Cricothyroidotomy: Comparison of three Different Techniques on a Porcine Airway

We compared three different cricothyroidotomy techniques on a cadaveric porcine airway model to determine the most rapid, successful and safe method in emergency situations. In this observational comparative bench-test, surgical or scalpel cricothyroidotomy (ST), Cook Melker Cricothyrotomy Kit (CM) and Portex Cricothyroidotomy Kit (PCK) were evaluated. After a familiarisation program, four operators performed five procedures using each of the techniques. A dissected pig airway was housed in an airway training manikin. Time to successful completion of the procedure, complications and anatomical variations in the pig larynx were recorded.

A patent airway was established in 20 of 20 (100%) attempts with CM technique, 11 of 20 (55%) with ST and six of 20 (30%) with PCK technique. The CM technique was associated with a higher success rate (P <0.001). There was no significant difference (P=0.4) in the median time (interquartile range) taken to achieve a patent airway; CM 50 seconds (40 to 57), ST 47 seconds (41 to 55) and PCK 63 seconds (41 to 150). There was a higher rate of posterior tracheal wall injury with the PCK technique (n=11) and ST technique (n=5). No complications were observed with CM technique. There were no significant anatomical variations in the pig larynxes.

We conclude that the CM technique is safe, rapid and has a significantly higher success rate in achieving an artificial airway in this airway model. Overall, all the participants in our study preferred to use this kit in an emergency situation.

Monitoring of Cd pollution in soils and plants irrigated with untreated sewage water in some industrialized cities of Punjab, India

The disposal of industrial and sewage water is a problem of increasing importance throughout the world. In India, and most of the developing countries untreated sewage and industrial wastes are discharged on land or into the running water streams which is used for irrigating crops. These wastes often contain high amount of trace elements which may accumulate in soils in excessive quantities on long term use and enter the food chain through absorption by the plants. Among the trace metals, Cd has received the greater attention because of its easy absorption and accumulation in plants and animals to levels toxic for their health. The objective of this study conducted in three industrially different cities viz., Ludhiana, Jalandhar and Malerkotla was to monitor the extent of Cd accumulation in soils and plants receiving untreated sewage water. Plant and soil samples were collected from sewage and tubewell irrigated areas. Soil samples were analysed for texture, pH, EC, organic carbon (OC), CaCO(3), bioavailable DTPA-Cd and plant samples were analysed for total Cd. In sewage irrigated soils, the mean values of pH were lower but organic carbon and electrical conductivity were generally higher both in surface and sub-surface layers of all the three cities as compared to tubewell irrigated soils. The mean DTPA- extractable Cd in sewage irrigated soil was 6.3- and 4.36-fold in Ludhiana, 3.38- and 1.71-fold in Jalandhar and 3.35- and 6.67-fold in Malerkotla in 0-15 and 15-30 cm soil depth, respectively, compared with the values in tubewell irrigated soils. The accumulation of DTPA-Cd in sewage irrigated soils was restricted to 30 cm depth after which the values were generally close to values in tubewell irrigated soils. Soil pH, OC, CaCO(3), clay and silt collectively accounted for 37.1%, 65.1% and 53.9% DTPA-extractable bioavailable Cd in soils of Ludhiana, Jalandhar and Malerkotla, respectively. Lower R(2) values in Ludhiana suggest that factors other than the ones mentioned may be affecting Cd availability. At all sites plants receiving sewage irrigation had elevated levels of Cd as compared to the plants receiving tubewell irrigation. The mean Cd content of sewage irrigated plants irrespective of the city was 5.96 microg g(-1) dry matter as compared to 0.98 microg g(-1) dry matter in tubewell irrigated plants. The results suggest that the intake of Cd obtained from consumption of crops grown on sewage irrigated soils would be much higher than the tolerable limits set by WHO and may, therefore, prove potentially toxic leading to various health ailments to humans and animals.

Insulin U-500 in severe insulin resistance in type 2 diabetes mellitus

Some patients with type 2 diabetes mellitus (T2DM) are profoundly insulin resistant and require large insulin doses to achieve optimal glycaemic control. However, large volumes of subcutaneous conventional U-100 insulin can cause discomfort at the injection site, resulting in poor concordance with insulin therapy. One therapeutic option is the use of U-500 insulin, thus reducing the insulin volume by 80%. This review will address the practical issues associated with the use of U-500, clinical efficacy and safety aspects of this concentrated insulin, which has an important role in a subgroup of patients with T2DM.

Atrial fibrillation in a tertiary care multidisciplinary intensive care unit--incidence and risk factors

Atrial fibrillation is a common arrhythmia in an intensive care unit. We performed a prospective observational study over a period of three months, to study the incidence, risk factors and outcome of patients who develop atrial fibrillation in a multidisciplinary intensive care unit. All patients above the age of 50 years were eligible. Exclusion criteria were: cardiac or oesophageal surgery during current hospitalisation, atrial fibrillation at admission, implanted pacemaker and expected intensive care unit stay of less than 24 hours. Sixty-one patients were included in the study. Eighteen patients (29.5%, confidence interval 18-40) developed atrial fibrillation. Incidence of atrial fibrillation was 4.02 episodes per 100 patient days. Patients who developed atrial fibrillation had higher age (71.3 years vs. 63.2 years, P=0.001), severity of illness (APACHE II 25.4 vs. 20.0, P=0.005) and sepsis at admission (9/18 vs. 9/43, P=0.01). They also had higher in-hospital mortality (Risk ratio 2.7, 95% confidence interval 1.3-5.4). Standardised mortality ratio was higher in patients who developed atrial fibrillation (1.08 vs. 0.63). Patients who developed atrial fibrillation required a longer period of mechanical ventilation and inotropic support. Multivariate logistic regression analysis showed age >75 years, APACHE II score >20 and sepsis at admission were independent predictors for development of atrial fibrillation in critically ill patients. Although atrial fibrillation by itself is unlikely to be the cause of higher mortality, it is likely to be a marker for increased mortality and resource utilisation in the intensive care unit.

What influences outcome of patients with suicidal hanging

AIM

Suicidal hanging is an uncommon medical emergency with significant neurological morbidity. The aim of the study was to identify factors that have a bearing on the final outcome.

MATERIALS AND METHODS

Retrospective analysis of 37 consecutive cases of suicidal hanging admitted to our ICU from July 1996 - December 2002 was performed. Outcome at discharge was defined as good (complete neurological recovery) or poor (death or incomplete neurological recovery). Three clinical variables (at presentation) namely Glasgow Coma Scale (GCS) at presentation, time lapse (in hours) from the incident to arrival at our hospital and the presence of Hypotension (defined as a systolic blood pressure < or = 90 mm Hg) at admission were recorded and tested individually for an association with the outcome. Statistical analysis was done using the Odds ratio (OR +/- 95% Confidence Intervals) and Chi-square test of significance for categorical data.

RESULTS

Patients with suicidal hanging constituted < 1% of ICU admissions (mean age 27 years). 34/37 survived giving a survival rate of 92%. Of those who survived, 31 patients (91%) had complete neurological recovery at the time of discharge from hospital. Among those who presented <4 hours of the incident (25 patients), 2 had an adverse outcome as compared to 4/10 patients who presented 4 hours or more after the incident (OR 7.6,95% CI 1.12-52.3). A low GCS (GCS <7) at presentation was also statistically associated with a poor outcome (OR 10.4, 95% CI 1.08-102.1). Hypotension was present in approximately 33% of patients (12/37) at presentation. Of these 12 patients, 3 had an adverse outcome as opposed to 3 patients among the remaining 25 (OR 1.6, 95% CI 0.41 - 14.47, NS).

CONCLUSIONS

Suicidal hanging is an unusual medical emergency that is common among young individuals in developing countries. Our study indicates that a delayed presentation to a medical facility and a low GCS at presentation predict a poor outcome.

Rodenticide-induced hepatotoxicity

Hepatotoxicity following acute poisoning with rodenticides has been infrequently reported in literature. To emphasize the fact that this form of clinical presentation is not unusual we are reporting two cases of rodenticide poisoning masquerading as severe hepatic dysfunction.

Cardiorespiratory effects of manually compressing the rib cage during tidal expiration in mechanically ventilated patients recovering from acute severe asthma

OBJECTIVES

To determine the cardiorespiratory effects of manual expiratory rib cage compression in mechanically ventilated patients recovering from acute severe asthma; and to extrapolate these findings to emergency asthma management where ventilation cannot be achieved by positive-pressure ventilation.

DESIGN

A prospective, clinical study.

SETTING

Intensive care unit.

PATIENTS

Four intubated, mechanically ventilated (volume-controlled), adult patients recovering from acute severe asthma.

INTERVENTIONS

Patients were studied before, during, and after a 2- to 3-min period of manual compressions applied bilaterally over the lower rib cage (ribs 8 to 10) during consecutive tidal expirations.

MEASUREMENTS AND MAIN RESULTS

Air flow (pneumotachograph), airway pressure, radial or brachial arterial pressure, and the hand pressure applied to the patient's rib cage were monitored and recorded on magnetic tape. Playback of the recorded data enabled measurement of changes in lung volume (air flow integration). Changes during rib cage compression consisted chiefly of small decreases in lung volume and peak inspiratory airway pressure that were only observed in the least obstructed patient and were fully reversed after the cessation of compressions. Air flow-time and air flow-volume plots demonstrated expiratory air flow limitation during essentially the entire tidal expiration in each patient, except the least obstructed patient.

CONCLUSION

The results suggest that manual compression of the rib cage during consecutive tidal expirations would be ineffective in reducing pulmonary hyperinflation during the emergency management of asthma when air flow obstruction is so severe that ventilation cannot be achieved by positive-pressure ventilation.

Comparison of cardiovascular risk factors in type II (non-insulin dependent) diabetics with and without coronary heart disease

Cardiovascular risk factors in NIDDM were studied by comparing 175 subjects with coronary heart disease (CHD) to 173 subjects without CHD; both groups were matched with regard to male to female ratio, age at diagnosis of diabetes and body mass index. The risk factors included were hypertension, poor metabolic control, smoking and lipid abnormalities. Since the mean known duration of diabetes in subjects with CHD was longer compared to those without CHD (12.93 +/- 7.23 and 6.25 +/- 5.66) and sub sample of subjects from both groups with duration of diabetes with 15 years or less were also analysed for comparison. Even after adjustment of duration the clustering of vascular complication in the subjects with CHD was striking. Presence of low HDL cholesterol was significant in both men and women diabetics with CHD (p < 0.01); while hypertension and poor metabolic control showed a strong positive correlation to CHD in women (p < 0.01 & p < 0.05). Multiple logistic analysis carried out separately in men and women showed that both low HDL cholesterol and elevated serum triglycerides showed strong association to CHD in both sexes; while in women in addition hypertension and insulin therapy also had a positive correlation to CHD (p < 0.01). Furthermore the influence of known duration of diabetes was not observed to be a significant contributor to the cardiovascular risk factors, since the above mentioned risk factors remained statistically significant in the subsample of patients with duration of diabetes less than 15 years.

Response to antituberculous chemotherapy after splenectomy

A case of a 17-year-old Indian male with disseminated tuberculosis is reported. While on chemotherapy, he was detected to have splenic abscesses. The patient remained unresponsive to antituberculous drugs until a splenectomy was performed.

Betamethasone in tetanus patients: an evaluation of its effect on the mortality and morbidity

The effect of betamethasone on the outcome in moderate to severe tetanus was studied in a randomised, double blind, placebo controlled study in 22 patients. The mortality rate was reduced by 36.1% with the addition of corticosteroids to the regime of treatment. Betamethasone did not alter the duration of intensive care in those requiring it, but reduced the need for tracheostomy and ventilation. The mean daily dose of diazepam required was not significantly different between the two groups and there was no increase in the incidence of infections in the betamethasone group.