Inhaled Isopropyl Alcohol for Rapid Treatment of Nausea

You are quietly typing away at your computer when the familiar (but not entirely pleasant) sound of retching fills the air. You look out onto the side and see a young woman dry-heaving into a pink plastic bucket, looking miserable. This person will obviously need anti-emetics, but you know that 30+ minutes may pass before she has a line to administer them.

 

Is there anything we can do meanwhile to help relieve patient’s symptoms?

 

Lurking in the Anesthesia literature is the curious finding that nasally inhaled Isopropyl Alcohol often outperforms Zofran and Promethazine in its anti-emetic effect, and does so in a much faster time. But where could we possibly find a steady supply of Isopropyl Alcohol in the ED? Surely we don’t have a bottle in the Pyxis…maybe run to the nearest bar?

 

 

Ah yes, the lowly Alcohol prep-pad. Much used and often unheralded, this little guy contains 70% Isopropyl Alcohol, costs mere pennies, and has a convenient packaging, ready for the patient to start sniffing.

 

And while anesthesia literature is appropriate for post-operative patients, can these findings carry over to the ED?

 

Beadle et al. performed the first randomized, placebo controlled, double-blinded study on ED patients who presented with a chief complaint of nausea and/or vomiting. They compared Isopropyl Alcohol inhalation to the inhalation of Normal Saline, and utilized an 11-point verbal numeric response scale score for nausea, as well as patient satisfaction. 37 patients were assigned to the alcohol group, while 43 were in the saline group. 

 

The study showed that after only 10 minutes, the “median nausea verbal numeric response scale score was 3 in the isopropyl alcohol arm vs. 6 in the placebo arm, for an effect size of 3 (95% CI 2 to 4)…[and then] median satisfaction score was 4 in the isopropyl alcohol arm versus 2 in the placebo arm, for an effect size of 2 (95% CI 2 to 2).”

 

In other words, nausea went down, while patient satisfaction went up.

 

A simple method of administration would be to tear open an Isopropyl Alcohol prep pad, keep it in the wrapper, and instruct the patient to keep it close to his/her nose, inhaling through the nose and out through the mouth. A new pad can be opened when the intensity of the smell starts to diminish, signifying evaporation of the alcohol. This can be done while preparations are made to draw labs and place a line.

 

Conclusion: If this study’s results can be recreated, this extremely simple, readily available modality to treat nausea in the very short-term can be an effective bridge to longer lasting anti-emetics during the patient’s hospital stay. Also, given how important patient satisfaction is to hospital metrics, this can make the nauseated patients, his/her neighbors, and the provider happy by minimizing the sonic assault that occurs while someone attempts to bring up their gastric contents in a busy ED hallway.

 

References: Beadle KL, Helbling AR, Love SL, April MD, Hunter CJ. Isopropyl Alcohol Nasal Inhalation for Nausea in the Emergency Department: A Randomized Controlled Trial. Ann Emerg Med. 2015; doi: http://dx.doi.org/10.1016/j.annemergmed.2015.09.031.

Cotton J, Rowell L, Hood R, Pellegrini J. A comparative analysis of isopropyl alcohol and ondansetron in the treatment of postoperative nausea and vomiting from the hospital setting to the home. AANA J. 2007;75(1):21-26. [PubMed]

Automatic Blood Pressure Cuffs: Sorcery or Engineering

Did you ever wonder how your automatic blood pressure cuff actually works? No? Just me? Well…no surprise there.

When the machine inflates the cuff, its goal is to get it above the patient’s systolic blood pressure (table how it knows that for one second). It then uses this as its estimate for the next time it cycles. Incidentally, this is why the first pressure cycled on a new patient can be remarkably uncomfortable sometimes, or take a really long time.

While the cuff is cycling, a pressure sensor in the machine is looking for variance of the oscillations of the pressure in the cuff. When the cuff pressure exceeds the patient’s SBP there is no flow in the limb, and when the cuff pressure is below the patient’s DBP there is smooth flow in the limb, and the cuff pressure oscillations don’t vary much. In between, there are variable amplitude micro-oscillations measurable in the cuff with each beat as some blood is squished through the artery.

Image result for oscillatory blood pressure cuff

As it turns out, these oscillation amplitudes as maximal at the patient’s MAP. The SBP and DBP are calculated by proprietary, trade-secret algorithms. Each company has its own, and different machines applied to the same patient might give you different answered.

What does this mean? The MAP your machine gives you is the most reliable number. Bradycardic patients or patients with other arrhythmia can be relatively confusing to these machines. Two different BPs in each limb of the same patient should be a lot less scary if the MAPs are the same. I’m sure you can think of plenty more implications.

Knowing how your machines make your numbers is part of being a good user of your machines!

Image Source

The 52 in 52 Review: ProCESS

Title: “The 52 in 52 Review: ProCESS”

Article Citation: ProCESS Investigators, Yealy DM, Kellum JA, Huang DT, et al. A randomized trial of protocol-based care for early septic shock. N Engl J Med. 2014 May 1;370(18):1683-93. PMID: 24635773.

What we already know about the topic: Rivers shocked the world in 2001 with his revolutionary, if cumbersome, protocol for the care of septic patients. In the years since then, we’ve learned a lot, and many emergency physicians and intensivists have abandoned or significantly modified the care model developed by Rivers.

Why this study is important: Rivers called for a lot of invasive monitoring, therapies titrated to targets that were logistically challenging to follow, and (by modern standards) aggressive blood transfusion goals. The problem was, no one knew what subsets of this protocol actually were responsible for the observed mortality benefits, and as care relaxed around different aspects of the protocol, we needed to find out what, if anything we were losing.

Brief overview of the study: Septic patients with fluid refractory hypotension or lactate > 4 mmol/L, and without significant concurrent acute disease (ACS, CHF, GIB, trauma or similar) were identified in the emergency department. At this point they were randomized to one of three arms — Rivers Protocol, protocolized standard care (in which the blood transfusion, CVC, and inotrope rules were removed from Rivers), and usual care (in which an intensivist could make the plan as they saw fit). This was done in a multi-center, open label, random fashion.

Limitations: This trial was a pragmatic, intention to treat trial, and not everyone in the protocolized arms got the full protocol every time, possibly diminishing some effect size. Additionally, the researchers changed their definition of “fluid refractory hypotension” during the trial, though it remained within commonly established research parameters.

Take home points: This paper was the first of the triple threat of ProCESS, ProMISe, and ARISE which in some ways put EGDT to rest, once and for all. Specifically, ProCESS showed no difference in all cause mortality at 60 days in patients between the three arms. In some ways, this can be considered a good thing — we’re liberated of the cumbersome Rivers protocol. In another light, it’s humbling that in approximately one and a half decades all of medicine still can’t beat the results of one guy that thought really hard about this problem in the late 1990s.