To Nebulize or Inhale? That is the Question

Vintage image of a nebulizer

Nebulizers and inhalers of short-acting bronchodilators are in no short supply at most urban emergency departments. When someone comes in with an acute asthma exacerbation, the front-line ED nurses are quick to start them on some sort of bronchodilator. Of all the EDs I’ve worked at, this is a universal truth.

The method of delivery, however, is another issue. At my emergency department in Alberta, a typical asthma exacerbation order for bronchodilators is:

Salbutamol 4-6 puffs inhaler with spacer q20-30mins times 3 doses

Conversely, at my emergency department in British Columbia, it is:

Salbutamol 5 mg nebs q20-30mins times 3 doses

Metered-dose-inhaler (MDI) with spacer versus nebulizer: staff at both sites are quick to take sides with one route and talk about the failures of the other. Of course, this raises the question: is one side better than the other? Are both equally good?

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Thinking Outside Standard Treatment for Refractory Hypoglycemia

This post from Pulmcrit presents a totally different way of looking at hypoglycemia management. Admittedly there isn’t tons of practical evidence and these cases tend to be unusual but I love that this post goes beyond standard thinking and presents some alternative ideas. One of the most interesting ideas here is using steroids to assist in managing refractory  hypoglycemia. I haven’t seen any cases where this has been done but it seems like a great concept to have in your back pocket!

PulmCrit – Treatment of massive insulin poisoning refractory to glucose

 

Joining the Percussion Bandwagon

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Like the rest of my social-media savvy colleagues in the emergency department, discussions about the latest and greatest in clinical innovation occurs on social media. Some posts are clearly venting outlets of new unit policies or outdated practices. Some, however, like this one below highlights something that we usually take for granted:

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Electrical Storm: Can We Kill It With Kindness?

Image retrieved from Life In The Fast Lane.com

Diagnosis Electrical Storm:

Electrical Storm is defined as 3 or more sustained episodes of ventricular tachycardia or ventricular fibrillation or appropriate implantable ICD shock over a 24h period [1].

By all accounts this is a really exciting sounding diagnosis. As an Emergency Nurse I have seen this only a few times, but enough times to know that there is room for improvement in our approach. It’s a situation that benefits from having staff with previous experience in the room. It’s something that is downright terrifying to staff because it is so hard to get under control. The bigger problem, which I see somewhat overlooked by the team, is how terrifying this is for the patient.

Imagine the patient’s perspective, especially if they have already had several shocks from their ICD. It’s not just painful because they are receiving electricity to their heart: for a few seconds prior, they know it is coming. The fear component with repeated ICD firing is high. Yes, I know they would die without the ICD and as rational health care professionals we can think that the pain/fear component is secondary to their survival, but is it actually only secondary? Continue reading

ICU ECMO

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Another excellent ECMO site. This time from the ICU level in Australia- the podcast series is very well done and walks through some potential complications. I love all things ECMO so I am biased but this is really well put together and very helpful to both the ICU and ER practitioner.

 

ECMO

ED ECMO

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It’s a revolutionary way to think of resuscitation and although it isn’t new technology the application of it in the ED setting is the revolution. If we can support the heart and lungs right away in an arresting patient while we reverse the cause of arrest, ECMO in the ED will save lives.

Although ED ECMO certainly isn’t available in most ED’s just yet, this is the site for anything you want to know about it.

Basic Airway Management

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Although I am lucky enough to usually have my awesome RT colleagues to rely on, they do get called away and often as the ER nurse I am the first staff member at the bedside of the respiratory distress/arrest patient. It is so important to remember the basics so we don’t allow the patient to become hypoxic while we are calling for back up!

Here is an excellent summary of basic airway management from First10EM that all ED staff should be confident with:

Emergency Airway Management Part 1: Optimizing the basics