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 #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/