Temporary Wayne Catheter Replacement Kits

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I wanted to make you aware of the new *temporary* replacement pigtail kits that we have available right now. We have ordered the normal Wayne catheter replacements, but they will take a little more time to come. You can find the pigtail kits in the cabinets between Resus 51/52. I've attached the picture of the packet, and a quick video tutorial (https://tinyurl.com/578wnbve) that shows you how to use it.

Contents of the new kits:

- short needle
- guide wire
- 3-way stopcock
- Heimlich valve
- pigtail catheter
- dilator

This is a very basic kit, so I recommend that you grab the following supplies that are not included in the packet.

- 10cc syringe to attach to the needle
- Lidocaine supplies (lido, syringe, blunt needle, subQ needle)
- Chloraprep
- Sterile supplies: gown, sterile gloves, drape
- Gauze
- 11 blade scalpel
- Suture material, needle driver
- Occlusive dressing materials

Please note - there's no separate trocar! The kit requires you to use the guide wire as the trocar... so make sure you dilate well. If your patient has a higher BMI, talk to your attending about whether or not this is the appropriate kit for them.

Gun Violence

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Growing up in a South Asian family in the Bay Area, CA, I can’t say I know the first thing about guns. So today I’m going to touch on some of the basics of guns and the demographics of gun violence in the United States. This email is meant to be purely educational, so I apologize if any of this information ends up being upsetting to anyone. Also, this is a massive topic, so I’ve just chosen just a few points to touch on. 

Epidemiology:

  • In 2020, 45,222 people died from gun violence according to the CDC. There was a 34% increase from the year before.

  • There are over 70,000 ED visits for nonfatal gun violence each year.

  • 80% of US homicides involved a firearm in 2020

  • Suicides account for 55% of firearm deaths, while homicides account for most of the remainder. 

    • Most suicide attempts with firearms are fatal, while most most assaults are nonfatal. 

  • Mass shootings are defined as events where 4+ victims are killed

    • They account for <1% of gun deaths in the USA

Demographics:

  • Firearm homicide disproportionately affects African American men, accounting for nearly 60% of firearm deaths despite making up only 13% of the population

  • Males account for 86% of firearm deaths and 87% of nonfatal firearm injuries

  • Majority of victims are between 15-34 years of age

  • Firearm suicide rates are the highest among adults 75+ years old

More quick facts:

  • The United States has some of the highest rates of gun ownership of the developed world

    • Highest rates of gun ownership in Montana (66% of residents), Wyoming, and Alaska

  • El Savador & Venezuela have the highest gun fatality rates 

  • The US spends $230 billion / year on gun-related violence. This equates to each murder costing approximately $500,000.

  • There are 400 million guns in the US across 82 million Americans. 

3 major types of guns:

  • Handguns / pistols: short barrel with thick walls to withstand high pressures 

    • Accounts for 45% of all homicides

    • 80% of firearm injuries are due to handguns

    • Used to fire at stationary target typically

  • Rifles: long barrel with thick walls to withstand high pressures

    • The rifle puts a spiral spin on the bullet, thus increasing the accuracy and distance

    • These bullets are bigger and have higher velocities

    • Usually they’re used for firing at stationary targets 

    • Accounts for 2% of homicides

    • Assault rifles are subtypes that became popular during World War II, the most famous name being AK-47

      • They are typically selective fire

      • More dangerous because they can fire more bullets and have larger magazines

      • Banned in 7 states, including New York

  • Shotguns: long barrel and thin walled to reduce pressure

    • Typically used to shoot at moving targets in the air

Key terms:

  • Caliber: describes the diameter of the bullet, typically in inches or millimeters

    • Clinical correlation: fatal shootings are usually higher diameter relative to nonfatal shootings

  • Automatic: 

    • Often referred to as machine guns

    • Squeezing the trigger fires cartridges repeatedly until released

    • These are a little harder to purchase – you have to pay $200 to pass a federal background check that shows no history of domestic violence or felony convictions

    • Banned in some states like California, Iowa, and Kansas

    • Clinical correlation: 

  • Semi-automatic:

    • Firearm that fires one bullet / trigger squeeze and then automatically reloads the chamber

    • AR-15 falls under this category – it typically holds 30 bullets before the operator needs to reload the gun. The reason these are tricky weapons is because they can be macgyvered into becoming an automatic weapon by using a “bump stock.” This was the case for the Las Vegas shooting and many other mass shootings.

  • Selective fire: this is a feature of assault rifles. They have the ability to toggle between automatic and semi-automatic modes

  • Safety:

    • Built in mechanism to prevent accidental discharge

  • Muzzle velocity: The average speed of a handgun bullet travels at 300m/s when it leaves the barrel, this is referred to as the “muzzle velocity.” Assault weapons are > 700m/s. As a throwback, just remember: KE=½ mv^2.

  • Magazine: the container that holds the ammunition

Recommendations for physicians:

It's advised that physicians talk to their patients about safe storage options. While this is typically a conversation that should occur with a PCP, it may be relevant at times in the ED setting:

  • Have these conversations in a non-judgmental way. Identify high risk patients.

  • Stored guns should be: 

    • Unloaded

    • Locked

    • Separate from ammunition

    • Locked in a way that's inaccessible to others/children

  • The parents should always assume that other people in the house know where it is.

  • There's a few recommended storage options:

    • Lock boxes: combination locks, keys, fingerprinted

    • Gun safes: can store many sizes of guns. Tend to be more expensive.

    • Cable locks: temporarily prevents it from being loaded or fired

    • Trigger lock: blocks the trigger from being fired. You can still load the gun. Sometimes can still accidentally allow for firing, so it's not super safe.

    • Trigger locks: prevents you from pulling the trigger. It’s important these guns are not loaded because otherwise using the trigger lock can lead to misfiring.

  • If you have a high risk patient, you can also recommend temporarily transferring ownership. Most gun retailers or shooting ranges will store them for a small fee. Some states also allow you to transfer the gun to another individual as long as they're 18+ years old and not prohibited from ownership. The temporary holder may not use the firearm during this time. 

I hope this was educational for you. I know there was some explicit detail here, but I think it’s important for physicians to understand the mechanisms and the terminology in order to participate in policy-making and advocacy at all levels since we see the effects of gun violence in our line of work. Feel free to chime in with additional information or clinical pearls.

References:

Olanzapine + Benzodiazepines

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Today, I’m going to touch on the co-administration of olanzapine with benzodiazepines.

Data is controversial regarding this, but the co-administration has not been studied in depth, which is why it is not currently recommended to give both. 

What’s the FDA’s stance?

“Concomitant administration of intramuscular olanzapine along with benzodiazepines is not recommended due to the potential for excessive sedation and cardiorespiratory depression.”

This advisory came about after there were 160 adverse events and 29 fatalities associated with IM olanzapine in 2005. 


Possible side effects of co-administration: Severe hypotension, respiratory depression

Why the FDA warning?

There was a study (n=29) looking at patient fatalities involving the administration of olanzapine.

3/29 fatalities involved olanzapine monotherapy.

1/29 fatalities involved IM olanzapine + benzodiazepine dual therapy

25/29 fatalities involved IM olanzapine + PO/IM/IV benzodiazepines + many other medications

The interesting thing about the study is that 12 patients died over 24 hours after administration of the medications. So it’s difficult to determine causality. 

Some olanzapine quick facts:

  • Olanzapine is an atypical antipsychotic

  • Side effect profile includes: neuroleptic malignant syndrome, hyperglycemia, constipation, dry mouth, tachycardia, orthostatic hypotension

    • Mortalities and increased risk of cerebrovascular accidents have been linked to elderly patients with dementia

  • IM olanzapine is 5 times more potent than PO olanzapine. 

  • ½ life: 21-54 hours

  • Peak: within 15-45 minutes

Why is this conversation controversial?

Well, if you look at the data regarding co-administration < 60 minutes apart studied in 41 patients, you see that their vitals are actually fine.

**** 4 Key takeaways ****

  1. According to the European Medicines Agency, it’s likely safe to administer olanzapine and a BZD at least 60 minutes apart. 

  2. It’s safer to use PO agents over IM agents. Our ED pharmacy team does not recommend administering IM of both. 

  3. Avoid co-administration particularly in high risk groups: elderly, dementia, acute alcohol intoxication, or patients requiring polypharmacy.

  4. If you’ve already used olanzapine, and you’re looking for an additional agent, ketamine is likely a safer option.

References: 

https://www.aliem.com/combination-parenteral-olanzapine-benzodiazepines-agitation-adverse-events/ 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6125121/ 

https://foamcast.org/2019/10/29/black-boxed-medications-in-the-ed-acep-2019/ 

https://meridian.allenpress.com/mhc/article/8/5/208/37281/Coadministration-of-intramuscular-olanzapine-and