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We performed a prospective, randomized, placebo-controlled, double-blind clinical trial of antibiotic administration to treat possible occult bacteremia in febrile children. A total of 955 children aged 3 to 36 months with temperatures greater than or equal to 39.0 degrees C and no focal bacterial infection were enrolled at the emergency departments of two children's hospitals from January 1982 until July 1984. Blood samples for culture were obtained, and the children were randomly assigned to receive either oral amoxicillin or placebo and were restudied approximately 48 hours after enrollment. Data were also collected on 228 children who could not be randomly assigned. Twenty-seven of the randomly assigned children (2.8 percent) had bacteremic infections with pathogenic organisms (Streptococcus pneumoniae, Haemophilus influenzae, and salmonella). There were no differences in the incidence of major infectious morbidity associated with bacteremia between the antibiotic and placebo groups--2 of 19 patients (10.5 percent) in the antibiotic group and 1 of 8 (12.5 percent) in the placebo group--although the power for this comparison was low. Antibiotics reduced fever (P less than 0.005) and improved the clinical appearance (P = 0.07) in the children with bacteremia but not in those without bacteremia. Although there were no statistically significant differences in the incidence of side effects, diarrhea tended to occur more often in the patients treated with amoxicillin (15 vs. 11 percent, P less than 0.10). We conclude that our data do not support the routine use of standard oral doses of amoxicillin in febrile children who do not have evidence of focal bacterial disease.

H azardous chemical emergencies and related poisonings result from various exposures, including inadvertent residential, industrial, occupational, or transportation mishaps; natural disasters; and hazardoussubstance releases that are intended to cause harm. 1-3 Up to 100,000 industrial chemicals are used each day in the United States, 4 and federal authorities estimate that more than 10,000 potentially consequential releases of hazardous substances occur annually. 4,5 In addition, numerous compounds have been developed primarily as military weapons, with exceedingly high toxicity. 6-8 Both toxic industrial chemicals and military chemical weapons are capable of causing mass casualties in a substantive release and may be deployed intentionally in the context of chemical terrorism, 8-10 targeted assassination attempts, 8,11,12 or wartime attacks on civilian populations, as tragically shown in the current Syrian war. 13,14 A toxidrome-based, emergency medical systems (EMS) approach to chemical weapons attacks was presented recently by Ciottone in the Journal. 8 (Toxidromes are constellations of clinical signs, particularly vital signs, mental status, and ocular, respiratory, neurologic, and skin findings, that are characteristic of general classes of poison.) A similar approach is useful for the myriad possible entities in nonintentional hazardous chemical incidents. We review the toxicology and hospital-based management of acute poisonings caused principally by dermal and inhalational exposure to several representative chemical-agent classes in incidents involving the release of hazardous substances or chemical attacks (Table 1). Cyanide and organophosphate poisonings are emphasized, since they can also affect individual patients in the more familiar contexts of occupational and residential exposures or ingestions with suicidal intent and since specific emergency antidotal therapy is crucial for good outcomes. Ov erv iew of Hospita l-Ba sed Emergenc y M a nagement Incidents involving the release of hazardous chemicals may result in widespread chaos and confusion, affecting the EMS response and emergency department (ED) care. 2,8 A rapid influx of multiple critically ill victims with unfamiliar illnesses, as well as numerous low-risk but understandably anxious patients, potentially far outnumbering the seriously ill, 1 poses significant challenges to hospital-based emergency care providers. Patients may bypass prehospital care and arrive at the hospital unaware of or misinformed regarding the cause of their symptoms, with the potential to chemically contaminate bystanders and staff. 2,15-17 Thus, prompt recognition of the chemical event is important so that ED staff and hospital emergency management personnel can secure hospital entrances and decontaminate contami