Use of glucometer testing to detect CSF leaks

Emerg Med J 2005;22:556-557 doi:10.1136/emj.2004.022111

• Short report

New insights into the glucose oxidase stick test for cerebrospinal fluid rhinorrhoea

Abstract

Rhinorrhoea is a clinical sign of cerebrospinal fluid (CSF) leakage in patients with skull fracture, but can also be attributable to respiratory secretions or tears. Laboratory tests confirming the presence of CSF are not sufficiently rapid to support clinical decision making in the emergency department and may not be universally available.

Detection of glucose in nasal discharge was traditionally used to diagnose CSF leak at the bedside, but has fallen into disuse as it has poor positive predictive value. We propose an algorithm to improve the diagnostic value of this test taking into consideration factors we have found to affect the glucose concentration of respiratory secretions. In patients at risk of CSF leak, nasal discharge is likely to contain CSF if glucose is present in the absence of visible blood, if blood glucose is <6 mmol.L⁻¹, and if there are no symptoms of upper respiratory tract infection.

FREE CEU's - Emergency Preparedness Courses in SC

FREE !

Preparedness Courses

For SC Pre-Hospital Personnel

 

(EMTs, paramedics, and other non-hospital emergency care personnel)

Brought to you by: SC DHEC and Emergency Services Special Operations Group

Mass Casualty Incidents/START Triage (Lecture with practical exercise/scenario) During a mass casualty incident (MCI), local resources will be overwhelmed. By utilizing the Simple Triage and Rapid Transport/Treatment method of sorting victims of an MCI responders will be able to “Do the best for the most.”

Meth Lab Awareness (Lecture)

Meth labs are more prevalent than ever and first responders need to know how to identify the properties and uses for methamphetamines, identify the hazards associated with and what actions to take when responding to a methamphetamine lab, and treat victims of a methamphetamine incident appropriately.

Pandemic Influenza (Lecture) Considerations for Emergency Medical Services participants will support the development of or review their organization’s pandemic influenza plan, know their role, and ensure they are ready to clinically respond in the event of pandemic influenza.

May 15^th 

Greenville Tech, Pandemic Influenza for EMS and WMD Awareness

Berkeley County Emergency Services Training Center, START Triage and Meth Lab/IED

May 22^nd  

Florence EMS Training Center, Pandemic Influenza for EMS and WMD Awareness

Lexington County EMS, START Triage and Meth Lab/IED

May 29^th  

Berkeley County Emergency Services Training Center, Pandemic Influenza for EMS and WMD  
Greenville Tech., START Triage and Meth Lab/IED

June 5^th  

Lexington County EMS, Pandemic Influenza for EMS and WMD Awareness
Florence EMS Training Center, START Triage and Meth Lab/IED

Session times: 10:00 a.m. – 3:00 p.m. Lunch is on your own from 12:00 to 1:00

No Registration Required

For additional information please contact:

C. J. Johnson, BHS, NREMT-P (Ret.), Owner/President, Emergency Services Special Operations Group, LLC, Medford, Oregon, 843-991-3928

or

Lorraine Dillon, MS, CHES, LPN, BT Training and Development Director, Division of EMS & Trauma, SC DHEC, (803) 545-4273, dillonla@dhec.sc.gov

Feb 18th 2010 ~ National Critical Care Transport Nurses Day~

Study questions the standard of C-Collars

Baylor study doubts neck brace standard
In some cases, device might hurt accident victims

By TODD ACKERMAN
HOUSTON CHRONICLE

1/25/10

   Applying a brace to the neck of a trauma patient, standard procedure for many decades, can worsen the injury and lead to severe paralysis or death, according to a new study by Houston researchers.

   Baylor College of Medicine doctors used cadavers to confirm that so-called cervical collars can be counterproductive, a finding that could upturn the way emergency medical personnel and doctors act to stabilize and protect the upper spine in potentially fatal neck injuries, such as those that commonly occur in bad automobile accidents.

   "This study is a proof of concept that in cases of severely unstable neck injuries, cervical collars are not only not helpful, but harmful in many situations," said Dr. Peleg Ben-Galim, a professor of orthopedic surgery and the study's lead author. "More research needs to be done, but it might be that we can prevent some of the deaths and quadriplegia that occur in these injuries."

   The study appeared this week in the Journal of Trauma.

   Dr. David Persse, medical director of Houston's Emergency Management Services, called the study "compelling" and "concerning" and said it will come up for discussion at the annual meeting of the nation's 30 largest EMS departments in Dallas next month. But he also said he doesn't want to overreact.

   "We need to look at this thoughtfully before we change the standard of care," said Persse. "It concerned a particular kind of injury. It may apply to other injuries as well, but we don't know that yet."

   But Persse added that he understands the need to act quickly, that "it's not like a lot of areas where there's not as serious downside to waiting for the next study."

Car-crash victims

   Ben-Galim said cervical spine injuries are found in the autopsies of up to 94 percent of people who die in car crashes, which claim about 44,000 U.S. lives annually. There are about 11,000 people annually who survive spinal cord injuries.

   There is no obvious alternative to cervical collars, though hospitals often place sandbags under the back of the patient's head and, less commonly, some EMS teams at the scene of the crash wedge the head of the patient between foam bolsters on the backboard.

   The injuries in question involve the area where the brain connects to the spinal cord. Doctors treating such injuries work to stabilize the ligaments, muscle and bone to prevent secondary injury and to protect the brain stem and cord.
  
   Baylor researchers undertook the study after a case in which a broken jaw precluded the use of a cervical collar on the survivor of a car wreck brought to Ben Taub. When the doctors started to put a collar on the patient, fluoroscopy showed two of the patient's vertebrae separate, causing doctors to immediately remove the collar. The treated patient ultimately walked out of the hospital on his own.

   Ben-Galim noted that there are other such case histories in medical literature.

   To study the phenomenon, Baylor researchers made an incision in cadaver neck ligaments based on patient X-rays, then simulated clinical scenarios by applying cervical collars and putting the bodies in ambulances and driving a distance.

   In all of the cadavers, imaging technologies found that the collar increased the rupture.

   In effect, the collars pushed the head away from the shoulders, Ben-Galim said.

   He said the rupture stretching occurs because of both the application of the collars and their continued use.

   One national expert called the study interesting but said he wasn't sure it would one day change the standard of care.

   "There are certain cases, like the ones in this study, that can be dangerous, but they're rare -- most people who suffer high neck injuries die immediately," said Dr. Tom Scaletta, the past president of the American Academy of Emergency Medicine. "I think the study's importance will be to raise awareness about the special care that must be taken -- preserving patients' normal head position, making sure they're not having difficulty breathing."

Anecdotal cases

   Dr. Walter Lowe, director of the Memorial Hermann Sports Medicine Institute and team physician for the Houston Texans football team, said the study wouldn't change the care of injured football players removed from the field in collars and on stretchers because those injuries tend to involve lower areas of the spine.

   Ben-Galim said that since the study was undertaken, Ben Taub doctors have saved patients with severe neck injuries by loosening or removing cervical collars early and rushing them to the operating room, but he acknowledged such cases are anecdotal.

   He said the research team looked at 400 articles and found no scientific evidence that cervical collars can stabilize severely unstabilized spine injuries.

Original source: http://www.seattlepi.com/health/414631_Neck25.html

Pain Scale - "Zero to Ten"...!

In this business of ER/EMS/Healthcare, we have been tasked with an attempt to objectify a patient's "pain".  Apparently many bean-counters and doctoral candidates have done research on how to do this, and as such the "Zero to Ten" scale was born.

Now most of you reading this are undoubtedly of the ER/EMS genre' and are all too familiar with this "scale".  Our instructors, mentors, preceptors, managers, educators (ad nauseum); pound it into us to use this scale.  It's pretty easy for them to say that because on paper it looks good, but as most of you, my readers know, it is haphazard at best to apply effectively...  Oh, wait, let me also throw in what they told us in feel-good-nursing-school, "pain is whatever your patient says it is".   So, we are asked to unquestioningly document "whatever" the patient says about their pain.

By itself, this is not too bad, however, it is when the patient is savvy to this whole pain scale thing that they begin to manipulate it to suit their own needs and wants.  We are left to unquestioningly just "write it down" with no practical attempt to help the patient understand what we are trying to measure.

So we write what the patient says, then we spend the next 5-10 minutes charting all those "little things" that we observe about the patient's behaviors - those things that seem to make the patient's self-assessment inconsistent at best....

"patient talking/texting/IM'ing on cell phone..."

"patient laughing, joking with friends..."

"patient walks to room with steady, coordinated gait..."

"patient smiling..."

"patient resting (sleeping) on stretcher spooning with boyfriend...!"

...and on and on

Sometimes we go further to note more objective findings such as the vital signs:

-reported pain score "10"

-Pulse rate: 56....???

However, in an attempt to further quantify this pain scale, and maybe to help the patient understand what we're looking for, I came across this table (see below) which strives to put some defining characteristics to the different pain levels....

Comparative Pain Scale
	0	No pain. Feeling perfectly normal.
Minor Does not interfere with most activities. Able to adapt to pain psychologically and with medication or devices such as cushions.	1 Very Mild	Very light barely noticable pain, like a mosquito bite or a poison ivy itch.
	2 Discomforting	Minor pain, like lightly pinching the fold of skin between the thumb and first finger with the other hand, using the fingernails.
	3 Tolerable	Very noticable pain, like an accidental cut, a blow to the nose causing a bloody nose, or a doctor giving you an injection.
Moderate Interferes with many activities. Requires lifestyle changes but patient remains independent. Unable to adapt to pain.	4 Distressing	Strong, deep pain, like an average toothache, the initial pain from a bee sting, or minor trauma to part of the body, such as stubbing your toe real hard
	5 Very Distressing	Strong, deep, piercing pain, such as a sprained ankle when you stand on it wrong, or mild back pain. Not only do you notice the pain all the time, you are now so preoccupied with managing it that you normal lifestyle is curtailed.
	6 Intense	Strong, deep, piercing pain so strong it seems to partially dominate your senses, causing you to think somewhat unclearly. Comparable to a bad non-migriane headache combined with several bee stings, or a bad back pain.
Severe Unable to engage in normal activities. Patient is disabled and unable to function independently.	7 Very Intense	Same as 6 except the pain completely dominates your senses, causing you to think unclearly about half the time. Comparable to an average migraine headache.
	8 Utterly Horrible	Pain so intense you can no longer think clearly at all.. Comparable to childbirth or a real bad migraine headache.
	9 Excruciating Unbearable	Pain so intense you cannot tolerate it and demand pain killers or surgery, no matter what the side effects or risk. Comparable to throat cancer.
	10 Unimaginable Unspeakable	Pain so intense you will go unconscious shortly. Most people have never experienced this level of pain. Those who have suffered a severe accident, such as a crushed hand, and lost consciousness as a result of the pain and not blood loss, have experienced level 10.

So, now, here's your clinical story to illustrate the use of this scale...

Dr: "Between zero, being no pain and 10 being the worst you can imagine, how would you rate your pain?"

Pt: (calmly)..."a 10"....

Dr: "Okay, at 10 would be you getting hit in the face with a 15 pound sledgehammer, and unconscious from the pain, not the head injury.  Most people have never and will never experience this pain level ~ and if they do, will undoubtedly be unconscious..."

Pt: (again calmly)..."okay, 9-and-a-half..."

Twas' the Night Before Christmas - Nurse Style

Twas the Night Before Christmas -A Nursing Version

Twas the night before Christmas, and all through the floor
Lasix was given, filling foleys galore.
Stockings were worn to prevent emboli,
they came in two sizes, knee and thigh high.

The patients were nestled half-@$$ed in their beds,
while visions of stool softeners danced in their heads.
We in our scrubs, and they in their gowns,
Fashion created to hide extra pounds.

When down in the ER it became such a zoo,
they called with admissions for me and you.
They're coming, they're going, and they're all looking the same.
My patience for patients is starting to wane.

Now call lights are ringing, the patient 400 pounds,
says "Didnt get my pericare, send my nurse now".
And now delegation seems the best plan,
We try to send others, for the needs of this man.

When what to my wondering eyes should appear,
But Santa himself and 8 tiny reindeer.
Hey says he comes from Central Supply.
To bring us LR, NS, & D5.

The doctors then scribbled what no one could read.
Orders on patients, to measure their pee.
We try to decipher illegible words,
orders for patients, to guaiac their turds.

The new shift arriving, our day is now through,
How did stool & emesis get in my shoe?
We give them report and pass on the facts,
and tell them of duoderm lining the cracks.

And the nurses exclaim as they limp out of sight,
"Ativan to all, and to all a good night".

Nurses' Perks For Working on Christmas

There truly are advantages to working on Christmas and other holidays.  If you are scheduled to work a holiday, don't despair!  Look at the bright side.

OVERTIME PAY:  This is one perk that most nurses appreciate when working a holiday like Christmas.  The extra money can help with holiday expenses.  If you are really on the ball, you can start paying off your bills quicker – get a jump on your New Year's resolution.  If your loved ones are upset that you are not going to be there part of the day on Christmas, plan something special with them later in the week!  Let them know in advance what you will be doing.

YOU DON'T HAVE TO COOK:  Health care facilities go full scale on Christmas to make a fantastic meal for patients and family members.  Staff members working Christmas reap the benefit of a great holiday meal without the cooking and clean-up!

YOU GET TO WITNESS SPECIAL MOMENTS BETWEEN PATIENTS AND FAMILY MEMBERS:  You get a front row seat to those special holiday moments shared between patients and their family members.  You see the hugs from grandkids, the gifts exchanged, and hear the resolutions and hopes for the New Year.  This is a gift you can't and won't want to exchange!

YOU ARE REMINDED HOW LUCKY YOU ARE:  By seeing those special moments, you are reminded of how lucky you are and all of the great gifts in your own life.  After all, you get to leave the health care facility after your shift – conversely the patients have to stay!

YOU ARE NOT WORKING THE ENTIRE 24 HOUR PERIOD:  You still have about 12 hours of the day to spare.  Make plans to do something special on the holiday before or after your shift.  Create a unique and new tradition for your holiday this year!


Credit for this essay goes to Sue Heacock, RN