EM:RAP and Procedural Sedation (November 2018)
AIR: Procedural Sedation
EM:RAP for Asynchronous Learning! For credit, first, listen to the entire podcast. Your participation in the discussion board here is your attestation that you have listened and engaged with the content in a meaningful way.
When you have finished listening to the podcast, answer the following questions:
- Please list three things you learned from this podcast that you were not aware of before.
- Are there any areas of your practice that you would change after listening to this podcast? If so, what would you do differently?
- What topics mentioned in this podcast is considered too “bleeding edge” (ex. too new, lacks enough evidence, not ready for prime time). Are there any practices mentioned in this podcast that you would consider to not be applicable to our practice setting here at BMC?
10 comments
1. Please list three things you learned from this podcast that you were not aware of before.
Nitrofurantoin beats single dose fosfomycin in clinical resolution of UTI’s, seemingly by a large margin, but is it me or do both kinda suck? 70% and 58% resolution at 28 days don’t seem like great numbers for first line therapy in uncomplicated UTI’s. Also interesting that fosfomycin covers VRE.
Are there really residents out there mixing their own flavors of push dose pressors to keep in their pockets? Interesting. I remember some residents talking about push dose pressors in the peri-intubation setting to stave off hypotension, but it’s nice to know how broad its use can be.
2. Are there any areas of your practice that you would change after listening to this podcast? If so, what would you do differently?
I’m feeling somewhat empowered to start chronic hypertension therapy in the ED (please don’t kill me).I really like the idea of single dose fosfomycin but 58% is too low of a clinical cure rate. I might avoid it. I will not practice in rural northern Canada as a result of the hair clip story. Scary stuff.
3. What topics mentioned in this podcast is considered too “bleeding edge” (ex. too new, lacks enough evidence, not ready for prime time). Are there any practices mentioned in this podcast that you would consider to not be applicable to our practice setting here at BMC?
The whole “fluid filled airway” chapter went over my head a bit, mostly because I don’t have much experience with airways yet and I won’t be in those situations for some time. Then he really lost me when he suggested intubating the esophagus and spraying stomach contents all over the place. Re: pal care chapter- I very much hope that I never have to give a dying patient rectal analgesia or antiemetics, and I feel like its invasiveness is on par with or worse than a peripheral IV. A lot of the conversation revolved around symptom management and I understand the importance of “getting the medicine inside” but I there surely must be some value in protecting the dignity of a patient, and helping them to feel that their body is still their own, and not just an array of mucous membranes across which medicines may be delivered.
1. I was unaware of how old the yankauer suction device is! I was also unaware that it was primarily designed for comfort and to be gentle in patient’s who had just had a tonsillectomy performed. It is not designed to be efficient at suction. Why do we not stock at least some wide bore suction devices which are designed to move larger volumes of fluid away from a flooded airway? Several other tips frrom the “fluid in the airway” portion of this month’s EMRAP were helpful suggestions for visualizing the cords when a patient is actively vomiting. I particularly enjoyed the suggestion of placing an LMA to prevent aspiration then replacing the LMA over a bougie with an ETT that you can then railroad over the bougie while it is being held in place and terminating through the cords. Other suggestions included a two-person suction technique, leaving the suction on the right side of the mouth within the mouth when intubating, and placing the suction tip through the cords and intubating with a bougie through that.
2. I thought Scott Weingart’s section on push dose pressors was super important. I think people are coming to recognize what the anesthesiologists and critical care docs have known for years, that when used in appropriate situations, these medications are life-saving. I especially liked the section suggesting the creation of poster boards within the ED or trauma bays with instructions on how to appropriately up these meds. I also agree that it is likely best to learn how to prepare one single push dose pressor for an entire department and stick with using that for all of these peri-arrest situations rather than having 3 or 4 possibilities which can lead to mistakes on many levels.
3. While I believe that the culture of an institution has to be adaptable I understand that change is difficult for some people. I think the section on palliative care and the ED was super appropriate I also think that unless a comprehensive care plan is put in place by the powers that be, getting people on board to administer medications rectally via foley and administering subcutanous IVF will be hard for people to get on board with. I cant personally see many of our nurses feeling comfortable with many of these practices – mostly because they are likely foreign to them.
1a. 40% chance of losing a blood patch with heavy lifting, straining etc. Strict discharge instructions required!
1b. Nitrofurantoin beats single dose fosfomycin in clinical resolution of UTI’s, seemingly by a large margin, but is it me or do both kinda suck? 70%/58% resolution at 28 days don’t seem like great numbers for first line therapy in uncomplicated UTI’s. Also interesting that fosfomycin covers VRE.
1c. Are there really residents out there mixing their own flavors of push dose pressors to keep in their pockets? Interesting. I remember some residents talking about push dose pressors in the peri-intubation setting to stave off hypotension, but it’s nice to know how broad its use can be.
2.I’m feeling empowered to start chronic hypertension management from the ED (please don’t kill me). I really like the idea of single dose fosfomycin but 58% is too low of a clinical cure rate. I might avoid it. I will not practice in rural northern Canada as a result of the hair clip story. Scary stuff.
3. The whole “fluid filled airway” chapter went over my head a bit because it’s not something I have experience with, and I won’t be in those situations for some time. Then he really lost me when he suggested intubating the esophagus and spraying stomach contents all over the place. Re: pal care chapter- I very much hope that I never have to give a dying patient rectal analgesia or antiemetics, and I feel like its invasiveness is on par or worse than a peripheral IV. A lot of the conversation revolved around symptom management and I get the importance of “getting the medicine inside” but there surely must be some value in preserving the dignity of a dying patient, and helping them to feel that their body is still their own, and not just an array of mucous membranes across which medicines may be delivered.
1. Definitely did not know that a yankauer is a bad device when you are looking for powerful suction. It is all I have ever seen in all my clinical experience except for the tiny ENT suction devices. I think we should stock alternatives! Also did not know about push-dose pressors as a thing to consider in an HoTN patient. Good to know. I dug a bit more online to find out how to mix this myself. Very simple–but what was more interesting is that there is no research to back this apparently. Unless I missed that. But it seems like a thing anesthesia does in the OR but does not clearly have a mortality benefit? Also I was always much more fascinated by what the rectal foreign body was than to consider the health implications. I learned that bowel ischemia can result from prolonged pressure and so important history to obtain is how long it was in place and my exam should be focused around trying to determine if there is peritonitis. And if concern for early peritonitis or development of it, the pt should be admitted for serial exams as this can take some hours to develop after foreign body removal.
2. I will definitely lead with suction on my intubations now. I will know what to consider when a pt with a rectal foreign body comes in. And I will try to frame to families of pts going to the ICU that I don’t think will live that they are likely entering the dying process. We do a lot to try to prepare pts to die, but we do very little to prepare their families. The palliative talk was very interesting for that perspective.
3. I think push dose pressors needs more data to prove mortality benefit vs waiting the 8-10 minutes it takes pharmacy to make the drip. Mixing 1 cc of code epi with 9 cc of saline and pushing 1 cc every 5 minutes seems fine, but is it really helpful?
1. Definitely did not know that a yankauer is a bad device when you are looking for powerful suction. It is all I have ever seen in all my clinical experience except for the tiny ENT suction devices. I think we should stock alternatives! Also did not know about push-dose pressors as a thing to consider in an HoTN patient. Good to know. I dug a bit more online to find out how to mix this myself. Very simple–but what was more interesting is that there is no research to back this apparently. Unless I missed that. But it seems like a thing anesthesia does in the OR but does not clearly have a mortality benefit? Also I was always much more fascinated by what the rectal foreign body was than to consider the health implications. I learned that bowel ischemia can result from prolonged pressure and so important history to obtain is how long it was in place and my exam should be focused around trying to determine if there is peritonitis. And if concern for early peritonitis or development of it, the pt should be admitted for serial exams as this can take some hours to develop after foreign body removal.
2. I will definitely lead with suction on my intubations now. I will know what to consider when a pt with a rectal foreign body comes in. And I will try to frame to families of pts going to the ICU that I don’t think will live that they are likely entering the dying process. We do a lot to try to prepare pts to die, but we do very little to prepare their families. The palliative talk was very interesting for that perspective.
3. I think push dose pressors needs more data to prove mortality benefit vs waiting the 8-10 minutes it takes pharmacy to make the drip. Mixing 1 cc of code epi with 9 cc of saline and pushing 1 cc every 5 minutes seems fine, but is it really helpful in practice?
1. intubate at a 20 degree angle to prevent aspiration, consider tilting to reverse trendelenberg if you are worried about spinal injury. Think carefully before jumping to bag-valve mask ventillation and think about LMA instead. Think about using Roc because the patient is less likely to regain muscle tone during procedure. Remember the yankauer has really inefficient suction! Very sick patients may benefit from push dose pressors and we as physicians should know how to mix them without a pharmacist present. You can probably just get by using only epinephrine, but some argue phenylephrine for tachydysrhythmias. And I’m an intern, so I learned a lot about rectal foreign bodies, pediatric ultrasound tips, and sticking with macrobid for UTIs. And as someone breastfeeding at the moment I very much appreciated that section. But I’m going to stop here instead of listing 50 things I learned.
2. Are there any areas of my practice I will change? I think I will be much more willing to treat breastfeeding patients. I’ve already had a couple that I was probably too cautious giving meds to. IThe day after I listened to the rectal foreign body section I had a patient with a vaginal foreign body and similar issues arose. I’m glad I reminded myself to not fish around in case it is something sharp and to try to get an xray first to know what you might be dealing with. I’m not exactly intubating a lot right now or using pressors on my patients, but I can imagine those parts of my future practice will be affected – I will probably use Roc more and try to elevate the head of the bed, if possible. And I’ll consider push dose epi.
3. I think they were pretty clear that there isn’t and probably won’t ever be great evidence for push dose pressors because these studies are almost impossible. But it’s good to get some anecdotal information. I think it’s also hard adopting new techniques like elevating the head of the bed for intubation because people in the room who aren’t familiar may strongly question you.
1. Learned a lot about rectal FBs. Did not realize plain films had such a role. It makes sense to observe them after removal, though if this should be in the ED (4-6 hrs) v on the floor remains up for debate, probably related to item and time in the rectum. Return precautions including expect a small amount of bleeding is a good thing to remember at discharge. Role of sedation/analgesia prior to removal and how this can make the patient relaxed enough that the object becomes easier to remove also makes sense. The peds ultrasound tips including how to obtain the LUQ view I thought was useful.
2. I think push-dose pressors should have a bigger role and something that I would consider having ready in the crashing airway. It’s not something I have really done that often, only once, but more often I have norepi up and ready. I agree that we should feel comfortable mixing up a syringe since pharmacy is not always available at BMC or offsite or at future jobs. I also felt reinforced in my practice after listening to the asymptomatic HTN.
3. DRIP score, like a lot of sepsis things these days, seems to need a more hospital-wide acceptance before being implemented. I like the idea of not having to give everyone vanc/cefepime but also do not like giving one antibiotic in the ED only to have it changed on arrival to the floor/ICU and then subsequently changed again. I think we need to consider using the DRIP score (with a better name) as a hospital.
1. Pretty much everything regarding the rectal foreign bodies was news to me. I hadn’t thought much about the important aspects of the history (beyond what the object is) and I don’t think I’d be bold enough to try to remove most things myself. The idea of plain films and an observation period to assess for bowel necrosis and perforation was really interesting. The breakdown of how the biologics are named was also very interesting. A third thing was that there are very few circumstances in which a woman should stop breastfeeding.
2. I think the “1 dose” fosfomycin could change my practice (although the success rate isn’t great), especially in patients with poor adherence or homeless patients who have difficulty obtaining and storing medications. The breastfeeding advice is also important; I don’t take care of breastfeeding mothers too often, so I will now feel better equipped to advise them on starting or continuing certain medications.
3. I agree with Dr. Nicholson that the DRIP score probably isn’t ready for primetime given that it would require buy-in across specialties and a culture shift since the expectation in the ED is that our antibiotic coverage is broad for all admitted patients.
– I did not know much about how to manage post LP headaches. Learned that post LP headaches occur in 10-30% of lumbar punctures. They occur due to CSF leak from the dura punctured hole. They are usually self-limited and may last 10-14 days but when HA lasts greater than 14 days, you should consider the possibility of a CSF fistula (MRI spine??). First line treatments is bed rest IVF and analgesia. If headache persists perform blood patch.
– I Love the idea of push dose pressors even though there is no mortality data, I think there is benefit to actively thinking and doing something about pt with transiently low BP. For many pt who are pseudo-stable and you don’t know which way they are going to go the process of preparing and giving therapies like fluids or push dose pressors is likely beneficial, plus there doesn’t seem to be downsides to it. I am guessing if we study this in the ED, and looked at outcomes other than just mortality including time to initiating hemodynamically stabilizing therapies, ED length of stay, hospital LOS we may see some benefits. I don’t know if residents carrying syringes or push dose pressors would fly with nursing or pharmacy. But I would like to incorporate into my practice.
– The session on choosing abx for pneumonia was interesting although I thought the DRIP score concept redundant as there is the MDR score which also serves the same function. It would have been great to have heard them comparing DRIP vs MDR scores to see which performs better. However, I want to incorporate using an aid (DRIP or MDR) into choosing abx for patients as I rarely ever use anything.
1.
– You can bag a patient directly into a nasal trumpet with the mouth closed or can put a pediatric mask over the nose for effective ventilation in adults.
– If a patient is bleeding from the esophagus, you can leave a suction catheter in the esophagus while attempting intubation. This makes sense, but it never occurred to me that this was an option. Also really interesting that you can insert an ETT into the esophagus to tamponade and divert blood.
-You should use IV contrast only to look for a foreign body in the rectum or bowel. This can help you determine if there is a microperforation which would change management acutely.
-I learned that the -mab medications can cause autoimmune diseases in patients. I figured that patients with diseases like IBD and RA are more likely to develop other autoimmune diseases, but was unaware that the drugs used to treat them can cause the development of other autoimmune disorders.
2.
– I will be more likely to ask if a patient is breastfeeding- I don’t often ask this question if the chief complaint is not related to OB.
– I will also use ultrasound to see if there is urine in the bladder prior to ordering a cathed urine fir pediatrics patients. Catheterizing children can be very traumatic and it makes sense to set yourself (or nurses) up for success prior to performing the procedure.
3. Agree with all of the comments on the DRIP score. While I would be ready to incorporate this into my practice, I feel that it needs to be hospital-wide or else antibiotics will just be changed once the patient was admitted.