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SOBRE EL AUTOR **

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

WORLD EMERGENCY MEDICINE SOCIETIES

Cranial Nerve VI Palsy Emergency

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Contenido:

lunes, 11 de diciembre de 2017

Chest Pain

Resultado de imagen de academic life in emergency medicine
ALiEM - December 11, 2017 | By: Derek Monette
"Emergency Medicine has made significant contributions to the proliferation of Observation Medicine, an attractive alternative to admission for patients with low- and moderate-risk chest pain. Selecting the right patient, identifying appropriate interventions, and documenting appropriately are just some of the challenges discussed in the latest ACEP E-QUAL Network podcast, a partnership with ALiEM to promote clinical practice improvements. We review highlights from a podcast with experts Dr. Anwar Osborne (Emory University) and Dr. Michael Granovsky (LogixHealth)."

Push vs Short Infusion

The Skeptics Guide to Emergency Medicine
SGEM#198 - November 28, 2017 - By Salim Rezaie
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"Clinical Question: Does increasing the duration of the ketamine from IV push (3 – 5 min) to a slow infusion (10 – 15 min) mitigate some of the untoward side effects, while maintaining analgesic efficacy?
SGEM Bottom Line: Slowing down the rate of low-dose IV ketamine infusion to 15 minutes significantly reduces rates of the feeling of unreality and sedation with no difference in analgesic efficacy when compared to IV push over 3 – 5 minutes."

ROTEM

MCC Project -  December 4, 2017 - By Jim Lantry
"Join me in welcoming Kenichi Tanaka, M.D., MSc., Professor of Anesthesiology and Division Chief Cardiothoracic Anesthesiology at the University of Maryland Medical Center. Dr. Tanaka started his Anesthesia training at Pittsburgh, then specialized in Cardiothoracic Anesthesia at Emory where he also earned a Masters in the Science of Clinical Research. Since joining UMMC in 2014 Dr. Tanaka has raised the bar in regards to academic research by publishing > 100 peer-reviewed journals and serving on the editorial boards of British Journal of Anaesthesia (Associate Editor), Anesthesia & Analgesia (Senior Editor), and Journal of Cardiothoracic Vascular Anesthesia. Today Dr. Tanaka sacrifices time from his busy schedule to delve into the dynamics of Thromboelastometry. I can assure you, if you ever plan to remedy coagulopathy in the ICU you will be glad you took 40 minutes to listen to this lecture!"

Chest compression point

MEDEST - December 8, 2017
Clinical pilot study of different hand positions during manual chest compressions monitored with capnography
Image attribution: Qvigstad E, et al. Clinical pilot study of different hand positions during manual chest compressions monitored with capnography. Resuscitation (2013), http://dx.doi.org/10.1016/j.resuscitation.2013.03.010

"Actual applications for clinical practice
  • The recommended chest compression point can be ineffective to generate enough outflow because the Area of Maximum Compression is not on the Left Ventricle but either on the Aortic Valve or the Ascending tract of the Aorta
  • Emergency providers can adjust the compression point based on EtCO2 values.
  • If, despite technically correct chest compressions, the EtCO2 remains below 10, try to adjust the compression point.
  • In those cases, the Optimal Compression Point is usually positioned caudally to the recommended one on the lower third of the sternum"

lunes, 27 de noviembre de 2017

Sepsis, Diastolic Dysfunction & Hypernatremia

PulmCCM
PulmCCM - November 26, 2017 - By Jon-Emile S. Kenny
..."Diastolic dysfunction complicated by clinical heart failure is a complex interplay between the heart and the vascular system. One may be tempted to be more liberal with intravenous fluids in patients with diastolic dysfunction – with fear allayed by the words ‘preserved ejection fraction.’ However, patients with this form of heart failure are just as insulted by excessive salt and water as their counterparts with reduced ejection fraction..."

iSepsis: bolus? Yes or No

EMCrit - November 26, 2017 - By Paul Marik
"The Current Surviving Sepsis Campaign “recommends that, in the resuscitation from sepsis induced hypoperfusion, at least 30 mL/kg of IV crystalloid fluid be given within the first 3 hours” (with no exceptions) (STRONG RECOMMENDATION).
Do you support/agree with the above recommendation? The answer is a Yes or No (NO conditional answers)
Results from the Surviving Sepsis Campaign Committee members
The number of “NO” votes exceeds the threshold of 20% established by the Guideline Rules and therefore this recommendation must be rejected."

D2F

R.E.B.E.L. EM - Emergency Medicine Blog
R.E.B.E.L.EM - November 27, 2017 
"Clinical Take Home Point: We must be careful in making brash conclusions from this study. Although the authors conclude early treatment with IV loop diuretics is associated with lower in-hospital mortality, it is important to remember, patients in the early treatment group were more likely to arrive by ambulance, have an onset of symptoms that was more abrupt, and have more obvious signs of volume overload. All these confounders, would lead to earlier treatment with IV diuretics, meanwhile the quality of care as well as other treatments not accounted for (i.e. NIPPV and/or nitrates) may be the reason why mortality was improved."

viernes, 24 de noviembre de 2017

Ottawa SAH Rule

EMOttawa - By: Jeffrey Perry - November 13, 2017

"Dr. Perry and Colleagues have previously derived and validated the Ottawa SAH rule for patients with suspected subarachnoid hemorrhage, here we present the multicenter prospective validation of the rule, with some insight on the rule from Dr. Perry himself!"

HIV screening

St.Emlyn’s - By Gareth - November 24, 2017
"So in summary
  • I think these guidelines make a lot of sense.
  • A step wise approach to HIV screening in hospitals depending on local prevalence rates.
  • Embedding HIV screening as a routine part of ED practice may help reduce the stigma associated with testing for the disease.
  • We have a captured audience in the emergency department and are the perfect place for public health initiatives like this.
  • It makes sense because we take blood for lots of things we don’t need (coagulation screen anyone?). Taking a bottle for something we do need is obvious and logical.. I mean, I’d like to know my HIV status far more than I would my PT any day.
  • I know we’re busy and at a time when we’re stretched, asking us to do more and more is probably the last thing a ED clinician wants to hear but if we really think about it.. when we realise it is just one extra bottle of blood, your patients might just that you for saving their life."

jueves, 23 de noviembre de 2017

Running Codes

EMsandox - November 22, 2017 - By jfhine
"In this podcast we discuss coding patients in cardiac arrest and the barriers to a successful resuscitation.
Review Questions:
  1. What are the two interventions shown to improve survival in cardiac arrest?
  2. Define compression fraction.
  3. What are the major barriers we outlined to maintaining a good compression fraction?
  4. In the nurse-led code model, what responsibilities fall on the nurse leader? What ones fall on the doctors?"

Sinusitis Mimics

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emDocs - November 22, 2017 - Author: Cooper J - Edited by: Koyfman A and Long B
"Take home points:
  • Sinusitis symptoms overlap with many other diseases, only some of the prominent diseases were covered here.
  • CTS presents with unilateral retroorbital and frontal headache and cranial nerve deficits. CTS and sinusitis can occur concurrently. Include a detailed ocular and neurologic exam in your assessment to help clue you in.
  • Brain abscesses can result as a direct extension of sinusitis. Headache is a common presenting feature, which may be frontal or retroorbital. Fevers are also common to both. In patients with sinusitis, consider a brain abscess if they have mental status changes, lethargy, or subtle or progressive neurologic deficits.
  • Meningitis presents with headache and fever and can mimic sinusitis. Be wary of sinusitis directly extending to the CNS. Physical exam is unreliable for ruling out meningitis. Maintain a high index of suspicion in sinusitis patients that have other symptoms suggestive of meningitis.
  • Orbital cellulitis often occurs as a direct extension of sinusitis. Be suspicious when patients have vision complaints and ocular findings on exam including proptosis and antalgic eye movements. These often require surgical management
  • Mucormycosis is a surgical emergency! Always do a thorough oral and nasal exam to look for necrotic tissue and black eschar in the immunocompromised and diabetics
  • Think nasal foreign body in a kid with unilateral congestion. Be sure to check all orifices as kids like to put things everywhere.
  • Headache with positional changes or progression can be a brain tumor. Be sure to evaluate for these signs in a sinusitis patient."

miércoles, 22 de noviembre de 2017

ED Temperature and ICU Survival

The Skeptics Guide to Emergency Medicine
SGEM#195 - November 11, 2017
"Clinical Question: Does patient body temperature in the emergency department predict survival of adult patients with severe sepsis and septic shock admitted to the intensive care unit?
Screen Shot 2017-11-10 at 7.08.43 PM
Primary Outcome: In hospital mortality was inversely correlated with body temperature.
SGEM Bottom Line: We should pay greater attention to patients presenting with features of severe sepsis and septic shock that do not have fever in the emergency department as they have an associated high mortality rate."

Pericarditis

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emDocs - November 21, 2017 - Author: Santistevan J - Edited by: Koyfman A
"What are the main ECG pointers for pericarditis?
  • Pericarditis and STEMI can be very difficult to differentiate on ECG!
  • The ST elevation of pericarditis should be concave (smiley-face)
  • The ST elevation should be diffuse, not localized to a single vascular territory
  • In pericarditis, ST depression should only be found in aVR and V1
  • If you’re not sure, get serial ECGs and err on the side of caution!"

martes, 21 de noviembre de 2017

TXA in Massive Hemorrhage

R.E.B.E.L.EM - Nov 20, 2017
Background: Bleeding from massive hemorrhage in trauma and post-partum are a major cause of death worldwide. There have been two large randomized controlled trials, in trauma and post-partum hemorrhage that have shown administration of TXA within 3 hrs of bleeding onset reduces death due to bleeding. The current meta-analysis that we are going to review sought to quantify the effect of treatment delay in acute severe bleeding by analyzing individual patient-level data from the two randomized clinical trials mentioned above...
Clinical Take Home Point: 
  • In patients with massive bleeding from trauma or post-partum hemorrhage, giving TXA as soon as bleeding is suspected, reduces mortality from bleeding.
  • Most deaths, in trauma and postpartum from hemorrhage, occur within hours of bleeding onset
  • The mortality benefit of TXA appears to diminish over time and is lost at 3 hours after major hemorrhage begins
  • In this trial, there was no evidence of adverse effects (vascular occlusive events) associated with TXA treatment"

Headache in the ED

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emDocs - Nov 20, 2017 - Author: Long B - Edited by: Koyfman A
"Key Points:
  • Headache is divided into benign, primary causes and dangerous, secondary etiologies. Focused history and examination are recommended.
  • Benign headaches include migraine, tension, cluster, and several others, but a specific diagnosis is not required in the ED.
  • Management should also focus on symptom treatment for pain and nausea.
  • A combination of medications is advised.
  • Antidopaminergics have the strongest literature support. These should be used with NSAIDs and/or acetaminophen.
  • Steroids likely decrease headache recurrence.
  • Other treatments include ketamine, propofol, and nerve blocks. These are options for refractory headaches to other treatments."

LVH on ECG

JournalFeed
 Peguero J et al. J Am Coll Cardiol. 2017; 69(13):1694-1703. 
doi: 10.1016/j.jacc.2017.01.037. Peer reviewed by Clay Smith, MD.
"The Lo down on the Peguero-Lo Presti criteria for LVH
This study retrospectively evaluated a combined 216 patients in a test cohort and a validation cohort. Using echocardiography as the reference standard, the study compared the Peguero-Lo Presti criteria (SD + SV4) to several other commonly used ECG criteria for LVH. Using cutoffs of >/=2.3mV for females and >/=2.8mV for males, the Peguero-Lo Presti criteria had a far superior sensitivity for LVH (62%) compared to the next highest performer (Cornell voltage criteria, 35%). One millivolt = 10 small vertical boxes, 2 large boxes. The Peguero-Lo Presti criteria maintained specificity at 90%, which was similar to the other criteria evaluated."

The 4AT for delirium detection

4AT - RAPID CLINICAL TEST FOR DELIRIUM

The 4AT is a rapid clinical instrument for delirium detection.
It is a short and practical tool designed for use in busy areas where assessment for delirium is needed.
The 4AT is among the most widely-used clinical tests for delirium internationally.
The 4AT is free to download and use."

sábado, 18 de noviembre de 2017

Aortic Dissection

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ACEPNow - By Anton Helman - November 13, 2017
Living Art Enterprises / Science Source
"Take-Home Points
  • Remember the big pain pearls when taking a history:
    • Ask the three important questions.
    • Aortic dissection should be considered the subarachnoid hemorrhage of the torso.
    • Migrating pain, colicky pain, plus need for IV opioids should raise your suspicion.
    • Intermittent pain can still be a dissection.
  • Look for Marfan syndrome, listen for an aortic regurgitation murmur, and feel for a pulse deficit.
  • Think not only about CP +1 but also 1+ CP.
  • Know the radiographic findings of loss or aortic knob/aortopulmonary window and the calcium sign, and use POCUS to look for an intimal flap and pericardial effusion.
  • Don’t be misled by a troponin or D-dimer."

Spontaneous Bacterial Peritonitis

R.E.B.E.L. EM - Emergency Medicine Blog
R.E.B.E.L.EM - Novembre 16, 2017

"Take Home Points:
  • SBP is a difficult diagnosis to make because presentations are variable. Consider a diagnostic paracentesis in all patients presenting to the ED with ascites from cirrhosis
  • An ascites PMN count > 250 cells/mm3 is diagnostic of SBP but treatment should be considered in any patient with ascites and abdominal pain or fever
  • Treatment of SBP is with a 3rd generation cephalosporin with the addition of albumin infusion in any patient meeting AASLD criteria (Cr > 1.0 mg/dL, BUN > 30 mg/dL or Total bilirubin > 4 mg/dL)"

miércoles, 15 de noviembre de 2017

Sepsis interprofessional curriculum

MCC Project - By Jim Lantry
"Please enjoy complimentary access to a sepsis curriculum created by two esteemed faculty members here at the University of Maryland Medical School: Jeffrey P. Gonzales, PharmD, FCCM, BCPS, BCCCP and Nirav G. Shah, MD, FCCP.
Dr. Gonzales is an Associate Professor of Critical Care and a faculty member at the University of Maryland School of Pharmacy where he is the director of the Post-Graduate Year One and Year Two Pharmacotherapy Residency Program. He is a staple on MICU rounds and has been a driving force for pharmacy integration into the critical care fellow’s curriculum.
Dr. Shah is an Associate Professor of Medicine in the Division of Pulmonary & Critical Care Medicine, the Course Director of Pathophysiology & Therapeutics I; and also acts as the Director of the Pulmonary & Critical Care Fellowship Program here at the University of Maryland Medical Center. Despite his many administrative duties, Dr. Shah continues to be rated as one the best MICU educators by the medicine and critical care fellows."

Fluoroquinolonas

Emergency Medicine PharmD - By Tony Mixon - November 15, 2017
"Many institutions have implemented antimicrobial restriction programs where specific agents, based on toxicity, cost, or broad-spectrum of activity, require special permission for use. Often a page is required to initiate the request. During my infectious diseases PGY-2 I carried this antimicrobial approval pager, either approving the use of restricted agents or offering suggesting on alternative therapy. Fluoroquinolones (FQs) were by far, the most requested restricted antimicrobials, and also the most denied. In emergency departments without such programs, pharmacists play a vital role in antimicrobial stewardship, steering therapy to optimize clinical outcomes while minimizing unintended consequences. With their broad spectrum of activity, oral formulation, and seemingly minimal adverse effect profile, FQs were highly touted when originally approved. However, after decades of clinical use and research, is it time we rethink their greatness?"
Take Home Points
  • FQs have been associated with many severe adverse reactions, including but not limited to QT prolongation, CDI, seizures, peripheral neuropathy, hypo/hyper glycemia, GI perforation, tendinopathy, retinal detachment, aortic dissection/aneurysm, as well as causing drug-drug interactions.
  • FQs carry multiple black box warnings surrounding their safety.
  • FQs have a low barrier to resistance.
  • Resistance rates to FQs have increased rapidly. Look at your antibiogram!
  • Ciprofloxacin and levofloxacin are our only oral agents with reliable activity against Pseudomonas spp.
  • FQs should be reserved for a few clinical scenarios where other antibiotics are not safe or feasible.

lunes, 13 de noviembre de 2017

NSTEMI mimics

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emDocs - November 13, 2017 - Author: Folse M - Edited by: Koyfman A and Long B
"Summary
  • Type 1 NSTEMI involves a new, partial occlusion of the cardiac vessel. Type 2 NSTEMI involves a supply-demand deficiency.
  • Always check for reciprocal ST-segment elevation when observing ST-segment depression.
  • Posterior MI diagnosis requires ST-segment elevation of 0.5mm or greater.
  • Upsloping ST-segment depressions with tall T-waves through V1-V6 is a STEMI equivalent.
  • The American Heart Association recognizes aVR ST-segment elevation in the setting of anterolateral ST-segment depression as an indication for emergent cardiac catheterization.
  • PE and dissection are important mimics of NSTEMI.
  • Consider inflammatory markers in suspected cases of myocarditis and pericarditis.
  • Differentiation of NSTEMI-mimics that involve a physiologic increase in post-left/right ventricular afterload (HOCM, AI, AS, PAH, COPD) can generally be made by careful examination of the patient’s medical history and clinical presentation."

Angiography

Resultado de imagen de new england journal of medicine
Weisbord S. et al. New England Journal of Medicine - November 12, 2017
DOI: 10.1056/NEJMoa1710933
"CONCLUSIONS
Among patients at high risk for renal complications who were undergoing angiography, there was no benefit of intravenous sodium bicarbonate over intravenous sodium chloride or of oral acetylcysteine over placebo for the prevention of death, need for dialysis, or persistent decline in kidney function at 90 days or for the prevention of contrast-associated acute kidney injury. (Funded by the U.S. Department of Veterans Affairs Office of Research and Development and the National Health and Medical Research Council of Australia; PRESERVE ClinicalTrials.gov number, NCT01467466.)"

domingo, 12 de noviembre de 2017

CCB Overdose

The Original Kings of County - by kkelson - November 9, 2017
“He took all his medication,” you chuckle to yourself as you read the chief complaint on the board. “Man, isn’t that what we try to get all our patients to do?”
As you open up the patient’s chart, however, your smugness quickly turns to unease when you read through the triage note; “Per wife, patient took a whole month’s supply of his amlodipine.” Oh no. He took ALL his medication. Your grin melts as you see the vitals: bradycardic, mildly hypotensive..."
  • Time to call poison control
  • Mechanism
  • Initial Management
  • High-Dose Insulin
  • The Kitchen Sink
  • We have no idea what we’re doing

Renal colic mimics

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emDocs - November 8, 2017 - Author: Crain N - Edited by: Koyfman A and Long B
"Summary:
  • Flank pain and hematuria are the hallmarks of renal colic, however the presentation is variable.
  • Diagnosis can be confirmed with CT scan, which will show most other potential items in the differential if the scan is negative for a stone.
  • Patients with a good story for stone who are young and healthy at baseline can receive renal US to evaluate for hydronephrosis, rather than CT.
  • Nephrolithiasis and nearly all of its mimics are confirmed with imaging.
  • Some mimics of renal colic that may arrive at the ED include: upper UTI’s, ectopic pregnancies, ovarian torsion, adnexal masses, testicular torsion, acute aortic syndromes, renal artery aneurysms, renal infarction, splenic infarction, bowel obstruction, diverticulitis, appendicitis, biliary colic, cholecystitis, acute intestinal ischemia, pneumonia, pulmonary embolism, retroperitoneal hematoma, iliopsoas abscess.
  • Focused history and physical exam are paramount due to the multitude of structures in the area and potentially dangerous conditions that may mimic renal colic."

ACEP 2017

R.E.B.E.L.EM - November 9, 2017
"This year ACEP 2017 took place in Washington D.C. from Oct. 29th – Nov 1st, 2017. There were lots of amazing speakers and topics as was evidenced by the eruption of everyone’s twitter feeds with the #ACEP17 hashtag. I was fortunate enough to attend this amazing conference and approached by several attendees if I would put together a list of my favorite pearls from this conference. I decided to put a top 10 list together, in no particular order."

Enfermedades tropicales

Resultado de imagen de infurg semes
Fecha: 07-11-2017
"La sección de Medicina Tropical y del viajero del grupo INFURG-SEMES presenta los primeros números de una serie de Protocolos de actuación en urgencias en enfermedades procedentes del trópico.
Puede acceder directamente a los siguientes protocolos (seleccione para poder acceder al contenido): 

martes, 7 de noviembre de 2017

Critical Pulmonary Embolism Patient

R.E.B.E.L.EM - Novemeber 6, 2017 
"Background: Previously, I had given a talk on the use of thrombolytics in submassive PE in 2016. This year, I had the privilege of speaking at ACOEP 2017 again with an update on the critical pulmonary embolism patient. This post will serve as a reference for that talk.
There are many ways to classify pulmonary embolism, but the best clinical definition would depend on the hemodynamic consequences. For example, massive pulmonary embolism can be defined as systemic hypotension (SBP < 90 mmHg or a drop in SBP of at least 40mmHg for at least 15 min) or shock (tissue hypoperfusion, hypoxia, altered mental status, oliguria, or cool clammy extremities.) There is a second subset of patients that also warrant discussion; submassive pulmonary embolism. These patients are defined as lack of systemic hypotension (<90mmHg), but have right ventricular dysfunction/hypokinesis. RV dysfunction tells us that there is severe pulmonary artery obstruction and impending hemodynamic failure..."

Diabetic Ketoacidosis

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emDocs - November 6, 2017 - Authors: Reynolds C and Fairbrother H
Edited by: Koyfman A and Long B
"Key Points
  • Always rule out serious life-threatening conditions that may have precipitated a patient’s DKA. DKA is never simple, and the EM physician’s job is not over with the diagnosis and initiation of the insulin drip.
  • Consider DKA in populations with diabetes risk factors, even in patients with no known history of diabetes; particularly in patients suffering CVAs, pregnant patients, patients on high risk medications (olanzapine, risperidone or clozapine) or substance use disorders.
  • Make sure to consider DKA on the differential even in euglycemic patients, particularly those on the novel SGLT2 inhibitors.
  • Persistent tachycardia in DKA in aseptic patients after adequate volume resuscitation may be due to hyperthyroidism.
  • Make sure to consider possible underlying infections or ischemia in DKA patients who present with diffuse abdominal pain as attributing this pain solely to DKA may mask the underlying pathology.
  • Consider cardiac ischemia as MI can be a trigger of DKA, but DKA can also act as a cardiac stress test.
  • Consider DKA in the setting of natural and manmade disasters where the supply of insulin may become unavailable to patients."

viernes, 3 de noviembre de 2017

Submassive PE

MCC Project - By Scott Michael - November 3, 2017
"Today we welcome back one of our favorite graduates of the EM/IM/CCM residency/fellowship here at University of Maryland, Michael C. Scott, MD. Luckily he stayed local and has been paving his own path across town at St. Agnes Hospital of Baltimore, Maryland. Dr. Scott originally hails from San Antonio Texas, where he graduated from the University of Texas Medical School Medical School before heading up to the North East. Since his arrival to Baltimore, Mike has demonstrated a wide knowledge of modern academic literature and has continued to challenge the status quo in medicine! Dr. Scott has proved time and time again that there are no definitives in medicine and today he tackles a very polarizing topic: what to do with a submassive PE?.."

miércoles, 1 de noviembre de 2017

Damage Control Resuscitation

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emDocs - September 13, 2017 - By McAninch S - Edited by: Koyfman A and Long B
"Trauma patients with significant injuries may arrive at the non-trauma designated hospital by various means: they may check-in through triage, be “dropped off” unexpectedly (in the parking lot), or arrive under the care of pre-hospital providers. Trauma patients with significant injuries and illness have better outcomes if transferred to a designated trauma center. Trauma center transfer guidelines exist to help identify such patients. Additionally, in pediatric patients, a Revised Trauma Score of < 12 or a Pediatric Trauma Score of < 8 are indications for transfer to a pediatric trauma center. If you are working in a non-trauma center, and your trauma patient appears “sick” at any point in care (even if on primary survey), meets any aforementioned criteria for transfer to a trauma center, or may require resources beyond you or your facility, then your priorities are to provide life-stabilizing care and then transfer to the nearest accepting trauma center as soon as possible. In the first of this two-part series, we will discuss personal mental preparation and creating a calm and safe resuscitation environment for the “sick” trauma patient in the non-trauma center. The second part of the series will discuss the clinical aspects of a focused trauma resuscitation in the non-trauma center and process improvement..."
*
emDocs - October 31, 2017 - By McAninch S - Edited by: Koyfman A and Long B
"Part One discussed creating and maintaining a calm, orderly, and relatively quiet resuscitation environment that is goal-oriented to complete life-saving tasks. Part two will discuss the clinical care of the “sick” trauma patient in the non-trauma center and suggestions for trauma process improvement. Clinical care includes early activation of transfer process, prioritized trauma survey physical exam, and application of “damage control resuscitation” treatment principals, as feasible in the non-trauma designated center..."

Emergency vs Internal Medicine

The CurbiderS #65 - October 30, 2017 - By Matthew Watto
"Fighting with Emergency Medicine colleagues is stupid. Learn how EM doctors think and avoid the petty infighting with tips from Dr Scott Weingart, MD FCCM FUCEM DipHTFU, of the EmCrit podcast and Clinical Associate Professor and Chief, Division of Emergency Critical Care at Stony Brook Hospital, NY. We discuss heuristics, how to avoid anchoring bias, the devil of the gaps, why the elderly always get admitted, how to build relationships with the ED, and Scott’s pet peeves..."

Overcrowding in the ED

Medical Bag
Medicalbag - October 31, 2017 - By Joel Cooper
"Emergency departments (EDs) are the Grand Central Station of medicine in this country. Serving an estimated 141.4 million patients a year and providing an average of 47.7% of all medical care delivered in the United States,1EDs are the hub, the core, the main cattle crossing, and the big monkey cage of medicine.
Like giant mirrors, EDs reflect everything good and bad about our nation's healthcare system. And like lightning rods in a raging thunderstorm, they bear the brunt of all negative energy resulting from their often-cited and harshly criticized overcrowding problem.
But the truth is that fierce logjams in the ED, and the resulting plethora of proposed yet often unheeded solutions, are certainly nothing new. In fact, the whole topic of ED overcrowding is newsworthy only because it's pathognomonic of a deeper healthcare delivery system malady, and a failure on society's part to confront and come to grip with the real issues..."

martes, 31 de octubre de 2017

Sepsis

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emDocs - October 30, 2017 - Authors: Boushra M and Miller S
Edited by: Koyfman A and Long B
"Summary
In the acutely ill patient without an apparent source, consider musculoskeletal, cardiac, nervous system, and abdominal sources of sepsis. A thorough physical examination, abdominal CT scan, and lumbar puncture may help reveal the source of sepsis. Keep the differential broad when treating the hyperthermic, tachycardic patient, as many conditions can mimic sepsis. A review of the patient’s medical history and medications may be invaluable in pinpointing the source of the patient’s fever and tachycardia. Summarized below are features of sepsis mimics and their treatment."

NIMV (ERS/ATS) 2017

AnestesiaR -
AnestesiaR - Octubre 30, 2017 - By Vizuete
Artículo original

Bochwerg B, Brochard L, Elliott MW, Hess D, Hill NS, Nava S et al. Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure. Eur Respir J 2017; 50: 1602426 (Pubmed) (HTML) (PDF)
"La insuficiencia respiratoria aguda sigue siendo una patología frecuente en la Unidad de Cuidados Intensivos, teniendo su origen en diversas patologías. El tratamiento de la IRA debe ser el de la causa que lo provoca, siendo la ventilación mecánica el soporte necesario para mantener al paciente oxigenado mientras se curan los daños pulmonares causantes de la misma. El soporte respiratorio puede variar desde la simple aplicación de oxigenoterapia, hasta la intubación orotraqueal y conexión a la ventilación mecánica invasiva, pasando por la ventilación no invasiva en diferentes modalidades."
(AnestesiaR - Oct 30, 2017 - Por Jiménez Vizuete JM, Iñiguez De Onzoño A, Sánchez López)


Tabla 1. Resumen de las recomendaciones ERS/ATS sobre el uso de la VNI en la insuficiencia respiratoria aguda.