Posts Tagged ‘epinephrine’

Croup treatment has and hasn’t changed

December 21, 2017

With a cough like the bark of a seal
And the kiddy so good doesn’t feel
There’s no way to avoid
A dose of steroid
Croup must be treated with zeal.


Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. A month in the Arctic followed a month in Iowa followed 3 months in British Columbia, to which we have returned. Any identifiable patient information has been included with permission.
I had cause to contemplate how things do and don’t change in medicine. Consider, for example, croup. If a virus swells a child’s narrow airway, a barking cough, much like a seal asking for a fish, follows. Death can ensue if the airway narrows to the point of closing, or if the child stops breathing out of exhaustion.
The pediatric ward in the hospital where I did my residency had two outdated features for treating croup when I arrived.
One consisted of a tiled room that could be filled with water vapor; a large cloud chamber that could sleep 8. During my tenure its only use was storage.
But the spacious balcony on the other side of the nurses’ station told a different story. It had sliding glass doors and space for 6 cribs. In a bad croup year, the nurses bundled the children up, to sleep with their faces uncovered in the cold, dry Wyoming air.
It worked for most of the kids, and I still recommend that strategy, saying, “Now if the spasm of croup doesn’t clear in 3 breaths you’re already headed to the ER.”
Treatments have come and gone and come back. Antibiotics, we found, did no good. Theophylline (a close cousin of caffeine, and found in pharmacologic amounts in chocolate) helped, but not much, and had a lot of side effects so has since been completely displaced by the albuterol (in Canada, salbutamol) updraft.
Every winter, during the peak croup season, I’d ask my pediatrician friends if we’d gotten anything new for croup, and every winter they’d shake their heads.
We used to use inhaled adrenaline (also called epinephrine). It has come and gone in five year cycles. A year and a half ago I thought for sure that I’d never use it again when I heard a study showed it did no better than inhaling saline (salt water).
We used steroids a lot and stopped for a while in the 90s, started again just before the millennium, and continue to this day. Controversy remains regarding dose, and method of administration.
But croup has changed. The really, really bad version, where the epiglottis (the flap valve between the airway and the swallow tube) swells has disappeared with modern immunizations for diphtheria and Hemophilus influenza. And with the decreasing smoking rates we don’t see nearly as much as we used to.
I had cause to research croup treatment recently, finding, to my surprise, that all my internet sources recommend inhaled epinephrine and steroids. Just like 1982.

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The knife slipped gutting a deer and the wound won’t stop bleeding.

December 18, 2010

A mistake while gutting a deer

Caused the blood to appear

     Despite all my reading

    It’s hard to stop bleeding

Surgery’s not my career

The patient involved gave me permission to write about him.

His knife slipped while he field dressed the doe he shot Friday morning, the blade went about and inch and a half (3 cm) into his right thigh. He pulled it out, and it bled vigorously and he came to the hospital for stitches.

The Nurse Practitioner on duty in the ER tried local pressure to stop the bleeding, which didn’t work.  She asked me to step away from the clinic to give her a hand.

The wound itself, about an inch long, filled up with blood as I watched it. I tried a pressure dressing with 4×4’s and an ace bandage for 30 minutes.

Dark red blood continued to well up.

I am not a surgeon, and every time I thought I could be one I witnessed horrendous complications in the hands of competent men and women, who pulled the chestnuts from the fire every time, even if they sweated to do so. I gave up decades ago on my fantasies of surgical practice. I do OK on skin, but I don’t like to go deeper than that. 

I know what to do when I don’t know: call someone who knows more.  I phoned the hospital of the patient’s choice and asked for the trauma surgeon on call.  Of course I my communication got shunted to the emergency doctor.

The conversation passed between us with one good idea exchanged.  “I’d just elevate it and put ice on.”

Elevate?  Sure, a great idea: use gravity as an ally.  Ice? I just took the Advanced Trauma Live Support (ATLS) course; one of the scenarios had to do with a young patient bleeding profusely from a thigh wound.  Applying pressure slows bleeding, it doesn’t always stop it, neither does ice, and I didn’t want to send a bleeding patient home.

The patient’s cut, outside my comfort zone for treatment, didn’t justify transporting the patient to a surgeon.

I gathered my breath and decided that whatever else I can or can’t do, I could anesthetize the wound and irrigate it.

I used five millilitres of 1% Lidocaine with epinephrine, a medication that constricts blood vessels and slows bleeding.  I injected as I advanced the 1 1/2 inch needle to the hub.  When the red river slowed to a trickle I could see a significant bleeder, right at the skin edge.  I clamped it with a hemostat and tied it off with 3-0 chromic, and the bleeding stopped. 

By then I’d spoken with a real surgeon, who advised against closing a wound containing contaminated by deer fat and clothing fibers.

I relieved the patient when I announced I wouldn’t be sending him by ambulance to a different ER and a surgeon.

But we talked a lot about deer hunting.