Nursing FOAMed Review #5 (Sept 23rd – Oct 12th)
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!