6 PEM papers that could change your practice – #6 – getting urine from neonates

Simon Binks, an Emergency Medicine doc in Wollongong Hospital recently gave an awesome talk on six papers that changed his paediatric emergency medicine practice in the last year. This week we are posting one each day. You can hear the talk on Joe Lex’s Free Emergency Medicine Talks site.

See all the papers and discussion:

  1. The downsides of codeine in kids
  2. The outcomes of absorbable sutures in facial lacerations
  3. Abdo x-rays to rule out intussusception
  4. Bloods markers as predictors of serious bacterial infection
  5. High flow nasal cannulae for acute respiratory insufficiency
  6. Urine samples from neonates

Here I summarise the sixth paper he identified and his key points.trans 6 PEM papers that could change your practice   #6   getting urine from neonates

6.  Getting urine from babies is like getting blood from a stone

We have all spent time pondering over how long to wait for a urine sample and when to just do an in-out catheter or suprapubic aspiration.

A paper in Archives of Disease in Childhood looked at a new way of collecting urine in neonates.

Sounds great, what's the new way?

Give the baby a feed and then wait for 25 mins.

Get one other person to help you.

Hold the baby up (under the arms); tap on the bladder (100 taps per minutes) for 30 seconds; and massage the lower back for 30 seconds.

And they wee!

urine 130x300 6 PEM papers that could change your practice   #6   getting urine from neonates

Looks amazing.

Who were the patients?

This study looked at 89 patients. They were all neonates – with a mean age of six days.

And did it work?

86% voided within five minutes. The mean time to void was 57 seconds.

Worth a try? I’ve never used this but I intend to now. It would be interesting to know if it can  be applied to older infants.

References

Herreros Fernández ML, González Merino N, Tagarro García A, Pérez Seoane B, de la Serna Martínez M, Contreras Abad MT, García-Pose A. A new technique for fast and safe collection of urine in newborns. Arch Dis Child. 2013 Jan;98(1):27-9.

 

 

 

 

The post 6 PEM papers that could change your practice – #6 – getting urine from neonates appeared first on Don't Forget the Bubbles.

Cefalea e diplopia

Non è comune vedere entrare nella sala visita persone sorridenti, il che, ovviamente, è comprensibile, visto il luogo in cui operiamo. Quando succede ci sentiamo però anche noi più sereni e contenti, almeno questo è quanto succede a me. Maria è una donna di oltre 80 anni, splendidamente portati. nessun problema importante in anamnesi a […]

The post Cefalea e diplopia appeared first on EM Pills.

Umbilical Vein Catheterization

During the resuscitation of a critically-ill newborn who requires vascular access, umbilical vein catheterization can be a life-saving procedure. The umbilical vein can remain patent for approximately 1 week after birth and when catheterized, allows the administration of fluids and medications. Contraindications to the procedure include necrotizing enterocolitis, omphalitis, and peritonitis.  Reviewing the anatomy of the umbilical cord, remember there are […]

The post Umbilical Vein Catheterization appeared first on the EMPA Blog site.

Syncope and ST Segment Elevation. And another finding. How well does the computer interpretation perform?

A woman of approximately 50 years of age had been feeling weak and febrile, then had syncope.  EMS recorded this ECG:
Sinus Rhythm. 
The ECG computer read "ST Elevation, Anterior Injury, *****ACUTE MI*****"
The medics activated the cath lab prehospital.
Is the computer accurate?










No.  This is not the morphology of anterior STEMI, nor even of right ventricular STEMI, though there are similarities. 

There is right ventricular conduction delay (R' wave), with downsloping ST elevation and T-wave inversion (TW inversion is slight in this case).  This morphology is Brugada pattern, or at least very similar to Brugada pattern, and could actually be Brugada, though not necessarily, but it is not completely classic, as this one is

On arrival, she was febrile (39.4 degrees C), and this ECG was recorded:
The ST elevation is not as pronounced now.
What else is present?







If you look closely, it appears that the QT interval is very long in lead II (about 400 ms, with QTc of 500ms).  However, if you look at leads V2-V5 (especially V4 and V5), you see prominent U-waves.  A U-wave then probably accounts for the apparently long QT in lead II (in other words, what appears to be a QT interval is a QU interval).

The patient had a K of 3.8 mEq/L, but the Magnesium level was 1.2 mEq/L, which is slightly low.  It is well known that hypoMg causes hypoK, which of course leads to U-waves, but there is also some evidence that hypoMg alone, even in the absence of HypoK, produces prominent U-waves.  There may or may not be a causal relationship here.

Lesson:

1. The computer is very unreliable in diagnosing acute STEMI.  The literature would indicate that this shortcoming is usually in poor sensitivity (around 60%) but with reasonably good specificity (not many false positives).  In my experience, the computer has many false positives.  Because of the limited accuracy of the computer aided diagnosis, our protocol requires not only that the computer reads ***Acute MI***, but that the patient also have active chest pain.  Although this protocol will miss many STEMIs, it limits the false positives. 
2. The computer is very unreliable at measuring the QT interval when it appears long to the naked eye
3. The computer is very unreliable at finding U-waves. I do not ever remember a computer diagnosis mentioning U-waves.  I am not even sure if they are part of the algorithm.
4. Brugada pattern ECG is a common PseudoSTEMI pattern.  Although there is ST elevation, its morphology is completely different from ischemic ST elevation.  The T-wave inversion morphology is also completely different from ischemic T-wave inversion.


Outcome

The emergency physicians immediately recognized this as Brugada pattern and de-activated the cath lab.  Closer history also revealed that she had only had pre-syncope; she remember the entire event.  There was no family history of sudden death or syncope.

She was admitted and ruled out for MI and will get cardiology follow up.  She had influenza.

Here is her ECG when not febrile:
Findings have mostly resolved.  Perhaps the prehospital ECG had some fever-induced Brugada pattern.





La situazione critica dei pronto soccorso italiani

Il sovraffollamento dovuto all’impossibilità di ricoverare i pazienti nei reparti di destinazione

Gian Cibinel, presidente nazionale Simeu

Sulla questione riportata da alcuni organi di stampa nelle ultime ore relativa al sovraffollamento dei pronto soccorso italiani e alla mortalità nei reparti di emergenza ospedaliera, Gian Alfonso Cibinel, presidente nazionale Simeu, Società italiana della Medicina di emergenza-urgenza, commenta:

L’aumento della mortalità in pronto soccorso negli ultimi 10 anni è un fenomeno multifattoriale.

Attualmente, rispetto agli anni passati, è più frequente che pazienti con patologie croniche gravi non curabili siano trasportati in pronto soccorso in fase di peggioramento, invece di essere seguiti a domicilio; si tratta di un problema culturale, prima ancora che organizzativo.

I dati del problema

In Italia non disponiamo di dati certi sul rapporto causa-effetto tra la permanenza in pronto soccorso e l’aumento di mortalità; in molti casi i decessi si verificano in pronto soccorso semplicemente perché i pazienti sono in pronto soccorso e non in un reparto di degenza, ma la causa della morte sta nella gravità della compromissione funzionale, non nella sede di collocazione.

Peraltro molte evidenze da studi internazionali hanno dimostrato che:

  • la mortalità effettivamente aumenta di circa il 30% quando i dipartimenti di emergenza e gli ospedali sono affollati;
  • gli eventi sentinella in pronto soccorso (morti inattese, incidenti, errori) sono correlati in 1/3 dei casi a situazioni di affollamento;
  • l’affollamento dei pronto soccorso è associato a ritardi nel riconoscimento e nel trattamento di condizioni a elevato rischio evolutivo (infarto miocardico, ictus cerebrale, polmoniti, sepronto soccorsoi, traumi, patologie addominali acute);
  • l’affollamento dei pronto soccorso è associato a ritardi nel controllo dei sintomi (dolore, ansia).

L’affollamento dei pronto soccorso determina inoltre conseguenze negative sugli aspetti personali e relazionali:

  • impossibilità a garantire un controllo adeguato dell’ambiente fisico (violazione della privacy);
  • limitazione delle possibilità di comunicazione tra il personale e i pazienti.

Cause dell’affollamento dei pronto soccorso

Le cause dell’affollamento dei pronto soccorso non sono tanto e solo collegate agli accessi impropri, che negli ultimi anni sono diminuiti, e pesano solo per un 20-30% sul problema; la causa principale dell’affollamento dei pronto soccorso è invece l’impossibilità di inviare nei reparti i pazienti che necessitano di ricovero.

In pronto soccorso arrivano molteplici richieste di aiuto da parte dei cittadini e di altri soggetti pubblici e privati: oltre a quelle sanitarie anche domande preventive, personali, sociali, giudiziarie, assicurative, amministrative. Le strutture di pronto soccorso e di Medicina d’Urgenza si sono attrezzate per rispondere al meglio alle nuove domande, ma è necessaria una risposta globale da parte delle aziende e del sistema sanitario.

Il monitoraggio dell’adeguatezza dei servizi non può limitarsi a valutare quanto si deve attendere per una prestazione non urgente ambulatoriale (come un’ecografia) oppure ospedaliera (come un intervento chirurgico elettivo); è indispensabile valutare il sistema anche per come risponde nelle emergenze e urgenze (quanto si attende in pronto soccorso prima di essere valutati da un medico e soprattutto quanto si resta in barella in pronto soccorso dopo che è stato deciso il ricovero).

Nella valutazione dei problemi e delle possibili soluzioni devono essere coinvolti i medici e gli infermieri impegnati dell’emergenza e urgenza, per una maggiore efficacia degli interventi; perché le risorse siano impiegate in base alla criticità della domanda sanitaria; per la sostenibilità del sistema, riguardo alle condizioni di lavoro degli operatori.

Push my Buttons – Mechanical CPR

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PRINTABLE HANDOUT PDF DOWNLOAD

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Automated Cardiopulmonary Resuscitation

Mechanical CPR

Good quality cardiopulmonary resuscitation (CPR) may improve cardiac and neurologic outcomes following cardiac arrest and this can theoretically be facilitated by various Mechanical CPR Devices that we will look at in this discussion.  Early CPR has been associated with increased survival and is therefore very important in the ‘chain of survival‘ following cardiac arrest.   For example, studies in the 1980s and 1990s suggested significant benefit from early bystander CPR and large observational studies in Japan have shown that compression only CPR may be favourable in adult cardiac arrest patients.  These studies have begun trends towards widespread public health promotion of hands only CPR:

Hard and Fast

Push Hard – Push Fast

The chain of survival (shown below) emphasises the key steps in attempting to achieve an improvement in the currently low rates of survival in sudden cardiac arrest.

The chain of survival includes recognition (and calling for help), early CPR, early defibrillation and expert post resuscitation care including angioplasty therapy in the catheter lab.

Disappointingly, overall mortality rates have only marginally improved in the last 10 years despite rollout of public education, training of healthcare professionals and improvement in emergency medical systems.  On-going  discussion of how to improve survival from cardiac arrest is an important public health issue.

The Chain of Survival

The Chain of Survival

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Phases of CPR

It can be helpful to think of CPR in 3 distinct phases:

  • Phase 1 - The Electrical Phase – an early shock should result in a Return of Spontaneous Circulation (ROSC) in patients with Ventricular Fibrillation (VF).
      • A Key concept in the “Chain of Survival”
      • Principle behind early defibrillation (and precordial thump) in witnessed arrests in hospital
      • DC shock should be administered as early as possible here
      • The basis behind the widespread uptake of Automated Electrical Defibrillators (AEDs) in the out of hospital setting

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  • Phase 2 - The Circulatory Phase – effective CPR will theoretically “prime the pump”.
      • Good quality (early) CPR is more likely to result in a Return of Spontaneous Circulation (ROSC).
      • Patients with ‘non shockable’ rhythms such as Pulseless Electrical Activity (PEA) and Asystole start in this phase.
      • This is the principle behind the emphasis on good quality CPR in the updated International Liaison Committee on Resuscitation (ILCOR) recommendations for resuscitation from 2010.
      • Several shocks may be required to revert VF.
      • Drugs may be helpful (at least in theory) to obtain ROSC.
  • Phase 3 - The Metabolic Phase – things ‘look really bad’ now!
      • There is a low chance of Return of Spontaneous Circulation (ROSC) due to accumulation of metabolic abnormalities.
      • There is ischaemia and cell death associated with prolonged hypoperfusion and a progressive severe metabolic acidosis.
      • End Tidal CO2 if often in the refractory low range (<10).  Specific patient groups are more likely to survive (hypothermia and toxicology).
3 Phases of CPR

3 Phases of CPR

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Automated CPR Machines

Automated CPR machines were introduced in the 1990s and have been used in limited clinical practice since then.

There are three main ways to deliver CPR – conventional manual compressions, pneumatic piston devices (i.e. Michigan® and Lucas®) and battery powered band compression machines (i.e. Zoll AutoPulse®)

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Automated CPR machines (‘thumpers’ and ‘band’ types) can provide consistent, good quality uninterrupted chest compressions.  They have the potential to improve outcomes in sudden cardiac arrest and may ‘buy time’ if used early in appropriate patients.

What is the Evidence Base?

There is some good evidence for increased efficiency in experimental and animal studies but to date there has been a lack of high quality clinical studies demonstrating an overall mortality benefit.  In fact, historically, results have been quite mixed with a landmark edition of JAMA in 2006 having two conflicting studies. One study (that was stopped early) showed a trend towards worsening outcomes with mechanical CPR and another study in the same issue suggested a potential benefit from a similar intervention.

Interestingly, in another negative study a year earlier called ASPIRE there appears to have been significant study protocol issues.  In the ASPIRE study there was trending towards harm from using the Zoll AutoPulse and the research was subsequently terminated after an interim analysis.  However, in the ASPIRE study there was a significant delay in applying the mechanical device in several patients in which time no active CPR was given.  One study centre recorded >10mins of delay to apply the device in most cases which may have worsened outcomes significantly in the mechanical CPR group.  Although the study was stopped early, later analysis suggested that this may have been due to protocol errors at one particular site rather than a truly harmful effect from mechanical CPR.

Provisional Results of the “CIRC” Trial are now undergoing scrutiny having been presented at various conferences.

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Potential Benefits of Mechanical CPR

  • CPR is a challenge in during transport – especially in a moving ambulance.
  • Defibrillation success is dependent on maintenance of an adequate circulation (e.g. ‘circulatory phase’ above)
  • Safety for staff
      • Injury of rescuers from exertion or being thrown in the motor vehicle
  • Minimising CPR rescuer tiredness
  • Free up rescuers to do other tasks (cannulation, airway, handover)
  • Consistent chest compressions (e.g. no fatigue factor)
  • Continuous chest compressions (e.g. no need to stop CPR for transfer or rescuer change)
  • Less Injury to the patient during CPR

Potential Harms and Limitations

  • Conflicting results have been seen in past studies of Mechanical CPR – some studies have shown worsening of mortality and neurological outcome
  • Cost of Purchase and Cost-effectiveness
    • Replaceable parts – a Zoll ‘life band’ costs in excess of $130
    • Device Cost – an initial outlay on the equipment is required to provide mechanical CPR
    • Training – staff need to be highly trained in the safe and effective use of the equipment
  • Cleaning and Maintenance
  • Time Taken to Place the machine effectively on the patient

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Specific Mechanical Devices

Zoll Autopulse

Zoll Autopulse

  • Cost
Cost

Cost

  • Zoll Limitations
      • Only use in patients under 130kg
      • Only use in patients over the age of 18
      • Only use in ‘non traumatic’ cardiac arrest
  • Pros
      • Circumferential band is less traumatic than thumper or manual CPR
      • Potential to read rhythm and give DC shocks ‘through’ on-going CPR
      • Relatively Easy to put on
      • Automated System
  • Cons
      • Cost (of both unit and disposable parts)
      • Noisy (but less so than the pneumatic devices described below)

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A Brief Video of the Zoll AutoPulse in Action

A Longer Tutorial Exploring Functions and Menu System

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  • Michigan Instruments
Pneumatic Thumper

Pneumatic Thumper

  • Thumper Costs
      • In the range of 1000 dollars (variable price)
  • Limitations of the Thumper Device
      • Overall Crudeness
      • Portability
  • Pros
      • Familiarity (device has been available since the 1990s and was widely used in some centres)
      • Cost
  • Cons
      • Trauma (rib/sternal injury)
      • Can be difficult to attach to the patient
      • Continues to ‘thump regardless’ – may injure patient or staff
      • Noisy

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Lucas Device

The LUCAS 2 Device

  • Costs
      • The LUCAS 2 is in the range of $15,000 to $20,000
  • LUCAS Limitations
      • Only in adults
      • Contraindicated in very obese or pregnant patients
      • The Original LUCAS had a high pressured gas consumption and a theoretical fire risk when O2 was used as the pressurising gas
  • Pros
      • Creates an active ‘decompression suction’ on upstroke
      • Portability (can be moved in bag and easily assemble)
      • Can work off a mains power supply or battery source
  • Cons
      • Training – adjustment is not automated unlike the AutoPulse
      • Trauma (rib/sternal injury)
      • Battery needs to be in housing for device to work
      • Cost
      • Compressed gas consumption
      • Noisy
      • Initial Pilot Study of its use failed to show benefit

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The LUCAS Device

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Conclusions

Mechanical Cardiopulmonary Resuscitation is likely to have an increasing role in the future of CPR.  Despite a lack of a current evidence base for its use it may be useful in selected cases especially  where prolonged CPR is required.  For example, it may be helpful to use Mechanical CPR in patients with refractory VF, Thrombolysis for Massive PE, Toxicological Arrest, Hypothermic Arrest and in arrested patients who are being transferred onto rescue VA ECMO.

Mechanical devices increase the efficiency and quality of CPR provided in experimental studies, which should intuitively improve outcomes.  However, in a clinical setting further studies are needed to confirm or refute the benefit of these devices in real life practice.


AutoPulse