The assistant U.S. Surgeon General has released the strongest statement yet about the lack of credible scientific links between Autism and the vaccine preservative, Thimerosal.
I have talked about this issue here and over at the MedicCast site numerous times. I have also talked with other medical podcasters, like Dr. Mike of the Pediacast podcast. We all agree that knowledge is power and access to thoroughly researched information is the best way to educate our patients. I urge you to read this article and share the information inside with others in the healthcare arena.
Phenytoin (commonly known by the brand name Dilantin® ) has been used since the 1930’s as an anticonvulsant and is still a first-line drug used for some seizure disorders. Many overdoses with phenytoin are reported to poison centers, but fatalities are rare.
Absorption of oral doses of phenytoin is often erratic and delayed. It’s not unusual to see gastrointestinal absorption continue for several days. Phenytoin is highly protein bound and rapidly distributed to all tissues. Therapeutic levels are 10-20 mcg/mL.. Labs routinely test for total phenytoin; however, only free or unbound phenytoin is responsible for clinical effects. More than 95% of the drug is metabolized by the liver. The half-life of phenytoin is 6-24 hours with therapeutic doses but is prolonged in overdoses, to 20-60 hours.
Acute phenytoin toxicity produces mainly neurologic symptoms that may persist for days to a week or more. Phenytoin concentrations greater than 15-20 mcg/mL are associated with horizontal and/or vertical nystagmus, ataxia is seen with levels greater than 30 mcg/mL , and slurred speech, confusion and lethargy appear at levels greater than 40-50 mcg/mL. Large overdoses may also result in tremor, delirium, hyperreflexia, dyskinesias, hallucinations, and coma. Nausea and vomiting can occur following phenytoin ingestions because of the large amount of undissolved drug in the stomach. Respiratory depression rarely occurs. High doses of intravenous phenytoin or rapid infusions can result in hypotension, bradycardia and dysrhythmias due to myocardial conduction depression. These cardiovascular effects are thought to be due to the propylene glycol diluent in the parenteral form of phenytoin. Cardiovascular toxicity following oral overdoses has not been reported; therefore, patients who ingest large amounts of phenytoin do not need cardiac monitoring.
Treatment consists of supportive care and activated charcoal. Repeat doses of charcoal are often recommended to prevent further absorption of any drug that persists in the GI tract. Ataxic patients should be observed closely and steps taken to prevent falls. Because of its erratic absorption, phenytoin levels should be repeated every six hours after an acute overdose.
See Also - these poisoning and overdose segments on the Nursing Show:
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Researchers at Children’s Hospital of Philadelphia (CHOP) conducted a study of preventative health screenings of children in the first years of life and how those screenings were affected by continuity of care. In this case continuity of care referred to having the same medical provider perform assessments and care during the first six months of life.
The study focused on the children most at risk for preventable and treatable diseases like lead poisoning and tuberculosis exposure. Children in urban, low income families were more likely to have a variety of providers assessing them over the early months and years of life. Without a clear understanding of baseline responses that a provider might establish over a series of well and sick child visits (is the child normally irritable, has the child been developmentally appropriate, etc.), the child is more likely to have preventable conditions assessed and correctly diagnosed early.
For those of us who deal with these at risk populations, early recognition and treatment is key to preventing long term negative outcomes. When dealing with the parents of these children, stress to them the importance of returning to the same clinics and even to the same nurse, nurse practitioner, or physician’s assistant if not to the same doctor.
More news to come out of the studies presented at the International Stroke Conference in New Orleans last week. Yesterday I reported on the reports of some positive effects in aggressively reducing blood pressures in the treatment of Hemorrhagic strokes. Today the results seem to be more mixed with regards to some studies on strokes caused by thrombi.
Current treatments are often effective when thrombolytic agents are administered within three hours of the onset of symptoms. The new studies are searching for a treatment that is effective past that three hour mark. The results are mixed on the treatments and medications that have been tried.
One study looked at administering tPA as late as five hours after onset of symptoms. The goal was to save peripheral brain tissues not yet completely affected by the stroke. Another treatment tried involved a catheter based vacuum device to remove the clot directly, however while it showed some promise, the device caused some bleeding.
One attendee stated that the studies were small and might be shown to be more promising with a larger trial.
The study authored at the University of Sydney, in Australia, looked at 404 hemorrhagic stroke patients in Asia and Australia. In the study they looked at aggressively decreasing blood pressure in these stroke patients using hypotensive agents. Remember Cushing’s triad — when intracranial pressure increases, respirations decrease (or become eratic) and heart rate decreases while blood pressure increases.
Current theory held that decreasing pressures to 180 systolic was the best treatment. This study found improvement by lowering systolic BPs to 140 as a target. The study had 1/3 less bleeding in the aggressively decreased patients without any significant side effects noted. This could be a major treatment improvement in a type of stroke that was often fatal.
The Australian government plans to fund a larger, more ambitious study later this year with 2500 patients. The hope is to replicate and further refine the target numbers to find the best range for maximal blood pressure during hemorrhagic strokes.
The World Health Organization has released data from a recent study that points to an alarming increase in the rates of multi-drug resistant forms of tuberculosis (MDR-TB). The study looked at TB reports from 81 different countries from 2002-2006. They found MDR-TB reported in 57 of those countries.
The report also found a possible link between HIV positive patients and higher rates of MDR-TB. This finding refers to studies of HIV patients in the Ukraine and Latvia. Overall, the WHO study states that 5% of the 9 million reported cases of tuberculosis worldwide are of the multi drug resistant variety.
The fear discussed in this article is that unless a major assault on MDR-TB is not coordinated by world health leaders, this disease may eclipse HIV as the major infectious disease of the world. Find out what the situation is in your region. Know what the status of recent TB and MDR-TB reports are for your community.
A study looking at ways to cut childhood obesity and hypertension found that by cutting dietary salt, they could cut down on the amount of sugared soft drinks consumed by children.
The study was released in Hypertension: Journal of the American Heart Association and was conducted by researchers at St. George’s University of London, England.
The researchers looked at 2000 people between the ages of 4 and 18 who participated in a 1998 dietary survey. They found that children who had low salt diets consumed less liquid. They correlated a decrease of 1 gram of salt with a decrease of 100 mL of fluid intake. The authors further offered that by cutting average salt intake in half, children would consume 2 fewer sweetened soft drinks per week (amounts to 250 kcal less per week).
This is an important look at how simple changes in lifestyle have major long term health effects. This change in food preparation and choices has a long term health effect on development of hypertension and obesity.
The question is bound to come up sometime — When is the best time to have your heart attack or cardiac arrest when you are in the hospital (it’s important to plan ahead)?
There was a study a year or so ago that focused on the increased mortality rates for cardiac arrest patients in different facilities (rural, urban, suburban) and on different days of the week. Not surprisingly, the study found that small rural hospitals and most hospitals on weekends had poorer survivability from cardiac arrest.
What about the time of day? Well someone else thought to ask and that study has now been released. The authors found in their case review that 15% of cardiac arrest in hospitals survived between the hours of 11 PM and 7 AM compared to 20% during the daytime hours. Again, I’m not terribly surprised. After hours, staffing ratios fall as many patients are asleep. Often in small hospitals, the only doctor in the building is in the emergency department after 8 or 9 PM.
Try running a code simultaneously in the ICU at one end of a building and in the ED at the other. Difficult to do, right? It’s important to review this information for your facility and determine whether a different set of standing orders needs to be in place for after hours care in the onset of acute emergencies requiring ACLS interventions.
Many med-surg nurses don’t maintain their ACLS certifications (because they’re not required to) or perhaps never got them to begin with. There needs to be a code team in place to handle the onset of multiple cardiac events even in — or perhaps especially in — smaller hospitals so that patient care and survivability can reach its full potential.
In another study about antibiotic effectiveness, the analysis by the Dutch researchers is that the use of antibiotics for the treatment of inner ear in children is not effective in reducing fluid build up or effusion in the middle and inner ear. They recommend that the use of antibiotics as a method of reducing the associated fluid build up during these infections.
Opponents of this report don’t dispute the dangers of overuse of antibiotics but point out that in cases of Otitis Media, these patients are getting their antibiotics not to reduce effusion but to reduce the infection causing the inflammation and pain, something this meta analysis did not look at.
Alternatives may need to focus on pain reduction rather than treatment of infection if indeed the presentation of fluid build up behind the ear drum is happening regardless of treatment and resolves on its own. Look for more articles on this study and further trials to look into the effectiveness of antibiotic treatment for this and other common infections in the future.
The assistant U.S. Surgeon General has released the strongest statement yet about the lack of credible scientific links between Autism and the vaccine preservative, Thimerosal.
