Who got that stank?

Neutralizing ED Stank

Patients that stink can really hinder an ED. It creates a difficult work environment for ED staff and makes nearby patients, families and visitors uncomfortable. Here are a few ways I came across to neutralize the stank:

Nebulize stuff in the patients room

 

  • Nebulized OJ (works well for malodorous feet)
  • Nebulized coffee (works well for melena)
  • Will partially mask the smell
  • Works better in enclosed rooms w doors

 

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For when you have to remove shoes & socks (malodorous feet):

1. Maalox booties

  • Place feet in large trauma booties
  • Fill w Maalox and allow to soak

2. Towel Soaks

  • Mix warm water, betadine, peroxide and hibiclens (chlorhexidine) in basin
  • Soak towels in solution then wrap feet
  • Wrap feet and towel w blue pad
  • Allow 15 minute soak

3. Topical sodium bicarb

  • Use 1 amp per foot, apply topically
  • Neutralizes most odors
Post by: Dr. David Traficante (@davetraf)
References:
 

Getting ready to intubate? Let’s pray they don’t DESATurate!

You head over to bed 44 to meet the BLS crew as they start telling you about an 82 year old man who has been having trouble breathing and is “confused” as per his family.  His oxygen saturation when you check is 76% and quicker than you can say “sepsis”, the eager resident has popped the grey airway box open and is setting up to intubate.

You slap the NRB on and turn the O2 up all the way.  So why is the resident so focused on finding and placing a nasal cannula too?!

Apneic oxygenation (AO) is used to extend the time until critical arterial desaturation (SaO2 88-90%) following cessation of breathing/ventilation that occurs during intubation.  AO, similar to our other RSI preparation, premedication, and positioning, is used to optimize the patient prior to the first intubation attempt.

First demonstrated by anesthesiologists over 50 years ago, the alveoli of the lungs will continue to take up oxygen even in the absence of active breathing.  AO focuses on increasing a patient’s oxygen saturation through “nitrogen washout” in first the alveoli, and then throughout the circulation.  This effectively replaces the nitrogen one inhales in normal atmospheric air with oxygen and increases the patient’s overall oxygen storage in both the lungs (95% of a person’s natural reservoir) and bloodstream.  Maximizing pre-oxygenation provides us an additional buffer of time for “safe apnea” during oral intubation.  In a 2011 article in the Annals of Emergency Medicine, Weingart et al outline recommendations to reduce the risk of hypoxemia during emergency tracheal intubations which include emphasis on:

Pre-oxygenation for every patient

  • Nasal Cannula set at 15 L/min is the most effective method of AO
  • Non-rebreather mask at rates as high as possible
  • HOB elevated 20-30 degrees or Reverse Trendelenburg in suspected C-spine injuries
  • Minimum of 3 minutes total or 8 deep breaths, if possible

Take home:  Keep in mind the acronym “NO DESAT” which stands for “Nasal Oxygen During Efforts Securing A Tube”.  A nasal cannula with high flow rates should be placed on every patient prior to endotracheal intubation and left in place during attempts in order to reduce the risk of hypoxemia and deterioration.

Just because she cannot pee, does not mean “No UCG”

Let’s face it, we’ve all done it. And, believe me when I tell you all the cool cats are doing it, too.  Of course, I am referring to the use of whole blood to determine a woman’s pregnancy status in the Emergency Department using the urine pregnancy test strip. ucg-bcg-photo-brancato

Did you know that the common ICON 25 Beckman-Coulter hCG tests are actually approved for both urine and serum? Don’t feel bad; I didn’t until I read a recent article. Whole blood, which is comprised of serum (54%), hematocrit (45%) and leukocytes/platelets (1%), was rumored to detect a woman’s pregnancy status.  Now, we have research that confirms our suspicions and demonstrates that whole blood pregnancy testing performs quite excellently.

In a study published in 2012, whole blood pregnancy tests were found to be 96% sensitive, 100% specific with a negative predictive value of 98% and positive predictive value of 100%. Translation: Trust a positive test, it will not be wrong.  Can it miss? Yes, it can; however, there’s a good chance that the urine test will be negative at that point, too (5 of 9 that were missed with whole blood testing of the studied 425 pregnancies were also negative on the urine testing—the other 4 of  9 did not undergo urine testing).

As troops on the front lines of medicine, we are presented often with little time to think or to act. We are adroit at putting puzzle pieces together, often with little information. This is our creed and such is our nature.  It is during these critical cases, that the application of using whole blood pregnancy testing has its greatest application.

Post by: Raphael Brancato, DO (@DrRayFields )

Fixed dose PCC?

In the past, vitamin K and FFP were the mainstays of reversing warfarin, but now we have fancy new drugs like four-factor prothrombin complex concentrate (4F-PCCs).  4F-PCCs can rapidly reverse the INR of warfarin induced coagulopathy with less volume and quicker than FFP.  Many of the dosing regimens base the dose on the patient’s presenting INR and body weight, with ranges from 25-50 IU/kg.  A few problems arise with this approach, first the INR is not immediately available.  Second, 4F-PCCs are not cheap; costing up to $7,000 per patient in some cases.  Is there a fixed-dose regimen that we can give to patients on vitamin K antagonists without having to wait for the INR?

Some studies have looked at using 500 IU and 1000 IU fixed dose regimens for reversing the INR.  The 500 IU only corrected the INR in 43% of the patients, whereas the 1000 IU fixed dose study showed better clinical outcomes in 83.5% of the patients, but there is concern that the obesity epidemic in the United States will dilute the IU/kg concentration of the 4F-PCC and not be as efficacious.  Klein et al looked at using a fixed dose of 1500 IU of 4F-PCC for reversal of warfarin in 2015.  It was a relatively small sample of 38 patients on warfarin with the vast majority of them presenting with an intracranial hemorrhage.  Each patient had their INR drawn and then 1500 IU given before the result of the INR returned.  92.3% of the patients had their INR lowered to less than 2.0 after the 1500 IU of 4F-PCC and they reported no thrombotic events within the subsequent 7 days.  The presenting INR median was 3.3 (2.5-4.0) which was reduced to 1.4 (1.2-1.6) after administration of the 4F-PCC.  Additionally, this saved $40,273 dollars when compared to the typical INR and weight based dosing regimen for their patient sample.

We’ll have to figure out whether this fixed dose regimen of 1500 IU is the way to go, or should we base the dose solely on the patient’s weight and not worry about waiting on the INR.  Does waiting the extra 20 minutes for the INR lead to improved clinical outcomes?  And if we are going to start using a standard dose, is there a role for pre-hospital administration of the 4F-PCCs?

Post by: Terrance McGovern DO, MPH (@drtmcg13)

Octreotide for sulfonylurea poisoning

Newer second generation sulfonylureas are used extensively for treating type-2 diabetes mellitus (i.e. glyburide, glipizide, glimepiride and gliclazide). They are rapidly absorbed and reach peak plasma concentration typically within 2-4 hours; and have a duration of action up to 24 hours long. In 2010, the American Association of Poison Control centers reported nearly 4,000 cases of sulfonylurea exposures that led to no reported fatalities. Previous treatment has revolved around IV dextrose and glucagon for treatment of sulfonylurea associated hypoglycemia, but octreotide is another option for treating these exposures.

Mechanism of Octreotide and Sulonylureas

Sulfonylureas help to increase the amount of endogenous insulin release from the pancreatic beta cells. They bind to sulfonylurea receptors that are associated with ATP dependent potassium channels on the pancreatic beta cell membrane. By inhibiting potassium efflux, the membrane depolarizes causing influx of calcium and subsequent exocytosis of insulin. Octreotide counters this mechanism by closing the calcium channels after binding to somatostatin receptors, which prevents the secretion of the insulin.

Dosing

For adults we can use 50-100ug SC every 6-12h and for children 1-2 ug/kg SC up to 50ug q6-12h. Typically the patient will received 3 doses of octreotide as well as supplemental IV dextrose which can be gradually tapered off as tolerated. An extended length of observation may be needed for patients with renal impairment as sulfonylureas and insulin clearance will be impaired.

Check out The Poison Review for a couple posts on using octreotide for sulfonylurea poisoning here and here.

Post by: Terrance McGovern DO, MPH (@drtmcg13)

When kids eat coins

Kids eat up your money in more ways than one.  Some may eat it up in the form of $50,000 a year in college tuition and some eat it up as a meal.  For coins that get stuck in the esophagus the American Society for Gastrointestinal Endoscopy recommends watching asymptomatic patients for a period of 24 hours prior to any intervention.  Once the coins passes into the stomach most will traverse the GI tract without any complication.  There are multiple different methods of retrieving coins that are lodged in the esophagus: endoscopy, foley catheter technique, glucagon and bougienage is a method of pushing the coin into the stomach.  Classically, you use a Hurst dilator (or build your own) and advance it down the child’s esophagus to push the coin past the lower esophageal sphincter (step-by-step instructions).  Bougienage, when used on appropriate patients, is a safe modality for treating esophageal coins with only minor complications reported.  Some have reported success rates as high as 95%; however, you have to stick to the following inclusion criteria:

  1. Witnessed ingestion
  2. Foreign body is a coin
  3. Coin is seen in the esophagus on x-ray
  4. Single coin is present
  5. Ingestion < 24 hrs
  6. No previous esophagus procedure or pathology
  7. No respiratory symptoms
  8. Performed by trained personnel

If you successfully get the coin to pass into the stomach then the patient can be discharged home.  If the piggy bank doesn’t give up the coin in the next 2 weeks, then the patient will need a repeat xray to see where it is.  Check out this ACEP Now article for a more detailed discussion of bougienage.

Post by: Terrance McGovern DO, MPH (@drtmcg13)