FOAM Party: January 2016

As part of our revamp, we’re pleased to bring you a new monthly blog series, FOAM party. Drs. Tal Berkowitz and Maneesha Agarwal will scour the FOAM universe to bring you the very best from the past month for you to review. Want to know why your EM resident wants to use an alcohol pad to treat his patient’s vomiting? You’ve come to the right place…

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A recent post on ALiEM discusses the use of inhalation of isopropyl alcohol pads for nausea and vomiting.  It is readily available and they recommend 3 inhalations within 15 minutes up to 2 times.

The FOAM piece states that there is one pediatric article that found it to be “too noxious,” despite being effective. This was an anesthesia article from 1999 looking at post-op nausea and vomiting in children and reported that while there was effect above placebo from the inhaled isopropyl, there were high rates of recurrent nausea and vomiting requiring further medications. The study included children above 6 years old so there are no studies looking at younger populations.

The lesson we have taken from this is that it may be an effective, immediately available intervention for the actively vomiting patient while awaiting alternatives such as ondansetron to arrive or kick in.

1. Wang SM, Hofstadter MB, Kain ZN. An alternative method to alleviate postoperative nausea and vomiting in children. J Clin Anesth. 1999; 11(3): 231-4. PMID: 10434220

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Life In The FastLane (LITFL) has some updates to their critical care compendium with a nice overview of preoxygenation prior to intubation. There is a lot of discussion in the adult FOAM/literature regarding optimal ways to intubate critically ill patients. Many blogs (LITFL, ALiEM, and EMCrit) have some great summaries regarding how some of them tackle these difficult situations, including intubating DKA patients. Not all of these recommendations are evidence based, as for many of these scenarios there is no evidence, but they represent experienced thought processes for tackling these stressful scenarios.

The main lessons to be learned from the preoxygenation discussion are the limitations to various devices (BVM, NRB), troubleshooting some devices, and ways to consider improving preoxygentation and apneic oxygenation considering even using a standard nasal cannula at 15L/min under a NRB or NPPV device and leaving it in place during intubation. As children have even less capacity for maintaining oxygen sats during apnea, some of these methods may be even more relevant for us to try. You can also read about our own Dr. Wendy Little’s take on the subject.

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 Ever challenged with finding an IV on one of your patients? Song or Stories, a relatively new blog from the perspective of a pediatric anesthesiologist, has some great tips and tricks for IV placement to consider. Consider giving it a whirl when waiting for the IV team, NICU team, flight team, or whatever other IV expert you’ve called on. Bonus points if you consider ultrasound!

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If we’re talking about poking kids with a needle, we also have to talk about lumbar punctures. The folks over at Don’t forget the bubbles have a great post on some simple tricks to improve your likelihood of getting that champagne tap. Do you know where to find Tuffer’s line?

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While perhaps to basic for PEM/UC faculty, ALiEM also recently published pearls on pediatric causes of chest pain. It’s not a bad quick read/review, and given that this is a popular blog with EM residents around the country (including our own fabulous Emory EM residents), it’s worth perusing so you know what that resident is talking about when they quote that pediatric chest pain is cardiac in only 6% of cases.

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Peds EM Morsels has a nice review of indications for discharge after successful enemareduction of intussusception. In summary, discharge may be appropriate for a child with successful reduction by air-contrast enema who does not have signs of perforation or peritonitis, is able to tolerate PO, is afebrile and pain free, has undergone a brief post-enema observation period in the ER, and has the capability to easily return if symptoms recur or if they become ill.

A few articles are referenced, including one by one of our pediatric surgeons,  Dr. Mehul Raval, in which nearly half of patients who were reduced in radiology were successfully discharged home with only one patient returning for recurrence. They reported improved cost-effectiveness with this approach.

Raval MV1, Minneci PC2, Deans KJ2, Kurtovic KJ3, Dietrich A4, Bates DG5, Rangel SJ6, Moss RL2, Kenney BD2. Improving Quality and Efficiency for Intussusception Management After Successful Enema Reduction. Pediatrics. 2015 Nov;136(5):e1345-52. PMID: 26459654.

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The folks over at ALIEM have also recently posted a neat trick for reducing a mandible dislocation extra-orally – without putting your fingers in the patient’s mouth! They have a fabulous video and claim that this approach works without sedation too. Might be worth a whirl next time one of these patients lands in our ED…

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Finally, from our very own Dr. Mike Greenwald, chair-elect for the ACEP Section of Pediatrics, poses a great question as we face the second half of the winter volume surge: is teaching and clinical productivity truly mutually exclusive? Dr. Greenwald argues (and exemplifies) why it isn’t. 

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Seen another fabulous piece of FOAM not covered in this month’s FOAM party? Send it our way for inclusion in next month’s FOAM party.

Keep FOAMing,

TB & MA

FOAM Party: Academic Life in EM

If you decide to talk #FOAM with any EM resident, you must know about Academic Life in EM (ALiEM). This is American FOAM at it’s very best. This site started in 2009 as the brainchild of Dr. Michelle Lin at UCSF. She was single individual, looking up and posting interesting tidbits related to cases she encountered, contributing in her own free time. Nearly 1500 posts later and ALiEM is HUGE!!!

The ALiEM website is visually appealing, and it’s wealth of information is well-organized. If you’re new to ALiEM, what I’d highlight for you as a PEM physician includes:

• The main page: This is what was just published, and it’s possible that your EM resident may have read some of these posts recently. You probably want to check out the post on 4/21 on ultrasound confirmation of pediatric ET tubes so we have some sort of response ready when those EM residents ask you about it!
• The videos section (top right bar): These educational videos are fairly basic and geared towards medical students and residents, but are a great review of key EM concepts.
• The PV cards (top right bar): These brief cards are rapid reviews on key concepts ranging from Brugada syndrome to c-spine fractures and more. Easily downloadable to your smart phone.

I find ALiEM particularly helpful when reviewing more “adult” topics as this site is based in the world of EM. It’s also interesting to see what our general EM colleagues are buzzing about. They’ve recently had some nice series on professional/personal development, such as the “How I Work Smarter” series.

ALiEM has also been a leader in FOAM innovation. They now feature peer-reviewed posts and are prominent partners with EM:RAP (to be discussed in a future FOAM Party post), Annals of Emergency Medicine, and Council of Emergency Medicine Residency Directors (CORD). They even host online journal clubs and book clubs!

Dr. Lin still acts as editor-in-chief and has successfully used ALiEM to grow her career into a high-profile, frequently in-demand speaker and associate professor of EM. ALiEM now hosts an entire team of regular contributors and welcomes blog posts from the general EM community as well. At over 1500 posts, ALiEM is a massive force in the FOAM the community that is sure to grow and evolve. And while many posts are relevant to pediatrics, only ~50 posts (< 5%) are exclusively dedicated to PEM; just a little more proof that we as PEM physicians must be active in #FOAM!

What do you think about ALiEM?

By Maneesha Agarwal

FOAM Party: What is FOAM?

How would you like:
… access to the latest literature and what others think about it
… the ability to exchange ideas with colleagues around the world
… educational materials in formats ranging from podcasts to videos to short blurbs
… being able to review pearls of wisdom at any hour of the day
… and to have all of this for free?