¿Cargar y llevar o quedarse en la escena en el paciente de trauma? / Trauma: Should You Stay or Should You Go?

¿Cargar y llevar o quedarse en la escena en el paciente de trauma? / Trauma: Should You Stay or Should You Go?

TITULAR: 
Cosen a navajazos a un joven a las puertas de una discoteca en Carabanchel
El agredido recibió al menos siete heridas de arma blanca en tórax y espalda, una de ellas penetrante, así como golpes y contusiones en la cara y cabeza

Ese sistema va contra de todo lo estipulado en los libros de trauma, en todo lo visto en congresos por expertos internacionales, dilatar innecesariamente a un paciente en la escena, cuando estamos a minutos de hospitales de trauma de alto nivel y estándar con cirujanos de trauma 24/7/365, con capacidad de transfusion, veo un riesgo a correr con la vida del paciente quedarse a hacer procedimientos realmente dilatorios en la escena. es comun ver estos casos en Europa, pero de verdad prefiero la medicina de acción Americana en la que el paramedico no asume procedimientos dilatorios en la escena y lleva al paciente a la sala de urgencias en donde se sobran personal y recursos. Opinion Personal -Profesional @drramonreyesmd 21/04184 Colegiado en España

¿Digo yo en mi ignorancia como medico, no seria mas facil llevar al paciente al hospital y hacer sus cosas en el camino, al final eso es asunto de cirugia? Digo yo en mi ignorancia como MEDICO... by Dr. Ramon Reyes, MD

Pongo el numero de colegiado en España, por encontrar uno que otro experto en la materia que ante la incapacidad de discutir en base medicina basada en evidencias, pues tratan de descalificar a quien suscribe y a cuantos digan lo contrario de sus acciones,,, pero lo siento, no tengo la capacidad de ver algo que entiendo en base a mas de 30 años en las calles milles de millas recorridas, miles de horas de practicas en salud y educación, pues alguien tiene que decir, la Foto muy bonita, pero please al quirófano, es el destino final y mientras mas rapido, pues mejor, porque sangre se sustituye con sangre y hacer muchos procedimientos en medio de una ciudad, pues como que no,,, diferente si hablamos de medicina de combate, medicina austera, medicina de desastre, medicina remota, etc, ahi si o si, debes de hacer algo mientras puedes evacuar al paciente a una facilidad final de mayor nivel de atención.

 by @DrRamonReyesMD

CREO SER EL UNICO IGNORANTE EN EL MUNDO QUE LO VE,,, PUES CREO QUE SI

Trauma: Should You Stay or Should You Go?

11/22/2012

ACEP

WASHINGTON-The results of a 14-year study of trauma patients brought to a level I trauma center come close to settling the debate over the "load and go" versus "stay and stabilize" approach to patient care in the out-of-hospital setting: the answer depends on whether the injuries are penetrating or blunt ("Emergency Medical Services Out-of-Hospital Scene and Transport Times and Their Association with Mortality in Trauma Patients Presenting to an Urban Level I Trauma Center").

The study—the first of its kind to analyze data spanning more than a decade—was published recently in Annals of Emergency Medicine.

"We observed an association between longer out-of-hospital times, in particular scene times, and mortality in patients with penetrating trauma," said lead study author C. Eric McCoy, MD, MPH, of the University of California Irvine School of Medicine in Orange, Calif. "Given the challenges of providing out-of-hospital care to heterogeneous populations through a heterogeneous delivery system, it is imperative that the medical community identify patients who may benefit from timely care before abandoning the notion that faster is better for all patients in the out-of-hospital setting."

Researchers analyzed records for 19,167 trauma patients. Eighty-four percent of the injuries were blunt and 16 percent were penetrating. For patients with penetrating trauma, higher odds of mortality were observed when treatment delivered at the scene exceeded 20 minutes. Longer transport times were not associated with increased odds of mortality in patients with penetrating trauma. For patients with blunt trauma, there was no association between scene or transport times and increased odds of mortality.

"Our findings support the 'golden hour' concept of trauma care and are consistent with the previously demonstrated hospital-based beneficial effect on survival," said Dr. McCoy. "Our study also supports the conclusion that even if transport time is longer because of geographical distance from the scene to a trauma center, seriously injured patients benefit by being transported to trauma centers for hospital-based care."

Annals of Emergency Medicine is the peer-reviewed scientific journal for the American College of Emergency Physicians, the national medical society representing emergency medicine. ACEP is committed to advancing emergency care through continuing education, research, and public education. Headquartered in Dallas, Texas, ACEP has 53 chapters representing each state, as well as Puerto Rico and the District of Columbia. A Government Services Chapter represents emergency physicians employed by military branches and other government agencies. For more information visit www.acep.org.

https://www.emsworld.com/news/10832964/trauma-should-you-stay-or-should-you-go

Prehospital care - scoop and run or stay and play?

Injury. 2009 Nov;40 Suppl 4:S23-6. doi: 10.1016/j.injury.2009.10.033. Smith RM1, Conn AK.

Author information

Abstract

Improved training and expertise has enabled emergency medical personnel to provide advanced levels of care at the scene of trauma. While this could be expected to improve the outcome from major injury, current data does not support this. Indeed, prehospital interventions beyond the BLS level have not been shown to be effective and in many cases have proven to be detrimental to patient outcome. It is better to "scoop and run" than "stay and play". Current data relates to the urban environment where transport times to trauma centres are short and where it appears better to simply rapidly transport the patient to hospital than attempt major interventions at the scene. There may be more need for advanced techniques in the rural environment or where transport times are prolonged and certainly a need for more studies into subsets of patients who may benefit from interventions in the field.

PMID:

 

19895949

 

DOI:

 

10.1016/j.injury.2009.10.033 .  

https://www.ncbi.nlm.nih.gov/pubmed/19895949

Prehospital trauma care: a clinical review.

Beuran M1, Paun S, Gaspar B, Vartic N, Hostiuc S, Chiotoroiu A, Negoi I.

Author information

Abstract

INTRODUCTION:

There are many controversies related to the trauma patient care during the pre-hospital period nowadays. Due to the heterogeneity of the rescue personnel and variability of protocols used in various countries, the benefit of the prehospital advanced life support on morbidity and mortality has been not established.

METHOD:

Systematic review of the literature using computer search of the Library of Medicine and the National Institutes of Health International PubMed Medline database using Entre interface.We reviewed the literature in what concerns the basic and advanced life support given to the trauma patients during the prehospital period.

RESULTS:

Although the organization of the medical emergency system varies from a country to another, the level of patient'scare can be classified into two main categories: Basic Life Support (BLS) and Advanced Life Support (ALS).There are many studies addressing what to be done at the scene.The prehospital care can be divided into two extremes: stay and play/treat then transfer or scoop and run/load and go.

CONCLUSIONS:

A balance between "scoop and run" and "stay and play" is probably the best approach for trauma patients. The chosen approach should be made according to the mechanism of injury (blunt versus penetrating trauma), distance to the trauma center (urban versus rural) and the available resources.

RevistaChirurgia.  https://www.ncbi.nlm.nih.gov/pubmed/23116846

https://www.abc.es/espana/madrid/abci-cosen-navajazos-joven-puertas-discoteca-carabanchel-201903301816_noticia.html#vca=rrss&vmc=abc-es&vso=fb&vli=cm-general

https://www.reddit.com/r/ems/comments/8k2t0g/stay_and_play_or_transport_with_a_cardiac_arrest/

Hemos avanzado en el manejo prehospitalario en los ultimos años con la entrada de la TELEMEDICINA, REBOA, ECOFAST, etc 


Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA)? by Endovascular Resucitation and Trauma Management / Uso actual del balón de resucitación aórtico endovascular (REBOA) en trauma 
https://emssolutionsint.blogspot.com/2017/09/resuscitative-endovascular-balloon.html

TEMPUS PRO vital signs monitor with integrated telemedicine, use in remote medicine

http://emssolutionsint.blogspot.com/2018/05/tempus-vital-signs-monitor-with.html

Dr Ramon REYES, MD,
Por favor compartir nuestras REDES SOCIALES @DrRamonReyesMD, así podremos llegar a mas personas y estos se beneficiarán de la disponibilidad de estos documentos, pdf, e-book, gratuitos y legales..

Manual de Urgencias Carlos Bibiano Guillen. Jefe del Servicio de Urgencias del Hospital Universitario Infanta Leonor

Manual de Urgencias Carlos Bibiano Guillen.  Jefe del Servicio de Urgencias del Hospital Universitario Infanta Leonor

Enlace para DESCARGAR pdf Gratis  

Post By Dr. Ramon REYES, MD

MANUAL DE URGENCIAS 2º Edición By Dr. Carlos Bibiano Guillén

MANUAL DE URGENCIAS 2º EDIC.

Más de ciento cincuenta médicos de Urgencias y especialistas de más de 30 centros distintos han colaborado durante cerca de un año en la elaboración de esta obra cuya coordinación editorial ha dirigido el Dr. Carlos Bibiano Guillén, jefe del Servicio de Urgencias del Hospital Universitario Infanta Leonor. 

MANUAL DE URGENCIAS 2º Edición By Dr. Carlos Bibiano Guillén, 

jefe del Servicio de Urgencias del Hospital Universitario Infanta Leonor

Pincha aquí para descargar

Otros 

4ª edición del manual de Protocolos y Actuación en Urgencias (bajar gratis en PDF) 

http://emssolutionsint.blogspot.com/2016/07/4-edicion-del-manual-de-protocolos-y.html

Dr. Ramon Reyes, MD

http://emssolutionsint.blogspot.sg/2017/04/curso-tecc-tactical-emergency-casualty.html 

erisipela. erisipelas ampollosas

erisipela. erisipelas ampollosas

La erisipela es un tipo clínico superficial de celulitis: una infección cutánea que puede afectar a la dermis y al tejido celular subcutáneo (hipodermis).

Es una enfermedad infectocontagiosa aguda y febril producida por estreptococos.

DIAGNÓSTICO

Se caracteriza por una placa eritematosa roja de extensión variable, de bordes bien definidos y que puede causar dolor y prurito.

En el 90% de los casos la erisipela se manifiesta en las piernas y comienza a través de una herida (puerta de entrada).

Los factores de riesgo son numerosos. Influyen las condiciones locales (pie de atleta, úlceras de pierna) así como las enfermedades asociadas (linfedema, diabetes, alcoholismo).

El diagnóstico clínico de erisipela es fácil en su forma típica. En algunos pacientes en quienes la enfermedad es más profunda se dificulta por su apariencia y la posibilidad de que esté involucrada otra bacteria.

Cuanto más dérmica es la localización de la erisipela, más definidos están los límites del eritema y el edema.

Cuando la localización es profunda, sus límites están más indefinidos y su coloración es rosada. En estos sujetos es frecuente un origen estreptocócico, pero no es la única posibilidad y puede haber otras bacterias asociadas.

TRATAMIENTO

La rápida respuesta favorable a los medicamentos apoya el diagnóstico.

En 24 a 72 horas desaparece la fiebre y el dolor se reduce al igual que los signos cutáneos.

Si esto no es así, se debe analizar la posibilidad de complicaciones o tener en cuenta los marcadores de gravedad clínica citados más arriba.

Al resolverse el cuadro se produce un proceso de descamación.

En la erisipela de la pierna y en la celulitis, la primera medida de tratamiento es el reposo durante varios días con la pierna elevada. Esto reduce el edema y el dolor y es importante para combatir la fiebre.

Una vez que el paciente puede andar, las medias elásticas permiten una mejor contención. También reducen la recurrencia del edema así como el riesgo de linfedema. 

Se caracteriza por la presentación súbita y con fiebre, unas horas antes de la aparición de los signos cutáneos.

https://www.clinicadermatologicainternacional.com/es/tratamiento/erisipela/

celulitis por infección bacteriana

La celulitis es una infección bacteriana común de la piel que causa enrojecimiento, inflamación y dolor en el área infectada. De no tratarse, puede propagarse y causar problemas de salud graves.

El buen cuidado de las heridas y la higiene son importantes para prevenir la celulitis.

secreciones y cúbralas con una venda limpia y seca hasta que sanen.

médico examinando una herida abierta en la pierna de una paciente

Consulte a un médico

Consulte a un médico si tiene heridas punzantes u otras heridas profundas o graves.

Proteja las heridas e infecciones

Si tiene una herida abierta o una infección, evite pasar tiempo en los siguientes lugares:

Bañeras de hidromasaje.

Piscinas.

Cuerpos de agua naturales (p. ej., lagos, ríos, mares).

Las personas con diabetes deben revisarse los pies a diario para ver si tienen lesiones o signos de infección.

https://www.cdc.gov/groupastrep/diseases-public/cellulitis-sp.html

New Seizure treatment for EMS

Seizure treatment study: Implications for EMS

Being able to use an auto-injector can simplify the procedure and speed up the delivery time

By Art Hsieh

Seizures are a common call for EMS systems. Often the physical manifestations of the seizure activity is over by the time we arrive; rarely do we have to manage the more serious condition of status epilepticus.

Related Article: Study: Injection offers faster help for seizure patients

Because of its commonality, we might not consider the impact that seizures can have upon the patient, long after we managed their acute condition.
An advance like this has the potential to dramatically improve the overall health of the individual, and possibly reduce the need for emergency services.
There are also implications for EMS providers as well. It can be a challenge to administer an intravenous benzodiazepine when the patient is actively seizing.
Being able to use an auto injector can simplify the procedure and speed up the delivery time. It might also mean that terminating an active seizure might become a basic life support procedure. This can improve a system's overall ability to respond to these common calls.
That time might be some ways off. However, it's another interesting development in our business that benefits both patients and providers alike

About the author

EMS1 Editorial Advisor Art Hsieh, MA, NREMT-P currently teaches at the Public Safety Training Center, Santa Rosa Junior College in the Emergency Care Program. In the profession since 1982, Art has worked as a line medic and chief officer in the private, third service and fire-based EMS. He has directed both primary and EMS continuing education programs. A Past President of the National Association of EMS Educators, former Chief Executive Officer of the San Francisco Paramedic Association, and a scholarship recipient of the American Society of Association Executives, Art is a published textbook author, has presented at conferences nationwide, and continues to provide patient care at a rural hospital-based ALS system. Contact Art at Art.Hsieh@ems1.com.

 

 

 

Study: Injection offers faster help for seizure patients Results probably will change how seizures are treated by paramedics

Link to original information
 
By Erin Allday
The San Francisco Chronicle

Expert Analysis Seizure treatment study: Implications for EMS By Art Hsieh Seizures are a common call for EMS systems. Often the physical manifestations of the seizure activity is over by the time we arrive; rarely do we have to manage the more serious condition of status epilepticus. Because of its commonality, we might not consider the impact that seizures can have upon the patient, long after we managed their acute condition. An advance like this has the potential to dramatically improve the overall health of the individual, and possibly reduce the need for emergency services. Continue reading Seizure treatment study: Implications for EMS

SAN FRANCISCO —  Injecting patients in the thigh with a drug-loaded syringe is a safe and effective way to stop a seizure in an emergency, according to results of a national study released Wednesday, a finding that could pave the way toward making such syringes as widely available as EpiPens used to treat severe allergic reactions.
The two-year study, published in the New England Journal of Medicine, concluded that a single stab from an auto-injector was more effective in stopping a prolonged seizure than the traditional method of inserting an intravenous line and delivering the drug directly into the bloodstream.
The results probably will change how such seizures, which can be life-threatening if they're not stopped right away, are treated by paramedics. But they could have more long-term repercussions if doctors start giving the auto-injectors to epileptic patients, some of whom have several severe seizures a year, to use at home, much as people with severe allergies carry epinephrine syringes with them.
"I don't think we're ready to hand these out at epilepsy clinics for people to take home right now," said Dr. J. Claude Hemphill, chief of neurology at San Francisco General Hospital, who led the San Francisco arm of the study. "But that may be a follow-up some folks want to do."
The U.S. Department of Defense also has taken special interest in the study, because auto-injectors would be much more convenient than IV drug treatment in a large-scale bioterrorism attack involving seizure-inducing nerve gas.
"The advantage is you can give it the auto-injection faster," said Dr. Walter Koroshetz, deputy director of the National Institute of Neurological Disorders and Stroke. "If you have 100 people simultaneously seizing, no way can you do all those IVs. But you could just run around and inject everybody for their seizures."
Seizures are caused by a disruption in the brain's electrical system, and in most cases they resolve themselves after a minute or so. Roughly 2 percent of Americans have epilepsy, a condition marked by chronic seizures.
Some seizures, known as status epilepticus or prolonged seizures, can last several minutes or longer, and they may require drugs to stop them. More than 50,000 people in the United States die from prolonged seizures every year, either from brain damage due to the seizure itself or from accidents related to passing out mid-attack.
The study, which was funded primarily by the National Institutes of Health, involved 79 hospitals nationwide, including several in the Bay Area. More than 4,000 paramedics were trained to participate in the study and 893 patients were treated.
A drug and a placebo
Every patient was given both the auto-injector shot, usually to the thigh, and an intravenous injection. But in half the cases the auto-injector was filled with a placebo, and in the other half the IV drug was a placebo. Neither patients nor paramedics knew which treatment was the placebo in any given case.
Researchers found that 73 percent of patients who were given the auto-injector drug had stopped seizing by the time they reached the emergency room; 63 percent of patients who got the IV drug were seizure-free.
Patients who were given the auto-injector drug were less likely than the IV group to be admitted to the hospital after their seizure.
"This auto-injection should be the new standard of care," said Dr. James Quinn, a professor of surgery and emergency medicine at Stanford who led the study there. "It's great when you can do a study and it's probably going to change how we do things."
Although two different drugs were used in the trial - midazolam for the auto-injector and lorazepam for the intravenous injection - researchers don't believe that the drugs made a difference in how effective the treatments were. Rather, they said, the auto-injectors are simply easier to use.
It's much simpler to give a single shot than to try to start an intravenous line on a patient who is actively convulsing, doctors and paramedics said. In the study, 42 patients did not receive the intravenous treatment because the paramedic couldn't start the IV, whereas only five patients didn't receive the auto-injector shot because the syringe malfunctioned.
"It takes time to set up an IV. You have to find a vein that's going to be good, you have to isolate the arm and hold it still, you have to clean the arm, you have to insert the needle," said Judy Klofstad, a paramedic with the San Francisco Fire Department who participated in the study. "If you're really good, it can take 2 1/2 minutes."
Paramedics took on average just 20 seconds to use the auto-injector, according to the study. "You just hold their thigh down, target it, and it can go right through their clothing, through jeans even," Klofstad said.
Doctors said that because the auto-injection drug causes heavy sedation and can lead to respiratory problems and low blood pressure, more research is needed before the syringes are handed out to patients.
But Tiffany Manning, who has epilepsy and suffers a prolonged seizure every two or three months, said she's excited about someday being able to carry around an auto-injector. Her doctor at the UCSF epilepsy clinic has prescribed an oral drug that her parents can give her when she has a seizure, but it can be time-consuming and difficult to measure out the proper dosage and make sure she swallows it, she said.
"And when I wake up I have a funny taste in my mouth," said Manning, 30. "My doctor doesn't prescribe it very often. You can overdose someone on it. ... I'd rather just have a shot in the leg."

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Copyright 2012 San Francisco Chronicle
All Rights Reserved

Effective Prehospital Care for a Scorpion Sting. Are antivenins always necessary?

Scorpion Centruroides exilicauda

Bryan Bledsoe, DO, FACEP, FAAEM, EMT-P | From the April 2013 Issue | Wednesday, March 27, 2013

FROM www.jems.com 

There’s much more to Las Vegas than the casinos, bars and the bright lights of the Strip. Many wonderful parks and unique points of interest are nearby and offer respite from the constant grind of the city. One such park is the Valley of Fire State Park located just north of Las Vegas. This is a beautiful and striking collection of rocks and escarpments and is often used for movie and television shoots.

During the early summer, a 24-year-old Canadian tourist was visiting the park and climbing the various trails that wind through the wondrous rock formations. Evidently, the patient reached up onto a rock and felt a severe burning sensation on the dorsal surface of her right hand. She immediately withdrew her hand and saw a scorpion fall to a rock below. The burning sensation soon became intense pain and itching, and she developed shortness of breath followed by generalized hives. Her boyfriend was at her side and quickly scooped up the scorpion into a paper cup and helped his girlfriend down to the base of the trail. By that time, she was more short of breath and slightly diaphoretic. He placed her into their car and drove quickly to a nearby convenience store. There, the clerk summoned local EMS.

Prehospital Care
First responders arrived approximately eight to 10 minutes following the initial call. They began their primary assessment, administered supplemental oxygen and awaited arrival of paramedics. They questioned the patient about whether she had an EpiPen or similar epinephrine auto injector. She didn’t.

Soon, paramedics arrived and took over assessment. Their primary assessment revealed the patient to be anxious, short of breath and diaphoretic, with hives. The initial vital signs were a blood pressure of 100/68, a pulse of 100, respirations of 24, and SpO2 of 95% on a non-rebreather mask. The paramedics promptly placed an IV line and administered 0.3 mg of epinephrine 1:1000 intramuscularly. The patient had an episode of transient tachycardia; however, her breathing improved and most of the hives disappeared. Although her breathing was better, the pain from the scorpion sting was increasing fairly quickly. In addition, she had developed some unusual twitches and jerkiness. As paramedics inspected the patient’s right hand, they noted it to be swollen and extremely tender. There was an area at the center of the swelling that appeared to be the location of the sting.

The paramedics administered a one-liter fluid bolus of normal saline followed by 5 mg of morphine sulfate via IV. The patient was somewhat nauseated and received 4 mg of ondansetron (Zofran) via IV. This resulted in improvement of her pain and normalization of her vital signs. She was subsequently transported to University Medical Center (UMC) for additional care.

Hospital Course
At UMC, the emergency medicine staff promptly evaluated the patient. Although she improved initially following the prehospital care provided, her pain and shortness of breath were starting to recur. An additional 5 mg dose of morphine was provided and standard laboratory tests were obtained. Examination of the right hand revealed swelling and a small area of ecchymosis. The pulses remained strong and the patient was fully alert. In addition, the patient again became nauseated and subsequently vomited. Following this, 1.25 mg of droperidol (Inapsine) was administered via IV. Her nausea and vomiting resolved.

On physical exam, the patient was in considerably more distress than what paramedics had reported on scene. She was carefully reassessed to try to determine whether her signs and symptoms were due to an allergic reaction to the scorpion sting or due to scorpion envenomation. The venom from scorpions in the U.S. is neurotoxic yet rarely fatal. Although rare, envenomation from certain scorpion species (e.g., bark scorpion) can cause uncontrolled muscle jerking, eye twitching (called opsoclonus) and increased salivation in addition to the localized pain, swelling and itching. Based on the examination, the patient didn’t have signs of envenomation.

Although an antivenin is available for scorpion stings, it wasn’t deemed necessary in this case. The patient received additional fluids as well as 25 mg of diphenhydramine (Benadryl) and 125 mg of methylprednisolone (Solu-Medrol) via IV. She was observed in the emergency department for approximately four hours and discharged home with medications for pain as well as antihistamines and corticosteroids.

Discussion
Scorpions, which are eight-legged venomous invertebrates that are related to spiders and ticks, are common in the southwestern U.S., and the second-most common cause of poisonous stings worldwide. In the U.S., only four deaths in 11 years have occurred as a result of scorpion stings. Interestingly, in Mexico, approximately 1,000 deaths from scorpion stings occur per year.1

Scorpions primarily live in the desert and have adapted to the heat and lack of water. There are approximately 70 species of scorpions in the U.S. Of these, only the bark scorpion (Centruroides exilicauda) can cause clinically significant signs and symptoms. In actuality, significant scorpion envenomation is rare in the U.S. When it does occur, infants, children and the elderly are at increased risk.

The signs and symptoms of envenomation usually occur within 15 minutes following the sting. The severity of the symptoms depends on the amount of venom injected. For most people, the signs and symptoms of a scorpion sting are localized and include pain, swelling and itching.

In rare instances, significant envenomation from a bark scorpion sting can cause systemic signs and symptoms. These include the various neurologic symptoms detailed earlier. An antivenin (Anascorp) is available for significant stings. It’s derived from horse serum and is effective. However, it’s expensive and has associated allergic/anaphylactic risks because it’s derived from animal sources. It’s reserved only for severe, life-threatening envenomation where the benefits clearly outweigh the risks. It shouldn’t be used routinely unless neurotoxic signs and symptoms are noted. Most hospitals in the southwestern U.S. stock or have access to this antivenin.2,3

The use of antivenins in EMS is controversial. There are antivenins available for the bites and stings of numerous dangerous animals. These include snakes, spiders and scorpions. In some situations, such in the Australian state of Queensland, it makes sense for EMS providers to carry and administer antivenin. There are jellyfish species, primarily the box jellyfish (Chironex fleckeri), in the waters off Queensland and other parts of Australia that are extremely toxic, and stings can be rapidly fatal. In such cases, antivenin administration can be lifesaving. However, in most of the U.S., patients are able to access a hospital fairly rapidly and can receive antivenin there as needed.

Certainly, some rural EMS systems have prolonged out-of-hospital times and respond in areas where poisonous animals are found. In these systems, there may be a role for antivenin based on transport times and the types of indigenous poisonous species found in the region. Most of these cases would certainly be due to snakes, with insect bites and stings being less common.

It’s important to remember that the administration of antivenin isn’t always simple and without risk. Allergic reactions and other systemic reactions are common. In addition, many of these antivenin products are expensive and require special preparation to administer.

Interestingly, Miami-Dade (Fla.) Fire Rescue (MDFR) operates the world-recognized Venom Response Program.4 It consists of highly specialized paramedic/firefighters who are trained in the response, management and treatment of envenomations.

The program is necessary because Miami-Dade County is home to numerous venomous and poisonous animals, and is also the point of entry for a wide variety of venomous animals imported into the U.S. As in Miami, all EMS providers should be familiar with the identification and treatment of common animal bites and envenomations that can occur in their response area.

Summary
The case detailed here is relatively straightforward. We describe the case of a tourist who sustained a scorpion sting in a local state park. Her symptoms were more significant than typically seen with simple scorpion stings. The scorpion that was caught by her boyfriend was later determined to be a bark scorpion. However, following adequate prehospital treatment and detailed evaluation in the emergency department, the patient improved. It was determined that scorpion antivenin wasn’t indicated because of the lack of systemic signs and symptoms. The patient ultimately did well and completed her vacation in Las Vegas.

References
1. Chippaux JP, Goyffon M. Epidemiology of scorpionism: A global apprasial. Acta Trop. 2010;107:71–79.
2. Quan D. North American Poisonous Bites and Stings. Crit Care Clin. 2012;28:633–659.
3. Boyer LV, Theodorou AA, Berg RA, et al. Antivenom for critically ill children with neurotoxicity from scorpion stings. N Engl J Med. 2009;360:2090–2098.
4. Miami-Dade Venom Response Program. (Jan 19, 2012). In Miami-Dade County. Retrieved Feb. 17, 2013, from www.miamidade.gov/fire/about-special-venom.asp.

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Patient Care

Drug Expiration Dates — Do They Mean Anything?

Drug Expiration Dates — Do They Mean Anything?

If your medicine has expired, it may not provide the treatment you need. In this Consumer Update video, FDA Pharmacist Ilisa Bernstein explains how expiration dates help determine if medicine is safe to use and will work as intended.

What Your Pharmacist Can't Tell You About Drug Expiration Dates: 'It's Complicated'

Jul 15, 2015 09:00 AM By Susan Scutti

Medical Daily

One of the most common questions people ask health care providers is, Can I use my old drugs past their expiration dates?

The short, safe answer is a simple “no.” However the truth of the matter is much more intricate, a lot more interesting, and requires a bit of knowledge about the Food and Drug Administration (FDA).

In the late 1970s, the FDA first began requiring expiration dates on both prescription and over-the-counter medications.

“To assure that a drug product meets applicable standards of identity, strength, quality, and purity at the time of use, it shall bear an expiration date determined by appropriate stability testing,” reads the agency’s regulation. The FDA permits “reasonable variation,” meaning manufacturers are given a little leeway, so long as the any medication marketed in the United States contain between 90 percent to 110 percent of the amount of the active ingredient claimed on the label.

“Just having the slight variation of 90 to 110 percent, well, it would be very difficult, from a manufacturing standpoint, to hone it down even more than that,” Dr. Lee Cantrell, of the California Poison Control System and UC San Francisco School of Pharmacy, told Medical Daily.

The legal code adopted by the FDA also notes that manufacturers must account for storage conditions (and reconstitution conditions for certain drugs) in the expiration date. As a result of FDA rules, then, you will find a date, usually following the letters ‘EXP,’ either printed on the label or stamped onto the bottle or carton of drugs you buy, and in other cases, crimped into the tube of certain ointments you purchase.

The expiration date of most medicines is 12 to 60 months after manufacture, reports Pharmacy Times. According to Pittsburgh-Post Gazette, pharmacists further shorten the time a medicine can be used when they add their own "discard after" or "beyond-use" date to the prescription label itself. From manufacturer to FDA to pharmacist, the underlying principle is maximum safety.

And, to underscore its own message, the FDA made a brief video a few years back:

Seems like the end of the story, at least from the FDA’s perspective. However, if you are looking for an intelligent rebuttal of expiration dates, the best place to turn is to the very same alphabet soup government agency, the FDA.

Stockpiled Drugs

In the mid-1980s, as described by an article appearing in Biosecurity and Bioterrorism, the Air Force approached the FDA about “the possibility of safely extending the expiration dates of some of the drugs that it had stockpiled.” The Department of Defense routinely stockpiles medications for future use by both the military and civilians. This expensive process includes costs for planning, proper storage, and also reeplacing expired drugs. Since the latter cost eats up a significant portion of the Air Force budget, the Shelf Life Extension Program (SLEP) was proposed and undertaken by the FDA in 1985 to determine the actual shelf life of stockpiled drugs. In short, SLEP was born to save taxpayer dollars.

In its inaugural 1985 run, the program tested 56 drugs and found it was possible to extend the shelflife of 80 percent of them (and 84 percent of the tested lots) by as much as three years.With lots of dollars saved, the program naturally didn’t end there. An update of SLEP in 2006 investigated stability profiles for 122 different drug products (slightly more than 3,000 different lots) and resulted in a lifespan extension of at least one year beyond the original expiration date for 88 percent of the lots. The average additional time added to each drug was 66 months.

Among the drugs tested and approved for continued use were two antibiotics, amoxicillin(commonly prescribed to children) and ciprofloxacin (commonly called 'cipro' and used to treat anthrax infections), an antihistamine (diphenhydramine, often used to treat allergies), and a morphine sulfate injection (a painkiller).

Drug Safety Derek Gavey, CC by 2.0

Certainly, the FDA has provided comprehensive information suggesting required expiration dates may not be as firm as most consumers suppose, and this is substantiated by the work of others. In 2009, The Medical Letter, an independent nonprofit that provides unbiased drug-prescribing recommendations to professionals, reviewed the most recent data on the same subject. Importantly, the publication addresses safety first.

The authors found just one report of a patient who may have been harmed by taking an expired drug. This singular case, involving a patient who may have suffered kidney damage after taking expired tetracycline (an antibiotic), occurred more than 40 years ago. (Since that era, tetracycline products have been reformulated.)

Noting storage in heat and high humidity may shorten a drug’s half-life, The Medical Letterreport also acknowledges that in many published studies a variety of medications stored under “stress” conditions remained chemically and physically stable for up to nine years beyond their expiration dates. Generally, the authors warn, liquid drugs are not as stable as solid dosages, and should a liquid become cloudy, discolored, or show signs of precipitation, it should not be used.

“Many drugs stored under reasonable conditions in their original unopened containers retain 90 percent of their potency for at least 5 years after the expiration date on the label, and sometimes much longer,” The Medical Letter report concludes, with one important caveat: “Epinephrine in EpiPen is an important exception” as these products gradually lose potency once the expiration date passes.

Cantrell and his colleagues travel an inspired path to scientific gold, arriving at a similar conclusion for their 2012 study.

In his wanderings, Cantrell “stumbled across” a box of drugs, all of which had expired 28 to 40 years prior. Unearthed in a family-owned pharmacy generations old, the box contained drugs which had remained in their original, unopened containers for decades. In “the name of science,” Cantrell and friends undertook analysis of the drugs.

In the lab, tablets were dissolved, isotopes diluted, chromatography tests run. Three times, the science crew tested and retested samples for listed active ingredients. What did they discover?

Of the 14 drugs, 12 (or 86 percent) were present in concentrations at least 90 percent of the labeled amounts, which is the generally recognized minimum acceptable potency.  Surprisingly, three of these compounds were present at greater than 110 percent of the labeled content. The team found two compounds (aspirin and amphetamine) in amounts of less than 90 percent; meanwhile, another ingredient (phenacetin) appeared at greater than 90 percent in one drug but less than 90 percent in another.

“Given the potential cost-savings, we suggest the current practices of drug expiration dating be reconsidered,” Cantrell and his co-authors wrote in the conclusion.

Speaking with Medical Daily, Cantrell advised caution.

“My study didn’t convey anything about safety, I just looked at potency of active ingredients,” he said. Though an active ingredient may be as strong as the manufacturer originally intended, this does not mean the overall drug — a chemical jamboree, essentially — remains non-toxic, he explained. In fact, no scientific study has ever tested expired medications in human subjects and so he does not advocate using drugs past their due dates.

“I myself wouldn’t feel comfortable taking an outdated antibiotic, if you’re trying to kill a potentially life-threatening bug invading my system,” he said.

Drug Expiration Dates — Do They Mean Anything?

The Family Health Guide

With a splitting headache you reach into your medicine cabinet for some aspirin only to find the stamped expiration date on the bottle has passed - two years ago. So, do you take it or don’t you? If you decide to take the aspirin will it be a fatal mistake or will you simply continue to suffer from the headache?

This is a dilemma many people face in some way or another. A column published inPyschopharmacology Today offers some advice.

It turns out that the expiration date on a drug does stand for something, but probably not what you think it does. Since a law was passed in 1979, drug manufacturers are required to stamp an expiration date on their products. This is the date at which the manufacturer can still guarantee the full potency and safety of the drug.

Most of what is known about drug expiration dates comes from a study conducted by the Food and Drug Administration at the request of the military. With a large and expensive stockpile of drugs, the military faced tossing out and replacing its drugs every few years. What they found from the study is 90% of more than 100 drugs, both prescription and over-the-counter, were perfectly good to use even 15 years after the expiration date.

So the expiration date doesn’t really indicate a point at which the medication is no longer effective or has become unsafe to use. Medical authorities state expired drugs are safe to take, even those that expired years ago. A rare exception to this may be tetracycline, but the report on this is controversial among researchers. It’s true the effectiveness of a drug may decrease over time, but much of the original potency still remains even a decade after the expiration date. Excluding nitroglycerin, insulin, and liquid antibiotics, most medications are as long-lasting as the ones tested by the military. Placing a medication in a cool place, such as a refrigerator, will help a drug remain potent for many years.

Is the expiration date a marketing ploy by drug manufacturers, to keep you restocking your medicine cabinet and their pockets regularly? You can look at it that way. Or you can also look at it this way: The expiration dates are very conservative to ensure you get everything you paid for. And, really, if a drug manufacturer had to do expiration-date testing for longer periods it would slow their ability to bring you new and improved formulations.

The next time you face the drug expiration date dilemma, consider what you’ve learned here. If the expiration date passed a few years ago and it’s important that your drug is absolutely 100% effective, you might want to consider buying a new bottle. And if you have any questions about the safety or effectiveness of any drug, ask your pharmacist. He or she is a great resource when it comes to getting more information about your medications.

November 2003 Update