Dr. Gussow is a voluntary attending physician at the John H. Stroger Hospital of Cook County in Chicago (formerly Cook County Hospital), an assistant professor of emergency medicine at Rush Medical College, and a consultant to the Illinois Poison Center. He is also the editor of his own blog, The Poison Review.
More than half a million apps are available in the iTunes app store, many of interest to toxicologists and emergency physicians. The apps I review this month are available for the iPhone and iPad.
PEPID Elements (free): This app contains the toxicology section excerpted from the enormous (and pricey) collection of medical information called PEPID Platinum Suites. The blurb in the iTunes app store assures us that “[r]egular updates keep content current with the latest medical and clinical information.” Unfortunately, I checked out some of the key topics that serve as my benchmarks for medical toxicology, and I found material that was poorly organized and distinctly dated.
Much of the toxicology world, for example, considers whole bowel irrigation to be so 1990s, as I discussed last month. The intervention has definite risks but no proven benefit, and many poison experts avoid the procedure, especially in overdoses of sustained-release calcium channel blockers and other cardiovascular medications. Yet, under indications for whole bowel irrigation, PEPID Elements lists enteric-coated tablets or sustained release preparations without any caveat or suggestion that the recommendation is at best controversial.
Similarly the section on treating calcium channel blocker toxicity is years out of date. Today, many if not most toxicologists would recommend early treatment with high-dose insulin for significant calcium channel blocker poisoning. Yet PEPID Elements classifies insulin as only an “investigational” treatment, lower down on the list of interventions than glucagon, pressors, amrinone, inamrinone, enoximone (!?), and 4-aminopyridine (!!??). The mention of enoximone, as far as I can tell, is based on a single case report. I have no idea why 4-aminopyridine is mentioned at all. My recommendation for calcium channel blocker toxicity is forget PEPID, put down the iPad, and call your local poison control center now.
Toxic Killers ($0.99): Though less than a dollar, this app is rather sparse and does not really provide value. Subtitled “Top 30 Most Venomous Animals in the World,” Toxic Killers supplies just a little bit of information on each of 30 poisonous critters, including the black mamba, fugu (blowfish), Arabian carpet viper, and banana (Brazilian wandering) spider. Where is Chironex fleckeri, the box jellyfish? Each of the threatening 30 has decent pictures, but the whole thing is underpowered and seems like a waste of memory.
Bites & Stings ($1.99): You may be better off with this app than Toxic Killers, even at twice the price. It has information on more than 70 poisonous creatures, and describes itself as a “reference guide designed to identify and describe some of the world's most dangerous animals and what happens in the event of a bite,” but I would not trust any of its medical recommendations. The text reads like a confused translation from an obscure language, and treatment suggestions can be ridiculous and contradictory. Its tips for bites by the American Copperhead say to immobilize or freeze the bitten area and also never apply ice on the copperhead snake bite. Say what?
As with Toxic Killers, Bites & Stings does not discuss the box jellyfish, a fascinating creature that does not deserve to be overlooked. Weaknesses aside, it is fun to browse through the content on this app, and encounter strange critters with some amazing defense mechanisms. One of my favorites — new to me — is the bombardier beetle. The app explains: “The bombardier beetle is a small insect that is armed with a shockingly impressive defense system. Whenever threatened by an enemy attack, this spirited little beetle blasts irritating and odious gases, which are at 212 degrees F, out from two tail pipes right into the unfortunate face of the would-be aggressor.”
Bites & Stings also explains that the beetle accomplishes this amazing feat by synthesizing different chemicals, including hydrogen peroxide, that combine in a special anatomical explosion chamber to produce an exothermic reaction. The increased pressure in the chamber forces a pulsating stream of fiery gas and liquid out the insect's anus. Imagine the surprise of an unsuspecting predator coming in for what should be an easy kill.
Bites & Stings is not optimized for the iPad so the interface is just iPhone-sized; the print and pictures become noticeably grainy if expanded to fill the entire iPad screen. Nevertheless, the app provides a good deal of fun and some interesting tidbits, although I wouldn't rely on it when the next Green Mamba bite rolls through the door.
Every emergency practitioner and responder will want to have these apps from the National Institutes of Health (NIH) and the National Library of Medicine (NLM):
LactMed (free): This app, associated with the NLM's Toxicology Data Network (TOXNET), provides information about pharmaceuticals and dietary supplements that affect lactation and may be present in breast milk. It also suggests alternate drugs, but this feature is less than satisfactory. It unhelpfully states that alternative drugs to phenytoin are “dependent on the condition being treated.” It suggests trimethoprim-sulfamethoxazole as an alternative to Bactrim, which is confusing and misses the point. Nevertheless, the information here is evidence-based and referenced, and the app is well worth installing on your device.
WISER (free): The Wireless Information System for Emergency Responders was designed by the NLM to provide information on how to manage chemical, biological, and radiologic agents for emergency responders to hazardous materials incidents. It contains extensive extracts from the TOXNET Hazardous Substance Data Bank. So much material is crammed into this app that the print tends to be rather small (even on the iPad) and the presentation overwhelming. This is good information to have on hand despite these flaws.
Mobile REMM (free): This app contains material extracted from the NLM's Radiation Emergency Medical Management website. (See FastLinks.) It has management algorithms, triage information, and countermeasures for treating internal contamination. Much of the material does not primarily involve medical toxicology, and the cumbersome algorithms will not be much use in an emergency situation, but it's helpful to have easy access to information about specific isotopes such as I-131 and Po-210 and emergency numbers to contact in case of known or suspected incidents involving radiation.
Click and Connect! Access the links in EMN by reading this issue on our website or in our iPad app, both available on www.EM-News.com.
* Visit the National Library of Medicine's Radiation Emergency Medical Management website at www.remm.nlm.gov.
* Visit Dr. Gussow's blog at www.thepoisonreview.com.
* Read all of Dr. Gussow's past columns at http://bit.ly/GussowToxRounds.
* Comments about this article? Write to EMN at firstname.lastname@example.org.