Orthostatic vitals

Figure 1

I hate assessing postural vitals! Personally, I think there's nothing more damaging to a clinicians credibility than to reflexively order postural vitals on all patients over the age of 70. Because I'm willing to vent my anger on this topic to anyone willing to listen, I feel the need to keep the stats that support my self righteous nerd-anger fresh in my mind. One of the best articles for this is a 2015 narrative review by James Frith "Diagnosing orthostatic hypotension: a narrative review of the evidence". While the article doesn't directly address the causes of orthostatic hypotension; it does, in my opinion, offer the best summation of the futility of performing postural vitals.  

As the title suggests this is narrative review of English language articles discussing orthostatic hypotension (OH). Unfortunately this isn't a systematic review, so we don't know the exact search strategy, inclusion or exclusion criteria, the number of articles reviewed, or the exact data extraction process. 

Frith starts by summarizing current guidelines on the diagnosis of OH which vary slightly depending on the national committee. The European Federation of Neurological Sciences (EFNS) guidelines (figure 1), although of poor quality (level C), are the most comprehensive and complete of the guidelines, and align well with the available evidence.

Figure 2

Frith reviewed and evaluated the evidence used to:

• define baseline blood pressure, 
• the method used to illicit the orthostatic challenge (sit to stand vs tilt table etc), 
• the frequency and duration of BP testing (how often to cycle the BP cuff, and how long to wait before starting and finishing the test), 
• and the cutoff for defining BP drop. 

Frith determined that all the data came from low quality heterogeneous studies. Frith points out that the diagnostic power of the tool is questionable: the sensitivity varies from 25- 37%, that the inter-rater reliability is low (kappa 0.12-0.32); and that the prevalence of OH is high (up to 59%). Based on the synthesized evidence he made the following recommendations for assessing OH (figure 2). The recommendations align well with, and add considerable clarity to, the EFNS guidelines.

I think the evidence presented in this article clarifies the finer points of how to "properly" assess postural vitals; but more importantly I think it does an excellent job of pointing out the fallibility of the test: it highlights the high prevalence of OH, the low sensitivity of postural vitals, and poor inter-rater reliability of the test. 

I would suggest that the most important take home point here is that the only "proper" way to assess for OH is to simply stand the patient up and see if they become dizzy!

Frith, J. (2015). Diagnosing orthostatic hypotension: a narrative review of the evidence. British medical bulletin, 115(1), 123-134.

If you're looking for additional FOAMed resources to fuel your postural BP hatred you may also like:

http://ccareanywhere.blogspot.com/2015/01/did-you-get-orthostatics-yet.html

https://lifeinthefastlane.com/futility-orthostatic-measurements/

FOANed Review #23

Salim Razie reviewed the Paediaric Acute Respiratory Interention Study (PARIS) on REBEL EM this week. The PARIS trial was an un-blinded, multi-center RCT that compared standard therapy to standard therapy with high flow nasal cannula (HFNC) in children less than one year of age with bronchiolitis. The results suggest that HFNC are a safe treatment option, and that infants treated with HFNC for bronchiolitis tended to have less escalations in care (transfer to ICU). The findings were even more pronounced in hospitals that didn't have access to pediatric ICU's - Good reading for anyone that looks after kids; great reading for those in rural or community settings where pediatric ICU admission means transfer.

http://rebelem.com/the-paris-trial-hfnc-in-infants-with-bronchiolitis/

There's a great case report by Jennifer Leckie and Minh Le Cong and Viran Kaul  that was published on prehospitalmed.com. It's a brief report of an Australian ICU nurse self administering nasal lidocaine to treat a cluster headache not relieved with her usual regimen of triptans, aspirin and acetaminophen. The nurse "snorted" a 5ml tube of 2% lidocaine (100mg), assumed the "Rose position" and allowed the gel to drip down her nasopharynx. The headache was completely resolved within 50 minutes of the treatment - This may not be applicable to your practice; but it's a fun read for all the self sufficient clinicians out there.

https://prehospitalmed.com/2018/04/06/a-novel-self-treatment-technique-for-cluster-headache/

There was a post on EMCrit this week that reopens the FOAMed discussion on the "unopposed alpha phenomena". Unopposed alpha blockade is the premise that treating stimulant toxicity (specifically cocaine) with beta-blockers puts the patients at risk for a situation where the heart's (beta driven) contractility is blocked to the point where it can't overcome the afterload generated by peripheral vascular tone (alpha driven). The EMCrit post by Jeff Lapoint is in direct response to an older post by John Richards on LITFL. Jeff raises interesting questions about equivalency fallacies, and whether we should just because we could use beta-blockers for cocaine toxicity. That being said the original LITFL post still poses a valid question in asking if blanket avoidance of bet-blockers in stimulant toxicities is indeed dogma - Regardless of which camp you're in; both posts are well worth the read for anyone interested in toxicology. 


https://emcrit.org/toxhound/cocaine-beta-blockers-dogmalysis-wont-hunt/

https://lifeinthefastlane.com/beta-blockers-cocaine-stimulant-toxicity-time-retire-old-dogma-not-care/




Gus Garmel posted some true FOANed clickbait on ALIEM with: "10 Tips to improve patient satisfaction in the emergency department". Here's the overview:

1. Greet everyone warmly
2. Connect with everyone in the room
3. Sit down if you can
4. Listen actively
5. Take your time
6. Ask for their perspective
7. Use at least one empathetic statement
8. Check in with your patient
9. Close the communication loop
10. Show kindness & respect

- There's probably a lot here you do already, but it's nice to have it presented in a way that's easy to connect to - an easy read that's applicable to all clinicians.

https://www.aliem.com/2018/03/10-tips-improve-patient-satisfaction/

Matt Douma offered up some experienced provider tips on ACLS at RescueScience. These tips and tricks are not intended for those new to, or attending their first ACLS class; rather it's further reading and the science behind the recommendations intended for those with ACLS "mastery". There are some good clinical pearls for maximising team dynamics: pre-charging the defibrillator, DSD pad placement, and how to cognitively offload the algorithm to focus on reversible causes - A great post for those comfortable with ACLS content and looking to augment whats taught on standard courses.


http://rescuescience.org/2018/04/11/advanced-life-support-course-2015-instructor-notes-for-aptil-10th-11th-class/

FOANed Review #22

I recently started a new position as an RN at a metro trauma center. Moving cities created it's own time constraints, but so too did the formal education and informal learning required to practice in a new clinical environment. The pressure created strains in all aspects of my life, but from a professional stance it placed engaging with the online FOAM/FOANed community of practice against my clinical practice environment. My day job won out (obviously); a recent editorial by David Oliver, published in this months BMJ Open discussed the same conflict at a higher level. His editorial is critical of nursing management within the NHS, he is critical of its refusal to adopt minimum staffing levels suggested by NICE, and his perceived lack of opposition coming from the heads of nursing at large health trusts. Oliver suggests that part of the problem is that the individuals at the managerial level of nursing no longer "experience the job": that nurses in managerial roles tend to "leave the bedside", which distances them from the clinical realities of nursing. I would suggest that the lack of "job experience" extends beyond nursing management to nursing education, policy development and research as well. As an outsider I can't claim to appreciate the intricacies of English health care; nor can I support his critique of nurse managers within the NHS, but I do think that he has hit upon an important issue in nursing: which is our professions struggle to reconcile education, management and research with clinical practice.

http://www.bmj.com/content/352/bmj.i978



The American Journal of Medicine published a study that examined the relationship between inadequate physician assessment and medical errors. The study used a questionnaire that was emailed to approximately 5000 physicians that solicited clinical vignettes of instances where oversights in physical examination led to errors, and asked providers to answer several multiple choice questions about their examples. The most reported inadequacy was a failure to perform the physical exam (63%), the most common negative outcomes were delayed or missed diagnosis (76%), delayed treatments (42%), and unnecessary diagnostic costs and radiation (25% & 17%). Unfortunately the design of this study is quite weak: the questionnaire was widely circulated (it's unknown precisely how many providers were solicited), response rates were low 263/5000 (~5%), many of the responses were excluded (55, 0.21, n=208), the findings are difficult to generalize without provider demographics, and the vignettes reveal little about the root causes of error. Those weaknesses however do not detract from the fact that this is an important area for research. It would be difficult to capture how well clinicians perform physical assessments in their practice, how often they fail to perform an assessment, and how often it would lead to a negative outcome. This may hopefully provide a basis apon which future research could be built, and a call to all providers to not become over reliant on technology for treating patients.

http://www.ncbi.nlm.nih.gov/pubmed/26144103

The European and American critical care societies (ESICM-SCCM) sepsis task force released their third international consensus definition of sepsis this week in JAMA. The key points in this update are changes to the definition of
sepsis, and a shift in the screening tools used. The definition has dropped the idea of "severe sepsis", and the use of the SIRS criteria in defining sepsis. The screening tool likewise has moved from a SIRS based model to one using the SOFA/qSOFA (Sequential Organ Failure Assessment tool). Discussion on Social Media and in the FOAMed community has been dominated by this topic for the last week, so rather than delving into the topic on this review I would suggest checking out RebelEM, and St.Emlyn's for their great summaries, and First10EM and EmCrit/PulmCrit for critiques, I've also weighed in on the topic here. This is a topic that I'm sure will continue to be discussed, and hopefully validated with a prospective study.

http://jama.jamanetwork.com/article.aspx?articleid=2492875






There was a post by Jennifer Jackson on the InjectableOrange discussing her masters thesis. Her topic examines the relationship between workplace stress, and the transition to resilience or burnout. Jackson discusses some personal and systematic factors that impact resilience, particularly when it comes to managing stressors. This is an issue I'm sure almost all nurses have experienced, either personally or amongst co-workers. There are links in the post to the full thesis, as well as to video summaries. This is a great post, and a great example of the spirit of FOANed, I hope that more academics will look to engage with their communities of practice at large through online and social media platforms.

Brian Ericson released a compilation of his top FOANed resources on erNURSEpro, it's worth taking a look at, you might find a new site worth following!

First10EM had a great post discussing the clinical approach to an unconscious patient with a discussion of red flags, and of course AEIOU TIPS! this is a common ED presentation, and the topic is always worth reviewing

HEFTEMCAST provided a review of the new NICE guidelines for trauma, an excellent post for any professional working with trauma patients.

The New York Times ran a summary of a study that examined the prevalence of genital warts in American HPV vaccinated adolescents. It would appear that the vaccine is quite effecive, it would also appear that the the public health system in Rwanda is doing better (93%) than it's western counterparts in adopting evidence based immunization policy.

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.

http://blog.ercast.org/is-my-patient-suicidal/




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.

http://thenursepath.com/2015/09/22/i-praise-of-the-pre-filled-syringe/

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.

http://stemlynsblog.org/jc-self-extrication-vs-assisted-extrication-st-emlyns/

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.  

http://pemplaybook.org/podcast/intranasal-medications-and-you/

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.

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.

Weekly Review #15

I've worked in sites that use recorded shift reports - they're ridiculous: first you spend 10 minutes recording it, then I spend 10 minutes listening to it, and then we end up talking about it for another 10 minutes so you can answer my questions and give me updates. 30 minutes instead of just a 15 minute in-person handover! I've always hated them; but now I have some evidence to support my dislike for them: an article by Judymae Ofori-Atta discussing the superiority of person to person bedside reports (BSR). Bedside reports are given between nurses in the presence of the patient and family they've been shown to improve work flow and patient safety, as well as patient involvement and satisfaction: a win all round, and applicable to all nurses. Hopefully this helps you bury the voice recorder for good!

http://journals.lww.com/nursing/Fulltext/2015/08000/Bedside_shift_report__Implications_for_patient.20.aspx

There was an online article published in the Journal of Emergency Medical Services by Douglas Dixon and Darren Braude on managing the airway of bariatric patients. Nursing considerations of bariatric patients has become a recurrent theme here: last week I discussed a REBELCast review of the accuracy of the Broslow Tape in estimating weight in obese children, and a review from the Nurse Path post on surgical considerations in weekly review 8. This article focuses specifically on airway management. Dixon and Braude start with a brief overview of the epidemiology of obesity and the physiological changes that accompany it: a reduced functional residual capacity due to decreased chest wall compliance and reduced diaphragm movement. Because of these changes obese patients will more quickly become hypoxic and will need extra attention paid to optimizing their ventilatory effort. They make some suggestions on positioning (ramped, or reverse trendelenberg), discuss how three handed BVM ventilation may be necessary to maintain good mask seal and overcome increased airway resistance, how to provide apneic oxygenation with high flow nasal cannula, and how drug dosing for RSI may need to be adjusted from total to ideal body weight (the Nurse Path post has a great overview of this). This is a good starting point if you're looking for tips for bariatric patients, and a good reminder to attend to patient position, especially for nurses working in the ED where patients may not always be able to adjust the position of the cot on their own.

http://www.jems.com/articles/print/volume-40/issue-8/features/bariatric-airway-management-is-about-more-than-intubation.html?cmpid=jemsnowenl08202015&eid=288528567&bid=1157558  




There was a great mnemonic (MADE NICER) created by Anali Maneshi and Matthew Cherian posted on BoringEM this week. It's a mnemonic to help assess possible differentials for geriatric patients presenting with weakness:

Medication - Screen for medication causes: steroids, statins, antipsychotics, diuretics, insulin, opioids, and sedatives; assess for recent dosage changes,
Anemia - Either due to blood loss (overt or occult), or impaired production malignancy, nutritional deficiency,
Dehydration - Diarrhea, diuretics, or vomiting,
Endocrine - Hyper/hypoglycemia, adrenal insufficiency, hypothyroidism can all cause glucose/electrolyte derangement,
Neurological conditions - Acute (stroke, SAH) and chronic conditions (lesion, MS, Parkinsons, etc) can result in weakness,
                                 Infection - Any infection can result in weakness,
                                 Cardiac - Presyncope from cardiac cause, angina or atypical MI presentation (malaise), and CHF may present as weakness,
                                 Electrolyte imbalance
                                 Rheumatological - SLE temporal arteritis

The typical ED will see a large number of geriatric patients, they're less capable of tolerating challenges to their systems, may be multiply co-morbid, and may have medications masking or contributing to their physical findings; having a mnemonic to help work through differential causes for a common presenting complaint is useful for all ED nurses when attempting to triage a vague complaint.

http://boringem.org/2015/08/24/tiny-tips-weakness-made-nicer/

There's been an increasing number of deaths in Canada recently from intentional and unintentional use of fentanyl. There is starting to be some reaction from the medical community, as studies are showing a 4% mortality rate associated with prescribed large doses of opioids. However there is still a large volume of diverted narcotics that are finding their way into other recreational drugs. The news is likely not news for many; but it is an excellent segue to highlight some more research on low dose titrated naloxone for opioid toxicity in the ED. A summary and how to for titrated naloxone can be found in a post by ALiEM. Worth a read for nurses working in the ED, also worth remembering is that obtunded patients without a history of narcotic use may still have unintentionally ingested fentanyl. . 

http://www.cbc.ca/news/canada/edmonton/alberta-slow-to-react-to-sharp-rise-in-fentanyl-deaths-critics-say-1.3191075



There was a podcast by Brian Ericson on erNURSEpro posted this week discussing hyponatremia, one of the most common electrolyte imbalances seen in the ED. The discussion begins with a discussion about the difference between acute and chronic hyponatremia, classification and explanation of  the differences between hypo/hyper/normo-tonic and hypo/hyper/eu-volemic hyponatremia. There is a discussion about the causes of hyponatremia: pre-renal (excess sweating/diarrhea/burns etc); versus renal (CRF/addisons disease/etc), neurogenic causes (SIADH), treatment, as well as the complications associated with correcting sodium. Brian discusses the difference in acute vs. chronic hyponatremia, and offers a great clinical pearl on suspecting hyponatremia in seizing patients who are not responding to benzo's. This is a great podcast, a little too in depth to fully absorb while driving; but worth the 25 minutes when you have some time to dedicated to listening. 

http://www.ernursepro.com/#!podcast-episodes/c1enr

I came across a blog called Rescue Science) by Matthew Douma with some great posts that I'm looking forward to reviewing in more detail in coming weeks. There's some standout posts on dead space in IV extensions, methods for pushing adenosine, and a fantastic review of the role for external aortic pressure in junctional bleeds to check out. Some of these have been out for a while, but they're directly applicable to nursing practice, thorough and well written. An awesome resource, I'm looking forward to future posts.

Check out Injectable Orange this week for a review of Sketchy EBM. I would also like to congratulate Jesse on winning the Symplur Signals Research Challenge. 

Ian Miller from the Nurse Path has 28 step guide to hanging an IV that is pretty well spot on for your first shift back, as well as some tips for handling messy situations. I'm glad to see you up and running on Facebook again!

CriticalEd had a discussion about the role of a "nurse curator" in staff development: what it is, what the role would include, what to call it etc. An exciting idea to suggest a formalized role for FOANed in clinical practice. Give it a read, he's looking for feedback and suggestions if you have any. 

Weekly Review #11

Ian Miller from the Nurse Path had a review on the emotional burden of providing care especially when providing that care presents a moral dilemma. Miller uses the stories of the staff who cared for both the victims and, more to the point of the discussion, the perpetrator of the 1996 Port Arthur massacre. Miller discusses some of the cardinal signs and symptoms of the stress response, and the role of Critical Incident Stress Management (CISM) in helping providers to cope with moral trauma. I think there's more for nurses here than simply how to look after people who have done bad things; it serves as a talking point on PTSD and role of CISM services. Occupational stress doens't come only from conflict, from massacres, or from trauma; it can come from the consistent emotional burden of providing care. There has been increased attention paid to the fact that stress is claiming the lives of many care providers through either suicide or substance abuse. Looking for help is good, it's normal, I think we all need to discuss and normalize the burden of care, I'm glad to see Ian Miller is doing just that.

http://thenursepath.com/2015/07/24/when-good-people-must-care-for-bad-people/

Great posts by Christina Shenvi and Jacob Avila from the ALiEM team this week. Jacob Avila had a novel approach to confirming IO placement. This post reviews an animal study that found the "squeeze test" to be an effective method for confirming IO placement in porcine extremities. The basic idea is that you compress the area around the IO cannula and observe for changes in the flow rate. If the IO is placed correctly in the bone compressing the soft tissue should have no effect on the flow rate. This seems like a quick way to trouble shoot a questionable IO placement. I don't think it could be considered a true "confirmation" of placement, but if you're using IO access the odds are good that whatever you're doing will need to suffice for a presumptive positive placement.
http://www.aliem.com/trick-of-the-trade-squeeze-test-for-confirmation-of-io-placement/


Christina Shenvi posted a review of delirium in older adults. She discusses diagnostic criteria, the concepts of "homeostenosis"- the narrowing of physiological reserve and ability to compensate for insult, predisposing factors, and management. She uses the DELIRIUM mnemonic to look for precipitating factors:
Drugs- Medication side effects, sedatives, as well as drug interactions can lead to acute delirium
Electrolyte Abnormalities
Lack of Drugs- Withdrawal from opioids, benzos and alcohol.
Infection- not just CNS infection buut also UTI and pneumonia
Reduced sensory input- Not having access to vision/hearing aides can worsen delirium
Intracranial pathology- CVA, tumors, or intracranial bleeds,
Urinary/fecal retention
Mocardial/Pulmonary- Infarct or diseases reducing gas exchange can lead to hypoxia and confusion

http://www.aliem.com/delirium-in-older-adults/




Simon Laing from HEFTEMCAST had a truly fantastic post on EMS handovers. He reviewed the amount of critical information that is typically missed in handovers (72.9%). He provided advice on taking handovers: shut up, maintain eye contact, and don't interrupt (handover time reduced by 15%, interruptions by 93-41%, and EMS needing to repeat information reduced by half!). He gives some general recommendations about the usefulness of structured handovers- a MIST handover, to the designated team lead. This is one of the best post or podcasts I've seen in the last while, it's a free evidence based human factor intervention. Definitely worth a listen for all providers.

http://www.heftemcast.co.uk/ems-handover-make-a-difference-to-all-alerted-patients/




Neuraz et al., published a study in Critical Care Medicine examining the relationship between staffing levels and workload and patient mortality. This study was a longitudinal review of 8 French teaching ICU's. It examined all (5718) patients cared for during 2013 (11,666 shifts). staffing level information was determined by examining billing/staffing databases and merged with patient information that was retrieved from medical records. The primary outcome measure was patient mortality per shift (patients with DNR's were excluded).

Mortality rates (adjusted to age, SAPS score, diagnosis, sex, and comorbidity) were compared to nurse and physician staffing levels, as well as to workload. Nurse patient ratios were split into quintiles ([N:Pt] 1:≤1, 1: 1.1-1.5,  1: 1.6-2.0,  1: 2.1-2.5,  1: >2.5). Physician to patient ratios to quartiles ([P:Pt] 1:≤8,  1: 8.1-10,  1: 10.1-14,  1: >14). Turnover rate (admission+discharges) and the number of life sustaining procedures (LSP) performed in a shift were used as corollaries for workload.

The average(SD) shift had a patient load of 1.8(0.4) patients per nurse, which tended to be fairly constant across shift times (AM vs PM), though higher on weekends. There were on average 5.6(3.2) patients per physician, with a fairly significant difference between day and night periods (~4 vs. 8). Turnover averaged 6.9(9.0) patients per shift, the majority occurring during the day (0700-1900hrs), unit census averaged 13.3(5.1) patients, with 1.3(0.3) LSP performed per shift. The typical patient was a 60.6(4.9) year old male (0.7[0.1]) surgical patient (0.6[0.1]) with a SAPS score of 50.5(6.4).

Neuraz et al., recommend a threshold of 14 patient per physician and 5 patients per 2 nurses. Patient mortality increased when patient to nurse ratios exceeded 2.5 (RR 3.5[1.3-9.1]), when patient physician ratios exceeded 14 (RR 2.0[1.3-3.2]), and as workload and patient acuity increased (turnover adjusted risk RR 5.6 [2.0-15.0], LSP RR 5.9 [4.3-7.9], SAPS 1.5 [1.3-1.7]).

This study is not the first to examine the relationship between staff ratios and mortality, but it is one of the few to examine daily staff compliment as a continuous value (rather than the traditional method of discrete fixed staff ratios). It also acknowledges that it's workload, the timing of the work and not just the staffing ratios that have the largest effect on patient outcomes. From a nursing perspective I don't think that there's any particularly surprising news here; we call all appreciate that as patient staff ratio and clinical acuity increase so too do adverse outcomes. But I think that this research is important, it moves away from examining fixed patient nurse ratios to examining continueous data. It provides a framework that future studies could use in environments where patient to staff ratios are higher and workload more variable.

http://www.ncbi.nlm.nih.gov/pubmed/?term=25867907

Weekly Review #8

Sean Fox had a nice summary of how to approach an inconsolably crying infant posted on PedEmMorsels this week. These can be difficult patients, not only because they can 't tell you what's bothering them; but also because it can be quiet challenging to the parent to be unable to comfort their child. It's easy to dismiss complaints of crying as colic, but life threatening process should be ruled out. Fox describes the mnemonic IT CRIES to assist with this.

 Infection: Meningitis/Sepsis are the bad ones; but an ear infection or UTI can be quiet painful as well,
 Trauma: Fractures, Head Injuries or Non-accidental trauma.
 Cardiac Disease: SVT or congenital heart abnormalities,
                                Reaction/Reflux/Rectal: Is there new medication, or a history of acid reflux? Assess for constipation, diaper rash and anal fissures,
                                Intussusception: A good abdominal exam and diagnostics may be required for intestinal intussusception.
                                Eyes: FOB, Ocular Pressure, Abrasion: kids have sharp nails and poorly coordinated movement,
                                Strangulations: Hernia, Torsion (Ovarian/Testicular), Hair tourniquet.

From a nursing perspective a thorough history and head to toe, watching for any LOC altering processes: hypoglycemia/ICP, ruling out trauma and typical infancy related processes should be performed. to rule out any life threatening conditions before you attribute crying to colic, and dismiss the parents as "anxious".

http://pedemmorsels.com/inconsolable-infant/

Steve Mathieu from The Bottom Line Review and WICS posted a review of an Australian study on the effects of paracetamol on mortality in ICU patients by Suzuki et al., published in Critical Care this April (I reviewed this study in Weekly Review #3). The study was a retrospective observational study of 15,808 patients across 4 ICU's who received at least 1g of paracetamol (Tylenol) during their stay. The study found Paracetamol administration to be an independent predictor of a significant reduction in hospital mortality. However Mathieu points out that this relationship disappears in the presence of fever; and that there are significant differences between the groups. These differences could be responsible for the differences in mortality, and as such limit the usefulness of the findings. From a nursing perspective this adds little to practice, other than to confirm that paracetamol is quiet a safe drug. There is a RCT on paracetamol, due for publication soon (the HEAT trial) that will hopefully provide some clarity on the issue.

http://www.wessexics.com/The_Bottom_Line/Review/index.php?id=3959700805090541633




There was a great post from Jeffry Dela Cruz on Core EM on traumatic ocular injuries. The post discusses: globe rupture, hyphema, retrobulbar hematoma, retinal detachment, and corneal ulceration, with suggestions provided for clinical approach to diagnosis, possible diagnostic studies, and management for each condition. From a nursing perspective there is some great information for review here: differentiating the conditions, the mechanisms typically associated with each condition, and what type of management to expect for each presentation. The real take home from this post is maintain a high degree of suspicion and to avoid under-triage of these patients as they may require urgent referral.

http://coreem.net/core/traumatic-ocular-injuries/




Ketaminh posted a link to some research published by Hyldmo et al.,in the Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (SJTREM) on PHARM this week. The article examined if there was any relationship between supine positioning and airway patency in trauma patients. This was a systematic review and meta analysis of publications published in PubMed CINAHL, MedLine, EMBASE, PROSPERO, Cochrane, and British Nursing Index related to airway patency, LOC and patient position. 1309 studies were reviewed, 39 met inclusion criteria. Unfortunately there weren't any articles published that met the trauma, position and airway criteria; however the data did show there was a relationship between supine positioning and worse outcomes with sleep apnea studies, peri-operatively and with patients who had a TIA/stroke. There was also evidence that prone/recovery/lateral positioning improved oxygenation measures (SpO2/destauration incidences). While this study didn't identify any studies offering evidence that supine positioning worsens airway patency in trauma specifically; it did find a fair number that suggest there may be some benefit to lateral positioning of patients in general. Taken with the evolving evidence for prone positioning of ICU patients, this. as well as previous research by Hyldmo on the Scandinavian trauma position that there may be some benefit in changing the standard of practice from supine to lateral position for transport. From a nursing perspective this research suggests that it's time we reassess the dogmatic transport of patients in the prone position.

http://www.sjtrem.com/content/pdf/s13049-015-0116-0.pdf

This week Ian Miller from the Nurse Path discussed the peri-operative management of obese patients. Miller's post discusses the highlights of an article publish in Anesthesia, which provides peri-operative guidelines for caring for obese patients. There are some formulas included in his post  on calculating body weight, ideal body weight, and lean body weight: lean weight should be used when calculating weight based drug doses. There is a synopsis of some of the physiological changes to the cardiovascular, respiratory, and hemostatic systems, and what the implications of these changes are. Ian finishes with some ICU and general nursing considerations for caring for bariatric patients.
There was also a similar post by Haney Mallemat from emDocs discussing the epidemiology of and physiological changes associated with obesity, if you're interested in some additional reading. Mallemat discusses treatment challenges and offers some clinical pearls about managing and supporting oxygenation. I have a synopsis of this post available in Weekly Review #1. From a nursing perspective this post has both information and suggestions on practice that are applicable to all nurses,  Considering that obesity related hospital admission between 2002-12  had an eleven fold increase I would think that both of these posts are worth a read.

http://thenursepath.com/2015/07/02/perioperative-management-of-the-obese-patient/

Anna Pickens from EM in 5 had a great video on the general approach to a patients with an altered LOC. She briefly discusses the importance of a thorough history on determining the cause of altered LOC, looking for associated symptoms, chronic conditions and social/lifestyle risk factors. She also discusses vital signs, and physical assessment findings and how they can help to isolate the cause of altered LOC. Unfortunately a large portion of these patients will be unable to answer questions, and as such a process of ruling out possible differential causes will begin. She discusses the mnemonic for differentials: AEIOU TIPS:



Alcohol: the usual suspect, a large percentage of patients with altered LOC will be intoxicated; unfortunately a large percentage of intoxicated patients will also have head injuries;
Epilepsy: Has the patient seized previously? are they on any anti-convulsant medications? were there any changes to doses, or changes in body weight that may have affected serum levels (especially relevant in pediatric patients);
Insulin: Check for medic-Alert tags, and prescriptions for hypoglycemics. Always check the blood glucose level of a patient with altered LOC;
Oxygenation/Overdose: Is the patient hypoxic, or obtunded from an accidental/intentional overdose? Assessing vitals goes without saying, the patient should be screened for toxicities.
Uremia: Screening for kidney disease, these patietns will likely (but not always) have a fairly extensive medical history, labs will confirm this.
Trauma: really this is what we're trying to rule out, until proven otherwise it's safest to assume all altered LOC may have occult head injury. Consider occult trauma and blood loss.
Infection: Meningitis can present with altered LOC, as can septic shock. Immuno-compromised, or patients on immunomodulating/chemotherapeutic drugs are at higher risk.
Psychiatric/Poisoning: Acute pyschosis can have widely varied presentation. Non drug related poisonings like carbonmonoxide, metal, and organophosphate toxicities also present as altered LOC,
Stroke/Shock: Not just occlusive strokes: lesions, diffuse axonal injuries and hemmorhages will present with altered LOC, as will profound hypotension.

Pickens finishes with some treatment options, common pitfalls and clinical pearls. Altered mental status is one of a few presentations where I frequently see under-triage, and have seen collegues and hospitals in court as a result. As a nurse, especially if one working in triage, I feel the AEIOU TIPS mnemonic to be exceptionally useful.

http://emin5.com/2015/06/22/approach-to-altered-mental-status/