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Trick of Trade: Alternative to a Pressure Bag for IV Fluids

pressure bag IV fluidsYou have a severely dehydrated patient with a peripheral IV line, requiring urgent fluid resuscitation. However, the crystalloid fluids are not flowing freely. Multiple attempts were made to place this line with the latest having a flash of blood return and a smoothly flowing saline flush. You can not seem to find your pressure infusion cuff to squeeze the IV bag and accelerate fluid administration.

Trick of the Trade: Manually provide positive pressure fluids using a 3-way stopcock

  1. Attach a 3-way stopcock between the angiocatheter and IV tubing.
  2. In the unused port, attach a 10 or 20 cc syringe.
  3. Fill the syringe with fluids from the IV bag (turn off flow to the angiocatheter using the stopcock)

Trick of the trade stopcock pressure infusion IV fluids syringe start

  1. Rotate the stopcock 180-degrees and push the syringe fluid into the angiocatheter.

Trick of the trade stopcock pressure infusion end

  1. Repeat this process several times.
  2. After manually pushing 100-200 cc of fluid through the line, turn the stopcock to shut off the syringe port. The fluids should flow more rapidly with gravity alone.

Word of Caution: Syringe Fluid Contaminant

Thanks to Twitter feedback from @cpatrick_89, be careful of introducing bacteria when attaching these pieces to the IV tubing, based on an in vitro study. Wearing gloves helped reduce bacterial contamination [1].

Note that conventional pressure bags may not be readily available in emergency departments and could blow the line you worked hard to secure. This “gentle pressure” technique allows the clinician to gauge how much positive pressure to administer to minimize the risk of fluid extravasation.

Interested in Other Tricks of the Trade?

Reference

  1. Kawakami Y, Tagami T. Pumping infusions with a syringe may cause contamination of the fluid in the syringe. Sci Rep. 2021;11(1):15421. Published 2021 Jul 29. doi:10.1038/s41598-021-94740-1
By |2023-07-22T16:33:15-07:00Jul 22, 2023|Cardiovascular, Critical Care/ Resus, Tricks of the Trade|
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ALiEM AIR Series | Infectious Disease 2023 Module

ALiEMU AIR Series infectious disease 2023

Welcome to the AIR Infectious Disease Module! After carefully reviewing all relevant posts in the past 12 months from the top 50 sites of the Digital Impact Factor [1], the ALiEM AIR Team is proud to present the highest quality online content related to related to infectious diseases in the Emergency Department. 6 blog posts met our standard of online excellence and were approved for residency training by the AIR Series Board. More specifically, we identified 1 AIR and 5 Honorable Mentions. We recommend programs give 3 hours of III credit for this module.

AIR Stamp of Approval and Honorable Mentions

In an effort to truly emphasize the highest quality posts, we have 2 subsets of recommended resources. The AIR stamp of approval is awarded only to posts scoring above a strict scoring cut-off of ≥30 points (out of 35 total), based on our scoring instrument. The other subset is for “Honorable Mention” posts. These posts have been flagged by and agreed upon by AIR Board members as worthwhile, accurate, unbiased, and appropriately referenced despite an average score.

Take the AIR Infectious Disease Module at ALiEMU

Interested in taking the AIR quiz for fun or asynchronous (Individualized Interactive Instruction) credit? Please go to the above link. You will need to create a free, 1-time login account.

Highlighted Quality Posts: Infectious Disease

SiteArticleAuthorDateLabel
SGEMLumbar punctures in febrile infants with positive urinalysis – it’s just overkillDennis Ren, MDDecember 31, 2022AIR
EMDocsBacterial MeningitisMounir Contreras Cejin, MD January 28, 2023HM
ALiEMThe Febrile InfantCorey Ziemba, MD, Justin Hacnik, MD and J.D. Cambron, DOMarch 29, 2023HM
EMCritApproach to CNS infectionJosh Farkas, MDAugust 15, 2022HM
Core EMUpdates in STI CareDaniel Imas, MDMarch 17, 2022HM
REBEL EMShort course antibiotics for Peds CAPMarco Propersi, DODec 5, 2022HM

(AIR = Approved Instructional Resource; HM = Honorable Mention)

 

If you have any questions or comments on the AIR series, or this AIR module, please contact us!

Thank you to the Society of Academic Emergency Medicine (SAEM) and the Council of EM Residency Directors (CORD) for jointly sponsoring the AIR Series! We are thrilled to partner with both on shaping the future of medical education.

 

Reference

  1. Lin M, Phipps M, Chan TM, et al. Digital Impact Factor: A Quality Index for Educational Blogs and Podcasts in Emergency Medicine and Critical Care. Ann Emerg Med. 2023;82(1):55-65. doi:10.1016/j.annemergmed.2023.02.011, PMID 36967275
By |2023-07-21T14:46:01-07:00Jul 20, 2023|ALiEMU, Approved Instructional Resources (AIR series), Expert Peer Reviewed (Clinical), Infectious Disease|
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Phenobarbital as First-Line Medication for Alcohol Withdrawal: Have You Switched From Benzodiazepines Yet?

phenobarbital first line monotherapy for alcohol withdrawal

Are you using phenobarbital instead of benzodiazepines as the first-line monotherapy for patients in alcohol withdrawal in the Emergency Department (ED)? If not, you probably should be. Another old drug for a new indication, right? Well not exactly. Phenobarbital is indeed an older and relatively cheap drug (less than $20 per loading dose) that has gained some press recently for the treatment of acute alcohol withdrawal [1-3].

Why should you consider using phenobarbital as monotherapy rather than benzodiazepines?

Phenobarbital used to be one of the standard treatments for ethanol (EtOH) withdrawal prior to the introduction of benzodiazepines. However, there are key advantages over benzodiazepines.

  1. Phenobarbital has a dual mechanism of action, binding both the GABA receptor and glutamate receptors in the CNS [3]. This helps EtOH withdrawal symptoms by up-regulating GABA activity and down-regulating excitatory glutamate activity.
  2. Phenobarbital has a predictable metabolization with a long half-life of approximately 3-5 days, which allows the drug to self-taper after the initial loading dose and symptom control in the ED [1, 2]. This contrasts the relatively shorter half-life of many available benzodiazepines, which often require more frequent redosing.

Is phenobarbital safe for the treatment of EtOH withdrawal in the ED?

In short, yes. Several studies have indicated that dosing with phenobarbital (PO or IV) is safe and effective at decreasing the need for escalating doses of benzodiazepines for EtOH withdrawal [1-6]. In comparison to benzodiazepines, it demonstrated:

  • Fewer episodes of hypotension and apnea [1-6]
  • Decreased hospital and ICU stay duration in admitted patients [1]
  • Decreased requirement for ICU level care [1]

Dosing regimens

  • Common regimen: 10-15 mg/kg of IDEAL body weight (IBW) IV bolus over 30 minutes and administering 130-260 mg aliquots every 15-30 minutes for persistent symptoms [2]
    • Note that the patient’s IBW may be much lower than the actual body weight.
    • Use the MD Calc calculator for a patient’s IBW
    • Examples based on the average American height:
      • Male: 5’9” –> 71 kg IBW –> phenobarbital 710-1065 mg IV initial bolus
      • Female: 5’4” –> 55 kg IBW –> phenobarbital 550-825 mg IV initial bolus
  • Alternative lower dosing regimen: 130-260 mg IV boluses with repeated dosing as needed [3]
  • Maximum dose
    • No established maximum, but the absolute upper limit for dosing in epilepsy is 20-30 mg/kg [11]
    • Some sources recommend limiting the dose of phenobarbital in alcohol withdrawal to 15 mg/kg/day [3]
  • Adjuncts: Benzodiazepines may be added without decreasing safely [1]

Do patients need phenobarbital dosing adjustments if they have liver dysfunction?

  • Phenobarbital undergoes metabolization primarily in the liver, mostly by CYP2C9 [9].
  • “Dose adjustment” is recommended by the manufacturer in hepatic dysfunction, but no value is provided [10].
    • Since there is no recommended dosing adjustment in patients with cirrhosis and liver dysfunction, a conservative approach starting with the 130 mg boluses and titrating to the minimum effective dose would likely be the safest approach.
  • Clinical pearl: Hepatic encephalopathy is a strong contraindication to phenobarbital [9, 10].
    • Before administering a barbiturate to a cirrhotic patient for EtOH withdrawal, first ensure that hepatic encephalopathy is not the cause of the agitation or altered mental status.
    • Because patients with hepatic encephalopathy experience excess GABA stimulation, they are very sensitive to GABAergic medications (e.g., barbiturates or benzodiazepines).
    • Administration of benzodiazepines or barbiturates to these patients risk inducing a prolonged comatose state.

Is it safe to give phenobarbital to a patient who has already received benzodiazepines?

  • The concern with concurrent phenobarbital and benzodiazepine administration is oversedation. There is a paucity of evidence for this question, although preliminary data suggests that it is safe without significant mortality risk [1].
  • As a corollary, exercise caution when administering phenobarbital to patients at risk for sedation from any cause, such as hepatic encephalopathy, benzodiazepine abuse, and opioid abuse.
  • Suggested approach: If benzodiazepines have already been given, consider using the alternative, more conservative, lower dose regimen protocol (130-260 mg doses) up to 10-15 mg/kg total with close monitoring after every up-titration. Avoid giving benzodiazepines concurrently during the phenobarbital up-titration period to minimize the risk of oversedation and apnea [11].

Which patients treated with phenobarbital require admission?

There is a dearth of evidence about which patients require medical admission in the setting of phenobarbital administration. The American Society of Addiction Medicine has developed a tool to assist providers with disposition planning for patients with alcohol withdrawal syndrome for all-comers (not necessarily those treated with phenobarbital) [2]. Their recommendations are as follows:

  • Outpatient management
    • Able to follow return precautions
    • Likely to continue with alcohol use disorder treatment
    • Supportive living environment
  • Inpatient management
    • Requires frequent physician and nursing intervention
    • Heavy sedation requirements or active delirium tremens
    • Coexisting medical diagnoses that require inpatient management (severe electrolyte anomalies, infections, pancreatitis, hepatic encephalopathy, etc.)
    • History of severe withdrawals, pregnancy, or concurrent medical condition requiring treatment

Conclusion

Phenobarbital has gained significant popularity for use in EtOH withdrawal in the last few years. Several factors make it ideal for use in EtOH withdrawal, primarily its long half-life allowing for a multi-day, self-tapering effect. The most commonly recommended dosing regimen starts with a 10 mg/IBW kg bolus followed by titration every 30 minutes afterwards. Patients in the ED often can be safely phenobarbital-loaded and discharged, assuming hemodynamic stability, normal alertness, and resolution of withdrawal symptoms. More rigorous studies are needed determine dose thresholds that warrant hospital admission.

References

  1. Rosenson J, Clements C, Simon B, et al. Phenobarbital for Acute Alcohol Withdrawal: A Prospective Randomized Double-blind Placebo-controlled Study. The Journal of Emergency Medicine. 2013;44(3):592-598.e2. doi:10.1016/j.jemermed.2012.07.056. PMID: 22999778
  2. Wolf C, Curry A, Nacht J, Simpson SA. Management of Alcohol Withdrawal in the Emergency Department: Current Perspectives. Open Access Emerg Med. 2020;12:53-65. doi:10.2147/OAEM.S235288. PMID: 32256131
  3. Long D, Long B, Koyfman A. The Emergency Medicine Management of Severe Alcohol Withdrawal. The American Journal of Emergency Medicine. 2017;35(7):1005-1011. doi:10.1016/j.ajem.2017.02.002. PMID: 28188055
  4. Staidle A, Geier C. Phenobarbital and/or Benzodiazepines for Recurrent Alcohol Withdrawal: A Self-Controlled, Retrospective Cohort Study. The American Journal of Emergency Medicine. 2022;54:263-266. doi:10.1016/j.ajem.2022.02.020. PMID: 35219012
  5. Lebin JA, Mudan A, Murphy CE, Wang RC, Smollin CG. Return Encounters in Emergency Department Patients Treated with Phenobarbital Versus Benzodiazepines for Alcohol Withdrawal. J Med Toxicol. 2022;18(1):4-10. doi:10.1007/s13181-021-00863-2. PMID: 34697777
  6. Hendey GW, Dery R, Barnes R, Snowden B, Mentler P. A Prospective, Randomized, Trial of Phenobarbital Versus Benzodiazepines for Acute Alcohol Withdrawal. The American Journal of Emergency Medicine. 2011;29(4):382-385. doi:10.1016/j.ajem.2009.10.010. PMID: 20825805
  7. Hoffman PL, Grant KA, Snell LD, Reinlib L, Iorio K, Tabakoff B. NMDA Receptors: Role in Ethanol Withdrawal Seizures. Annals of the New York Academy of Sciences. 1992;654(1):52-60. doi:10.1111/j.1749-6632.1992.tb25955.x. PMID: 1321581
  8. Young GP, Rores C, Murphy C, Dailey RH. Intravenous Phenobarbital for Alcohol Withdrawal and Convulsions. Annals of Emergency Medicine. 1987;16(8):847-850. doi:10.1016/S0196-0644(87)80520-6. PMID: 3619162
  9. Patsalos PN, Spencer EP, Berry DJ. Therapeutic Drug Monitoring of Antiepileptic Drugs in Epilepsy: A 2018 Update. Therapeutic Drug Monitoring. 2018;40(5):526-548. doi:10.1097/FTD.0000000000000546. PMID: 29957667
  10. Lewis CB, Adams N. Phenobarbital. In: StatPearls. StatPearls Publishing; 2023. Accessed April 16, 2023.
  11. Farkas J. Alcohol withdrawal. EMCrit Project. Published March 29, 2023. Accessed April 18, 2023.

By |2023-05-31T19:25:45-07:00Jun 1, 2023|Neurology, Tox & Medications|
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Trick of Trade: Dual Foley catheter to control massive epistaxis

Massive epistaxis is considered a medical emergency that requires immediate attention. Symptoms of massive epistaxis include sudden and heavy bleeding from the nose, difficulty breathing, dizziness, and a rapid heartbeat. If left untreated, it can lead to significant blood loss, shock, airway obstruction, and even death. We report a case of a 50-year-old man with end stage renal disease with massive nasal bleeding from the left nostril, shortness of breath, and confusion.

Initial Management

After a rapid assessment, we inserted an anterior nasal pack, soaked in epinephrine, TXA, and an antibiotic-based lubricant. However, the bleeding continued from his nares and posterior oropharynx. We thus removed the anterior packing and instead inserted a Foley catheter into the posterior nasal space and inflated the balloon. Unfortunately, the bleeding still continued. Because he presumably had uremia-induced thrombasthenia (weak platelets), he received blood transfusions and IV TXA. And still — he continued bleeding heavily.

Trick of the Trade: Dual Catheter Technique

To provide optimal surface area coverage and tamponade effect of the posterior vessels, concurrent anterior packing is usually needed [1]. You can use commercial devices that have a dual balloon setup, but we did not have that available.

dual balloon for massive epistaxis

Illustration by Dr. Abdelhameed with patient-consented photo of dual balloon technique

Technique

  1. Insert the a 14-French Foley catheter into the nares with the patient’s mouth open (balloon 1). Stop when you see the tip of the catheter dangling in the posterior oropharynx.
  2. Inflate the balloon partially with 15-20 cc of air.
  3. Gently pull the catheter anteriorly until you feel resistance such that the balloon is snuggly positioned.
  4. If the bleeding still continues, insert a second Foley catheter until you meet resistance (balloon 2). Inflate this second balloon with 15 cc of air.

For our case, this dual catheter compression technique succeeded in halting the bleed.

Interested in Other Tricks of the Trade?

Reference

  1. Goralnick E. Posterior Epistaxis Nasal Packing. Medscape. Published Dec 9, 2020

By |2023-05-23T23:11:19-07:00May 29, 2023|Genitourinary, Pediatrics, Tricks of the Trade|
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