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Thursday, November 24, 2022

ACE Inhibitor Angioedema

EM Ottawa - By Nathaniel Murray, Talal Alkhaldi - November 24, 2022
When encountering patients with angioedema, we have historically used a similar approach to anaphylaxis, mostly out of a lack of evidence supporting a particular practice. Here, we take a deep dive into ACE inhibitor-induced angioedema to provide the most up to date evidence and approach!

Tuesday, November 22, 2022

Right Heart Failure

emDOCs - November 22, 2022 - By Matt Kostura, Courtney Smalley
Reviewed by: Marina Boushra; Alex Koyfman; Brit Long
Pitfalls and Pearls
  • Keep RHF on the differential diagnosis in patients with underlying pathology that affects the right heart and lungs.
  • Treat the underlying cause of an acute RHF exacerbation while optimizing preload, afterload, and contractility.
  • POCUS, along with patient history and physical exam, is key to assessing patient volume status.
  • Dobutamine or milrinone can improve the contractility of the RV. Phenylephrine should be avoided when possible due to increase in PVR.
  • Avoid systemic hypotension and be quick to use norepinephrine and/or vasopressin if the patient decompensates.
  • Avoid intubation when possible, utilizing HFNC or NIPPV first, as mechanical ventilation worsens RV hemodynamics.

Saturday, November 19, 2022

Infectious Mononucleosis

EM@3AM - November 19, 2022 - By Devin Morris; Colin Danko
Reviewed by: Sophia Görgens; Cassandra Mackey; Brit Long; Alex Koyfman
Summary and Pearls
  • If a patient presents with mononucleosis-like syndrome but has abrupt onset of symptoms, diarrhea, or mucocutaneous lesions, consider HIV work up
  • Axillary, inguinal, or posterior cervical adenopathy, palatal petechiae, and splenomegaly greatly increase likelihood of mononucleosis in the correct clinical setting
  • Splenic rupture is a rare but potentially fatal effect of IM. The greatest risk is in males under the age of 30, within 4 weeks of symptom onset. Avoid contact sports for 4 weeks and give return precautions for any new-onset abdominal pain
  • False-negative rate of heterophile antibody testing can be as high as 25% in first week of symptoms, consider repeat test or EBV specific antibody testing, especially for pregnant patients

Friday, November 18, 2022

Post-Cardiac Arrest Hypotension

TAMING THE SRU
Taming The SRU - November 18, 2022 - By Kletzel Max 
Ref: Bougouin W, Slimani K, Renaudier M, et al. Epinephrine versus norepinephrine in cardiac arrest patients with post-resuscitation shock. Intens Care Med 2022;48(3):300–10. 10.1007/s00134-021-06608-7
DISCUSSION
This was a large cohort study that found an increase in all-cause mortality, as well as cardiovascular-specific mortality and poorer neurological outcomes, amongst post-ROSC patients receiving an epinephrine infusion for post-resuscitation shock. Physiologically, this can likely be explained by the pro-arrhythmogenic properties of a beta-adrenergic medication acting on a stunned myocardium. Furthermore, the alpha-adrenergic properties of norepinephrine likely mitigate the sepsis-like vasoplegic state seen in the post-ROSC period, without irritating the already dysfunctional heart tissue. Nonetheless, it is difficult to generalize these results to US population where survival of OHCA to hospital discharge is approximately 7%, compared to 30% reported in this European study.(4) Furthermore, despite the propensity analysis, it is difficult to ignore the glaring characteristic differences between the epinephrine and norepinephrine groups and question the presence of underlying confounders. Overall, this study certainly makes one think twice before reflexively reaching for an epinephrine infusion in a patient who recently achieved ROSC and is now exhibiting signs of shock. Yet more definitive data, and especially a randomized control trial, is needed before this ongoing debate is settled. Until then, clinicians will likely continue to rely on the clinical data available to them, including vital signs, EKG, and bedside ultrasound, when choosing the ideal vasopressor for combating post-ROSC shock.

Wednesday, November 16, 2022

Methemoglobinemia

REBEL Core Cast 90.0 / REBEL EM - By Anand Swaminathan - November 16, 2022
Take Home Points
  • Methemoglobinemia can result from exposure to a number of different medications. The most common are dapsone and topical anesthetic agents (i.e. benzocaine)
  • Consider the diagnosis in any patient with cyanosis and hypoxia that doesn’t respond to oxygen administration
  • Administer methylene blue to any patient with abnormal vital signs, metabolic acidosis, end organ dysfunction or, a serum level > 25%

Large volume paracentesis

empills - Di Davide Tizzani - 16 Novembre 2022
…Ogni mese lo stesso accesso. Ogni mese la stessa procedura: paracentesi di largo volume, osservazione in pronto e dimissione. Oggi tocca a me. Copio ed incollo i verbali delle visite di pronto soccorso precedenti, ma alcune domande mi toccano e non so la risposta?
  1. Esistono trips end ticks che mi permettono di eseguire una paracentesi in modo più sicura?
  2. Quanto è sicura una paracentesi di largo volume e quando è sicura rimandare a casa petre?
  3. Devo davvero somministrare albumina dopo il drenaggio ed a che dosaggio?
Ci tocca ancora, e per sempre, studiare. Lo studio: l’eterno castigo e dannazione della nostra professione ma anche strumento per mantenersi, per spendersi senza spegnersi…

Monday, November 14, 2022

Steril gloves for laceraciones?

First10 EM - By Justin Morgenstern - November 14, 2022
Bottom line
The two biggest trials (Perelman and Zwaans) have very similar numbers, and although both have potential sources of bias, there is nothing that makes me think that bias would push the results in either direction. It is not possible to exclude a very small benefit, but I think we can be pretty comfortable that basic clean gloves are good enough for routine laceration repairs.

POCUS for aortic dissection

emDOCs - November 14, 2022 - By Joseph R. Peters and Jeremy Owens
Reviewed by: Stephen Alerhand, Brit Long
Summary
AAD with neurologic symptoms at onset is an uncommon presentation in the ED. The neurologic symptoms may be transient, and up to one-third of these patients may present without pain. Stroke is a dreaded complication of AAD and can present with altered mental status or aphasia making the expression of pain impossible.  Patients presenting with stroke symptoms or thoracic pain demonstrating unusual combinations of vital signs or exam findings may harbor AAD as the etiology of their condition. POCUS demonstrates the ability to rapidly rule in AAD in these patients via the identification of an intimal flap in any of the multiple locations the major arteries can be visualized: the aortic root, aortic arch, common carotid arteries, the descending thoracic aorta, and abdominal aorta. A dilated aorta or pericardial effusion may represent an indirect sign that an AAD is present. POCUS of the heart, the thoracic aortic arch, the carotid arteries, and abdominal aorta revealing these signs expedites advanced imaging, consultant mobilization, and accurate decision-making in the care of patients with AAD.

Tuesday, November 8, 2022

LUS and Chest X-Ray

Canadi EM - By Neil Sengupta - November 8, 2022
Clinical question
What is the sensitivity and specificity of lung PoCUS compared to chest radiograph for diagnosis of acute decompensated heart failure?
Bottom Line
Lung ultrasound is more sensitive and similarly specific in comparison to chest x-ray, and can be considered a useful adjunct to clinical exam in the diagnosis of acute heart failure.

Monday, November 7, 2022

Laceración Irrigation

First10 EM - By Justin Morgenstern - November 07, 2022
In part 2 of the laceration evidence series, we are going to tackle all of the evidence around wound irrigation and cleansing. The value of irrigation seems pretty obvious. Traumatic wounds are contaminated, and we should do our best to clean them. “The solution to pollution is dilution.” Therefore most of the (relatively limited) evidence focuses on exactly how we should irrigate. That being said, we should always question our assumptions, so in addition to questions about how we should be irrigating, we will also consider the very basic question of whether irrigation helps at all. 
Bottom line: Tap water is definitely no worse than saline, and may in fact be better. When you consider the costs and environmental impacts of sterile saline, tap water is almost certainly better. The most interesting part of this data is that, based on the limited data we have, tap water irrigation is also no different than no irrigation at all, which really does raise questions of the value of irrigation in general.

POCUS in Cardiac Arrest

TAMING THE SRU
TAMING THE SRU - By Sim Mand - November 07, 2022
SUMMARY 
Echocardiography can be a powerful tool in the rapid evaluation and management of reversible causes of non-traumatic, non-shockable cardiac arrest. Preliminary literature remains promising in the utility of echocardiography as a prognostic tool in cardiac arrest to identify patients with higher likelihood of achieving ROSC with cardiac activity present, or those that may benefit from earlier termination of resuscitation with cardiac standstill. However, at this time, the evidence is not robust enough to support POCUS use as a single prognosticating factor to terminate resuscitative efforts.

Saturday, November 5, 2022

Sigmoid Volvulus

EemDOCs / EM@3AM - By Tony Mathew and Taylor Terlizzese - November 05, 2022
Reviewed by: Sophia Görgens; Cassandra Mackey and Brit Long
Pearls:
  • Patients with suspected sigmoid volvulus that present with symptoms of bowel gangrene or perforation – hemodynamic instability, fever, obstipation, abdominal rigidity – require emergent surgical intervention. Manage ABCs, administer IV fluids and broad-spectrum
  • Plain films are sensitive but are not specific for sigmoid volvulus. Look for the classic ‘coffee bean sign’. CT non-contrast can be used to confirm sigmoid volvulus or identify alternative causes of LBO. 
  • Prognosis of sigmoid volvulus is good if detected early with initial treatment of endoscopic decompression via sigmoidoscopy. However, high rates of recurrence and high mortality is associated with solely non-operative reductions.
  • Gold standard treatment for sigmoid volvulus involves elective resection of the sigmoid colon and anastomosis (ELRSA).

Tuesday, November 1, 2022

Death After Trauma

EM Ottawa - By Mark Froats, Josee Malette - November 1, 2022
Paramedics often respond to patients who have no vital signs after being involved in a traumatic event. These cases are especially notable for the tragic and violent means by which persons suddenly meet their end. Most patients who do not have vital signs after trauma will not survive. The role of the paramedic is to rapidly determine if there are any immediately reversible causes of death that can be safely addressed in the field or a trauma hospital. Unfortunately, we do not have the same evidence to guide our decision-making for traumatic cardiac arrest that we do for medical cardiac arrests. Nevertheless, we do know why patients who experience trauma die, and as such we know the common preventable causes of death. It is this latter pathology that prehospital providers must be experts at identifying and treating...

Thursday, October 27, 2022

Priapism

TAMING THE SRU
TAMING THE SRU - By Martina Díaz - October 27, 2022
Priapism is a persistent erection that is no longer associated with sexual stimulation or desire, and it becomes concerning when it lasts over four hours. There are two types, generally referred to as ischemic (low flow) or non-ischemic (high flow). The etiology and management tend to differ and emergent therapies will be discussed here. 

Wednesday, October 26, 2022

Acute Chest pain (ACC 2022)

Fist10EM - By Justin Morgenstern - October 26, 2022
The paper: Writing Committee, Kontos MC, de Lemos JA, Deitelzweig SB, Diercks DB, Gore MO, Hess EP, McCarthy CP, McCord JK, Musey PI Jr, Villines TC, Wright LJ. 2022 ACC Expert Consensus Decision Pathway on the Evaluation and Disposition of Acute Chest Pain in the Emergency Department: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol. 2022 Oct 6:S0735-1097(22)06618-9. doi: 10.1016/j.jacc.2022.08.750. Epub ahead of print. PMID: 36241466
Summary
  • Their assumptions about CCTA seem unfounded
  • I like their assumption about clinical judgment (but it might be equally unfounded
  • Low risk patients don’t need more testing
  • Phasing out “atypical”
  • Moving beyond “STEMI”
  • I think their comments about echocardiography, although probably true, are problematic for many emergency doctors
  • Detectable troponin is never normal, but it isn’t all ACS
  • We should be using age and sex adjusted troponin thresholds
  • MI can be ruled out with a single high sensitivity troponin at time zero in many patients
  • Clinical decision pathways using either 0 and 1 hour or 0 and 2 hour high sensitivity troponins are recommended
  • Risk scores don’t help
  • The treatment is different, but don’t downplay the importance of type 2 MI
  • Seriously, stop with the stress tests

Tuesday, October 25, 2022

IV Prostaglandin in Frostbite

CanadiEM - By Samuel Wilson - October 25, 2022
Ref: Crooks S, Shaw BH, Andruchow JE, Lee CH, Walker I. Effectiveness of intravenous prostaglandin to reduce digital amputations from frostbite: an observational study. Can J Emerg Med. Published online July 23, 2022:622-629. doi:10.1007/s43678-022-00342-9

When we are dealing with frostbite in the ED, traditionally, management is focused on re-warming (of both an extremity, or simply the entire patient!). Depending on severity and patient characteristics, the question is whether or not amputation is required to debride necrotic tissues (or digits…) that are too severe or late for rewarming. Studies in the past have looked at using prostaglandin to help prevent amputation, and have shown considerable benefit in healthy (we’re talking your mountaineers…) patients, though your typical ED patient had never been studied until now!
The authors of this paper compared the amputation rates of patients who were eligible and received IV prostaglandin, vs those who received a placebo. The results signal potential for massive benefit. This benefit is most substantial in the most severely affected patients, though remains throughout. Moving forward, consider reaching out to your admitting plastic surgery consultants when you see your next patient who may benefit.

Monday, October 24, 2022

Laceration repair

First10EM - By Justin Morgenstern - October 24, 2022
Summary
It is not even clear if the infection rate increases when patients present late after their injury. The highest quality data we have seems to suggest they don’t. If infection rates don’t change, there is no reason to treat these lacerations any differently than our usual lacerations. 
However, the evidence is imperfect, and it is possible that there is a small increase in infection in patients presenting many hours after their original injury. If the infection rate was higher, we would have to ask: what is the best treatment option when faced with a wound at high risk of infection? There is not a single emergency department trial to help us answer this question, so there is no perfect answer. However, the surgical literature suggests better outcomes, without increased rates of infection, if you just suture right away. Physiologically speaking, that makes sense to me. Knowing basic biology, there is no reason that sutures should affect infection rates in this group of patients. What is your alternative? Open wounds definitely have a high rate of infection, and worse outcomes for other important factors, like cosmesis. 
There are other reasonable questions to ask. Do patients presenting late warrant antibiotics? Does it impact your wound preparation or aftercare instructions? There doesn’t seem to be any science to answer those questions either. Personally, I just inform the patient that they might have a slightly higher risk of infection because of the delay, but repair the laceration exactly like I always do, and ask the patient to monitor closely for signs of infection.

Saturday, October 22, 2022

Splenomegaly

EM@3AM - By Elizabeth Adams - October 22, 2022
Reviewed by: Sophia Görgens, Cassandra Mackey and Alex Koyfman
Take-home Points: 
  • Bedside ultrasound in combination with physical exam is more sensitive for identifying splenomegaly compared to physical exam alone.
  • The differential diagnosis for splenomegaly is broad but can be simplified into 3 main groups: 1) increased vascular pressure; 2) hemolysis of blood; 3) infiltration by cells/material.
  • Management of splenomegaly in the emergency department is centered on initial testing to identify possible underlying causes and appropriate determination of the need for expedited inpatient workup versus outpatient workup and possible referral to hematology.
  • Undiagnosed splenomegaly can lead to a delay in diagnosis of the underlying condition or potential splenic rupture, particularly in those involved in contact sports.

IV Fluid in Pancreatitis

REBEL EM - By Anand Swaminathan - September 29, 2022
Article: de-Madaria E et al. Aggressive or Moderate Fluid Resuscitation in Acute Pancreatitis (WATERFALL). NEJM 2022. PMID: 36103415
Clinical Question: Does the use of moderate fluid resuscitation in acute pancreatitis decrease the rate of progression to moderate/severe pancreatitis in comparison to aggressive fluid resuscitation?
Authors Conclusions: “In this randomized trial involving patients with acute pancreatitis, early aggressive fluid resuscitation resulted in a higher incidence of fluid overload without improvement in clinical outcomes.”
Our Conclusions: We agree with the authors. Aggressive fluid administration results in an increased likelihood of fluid overload. Though not statistically significant, the primary outcome as well as many of the important secondary outcomes favor the moderate fluid group as well.
Potential to Impact Current Practice: The tide has been turning against the use of aggressive fluid resuscitation in acute pancreatitis and this high-quality study should increase the push for a paradigm change. Administer smaller fluid boluses (10 cc/kg) in patients with hypovolemia (and no bolus in those with normovolemia) and start maintenance fluids at 1.5 cc/kg/hour.

Thursday, October 20, 2022

Fall of FOAM

ALiEM - By: Michael Gisondi, Michelle Lin, Teresa Chan et al - October 19, 2022
The landscape of emergency medicine and critical care (EM/CC) blogs and podcasts has changed dramatically over the past 20 years. The number of free, open-access EM/CC blogs and podcasts has plummeted. As reported by Lin and colleagues in JMIR Education (2022), these sites decreased in number from 183 in 2014 to just 109 this year– a drop of 40.1%

Antiarrhythmic Drugs and ROSC

emDOCs (52 in 52 #16) - By Cristiana van Nispen & Brannon Inman
October 20, 2022
Effect of Time to Treatment with Antiarrhythmic Drugs on Return of Spontaneous Circulation in Shock-Refractory Out-of-Hospital Cardiac Arrest
Welcome back to the “52 in 52” series. This collection of posts features recently published must-know articles. Our sixteenth post looks at antiarrhythmics in shock refractory OHCA.
My Take:
Based on the results of these data I will continue ACLS in the way I always have with a primary focus on good-quality CPR and early defibrillation. I may consciously shift to using earlier antiarrhythmics based on these data in select patients. I would consider lidocaine instead of amiodarone in patients in persistent VF or pVT in whom amiodarone has already been given (consistent with current ACLS guidelines) or who arrive at the hospital still in VF/pVT after prolonged downtime.

Wednesday, October 19, 2022

Top Trauma Papers EuSEM 2022

St Emlyn´s - By Simon Carley - October 19, 2022
It’s fantastic to be here in Berlin at the 2022 EuSEM conference. All conferences have their own personalities and this is no exception. There is something special about the cosmopolitan nature of EuSEM. It brings so many different healthcare experiences together under one roof, with a feeling that we are all the same, but also slightly different. I find that I learn a lot here from European colleagues who are willing to share, and also from those from further afield. It’s hard to articulate, but it just feels like a really friendly and positive learning experience.
Anyway, back to this year’s top ten trauma papers. In truth it’s been a relatively quiet year which I think reflects the delays to a lot of trials that took place during COVID. Many trauma trials were paused during that time and as a result we will need to wait a little longer for results. On a positive note I’m expecting a bumper year in 2023!
There are some good studies out there though, these are some of my favourites as suggested by friends and colleagues from the St Emlyn’s team and other #FOAMed sites.

Epiglottitis

emDOCs Podcast / Episode 64 - By Britt Long - October 18, 2022
Pearls:
  • More common in adults who present with odynophagia, dysphagia, and over a more subacute time frame
  • Normal oropharynx occurs in 90% of adults with epiglottitis
  • Lateral neck radiographs are a screening tool which may show the thumbprint or vallecula sign though have a high false positive rate
  • Factors associated with increased rates of intubation are diabetes mellitus, symptoms over 12-24 hours, stridor, drooling, tachypnea, hypercarbia, epiglottic abscess, and subglottic extension
  • Airway management has shifted from intubation/surgical airway in the operating room to awake fiberoptic intubation
  • Corticosteroids and nebulized epinephrine may assist in decompensating patients, but the literature is controversial

Edema Cerebral

AnestesiaR - Por Andrea Piano - 17 de octubre 2022
El edema cerebral es una de las causas de aumento de la presión intracraneal, una entidad con pronóstico negativo que se observa con frecuencia en las unidades de cuidados críticos y que precisa de tratamiento precoz. El objetivo del manejo de este fenómeno es mantener una presión intracraneal normal (<22mmHg) para poder garantizar una correcta presión de perfusión cerebral y reducir lesiones secundarias. La finalidad de este artículo es revisar la fisiopatología del edema cerebral y su papel en el aumento de la presión intracraneal, así como abordar las posibles medidas que se pueden tomar en las unidades de cuidados críticos. Para su realización se ha realizado una revisión literaria de los trabajos publicados en la base de datos Pubmed entre 2012 y abril 2022 usando como palabras claves “cerebral edema”, “intracranial hypertension”, “brain compression”, “neurocritical care”.

Thursday, October 13, 2022

Anticoagulation reversal

EMOttawa - By Cameron Leafloor, Courtney Price, Sam Wilson - October 13, 2022
How many times on shift do you see a patient that is on an anticoagulant or antiplatelet agent? The answer is probably almost always. The use of these agents and their complications are extremely common. And in particular cases, such intra-cerebral hemorrhage (~15-20%) (1), or unstable trauma patients, having an approach to reversal of these agents can be life-altering.
Two important questions for any bleeding patient on these agents:
  1. When should I reverse?
  2. What is the agents
This post will review indications for reversal in the emergency room patient and provide you with an up-to-date, evidence-informed approach to anticoagulation (Warfarin, DOACs) and antiplatelet reversal for your next shift.

Sunday, October 9, 2022

HeartMate 3 LAVD

EMCrit RACC
EMCrit 334 – CV-EMCrit - By Katrina Augustin - October 07, 2022
Due to the improving LVAD design, decrease in adverse effects, and increased indications for LVAD implantation—patients with these devices are increasing in prevalence. Hence, it is imperative that emergency providers can not only troubleshoot these devices but also treat emergent pathology that arises…
Take Home messages:
  • Contact the patient’s LVAD coordinator or nearest LVAD center EARLY
  • For patients presenting in extremis—always trouble shoot the LVAD first
  • LVAD patients in cardiac arrest with a non-functional LVAD should be treated with standard ACLS including CPR and defibrillation
  • Consider ECMO in LVAD patients in extremis who are bridge to transplant

Monday, October 3, 2022

HACA-IHCA

First10EM - By Morgenstern Justin - October 3, 2022
The paper
HACA-IHCA: Wolfrum S, Roedl K, Hanebutte A, Pfeifer R, Kurowski V, Riessen R, Daubmann A, Braune S, Söffker G, Bibiza-Freiwald E, Wegscheider K, Schunkert H, Thiele H, Kluge S. Temperature Control After In-Hospital Cardiac Arrest: A Randomized Clinical Trial. Circulation. 2022 Sep 28:101161CIRCULATIONAHA122060106. doi: 10.1161/CIRCULATIONAHA.122.060106. PMID: 36168956 [free full text]
Bottom line
HACA-IHCA is too small and too flawed to add much to the overall debate, but it is another small piece of data that suggests hypothermia is not needed after cardiac arrest.

Sunday, October 2, 2022

HFNC vs NC for RSI

REBEL Cast Ep 112 - By Salim Rezaie - September 08, 2022
Paper: Chua MT et al. Pre- and Apnoeic High-Flow Oxygenation for Rapid Sequence Intubation in the Emergency Department (the Pre-AeRATE Trial): A Multicentre Randomised Controlled Trial. Ann Acad Med Singap 2022. PMID: 35373238 [Access on Read by QxMD]
Clinical Question: Does HFNC oxygenation for preoxygenation and apnoeic oxygenation maintain a higher oxygen saturation (SpO2) during RSI in ED patients compared to usual care (Nasal Cannula)?
Author Conclusion: “Use of HFNC for preoxygenation and apnoeic oxygenation when compared to usual care, did not improve lowest SpO2 during the first intubation attempt but may prolong safe apnoea time.”
Clinical Take Home Point: I am not surprised by these results. In a population of predominantly neurologic emergencies, HFNC used for preoxygenation and apneic oxygenation did not show improvement in median lowest SpO2 achieved during the 1st intubation attempt. However, HFNC did seem to prolong safe apnea (≈3min) and decrease the risk of SpO2 falling below 90% compared to NRB + NC. HFNC could be considered as an intermediary step for patients in cardiopulmonary extremis or with perceived difficult airways when not tolerating NIV.

Thursday, September 29, 2022

CV Risk in Transgender Persons

EMOttawa - By Rebecca Seliga, Alex Coutin - September 29, 2022
Question:
Are transgender and gender-diverse (TGD) persons on testosterone at a higher risk for acute coronary syndrome (ACS)?
Evidence:
There is very little literature on the topic of TGD persons who take testosterone with regards to cardiovascular risk. We know that the FDA has previously issued a warning for testosterone taken for hypogonadism in cisgender (cis) men as it may increase the risk of myocardial infarction. This warning has been controversial as some subsequent studies have been discordant. However, patients who take testosterone as gender-affirming hormone therapy (GAHT) generally take at minimum two-fold higher doses in the first year of treatment, and may be subject to even higher risks.
One study published in 2019 found that trans men are at a four-fold higher risk of MI than cis women, and a two-fold higher risk of MI than cis men. Possible mechanisms of increased cardiovascular risk for trans men taking GAHT include increases in blood pressure, insulin resistance, changes in lipid profiles (most notably decreases in HDL, increases in triglycerides and LDL), and increased BMI. We do know that TGD persons are at higher risk for venous thromboembolism.

IV Fluids in Pancreatitis

REBEL EM - By Anand Swaminathan - September 29, 2022
Article: de-Madaria E et al. Aggressive or Moderate Fluid Resuscitation in Acute Pancreatitis (WATERFALL). NEJM 2022. PMID: 36103415
Clinical Question: Does the use of moderate fluid resuscitation in acute pancreatitis decrease the rate of progression to moderate/severe pancreatitis in comparison to aggressive fluid resuscitation?
Authors Conclusions: “In this randomized trial involving patients with acute pancreatitis, early aggressive fluid resuscitation resulted in a higher incidence of fluid overload without improvement in clinical outcomes.”
Our Conclusions: We agree with the authors. Aggressive fluid administration results in an increased likelihood of fluid overload. Though not statistically significant, the primary outcome as well as many of the important secondary outcomes favor the moderate fluid group as well.
Potential to Impact Current Practice: The tide has been turning against the use of aggressive fluid resuscitation in acute pancreatitis and this high-quality study should increase the push for a paradigm change. Administer smaller fluid boluses (10 cc/kg) in patients with hypovolemia (and no bolus in those with normovolemia) and start maintenance fluids at 1.5 cc/kg/hour.

TEG-Guided Resuscitation

REBEL Crit, REBEL EM - By Cheng Ng - September 26, 2022 
Article: Kumar M et al. Thromboelastography-Guided Blood Component Use in Patients With Cirrhosis With Nonvariceal Bleeding: A Randomized Controlled Trial. Hepatology. 2020;71(1):235-246. PMID: 31148204
Clinical Question: Does a TEG-guided transfusion strategy lead to lower use of blood products compared with standard practice (guided by PT and INR) in acute non-variceal bleeding among patients with advanced cirrhosis? 
Author’s Conclusion: “Among patients with advanced cirrhosis with coagulopathy and nonvariceal upper GI bleeding, TEG guided transfusion strategy leads to a significant lower use of blood components compared with SOC (transfusion guided by INR and PLT count), without an increase in failure to control bleed, failure to prevent rebleed, and mortality.”
Our Conclusion: Overall, we agree with the authors’ findings. Patients with advanced cirrhosis and nonvariceal upper GI bleeding transfused using a TEG-guided strategy required less FFP, platelets, and cryoprecipitate. In addition, they experienced fewer transfusion-related reactions, with no difference in mortality rates compared to the SOC group. We would advocate for using a TEG-guided transfusion strategy in this patient population as it would conserve precious resources while obtaining similar health outcomes. However, EGD results confirming nonvariceal bleeding would likely be unavailable outside the ICU.

ABCDE Approach

CanadiEM - By Devika Singh - September 27, 2022
The ABCDE approach applies to the initial assessment of critically ill patients. For each step, appropriate treatment should be started regardless if there is a definitive diagnosis.

TNK for AIS

SGEM#37 - By admin - September 24, 2022
Reference: Menon et al. Intravenous tenecteplase compared with alteplase for acute ischaemic stroke in Canada (AcT): a pragmatic, multicentre, open-label, registry-linked, randomised, controlled, non-inferiority trial. The Lancet 2022
CLINICAL QUESTION: IS TENECTEPLASE NON-INFERIOR TO ALTEPLASE IN TREATING ACUTE ISCHEMIC STROKE?
KEY RESULT: TENECTEPLASE WAS NON-INFERIOR TO ALTEPLASE IN STROKE PATIENTS TREATED WITHIN 4.5 HOURS OF SYMPTOM ONSET
SGEM BOTTOM LINE: WE REMAIN SKEPTICAL ABOUT THROMBOLYSIS FOR ACUTE ISCHEMIC STROKE WHETHER IT IS DONE WITH ALTEPLASE OR TENECTEPLASE

Tuesday, September 20, 2022

HINTS Exam

SGEM#376 - September 17, 2022 - By admin
Reference: Gerlier C, et al. Differentiating central from peripheral causes of acute vertigo in an emergency setting with the HINTS, STANDING and ABCD2 tests: A diagnostic cohort study. AEM 2021
The paper we will discuss compares the HINTS exam to the STANDING protocol. STANDING is an algorithm by Dr. Vanni et al. published in Frontiers in Neurology 2017.


"CLINICAL QUESTION: CAN EMERGENCY PHYSICIANS LEARN AND PROPERLY USE VERTIGO PROTOCOLS TO ASSESS PATIENTS WITH ACUTE VESTIBULAR SYNDROME, AND IS ONE PROTOCOL BETTER THAN OTHERS?
KEY RESULT: IN THESE NINE TRAINED EMERGENCY PHYSICIANS, THE HINTS EXAM, AND THE STANDING ALGORITHM OUTPERFORMED ABCD2 IN DIAGNOSING CENTRAL CAUSES OF VERTIGO.
SGEM BOTTOM LINE: THIS STUDY SHOWS THAT EMERGENCY PHYSICIANS CAN USE THE HINTS EXAM TO RULE OUT STROKE ON PATIENTS WITH CONSTANT VERTIGO AND NYSTAGMUS, WHO SCREEN NEGATIVE FOR CENTRAL FEATURES OF VERTIGO, AND HAVE AN OVERALL HINTS PERIPHERAL RESULT"

High-Risk Syncope Mnemonic

emDOCs - September 19, 2022 - By Matthew Christensen and Kristy Schwartz
Reviewed by: Jamie Santistevan; Manpreet Singh and Brit Long
Syncope is a relatively common chief complaint in the emergency department, with a broad differential that ranges from reassuringly benign to acutely life-threatening. While there is no substitute for a thorough history and physical exam, obtaining an electrocardiogram (ECG) is a key aspect of nearly every syncope workup. Prompt recognition of high-risk ECG patterns is a critical skill for emergency medicine attendings, residents, and medical students alike. Here we introduce the mnemonic “ABCDE Left Right”, a memory aid to help EM providers quickly recall seven ECG patterns of high-risk syncope: AV block, Brugada pattern, QTc prolongation, delta waves (Wolff-Parkinson-White), epsilon waves (arrhythmogenic right ventricular cardiomyopathy), left ventricular hypertrophy, and right ventricular strain.
For a refresher on the broader approach to syncope in the emergency department and take a closer look at non-cardiac causes of syncope, see the emDocs article Syncope and Syncope Mimics.