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Tuesday, July 5, 2022

MACE Incidence in non-low risk patients

SGEM#370 - By admin - July 02, 2022
Reference: McGinnis et al. Major adverse cardiac event rates in moderate-risk patients: Does prior coronary disease matter? AEM June 2022.
…”Many patients risk stratified as “non-low” risk are admitted, but the benefit of objective cardiac testing in this cohort is unclear in the absence of elevated troponins or abnormal EKGs [6-9]. The study we will be reviewing today seeks asks if the presence of known coronary artery disease is predictive of major adverse cardiac events (MACE) in a previously identified non-low risk group of patients…”
SGEM BOTTOM LINE: IT MAY BE REASONABLE, IN PATIENTS WHO ARE MODERATE RISK BY THE HEART SCORE BUT DO NOT HAVE EXISTING KNOWN CAD, TO PURSUE OUTPATIENT FOLLOW UP INSTEAD OF URGENT INPATIENT WORKUP.

Sunday, July 3, 2022

vWD, HHT, ITP

emDOCs / EM@3AM - July 02, 2022 - By Shane O’Donnell and Zachary Aust
Reviewed by: Alex Koyfman and Brit Long
Pearls:
  • vWD (Von-Willebrand Disease) is the most common inherited bleeding disorder, but do not forget to evaluate for the acquired form
  • DDAVP (Desmopressin) should be considered for all patients presenting with vWD
  • HHT (Hereditary Hemorrhagic Telangiectasia) can present at any age but most commonly is associated with recurrent epistaxis
  • ITP (Immune Thrombocytopenia) can be an incidental primary finding or secondary to another disease process
  • Platelet transfusion has demonstrated success in both children and adults with the right indications and admission should be considered for any bleeding that required intervention

Critical Aortic Stenosis

EMCrit RACC
CV-EMCrit 327 - July 1, 2022 by Katrina Augustin
Take Home Messages 
  • Always include valvular heart disease in your differential in patients with unexplained shock
  • Severe aortic stenosis is often associated with significant LVH & diastolic dysfunction making patients dependent on adequate preload and slower heart rates to allow time for LV filling
  • Maintain adequate diastolic blood pressure to ensure coronary perfusion and prevent ischemia of the hypertrophied left ventricle
  • Early consultation is imperative as these patients may need mechanical circulatory support or balloon aortic valvuloplasty in addition to medical therapy to stabilize them till definitive interventional or surgical treatment

Thursday, June 30, 2022

Safe CT scanning

Canadi EM - By Christopher Speirs - June 30, 2022
A career in emergency medicine involves management of risk and uncertainty. We balance multiple competing priorities and make important trade-offs on a daily basis. None more so than the delicate balance between speed and safety.
You may have heard the CT scanner being spoken about in a tongue in cheek fashion as “the doughnut of death.” While there is an element of dark humour here, there is also an element of truth. So why, you may ask, do we want to take out sickest, and often most complex patients, to this unfamiliar and dangerous environment?
Well… we can’t usually fix these patients in our resus room. Many patients in this cohort have multiple injuries, or have a time critical emergency which requires urgent intervention. CT scanning is an important aid to decision making in adult trauma patients, and appropriate CT scanning has a proven mortality benefit.​1​ Acquisition of these images requires moving complex and unwell patients from the resuscitation room to the CT suite in a time-critical manner.
At Gold Coast University Hospital in Southport, Australia we have been exploring how to do this better through the lens of simulation. This blog post offers five tips we have found useful thus far on our journey.

Monday, June 27, 2022

Sore Throat

REBEL Core Cast - Basics of EM - By Ellsworth Wright
Take Home Points
  • Look for the red flags – fever, drooling, neck stiffness, toxic ingestion, uvula deviation, voice changes
  • Steroids help with swelling
  • Obtain CT soft tissue neck for concerning presentations
  • Don’t be a cowboy/cowgirl – get consultants involved early – ENT/Anes/OMFS
  • Make sure you repeat vital signs prior to discharge – if patient remains tachycardic, think about myocarditis

ATBs in COPD

REBEL EM - June 27, 2022 - By Anand Swaminathan
Clinical Question: Is a 2-day course of levofloxacin non-inferior to a 7-day course for clinical cure in patients with a COPD exacerbation?
Authors Conclusions: “Levofloxacin once daily for 2 days is not inferior to 7 days with respect to cure rate, need for additional antibiotics and hospital readmission in AECOPD. Our findings would improve patient compliance and reduce the incidence of bacterial resistance and adverse effects.”
Our Conclusions: We agree that this study demonstrates non-inferiority of a 2-day course of levofloxacin to a 7-day course. However, the trial has a number of issues including the subjectivity of the outcome measure which may bias the results. Subsequent studies should focus on generating high-quality data looking at short-course antibiotics versus no antibiotics.
Bottom Line: It remains unclear if mild to moderate AECOPD benefit from antibiotics but, if you are going to prescribe them, a short course appears to be adequate.

HALT-IT

emDocs - June 27, 2022 - By Brannon Inman / Reviewed by: Alex Koyfman
Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomized, double-blind, placebo-controlled trial
Take away: This is a negative trial.
  • Included patients with upper and lower GI bleeds as one group, which is not how we typically classify these patients. The majority of patients had variceal bleed, accounting for 75% of deaths. Less than 10% of included patients were on anticoagulants.
  • Only 69% of patients required transfusion, and 87% had SBP > 90 mm Hg with 30% having a HR > 107.
  • Time from onset to randomization < 3 hours was present in 16% of patients. Most patients received TXA over 8 hours from time of bleeding onset.
  • Primary outcome changed from all-cause mortality to GI bleeding related mortality in 5 days. Reportedly this decision was made blind to the accumulating data. Changing a primary outcome from a patient-centered outcome to a disease-centered outcome is odd. Our patients do not care what they die from, nor do their families. With the used primary outcome, patients could have been dying from TXA complications, and this would not have been captured (albeit this is unlikely).
  • Very few trials have shown harm associated with TXA. This trial showed a statically significant risk of VTE and seizures.
My take
  • This is a well-constructed, multicenter RCT comparing TXA versus placebo for patients with acute GI bleeding. Based on the results from this RCT, TXA does not reduce death from GI bleeding and may increase risk of VTE and seizure.
  • I won’t be using TXA for GI bleed patients in my clinical practice.

Friday, June 24, 2022

Surviving Sepsis

EMOttawa - By Doran Drew, Amanda Mattice - June 23, 2022
A review of some of the most relevant elements of the 2021 surviving sepsis campaign for the emergency physician.

PETMAC

CanadiEM - By Sam Buchanan - June 23, 2022
An estimated 300,000-500,000 patients present to the emergency department (ED) every year inCanada with complaints of chest pain.​1​ In USA, the numbers are even more staggering at 8 million per year.​ Given its prevalence, having a structured and rapid approach to chest pain is essential. Use the mnemonic PETMAC as an approach to these 6 cannot-miss causes of chest pain in the ED. Just think of your friendly neighbourhood pet, Mac!

Tuesday, June 21, 2022

Lemierre’s Syndrome And Retropharyngeal Abscess

emDOCs Podcast - Episode 56 - June 21, 2022 - By Brit Long and Rachel Bridwell
Lemierre’s Syndrome Pearls
  • The classic triad includes pharyngitis, anterior neck tenderness/swelling, and non-cavitary pulmonary infiltrates, though only 52% of patients have neck tenderness or swelling on exam
  • Diagnosis includes CT with IV contrast of the neck
  • Management includes resuscitation/stabilization and antibiotics
Retropharyngeal Abscess Pearls
  • New data demonstrate decreased rates of drainage when steroids used
  • Consider in toxic child preferring to lie flat with normal oropharyngeal exam and painful tracheal rock
  • Lateral neck radiographs can be used initially, many patients require neck CT for operative management

Friday, June 17, 2022

sICH

EMCrit 326 – NeuroEMCrit - June 16, 2022 - By Scott Weingart
The Guidelines: sICH guidelines
… ICH although a less frequent cause of stroke is associated with a high mortality (30-40%) and disproportionately effects Black and Mexican Americans than white Americans and we have not seen a significant reduction in mortality or morbidity from this disease.
What is changing is our understanding of the underlying pathophysiology and how to better understand the long term hemorrhage risk in these complex patients, especially those with CAA.
Reading the guidelines emphasizes there are so many basic aspects of management we still don’t have great evidence to best practice...”

UTI

EM Ottawa - By Graham Wilson, Josee Malette - June 16, 2022
“As Emergency physicians, you make and/or consider urinary tract infection (UTI) multiple times per shift. Actually, up to 5% of ED visits are related to genitourinary complaints. From simple cystitis, to pyelonephritis, and even life-threatening urosepsis, UTI’s and their wide spectrum of presentations are the MOST COMMON indication for empiric antibiotics. However, in 2014, the Centers for Disease Control and Prevention reported that antibiotic use in UTIs was avoidable 40% of the time…”

Cocaine overdose

EM Pills - di Francesco Patrone (Fra Doc) - 15 Giugno 2022
… La cocaina (benzoilmetilecgonina) è una sostanza stupefacente che agisce come potente stimolante del sistema nervoso centrale, vasocostrittore e anestetico.
È un alcaloide che si ottiene dalle foglie della coca (Erythroxylum coca), pianta originaria del Sud America, principalmente del Perù, della Colombia e della Bolivia.
L’effetto principale della cocaina è il blocco della ricaptazione della noradrenalina mentre il suo effetto secondario è il rilascio marcato di noradrenalina. La cocaina provoca anche un modesto rilascio, associato a un blocco della ricaptazione, della serotonina e della dopamina.
Sul cuore, la cocaina si comporta con meccanismo sovrapponibile a quello dei farmaci di classe IC (bloccanti i canali del sodio) della classificazione di Vaughan-Williams. Inoltre agisce anche sui canali del potassio e sullo scambio sodio-calcio in alcune membrane cellulari. È una sostanza liposolubile che attraversa liberamente la barriera emato-encefalica…

Friday, June 10, 2022

Contrast Induced Nephropathy

First 10EM - By Justin Morgenstern - June 8, 2022
The paper: Macdonald DB, Hurrell C, Costa AF, McInnes MDF, O’Malley ME, Barrett B, Brown PA, Clark EG, Hadjivassiliou A, Kirkpatrick IDC, Rempel JL, Jeon PM, Hiremath S. Canadian Association of Radiologists Guidance on Contrast Associated Acute Kidney Injury. Can Assoc Radiol J. 2022 May 24:8465371221083970. doi: 10.1177/08465371221083970. Epub ahead of print. PMID: 35608223 [free full text]
Bottom line
These guidelines provide a reasonable summary of the evidence around IV contrast and kidney injury.
If a CT is urgent, you should never delay the CT out of consideration for renal function.
Contrast is still recommended in patients with severe chronic kidney disease or acute kidney injury if the contrast is required to make an important diagnosis and there is not a reasonable alternative diagnostic test. Therefore, if you know that a contrast CT is the only reasonable test, and you are going to order it no matter what the blood work shows, you should not delay the CT just to see the blood work results. Doing so can only hurt your patient.
The only context that blood work is reasonable prior to CT in the emergency department is if there is a reasonable alternative diagnostic test, and the delay caused by adding blood work will not result in any harm.

STI Guidelines

Taming The SRU
Taming The SRU - June 08, 2022 - By Melanie Yates
"Rates of sexually transmitted infections (STI), including syphilis, gonorrhea, and chlamydia, have been increasing over the past 10 years. Emergency department (ED) visits with an STI diagnosis increased 39% from the time period of 2008-2010 to 2011-2013. From 2011-2013 alone, that equals a total of 506,000 visits with STI diagnoses in the ED. EDs fill the gap in STI diagnosis and treatment, especially in the setting of closed STI clinics and difficulty in accessing primary care providers. STIs are important to diagnose and manage early to avoid complications such as pelvic inflammatory disease (PID), infertility, sepsis, or even death.
In 2021 the CDC Treatment Guidelines for STIs were updated, which are the main source of information for treatment recommendations in the ED: these will be reviewed here."

Saturday, June 4, 2022

Indefinite anticoagulation

EM Pills - di Carlo D'Apuzzo - 1 Giugno 2022
"Tra gli aggiornamenti periodici di UpToDate sono stato colpito da uno dal titolo “Selecting adult patients with lower extremity deep venous thrombosis and pulmonary embolism for indefinite anticoagulation” link. Un argomento certamente caldo e su cui non mancano diversità di opinioni..."

Sunday, May 22, 2022

Monkeypox

First10EM - By Justin Morgenstern - May 19, 2022 / Updated May 18, 2022
In the Rapid Review series, I briefly review the key points of a clinical review paper (or two). With reports of monkeypox cases arising around the world (Canada, United Kingdom, Europe, and United States), I figured we had better do a quick review of the disease, because it was either never taught in my medical school curriculum, or I missed that day.
The papers: 
  • Di Giulio DB, Eckburg PB. Human monkeypox: an emerging zoonosis. Lancet Infect Dis. 2004 Jan;4(1):15-25. doi: 10.1016/s1473-3099(03)00856-9. Erratum in: Lancet Infect Dis. 2004 Apr;4(4):251. PMID: 14720564
  • McCollum AM, Damon IK. Human monkeypox. Clin Infect Dis. 2014 Jan;58(2):260-7. doi: 10.1093/cid/cit703. Epub 2013 Oct 24. Erratum in: Clin Infect Dis. 2014 Jun;58(12):1792. PMID: 24158414


Compartment Syndrome

REBEL Core Cast 80.0 - May 04, 2022 - By Anand Swaminathan
Take Home Points
  • Compartment syndrome is a life and limb threatening emergency that requires early recognition, prompt diagnosis and immediate management with fasciotomy
  • While clinical evaluation is flawed, pain out of proportion to injury and pain with passive stretch of muscles within the compartment are the best screening tools.
  • Do not wait for the development of pallor, absence of pulse or paralysis to consult surgery. These are late findings that may only arise once the limb is non-salvageable. 
  • In unconscious patients, there should be a low threshold to measure compartment pressure in patients who are at risk as clinical signs cannot be evaluated
  • When measuring compartment pressures, look for an absolute pressure > 30 mm Hg and perfusion pressure (DBP – compartment pressure) of < 30 mm Hg. All patients with a clinical suspicion and normal pressures should have repeat pressures measured.

Monday, May 16, 2022

Alcohol Withdrawal Syndrome

emDOCs - May 16, 2022 - By Jack Yancey; Drew Micciche
Reviewed by: Todd Phillips; Alex Koyfman; Brit Long
Summary
  • CNS hyperexcitation is the primary physiological abnormality seen in AWS
  • AWS is a clinical diagnosis, and a diagnosis of exclusion. Consider other disease mimickers and rule them out during your workup
  • Early diagnosis and treatment of AWS prevents symptom progression into life-threatening complications (withdrawal seizures, delirium tremens)
  • Stages of AWS: withdrawal symptoms, hallucinations, withdrawal seizures, delirium tremens
  • Benzodiazepines are the mainstay of treatment
  • Patients with signs of mild withdrawal can be considered for discharge after receiving treatment
  • Treat severe AWS with rapidly escalating doses of benzodiazepines to reduce risk of withdrawal seizures, delirium tremens, and need for intubation. Appropriate level of sedation is drowsy yet arousable
  • Use phenobarbital for benzodiazepine-refractory AWS
Pearls/Pitfalls
  • CIWA scores have questionable utility in the ED setting. They are nursing driven, and are not diagnostic for AWS.
  • Inspect all patients for signs of head trauma and neurological deficits. Have a low threshold for CT head imaging
  • Certain patients may develop withdrawal with mild to modestly elevated ethanol levels, however their clinical presentation and daily alcohol consumption should always be factored into the equation when determining whether the patient is in acute withdrawal.

Thursday, May 12, 2022

In-Flight Emergencies

EM Ottawa - By Steven Sanders, Sam Wilson, Josee Malette - May 12, 2022
To conclude, I leave you with a few general take-home points:
  • Given the growth of air travel, and the aging, generally more comorbid population, in-flight medical emergencies are becoming more common.
  • We are emergency experts. We’re experts in dealing with uncertainty. Experts in working with limited resources. Experts in chaos. These problems fall squarely in our wheelhouse, and we should be ready to deal with them. I hope this blog post helped you feel a little bit more prepared.
  • Trying to navigate the laws is too complicated – don’t worry about it too much. We have ethical and professional duty to help and know that we a well-protected in doing so.
  • This is an austere, uncomfortable environment. As you’ve read, the emergency medical kits are limited and vary by airline. Do what you can with what you have. Know your limitations and accept them.

Saturday, May 7, 2022

AKI ED Management

emDOCs - May 06, 2022 - By Anton Helman
Originally published at EM Cases. Reposted with permission
Listen to accompany podcast HERE
Take Home Points for AKI ED Management
  • First and foremost, rule out immediate life threats – hyperkalemia and severe acidosis
  • Most patients with AKI simply require “fluids and a foley”, however a more nuanced treatment algorithm should be considered in complex cases
  • Have respect for new severe hypertension in the setting of AKI as these patients may have an intrarenal cause that requires urgent BP control and internal medicine consultation for further workup
  • Get help from ICU for patients with AKI, pulmonary edema and cardiogenic shock as these patients are challenging to manage
  • Not all patients with AKI require imaging; bilateral ureteric obstruction is a rare cause of AKI
  • Avoid nephrotoxins in patients with AKI whenever possible (NSAIDs, ACEi/ARBs, gentamicin, amphotericin)
  • The resuscitation fluid of choice in AKI patients is Ringer’s Lactate in small boluses with frequent assessments of volume status
  • Use AEIOU mnemonic for emergency indications for dialysis; for other AKI patients it is generally safe to delay dialysis for 1-2 days
  • IV bicarb is reasonable in AKI patients with refractory severe metabolic acidosis

Sunday, May 1, 2022

Pericarditis and Myocarditis

EM Ottawa - By Maria Doubova & Lucy Karp - April 28, 2022
Chest pain is one of the most common presentations to the emergency department (ED) and includes a wide differential diagnosis. In today’s post, we will review a less common cause of chest pain seen in the ED: pericarditis and myocarditis. We will also review considerations for these disease processes as it pertains to COVID-19…
Take Home Points
  • Keep myocarditis on the differential diagnosis for young patients presenting with chest pain and dyspnea. Have a low threshold to order a troponin in the workup of these patients.
  • The prognosis following a diagnosis of myocarditis is highly dependent on the underlying etiology.
Take Home Points (in the setting of Covid-19)
  • Investigate for post-vaccine myocarditis in patients within 42 days of COVID-19 mRNA vaccination.
  • Most patients have good prognosis following the disease.
  • Fill out the Adverse Events form for these patients.

ED Procedures without an IV

REBEL EM - By WriSalim Rezaie - October 04, 2018
Background: Establishing IV access has become the norm for patients presenting to the ED. However with increasing patient volumes, difficulty and delays in acquiring IV access, it seems that anything that could expedite care, reduce pain and suffering, and improve patient care would be welcomed in the ED. There are several tricks I have learned along the way to achieve just this: No IV access, no problem…performing procedures like a boss…
  • Isopropyl alcohol inhalation for nausea/vomiting is reasonable
  • Sphenopalatine ganglion block for frontal headaches may have a roll
  • Modified valsalva maneuver for stable SVT is superior to standard valsalva techniques
  • Use a spinal needle with sheath (for better visibility and protection) and disposable speculum (to put the light source anteriorly) for peritonsillar abscess drainage
  • Davos and Spaso techniques with intra-articular lidocaine could reduce procedural sedation with anterior shoulder dislocation
  • Nebulized TXA can be a temporizing measure to halt acute bleeding in patients with acute hemoptysis

DKA Myths

REBEL EM - By Salim Rezaie - November 02, 2015
„Recently, I was asked to give a lecture to both my residents and nurses at the University of Texas Health Science Center at San Antonio (UTHSCSA) on some common DKA myths. Now this topic was originally covered by my good friend Anand Swaminathan on multiple platforms and I did ask his permission to create this blogpost with the idea of improving patient care and wanted to express full disclosure of that fact. I specifically covered four common myths that I still see people doing in regards to DKA management…“
Myth #1: We should get ABGs instead of VBGs in DKA
Myth #2: After Intravenous Fluids (IVF), Insulin is the Next Step
Myth #3: Once pH <7.1, Patients Need Bicarbonate Therapy
Myth #4: We Should Bolus Insulin Before Starting the Infusion

Tuesday, April 26, 2022

Gout

emDOCs - April 25, 2022, By Shannon M. Burke and Benjamin H. Schnapp
Reviewed by: Michael J. Yoo, Alex Koyfman and Brit Long

                            
Key Points:
  • It’s possible to diagnose acute gout flares clinically, but the gold standard is arthrocentesis. Use this whenever there is concern for a septic joint or if the clinical picture is not entirely consistent with an acute gout flare.
  • Treatment of gout is anti-inflammatory medications, and this mostly means NSAIDs, corticosteroids, and colchicine.
    • Avoid the combination of NSAIDs and corticosteroids due to additive GI toxicity.
    • Remember there are contraindications to these medications. Pay attention to a patient’s kidney function, liver function, and history of diabetes.
    • Certain patients may also be eligible for initiation of urate-lowering therapy even in an acute gout flare.
  • Opioids are not a first-line treatment for gout, although they may be used if there are significant contraindicationsto anti-inflammatory medications.

Saline or Blood in Trauma

First10 EM - By Justin Morgenstern - April 25, 2022
Trauma patients aren’t bleeding salty water, so why would you give them intravenous salty water? It doesn’t make any sense. Obviously, if they require fluid resuscitation, it should be with the fluid they are losing. So when we compare blood products to normal saline in an RCT (the RePHILL study), we are bound to see a massive benefit, right? RIGHT?!
The paper: The RePHILL trial. Crombie N, Doughty HA, Bishop JRB, Desai A, Dixon EF, Hancox JM, Herbert MJ, Leech C, Lewis SJ, Nash MR, Naumann DN, Slinn G, Smith H, Smith IM, Wale RK, Wilson A, Ives N, Perkins GD; RePHILL collaborative group. Resuscitation with blood products in patients with trauma-related haemorrhagic shock receiving prehospital care (RePHILL): a multicentre, open-label, randomised, controlled, phase 3 trial. Lancet Haematol. 2022 Apr;9(4):e250-e261. doi: 10.1016/S2352-3026(22)00040-0. PMID: 35271808 ISRCTN62326938
Bottom line
Despite some very strong physiologic reasons that blood should be preferred in trauma patients, this RCT failed to demonstrate any benefit over normal saline. I still would never preferentially use saline if I thought a patient needed blood, but this trial should reassure you if you need to give a small crystalloid bolus while waiting for blood to arrive.

HEART Score

EMOttawa - By Graham Mazereeuw - April 25, 2022
Questions and Methods: This study compared agreement in HEART scores derived by ED physicians and those derived by researchers using a prospective cohort study of adults with cardiac chest pain.
Findings: In a sample of 336 patients, HEART score agreement between ED clinicians and researchers was moderate: 78% (Cohen’s Kappa 0.48, 95% confidence interval 0.37 to 0.58).
Limitations: Research-derived HEART scores performed poorly at predicting 30-day MACE, verification bias limited the discovery of MACE in low-risk HEART score patients, and the study was powered for an outcome other than the primary outcome.
Interpretation: HEART scores completed by ED physicians are highly sensitive at ruling out 30-day MACE in patients with chest pain, despite only moderate agreement between clinicians and researchers. HEART scores may be most relevant to the management of patients with a moderate pre-test probability of CAD.


Friday, April 15, 2022

AHF Disposition

emDOCs
emDOCs Podcast: Episode 51 - April 13, 2022 By Brit Long
Welcome back to emDOCs cast with Brit Long, MD. Today we have the last in the podcast series evaluating acute heart failure: disposition.
Introduction:
  • Over 6.2 million patients live with HF in the U.S., and over 8 million cases of HF are projected by 2030.
  • More than 90% of patients in AHF present to the emergency department (ED), and over 80% of these patients are hospitalized in the U.S.
  • Mortality ranges from 4-12% for admitted patients, which may reach 25% in high-risk patients.
  • Disposition can be challenging: multiple comorbidities, different precipitating factors, range of cardiac abnormalities, and presenting signs and symptoms. There are also potential issues with health literacy, self-care, and ability to follow-up for short-term re-evaluation.
  • While discharge rates in the U.S. are low, they are higher in other countries (Canada) for heart failure.

MRI for TGA

SGEM#364 - By admin - April 9, 2022
…Transient global amnesia (TGA) is an idiopathic acute neurological disorder that presents with sudden onset anterograde memory loss. It was first described as a syndrome in 1956 by Courjon and Guyotat and also by Bender. Fisher and Adams formally described as TGA in 1964. The usual presentation is a patient between 50 and 70 years of age who are cognitively and neurologically intact but asking repetitive questions, unable to form new memory. Symptoms do not last very long and resolve within 24 hours. The incidence has been reported as 23.5 per 100,000 people per year and is more common in people who get migraine headaches. TGA is often precipitated by physical or emotional stressors, pain, the Valsalva maneuver, hot or cold-water immersion or sexual intercourse. Diagnosing TGA combines items put forward by Hodges and Warlow and Caplan. This results in seven diagnostic criteria for TGA…
CLINICAL QUESTION: WHAT IS THE SENSITIVITY OF DIFFUSION-WEIGHTED MAGNETIC RESONANCE IMAGING (DW-MRI) AS A FUNCTION OF TIME FROM SYMPTOM ONSET COMPARED TO CLINICAL DIAGNOSIS OF TGA?
SGEM BOTTOM LINE: URGENT DW-MRI FOR PATIENTS MEETING STANDARD DIAGNOSTIC CRITERIA FOR TGA IS A LOW YIELD INTERVENTION.


Sunday, April 10, 2022

Rib Fractures

emDOCs
EM@3AM - April 9, 2022 - By Seth Cohen; Joshua Kern
Reviewed by: Alex Koyfman and Brit Long
Key Points: 
  • Rib fractures can have serious complications including hemo/pneumothorax, aortic injury, and splenic/liver lacerations
  • Adults, especially elderly patients, have a high risk of complications with rib fractures
  • Evaluate with a chest x-ray. Follow up with a CT if there is suspicion for any chest/abdomen injuries that would require a change in management
  • Reinforce the importance of an incentive spirometer and appropriate analgesia

Thursday, April 7, 2022

Bariatric Surgery Complications

EMOttawa - By Renee Bradley, Lucy Karp - April 7, 2022
As emergency physicians, we frequently see patient with metabolic syndromes and obesity. Globally, a significant rise in obesity has been observed over the last 30 years, including a dramatic rise in Canada28,32. From 1985 to 2016, obesity increased by more than 300% in Canada29, and currently 1.2 million Canadians have severe obesity23. It is estimated that 1000 bariatric surgeries were performed in 2017, and these numbers are rising. Although the advancement of modern laparoscopic surgical procedures has decreased the rates of post-operative complications, hospitalizations and death, these risks are still present for patients undergoing bariatric surgery…

Digoxin Toxicity

REBEL EM - Febrero 21, 2022 - By Santiago Lopez, Katrina D’Amore, John Kashani
Post Peer Reviewed By: Anand Swaminathan and Salim R. Rezaie
Take Home Points
  • Although the overall prevalence of digoxin toxicity seems to be decreasing, one must think of this toxicity when facing a patient with bradycardia and “something else”
  • Obtain a 12 lead EKG, serum electrolytes and serum digoxin level initially
  • Digoxin toxicity may mimic several different EKG patterns
  • “Scooped” ST segments signify that the patient is taking digoxin (“dig effect”) and is not an indication of digoxin toxicity
  • Simple doses to remember for Digibind
    • 5 vials in hemodynamically stable patients
    • 10 vials in unstable patients
    • 20 vials in the setting of cardiac arrest
    • Of note: consult your pharmacy to see how many vials are available at your local hospital

Monday, April 4, 2022

Pericardial Effusion

emDOCs
emDOCs - April 4, 2022 - By Taylor Franz, Janet S. Young
Reviewed by: Stephen Alerhand; Alex Koyfman; Brit Long
Pearls:
  • Predictive morbidity of developing tamponade may be dependent upon causative etiology. Malignant and tuberculous/bacterial effusions are more likely to develop cardiac tamponade when compared to viral or iatrogenic causes.
  • Tachycardia is the most common presenting sign for pericardial effusion. EKG findings are tachycardia, low voltage, and electrical alternans. Bedside ultrasound is diagnostic.
  • Hemodynamically stable cardiac tamponade can be managed with pericardiocentesis or pericardial window.
  • Hemodynamically unstable patients need emergent ultrasound-guided pericardiocentesis. Prep a large area of the chest in case you need to change your approach. Keep your needle in-plane at all times to avoid damage to surrounding structures.

Overdiagnosis

First10EM - By Justin Morgenstern - April 4, 2022
The paper: Vigna M, Vigna C, Lang ES. Overdiagnosis in the emergency department: a sharper focus. Intern Emerg Med. 2022 Mar 5. doi: 10.1007/s11739-022-02952-8. Epub ahead of print. PMID: 35249191
…“ The essential basic concept is that sometimes (perhaps often) making a diagnosis can actually cause a patient harm. This might occur with incidental findings, when normal human variation is transformed into disease. It might occur with self resolving illnesses, such that a condition that would have disappeared on its own is medicalized, resulting in side effects from treatment but no chance of benefit. It might occur with very slowly progressive pathology which would have never caused the patient harm, but is now pursued with unnecessary interventions. False positives are technically a different concept, in that they represent an error with no true underlying pathology, but the result is the same: a patient receives an unnecessary or inappropriate label that ends up resulting in harm...“

Sunday, April 3, 2022

Thrombolytics in DOACs

ALiEM - April 2, 2022 - By: Bryan D. Hayes and Mike O'Brien
Bottom Line
  • The management of acute ischemic stroke in patients receiving prior anticoagulation presents a challenging clinical scenario.
  • Studies to date fail to include enough patients to evaluate the true risk of bleeding.
  • This study supports the current guideline recommendation to avoid alteplase in patients receiving a DOAC within 0-48 hours due to the increased risk of intracranial hemorrhage.