PrairiEDocs e-newsletter #3

Other archived PrairiEDocs e-newsletters

Surveying the land (and web) for news (and more)
for the emergency medicine practitioner…

Issue #3 "fasten your seat belt and adjust your headrest as this
electronic ed-venture gets underway" June 27, 2000

In this issue:

A look at (but no touching) Poison Ivy

Vasopressin in cardiac arrest?

Alternative ways of performing CPR?

Fireworks

Too few new flu vaccinations available this fall?

A plus B plus 21 equals A and/or B plus 180?

Words of Wit and Wisdom

Financial support; how to contact us

A look at (but no touching) Poison Ivy

It's that time of year again---visits to the ER by patients who have been in contact with any of the nasty threesome--- poison ivy , poison sumac, and poison oak. According to the American Academy of Dermatologists (AAOD),
they are the single most common cause of allergic reactions in the United States as every year between 10 and 50 million Americans develop a rash after contact with these plants. Poison ivy is found east of the Rocky Mountains, while poison sumac grows in southern Canada, throughout the northeast and Midwest. Poison oak is typically found along in the southeast and in the western US.

"Leaves of three, let it be" is good advice for those wary of poison ivy and poison oak (though botanists clarify that these are actually clusters three
"leaflets" of single leaves on each stem). Poison sumac, commonly found in wet boggy areas, has seven to 13 leaflets (per leaf) all directly opposite one another on the stem except for the one slightly longer one on the end or tip.

The contact dermatitis is caused by contact with an oil found throughout the
plant (throughout the year) called urushiol (you-ROO-shee-ohl). Urushiol is a mixture of catechol derivatives. The major catechol on poison ivy leaves is pentadecylcatechol. If urushiol is washed off the skin quickly, the reaction can be largely prevented. However, if left on the skin, some diffuses through the skin, where it is metabolized to quinone derivatives. These form covalent complexes with skin proteins such as keratin. These complexes appear foreign to the immune system, which therefore attacks them. Urushiol is typically clear or pale yellow, the oil darkens with prolonged exposure to air. Contact occurs with-- 

1) direct contact with any part of the plant, 

2) indirect contact as the oil is on another object (gardening tools, animal fur, clothing), and 

3) airborne particles when the plant is burned and comes in contact with skin or breathed into the lungs (this is one of the leading causes of disability in forest firefighting teams). Nearly one-third of forestry workers and firefighters who battle forest fires in California, Oregon and Washington develop rashes or lung irritations from contact with poison oak, which is the most common of the three in those states.

Penetration begins within minutes of contact and the characteristic linear rash accompanied with itching presents within 12-48 hours. Blistering is not uncommon, and the rash can take 10-20 days or more to resolve.

The rash does not spread itself; first appearing in thin-skinned areas like the face; it appears to be absorbed more slowly in thicker skinned areas with the rash appearing later in these areas---giving rise to the belief that the rash is "spreading." Reactions seldom occur with the first exposure---second exposures produce a reaction in about 85% of the population. Sensitivity appears to decline with age, some say that the sensitivity is cut in half as children with repeated exposures transition into early adulthood. Immunity is possible through the use of a prescription version of the urishiol-this process can take four months to accomplish and the medication must be continued to sustain the effect. Barrier skin creams containing bentoquatum can be applied prior to exposure (e.g. IvyBlock) and provide limited protection.

Newer products being developed focus on blocking the absorption of urishiol.

Post-exposure considerations----

If you suspect an encounter with poison ivy, poison oak or poison sumac, follow these simple steps:

1. Wash exposed areas with cold running water as soon as you can reach a stream, lake or garden hose. If you can do this within five minutes, the water may keep the urushiol from contacting your skin and spreading to other parts of your body. Within the first 30 minutes, soap and water are helpful.

2. Relieve the itching of mild rashes by taking cool showers and applying OTC preparations like calamine lotion or Burrow's solution.* Soaking in a lukewarm bath with an oatmeal or baking soda solution also may ease itching and dry oozing blisters. Over-the-counter hydrocortisone creams are not strong enough to have any effect on poison ivy rashes, according to literature from the AAOD. The FDA considers them effective in managing some of the itching.

*aluminum acetate (Burrows solution) --baking soda --Aveeno (oatmeal bath) --aluminum hydroxide gel --calamine --kaolin --zinc acetate --zinc carbonate --zinc oxide --manganese sulfate solution --jewel weed (homeopathic)

Severe reactions can be treated with prescription oral corticosteroids.

Phillip M. Williford, M.D., assistant professor of dermatology, Wake Forest University, prescribes oral corticosteroids if the rash is on the face, genitals, or covers more than 30 percent of the body. The drug must be taken for at least 14 days, and preferably over a three-week period, says FDA's Ko. Shorter courses of treatment, he warns, will cause a rebound with an even more severe rash.

3. Wash your clothing in a washing machine with detergent (be careful that you do not transfer the urushiol to any surfaces as you bring the clothing into
the house). Dry cleaning is also effective. Do not forget to clean tents, and hunting and fishing gear---the oil can remain active for many months.

William L. Epstein, M.D., professor of dermatology, University ofCalifornia, San Francisco, recommends the following more specific regimen:

1. Cleanse exposed skin with generous amounts of isopropyl alcohol. (Don't return to the woods or yard the same day. Alcohol removes your skin's protection along with the urushiol and any new contact will cause the urushiol to penetrate twice as fast.)

2. Wash skin with water. (Water temperature does not matter; if you're outside, it's likely only cold water will be available.)

3. Take a regular shower with soap and warm water. Do not use soap before this point because "soap will tend to pick up some of the urushiol from the surface of the skin and move it around," says Epstein.

4. Clothes, shoes, tools, and anything else that may have been in contact with the urushiol should be wiped off with alcohol and water. Be sure to wear
gloves or otherwise cover your hands while doing this and then discard the hand covering.

For further information and investigation, consider the following resources via
the Internet:

http://www.poison-ivy-protection.com/

http://www.bio.umass.edu/immunology/poisoniv.htm poison ivy immunology

http://poisonivy.aesir.com/welcome (includes treatment and lots of photos)

http://www.aad.org/pamphlets/PoisonIvy.html (American Academy of Dermatology)

http://www.fda.gov/fdac/features/796_ivy.html

http://www.agnr.umd.edu/users/mg/baspois.htm (safely removing the plants)

Vasopressin in Cardiac Arrest Management?

Despite years of scrutiny and research, survival rates for patients undergoing 
cardiopulmonary resuscitation remain at 5-15%. Some of the most recent pharmacological interventions under investigation (for possible consideration in ACLS guideline revisions to be published this fall) include the use of vasopressin as a vasopressor, amiodarone for the treatment of ventricular fibrillation and tachycardia, and adenosine antagonists (i.e., theophylline) for bradyasystolic rhythms. More innovative approaches include the use of thyroid hormone and endothelin. This article will concentrate on vasopressin, with future articles looking at other pharmacology and revisions in the technique of CPR itself.

Epinephrine's role in cardiac arrest is primarily for its alpha properties---vasoconstriction, and enhancing internal carotid and coronary perfusion. It's beta-agonist properties are controversial in the peri-arrest state-increasing oxygen consumptive demands and reducing subendocardial vascular perfusion. ((Frishman, Vahdat, and Bhatta, 1998). Studies comparing pure alpha adrenergic agents have not shown that they are superior to epinephrine at restoring spontaneous circulation. Recent research has identified a promising alternative to epinephrine-vasopressin. As a hormone, vasopressin has roles as an antidiuretic, and in adrenocorticotropic hormone (ACTH)-releasing activity. Vasopressin is a potent vasoconstrictor that increases blood pressure and systemic vascular resistance, and decreases cardiac output, heart rate, left ventricular oxygen consumption, and  myocardial contractility. With regard to cerebral blood flow, vasopressin not only increases flow to a greater degree than epinephrine, it also improves cerebral oxygenation and decreases venous hypercarbia (Prengal, Lindner, & Keller, 1996).

Back in 1996, investigators reported in the Annals of Internal Medicine about the startlingly successful use of vasopressin in the treatment of eight patients in cardiac arrest refractory to epinephrine and defibrillation. Patients were given 40 U of intravenous vasopressin followed by defibrillation. In all eight patients the defibrillation was successful, and three of the eight were discharged from the with intact neurological function (the other five lived for 0.5-82 hours).

Caution: this presents an issue currently being investigated and does not 
necessarily represent or advocate a change in guidelines for clinical practice. Additional investigation and consideration is required of the reader.

Several abstracts focusing on the efficacy of vasopressin have been placed on the ACUTE CARE, INC. website. Review them by logging on to:
http://www.acutecare.com/vasop.htm

Alternative ways of performing CPR?

Much-anticipated revelations in the revision of theory and practice guidelines 
for BCLS, ACLS and PALS aren't due until the August 15th publication of 
Circulation, an American Heart Association journal (instead of the JAMA, 
as has been past tradition). For nearly two years, the process of collecting 
information and evidence, reviewing it, and discussing implementation 
strategies has been underway. Following committee meetings this past February, participants in the process now have pledged not to disclose findings early. There has been a fair amount of public discussion and debate regarding revisions in BCLS, particularly when dealing with the lay public. While we await definitive word regarding changes, we provide the following two sites for your perusal concerning alternative CPR techniques for healthcare providers. 

http://www.vet.purdue.edu/iaccpr/
IAC (interposed abdominal compressions) CPR

http://lal.cs.byu.edu/ketav/issue_2.5/cardio.html
vest-assisted and ACD active compression-decompression CPR

Fireworks 

(Want to have some safety handouts available at your facility? Reproducible 
forms describing safe fireworks purchase and use are available on the following website: http//:www.acutecare.com/fireworksafety.htm for your use with permission by the National Council on Fireworks Safety.  Their homepage is located at http://www.fireworksafety.com/)

Federal safety regulations, perhaps with increased consumer awareness, are 
making the Fourth of July holidays safer than ever. Fireworks injury rates are 
at an all-time low dropping 44% just from 1994 to 1998. The U.S. Consumer 
Product Safety Commission (CPSC)* (using a sampling technique in surveying selected hospitals and subsequently estimating the number of fireworks-related injuries) estimates that 7,000 people were treated for fireworks-related injuries in 1998. This is down from an estimated 8,300 in 1997 (and 10,900 injured in 1995 and 12,500 in 1994). These figures include commercial and homemade items, as well as large (and illegal) explosive devices. The explosive devices like M-80s and M-100s have been banned since 1966, though these illegal explosives still account for one-third of all Fourth of July injuries. A recent report prepared by CPSC analyzed injury data collected over a seven year period, and concluded that "legal fireworks" accidents were relatively minor, did not result in hospitalization and most often involved "misuse" rather than "malfunction." 

In 1976, the Consumer Product Safety Commission moved to regulate legal 
fireworks products. All fireworks now legally available for sale to consumers 
must comply with the CPSC rules. States, counties and municipalities regulate their availability and use. Since the adoption of these regulations, the amount of fireworks used each year has doubled, suggesting that the injury rate in terms of injuries per one million pounds of fireworks ignited has declined significantly. This Fourth of July, legal fireworks that meet the safety regulations of the CPSC will be on sale in 40 of 50 states and the District of Columbia.  Recently, legal fireworks were reclassified within two major categories (consumer and display). "Consumer" fireworks are those fireworks devices formerly classed as "Class C Common Fireworks" and now classed at "Fireworks 1.4G" by the U.S. Department of Transportation [Title 49, Code of Federal Regulations, Part 173.56 (j)]. State laws may vary as to what types of devices are deemed to be "fireworks" under state law. "Consumer" fireworks include cone fountains, cylindrical fountains, roman candles, sky rockets, firecrackers, mines and shells, helicopter-type rockets, certain sparklers and revolving wheels.

Some examples from Midwestern states are listed below (from information from the American Pyrotechnics Association): Please note-Below is a summary of state laws and not intended to be the sole or definitive statement of the individual laws. Local city and county laws may be more stringent that the state laws. This listing is to be used as a guideline only. State and local laws should be consulted before purchasing and/or using fireworks. For overview information on other states, please refer to the National Council on Fireworks Safety's website at http://www.fireworksafety.com/

Kansas
specifically permitted - all pyrotechnic devices classified as "consumer fireworks" by US DOT and labeled as Class C except certain rockets.
Specifically prohibited - any rocket mounted on a wire or stick, including any device containing such rockets.
Selling period - June 27-July 5 including delivery of mail order fireworks.

Illinois
specifically permitted - sparklers, snake/glow worm pellets, smoke devices, trick noise makers, plastic and paper caps.
specifically prohibited - firecrackers, torpedoes, skyrockets, roman candles, bombs

Iowa
specifically allowed - gold sparklers containing no magnesium, chlorate or perchlorate, flitter sparklers not more than 1/8" in diameter, snakes containing no mercury.
specifically prohibited - firecrackers, torpedoes, skyrockets, roman candles, dayglo bombs.

Minnesota  
specifically allowed - none.
specifically prohibited - firecrackers, torpedoes, skyrockets, roman candles, dayglo bombs, sparklers.

Missouri
specifically permitted - fireworks that comply with the US consumer Product Safety commission regulations
specifically prohibited - ground salutes that exceed DOT Class C limits
selling period - June 20-July 10, Dec. 20-Jan 2.
age to purchase - 14 unless accompanied by an adult.

Nebraska
specifically permitted - gold and silver sparklers (colored sparklers prohibited after 1999 season), spray fountains, torches, color fire cones, star and comet type aerial shells without explosive charge, lady fingers not to exceed 7/8" in length and 1/8" in diameter, total pyrotechnic composition not to exceed 50 mg each, color wheels and any other item approved for sale by fire marshal. Samples must be submitted to fire marshal prior to sale, for examination. Permissible fireworks list issued annually.
selling period - June 25-July 4.

Too few new flu vaccinations available this fall?

U.S. health officials announced on Thursday (June 22) that production problems will delay distribution and could lead to a flu vaccine shortage this fall. Two of the four manufacturers, Parkedale Pharmaceuticals Inc. (Rochester, Michigan) and Wyeth Laboratories Inc. (Marietta, Pennsylvania) were cited by the FDA's Center for Biologics for manufacturing problems. Parkedale was notified back on March 20 to cease production and distribution of flu vaccine until the problems were corrected. 

Production appears problematic because one of the strains in this year's vaccine is growing slower than anticipated under laboratory conditions. Reuters reports that Dr. Nancy Cox, chief of the influenza branch of the Centers for Disease Control and Prevention, has stated "We've never had a situation that was quite this dramatic." Dr. Cox states that she is uncertain about "..the full extent of vaccine production for this year," with both the FDA and CDC attempting to identify likely on-hand quantities for later this year. 

A+B+21 = A and/or B+180?

This past April at the 10th International Symposium on Viral Hepatitis and 
Liver Disease in Atlanta, researchers reported success in immunizing against 
hepatitis A and B with a combined vaccine on an accelerated 21-day schedule. Dr. Jane N. Zuckerman from the Royal Free Hospital School of Medicine, in London, UK, and collaborators presented their findings after performing a multi-center study. A total of 497 volunteers received a combined hepatitis A/B vaccine known as Twinrix(TM), given on a rapid 0,7- and 21-day schedule. They then measured the patients' immunoreactivity and compared them with a group who had received the hepatitis B vaccine Engerix(TM)-B on days zero, seven and 21 and the hepatitis A vaccine Havrix(TM) on day zero. Researchers found that the rapid schedule yielded a strong immune response against hepatitis A and B and required fewer injections. Accelerating the administration schedule may prove to be useful in providing immunization support for travelers and others in need of more rapid support than current schedules. Zuckerman hopes that by year's end Twinrix (15 years old and above) and Twinrix Junior (1-15 years old) will be licensed for distribution in the US. It is currently available in Canada and Europe.

(TWINRIX™ is a combined vaccine for adults formulated from the same bulk 
vaccines that are used to produce HAVRIX™ (inactivated hepatitis A vaccine) 
and Engerix-B® (hepatitis B surface antigen, recombinant). Each 1.0 ml dose 
contains 720 ELISA units of inactivated hepatitis A viral antigen and 20 ug of 
hepatitis B purified surface antigen protein. The recommended adult dose is 1.0 ml, injected intramuscularly, preferably in the deltoid region. Three primary doses are recommended, currently at intervals of 0, 1, and 6 months. The need for and timing of booster doses have not been established. The most frequent adverse effect is mild injection-site soreness, reported after about 40% of doses. Other reported side effects include redness at injection site, headache, fatigue, malaise, and nausea. Side effects of the combined vaccines do not differ in frequency or severity from the monovalent vaccines).

Words of Wit and Wisdom

Sometimes there's no greater wisdom to be found than in the gentle humor of the late Will Rogers. Amongst his social truths:

"If you're ridin' ahead of the herd, take a look back every now and then to make sure it's still there."

" If you get to thinkin' you're a person of some influence, try orderin' somebody else's dog around."

"Never kick a cow chip on a hot day."

"Lettin' the cat outta the bag is a whole lot easier 'n puttin' it back in."

"If you find yourself in a hole, the first thing to do is stop diggin'."

"There's two theories to arguin' with a woman. Neither one works."

"The quickest way to double your money is to fold it over and put it back in your pocket."

And finally from retired Tonight Show host Johnny Carson, "If life were fair, Elvis would be alive and all the impersonators would be dead."

This e-newsletter is available through the generous unrestricted support of 
ACUTE CARE, INC. You can find out more about ACUTE CARE, INC.
by going online to http://www.acutecare.com
Archived copies of this newsletter are available at that site.

If you have questions, concerns or ideas;
Or you have trouble with the display of this e-mail, 
please send your message via e-mail to: prairiEDocs@aol.com
If you wish to no longer receive issues of this e-newsletter, send your
'unsubscribe" message to the same e-mail address.