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  • Critical Care Toxicology

  • Jeffrey BrentSenior Editor

    Keith Burkhart Paul DarganBenjamin Hatten Bruno MegarbaneRobert Palmer Julian WhiteEditors

    Critical Care Toxicology

    Diagnosis and Management ofthe Critically Poisoned Patient

    Second Edition

    With 675 Figures and 487 Tables

  • Senior EditorJeffrey BrentDepartment of MedicineDivision of Clinical Pharmacologyand ToxicologyUniversity of ColoradoSchool of MedicineAurora, CO, USA

    EditorsKeith BurkhartFDA, Office of NewDrugs/Immediate OfficeCenter for Drug Evaluationand ResearchSilver Spring, MD, USA

    Paul DarganClinical ToxicologySt Thomas HospitalSilver Spring, MD, USA

    Benjamin HattenToxicology AssociatesUniversity of ColoradoSchool of MedicineDenver, CO, USA

    Bruno MegarbaneMedical Toxicological IntensiveCare UnitLariboisiere HospitalParis-Diderot UniversityParis, France

    Robert PalmerToxicology AssociatesUniversity of ColoradoSchool of MedicineDenver, CO, USA

    Julian WhiteToxinology DepartmentWomens and Childrens HospitalNorth Adelaide, SA, Australia

    ISBN 978-3-319-17899-8 ISBN 978-3-319-17900-1 (eBook)ISBN 978-3-319-17901-8 (print and electronic bundle)DOI 10.1007/978-3-319-17900-1

    Library of Congress Control Number: 2017930938

    1st edition: # Mosby 2005# Springer International Publishing AG 2017, corrected publication 2017This work is subject to copyright. All rights are reserved by the Publisher, whether the whole orpart of the material is concerned, specifically the rights of translation, reprinting, reuse ofillustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way,and transmission or information storage and retrieval, electronic adaptation, computer software, orby similar or dissimilar methodology now known or hereafter developed.The use of general descriptive names, registered names, trademarks, service marks, etc. in thispublication does not imply, even in the absence of a specific statement, that such names are exemptfrom the relevant protective laws and regulations and therefore free for general use.The publisher, the authors and the editors are safe to assume that the advice and information in thisbook are believed to be true and accurate at the date of publication. Neither the publisher nor theauthors or the editors give a warranty, express or implied, with respect to the material containedherein or for any errors or omissions that may have been made. The publisher remains neutral withregard to jurisdictional claims in published maps and institutional affiliations.

    Printed on acid-free paper

    This Springer imprint is published by Springer NatureThe registered company is Springer International Publishing AGThe registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

  • Foreword

    Critical Care Toxicology belongs in every critical care unit, emergency depart-ment, poison center, library, emergency response center, and on the most easilyreached shelf for anyone interested in or who comes in contact with medicaltoxicology. This masterful compilation of information has many attributes,among which are:

    Evidence based well-referenced information Editors and authors who are experts in their fields Concise and clear presentation Tables that convey critical data Figures and diagrams that are clinically relevant Paragraph headers that allow focused access to information Calculations and formulas that are fully explained Lists of treatment materials to obtain in advance with contact information of

    unusual items Therapeutic dosages that are detailed enough to be utilized without addi-

    tional references

    In most cases, diagnostic and therapeutic information can be obtained in afew minutes given the books careful organization. For those patients pre-senting with complicated or multiple exposures, the structure provides astraightforward method of rapidly developing and working through a differ-ential diagnosis.

    The quality of this book should come as no surprise after looking at theimpressive listing of authors. The editors, each of whom I have known, workedwith, and respected for many years, have selected an international group ofexperts whose credibility is unmatched. They represent the best of our profes-sion of medical toxicology and have written a large percentage of the mostimportant and groundbreaking publications in our field. The editors andauthors are the most sought-after educators in our annual toxicology meetingsaround the world and provide clinical expertise as well as leadership andtraining for all of us who work in this wide and varied area.

    In the preface to the first edition of Critical Care Toxicology, the wordpassion occurs in the very first sentence. For all of us who have ever written ascientific monograph, paper, chapter, book, or prepared a teaching session, theword passion certainly defines a major requirement for preparation of materials


  • that will communicate the knowledge that is intended. It takes time and effortto write something that will stand the test of time, and when written withpassion it means that the author has not skipped over anything and left nothingof importance unaddressed. It requires thorough knowledge of the subject, realworld experience, fully researched literature, and draft after draft until com-munication is assured. When reading this book, it is apparent that the editorsand authors have achieved their goal.

    Before writing this foreword, the editors provided me with some chaptersfrom the second edition. In reviewing four of them Acid-base, Hypoten-sion and Shock, Seizures, and Acute Respiratory Distress Syndrome itwas readily apparent that this second edition is an improvement on an alreadyexcellent book. More current materials are included as expected, but usingthese chapters as examples the authors have dramatically improved this book.Acid-base in the critical care setting is a complicated and often difficult issue.To address that the authors have doubled the length of this chapter andsubstantially added information which will be valuable to all who utilize it.The chapters on hypotension and shock and acute respiratory distress syn-drome have been broken out of their previous locations and addressed com-prehensively to reflect their importance. The chapter on seizures has also beendoubled in length and contains a considerable amount of new information thatis clearly presented.

    The authors have also added speed of access to this book through the use ofa table of contents at the beginning of each chapter. This further enhances theability of the reader to get to an answer under emergent circumstances.

    The book also has another purpose than just providing critical informationin a clinical setting. It provides a very readable and understandable educationalexperience for all those who are studying this area. This must includeaddressing controversial areas with which the reader may be familiar and ifnot familiar ought to be familiar, and this book engages all of this.

    Even those of us who have been in this field for a long time stand to learnsomething from this book. The discussion of the strong anion gap in the acid-base chapter coupled with the very practical explanations of the other factors inthis important area is the clearest I have ever read. An area in which I have littleknowledge is malignant hyperthermia, and this chapter provides a clear expla-nation along with even a phone number and website to get additional updatedinformation in what is apparently a rapidly evolving issue. The editors clearlywant readers to get the right answers to their questions.

    Critical Care Toxicology covers all of the areas in medical toxicology in aseries of well-written chapters following the excellent chapters that provide anapproach to the critically poisoned patient and an understanding of toxicsyndromes. Images of various aspects of toxicological encounters providevisual reinforcement of the written materials.

    The index is very well done and comprehensive. Unlike the 7th edition in1959 of Nelsons pediatric text where the editors daughter, who hated havingto produce the index, entered under B Birds, for the and listed the entirebook, the index of Critical Care Toxicology was obviously prepared bysomeone who had a passion for helping readers get to answers.

    vi Foreword

  • Critical Care Toxicology provides a very valuable contribution to allaspects of medical toxicology from education to, as the title states, criticalcare. It should be readily accessible to everyone who may face this issue fromforming a differential diagnosis to rendering care.

    Rocky Mountain Poison and Drug Center Barry H. RumackDenver, Colorado Director EmeritusUSA

    Foreword vii

  • Preface to the Second Edition

    Those readers who are familiar with the first edition of Critical Care Toxicol-ogy (CCT) know that it was about passion our collective passion for caringfor patients with the group of fascinating physiological derangements causedby exogenous chemical exposures. While our passion for the field of clinicaltoxicology remains unabated, an additional theme that characterizes the sec-ond edition of Critical Care Toxicology is scientific evidence.

    In the 10 years since the publication of the first edition, a considerable bodyof new scientific evidence has emerged, new antidotes have become available,and systematic reviews andmeta-analyses have becomemore commonplace inthe field of clinical toxicology. Seizing upon the opportunity to provide acompendium of this accumulated evidence-based knowledge, we have workedwith our chapter authors to assure that they have stayed true to the existingbody of empirical data and, in the many places, where data gaps exist identifythem so that the user of this book will understand the b


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