Nursing FOAMed Review #12 (August 2019)
Thinking Critical Care has a link to a lecture on acid/base done by Rory Spiegel. This is from a series called H&R2019 (standing for hospitalist and resuscitationist 2019) – there are more lectures linked to the bottom of the lecture. Guys – I can’t stress this enough – this is one of the most amazing lectures I’ve ever listened to. I have tried at least five different ways of understanding acid/base – and I always come away a bit frustrated. Listening to Rory simplify something this complicated is amazing. Listen, learn, and see why people like me pay money to go see this guy when he lectures.
Listen to enough international FOAMed podcasts and you have definitely heard of Droperidol. What gives? Why can’t we find this drug here in US hospitals?
Never fear – Droperidol is apparently back. Dr. Cisewsky writes for EMDocs about the reintroduction of this once incredibly popular drug. Read the article and find out why you may be getting a lot more verbal orders for Droperidol and hearing a lot less about Haldol.
But wait – you might have done a quick Google search and found out that Droperidol has a black box warning for QT prolongation, leading to possible TdP. So maybe we will just stick with Haloperidol. But then you remember – Haldol prolongs QT as well. The article does a great job thoroughly reviewing the history behind this black box warning – read on and become familiar with a drug that you will probably see a lot more of in the next few years.
Dr. Jenna Pallansch has added to the ToxCard bundle at EMDocs with a really thorough article on toxicological paralysis mimics. This is a HUGE differential – and I don’t know how realistic it is to expect to read something like this and walk away feeling like you have this differential memorized. Honestly, this is the kind of thing where it makes more sense to “save the link” than it does to try to memorize and walk away. While intimidating at first, what I love about articles like these is that they expand the bedside differential for a relatively common ED complaint. Instead of potentially getting lazy (AKA putting 100% of our faith in the gospel of horses over zebras) and oversimplifying every bedside dx, it is really handy to have an article like this to help us remember that complaints like paresthesia and new onset limb weakness have rather complex differentials.
Josh Farkas has added quite a bit to the IBCC (Internet book of critical care) for those that are interested. One of the chapters that I found pretty timely was on VAPI, or Vaping Associated Pulmonary Injury. I have seen a bit on social media recently – a recent article in the Washington Post is making the rounds – about vape addicted kids needing ET tubes. While I have not seen this in my ED, the fact that EMCRIT is taking notice means (to me at least) it isn’t complete bunk. And who is really surprised? You mean to tell me that inhaling a bunch of chemicals directly into the lungs can have health consequences? And the producers of these expensive chemicals say it is perfectly safe? I have NEVER heard of such a thing. Oh… wait. Yes I have.
Rory Speigle continues to talk nerdy to us through his EMNerd series on EMCRIT. “The Case of the Ecological Ambiguity” is a fascinating read on some incredible research done by Maitland et al. Maitland et al published the FEAST and TRACT trials – and really challenge some deeply held Emergency Medicine dogma. But, as Dr. Speigle points out – we haven’t really seen any serious discussion about change in practice since the publication of these trials – mainly due to the concept of “external validity”.
So FEAST shows us that fluid bolus in sepsis (as opposed to sustained drip only) may add to mortality. And TRACT shows that blood transfusion at higher H&H, and the transfusion based maintenance of a higher H&H may ALSO leads to higher mortality. So what is the deal? What does this mean? As Rory points out here at the end of the article:
“We are stuck in an endless cycle of dismissal and denial. A trial like this could not have been done outside of this population, but we are unable to apply the results generally because of the population in which it was conducted. And while it remains unclear whether the results of the TRACT trial are generalizable to blood transfusion strategies outside the confines of this cohort, the results should cause us to question the absurd dichotomy in which we currently exist. Where a patient with a hemoglobin of 7.1 g/dL is fine and that same patient at 6.9 g/dL is in urgent need of red blood cells, with no consideration of the clinical context which surround these abstract data points.”
Following up with EMCRIT’s appraisal of FEAST and TRACT trails, The Bottom Line comments on the TRACT trial as well – and Dr. Fraser Magee gives a very thorough analysis. This trial analysis goes into a deep dive on the numbers and P-values and comes away with what I think is a more measured approach to what they TRACT trial may be showing us. I think that it is worth a read – but if you don’t have the time the “bottom line” is this: Early transfusion for severe anemia is better than delayed, but higher initial blood transfusion volumes, and maintenance of higher H&H are not necessarily clinically superior.
Anand Swaminathan brings us his opinions on the YEARS algorithm adapted for pregnancy. I have already shared the original article in previous FOAMed round ups but will do so again here. Two reasons I wanted to share this again from R.E.B.E.L. EM. The first reason is that I think we may start to see this in EDs soon – the evidence seems pretty solid and god knows we hate sending pregnant patients to US when our suspicion for PE is low, but feel trapped by a lack of negative DDimer. Secondly – it appears that MDCalc now has the algorithm up! This means we have a simple reference to back up the use of the Dimer. If you haven’t heard anything about the YEARS algorithm and how it can be used to streamline pregnant patients out of the ED this is definitely worth the read.
Rick Pescatore writes for R.E.B.E.L. EM about Calcitonin Gene–Related Peptide Receptor Antagonists for migraine headache. HA is a common complaint – and after reading this article I realized that I have been pretty lazy in keeping up with my understanding of the pathophysiology behind this all to common complaint. The study that the article sites is unimpressive and doesn’t really need to be mentioned – this write up is more important as a refresher on migraine treatment and patho than it is as a reference to a new study. Click on the above link – and be ready to go off on some Google tangents if you don’t know, or just want to know more, about:
- Triptan therapy and neuroleptic therapy for HA
- Why opioids might not be working for your migraine patients
- What in the world is a gene-related peptide receptor antagonist?
- Why cerebral vasospasm is a potentially lazy and incorrect explanation of the awful symptoms that your patient is experiencing
Dr. Salim Rezaie from R.E.B.E.L. EM discuses another study published in Resuscitation concerning Epinephrine in out of hospital cardiac arrest. The PARAMEDIC-2 trial has forced the EM community to to confront the available evidence about Epi and how/why we use it. AHA’s ACLS dogma about the sacrosanct place Epi holds in arrest management is being put to the test – and that is what evidence based medicine is all about right? In this review by Rezaie, we see yet more evidence that Epi isn’t the panacea that the AHA preaches.
First10EM brings us a rapid review from Dr. Noren Khamis on Measles. I’m still waiting to see my first confirmed case – but I fear I don’t have much longer to wait. I’m sure that the anti-vax movement will eventually deliver my first patient. The season for the virus is late Winter to Spring – but no better time to learn than now! I like this little refresher because it gives us the brass tacks. Review the viral prodrome, remember to ask where the rash started and why you’re supposed to look at the palms of the hands, and take a look at the fantastic (probably best I’ve seen so far) photo of Koplik’s spots. If you don’t know all of this stuff off the top of your head – just give the article a quick 10 minute read and enjoy the refresher.