Optimistic Nihilism

Optimistic Nihilism in Medicine

EMOttawa - By Shahbaz Syed - March 23, 2023

Spiritualism represents an important aspect within the domains of wellness. Now, spiritualism is a very personal and individual thing, but having some element of spiritualism has demonstrated benefits to one’s mental health, and our personal philosophies can help shape how we experience the world, and as a result, how medicine can impact us…

Conclusions

The biggest issue with occupational wellness within medicine is the lack of control. A true approach to wellness requires us to acknowledge that there are only certain variables that we do have control over, and ultimately it is our mind within our own control. Our physiologic stress response to the morale distress we encounter, to how our external world influences us is ultimately, within our control.

But controlling our responses takes work, and deliberate practice.

1. Wellness isn’t fluffy BS
2. It does take work
3. You need perspective
4. Morale distress is inevitable
5. Personal agency is important and requires reflection
6. Don’t stress about things that you cannot control
7. Communicate
8. Practice mindfulness

Balance transfusion

Balanced transfusion: Less evidence than you might think

First10 EM - By Justin Morgenstern - March 27, 2023

Bottom line

Although it is reasonable to use a balanced transfusion strategy while waiting for more science, it is unreasonable to talk about it as a proven standard of care. 

We need to be careful in our choice of language. Evidentiary amnesia leads to the repeated phenomenon of “medical reversal”, even though these supposed “reversing” studies perfectly match with the available research. Given that the only RCT ever published on balanced transfusion was negative, we shouldn’t be surprised if a future high quality RCT is also negative. (Especially when the other pilot RCT had massively worse outcomes.)

Most importantly, when we discuss medical interventions, let’s try to avoid evidentiary amnesia. Let’s openly discuss our uncertainty. I think it will help end the seemingly endless cycle of predictable ‘medical reversals’.

Communication

EMCrit RACC

COMMS Lab – Resus Communication with Hayden Richards

EMCrit 346 - March 25, 2023 - By Scott Weingart

Today, we speak about communications: difficult conversations, feedback, conflict–you know all of the juicy, tough stuff.

Hayden Richards

Hayden runs a youtube channel called COMMS Lab with some of the best and most enjoyable medical communication videos that I have come across.

Haemophilia

HAEMOPHILIA

Don`t forget the Bubles - By Jessica Wong and Carly George - 23/03/2023

Haemophilia is a clotting factor deficiency

Clotting factors are proteins in the blood that help control bleeding. When you bleed, your clotting factors form a blood clot. Haemophilia is a bleeding disorder due to low levels of a specific clotting factor. In Australia, haemophilia affects more males at 1 in 6000 to 10,000 than females at less than 1 in 300,000. 

There are three main types of haemophilia: Haemophilia A (“Classic Haemophilia”), a clotting Factor VIII (8) deficiency; Haemophilia B (“Christmas Disease”), a clotting Factor IX (9) deficiency; and Haemophilia C, a clotting Factor XI (11) deficiency. 

Haemophilia A and B are X-linked disorders, while Haemophilia C is a rare autosomal recessive disorder associated with variable bleeding phenotypes. Haemophilia A is the most common, accounting for roughly 85% of haemophilia cases; Haemophilia B accounts for 15% of cases; and Haemophilia C is the rarest, comprising less than 1% of cases. In this article, we’ll concentrate on the most common, Haemophilia A and B.

Climate Crisis and EM

The Climate Crisis and Emergency Medicine

Part 1 of 2

canadiem - By Rhiannan Pinnell - February 17, 2022

Conclusion
The growing climate crisis is already profoundly impacting emergency departments across Canada. We have only discussed a few direct health risks, but many more exist.​1,2,9​ This situation will continue to worsen in the coming years. Additionally, malnutrition and childhood exposure to pollution will likely increase susceptibility to chronic disease, increasing ED presentations in the long term.​2,10​ Part two of this series will address the ways in which emergency medicine practice harms the environment, and how we can find opportunities for improvement.

The Climate Crisis and Emergency Medicine

Part 2 of 2

canadiem - By Sarah Walton - March 21, 2023

Conclusion
In taking measures to become informed and active in planetary health, emergency staff can better care for patients of the present and future. At a time when the demands on EM seem to be at their peak, it is essential to maintain a future-oriented view of healthcare delivery that is resilient to the ever-growing incidence of natural disasters outlined clearly in part one of this series. EM has been pivotal in pandemics and crises of the past. The climate emergency is a significant healthcare crisis that we are already facing. Without significant adaptation to and mitigation of climate change, our health systems will not withstand the resulting health effects. Emergency staff can lead the way to system-wide change that ensures quality healthcare delivery for generations to come.

Prehospital plasma in Trauma

The “PAMPer” Study

52 in 52 – #29 emDOCs - March 16TH, 2023 - By Christiaan van Nispen and Brannon Inman

Reviewed by: Alex Koyfman; Brit Long

Clinical question: In patients at risk for hemorrhagic shock, is there a mortality benefit to pre-hospital transfusion of plasma as the initial resuscitation fluid compared to the standard of care?

Take aways:

• Positive trial: pre-hospital plasma appears superior to standard of care alone.
• Intervention group was less likely to be administered prehospital pRBCs (26.1% vs. 42.1%) and received lower median crystalloid volume (500mL vs. 900mL) yet had better 30-day mortality outcomes.
• Effect was larger in the patients transported from scene compared to patients transported from a referring ED, suggesting that earlier plasma transfusion might be better, though more research is necessary for validation.
• Though statistically significant, it is unlikely that the 0.1 difference in initial prothrombin time is physiologically or clinically meaningful enough to account for the apparent mortality benefit.
• The study is appropriately powered and has limited loss to follow-up.

My take:

• In patients with pre-hospital signs of hemorrhagic shock, pre-hospital plasma transfusion in conjunction with pRBCs and/or crystalloid appears superior to pRBCs and/or crystalloid alone, which tracks with other recent data demonstrating that balanced transfusion and the avoidance of crystalloid are best practices.
• More research is needed to validate the results of this trial, with better standardized local protocols regarding the transfusion of other blood products and crystalloid.

Thyroid Storm

Confronting the Storm: The Overactive Thyroid

EMOttawa - By Josee Malette - March 16, 2023

Conclusion

• Consider THYROID STORM as a potential Zebra in any of your “Hot and Crazy” presentations, especially when no alternative cause can be found.
• Recognition of Thyroid Storm is the most important. 
• Thyroid storm is a CLINICAL DIAGNOSIS. Composed of a triad of pyrexia, AMS and tachycardia, with end-organ damage evidence on biochemical assays.
• In the ED, treatment should focus on early administration of MMI or PTU (Thyroid Peroxidase Inhibitors), to inhibit the synthesis of additional thyroid hormone. In addition to acute rescucitation of your ABCs. 
• Be cautious of the use of beta-blockers in the severe thyroid storm with shock. Assess LV function and risk of cardiogenic shock before preceding with their administration.

Acute Hydrocephalus

Taming The SRU

Diagnostics: The Shunt Series

Taming The SRU - March 14, 2023 - By Cody Stothers

INTRODUCTION

Hydrocephalus is an accumulation of cerebrospinal fluid (CSF) in the cerebral ventricular system secondary to a mismatch between CSF production and resorption. Excessive production of CSF is rare and occurs with choroid plexus papillomas or other tumors. Impaired drainage or resorption of CSF is a far more common cause of hydrocephalus and can occur due to congenital malformations, tumors, trauma, or infection. Rapid development of hydrocephalus in the acute setting presents with signs and symptoms of increased intracranial pressure and represents a surgical emergency because of the risk of herniation syndromes. 

TREATMENT

If a patient is herniating in front of your eyes – hypertensive, bradycardic, altered, and not protecting their airway – secure the ABCs, provide hypertonic fluids (3% normal saline, mannitol), hyperventilate the patient, elevate the head of the bed and call neurosurgery. Definitive management in these, and less acute cases, is often the placement of a ventriculoperitoneal (VP) shunt. 

More on this below as we work through a few cases

Adrenal Crisis

Casa di Acqua

empills - Di Davide Tizzani - 15 Marzo 2023

Conclusione

1. La crisi surrenalica è una life-threatening emergency; il riconoscimento precoce ed il trattamento aggressivo sono le uniche possibiltà di cure adeguata
2. Lo Hallmark clinico è l’ipotensione refrattaria a fluidi e vasopressori: < 50% dei pazienti avranno una diagnosi formale al momento della presentazione
3. Il trattamento con idrocortisone 100 mg ev spesso necessità di essere empirico in caso di sospetto, soprattutto nel caso di fattori di rischio (terapia cronica con steroidi, storia di malattia autoimmune, sepsi da cocchi gram positivi, condizione di postpartum).

DON’T DELAY STEROID ADMINISTRATION 

IN SUSPECTED ADRENAL CRISIS“

Neurogenic Shock

Neurogenic Shock: Definition, Identification, 

and Management in the ED

emDOCs - March 13, 2023 - By Kira Brayan; Jenny Beck-Esmay

Reviewed by: Jessica Pelletier, Marina Boushra, Alex Koyfman; Brit Long

Pearls and Pitfalls 

-Consider neurogenic shock in hypotensive trauma patients with high-level spinal injuries who present with signs of vasodilation but do not have compensatory tachycardia.

-Focal neurologic deficit is not a defining feature of neurogenic shock and neurogenic shock can be present in the setting of a normal neurologic exam. Physical exam of the thoracolumbar spine has poor sensitivity for spine and spinal canal injury. There should be a low threshold to obtain imaging in patients presenting with symptoms of neurogenic shock

-Neurogenic shock is a diagnosis of exclusion in trauma patients. Other causes of hypotension should be considered, particularly hemorrhagic shock in trauma patients, before coming to the diagnosis of neurogenic shock

–CT is the gold standard for bony spinal trauma, but MRI is necessary for suspected spinal cord injuries

-IV fluids are not adequate for hypotension caused by neurogenic shock and these patients will require vasopressors (norepinephrine is first line) to maintain adequate blood pressure.

Lateral canthotomy

One snip lateral canthotomy

Fist10EM - By Justin Morgenstern - March 13, 2023

The lateral canthotomy is a core emergency medicine procedure. It was one of the earliest topics covered on First10EM. Early intervention improves outcomes, but despite that, ED physicians frequently delay performing the procedure until the arrival of a specialist. (Beams 2016) A “one-snip” approach has been described that, based on limited cadaveric studies, is equally effective at relieving intraocular pressure while simplifying the procedure. (Blandford 2018; Yarter 2023) (A related procedure, called the ‘vertical split’ adds a second cut through the upper eyelid, and is widely used for elective surgeries, as well as having cadaveric evidence of efficacy.) (Elpers 2020) Although the evidence is limited, the anatomic effect is identical, and failure is immediately identifiable (no decrease in intraocular pressure), allowing one to proceed with a more traditional surgical approach. Therefore, I think this is a reasonable first technique for this rare, vision threatening emergency.

Fluids in Sepsis

EMCrit RACC

I Guess We Need to Talk about CLOVERS and Fluids in Sepsis 

(Hopefully for the Last Time Ever)

EMCrit 345 - March 10, 2023 By Scott Weingart

Multicenter, randomized, unblinded superiority trial.

Inclusion

• Patients over 18 years old with either a suspected or confirmed infection and sepsis-induced hypotension (SBP<100 after 1 liter fluid)

Pertinent Exclusion

• More than 3L of IVF prior to enrollment (including EMS fluids)
• Fluid Overload
• Severe volume depletion from non-sepsis causes

Intervention and Comparison

Both groups received 1-3 L of fluid prior to randomization

3 Big Sepsis Trials (PROMISE, ARISE, PROCESS) got between 2-3 liters of fluid

Ran the Protocol for 24 hours

Cefiderocol

E questo cosa è? – 3

empills - Di Davide Tizzani - 8 Marzo 2023

La comparsa e la diffusione di microrganismi multiresistenti (MDRO) rappresenta una problematica sanitaria globale rilevante per la quale la World Health Organization ha raccomandato una necessità di grado elevato ed una urgente priorità per ricerca nuovi efficaci chemioterapici.

Artificial intelligence (AI)

Do Not Fear AI, Puny Humans…

St Emlyn´s - By Stevan Bruijns - March 7, 2023

Okay, full disclosure: this heading is not original.

It was first used in an article on the progress of artificial intelligence (AI) by Ethan Mollick, an Associate Professor at the Wharton School of the University of Pennsylvania. Ethan teaches innovation and entrepreneurship (and if you’re not following Ethan on twitter, you really should). In a way, using an unoriginal title for this blog post, pays homage to Ethan’s fantastically well-informed, balanced, tongue-in-cheek take on AI, and also summarises both where we are with AI and what it is we get when we use it.

(Spoiler alert: the outputs of large language models may not be original, but their sheer scope of application should leave you in awe)

There is really nothing to fear; and resistance isn’t as much futile as it is completely unnecessary. But I do I get the frenzy that has unfolded around ChatGPT, an AI language model developed by OpenAI. This blog post is an interview with ChatGPT. To prepare for writing this blog post, and come up with the questions I used for the interview, I read several takes on AI language models (from blog posts, to twitter threads, to editorials published in academic papers).

Dexmedetomidine

Dexmedetomidine, almost as many uses as there are letters

emDOCs - March 6th, 2023 - By Gage A. Stuntz

 Reviewed by: Mark Ramzy; Alex Koyfman; Brit Long

Summary

• There is literature to support the use of dexmedetomidine in patients with sympathomimetic toxidrome. It may be a reasonable approach to utilize Dex, with or without a bolus, while closely monitoring these patients in an ED setting.
• In patients having difficulty tolerating non-invasive ventilation, Dex may assist in promoting compliance and possibly decreasing the rate of intubation when compared to benzodiazepines.
• Dex has a well-established role in sedation in the post-extubation setting, and may have a role in ED extubations, although this has not been studied.
• In pediatric patients, Dex promotes compliance with procedural and imaging sedation with a longer onset of action and longer duration of action compared to propofol and benzodiazepines. Dex is associated with a decreased risk of requirement of airway intervention compared to propofol.
• Although bradycardia and hypotension are common reasons for not using Dex, this has been consistently shown across multiple indications to rarely affect the choice of sedation and have not been shown to cause increased morbidity and mortality. Propofol has similar rates of hypotension and bradycardia in comparable large studies.

Nitrite Abuse

Nitrite Abuse

emDOCs ToxCard - March 03, 2023 - By Anthony James; Kathryn T Kopec

Reviewed by: James Dazhe Cao; Alex Koyfman; Brit Long

Clinical Pearls: 

1. Nitrites are commonly used for recreational purposes and are easily accessible in “commercial products”
2. Asking patients about their use of nitrites in a non-judgmental manner can aid in diagnosing associated adverse effects and complications
3. Complications of nitrites tend to be more severe with routes of exposure other than inhalation such as ingestion or aspiration
4. Methemoglobinemia is a less common but potentially life-threatening complication of nitrite exposure
5. Treatment is supportive care and methylene blue administration
6. Harm reduction conversations should include avoiding concurrent use of alcohol and PDE inhibitors if a patient plans to continue using alkyl nitrites recreationally

Epistaxis Management

11 Tips to Improve Epistaxis Management in the Emergency Department

ALiEM - By Gus M Garmel - March 03, 2023

Managing epistaxis is often challenging, time-consuming, and takes practice. Even under the best circumstances, epistaxis often results in return visits for rebleeding and poor outcomes. Rarely should you do “nothing” for adults who present to the ED with or following epistaxis. If it produced enough blood to seek care (even without hemodynamic compromise), epistaxis frequently recurs even if currently resolved. This is a less true in pediatric patients. A careful and comprehensive evaluation is essential in both populations, whether epistaxis is ongoing.

The following 11 pearls with a bonus tip should help you avoid common pitfalls, improve outcomes, and increase both patient and physician satisfaction.

Single Troponin to Rule-out ACS

Can We Rule Out ACS By A Single Prehospital Troponin Measurement?

St. Emlyn`s JC - By Iain Beardsell - March 03, 2023

The Paper

The paper we will be discussing is from the European Heart Journal. As ever, we recommend that you read the whole paper yourself, and brilliantly the full text is free and available here

“Cyril Camaro et al. Rule-out of non-ST-segment elevation acute coronary syndrome by a single, pre-hospital troponin measurement: a randomized trial, European Heart Journal, 2023”; https://doi.org/10.1093/eurheartj/ehad056

Summary and final thoughts

I think point-of-care testing has real potential to help us both risk stratify and also rule out certain conditions before the patient even gets to hospital. We need to be bold and consider where and when we can use these strategies and then support and educate the staff who are using them. The early data from the ARTICA trial suggests that this method may be safe and would be incredibly helpful in a significant large group of patients who currently need to be seen in hospital.

Amanita Phalloides Tox

Attenzione a quello che mangi!

empills - Di Isabelle Piazza - 2 Marzo 2023

Nuovo post nell’angolo dello specializzando, grazie al prezioso contributo di Mauro Belotti, Alessandra Marchetti e Alice Paludo, specializzandi MEU dell’Università degli studi di Milano…

Approfondiamo il tipo di fungo: Amanita Phalloides

HF O2, ACS and mortality

High Flow O2, Suspected ACS, and Mortality?

REBEL Cast Ep114 - By Salim Rezaie - March 02, 2023

Paper: Stewart, RAH et al. High Flow Oxygen and Risk of Mortality in Patients with a Suspected Acute Coronary Syndrome: Pragmatic, Cluster Randomised, Crossover Trial. BMJ 2021. PMID: 33653685

Clinical Question: Is there an association between high flow supplementary oxygen and 30-day mortality in patients presenting with a suspected acute coronary syndrome (ACS)?

Author Conclusion: “In a large patient cohort presenting with suspected ACS, high flow oxygen was not associated with an increase or decrease in 30 day mortality.”

Clinical Take Home Point: Unfortunately, this is a completely flawed trial that did not achieve any difference in SpO2 between groups (98% vs 96%), included >50% of patients without ACS, and had no granular details (troponin levels, echo findings, quality of life, treatments given between groups). Until further better evidence is produced, I recommend continuing to not use oxygen in patients with ACS who are normoxemic.

HEART score

To HEART score, or not to HEART score

EM Ottawa - By James Worrall - March 02, 2023

To HEART score, or not to HEART score – now that is a question. In the past five years it has become increasing common to hear Emergency Medicine providers and residents reference the HEART score when reviewing chest pain cases. This is especially true when they are justifying plans to discharge a patient.

At that stage of training, the HEART score may provide a helpful framework, but mid and late-career Emergency Physicians may not have heard it, utilize it, or find it as particularly helpful – so its time for a deep dive.

No more transfusion

No more transfusion

empills - Di Davide Tizzani - 23 Febbraio 2023

Conclusione

La terapia marziale endovena è stato dimostrato essere efficace e sicura alternativa alle trasfusioni di sangue nella maggiore parte dei casi di anemia sideropenica severa e dovrebbe essere la terapia di prima scelta nei pazienti emodinamicamente stabili. Fondamentale come sempre un percorso lineare e collaudato con strutture extrapronto soccorso, in questo caso le “anemia clinics” o detto in italiano, le banche del sangue/medicina trasfusionale, con cui si deve iniziare a parlare la stessa lingua.

Rimane allora il dubbio: ma davvero dobbiamo eseguire una terapia in pronto per una situazione non ermegenziale? la risposta è nella vita quotidiana: quante volte il pronto da risposte di salute non urgenti. Ma soprattutto conoscere le nuove opzioni di terapia marziale permette un risparmio in termine di trasfusioni di emazie concentrare in un epoca di rarità di fornitura.

Forse il significato di questo post è non quando fare il ferro ma quando non fare la trasfusione. Perchè le indicazioni alla trasfusione in regime di urgenza sono forse davvero poche.

Dobbiamo fare nostre sole le raccomandazioni di “Choosing wisely”: “don’t transfuse more units of blood than absolutely necessary” e “don’t transfuse RBCs for ID without hemodynamic instability even with low Hb levels”. Nonostante ciò, ancora oggi un regime di ipertrasfusione si verifica fino al 90 % dei pazienti anemici che giungono in DEA. Cerchiamo di essere noi il cambiamento.

Bacteremia

Bacteremia: ED Presentations, Evaluation, and Management

emDOCs - February 20, 2023 - By Mary E. Lewis; Shannon Burke

Reviewed by: Summer Chavez; Alex Koyfman; Brit Long; Marina Boushra

Key Points:

• Bacteremia has significant morbidity and mortality.
• High-risk factors for development of bacteremia include the presence of central venous catheter, discitis, vertebral osteomyelitis, spinal epidural abscess, acute non-traumatic native septic joint, meningitis, septic shock, and ventriculoatrial shunt infections.
• Rapid identification of potential bacteremia and the initiation of broad-spectrum antibiotics is important. In the ED, physicians should always treat empirically when bacteremia is suspected, even when the specific bacteria is not confirmed.
• Triage tools may be useful for identifying patients at risk for bacteremia, but clinical judgment should supersede these scores.
• Molecular models may be a useful adjunct to blood cultures for the rapid identification of pathogens and susceptibilities but are not always readily available.

Agitated Patient

Anger Management: Agitated Patients in the ED

EM Ottawa - By Jessica Tat - February 16, 2023

The Emergency Department is no stranger to the acutely agitated patient. Agitation remains a broad and multifactorial syndrome with a high potential for significant morbidity or mortality if not recognized and managed appropriately. This can be tricky at times when there is a lack of agreement among practitioners as what is considered first line treatment.This post aims to provide a four-step approach to managing the acutely agitated patient in the Emergency Department based on expert consensus with the goal of ensuring safety of the patient, staff, and others, minimizing use of coercive interventions, and encouraging patients to regain control to manage their emotions.

Anisocoria

Anisocoria in the ED: Pathophysiology, Evaluation, and Management

emDOCs - February 13, 2023 - By Emilie Lothet; Aaron Lacy

Reviewed by: Jessica Pelletier; Marina Boushra

Pearls:

• Anisocoria can be classified into three groups based on pupillary reaction to light: (1) Physiologic anisocoria, ( (2) a pathologically large pupil, or (3) a pathologically small pupil
• Up to 30% of anisocoria is physiologic and asymptomatic, but this must be a diagnosis of exclusion.
• The most concerning cause of the pathologic large pupil is a cranial nerve III palsy, which can be a marker of compressive neoplasm or aneurysm.
• The most concerning cause of the pathologic small pupil is Horner syndrome, most commonly caused by carotid artery pathology.
• Pharmacologic evaluations can help differentiate between etiologies of anisocoria when the physical exam is inconclusive,with limitations in the emergency setting.

LP in febrile Infants

The Physician Doth LP Too Much, Methinks

First10 EM - By Brian Lee and Denis Ren - February 13, 2023

The paper: Mahajan P, VanBuren JM, Tzimenatos L, et al; Pediatric Emergency Care Applied Research Network (PECARN). Serious Bacterial Infections in Young Febrile Infants With Positive Urinalysis Results. Pediatrics. 2022 Oct 1;150(4):e2021055633. doi: 10.1542/peds.2021-055633. PMID: 36097858

Outcomes: The primary outcome was the prevalence of bacteremia or bacterial meningitis in infants with a positive urinalysis (growth of a pathogen in the urine or CSF culture). There were no secondary outcomes.

Our thoughts: Not surprisingly, infants </= 60 days with a positive urinalysis demonstrated higher rates of bacteremia, supporting the current practice of obtaining a blood culture in this population. With respect to meningitis, the presence or absence of a positive urinalysis did not alter the risk of bacterial meningitis in the first month of life. In older infants (>28 days), the authors report no cases of bacterial meningitis in patients with a positive urinalysis. While certainly reassuring, the low prevalence of bacterial meningitis in this age group is blessing and a curse. A recent meta-analysis reported that infants with a positive urinalysis had similar rates of meningitis to those with negative urinalysis. Ultimately, these finding further supports the most recent American Academy of Pediatrics guideline suggesting that not all infants >28 days old require CSF analysis and that the decision to perform lumbar puncture in this age group should be made using shared decision making with the family.

SJS/TEN

Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis

emDOCs / EM@3AM - February 11, 2023 - By Jackie Nguyen; Joshua Kern

Reviewed by: Sophia Görgensmand and Cassandra Mackey; Alex Koyfman; Brit Long

Pearls 

• Consider SJS/TEN when a patient is presenting with blistering rash and fever in the setting of new medication usage or recent viral illness.
• The rash will often have mucous membrane involvement and there can be extra-cutaneous manifestations.
• Medications to support suspicion include the following: NSAIDs, anticonvulsants, sulfa-derived, ß-lactams, antigout, contrast agents, and antiretrovirals.
• Cease medications suspected to be causative immediately and admit to a burn center if possible.

VV ECMO

EMCrit RACC

Who to Refer for VV ECMO

Patient Selection and When to Call for Help

EMCrit 343 / CV-EMCrit - February 9, 2023 - By Scott Weingart

VV ECMO has demonstrated trends towards increased survival in ARDS compared to conventional treatment (PMID: 30642776, PMID: 29791822). There has been increased utilization of ECMO during the COVID-19 pandemic and its applications continue to expand with it recently being incorporated into the ASA practice guidelines for management of the difficult airway (PMID: 34762729). However, despite increased utilization, implementation of this therapy is limited by lack of universal availability as well as nuanced patient selection and constantly evolving relative contraindications.

While this continues to be an evolving topic, the goal of this post is to discuss patient selection for VV ECMO and when to call for help if working at a non-ECMO center.

Flash Pulmonary Edema

Heart Failure and Flash Pulmonary Edema

emDOCs / The EM Educator Series - February 08, 2023 - By Alex Koyfman

Reviewed by: Brit Long and Manpreet Singh

Welcome back to the EM Educator Series. These posts provide brief mini-cases followed by key questions to consider while working. The featured questions provide important learning points for those working with you, as well as vital items to consider in the evaluation and management of the specific condition discussed.

This week has another downloadable PDF document with questions, links and answers you can share with learners as educators in #MedEd. Please message us over Twitter and let us know if you have any feedback on ways to improve this for you. Enjoy

Abdominal Compartment Syndrome

Abdominal Compartment Syndrome

emDOCs Podcast – Episode 71 - February 07, 2023 - By Brit Long

Today on the emDOCs cast with Brit Long, MD (@long_brit), we discuss abdominal compartment syndrome, a challenging diagnosis in the ED.

Remi vs NMB for RSI

Keep On Blocking In The Free World

Remi Vs. NMB For RSI

JC St Emlyn’s - By Dan Horner - February 4, 2023

Lots of excellent literature out recently. We would heartily recommend a look at all the parallel releases from the SCCC 2023, including the CLOVERs trial and others. There has also been some great work on thromboprophylaxis in trauma which we will try and get to shortly. 

But first on the list, was this randomised controlled trial comparing conventional rapid sequence induction in patients with aspiration risk using neuromuscular blockade (NMB), to deep analgosedation with remifentanil. What’s this all about then? RSI has undergone enough changes recently thankyou very much. Most centres are still barely catching up. And now someone wants to drop neuromuscular blockade? Sounds bonkers….. 

Or does it? Many remifentanil proponents have long argued for its rapid onset efficacy in achieving adequate muscle relaxation to facilitate most things. The rapid offset also solves all those awkward problems of what to do if the view is not as expected, or you run into problems, or you just don’t like the cost of an emergency dose of sugammadex….

Canadian CT Head Rule

We should stop using the Canadian CT head rule

First10 EM - By Justin Morgenstern - February 6, 2023

The paper

Stiell IG, Clement CM, Grimshaw JM, Brison RJ, Rowe BH, Lee JS, Shah A, Brehaut J, Holroyd BR, Schull MJ, McKnight RD, Eisenhauer MA, Dreyer J, Letovsky E, Rutledge T, Macphail I, Ross S, Perry JJ, Ip U, Lesiuk H, Bennett C, Wells GA. A prospective cluster-randomized trial to implement the Canadian CT Head Rule in emergency departments. CMAJ. 2010 Oct 5;182(14):1527-32. doi: 10.1503/cmaj.091974. Epub 2010 Aug 23. PMID: 20732978

Bottom line

This has been true for over a decade, but nobody should be using the Canadian CT head rule. It is one of the few decision rules that we have implementation research for, and this cluster RCT demonstrates no benefit, and I believe suggests harm, despite being the best possible scenario for the Canadian CT head rule.

Clinical decision rules

Clinical decision rules are ruining medicine

First10 EM - By Justin Morgenstern - February 2, 2023

This evidence review is the handout for the talk I gave at the Emergency Medicine Cases Summit entitled “Decision rules are ruining medicine”.

There is a common assumption that clinical decision rules must improve decision making and clinical care. This is based on the fact that clinical decision making (like all human decision making) is flawed, subject to many biases, and highly variable. However, this assumption is unproven, and probably not consistent with what we know about clinical decision rules. 

Summary

Overall, the way they are currently used, I honestly think that medicine would be better off without any decision rules at all. But we don’t need to be that extreme. We shouldn’t throw the baby out with the bathwater.

Decision rules are like any diagnostic test. Decision rules are like a D-dimer in sheep’s clothing. The D-dimer is a horrible test when used indiscriminately, but can be very helpful when used thoughtfully. We have to think about our decision rules like D-dimers. We should use them, but we need to use them very carefully. 

We need to be much more cautious in our application of decision rules. We need rules that are proven to provide patient oriented benefit. We need rules that are better than clinical judgement.

Ideally, rules should not be adopted until we see impact analyses in multiple settings proving patient oriented benefit, or at least cost or time savings. Rules without impact analyses should not be used as rules. If they are broadly validated, it is reasonable to consider risk predictions of the rules in clinical decision making, but without impact analyses these rules should not be used clinically, recommended in guidelines, nor used in courts or by governing bodies. 

Decision rules are ruining medicine and we need to act now to solve this problem.

Fomepizole for APAP

Fomepizole for Acetaminophen Toxicity

emDOCs / ToxCard - February 1st, 2023 - By Morgan Penzler; Kathryn T Kopec

Reviewed by: James Dazhe Cao; Alex Koyfman; Brit Long

Indications for Fomepizole Treatment in APAP Toxicity:

Currently, fomepizole has only been used experimentally in patients who are at a high risk of developing significant hepatotoxicity. One method of determining risk of severe hepatotoxicity is using the aminotransferase multiplication product. An aminotransferase multiplication product of > 10,000 mg/L x IU/L has been associated with a high likelihood of developing hepatotoxicity. This level is obtained by multiplying the serum APAP concentration by the alanine transaminase activity (ALT) level. Other markers that may indicate patients that are at high risk for subsequent development of significant hepatotoxicity include a history of chronic ethanol use (as these patients have upregulated CYP2E1), delay in administration of NAC > 8 hours after ingestion, or a serum APAP half-life of > 4 hours.It has also been suggested that in massive overdoses, APAP levels of > 600 mcg/mL the use of fomepizole may be beneficial.

Dosing of fomepizole is not yet standardized in its use for APAP toxicity. In one study, the standard dosing for toxic alcohol ingestion was used (15 mg/kg IV over 30 min, with repeated doses of 10 mg/kg every 12 hours) at the physicians’ discretion or until APAP levels were undetectable.7,16 Other case reports have noted using a single dose of 15 mg/kg IV.

Chat-GPT

Chat-GPT e Medicina d’Urgenza

empills - di Carlo D'Apuzzo - 1 Febbraio 2023

Di cosa stiamo parlando

L’utilizzo dell’ intelligenza artificiale (AI) come supporto alle attività umane è noto a tempo, ma Chat-GPT sembra avere imresso decisamente una svolta a questo processo.

In pratica collegandosi al sito di open-AI è possibile interagire in tempo reale, in una chat appunto, con l’intelligenza artificiale, la quale pare in grado di fornire non solo risposte alle nostre più svariate domande ma anche di metterle in pratica.

Da scrivere una tesi di laurea a compilare un sito web o un applicazione sembra in grado di poterci “aiutare” in moltissimi campi ma…