Not all screens are created equal: examination of surface features and other physical properties of commonly used screen materials for smoking drugs.

BACKGROUND: Brass screens are considered an essential part of the safer drug smoking/inhalation supplies and are widely distributed by harm reduction programs in Canada. However, the use of commercially available steel wools as screens for smoking crack cocaine remains a common practice among people who smoke drugs in Canada. Use of these steel wool materials is associated with different adverse effects on health. This study aims to determine what changes folding and heating have on several filter materials, including brass screens and commercially available steel wool products, and examine the implications of these changes on health of people who smoke drugs. METHODS: This study investigated the microscopic differences, studied by optical and scanning electron microscopy, between four screen and four steel wool filter materials used in a simulated drug consumption process. New materials were manipulated, compacted into its own Pyrex® straight stem using a push stick and then heated with a butane lighter simulating a common method in preparing drugs for consumption. The materials were studied in the as-received (new), as-pressed (compressed and inserted into the stem tube but without heating) and as-heated (compressed and inserted into the stem tube and heated with a butane lighter) conditions. RESULTS: The steel wool materials with the smallest wire thicknesses were found to be the easiest to prepare for pipe use, but degrade significantly during shaping and heating, making them wholly unsuitable as a safe filter material. In contrast the brass and stainless steel screen materials remain mostly unchanged by the simulated drug consumption process. After the stainless steel pellet screen, the Brass Impact 2.0 screen material had the best characteristics of the materials tested due to its mesh wire diameter, pitch, alloy choice and its pre-strained state. CONCLUSION: Commonly used steel wool alternatives degrade during the handling and stem insertion, and heating the screens in the stem. Debris is generated by wool deformation on insertion and after heating that easily separates from the screen and can be inhaled during drug consumption. The brass and stainless steel screen materials are safer to use as they remain mostly stable during the simulated drug consumption process.

Humerus Intraosseous and Intravenous Administration of Epinephrine in Normovolemic and Hypovolemic Cardiac Arrest Porcine Models.

OBJECTIVE: The aim of this study was to compare area under the curve (AUC), frequency, and odds of return of spontaneous circulation (ROSC) when epinephrine was administered in hypovolemic and normovolemic cardiac arrest models. METHODS: Twenty-eight adult swine were randomly assigned to 4 groups: HIO Normovolemia Group (HIONG); HIO Hypovolemia Group (HIOHG); IV Normovolemia (IVNG); and IV Hypovolemia Group (IVHG). Swine were anesthetized. The HIOH and IVH subjects were exsanguinated 35% of their blood volume. Each was placed into arrest. After 2 minutes, cardiopulmonary resuscitation was initiated. After another 2 minutes, 1 mg of epinephrine was given by IV or HIO routes; blood samples were collected over 5 minutes and analyzed by high-performance liquid chromatography. Subjects were defibrillated every 2 minutes. RESULTS: The AUC in the HIOHG was significantly less than both the HIONG (p = 0.047) and IVHG (p = 0.021). There were no other significant differences in the groups relative to AUC (p > 0.05). HIONG had a significantly higher occurrence of ROSC compared to HIOHG (p = 0.018) and IVH (p =0.018) but no other significant differences (p > 0.05). The odds of ROSC were 19.2 times greater for HIONG compared to the HIOHG. CONCLUSION: The study strongly supports the effectiveness of HIO administration of epinephrine and should be considered as a first-line intervention for patients in cardiac arrest related to normovolemic causes. However, our findings do not support using HIO access for epinephrine administration for patients in cardiac arrest related to hypovolemic reasons.

Endotracheal Administered Epinephrine Is Effective in Return of Spontaneous Circulation Within a Pediatric Swine Hypovolemic Cardiac Arrest Model.

OBJECTIVE: Early administration of epinephrine increases the incidence of return of spontaneous circulation (ROSC) and improves outcomes among pediatric cardiac arrest victims. Rapid endotracheal (ET) intubation can facilitate early administration of epinephrine to pediatric victims. To date, no studies have evaluated the use of ET epinephrine in a pediatric hypovolemic cardiac arrest model to determine the incidence of ROSC. METHODS: This prospective, experimental study evaluated the pharmacokinetics and/or incidence of ROSC following ET administered epinephrine and compared it to these experimental groups: intravenous (IV) administered epinephrine, cardiopulmonary resuscitation only (CPR), and CPR + defibrillation (CPR + Defib). RESULTS: Endotracheal administered epinephrine, at the Pediatric Advanced Life Support (PALS) recommended dose, was not significantly different than IV administered epinephrine in maximum plasma concentrations, time to maximum plasma concentration, area under the curve, or ROSC, or mean plasma concentrations at various time points (P > 0.05). The odds of ROSC in the ET group were 2.4 times greater than the IV group. The onset to ROSC in the ET group was significantly shorter than the IV group (P < 0.0001). CONCLUSIONS: These data support that ET epinephrine administration remains an alternative to IV administered epinephrine and faster at restoring ROSC among pediatric hypovolemic cardiac arrest victims in the acute setting when an endotracheal tube is present. Although further research is required to determine long-term outcomes of high-dose ET epinephrine administration, these data reinforce the therapeutic potential of ET administration of epinephrine to restore ROSC before IV access.

Airway Management in the Prehospital, Combat Environment: Analysis of After-Action Reviews and Lessons Learned.

INTRODUCTION: Airway compromise is the second leading cause of potentially survivable death on the battlefield. Studies show that airway management is a challenge in prehospital combat care with high error and missed opportunity rates. Lacking is user information on the perceived reasons for the challenges. The US military uses several performance improvement and field feedback systems to solicit feedback regarding deployed experiences. We seek to review feedback and after-action reviews (AARs) from end-users with specific regard to airway challenges noted. METHODS: We queried the Center for Army Lessons Learned (CALL), the Army Medical Department Lessons Learned (AMEDDLL), and the Joint Lessons Learned Information System (JLLIS).Our queries comprised a series of search terms with a focus on airway management. Three military emergency medicine expert reviewers performed the primary analysis for lessons learned specific to deployment and predeployment training lessons learned. Upon narrowing the scope of entries to those relevant to deployment and predeployment training, a panel of eight experts performed reviews. The varied nature of the sources lent itself to an unstructured qualitative approach with results tabulated into thematic categories. RESULTS: Our initial search yielded 611 nonduplicate entries. The primary reviewers then analyzed these entries to determine relevance to the project-this resulted in 70 deployment- based lessons learned and four training-based lessons learned. The panel of eight experts then reviewed the 74 lessons learned. We categorized 37 AARs as equipment challenges/malfunctions, 28 as training/education challenges, and 9 as other. Several lessons learned specifically stated that units failed to prioritize medic training; multiple comments suggested that units should consider sending their medics to civilian training centers. Other comments highlighted equipment shortages and equipment malfunctions specific to certain mission types (e.g., pediatric casualties, extreme weather). CONCLUSIONS: In this review of military lessons learned systems, most of the feedback referenced equipment malfunctions and gaps in initial and maintenance training.This review of AARs provides guidance for targeted research efforts based the needs of the end-users.

Prehospital Airway Management in Iraq and Afghanistan: A Descriptive Analysis.

OBJECTIVES: Airway failures are the second leading cause of potentially preventable death on the battlefield. Improvements in airway management depend on identifying current challenges. We sought to build on previously reported data on prehospital, combat airway management. METHODS: We used a series of emergency department procedure codes to identify patients within the Department of Defense Trauma Registry from January 2007 to August 2016. This is a subanalysis of those with a documented prehospital airway intervention. RESULTS: Of the 28,222 patients in our dataset, 1379 (4.9%) had a documented prehospital airway intervention. Airway devices consisted of 49 airway adjuncts (17 nasopharyngeal airways, 2 oropharyngeal airways, remainder listed as unspecified), 230 cricothyrotomies, 1117 endotracheal intubations, and 27 supraglottic airways. Patients undergoing airway intervention were mostly members of the US military (42.2%). Compared with those without airway intervention, they were slightly younger (median 24 vs 25 years, P < 0.001), more frequently injured by explosives (57.7% vs 55.2%, P < 0.001) and gunshot wound (28.7% vs 23.3%, P < 0.001), with higher injury severity scores (composite and by body region) except the superficial body region, and less likely to survive to discharge (73.5% vs 96.6%, P < 0.001). Vecuronium (35.4%) and midazolam (27.9%) were the most frequently used paralytic and sedative, respectively. CONCLUSIONS: Patients undergoing airway intervention were most frequently injured by explosive or gunshot wound. Intubations and cricothyrotomies were the most frequent airway interventions performed. Patients undergoing interventions were more critically injured, with higher mortality rates. Further research is needed to determine methods to reduce mortality in this critically injured population.

Management of Emergence Delirium in Adult PTSD Patients: Recommendations for Practice.

Emergence delirium is a known phenomenon which occurs after general anesthesia in approximately 5% of the general population. However, individuals who have been diagnosed with post-traumatic stress disorder may present with symptoms refractory to conventional methods of reorientation. In the past several years, literature has begun to address the problem, but no standardized guidelines exist at present. The authors synthesize the available literature, combining data with evidence-driven principles from multiple disciplines, to submit an initial set of guidelines until research either supports or disproves these recommendations.

The effects of chrysin, a Passiflora incarnata extract, on natural killer cell activity in male Sprague-Dawley rats undergoing abdominal surgery.

Chrysin, a passion flower extract, may be beneficial because of its potential to attenuate surgical suppression of natural killer (NK) cell activity. We divided 37 male Sprague-Dawley rats into 3 treatment groups: (1) rats undergoing abdominal surgery and administered isoflurane and a 5% solution of dimethyl sulfoxide in saline (vehicle), (2) rats undergoing abdominal surgery and administered isoflurane and chrysin solubilized in 5% dimethyl sulfoxide, and (3) rats not undergoing surgery but administered isoflurane and chrysin. Natural killer cell activity was measured before and 24 hours after the experiment. Analysis of covariance, with preoperative NK cell activity as the covariate, was used to compare differences in NK cell activity among groups. The Scheffe procedure was used to make post hoc comparisons. Analysis revealed a significant difference (P = .006) such that group 2 had significantly less NK cell suppression compared with groups 1 and 3. These findings suggest that chrysin may attenuate surgical suppression of NK cell activity, thereby minimizing metastatic spread of cancer.