Pharmacokinetics of sternal intraossesous atropine administration in normovolemic and hypovolemic swine.

OBJECTIVE: Characterize and compare the pharmacokinetics of atropine administered via the sternal intraosseous (IO) route in a normovolemic and hypovolemic swine model. DESIGN: Prospective, experimental study. SETTING: Vivarium. SUBJECTS: Yorkshire-cross swine (N = 12). INTERVENTION: Atropine was administered via the sternal IO route to normovolemic and hypovolemic swine. Blood samples were drawn at regular intervals after atropine administration and analyzed for plasma atropine concentration. Pharmacokinetic parameters were obtained from modeling the plasma concentrations. MAIN OUTCOME MEASUREMENTS: Pharmacokinetic parameters, maximum concentration (Cmax), and time to maximum concentration (Tmax). RESULTS: The normovolemic and hypovolemic models reached peak plasma concentration immediately and had a very rapid distribution phase with no apparent absorption phase for the IO groups. The hypovolemic group had slower clearance and longer half-life compared to the normovolemic group. CONCLUSION: The sternal IO route is an effective method of administering atropine and is comparable to the previously reported tibial IO and intravenous data even under conditions of significant hemorrhage.

Macrophage activation syndrome or septic arthritis: a case of mistaken identity.

We present an interesting case of macrophage activation syndrome in a 2-year-old, with no previous rheumatological diagnoses, incorrectly diagnosed with septic arthritis, to highlight the diagnostic difficulties, especially in small hospital units. We aim to present the similarities between the two conditions and to summarize the clinical, radiological and epidemiological features of macrophage activation syndrome, an underdiagnosed condition. A review of the current literature was performed, and a diagnostic algorithm was created. No current set treatment regimen exists, but current recommendations have been included. We have demonstrated the pitfalls in diagnosis and the importance of immediate treatment in optimizing prognosis.

Interhospital patient transport by rotary wing aircraft in a combat environment: risks, adverse events, and process improvement.

BACKGROUND: Helicopter transport of injured or ill patients in Operation Iraqi Freedom is a necessary but often high-risk endeavor. Our facility initiated a thorough process improvement and standardization initiative after several adverse outcomes. This report describes the results after this initiative, and evaluates the applicability of a civilian transport risk assessment tool to the combat environment. METHODS: Review of all preflight, in-flight, and postflight records for helicopter medevac missions over a 7-month period. Adverse events included major equipment failures, clinical deterioration, or the need for urgent interventions on arrival. Transport risk scores (TRS) were calculated and assessed for correlation with adverse events. RESULTS: There were 149 patient transports identified, 95 (64%) for trauma (mean Injury Severity Score, 21) and 54 (36%) for medical illness. Major surgical intervention before the flight was required in 66 (44%), massive transfusion in 29 (20%), and the majority were transported within 8 hours of surgery. In-flight mechanical ventilation was required in 53%, and 20% required vasopressors or cardioactive medications. Adverse events included equipment failures in 17% of flights, in-flight clinical deterioration in 30%, and 9% required an urgent intervention on arrival. However, there were no deaths or significant flight-related morbidities identified. The mean TRS was significantly higher in patients with adverse events (9.1) versus those without (7.4, p < 0.05), but it showed only moderate discriminative ability (area under curve = 0.65, p < 0.01). CONCLUSIONS: Helicopter transport in a combat environment carries significant risk of adverse events because of the patient characteristics and inherent limitations of the transport platform. Strict attention to standardization, training, and process improvement is necessary to achieve optimal outcomes. The civilian TRS had lower discriminative ability in this military setting.

Using 'cling film' to protect lower limb plaster casts in babies with club foot.

Clubfoot or congenital talipes equinovarus is a common condition affecting babies and non-surgical treatment involves serial manipulation and plaster casting for many weeks. The casts are susceptible to soiling during this time, which makes management and child care even more challenging. The authors report initial experience in a typical district general hospital clubfoot clinic where the parents of a baby used conventional cling film to cover the casts and provide a low-cost, effective and well-tolerated method of protection. Informal reports received from these parents were very positive and encouraging throughout the duration of treatment. The authors believe parents with babies undergoing such treatment for clubfoot could be advised of the benefits of using cling film to protect plaster casts. More formal analysis of feedback from parents and collaborative experience with other hospitals is required before widespread use is recommended. There may also be scope for using cling film to protect lower limb casts used in managing developmental dysplasia of the hip or fractures in children and potentially adults.