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November 2008
Y. Bentur et al

Background: The Israel National Poison Information Center, Rambam Health Care Campus, provides telephone consultations on clinical toxicology as well as drug and teratogen information around the clock. The Center participates in research, teaching and regulatory activities, and also provides laboratory services.

Objectives: To analyze data on the epidemiology of poisonings and poison exposures in Israel.

Methods: We conducted computerized queries and a descriptive analysis of the medical records database of the IPIC[1] during 2007.

Results: Overall, 26,738 poison exposure cases were recorded, a 118.5% increase compared to 1995. Children under 6 years old were involved in 45% of cases; 73% of the calls were made by the public and 25.5% by physicians; 74.4% of exposures were unintentional and 9.2% intentional. Chemicals were involved in 37.9% of cases, pharmaceuticals in 44.2%, bites and stings in 4.3% and poisonous plants in 1.2%. Substances most frequently involved were analgesics, cleaning products and antimicrobials. Clinical severity was moderate/major in 3.5%. Substances most frequently involved in moderate/major exposures were insecticides, drugs of abuse and corrosives. Eight fatalities were recorded – three unintentional exposures (all chemicals) and five intentional (chemicals, medications, drugs of abuse).

Conclusions: The rates of poison exposures and poisonings in Israel have increased significantly, contributing substantially to morbidity and mortality. The IPIC database is a valuable national resource for collecting and monitoring cases of poison exposure and can be used as a real-time surveillance system. It is recommended that reporting to the IPIC become mandatory and that its activities be adequately supported by national resources.

 






[1] IPIC = Israel National Poison Information Center


G. Markel, A. Krivoy, E. Rotman, O. Schein, S. Shrot, T. Brosh-Nissimov, T. Dushnitsky, A. Eisenkraft
The relative accessibility to various chemical agents, including chemical warfare agents and toxic industrial compounds, places a toxicological mass casualty event, including chemical terrorism, among the major threats to homeland security. TMCE[1] represents a medical and logistic challenge with potential hazardous exposure of first-response teams. In addition, TMCE poses substantial psychological and economical impact. We have created a simple response algorithm that provides practical guidelines for participating forces in TMCE. Emphasis is placed on the role of first responders, highlighting the importance of early recognition of the event as a TMCE, informing the command and control centers, and application of appropriate self-protection. The medical identification of the toxidrome is of utmost importance as it may dictate radically different approaches and life-saving modalities. Our proposed emergency management of TMCE values the “Scoop & Run” approach orchestrated by an organized evacuation plan rather than on-site decontamination. Finally, continuous preparedness of health systems – exemplified by periodic CBRN (Chemical, Biological, Radio-Nuclear) medical training of both first responders and hospital staff, mandatory placement of antidotal auto-injectors in all ambulances and CBRN[2] emergency kits in the emergency departments – would considerably improve the emergency medical response to TMCE.

 


[1] TMCE = toxicological mass casualty event

[2] CBRN = chemical, biological, radio-nuclear 
July 2008
I. Makarovsky, G. Markel, T. Dushnitsky and A. Eisenkraft
May 2008
I. Makarovsky, G. Markel, T. Dushnitsky and A. Eisenkraft
April 2008
I. Makarovsky, G. Markel, T. Dushnitsky and A. Eisenkraft
February 2008
I. Makarovsky, G. Markel, A. Hoffman, O. Schein, T. Brosh-Nissimov, Z. Tashma, T. Dushnitsky and A. Eisenkraft
October 2007
I. Makarovsky, G. Markel, A. Hoffman, O. Schein, A. Finkelstien, T. Brosh-Nissimov, Z. Tashma, T. Dushnitsky and A. Eisenkraft
September 2007
I. Makarovsky, G. Markel, A. Hoffman, O. Schein, T.M. Brosh-Nissimov, A. Finkelstien, Z. Tashma, T. Dushnitsky and A. Eisenkraft
July 2002
Amir Vardi, MD, Inbal Levin, RN, Haim Berkenstadt, MD, Ariel Hourvitz, MD, Arik Eisenkraft, MD, Amir Cohen, MD and Amital Ziv, MD

With chemical warfare becoming an imminent threat, medical systems need to be prepared to treat the resultant mass casualties. Medical preparedness should not be limited to the triage and logistics of mass casualties and first-line treatment, but should include knowledge and training covering the whole medical spectrum. In view of the unique characteristics of chemical warfare casualties the use of simulation-assisted medical training is highly appropriate. Our objective was to explore the potential of simulator-based teaching to train medical teams in the treatment of chemical warfare casualties. The training concept integrates several types of skill-training simulators, including high tech and low tech simulators as well as standardized simulated patients in a specialized simulated setting. The combined use of multi-simulation modalities makes this maverick program an excellent solution for the challenge of multidisciplinary training in the face of the looming chemical warfare threat.

Ronen Rubinshtein, MD, Eyal Robenshtok, MD, Arik Eisenkraft, MD, Aviv Vidan, MD and Ariel Hourvitz, MD

Recent events have significantly increased concern about the use of biologic and chemical weapons by terrorists and other countries. Since weapons of mass destruction could result in a huge number of casualties, optimizing our diagnostic and therapeutic skills may help to minimize the morbidity and mortality. The national demands for training in medical aspects of nuclear, biologic and chemical warfare have increased dramatically. While Israeli medical preparedness for non-conventional warfare has improved substantially in recent years especially due to extensive training programs, a standardized course and course materials were not available until recently. We have developed a core curriculum and teaching materials for a 1 or 2 day modular course, including printed materials.

Aviv Vidan, MD, Shai Luria, MD, Arik Eisenkraft, MD and Ariel Hourvitz, MD

The chemical warfare agent sulfur mustard affects primarily the eyes, skin and respiratory tract. Of these, ocular injury is the most immediate and distressing. Learning to recognize ocular injury enables the treating physician to provide early and suitable treatment, which will reduce complications and allow the victim a rapid recovery.

January 2002
Bianca Raikhlin-Eisenkraft PhD and Yedidia Bentur MD

Background: Ciguatera poisoning is the commonest fish-borne seafood intoxication. It is endemic to warm water tropical areas and is caused by consumption of bottom-dwelling shore reef fish, mostly during spring and summer. The causative agent, ciguatoxin, is a heat-stable ester complex that becomes concentrated in fish feeding on toxic dinoflagellates. The common clinical manifestations are a combination of gastrointestinal and neurologic symptoms. Severe poisoning may be associated with seizures and respiratory paralysis.

Objective: To describe a series of patients who sustained ciguatera poisoning from an uncommon region and an unexpected source.

Patients: Two families complained of a sensation of “electrical currents,” tremors, muscle cramps, nightmares, hallucinations, agitation, anxiety and nausea of varying severity several hours after consuming rabbitfish (“aras”). These symptoms lasted between 12 and 30 hours and resolved completely. The temporal relationship to a summer fish meal, the typical clinical manifestations along with the known feeding pattern of the rabbitfish suggested ciguatera poisoning.

Conclusions: The Eastern Mediterranean basin is an unusual region and the rabbitfish an unusual source for ciguatera poisoning. There are no readily available and reliable means for detecting ciguatoxin in humans. A high index of suspicion is needed for diagnosis and a thorough differential diagnosis is essential to eliminate other poisonings, decompression sickness and encephalitis. Supportive therapy is the mainstay of treatment.

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