
• Octreotide binds with somatostatin receptors, closing calcium channels, preventing the influx of calcium and subsequent insulin release.
• The dose is 100 mcg SUBCUTANEOUSLY, repeated every 8 hours as needed.

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• Approved for CAP and Skin/Skin structure infections

• “Fifth generation” cephalosporin- implies activity against MRSA, although has broad spectrum

• Resistance is expected to be limited, with the exception of VRE, and VSE (vanco resistant or sensitive enterococcus faecalis)

• Renally excreted

• Common side effects: diarrhea, nausea, headache

• Serious side effects: anaphylaxis, renal failure, hepatitis, seizure

• Low incidence of C. difficile

• Dose : 600 mg IV (over 1 hour) q12 hours X 5-7 days

High dose insulin is recommended in treatment of beta-blocker and calcium channel blocker overdose. In a recent observational case series of cardiogenic shock, high dose insulin was evaluated for efficacy and safety.

• Insulin doses were given at a maximum of 10 units/kg/hour.

• Seven patients who were on vasopressors when enrolled were tapered off when placed on high dose insulin.

• 11/12 patients lived and were discharged from the hospital.

• Adverse effects included hypoglycemia (19 events) and hypokalemia (8).

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Salicylates:

• stimulate the respiratory center in the brainstem, causing respiratory alkalosis
• interfere with the Krebs cycle, limiting ATP production, leading to an anaerobic metabolism
• uncouple oxidative phosphorylation, causing accumulation of pyruvic and lactic acid and heat production, resulting in acidosis and hyperthermia
• increase fatty acid metabolism, generating ketone bodies

Overall, this results in a mixed respiratory alkalosis and metabolic acidosis. 

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There are an increasing number of intranasal medications commercially available for use, which is opportune as more and more intravenous medications become scarce.

These now include:

*******In addition, you can administer glucagon, midazolam and narcan intranasally as well.

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o   The FDA is now asking manufacturers to limit the amount of acetaminophen in combination products to 325 mg per dose.

o   The higher dose formulations will be phased out by 2014.

o   The FDA is also considering lowering the maximum total to 3 gm per day, and a maximum dose of 650 mg per dose

o   This does not pertain to OTC, but this is likely to change in the near future; Johnson & Johnson (manufacturer of Tylenol) has already adopted these recommendations.

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IV acetaminophen has been approved for use since November 2010

It is indicated for the:

• Treatment of mild to moderate pain
• Combination therapy with opioids for treatment of moderate to severe pain
• Fever reduction

The results of studies demonstrating opoid sparing effects have been mixed; some studies have not demonstrated either a reduction in opioid dose or opioid side effects.

The dose is the same for acetaminophen administered by other routes.

It must be administered over 15 minutes, and onset of activity is 15 minutes. Peak effect occurs at one hour.

The MAJOR drawback is the cost, which is $13 dollars per vial. This is compared to oral acetaminophen and ibuprofen, which are pennies.

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·      In the event a nuclear power plant accident, people may be exposed to a mixture of radioactive products. The main radionuclides representing health risk are radioactive caesium and radioactive iodine.

·      Iodine-131 is concentrated in the thyroid gland and may eventually lead to development of thyroid nodules and thyroid cancer.

·      Radioiodine uptake by the thyroid can be blocked by taking potassium iodide (KI) pills or solution, preventing these effects.

·      KI should not be taken in the absence of a clear risk of exposure to a potentially dangerous level of radioactive iodine because KI can cause allergic reactions, skin rashes, salivary gland inflammation, hyperthyroidism or hypothyroidism.

·      Since radioactive iodine decays rapidly, current estimates indicate there will not be a hazardous level of reaching the United States from this accident.

·      There are three FDA approved KI products: Iosat, Thyrosafe and ThyroShield.

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Recently a case report was published in which a child was incorrectly diagnosed with MRSA. He actually had systemic loxoscelism from a Brown Recluse spider bite.

A patient who has been bitten by brown recluse spider bite may present with pruritis, pain and swelling. The classic lesion has a bluish-purple central region, surrounded by concentric rings of pale ischemia and erythema. (“red, white and blue”) Bites may progress over days to a bleb with necrosis and eschar formation, followed by ulceration.

Systemic loxoscelism presents with a scarlatiniform rash that spreads dependently. It may have the classic purple lesion surrounded by concentric rings of pale ischemia and erythema. The patient may be uncomfortable but is usually stable. Treatment is supportive care.

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• Vitamin K can be used intravenously for management of the NON bleeding patient with a high INR (>9).
• Although anaphylactoid reactions have been described, most cases occurred with large doses of vitamin K, administered rapidly, and with little dilution.
• It is estimated that the incidence of anaphylaxis is 3:10,000 doses.
• The subcutaneous route of administration is not recommended because of its delayed and unpredictable responses.

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