Bruce Springsteen on Pete Seeger

Wonderful tribute by The Boss at Seeger’s 90th birthday celebration. Pete’s and his music were a lifelong inspiration for me, from “Goodnight, Irene” to “The Weavers at Carnegie Hall” to his environmental work with the Hudson River Sloop Clearwater Foundation.

And there was, always, his unwavering and indomitable political courage. This incredible performance was aired on CBS’s The Smothers Brothers Comedy Hour in 1968, in the midst of the war in Vietnam:

When Toshi Seeger, whom Pete married in 1943, died last year, I knew it wouldn’t be long before he followed. Still, it’s a shock, and the world is a little emptier today.

And one more song (Tip of the Hat to Joe Lex):

Epidemic of heroin/fentanyl overdose deaths in Western Pennsylvania

KDKA-TV, the local CBS station in Pittsburgh, reported yesterday that at least 22 people have died recently from narcotic overdoses in Western Pennsylvania. Authorities believe the deaths are related to products containing heroin and/or  fentanyl sold on the street and derived from supplies stamped with the labels “Theraflu,” “Bud Ice,” or “Income Tax.’

This outbreak is reminiscent of previous events. In the early 1990s, fentanyl-laced heroin sold as “Tango and Cash” killed dozens of victims. In 2006, the Philadelphia Medical Examiner’s Office reported 252 overdose deaths that tested positive for fentanyl. The read my Emergency Medicine News column about these outbreaks, click here.

Hat tip to @DavidJuurlink

What I’m reading: NG hydration in bronchiolitis – Really?

Certainly you will be seeing some sicker children with bronchiolitis this winter who have issues with feeding. The copious nasal congestion and increased work of breathing may preclude adequate oral intake. Some of these children will merit admission and generally we obtain IV access for hydration. But why can’t we use their gut via a nasogastric tube? Logically this makes sense – but it hadn’t (re)ocurred to me until I read the following article from Lancet Respiratory Medicine.

Oakley et al. conducted a multicenter randomized study in Australia and New Zealand of almost 800 infants aged 2-12 months with bronchiolitis who were admitted. They used computerized block stratified randomization. What does that mean? Well, they randomized within 2 groups (stratification) – 2 to <6 months and 6 to 12 months – and in small blocks (a few patients in a row got the same treatment). The stratification is done to try to account for age related differences, and the block randomization helps keep things more convenient – especially across different sites.

The primary outcome was length of hospital stay. Secondary outcomes included rates of intensive-care unit admission, adverse events, and success of insertion.

They found that the mean length of stay for 381 infants randomized to NG hydration was 86.6 hours (SD 58·9) vs 82·2 h (58·8) for 378 infants assigned intravenous hydration.  The Risk difference of 4·5 h [95% CI -3·9 to 12·9] was not significant with a p=0·30. There was no difference in rates of admission to intensive-care units, need for ventilatory support, and adverse events. It is important to note that a number of patients “crossed over” to the opposite group (i.e. couldn’t get an IV so they went to NG). When you see this in a study you’ll want to look for intention to treat. This is important because the randomization was initially done to account for all variability in the groups that could ultimately affect the results. “Once randomized always analyzed” – essentially means that patients should stay in their original groups that they were randomized into even if they didn’t get the intervention the investigators initially thought they would. Of note in this study 275 (85%) of 323 infants in the NG group and 165 (56%) of 294 infants in the IV group required only one attempt for successful insertion.

So, there was no significant difference in length of stay – nor the secondary outcomes. So does this mean that NG hydration is inferior? Not necessarily. For the child that needs 5-6 attempts at a peripheral IV suggesting NG hydration may be amenable to the parents and nurses. So, it is worth considering, and I plan to think about it the next time I encounter a bronchiolitic in need of continuous hydration.

Check out the article here (may require institutional account to get the full pdf)

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Surgical airways in the field?

Surgical airways have fallen out of favor in the hospital setting due to the advent of RSI and supraglottic airway devices, and now represent less than 3% of attempted intubations. In the prehospital setting, they can represent up to nearly 15% of attempts, however. It’s been said that the only absolute contraindication to cricothyrotomy is securing the airway by some other means. Even with the A in ABC taking a backseat recently, there are certainly circumstances that require definitive airways. Accomplishing this task while in an austere environment adds more difficulty to the equation.

So how skilled are providers at performing surgical airways in the pre-hospital environment? And what differences are there to devices and techniques in the austere setting, versus in a hospital? The authors of this article set out to find those answers. The impetus appeared to be a case report published in the same issue of Wilderness & Environmental Medicine by one of the authors of the review article.

The better part of the article is where it discusses the improvised techniques for the austere environment. Lots of items have been used in place of standard items, including: 3 mL syringe barrels (modified by cutting), nasal specula, straws from sports bottles, and ETT, as well as devices made specifically for surgical airways.  There may be anecdotes about using pen barrels, but nobody has bothered to publish a case report on an actual patient yet. Don’t fret though, if you want to be the first, somebody else has done the legwork on which ones to use, namely: 

The 2 pens ultimately deemed acceptable were the Baron retractable ballpoint pen and the Bic Soft Feel Jumbo.

Importantly, they point out that using the spike from an IV drip chamber will only work if you’ve got a jet ventilator. The inner diameter simply doesn’t allow proper ventilation.  I’m guessing if you thought to carry one of those into the wilderness, you’ve probably got better equipment to do a proper surgical airway. Likewise, needle crics may allow you to oxygenate, but you will not be able to ventilate, so at best they would be temporizing. Continuing the theme of improvising, the authors also describe using a bent 14 gauge needle as a makeshift hook, but sadly not how to make one.

Moving on to how successful the techniques are, in a review of 13 aeromedical papers on crics, the authors reported a 97% success rate on 296 patients, but they don’t break down physician vs flight nurse vs paramedic. A second review of ground EMS papers shows a lower rate of success at 89% for 405 patients, and this too includes all comers. A meta-analysis performed by other authors and referenced here showed no difference between flight and ground, but did show needle crics were much less successful at 66%, compared to the 90% for standard surgical airways.

Like many review articles, they have plenty of dry explanations of background, landmarks, indications, and contraindications. They review the incidence using prehospital and military literature, which is where the aforementioned statistics come from. They also mention that only one case report in the wilderness setting, also previously mentioned. There is then a table describing 12 current techniques for surgical airways. Taking up an entire page, it is a good primer, but not detailed enough to be your only source.

The authors recommend that providers pick a technique, and train in it often. Practicing less frequently than every 6 months leads to decreased skill maintenance, and perhaps training is needed as often as every month. Fidelity is important, as live-tissue models, and fresh cadaver specimens are much more realistic than mannequins. These recommendations are valid, as you don’t want to be trying something for the first time, when all you’ve got is what’s in your pack.

Optimizing emergent surgical cricothyrotomy for use in austere environments.

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