Frank G Walter

Interests

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Courses

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Scholarly Contributions

Books

• Walter, F. G., Alvarado, A. I., & Lugo Moran, A. (2023).

  AHLS Manual de Proveedor (Advanced Hazmat Life Support Provider Manual), ed 5, in Spanish

  . Tucson, Arizona: The University of Arizona, Arizona Board of Regents.
• Kazzi, Z., Nemhauser, J. B., Feldman, R. J., & Walter, F. G. (2021). Advanced Hazmat Life Support for Radiological Incidents and Terrorism, ed 5, in Spanish.. Tucson, Arizona: The University of Arizona, Arizona Board of Regents.
• Lawless, A., Ehnert, T., Walter, F. G., Kelly, P., Lyons, W., Roepke, D., & Van Wyke, D. (2021). Arizona Crisis Standards of Care Plan: A Comprehensive and Compassionate Response, ed 4. Phoenix, Arizona: Arizona Department of Health Services.
• Kazzi, Z., Nemhauser, J. B., Feldman, R. J., & Walter, F. G. (2020). Advanced Hazmat Life Support for Radiological Incidents and Terrorism, ed 5.. Tucson, Arizona: The University of Arizona, Arizona Board of Regents.
• Lawless, A., Ehnert, T., Walter, F. G., Kelly, P., Lyons, W., Roepke, D., & Van Wyke, D. (2020). Arizona Crisis Standards of Care Plan: A Comprehensive and Compassionate Response, ed 3. Phoenix, Arizona: Arizona Department of Health Services.
• Lawless, A., Ehnert, T., Walter, F. G., Kelly, P., Lyons, W., Roepke, D., & Van Wyke, D. (2018). Arizona Crisis Standards of Care Plan: A Comprehensive and Compassionate Response, ed 2. Phoenix, Arizona: Arizona Department of Health Services.
• Meislin, H. W., & Walter, F. G. (2017). Advanced Hazmat Life Support Instructor Manual, 4th edition. Tucson, AZ: The University of Arizona, Arizona Board of Regents.
• Walter, F. G. (2017). Advanced Hazmat Life Support Provider Manual, 5th edition. Tucson, AZ: The University of Arizona, Arizona Board of Regents.
• Gaither, J. B., French, R., Rice, A. M., Hurst, N., Ori, M. R., & Walter, F. G. (2016). Advanced Hazmat Life Support for Tox-Medics, ed 1.. Tucson, Arizona: The University of Arizona, Arizona Board of Regents.
• Kazzi, Z., Nemhauser, J. B., & Walter, F. G. (2016). Advanced Hazmat Life Support for Radiological Incidents and Terrorism, ed 4.. Tucson, Arizona: The University of Arizona, Arizona Board of Regents.
• Kazzi, Z., Nemhauser, J. B., & Walter, F. G. (2015). Advanced Hazmat Life Support for Radiological Incidents and Terrorism, ed 3.. Tucson, AZ: The University of Arizona, Arizona Board of Regents.
• Lawless, A., Ehnert, T., Walter, F., Kelly, P., Lyons, W., Roepke, D., & Van Wyke, D. (2015). Arizona Crisis Standards of Care Plan: A Comprehensive and Compassionate Response, ed 1. Phoenix, Arizona: Arizona Department of Health Services.
  More info

  Published Feb 2015
• Walter, F. G., & Guimarães, H. (2014). AHLS Suporte Avancado de Vida em Emergencias com Produtos Perigosos: Manual do Profissional (Advanced Hazmat Life Support Provider Manual), ed 4, in Portuguese.. Sao Paulo, Brazil: The University of Arizona, Arizona Board of Regents.

Chapters

• Bronstein, A. C., & Walter, F. G. (2017). Chapter 2: Important Properties of Hazardous Materials. In AHLS (Advanced Hazmat Life Support) Provider Manual, 5th edition(pp 23-41). Tucson, AZ: Arizona Board of Regents.
• French, R. N., & Walter, F. G. (2017). Anticholinergic plants. In Critical Care Toxicology, 2nd edition(pp 2175-2186). Cham, Switzerland: Springer International Publishing, AG.
• French, R. N., & Walter, F. G. (2017). Atropine. In Critical Care Toxicology, 2nd edition(pp 2725-2731). Cham, Switzerland: Springer International Publishing, AG.
• Hall, A. H., & Walter, F. G. (2017). Chapter 10: Antidote: Methylene Blue. In AHLS (Advanced Hazmat Life Support) Provider Manual, 5th edition(pp 173-177). Tucson, AZ: Arizona Board of Regents.
• Hall, A. H., & Walter, F. G. (2017). Chapter 11: Antidote: Amyl Nitrite. In AHLS (Advanced Hazmat Life Support) Provider Manual, 5th edition(pp 179-182). Tucson, AZ: Arizona Board of Regents.
• Hall, A. H., & Walter, F. G. (2017). Chapter 12: Antidote: Sodium Nitrite. In AHLS (Advanced Hazmat Life Support) Provider Manual, 5th edition(pp 185-189). Tucson, AZ: Arizona Board of Regents.
• Hall, A. H., & Walter, F. G. (2017). Chapter 13: Antidote: Sodium Thiosulfate. In AHLS (Advanced Hazmat Life Support) Provider Manual, 5th edition(pp 191-194). Tucson, AZ: Arizona Board of Regents.
• Hall, A. H., & Walter, F. G. (2017). Chapter 25: Antidote: Calcium Gluconate. In AHLS (Advanced Hazmat Life Support) Provider Manual, 5th edition(pp 335-339). Tucson, AZ: Arizona Board of Regents.
• Hall, A. H., & Walter, F. G. (2017). Chapter 26: Antidote: Calcium Chloride. In AHLS (Advanced Hazmat Life Support) Provider Manual, 5th edition(pp 341-345). Tucson, AZ: Arizona Board of Regents.
• Hall, A. H., & Walter, F. G. (2017). Chapter 8: Antidote: Normobaric Oxygen. In AHLS (Advanced Hazmat Life Support) Provider Manual, 5th edition(pp 161-164). Tucson, AZ: Arizona Board of Regents.
• Hall, A. H., & Walter, F. G. (2017). Chapter 9: Antidote: Hyperbaric Oxygen. In AHLS (Advanced Hazmat Life Support) Provider Manual, 5th edition(pp 167-170). Tucson, AZ: Arizona Board of Regents.
• Hall, A. H., Walter, F. G., & Hays, D. P. (2017). Chapter 23: Antidote: Pyridoxine. In AHLS (Advanced Hazmat Life Support) Provider Manual, 5th edition(pp 317-320). Tucson, AZ: Arizona Board of Regents.
• Tomassoni, A. J., & Walter, F. G. (2017). Identificação Sindrômica e Tratamento de Exposições Químicas e Biológicas (Syndrome Identification and Treatment of Chemical and Biological Exposures). In Manual de Medicina de Emergencia (Manual of Emergency Medicine)(pp 877-906). Sao Paulo, Brazil: Atheneu.
  More info

  Guimaraes HP, Alegretti Borges LA, de Assuncao MSC, Lima Reis HJ (eds)
• Walter, F. G. (2017). Chapter 5: Toxidromes and Toxicodynamics. In AHLS (Advanced Hazmat Life Support) Provider Manual, 5th edition(pp 91-95). Tucson, AZ: Arizona Board of Regents.
• Walter, F. G., & Hall, A. H. (2017). Chapter 17: Antidote: Pralidoxime. In AHLS (Advanced Hazmat Life Support) Provider Manual, 5th edition(pp 231-238). Tucson, AZ: Arizona Board of Regents.
• Walter, F. G., & Hall, A. H. (2017). Chapter 18: Antidote: Atropine. In AHLS (Advanced Hazmat Life Support) Provider Manual, 5th edition(pp 241-248). Tucson, AZ: Arizona Board of Regents.
• Walter, F. G., & Ng, V. (2017). Chapter 31: AHLS Tabletop Exercises. In AHLS (Advanced Hazmat Life Support) Provider Manual, 5th edition(pp 457-465). Tucson, AZ: Arizona Board of Regents.
• Williams, A. S., Crounse, D. M., & Walter, F. G. (2017). Chapter 4: Conducting an AHLS Course. In Advanced Hazmat Life Support Instructor Manual, 4th edition(pp 37-47). Tucson, AZ: The University of Arizona, Arizona Board of Regents.
• Williams, A. S., Crounse, D. M., & Walter, F. G. (2017). Chapter 5: A Checklist for Conducting an AHLS Course. In Advanced Hazmat Life Support Instructor Manual, 4th edition(pp 49-55). Tucson, AZ: The University of Arizona, Arizona Board of Regents.
• Williams, A. S., Crounse, D. M., Meislin, H. W., & Walter, F. G. (2017). Chapter 1: Introduction to AHLS. In Advanced Hazmat Life Support Instructor Manual, 4th edition(pp 5-8). Tucson, AZ: The University of Arizona, Arizona Board of Regents.
• Williams, A. S., Crounse, D. M., Meislin, H. W., & Walter, F. G. (2017). Chapter 2: AHLS Infrastructure. In Advanced Hazmat Life Support Instructor Manual, 4th edition(pp 11-20). Tucson, AZ: The University of Arizona, Arizona Board of Regents.
• Williams, A. S., Crounse, D. M., Meislin, H. W., & Walter, F. G. (2017). Chapter 3: AHLS Courses. In Advanced Hazmat Life Support Instructor Manual, 4th edition(pp 23-33). Tucson, AZ: The University of Arizona, Arizona Board of Regents.
• French, R., & Walter, F. G. (2016). Anticholinergic plants. In Critical Care Toxicology, 2nd ed., online. Germany: Springer. doi:DOI 10.1007/978-3-319-20790-2_111-1
• French, R., & Walter, F. G. (2016). Atropine. In Critical Care Toxicology, 2nd ed., online. Cham, Switzerland: Springer. doi:DOI 10.1007/978-3-319-20790-2_153-1
• Ng, V., & Walter, F. G. (2014). Chapter 18: AHLS Tabletop Exercises. In AHLS (Advanced Hazmat Life Support) Chemical Burns & Toxic Products of Combustion, 2nd edition(pp 221-227). Tucson, AZ: Arizona Board of Regents.
• Ng, V., & Walter, F. G. (2014). Chapter 21: Poisoning Predicament. In AHLS (Advanced Hazmat Life Support) Toxic Terrorism: Chemical, Biological, Radiological, & Nuclear Casualties, 2nd edition(pp 297-299). Tucson, AZ: Arizona Board of Regents.
• Ng, V., & Walter, F. G. (2014). Chapter 31: AHLS Tabletop Exercises. In AHLS (Advanced Hazmat Life Support) Provider Manual, 4th edition(pp 457-466). Tucson, AZ: Arizona Board of Regents.

Journals/Publications

• Maciulewicz, T. S., Kazzi, Z., Navis, I. L., Nelsen, G. J., Cieslak, T. J., Newton, C., Lin, A., West, D. J., & Walter, F. G. (2024).

  Pediatric Medical Countermeasures: Antidotes and Cytokines for Radiological and Nuclear Incidents and Terrorism

  
  
  
  

  . Disaster Medicine and Public Health Preparedness, 18. doi:https://doi.org/10.1017/dmp.2024.35
• Smelski, G., Watkins, S. A., Wilson, B., Ramirez, J., Shirazi, F. M., & Walter, F. G. (2024). Evaluation of the International Society on Thrombosis and Haemostasis Definition of Major Bleeding in Arizona Rattlesnake Bites. Clinical Toxicology, 62, 1-5. doi:10.1080/15563650.2024.2385671
• Whalen, M. J., Aizenberg, A. M., Shirazi, F. M., Berrigan, J. J., & Walter, F. G. (2024).

  Skin Decontamination With and Without Water Irrigation 

  
  
  
  

  . Disaster Medicine and Public Health Preparedness, 18, e220. doi:10.1017/dmp.2024.118
• Feldman, R. J., Kazzi, Z., & Walter, F. G. (2023). Radiation Injuries: Acute Radiation Syndrome in Children. Pediatric Annals.
• Elizabeth, G. A., Walter, F. G., Ashley, B., & Daniel, K. E. (2022). Crotalus morulus (Viperidae: Crotalinae) envenoming and treatment with F(ab') 2 antivenom. Toxicon: An Interdisciplinary Journal on the Toxins Derived from Animals, Plants and Microorganisms, 216, 45-49. doi:10.1016/j.toxicon.2022.06.013
  More info

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• Hurst, N. B., Grossart, E., Knapp, S., Stolz, U., Groke, S., Solem, C., Williams, A., French, R. N., Appel, J., & Walter, F. G. (2022). Do Mnemonics Help Healthcare Professionals Learn & Recall Cholinergic Toxidromes?. Clinical Toxicology. doi:10.1080/15563650.2022.2042551
• Wilson, B. Z., Bahadir, A., Andrews, M., Karpen, J., Winkler, G., Smelski, G., Dudley, S., Walter, F. G., & Shirazi, F. (2022). Initial Experience with F(ab’)2 Antivenom Compared with Fab Antivenom for Rattlesnake Envenomations Reported to a single poison center during 2019. Toxicon: An Interdisciplinary Journal on the Toxins Derived from Animals, Plants and Microorganisms. doi:https://doi.org/10.1016/j.toxicon.2022.01.007
• Mhayamaguru, K. M., Gaither, J. B., French, R. N., Christopher, N. D., Waters, K. E., Jado, I., Rice, A. D., Beskind, D., Knotts, M. C., Ronnebaum, J. A., Smith, J. J., & Walter, F. G. (2021). Availability and Use of Medications by Prehospital Providers Trained to Manage Medical Complications of Patients in Hazardous Materials Incidents. American Journal of Disaster Medicine, 16(3), 215-223. doi:https://doi.org/10.5055/ajdm.2021.0404
• Rinner, G. R., Watkins, S. A., Shirazi, F., Fernandez, M. C., Hess, G., Mihalic, J., Runcorn, S., Waddell, V., Ritter, J., Reagan-Steiner, S., Thomas, J., Yip, L., & Walter, F. G. (2021). Fatal abrin poisoning by injection. Clinical Toxicology, 59(2), 169-171. doi:10.1080/15563650.2020.1771360
• Rinner, G., Shirazi, F., & Walter, F. G. (2019). Rare Side Effects of Initiating Antihypertensive Therapy. Clinical Toxicology, 57(10), 917-918. doi:10.1080/15563650.2019.1636569
• Smith, G., Beger, S., Vadeboncoeur, T., Chikani, V., Walter, F., Spaite, D. W., & Bobrow, B. (2019). Trends in overdose-related out-of-hospital cardiac arrest in Arizona. Resuscitation, 134, 122-126.
  More info

  Opioid overdose mortality has increased in North America; however, recent regional trends in the proportion of treated overdose-related out-of-hospital cardiac arrest (OD-OHCA) compared to out-of-hospital cardiac arrest of presumed cardiac etiology (C-OHCA) are largely unknown. Our aim is to assess trends in the prevalence and outcomes of OD-OHCAs compared to C-OHCAs in Arizona.
• Mhayamaguru, K., Bellafiore, A. L., Lederer, E., Youngs, C. R., French, R., Gaither, J. B., Waters, K. E., & Walter, F. G. (2018). Prehospital Availability and Use of Medications for Managing Hazmat Emergencies. Prehospital and Emergency Care.
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  1. Mhayamaguru KM, Bellafiore AL, Lederer ET, Youngs CR, French RNE, Gaither JB, Waters KE, Walter FG. Prehospital Availability and Use of Medications for Managing Hazmat Emergencies. Prehospital Emerg Care; 2018; 22(1): 134.
• Chase, P. B., Hawkins, J., Mosier, J., Jimenez, E., Boesen, K., Logan, B. K., & Walter, F. G. (2016). Differential physiological and behavioral cues observed in individuals smoking botanical marijuana versus synthetic cannabinoid drugs. Clinical toxicology (Philadelphia, Pa.), 54(1), 14-9. doi:DOI:10.3109/15563650.2015.1101769
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  Synthetic cannabinoid use has increased in many states, and medicinal and/or recreational marijuana use has been legalized in some states. These changes present challenges to law enforcement drug recognition experts (DREs) who determine whether drivers are impaired by synthetic cannabinoids or marijuana, as well as to clinical toxicologists who care for patients with complications from synthetic cannabinoids and marijuana. Our goal was to compare what effects synthetic cannabinoids and marijuana had on performance and behavior, including driving impairment, by reviewing records generated by law enforcement DREs who evaluated motorists arrested for impaired driving.
• French, R., Brooks, D., Ruha, A., Shirazi, F., Chase, P., Boesen, K., & Walter, F. (2015). Gila monster (Heloderma suspectum) envenomation: Descriptive analysis of calls to United States Poison Centers with focus on Arizona cases. Clinical toxicology (Philadelphia, Pa.), 53(1), 60-70.
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  The Gila monster (Heloderma suspectum) is a venomous lizard native to the deserts of southwestern United States (US) and northern Mexico. The purpose of this study was to describe human exposures to Gila monsters reported to US poison control centers (PCCs) with a focus on Arizona cases.
• Groke, S. F., Jarrell, D. H., Edwards, C. J., Chase, P. B., Murphy, M. J., & Walter, F. G. (2015). Sodium acetate as an alkalinizing agent for salicylate intoxication: A case report.. Journal of Clinical Toxicology, 5(2), 237 plus one more online page. doi:DOI: 10.4172/2161-0495.1000237
• Tomassoni, A. J., French, R. N., & Walter, F. G. (2015). Toxic industrial chemicals and chemical weapons: exposure, identification, and management by syndrome. Emergency medicine clinics of North America, 33(1), 13-36. doi:DOI.org/10/1016/j.emc.2014.09.004
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  Toxidromes aid emergency care providers in the context of the patient presenting with suspected poisoning, unexplained altered mental status, unknown hazardous materials or chemical weapons exposure, or the unknown overdose. The ability to capture an adequate chemical exposure history and to recognize toxidromes may reduce dependence on laboratory tests, speed time to delivery of specific antidote therapy, and improve selection of supportive care practices tailored to the etiologic agent. This article highlights elements of the exposure history and presents selected toxidromes that may be caused by toxic industrial chemicals and chemical weapons. Specific antidotes for toxidromes and points regarding their use, and special supportive measures, are presented.
• Shultz, J. M., Thoresen, S., Flynn, B. W., Muschert, G. W., Shaw, J. A., Espinel, Z., Walter, F. G., Gaither, J. B., Garcia-Barcena, Y., O'Keefe, K., & Cohen, A. M. (2014). Multiple vantage points on the mental health effects of mass shootings. Current psychiatry reports, 16(9), 469.
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  The phenomenon of mass shootings has emerged over the past 50 years. A high proportion of rampage shootings have occurred in the United States, and secondarily, in European nations with otherwise low firearm homicide rates; yet, paradoxically, shooting massacres are not prominent in the Latin American nations with the highest firearm homicide rates in the world. A review of the scientific literature from 2010 to early 2014 reveals that, at the individual level, mental health effects include psychological distress and clinically significant elevations in posttraumatic stress, depression, and anxiety symptoms in relation to the degree of physical exposure and social proximity to the shooting incident. Psychological repercussions extend to the surrounding affected community. In the aftermath of the deadliest mass shooting on record, Norway has been in the vanguard of intervention research focusing on rapid delivery of psychological support and services to survivors of the "Oslo Terror." Grounded on a detailed review of the clinical literature on the mental health effects of mass shootings, this paper also incorporates wide-ranging co-author expertise to delineate: 1) the patterning of mass shootings within the international context of firearm homicides, 2) the effects of shooting rampages on children and adolescents, 3) the psychological effects for wounded victims and the emergency healthcare personnel who care for them, 4) the disaster behavioral health considerations for preparedness and response, and 5) the media "framing" of mass shooting incidents in relation to the portrayal of mental health themes.
• Walter, F. G., Stolz, U., French, R. N., Chase, P. B., McNally, J., & Shirazi, F. (2014). Epidemiology of the reported severity of cottonmouth (Agkistrodon piscivorus) snakebite. Southern medical journal, 107(3), 150-6.
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  The goal of this study was to analyze trends in the annual rates of reported medical outcomes of cottonmouth (Agkistrodon piscivorus) snakebites in the United States, published in the annual reports of the American Association of Poison Control Centers in the course of 29 years.
• Sheikh, S., McCormick, L. C., Pevear, J., Adoff, S., Walter, F. G., & Kazzi, Z. N. (2012). Radiological preparedness-awareness and attitudes: a cross-sectional survey of emergency medicine residents and physicians at three academic institutions in the United States. Clinical toxicology (Philadelphia, Pa.), 50(1), 34-8.
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  Emergency preparedness has been increasingly recognized as important. Research shows many medical personnel feel unprepared to respond to radiation incidents. Knowledge and attitudes of emergency medicine residents and faculty are largely unstudied, regarding their abilities to provide care for radiation disaster victims. It is unknown whether receiving training in radiological emergency preparedness improves knowledge and attitudes.
• Walter, F. G., Stolz, U., Shirazi, F., Walter, C. M., & McNally, J. (2012). Epidemiology of the reported severity of copperhead (Agkistrodon contortrix) snakebite. Southern medical journal, 105(6), 313-20.
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  The goal of this study was to analyze trends in the annual rates of reported medical outcomes of US copperhead (Agkistrodon contortrix) snakebites published in the annual reports of the American Association of Poison Control Centers in the course of 26 years.
• Lehman-Huskamp, K., Rebmann, T., Walter, F. G., Weber, J., & Scalzo, A. (2010). Disaster preparedness education and a Midwest Regional Poison Center. American journal of disaster medicine, 5(4), 229-36.
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  To assess knowledge and comfort related to disaster preparedness and response gained and retained from a disaster medicine workshop given to Certified Specialists in Poison Information (CSPI).
• Walter, F. G., Stolz, U., Shirazi, F., & McNally, J. (2010). Temporal analyses of coral snakebite severity published in the American Association of Poison Control Centers' Annual Reports from 1983 through 2007. Clinical toxicology (Philadelphia, Pa.), 48(1), 72-8.
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  The only U.S. Food and Drug Administration-approved coral snake antivenom was officially discontinued in 2007, causing ever-diminishing supplies. This study describes the severity of U.S. coral snakebites during the last 25 years to determine trends in annual rates of these bites' medical outcomes.
• Chase, P., Boyer-Hassen, L., McNally, J., Vazquez, H. L., Theodorou, A. A., Walter, F. G., & Alagon, A. (2009). Serum levels and urine detection of Centruroides sculpturatus venom in significantly envenomated patients. Clinical toxicology (Philadelphia, Pa.), 47(1), 24-8.
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  Envenomation by Centruroides sculpturatus can cause systemic signs and symptoms requiring treatment. The toxicokinetics of C. sculpturatus venom has not been described.
• Walter, F. G., Stolz, U., Shirazi, F., & McNally, J. (2009). Epidemiology of severe and fatal rattlesnake bites published in the American Association of Poison Control Centers' Annual Reports. Clinical toxicology (Philadelphia, Pa.), 47(7), 663-9.
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  No study has focused on the nationwide epidemiology of severe and fatal rattlesnake bites during the last 25 years. We examined rates and temporal trends of severe and fatal rattlesnake bites across the United States. Our hypothesis was that nationwide annual rates of both severe and fatal outcomes from rattlesnake bites have remained unchanged over time.
• Denninghoff, K., Walter, F. G., Langa, A. J., He, Y., & Chipman, R. A. (2008). Spectrophotometry of hydroxocobalamin and hemoglobin reveals production of an unanticipated methemoglobin variant. Clinical toxicology (Philadelphia, Pa.), 46(6), 545-50.
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  Cyanide-poisoned patients often require pulse oximetry and co-oximetry to measure oxyhemoglobin, deoxyhemoglobin, carboxyhemoglobin, and methemoglobin. These and other critical laboratory measurements can be confounded by the cyanide antidote hydroxocobalamin. The postulated mechanism of this confounding is direct optical interference.
• Lin, T. J., Walter, F. G., Hung, D. Z., Tsai, J. L., Hu, S. C., Chang, J. S., Deng, J., Chase, J. S., Denninghoff, K., & Chan, H. M. (2008). Epidemiology of organophosphate pesticide poisoning in Taiwan. Clinical toxicology (Philadelphia, Pa.), 46(9), 794-801.
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  The nationwide epidemiology of organophosphate pesticide (OP) poisoning has never been reported in detail for Taiwan.
• Madadi, P., Shirazi, F., Walter, F. G., & Koren, G. (2008). Establishing causality of CNS depression in breastfed infants following maternal codeine use. Paediatric drugs, 10(6), 399-404.
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  We recently reported on a breastfed infant who succumbed to opioid toxicity following exposure to morphine, the active metabolite of codeine, which was prescribed to his mother who was a cytochrome P450 2D6 (CYP2D6) ultrarapid metabolizer. This report is believed to be the first case of neonatal fatality as a direct result of maternal drug excretion into breast milk and, therefore, it is critical to corroborate the causative relationship between maternal codeine use during breastfeeding and neonatal opioid toxicity with other existing evidence.
• Walter, F. G., Chan, J. T., Winegard, B., Chase, P. B., Shirazi, F., Chow, Y., de Boer, M., & Denninghoff, K. (2008). Hazmat disaster preparedness in Hong Kong: what are the hazardous materials on Lantau, Lamma, and Hong Kong Islands?. American Journal of Disaster Medicine, 3(4), 213-33.
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  Hazmat disaster preparedness is critical, especially as Hong Kong prepares for major international events, such as the 2008 Olympic Equestrian Games. No published medical study describes the identities and quantities of hazardous materials (HMs) in Hong Kong and lists what antidotes are needed for these dangerous goods (DGs). This study describes what HMs are most common in Hong Kong to prioritize disaster preparedness and training.
• Walter, F. G., Chan, J. T., Winegard, B., Shirazi, F., Chase, P. B., Chow, Y., de Boer, M., & Denninghoff, K. (2008). Hazmat emergency preparedness in Hong Kong: what are the dangerous goods in Kowloon?. Hong Kong Journal of Emergency Medicine, 15(4), 156-176.
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  Hazmat disaster preparedness is critical, especially as Hong Kong prepares for major international events, such as the 2008 Olympic Equestrian Games. No published medical study describes the identities and quantities of hazardous materials (HMs) in Kowloon and lists what antidotes are needed for these dangerous goods (DGs). This study describes what HMs are most common in Kowloon to prioritize disaster preparedness and training.
• Leikin, J. B., McFee, R. B., Walter, F. G., Thomas, R. G., & Edsall, K. (2007). Radiation emergencies: a primer to nuclear incidents. JEMS : a journal of emergency medical services, 32(3), 122-4, 126, 128-32, passim; quiz 138.
• Leikin, J. B., Mcfee, R. B., Walter, F. G., Thomas, R. G., Thomas, R. G., & Edsall, K. (2007). A primer for nuclear terrorism preparedness. Journal of Emergency Medical Services, 32, 122-124,126,128-132,138.
• Leikin, J. B., Vogel, S., Samo, D., Stevens, P., & Walter, F. G. (2006). Reimbursement profile of a private toxicology practice. Clinical toxicology (Philadelphia, Pa.), 44(3), 261-5.
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  This article presents two years of billing and collection data for a bedside toxicology consultation service. The collections rate was 34% or dollars 26.19 per hour of consultative time. There was an inverse correlation between collection rates and patient acuity.
• Walter, F. G., Chase, P. B., Fernandez, M. C., Cameron, D., Roe, D. J., & Wolfson, M. (2006). Pyridoxine does not prevent hyperbaric oxygen-induced seizures in rats. The Journal of emergency medicine, 31(2), 135-8.
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  Normobaric supplemental oxygen can prolong seizures not caused by hyperbaric oxygen therapy. In addition, hyperbaric oxygen therapy can cause seizures. The mechanism of hyperbaric oxygen-induced seizures is unknown. We hypothesized that pretreatment with pyridoxine may delay the onset of hyperbaric oxygen-induced seizures, recognizing that pyridoxine is already an antidote for some epileptogenic poisons such as isoniazid and monomethylhydrazine. Therefore, rats were pretreated with intraperitoneal injections of pyridoxine at 48, 24, and 2 h before undergoing hyperbaric oxygen (HBO) treatment at 3 atmospheres absolute with 100% oxygen and were compared to a control group of HBO-treated rats for time to onset of seizures. There was no difference in onset of seizure time between the pyridoxine-treated group of rats and the control rats. Supplemental pyridoxine pretreatment did not alter the time to onset of seizures during HBO treatment in this study.
• Walter, F. G., Meislin, H. W., Munger, B., & Crounse, D. (2004). Advanced Hazmat Life Support (AHLS): Development and Demographics from 1999 through 2003. Internet Journal of Rescue and Disaster Medicine, now accessed through Internet Journal of Internal Medicine, 5(1).
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  This is a prospective, descriptive, feasibility study to determine whether an interdisciplinary group of healthcare experts could design and successfully deliver an international, life support, continuing education program that teaches the medical management of hazmat patients. The interdisciplinary experts designed and delivered the two-day Advanced Hazmat Life Support (AHLS) Provider Course, the six hour AHLS Instructor Course, and the five hour AHLS for Toxic Terrorism Course. The AHLS Provider Course trained 3,036 healthcare professionals worldwide from 1999-2003. The AHLS Instructor Course trained 1,346 healthcare professionals worldwide from 1999-2003. The AHLS for Toxic Terrorism Course trained 138 healthcare professionals, starting in 2003. Healthcare professionals from 43 countries received AHLS training. The Advanced Hazmat Life Support Program is feasible and meets the continuing education needs of healthcare professionals around the world.
• Wax, P. M., Ford, M. D., Bond, G. R., Kilbourne, E. M., Walter, F. G., Avery, A. N., Clark, R. F., & Liebelt, E. L. (2004). The Core Content of Medical Toxicology. Annals of Emergency Medicine, 43(2), 209-214. doi:10.1016/j.annemergmed.2003.09.003
• Leikin, J. B., McFee, R. B., Walter, F. G., & Edsall, K. (2003). A primer for nuclear terrorism. Disease-a-month : DM, 49(8), 485-516.
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  Mass exposure to radiologic substances presents a unique challenge to the entire response effort, which includes health care professionals, law enforcement personnel, and other first responders. Recognition of signs and symptoms of exposure, and focus on removal and decontamination are priorities of management. Radiation injuries require specialized equipment and access to experts. Patients can have complex patterns of injury, ranging from trauma and the immediate results of an explosion or exposure, to progressive damage associated with radiation sickness. Both conventional injury and radiation illness may require critical care management. Remembering the essentials of first response, that is, treat the patient, not the poison, by addressing the ABCs of airway, breathing, and circulation, is critical to appropriate treatment of radiation exposure. Understanding the basic science of radiologic agents will aid the provider in managing affected patients and preventing further casualties.
• Platz, E., Bey, T., & Walter, F. G. (2003). International report: current state and development of health insurance and emergency medicine in Germany. The influence of health insurance laws on the practice of emergency medicine in a European country. The Journal of emergency medicine, 25(2), 203-10.
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  Germany has a comprehensive health insurance system, with only 0.183% of the population being uninsured. Access to office-based medicine and to hospitals is easy and convenient. Due to enormous financial pressures, Germany is currently decreasing the number of beds in hospitals, introducing the Diagnosis Related Groups (DRG), and restricting accessibility to specialists. In contrast to Anglo-American countries, Germany follows the concept of bringing the physician to the patient in the prehospital setting, with Emergency Medical Services (EMS) physicians responding to all Advanced Life Support (ALS) calls. Despite a mature EMS system with sophisticated medical equipment and technology, both in the prehospital and hospital setting, logistical issues such as a single emergency telephone number or multidisciplinary Emergency Departments have yet to be established. Within the hospital, this "Franco-German model" considers Emergency Medicine a practice model that does not merit specialty status. Spending restrictions in the health care system, with less access to hospital beds and office-based physicians, will increase the demand for hospital-based emergency care when patients experience problems accessing the medical system. Currently, the German hospital system is unprepared to care for greater numbers of emergency patients. This may call for changes in the German health care system as well as the medical education system, with the introduction of hospital-based Emergency Medicine as its own specialty, similar to Anglo-American countries.
• Walter, F. G., Bates, G., Criss, E. A., Bey, T., Spaite, D. W., & Valenzuela, T. (2003). Hazardous materials responses in a mid-sized metropolitan area. Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors, 7(2), 214-8.
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  To determine the chemicals involved in fire department hazardous materials (hazmat) responses and analyze the concomitant emergency medical services' patient care needs.
• Bey, T. A., Walter, F. G., Gibly, R. L., James, S. T., & Gharahbaghian, L. (2002). Survival after ethylene glycol poisoning in a patient with an arterial pH of 6.58. Veterinary and human toxicology, 44(3), 167-8.
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  This ethylene glycol poisoning case had a blood pH of 6.58 and severe hypothermia (30.9 C). The patient received supportive care with dialysis and ethanol therapy. He survived in his premorbid state after 23 days in the hospital. A similar case survived ethylene glycol poisoning neurologicaly intact with an initial pH of 6.46. Although severe acidosis in the presence of serious illness is usually associated with a poor prognosis, our case emphasized the importance of aggressive supportive care and antidotal therapy for ethylene glycol poisoning even when there is a low pH.
• Chase, P. B., Walter, F. G., & James, S. (2002). Whole bowel irrigation, hemodialysis, and continuous venovenous hemodiafiltration in the successful treatment of severe salicylate poisoning: Case report. Dialysis & Transplantation, 31(6), 387-392.
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  An 18-year-old woman attempted suicide by ingesting 195 grams of aspirin. Initially, she was treated with oral multi-dose activated charcoal (MDAC) and a continuous IV infusion of sodium bicarbonate with potassium while awaiting hemodialysis (HD), because her 2-hour post-ingestion serum salicylate level was 674 mg/L. Treatment with HD, MDAC, and alkalinization with a sodium bicarbonate infusion achieved a serum salicylate nadir of 455 mg/L immediately after completing her first HD. Thereafter, her serum salicylate levels rose to 828 mg/L, indicating ongoing salicylate absorption. Therefore, she received whole bowel irrigation (WBI) and an additional course of HD. After her salicylate level had fallen to 410 mg/L at the end of her second HD, she received continuous venovenous hemodiafiltration (CVVHD) until her salicylate level was undetected. This case report documents ongoing salicylate absorption and worsening salicylism in spite of initial improvement during the patient's first HD. This was successfully treated with more HD and the addition of WBI and CVVHD. A MEDLINE review from 1966 to the present indicates that this is the first report documenting the use of CVVHD in salicylate toxicity.
• Clark, R. F., McKinney, P. E., Chase, P. B., & Walter, F. G. (2002). Immediate and delayed allergic reactions to Crotalidae polyvalent immune Fab (ovine) antivenom. Annals of emergency medicine, 39(6), 671-6.
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  Allergic reactions are the most commonly reported adverse events after administration of antivenoms. Conventional horse serum-based crotalid antivenom used in the United States (Antivenin [Crotalidae] polyvalent) can lead to both immediate and delayed hypersensitivity reactions. Crotalidae polyvalent immune Fab (ovine) (CroFab; FabAV) has recently been approved for use in the United States. Experience from premarketing trials of this product and in the administration of other types of Fab, such as in digoxin poisoning, has demonstrated these fragments to be safe and effective, with a low incidence of sequella; however, allergic reactions can occur when any animal-protein derivatives are administered to human subjects. We report in detail the nature and course of allergic reactions that occurred in 4 patients treated with FabAV. Cases of anaphylaxis, acute urticaria, angioedema, and delayed serum sickness are described. All reactions were easily treated with some combination of antihistamines, epinephrine, and steroids, with prompt resolution of signs and symptoms enabling further dosing of antivenom as required. Several of these cases may have resulted from batches of antivenom contaminated with Fc fragments. The overall incidence of immediate and delayed allergic reactions to this product appears so far to be lower than that reported with conventional whole-immunoglobulin G (IgG) antivenom, but postmarketing surveillance is warranted.
• Leikin, J. B., Thomas, R. G., Walter, F. G., Klein, R., & Meislin, H. W. (2002). A review of nerve agent exposure for the critical care physician. Critical care medicine, 30(10), 2346-54.
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  Nerve agents are discussed. The article discusses their properties, routes of exposure, toxicodynamics, targets of toxicity, and treatment. It is concluded that a focused organized approach to the treatment of nerve agents is key to its successful management.
• Barnewolt, B. A., Walter, F. G., & Bey, T. A. (2001). Metabolic effects of metaproterenol overdose: hypokalemia, hyperglycemia and hyperlactatemia. Veterinary and human toxicology, 43(3), 158-60.
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  This case report of metaproterenol toxicity was associated with hypokalemia, hyperglycemia and hyperlactatemia. A similar triad has been reported in acute theophylline poisoning. Hypokalemia and hyperglycemia have been reported with other beta-agonists, but not metaproterenol. Patients presenting with the metabolic triad of hypokalemia, hyperglycemia, and hyperlactatemia should have theophylline and beta-agonist toxicity included in their differential diagnosis because the prognosis and therapy of these 2 intoxications is markedly different.
• Tokish, J. T., Benjamin, J., & Walter, F. (2001). Crotalid envenomation: the southern Arizona experience. Journal of orthopaedic trauma, 15(1), 5-9.
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  To review a regional experience with the treatment of snakebites.
• Brammer, G., Gibly, R., Walter, F. G., Bey, T., Torres, R., & Kohler, S. (2000). Continuous intravenous flumazenil infusion for benzodiazepine poisoning. Veterinary and human toxicology, 42(5), 280-1.
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  This is the first US report of continuous iv flumazenil infusion for benzodiazepine poisoning. A MEDLINE search from 1966 to 1999 revealed no similar reports in the US literature. A 24-y-o woman ingested 50, 2 mg (=100 mg) flunitrazepam tablets in a suicide attempt. She presented 30 min after ingestion with a temperature of 36.5 C, blood pressure of 90/36 mmHg, pulse of 84/min, and shallow respirations of 8/min. Her Glasgow coma scale (GCS) was 8. Her ECG showed sinus rhythm at 80/min, a QRS axis of 30 with no terminal 40 msec deviation, and a QRS interval of 84 msec. She received 0.2 mg flumazenil iv and her GCS improved to 15. She was orogastrically lavaged and given 50 g of activated charcoal. Resedation to a GCS of 8 recurred twice, requiring additional 0.3 mg and 0.5 mg boluses of flumazenil iv, totaling 1.0 mg over 1 h. Then, a continuous flumazenil infusion was started at 1.0 mg/h, maintaining her GCS at 15. Fourteen h later, the continuous flumazenil infusion was terminated, resulting in resedation and clinical hypoventilation. Flumazenil infusion was restarted at 1.0 mg/h with resolution of sedation and hypoventilation. Thirty h after overdose flumazenil infusion was terminated without resedation or hypoventilation. Continuous iv flumazenil infusion is not US Food and Drug Administration approved, and further study is necessary in carefully selected patients to determine its safety and efficacy.
• Boyer, L. V., Seifert, S. A., Clark, R. F., McNally, J. T., Williams, S. R., Nordt, S. P., Walter, F. G., & Dart, R. C. (1999). Recurrent and persistent coagulopathy following pit viper envenomation. Archives of internal medicine, 159(7), 706-10.
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  Coagulation abnormalities following crotaline (pit viper) snakebite have traditionally been considered short-lived, but laboratory studies have rarely been reported beyond the first few days of treatment for envenomation. During the course of an antivenom clinical trial, we observed coagulation defects as late as 2 weeks following envenomation.
• Gibly, R., Williams, M., Walter, F. G., McNally, J., Conroy, C., & Berg, R. A. (1999). Continuous intravenous midazolam infusion for Centruroides exilicauda scorpion envenomation. Annals of emergency medicine, 34(5), 620-5.
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  We sought to describe the effects of continuous intravenous midazolam infusion as therapy for severe bark scorpion (Centruroides exilicauda) envenomation.
• Walter, F. G., Bilden, E. F., & Gibly, R. L. (1999). Envenomations. Critical care clinics, 15(2), 353-86, ix.
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  Envenomations are uncommon, challenging causes of critical care admissions. This article describes the diagnosis and treatment of envenomations that cause the most critical care admissions in the United States. Most are caused by the following animals: rattlesnakes, copperheads, cottonmouths, coral snakes, brown recluse spiders, and bark scorpions.
• Bey, T., Waer, A., Walter, F. G., Fortune, J., Seeger, J., Fryburg, K., & Smith, W. (1998). Spinal cord injury with a narrow spinal canal: utilizing Torg's ratio method of analyzing cervical spine radiographs. The Journal of emergency medicine, 16(1), 79-82.
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  A 65-year-old inebriated man crashed his car and presented with spinal shock and neurogenic shock from a cervical spinal cord injury without cervical spine fracture or dislocation. The lateral cervical spine radiography was initially read as normal, except for degenerative disk disease; however, Torg's ratio method of analyzing cervical spinal canal sagittal width indicated the spinal canal was congenitally narrow. Magnetic resonance imaging confirmed this and showed bulging and herniation of multiple invertebral disks between C2 and C7. This case illustrates the value of using Torg's ratio method of analyzing lateral cervical spine radiographs. Although Torg's method has not been prospectively validated, it may be useful to identify patients at risk for cervical spinal cord injuries without fractures or dislocations. An abnormal Torg's ratio may be the only clue to the fact that the patient is at higher risk of spinal cord injury when the patient's history or examination is questionable because of head injury, drug intoxication, or therapeutic sedation and paralysis.
• Gibly, R. L., Walter, F. G., Nowlin, S. W., & Berg, R. A. (1998). Intravascular hemolysis associated with North American crotalid envenomation. Journal of toxicology. Clinical toxicology, 36(4), 337-43.
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  This is a case of severe intravascular hemolysis, without significant coagulopathy, following envenomation by a North American crotalid. A MEDLINE search from 1966-1997, and a review of older literature, revealed no similar cases. A 4-year-old girl was envenomated in her right foot by a 2.5 foot-long rattlesnake whose description matched that of the Hopi rattlesnake (Crotalus viridis nuntius). The snake was not captured. Her initial hematocrit was 45%. In spite of treatment with antivenin and improvement in her lower extremity pain and swelling, her hematocrit decreased to 20.4%. Laboratory tests and clinical exam showed a Coombs positive hemolytic anemia without significant signs of coagulopathy.
• Walter, F. G., Gibly, R. L., Knopp, R. K., & Roe, D. J. (1998). Squamous cells as predictors of bacterial contamination in urine samples. Annals of emergency medicine, 31(4), 455-8.
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  To determine whether squamous cells in urine indicate bacterial contamination.
• Williams, M., Walter, F. G., & Gibly, R. L. (1998). Continuous intravenous midazolam infusions for Centruroides excilicauda envenomations. Clinical Toxicology, 36(5), 460-461.
• Atkin, D. H., Levine, N., & Walter, F. G. (1997). Single patch of hair at a denervated site in a patient with alopecia universalis. Journal of the American Academy of Dermatology, 37(5 Pt 1), 796-7.
• Bey, T. A., & Walter, F. G. (1997). Glucagon and phenol toxicity. Annals of emergency medicine, 30(3), 353-4.
• Bey, T. A., Boyer, L. V., Walter, F. G., McNally, J., & Desai, H. (1997). Exotic snakebite: envenomation by an African puff adder (Bitis arietans). The Journal of emergency medicine, 15(6), 827-31.
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  We report an envenomation by the African puff adder (Bitis arietans), an exotic snake in the United States. The patient developed swelling and ecchymoses in the affected extremity, and cutaneous necrosis of the envenomated fingertip. There was no significant coagulopathy. He received 20 vials of specific antivenin (Schlangengift-Immunserum Behring Zentralafrika, Behringwerke, Marburg, Germany) and debridement of devitalized finger tissue. The only permanent sequelae were cutaneous scarring and permanent loss of the fingernail on the envenomated finger. Exotic snakebite is a rare presenting problem in emergency departments. The initial approach to a patient envenomated by an exotic venomous snake is discussed. Use of antivenin and supportive care are emphasized.
• Bey, T. A., Walter, F. G., & McNally, J. (1997). Exotic envenomation. Annals of emergency medicine, 29(1), 195.
• Bey, T. A., Walter, F. G., Lober, W., Schmidt, J., Spark, R., & Schlievert, P. M. (1997). Loxosceles arizonica bite associated with shock. Annals of emergency medicine, 30(5), 701-3.
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  Envenomation by the brown recluse spider (Loxosceles reclusa) is associated with shock, significant hemolysis, renal insufficiency, and disseminated intravascular coagulation (DIC). Shock has never been associated with envenomation by L arizonica, a related species indigenous to Arizona, southern California, and northwestern Mexico. We report the case of a 13-year-old girl, bitten by a specimen of L arizonica (the spider was identified by an entomologist), in whom shock and a typical cutaneous lesion developed. She did not experience renal insufficiency or disseminated intravascular coagulation. Infectious causes of shock were excluded. She recovered completely with supportive care.
• Gibly, R. L., Walter, F. G., Kloster, J., Theodorou, A. A., & Osterloh, J. (1997). Cisapride poisoning. Veterinary and human toxicology, 39(4), 231-3.
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  A MEDLINE search from 1966-1996 revealed no reports of cisapride poisoning. An 8-mo-old, 8.9 kg girl received 8 mL of cisapride (Propulsid Suspension, 1 mg/mL, Janssen Pharmaceutica, Titusville, NJ) rather than the usual dose of 0.8 mL, resulting in an inadvertent, 10-fold, iatrogenic, dosing error. She developed emesis, hyperactive bowel sounds, abnormal behavior, mild hyperthermia, tachycardia, hypertension, and thrombocytosis. This is the first published report of poisoning with cisapride.
• Russell, F. E., Walter, F. G., Bey, T. A., & Fernandez, M. C. (1997). Snakes and snakebite in Central America. Toxicon: Official Journal of the International Society on Toxinology, 35(10), 1469-522. doi:https://doi-org.ezproxy2.library.arizona.edu/10.1016/S0041-0101(96)00209-7
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  This review treats the general biology, taxonomy, distribution and venom apparatus of the venomous snakes of Central America. Consideration has been given to the chemistry, pharmacology and immunology of the venom, and particular attention is dispensed to the clinical problem, including the treatment, of envenomations by these reptiles.
• Fernandez, M. C., Walter, F. G., Kloster, J. C., Do, S. M., Brady, L. A., Villarin, A., Ruffenach, S. J., Prosnitz, E. H., & Salmon, J. V. (1996). Hemodialysis and hemoperfusion for treatment of valproic acid and gabapentin poisoning. Veterinary and human toxicology, 38(6), 438-43.
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  A 31-y-old epileptic man developed coma and shock after suicidally ingesting large amounts of valproic acid and gabapentin. His peak valproic acid, level was 1306.9 micrograms/mL (therapeutic range = 30-100 micrograms/mL). His peak gabapentin level was 60.0 micrograms/mL (therapeutic range = 2.0-8.0 micrograms/mL). His hypotension was refractory to crystalloid and pressor infusions, but resolved during concurrent hemoperfusion and hemodialysis to enhance elimination of valproic acid. Concurrent hemoperfusion and hemodialysis, in series, produced a maximum valproic acid plasma clearance of 55.4 mL/min versus a maximum reported intrinsic valproic acid plasma clearance of 10.6 mL/min. concurrent hemoperfusion and hemodialysis, in series, should be considered in hemodynamically unstable patients with valproic acid poisoning whose clinical condition is worsening in spite of aggressive supportive care.
• Fernández, M. C., Walter, F. G., Petersen, L. R., & Walkotte, S. M. (1996). Gabapentin, valproic acid, and ethanol intoxication: elevated blood levels with mild clinical effects. Journal of toxicology. Clinical toxicology, 34(4), 437-9.
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  A suicidal, epileptic patient ingested ethanol, valproic acid, and gabapentin, a new antiepileptic drug. He did well clinically despite elevated blood gabapentin, valproic acid, and ethanol.
• Walter, F. G., Bey, T. A., Ruschke, D. S., & Benowitz, N. L. (1996). Marijuana and hyperthermia. Journal of toxicology. Clinical toxicology, 34(2), 217-21.
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  Animal and human laboratory studies suggest marijuana may cause hyperthermia. However, there are no clinical case reports of life-threatening hyperthermia associated with use of marijuana alone.
• Burningham, M. D., Walter, F. G., Mechem, C., Haber, J., & Ekins, B. R. (1994). Wound botulism. Annals of emergency medicine, 24(6), 1184-7.
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  Wound botulism is a rare infectious and toxicologic complication of trauma and i.v. drug abuse. Only 39 cases have been reported in detail in the English literature. This case report describes a patient with wound botulism who presented to four medical facilities before receiving definitive diagnosis and treatment. Although his history and physical examination were consistent with wound botulism, diagnosis and therapy were delayed because this rare disease was not considered initially in the differential diagnosis. Wound botulism should be considered in trauma patients and i.v. drug abusers who present with cranial nerve palsies and descending paresis.
• Mechem, C. C., & Walter, F. G. (1994). Wound botulism. Veterinary and human toxicology, 36(3), 233-7.
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  All published cases of wound botulism were reviewed to describe the epidemiology, clinical manifestations, diagnosis, and treatment of this rare infection. The MEDLINE data base of English-language literature was searched from 1966 to 1992, using the keywords "wound botulism". Cases published during this period were identified, and the bibliographies of these articles were used to identify cases published before MEDLINE's search limit of 1966. Because of the limited number of published cases, all were reviewed. Data related to epidemiology, clinical manifestations, diagnosis and treatment were collected on each case. When possible, cross-references from case series or reviews were used to corroborate and supplement data for a given case. There were 40 cases identified as wound botulism. The case fatality rate was 10%. The 36 survivors had significant morbidity requiring prolonged medical care. Wound botulism is a rare life-threatening complication of trauma and i.v. drug abuse. The diagnosis should be considered in any patient with either of these risk factors who develop paresis of cranial nerves and a descending pattern of weakness. Treatment, including administration of antitoxin, should be initiated prior to definitive diagnosis by microbiologic laboratory tests.
• Tighe, T. V., & Walter, F. G. (1994). Delayed toxic acetaminophen level after initial four hour nontoxic level. Journal of toxicology. Clinical toxicology, 32(4), 431-4.
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  Antidotal therapy for acetaminophen poisoning is routinely based on a single acetaminophen level obtained four or more hours after ingestion. Some experts recommend additional acetaminophen levels if there are coingestants. This case report describes a 20-year-old woman who ingested acetaminophen 13 g, propoxyphene napsylate 2 g and naproxen sodium 3.75 g. A 4.5 h acetaminophen level was 83.5 mg/L (nontoxic). A 6.75 h acetaminophen level was 124.6 mg/L (toxic). The patient was treated with N-acetylcysteine and recovered without sequelae. This is the first published report of a delayed toxic acetaminophen level occurring after an initial nontoxic level. Although rare, the possibility of a delayed peak acetaminophen level merits consideration, particularly with coingestions that delay gastric emptying.
• Fisher, A. K., Walter, F. G., & Szabo, S. (1993). Iodoquinol associated seizures and radiopacity. Journal of toxicology. Clinical toxicology, 31(1), 113-20.
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  This case report describes seizures and encephalopathy in a nine year-old boy treated with iodoquinol for amebiasis. The toxicity of iodoquinol and other 8-hydroxyquinolines is discussed. The radiopacity of this medication, used worldwide for the treatment of diarrheal illnesses and dermatitis, may be diagnostically useful.
• Walter, F. G., Frye, G., Mullen, J. T., Ekins, B. R., & Khasigian, P. A. (1993). Amelioration of nifedipine poisoning associated with glucagon therapy. Annals of emergency medicine, 22(7), 1234-7.
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  Glucagon relieves calcium channel blocker-induced hypotension in animal studies. There are no published case reports of glucagon relieving hypotension in patients with calcium channel blocker poisoning. We describe a patient who developed hypotension after ingestion of 900 mg nifedipine. Therapy with IV lactated Ringer's solution and calcium chloride alone did not relieve his hypotension. However, hypotension rapidly resolved after the addition of IV glucagon therapy. This is the first case report of glucagon therapy at least temporally associated with relief of hypotension in a patient with calcium channel blocker poisoning. More research is needed to determine the appropriate role for glucagon in treating patients with calcium channel blocker poisoning.
• Walter, F. G., Shimizu, G., Olson, K. R., & Keller, K. H. (1991). Acetaldehyde analysis in severe metaldehyde poisoning. Veterinary and Human Toxicology, 33(4).
• Walter, F. G. (1990). Urine sampling in ambulatory women. The Journal of emergency medicine, 8(5), 653.
• Walter, F. G., & Knopp, R. K. (1989). Urine sampling in ambulatory women: midstream clean-catch versus catheterization. Annals of emergency medicine, 18(2), 166-72.
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  We conducted a study to determine if there were any significant differences in urinalyses or urine cultures obtained by midstream clean-catch (MSCC) urine sampling in comparison with in-and-out catheterization (CATH). One hundred five women with symptoms suggestive of a urinary tract infection were studied prospectively. Each woman had a MSCC urine sample obtained initially, followed by a CATH sample. The MSCC and CATH urine samples were analyzed and compared for urine culture, leukocyte esterase, nitrites, microscopic bacteriuria, and pyuria. Of the 105 patients, 42 (40%) had a culture-proven urinary tract infection. The concordance rates between MSCC and CATH urine cultures, nitrites, leukocyte esterase, significant microscopic bacteriuria, and pyuria were 96%, 94%, 93%, 90%, and 90%, respectively. There were no statistically significant differences between MSCC and CATH sensitivities, specificities, or positive or negative predictive values for any urinalysis variable (leukocyte esterase, nitrites, significant microscopic bacteriuria, or pyuria). We conclude that if proper MSCC technique is used, the differences between MSCC and CATH urinalyses or urine cultures do not appear to be significant in the majority of ambulatory women without active vaginal bleeding who present with symptoms suggestive of a urinary tract infection.

Presentations

• Rice, A., Gaither, J. B., French, R. N., Beskind, D. L., Smith, J., Shirazi, F., & Walter, F. G. (2020, January). EMS Medical Directors Advanced Hazmat Life Support for Tox-Medics. National Association of EMS Physicians (NAEMSP) 2020 Annual Meeting. San Diego, CA: NAEMSP.
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  Full day pre-conference workshop presentation
• Rice, A., Gaither, J. B., French, R. N., Beskind, D. L., Smith, J., Shirazi, F., & Walter, F. G. (2020, January). EMS Medical Directors' Advanced Hazmat Life Support for Tox-Medics. National Association of EMS Physicians (NAEMSP) 2020 Annual Meeting. San Diego, CA: NAEMSP.
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  Full day pre-conference workshop presentation

Poster Presentations

• Mo, J. E., Aizenberg, A. M., Clark, S., Gaither, J. B., Larsen, J., French, R. N., Shirazi, F., & Walter, F. G. (2023, Sep. 27 – Oct. 1, 2023).

  The Role of the Poison Center in Emergency Response to a Nitric Acid Transport Spill

  . North American Congress of Clinical Toxicology. Montreal, Quebec, Canada: American Academy of Clinical Toxicology.
• Rinner, G., Shirazi, F., & Walter, F. G. (2019, September). Rare Side Effects of Initiating Antihypertensive Therapy. North American Congress of Clinical Toxicology, September 23-27, 2019, Nashville, Tennessee. Nashville, Tennessee: American Academy of Clinical Toxicology (AACT).
• Mhayamaguru, K., Bellafiore, A. L., Lederer, E., Youngs, C. R., French, R. N., Gaither, J. B., Waters, K. E., & Walter, F. G. (2018, January 10-13, 2018). Prehospital Availability and Use of Medications for Managing Hazmat Emergencies. National Association of EMS Physicians 2018 Annual Meeting, January 10-13, 2018, San Diego, California. San Diego, California: National Association of EMS Physicians (NAEMSP).
• Appel, J., Groke, S., Hurst, N., Solem, C., Williams, A., Stolz, U., French, R., & Walter, F. G. (2013, June). Do Mnemonics Help Healthcare Professionals Learn and Recall Toxic Syndromes for Cholinergic Hazardous Materials?. SAEM National Research Meeting. Atlanta, GA.