NG tube utility in bowel obstruction

another food-for-thought tidbit after a bit of a long layoff…

 

Best BETs from the Manchester Royal Infirmary. BET 1: Is routine nasogastric decompression indicated in small bowel occlusion?

–found all of one useful/relevant paper (below)

 

Fonseca et al: Routine nasogastric decompression in small bowel obstruction: is it really necessary?

• Key points:
  • 65-80% of SBOs (small bowel obstructions) are treated non-operatively (bowel rest, IVF, obs)
  • NG (nasogastric) tube often used for decompression
  • NG tube complications can include: pneumothorax/perf, pneumonia, nasal trauma/infection, patient discomfort, etc.
• Retrospective study highlights:
  • 290 patients >18 yo with SBO
  • causes included adhesions, malignancy, unknown (excluded incarcerated hernias)
  • 235 patients got NG tubes (so 55 didn’t)
  • NG tube was not associated with avoidance of surgery
    • 37% (87/235) with NG tubes needed OR intervention
    • 24% (13/55) without NG tube needed OR intervention
  • Days to resolution (average)
    • 3.55 days in NG tube group
    • 1.67 days in non-NG tube group
  • Hospital length of stay (average)
    • 10.16 days in NG tube group
    • 3.18 days in non-NG tube group
    • similar trend excluding the patients who needed OR intervention
  • Significantly higher rate of pneumonia in the NG tube group (11.59% vs. none, P=0.007)
  • author conclusion: “…we recommend the judicious use of NGT, especially in patients presenting without emesis.”

 

old article, but often cited: Singer et al: Comparison of patient and practitioner assessments of pain from commonly performed emergency department procedures

• most painful procedures according to patients (in descending order)
  • nasogastric intubation
  • abscess drainage
  • fracture reduction
  • urethral catheterization

 

Food for thought.

 

References: Best bet article, Fonseca article, Singer article, picture

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visual aid: Davos shoulder reduction

here’s a couple quick visuals to help add this shoulder reduction technique to your bag of tricks (which worked in 86/100 patients in one study):

Note: if you only have 1 minute, start watching at the ~1:30 mark.

 

as opposed to the video, the article suggests wrapping the elastic bandage around the leg as well, which means you don’t have to rely as much on the patient to keep their arms in position (makes sense to me).

 

There you go. Add it to the toolbox.

 

References: article; video; picture

 

visual aid: slit lamp tutorial

a nice quick video tutorial on the slit lamp exam from this old ALiEM post:

if you only have a couple minutes, the ~2:00 to 4:00 minute mark are nice reminders of a few knobs and how to adjust the level and light window.

also, there’s a nice example of cell & flare at the ~5:30 mark.

Go forth, look at eyeballs.

 

References: ALiEM post (with other eye exam videos also)

IO craniotomy?

back after a bit of a layoff with a bit of an interesting, if maybe not ready for primetime procedure idea, via this Austrailian resus blog:

basically, in the setting of an expanding intracranial hematoma, evacuating the pressure to temporize (the alternative being herniation, then death).

while burr holes are preferred, if you have nothing else, interesting to see this on the horizon as a potential option.

 

References: resus blog post & photo

ECG [anatomical] visual aid

quick anatomical reference for your ECG thought process (particularly for browsing contiguous leads), via an old emDOCs post:

for your reference, a simple anatomical diagram below:

The emdocs post also has some nice echo videos and many more photos from different perspectives, if you need some additional spacial orientation.

 

References: emdocs post; coronary artery photo

ultrasound visual aid (part 2): glove assist

on a recent post, referenced the idea of using an IV saline bag to ultrasound through to visualize tricky irregular and superficial surfaces (e.g. hand/digits).  

Here’s a handy visual aid for the same idea, only using a water-filled latex glove (via an 2016 emed journal article):

Add it to the toolbox.

References: emed journal article (& photo)

Thyroid Emergencies (quick review)

submitted by Amit Kumar, M.D.

 

THYROID STORM

-Risk factors:

Longstanding untreated thyroid issues (Grave’s, toxic multinodular goiter, solitary toxic adenoma), but more commonly surgery, trauma, infection, parturition, recent iodine load

 

-Diagnosis:

Hyperpyrexia, AMS, cardiac dysfunction (tachycaria, A-fib, CHF, etc.) in a patient with elevation of T4/3 and supression of TSH

 

-Treatment:

• 1) Control increased adrenergic tone: B-blocker
  • PO: Propranolol 60-80mg q4-6h (monitor HR, BP)
  • IV: Esmolol 250-500mcg/kg followed by 50-100mcg/kg/min
• 2) Block new hormone synthesis
  • PTU 200mg q4h (safe during pregnancy) or
  • Methimazole 20mg q4-6h
• 3) Block further release of hormone
  • Iodine (1h post step 2, or else will be used to make more T4)
• 4) Inhibit peripheral conversion of T4 -> T3
  • PTU,
  • steroids such as hydrocortisone 100mg q8h (also treats relative assoc. adrenal insufficiency)

 

 

MYXEDEMA COMA

-Risk factors:

Acute event (ex: MI, cold exposure, sedative drugs such as opioids) in poorly controlled hypothyroid patient, drug induce (ex: lithium, amiodarone)

 

-Diagnosis:

Depressed mental status + hypothermia, hyponatremia, and/or hypercapnia (due to hypoventilation); hx of thyroidectomy scar or recent radioiodine therapy

Primary (with high TSH) or central (with low TSH)

 

 

-Treatment:

• 1) Thyroid hormone
  • Combined T4 (200-400mcg IV) and T3 (5-20mcg IV). Both are continued thereafter.
• 2) Glucocorticoids (until concominant adrenal insufficiency is ruled-out)
  • Hydrocortisone 100mg q8h
• 3) Supportive care
  • Non-dilute fluids (due to hyponatremia), passive rewarming, pressors (if hypotension doesn’t resolve)

 

 

References:

-Brunette DD, Rothong C. Emergency department management of thyrotoxic crisis with esmolol. Am J Emerg Med 1991; 9:232.

-Cooper DS, Daniels GH, Ladenson PW, Ridgway EC. Hyperthyroxinemia in patients treated with high-dose propranolol. Am J Med 1982; 73:867.

-Cooper DS, Saxe VC, Meskell M, et al. Acute effects of propylthiouracil (PTU) on thyroidal iodide organification and peripheral iodothyronine deiodination: correlation with serum PTU levels measured by radioimmunoassay. J Clin Endocrinol Metab 1982; 54:101.

-Jonklaas J, Bianco AC, Bauer AJ, et al. Guidelines for the treatment of hypothyroidism: prepared by the american thyroid association task force on thyroid hormone replacement. Thyroid 2014; 24:1670.