Anaphylaxis is a fairly common presentation, in a previous post I reviewed Justin Morgenstern's (First10EM) post on the basics of managing these patients (Weekly Review #10). This week Brad Sobolewski's goes more in depth and discusses the evidence for using IM epi in anaphylaxis on Pediatric Emergency Medicine Blog (PEMBlog). While this post doesn't add a great to Morgenstern's general approach; it does add is a great review of the cornerstone of treatment: IM epi. Brad covers the typical dosing for adult and pediatric patients, the difference between SC and IM absorption rates, and epi's mechanism of action. He provides current evidence to support early epi administration, as well as his rationale for why you really can't go wrong in giving it. This is a succinct review, well worth a read either in conjunction with the post by EM in 10, or in isolation.http://www.pemcincinnati.com/blog/why-we-do-what-we-do-epinephrine-in-anaphylaxis/
There was a video posted by Minh Le Cong on Pre-Hospital and Retrieval Medicine (PHARM) in response to a tweet made by Mike Abernethy. The video shows how to create PIP, and maintain PEEP using a high flow nasal cannula and occlusive dressing or bag. This is not something you will be likely to need in a metro center; but I've worked in isolated and remote areas without access to Bi/CPAP, were techniques such as this could have been useful. If you find this video interesting I would suggest another video, posted by Scott Weingart, on using high flow nasal cannula with a BVM. A good technique to know for nurses working in austere, isolated or remote areas.http://prehospitalmed.com/2015/08/17/crashing-heart-failure-patient-no-cpap-no-problem-macgyver-it/
There was a post on Songs or Stories showcasing some tips and tricks for pediatric IV cannulation. Some of the fundamentals of good IV technique are covered here: correct preparation, position and anchoring. There are also some suggestions on anatomical references, the use of ultrasound, and a few others novel techniques that may be new to you. Worthwhile for all nurses as the tips can be used across patient populations.http://songsorstories.com/2015/08/15/top-tricks-for-little-pricks/
In part 2 of his REBELCast Salim Rezaie discussed the effectiveness of using a length based tools, the Broslow Tape (BT), to estimate the weight of children. This was a review of a 2012 Canadian study that compared the actual weights of pediatric populations to their estimated weight using the BT. What they found was that on average weights were underestimated by ~7%. Even more importantly they found that 43.7% of patients had estimated weights 10% or greater different than their actual weight. This error in estimation could result in the under-dosing of patients in medication, electricity, and equipment size. Rezaie acknowledges that the BT is an estimation tool, that when used in an emergency or resuscitation situation will be accurate enough; however he does recommend getting a true weight on pediatric patients whenever possible. I would also suggest that the difference in weight also raises the concern of composition. As obesity will have an effect on not only total weight, but also ideal body weight, and total body water, which can have an impact of pharmacokinetics. There was a great review posted by Ian Miller from the Nurse Path (weekly review 8) that discusses these concerns from a nursing perspective in greater detail. The podcast by Salim Rezaie will be of interest to nurses working in pediatrics or emergency; the review from Ian Miller to all nurses.http://rebelem.com/august-2015-rebelcast/
Justin Morgenstern discussed the management of life threatening asthma on First10EM. He starts with a review of the ABC's of care, provides a brief description of inhaled bronchodilators and the roll of epi. The discussion about the definitive management of the airway and breathing is comprehensive, and this is where the post truly shines. He discusses why a conservative approach to airway management is warranted, offers suggestions for providing NIPPV, and discusses ventilator settings in the event the patient is intubated. There are great links to additional resources, as well as a summary of typical medications and dosages. Although there is little mention of the nursing role in managing these patients, I think it's still worth a read for emergency nurses: primarily for its review of ventilator settings. http://first10em.com/2015/08/18/asthma/#more-661
I like the EM mindset series of posts on emDocs (Weekly Review #4). This week Daniel Cabrera had a post discussing "organizing chaos"; the triage process of identifying meaningful information using context, identifying priorities, and handling the fear of uncertainty. This is a post that will resonate beyond the emergency department walls, something that all care providers working in an overtaxed system can identify with.
PBS NewsHour ran a news story by Shefali Luthra about the difficulty of getting sleep in hospital. This is basically a discussion about the need for frequent checks on patients. I understand the sentiment of the author, who lamented their lack of sleep while admitted to the hospital, the loud and bright environment, and the frequent unnecessary interruptions to their sleep for routine care. As the person causing these interruptions to rest I acknowledge that there is a role for nurses to play in reducing them: by clustering care, being mindful to minimize noise, and in many cases by discussing with the responsible physician if the required frequency of assessment and medication administration is appropriate to the acuity of the patient.http://www.pbs.org/newshour/updates/wont-hospitals-let-patients-sleep/#.VdNoMkXJE_A.twitter
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