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/

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 #18

Matthew Limb discusses an Israeli study that examined the impact of rudeness on medical team performance. The research led by Arieh Riskin determined that incivility amongst healthcare professionals negatively impacts team performance, and could result in iatrogenesis. In this study physician/nurse teams were exposed to an introductory message, than assessed as they performed simulated care on an ill preterm infant. The teams exposed to incivility as part of the introductory message made 12% more errors in both procedural and diagnostic domains than those exposed to a neutral introductory message. The experimental arm had worse information sharing, reduced helpfulness, worse cognitive function, and decreased performance of collaborative processes. The unmeasured consequences of decreased performance due to incivility could potentially be huge. From a nursing perspective the message here is clear: if civility for the sake of it isn't enough reason to keep negative commentary to yourself perhaps the increased risk to patients and liscensure is.

http://careers.bmj.com/careers/advice/Rudeness_in_medical_teams_harms_clinical_performance,_study_finds




Jesse Spurr hosted a discussion this week on Injectable Orange with Damian Roland and Victoria Brazil on their recently published article "Top 10 ways to reconcile social media and 'traditional' education in emergency care". There is a 30 minute podcast with accompanying slides, in which the authors discuss each of the 10 points covered in the paper. Roland and Black argue that using social media is no different from using "traditional" approaches to education; and that the discussion about social media in medical education ought to be one that discusses FOAMed as a how (a means) rather than a what (a curriculum) of medical education. They suggest that education has always faced the challenges that are now present with learning using social media, and offer specific commentary on the critical appraisal skills and scrutiny that are required with FOAMed as well as traditional forms of literature. They highlight the particular effectiveness of social media at contextualizing research, of translating and distilling information into something that is easy for clinicians to connect with. There is additional commentary on the effectiveness of social media on reflective practice and faculty development. I would suggest that this discussion summarizes quiet nicely the similarities of FOAMed to traditional education, both in the sense of formal learning academic articles, and informal education (peer based learning): an excellent resource for nurses wanting to increase their understanding of the role of social media in clinical education.

http://injectableorange.com/2015/09/podcast-ep-6-reconciling-social-media-with-traditional-education/




The Annals of Internal Medicine published a systematic review of the science of cleaning hospital surfaces. It turns out we don't actually know a great deal about what we're doing. 80 studies were identified, 49 examined cleaning processes, 14 monitoring, and 17 implementation of strategies; of these only 5 were randomized controlled trials. Most of the studies on cleaning processes examined the effects of different cleaning agents on surface bacterial/spore levels: either as a preventive measure or in relation to infection incidence rates. Strategies for monitoring cleanliness assessed the percentage and frequency of targeted areas cleaned, and surface microbial burden. The studies examining implementation mostly used before/after designs and assessed surface contamination rates. Unfortunately the lack of studies directly comparing cleaning agents, the poorly articulated standard for defining "clean", the poorly standardized process for using cleaning agents, and our inability to isolate surface cleaning effects from hand hygiene effects prevent the authors from being able to synthesize the information, and from making specific recommendations about cleaning strategies. This review does highlights how little we actually know about cleaning; disappointing given the amount of time, labor, money, and administrative effort we put toward cleaning. Hopefully this review can identify some avenues for directly comparing agents, for standardizing processes, and may offer some suggestions on linking cleaning with meaningful clinical metrics.

http://annals.org/article.aspx?articleid=2424875

An article published in Nursing reviewed the effects of a mentorship program on student success and retention in a college practical nursing program. The mentorship model used third or fourth semester nursing students to provide peer support to first semester students. Mentors received 3 hours of training, mentored 2 "mentees", and were in turn supported by two faculty staff members. The mentor began by discussing the mentorship program, outlining expectations, and by helping to set goals for the mentee, they would than reach out to the mentee at times of peak stress, and at an as needed basis (an average of 6 times/semester). There was a significant impact on success rates with those who were mentored, with 76% completing the semester, and 83% the term. Those not mentored averaged only a 36% success rate for the semester, and a 56% rate for the term. Menteees also reported higher grades, more confidence, and less stress. The results of this study, as well as anecdotal experience would suggest that mentorship programs, in general, are beneficial; however I would be hesitant to say that this research contributes meaningfully to our net understanding of these programs in any way. The students in the intervention arm self selected to join the program, as a result the intervention arm may likely be more motivated individuals, which will confound the results. We know that there were 23 students in the intervention arm, we don't know how large the total population of students is, so assessing a population impact is impossible. In addition to the confounding variables, and the poorly articulated population, the extremely high fail rate (44-64%) of this private college likely outstrips the average of publicly funded institutions, and limits the generalizability of the findings. This study set out to show the benefit of a peer mentorship program, which they did, although the findings are much too weak to generaelize. What they also did however was show an extremely high fail rate at their nursing school. I think this study raises some questions about not only their quality of nursing education, their student recruiting practices, and the ethics of what would appear to a predatory process of recruiting and accepting tuition from students that are unlikely to succeed.

http://journals.lww.com/nursing/Citation/2015/09000/A_peer_mentorship_program_boosts_student_retention.6.aspx

In keeping with the spirit of civility Rob Bryant contributed to the EM mindset series on emDocs. His post: "seven rules to make me nicer" offers, unsurprisingly, 7 tips that will not only make you nicer to work with; but also perhaps a better clinician. This post is approachable and is general enough for all healthcare professions to have something to take home.

Anna Pickens discussed cardiogenic shock in a video posted on EMin5. The video begins by describing the physiology of cardiogenic shock, how to determine the cause, and suggestions for maintaining blood pressure. She offers some specific recommendations about NIPPV, fluid therapy and balancing pressors and ionotropes to correct hypotension. A very approachable 4 minute video.

Ian Miller linked to a TedTalk on palliative care by a HPC physician BJ Miller, who discusses the difference between pathology vs patient centered care, the difference between loss and regret, and the power of changing our perspective on death: from one of repugnance; to one where we accept that dying is an integral part of living. A great talk on medicine not as simply removing suffering,  but as tending to human dignity.

Ian Bodford posted a great review on emDocs this week that reviews toxic alcohol poisoning. Toxic alcohols are non-ethanol bases alcohols and include methanol (windshield washer fluid), isopropyl (rubbing alcohol), and ethylene glycol (antifreeze). Bodford offers some suggestions on maintaining a degree of suspicion with all inebriated patients, suggests some lab studies, and highlights treatment options for patients with toxic alcohol poisoning. A good review for ED nurses, and a good reminder to avoid assumptions when dealing with inebriated patients.

Laurie Bickhoff's post "Sending Nursing Education Viral" on Defining Nursing serves as a nice adjunct to Jesse Spurr's video on social media in education. This post offers some nursing applications for social media and highlights it's usefulness as a tool for: continuing education, engaging and networking with peers, conducting research, and curating clinical resources.

Weekly Review #16

In the first of two posts this week on SVT BoringEM reviewed a Canadian EMS treat and release trial for SVT. Calgary EMS sought to determine if uncomplicated SVT could be treated in the prehospital environment, and to determine what the 72hr complication rate would be. EMS treated a total of 40 individuals, for 75 episodes (of a possible 225) of SVT. There was only one multiply co-morbid individual presented to hospital following EMS treatment, although that the one individual presented a total of 14 times, there was no incidence of cardiac arrest, defibrillation, or cardioversion required. There were unfortunately 22 EMS errors in following the protocol; but on a whole it would appear that a treat and release model of managing SVT may be worthwhile. From a nursing perspective this doesn't change practice; it may however suggest that there could be some additional research coming, a large scale trial, with longer follow up period, and potentially a increased nurse role if treating SVT is delegated to non-medical colleagues.

http://boringem.org/2015/08/28/cjem-infographic-prehospital-management-of-uncomplicated-svt/




Rick Body discussed a trial published in the Lancet this month that examined the effects of modifying the valsalva maneuver on rates of converting SVT. This modification was first documented in a small 2010 study, but this is the first intention to treat trial. There were 214 patients included in each arm (traditional vs. modified valsalva). The valsalva maneuver in this trial was a forced exhalation at 40mmHg for 15 seconds, the modification was the addition of laying the patient supine and performing a passive leg raise immediately following the valsalva maneuver. The data showed a doubled success rate in the modified valsalva group (43% vs 17%), which translated to a reduced requirement for adenosine (57% vs. 80%). This could translate to significant improvements in patient care, as receiving adenosine can be quiet psychologically traumatic. This research is fantastic news for patients as well as care providers: it's a no cost intervention, with no obvious risk or side effects, that more than doubles our odds of being able to treat patients without causing distress. Great stuff worth a read for all care providers!

http://stemlynsblog.org/the-revert-trial/




There were two great posts this week by Ian Miller from the Nurse Path one detailing the use of a running narrative, the other discussing CPR. A running narrative of the care you're providing Ian suggests is important for two reasons: It informs the patient of what you're doing, and it helps to keep you focused on the task at hand. I would also suggest that in addition it helps to keep your teammates abreast of what you're doing: particularly important during a code, or while working in a trauma team- although you may want to be a bit more brief in these scenarios than what Ian describes. His second post, on improving CPR, is an observation of the interruption of quality CPR during the patient transfer from the ambulance  to ED. Ian proposes that rather than waiting to transfer the patient from the ambulance stretcher to resuscitation stretched in the resuscitation bay, the transfer be made in the ambulance bay, so that the EMS team is not attempting to provide poor quality compressions while walking beside the patient. Once the patient is on the resuscitation stretcher a member of the resuscitation team than straddles the patient and "hitches a ride" while performing CPR. This is something I've seen performed in practice, and it works quiet well, provided there is advanced warning of the arrest, the personnel available to do so, and room in the ambulance bay.

http://thenursepath.com/2015/09/01/improving-quality-of-cpr-between-ambulance-and-resuscitation-room/

http://thenursepath.com/2015/08/29/give-a-running-narrative-of-your-care-delivery/

An article by Colleen Bockhold and Sherron Cumpler discussing pulmonary related transfusion reactions was published in Nursing this month. They discuss the two leading causes of transfusion related death: transfusion related circulatory overload (TACO), and transfusion related acute lung injury (TRALI). They begin by discussing how to recognize TACO (evidence of fluid overload, hypertension, respiratory distress, etc); discuss strategies for preventing TACO (close monitoring and conservative transfusion rates); and how to manage patients who develop TACO (diuresis, and respiratory support). They than move to discussing differing theories of the inflammatory process of TRALI, and the process of pulmonary damage: interstitial leakage, and resultant pulmonary edema. Signs and symptoms of pulmonary edema are described (SOB, hypoxia, tachycardia, etc), prevention strategies are discussed (antigen screening, and leuko-reduction), and treatments are reviewed (supportive). This is an open access article, is clearly written and easily understood, and provides a succinct review of transfusion reactions.

http://journals.lww.com/nursing/Fulltext/2015/09000/Responding_to_pulmonary_related_blood_transfusion.10.aspx

Emergency Physician Monthly published an article written by Paul Rostykus that suggests D10W may be superior to D50W in the management of hypoglycemia. In a great example of dogmalysis Rostykus compares the amount of glucose, the tonicity, and the effectiveness and safety of D50W and D10W. He makes a great argument for using the more isotonic D10W, highlighting that it is less likely to cause tissue necrosis in the event of extravasation, and is less error prone than D50W in pediatric patients as it doesn't require dilution. In trials patients who received D10W received less total glucose and are were less likely to experience hyperglycemia, yet had no difference in recovery time. Anything that's safer, easier, and as effective is worth consideration. Great read, another example of low (no) cost modifications to care that can translate to better outcomes.

http://epmonthly.com/article/d10-may-be-better-than-d50-for-acute-hypoglycemia/

There was a brief post on using FOAMed to keep up to date in EM on HEFTEMCAST. Likely these tips are old news for most, but for those just joining the FOAM/FOANed communities it's well worth a visit as it offers some suggestions on how to access content.

Where I work the majority of chest tubes are removed by nurses, there was a video posted by regionstraumapro with some good tips on preparation, an explanation about why removing the tube during high intra-thoracic pressures (Valsalva) prevents air from entering the chest cavity. While you're there take a look at the IO resources that are posted.

There was a great video posted on PHARM about removal of body piercings. This video has everything you could possible want: cheesy infomercial music, a how to guide for removing piercings (from: ears, noses, eyebrows, tongues, nipples, bellybuttons, sadly nothing below the belt), how to remove each type of piercing (rings, barbells, labrets, and those cheerio looking spacers), workarounds to avoid removing jewelry, and an overly serious jaws-of-life wielding firefighter. FOAM/FOANed fromage at it's finest!

This week BoringEM examined pediatric nicotine toxicity. There's a rising trend in e-cigarette use, as well as nicotine poisonings. Nicotine is rapidly absorbed, has no antidote, and e-cigarette refills contain a lethal dose. This post describes presentations, treatments (supportive with a limited role for activated charcoal). This is a concise overview of nicotine toxicity, and describes the hazards of e-cigarettes well, worthwhile for anyone working in emergency.

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 #12

I recently started using twitter, originally as a way to curate FOAMed and FOANed content, it didn't take long for me to want more. When I first started using it as a way to not only curate; but to connect with the FOANed community I was at a loss. I wasn't looking to have another social media account where I got game request and cute inspirational posters with cats and Minion characters; I wanted a resource for sharing knowledge. I wasn't sure what proper twitter etiquette was, how to connect with like minded individuals, compose tweets, or how to target my communications to the individuals and communities I wanted to engage with. I learned; but I would have appreciated a tutoridal. Jesse Spurr from Injectable Orange has made one. It's basically a curated set of 10-20 minute long video tutorials on how to interact on twitter. I would recommend it to anyone interested in using twitter in general, especially if they're interested in joining the FOAM/FOANed community.

http://injectableorange.com/2015/08/lose-the-egg-take-off-on-twitter/

There was a post by by Ryan Mason and Alex St.John on emDocs on wound irrigation that is highly applicable to nursing. In it they review the literature for the effectiveness and safety of sterile saline versus tap water, and the best practices for irrigation pressure and volume. Their results are clearly summarized and presented along with links to the source research. A Cochrane review found tap water (for cleaning small uncomplicated lacerations in otherwise well patients) is as safe and effective as saline in general. Other research suggested that tap water was associated with fewer infections, and that, unsurprisingly, yielded a ten fold reduction in cost compared to saline. The literature examining irrigation pressure suggests that ideal pressure of ~43PSI could be achieved using a 19 gauge needle attached to a 35 or 65cc syringe. Standard lab faucets have an average pressure of ~45psi: irrigation can be performed in the sink, saving supplies and clean up time, great! They were unable to find any data to support what ideal irrigation volumes are; but most texts suggest about 60ml/cm, or as high a volume as possible. From a nursing perspective this is great online content: it's well presented, easy to read, and highly applicable to nursing practice. Knowing that tap water is safe and effective for simple wounds is great; but knowing that tap water is faster, cheaper, an potentially even safer is awesome, from a nursing perspective this is certainly news worth sharing!

http://www.emdocs.net/antediluvian-methods-an-evidence-based-approach-to-wound-irrigation/




I'm fascinated with lipid therapy (see Weekly Review #1): it's not a widely used antidote, it's mechanism of action is not fully understood, and we're still determining what toxins it can be used for. This week I read a case series report by a Turkish group  who used intravenous lipid emulsion (ILE) to successfully reverse synthetic cannabinoid (SC) toxicity. Commercially available SC are known by many names (K2, Spice, Bonzai, Kronic) and have varying unknown compositions of mixtures of cannabinoid containing compounds. Cannabinoids are strongly lipophylic, can be 5 times as psychoactive as THC, and are associated with many different CNS/CVS effects. There were 4 patients reviewed in this case series; all of them presented with varying levels of CNS/CVS depression, and all were treated with a bolus dose of 1.5ml/kg of 20% lipid emulsion, followed by 0.25ml/kg/min for 60 minutes afterward.

Patient #1 was a 35 year old male, with a history of IV heroin use, who was found unconscious by family with empty SC packaging and brought to hospital. On arrival he was unresponsive, with unequal pinpoint pupils, a GCS of 3, was hemodynamically stable (BP 110/75, HR 95) with ECG showing LBBB; but in respiratory acidosis (SpO2 65%, pH 6.9, PaCO2 125mmHg). The patient was intubated and received ILE (but not narcan as it wasn't available). 5 minutes after the bolus dose of ILE ECG showed narrowing and normalizing QRS appearance. There was no improvement to GCS, and the patient eventually died of ARDS and multisystem failure.

Patient #2 was a 19 year old male brought to hospital after smoking SC. On arrival the patient was confused (GCS 14), hypotensive (70/30mmHg), and bradycardic (HR 42). A 2 liter bolus failed to correct the hypotension so the team initiated ILE therapy. 5 minutes after the bolus dose HR had increased to 50-55/min, by 60 minutes hypotension was resolved (BP 110/70mmHg), and by 2hrs confusion was resolved (CGS 15). The patient was discharged by 24hrs.

Patient #3 was a 15 year old male who had smoked SC. On arrival he was obtunded (GCS 8), and bradycardic (HR 36, BP 80/40mmHg). This patient also received a 2 liter IV bolus, and ILE. The patients bradycardia had resolved by 5 minutes post bolus dose ILE, by 2hrs GCS was 15, and at 24hrs the patient was discharged home.

Patient #4 was a 17 year old male who presented confused after smoking SC. On arrival his GCS was 13, vital signs were within normal limits, and ECG showed accelerated junctional rhythm with bigeminal PVC's. ILE therapy was initiated: PVC frequency was reduced by 5 minutes post ILE bolus, completely resolved (NSR) by 60 minutes, GCS was 15 by 4 hours, and the patient was discharged at 24hrs.

This case series details a novel approach to treating SC toxicity. The reported sample was small and homogenous, there were no controls, and SC toxicity usually presents with arterial hypertension; so caution should be used when attempting to generalize these findings. Given that there are no known antidotes for SC toxicity to date, ILE may become increasingly used as evidence to support it's use accumulates. Dosing information as well as additional case reports can be found at lipidrescue.org, and ALiEM. There are no unique nursing considerations for administering lipid rescue, but institutional policy should be consulted. 

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4442263/




Where I work the nurses tend apply the vast majority of back-slabs, immobilization devices, air boots, and casts. There was some great FOAM/FOANed content posted by Neil Long on Life in the Fast Lane (LITFL) this week. This is a straightforward post with links to videos showing how to place back-slabs, with tips and tricks on placement, and when each technique would be used. If you apply casts or back slabs on a regular basis this may serve as a handy go to reference.

http://lifeinthefastlane.com/practical-guide-to-the-backslab/

EMSWorld posted about a South Florida trial of heads up (Reverse trendelenberg) CPR. This will be an expansion of small scale trials performed by South Beach County Fire Rescue that have seen dramatic improvements in all-rhythm ROSC (an improvement from 16 to 48%). This trial will see responders elevating the head of the stretcher, and using automated CPR devices for OHCA. Reverse Trendelenberg CPR is something I've been watching with excitement develop for a while now (See Weekly Review #1). Previous animal studies have yielded promising results, showing that reverse trendelenberg CPR is associated with: a significant decrease in ICP, an increase in venous return from the brain, and improved neurological outcomes. I'm excited to see the innovation being put into practice by an EMS service, I would love to see a similar trial performed in hospital. The intervention is free, easy, and could potentially have a large impact on how we perform resuscitations.

http://www.emsworld.com/article/12088616/heads-up-cpr

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 #1

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





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





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





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

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

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