Thursday, 24 September 2015

Weekly Review #19

Rob Orman posted a great podcast on ercast called "is my patient suicidal". The podcast discusses the intricacies of differentiating suicidal ideation from intent. Orman uses the Columbia Suicide Severity Rating Scale as a framework for discussing the questions to ask a patient to determine suicidal intent. He offers some great suggestions for how to phrase the questions, how one questions will lead into the next, how to assess for protective factors, and a great clinical pearl on including family and friends to increase the sensitivity of the interview tool. Orman offers some suggestions about why removing the means for suicide (specifically firearms) is important, and offers some interesting evidence to support his claim. This is an excellent post on a topic that doesn't receive a great deal of attention: the podcast is engaging, the post is concise and easy to read, there are links to the screening tools, and he offers additional information and links to resources. I would recommend this for all triage nurses as separating suicidal ideation from intent is the key to accurate triage of these patients.

Ian Miller discussed mini-jets or prefilled syringes in a post this week on the Nurse Path. Ian reviewed an Australian study that examined the speed of administration and error rates when using adrenaline packaged in ampule (1:1000, and 1:10,000) vs pre-filled syringe form. The study showed superior speed of administration and greater dose accuracy when using pre-filled syringes. I would be surprised if the difference in administration speed was relevant clinically, but the increase in dosing errors certainly is. The study mentions previous research into this subject, and I personally have had near miss errors when both cardiac (1:10,000) and IM (1:1000) Epi are stocked in the crash cart. Pre-filled syringes ensure that cardiac and IM formulations are not confused, and this alone is enough to justify their existence.

St. Emlyn's Journal club reviewed a study published in the September edition of the Emergency Medical Journal that examined the best methods for extricating patients from vehicles. The experimental study used biomechanical sensors and high speed cameras to assess for c-spine movement along 3 planes as trained crews removed simulated patients from a vehicle. 16 patients of differing height and weight were extricated by professional paramedics and firefighters using 6 different methods:

1. Self extrication without C-collar                    
2. Self extrication with C-collar
3. C-collar and long spine board - drivers side  
4. C-collar and long spine board - passenger side
5. C-collar and long spine board - rear window  
6. C-collar + short extrication jacket lifted through drivers door

The patients extricated through the rear window had the smallest degree of movement, although the difference was insignificant when compared to self extrication techniques. They also found that an increase in patient size (both height and weight) resulted in more movement. This is a small study using healthy volunteers, it was performed in a controlled setting and with optimal staffing levels, and it's findings are therefore not generalizable to clinical practice. The findings do however suggest that self extrication could be a safe possibility, and do raise the question of whether or not current practice is evidence based.

A fantastic post on Pediatric Emergency Playbook reviews intranasal (IN) medication administration. I love using IN medications in pediatric patients: it's fast, safe, prevents unnecessary IV's, and allows you to provide if not permanent; than at the least temporary, pain control as you set up for something more definitive. In this podcast Tim Thoreczko discusses IN drugs, dosing, administration and timing, specifically: ketamine, midazolam, fentanyl, sufentanyl, or dexmedetomidine. Thorseczko discusses dosing and onset times (which can differ significantly from IV), and the methods of administration. IN administration uses a syringe and atomizer inserted into the nostril, to deliver volume doses of 0.25-0.3ml (max 1ml) per nare. Tim offers some practical advice about placing the patient into the sniffing position, seeking out the highest concentration possible, ensuring you adjust for the dead space of the atomizer, and to depress the plunger as forcefully as possible to atomize the medication. I've seen all of these medications used nasally with great results, the exceptions being sufentanyl (which we used buccaly for palliative incident pain control) and dexmedetomidine (a drug similar to clonidine that's used for sedation), as well as naloxone although it's not discussed here. Worth a review for anyone working with pediatric patients.

Anand Swaminathan posted "A simplified Approach to Tachydysrhythmias" on CoreEM. Oddly the part about this post that I like best is that it isn't oversimplified. Unlike the ACLS algorithm which differentiates treatments based on simply stable vs unstable and narrow vs wide complex this diagram covers the large range of diagnoses associated with tachydysrhythmias and offers suggestions for each.

There's a great re-post from CoreEM on emDocs discussing ocular trauma. Jeffret Cruz and Anad Swaminathan discuss presentation, workup, and treatments for some of the typical ocular injuries that will present to the ED: globe rupture, hyphema, retrobulbar hematoma, retinal detachment, corneal abrasion. This is a quick review, the take home message for nurses is to maintain a high degree of suspicion for all ocular injuries.

This months Emergency Medicine News published a special report on the Glasgow Coma Scale by Gina Shaw. This report focuses on the shortcomings of the GCS scale: its complicated scoring system, poor inter-rater reliability, and limited prognostic value. Shaw acknowledges that the GCS has flaws, but describes how poor utilization of the tool "gestalt scoring", poor communication "GCS = 9" (what are the subset scores), and poor understanding of what the tools is designed for (it has poor predictive power) have generated criticism. The GCS has it's flaws; but it's a universal standard, it's useful for tracking changes, and it's likely here to stay. This is a good reminder to use the tool to the best of its ability, and to take the time to score patients accurately and deliberately.

I reviewed a 2014 article this week on FOANed Reviews that discussed evidence based approaches for de-implementing non-evidence based practices. The article discussed strategies for the discontinuation of practices that are known to be ineffective, practices that are lacking direct evidence, and novel medical practices. The article unfortunately fails to clearly link evidence to their suggested strategies and the strategies are lacking concrete action points; however I think the research is still well worth a read. The topic is certainly interesting, and the case studies offer an insight into how prevalent non-evidence based practice is.