The throw-up throw-down

The Annals of Emergency Medicine published a study by April et al., that compared inhaled isopropyl alcohol to oral ondansetron for acute nausea. Although this isn't the first time isopropyl aromatherapy for nausea has been assessed; it is the best designed study, and assessed patients over a longer period than had been previously studied. This was a single center randomized, blinded placebo controlled trial that enrolled 122 nauseated adults who didn't require IV access into one of three arms:

1. inhaled isopropyl plus 4mg oral ondanseton 
2. inhaled isopropyl plus oral placebo 
3. inhaled saline plus 4 mg oral ondansetron 

A convenience sample of 208 patients with a presenting chief complaint of nausea or vomiting were screened for inclusion with 122 meeting inclusion/exclusion criteria.

• age > 18years
• presenting complaint of nausea or vomiting with a severity of 3/10 or greater

Exclusion criteria were:

• Isopropyl or ondansetron allergy
• inability to inhale through nose
• recent ingestion of medication contraindicated with alcohol
• altered mental status
• history of prolonged QTc
• suspected or known pregnancy
• patients who had IV access established
• Provider discretion

Reported nausea scores (0-100) were collected from patients at the 0, 10, 20, and 30 minute points. Initial nausea scores were similar across all three treatment arms. The findings noted a significant reduction in need for rescue antiemetic and patient reported nausea within both isopropyl aromatherapy arms; but not in the saline plus ondansetron arm.

This was a well designed study of emergency department patients who presented with a common emergency complaint, the clinical findings are impressive and are significant when considered in association with previous research on the topic. The results of this study alone should be interpreted with caution, however given that it was a single center trial with a small sample size. Additionally there was no discussion of statistical power, the confidence intervals were large and often crossed zero (although this could be due to an under-powered sample size), and that patients were often able to deduce which treatment they had received.

Despite the lack of statistical power this is a study that has the potential to change nursing practice: it suggests that isopropyl aromatherapy may be effective for a prolonged period, that it may show superiority to ondansetron and that it seems to be safe for people with mild to moderate nausea. This is a cheap easily executed therapy, one that doesn't require a prescription, it could be used effectively as a temporizing measure, or as an adjunct to other antiemetics. 


April, M. D., Oliver, J. J., Davis, W. T., Ong, D., Simon, E. M., Ng, P. C., & Hunter, C. J. (2018). Aromatherapy Versus Oral Ondansetron for Antiemetic Therapy Among Adult Emergency Department Patients: A Randomized Controlled Trial. Annals of emergency medicine.

Weekly Review #21

Brian Erikson hosted a couple of great guests on erNURSEpro. He discussed ED process improvement with Deb Delaney, and Delirium with Christina Shenvi.

Deb Delaney had some insight on improving ED through-put and made some specific suggestions about internal queues, flow facilitation, use of mid level providers, streamlined ancillary services, room utilization, huddle & hand-off processes, and communication. I've seen several departments use internal queuing, or intra-departmental waiting areas, to create a "fast-track" area and increase throughput of less acutely ill patients. The "flow facilitator" role is often performed by a charge nurse, in small departments this may work well, but in large centers, or during times of peak traffic it does not. Dedicating one person to this role, even if only during peak volume can help clear bottle necks, ensure patients are moving through the system, and ensure that the charge nurse isn't being removed from performing their function, I particularly like the push-pull model of moving patients, as well as bed-side handoffs and impromptu huddles. Delaney offers a few other suggestions, and likely has something that could be implemented at your department, a good review for any nurses working in a charge, or managerial role.

Brian also hosted a talk with Christina Shenvi, a physician and fellow in geriatric emergency medicine. Christina discusses a three step approach to patients with delirium: immediate stabilization and correction of rapidly reversible causes (hypoxia, hypovolemia, AMI), establishing a baseline for the patient (call family, support workers, or care home staff), and the process of ruling out possible causes of delirium using the DELIRIUM mnemonic (covered in weekly review #11). She then discussed possible causes, risk factors, and considerations for interacting with these patients. There are some great pearls on pain assessment, preventing delirium, and steps that can be taken to make an emergency department more friendly to geriatric patients. This is a great podcast, Brian includes some relevant links in the show notes, the discussion is straightforward and informative, and the content is applicable to almost all sub-specialties of nursing; if you're going to listen to only one podcast this week, make this the one!

http://www.ernursepro.com/#!ERNP-029-Become-a-Delirium-Rockstar-in-Your-Department/clp2/5636120a0cf2f97533d29a3d





There was a lot of FOAMed coverage this month on the new 2015 CPR/ECC guidelines. HEFTEMCAST, RebelEM, and BIJC, have all provided great summaries of the updates; but from a readability perspective I would like to highlight the review by Justin Morgenstern on First10EM. His post starts with a review of the evidence informing the changes, then discusses the key recommendations and changes by topic, starting with: CPR, medications, capnography, technology, post resuscitation care, and finally by special patient populations: pregnant, hypothermic, trauma, pediatric and neonate patients. The team at BoringEM also deserve a huge acknowledgement for their amazing infographic series which can be downloaded here, a fantastic review for any nurse that participates in cardiovascular resuscitation.

http://first10em.com/2015/10/21/acls-2015/

The Journal of Trauma and Acute Care Surgery published an analysis by Afshar et al., that examined the association of blood alcohol content with in hospital death, injury severity, and mechanism of injury. This is a retrospective examination of patients treated at an American shock trauma center between January 2002 and October 2011. The study assigned patients into 4 categories based on blood alcohol content (BAC): undetectable (<1mg/dL), moderate (1-100mg/dL), high (101-230mg/dL), or very high (>230mg/dL), then examined for severe injury (ISS >16), dichotomous injury pattern (blunt or penetrating), hypotension (MAP < 66mmHg), shock index (SBP/HR - greater/less than 1), and death.

There were 46,222 patient records examined, 44,502 (96%) had blood alcohol content (BAC) assessed, 12,535 (28.2%) were exposed to alcohol with the a median BAC of 167mg/dL (high). Baseline characteristics showed an increase in male representation with increasing BAC quartile (66, 77.5, 79.8, 83.1%). Patients with moderate BAC were more likely to have penetrating injury patterns (typically gunshot wounds), severe injury, hypotension, pulseless arrival, and in-hospital mortality compared to other groups. The very high BAC had the greatest proportion of blunt trauma, falls and fights, the lowest proportion of vehicle collisions, and the lowest odds for in-hospital mortality.

When I first read this research I was a little confused as to what it added to the overall knowledge of alcohol and trauma, other than to say that mechanism varied across intoxication levels. However when this research, on injury mechanisms by BAC quartile, is used in addition to previous research, on alcohol and mortality, we begin to understand why some of the noted effects are occurring. This may be interesting research for nurses working in trauma who are particularly keen on the epidemiology of trauma, but from a straightforward nursing perspective it has little to add to the general approach toward trauma patients.

http://www.ncbi.nlm.nih.gov/pubmed/26402540

I recently moved from a small rural ER to a large metro trauma center. On one of my first orientation shifts a patient in DKA was transferred to our department from a rural site. Some of the nurses made disparaging comments about the choice of SC insulin over IV insulin infusion, which started an interesting dialogue. Although I've typically seen these patients treated with IV insulin infusions I do know that the evidence, as well as CDA guidelines, acknowledge that either will produce similar outcomes. I've seen some support for the practice in EPMonthly, which acknowledged similar efficacy between the two, but a new review by EMPharmD offers not only a succinct review of the existing literature, but also a fresh perspective on titrating doses from rapid to a long acting insulin, an approach that if supported by evidence could significantly lower the amount of time and resources required to treat patients with DKA. A great read for nurses working ER/ICU or medicine, and one of my newly discovered favorite sources for FOAMed content.

http://empharmd.blogspot.ca/2015/10/just-little-prick-iv-vs-sq-insulin-for.html

On InjectableOrange Jesse Spurr hosted a post by fellow Canadian RN Jennifer Jackson on why nurses need to be politically active: to advocate for patients, to advance the nursing profession, and to effect change on our work environment - very timely given our recent federal election. He also posted some links and information for those lucky enough to attend the 2015 SMACC conference in Dublin.

I've reviewed a post by Ian on pre-filled syringes before and strongly feel that they are an effective way to prevent medication errors. One drug in particular where this is of concern is Epi. The differences in concentration between cardiac and anaphylaxis doses is 10 fold. Taft Micks offers a review on the differences between the two on  BoringEM, discussing the risks, and deciphering the labels of the two different doses.

EMin5 reviewed the different presentation, treatment and complications associated with parasitic skin infections. Anna Pickens reviewed the differences between scabies, lice (head, pubic, or body) and bedbugs. This five minute video offers up great photos, neatly summarizes the treatments, and includes a fantastic table that summarizes the video. An excellent review for emergency, correctional, camp, public health, or school nurses.

Weekly Review #20

A systematic review in the BMJ examined how well health professionals understand diagnostic tests. Using “statistics”, “healthcare”, and “accuracy” keywords the reviewers searched EMBASE, PsycINFO, and MEDLINE databases identifying 4818 hits. 74 were reviewed as potentially relevant based on title and abstract, with 28 meeting full inclusion criteria. Due to the heterogeneity of studies the systematic review was limited to presenting its findings in narrative format. The authors categorized the findings into four themes: self-rating, accuracy of definition, Bayesian reasoning, and presentation format categories. 

Two studies examined clinicians’ self-reported familiarity of statistical measures. In one study 13/50 clinicians reported understanding sensitivity, specificity, and positive predictive value; although only one was able to provide a correct definition when asked to do so. The other study found that only 58% of clinicians actually used statistical measures in their practice (although 82% claimed to do so). 

6 studies examined clinicians’ understanding of statistical definitions; they found that on average clinicians could provide a correct definition for sensitivity 76-88% of the time, specificity 80-88% of the time, but only 17% could correctly identify the correct definition for likelihood ratios.

22 studies examined how well clinicians’ were able to use pre-test probability and test accuracy to determine post-test probability (Bayesian reasoning). The studies found that in general clinicians had a poor understanding of Bayesian reasoning and were unable to determine post-test likelihood the majority of the time (0-61% success), clinicians also tended to overestimate post-test probability by 46-73%, and in one study clinicians inverted the likelihoods incorrectly interpreting patients with negative results as having a higher post-test likelihood of having a disease.

The 5 studies that examined presentation format found that healthcare providers were more accurate in their post-test estimates if the findings were expressed as natural frequencies (50 out of 100) rather than as probabilities (50%). The use of graphical aides improved clinician post-test accuracy to 73% compared to 48% when natural frequencies alone were used to communicated test power, or 23% when probabilistic language was used to describe tests.

This systematic review suggests that not only are we as healthcare providers poor at using probabilistic reasoning; but that we’re also oblivious to our weakness in this area. As a nurse I know that the preparation I received in school to interpret and use statistics was severely lacking. This research, which focused primarily on physicians, would suggest that this is a common area of weakness. This research highlights how little we all know about the tools we use on a daily basis, it may also shed some light on why so few of our colleagues engage with research, and I would suggest that most importantly it empirically shows that we could all use some brushing up on how to use statistics. I’ve covered some great resources to help with this is a few previous weekly reviews (#4 & #6) and would suggest that anyone looking for a brief intro into using Bayesian statistics take a look at the first few chapters of this online book. 

http://www.ncbi.nlm.nih.gov/pubmed/26220870

Steve Mathieu reviewed the HEAT trial of acetaminophen for fever in critically ill patients on The Bottom Line Review. This study was a double blind RCT of 700 patients that sought to determine if the administration of paracetamol to critically ill patients had any effect on: ICU free days, mortality, length of stay (LOS), number of days on organ support, and its effect on lab values and temperature. Patients were block randomized to receive either 1g IV paracetamol, or IV D5W every 6hrs for 28 days or until: ICU discharge, fever resolution, cessation of antibiotics, death, or contraindication. The study found no statistical difference in mortality, LOS, ICU free days, or organ support, although patients who received paracetamol had a lower (0.25C) average temperature. This research is contrary to a retrospective study published earlier this year that found a mortality benefit associated with paracetamol administration, it has a much higher quality design, and is one that I've been waiting to see published. Mathieu's summary of this research is concise, easy to interpret, and very timely; the summaries on this site are consistently of very high quality, this review and the site in general are a fantastic resource.

http://www.wessexics.com/The_Bottom_Line/Review/index.php?id=7257804966227311886

A retrospective analysis of tourniquet use in the pre-hospital setting was published in the Journal of Acute Care Surgery this month. Ode et al., examined the EMS use of tourniquets in a metro North Carolina ambulance service during 2012-2013. They examined patients with uncontrolled hemorrhage to determine the frequency of “correct” tourniquet (Tk) application, the efficacy of Tk as a treatment, and the frequency of Tk related adverse outcomes. 98 patients met the inclusion criteria (uncontrolled hemorrhage), 42 were excluded because they were treated outside of the metro area. Of the remaining 56 patient: 24 received a Tk (19 Combat Application Tourniquet, 5 improvised), although 5 were deemed unnecessary (the patients weren’t in shock - SBP>80mmHg) and 4 were delayed. Of the 32 who didn’t receive tourniquets three were indicated, but did not receive treatment.

The patients treated with a Tk, compared to those not, had significantly higher rates of: shock (50 vs 12.5%), vascular injury (69.6 vs 25.8%), blood transfusion (37.5 vs 9.4%), rates of admission (77.3 vs 38.7%), and mortality (8.3 vs 3.1%). None of these findings are surprising given that the protocol for application of a Tk was quiet conservative, requiring patients to be in shock, and therefore significantly sicker. Secondary analyses showed that patients who were indicated to receive a Tk but didn’t had higher incidence of shock compared to those who did (85.7 vs 60%), and that those who weren’t indicated (not in shock) but did receive a treatment by tourniquet had no adverse outcome as a result.

Due to the overly conservative treatment protocols, the small sample size, and the lack of an equivalent control arm the primary results of this study have little to contribute to the overall body of evidence for Tk use in civilian trauma. The secondary analysis does show worse outcomes for patients with missed Tk’s, and no complications associated with liberal Tk (non-indicated) use; although the numbers (n=22) are too small to reach statistical significance. From a clinical perspective this research would seem, in a small way, to support that liberal Tk use isn’t associated with worse outcomes, and that even extremely conservative (only once shock becomes apparent) Tk use imparts benefit. From a practical perspective this research provides weak evidence to support Tk use in civilian trauma, it also suggests that the current military research may be generalizable to the civilian population, and indirectly it would seem to suggest the need for a liberalization of Tk protocols among EMS services. 

http://www.ncbi.nlm.nih.gov/pubmed/26402532

Using the current VW emission scandal as a comparison piece Richard Smith offered a critique of scientific misconduct on his BMJ blog, and suggests that scientists should face criminal charges if found guilty. Criminal charges have been used to punish scientific misconduct before, as was the case with June Dong-Pyou Hon’s faking of HIV immunization results; and Smith offers three additional reasons why misconduct should be investigated criminally: Because inappropriate use of research funding is financial fraud, because universities are poorly equipped to conduct investigations, and because investigations by the university would be a conflict of interest. I would also suggest that there is a basis for criminal charge based on harm to the patient, for example the intentional non-disclosure of the increased risk for suicide when paroxetine is used to treat pediatric depression, and Andrew Wakefield's fabrication of evidence that immunizations result in autism. A thoughtful and timely piece by Smith, maybe one that will find increased traction.

http://blogs.bmj.com/bmj/2015/09/28/richard-smith-if-volkswagen-staff-can-be-criminally-charged-so-should-fraudulent-scientists/?utm_source=feedburner&utm_medium=feed&utm_campaign=Feed%3A+bmj%2Fblogs+%28Latest+BMJ+blogs%29&g=w_blogs_bmj-com

On the Trauma Professionals Blog Micheal McGonigal discusses the reflexive way that many clinicians treat low oxygen saturation readings. He discusses factors that can result in artificially low reading, patient groups where a low reading is normal, the absence of a good definition of "normal values", and suggests that if the patient is not distressed on examination they likely don't need supplemental oxygen. This is a quick reminder to treat the patient and not the number.

Mark Culver discussed the differences between intermittent and continuous PPI therapy for UGIB on Emergency Medicine PharmD. There has been a fair bit of research into this topic lately, and UpToDate had suggested changing practice from continuous to intermittent PPI therapy last year; however the practice remains widespread. This post offers a great review of the research behind the change in recommendations. The cost savings, and reduction in nurse time this practice change could result in make this post well worth the read.

There was a podcast review of fluid resuscitation in hemorrhagic shock on HEFTEMCAST. This podcast reviews the key evidence and discusses the concepts of: damage control resuscitation: permissive hypotension, hemostatic resuscitation, and damage control surgery. The review includes seminal work from the military as well as evidence from civilian trauma, it nicely summarizes the key literature, and provides links to the source research. This 16 minute review is well worth a review for anyone working in an emergency settings.

Josh Farkas offered a well balanced review of the SPLIT trial on PulmCrit. The SPLIT trial examined the differences between PlasmaLyte and Saline in patients admitted to the ICU, and found that there was no significant difference between the two fluids. Farkas acknowledges that the findings are valid among the patients reviewed, but critiques the external validity of the study; he points out that the small volumes of fluid received, the admission reason (elective post-operative), and the low illness severity observed among the patients in this cohort are not generalizable to the typical ICU population.

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/

Activated Charcoal

Activated charcoal is the most commonly used treatment in patients with poisoning (Lai et al., 2006). It may be used for a variety of poisonings, except with corrosives, iron, lithium, arsenic, and alcohols, for which AC is unable to bind (Olson 2010).

Activated charcoal (AC) is a porous carbon product, with a large surface area for binding with drugs, chemicals, and organic compounds. This binding or "adsorption" is useful in the clinical context because when ingested it bind with toxins preventing gastric absorption. The AC bound chemicals are then excreted in feces.

There is debate about the efficacy of AC in toxicities. To date there hasn't been any high quality evidence linking morbidity or mortality improvements with the use of AC (Chyka et al., 2004). The evidence that is available comes from: small non-blinded trials, case reports, animal studies and trials performed on volunteers (some of which are RCT's) that examined serum toxicity levels as corrolary for clinical measures (Olson, 2010). Regardless of the lack of clear clinical benefit AC is widely used  as a first line treatment of toxic ingestion because it is relatively safe, has a has been shown to lower serum drug levels, and is widely endorsed as by professional groups and organizations.

Most current recommendations are that AC may reduce toxin absorption if administered within 1 hour of poison ingestion (although it can be administered later), that AC should not be used in patients who cannot maintain their own airway, because of the risk for AC aspiration and resultant pneumonitis (Chyka et al., 2004), and that AC should also not be given to patients with, or at risk for, GI perforation as it will obscure endoscopic investigation of the stomach (Chyka et al., 2004). Indeed in many patients it may be safer, and more effective to use specific antidotes ex: mucomyst (Olson 2010). Regional practice may also be guided by specific institutional policies which may vary from these guidelines.



Activated charcoal dosing is usually 0.5-1g/kg in pediatric populations. For adults there is typically an initial dose of 50-100g, which may be followed with 50g every 4 hours (which may be divided) (Chyka et al., 2004). If activated charcoal is administered by nasogastric (NG) tube it is essential to ensure correct tube placement, for the same reason that AC should not be given to patients unable to maintain their own airways, because it can cause severe chemical pneumonitis (Bond 2002). Because NG insertion can also be traumatic, painful, and poorly tolerated, most patients will be given AC orally. Most patients will tolerate AC orally; however palatability can be a major barrier, especially in the pediatric populations.

A number of studies have sought ways to improve and measure the palatability of AC, the majority have used readily accessible mixes such as juice, milk or cola. Most of these studies have examined pediatric populations and the effects of mixes have on flavor and ease swallowing the AC mixture: Cola  has consistently been selected as the preferred mix for AC in pediatric populations in terms of flavor, ease of swallowing, and overall preference (Dagnone et al, 2002., Skokan et al, 2001). Unfortunately there hasn't been much in the way of similar research among adult patients.

Anecdotally I have seen a huge difference in compliance of AC administration when mixed with cola in both the pediatric and adult populations. For children there is an improvement in flavor, the fizz is fun, and the color of the cola doesn't change with the addition of AC, for adults there is less of a chance that allergies or aversions to dairy will present a barrier of using it as a mixture. From a pragmatism perspective cola is a clear winner as it's shelf stable, and readily available wherever there is a vending machine.




Bond, G. R. (2002). The role of activated charcoal and gastric emptying in gastrointestinal decontamination: a state-of-the-art review. Annals of emergency medicine, 39(3), 273-286.

Chyka, P. A., Seger, D., Krenzelok, E. P., & Vale, J. A. (2004). Position paper: Single-dose activated charcoal. Clinical toxicology (Philadelphia, Pa.), 43(2), 61-87.

Dagnone, D., Matsui, D., & Rieder, M. J. (2002). Assessment of the palatability of vehicles for activated charcoal in pediatric volunteers. Pediatric emergency care, 18(1), 19-21.

Lai, M. W., Klein-Schwartz, W., Rodgers, G. C., Abrams, J. Y., Haber, D. A., Bronstein, A. C., & Wruk, K. M. (2006). annual report of the American Association of Poison Control Centers toxic exposure surveillance system.Clinical Toxicology, 44(6-7), 803-932.

Olson, K. R. (2010). Activated charcoal for acute poisoning: One toxicologist’s journey. Journal of medical toxicology, 6(2), 190-198.

Skokan, E. G., Junkins, E. P., Corneli, H. M., & Schunk, J. E. (2001). Taste test: children rate flavoring agents used with activated charcoal. Archives of pediatrics & adolescent medicine, 155(6), 683-686.

Weekly Review #3

A French research team led by Helene Goulet published a study in Critical Care examining unexpected deaths of patients admitted through emergency departments. This multi-center retrospective study examined the patient records of 4 metro Paris hospitals for death within 72 hours of ED attendance. Exclusion criteria were: admission to ICU, expected death (ex: inoperable intracranial hemmorage), and presence of DNR. Primary endpoint was determining cause of preventable death, secondary endpoints were process breakdowns that may have contribute to death. Of the 208549 admissions during the study period 70 died unexpectedly. Due to incomplete ED records only 47 met full inclusion criteria. 24 of the 47 deaths (51%) were deemed preventable. 55% of these patients died in the ED, 40% in a medical ward. Delay in recognition and treatment of sepsis accounted for 38% of deaths, while under-triage or under-recognition of critical illness contributed to death in 4 (16%) patients. Of the process breakdowns the most common were: incorrect treatment choice (47%), failure to order correct diagnostics (38%), incorrect admission ward (47%), and incorrect triage (45%). Goulet et al acknowledge that previous studies of this nature have not shown sepsis death rates quiet as high, they don't offer specific recommendations other than to stress the importance of recognizing and treating sepsis. This study has some obvious limitations: it has a small sample size and didn't capture unexpected deaths of patients discharged/transferred from hospital. The reviewers were also aware of patient outcome (death), and as such would have been more critical in their reviews; combining this with the current practice changes associated with the Surviving Sepsis campaigns and EGDT could explain the higher than previous rates of mortality associated with sepsis. There was also no discussion on whether or not the unexpected deaths would have been prevented with correct treatment. From a nursing perspective this reinforces the need to be diligent in triage, and speaking up if obvious orders or treatments have been overlooked.

http://ccforum.com/content/19/1/154/abstract




There was a post by Josh Farkas on PulmCrit about sleep protective patient monitoring. The post is essentially suggesting that not all patients need nocturnal blood pressure or temperature monitoring- monitoring which wakes patients up and puts them at increased risk for delirium. As an alternative he suggests using urine output as a corollary measure of cardiac output, as good urine production is a reliable indicator of end organ perfusion. This approach is obviously only possible in patients with indwelling catheters, and should not be used with patients in shock, with cardiac problems, or on diuretics. From a nursing perspective we can all appreciate the frustration at having to wake a hemodynamically well patient from sleep to assess their BP, and this may provide an alternative. While it certainly can't override unit policy, it may provide a step from which to discuss the implications of "routine vital signs" order, and an alternative course of action.

http://www.pulmcrit.org/2015/04/sleep-protective-monitoring-to-reduce.html

There was a post by Ian Miller of The Nurse Path reviewing male Foley catheter and urinary drainage bag stabilization. It appears that there is differing opinion on catheter stabilization techniques: Either to the stomach; or to the thigh.  That it should be in a soft "S" shape is the common point in both methods. He discussed the potential for necrosis due to tension or bending of the penis. Unfortunately he didn't discuss the negative implication of not securing the catheter at all, as happens all too often, and is associated with increased rates of Catheter associated UTI 's, and penile trauma. This post is directly applicable to nursing practice, it questions routine practice, it describes good practices, and the survey could help inform determine where nurses are in their practice. It's worth looking at, and please remember to fill out the survey.

http://thenursepath.com/2014/10/31/are-you-securing-male-catheters-in-the-right-place/?utm_content=buffer6f208&utm_medium=social&utm_source=twitter.com&utm_campaign=buffer

http://thenursepath.com/2014/10/06/tips-on-catheter-and-leg-bag-management/?utm_content=buffer63604&utm_medium=social&utm_source=twitter.com&utm_campaign=buffer

http://www.nursingtimes.net/5003963.article




I came across a post by Barrier & Chow of Critical Caring about oxygen therapy. They have a very readable discussion on the pitfalls and negative effects of unnecessary oxygen use. Specifically they discuss how supplemental oxygen was harmful in neonates with patent ductus arteiosum (PDA). Oxygen in these patients can cause the PDA to prematurely close and result in worse outcomes. They also discuss how supplemental oxygen results in worse outcomes for patients with: STEMI, COPD, Stroke, ARDS, and mechanically ventilated patients in general. Barrier & Chow discuss the four types of hypoxia (there a great explanation on ER/Trauma 101), and how supplemental oxygen should be targeting hypoxemic hypoxia. This post is directly applicable  to nursing practice, we've all received a patient who is inexplicably on oxygen, oxygen is something many nurses give little thought to, and challenging complacency in these "routine" practices can yield great results. The bottom Line? Maybe the your patient can be weaned off of oxygen... or perhaps they don't need it all.

http://www.critical-caring.pro/2014/11/oxygen-savior-or-devil-in-green-dress.html

http://er-trauma101.blogspot.ca/2011/04/four-hypoxias.html



Suzuki et al., published a study on the effects of paracetamol on mortality in ICU patients. This was a retrospective observational study of 4 Australian ICU's, the largest of it's type. It examined approximately 15000 patients greater than 2 years of age who received > 1g paracetamol during their ICU stay. Patients were studied globally, and with additional analyses performed according to route of administration (IV/PO), service (medical/surgical/ICU), temperature (<35, >38, >38.3, >38.5, >39), patients with liver cirrhosis, patients with infections, and by illness severity. The average patient in both groups were male 64 years of age with similar illness scores. The average daily dose of paracetamol in the control arm was 1.9g with an average total dose of 3g. Overall 14% of patients died, patients who received paracetamol were less likely to die (adjusted OR 0.60, 95%CI 0.53-0.68), this relationship persisted throughout further analysis. There was little discussion as to causal factors, although the authors suggest that paracetamol administration may result in diversion away from opioids or NSAID's for analgesia. although this may be true; there were significant differences between arms that could could have contributed to the overall effect. Significantly more of the patients in the intervention arm were admitted after surgery (70 vs. 51%) many of which were elective (55 vs. 37%). Furthermore illness severity scores appear to have determined post-operatively. Surgical patients, especially those presenting for elective surgeries, are likely to be healthier overall than similar patients admitted for medical reasons, unfortunately there is no discussion or adjustment for this, which severely limits the findings of this research. From a nursing perspective this research seems to add little to the breadth of knowledge available for the safety of paracetamol. Fortunately there are some recent systematic reviews of the literature that suggest there is no difference in mortality in patients given paracetamol; and a RCT is underway.  

http://ccforum.com/content/19/1/162/abstract