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FACP. Colegio de médicos de Tarragona Nº 4305520 / fgcapriles@gmail.com




Tuesday, February 7, 2023

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.

Monday, February 6, 2023

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

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.

Sunday, February 5, 2023

Clinical decision rules

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. 
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.

Wednesday, February 1, 2023

Fomepizole for APAP

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.


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…

Sunday, January 29, 2023

Mild TBI outcomes

St Emlyns JC - By Stevan Bruijns - January 29, 2023
Annually, around 1.4 million people in England and Wales attend emergency departments (EDs) following a head injury. This may sound like a lot, but actually, the incidence of death in this cohort is very low. Unsurprising, at least 95% of these patients present with a normal or minimally impaired conscious level.
A normal CT brain on top of this may be reassuring, but a growing pool of evidence suggest that mild traumatic brain injury (TBI) is not as innocuous as it may seem at first. Many patients suffer with persistent symptoms following a diagnosis of mild TBI, restricting their daily lives and affecting their livelihoods.
In this study (Outcomes in Patients With Mild Traumatic Brain Injury Without Acute Intracranial Traumatic Injury), Debbie Madhok and her team show that following mild TBI, a fairly high number of patients continue to suffer with persistent symptoms at 2 weeks and 6 months. The abstract is below, but as always we strongly recommend you read the full paper yourself.

Bacterial Meningitis

emDOCs / EM@3AM  - January 28, 2023 - By Mounir Contreras Cejin; Zachary Aust
Reviewed by Sophia Görgens; Cassandra Mackey; Alex Koyfman; Brit Long
Pearls and Pitfalls
  • The classic triad of fever, nuchal rigidity and altered mental status is seen in less than 50% of adult cases of bacterial meningitis.
  • Do not rely on Kernig or Brudzinski signs, as these have poor sensitivity.
  • Use broad spectrum antibiotics while performing your evaluation.
  • Delaying antibiotic therapy until the LP is completed is the most common error in ED management of meningitis. IV antibiotics given 2 hours or less before the LP will not affect the CSF results.
  • Steroids should only be given before or accompanied with the first dose of antibiotics; giving them after may result in harm.
  • Provide chemoprophylaxis to close contacts of those diagnosed with meningococcemia.

Monday, January 23, 2023

Cardiogenic Shock

emDOCs - January 23, 2023 - By Mary Hamblen; J.D. Cambron
Reviewed by: Jessica Pelletier; Marina Boushra; Brit Long
Pearls and Pitfalls
  • Recent MI is the most common cause of CS.
  • Norepinephrine is often the vasopressor of choice in CS unless a significant contraindication exists.
  • The RV benefits from lower PEEP. The LV benefits from higher PEEP.
  • NIPPV/HFNC are the first-line interventions for respiratory distress in CS, but if the patient needs to be intubated, the use of hemodynamically-stable induction agents such as etomidate and ketamine is advised.
  • It is important to have an idea of the primary cause of CS since treatment varies by etiology.
  • Avoid CCB in all forms of CS.

Saturday, January 21, 2023

Tromboprofilassi del viaggiatore

empills - di Carlo D'Apuzzo - 19 Gennaio 2023
Proprio su questo argomento ho trovato un articolo su UpToDate: Prevention of venous thromboembolism in adult travelers – link Vediamo cosa dice.
Cosa consigliano i redattori di UpToDate
  • I viaggiatori a rischio di VTE ( persone con fattori di rischio che viaggiano più di 4-6 ore) possono avere beneficio dall’uso delle calze elastiche oltre che dalle generali sempliici misure di prevenzione.
  • Non ci sono dati sufficienti che sostengano l’uso della profilassi farmacologca (EBPM o aspirina) in questa classe di soggetti, anche se possono essere valutate dal medico curante su base individuale tenendo conto del bilancio rischio beneficio.
  • Nei viaggiatori senza fattori di rischio le misure generali di prevenzione non sono indicate, ma neanche dannose.
  • I pazienti in trattamento anticoagulante per qualsiasi indicazione non necessitano di altre misure di prevenzione.

Friday, January 20, 2023

Key literature for EM interns

ALiEM - By N Shane Dulin et al January 20, 2023
How can I keep up with so many landmark articles in Emergency Medicine (EM)? This is an often asked question we hear from interns and residents. Published in 2013 (1st edition) and 2016 (2nd edition), the “52 Articles in 52 Weeks” compendium is a compilation of 52 journal articles provided interns a list to read over a 52-week period, at an average pace of 1 journal article per week. We present the updated 2022 compilation.

Thursday, January 19, 2023


EMOttawa - By Patrick Fisk - January 19, 2023
This post seeks to provide some insights and discussion around CBRNE events (Chemical, Biological, Radioactive, Nuclear and Explosive). We want to review procedures within a mass casualty CBRNE event, principles related to decontamination, PEE, and review the management of potential chemical agents.
Refers to incidents where patients are exposed to chemical, biological, radiological, nuclear, explosive or hazardous material either intentionally or accidentally. The nature of these incidents often results in multiple people being exposed to the agent or there being concurrent trauma.
These events all carry with it a higher mortality and morbidity than the isolated trauma associated with the incident. Be it through direct physiological consequences of the agents or, more likely, through delays in treatment. There may also be secondary increase in mortality and morbidity to those that are not involved in the incident itself due to diversion of resources.

Monday, January 16, 2023

DEX for Acute Renal Colic

SGEM #389 - By admin - January 14, 2023
Reference: Razi et al. Dexamethasone and ketorolac compare with ketorolac alone in acute renal colic: A randomized clinical trial. AJEM 2022
Comment on Authors’ Conclusion Compared to SGEM Conclusion: We think the authors are over-interpreting their evidence. Without additional information on how accurate the diagnosis, stone size and location, rate of adverse events and use of adjunct medication we should consider this preliminary data hypothesis generating.

Saturday, January 14, 2023

Cushing’s Syndrome

emDOCs EM@3AM - By Rahul Ramraj; Pinaki Mukherji
Reviewed by: Sophia Görgens; Cassandra Mackey; Brit Long
  • Consider CS when one sensitive and one specific sign (i.e.: obesity + striae; hirsutism + new psychosis)
  • Begin empiric treatment if severe CS suspected: metyrapone, ketoconazole, or etomidate
  • Confirm suspicion with random serum cortisol > 36 µg/dL (1000 nmol/L)
  • Treat associated disorders – cardiovascular disease (cardiac failure, hypertension), venous thrombosis, infections (sepsis, peritonitis), metabolic complications (diabetes, hypokalemia)
  • Bilateral adrenalectomy – when refractory to medical interventions in severe CS

Friday, January 13, 2023

Rivaroxaban vs Apixaban in AF

emDOCs - 52 in 52 – #25 - January 12, 2023 - By Brannon Inman
Reviewed by: Alex Koyfman and Brit Long
Take away:
  • Statistically higher odds of ischemic and hemorrhagic events in the rivaroxaban group compared to apixaban.
  • Overall, this was an interesting study comparing 2 of the most popular direct oral anticoagulants currently used in the United States.
  • It’s not very often you get to see studies comparing one brand name drug to another. Even more interesting is this study was funded by a grant from the national heart lung and blood institute (NHLBI) rather than one of the pharmaceutical companies of interest.
  • While the authors utilized a relatively convenient sample of registry patients, this was a large study with hundreds of thousands of patients in each group.
  • While the methods were highly selective, they were well outlined in the study.
  • There were more patients in the apixaban group than the rivaroxaban group. This resulted in the data having to be adjusted to patient years in order to make meaningful interpretations from the data. With > 100,000 patients in each group, it’s less likely observations are due to chance.
  • These are still observational data. The reasons for clinician choice regarding one medication over the other was not captured in this study.
  • I would love to see a randomized controlled trial. However, with another registry trial on the horizon looking at the recurrence of DVTs, this will likely be the highest quality evidence we receive on this subject.

Thursday, January 12, 2023

Caustic Skin Injuries

Taming The SRU - January 11, 2023 - By Ann Wolsey
  • Chemical burns come with complications that thermal burns do not. Specifically: 
  • Chemical burns are more likely to involve prolonged exposure, both before ED arrival and throughout hospital stay.
  • The human body protects against continued protein denaturation in thermal burns through immediate and irreversible protein coagulation. In chemical burns, protein denaturation does not halt, but instead continues through hydrolysis.
  • Chemical burns cause systemic effects, including distant organ damage and electrolyte abnormalities, which can in turn cause fatal cardiac arrhythmias.
  • Almost all chemical burn patients require hospitalization. Das (2015) reports that 0.13% of the chemical burn patients studied were treated as outpatients, compared to over 50% of thermal burn patients. 
  • Even when chemical burns and thermal burns are of similar size, hospitalization for chemical burns is 30% longer.
  • Close to 55% of chemical burns go on to require surgery.
  • Chemical burns produce more hypertrophic scarring than thermal burns; this can in turn lead to decreased quality of life and mental health decline.
Chemical burns are also an evolving pathology, with thousands of new chemicals added to the market each year. Since 2000, both assault and warfare with chemical weapons have increased, although these pathologies vary based on practice location. For instance, chemical burns can comprise up to 14% of burns in the developing world, compared to 3% in the US and Europe. It is therefore important to understand your local chemical burn patterns, in much the same way providers learn local patterns of antibiotic resistance.

Monday, January 9, 2023

Diltiazem vs Metoprolol in AF+HFrEF

SGEM#388 - By admin - January 07, 2023
  • No statistical difference in any of the components of the composite outcome except for worsening CHF symptoms (33% vs. 15%, P = 0.019).
  • Worsening CHF was driven by increased oxygen requirement within four hours

Thursday, January 5, 2023

2022 SIH Guidelines

EMOttawa - By Emma Ferguson, Courtney Price - January 05, 2023
While most strokes we see are ischemic in nature, 10% of stroke presentations are intracerebral hemorrhages (ICH) 1. However, unlike ischemic strokes that have clear and evolving pathways for treatments, novel treatments for spontaneous intracerebral hemorrhages (ICH) are lacking. Because of this, the American Heart Association and American Stroke Association created guideline recommendations for the management of spontaneous ICH. 
This blog post will provide you with a focused review of this evidence tailored to the emergency clinician. Before you dive into the details, it is important to remember that the management of spontaneous ICH is an emergency medicine condition. And just like an acute ischemic stroke, time = brain in these cases.

2022 CanadiEM Top Articles

CanadiEM - By Daniel Ting - January 2, 2023
Our Top 10 Most-Viewed Articles from 2022:
  1. Tiny Tips: PETMAC as a mnemonic for the 6 deadly causes of chest pain (Samantha Buchanan) 
  2. Hyperthermic Conditions in the Psychiatric Patient (Victoria Forcina, Edward Feng)
  3. Clinical Question: When should patients be allowed to eat in the Emergency Department? (David Zheng, Joseph Boyle, Jeremi Laski, Fadi Bahodi, Edward Feng, Daniel Ting)
  4. Hyperthermia in Methamphetamine Toxicity (Amar Chakraborty, Sarah Delaney, Emily Austin)
  5. Tiny Tips: The COWS Scale (Isabelle Gray)
  6. Emergency Management of Frostbite (Darla Palmer, Sarvesh Logsetty)
  7. Diagnosing Acute Aortic Syndrome: A Canadian Clinical Practice Guideline Infographic (Shauna Jose, Selene Chen, Ashish Mathews)
  8. PoCUS Previews 02: Intro to Image Generation (Revathi Nair)
  9. The ABCDE Approach (Devika Singh)
  10. Bimanual technique to reduce pediatric inguinal hernia (Garth Meckler)

Tuesday, January 3, 2023

Laceration: Aftercare Instructions

First10 EM - Justin Morgenstern - December 26, 2022
For such a common problem in emergency medicine, there is a striking paucity of evidence to guide our care of lacerations. Nothing I found allowed for definitive conclusions, so clinical judgment and shared decision making are, like always, necessary.
Personally, I tell patients:
  • A dressing isn’t required, but you probably want one for the first 24 hours, as some bleeding may still occur. After that point, I would suggest applying a dressing if you are in an environment where the wound might become contaminated, or if you prefer one for cosmetic sake, but I want you to remove the dressing every day to check for signs of infection.
  • It is fine to get the wound wet, and in fact I like the idea of keeping the area clean with soap and water. However, I would avoid obviously contaminated water sources, like lakes and public pools until the wound is completely healed.
  • Topical antibiotics probably aren’t necessary. They might prevent small pimple-like infections, but there is a risk of an allergic reaction. You can use an over-the-counter preparation if you like. 
  • I don’t think there is any evidence that vitamin E or expensive scar creams help. Applying a very light layer of vaseline during the first week, to keep the wound moist as it heals, might make sense.
Obviously, all of these recommendations can be adjusted based on clinical judgment, such as if the patient has immunosuppression. 

emDOCs 10 Top Posts

emDOCs - January 01, 2023 - By Brit Long; Manpreet Singh and Alex Koyfman
Thank you for everything you do and the amazing year!
We appreciate your support of our site and podcast this past year. We cannot do what we do without your views, feedback, and assistance. New changes in 2023, so be on the lookout!
Here is our list of top posts from 2022 based on viewership from you, the readers:

EM Cases Top 2022

EM Cases - By Anton Helman - January 02, 2023
EM Cases Top 10 of 2022…

Thursday, December 22, 2022

Tubo-Ovarian Abscess

emDOCs Podcast / Episode 68 - December 20, 2022 -By Brit Long
Key Points: 
  • Key risk factors to consider for TOA include PID, presence of IUD, multiple sexual partners, DM, and immunocompromised states.
  • History and physical examination are non-specific; TOA should be considered in the female patient with lower abdominal pain and fever/chills.
  • Elevations in CRP can be a predictor of more severe disease though elevations in inflammatory markers are non-specific.
  • US and CT can be used for diagnosis, though CT has higher sensitivity.
  • Management includes consultation with the OBGYN specialist and administration of parenteral antibiotics covering sexually transmitted infections and polymicrobial gastrointestinal bacteria.
  • Factors associated with failed medical management include larger abscess size or bilateral abscesses, fever, older age, parity, and significantly elevated inflammatory markers on laboratory evaluation.

Monday, December 12, 2022

N95 trial

First 10EM - By Justin Morgenstern - December 12, 2022
The paper
Loeb M, Bartholomew A, Hashmi M, Tarhuni W, Hassany M, Youngster I, Somayaji R, Larios O, Kim J, Missaghi B, Vayalumkal JV, Mertz D, Chagla Z, Cividino M, Ali K, Mansour S, Castellucci LA, Frenette C, Parkes L, Downing M, Muller M, Glavin V, Newton J, Hookoom R, Leis JA, Kinross J, Smith S, Borhan S, Singh P, Pullenayegum E, Conly J. Medical Masks Versus N95 Respirators for Preventing COVID-19 Among Health Care Workers : A Randomized Trial. Ann Intern Med. 2022 Nov 29. doi: 10.7326/M22-1966. Epub ahead of print. PMID: 36442064 NCT04296643
Bottom line
This study is a mess, and I don’t think you should draw many conclusions from it. The best scientific guess, based on this addition of this trial to the existing literatures, is that there is a small benefit of N95s over surgical masks at preventing the transmission of respiratory infections, but the magnitude of that benefit will depend heavily on baseline risk at any given time.

Saturday, December 10, 2022


emDOCs / 52 in 52 #22 - December 9TH, 2022 - By Brannon Inman 
Reviewed by: Alex Koyfman; Brit Long
My Take:
These are relatively fragile data supporting the use of VAM in resuscitation in IHCA. At the individual level, I will keep this in my back pocket when it comes to “pulling out all the stops”. Based on current guidelines I will not use this as a routine. However, at the big table, we need to be having discussions about the inclusion of VAM in standard resuscitation of IHCA.

Tuesday, December 6, 2022


St Emlyn`s - By Liz Crowe - December 6, 2022
The term ‘burnout’ has become ubiquitous within the common vernacular. Yet what do we actually mean when we say we feel burnt-out? 
There are approximately 140 definitions for burnout in approximately 15 000 peer reviewed papers (Hewitt et al, 2020, Hillert et al, 2020) with little consensus for the criteria for symptoms and characteristics of burnout (Bianchi et al, 2019). Commonalities amongst definitions are an acknowledgement that burnout is an occupational experience, it involves psychological and physical exhaustion, burnout has a negative impact on individuals, and it is multidimensional. If we are all referring to burnout with no common understanding, then our desire to create interventions to prevent it become incredibly difficult.

Thursday, December 1, 2022

Pigtail Catheter vs Large Bore Chest Tube

REBEL EM - By Jessica DiPeri - December 01, 2022
Article: Chang, Su-Huan et al. “A Systematic Review and Meta-Analysis Comparing Pigtail Catheter and Chest Tube as the Initial Treatment for Pneumothorax.” Chest vol. 153,5 (2018): 1201-1212. PMID: 29452099 Prospero: CRD42017078481
Clinical Question: Is a pigtail catheter (PC) more effective than a large bore chest tube (LBCT) for treating pneumothorax?
Author’s Conclusions:We found that for spontaneous pneumothorax, the drainage duration and hospital stay are shorter in the PC group. Furthermore, for secondary spontaneous pneumothorax, the complication rate is significantly lower in the PC group. Collectively, results of the meta-analysis suggest that PC drainage may be considered as the initial treatment option for patients with primary or secondary spontaneous pneumothorax.”
Our Conclusion: We agree with the author’s conclusion. PC performed as well as LBCT in terms of successful drainage and was associated with fewer complications, decreased drainage duration, and decreased length of hospital stay, driven by data on spontaneous pneumothorax.

Awake Intubation

EM Ottawa - By Nicholas Choi - December 01, 2022
Bottom Lines:
  • Recognize it! A number of our patients needing intubation in the ED are candidates for an awake intubation, particularly the physiologically difficult cases, and we almost always have more time than we think. You don’t always have to do it, but you should always consider it.
  • Awake intubation, when performed correctly, is a safe, low risk, accessible technique that should be considered first-line in any airway where RSI may jeopardize patient safety.
  • Every awake intubation should have a backup plan and exit strategy ready to go at the bedside (e.g. RSI equipment and drugs drawn up, surgical airway equipment kit ready, etc.). There should be no delay to implementing plan B if awake intubation fails – it’s what you would have done anyway.

Tuesday, November 29, 2022


EM Ottawa - By Michael Austin, Josee Malette - November 29, 2022
Pain is common in the prehospital setting. Acute pain derives from the combined effects of stimulated nociceptors, local inflammation, systemic stress response mediators, and psychological factors. No single treatment will intervene to treat each factor; rather, a combination of modalities should be utilized to reduce pain perception. Because of individual variation, acute pain management plans should be tailored for the needs of each patient. Continued monitoring of your patients’ response to your interventions is key to ensure a patient-centred approach to care. This includes good documentation of verbal numeric pain scores (0-10). The use of splinting, repositioning and reassurance should be continued with other modalities such as acetaminophen, NSAIDs and opioids in order to optimize pain relief. Ultimately, the patient with improved acute pain management yields increased satisfaction, decreased risk of chronic pain, and decreased overall morbidity.

Andexxa Vs 4F-PCC in ICH

REBEL EM - November 28, 2022 -By Carlton C.L. Watson
Article: Costa O.S. et al. Andexanet alfa versus four-factor prothrombin complex concentrate for the reversal of apixaban- or rivaroxaban-associated intracranial hemorrhage: a propensity score-overlap weighted analysis. Crit Care 26, 180 (2022). PMID: 35710578
Clinical Question: Compared to 4F-PCC, is Andexanet-alfa safe and effective for the reversal of factor Xa inhibitor-associated intracranial hemorrhages?
Author’s Conclusion: Our indirect comparison analysis of ANNEXA-4 derived Andexanet alfa patients and a synthetic control arm of 4F-PCC patients from a US healthcare system showed that Andexanet alfa was associated with better hemostatic effectiveness and reduced odds of all-cause mortality at 30 days. Our findings support current consensus guidelines, which preferentially recommend using Andexanet alfa over 4F-PCC for the management of apixaban- or rivaroxaban-associated life-threatening bleeds, including intracranial hemorrhage.”
Our Conclusion: The numerous methodologic concerns and conflicts of interest in this trial and the parent (ANNEXXA-4) trial make us wary about the data presented. Until large, externally validated, randomized controlled trials prove otherwise, we remain skeptical about the efficacy of Andeaxanet alfa for managing apixaban- or rivaroxaban-associated life-threatening bleeds, including intracranial hemorrhage.

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 - 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
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.