Weekly Review #1

The Academic Life in Emergency Medicine (ALiEM) team, had a guest contributer Matthew Zuckerman discussing Lipid Rescue. Lipid rescue is an approach for reversing Local Anesthetic Systemic Toxicity (LAST) using 20% lipid emulsion. The best evidence for this therapy is with local anesthetics, (especially bupivicaine); but there are also case reports of lipid therapy being used for other lipophilic drug toxicities: atypical antidepressants/psychotics, TCA's, beta blockers, and calcium channel blockers. Dosing information as well as case reports can be found at lipidrescue.org. There are no unique nursing considerations for administering lipid rescue, but institutional policy should be consulted.  (http://www.aliem.com/lipid-rescue-why-arent-we-using-it/)





The National Trauma Triage Protocol (NTTP) is a US system used by EMS personnel to prioritize patients in the field. There is however; a 50% under-triage rate for patients >65 years of age, and a 4 fold increase in mortality for these patients compared to younger under-triaged patients. Brown et al. attribute this under-triage in part to poor sensitivity of current triage criteria. The current NTTP field triage tool uses a systolic blood pressure (SBP) < 90mmHg as criteria to transfer a trauma patient to the local trauma center. Brown et al. wanted to investigate if changing the SBP criteria for trauma patients > 65years to 110mmHg would decrease under-triage. To do so they reviewed trauma patients from the National Trauma Data Base and substituted 110mmHg for 90mmHg. These "re-triaged" patients were found to have similar mortality odds as younger patients triaged with the SBP < 90mmHg criteria. Using a higher SBP cutoff for patient >65years could reduce mortality and cost associated with geriatric trauma patients. This knowledge can be directly applied to the Canadian Traige Acuity Scale (CTAS) used by ED nurses which doesn't have empirical SBP triage criteria; but uses clinical gestalt to determine if there are "signs of shock" to assign a patient a higher tirage score. (http://www.ncbi.nlm.nih.gov/pubmed/25757122)





The Journal of Emergency Services (JEMS) had a review of an article published in Resuscitation on reverse trendelenberg position during CPR and the effects it had on intracranial pressure (ICP) in porcine model resuscitation. They found a significant decrease in ICP, and an increase in venous return from the brain, The team also found that there was improved neurological outcomes for the pigs in the treatment arms. While this hasn't been translated into human models, the challenge to accepted practice is exciting, especially given that the intervention can be implemented at effectively zero costs. (http://www.jems.com/articles/print/volume-40/issue-3/departments-columns/street-science/tilt-angle-significantly-affects-cpr.html)





A review on providing emergency care for obese patients by Haney Mallemat from emDocs was featured on Life in the Fast Lane. The article discusses the epidemiology of and physiological changes associated with obesity. Mallemat discusses treatment challanges and offers some clinical pearls about managing and supporting oxygenation. There are some nurse specific tips about patient positioning and vital sign assessment. (http://www.emdocs.net/em-care-of-the-obese-patient-pearls-pitfalls/)

There was an excellent editorial written by Brent Thoma of BoringEM challenging the current trend of "patient blaming" for long ED wait times. His critique is that the average "not sick" ED patient won't be admitted, and that "access block" should not be attributed to patients; but to poor policy decisions. The problem with "patient blaming" Thoma says is that it can dissuade those who need attention: the stoic unwell pt, those without access to primary care, and those who need access to urgent care (domestic abuse victims) from access the health care system. (http://boringem.org/2015/03/26/keep-emergency-for-emergencies/)

A group of researchers and the Boston Trauma Collaborative reviewed patients injured and treated with tourniquets during the Boston Marathon bombing in 2013. They identified a total of 66 patients identified with extremity injuries, of these 27 where treated with improvised tourniquets applied both by EMS and bystanders. The two groups were similar in injury type/severity, age and major vascular injury death. Although the outcomes were comparable between the two arms the authors believe this could be attributed to rapid evacuation times, access to trauma centers, and short period of time to definitive care. At one of the sites every improvised tourniquet needed to be replaced with a commercial product to correct paradoxical bleeding as venous only tourniquets can actually speed the bleeding process. It is important that nurses are vigilant in monitoring for this, and know how to apply commercial equivalents if available. The authors raise the question of why commercially available tourniquets weren't available. Commercially available tourniquets have a breadth of battlefield evidence showing superior results, and are being used by provincial EMS in Alberta, Canada, (http://www.ncbi.nlm.nih.gov/pubmed/25710432)