Weekly Review #12

I recently started using twitter, originally as a way to curate FOAMed and FOANed content, it didn't take long for me to want more. When I first started using it as a way to not only curate; but to connect with the FOANed community I was at a loss. I wasn't looking to have another social media account where I got game request and cute inspirational posters with cats and Minion characters; I wanted a resource for sharing knowledge. I wasn't sure what proper twitter etiquette was, how to connect with like minded individuals, compose tweets, or how to target my communications to the individuals and communities I wanted to engage with. I learned; but I would have appreciated a tutoridal. Jesse Spurr from Injectable Orange has made one. It's basically a curated set of 10-20 minute long video tutorials on how to interact on twitter. I would recommend it to anyone interested in using twitter in general, especially if they're interested in joining the FOAM/FOANed community.

http://injectableorange.com/2015/08/lose-the-egg-take-off-on-twitter/

There was a post by by Ryan Mason and Alex St.John on emDocs on wound irrigation that is highly applicable to nursing. In it they review the literature for the effectiveness and safety of sterile saline versus tap water, and the best practices for irrigation pressure and volume. Their results are clearly summarized and presented along with links to the source research. A Cochrane review found tap water (for cleaning small uncomplicated lacerations in otherwise well patients) is as safe and effective as saline in general. Other research suggested that tap water was associated with fewer infections, and that, unsurprisingly, yielded a ten fold reduction in cost compared to saline. The literature examining irrigation pressure suggests that ideal pressure of ~43PSI could be achieved using a 19 gauge needle attached to a 35 or 65cc syringe. Standard lab faucets have an average pressure of ~45psi: irrigation can be performed in the sink, saving supplies and clean up time, great! They were unable to find any data to support what ideal irrigation volumes are; but most texts suggest about 60ml/cm, or as high a volume as possible. From a nursing perspective this is great online content: it's well presented, easy to read, and highly applicable to nursing practice. Knowing that tap water is safe and effective for simple wounds is great; but knowing that tap water is faster, cheaper, an potentially even safer is awesome, from a nursing perspective this is certainly news worth sharing!

http://www.emdocs.net/antediluvian-methods-an-evidence-based-approach-to-wound-irrigation/




I'm fascinated with lipid therapy (see Weekly Review #1): it's not a widely used antidote, it's mechanism of action is not fully understood, and we're still determining what toxins it can be used for. This week I read a case series report by a Turkish group  who used intravenous lipid emulsion (ILE) to successfully reverse synthetic cannabinoid (SC) toxicity. Commercially available SC are known by many names (K2, Spice, Bonzai, Kronic) and have varying unknown compositions of mixtures of cannabinoid containing compounds. Cannabinoids are strongly lipophylic, can be 5 times as psychoactive as THC, and are associated with many different CNS/CVS effects. There were 4 patients reviewed in this case series; all of them presented with varying levels of CNS/CVS depression, and all were treated with a bolus dose of 1.5ml/kg of 20% lipid emulsion, followed by 0.25ml/kg/min for 60 minutes afterward.

Patient #1 was a 35 year old male, with a history of IV heroin use, who was found unconscious by family with empty SC packaging and brought to hospital. On arrival he was unresponsive, with unequal pinpoint pupils, a GCS of 3, was hemodynamically stable (BP 110/75, HR 95) with ECG showing LBBB; but in respiratory acidosis (SpO2 65%, pH 6.9, PaCO2 125mmHg). The patient was intubated and received ILE (but not narcan as it wasn't available). 5 minutes after the bolus dose of ILE ECG showed narrowing and normalizing QRS appearance. There was no improvement to GCS, and the patient eventually died of ARDS and multisystem failure.

Patient #2 was a 19 year old male brought to hospital after smoking SC. On arrival the patient was confused (GCS 14), hypotensive (70/30mmHg), and bradycardic (HR 42). A 2 liter bolus failed to correct the hypotension so the team initiated ILE therapy. 5 minutes after the bolus dose HR had increased to 50-55/min, by 60 minutes hypotension was resolved (BP 110/70mmHg), and by 2hrs confusion was resolved (CGS 15). The patient was discharged by 24hrs.

Patient #3 was a 15 year old male who had smoked SC. On arrival he was obtunded (GCS 8), and bradycardic (HR 36, BP 80/40mmHg). This patient also received a 2 liter IV bolus, and ILE. The patients bradycardia had resolved by 5 minutes post bolus dose ILE, by 2hrs GCS was 15, and at 24hrs the patient was discharged home.

Patient #4 was a 17 year old male who presented confused after smoking SC. On arrival his GCS was 13, vital signs were within normal limits, and ECG showed accelerated junctional rhythm with bigeminal PVC's. ILE therapy was initiated: PVC frequency was reduced by 5 minutes post ILE bolus, completely resolved (NSR) by 60 minutes, GCS was 15 by 4 hours, and the patient was discharged at 24hrs.

This case series details a novel approach to treating SC toxicity. The reported sample was small and homogenous, there were no controls, and SC toxicity usually presents with arterial hypertension; so caution should be used when attempting to generalize these findings. Given that there are no known antidotes for SC toxicity to date, ILE may become increasingly used as evidence to support it's use accumulates. Dosing information as well as additional case reports can be found at lipidrescue.org, and ALiEM. There are no unique nursing considerations for administering lipid rescue, but institutional policy should be consulted. 

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4442263/




Where I work the nurses tend apply the vast majority of back-slabs, immobilization devices, air boots, and casts. There was some great FOAM/FOANed content posted by Neil Long on Life in the Fast Lane (LITFL) this week. This is a straightforward post with links to videos showing how to place back-slabs, with tips and tricks on placement, and when each technique would be used. If you apply casts or back slabs on a regular basis this may serve as a handy go to reference.

http://lifeinthefastlane.com/practical-guide-to-the-backslab/

EMSWorld posted about a South Florida trial of heads up (Reverse trendelenberg) CPR. This will be an expansion of small scale trials performed by South Beach County Fire Rescue that have seen dramatic improvements in all-rhythm ROSC (an improvement from 16 to 48%). This trial will see responders elevating the head of the stretcher, and using automated CPR devices for OHCA. Reverse Trendelenberg CPR is something I've been watching with excitement develop for a while now (See Weekly Review #1). Previous animal studies have yielded promising results, showing that reverse trendelenberg CPR is associated with: a significant decrease in ICP, an increase in venous return from the brain, and improved neurological outcomes. I'm excited to see the innovation being put into practice by an EMS service, I would love to see a similar trial performed in hospital. The intervention is free, easy, and could potentially have a large impact on how we perform resuscitations.

http://www.emsworld.com/article/12088616/heads-up-cpr