Cyanide exposure in fires

Tablets

PERCOCET:5 C

Brief Summaryof PrescribingInformation DESCRIPTIONEach tablet of PERCOCET®-5contains 5 mg oxycodonehydroehloride(WARNING:May be habit forming), 325 mg acetaminophen (APAP). INDICATIONSFor the relief of moderateto moderately severe pain. CBNTRAINDICATIONSHypersensitivity to oxycodoneor acetaminophen. WARNINGSDrugDependenceOxycodonecan produce drug dependenceof the morphine type and, therefore, has the potential for being abused. Psychic dependence,physical dependenceand tolerance may develop upon repeated administration of PERCOCET®-5,and it should be prescribed and administered with the same degree of caution appropriate to the use of other oral narcotic-containing medications. Like other narcotic-containing medications, PERCOCET®-5is subject to the Federal Controlled Substances Act. Usagein ambulatorypatientsOxycodonemay impair the mental and/or physical abilities required for the performanceof potentially hazardoustasks such as driving a car or operating machinery. The patient using PERCOCET®-5should be cautioned accordingly,

Hemophilus meningitis in Portsmouth. W a r e SJ, McL a u c h l a n S, Lancet 2:197-199, (Jul) 1978. Hemophilus influenzae is the most common cause of bacterial meningitis in children under 4 years of age. The clinical presentation and subsequent course of 25 cases seen at a British hospital are presented. Lethargy and vomiting are the most reliable presenting symptoms, seen in 84%; convulsions occurred in 20%, and meningeal signs were absent in 20%. The value of lumbar puncture and blood culture is emphasized. Outcome depended on several factors, poorer outcome being related to a) age less than 9 months; b) seizures; c) late diagnosis; d) combination of antibiotics, and e) poor home situation. Chloramphenicol alone appeared to have better results t h a n c h l o r a m p h e n i c o l in c o m b i n a t i o n w i t h a m p i c i l l i n . (Editor's note: The diagnosis of meningitis is not easy. In addition to stressing the value of lumbar puncture, there are two interesting points in this paper. First is the high correlation of blood culture. Second is the adverse effect of chloramphenicol in conjunction with ampiciltin. Perhaps a return to penicillin, sulfa and chloramphenicol makes the most sense especially since Gram stains are also misleading.) Frank Purdie, MD

Interactionwith othercentralnervoussystem depressantsPatients receiving other narcotic anal-

meningitis, hemophilus

gesics, general anesthetics, phenethiazines,other tranquilizers, sedative-hypnotics or other CNS depressants (including alcohol) concomitantly with PERCOCET®-5may exhibit an additive CNS depression. When such combined therapy is contemplated, the dose of one or both agents should be reduced. Usagein pregnancySafe use in pregnancyhas not been established relative to possible adverseeffects on fetal development.Therefore,PERCOCET®-5should not be used in pregnant women unless, in the judgment of the physician, the potential benefits outweigh the possible hazards. Usagein childrenPERCOCET®-5should not be administered to children.

Cyanide exposure inflres. S y m i n g t o n IS,.Ap.derson RA, O l i v e r JS, et al, Lancet 2:91-92, ( l u l l 1 9 7 8 . ..... ~.~ Although carbon monoxide :(CO) is the major to~/ic substance produced in fires, substantial quantities of organic cyanides are produced in combustion of nitrogen-containing materials used in domestic furnishings. Cyanide is a recognized potent metabolic poison. The blood level suggested as fatal is 112 p tool/liter. In this study, only 4% of fatalities had blood levels in t h i s range, but t h r e e s u r v i v i n g victims were symptomatic (myocardial ischemia) with elevated cyanide and normal CO levels. This toxin ought to,be considered in any patient suffering an inhalation injury. (Editor's note: This may indeed be a more common problem than has been perceived. The victims of the Midway plane crash in 1972 were thought to have died from cyanide poisoning caused by the seat materials as they burned rather than smoke or flame.) Frank Purdie, M D

cyanide, fires

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PRECAUTIONSHead injuryand increasedintracranial pressureThe respiratory depressant effects of

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The effectiveness of surgical treatment of acute aortic, dissection. T h o m a s CS, A l f o r d WC, B u r r u s G R , et al~: . Ann Thorac S u r g 26:42-49, ( l u l l 1978. "~ ~' As a growing number of patients are surviving operative repair of acute aortic dissection, a retrospective study of ten consecutive patients was undertaken. Half of this group had ascending dissections while the other half had descending dissections. Four out of five patients in each group survived. All survivors had postoperative aortography after recovery. Results of follow-up angiography revealed a significant residual false lumen (beyond area repaired) in all but one patient. However, no proximal dissection occurred and no deaths resulted from this abnormality. It is felt that the success of this operation is related to removing the major causes of death, namely aortic rupture at the site of the intimal tear, or r e t r o g r a d e dissection into the p e r i c a r d i u m or pleura. Therefore, surgical treatment of aortic dissection is effective because it avoids the major sources of mortality. The authors are unsure of the clinical significance of residual abnorr e a l i t i e s and s u g g e s t close follow-up of t h e s u r v i v o r s . (Editor's note. Spontaneous [as opposed to posttraumatic] dissection is a rare emergency department presentation. When it does occur, it is most often confused with acute myocardial infarction with eardiogenic shock. Clues are the presence of severe pain unrelieved by morphine, back pain, loss of leg pulses and less frequently, a tearing sensation in the chest. Aortography is neces'sary to confirm the diagnosis.) W. Lucke, MD

DEAOrderFormRequired. PERCOCET® is a U.S. registeredtrademarkof Endo Inc.

Inc. Manati, PuertoRico00701 Subsidiaryof EndoLaboratories,Inc.

aortic rupture; aortography 76/21 4

narcotics and their capacity to elevate cerebrospinal fluid pressure may be markedly exaggeratedin the presenceof head injury, other intracranial lesions or a pre-existing [hcrease in intracranial pressure. F~rthermo~ narcotics produce adverse reactions • W~ic~.i,ma~'obscurethe clinical course of patients with heart irijdrie's. Acute~BdbminalconditionsThe administration of PERCOCEI-®-5or other narcotics may obscurethe diagnosis or clinical course in patients with acute abdominal conditions, SpecialriskpatientsPERCOCET®-5should be given with caution to certain patients such as the elderly or debilitated, and those with severe impairment of hepatic or renal function, hypothyroidism,Addison's disease, and prostatic hypertrophyor urethral stricture• ADVERSEREACTIONSThe most frequently observed adverse reactions include light-headedness, dizziness, sedation, nausea and vomiting. These effects seemto be more prominent in ambulatorythan in nonambulatery patients, and some of these adverse reactions may be alleviated if the patient lies down. Other adverse reactions include euphoria, dysphofia, constipation, skin rash and pruritus. DOSAGEAND ADMINISTRATIONDosageshould be adjusted according to the severity of the pain and the responseof the patient. It may occasionally be ' necessaryto exceedthe usual dosage recommended below in cases of more severe pain or in those patients who have becometolerant to the analgesic effect of narcotics, PERCOCET®-5is given orally. The usual adult dose is one tablet every6 hours as neededfor pain. DRUGINTERACTIONSThe CNS depressant effects of PERCOCET® -5 may be additive with that of other ONS depressants.See WARNINGS, 6085 BS

Subsidiary of the DuPont Company

JACEP

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8:5 ( M a y ) 1979