Field Expedient Vasopressors During Aeromedical Evacuation: A Case Series from the Puerto Rico Disaster Response.

IntroductionEmergency physicians are using bolus-dose vasopressors to temporize hypotensive patients until more definitive blood pressure support can be established. Despite a paucity of clinical outcome data, emergency department applications are expanding into the prehospital setting. This series presents two cases of field expedient vasopressor use by emergency medicine providers for preflight stabilization during aeromedical evacuation to a hospital ship as part of the United States Navy disaster response in Puerto Rico. A critical approach and review of the literature are discussed.Case ReportTwo critically ill patients were managed in an austere environment as a result of the devastation from Hurricane Maria (Yabucoa, Puerto Rico; 2017). They both exhibited signs of respiratory distress, hemodynamic instability, and distributive shock requiring definitive airway management and hemodynamic support prior to aeromedical evacuation.DiscussionThe novel use of field expedient vasopressors prior to induction for rapid sequence intubation was successfully and safely employed in both cases. Both patients had multiple risk factors for peri-induction cardiac arrest given their presenting hemodynamics. Despite their illness severity, both patients were induced, transported, and ultimately admitted to the intensive care unit (ICU) in stable condition following administration of the field expedient vasopressors.Conclusion:Field expedient vasopressors were safely and effectively employed in an austere field environment during a disaster response. This case series contributes to the growing body of literature of safe bolus-dose vasopressor use by emergency physicians to temporize hypotensive patients in resource-constrained situations. HardwickJM, MurnanSD, Morrison-PonceDP, DevlinJJ. Field expedient vasopressors during aeromedical evacuation: a case series from the Puerto Rico disaster response. Prehosp Disaster Med. 2018;33(6):668-672.

The practical experience of exercise and diabetes

Individuals with diabetes mellitus are being encouraged to engage in regular sports and other recreational activities for a variety of reasons. These include personal enjoyment, to overcome a sense of feeling different from peers, to feel better from both a physical and psychological perspective, and to enjoy the numerous health benefits of regular activity. Increasing evidence supports the important role of increased physical activity levels in reducing cardiovascular risk, and important consideration in people with diabetes. The major challenge to the individual with type 1 diabetes and the health care provider is to devise a strategy to accommodate increased exercise safely without an excessive risk of acute metabolic decompensation. This is best accomplished with an individualized treatment algorithm which takes into account the patient's food and insulin pattern, the type and duration of exercise, and his or her previous experience with similar types of exercise. Because of interindividual differences, frequent testing of blood glucose levels is important to gauge the response to exercise. Development of an individual routine with regard to the time of day of exercise, and its relation to meals, allows for a greater degree of predictability of the response to exercise. Insulin regimens which provide increased numbers of injections (3 - 4 per day), or the continuous delivery of subcutaneous insulin, generally provide the patient with greater ease in making appropriate adjustments of insulin doses before and after exercise. In patients with type 1 diabetes, these include Multiple Dosing of Insulin regimens which provide short-acting insulin before each meal with bedtime intermediate-acting insulin, or the use of an insulin pump. The latter offers distinct advantages for the endurance athlete, who needs to provide a constant delivery of a small amount of insulin over the duration of exercise. Anecdotal reports of the use of fast-acting Humalog (lispro) insulin in the insulin pump suggest that this may allow for more rapid adjustments in insulin dosing immediately before and after exercise, without loss of glycaemic stability. In type 2 diabetes, the individuals is less prone to ketosis, but may s till develop marked hyperglycaemia due to exercise, especially if dehydration occurs. In addition, the usual presence of insulin resistance makes these individuals less likely to develop significant degrees of hypoglycaemia during or after exercise.(AU)

Exercise in the treatment of type 1 diabetes

REVIEW OF FUEL METABOLISM DURING AND AFTER EXERCISE: Increased skeletal muscle glucose uptake induced by exercise *regional effects (exercised vs nonexercise muscle) *type of exercise (concentric vs eccentric). Importance of skeletal muscle glycogen depletion and replention in glucose homeostatis. Role of the liver in glucose production *hormonal control. Ketone body metabolism *importance of ambient insulin and counterregulatory *hormone concentrations at the onset of exercise. Amino metabolism *acute catabolic effects of exercise *post-exercise anabolic effects of exercise. METABOLIC RESPONSE TO EXERCISE IN TYPE 1 DIABETES: Glycaemic response to acute exercise *dependence on ambient insulin concentratios *effects of intensity and duration of exercise *accelerated ketogenesis in the insulin-deprived state *intact net protein anabolic effect following exercise *altered mechanisms in the insulin-deprived state. CLINICAL EFFECTS OF PHYSICAL EXERCISE IN TYPE 1 DIABETIC SUBJECTS: Risks of hypoglycaemia *during exercise *following exercise, long-term benefits of increased physical activity *glycaemic control * cardiovascular risk factor reduction, Risk of worsening diabetic complications due to exercise *retinopathy *proteina *neuropathy *peripheral *autonomic *cardiovascular disease. CLINICAL STRATEGIES TO PREVENT METABOLIC DECOMPENSATION BY EXERCISE: Carbohydrate intake *before and during exercise *following evening exercise. MULTIPLE DOSING OF INSULIN (MDI) REGIMENS: adjustments of short-acting insulin preparations for exercise, regular vs humalog (lispro) insulin, insulin pump (CSII) therapy, regular vs humalog insulin. RESOURCES FOR THE PATIENT AND THE HEALTH CARE PROFESSIONAL: published materials, International Diabetes Athletes' Association (IDAA).(AU)

Exercise in the treatment of type 1 diabetes

The benefit of exercise are far-reaching but are more related to cardiovascular health rather than glycaemic control for the person with type I diabetes, although insulin needs may be reduced. Persons with type 2 diabetes with insulin resistance will benefit more than persons with type 1 diabetes. The main benefit for the persons with Type 1 diabetes is a sense of well-being, and knowing that they are able to participate in sport and competition safely. The risks associated with exercise are hypoglycaemia, ketosis, hyperglycaemia and increased risk of complications such as retinopathy, albuminuria and early diabetic kidney disease, peripheral autonomic neuropathy and cardiovascular risk. Retinopathy by itself is not a contraindication to exercise. However, exercise which raises the blood pressure or raises the risk for haemorrhage should be avoided.(AU)

Exercise in the treatment of type 1 diabetes

The benefit of exercise are far-reaching but are more related to cardiovascular health rather than glycaemic control for the person with type I diabetes, although insulin needs may be reduced. Persons with type 2 diabetes with insulin resistance will benefit more than persons with type 1 diabetes. The main benefit for the persons with Type 1 diabetes is a sense of well-being, and knowing that they are able to participate in sport and competition safely. The risks associated with exercise are hypoglycaemia, ketosis, hyperglycaemia and increased risk of complications such as retinopathy, albuminuria and early diabetic kidney disease, peripheral autonomic neuropathy and cardiovascular risk. Retinopathy by itself is not a contraindication to exercise. However, exercise which raises the blood pressure or raises the risk for haemorrhage should be avoided.