Learning thread (ER medicine)

WOW, this is a really good idea! Makes sense to me..

Speaking of strep throat........how come nurses are not educating their patients to toss the toothbrush? I thought the nurse was to educate their patient. I have had a lady to come to the ER 5+ times for strep throat and when I was discharging her, I advised her to toss the toothbrush and go to the dollar store and buy the pack that has a few in a box for a dollar. I told her that after she used one toothbrush that day that she needed to toss it in the trash and the next day use a new one. Then after a few days she can get a more suitable toothbrush that she would like. She told me that no one has ever told her that. Well, I haven't seen her and it has been several weeks. Maybe I am a bit extreme with using a different toothbrush for a few days but strep throat is not a comfortable feeling and there are risks involved. I am a new ER nurse and I have found out that no one in my ER educates about tossing the toothbrush. So far, my advise has been very successful. No one that has followed my advised has had to return for reoccurring strep throat.

("succs is contraindicated in head trauma with intercranial pressure. u dont want the vesiculations, you can premedicate with lido to reduce them.")

Just to clarify a few misconceptions- Most research shows that succs is not contraindicated in the head injured patient. Yes it does cause a brief rise in intercranial pressure but the research shows that it does not have an effect on patient outcome. Now, there are several ways to counter the ICP increase. You could use fentanyl or thiopental as your sedative and they both cause a decrease in ICP. Lidocaine when used in combination with rapid sequence induction is a moot point. It has never in any research showed to cause a decrease in ICP for head injuries. What lidocaine is supposed to be used for is to blunt the gag reflex associated with intubation which causes a brief increase in ICP. If you are doing RSI with succs then there won't be a gag. Fasiculations are caused from succs being a depolarizing agent. Fasiculations become worrisome for a head injury or more so a unstable cervical fracture. They are easily delt with by given a small dose of a non-depolarizing agent such as vecuronium prior to the RSI. The problem lies in do you need the airway managed right now. When giving a non-depolarizer you need to wait 2-5 minutes to reach effect. So your RSI would go like this-

1. Vecuronium 1.0mg ivp wait 2-3 minutes and (2)Rapid push your sedative (etomidate, thiopental, versed, fentanyl etc.)(3) RAPID push your succs and wait for patient to become flacid- you should not see fasiculations.(4) intubate and confirm placement (5) longer sedative, pain meds and non depolarizing agent.

As for contraindications for succs: Burns over 24 hours, crush injuries, hx of malignanthyperthermia, neuro conditions (myasthenia, ms etc.) renal disease or other possible high K+ problems.

Last- someone mentioned that they take the temp on thier patients for an hour after succs use to look for MH. Long before your temp rises your CO2 will rise as well as an increased HR. Most books say if you wait for a temp increase you have lost the battle.

Hope this helps

Qanik

I took TNCC last week and am taking ENPC starting tomorrow so this thread is so timely!

Okay, here is a question:

What is the normal urine output for an infant? Why is that of particular importance?

Great thread!

Here is one I had last week.

Pt pressents with abd pain and htn (BP 230/120). Non-contrast Ct abd and pelvis shows non-disecting AAA. MD orders nipride to titrate for BP >160/90. What type of medication does this pt need prior to nipride and why?

Kevin

Heres an idea. once you learn something new regarding ER medicine, post it here. it will become a nice discussion and we can all learn something. post something that you think most ER rns wont know. you can even make it a trivia question.

ill start, what kind of med do you never give a cocaine induced MI? (that ones easy)

Great thread!

Here is one I had last week.

Pt pressents with abd pain and htn (BP 230/120). Non-contrast Ct abd and pelvis shows non-disecting AAA. MD orders nipride to titrate for BP >160/90. What type of medication does this pt need prior to nipride and why?

Kevin

Betablocker to decrease shearing effect of nipride. Reasearch shows you are better off with a gtt of esmolol then a repeated single dosing of other beta blockers.

Qanik

I've enjoyed and learned much from this thread. Keep 'em coming.

What are the contraindications with giving succs bolus/drip (dose: alot!!) to cocaine overdose pt presenting in the ER for the 2nd time this week?

There IS NO contraindications...give them as much as you want. :chuckle

Im sorry - I couldnt resist.!

Ok, now Im serious..I have found a good way of keeping beligerant, intoxicated, maybe confused/maybe not..pts from leaving the ER undetected. (you know, sometimes, when they get mad that they arent getting the attention they deserve - they will just leave unnoticed).

ANSWER: I help them get undressed when they first get there - get them in a gown. Put their belongings in a bag. We keep their belongings at the desk. Pts arent going to leave the er without their wallet and clothes...and if they truly are confused and leave anyway - they wont get far in a gown without security or someone noticing them.

Clipped for brevity.....

Ok, now Im serious..I have found a good way of keeping beligerant, intoxicated, maybe confused/maybe not..pts from leaving the ER undetected. (you know, sometimes, when they get mad that they arent getting the attention they deserve - they will just leave unnoticed).

ANSWER: I help them get undressed when they first get there - get them in a gown. Put their belongings in a bag. We keep their belongings at the desk. Pts arent going to leave the er without their wallet and clothes...and if they truly are confused and leave anyway - they wont get far in a gown without security or someone noticing them.

I LOVE THAT IDEA!!!!!

I may need to try this the next time I get one of these "special" people. :rotfl:

This is a refreshing thread, thanks Chris. Got tired of threads about how nurses should speak "more" better english. I do have a question, after a pt has been intubated and placed on a vent, what is prefered oral or naso gastric tube and why?

Betablocker to decrease shearing effect of nipride. Reasearch shows you are better off with a gtt of esmolol then a repeated single dosing of other beta blockers.

Correct! Betablocker gtt is started prior to antihypertensive to prevent reflex tachycardia. Most of our docs prefer esmolol.

Normal urine output for an infant/child is 1-2cc/kg/h for whoever it was that asked.