POTD: Sleep Hygiene

The term “sleep hygiene” refers to a series of healthy sleep habits that can improve your ability to fall asleep and stay asleep. These habits are a cornerstone of cognitive behavioral therapy, the most effective long-term treatment for people with chronic insomnia. CBT can help you address the thoughts and behaviors that prevent you from sleeping well. It also includes techniques for stress reduction, relaxation and sleep schedule management.

Here are some general tips for good sleep habits from the CDC:

• Be consistent. Go to bed at the same time each night and get up at the same time each morning, including on the weekends (this one is admittedly hard for the ER doctor, especially as a resident!)

• Make sure your bedroom is quiet, dark, relaxing, and at a comfortable temperature

• Remove electronic devices, such as TVs, computers, and smart phones, from the bedroom

• Avoid large meals, caffeine, and alcohol before bedtime

• Get some exercise. Being physically active during the day can help you fall asleep more easily at night.

If you’re still having difficulty falling asleep, consider keeping a two-week sleep diary to analyze your sleep trends.

In our modern-age of electronics, here are some tips to effectively manage electronic screen time in preparation for sleep:

• Set your iPhone to “Do Not Disturb”

  • This will prevent your phone from alerting you with text messages or phone calls while you’re sleeping. Critical calls will still make it through if you toggle the “repeated calls” setting (i.e. a second call from the same person within 3 minutes will not be silenced)

  • You can also have automatic message replies if people attempt to call you when “do not disturb” is turned on

  • You can schedule when “do not disturb” is turned on

  • You can ensure that certain phone calls will always go through

  • Essentially there is NO REASON why this button shouldn’t be turned on!

• If you have an Apple Watch, in addition to “do not disturb,” you can place your watch on “theater mode”

  • This will prevent your watch from lighting up with movement while you sleep

• Download sleeping apps:

  • Sleep tracking apps

    • Sleeptracker

    • Sleep Watch

    • Sleep Cycle

  • Sleep sounds:

    • Relax Melodies

    • Sleep Sounds by Sleep Pillow

    • White Noise Deep Sleep Sounds

What about melatonin?:

Melatonin production in humans has a pronounced circadian rhythm; nocturnal plasma melatonin concentrations are at least 10-fold higher than daytime concentrations. The nocturnal rise in melatonin secretion plays an important role in the initiation and maintenance of sleep.

Nocturnal melatonin plasma concentrations decline with age; many older adult individuals develop age-associated insomnia (eg, waking up during the night, diminished sleep efficiency). Physiologic doses of melatonin may be beneficial for these individuals. Exposure to light suppresses the normal nocturnal rise in plasma melatonin concentrations. Can use low, physiologic doses (0.1 to 0.5 mg) for insomnia or jet lag. High-dose preparations raise plasma melatonin concentrations to a supraphysiologic level and alter normal day/night melatonin rhythms. 

In a randomized, double-blind, replicated crossover trial performed on EM residents in 2018 regarding melatonin vs placebo in regards to sleep efficiency, it was found that there was essentially no difference in sleep quality between the groups, although a minor decrease in drowsiness was found in the melatonin group.

My take away is that good sleep hygiene practices supersede any supplements to promote healthy sleep.

References

https://www.cdc.gov/sleep/about_sleep/sleep_hygiene.html

http://sleepeducation.org/essentials-in-sleep/healthy-sleep-habits

https://www.uptodate.com/contents/physiology-and-available-preparations-of-melatonin?search=melatonin&source=search_result&selectedTitle=1~108&usage_type=default&display_rank=1

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6117540/ 

POTD: Chest Tube/Pig Tail Drain Suturing

There are several different techniques, so I wanted to illustrate a few of them. The common theme is start from above or below the chest tube and throw your first knot to the skin:

1) Wrapping technique (this is my go-to technique)

- begin by throwing your first knot into the skin above the tube, then wrap the suture material around the base of tube (at the level of the tube insertion site)multiple times and then tie into place

- this can be repeated from below the tube for extra security

- video: https://www.youtube.com/watch?v=v2y-g0RAImw

2) The “ps and qs” technique (here called the easy L)

- essentially throw your first stitch in the skin and then perform 3 “p” stitches or 3 “q” stitches and vice versa

- finish by performing hand ties

- video: https://www.youtube.com/watch?v=Qsq1fPxYNrQ

3) The “big S” technique

- similar to a nautical knot, called the clove hitch

- essentially form an “S” shape underneath the chest tube (after you throw your first stitch)

- video: https://youtu.be/4lkyq7U6fpg

Other techniques include purse string sutures or horizontal mattress sutures.

POTD: Cervical Artery Dissection

Clinical Scenario:

A 25-year-old woman presents with neck pain, headache, nausea, left-sided facial numbness, and an unsteady gait. She says the headache began 7 days earlier shortly after a chiropractic treatment for chronic neck pain. Vital signs are normal; the unsteady gait is noted on ambulation. Noncontrast head CT findings are normal.

Which of these tests should be ordered next?

A. CT angiography of the neck with contrast

B. CT of the neck without contrast

C. Duplex ultrasonography of the carotid arteries

D. Duplex ultrasonography of the vertebral arteries.

The answer is A. 

Cervical Artery Dissection

What is it?

• Cervical artery dissections is the collective term for dissections of the carotid or vertebral arteries

  • internal carotid artery is most commonly affected

  • vertebral artery dissections are uncommon

• Dissection of the cervical arteries is a common cause of stroke among young and middle-aged persons. 

  • ~ 20% of strokes in the young are caused by carotid artery or vertebral artery dissections in the neck, compared to only 2.5% in older patients

• Caused by minor trauma in the setting of neck manipulation (e.g. by a chiropractor) or a minor sports injury. There are some case reports of these injuries occurring from riding roller coasters. 

• Seen more commonly in patients with connective tissue disorders or vascular pathologies (e.g. HTN, Marfan’s syndrome, fibrocystic dysplasia, etc)

Presentation

• Classic presentations include neck pain and headache that might precede development of neurologic symptoms (hemiplegia, hemisensory loss) by hours or up to 14 days.

• Vascular bruits (absence does not exclude dissection, e.g. present in only about 1/3 of carotid dissections)

• carotid dissection tends to present with some or all of the following:

  • frontal headache

  • anterior neck pain

  • eye, ear, or face pain

  • Ipsilateral Horner’s syndrome (due to expansion of the internal carotid artery with compression of sympathetic nerve fibers)

• vertebral artery dissectiontends to present with some or all of the following:

  • occipital headache

  • posterior neck pain

  • unilateral facial numbness, dizziness, ataxia, vision disturbances (diplopia), and nausea or vomiting

Evaluation

• Diagnosis is via CT angiography of the neck. Although it might take longer to obtain, MRA is also an acceptable diagnostic test. 

Treatment

• Anticoagulation with heparin intravenously followed by warfarin.

• tPA may be considered in some patients with stroke due to spontaneous extracranial dissection

• Endovascular therapies include stenting

  • usually used for extracranial carotid or vertebral artery dissection when medical management fails or is contraindicated

  • improved outcomes are associated with reconstitution of flow within 6 hours

References
PEER IX

https://lifeinthefastlane.com/ccc/cervical-artery-dissection/