Sean Fox had a nice summary of how to approach an inconsolably crying infant posted on PedEmMorsels this week. These can be difficult patients, not only because they can 't tell you what's bothering them; but also because it can be quiet challenging to the parent to be unable to comfort their child. It's easy to dismiss complaints of crying as colic, but life threatening process should be ruled out. Fox describes the mnemonic IT CRIES to assist with this.
Infection: Meningitis/Sepsis are the bad ones; but an ear infection or UTI can be quiet painful as well,
Trauma: Fractures, Head Injuries or Non-accidental trauma.
Cardiac Disease: SVT or congenital heart abnormalities,
Reaction/Reflux/Rectal: Is there new medication, or a history of acid reflux? Assess for constipation, diaper rash and anal fissures,
Intussusception: A good abdominal exam and diagnostics may be required for intestinal intussusception.
Eyes: FOB, Ocular Pressure, Abrasion: kids have sharp nails and poorly coordinated movement,
Strangulations: Hernia, Torsion (Ovarian/Testicular), Hair tourniquet.
From a nursing perspective a thorough history and head to toe, watching for any LOC altering processes: hypoglycemia/ICP, ruling out trauma and typical infancy related processes should be performed. to rule out any life threatening conditions before you attribute crying to colic, and dismiss the parents as "anxious".
http://pedemmorsels.com/inconsolable-infant/
http://www.wessexics.com/The_Bottom_Line/Review/index.php?id=3959700805090541633
There was a great post from Jeffry Dela Cruz on Core EM on traumatic ocular injuries. The post discusses: globe rupture, hyphema, retrobulbar hematoma, retinal detachment, and corneal ulceration, with suggestions provided for clinical approach to diagnosis, possible diagnostic studies, and management for each condition. From a nursing perspective there is some great information for review here: differentiating the conditions, the mechanisms typically associated with each condition, and what type of management to expect for each presentation. The real take home from this post is maintain a high degree of suspicion and to avoid under-triage of these patients as they may require urgent referral.http://coreem.net/core/traumatic-ocular-injuries/
Ketaminh posted a link to some research published by Hyldmo et al.,in the Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (SJTREM) on PHARM this week. The article examined if there was any relationship between supine positioning and airway patency in trauma patients. This was a systematic review and meta analysis of publications published in PubMed CINAHL, MedLine, EMBASE, PROSPERO, Cochrane, and British Nursing Index related to airway patency, LOC and patient position. 1309 studies were reviewed, 39 met inclusion criteria. Unfortunately there weren't any articles published that met the trauma, position and airway criteria; however the data did show there was a relationship between supine positioning and worse outcomes with sleep apnea studies, peri-operatively and with patients who had a TIA/stroke. There was also evidence that prone/recovery/lateral positioning improved oxygenation measures (SpO2/destauration incidences). While this study didn't identify any studies offering evidence that supine positioning worsens airway patency in trauma specifically; it did find a fair number that suggest there may be some benefit to lateral positioning of patients in general. Taken with the evolving evidence for prone positioning of ICU patients, this. as well as previous research by Hyldmo on the Scandinavian trauma position that there may be some benefit in changing the standard of practice from supine to lateral position for transport. From a nursing perspective this research suggests that it's time we reassess the dogmatic transport of patients in the prone position.
This week Ian Miller from the Nurse Path discussed the peri-operative management of obese patients. Miller's post discusses the highlights of an article publish in Anesthesia, which provides peri-operative guidelines for caring for obese patients. There are some formulas included in his post on calculating body weight, ideal body weight, and lean body weight: lean weight should be used when calculating weight based drug doses. There is a synopsis of some of the physiological changes to the cardiovascular, respiratory, and hemostatic systems, and what the implications of these changes are. Ian finishes with some ICU and general nursing considerations for caring for bariatric patients.There was also a similar post by Haney Mallemat from emDocs discussing the epidemiology of and physiological changes associated with obesity, if you're interested in some additional reading. Mallemat discusses treatment challenges and offers some clinical pearls about managing and supporting oxygenation. I have a synopsis of this post available in Weekly Review #1. From a nursing perspective this post has both information and suggestions on practice that are applicable to all nurses, Considering that obesity related hospital admission between 2002-12 had an eleven fold increase I would think that both of these posts are worth a read.
http://thenursepath.com/2015/07/02/perioperative-management-of-the-obese-patient/
Anna Pickens from EM in 5 had a great video on the general approach to a patients with an altered LOC. She briefly discusses the importance of a thorough history on determining the cause of altered LOC, looking for associated symptoms, chronic conditions and social/lifestyle risk factors. She also discusses vital signs, and physical assessment findings and how they can help to isolate the cause of altered LOC. Unfortunately a large portion of these patients will be unable to answer questions, and as such a process of ruling out possible differential causes will begin. She discusses the mnemonic for differentials: AEIOU TIPS:
Alcohol: the usual suspect, a large percentage of patients with altered LOC will be intoxicated; unfortunately a large percentage of intoxicated patients will also have head injuries;
Epilepsy: Has the patient seized previously? are they on any anti-convulsant medications? were there any changes to doses, or changes in body weight that may have affected serum levels (especially relevant in pediatric patients);
Insulin: Check for medic-Alert tags, and prescriptions for hypoglycemics. Always check the blood glucose level of a patient with altered LOC;
Oxygenation/Overdose: Is the patient hypoxic, or obtunded from an accidental/intentional overdose? Assessing vitals goes without saying, the patient should be screened for toxicities.
Uremia: Screening for kidney disease, these patietns will likely (but not always) have a fairly extensive medical history, labs will confirm this.
Trauma: really this is what we're trying to rule out, until proven otherwise it's safest to assume all altered LOC may have occult head injury. Consider occult trauma and blood loss.
Infection: Meningitis can present with altered LOC, as can septic shock. Immuno-compromised, or patients on immunomodulating/chemotherapeutic drugs are at higher risk.
Psychiatric/Poisoning: Acute pyschosis can have widely varied presentation. Non drug related poisonings like carbonmonoxide, metal, and organophosphate toxicities also present as altered LOC,
Stroke/Shock: Not just occlusive strokes: lesions, diffuse axonal injuries and hemmorhages will present with altered LOC, as will profound hypotension.
Pickens finishes with some treatment options, common pitfalls and clinical pearls. Altered mental status is one of a few presentations where I frequently see under-triage, and have seen collegues and hospitals in court as a result. As a nurse, especially if one working in triage, I feel the AEIOU TIPS mnemonic to be exceptionally useful.
http://emin5.com/2015/06/22/approach-to-altered-mental-status/
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