POTD: "Push-pull" boluses - keep them sterile!

How do I appropriately use the push-pull technique to deliver a bolus to a pediatric patient?

Push-pull Technique

1. Hook up 3 way stopcock to IV tubing and attach syringe to 3rd port.

2. Turn off to patient, draw fluid from bag.

3. Turn off to bag, push bolus into patient with steady pressure.

4. Repeat 2-3 until full amount of bolus given.

Use

• To deliver adequate fluid resuscitation in a timely fashion to pediatric patients (superior to gravity)

• Similar flow rates as pressure bag, but with higher accuracy of volume

• For difficult IVs, you are able to feel resistance when giving the bolus and recognize a blown vein earlier

Contamination Concern!?

• A study showed that with repeated use, the contents inside the syringe may become contaminated (see fluorescein study below)

• Gross!!! This implies we may unwittingly introduce bacteria into systemic circulation....

Tips for Improvement

• Use syringe that is larger than the amount of the individual pushes (e.g. use a 60ml syringe to give 30ml at a time or a 20ml syringe to give 10ml at a time)

• Consider wearing sterile gloves and maintain aseptic technique

• Avoid touching the "ribs" (see below)

Resources

• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6314506/

• https://www.annemergmed.com/article/S0196-0644(07)01251-6/pdf

Trauma Tuesday POTD: Shock

How do I recognize shock in a trauma patient? 

We learn that shock in a trauma patient is usually hemorrhagic shock. 

Vitals are vital! 

Here's a chart from LITFL that goes through the different stages of hemorrhagic shock: 

The take away is that the patient can be in stage 1 hemorrhagic shock with normal vitals. Early signs are: 

1. Widened pulse pressure (difference between systolic and diastolic)

2. Cool extremities/pale skin

3. Mild anxiety (but which patient isn't anxious coming into the trauma bay?)

Patients don't read textbooks

The stages are useful to conceptualize, but there are several reasons a patient's  response may vary from the chart above: 

• Elderly patients have a blunted response

• Pediatric patients are able to compensate well

• Medications (e.g. beta blockers and other antihypertensives) or intoxication

• Extreme pain or anxiety

• Comorbidities

• Blunt vs penetrating trauma can have different physiologic responses

Bradycardia is possible with hemorrhagic shock

• Several theories exist as to why this happens (vagal stimulation, sympathetic response, post catecholamine surge...)

• Seen more with acute, severe blood loss

• Up to 1/3 of patients with hemorrhagic shock may be bradycardic

Give blood early!

POTD: Heatstroke Cooling in High Humidity

How do I cool my patient with heatstroke?

Heatstroke

• AMS

• Core body temp > 40.5 C (105 F)

• Exposure to high temperatures or exercise
  

Cooling down their core temperature ASAP provides mortality and morbidity benefit

• Delayed treatment can have a mortality as high as 70%!
  

We learn that evaporative cooling is the best method 
(spraying tepid water and cooling with fans). 

HOWEVER, when humidity is high this may not work! 

• Because sweat on the skin cannot evaporate into the surrounding air and body temperature cooling fails.

• This occurs in some studies at humidity levels >50-55%

So what else can you do?

Ice Bath

• Practically speaking, place the patient in a body bag up to their neck and add ice and water.
  

If an ice bath isn't possible, apply ice packs to neck, armpits, and groin. 

Stay cool!