Nursing FOAMed Review #10 (March 25th – May2nd)

            If increased ICP can lead to EKG changes – why not increased pressure in the abdomen? Enter this article by emDocs – an ECG post about the ST elevation variant known as “spiked helmet sign”. Anyone working in a busy emergency department knows that not all ST elevations equal acute MI. Beyond recognition of simple benign early repolarization (BER), there are many other ST elevation EKG signs that should give you a high index of suspicion for alternative causes of acute chest pain. Spiked helmet sign is pretty cool honestly – it is a diagnostic marker of increased pressure within the abdominal cavity that has actually affected the EKG waveform. Even if you aren’t an EKG geek this article is fantastic for another reason – it provides a handy chart of 16 different annotated EKGs with ST elevation, and breaks down the hallmark signs – everything from STEMI to pericarditis to electrolyte abnormalities. There is also a table with 10 different EKGs with ST elevation demonstrating signs that might widen your typical STEMI differential. So with forego the cath lab and drain your patient’s abdomen and fix your patient’s ST elevation.


Next time you’re sitting out in triage and a post-partum patient presents with headache you’ll be glad you read this emDocs practice updates article. Dr. Marina Boushra brings you a very thorough differential – and explains why a post partum patient with headache is potentially a lot less benign than it may seem.   The article comes with a handy history-taking graph including 9 pertinent questions as well as a list of symptoms to watch out for. Included in the differential are: primary headache disorders, post-dural puncture headache, pre-eclampsia/eclampsia, meningitis, Posterior Reversible Encephalopathy Syndrome (PRES), stroke, pituitary apoplexy and sinus venous thrombosis. This is some really high impact reading and necessary for anyone who has ever found themselves immediately assuming a simple post-partum headache is just a benign complaint.

            St. Emlyn’s has released a wonderful video with University of Maryland’s Dr. George Willis concerning the emergent treatment of aortic aneurisms. Some really great discussion here – some pearls include:

  • Access – to go central or peripheral? Do nurses need to hold off on large bore peripherals and set up for a central instead?
  • Hemodynamic monitoring – non-invasive BP measurements and which arm to focus on. Pharmacological hemodynamic management based on the soft BP arm or the strong BP arm? Know which side to place that cuff on!
  • Why HR is as important as BP in the emergent management of dissection.
  • A few good notes on pharmacologic agents. Lipid emulsion Clevidipine is discussed. This is a new one for me – I’ll be asking our attendings about it as soon as I get the chance.

            Thinking Critical Care has a really fascinating article on a piece of software being developed by Dr. Lawrence Lynn. If you’ve ever found yourself frustrated trying to define sepsis, you’ll find this article and attached video pretty incredible. Imagine a computer program that correlates the dozens of laboratory markers we know (or maybe just think?) contribute to a septic patient’s prognosis, and then places those markers into a graphic that could potentially tell you whether your treatment modalities are effective or not.

            Here is a quote from the discussion about the graphic software: “Research-wise, I think this really opens a whole new world, where different phenotypes of sepsis can be potentially described (work we are currently undertaking), and describing the phenotypes (as opposed to arbitrary cutoff definitions) may lead to better categorization and more importantly therapeutic research that may be better tailored to the phenotype.”

            The Bottom Line reviews the Woolum et al trial discussing thiamine administration for septic shock. For anyone who has been diving into the literature on sepsis treatment, this concept isn’t going to look new – but the Woolum trial is a bit different in that it ties thiamine administration with lactate clearance as a marker for treatment efficacy. Now, whether or not you believe that lactate clearance is an important treatment marker (which is, to my understanding, not a universally agreed upon concept), this trail’s conclusions are definitely worth the read. The author’s conclusion: “In patients with septic shock, intravenous thiamine, administered within 24 hours of ICU admission resulted in more rapid lactate clearance and a significantly reduced 28-day mortality.” Okay… so you have our attention. Fans of Dr. Paul Merik’s take on sepsis will find things they love in this article (use of thiamine) and things they hate (the focus on lactate). but go ahead and read the review by Jose Chacko to see why the article’s conclusionsth may or may not be applicable to a more universal septic shock patient population.

            R.E.B.E.L.EM brings us more dogmalysis in the form of another nail in the coffin concerning the usefulness of orthostatic vital signs. Dr Anand Swaminathan writes about this article published by White et al in the American Journal of Emergency Medicine – all about the uselessness of orthostatics in predicting 30 day serious outcomes of older patients in the ED presenting with syncopy. Okay – I’ll do your damn orthostatics and get them charted… but it’s probably going to be pretty far down my list of priorities in my busy ED.


  And another blow against the concept of contrast induced nephropathy. Dr. Salem Rezaie highlights another study questioning the dogmatic approach fo when/if to give contrast in our sick CT patients… Long story short here – this is a small, retrospective, single center trial, but yet another piece of evidence in our arsenal against withholding contrast in patient’s with elevated creatinine.  

            EMCRIT’s Josh Farkas brings us another entry for his Internet Book of Critical Care (IBCC) discussing VT/VF storm. There has been a lot of discussion about this over the past couple of years – with nurses running around the resuscitation room trying to make sense of all of these strange new instructions. Why am I getting a second defibrillator? Why are we stopping epinephrine and grabbing Esmolol? What the hell are these guys doing with the ultrasound machine poking around the patient’s neck? If you want to know more about VT/VF storm, why ACLS isn’t being dogmatically followed for every VF code you work, and where the science of cardiac arrest resuscitation may be heading in the near future – this podcast and IBCC chapter is really worth the time it takes to review.

            Thank you lord for medical student Josiah Butt and Dr. Mike Xue. These two stellar individuals just posted one of the most useful graphs I’ve come across in a while on CanadiEM. Next time you’re sitting down charting a skin assessment and having a hell of a time remembering the difference between a macular rash, papule, bullae, vesicle or plaque, just remember this post! Dr. Xue walks you through the proper terminology and how to easily remember what is what. This is the kind of simple graphic that is great to print out and just keep handy for a while.

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