Weekly Review #16

In the first of two posts this week on SVT BoringEM reviewed a Canadian EMS treat and release trial for SVT. Calgary EMS sought to determine if uncomplicated SVT could be treated in the prehospital environment, and to determine what the 72hr complication rate would be. EMS treated a total of 40 individuals, for 75 episodes (of a possible 225) of SVT. There was only one multiply co-morbid individual presented to hospital following EMS treatment, although that the one individual presented a total of 14 times, there was no incidence of cardiac arrest, defibrillation, or cardioversion required. There were unfortunately 22 EMS errors in following the protocol; but on a whole it would appear that a treat and release model of managing SVT may be worthwhile. From a nursing perspective this doesn't change practice; it may however suggest that there could be some additional research coming, a large scale trial, with longer follow up period, and potentially a increased nurse role if treating SVT is delegated to non-medical colleagues.

http://boringem.org/2015/08/28/cjem-infographic-prehospital-management-of-uncomplicated-svt/




Rick Body discussed a trial published in the Lancet this month that examined the effects of modifying the valsalva maneuver on rates of converting SVT. This modification was first documented in a small 2010 study, but this is the first intention to treat trial. There were 214 patients included in each arm (traditional vs. modified valsalva). The valsalva maneuver in this trial was a forced exhalation at 40mmHg for 15 seconds, the modification was the addition of laying the patient supine and performing a passive leg raise immediately following the valsalva maneuver. The data showed a doubled success rate in the modified valsalva group (43% vs 17%), which translated to a reduced requirement for adenosine (57% vs. 80%). This could translate to significant improvements in patient care, as receiving adenosine can be quiet psychologically traumatic. This research is fantastic news for patients as well as care providers: it's a no cost intervention, with no obvious risk or side effects, that more than doubles our odds of being able to treat patients without causing distress. Great stuff worth a read for all care providers!

http://stemlynsblog.org/the-revert-trial/




There were two great posts this week by Ian Miller from the Nurse Path one detailing the use of a running narrative, the other discussing CPR. A running narrative of the care you're providing Ian suggests is important for two reasons: It informs the patient of what you're doing, and it helps to keep you focused on the task at hand. I would also suggest that in addition it helps to keep your teammates abreast of what you're doing: particularly important during a code, or while working in a trauma team- although you may want to be a bit more brief in these scenarios than what Ian describes. His second post, on improving CPR, is an observation of the interruption of quality CPR during the patient transfer from the ambulance  to ED. Ian proposes that rather than waiting to transfer the patient from the ambulance stretcher to resuscitation stretched in the resuscitation bay, the transfer be made in the ambulance bay, so that the EMS team is not attempting to provide poor quality compressions while walking beside the patient. Once the patient is on the resuscitation stretcher a member of the resuscitation team than straddles the patient and "hitches a ride" while performing CPR. This is something I've seen performed in practice, and it works quiet well, provided there is advanced warning of the arrest, the personnel available to do so, and room in the ambulance bay.

http://thenursepath.com/2015/09/01/improving-quality-of-cpr-between-ambulance-and-resuscitation-room/

http://thenursepath.com/2015/08/29/give-a-running-narrative-of-your-care-delivery/

An article by Colleen Bockhold and Sherron Cumpler discussing pulmonary related transfusion reactions was published in Nursing this month. They discuss the two leading causes of transfusion related death: transfusion related circulatory overload (TACO), and transfusion related acute lung injury (TRALI). They begin by discussing how to recognize TACO (evidence of fluid overload, hypertension, respiratory distress, etc); discuss strategies for preventing TACO (close monitoring and conservative transfusion rates); and how to manage patients who develop TACO (diuresis, and respiratory support). They than move to discussing differing theories of the inflammatory process of TRALI, and the process of pulmonary damage: interstitial leakage, and resultant pulmonary edema. Signs and symptoms of pulmonary edema are described (SOB, hypoxia, tachycardia, etc), prevention strategies are discussed (antigen screening, and leuko-reduction), and treatments are reviewed (supportive). This is an open access article, is clearly written and easily understood, and provides a succinct review of transfusion reactions.

http://journals.lww.com/nursing/Fulltext/2015/09000/Responding_to_pulmonary_related_blood_transfusion.10.aspx

Emergency Physician Monthly published an article written by Paul Rostykus that suggests D10W may be superior to D50W in the management of hypoglycemia. In a great example of dogmalysis Rostykus compares the amount of glucose, the tonicity, and the effectiveness and safety of D50W and D10W. He makes a great argument for using the more isotonic D10W, highlighting that it is less likely to cause tissue necrosis in the event of extravasation, and is less error prone than D50W in pediatric patients as it doesn't require dilution. In trials patients who received D10W received less total glucose and are were less likely to experience hyperglycemia, yet had no difference in recovery time. Anything that's safer, easier, and as effective is worth consideration. Great read, another example of low (no) cost modifications to care that can translate to better outcomes.

http://epmonthly.com/article/d10-may-be-better-than-d50-for-acute-hypoglycemia/

There was a brief post on using FOAMed to keep up to date in EM on HEFTEMCAST. Likely these tips are old news for most, but for those just joining the FOAM/FOANed communities it's well worth a visit as it offers some suggestions on how to access content.

Where I work the majority of chest tubes are removed by nurses, there was a video posted by regionstraumapro with some good tips on preparation, an explanation about why removing the tube during high intra-thoracic pressures (Valsalva) prevents air from entering the chest cavity. While you're there take a look at the IO resources that are posted.

There was a great video posted on PHARM about removal of body piercings. This video has everything you could possible want: cheesy infomercial music, a how to guide for removing piercings (from: ears, noses, eyebrows, tongues, nipples, bellybuttons, sadly nothing below the belt), how to remove each type of piercing (rings, barbells, labrets, and those cheerio looking spacers), workarounds to avoid removing jewelry, and an overly serious jaws-of-life wielding firefighter. FOAM/FOANed fromage at it's finest!

This week BoringEM examined pediatric nicotine toxicity. There's a rising trend in e-cigarette use, as well as nicotine poisonings. Nicotine is rapidly absorbed, has no antidote, and e-cigarette refills contain a lethal dose. This post describes presentations, treatments (supportive with a limited role for activated charcoal). This is a concise overview of nicotine toxicity, and describes the hazards of e-cigarettes well, worthwhile for anyone working in emergency.