The Treatment of Toxic Trauma

So far, we have considered the nature of toxic trauma, how exposure can occur and the presentation and diagnosis of those affected. This chapter concerns detailed management of casualties, both in terms of early life support, antidote and supportive therapy, including the specific investigations and treatment required for each class of toxic agent. For a limited number of classes of toxic agent, both military and civil, there are antidotes available. However, in most cases, only general treatment measures are available. 

Because of the latency of certain toxic agents, both reactive and proactive approaches to treatment are necessary in toxic trauma, in order to manage immediate life-threatening conditions and also to mitigate developing pathophysiology with a longer latency. 

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The recognition that the treatment of toxic trauma based on these principles is only needed and would only be effective for people affected by chemical agents with high toxicity and short latency. 

There are two main stages in the management of toxic trauma, pre-hospital and hospital. Life-saving and other treatment must be provided seamlessly in both settings. In particular, provision of early treatment at the site of release of the toxic agent is of vital importance where the actions are of short latency and there is risk of death from respiratory failure. 

The treatment of acute PCP toxicity depends on the pattern of intoxication and the physical findings. On the prison wards of the LAC/USC Medical Center, approximately 60 percent of patients are treated and released within 24 hours. Most of these patients have minor patterns of intoxication and no medical complications. Another 10 percent of patients have minor problems with medical complications, usually trauma. 

LEE with chloroform from acidified serum is widely executedafter the method of Shiu and Nemoto. However, chloroform is of great toxicity and is not suitable for routine use. LLE with pentane at pH 6.4 was investigated for feasibility with seven barbiturates and was found to be specific for thiopental—an important barbiturate being used for anaesthetic medication and treatment of head trauma with severe brain injury. Comparing acetonitrile deproteinization with chloroform deproteinization, Shihabi demonstrated the feasibility of acetonitrile for extraction of pentobarbital. However, electropherograms obtained by extraction with chloroform are more sensitive and cleaner.Wu et al. used LLE with ether for extraction from serum, and chloroform for extraction from urine. They obtained recoveries of six barbiturates from 86.6% to 118%. 

Head trauma, meningitis, childhood fevers, brain tumors, and degenerative diseases of the cerebral circulation are conditions often associated with the appearance of recurrent seizures that may require treatment with anticonvulsant drugs. Seizures also may be a toxic manifestation of the action of central nervous system (CNS) stimulants and certain other drugs. Seizures often occur in hyperthermia (febrile seizures are very common in infants) sometimes in eclampsia, uremia, hypoglycemia, or pyridoxine deficiency and frequently as a part of the abstinence syn-... 

Iron deficiency is the most common cause of resistance to erythropoietic therapy. Evaluation and treatment of iron deficiency should occur prior to initiation of erythropoietic therapy as previously discussed (see Figs. 44—1 and 44—2). Inflammation (localized or systemic infection, active inflammatory disease, or surgical trauma) is associated with defective iron utilization known as reticuloendothelial block. Reticuloendothelial block is characterized by a reduction in iron delivery from body stores to the bone marrow, and is generally refractory to iron therapy. Failure to respond to erythropoietic therapy requires evaluation of other factors causing resistance, such as infection, inflammation, chronic blood loss, aluminum toxicity, hemoglobinopathies, malnutrition, and hyperparathyroidism. Erythropoietic therapy may be continued in the infected or postoperative patient, although increased doses are often required to maintain or slow the rate of decline in Hgb/Hct. Deficiencies in folate and vitamin Bi2 should also be considered as potential causes of resistance to erythropoietic therapy, as both are essential for optimal erythropoiesis. Patients on hemodialysis or peritoneal dialysis should be routinely... 

Shock may accompany almost any type of severe injury, exposure to toxic chemicals, a heart attack, loss of blood, burns, or any other severe trauma. It can be recognized from a number of characteristic symptoms skin cold to the touch (possibly clammy and bluish or pale), weakness, a rapid weak pulse, rapid irregular breath, restlessness, and exhibition of unusual signs of thirst. As the condition worsens, the victim will become unresponsive and the eyes may become widely dilated. The treatment for shock is ... 

Levels of platelet-activating factor are elevated in several neurological and visceral disorders, including brain trauma, seizures, stroke, multiple sclerosis, and viral and bacterial infections, as well as in a variety of other conditions such as asthma, thrombosis, toxic shock, and dermatitis. Administration of PAF antagonists slows down the progression of these disorders. Thus, the development of new non-toxic PAF antagonists would result in better treatment of visceral and neurological disorders. 

As has been noted, toxic trauma occurs in both the military setting, where the release of chemicals specifically designed to cause harm is a deliberate action or in civil life, where the release is usually accidental and involves toxic industrial chemicals that are used in chemical engineering and have coincidental harmful elfects. The continued development, transport and use of toxic industrial chemicals and the increasing likelihood of accidental and deliberate release make toxic trauma in civilians and their need for pre-hospital and hospital treatment an increasingly likely occurrence. 

The recognition that treatment of conventional or toxic trauma in potential toxic environments requires access to and use of appropriate personnel protective equipment. 

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