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Objectives: Easily administrated cyanide antidotes are needed for first responders, military troops, and emergency department staff after cyanide exposure in mass casualty incidents or due to smoke inhalation during fires involving many victims. Hydroxocobalamin has proven to be an effective antidote, but cannot be given intramuscularly because the volume of diluent needed is too large. Thus, intraosseous (IO) infusion may be an alternative, as it is simple and has been recommended for the administration of other resuscitation drugs. The primary objective of this study was to compare the efficacy of IO delivery of hydroxocobalamin to intravenous (IV) injection for the management of acute cyanide toxicity in a well-described porcine model. Methods: Twenty-four swine (45 to 55 kg) were anesthetized, intubated, and instrumented with continuous mean arterial pressure (MAP) and cardiac output monitoring. Cyanide was continuously infused until severe hypotension (50% of baseline MAP), followed by IO or IV hydroxocobalamin treatment. Animals were randomly assigned to receive IV (150 mg/kg) or IO (150 mg/kg) hydroxocobalamin and monitored for 60 minutes after start of antidotal infusion. The primary outcome measure was the change in MAP after antidotal treatment from onset of hypotension (time zero) to 60 minutes. A sample size of 12 animals per group was determined by group size analysis based on power of 80% to detect a one standard deviation of the mean MAP between the groups with an alpha of 0.05. Whole blood cyanide, lactate, pH, nitrotyrosine (nitric oxide marker) levels, cerebral and renal near infrared spectrometry (NIRS) oxygenation, and inflammatory markers were also measured. Repeated-measures analysis of variance was used to determine statistically significant changes between groups over time. Results: At baseline and at the point of hypotension, physiologic parameters were similar between groups., Published in Academic Emergency Medicine, v21 n11 p1204-1211, Nov 2014. Prepared in collaboration with the Department of Emergency Medicine, San Antonio Military Medical Center, San Antonio, TX and the David Geffen School of Medicine at UCLA, Harbor UCLA Medical Center, Los Angeles, CA.

Study objective: To determine whether hydroxocobalamin will improve survival compared with epinephrine and saline solution controls in a model of cyanide-induced cardiac arrest. Methods: Forty-five swine (38 to 42 kg) were tracheally intubated, anesthetized, and central venous and arterial continuous cardiovascular monitoring catheters were inserted. Potassium cyanide was infused until cardiac arrest developed, defined as mean arterial pressure less than 30 mm Hg. Animals were treated with standardized mechanical chest compressions and were randomly assigned to receive one of 3 intravenous bolus therapies: hydroxocobalamin, epinephrine, or saline solution (control). All animals were monitored for 60 minutes after cardiac arrest. Additional epinephrine infusions were used in all arms of the study after return of spontaneous circulation for systolic blood pressure less than 90 mm Hg. A sample size of 15 animals per group was determined according to a power of 80%, a survival difference of 0.5, and an of 0.05. Repeated-measure ANOVA was used to determine statistically significant changes between groups over time., Published in Annuals of Emergency Medicine v60 n4 p415-422 Oct 2012.

Study Objective: We compare the efficacy of hydroxocobalamin to sodium thiosulfate to reverse the depressive effects on mean arterial pressure in a swine model of acute cyanide toxicity and gain a better understanding of the mechanism of action of the hydroxocobalamin in reversal of the toxicity., Published in Annuals of Emergency Medicine v59 n6 p532-539 Jun 2012.

Objectives: Our objective was to assess patients understanding of emergency department (ED) wait times and why patients may leave the waiting room before seeing a provider. Methods: Survey of patients in the ED waiting room of an urban tertiary care military hospital where civilian and military patients are treated. Results: A total of 508/517 surveys (98%) were completed. Age ranges were 18 to 35 years (49%), 36 to 60 (31%), or older than 60 (20%). Education levels were high school (20%), some college (37%), or college graduate (39%). Of 503 respondents, 125 (25%) had left an ED waiting room before seeing a provider. The reasons included excessive wait times (91%) and family responsibilities (5%). Five hundred eight reported the factors that would motivate them to wait to see the physician (not leave without being seen [LWOBS]) were the severity of illness (64%), and if they received an update of wait times (26%); 82% (391/480) understood that severely ill patients were seen first. Patients attributed long wait times to doctors and nurses caring for other patients (292/583, 50%) and insufficient physician and nurse staffing (245, 42%). Of 802 responses for ideas to improve the wait, 34% said regular updates on estimated wait times, 21% said television shows or movies to view, 20% said books and magazines to read, and 11% said computers to access. Conclusions: Long wait times were the primary reason that patients left before seeing a provider, despite having ready access to care. Respondents attributed long wait times to patient volume and inadequate staffing. Regular updates on wait times and material for entertainment may improve the waiting experience and reduce LWOBS., Published in Southern Medical Journal v105 n10 p538-542 Oct 2012.

Objectives: In August 2007, the Food and Drug Administration (FDA) released a public health advisory recommending that over-the-counter cough and cold medications (CCMs) not be used in children younger than 2 years. Our objective was to assess parents awareness and understanding of the guidelines. Methods: We surveyed caregivers of children younger than 2 years in the emergency department of an urban tertiary care military hospital where civilian patients are also treated. After completing the survey, caregivers received a handout explaining the FDA s recommendations. Results: Our response rate was 99% (264/265). First-time parents constituted 45% (114/251) of responders. Education level was high school, 21%; some college, 36%; and college graduate, 40%. Thirty-one percent (77/247) were aware of the FDA guidelines. Of these 77, 44 (57%) reported the guidelines indicated CCMs were not safe in children younger than 2 years, and 18 (23%) saidCCMs have caused death. Twenty-six percent (68/264) did not give CCMs to their children younger than 2 years, and 40% of these reported it was because of learning about the guidelines; 63% (165/264) reported CCMs were effective, 11% ineffective, and 27% did not know. Fifty-seven percent (151/263) reported CCMs were safe, 12% unsafe, and 31% unsure. Twenty-two percent (31/143) planned to use or continue to use CCMs in their children, 34% did not, 23% not sure, and 21% only if their doctor advised it. Conclusions: The majority of caregivers were not aware of the FDA guidelines on CCM use in children younger than 2 years. Most thought CCMs were safe and effective., Published in Pediatric Emergency Care, v28 n9 p883-885, Sep 2012.