• @emergency__doctor Checkout my feature ‘A Day in the Life’ by @aoafordos !
A DAY IN THE LIFE:
Max Lazarus, DO, PGY 2 (@emergency_doctor)
Emergency medicine resident at a Level 1 Trauma Center in New York and graduate of @nyitcomdo
I had a somewhat ‘non traditional’ path to medicine. I worked as a personal trainer full time throughout college while I majored in exercise physiology. My career as a trainer made me realize I wanted to help people, and heal them with more than just exercise so I decided to become a physician.
I was specifically attracted to the holistic education and emphasis on the human body from my time learning about health, wellness and exercise.
After finishing college, I was fortunate to be selected to do a summer internship called ‘Project Healthcare’ in the Emergency Department at Bellevue Hospital. The program was started by Dr. Lewis Goldfrank, a pioneer in emergency medicine and toxicology.
I spent the summer after college working 5-6 days a week there and fell in love with emergency medicine. I realized I wanted to be on the front lines of medicine helping the most destitute and acutely ill patients at anytime. Emergency medicine is thrilling to me because you are the doctor that’s ready for anything at anytime. #doctorsthatdo #emergencymedicine #pgy2 #osteopathicmedicine #baferd #jaferd
Strangulation has been identified as one of the most lethal forms of domestic violence and sexual assault: unconsciousness may occur within seconds and death within minutes. When domestic violence perpetrators choke (strangle) their victims, not only is this felonious assault, but it may be an attempted homicide.
Strangulation is an ultimate form of power and control where the batterer can demonstrate control over the victim’s next breath: it may have devastating psychological effects or a potentially fatal outcome.
Do you ever wonder what happens to the kids and teens that witness DV every year in America? Camp HOPE America offers camps sessions around the nation for kids who have witnessed domestic violence in the home and/or been negatively impacted by DV. This organization offers year-round camping and mentoring program for both children and teens. The focus of the camps are ingrained in creating collaborative, trauma-informed, and hope-centered pathways for trauma-exposed kids to believe in themselves, in others, and in their dreams.
#lastwarningshot #allianceforhopeinternational#caseygwinn #gaelstrack #drbillsmock#camphopeamerica #camphope #hopehealscamp#havehopetogivehope #strangulation #allianceforhope#domesticviolence #camphopeamerica#emergencytraumamama #runswithtraumashears
As a trauma nurse that is cross-trained with a master of forensic science degree, I spend a lot of time thinking about recognition & assessment of strangulation patients. •
Strangulation and Domestic Violence
Strangulation has been identified as one of the most lethal forms of domestic violence. It is one of the best predictors for subsequent homicide. Prior strangulation increases the odds of strangulation homicide by more than seven times. For perpetrators, strangulation is the ultimate form of power and control. However, because there are often no visible injuries, patients, physicians, and law enforcement often minimize the possible health consequences of reported strangulation.
The vasculature of the neck is relatively unprotected and vulnerable to injury and vascular occlusion. The application of 4.4 pounds of pressure to the jugular veins causes venous outflow obstruction from the brain and thus stagnant hypoxia. Eleven pounds of pressure to the carotid arteries can cause loss of consciousness in approximately 10 seconds. Compression of the trachea requires significantly more force: 33 pounds of pressure for occlusion and 35 pounds to fracture tracheal cartilage.
Strangulation can be fatal in as little as four to five minutes. Mechanisms in addition to hypoxia due to vascular occlusion have been proposed. Pressure on the carotid body may cause bradycardia and subsequent cardiac arrest. Delayed mortality may be caused by carotid artery dissection, aspiration, postobstructive pulmonary edema, acute respiratory distress syndrome, or tracheal injury.
📓: ACEP Now, Heather V. Rozzi, MD, FACEP; and Ralph Riviello, MD, MS/April 2019
It’s critical to understand RAAS for critically ill/traumatically injured shock patients. The RAAS regulates blood pressure and fluid balance in the body. When blood volume or sodium levels in the body are low, or potassium is high, cells in the kidney release the enzyme, renin. Renin converts angiotensinogen, which is produced in the liver, to the hormone angiotensin I. An enzyme known as ACE or angiotensin-converting enzyme found in the lungs metabolizes angiotensin I into angiotensin II. Angiotensin II causes blood vessels to constrict and blood pressure to increase. Angiotensin II stimulates the release of the hormone aldosterone in the adrenal glands, which causes the renal tubules to retain sodium and water and excrete potassium. Together, angiotensin II and aldosterone work to raise blood volume, BP and sodium levels in the blood to restore the balance of sodium, potassium, and fluids in an attempt to normalize the BP in an otherwise “shocky” patient.
Hypovolemic shock occurs due to loss of in total volume of blood, available for circulation. Whether the bleeding is caused by blunt or penetrating trauma, the loss of blood stimulated baroreceptors in the carotid bodies and aortic arch to speed up the HR. HR X SV=CO.
When pts are trying to compensate hypovolemic shock, RAAS (Renin angiotensin aldosterone system) is activated.
The activated RAAS system releases angiotensin II. Angiotensin II causes vasoconstriction of arteries and veins, thereby increasing blood pressure. It also promotes adrenal cortex to secrete aldosterone. Aldosterone in turn stimulates sodium and water retention as well as excretion of potassium from kidneys. The resulting high sodium ions in the serum causes secretion of ADH (antidiuretic hormone). ADH intensifies water reabsorption, resulting in increased blood volume, BP (blood pressure) and CO (cardiac output). This is why we frequently see our hypovolemic trauma patients present with tachycardia and hypotension, depending on which stage of shock they present with.
#themoreyouknow #nclex #nclexprep #nclexstudying#nclexreview #nursingschool #nursingstudent#nursingstudentlife
💉🚑🚑💉💉🚑🚑💉💉🚑🚑🚑🚑 The lethal trauma triad of death is one of the things that increases trauma patients morbidity & mortality. By majority, the answer would be hypovolemic shock. Hypovolemia is defined as a state in which there is a decrease in plasma volume within the body. Hypovolemia, if severe enough, produces shock. Shock is defined as inadequate tissue perfusion combined with the inadequate removal of cellular wastes, ultimately producing a defect in oxidative metabolism and therefore a subsequent dysfunction in the way that the body transports, delivers, and utilized oxygen. Hypovolemic shock in trauma patients often stems from acute hemorrhage. •
Hypovolemic shock secondary to hemorrhage produces a lethal triad
Hypovolemic shock produces several defects in physiology. The decreased intravascular fluid volume decreases venous return to the heart, which ultimately reduces preload and stroke volume (SV). The body initially compensates for the decreased SV by increasing the heart rate in order to maintain cardiac output (CO). Eventually CO decreases and subsequently results in decreased end-organ perfusion.
As the body becomes deprived of oxygen, aerobic metabolism shifts to anaerobic metabolism. This shift causes the build up of lactic acid, which ultimately produces metabolic acidosis. The hemorrhage in hypovolemic shock results in extreme activation of prothrombin, which causes an excess of thrombin formation. The excess thrombin causes the conversion of fibrinogen to fibrin. Fibrin activation produces wide-spread clot formation. This process depletes coagulation factors. Overtime, secondary fibrinolysis and coagulopathy results in further bleeding. As the hemorrhage progresses, hypothermia results from excess shunting of blood away from extremities producing a “shocky” looking patient who is clamped down.
The patient usually has delayed cap refill and w/kids an early sign is a gap between central and peripheral pulses. Giving volume such as whole blood or 1:1:1 of PRBC’s/platelets/FFP is what the patient needs in order to achieve homeostasis, maintain normal perfusion and to hopefully achieve a MAP of 65.
Have you ever taken care of a pediatric patient who was left in a hot car during the summer and suffered from hyperthermia? •
Have you even thought about what kinds of clinical complications you may see w/this type of case? If so, tune in now to my new podcast episode….👂🏼
👶🏼🚁🚑🏩 #newpodcastalert #newpodcastepisode #pals #enpc #ena #emergencynurse #pediatrichyperthermia #rhabdomyolysis #hypoglycemia #electrolyteimbalance #emergencytraumamama
Being a trauma nurse means studying on your days off. It means reading EBP articles because you want to know what is “cutting edge”. It means going to a class on a Sunday morning because you want to do more, teach more, and above all save more lives. Stay thirsty for knowledge my friends 💉💯💪🏻
~The Verkinator ✌🏼
• @theedtraumacist Vancomycin is a tricyclic glycopeptide antibiotic used to cover gram➕bacteria such as methicillin resistant Staphylococcus aureus. 💉
Vancomycin works by inhibiting bacterial cell wall synthesis by binding to D-alanyl-D-alanine cell wall precursors, inhibiting polymerization and preventing linkage to the glycopeptide polymer located within the bacteria’s cell wall.
When dosing vancomycin a couple of factors should be considered including the patient’s weight, renal function, and presenting disease state. It is normally
dosed at 15-20 mg/kg, and even higher for more severe infections (25-30 mg/kg in patients with sepsis, infective endocarditis, meningitis, etc. with a max dose depending on your hospital protocol).
In a study by Fuller and colleagues that reviewed vancomycin management in the ED, they reviewed 4441 doses of vancomycin given to patients with a weight measurement available. Vancomycin was dosed correctly in only 22.1% of patients 😧 with 71 % of patients being dosed below the recommended dose of 15-20 mg/kg 😱. Vancomycin dosing is not one size fits all and patient specific characteristics should be considered when dosing this medication. 💉
#theedtraumacist #trauma #traumaninjas #miamitrauma #traumiami #emergencymedicine #emergencydepartment #pharmacy #pharmacylife #pharmlife #pharmvida #pharmsohard #pharmacystudent #pharmacyresident #pharmer
Have you ever taken care of a pt who had an altered mental status (AMS)? Patients with an altered mental status (or ALOC)are among the toughest to assess since there is no classic, “one size fits all” presentation.
The clinical presentation is often obscure, which makes recognizing changes in mental status a challenging endeavor. There are certain underlying pathophysiological conditions that can cause AMS. This is one of the largest differential diagnoses you may encounter in the ED, EMS or hospital setting.
1-START WITH THE ABCS, IV, O2, ✔️skins & 12 lead 🖤💙🖤
2-ASSESS the pt & extrapolate info from the family (i.e. med list) 💊
3-GET labs: ISTATs, & venous blood gas (VBG) 💉
4-Use AEIOUTIPS mnemonic to help w/DDx
5-Listen to emergency trauma mama’s new podcast to review a super interesting case study 😲💪🏻💯🤗
answer: C. Remember the epidural bleeds are a tear of the middle meningeal artery, which is located in temporal lobe. The biggest clue is location AND pt presentation. The pt has a period of lucidity, and then falls into a decreased LOC after “they appear fine” right after the incident. Case in point, Natasha Richardson’s skiing accident proved fatal after she fell, struck her head (no helmet) and did not go to the ED to get a scan. Sadly, she died from her epidural bleed.
Let’s talk about a + seatbelt sign and what that could mean when taking care of your trauma patients. Always anticipate the types of injuries that you will see such as:
1. Hemothorax, pneumothorax or hemopneumothorax
2. Clavicular fx’s
3. Blunt abdominal injury with active internal bleeds such as small bowel rupture or mesenteric artery tears. Initial FAST may or may not see so emphasis on pt presentation and repeat FAST exams are key especially in the case of fluctuating patient stability.
4. Traumatic kyphosis with paraparesis
5. Teardrop fx’s L-S spine
6. Chance fx’s-usually related to lap seatbelt use, this mechanism can result in complete ligamentous injury or a combination of bony, ligament, and disk involvement.
Lap belt ecchymosis or “positive seatbelt sign” accounts for approx. 20% of mesenteric, bowel and lumbar spine injuries.
#emergencymedicine #seatbeltsign#emergencytraumamama #emergencynurse #trauma#traumaassessment #fastexam #repeatfastexams#traumamama #traumanurse #traumajunkie#traumainformed #themoreyouknow#nursessupporttheiryoung #nursessupportingnurses#nursesofinstagram #nurseswholift #nurseswhoworkout#nurseswhorock #nurseswithtattoos #nursingstudent#ems #emsstudent #paramedicschool #paramedic
Different “strokes” for different folks.
CVA=Vascular injury that reduces cerebral blood flow to specific region of brain causing neuro impairment
determination of last known time when patient was at baseline is essential. Time = brain.
ISCHEMIC STROKE CAUSES
Thrombotic (80% of ischemic CVA)
verteberal & carotid artery dissection
Embolic (20% of ischemic CVA)
Arterial-arterial emboli from proximal source
Cardiac failure resulting in systemic
Berry aneurysm rupture
CINCINNATI PREHOSPITAL STROKE SCALE
1 .Facial droop
2. Arm drift
All 3 present >85% acute stroke
Also incorporated into public awareness “FAST” = face, arm, speech, time
Ischemic, cerebellar, transient ischemic attack (TIA), hemorrhagic, intracerebral,subarachnoid
Wikiem.org for more indepth. This is a HUGE topic with many different niches.
#brain #trauma #medicine #hospital #rn #nurse#paramedic #medic #medical #medicalstudent#medicalschool #stroke #hospital #trauma #golf #swing#ems #ambulance #learn #sports #club #emergency #ems#science #pga #golfing #athlete #train #practice #fire#firefighter #neurology #neuro
So let’s talk about this….because I think there is an obvious disconnect between what ppl learn in school, what is clinically relevant and why the hospital should probably talk more about HIPPA in hospital orientation. Under NO CIRCUMSTANCES is it ok to go nosing around in a chart because the case looks interesting. If you have ZERO medical necessity to be in that chart, you should never OPEN IT!! I realize that this case got a TON of media attention. As a medical professional though, it’s our JOB to protect everyone’s medical information with the same confidentiality as we would want our chart to be treated. I remember a similar situation arose when Britney Spears was hospitalized a long time ago at Cedars Sinai Hospital in LA. Ppl literally opened her medical chart to read about her psychiatric illness because they were NOSY. I mean really…srsly??! If you are not a psych nurse taking care of Britney, you CANNOT OPEN HER CHART. PERIOD! I am not sure why ppl thought it was ok to open Jussie Smollett’s chart. Perhaps they didn’t understand digital forensics. For every chart you open, Big Brother is ALWAYS watching. Every EMR can track who, what, when and how long you are in every chart you open. If you have no reason to be in a chart, you will be red-flagged…particularly on such a high profile case such as this. In addition, same name look-ups are also a HUGE NO-NO!!😱. I realize you don’t want to wait the extra 3-4 days before hearing your results from your regular PCP, but you CANNOT look up your own medical results. This is another huge RED FLAG in the EMR & it can potentially get you fired.
Oh, and btw, if you are posting anything about any case on social media you can also get fired. I know several nurses who have posted about a trauma case and got fired for it. The bottom line is, with everyone having a camera, recording device in their hand, taking pics or posting has become second nature. But the medical professional in you should always ask, how would I feel is I saw my partially amputated digit posted on the internet? It is such a serious epidemic and most hospitals have a written policy and procedure on it now.
Bottom line, learn from others mistakes and even if your curious, DON’T DO IT!! It could cost you your job and no breach of confidentiality of worth it.
-The Verkinator ✌🏼
Remember that the reversal agent for benzodiazepines (Xanax, Ativan, Valium)=Romazicon (flumazenil) 👇🏽👇🏽👇🏽 Narcan-CAN reverse NARCOTICS (morphine, heroin etc.). 👇🏽👇🏽👇🏽
Always have the reversal agents on hand for every drug that you are using, especially when performing a moderate sedation or any other type of procedure.
In addition, have an Ambu bag, & an
NP/OPA handy. Airway adjuncts are appropriate in the event the patient suffers from unanticipated respiratory issues, which are the most known side effect of the majority of these drugs. 👇🏽👇🏽👇🏽
Use your nasal cannula w/ETCO2 monitoring so you can ensure your patients oxygenation & ventilation status.
Maintain 35-45 and watch the waveform. 👇🏽👇🏽👇🏽
Senior RN tip: I usually bring the crash cart in the room and then I feel more prepared for any potential complications.
Case study initial care plan Post 1B:
Tension Pneumothorax, Internal Hemorrhage, TBI
M: Compression dressings (TQs/wound packing if continued bleeding)
A: Check SPO2, consider NPA, O2 if available
R: Look/Listen for bilateral rise and fall
C: Start IV/IO and prepare Whole Blood
H/H: Elevate head (Prevent the 3 H’s-Hypoytension, Hypoxia, Hyperventilation), Warm patient
New Grad Advice-From The Verkinator 👇🏽👇🏽
Shout out to all of the new grads or soon to be new grads 🔊🔈We all learn by repetition and NONE of us will ever be PERFECT. When you graduate, remember to take a deep breath and ask yourself, “is anyone dying?” If so, move quickly and ask for help from your senior nurses and charge. If not, still TAKE A DEEP BREATH and ask for help from your senior nurses or charge. None of us learned to run before we crawled. We all had to go through the emotional roller coaster of that 1st year of nursing. We have all cried on the way home from our 12.5-13 hour night shifts mentally, emotionally and physically exhausted. Sometimes certain cases or patients stick w/us, and you NEVER forget that really valiant resuscitation of the 16 y/o GSW or the peds trauma that you couldn’t save. Know that you are NEVER alone. You don’t wak your nursing journey alone because there are ppl like me and many others that are here to educate, support and mentor you. Yes, there are a LOT OF NEGATIVE NANCIES out there that can be bullies, passive aggressive, narcissistic, and have SUPER inflated egos but the majority of us care…A LOT!!! When you are feeling defeated in your first year, seek US out. Seek one of the good guys/gals, because we will always support, nurture and mentor our younger RN’s. Never walk in your nursing journey alone, I assure you we have ALL felt defeated at one time or another. You didn’t come this far to fail. Just remember take care of yourself first, be patient with yourself and that every shift you are learning.
You can DO this💪🏻💯👌🏼 .
. ✌🏼-The Verkinator
#nursingschool #nursesofinstagram #nurseswholift #nursestudent #nurseswithtattoos #nurseswithink #nursessupporttheiryoung #nurseseducatingnurses #nursestrong #nurse💉 #nurseinspiration #nurselife #nurseblogger #nurseeducator #emergencynurse #emergencytraumamama
Regram from IG@rishimd
Every day as an anesthesiologist, I reconstitute, draw up, and administer antibiotics, hypnotics, narcotics, paralytics, inotropes/pressors, blood products, fluids, vasodilators, and a myriad of other medications. Each year, the FDA receives over 100,000 reports associated with a suspected medication error causing hospitalization, life-threatening emergency, morbidity, and even death! 😷💉
In light of the recent headlines regarding the fatal administration of vecuronium instead of midazolam (Versed), I wanted to see how you all promote safe medication administration practices. Here are two things I do with virtually every medication:
First, I pre-label my syringes both sideways and circumferentially. Next, whenever I draw medications out of a vial, I have the inverted medication label facing me and the syringe label. This way, I can ensure I’m filling the right syringe with the right medication at the expected concentration. 💉👍
Whether it’s cross-checking certain medications with a licensed provider, separating medications which look and sound similar, using electronically generated labels from medication QR codes, or even simple “off-the-protocol” tips, drop me a comment with what you do regarding medication safety and a tag a friend who might be interested in seeing suggestions! We need to do better! 🙏🏽👇
HR 168, BP 140, paranoid, hyperactive. The stains on “wife-beater” indicated that it had gone a few rounds of if right-side-on/inside-out without ever seeing the inside of a washing machine. “What’d you do bro?” I asked. He quickly looked left, then right at the passing unicorns and chupacabras. “He said he swallowed a rock,” said the medic.
It really didn’t matter. When a body-packer(someone who is smuggling wrapped up drugs in their guts) has one of the packages burst, it is often times deadly. The massive bolus of the stimulant can cause tachycardia, arrhythmias, and death.
What would possess someone to knowingly ingest a meth rock when no cops were trying to bust him for posession?
I didn’t have time to solve that riddle. “Grab me 10mg of Ativan.” I saw the hesitancy in her eyes, but off to the Pyxis she went. “Push Ativan 4mg.” HR 167. BP holding steady.
“Another 4mg.” HR 167…like pissing on a forest fire.
“I’ll push the other 2mg, just grab 10mg more.”
6mg…4mg…HR 160. 10mg…HR 152, unicorns everywhere. 6mg…4mg…HR 144, gone were the chupacabras, but still awake and talking. 4mg…HR 135 and talking. 4mg…HR 124 and calm. 2mg….HR 115, drowsy but easily arousable, protecting the airway. “I think we’re good.” “Wrraaabbgghhh,” he said in agreement. HR 112, SBP 125, O2 sat 94% on room air.
Then the answer struck me. As a young scientist, we would do most experiments in vitro(in a test tube). Rarely in vivo(in a living cell). This addict realized that if he had smoked or shot up this entire rock, the massive bolus through his veins or lungs would have been immediately lethal. But swallowing this rock would allow his gut to slowly digest it. Allowing him to achieve the longest high while walking the thin line between life and death. This was his in vivo experiment.
Over the years, I’ve confirmed my hypothesis with other toothless scientific colleagues that repeated this in vivo experiment on a larger scale, but this is the only one with photographic evidence.
#tbt #moredrugsplease #ativan #methkills #resuscitology#toxicology #ER #dontdodrugs #EMS #paramedic#ambulance #Emergency #flightmedic #flightrn
Ceftriaxone (Rocephin) is an intravenous/intramuscular third generation cephalosporin that provides decent aerobic gram positive coverage (ie, pneumococcus although bacterial resistance is growing) but wonderful gram negative coverage against organisms like E. coli, Klebsiella, H. flu, and Proteus. Anaerobic bacteria and Pseudomonas are NOT covered by ceftriaxone. 🤓💉
As an intensivist, I use this antibiotic in a myriad of clinical situations ranging from spontaneous bacterial peritonitis (SBP) prophylaxis and community acquired pneumonia to genitourinary infections and meningitis (even late Lyme disease involving the central nervous system as ceftriaxone as penetrates the cerebrospinal fluid very well). 😷🧠
Similar to cefepime, ceftriaxone can also cause encephalopathy and altered mentation. Additionally, one must be aware of possible hepatobiliary impairment due to biliary sludging and cholecystitis. 👨🏽⚕️🏥
My favorite aspect of using ceftriaxone is that it can usually be dosed once-a-day (a key exception being meningeal dosing which is twice daily). 😊
Levetiracetam (Keppra) is an oral and intravenous antiepileptic drug (AED) indicated as adjunctive therapy for partial onset seizures, myoclonic seizures, and generalized tonic-clonic (“grand mal”) seizures in adults. The medication is used in the pediatric population as well for various reasons beyond my scope of practice. Most AEDs either enhance the release or limit the uptake of GABA – the primary inhibitory neurotransmitter in the central nervous system. Levetiracetam’s activity is thought to center around SV2A, a ubiquitous synaptic vesicle protein involved in regulating the exocytosis of neurotransmitters from vesicles. 💉🤓
Post-traumatic seizures (PTSs) are fairly common in patients who sustain traumatic brain injuries (TBIs), and the early initiation of AEDs like phenytoin help decrease early PTS in severe TBI; however NO AED prophylaxis I’m aware of helps prevent late TBIs. Lower levels of data suggest that newer AEDs like levetiracetam may be a safer alternative to phenytoin for early PTS prophylaxis. 👍🏥
As an anesthesiologist, I can’t remember when I last administered levetiracetam intraoperatively (general anesthesia tends to be a pretty good antiepileptic itself), but as an intensivist, I’ve written for this many times at the recommendation of my colleagues in neurology. Interestingly, the oral formulation of levetiracetam is ~100% bioavailable, and its renally-excreted metabolites have no activity. 😷
Regardless of why it’s given, levetiracetam can increase the risk of suicidal ideations (even within a week), so providers must remain vigilant about any unusual changes in mood or behavior in patients initiated on therapy. 👨🏽⚕️
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#drugoftheday Diltiazem (Cardizem)-drug class: calcium channel blocker (CCB) Diltiazem (Cardizem) is a Class IV antiarrhythmic and one of the most common pharmacological agents used for treatment of AFib w/RVR (rapid ventricular response). Class IV antiarrhythmics are Calcium Channel Blockers (CCBs), which inhibit intracellular calcium influx via calcium channel antagonism.🖤💙 Although dosages may vary based on physician orders, protocols and age, a standard initial dose is 0.25 mg/kg, ranging between 10-20 mg over 2 minutes, with a second dose of 0.35 mg/kg, ranging between 20-25 mg over 2 minutes, often followed by a 5-10 mg/hr infusion. 💉 Typically, patients are given a bolus, followed by a gtt (drip). Treatment of hemodynamically unstable patients in narrow QRS complex AFib w/RVR requires synchronized cardioversion at 120-200 J initially, and should not be delayed for administration of an anti-arrhythmic agent.
Quickie YT link:
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Regram @thewildrn What do you think of this rhythm? >80 y/o old M presents to ED for dysuria and 'orange-colored' urine. On assessment, the patient appears jaundiced with ascites. Labs show significantly elevated LFTs and BNP. During a routine vitals assessments, the patient has a brief syncopal episode during which this rhythm appears on the monitor. What is the priority intervention?🤔😱🤔 ⠀⠀⠀⠀⠀⠀⠀⠀⠀ A. Atropine IVP B. Transcutaneous pacing (TCP) C. Synchronized cardioversion D. Dopamine IV gtt
If you think you have had a “bad shift”, read about this MD’s shift the night of the MCI (mass casualty incident) happened in Vegas 1 October 2017.
If you haven’t tuned into this special on Oxygen on Saturday nights, you can watch it on demand. It’s a very interesting show about some retired detectives investigating a string of deaths of young men that are thrown into a body of water. The biggest twist is they feel it is a cell of ppl that are bonded via the dark web as the M. O’s are all extremely similar. The men have either GHB or TCA’s or an alternative drug in their system that would have helped to incapacitate them in some way, shape or form. In addition, the cases are years apart, different cities, and there is always graffiti of a smiley face found near where the body is dumped or found. From a forensic standpoint, some of these men’s deaths have been ruled “accidental” when in fact there are clues (as told by Dr. Cyril Wecht) that lead the team to help reopen the majority of cases, because they blatantly scream homicide. Very intriguing show!
Ex-Vanderbilt nurse charged with reckless homicide pleads not guilty
— Read on nurseslabs.com/ex-vanderbilt-nurse-charged-with-reckless-homicide-pleads-not-guilty/
#FOAMed Case: https://bit.ly/2UWuV15
• 17 y/o male, scalp mass growth 1 month, headaches radiating from it
• No fever, weight loss, vision changes, nausea, vomiting, difficulty walking.
• Mass was flesh colored; I&C at outside facility now red & bloody
• Neuro exam normal
Nurse accused of fatal drug exchange error, does not plead guilty
To all of my nursing students PAST AND PRESENT:
You ARE THE FACE OF NURSING. Represent this profession with the utmost confidence. Know that every patient room you walk into, you have the possibility to make a difference in their life. The ability to make a difference in someone’s life is a privilege and an honor. DO NOT TAKE THIS RESPONSIBILITY LIGHTLY. Question everything, take nothing at face value and never assume that something someone told you is always right unless they are a trusted colleague with a proven track record. Check and cross check your meds. If something doesn’t feel right IT PROBABLY ISNT. Follow your gut. Your intuition is correct. That tiny voice that is whispering “this patient is sicker than he seems” “that rash doesn’t look right” “that toddler is breathing too fast” TRUST YOUR GUT. It will not steer you wrong. If you are scared, nervous or unsure of a skill ask a senior trusted RN colleague. Don’t say you know it all. NO ONE knows it all. You will be in this profession for your whole career and never know it all. This is WHY we call nurses lifelong learners. This is why we rely so heavily upon EBP. Things change daily in nursing. Please take my words to heart. Long after I take my last breath this and have bequeathed all of my nursing knowledge, YOU ARE THE FUTURE OF NURSING IN AMERICA. Be the mentor, be the role model be the epitome of professionalism at all times. Be the nurse who walks into the patients room and looks to heal him physically, emotionally and mentally. Remember that every patient typically needs healing for their heart, body and mind. Be the nurse who takes care of patients not just for a paycheck, but because you have a passion for saving lives for a living. The art of nursing is making a difference in patients lives. Bring peace, kindness and empathy into every room that you walk into. Give compassion to those who have lived rough lives and are fighting addictions. Give some of your time to the elderly widow that needs to talk because she is lonely. Give your biggest smile to a scared child and remember to be understanding to his or her frightened parents. Remember that every patient is someone’s aunt, uncle, brother, husband or wife. Treat your patients the way you would want someone to treat you or your family. Be a patient advocate. Fight fiercely for those who can no longer speak or forget to advocate for themselves. Remember that nursing is a calling, and you are called to care for everyone equally no matter their race, creed, religion or political views. Be compassionate. Every patient. Every time. Be consistent, empathetic and work well with others. Learn something new each day. Smile when you walk down the hospital hall. Remember being new isn’t a disease. Remember when you are a new RN it’s a tough learning curve for a whole year. Also, find your nursing tribe and love them hard. Don’t allow negative self talk in your head. For every negative thing you say to yourself say 10 positive things. Find a hobby. Don’t pick up overtime your first year out of school. Most of all, be the kind of nurse you want to follow after a super busy 12 hour shift.
Follow these rules, you’ll be a-👌🏼©️emergencytraumama
This is the case study I featured in my podcast “Nurse Hathaway’s Heaven” this week.
Author: Juli Havens-Verkler
Copyright 2004 by the Emergency Nurses Association.
A73-year-old woman presented to the ED triage desk with the chief complaint of ‘‘legs not working.’’ She stated that she had had problems moving every- thing from the waist down since the previous week and had seen her primary care physician 5 days earlier. Results from both a magnetic resonance imaging scan of her back and hips and a lumbar sacral (LS) spine radiogram series were negative at that time. She denied having a fever or headache. Her vital signs at triage were as follows: temperature, 36.2jC (97.1jF); pulse, 77 beats per minute; respiratory rate, 14 breaths per minute; blood pressure, 179/85 mm Hg; and SpO2, 97% on room air. Her medications included simvas- tatin (Zocor), rofecoxib (Vioxx), and an antihypertensive drug. The patient had a history of hypercholesterolemia, angioplasty, myocardial infarction with stent placement in the left anterior descending coronary artery, chronic ob- structive pulmonary disease, pneumonia, and arthritis.
The emergency physician developed a differential diagnosis list that included myocardial infarction, exacer- bation of arthritis, musculoskeletal strain, carbon monox- ide poisoning, congestive heart failure, and transient ischemic attack. He ordered blood tests, chest and LS spine radiograms, and a computerized axial tomography scan of the head. We initiated an intravenous line and administered a bolus of 200 mL of 0.9% normal saline solution and then continued administration of the saline solution at a maintenance rate of 100 mL/h.
Interpretations of the patient’s EKG, computerized axial tomography scan, and chest and LS spine radiograms were negative, as were the results of her sedimentation rate, thyroid-stimulating hormone, troponin I, and brain natri- uretic peptide and carbon monoxide levels. (Abnormal test
JOURNAL OF EMERGENCY NURSING 9
Initial laboratory values
Neutrophils (%) Lymphocytes (%)
CK-MB Act CK-MB (%)
Cola – colored Protein Blood Leukocytes Bacteria WBC
53 mg/dL 1.6 mg/dL 27,680 IU/L 180 ng/mL 0.7
100 mg/dL Large Moderate Present 25/HPF
8 –23 mg/dL 0.6–1.1 mg/dL 24 –199 IU/L 0.0 ng/mL
Negative Negative Negative Absent
0 – 5/HPF
BUN, Blood urea nitrogen; CBC, complete blood cell count; CK, creatine phosphokinase; WBC, white blood cell count.
results are listed in Table 1.) What condition should the emergency nurse suspect?
Even at the lowest prescribed dose and in the absence of adverse drug interactions, ‘‘simvastatin. . . can cause potentially life-threatening rhabdomyolysis.’’
This patient was triaged to the ‘‘emergent’’ category and diagnosed by the emergency physician as having quadriceps muscle weakness, renal insufficiency, and rhabdomyolysis resulting from simvastatin use. She was admitted to the medical-surgical unit and had an excellent outcome as a result of a quick and accurate diagnosis and treatment.
Our patient had a textbook case of rhabdomyolysis, ‘‘characterized by muscle cell necrosis and release of muscle cell components into the circulation, most notably creat- inine phosphokinase and myoglobin.’’1 Emergency nurses
may see this condition most commonly in an elderly patient who sustains a ground level fall at home and then is ‘‘down’’ for a period of time because of a hip fracture.
Rhabdomyolysis may occur when certain drugs are taken in overdose (eg, cocaine or amphetamines), or even when drugs are taken in normal doses, such as the simvastatin described here. Our patient demonstrated some of the classic clinical manifestations of rhabdomyol- ysis, including muscle weakness, generalized malaise, and ‘‘Coca-Cola’’–colored urine. The change in the urine color was the result of myoglobinuria, where myoglobin clogs the renal tubules, thereby slowing the glomerular filtration rate and finally changing the urine color and decreasing the urine output. Our patient excreted approx- imately 350 mL of dark amber urine prior to her transport to the floor.
The incidence of rhabdomyolysis in the rapidly in- creasing population of patients taking ‘‘statin’’ drugs is approximately 5%.2 According to the Physicians’ Desk Reference, ‘‘Patients…[taking] simvastatin should be ad- vised of the risk of myopathy and told to report promptly unexplained muscle pain, tenderness, or weakness.’’3 A number of disparate drugs, such as erythromycin and verapamil, may increase the risk of myopathy when combined with simvastatin. However, even at the lowest prescribed dose and in the absence of adverse drug interactions, ‘‘simvastatin. . . can cause potentially life- threatening rhabdomyolysis.’’4 Older individuals and women also appear to be particularly predisposed to statin-induced rhabdomyolsis.5 Whether or not the patients also have acute renal failure, some have died from simvastatin-induced rhabdomyolysis.2
With the increasing number of physicians prescribing ‘‘statins’’ for hypercholesterolemia, be aware that there can be significant adverse effects from this class of drugs.
Treatment of rhabdomyolysis includes aggressive rehy- dration. Initially, our patient received an intravenous crys- talloid bolus of 200 mL and then received maintenance fluids of 0.9% normal saline solution at 100 mL/h. After we received the result of her creatinine phosphokinase, we increased the intravenous fluids to 500 mL/h. We inserted a Foley catheter with a urine meter to accurately monitor her hydration status. Our focus was to maintain an adequate urine output for our patient and prevent acute renal failure.
The key to our patients’ symptoms often can be found in the bags of medications that they bring to triage. With the increasing number of physicians prescribing ‘‘statins’’ for hypercholesterolemia, be aware that there can be significant adverse effects from this class of drugs, including serious neurologic effects such as severe memory loss.6 Timely triage, accurate diagnosis, and immediate interventions can prevent the patient from experiencing acute renal failure, as was well illustrated by this case. After the patient is stabilized, the physician may choose to decrease the dose of the ‘‘statin’’ medication or stop the medication completely.
1. Baggaley P. Rhabdomyolysis page [online] [retrieved 2001 Oc-
tober 21]. Available from: URL: http://members.tripod.com/
2. Merck & Co Inc. Website for simvastatin (Zocor) for healthcare professionals [online] [retrieved 2003 March 6]. Available from: URL: http://www.zocor.com/zocor/shared/documents/english/pi.pdf.
3. Physicians desk reference. 56th ed. Montvale (NJ): Medical Economics; 2002. p. 2221.
4. Pershad A, Cardello FP. Simvastatin and rhabdomyolysis—a case report and brief review. J Pharmacol Technol 1999;15: 88-9. Retrieved 2003 June 3 from: URL: http://jpharmtechnol. com/abstracts/volume15/May-June/88.html.
5. Ponte C. High dose simvastatin and rhabdomyolysis. Am J Health Systems Pharmacol 60(7);697-700. Retrieved 2003 June 3 from: URL: http://www.medscape.com/viewarticle/452570_3.
6. Orsi A, Sherman O, Woldselassie Z. Simvastatin-associated memory loss. Pharmacotherapy 2001;26:767-9.
This section features actual emergency situations with particular educational value for the emergency nurse. Contributions (4 to 6 typed, double-spaced pages) should include a case summary focused on the emergency care phase, accompanied by pertinent case commentary. Submit to:
Anne Marie Lewis, RN, BSN, BA, MA, CEN, Section Editor, c/o Managing Editor, 77 Rolling Ridge Rd, Amherst, MA 01002
800 900-9659, ext 4044 . email@example.com
February 2004 30:1 JOURNAL OF EMERGENCY NURSING 11
Antidepressants, particularly SSRI’s are common in your patient’s med list. It’s super important to understand how they work in the brain, some common side effects and what to look for in the case of overdose (OD), whether it be accidental or with suicidal intent.
On one of my most recent podcasts, I made a 2 part program about nurse bullying. Why? Because it is prevalent in today’s nursing profession and most hospitals DO KNOW it exists. What they neglect to do is to have any kind of policy and procedure outlining bullying behavior. Back when sexual discrimination was new on the scene, EVERY human resource (HR) employee was given hours of education and told, “we have a zero tolerance policy on this”. I am curious as to why hospitals, academic facilities and schools don’t do more about this issue. In nursing, there are STILL old school nurses that think it’s cool to “eat their young”. I have news for them, it was never cool, and I (as an older and experienced nurse) support the newer RN’s as they come into our profession. No one came into nursing knowing everything. I tell everyone “I will never know everything!” Nursing is about giving a hand out and a hand up so that we can all take great care of our patients. We all have the SAME goal at hand. Besides, teaching and supporting the newer RN’s gives me a sense that I am doing my part for the next generation. If I am ever a patient when I’m old, maybe a RN that I taught someday will be taking care of me. If that is the case, I am confident they will have amazing clinical skills, because I believe in supporting, nurturing, mentoring and coaching the new RN’s from novice to expert. That’s how I roll.
A long time ago, I was thrust into the preceptor role when we didn’t even have a preceptor “class”. Someone just said, “you like to teach, why don’t you take one of the new nurses and train her?” Of course, I agreed. That nurse that I taught has now been a certified flight RN #cfrn for over 15 years. 18 years ago, I decided to get my CEN #cen and that was my 1st certification exam. Today, I have taught numerous clinical rotations, paramedic interns, nursing students, residents, emergency nurses, trauma nurses and I am grateful that my certifications help to pave the way by showing my continued dedication to being a lifelong learner and nursing excellence. •
Follow BCEN certifications or anyone in the BCEN #instacrew (all members tagged in my pic) for more info about what being a certified RN means or how to prepare, sit for a certification exam 😃💯 #bcen #cen #tcrn #cpen #cfrn #ctrn #bcenmywhy #nurseeducator #traumamama #runswithscissors #showmeyourshears #emergencytraumamama
• @the_resuscitationist .
AUTOMATIVE CPR MACHINES: to include “lucas” “autopulse” etc.
BOTTOM LINE: these do NOT increase rates of survival and out of hospital discharge neurointact. .
POLARIZING statement I know… but this isn’t just an emotional based opinion. Multiple studies over the years (I can send them to you or a quick search) shows no increased survival when compared to manual (hands on chest) CPR. There’s added concern for the delay in compressions during placement.
HOWEVER: there is added benefit for small pre-hospital crews that the use of these machine does keep crews more safe and “free’s up hands” to prevent task saturation. In the ER setting, I typically wont take the time to place one. They also cover the chest and make any needed chest procedures difficult (pericardiocentesis, chest tubes, central lines, needle decompressions etc)
NOTE: cost roughly $15k per unit. If you’re system does not have these, do not think your CPR is inferior.
MY MAIN POINT: quality CPR principles include early chest compressions and limited interruptions. Peds has a few subtleties, but keys below -Intubate while compressions take place. – hard and fast (100-120 bmp) -ribs will likely crack. This is normal.
-place patient on hard surface
– don’t hyperventilate. Even bystander compressions only without rescue breaths is acceptable – keep compressions after shocks given
– coronary perfusion pressure (CPP) is greatly impacted from above principles.
QUALITY CPR SAVES LIVES.
#cpr #heartattack #acls #bls #ems #paramedic #anesthesia #medicine #emergency #er #emergencymedicine #arrest #compressions #chest #pulse #medicine #medical #research #science #rn #medic #paramedic #nurse #crna #doctor #doc #discuss #hospital #education #teach #learn #help
The Emergency Department Neuro Exam – Three YouTube Videos
— Read on www.tomwademd.net/the-emergency-department-neuro-exam-three-youtube-videos/