Weekly Review #17

This is an older post, by Micheal Douma, of a NENA presentation on abdominal-pelvic trauma. The presentation at it's core is a summary of basic hemorrhage control, and a discussion about the degree of force required to provide adequate compression to control hemorrhage. Specifically though Douma discusses controlling abdominal pelvic hemorrhage with External Aortic Compression (EAC). EAC is, in short, pressure applied to the aorta using a fist (landmarking from the umbilicus) with arms locked as though providing CPR. Effective aortic occlusion requires 80-120lbs of force, and requires constant pressure (Douma has a great graph on occlusion techniques).

Maintaining this pressure is of course difficult during transportation and resuscitation, so Douma covers some of the emerging technologies that seek to accomplish this task (REBOA, junctional clamps and tourniquets, and stasis foams). Unfortunately there is no discussion about when to use EAC, perhaps due to the research being in it's infancy, but it's something you might consider when faced with extremity or pelvic hemorrhage not controlled by binding, or tourniquet.

There are two messages here that I think are important for nurses: the first is obviously that there is a role for direct arterial pressure in hemorrhage control, which sometimes needs to be applied proximal to the injury, even if that means occluding the aorta. The second point is that controlling hemorrhage begins with basic techniques performed well, which requires a surprising amount of force - if your bandages are soaking through, you need to press harder. Douma quantifies what we would often teach in TCCC, the use of knees to provide this consistent pressure, he shows that it provides extremely effective transfer of weight, as an added benefit it frees your hands up for other tasks.

I often see hemorrhage control poorly performed (bandages aren't for absorbing blood, they're for providing pressure), I've seen the deadly consequences of pelvic trauma with overt or occult hemorrhage, and would encourage all nurses to pay attention to the messages in this post.

http://rescuescience.org/2015/06/06/nena-external-aortic-compression-presentation/




BoringEM had a post by Martin Badowski this week discussing delirium. Delirium is an acute, fluctuating change in cognition that effects ~10% of older adults in the ED, it's associated with a three fold increase in 6 month mortality and is identified in less than half of the patients (17-35%) who present with it. This post discusses the diagnostic strengths and weaknesses of different diagnostic tools (CAM, CAM-ICU, mCAM-ED, MMSE, DTS+bCAM), and offer a mnemonic to approach differentials: I WATCH DEATH

Infection - UTI, pneumonia,
Withdrawal - BZD, EtOH, hypnotics,
Acute Metabolic - Hyper/hypoglycemia, electrolyte derangement,
                           Toxins - Alcohol, recreational drugs, or prescription interactions,
                           CNS - Tumor/lesions, CVA, Infection,
                           Hypoxia - anemia, hypotension, pulmonary/cardiac failure,
                           Deficiencies - Thiamine, B12,
                           Endocrine - Adrenal, thyroid, parathyroid,
                           Acute Vascular - Shock,
                           Trauma,
                           Heavy Metals.

I have found other mnemonic a little easier to remember when it comes to assessing delirium (see AliEM post on Weekly Review 11), but this post really shines in it's discussion of the diagnostic tools, where it discusses the predictive value for each in detail. A great post for nurses working in emergency to brush up on delirium screening.

http://boringem.org/2015/09/07/medical-concept-delirium-tips-and-tools/

In an older post on Pacific Emergency Medical Training Doug Fraser discusses "big vs. small box" EMS education. The small box approach Fraser says is the classic protocol driven reductionist approach to EMS: defining your role by the "things you can do". On the other hand the "big box" approach to providing care requires that an appreciation of your role within the system as a whole, and by necessity the roles of others. This may mean building an understanding of procedures that are beyond your scope of practice, and understanding aspects of practice that you are not part of. When we do this he asserts we open the door to sharing knowledge with other professionals, we learn from them in either a direct or an indirect manner. and become better at our own job. He uses a person example of airway management, discussing how as a BLS paramedic he's learned the finer points of ventilating from anesthesiologists, while being able to bring new ideas to ALS paramedics. This idea spans all health care professions, and echos the very core message of FOAMed, as indeed upstairs care downstairs can only happen when we take an interest in what others are doing.

http://www.pacificemergencymedicaltraining.com/?page_id=15

Seth Trueger from MDAware contributed to the ongoing EM mindset series on emDocs. He discusses the role of addressing the mundane in EM, stratifying risk, and coordinating care, and his unifying theme of balancing limited time with clinical uncertainty is a great message for all healthcare providers. Truger discusses the mental process for deciding if patients need intervention, diagnostics, or transfer and suggests that if you're spending a prolonged amount of time making the decision you should probably err to the side of caution and go for it; this message I think is directly translatable to nursing. I've witnessed nurses debate calling a physician about a deteriorating patient: if there's that much question go ahead, do it, then use your mental effort and time doing something that helps the patient. His idea that the time spent doing something unimportant takes away from the you have to do something important is spot on, a great take home message.

http://www.emdocs.net/em-mindset-seth-trueger-resuscitation-risk-stratification-care-coordination/




There was a discussion on Taming the SRU by Matthew Stull about approaching the undifferentiated patient. This is a great discussion about how to perform a history and physical assessment in the ED, what he himself always does in clinical practice, and what can be omitted. I really appreciated the opening discussion about avoiding corollary information before assessing the patient. By avoiding reading too in depth into the chart Stull asserts that you're less likely to become biased toward the patient and their presentation. I think this is important because cognitive anchoring can easily lead a clinician to wrongly attribute signs and symptoms to chronic conditions and previous visits. I think this is a great message for nurses, we all have repeat patients who present with intoxication, but it doesn't mean that those people aren't presenting with acute conditions such as head injuries.

http://www.tamingthesru.com/blog/bread-and-butter/undifferentiated-patient

EMin5 discussed preparing for RSI using the SOAPME mnemonic (Suction, Oxygen, Airway, Positioning, Meds, Equipment/EtCO2). A nice succinct review of how to set up your equipment, medications, and patient.

It's been a couple of weeks since having a post on caring for obese patients. If you're needing a fix check out this EMC podcast. It has a great overview on adjusting your practice in relation to vitals, airway interventions, and medication dosing.

Check out the discussion on BIJC about the difference between hemoglobin and hematocrit values (spoiler alert: there is none).

There's some new research this week from Matthew Douma on the efficacy of "double-barreled" dual IO therapy, there's a nice review of this research on the Trauma Pro's blog.

A St.Emlyn's post discussed strategies for maximizing your sleep. It offers suggestions on sleep hygiene, discusses the negative consequences of sleep deficit, and offers tips for adjusting to rotating day night schedules. This is something many nurses may find helpful.

And finally, a 7 year prospective population study in China published in the BMJ found that those who more frequently ate spicy food had lower all cause mortality than those who did not. This study includes a large number of patients (half a million) and examined consumption of fresh or dried chili when assessing for spicy food. There are of course a number of factors (urban vs rural) that could be confounders in this study, and it's not really FOANed per-se; but hey it's a reason to eat some hot wings this weekend.