REBEL Review 73: Intranasal (IN) Medications

Created May 4, 2016 | Trauma | DOWNLOAD

April 21, 2016

Background: Airway management is a critical part of the management of patients presenting with traumatic brain injury (TBI). Emergency Physicians (EPs) have no ability to change the primary injury once it has occurred and so our focus is on preventing secondary brain injury. Hypoxemia and hypercarbia are major contributors to morbidity and mortality and management must focus on preventing them. Patients with TBI and depressed mental status frequently require definitive airway management in order to avoid these secondary insults. Rapid sequence intubation (RSI) with serial administration of a neuromuscular blocking agent (NMBA) and an induction agent is common practice. The most commonly used NMBAs are the depolarizing agent succinylcholine and the non-depolarizing agent rocuronium. There are strong proponents arguing for the dominance of one agent over the other based on qualities of the drugs but scant data investigating the question has led to clinical equipoise.

March 21, 2016

Background: Currently the Advanced Trauma Life Support (ATLS) guidelines recommend initial treatment of decompression of a tension pneumothorax, as needle thoracostomy (NT) using a 5cm angiocatheter at the 2nd intercostal space (ICS2) in the mid clavicular line (MCL). With the growth of size in our population worldwide, there has been increasing evidence about two things:
  1. A 5cm angiocatheter may not be long enough to reach the pleural space
  2. The 2nd intercostal space at the mid clavicular line (ICS2-MCL) may not be the ideal location for needle decompression

January 18, 2016

Background: CT scans are frequently done after minor head injury to evaluate for intracranial hemorrhage. While CT scans are an excellent tool for diagnosing or ruling out this disorder, they are not without harms including radiation exposure, cost and department delays. Much of the time, CTs are negative, or find injuries for which no intervention is ever done and do not clinically affect the patient. Clinical Decision Instruments may aid clinicians in determining which patients are higher risk and require imaging and which do not.

December 14, 2015

Background: Fingertip amputations are not an uncommon injury seen in the emergency department. Treatment options range from healing by secondary intention to flap coverage or replantation. Selection of the appropriate treatment modality depends on the nature of the injury, the physical demands of the patient, and the patient’s co-morbidities. Prophylactic antibiotic use in patients with fingertip amputations is controversial. The routine use of prophylactic antibiotics is universally recommended on grossly contaminated wounds, in immunocompromised patients, and in injuries with extensively destroyed/devitalized tissue as it is thought the infection risk is high in these circumstances. However, many reflexively prescribe antibiotics prophylactically in all distal tip amputations. Moreover, there is often an underlying tuft fracture and we reflexively give these patients antibiotics because we were all taught that any open fractures require antibiotics in addition to usual fracture care. Prior studies on distal fingertip amputations and the use of prophylactic antibiotics suggest no change in infection risk with the routine use of antibiotics but these studies were small and have done little to inspire an antibiotic-restrictive approach universally.