FOAMed for Rural Emergency Medicine
As rural doctors we are charged with responsibility for not just our primary care practice, but also for providing emergency medicine cover to rural hospitals. FOAMed can help us keep up to date with the almost overwhelming torrent of information in EM. The astute rural doctor will follow select blogs and subscribe to RSS feeds from trusted EM sources; to start I would recommend the following :
Emergency medicine reviews and resources from WA ED physicians – the originators of FOAMed at LifeInTheFastLane.com
Dr Scott Weingart’s mission to bring ‘upstairs care, downstairs‘ – a goal applicable to the small rural ED as much as the tertiary centre. Both Casey Parker at BroomeDocs.com and myself at KIDocs.org are on a mission to bring ‘quality care, out there’ for rural doctors. See more from Scott at EMCrit.org
Dr Cliff Reid’s excellent medical education blog on prehospital & EM resus topics at Resus.ME
Fellow rural doctor turned retrievalist and airway guru, RFDS Qld Dr Minh le Cong at Prehospitalmed.com
Dr Andy Buck’s mission to improve human factors in the ED and bring cutting edge concepts in trauma resuscitation (all the stuff they don’t teach on EMST) at Resusroom.Mx
…but see also the USEFUL LINKS option in top menu for many more useful sites.
Rather then a list of recent TOP 10 EM FOAMed topics, perhaps it is better to consider a selection of common EM presentations for which rural doctors need to be aware of new developments. Consider if you are au fait with these ideas for :
THE PATIENT WITH CHEST PAIN
This is a common yet potentially challenging presentation. The trick is to identify those at risk of ACS and discharge safely those who are not. The ADAPT trial is useful for deciding who can go home from ED or not. The se of sensitive troponin-I assay, TIMI score and ECG can be used to allow rapid discharge of low risk cardiac patients from ED for early followup.
Of course more sensitive troponin tests (most of us in the country have troponin T point-of-care testing, making ADAPT irrelevant) mean that we will pick up more cases of ‘raised troponin’ – and we need to be aware that not all raised troponin = cardiac damage. Read this post from StEmlyns for more on high sensitivity troponin assays.
Some may question whether rural doctors should be ordering troponins in their rooms rather than in the ED. My thinking is that if you are thinking of ACS, then the patient needs to be in a place where he/she can be monitored and repeat ECG/troponin’s performed – which usually means my ED. But of course, before embarking on such testing, we need to think hard about pre-test probability and also anticipated clinical course – is it worth testing for a troponin on a 24 yo who has chest pain after chopping wood? Or the 98 yo nursing home resident with renal failure and ‘NFR’ orders? Probably not! Listen to this podcast from Casey Parker and colleagues on investigation & disposition of the low risk chest pain patient.
Of course the ECG is pivotal to the assessment of chest pain – but correct interpretation is vital. In South Australia we are backed up by the excellent iCCNet or Integrated Cardiovascular Clinical Network to back up rural doctors with ECG interpretation and patient disposition. If you don’t have such backup and need a brush up on ECG’s, check out these videos from ‘The Little Medic’s Blog”
New guidelines for management of STEMI have been released – the big issue for rural doctors is thrombolysis vs PCI, the decision made on time to access cath lab. Read this summary from the StEmlyn’s crew.
Interpreting the ECG in a patient with chest pain in the presence of LBBB can be a challenge. Are you familiar with the Sgarbossa criteria to assist you in determining if there is an underlying MI?
Clearly not all chest pain is cardiac! Have a read of this blog post on cognitive bias, use of rule-in, rule-out tests and some of the difficulties in ACS/PE/chest pain decision making. Fascinating stuff from thos Canadians at TheChartReview
THE PATIENT WITH SHORTNESS OF BREATH
As a jobbing doctor back in the UK’s NHS, it was not unheard of for time-poor medical registrars to administer ‘Geri-Fix’ – a brew of steroid, frusemide and antibiotics given to the patient who presented with shortness of breath and for whom a diagnosis was uncertain. I am not advocating such a veterinary approach to the acutely dyspnoeic patient – instead and in it’s simplest, we will be considering either underlying cardiac or respiratory problems. What is new from FOAMed for this sort of patient?
First up, let’s consider those patients who are short of breath from acute heart failure. When I trained in the UK, standard teaching still taught that APO required frusemide (morphine having fallen out of failure). You may still find rural doctors administering a slug of frusemide for suspected APO.
In the context of the acutely dyspnoeic, tachycardic, hypertensive and hypoxic patient, LVH on ECG and a chest X-ray confirming they are ‘wet as a fish’, the trick is going to be breaking the cycle of catecholamine-driven increased afterload causing pulmonary oedema leading to more fear-induced catecholamine surge.
This patient needs nitrates – which we can give sublingual, topically or as an IV bolus (most drug refs suggest 10mcg/min, but FOAMed sources suggest that in APO higher doses and titration are warranted. Scott Weingart’s legendary podcast on SCAPE provides more details on nitrate bolusing.
You need to be au fait with IV nitrate protocols and have a protocol to administer – preferably easy to locate and with clear instructions for mixing up by nursing staff (who may be unfamiliar in a small rural hospital as incidence of such cases is relatively infrequent). I use small ‘action prompt cards’ filed at the head of the resus bay bed, laminated and used in such an emergency.
Concomitantly, this patient may benefit from NIPPV – evidence is that this will reduce afterload, with either CPAP or BiPAP. Your choice may depend on the type of ventilator you have available – but you can read more evidence here.
For the stable CCF patient, or where differentiation between CCF and an infective exacerbation of COPD is difficult, point-of-care proBNP may be useful – both to confirm diagnosis but also to follow clinical progress (along with usual measures such as daily weight, clinical examination, fluid balance etc)
THE PATIENT INVOLVED IN TRAUMA
EMST (ATLS) is the standard training for trauma delivery in the bush. Whilst I believe in the usefulness of such a framework (and direct courses in Australia), it is a reality that EMST & other courses lag behind current concepts on trauma care. On this Scott Weingart and I agree! Rather than accept such courses as the lowest common denominator, as rural doctors we can do better to bring ‘quality care, out there’
Listen to Weingart’s summary of the changes to the 9th Edition of ATLS EMST for 2013.
If you are pushed for time, consider your familiarity with the following FOAMed & click on the links to learn more
- Problems with the classic teaching of needle decompression for tension pneumothorax
- Finger thoracostomy for ventilated patients with suspected pneumothorax
- Role of ultrasound in trauma – not just FAST, but evaluation of pneumothorax - you can learn this in a few minutes!
- Minimal volume resuscitation for trauma, rather than aggressive infusion of ‘two litres stat’
- Early use of IV tranexamic acid in the bush for traumatic bleeding
- Managing major haemorrhage in the bush (without access to a major transfusion protocol & a range of blood products
- “the best clot is the one you’ve got” – a pragmatic approach to BP management in major trauma
SPINAL CORD INJURY
- No role for steroids in acute spinal cord injury
- Use of appropriate decision criteria for cervical imaging – BroomeDoc’s pragmatic approach on clearing the C spine in rural towns without access to CT & EMCrit’s views on NEXUS criteria and C-spine decision tools
- updates in spinal cord trauma from Minh le Cong at prehospitalmed.com
One of the hardest decisions can be whether a patient with isolated head injury needs an urgent CT head or not – particularly when such patients need to be transferred on for investigation. This is an area where you MUST play it safe. Casey Parker takes rural doctors through some of the decision-making and pitfalls in his post “a tolchock to the gulliver” parts one and two
BURR HOLES IN THE BUSH ? IT AIN’T BRAIN SURGERY
Faced with a deteriorating head injured patient in the bush, ipisliateral blown pupil? You need to think about extracranial haematoma – a condition with almost 100% lethality – and consider evacuating it ASAP.
I like this article from the Canadian Journal of Remote Practice - The Occasional Burr Hole, particularly the comic statement to ‘if you are in a hurry just read the bits in bold’. Not sure that running to the hardwar store for a 1/2 inch drill bit displayes appropriate pre-preparedness.
A more recent update from my colleague in London, Dr Mark Wilson (former rural GP, now HEMS doctor and neurosurgeon) is on the same topic – see Emergency Burr Holes – How to Do It. Mark emphasises the use of a clutched drill bit – not the usual brace & bit gathering dust in most rural OTs
Of course one needs to be familiar with the role of ketamine in trauma – not just for dissociation for rapid extrication and/or painful procedures in the ED, but also as the best induction agent in trauma .
Scoot over to the AIRWAY FOAMed section for more on ketamine & RSI. Suffice it to say that the myth of ketamine causing raised ICP in head injured trauma patient is busted. After all you don’t want to be a propofol assassin.
THE PATIENT WITH SEPSIS
Subsequent to these guidelines, FOAMed authors such as Weingart suggest that CVP placement and measurement is not that useful and indeed not without risk; instead of mucking around with CVP in the patient with septic shock, pour in empirical crystalloid fluids (initial bolus 30ml/kg), consider bedside USS of IVC filling to look at fluid responsiveness, whilst monitoring urine output and lactate clearance – all things which the rural doctor can achieve whilst awaiting transfer to ICU!
You may wish to listen to rural doctors discussing the fine art of “spotting the crook” - spotting sepsis and simple measures rural doctors can apply.
Also listen to Weingart’s views on SURVIVING SEPSIS here
Building on this, at SMACC2013 we heard Myburgh talk about vasopressors; as far as I can gather, noradrenaline > adrenaline > vasopressin (> dopamine). Again in the bush the only agent many of us have is adrenaline – so be familiar with setting up an adrenaline infusion and perhaps more importantly make sure that the staff around you can assist.
For the ventilated patient at risk of ARDS, using lung protective ventilation strategies is mandatory; tidal volume 5-7 ml/kg, Pplat < 30cmH2O, judicious use of PEEP & recruitment procedures. Don’t forget head up positioning, DVT prophylaxis & hyperglycaemia control.
Setting treatment goals and ceilings with patient & family is one of the strengths of the engaged rural doctor, who is often both the primary care doctor as well as the EM doctor & resuscitationist.
THE PATIENT REQUIRING EMERGENCY INTUBATION
Several new game changers in the past 18 months are important for the rural doctor faced with management of the airway in the ED, including:
- NODESAT / apnoeic diffusion oxygenation as a reservoir to buy time in RSI alongside standard preoxygenation
- Use of checklists and RSI kit dump
- Ketamine as induction agent
- Use of cricoid pressure vs external laryngeal manipulation
- Roc vs Sux for trauma RSI
- Difficult airway algorithms and equipment to manage the difficult airway
- Delayed sequence intubation
Have a look in the ‘Airway FOAMed’ option under ANAESTHESIA for more details.
THE PSYCHIATRIC PATIENT
Assessment of the acutely disturbed psychiatric patient is bread and butter for doctors in emergency. Some of the hardest decisions relate to safety in a resource-limited environment.
Check out Dr Andrew Webster’s guide to mental health assessment in the ED via BroomeDocs.
For the patient who you deem safe for discharge, assessment of suicide risk remains one of the most important skills. There is an excellent post here from Casey Parker at BroomeDocs. This is based on the TRAAPED SILO SAFE mnemonic for forming a narrative of suicide risk podcast from Rob Orman over at ERcast.com
Equally challenging can be the patient with acute agitation. He/she may require rapid take down and this requires a thorough understanding of not just sedation agents, but consideration of the ‘bigger picture’ – not least risk of respiratory depression, loss of airway protective reflexes & aspiration as well as safety for transfer.
I now approach psychiatric sedation in the same way that I would approach sedation in theatre – monitor not just SpO2, but also ETCO2 and use a validated agitation-sedation score. My fear of course is that over sedation means an unprotected airway, and that airway management may be difficult in some of these patients.
Dr Minh le Cong of RFDS QLD has a small case series of ketamine as a sedation agent for the psychiatric patient – where risk of over sedation and loss of airway or failed intubation is ameliorated by using ketamine for aeromedical transfer. Worthy considering for those faced with a psych patient with a potentially difficult airway yet requiring transfer. We are indeed living the ketamine dream.
Rural doctors need to be aware of excited delerium syndrome and other toxidromes/organic states that may mimic psychosis. Lots of quality FOAMed out there- check out Minh le Cong’s favourite resources at ‘excited delerium in 2013‘
THE INTRANASAL ROUTE FOR DRUGS
I have become a recent convert to the intranasal route for drugs. It’s great either prehospital or for those in whom IV access may be difficult, particulalry for short, unpleasant procedures. Full details are over at intranasal.net, but suffice it to say that the following drugs are well-suited to the IN route
The IN route allows procedures such as rapid extrication from entrapments, burns dressing changes, reduction & splinting of fractures, removal of nasal foreign bodies, pain relief and reversal of opiates – a useful tool for the rural doctor. Bear in mind that these drugs require careful drug dose calculation, appropriate delivery system & patient monitoring.
THE PAEDIATRIC PATIENT
Again, the game-changer in paediatrics has been use of the intranasal route, with IN ketamine a recent addition for paediatric limb injury management.
Other recent(ish) developments are that traditional EMST/APLS teaching of using uncuffed ET tubes has been replaced by use of cuffed ET tubes, and that in resus oxygen is ‘out’ for initial resuscitation of term neonates.
Continuing with resus themes. the old teaching was that atropine caused paradoxical bradycardia at low doses – however the myth of a minimum dose for atropine dosing has been busted.
Of course, iPad apps & games make engaging with paediatric patients easier, whilst specific apps & online calculators give us rapid access to current drug informtion in an emergency.
I often use the Royal Children’s Hospital Clinical Practice Guidelines and guidelines from the Royal Womens Hospital. Also useful is the excellent EM-PEM website and PICU calculators such as that supplied by NETS.
THE PATIENT WITH A LACERATION
Time was that we would prepare repair of an incisional wound with the same meticulous hygiene as we would for an open laparotomy. The fantastically-named ‘standing on the corner minding my own business’ ER blog busts this myth and reminds emergency doctors that
- fancy solutions for wound cleaning are not needed – these are skin cleansers for external use only. The choice is between sterile water/saline or tap water – and in terms of wound infection, a Cochrane review shows that clean tap water will do! It’s also cheaper.
- ditto the use of sterile gloves – clean gloves are adequate
- tissue adhesive (glue) has a role for non-gaping lacerations, with no discernible difference in wound breakdown, infection or subsequent cosmesis.
Don’t believe me? Read this post from SOCMOB on evidence based laceration repair
Whilst on the topic of lacerations, it may sound heresy amongst FOAMites to reduce the use of IV ketamine sorry Minh), but there is good evidence for the use of LAT gel in kids with a laceration (LAT = lignocaine-adrenaline-tetracaine gel in a 0.1ml/kg dose)
THE ROLE OF ULTRASOUND IN EMERGENCIES
I am a late adopter to ultrasound yet I realise that this tool is the stethoscope of the future. There are plenty of ultrasound courses and one-day workshops out there – but reality is that you need to go through an ugly period of hands-on, error-prone repeated examination of normal vs abnormal to gain competency. The cons are worth it though, with the reward of having ultrasound at your fingertip. ED uses include
- Nerve blocks in ED or OT
- Easier line placement
- Use to assess for badness in trauma (FAST)
- Assessment of fluid responsieveness via IVC
- Optic nerve sheath diameter assessment in closed head injury
- Ultrasound to exclude pneumothorax (more sensitive than X-ray!)
- Ultrasound to assess fractures
Useful resources include
See also this post on the RUSH EXAM from AcademicLifeinEM
RESUS ROOM MANAGEMENT
This is a topic to which we pay little attention – yet is actually pivotal to how well we function in an emergency. When things go well (or wrong) it is not usually down to technical skills and knowledge – it is more about how we manage ourselves, the team and the environment. Dr Andy Buck has devoted an entire blog to this at ResusRoom.Mx
I could go on about this for hours, but do take the time to read or listen to the following select resources :
- Use of a ‘time out‘ in the resus room
- Scott Weingart on ‘the mind of a resuscitationist‘, with the fact that “amateurs discuss strategy; experts discuss logistics“
- Tim Leeuwenburg on airway planning (part of the Rural Doctor Update video series accessible via main menu)
- Kevin Fong on human factors in medicine