FOANed Review #22

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

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



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

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

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

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






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

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

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

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

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

Weekly Review #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 #13

I quite like the EM in 5 site, they have brief, to the point tutorials discussing clinical topics. this week Anna Pickens discussed the assessment of chest pain, and ruling out the "deadly 6": Acute MI, pneumothorax, myocarditis/pericarditis/pericardial effusion, aortic dissection, and esophageal rupture. This post is a short video that starts by discussing a general approach to physical assessment and history taking, moves on to discussing the clinical features for each of the deadly differentials, and finishes with suggestions on diagnoses using cardinal findings, labs, and diagnostic imaging methods. I think this is a great review for nurses: it's clear, concise, and reviews foundational knowledge, well worth the 5 minutes.

http://emin5.com/2015/08/05/approach-to-chest-pain/




There was a nice review of managing asthma exacerbation by Anand Swaminathan posted simultaneously on both Core EM and REBEL EM this week. The post starts with a discussion of the epidemiology and pathophysiology of asthma exacerbation, discusses typical presentation features, reviews the fundamentals of medical management, and finishes with follow-up and discharge recommendations. This is a clear and concise review of the medications typically used for acute asthma exacerbations, their doses, mechanisms of action, and side effects. A great review for any nurse working in emergency.

http://coreem.net/core/basic-asthma-management/





Julie Miller published a review in Nursing 2015 of some dogmatic practices and controversies "sacred cows" of nursing practice. In this article she discusses the results of a 2356 nurse survey designed to assess nurses understanding of current best practices. This article is very readable, the content is presented as the original true/false question (as seen on the questionnaire), the percentage of responses as true/false, and a discussion of the correct answer with accompanying rationale and relevant research. This is a quick easy read, and the content reviewed is applicable to almost all fields of nursing. This is FOANed at it's finest!

http://journals.lww.com/nursing/Fulltext/2015/08000/20_questions__Evidence_based_practice_or_sacred.13.aspx

There are new NICE (National Institute for Health and Care Excellence) trauma guidelines out. St.Emlyn's provides links to the source documents: the full guidelines, key recommendations, and evidence behind the recommendations; as well as a brief synopsis of some of the recommendations. They strongly (thankfully) recommend against crystalloid fluids in actively hemorrhaging patients, endorse restrictive approaches to volume resuscitation, support early IO access, and TXA within 3 hours of injury. Well worth a read for all nurses working in Emergency/Trauma to keep abreast of current practice recommendations.


http://stemlynsblog.org/speak-up-nice-guidance-major-trauma/


St. Emyln's also had a two part review of the value of respiratory rate as a vital sign in the pediatric population. In these two posts Natalie May discusses a couple of articles that came out this month discussing raised respiratory rate in infants. She discusses and summarizes the key points discussed in the studies:

- Tachypnea can be a normal finding: Periodic breathing,
- That respiratory rate should be assessed using auscultation, and by listening for 60 seconds (In part two there's a great discussion about how terminal digit preference shows that we're not),
- Some tips on physical assessments and diagnostics to rule out life threatening processes,
- Suggestions on follow up once life threatening processes have been ruled out.

This is a great review, the source content is freely available, the review is succinct and highly applicable to nurses working in emergency, another great read.

http://stemlynsblog.org/jc-dont-write-off-the-respiratory-rate-1/

http://stemlynsblog.org/jc-dont-write-off-the-respiratory-rate-2/

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

Weekly Review #10

I listened to a podcast by Dr Jason Frank presented on the International Clinical Educator Network. The discussion reviewed an article on educational strategies to improve clinical reasoning. The article in question didn't discuss how they chose their strategies, or which strategies are most effective, so I don't think that the discussion can be appreciated in a meaningfully empirical manner. However there are strategies for teaching, and learning, covered in this podcast. The discuss focuses on 7 concepts of teaching:

Dual processing Model: The rapid interpretation of information through heuristics; and the slow analysis of novel information, with strategies to help learners switch between the two.

Conscious competence model: The movement from unconsciously incompetent to differing levels of competence. There is a great discussion about how peer learning, and how being able to remember being a new learner is a valuable tool for teachers.

Knowledge Organization: Different tools to structure knowledge of illness to typical presentations and the diagnoses.

Data Gathering and Data Processing: The use of standardized approaches and mnemonics to guide history taking and physical assessment, and how to filter through information to decide what information is pertinent to the clinical presentation.

Metacognition: Different ways to approach how you're reasoning through a clinical encounter.

This is a relatively quick podcast, the strategies for teaching are easily applied to learning. I think clinical reasoning is something that is continually perfected, and that there's something here for all learners.

http://icenetblog.royalcollege.ca/2015/07/10/keylime-89-clinical-reasoning-and-the-clinician-educator/

There was a study published in the BMJ by Lyle Moncur et al., that examined the correlation between the socio-economic deprivation of a neighborhood in which a cardiac arrest occured and the rate of bystander initiated CPR. Moncur et al., did this by examining all OHCA registered with the North East Cardiac Arrest Network to determine how often bystander CPR was initiated, and the neighborhood in which the arrest occurred. The address was referenced to the Office of National Statistics to determine the level of socio-economic deprivation of the neighborhood (1 most deprived; 5 least deprived). The team was then able to compare the rates of bystander CPR by socio-economic neighborhood. 

There were 3862 OHCA calls screened for this study, 683 were excluded because of missing data. What the team determined is that as economic deprivation increase, rates of bystander CPR decrease: they found that CPR was initiated by a bystander nearly 40% as often when it occurred in an affluent neighborhood. These results are sad, but they`re certainly not new. Similar studies were performed in the US and Asia, showing similar results: as poverty increases bystander CPR decreases, they also cited differences in racial composition of neighbourhoods as a possible factor for differences in rates of bystander CPR. This study however was performed in an ethnically homogeneous region (>95% white), on a homogeneous patient population (96% white); and as such they're able to exclude race as a confounding factor. The study doesn't attempt to explain why this relationship occurs, although lack of access to training was cited as a potential cause. From a nursing perspective this will likely not impact in-hospital care of poor patients; but it may suggest that targeting CPR education to poor neighborhoods could be an effective public health mandate. 

http://emj.bmj.com/content/early/2015/06/25/emermed-2015-204643.abstract

Justin Morgenstern from First10EM posted a review of managing patients with anaphylaxis. He starts with the obligatory cry of "give the IM Epi stat!": something that still takes on average way too long. Morgenstern then discusses some possible approaches to  manage both difficult airways, as well as patients with developing angioedema. There is a good review of shock, with some links to push dose mixing charts, management tips for special populations and a "Dirty Epi Drip" set up. This is a great review for nurses, as Morgenstern makes suggestions not only on medical practice; but also on priorities of care for nursing. Great to see FOAMed that includes the whole care team!

http://first10em.com/2015/07/20/anaphylaxis/#more-614

Dr. Rebecca Schroll et al., published a study in the Journal of Trauma Acute Care Surgery earlier this year that compared the outcomes of military and civilian patients who were treated with tourniquets by pre-hospital providers for extremity trauma. This study retrospectively examined the records of patients treated with pre-hospital tourniquets from 9 level one trauma centers in the US and compared them to a prospective military study examining patients treated pre-hospitally with tourniquets during the Iraq war.

Schroll et al., reviewed the charts of patients meeting inclusion criteria (>18 years old with extremity trauma treated by tourniquet) and examined them for mortality, effectiveness of tourniquet at controlling  hemorrhage, change in SBP after tourniquet application, and complication rates. 197 patients met the inclusion criteria; the average patient was a 39.4(±1.1) year old male (85.8%) with a penetrating injury (56.3%) and ISS of 11. Tourniquets were successful for controlling hemorrhage 88.8% of the time, the overall mortality rate was 3.0%, the average complication rate was 32.4%, with 18.3% of patients requiring amputation.

The results were then compared to a seminal study of combat application tourniquets in Iraq performed by Kragh et al., in 2009, to determine how civilian tourniquet use compared to military use. Schroll et al., determined that the use of tourniquets in the civilian context tended to have better outcomes than the group from the Iraq war study; with both mortality (3 vs. 11%), and amputation rates (18.8 vs 41.8%) being lower. These are impressive statistics, and would seem to suggest that tourniquet use for extremity trauma is safe. They're especially impressive considering that 20% of the patients in the Schroll et al., review were treated with improvised tourniquets that were either self or bystander applied, with "no difference in the incidence of other complications".

There are however a few claims made by the authors that I think are overstating the level of this evidence. The study design is weak: there was no control arm to compare outcomes against, there was no discussion on which commercial tourniquets were used, or the indications for using them. The patients in this cohort have drastically different mechanisms from the military cohort; all of whom had blast injuries, tended to be more severely injured, and were being treated in an austere environment (compared to a level one trauma center). The military cohort is also missing key information about limb injury severity and time to "definitive" care, limiting the extent to which the groups can be compared. The claim that improvised tourniquet use had comparable results with no difference in complication rates is also questionable. The that total tourniquet time for this subgroup is unknown, and that the group treated with non-purposed tourniquets had a three fold rate of ischemic/reperfusion injuries (3/40 [7.5%] vs. 4/157 [2.5%]). The suggestion that improvised tourniquets were safe and effective is contrary to previous observational studies that noted higher error rates, and the need for tightening or application of commercial tourniquets when improvised tourniquets were used (see weekly review 1).

I think this research is important, it's the largest of it's type in the civilian context, and in general I think that the evidence supports the use of tourniquets in the civilian context. I don't think that the patient populations were homogeneous enough for this research to be used as a comparison to the Baghdad study by Kragh et al., and would not attempt to extrapolate their findings to the civilian context. I would also disagree with the claim that improvised tourniquets are safe and effective, there were too few patients recruited to make that claim and the outcomes (though underpowered) actually show a three fold increase in risk.

From a nursing perspective I think that this is weak evidence showing that tourniquets are safe for extremity trauma in general. It also shows that a large number of patients will present with improvised tourniquets, and these will need to be assessed as venous only tourniquet can actually speed exsanguination.

http://www.ncbi.nlm.nih.gov/pubmed/26091308

Dr. Geoff Jara-Almonte posted a review of neonatal resuscitation on emDocs this week. He touched on the major steps and take home messages you could expect to learn from an NRP course. The post discusses some of the controversy around the need to intubate, the when and hows of meconium suctioning, and the FiO2 that should be used during resuscitation. There is a quick review of resuscitation drugs and doses, as well as methods for gaining vascular access (umbilical cannulation). This is a great review for any nurse working in the ED, it certainly won't replace an NRP course nothing will replace real time simulations using the kit; but it's a succinct review of the need to know points of neonatal resuscitation.

http://www.emdocs.net/neonatal-resuscitation/ 

Weekly Review #9

ScanCrit reviewed a case report of double sequential defibrillation (DSD) published in the journal of Prehospital Emergency Care. DSD is a process of hooking a patient up to two defibrillators and providing sequential shocks. In this particular case the patient had refractory V-Fib and had received 7 unsuccessful shocks with lead placement changes. The team performed DSD using the standard anterior/apex as well as anterior/posterior placements, with the deliver shock button pressed as close to simultaneously as possible. DSD converted the patient to sinus rhythm, who went on to survive to discharge. The exact mechanism of why DSD works when standard defibrillation has failed is not known, there haven't been any good quality trials performed to date; until that happens this care report is unlikely to significantly change current practice. DSD is an exciting concept: it's a novel approach, and one that can easily be deployed without expensive new equipment. This may not be a game changer in the management of refractory arrest, but it's at least one more tool.

http://www.scancrit.com/2015/07/07/one-two-punch/#more-8222




On July 8 & 9th I participated in the inaugural Eastern Association for the Surgery of Trauma (EAST) journal club discussion. It was on an study published the Journal of Trauma and Acute Care Surgery on the use of hemostatic foam in recently deceased cadavers. The study by Mesar et al., was attempting to determine what a safe dose of foam would be. Essentially the team wanted to extend their animal models to humans to determine how much intra-abdominal pressure, and internal organ contact would be made with differing volumes of injectable foam.




The study used recently deceased cadavers (146 minutes, ± 34min), added IV fluids to the abdominal cavity to mimic blood volume, and injected foam into the cavity. Intra-abdominal pressures (IAP) where monitored and the abdomen measured every minute for 15 minutes; after 15 minutes the foam was removed to evaluate the amount of contact with internal organs.

Of the 409 patients screened 21 were recruited, 18 met inclusion criteria, 3 of the patients were excluded from the final results due to errors in administering the foam. 4 cadavers received either 45, 55, or 65mls of intra-abdominal foam using one of two purpose built delivery systems. The foam quickly reached peak volume, the resulting increase in IAP fell below the maximum threshold of 65mmHg; while the cadaveers given larger doses exceeded the IAP cutoff.

After 15 minutes the Cadavers all successfully had the foam block removed, in one piece, by laprotomy. The contact with underlying organs was noted in each case, and the average contact areas was determined. Best coverage, unsurprisingly, occurred with larger doses, and the foam didn't absorb extra fluid.

The goal of this study was to determine what a "safe" dose of intra-abdominal foam would be, and it appears that doses of 65ml will generally fall below their IAP cutoff of 65mmHg. There are some limitations to this study: the sample size is quite small, and IAP results appear to vary significantly between cadavers receiving similar doses, making predictions on average IAP by dose would be difficult. The delivery system could also use improvement, of 18 attempts there were 3 (16%) errors, one of which resulted in accidental bowel perforation. From a clinical perspective I think that this technology still needs a fair bit of refining: there is no clearly articulated target population (injury mechanism). The intent is clearly hemorrhage control, but the foam is too superficial to access major vessels (which is fine, REBOA can do that), but it also has poor contact with solid organs at doses below the IAP cutoff.

From a nursing perspective I think that this technology is exciting, abdominal bleeds account for a large number of battlefield deaths, and any tools that can increase survival for these injuries is worth investigating. I'm looking forward to additional research on this technology, and would love to see if can be used in human trials.

The moderators at the EAST journal club did an excellent job. Responses to questions were generally rapid, and they were able to offer some additional information not explicitly stated in the research article. I look forward to the next journal club discussion, this and future reviews are on twitter at #EASTjc.

http://journals.lww.com/jtrauma/Fulltext/2015/07000/Human_dose_confirmation_for_self_expanding.6.aspx







Ryan Radecki from emlitofnote had a post reviewing the specificity and sensitivity of urinalysis for UTI in febrile pediatric patients. This is a 15 year 276 patient multicenter review of infants less than three months of age with fevers, bacteremia and UTI. The goal of the study was to determine how effective urinalysis as in predicting urinary tract infection. The results are surprisingly positive, as a predictive tool urinalysis is impressively accurate: 

• Trace or greater leukocyte esterase: 97.6% (94.5-99.2) sensitive and 93.9% (87.9-97.5) specific.
• Pyuria, >3 WBC/HPF: 96% (92.5-98.1) sensitive and 91.3% (84.6-95.6) specific.
• Pyuria or any LE: 99.5% (98.5-100) sensitive and 87.8% (80.4-93.2) specific.

These results are interesting because as a screening tool UA alone is generally not effective in adult or geriatric populations. All three of these are worth a review, as the differing conclusions offer an excellent case study in Bayesian statistics and determining likelihood ratios. From a nursing perspective having a non-invasive tool with high diagnostic power is great news, taking blood from an infant is traumatic for the care team, the parents, and most importantly the patient.  

http://www.emlitofnote.com/2015/07/the-utility-of-urinalysis-in-young.html

A new study published in Critical Care by Acheampong and Vincent examined the relationship between fluid balance and mortality in ICU patients admitted with sepsis. This study was a prospective observational study of 173 patients admitted to a single Belgian ICU for sepsis in 2012. Inclusion criteria were: patients >15 years of age, admitted to ICU >48hrs for sepsis. These patients were treated using the "surviving sepsis" guidelines. Total enteral/parenteral volumes were recorded against total sensible fluid loss to determine net fluid balance; there were 225 patients enrolled, 173 met inclusion criteria. Patients with a net positive fluid balance, or in septic shock were more likely to have poor outcomes. Overall ICU mortality rate was 34%, and the results suggest that positive fluid balance was associated with an increase in mortality (HR 1.014/ml/kg: 1.008-1.027, P<0.001). Non-surviving patients however tended to be sicker (SOFA score 9.0±3.3 vs 7.7±3.3), to be in septic shock (97 vs. 68%), and to have an infection of pulmonary origin (53 vs. 30%). There were significant differences between groups; unfortunately vital sign parameters, and rates of vasopressor use were not discussed, making it impossible to determine if the relationship between fluid balance and mortality is one of cause or effect. This was a small single center study with no control arm, we know the patients who didn't survive tended to be sicker, and to be in septic shock: they likely needed more fluids to maintain BP and likely had higher rates of vascular leakage and therefore fluid retention. This study does establish that positive fluid balance is prognostic of mortality, but we knew that, from a nursing perspective this study adds little to our understanding of sepsis, or fluid resuscitation.

http://www.ccforum.com/content/19/1/251




TamingtheSRU had a discussion posted on their site by Dr. Brian Burns from Sydney HEMS. Where he was discussed the concepts of marginal gains, or aggregation of gains, and how they can be used to improve pre-hospital patient care. The talk wasn't about medical or technical skills; rather it focused on different human factor aspects of self mastery. There were several methods reviewed, but the discussion focused primarily on tools such as cognitive offloading, cognitive buildups, and cognitive rally points. Dr. Burns emphasized the usefulness of simulation, not only for difficult skills that are seldom performed, but also for common skills that need constant practice, and how to perform common skills in uncommon scenarios. This is an excellent video for all clinicians, as a nurse it's great to see some of the best clinicians around discussing simple strategies such as visualization and checklists, strategies that everyone can use to improve their everyday performance, as well as their performance in critical moments.


http://www.tamingthesru.com/blog/prehospital-medicine/when-that-1-makes-all-the-difference