A nice friendly reminder from PULMCCM that we need to pay attention to infection control. Clean those stethoscopes! If you need guideance from the CDC, PULMCCM is kind enough to link to the 161 page study by the CDC on disinfecting guidelines. Seriously. 161 pages. I didn’t read it. But I will be paying more attention to making sure I grab those sani-cloths after every auscultation.
emDocs mentions the ANDROMEDA-SHOCK trial recently published last month in JAMA. This is a really interesting study in that it challenges something that we all seem to know is garbage in and garbage out to begin with – the 2016 Surviving Sepsis Guidelines. Anyone who has ever been forced to hang 30ccs per kilo on a patient who quite obviously doesn’t need it (god forbid we flow that much into someone who could be HARMED by it) knows intrinsically that these guidelines are flawed – even without a deep reading into the literature. to keep the conversation simple, lets just agree that the guidelines state that we should be flushing lactate because lactate is bad. Right? Well… maybe not. A great quote (from a damn great FOAMed resource for those that don’t have it saved on their reading list yet) is here from pulmccm.org: “Within the 2016 Surviving Sepsis Guidelines lies the following recommendation: ‘normalize lactate in patients with elevated lactate levels as a marker of tissue hypo-perfusion.’ This, however, is graded as a weak recommendation, low quality of evidence. Interestingly, buried within the text, the guideline authors declare – correctly – that ‘serum lactate is not a direct measure of tissue perfusion.’ Could there exist a better indicator of tissue starvation in septic shock?”
This is where the ANDROMEDA-SHOCK trial comes into play. You can read all about the possible ramifications of this trial here on emDocs. Can a simple capillary refill test be a better marker for treatment efficacy than serial serum lactate measurements? The answer is: probably. And this is important – because what is means is that we may be able to potentially use another tool/marker – and ditch the high volume fluid boluses used to flush lactate during sepsis treatment. I wonder when we will get a tie in from my favorite sepsis treatment protocol skeptic Dr. Paul Merik?
Another altered patient roles into the ED through the ambulance bay. Is it time to bust out my favorite ridiculous diagnostic acronym AEIOUTIPS? Let’s hope not – with upwards of 20 separate etiologies in the bedside diagnostic differential for that acronym, I find it worse than useless. But let’s pretend that I’m able to remember all 20+ possible diagnoses within that insane acronym – this article from emDocs focuses on hepatic encephalopathy. (Somewhere buried in the E portion of the acronym, if you were wondering.) Doctors Setareh Mohammadie and Amy Zeidan have a trove of wonderful information here about HE. Some of the clinical pearls include:
- One study showed that over 630,000 adults in the United States in 1999 had cirrhosis. “With sweeping epidemics of hepatitis C related to IVDU over the last decade, these numbers likely represent an underestimation of data for 2018 and beyond.”
- Early clinical signs of HE can be insidious and include small personality changes such as sleepiness, apathy and loss of inhibition.
- There is an entire paragraph on the use of ammonia levels and it’s use as a diagnostic criteria. This paragraph alone is worth a serious read. Suffice it to say that ammonia alone is a poor diagnostic tool for HE.
- The article stresses the importance of paying close attention to serum sodium levels and possible dehydration as precipitating factors to HE. There is a great breakdown of the pathophysiology behind both processes.
St-Emlyn’s talks about P-Values and what they mean. If you like to read medical trials and don’t pay attention to p values, you really need to listen to this lecture. This is a great little podcast. It is only about 11 minutes long – but it packs a real punch in that it can really hone your ability to figure out what literature can be useful in your nursing practice, and what is just “good enough” to publish – but not necessarily applicable to your clinical setting.
- Null hypotheses – states that there is no difference between two treatments. Testing the null hypothesis shows that there may actually be a difference.
- the magical value of 0.05 – why it matters and why it doesn’t.
- What is a fragility index? Why is this important in context of p values?
- Why statistical relevance isn’t as important as clinical relevance.
emlitofnote.com has a pretty good write up on fragility index here, as well as a good explanation as to why, perhaps, a lot of recommendations from the EM studies we see may not be implemented any time soon. The article on emlitofnote.com is in reference to this article in Annuls of Emergency Medicine which found that the average fragility index in 180 randomized EM trials was only 4. Ouch. For those of you that are bad with statistics (like me…), what this simply means is this: if you were to take 4 patients and switch their results in a trial, you would get the opposite result for the trial. Fragile indeed. To put this another way – lets say we have a trial testing whether a certain dose of Epi is helpful for hypotension. 400 pt are enrolled and make it into the trial. So n = 400. Lets say the trial shows that the dose of Epi is indeed effective – the p value is 0.05 but the fragility score is 1. That means that if only 1 of the 400 patients had a different result, the entire trail would have the opposite outcome. Fragility index is important specifically because it helps us look beyond p values.
EMCRIT podcast #241 goes over more on the ANDROMEDA-SHOCK trial as well as the CENSER trial. Scott Weingart always has a lot to say about sepsis treatments – his take on the ANDROMEDA-SHOCK trial is interesting, and his breakdown of the CENSER trial is pretty spot on. I always advocate for early pressor use in my sick sepsis patients – but let’s be honest – there is a lot of fuzziness out there concerning pressors in the ED for septic patients. Which one to use, how early, what dose, which patients really need it, does it decrease hospital stays, etc etc etc. The CENSER trial is great because it gives us a low-risk, one size fits all solution. Low dose norepinephrine for our sick ED septic shock patients (define shock as MAP <65 in this studies population) to reduce mortality. Sounds too good to be true? Take a listen and see what Scott says.
Just in case you were interested, more on the CENSER trial here at The Bottom Line. As usual with The Bottom Line, the “strengths and weaknesses” portion of the review are incredibly helpful – especially when concerning the clinical external validity of a single center trial done in a relatively low ICU resource hospital.
Also, this just in from our friends at ALiEM – you need to hug your EM residents and tell them that you love them more. Seriously though. Also, in the increasingly strange meta world of medical literature and publishing – ALiEM submitted their study to Annuls of Emergency Medicine and the FOAMed study was published in the print world.
Taming the SRU brings us possibly the most information packed article in the FOAMed pack this last month with their discussion of the CBC. While this article may send you down a wiki black hole in search for definitions of diseases and abbreviations you may not remember – it is truly amazing if only for the infographic put together by someone who deserves a round of beers from all of us who will be pouring over this graphic for the next few weeks. I would estimate that about 100% of the patients I grab labs on get a CBC. If you are like me and only do a cursory read of the results from this lab, this article is for you!
If you work in a trauma center and are familiar with REBOA usage you might be in store for a bit of a sea change when it comes to the paradigm behind REBOA usage. REBELEM shares a post on why REBOA utilization may be getting a fresh look. Zaf Qasim of University of Pennsylvania school of medicine writes about JAMAs article: “Nationwide Analysis of Resuscitative Endovascular Balloon Occlusion of the Aorta in Civilian Trauma”. The study’s conclusions may be sensational, but don’t just skim through. Read JAMAs article but make sure to then read Qasim’s careful analysis. Long story short here: “placement of REBOA in severely injured trauma patients was associated with higher mortality compared with a similar cohort of patients who did not undergo REBOA placement.” But, per usual, there is a lot of nuance that can be missed when one just reads through an abstract and then skims the conclusions. There are 8 separate bullet points in Qasim’s analysis of the JAMA article that are very worth a thorough read. Either way – if you use REBOA in your trauma bay, this is a great bit of FOAMed worth sharing.
The large amount of cancer patients we receive in the ED shouldn’t really surprise anyone – cancer is the second leading cause of death globally. But nursing school does a poor job of preparing us for these ED visits. There is an oncology section in every Med Surg nursing text, but when a renal cell carcinoma pt visits your ED, you aren’t going to be treating his RCC – you will most likely be emergently treating a disease process caused by his RCC treatment. This EMDOCS post is a great refresher for some of the more common cancer related emergencies we see in our EDs. Some interesting pearls:
- IDSA guidelines for febrile neutropenia
- Why your cancer pt presenting as an appendicitis pt may actually have necrotizing enterocolitis.
- SVC Syndrome and a pretty cool bedside test called the Pemberton’s sign
- Just in case AEIOU-TIPS wasn’t a long enough acronym for altered mental status, remember that the list increases with oncological emergencies to include: “CNS metastases, raised ICP, electrolyte disturbances such as hypercalcemia, medication side effects, and hyperviscosity syndrome”.
- Renal failure and Rasburicase – also when and what to look for in Tumor Lysis Syndrome
Don’t know the difference between a partial simple seizure and a partial complex seizure? Having trouble remembering whether to prep for EEG, EKG or NCHCT? Don’t worry. EMDOCS has reposted a great review from CoreEM. Simple algorithms, and even simpler hand drawn diagrams, can help you remember what is what. This is a worthwhile 5 minute read.
If you have a difficult time with endocrine patho (doesn’t everyone?) EMCRIT has published a new chapter in the Internet Book Of Critical Care that is perfect for you. Thryoid storm has a high mortality and high missed diagnosis rate. Review Josh Farkas’ new chapter and come prepared.
- Clinical presentation along with a list of precipitating factors
- Beta Blockers – why we need to proceed with caution. Also an interesting aside on the use of Esmolol vs Propanolol
- A great thyroid storm treatment checklist in order to check and see if you are educated about/prepared for multiple treatment modalities.
- Watch the attached video from EMin5 at the bottom of the IBCC chapter.
Rory Spiegel explains why we don’t need to work up every patient presenting in the ED for PE. Spitting in the eye of the results of the PESIT trial is fun, spitting in the eye of the results of the PESIT trial because there is better data published in Annuls of Emergency Medicine is more fun. So read this, and now you can shake your head in disbelief every time someone orders a CT on a well appearing patient who had an idiopathic syncopal episode – AND cite a good source as the reason you’re why you are shaking your head.
More on REBELEM on this particular subject here
Short and simple from ALiEM, Jennifer Rabjohns brings us a review on ETCO2 and why we should be using it during our resuscitation efforts. If you aren’t using ETCO2 you’re really missing the boat. This tool helps us shape care, manage airways, decide on efficacy of compressions, and even gives us information that is useful in deciding when to “call the code” in patients that aren’t responding well to resuscitation. Not that I think that AHA is right all the time, but this is a standard of care in resuscitation – and one that I think we can all get behind.
CanadiEM throws more shade at the AHA’s infatuation with post resuscitation “Targeted Temperature Management” or TTM. Formerly known as “Therapeutic Hypothermia”, TTM is what I can only guess is the AHAs attempt to put this intervention on life support while they desperately search for ANYTHING that bolsters their argument for its use over the last 15 years. TTM isn’t causing harm. So there is that. So I would never waste my breath arguing AGAINST TTM – but good evidence supporting its use across the board for EVERY ROSC patient? I’m still looking for something that gives me the aggressive optimism displayed by the AHA.
CORE EM via Michelle Romeo has a great review on Le Fort fractures for all you trauma junkies out there. Check out this article for:
- Visual anatomic break downs of the different Le Fort fractures (type I, II and III)
- Management criteria with some really interesting pearls (43.5% of Le Fort III fractures require tracheostomy!?)
So at first I wasn’t going to write anything about this. But First10EM was the third or fourth FOAMed site that I saw with a review on this the NEJM article Andexanet Alpha. This is a worthwhile read for a number of reasons:
- The tyranny of for profit medical publications in knowledge transfer bias is a worthwhile discussion for anyone interested in EBM. The democratizing effect of FOAMed knowledge transfer comes with its own downsides – but not acknowledging the implicit biases in the design of for-profit medical publications is worse than dangerous.
- Justin Morgenstern does a really fantastic job breaking down some of the interesting tricks that go into questionable medical science publishing. I refrain from calling it junk – but there is an argument to be made there as well. How do drug companies manage to publish trials that show great outcomes when there is no scientific evidence of a great outcome? Read this article and click on some of the hyperlinks to find out.
- A lot of these expensive reversal agents on the market seem to slip into use in the same manner as Andexanet. KCentra is another one of these drugs with great optics but questionable patient outcome applications. See Rory Spiegel’s opinions about KCentra here and here.
I’ve been doing ultra sound guided IVs for a couple of years now – and I can say from a lot of bedside experience that it is a safe and dependable way to get access on your “hard stick” patients. Dr. Salem Rezaie from R..E.B.E.L.EM has a pretty great review on the efficacy and use of this procedure here, and there are some really interesting point:
- Discussion of bevel up vs bevel down for USIV placement.
- Why we should, or maybe should not, be using tegederms as barriers for our US probes???
I know that this is supposed to be an early February FOAMed review, But Dr Anna Pickens put out a great EMin5 video about measles. And I think we all know that we need to be more vigilant now about potential measles patients in our EDs. Every time a parent trusts a washed up 90s quasi porn star pop culture icon more than they trust science, we end up with an unvaccinated experiment walking into our ED. Watch and learn – and remain vigilant in the face of idiocy.
- 90% transmission rates??
- Contagious droplets in air for up to 2 HOURS??? Incredible
- How to look for Koplic spots – (I didn’t even know what Koplic spots were before this 5 minute video)
In a review on emDocs Lloyd Tannanbaum explains the physiologic causes of widening pulse pressures and bradycardia in Cushing’s Triad. So if you want a quick review of Cushing’s (i.e. why increasing CO2 leads to a MAP increase and the baroreceptor response) this is a great 5 minute read. The article’s main topic isn’t Cushing’s Triad though – it is the ECG changes that one can expect to see when dealing with a patient experiencing increased ICP. Tannenbaum sites an article that shows up to 56% of patients experiencing increased ICP will have a variety of ECG changes including ST depression, QT prolongation and T-Wave inversions. There is also mention of increased troponin – so how do we differentiate between MI and cerebral hemorrhage? The article continues to explain and dives into an explanation on “Cerebral T-Waves”. Great references at the end of the write up, with links to more articles and ECG samples on the Life in the Fast Lane FOAMed site.
Charles Murchison doesn’t want you to keep using Sodium Bicarbonate. In his review on emDocs he breaks down the evidence for Sodium Bicarbonate’s use in fighting acidosis – and systematically argues against the drug’s efficacy. The physiology review is so interesting, I can say that this has been my favorite FOAMed article read in the past couple of weeks. Some very cool pearls –
- Acidosis may not need as much correcting as we think – arguments (with peer reviewed reference obviously) for why acidosis my help the body in crisis states.
- A step by step chemistry and physiology process of how NaHCO3 “fixes” acidosis – and why your metabolic acidosis will convert to a respiratory acidosis if NaHCO3 does it’s job correctly. He argues that if you can’t ventilate off the extra acid, as is the case in a typical cardiac resuscitation, the NaHCO3 may be futile.
- A direct pull from the article: “50 mL or 50 meq of 8.4% sodium bicarbonate – will raise the Na by 1.0 meq and increase ECV by 250 mL”. Yikes right?
- A quick literature review discusses why there is so little evidence to support sodium bicarbonate’s use during cardiac arrest.
It looks like St. Emlyn’s is commenting on the giant body of evidence questioning the efficacy of neuro-protective hypothermia. Dr. Dan Horner writes in St. Emlyn’s about JAMA’s POLAR trial – and the results aren’t really all that surprising. Simply put, POLAR is a high quality RCT (N=511) that shows no real difference in outcomes for patients that underwent hypothermic protocols post TBI vs those that were not subjected to cooling. If you are interested in studies that show the efficacy (or non-efficacy) of hypothermic treatments, this is an interesting read. Advocates of hypothermia are found in trauma, cardiology, resuscitology, neurology and all different kinds of “ology” – but at the end of the day it seems like recommendations for these treatments are based more on bench concepts and less on actual practical results. I’ll continue to keep an eye on hypothermia RCTs for post cardiac arrest patients – but as long as AHA pushes hypothermic protocols for every comatose ROSC patient, I’m sure we will continue to see these studies produced. As long as these studies aren’t showing that hypothermia is causing harm, I don’t think that we will see a huge push to ditch hypothermia-based protocols, but is this really an effective treatment? We will have to keep an eye out for more literature and how it affects our future treatment guidelines.
Total EM podcast #120 is all about tics and tic borne illnesses. If you like infectious disease, this Total EM podcast is a fascinating half hour discussion between Dr. Chip Lang and Dr. Michelle Perkins. If you don’t have time to listen there is a great write up here.
- Doxycycline is the antibiotic of choice for the majority of these tic-transmitted infections.
- Doxycycline is safe for use in children – all the tooth staining contraindications we learning about are true for tetracycline – but doxycycline is in the clear.
- Lyme and all of its controversy – including cardiac manifestations for lyme, which are really interesting. (Trigger warning for those of us who rail against “chronic lyme”)
- A quick discussion about tic-borne infection diagnostic labs
- Really thorough photographic entomology review for tics
Of note for those that wish to do a bit more of a “deep dive” for some of the AHA PALS basics out there – Total EM podcast #121 is dedicated to the emergent treatment of croup. Some really great info in here concerning risk stratification, when and when not to use epi, and why not every croup case is solvable by humidified air. This one is definitely worth a listen as we move into the croup season.
Dr. Josh Farkas adds another chapter in the Internet Book of Critical Care with something that everyone is familiar with – Hyperkalemia. We’ve all seen enough of these patients to know how serious they can be. But if you have worked in 5 different critical care areas, you have probably seen about 25 different ways to treat this potentially life threatening electrolyte imbalance. Listen to the 20 minute podcast for a great rundown of the IBCC chapter.
- EKG changes – what to expect and what NOT to expect. Why EKGs can help our prognostic/diagnostic outlook, but why we need a more holistic approach.
- Pseudo Hyper K / Iatrogenic (Including Heparin!) / extracellular acidosis DKA or HHS / cellular lysis / renal failure / RAS dysfunction
- a quick conversion about risk analysis for your hyperkalemia patients.
- Why kayexalate probably has no place in emergency care of hyperkalemia
- Why our NS vs LR dogma is harming our patients! Put the NS away and grab LR (or maybe isotonic bicarb drips!).
Dr Emily Roblee writes for Taming the SRU about preeclampsia in the ED. Any nurse who sits at triage will want to read this article from beginning to end. As Dr Roblee points out, preeclampsia is a “can’t miss” emergency – if we don’t catch preeclampsia we could contribute to significant increases in the patient’s mortality/morbidity. There are some really fantastic PDFs in this article that do a wonderful job of graphically simplifying the information presented. Among the pearls in this article –
- Wonderful breakdown of symptoms that should make us suspicious of preeclampsia at the triage station. It’s not all about the BP.
- A quick guide to differentiating between chronic hypertension of pregnancy: , gestational hypertension, preeclampsia and actual eclampsia
- A quick discussion about HELLP
- Lab work and a breakdown of the evidence behind the risk factors as shown on our lab results.
Ryan Radecki shares his thought on Emergency Medicine Literature of Note about the PREMVA trial. Bacterial Vaginosis is associated with premature labor. So treatment of early-detected BV should result in fewer pre term deliveries right? Apparently not. The full text from the Lancet website can be found here. Whether this changes practices across EDs or not is doubtful – but blind, prospective RCTs that test dogma are important for just this reason. A great commentary by Radecki and why these seemingly simple trails have such an important place in EBM.
Dr. Skyler Lentz shares his thoughts on emDocs concerning emergency airway support for patients presenting with respiratory distress due to pneumonia. In short, this is a great discussion (linked with citations) about when to consider the use of NiPPV (Non invasive positive pressure ventilations, i.e. BiPAP, or CPAP), intubation or HFNC (high flow nasal cannula).
Dr. Lentz explains his thoughts concerning HFNC as the first airway intervention in certain patients presenting ot the ED with acute respiratory distress due to suspected non-complicated pneumonia. There is evidence seems to indicate that HFNC leads to a decreased mortality in this particular patient population. This may seem like splitting hairs, but for anyone who has watched a patient struggle against a BiPAP machine, the idea of being able to switch out NiPPV for HFNC seems like a fantastic idea.
emDocs also has this review on insulin as a treatment for hyperkalemia. Thank you Kayvan Moussavi, PharmD and Scott Fitter, PharmD for a really well put together article! At first glance this looks like a pretty simple paper discussing dosing recommendations – but read carefully and you’ll see some VERY cool pearls. My favorite part of this review is that it purports to give a range for potassium depletion with the typical 10 units of insulin dose that most ED nurses are familiar with. Expect a drop of 0.6 to 1.2 mEq/1h with your boilerplate 10-unit dose. I’ve been looking for that number for about 6 months – so I’m super happy to have that number handy. You’ll also find some great warnings about insulin dosing and rebound hypoglycemia – especially in the ESRD patient. Expect the potential for hypoglycemia up to 6 hours, YES 6 HOURS, after insulin administration; and the probability of that rebound hypoglycemia occurring rises in our patients with poor kidney function.
Owner and editor in chief of St. Emlyn’s, Dr. Simon Carley, writes about the prospects for learning, mentoring, and continuing education while working in a busy ED. Anyone who works in a busy environment should read this article. If you work in an inner city ED, or any level 1 Trauma, you probably feel pretty overwhelmed most of the time. Unsafe patient ratios, stacked hallways, and double-digit hour wait times are all normal. But how is it that most of us end up walking away from these experiences with an educational net gain. We find ways to make it work – and we innovate informal ways to help mentor and teach each other. Dr. Carley gives us some great advice in this article – and better than advice, he actually shares some of his teaching techniques that he feels are perfect for busy EDs. Read, share and repost. This is one of the most inspiring things I’ve read in a long time.
EMCrit has a great podcast with Zack Shinar and Scott Weingart about the science behind our cardiac arrest interventions. This is a wonderful review of some of the most cutting edge science behind our more advanced intervention options (VF storm arrest algorithms and ECPR) as well as a very thorough “rethinking” of our pre-hospital treatment options and prognostic guidelines. Listen if resuscitation is your thing. Maybe listen twice if it isn’t. Among the great discussion points in the podcast and EMCrit write up are:
- Pre-hospital prognostication guidelines
- How to think about “no-flow” and “low-flow” times
- Discussions of programs with up to 40% survival rates on initiated ECPR!
- Perhaps a new way of thinking about asystolic arrests in the ED?
- Cost of quality adjusted life year with ECPR (or any ECMO) vs. other extremely expensive interventions for other diseases. An interesting “rationalization” of the cost of ECPR in inner city EDs.
Howard Greller writes about huffing (dusting, sniffing, etc) in a new Tox and Hound installment on EMCrit. When I was still a medic I used to pick up a lot of obtunded kids that huffed Dust-Off or other inhalants. Some of them went into cardiac arrest. Interestingly, our protocol was always to call poison control (1-800-222-1222 – if you don’t have that number memorized … well, there you have it!) and every time, EVERY SINLGE TIME, I was told to administer benzodiazepines. That probably didn’t help much and this article explains why.
- If you know your patient was “dusting” your patient has a chance of going into sudden cardiac arrest – and if they haven’t died yet, make sure you don’t give them the opportunity to experience a sudden catecholamine surge.
- Your huffing patient is less of a respiratory patient and probably more of a high risk cardiac patient – they need to be kept on a cardiac monitor at all times!
- Beta Blockers or Amiodarone might be a better idea than a Benzo
Dr. Amy Chung on CanadiEM has an article reviewing the possible ED visits nurses may encounter related to irAEs. You don’t know what irAEs are? Well, that’s okay. I’d never heard of anything referred to as an “irAE” either. But I have heard a little about Immune Checkpoint Inhibitors. And I have heard the names of drugs referred to as biologics and immunologics like: ipilimumab, nivolumab, pembrolizumab, atezolizumab, durvalumab.
This is a review on the toxilogical events that can be caused by a group of drugs that are so new to oncology that they haven’t even made their way into our nursing pharmacology text books. Take a gander and walk away with some pretty good pearls:
- unlike chemotherapy, which targets and destroys cells, these drugs proliferate immunologic responses – toxic events are going to be treated the same as an autoimmune flare-up.
- take a look at the three different types of Immune Checkpoint Inhibitors – and maybe even memorize which ones are more likely to cause irAEs.
- the article has a great table of common presentations or irAEs and even a chart that grades of severity of common symptoms – along with guidelines for probable treatments.
Dr Lauren Westafer speaks on the SGEM about more medical dogmalysis. (Podcast Link Here) There has been a lot of talk in the FOAMed community recently about contrast CT and related AKI. Every ED nurse I know has had at least one experience where he/she has had to wait bedside for a creatinine blood result before transporting a severely ill patient for much needed CTA. Suspected stroke but no access? Wait for the creat before CTA. Other examples abound. But it looks like we have been waiting for nothing. SGEM#234 is here with a really fantastic review of the newest evidence against CTA associated AKI. It can all be summed up here with the SGEM’s bottom line: “The risk of AKI from CT contrast is not as great as it was thought to be, and it might not even exist. The risk of missed or delayed diagnosis likely outweighs any from the exposure in a patient who requires a contrast CT study.”
Listen to the SGEM – and then try to convince the radiologists that we don’t need to wait for the creat before CTA!
Just a fun thing here from Taming the SRU – how to make paperclip eyelid retractors. Patient can’t open his/her eye and you can’t touch the orbit or lid because of pain response? Need to get a good glance at that globe? Just follow these instructions and you’ll have eyelid retractors in no time. Little learned skills like these can save us time in already stretched-thin EDs. They can also decrease patient morbidity. While everyone else is running around trying to find the misplaced ring cutter, you could be the one using string (I use iodoform gauze) to take off that ring. These random skills have a valued place in any nurse practice.
Christina Shenvi and Leah Hatfield write in Emergency Physician Monthly about Kratom – AKA: Thang, Kakuam, Thom, Ketum, Krypton, Ketum and Thom, among others. Never heard of it? Me neither – but it is a legal drug of abuse and has effects similar to opioids at high doses. With the opioid crisis in full swing, and with Kratom being known “on the streets” as a legal option/drug that can alleviate opioid withdrawal, we may be seeing some Kratom patients in our EDs.
Dr Selim Rezaie gives us more ammunition in the fight against Tamiflu. He presents three different studies that tackle the efficacy of Tamiflu – and as you can probably guess, the results are underwhelming. So again – unless your patient is very old, or very immunocompromised (or maybe you think they’ll just really enjoy diarrhea on top of their typical flu symptoms) Tamiflu is probably not worth the cost of the drug. Tell that to Roche – the company has made more than $18 billion off Tamiflu since they released the drug in 1999.
emDocs has a new Tox Card for pediatric ingestion of button batteries. I have always been told that these ingestions are dangerous, and need to be treated as potentially life threatening emergencies, but I think that this is the first real article I’ve ever come across on the subject. Some very good clinical pearls for nurses here including:
- What to expect at triage with initial presentation – some common signs and symptoms
- X-Ray findings (very cool “halo” or “double shadow” sign)
- Understanding that serious injury can occur in as little as 30 minutes and necrosis can occur in as little as 2 hours
- the potential dangers of co-ingestion with magnets
A great review if you ever triage pediatric patients, and/or you don’t already currently feel like you’re an expert on toxic sequelae of battery ingestion.
Brush up on the significant signs and symptoms that would increase your clinical suspicion (and nurse-led triage potential diagnosis) for compartment syndrome in this article from emDocs by Brit Long MD. We were all taught the “5 P’s” during nursing school – but a quick review shows that most of these signs are horrendously non-sensitive (13% to 19%), so going over lab values and alternative methods to solidify a clinical diagnosis is necessary. The article also goes over risk factors, advanced diagnostic techniques (probably left for the practitioners but some POCUS options are available for the braver and more comfortable bedside nurse), and some bedside management techniques such as affected limb placement and splint removal.
Most importantly Dr. Brit explains that this is a time sensitive surgical emergency. Mortality and morbidity increase drastically if the diagnosis is missed, with one study showing irreversible damage and tissue necrosis in up to 37% of cases after only 3 hours of symptom onset! The first person to suspect this diagnosis should be the triage or bedside nurse. Review the article to brush up on the basic signs, symptoms and risk factors.
Is that wide or is it narrow? Ventricular or supraventricular? This review by Lloyd Tannenbaum MD goes through a myriad of ways to differentiate between wide complex supraventricular aberrancies, versus true ventricular driven tachycardias. There are some great pointers in here, which include a very difficult EKG and case study from Dr. Amal Mattu (does he ever do easy EKGs?). The article walks you through the different diagnosis criteria step by step. But at the end of the day, this article is the same as the other thousand articles on this topic – until you get to the very end. So yeah… we slog through a half dozen incredibly complicated methods to differential SVT with aberrancies versus VT. Most of these methods I only half comprehend and, truthfully, don’t really see myself using at the bedside (maybe later in the break room I’ll steal some calipers and geek out). but then at the end of the article Dr. Tannenbaum shares an article published in 2010 by Brugade et al that shows that if RWPT (R Wave Peak Time) in lead II is over 0.050 seconds (basically a little bit more than 1 small box on your EKG strip) you have a high specificity for VT. Holy hell… this is why you have to read all the way to the end!
Ryan Radecki writes in Emergency Literature of Note about one of my favorite topics: surgery vs. antibiotics for acute appendicitis. If you aren’t familiar with the arguments against surgery for every acute appendicitis patient presenting in your ED, a quick GoogleFOAM search will really open your eyes to the controversy of the American mode of treatment. Anyway… JAMA recently published the 5 year follow up results of the APPAC trial (done in Finland) and the results are pretty interesting. Short but sweet: 40% of the patients that are sent home on antibiotics come back for surgery within 5 years. That sucks for the antibiotics proponents. Or does it? If you look at these results from a different angle – we just avoided surgery on 60% of our appendicitis patients. Really interesting commentary by Dr. Redecki.
EmCrit also wrote about the results here – with further amazing opinions and commentary from the ever-present Rory Spiegel. Rory correctly asks the question: “Are there specific markers that predict patients who will go on to fail medical management?” I would love to see someone retrospectively go back to the APPAC trial and see if it is possible to score the patients using the Alvarado Score for Acute Appendicitis. Do lower scores result in lower return surgical visits? Who wants to commit some time and help me do a retrospective look?
Josh Farkas writes for PulmCrit about using phenobarbital for acute alcohol withdrawal. Of all the Attendings I work with, I only know one that uses phenobarbital instead of benzodiazepines. After reading this article I wish everyone I worked with would ditch the benzos. Some great points in this article include:
- Without the benzodiazepines we can get rid of the ridiculously complicated CIWA-Ar scale and replace it with a very simple RASS (Richmond Agitation Sedation Scale)
- Phenobarbitol results in fewer unneeded intubations.
- We basically can’t overdose our patients with phenobarbital if we use common sense
We all need to take a moment in the next few weeks and take a look at the two “Tox and Hound” entries in EmCrit concerning synthetic cannabinoids. Anyone working in inner-city emergency medicine knows that we get a fair number of “K2” patients rolling through the doors. These patients are scary and unpredictable. The vast majority will be hallway MTFers and we will keep watch while they “metabolize to freedom”. But some of them die, and there is rarely anything we can do about it. Read here to learn about the history behind synthetic cannabinoids and why we probably won’t see a decrease in these patients for some time. Read here to learn about one of the scariest outcomes from a subset of these patients who may be smoking “super warfarins” and why we sometimes see massive hemorrhage in this population. Very interesting stuff.
Two things about this article from RESUS.ME. One – It is a fantastic break down on how to, and how not to, manipulate your patient’s arm when they have a humeral head IO placed. Two – this is the first post on one of my favorite FOAMed blogs since April, so I’m pretty excited. Hopefully we will have more from RESUS.ME soon.
So here is the result: you can abduct the arm and rotate the humeral head inferiorly (think “thumbs down”), but you cannot abduct and rotate anteriorly (think “stick ‘em up!”). There is a very cool video with IO placement on a cadaver and the results of the various patient shoulder manipulation techniques on IO placement, as well as the actual damage done to the IO needle when anterior rotation is combined with abduction. (Take a look at the literature review at the end of the article to get a glimpse at some of the cool articles published in journals on IO efficacy vs other types of peripheral access.)
Should nurses be taking off the c-collar in the triage area? According to Kevin Milne at the SGEM, the answer is a resounding “yes”. According to a study published by the Annuls of Emergency Medicine in Oct 2018 (full text available for free online), if nurses are properly trained to remove c-spine precautions, the chances of them inappropriately clearing c-spine is incredibly low. In fact, for this particular trial, the nurses under the microscope … ready for this?… “triage nurses removed 41% of immobilized patients’ collars and missed zero c-spine injuries.” That is incredible. The idea here is that triage nurse removal of inappropriate c-spine precautions can cut ED output and throughput times. Amazing idea right? The hyperlink will take you to the SGEM website, but the podcast is always worth a listen.
SMACC has a great podcast on the benefits of trying to practice evidence-based medicine, and why it is our best bet in the fight against medical mumbo-jumbo. Justin Morganstern (from First10EM) is the speaker – and if you go to the hyperlinked website above you can view the power point presentation along with the podcast if you want to follow along with the lecture. Listen if you want to hear an EBM take on why:
- pop media is a terrible source for medical information
- external validity is always something we should question
- meta-analysis can be garbage science
- there is an important distinction between false positives and over-diagnosis
Overall this is just a very entertaining 35 minutes of FOAMed podcasting brought to you by the SMACC team. This is definitely worth a listen.
Michael Misch writes for Emergency Medicine Cases and presents us with a critical patient suffering from a GI bleed. What’s the catch? The patient is utilizing an LVAD. LVAD cases are nightmare scenarios for most ED nurses to begin with – but what happens when your patient has an LVAD, but a chief complaint separate from the LVAD device itself? What’s worse than a nightmare? Night terror? I dunno.
This is a great article to read carefully and thoroughly. Lots of peals here for the ED nurse.
- How do we get a full set of reliable vitals (blood pressure anyone?) on a patient with an LVAD?
- Beyond assessing the patient – how do we assess the device?
- How LVAD pumps and medications that are necessary for life on an LVAD can affect your patient’s other acute emergency issues/diagnoses.
- The importance of POCUS in motoring fluid volume and resuscitation.
This is a really great read. Even if you feel comfortable with LVAD patients ask yourself this – do you feel comfortable being the primary emergency nurse with LVAD patients that have something else wrong with them other than the LVAD? If you work in a VAD center, you train and prepare to deal with LVAD patients presenting to you ED with cardiac issues or LVAD trouble shooting issues. But what about LVAD + Sepsis, or LVAD + GI bleed? Read and prepare!
R.E.B.E.L.em goes beyond the AHA PALS requirements and brings us an article summarizing the beside creation of the Epinephrine push for the hemodynamically unstable pediatric patient. We’ve all seen the BristoJet Epi taken out of the crash cart and used on a crashing patient. This technique is often used – 1 to 2 mL of 1:10,000 Epinephrine pushed as a stop-gap between the team noticing a falling BP and getting the formal adrenergic drip de-jour dialed in and working. But what to do for the crashing or post resuscitation pediatric patient?
So let’s go back to some nursing pediatric resuscitation basics here. Epi dose for peds is 0.01 mg per kg. Sure – we all know that (or at least we should). But how do we make the Epi push needed to bridge until we get our Epi drip dialed in for the crashing pediatric patient? You just need to create your own 10cc BristoJet of Epi in a dose that matches your pediatric patient’s weight! Read the article for more detail, but here is the meat and potatoes:
- Step 1 – get your pediatric resuscitation Epi push dose (the aforementioned 0.01 mg/kg) and draw it up into a 10cc syringe.
- Step 2 – dilute the dose with NS until the 10cc syringe is full.
- Step 3 – push 1 cc at a time for your crashing patient- the same as you would for an adult.
This is a really cool article that gets into a great and simple method of making emergent Epinephrine pushes bedside. The folks at R.E.B.E.L.em call this an Epi-Spritzer. (Apparently there are a lot of names circulating for this type of bedside Epi push.) Either way what ends up happening here is a 1mcg/kg push, 1 cc at a time, from a 10cc syringe – and there is evidence that this may be best practice. All of the evidence, of course, is outlined beautifully (with hyperlinks) in the article itself.
Rob Bryant writes for R.E.B.E.L.EM about the BICAR-ICU study published in Lancet this past July. The paucity on 8.4% Sodium Bicarbonate (BristoJet 50ml) pushes for critically ill patients is pretty amazing. We all understand the simple concept behind the bicarb push – but do we know the data? This is what FOAMed is all about -taking something we take for granted and putting it to the test of a literature review. Are we using best practice? If not – what can we do better?
BICAR-ICU illustrated some good results in favor of bicarb use with patients at risk for or suffering from AKI. Some interesting advice here for ED folks as well – especially concerning kidney injury patients, the cursory AKIN score, and which boarding ICU patients we may want to suggest, or not suggest, bicarb drips and pushes for. If you need a refresher on the AKIN score and why it is useful for ED/ICU nurses just visit this page on derangedphisology.com.
Total EM’s podcast #113 talks about which patients should get a head CT when they present with minor head trauma and endorse use of blood thinners. The podcast is a response to a new article published by the British Journal of Heamatolgy that shows some surprising numbers – this meta-analysis shows up to 11% of patients presenting to the ED with minor head trauma may have head bleeds if they are on blood thinners.
There are some obvious issues with the paper – there are over 10,000 studies that could have been used, and the authors chose only 4, the exact definition of “minor” head trauma is not easily agreed upon , Warfarin was probably over represented as the thinner most often used within the population, etc etc etc…. But the takeaways here are good and the numbers are similar to other studies that have been broken down on previous FOAMed sites such as here on R.E.B.E.L.em, and here on St Emlyn’s. Takeaways here include:
- We should probably be advocating for head CT in all patients on blood thinners that have even minor head trauma – even if the GCS is 15
- We now have some interesting numbers to back our recommendations if the patient is iffy about heading to CT
- Common rule-out scales for head CT might not work on this particular patient population. The Canadian Head CT/Trauma Injury (aka the CCHR – linked here on MDCalc) and the New Orleans Criteria (aka the NOC – linked here on MDCalc) are both not applicable because patients on blood thinners were excluded from the studies verifying the sensitivity and specificity of the rule-out criteria.
- Keep these numbers in mind when assigning triage levels to patients with even the most minor head trauma. Even if they present in no distress and an obvious AOx4 and GCS of 15 – it is probably a good idea to up-triage and to the team know what just walked into the waiting room.
First10EM is the site I’ve chosen to dive into the craziness set off by the SPLIT trial and the SMART trial. If you haven’t taken a look at these studies, you might as well click on the links (if you have access). But even if you’ve never heard of either of them, you are probably going to feel the effects if you work in an ED or ICU. I’ve mentioned before that you might start noticing LR replacing some of your typical NS orders. Well, these trials are probably the reason for the switch.
Justin Morgenstern breaks this review into two parts. IV fluid choice part 1: The SPLIT trial reviews a the SPLIT trial – a trial that compares NS with Plasma-Lyte 148. It’s a good review – and goes into detail on the strengths and weaknesses of the trial itself, as well as a thorough discussion of what, if any, conclusions we can come to that may effect treatment protocol within the ED.
The discussion really hits its stride when it gets to IV fluid choice part 2: The SMART trial. The SMART trial was published in the NEJM back in March of 2018. Since then it has caused a bit of a stir to say the least. But while most folks tend to think that this trial shows the evils of NS, Justin may be in the minority here by doing a bit of statistical regression. Some issues with the study as outlined within the article by First10EM:
- The study has a very high fragility score when placed into a fragility index calculator
- The p-value of the primary outcome is 0.04 – while acceptable it is anything but ideal within a discussion of something as important as fluid resuscitation standards
- The primary outcome p-value itself is potentially up for discussion (maybe?).
- The studies population selection seems strange – a quote from First10EM:
“Only half of these patients were admitted from the emergency department, so extrapolation to ED practice isn’t easy. I will also note that this seems like a very healthy group of ICU patients, with only ⅓ using mechanical ventilation, and only ¼ receiving a vasopressor. That doesn’t sounds like any ICU I have worked in. The amount of fluid used was tiny, and not in keeping with most ICU practice I have seen. I would not have expected to see a difference in outcomes from only a single liter of fluid. Would we have seen bigger differences if larger volumes of fluid were used? Or does the tiny amount of fluid used decrease the biologic plausibility of this finding?”
Either way, even if you are oblivious to the primary literature itself, the SPLIT trial will probably cause a bit of friction in the near future. You’ll be hanging NS and then cancelling it and changing it to LR and back and forth … I can’t wait for shift changes, so the new attending can switch everything up based on their strongly held beliefs for or against the outcomes of this trial.
The FOAMed site Emergency Medicine Literature of Note has a brief intro by Ryan Radecki on an article showing a correlation between Flouroquinolone use and aortic dissection. The study, from the Journal of the American College of Cardiology, shows that the connective tissue issues with Ciprofloxacin aren’t limited to the Achilles tendon. A short but interesting read. Patients endorsing Cipro use who comes in with tearing back pain will be bumped up a bit on my triage list from here on out.
EMCrit has a wonderful review concerning idiopathic VT. VT is not a single thing – there are multiple different sub-types. Despite what we are typically taught via our every-two-year-AHA-merit badge approach, the knowledge that VT isn’t a single monolithic diagnosis is important. Not everyone who is stable is going to be hooked up to the ACLS 150 mg of Amiodarone over 10 minute boiler plate treatment protocol. You might be giving electricity first. Or maybe Adenosine as a cure?
You should consider reading this article if you are
- A huge EKG nerd
- Fuzzy on the difference between “outflow tract” or “fascicular” ventricular tachycardias.
- Under the impression that Adenosine is never used on VT or think that Adenosine can always be used on VT.
- Wondering if there is a simplified (algorithmic) method of treating multiple subtypes of stable VT or if you need to be a cardiology fellow to figure this stuff out.
Josh Farkas writes for PulmCrit (EMCrit) discussing his thoughts about the IOTA trial, his overall opinion on the sanctity of the meta-analysis, and what it means to judge a trial’s fragility index. When the IOTA trial came out in late April it made a pretty big splash. The trial purported to show that conservative oxygen management was clinically superior (lower mortality) when compared to liberal oxygen administration during treatment of acute illness. Obviously a study that shows we need to ease off the O2 (ahem….. read: pay attention to exact amounts and titrate based on actual physiological needs) was bound to cause a stir. We have previously tended to treat oxygen (at least in the field of nursing) like drug seekers treat Dilauded – the more we up the dose, the better the patient is going to feel! But Farkas is adept at finding the weak spots in any analysis – even a meta-analysis. His write up is great, his conclusions are solid – and he may just have changed some minds as to the inviolability of the meta-analysis.
Rory Spiegel writes again in EMNerd (EMCrit) and gives us The Case of the Needless Imperative. This is another brief review of the literature being thrown around right now concerning airway management during cardiac arrest treatments (pre-hospital in many cases) and focuses on the results of the PART trial and the results of the AIRWAY-2 trial. Both of these articles have shown poor outcomes for the ETT cohorts and have certain airway purists foaming at the mouth. Dr. Spiegel has a pretty measured take on things and it is always nice to hear a respected experts opinion when new data looks like it may start to upset the status quo.
Dr Anand Swaminathan writes for CORE EM about Cauda Equina. Nothing mind-blowing here, but sometime simple is best! This is an important review if you haven’t thought about this differential in a while. All those patients who come in with sciatica and lower extremity pain/weakness need to be asked important differential questions regarding urinary frequency/incontinence. Take a look at the symptom specificity and sensitivity breakdown here, and dive into the review – especially if you haven’t thought about Cauda Equina since nursing school.
Podcast #110 from TotalEM gives us a good literature review on IO access and how the IO drawback can effect our lab values. This is a question that gets thrown around a lot in the critical care bay. “If I get this blood from the IO, can I still use it to send samples down to the lab?” Or, “Can we use this stuff in an iStat POC test?”
This TotalEM podcast references two articles concerning the IO lab results question. Both studies are small (the 2010 study N=10 and the 2017 study N=31), but show that certain lab values on samples drawn from IO are consistently inaccurate. Some of these lab values are vitally important, and may dictate certain emergent treatment protocols (think about elevated serum potassium from an IO in a cardiac arrest patient which would point a resuscitation team to hyperkalemic protocols.) This is a great read (or listen) for those interested in having a more detailed answer next time the question about lab values and IOs is asked.
St. Emlyn’s has my favorite post for this entire FOAMed review with an article by Simon Carley concerning fluid resuscitation. The St. Emlyn’s post is mainly a response to a recent article published in Nature by Simon Finfer, John Myburgh & Rinaldo Bellomo entitled Intravenous fluid therapy in critically ill adults. Simon Carley brings us face to face with one of our most profoundly misunderstood interventions: IV fluids. This has been one of my favorite reads in a long time. Some of the incredible gems within (or at least linked to) Carley’s article:
- Why “normal saline” is anything but normal
- A quick literature review that may explain why you’re giving more LR and less NS recently.
- Why “fill ‘em up and diurese them later” may be more harmful than previously thought.
- Discussion about “buffered salt solutions” vs NS – for a more detailed discussion about the possible benefits of buffered solutions look at the original article hyperlinked above.
All in all, this is a fantastic write up, and I think that it should probably be shared as much as possible amongst any nurse that hangs fluids (everyone, right?). The pathophysiology breakdown concerning hypovolemia and the possible interventions, and how those interventions can be monitored, is truly fascinating. As nurses, we probably give more saline than any other drug. Read this article (and print out and read the original research by Dr. Finfer) if you want to have a better understanding of what it is you are doing to your patient when you hang that liter!
Steve Mathieu writes a great review for The Bottom Line concerning the above mentioned AIRWAY-2 Trial. Per usual with The Bottom Line, there are some amazing PDFs breaking down the results of the trial in true medical algorithm style.
One of the things that I find interesting (and maybe I’m missing something here, so if someone can write back and explain I’d love the assistance) is the survival rate of the patients that received NO AIRWAY adjunct at all and only received BVM intervention. These patients had up to a 25.2% survival rating as compared to 6.4% in the highest survival rating group amongst the SGQ vs ETT groups. I must be reading this wrong. Either that or the obvious results here tell us that we need to ONLY be using BVMs in the field if we care about patient outcomes.
The EM@3AM series from emDocs brings us a review on Ludwig’s Angina. I’ve never had a patient present with Ludwig’s while working in my ED, but I’ve had a few that had symptoms that put Ludwig’s high on the immediate differential – and it is enough to make everyone in the room pretty nervous. If you aren’t familiar with Ludwig’s Angina, it’s presentation or sequelae, this is a great article for you. There is a review of the typical case presentation, as well as the pathophysiology behind that presentation. The biggest takeaway should be that Ludwig’s Angina = airway emergency!! Not only do we need to get the airway cart out and prep for probable RSI, a surgical airway kit needs to be ready. A fair number of these patients require emergent surgical airway management. The other surprise is the high mortality rate these patients experience if not recognized and treated early (while those that are treated properly have a less than 8% mortality).
There is a short reference list at the end of the article as well as a link to a Life In The Fast Lane article that was updated this May if you are interested in a deeper FOAMed dive into Ludwig’s Angina.
Another nerve block technique for migraine headaches? Yup! I don’t know if I will ever really see this technique being used, but new information is always good – even if you don’t think you’ll personally ever use it. Dr David Cisewski at Icahn School Mt Sinai writes about GONB (greater occipital nerve blocks) for pain control in migraines refractory to treatment with Metoclopramide. This study by Dr. Friedman shows that the technique potentially effective in controlling migraine pain – but the study is small (N=28), the intervention seems unlikely to gain traction (Bupivacaine injected around the occipital nerve with sono assistance unlikely unless we want to start shaving heads) especially in emergency departments, as the definition of migraine within the contexts of the study doesn’t necessarily match any particular emergency definition, or restraint on the treatment, of severe headache pain.
Whether you plan on recommending Dr. Freidman’s technique or not, the emDOCS review is a great bit of reading. Dr. Cisewski reviews a formal definition of migraine (something I needed to review for sure) and goes over some standard treatment protocol. It also has a short discussion on the pitfalls of Hydromorphone use for headaches during this modern era of narcotic abuse.
This reminds me of another cringe worthy treatment option for headache brought up in ALiEM back early in 2017. How bad does your head have to hurt to do this stuff?
Leave it to ALiEM to write about Betel Nut. If you don’t know what Betel Nut is, just clink on the hyperlink. I once responded to a patient with a chief complaint of syncopal episode – her husband told us that it was from chewing too much Betel Nut. We spent more time on Google trying to figure out what the heck he was talking about than we spent looking at the patient. Medically obscure as Betel Nut poisoning may be – it is always fun to learn something new.
Dr Evan Kuhl, Natalie Sullivan and David Yamane write for ALiEM concerning resuscitation of a drowning victim. It’s summer and everyones at the beach or in the pool. This review is necessary not only because of timing, it is good information for any resuscitation, ED or CC nurse. The patient presenting with drowning is full of medical truisms – most of which end up as falsehoods the second we reference the literature . Get rid of all the BS and pack in the facts. As they say in FOAMed: it is time for some dogmalysis. Here are some great pearls from this review:
- Dry drowning is not a thing. I repeat – DRY DROWNING DOESN’T EXIST!
- Salt water drowning vs pool water vs bathtub vs brackish??? Nope, nope, nope! Volume of water inhaled into the lungs matters – composition of the water does not seem to have an effect on outcome.
- Isn’t cold water better to drown in than warm water? No. Submersion time is more important to outcome than submersion temperature.
Dive into (ahem… sorry for the pun) this article and go deep with the literature review at the end. 13 articles for your FOAMed leisure.
It really isn’t a FOAMed review without something from CanadiEM right? So here is a write up from those crazy Canadians (and some folks at The Johns Hopkins) about a new paradigm in resuscitation medicine. Introducing the CPR coach during ACLS resuscitation.
The article outlines an interesting concept. Add another team role to the mix – a leader amongst the CPR team that is called the CPR coach. This team role is only responsible for managing the quality of CPR quality during resuscitation. The idea is that the Team Leader can focus on ALS, complex procedures and Hs and Ts, while the CPR coach can focus on fixing our almost universally abysmal numbers related to compression depth, compression fraction, breathing rates, time-off-chest percentages etc etc etc. Some very interesting results in these preliminary studies. Definitely worth a read for those of us interested in resuscitation medicine.
Dr Anand Swaminathan was busy this last month. Not only did he do a quick review of Cauda Equina for CORE EM, but on R.E.B.E.L. EM, he also gets into the controversial results of the recent PRISMS study comparing Alteplase to Aspirin in mild stroke. In his review of this article, Dr. Swaminathan goes back to the results of the NINDS studies that ushered in the modern era of Alteplase use in stroke care. If you aren’t familiar with NINDS, and if you aren’t familiar with the controversy concerning Alteplase, you MUST read this article. While most cursory reviews of the PRISMS trial tend to lean towards Alteplase as the safe method of treatment, R.E.B.E.L. EM puts the onus of proof back on the advocates of Alteplase when he states that multitude of reasons why Alteplase is not necessarily the miracle drug it is treated as within certain circles. Read the review and ask yourself – “If I were having a mild stroke would I want Alteplase or Aspirin? It isn’t as easy a question to answer as some would have you think.
Taming the Sru has a quick review on ED diagnosis of Necrotizing Fasciitis. I’ll be the first to admit that dermatology isn’t my strong suit. But knowing that these patients have a high mortality morbidity, and that nurses are the front line for triaging the vast majority of these patients, I really think that any ED nurse could benefit from reading this review.
One great aspect of this article is the breakdown of the fragility of the LRINEC score system for diagnosis in the ED. Long story short – if you have this score saved under your MDCalc page, you might as well ditch it. The sensitivity is just too low for such a high risk diagnosis. So read the article and find out what to look for. Early recognition and treatment results in better outcomes for these patients! If you have a high index of suspicion for this diagnosis, it might be time to up-triage the patient or ask for a physician consult in the triage area.
Dr Benoit from Taming the SRU gives us a list of his top “practice-changing” articles for 2017-2018 in the “grand-rounds recap” series. An awesome line up of some really great articles for anyone who is interested in critical care or emergency medicine. Every article listed is conveniently hyperlinked to publication sites. So if you are in a med lit sort of a mood, email this link to yourself and get to your nearest medical library and do some reading. This might be the best power line-up of medical literature you’re going to see for a while. Some highlights:
- Effect of treatment delay on the effectiveness and safety of antifibrinolytics in acute severe haemorrhage: a meta-analysis of individual patient-level data from 40 138 bleeding patients
- Effect of Use of a Bougie vs. Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients With Difficult Airways Undergoing emergency Intubation
- Prevalence of Pulmonary Embolism in Patients With Syncope
- Mortality and morbidity in acutely ill adults treated with liberal versus conservative oxygen therapy (IOTA): a systematic review and meta-analysis
Dr Rick Body writes this article for St Emlyn’s about a vitamin supplement that could be giving us false negatives on our Troponin tests. Apparently Biotin (aka vitamin B7) supplementation can affect specific POC and laboratory Troponin tests. The article points out the up to 7.7% of American patients may be taking supplemental Biotin (probably for hair and nail growth – even though there is apparently no good evidence that Biotin works to correct these ailments). The article contains an exhaustive list of the specific Troponin assay tests that Biotin can affect. It’s an interesting read that makes me think perhaps nurses need to start asking about Biotin supplementation prior to pulling troponin immunoassay labs.
St Emlyn’s also has a short bit on some of their contributor’s favorite apps. I love sharing quality learning apps, so I have to share this link. These apps are supposed to be “new” – but looking at release dates, many of them have been out for a long time. Among those of real interest to me are the POCUS apps available. Some are free and some are expensive – but definitely worth a browse for anyone interested in a quick FOAMed diversion on their phone while standing in line at Starbucks.
emDocs has an incredible write up by Paul Zentko with some great clinical pearls on psychiatric medications in the ED. Some pretty eye opening numbers pertaining to psych meds contained within this article, such as: up to 1 in 6 adult adults in the US fill a psych med prescription at some point in the year, and up to 10% of ED visits due to adverse drug reactions are related to psychiatric medications. It is a short article but does a great job going through a relatively thorough review of:
- A quick SSRI med review – names, prevalence in the general population and discussion of relative safety and overdose concerns.
- Notes on the relative dangers of citalopram and escitalopram concerning seizure activity and EKG changes.
- Links to a wonderful and super helpful tox card on the differences between Neuroleptic Malignant Syndrome and Serotonin Syndrome
- Abrupt discontinuation leading to “discontinuation symptoms”
- Discussion of narrow therapeutic index and treatment considerations for acute v chronic overdose
- nice overview of lithium excretion/metabolism
- Typical v Atypical Antipsychotics
- Lists of common medications in these classes
- Good review of EKG changes to expect and what risks these medications can pose for our ED patients.
- Overdose treatment protocols
Another awesome aspect of this article is the to Dr Katy Hanson’s website. Check out her drawing at the bottom of the article with all the different psychiatric medications and tell me if you can think of a better way to learn these drugs!? Without her drawings I would have had to do a lot more dry and boring studying to get through anatomy and physiology. If you haven’t checked out her page yet you really should.
Dr Josh Farkas writes in PulmCrit about the use of BP monitoring in septic patients on vasoconstrictors. While this article at first appears to be only geared towards critical care docs, we need to take a moment and see how it can be applied to those of us (doctors and nurses) that work in an ED setting. Even if this literature review doesn’t change practice, we should all be aware of the information broken down in the review. Nurses caring for patients on pressors must be made to understand that there can be a propensity to over dose on pressors if radial sites are being used instead of femoral sites for arterial blood pressure monitoring. Read the article to understand the difference in accuracy between non-invasive BP monitoring and what the available literature tells us about the difference between radial and femoral arterial BP MAP monitoring when the patient is on pressors. Per usual with EMCrit, there is a phenomenal breakdown of the available high-quality data, a simple discussion of why this data may change our understanding and approach to invasive blood pressure monitoring, and then a recommendation for future practice.
Dr Sean Hickey writes this about TAPSE (a POCUS test called tricuspid annular plane systolic excursion) for PE risk assessment and prognostic considerations. It seems like an easy enough bedside test for anyone who has gone through a ultrasound course/fellowship. I like this article’s timing because it ties in so well with the thorough review of PE published in Emergency Medicine Cases that I have tagged in this same FOAM review. (Thank you EMCrit for the sources cited list – about 50 articles long here if you want to dive super deep into TAPSE tests.)
CanadiEM adds to their “Blood & Clots Series” with this article discussing PE diagnosis in late stage pregnancy. Dr. Eric Tseng writes about these main takeaways from the current literature that we need to be aware of:
- Wells Score and D-Dimer are not predictive within the pregnant population (at least not yet as there have been no published studies confirming utility) so we cannot be effectively utilizing those prognostic tools on these patients.
- Recommendation to use bilateral compression ultrasound as a precursor to V/Q and/or CT-PA as if the ultrasound comes back positive, treatment is the same.
- According to the literature sites in this article, both V/Q and CT-PA are deemed safe (sub-teratogenic) for pregnant patients.
Paula Sneath is a PGY1 that wrote a great piece on esophageal foreign body obstructions. Nothing mind-blowing here, but a great review of the anatomy, patient population, and possible negative sequelae on patients presenting to the ED with EFBOs. A couple of very interesting points:
- A quick discussion on Glucagon for these patients – to administer or not to administer, this is the question still apparently. Rosen’s says no, other sources are still clinging to weak evidence despite the known side effect of vomiting which can take this patient from bad to worse.
- A rundown on upper EFBO removal with a Foley catheter. Which, if I’m going to be honest, I am going to bring up EVERY time I see a upper EFBO from now on. Forever. I can’t wait to see someone shove a Foley down an esophagus, inflate it, and slowly pull up a meat bolus.
Dr Joseph Levin, a PGY4 at Bellevue writes for R.E.B.E.L.em about C-spine clearance in the ED for ETOH patients. this is a short but sweet review on this article from the Journal of Trauma and Acute Care Surgery. Among the interesting pearls:
- Not that it is highlighted – but the numbers seem to indicate that ETOH and illicit drug intoxication c-spine injuries are 2x that of ETOH alone. An interesting find when looking at the injury rates among different patient populations.
- This conclusion: “For intoxicated patients with a negative cervical spine CT, there appears to be little benefit to maintaining prolonged immobilization unless there is an obvious neurological deficit or high degree of suspicion for cord injury. This is consistent with previous literature in CT performance in obtunded patients.”
R.E.B.E.L.em also wrote a quick review on HFNC (high flow nasal cannula) for those that aren’t quite familiar with this wonderful tool. We are starting to see this used more and more in adult EDs across the country – as nurses we need to get used to the idea that HFNC is a tool we are going to need to be comfortable with. This hyperlink above is only the first part of the article – and reviews the functionality of HFNC and not it’s use in treatments. Stay tuned for “part 2”.
Dr Anton Helmen of Emergency Medicine Cases writes an incredibly thorough article on diagnosing PE in the Emergency Department. (There is a podcast to go with this article, which I will try to review later – but clear 93 minutes out of your schedule if you are interested in listening.) This article is thorough, specific and has loads of great hyperlinks to other opinions, articles and websites – backing up all the recommendations with well known studies and really taking a deep dive into the numbers that we should all be aware of. If you have the time to spend, this is a great review of diagnosis and treatment and care of PE in the ED.
- Mortality rates and, in my opinion, the absolutely terrifying finding that “85% of PE mortality in ED patients occurred in untreated patients while waiting for diagnostic confirmation according to EMPEROR Registry.”
- A high quality pearl on how to parse out true exertional dyspnea.
- A logical an no BS approach to how we should implement the PESIT trial (Syncope and PE in the ED). (Basically: we should be treating chief complaint of syncope like we do everyone else when considering or ruling out possible PE.)
- 50% of PEs are found in patients with no 0 Wells’ Score.
- A quick EKG rundown talking about the lack of sensitivity of S1Q3T3 and reminding us to look for inverted T waves anterior and inferior leads as this is the most specific finding on an EKG.
ALiEM brings us a great overview of maternal cardiac arrest. This article also comes with a link to ALiEM Cards on the same material. If you have never browsed the ALiEM Cards before – they are amazing and definitely worth your time. Articles such as this are always appreciated – any lesson on resuscitation that goes beyond the typical AHA ACLS course is worth a mention. Some really great takeaways here include:
- A great list of common causes of maternal cardiac arrest.
- How to anticipate potential magnesium and calcium based pharmacological treatment of arresting maternal patients.
- Recommendations of IO access above the diaphragm!
- Knowing to expect immediate C-section if ROSC is not within only 2 rounds of CPR.
- Intralipid use guidelines for patients with arrest after potential anesthetic toxicity.
A couple of very good FOAM sites have write ups on Morphine use in acute heart failure. Dr James Fletcher guest writes for R.E.B.E.L. EM on this post. The post references this article, a multicenter, observational, propensity matched cohort study, that compares mortality rates among two groups of acute heart failure patients – those that received Morphine and those that did not. There are some issues with the study, all of which are thoroughly discussed within the article written by Dr. Fletcher. There are also a few other studies mentioned that link Morphine with increased mortality in patients who present with acute heart failure.
One of the best takeaways from this review is this small segment: “The European Society of Cardiology guidelines on the treatment of heart failure recommend against the routine use of opiates, while the American Heart Association recommends opiate use in heart failure be limited to the palliative care of patients with end-stage HF and severe respiratory distress.” As a nurse, we sometimes find ourselves turning to Morphine for AHF patients, and sometimes not. This article can help us understand what our physicians are thinking.
emDocs did a similar article, but with a bit wider scope. Entitled Myths in Heart Failure: Part II – ED Management, this article is less of a single article review, and more of a case study about patients presenting to an emergency department with acute heart failure with concurrent hypertension. This emDocs article reiterates the lesson from R.E.B.E.L. EM about Morphine potentially increasing mortality for AHF patients, but there is also an incredibly thorough list of clinical pearls for AHF with hypertension such as: guidelines for diuresis, use of nitroglycerine, the aforementioned consideration of opioids, and a very cool bit on ultrafiltration for patients refractory to front line diuresis treatment. (This is the second part of a series from emDocs, the first in the series, an article called Myths in Heart Failure: Part I – ED Evaluation was published in late July and is definitely worth a look.)
A very prescient article concerning pain management from Annuls Of Emergency Medicine has sparked some chatter on emDOCS.net. Anyone who still works in an ED that is handing out Dilaudid like candy knows that we are contributing in our own way to the opioid epidemic. emDOCS.net shares a great article by Doctor Casey Wilson on nerve blocks on their use in emergency departments for the control of pain. (If you don’t have access to Annuls of Emergency Medicine there is a great podcast that gives you a quite thorough roundup here.) According to Dr. Wilson nerve blocks can be used for “fractures, joint reductions, complex laceration repairs, chest tube placements and paraphimosis” and have been shown to be even better than opioids for some older patients with femur fractures. Not that I wish any nurse to be flooded with paraphimosis cases – but the article is pretty cool in that it explains the simplicity of ultrasound guided nerve block procedures while providing readers with some great PDFs. Another really interesting point, especially for those wanting to increase throughput in the ED, references (small) study done in 2008 in the American Journal of Emergency Medicine which showed ultrasound guided nerve blocks for upper extremity injury actually reduced the average length of stay in the ED by 3 hours! A very cool share and worth a link to your Sono Fellowship director.
CoreEM brings us a great review on Acetaminophen overdose written by Dr. Magda Robak. This is a simple but effective teaching module for anyone who wants to review the most common single cause of acute liver failure in the US. The article reviews the Acetaminophen nomogram and also shares a simple but fantastic spreadsheet that I think can be very useful, especially for nursing triage and early nursing care:
Justin Morgenstern writes for First10EM and shares with us a case study on post tonsillectomy hemorrhage. This is one of those great FOAM articles that really packs a huge punch. First10EM takes a patient that seems simple enough – a potentially severe oropharyngeal bleed – and takes a quick, but incredibly thorough dive, into treatment considerations in the ED. There is a lot here for the ED nurse to unpack. Some highlights from this article include:
- Simple positioning of the patient makes a huge difference in management in the first minutes of patient care.
- This patient may need a blood transfusion! IV Tranexamic acid may be called for, but surprisingly DDAVP can also be empirically used, as undiagnosed Von Willebrand disease is apparently somewhat common in these patients.
- To use an NG tube or not to use an NG tube – a great discussion between two ED docs.
- Stop the bleeding is the name of the game – but what to do first? Try direct pressure with McGill’s forceps, or stick your fingers in the mouth and try to apply direct pressure with some gauze soaked in tranexamic acid and DDAVP? If none of those options work, or if they are not plausible, should we try to apply pressure to the carotid?
- Intubation considerations, and which drugs might need to be prepped for induction.
- Simple recommendations are sometimes the most amazing – while we are all running around focusing on stopping the bleed, make sure you don’t forget to recommend antiemetics! The patient has probably swallowed a lot of blood and an episode of violent emesis can destroy any clot that is beginning to form, so make sure to remember that the patient needs a hefty dose of antiemetics.
The Bottom Line writes a critical review of the PAMPer paper that was published in late July by NEJM. This trial aimed to find a difference in survivability between air transported trauma patients that received either fluid crystalloid boluses, or plasma. This Bottom Line post outlines the strengths and weaknesses of the PAMPer trial, as well as a short review of other similar trials, and why PAMPer is potentially so impactful. The paper showed a significant increase in survivability in the plasma group, as compared to severe trauma patients who received fluid crystalloids only. The study shows a 10% drop in mortality with an intervention of 600cc of thawed plasma. This mortality drop is so dramatic for such a slight intervention change, that there is a portion in The Bottom Line review that states the “biological plausibility” is questionable, which seems to be a nice way of saying that there are probably biases within the study that partially explain the survivability differences.
Either way, the PAMPer trial in NEJM, and The Bottom Line’s review of the article, are great reads for anyone who works air emergency treatment and/or Level 1 trauma medicine. We’ve known for some time that flooding patients suffering from hemorrhagic shock with NS increases our coagulopathy, acidosis (NS has a pH of approx. 5.5) and (unless the fluid is warmed) the likelihood of hypothermia. Treatment for traumatic hypovolemia that shoves the patient into the “trauma triad” should probably be avoided – so expect more trials like PAMPer and, hopefully, a change in paradigm in pre-hospital treatment for hemorrhagic shock patients.
Kristina Kipp writes for EMCrit to bring us a short review on an article that discusses the efficacy differences between Propanolol v Metoprolol in electrical storm arrests. This article from the Journal of American College of Cardiology is another piece of literature we can add to our arsenal of emerging information concerning electrical storm arrest patients. If you haven’t worked an electrical storm arrest resuscitation, this is a great article to get a glimpse at what may be different than a typical ACLS code. If you have worked an electrical storm resuscitation, read this article to see if your resuscitation team is following the newest recommendations in this emerging sub-class of VF or VT arrest. There is a great list of references at the end of the EMCrit article that is worth a review as well.
The first time I’d ever read about beta blockers during cardiac arrest was in CanadiEM almost a year ago. The infographics in the CanadiEM article are really fantastic and outline the basics of the pathophysiological logic that is applied to electrical storm arrests and why these particular resuscitations are so much different than our typical AHA ACLS boilerplate codes.
Not that this is typical FOAM sharing but – just wanted to link an incredible article from MSF on America’s attempt to ignore evidence-based practice and obliterate global women’s health access. The “Global Gag Rule” will link the funding of HIV treatment, tuberculosis programs, mother and child care, and other global health initiatives to regressive and morally bankrupt dogma. Read here to learn more about the view from the ground. https://www.doctorswithoutborders.org/new-global-gag-rule-more-dangerous-ever
AHA Every Two Years
I have been an AHA instructor for about 4 years now. I can honestly say that most days I love to teach, but like most people, I have certain groups that I prefer. My favorite classes tend to be heavy with advanced practitioners and doctors – oh, and I love teaching residents. AHA material can get dry after a while, but a great practitioner can be a walking and talking reference manual for my recertification courses; full of facts, able to cite pertinent studies from memory and, at least in my experience, most are willing to drop some awesome pearls for the benefit of the other members of the class.
But not all classes are a pleasure to teach. Recently I taught a PALS class that didn’t go so well. One of my favorite EM docs had a group of 3rd year residents that required a short notice recertification. A multitude of factors made this class less than ideal, but the attending and the training center both bent over backwards to accommodate the graduating residents. Let’s just say that it was a less than positive experience. The only question during the class was “how long is this going to take?”. The students chatted through the video material, generally tried their hardest to not pay attention, and engaged in such loud side conversations during lecture that I had to ask them to stop multiple times. It was, to say the least, a very disappointing class.
But here is the thing: I get it. Doctors spend residency being grilled and challenged and tested and pushed. These particular residents have studied under incredible doctors and have done rotations at one of nation’s leading children’s hospitals. They are eager to move on to new attending jobs, they are exhausted from years of outrageous study, and have (nearly) completed the almost super-human task of becoming a licensed physician in the US. Beyond their level of training and preparedness, there is also the fact that AHA courses are, unfortunately, just another merit badge class. Hospitals use these courses to create the convenient situation where the hospital can outsource provider training and therefore all liability and responsibility. Why spend time and money investing in staff education and training when the AHA gives out these fancy cards? I get it – it can really feel silly taking
So why in HELL do my outrageously overqualified doctors need to take ACLS and PALS? Who thinks this is a good use of time?I’ve created a checklist. It isn’t exhaustive and it’s just my opinion, but if you are a graduating resident, or even an attending, and you can only be dragged kicking and screaming in order to recertify PALS or ACLS, perhaps this list might help put these AHA classes in a different perspective.
#4 – You Know What They Say About Assumptions…
I love my residents. They are smart. They are incredibly motivated. And most of all they tend to have a sincere passion for medicine. But not every doctor I’ve ever recertified has been well rounded. I wish I could say that docs don’t need this stuff, but unfortunately there are some attendings out there that haven’t really studied this material in years. I’ve been in codes with docs who do some downright goofy stuff. I’ve had residents shoot me incredulous looks while we try to pace asystole or take 5 minutes to sono a coding patients heart – all under the orders of an attending. So no, we can’t assume doctors are proficient in AHA standards and you can’t skip the class – even doctors should be reminded of the ECC standard every two years.
#3 – Sharing Is Caring
This is especially important if you are one of the few, or the only, doctor in the classroom. Not everyone has your education, knowledge and experience. Please be a positive resource to the rest of the class! As mentioned earlier, the AHA material can get pretty dry. If you have a good story that pertains to the information being taught, please chime in. Some of the best and most memorable teaching moments have come from doctors telling the class how something works, or doesn’t work. Assist the instructors with some of the material – for crying out loud help make this stuff interesting! You have better stories than us. Please share and make this a great educational experience for everyone.
#2 – Times They Are a-Changin’
The AHA guidelines are updated every 5 years. But our field changes daily. This is a fantastic opportunity to sit down with your fellow doctors and review basic guidelines. If the guidelines are similar to your practice than great! Let’s discuss the evidence in support of the AHA benchmarks, and even better, lets discuss why we don’t do what we may have done in the past. But sometimes things change faster than the AHA can keep up with. Pediatric therapeutic hypothermia anyone? Why or why not? Antibiotics for pediatric sepsis? But of course – but what cocktail are you using? How much, at what point, and what are the other options? These classes are an incredible opportunity to hone your skills. The resident class I taught argued with the PALS recommendation for fluid resuscitation for pediatric cardiogenic shock. One of the students went so far as to say that fluid was stupid and that dopamine was the only serious option. Maybe that is true, but maybe there are other opinions in the room. Is there controversy right now about dopamine versus norepinephrine in shock patients?* If you are too busy proving you are too smart for the AHA course material, we won’t ever get to opportunity to have some pretty important discussions.
#1 – It’s Not All About You
This is the most important thing to remember: the standards set forth by the AHA may seem simple, pedantic, or even incorrect to your well-educated medical mind, but this is what all of your nurses, NPs, and PAs know as gospel! Your education and experience doesn’t mean you’re beyond AHA standard – it actually means you are responsible for the entire resuscitation team’s grasp on the AHA standards. Stop recertifying AHA courses with the idea that the instructor is only here to test you out on your skills. You’re an attending. You think I’m impressed that you know that ventricular fibrillation needs defibrillation? Of course not. Take this recertification course as an opportunity to sit down and think about your team. This isn’t an 8-hour recertification class for you – this is a course where you get to familiarize yourself with your staff’s training standards. I know these classes may seem pedantic to you, but this might be the most cutting edge resuscitation science your nursing staff has ever been exposed to. Don’t like what you see? Fantastic! Ask me why the AHA isn’t talking about dual sequential defibrillation for VF electrical storm. Ask me about ECPR. Let us discuss where the AHA gets it right and where you think it might get it wrong. These classes offer you the opportunity to see how your staff is being trained. Don’t like what you see? Fine – take the class and then go talk to your nurse educator and come up with a plan on how to expand the curriculum. But you have to take the class. I get that the videos are boring, and I know you’ll pass the test and breeze through the mega codes. But you have an opportunity here to be a great healthcare leader so take it – you owe it to your patients, and you owe it to your team.