- Email: [email protected]
Research article on “efficacy of normal saline solution vs. heparin solution” applauded
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could be a n t i c i p a t e d from the muscle b r e a k d o w n as two #16 intravenous lines were e s t a b l i s h e d in his left arm. We h a d learned from the initial p a t i e n t t h a t any smaller g a u g e intravenous line would not allow adequate fluid flow, probably b e c a u s e of i n c r e a s e d viscosity of the blood. By u s i n g only one arm for a c c e s s we allowed the lab p h l e b o t o m i s t a c c e s s to the opposite side for serial lab work. The e m e r g e n c y p h y s i c i a n w a s informed t h a t we m o s t likely h a d a p a t i e n t with rhabdomyolysis. B.B.'s initial CK w a s 88,000 U/L. He w a s initially r e s u s c i t a t e d with over 6 L of normal saline solution, a n d t h e n the fluids were c h a n g e d to DSW with sodium b i c a r b o n a t e to alkalinate his urine to at least a 7.5 pH. During his + d a y stay in the ICU he received IV fluids sufficient to m a i n t a i n a urine output of at l e a s t 200 c c / h o u r m e a s u r e d by Foley catheter. B e c a u s e his serum creatinine never e x c e e d e d 1.0, the nephrologist did not transfer the p a t i e n t for dialysis. After 4 days the p a t i e n t w a s d i s c h a r g e d with a resolving CK of 10,389 U/L. In addition, he did not require fasciotomy for c o m p a r t m e n t syndrome, w h i c h for this y o u n g adult w a s a more frightening scenario than the possibility of dialysis.--Diana Herking Kruse, RN,
MSN, CEN, Milford, Ohio More on the night shift
Dear Editor: I a p p r e c i a t e d Valerie G r o s s m a n ' s article ("Defying Circadian Rhythm: The E m e r g e n c y Nurse and the Night Shift," 1997;23:602-7). People who work at night are often invisible to the rest of the world, and their unique health and safety i s s u e s are u n d e r a p p r e c i a t e d . The article primarily d i s c u s s e d problems and challenges for night workers. While the s t a t e m e n t that "the effects...have b e e n proven to shorten life exp e c t a n c y " is not literally true (there is no r e s e a r c h proving t h a t working at night shortens life expectancy), night work can d e c r e a s e quality of health, safety, a n d quality of life w h e n night workers and employers fail to take appropriate actions. Fortunately, a great n u m b e r of m e a s u r e s can be taken by individual workers, their family members, and their m a n a g e r s to greatly improve the situation. (We have included some of t h e s e m e a s u r e s on our w e b s i t e at http://www.shiftwork.com). Ms. Grossman does include some advice in her article. However, one t i p - - " u s e shifts of 3 AM to 3 PM a n d 3 PM to 3 AM"--runs contrary to most shiftwork experts' r e c o m m e n d a t i o n s b e c a u s e it forces people on both shifts to disrupt the natural sleep period. Facilities using 12-hour shifts often find they have better results with changeovers bet w e e n 7 AM a n d 8 AM.
Thanks again for a d d r e s s i n g this important iss u e . - - E d Coburn, Publisher, Shiftwork Alert, Cam-
bridge, Massachusetts
Reply Good health does not always m e a n a longer life, y e t poor health often shortens one's life span. While no specific research studies were cited in the article proving a shortened life expectancy, a variety of information is available from which conclusions m a y be drawn. Studies highlighting the detrimental health effects believed to result from -working off shifts are well d o c u m e n t e d throughout the research literature. Lifestyles are highly individualized, m a k i n g e a c h person's outcome from working off shifts different. While health is a s s o c i a t e d with normal synchronized psychophysiologic circadian rhythms, there are some unique individuals whose rhythm m a y adjust well to an altered p a t t e r n of sleep. I e n c o u r a g e each interested reader to pursue the literature available. Doing so will h e i g h t e n the unders t a n d i n g n e c e s s a r y to create healthy work environm e n t s for our profession. A variety of r e c o m m e n d a tions are available that differ from one another. Some sources r e c o m m e n d grouping m a n y night shifts in a row, while others r e c o m m e n d no more than one or two night shifts at a time; still other sources recomm e n d that the changeover occur at 3 AM to 3 PM, and others r e c o m m e n d 7 AM to 7 PM. This article should bring attention to the challenges of rotating shifts and e n c o u r a g e all health care professionals to strive for their own ultimate quality of health. R e m e m b e r - - w e m u s t take care of the caretaker before the caretaker can take care of anyone
else.--Valerie G.A. Grossman, RN, CEN, CCRN, Rochester, N e w York Research article on "efficacy of normal saline solution vs. heparin solution" applauded
Dear Editor: I w a s h a p p y to see a research article in your A u g u s t issue (1997;23:306-9) a d d r e s s i n g the efficacy of normal saline solution versus heparin solution in m a i n t a i n i n g the p a t e n c y of peripheral IV catheters in children. I have long b e e n a believer in the effectiveness of using saline i n s t e a d of heparin in m a i n t a i n i n g peripheral IV lines, especially w h e n positive pressure is used. The research m e t h o d utilized by the author w a s thorough and scientific in its basis. However, I w a s d i s a p p o i n t e d w h e n reading the article to find t h a t the m e d i a n calculation of duration w a s only 2.5 hours. While the author d e s c r i b e s this as the average length of stay in an e m e r g e n c y depart-
April 1998 117
JOURNALOF EMERGENCYNURSING
ment, it would have been more beneficial to study the efficacy of saline solution as a routine flush in the hospitaI. Most intermittent infusion devices that are started and flushed in the emergency department are not accessed again until after the patient reaches the floor. This can add a cOnsiderable amount of time between times w h e n the IV line is accessed. Also, IV lines at our institution are flushed every 6 hours on the floor, a time m u c h greater than that studied by the author. Involvement of floor patients in this study would greatly add to its application to pediatric nursing practice in the m a n a g e m e n t of intermittent infusion
devices.--Elizabeth A. Paten, RN, BSN, CEN, Clinical Nurse Educator, Emergency Department, LeBonheur Children's Medical Center, Memphis, Tennessee
Expect the unexpected Dear Editor. A 10-month-old child was recently brought in by her parents. She had had chest congestion for I month and her mother was concerned about her "choking." She had taken an antibiotic for 2 weeks but was not improving. She had been playful and was taking her formula well, but was not eating "table food." Currently, her symptoms were: "sneezing," "coughing," and being "tired and fussy." Her tympanic temperature was 103 ° F. The child's color was good, she was in no acute distress. She did cough occasionally. Her CBC was normal. The chest radiograph showed a serendipitous finding, that is, a round object about the size of a nickel in her upper esophagus, which may or may not have been causing her symptoms. Her mother had no idea w h e n she had swallowed the coin. It may have been there for 4 weeks. Once again I was reminded that the unexpected should be the expected in emergency nursing and that with infants, who cannot directly tell us what is wrong, we need to have a high index of suspicion for foreign bodies.--Olaf Snyder, RN, BSN, MICN, CEN,
Transylvania Community Hospital, Brevard, North Carolina
Scombroid fish poisoning Dear Editor. A 24-year-old white w o m a n arrived at our emerg e n c y department complaining of "fast heart beat and dizziness." In triage, vital signs were as follows: temperature, 98.8 ° F by mouth; pulse, 148; respirations, 22; and blood pressure, 102/52. The triage nurse obtained a past medical history significant only for childbirth 6 months prior to this event. The patient
118 Volume 24, Number 2
denied any allergies and physical examination revealed facial flushing, complaints of anxiety, and dizziness. She denied having chest pain or shortness of breath. Lungs were clear to auscultation and pulse oximetry revealed an oxygen saturation of 96%. The patient stated that symptoms developed immediately after lunch; she reported having "fish" and a salad. The triage nurse classified the patient as emergent because of complaints of dizziness with tachycardia and the possibility of an allergic reaction. Cardiac monitoring revealed a sinus tachycardia at 156 and redness of the extremities and trunk with no edema noted. Intravenous access was established. The ED physician interviewed the client and found that the client had flesh tuna for lunch. An order was given for diphenhydramine (Benadryl), 50 m g intravenously, but no order was given for subcutaneous epinephfine--it was not needed because the patient was experiencing scombroid fish poisoning after ingesting dark fish meat that had not b e e n properly handled. The dark m e a t fish from the suborder Scombroidea include tuna, mackerel, bluefish, and mahi-mahi, but these foods may be served with other names like mackerel, swordfish, bonita, dolphin, amberjack, or tuna salad. Gases of scombroid poisoning have occurred in Hawaii, California, New York, Washington, Illinois, Michigan, and Connecticut, 1 but such poisoning can occur anywhere flesh fish has been flown in. The case reported here occurred in Philadelphia. Scombroid fish contain normal florae that, when exposed to heat, cause the formation of heat stable toxins. The toxins are a direct result of the bacteria attacking the dark meat in the fish. The scombrotoxin formation occurs between the time the fish is caught and the time it is cooked. Often boats do not properly refrigerate freshly caught fish. The activity of the bacteria on the meat contributes to the formation of histamine and histamine-like substances. The symptoms in our patient were a result of histamine overdose rather than an allergic reaction, with which it is often confused. 22 She was not allergic to fish and just needed antihistamines and histamine blockers. Patients may report that during ingestion of the fish they noted a metallic, bitter, or peppery taste. Symptoms develop abruptly within 20 to 30 minutes of ingestion of the fish. The most common symptoms are facial flushing, diarrhea, severe throbbing headache, palpitations, and abdominal cramps. Other symptoms such as dizziness, dry mouth, nausea, vomiting, and urticaria have also been reported. The majority of symptoms resolve after 6 hours; however, people have reported feeling weak and fatigued for a day after the event.
.
.
.
.
.
.
.
could be a n t i c i p a t e d from the muscle b r e a k d o w n as two #16 intravenous lines were e s t a b l i s h e d in his left arm. We h a d learned from the initial p a t i e n t t h a t any smaller g a u g e intravenous line would not allow adequate fluid flow, probably b e c a u s e of i n c r e a s e d viscosity of the blood. By u s i n g only one arm for a c c e s s we allowed the lab p h l e b o t o m i s t a c c e s s to the opposite side for serial lab work. The e m e r g e n c y p h y s i c i a n w a s informed t h a t we m o s t likely h a d a p a t i e n t with rhabdomyolysis. B.B.'s initial CK w a s 88,000 U/L. He w a s initially r e s u s c i t a t e d with over 6 L of normal saline solution, a n d t h e n the fluids were c h a n g e d to DSW with sodium b i c a r b o n a t e to alkalinate his urine to at least a 7.5 pH. During his + d a y stay in the ICU he received IV fluids sufficient to m a i n t a i n a urine output of at l e a s t 200 c c / h o u r m e a s u r e d by Foley catheter. B e c a u s e his serum creatinine never e x c e e d e d 1.0, the nephrologist did not transfer the p a t i e n t for dialysis. After 4 days the p a t i e n t w a s d i s c h a r g e d with a resolving CK of 10,389 U/L. In addition, he did not require fasciotomy for c o m p a r t m e n t syndrome, w h i c h for this y o u n g adult w a s a more frightening scenario than the possibility of dialysis.--Diana Herking Kruse, RN,
MSN, CEN, Milford, Ohio More on the night shift
Dear Editor: I a p p r e c i a t e d Valerie G r o s s m a n ' s article ("Defying Circadian Rhythm: The E m e r g e n c y Nurse and the Night Shift," 1997;23:602-7). People who work at night are often invisible to the rest of the world, and their unique health and safety i s s u e s are u n d e r a p p r e c i a t e d . The article primarily d i s c u s s e d problems and challenges for night workers. While the s t a t e m e n t that "the effects...have b e e n proven to shorten life exp e c t a n c y " is not literally true (there is no r e s e a r c h proving t h a t working at night shortens life expectancy), night work can d e c r e a s e quality of health, safety, a n d quality of life w h e n night workers and employers fail to take appropriate actions. Fortunately, a great n u m b e r of m e a s u r e s can be taken by individual workers, their family members, and their m a n a g e r s to greatly improve the situation. (We have included some of t h e s e m e a s u r e s on our w e b s i t e at http://www.shiftwork.com). Ms. Grossman does include some advice in her article. However, one t i p - - " u s e shifts of 3 AM to 3 PM a n d 3 PM to 3 AM"--runs contrary to most shiftwork experts' r e c o m m e n d a t i o n s b e c a u s e it forces people on both shifts to disrupt the natural sleep period. Facilities using 12-hour shifts often find they have better results with changeovers bet w e e n 7 AM a n d 8 AM.
Thanks again for a d d r e s s i n g this important iss u e . - - E d Coburn, Publisher, Shiftwork Alert, Cam-
bridge, Massachusetts
Reply Good health does not always m e a n a longer life, y e t poor health often shortens one's life span. While no specific research studies were cited in the article proving a shortened life expectancy, a variety of information is available from which conclusions m a y be drawn. Studies highlighting the detrimental health effects believed to result from -working off shifts are well d o c u m e n t e d throughout the research literature. Lifestyles are highly individualized, m a k i n g e a c h person's outcome from working off shifts different. While health is a s s o c i a t e d with normal synchronized psychophysiologic circadian rhythms, there are some unique individuals whose rhythm m a y adjust well to an altered p a t t e r n of sleep. I e n c o u r a g e each interested reader to pursue the literature available. Doing so will h e i g h t e n the unders t a n d i n g n e c e s s a r y to create healthy work environm e n t s for our profession. A variety of r e c o m m e n d a tions are available that differ from one another. Some sources r e c o m m e n d grouping m a n y night shifts in a row, while others r e c o m m e n d no more than one or two night shifts at a time; still other sources recomm e n d that the changeover occur at 3 AM to 3 PM, and others r e c o m m e n d 7 AM to 7 PM. This article should bring attention to the challenges of rotating shifts and e n c o u r a g e all health care professionals to strive for their own ultimate quality of health. R e m e m b e r - - w e m u s t take care of the caretaker before the caretaker can take care of anyone
else.--Valerie G.A. Grossman, RN, CEN, CCRN, Rochester, N e w York Research article on "efficacy of normal saline solution vs. heparin solution" applauded
Dear Editor: I w a s h a p p y to see a research article in your A u g u s t issue (1997;23:306-9) a d d r e s s i n g the efficacy of normal saline solution versus heparin solution in m a i n t a i n i n g the p a t e n c y of peripheral IV catheters in children. I have long b e e n a believer in the effectiveness of using saline i n s t e a d of heparin in m a i n t a i n i n g peripheral IV lines, especially w h e n positive pressure is used. The research m e t h o d utilized by the author w a s thorough and scientific in its basis. However, I w a s d i s a p p o i n t e d w h e n reading the article to find t h a t the m e d i a n calculation of duration w a s only 2.5 hours. While the author d e s c r i b e s this as the average length of stay in an e m e r g e n c y depart-
April 1998 117
JOURNALOF EMERGENCYNURSING
ment, it would have been more beneficial to study the efficacy of saline solution as a routine flush in the hospitaI. Most intermittent infusion devices that are started and flushed in the emergency department are not accessed again until after the patient reaches the floor. This can add a cOnsiderable amount of time between times w h e n the IV line is accessed. Also, IV lines at our institution are flushed every 6 hours on the floor, a time m u c h greater than that studied by the author. Involvement of floor patients in this study would greatly add to its application to pediatric nursing practice in the m a n a g e m e n t of intermittent infusion
devices.--Elizabeth A. Paten, RN, BSN, CEN, Clinical Nurse Educator, Emergency Department, LeBonheur Children's Medical Center, Memphis, Tennessee
Expect the unexpected Dear Editor. A 10-month-old child was recently brought in by her parents. She had had chest congestion for I month and her mother was concerned about her "choking." She had taken an antibiotic for 2 weeks but was not improving. She had been playful and was taking her formula well, but was not eating "table food." Currently, her symptoms were: "sneezing," "coughing," and being "tired and fussy." Her tympanic temperature was 103 ° F. The child's color was good, she was in no acute distress. She did cough occasionally. Her CBC was normal. The chest radiograph showed a serendipitous finding, that is, a round object about the size of a nickel in her upper esophagus, which may or may not have been causing her symptoms. Her mother had no idea w h e n she had swallowed the coin. It may have been there for 4 weeks. Once again I was reminded that the unexpected should be the expected in emergency nursing and that with infants, who cannot directly tell us what is wrong, we need to have a high index of suspicion for foreign bodies.--Olaf Snyder, RN, BSN, MICN, CEN,
Transylvania Community Hospital, Brevard, North Carolina
Scombroid fish poisoning Dear Editor. A 24-year-old white w o m a n arrived at our emerg e n c y department complaining of "fast heart beat and dizziness." In triage, vital signs were as follows: temperature, 98.8 ° F by mouth; pulse, 148; respirations, 22; and blood pressure, 102/52. The triage nurse obtained a past medical history significant only for childbirth 6 months prior to this event. The patient
118 Volume 24, Number 2
denied any allergies and physical examination revealed facial flushing, complaints of anxiety, and dizziness. She denied having chest pain or shortness of breath. Lungs were clear to auscultation and pulse oximetry revealed an oxygen saturation of 96%. The patient stated that symptoms developed immediately after lunch; she reported having "fish" and a salad. The triage nurse classified the patient as emergent because of complaints of dizziness with tachycardia and the possibility of an allergic reaction. Cardiac monitoring revealed a sinus tachycardia at 156 and redness of the extremities and trunk with no edema noted. Intravenous access was established. The ED physician interviewed the client and found that the client had flesh tuna for lunch. An order was given for diphenhydramine (Benadryl), 50 m g intravenously, but no order was given for subcutaneous epinephfine--it was not needed because the patient was experiencing scombroid fish poisoning after ingesting dark fish meat that had not b e e n properly handled. The dark m e a t fish from the suborder Scombroidea include tuna, mackerel, bluefish, and mahi-mahi, but these foods may be served with other names like mackerel, swordfish, bonita, dolphin, amberjack, or tuna salad. Gases of scombroid poisoning have occurred in Hawaii, California, New York, Washington, Illinois, Michigan, and Connecticut, 1 but such poisoning can occur anywhere flesh fish has been flown in. The case reported here occurred in Philadelphia. Scombroid fish contain normal florae that, when exposed to heat, cause the formation of heat stable toxins. The toxins are a direct result of the bacteria attacking the dark meat in the fish. The scombrotoxin formation occurs between the time the fish is caught and the time it is cooked. Often boats do not properly refrigerate freshly caught fish. The activity of the bacteria on the meat contributes to the formation of histamine and histamine-like substances. The symptoms in our patient were a result of histamine overdose rather than an allergic reaction, with which it is often confused. 22 She was not allergic to fish and just needed antihistamines and histamine blockers. Patients may report that during ingestion of the fish they noted a metallic, bitter, or peppery taste. Symptoms develop abruptly within 20 to 30 minutes of ingestion of the fish. The most common symptoms are facial flushing, diarrhea, severe throbbing headache, palpitations, and abdominal cramps. Other symptoms such as dizziness, dry mouth, nausea, vomiting, and urticaria have also been reported. The majority of symptoms resolve after 6 hours; however, people have reported feeling weak and fatigued for a day after the event.