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





01/06/2016 - 15:00PM: Lo mejor del Congreso Europeo de Insuficiencia cardíaca

Ultrasound Case of the Week - Ocular

Double Sequential Defibrillation - EM:RAP 21/06/2016

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martes, 31 de mayo de 2016

Interpreting waveform capnography

emDocs - May 30, 2016 - Author: Long B - Editor: Koyfman A and Singh M
"Capnography has shown great potential in several conditions and procedures in emergency medicine. Literature exists for its use in cardiopulmonary resuscitation, intubation for confirmation of ETT placement, resuscitation of critically ill patients with sepsis, monitoring response to treatment in patients with respiratory distress (specifically COPD, CHF, and asthma), pulmonary embolism, and procedural sedation. For more details, go HERE.
However, how do you interpret quantitative capnography waveforms? We own the resuscitation of critically ill patients, and with boarding increasing in EDs, we need to know how to interpret waveforms. This instrument can provide a great deal of important information if properly understood...
Use an algorithm for waveform capnography analysis.
  1. Look for presence of exhaled CO2 (Is a waveform present?)
  2. Inspiratory baseline (Is there rebreathing?)
  3. Expiratory upstroke (What is the shape i.e. steep, sloping, or prolonged?)
  4. Expiratory/alveolar plateau (Is it sloping, steep, or prolonged?)
  5. Inspiratory downstroke (Is it sloping, steep, or prolonged)
Ensure you evaluate the height, frequency, rhythm, baseline, and shape.
Understanding waveforms and how to interpret them can provide a great deal of information. We are the masters of resuscitation, and this is a vital component of caring for critical patients."

The Acidity of Normal Saline

PulmCCM - May 29, 2016 - By JE
normal saline
"How might you answer this oral board examination question? Describe the systemic effect on pH following 2 litres infusion of each of the following solutions: 
A. normal saline with a pH of 7.0
B. normal saline with a pH of 5.6
C. normal saline with a pH of 4.6.
Pick up a bag of normal saline [NS] and look at the reported pH [or half-normal saline for that matter]. Yes, normal saline is acidic, but firstly, how can pure water with admixed sodium cations and chloride anions have anything but a pH of 7.0? Secondly, how can there be a range of pH? Thirdly, should this make us pause when infusing it into a patient?"

lunes, 30 de mayo de 2016

The Cerebral Circulation and Sepsis-Associated Delirium

PulmCCM - May 28, 2016 - By JE
"The Journal of Intensive Care has newly published a series of sepsis-related organ dysfunction reviews. Additionally, a comprehensive yet concise overview of the cerebral circulation was just disseminated. This summary draws on both of these terrific primary resources as a point-of-departure for discussion of sepsis-associated delirium [SAD].
Cerebral blood flow [CBF] ultimately depends on 1. the arterial pressure head at the entrance to the cranial vault, 2. the cerebrovascular resistance and 3. the down-stream pressure typically estimated as the intra-cerebral pressure [ICP]. For pulmonary physiology enthusiasts, there is a glaring analogy here between alveolar pressure and intra-cerebral pressure. That is, waterfall physiology [or West Zone II in the lungs] tends to occur within the cranial vault as ICP supersedes jugular venous pressure. In other words, the pressure gradient is between the arterial input pressure and the pressure surrounding the veins [i.e. ICP]. This occurs because, normally, the central venous pressure [and therefore jugular venous pressure] approaches atmospheric pressure. Importantly, in states of very high central venous pressure [CVP] [e.g. acute cor pulmonale] and low ICP [e.g. hemicraniectomy, CSF over-drainage], the cerebral perfusion pressure may hold the CVP – rather than the ICP – as its pressure sink. In such a scenario, the transmural pressure of bridging veins will rise giving risk to their rupture..."
Figure 1: The normal cerebral autoregulation curve in orange. The x-axis is cerebral perfusion pressure [CPP] in mmHg, defined as the mean arterial pressure [MAP] less the intra-cerebral pressure [ICP]. Cerebral blood flow [CBF] is on the y-axis and is in litres/minute. The cartoon depicts the change in calibre of cerebral arterioles to defend CBF in response to changes in CPP. The pressure reactivity index [PRx] - in dashed lime green - is described in the text.

Controversies of Thrombolytics for PE

emDocs - May 28, 2016 - Author: Long B - Edited by: Santistevan J and Koyfman A
Screen Shot 2016-05-24 at 2.18.18 PM
"Pulmonary embolism (PE) is a disease with significant morbidity and mortality, with an annual incidence of 100,000 cases in the U.S. which increases with age, from 1 per 1500 in early life to 1 in 300 per year above age 80 years. As providers know, the clinical presentation varies, with up to 25% of patients experiencing sudden death, while other patients with large thrombus burden experiencing few symptoms...
The benefits of thrombolysis is established for massive pulmonary embolism, but the use of thrombolytics for submassive PE is controversial in the literature due to different definitions of submassive PE, different outcomes and definitions of benefit, and the risk of life threatening hemorrhage. Thrombolytic use may reduce intravascular thrombus size and pulmonary resistance; however, there is risk of major bleeding, including intracerebral hemorrhage (ICH). Thus, the conundrum for physicians and patients...
  • Submassive PE presents a challenge for physicians. Current literature including meta-analyses have inconsistent definitions of submassive PE, lack functional outcomes, have differing primary outcomes and assessments, and use different treatment protocols with thrombolytics and anticoagulation agents.
  • Support exists for improvement in long-term outcomes with thrombolytics, with increased risk of major bleeding in high-risk patients.
  • The risks and benefits of thrombolytic treatment should be considered on a case-by-case basis.
  • Shared decision-making with the patient discussing the risks and benefits of treatment is recommended.
  • Further studies that assess risk stratification, functional outcomes, and treatment protocols with thrombolytic dosing are needed."

sábado, 28 de mayo de 2016

Overconfidence in the ED

Resultado de imagen de St Emlyn´s
St Emlyn´s - May 28, 2016 - By Chris Gray
"If you have ever worked as or with a doctor, you’ve probably encountered something called a multi-source feedback form, or a “360 appraisal”. It is part of the process for junior doctors to progress to the next stage of our training, and is often a valuable tool as an anonymous insight into what our senior doctor, nursing, and allied health professional colleagues think about us, both good and bad.
On my most recent feedback form whilst on a rotation outside of the emergency department, there were two comments with mention that I was bordering on overconfidence. The rest of the feedback was very positive, but it was these comments that really stuck with me. I wasn’t sure what I was doing to give the impression of overconfidence. Was I actually overconfident? How would I know? What could I do to improve? And really, the most important question – was it affecting my patients?
This post brings together my reflection over the last few months...
Screenshot 2016-05-28 08.04.02
Final thoughts
The feedback process has helped me to be more mindful of how I make management decisions for my patients. I’m more conscious of my ability to make mistakes, and measures I can employ to try to minimise overconfidence, without taking it too far and losing confidence. I know there will still be times when I’m more confident than I will should be, but hopefully will be able to recognise this when it happens."

Medical emergencies in pregnancy

Resultado de imagen de emottawa
EMOttawa - May 26, 2016 - By Lauren Lacroix
"The pregnant or postpartum patient presents a unique set of challenges to the emergency physician. Although life-threatening emergencies are relatively rare, they require specialized protocols and different considerations than we’re used to (i.e. medications contraindicated in pregnancy and lactation). Maternal morbidity is increasing as women are seeking pregnancy at a later age – 1 in 12 births in the US in 2008 was to women greater than 35 years of age compared to 1 in 100 in 1970. According to the Public Health Agency of Canada, there were 6 deaths per 100 000 deliveries in 2011. The most common diagnosis associated with these deaths were diseases of the circulatory system. Finally, pregnancy-related emergencies can carry significant emotional distress, as there are two patients to consider.
Take Home Points 
  • Normal pregnancy causes significant physiologic changes. 
  • 70% of all PE's in pregnancy occur postpartum and the risk of PE increases with each trimester. 
  • Work up is unlikely to cause significant fetal radiation exposure, use a shared decision-making model.
  • Pregnancy increases the risk of MI 3-4 times, consider SCAD on the DDx. 
  • Consider cardiomyopathy in late pregnancy and puerperium. 
  • ZIKV test and counselling is available in Canada."

viernes, 27 de mayo de 2016

Pneumonia mimics

emDocs - May 26, 2016 - Authors: Long D and LongcB - Edited by: Koyfman A & Bright J
Many potentially deadly conditions can be confused for pneumonia. Unfortunately, many of these conditions are not considered until the patient fails to improve after treatment with antibiotics. The following should be considered in a patient presenting with signs of pneumonia:
  • Pulmonary embolism: suspect when a patient has signs/symptoms of PE including shortness of breath with pleuritic chest pain, tachypnea, and leg swelling in the setting of risk factors for DVT/PE.
  • Endocarditis/septic emboli: consider in febrile patients with risk factors including history of IV drug use, poor dentition, structural heart disease, or the presence of a prosthetic valve. Septic emboli leading to pulmonary infarction can present with multiple infiltrates on chest x-ray.
  • Systemic Lupus Erythematosus: pulmonary involvement is very common in lupus. Patients with SLE and lung involvement must always be evaluated for infection, and diffuse alveolar hemorrhage is a life-threatening complication.
  • Heart Failure exacerbation: suspect in a patient with cardiac history and signs/symptoms of heart failure (orthopnea, PND, peripheral edema, elevated jugular venous distension, etc.).
  • Tuberculosis: suspect in patients with risk factors for TB including substance abuse, malnutrition, systemic diseases, immunocompromise, or recent foreign travel.
  • Lung cancer: suspect in patients with insidious onset of symptoms and in patients complaining of constitutional symptoms such as weight loss or fatigue.
  • Acute Respiratory Distress Syndrome: suspect in toxic-appearing patients with white-out on chest x-ray who require high levels of FiO2 or positive pressure ventilation."

Shock liver

SCANCRIT.COM - Posted on May 26, 2016 - By K
"Interesting paper in AJEM. Hypoxic hepatitis (HH), ‘shock liver’, is defined as an increase in serum aminotransferase levels (20 times the upper normal level) after respiratory or circulatory failure. It is commonly seen in critical illness and after cardiac arrest. In ICU patients HH has been associated with poor outcomes but little is known about what it means in ROSC patients...
Take-home message
Hypoxic hepatitis in cardiac arrest reflects longer periods of global poor perfusion. HH is significantly related to death and poor (neurologic) outcome. As always the numbers are tiny but this could be useful for prognosticating these patients."

Low doses tPA in Acute Ischemic Stroke


R.E.B.E.L.EM - May 26, 2016 - Posted by Anand Swaminathan
Anderson CS et al. Low-dose versus standard-dose intravenous alteplase in acute ischemic stroke. NEJM 2016. PMID: 27161018
"Background: Despite continued debate on the efficacy of alteplase (tPA), it currently remains one of the major interventions directed at patients presenting with acute ischemic stroke. The current standard dose of the drug is 0.9 mg/kg given over 1 hour. It is unclear whether lower doses would be equally effective in increasing good neurologic outcomes after stroke while simultaneously decreasing the rate of intracerebral hemorrhage (ICH); the most serious side effect. Evidence showing that lower doses of tPA are non-inferior to standard-dose tPA could lead to a shift in treatment. 
Clinical Question: Is low-dose tPA non-inferior to standard-dose tPA in terms of death or disability at 90 days in the treatment of acute ischemic stroke presenting within 4.5 hours of symptom onset?
Author’s Conclusions: “This trial involving predominantly Asian patients with acute ischemic stroke did not show the noninferiority of low-dose alteplase to standard-dose alteplase with respect to death and disability at 90 days. There were significantly fewer symptomatic intracerebral hemorrhages with low-dose alteplase.”
Our Conclusions: Low-dose tPA did not meet the upper limit of the prespecified non-inferiority threshold for the odds ratio in comparison to standard-dose tPA for the primary outcome of death or disability at 90 days. However, low-dose tPA performed extremely well in this study. Low-dose tPA patients were more likely to be alive at both 7 and 90 days with a lower ICH rate.
Potential Impact to Current Practice: As this study did not show non-inferiority of the low-dose tPA approach, we do not think it will alter overall treatment strategies. However, in patients with CVA who are eligible for systemic thrombolytics and in whom the doctor and patient both think would benefit from the drug but have increased risk of bleeding, low-dose tPA may be provide an alternative approach.
Bottom Line: Low-dose tPA achieved similar outcomes to standard-dose tPA with lower mortality and ICH rates. Although this study does not prove non-inferiority of low-dose tPA, it also does not show superiority of standard-dose tPA.

jueves, 26 de mayo de 2016

tPA – For Minor Strokes

University of Texas - Houston
Emergency Medicine Literature of Note - May 25, 2016 - Posted by Ryan Radecki
Ref: “Utility of Computed Tomographic Perfusion in Thrombolysis for Minor Stroke” (abstract)
"It is well-established many patients with minor or rapidly improving stroke fail to thrive. The NIHSS is a crude tool, and its correlation with infarct size and ultimate disability is limited. It is not inconceivable some patients with minor stroke could be candidates for intervention...
This brief report is an interesting stepping stone on the pathway towards the practical realization of some of these issues. These authors present a retrospective review of patients with minor stroke (NIHSS ≤ 3) evaluated at their institution. Their institution routinely performs CT imaging with perfusion (RAPID software) on most stroke evaluations. They further trim out 73 of these patients for whom the CT perfusion demonstrated substantial volumetric deficits. Generally, these were patients with small (<5 mL) core infarcts surrounded by 20-40 mL of delayed perfusion, as would be reasonably expected for patients with minimal clinical symptoms.
There were 34 patients in this cohort who received tPA and 39 who were admitted without. Patients were generally similar, although the tPA cohort had twice the prevalence of prior stroke (29.4% vs. 16.7%) and – most importantly – double the area of delayed perfusion (41.3 mL vs. 25.1 mL with wide standard deviation). Despite these poorer prognostic features, 90-day mRS 0-1 were 91.2% in the tPA cohort and 71.8% in the standard care.
This is hardly practice changing in its crude, non-randomized, retrospective form. It does, however, have face validity for informing future study. It also fits with the paradigm of stroke care I’ve been promoting on this blog for years – the inanity of unselected tPA – and the requirements as above – to maximize potential benefit by ensuring those offered tPA have salvageable tissue (read: small core, large mismatch) and likely to recanalize (read: small vessel). There's virtually no question CTP or its equivalent needs to become part of the treatment decision-making process, rather than simple non-contrast CT or even CTA without evaluation of collateral flow."

Oral steroids for asthma attacks

Cochrane - Published: 13 May 2016 - Authors: Normansell R, Kew KM, Mansour G
"People with asthma sometimes have asthma attacks, wherein their symptoms such as cough, chest tightness and difficulty breathing become worse. Many patients with asthma attacks are treated with steroids, which are usually given as a short course of tablets or liquid medicine. Steroids work by reducing inflammation in the airways in the lungs, but they can have side effects (e.g. reduced growth in children, hyperactivity, nausea).
We set out to compare different doses or durations of oralsteroids given to people having asthma attacks. This is an important issue because different doses and durations of oral steroids are used for asthma attacks in different countries, and we do not know which regimen is most likely to improve symptoms while minimising unpleasant side effects...
Authors' conclusions: 
Evidence is not strong enough to reveal whether shorter or lower-dose regimens are generally less effective than longer or higher-dose regimens, or indeed that the latter are associated with more adverse events. Any changes recommended for current practice should be supported by data from larger, well-designed trials. Varied study design and outcome measures limited the number of meta-analyses that we could perform. Greater emphasis on palatability and on whether some regimens might be easier to adhere to than others could better inform clinical decisions for individual patients."

Pain in Older Adults

5 Tips for Managing Pain in Older Adults
ALiEM - By Christina Shenvi - May 25th, 2016
Pain is the most common reason people seek care in Emergency Departments. In addition to diagnosing the cause of the pain, a major goal of emergency physicians (EPs) is to relieve pain. However, medications that treat pain can have their own set of problems and side effects. The risks of treatment are particularly pronounced in older adults, who are often more sensitive to the sedating effects of medications, and are more prone to side effects such as renal failure. EPs frequently have to find the balance between controlling pain and preventing side effects. Untreated pain has large personal, emotional, and financial costs, and more effective, multi-modal pain management can help reduce the burden that acute and chronic pain place on patients. There is evidence that older adults are less likely to receive pain medication in the ED. The first step to improving, is being aware of the potential tendency to under-treat pain in older adults. Here are 5 tips to help you effectively manage pain in older adults on your next shift.

    Impact Brain Apnoea

    impact brain apnoea
    St Emlyn´s - May 25, 2016 - By Simon Carley
    "I’ll keep this post brief. This is not a critical appraisal and it’s not a review. It’s an invite to read a paper I was honoured to help write on the subject of Impact Brain Apnoea. The topic has been discussed on St.Emlyn’s before as it’s a condition that’s arguably been known about for many years, but in recent times may have been forgotten. It is only through the clinical observations of those who see patients with an understanding of what happens at the point of injury that we begin to understand how and perhaps why some people die from cardiovascular collapse following head injuries that seemingly leave little evidence of any significant anatomical injury..."

    miércoles, 25 de mayo de 2016

    Transverse Myelitis

    emDocs - May 25, 2016 - Author: Bodford I - Edited by: Koyfman A and Alerhand S
    Discovery Medicine, Timothy W. West
    • Neurologic symptoms include motor, sensory, and autonomic dysfunction. Sensory symptoms typically involve adermatomal level.
    • Causes are broad including demyelinating conditions, infections, and autoimmune disorders.
    • Rule out life-threatening disorders, including compression of the cord. Order MRI brain and spinal cord with and without contrast. A lumbar puncture must also be obtained.
    • Remember your ABCs! Resuscitate the patient first and foremost.
    • Mainstay of therapy is IV steroids +/- plasmapheresis. Get consultants involved early.
    • Admit the patient for a full workup.
    • Up to one third of transverse myelitis patients will have a recurrence, so if it is in the chart, always keep it on the differential."

    Placement of equipment for the intubation

    Advanced Paramedicine

    Advance Paramedicine - April 25, 2016

    "This is the current version of the kit dump that I have developed for ornge as of 2016-04-22.
    If there is not enough space for the full kit dump (as in patient bedside tray table or bigger), the sheet can be folded in half and the first left half contains most essential equipment that will fit on a standard mayo stand.
    Equipment is arranged from left to right in terms of most common plan A B C's. The kit dump would be placed between the intubator and the assistant such that both have ready access to equipment. The kit dump cognitively offloads the task of equipment setup and also provides a standardized place to find things as well as a quick way to see what equipment might be missing."

    Abdominal Compartment Syndrome

    emDocs - May 24, 2016 - Author: Simon E - Edited by: Koyfman A and Long B
    "The diagnosis of IAH and ACS begins with clinical suspicion. By maintaining a broad differential, to include ACS in the appropriate setting, the ED physician can take steps to address the morbidity and mortality associated with this condition.
    How does IAH/ACS result in systemic end organ dysfunction? Through direct transmission of intra-abdominal pressure (A figure from Rizoli et al.’s work includes the effects):
    Screen Shot 2016-05-22 at 12.41.56 AM
    Let’s Recap a Few ACS Take-Aways
    • IAH is prolonged IAP >12mmHg; ACS is IAP >20mmHg with end organ dysfunction. 
    • ACS has significant morbidity and mortality.
    • IAH and ACS should be on your differential for common ED presentations.
    • Trauma, shock, severe burns, pancreatitis, sepsis => anything requiring massive resuscitation.
    • Remember: ACS can occur s/p abdominal procedures, and can also occur in children.
    • Perform your H&P, send appropriate studies, and if you suspect IAH or ACS => check a bladder pressure.
    • ACS = Consult a surgeon
    • Temporize by evacuating intraluminal contents, improving abdominal wall compliance, optimizing fluid administration, optimizing tissue perfusion, and evaluating for undiagnosed etiologies in atraumatic ACS."

    Minor Facial Trauma: Part I

    NUEM Blog
    Citation: [Peer-Reviewed, Web Publication] Reuter Q, Macias M (2016, May 24). Quick Guide To Minor Facial Trauma: Part I. [NUEM Blog. Expert Commentary by Levine M]. 
    "In the emergency department, we commonly encounter minor injuries to the face and mouth. In a two part series, we will provide a short overview of some helpful strategies for dealing with these cosmetically sensitive injuries in an effective manner.
    Core facial laceration management principles
    • Cosmesis is very important to consider when deciding on closure of facial lacerations thus primary closure should be considered in all facial lacerations unless significant tissue loss or swelling is present.
    • Injury to important underlying structures of the face should always be ruled out and proper physical exam & consultation should be considered when appropriate. 
    • The facial skin has an abundant blood supply and as a result lacerations can be repaired up to a day after the injury occurred without a high risk of subsequent infection.
    • Facial nerve blocks should be considered to obtain anesthesia for lacerations that cross important facial creases or borders to avoid distortion of anatomy.
    • Proper alignment of the vermillion border or facial crease affected by a laceration is critical to avoid obvious cosmetic defects.
    • Sutures on the face should be placed approximately 1-2 mm from the skin edge and 3 mm apart to achieve optimal tissue approximation.
    • Hair does not increase in the risk of wound infection and shaving (such as the scalp or eyebrow) should be avoided."

    Diagnosing SBO in the ED

    BMJ Blog - 23 May, 16 - By rlloyd
    "Diagnosing small bowel obstruction (SBO) is bread-and-butter work for the emergency physician. It accounts for 2% of patients presenting to the ED with abdominal pain, and 20% of all surgical admissions. In the developing world the majority of SBO patients have had previous intra-abdominal surgeries causing adhesions… But I won’t delve into aetiology, let’s talk diagnostics...
    Ultrasonography comfortably outperformed plain radiography in detecting SBO. A sensitivity of 93.9% and specificity of 81.4% left AXR trailing behind with a sensitivity of 46% and specificity of 67%. Dilated loops on ultrasound proved to be far more sensitive than reduced peristalsis – probably because reduced peristalsis is generally considered to be a late finding in SBO, often seen with strangulation."

    ATLS Changes

    SCANCRIT.COM - Posted on May 24, 2016 - By Thomas D
    "We’ve often critisised ATLS. Part of it because many healthcare workers take the ATLS manual as divine law. And many of them don’t keep up with the changes in the new ATLS editions – so they cling to even older dogma. Pretty much everybody has stopped giving 2 L of saline, but many will still say things like the digital rectal exam is manadatory in ATLS. It isn’t. Or a hard cervical collar is mandatory. It isn’t.
    ATLS is now at the 9th edition, and the 10th edition is around the corner. What other dogma will they get rid of, and what will they add, and get more in line with current trauma thinking? Well, here’s a teaser:

    martes, 24 de mayo de 2016

    Balloon tamponade

    GI Bleed balloon tamponade cover art first10em
    First10EM - May 23, 2016
    "Although relatively rare, balloon tamponade is required to control upper GI bleeding when there is going to be a delay to definitive therapy, whether by endoscopy, surgery, or interventional radiology. There are a couple of different devices available, and each hospital is likely to stock only one. You don’t want to have to figure out the nuances of your specific device with a critically ill patient in front of you. This post will cover a general approach that is applicable to all balloon tamponade devices, but I would suggest taking out the device available in your department, reading the attached instructions, and playing with it, so you are sure how your specific device works..:"
    This series from EM:RAP HD and Jess Mason includes an overview, and specific instructions for the Blakemore, Minnesota, and Linton tubes:

    Electrical Storm

    Resultado de imagen de AAEM/Rsa
    - AAEM/RSA - May 22, 2016 - By Khalid M Miri
    "Cardiac electrical storm (ES) is often defined as three or more episodes of sustained ventricular tachycardia (VT) or ventricular fibrillation (VF) within 24 hours. It is a dangerous arrhythmia that leads to refractory VF and will kill most of its victims despite treatment with the current ACLS recommendations of epinephrine, antidysrhythmics, CPR, and defibrillation...
    With evidence suggesting potentially significant benefits to using beta blockers in refractory VF, Drs. McGovern and McNamee have suggested a new treatment algorithm for these grim cases. When faced with continued VF arrest after at least 3mg of epinephrine, 300mg of amiodarone (or one dose of another antidysrhythmic), and 3 attempts of defibrillation, use the following algorithm:
    • Add a second set of defibrillation pads in the opposite location of the first set. If the patient has pads anterior-posterior, add anterior-apex pads and vice versa (research shows double sequential external defibrillation in refractory VF significantly increases chances to terminate the VF and achieve ROSC vs single pads.)
    • Continue high quality CPR and consider withholding further doses of epinephrine. 
    • Rhythm check. If VF then defibrillate at 360 J from both sets of pads simultaneously from two separate devices. 
    • Bolus esmolol at 0.5 mg/kg and initiate a continuous infusion of esmolol at 0.1mg/kg/hr while CPR continues. 
    • Rhythm check. If VF then defibrillate again at 360 J from both sets of pads simultaneously from two separate devices. 
    • Continue esmolol infusion along with high-quality CPR and correct electrolytes, if not previously corrected. 
    • Terminate CPR if ROSC is achieved or patient is deemed unsalvageable by treating physician.
    Cases of refractory VF are often hopeless, but this research shows there might be a new way to treat these patients. Randomized controlled trials using beta-blockers for refractory VF are the next step, but until then it is worth discussing this research and new algorithm with our attendings and deciding whether your team wants to try this new approach before giving up on your next refractory VF arrest. You may save more lives than you thought possible."

    The Pathobiology of Sepsis

    Resultado de imagen de THe maryland cc project

    "Today we are very fortunate to welcome Franco Rafael D’Alessio MD, assistant professor of medicine at the Johns Hopkins University School of Medicine with a specialty on critical care medicine. If there is one thing that Dr. D’allasio knows, it is sepsis. In fact over the last several years he has published numerous papers on the immunology of lung disease, focusing on T cell use, macrophage response, and the changes to inflammation that occur with aging. Today he focuses his brilliance to a 45 minute talk that is essential if you ever want to truly understand what sepsis does to your patients!"
    Resultado de imagen de Vimeo

    Arm Position for US Guided SCL

    R.E.B.E.L. EM - Emergency Medicine Blog
    May 23, 2016 - R.E.B.E.L.EM - By Matt Astin
    "The subclavian route is known to be the site for central line placement with the lowest risk of infection, but can also lead to many mechanical complications [2]. The biggest risk of subclavian line placement is an iatrogenic pneumothorax. The use of ultrasound for subclavian line placement can greatly reduce this risk by watching the needle enter the vein. But does arm position matter for ultrasound guided subclavian central lines?
    The article attempting to answer this question is currently in press, entitled “The Influence of Arm Positioning on Ultrasonic Visualization of the Subclavian Vein: An Anatomical Ultrasound Study in Healthy Volunteers” (Anesth Analg 2016).

    Massive GI Bleed

    First10EM - May 23, 2016 
    "You are called urgently to resuscitation. Walking into the room, you recognize a familiar face. In fact, didn’t you discharge him home yesterday with epigastric pain that you attributed to his chronic alcohol use? Today’s diagnosis is not a mystery. There is already a puddle of blood on the floor, and he is quickly filling another emesis basin with bright red blood. A glance at the monitor reveals a heart rate of 135 and a blood pressure of 74/34…"
    • Get on personal protective equipment
    • Call for help
    • Be an emerg doc
    • Give blood
    • Reverse any known or potential coagulopathy
    • Control the airway
    • Get direct control of the bleeding

    Overcoming occult diuretic resistance

    PulmCrit- May 23, 2016 - By Josh Farkas 
    "Although the term dehydration is often used loosely, the medical definition of dehydration is loss of free water resulting in hypernatremia. This is common in the ICU, usually from failure to replace daily water losses. Normally, hypernatremia triggers thirst and water intake, but this is impossible among intubated patients.
    Hypernatremia should generally be aggressively corrected. Hypernatremia may make patients miserable, manifesting as “agitation” and leading to increased sedative administration (imagine being thirstier than you’ve ever been in your life yet unable to drink). I’ve seen some patients with significant agitation on the ventilator which persisted until we fixed their hypernatremia:
    To make matters even worse, dehydration does little to improve tissue edema (which is due to excessiveextracellular fluid volume). For example, imagine removing one liter of free water from a patient. Since water diffuses freely between the intracellular and extracellular spaces, water will be removed from both spaces. With an equal rise in osmolarity throughout the body, the amount of water loss from each space will be proportionate to its volume. Therefore, since the intracellular volume is about twice the size of the extracellular volume, removing a liter of free water will only remove one third of a liter from the extracellular space...
    • Critically ill patients often avidly retain sodium. This may cause diuresis attempts to fail, if patients excrete dilute urine leading to a loss of water without loss of sodium. Such patients may seem to respond to diuresis, but in fact they are merely becoming progressively dehydrated and hypernatremic (occult diuresis resistance).
    • Combining a loop diuretic and thiazide diuretic is proven to increase sodium excretion in the urine (natriuresis). A recent RCT confirms that this combination promotes balanced loss of sodium and water, allowing volume removal without dehydration."

    lunes, 23 de mayo de 2016

    Platelets for Intracranial Haemorrhage

    Intracranial Haemorrhage Platelet
    St Emlyn´s - May 22, 2016 - By Simon Carley
    "Unfortunately, many patients with haemorrhagic strokes are on antiplatelet drugs such as aspirin and clopidogrel, drugs with long durations of effect on platelet function. Understandably then there has been much interest in determining whether improving platelet function in these patients improves outcome, with the most obvious therapy being platelet infusion. Platelet infusion has been proposed as a way of counteracting the effect of antiplatelet drugs in the acute phase of intracranial bleeding…. but does it work?
    It’s a question tackled by researchers in the UK, Netherlands and France in the New England Journal of Medicine. The PATCH study was designed to specifically answer the question of whether patients who have a non-traumatic intracranial bleed, who are on antiplatelet drugs, benefit from platelet transfusions...
    The bottom line:
    Unless new evidence emerges, new trials are published, or alterations in therapy are proposed then if your patient has a non-traumatic intracerebral bleed, and they are on clopidogrel, aspirin or some other antiplatelet drug then don’t prescribe the platelets.
    The bottom line is that whichever way the authors looked at the data the indication is that platelet infusion worsens outcome."

    End of Life Care

    Posted on November 11, 2015 - By Christina Shenvi

    "What does Dr. Tintinlli do when she has a dying patient and a family who needs help to make decisions and understand the options? – She gets involved. She calls the PCP. She gets palliative care on the line. She advocates for the patient to help make sure their wishes are understood and honored. There comes a time when you go from prolonging life to prolonging death. Knowing when that point is can be hard. Listen to hear her thoughts in this post from 10/2015..."

    Chest Tube and Surgical Airway

    PHARM Prehospital and Retrieval Medicine Blog In Memory of Dr John Hinds

    PHARM - By ketaminh - May 3, 2015
    "Life threatening, critical care emergencies requiring immediate resuscitative techniques. Sound familiar?
    The dreaded Cannot Intubate, Cannot Ventilate
    The dreaded Tension pneumothorax
    Remarkably,similar strategies & techniques for both situations!

    1. Both time critical conditions and interventions
    2. Both require access to an anatomical space or lumen
    3. Both can be managed with needle ( temporarily) and/or scalpel ( definitively)
    4. With scalpel technique, gloved finger identification of correct anatomy is crucial to reliable performance, as demonstrated in this excellent video by Weingart and Strayer

    Same principle with surgical airway. Use your finger to feel the anatomy and to be sure you are in the correct space. Leaving your finger insitu whilst passing bougie is a reliable method but as long as you have digitally confirmed prior to bougie passage, you can remove your finger, pass bougie, then re-insert your finger to check the bougie is in correct space.
    The teaching point is use your gloved finger for both Chest tube and Surgical airway!"

    RV Failure and Pulmonary HT

    The original Kings of County - By Brian - May 21, 2016
    "The most common cause of pulmonary hypertension in the U.S. is left-sided heart failure, but many cases of pulmonary hypertension remain undocumented. Pulmonary arterial hypertension is a specific category of pulmonary hypertension and is a relatively rare disease. In the ED, we often do not consider this disease in the differential diagnosis of dyspnea. And, definitive diagnosis is often delayed as right-sided heart catheterization is required.
    When resuscitating a patient in respiratory distress secondary to pulmonary hypertension, there must be a delicate and dangerous balancing act to avoid right ventricle (RV) failure and hypotension. The most important concept to understand is that you cannot directly augment cardiac output (CO) due to fixed pulmonary vascular resistance, so you must try to prevent further hypoxemia, pulmonary vascular constriction, and reductions in CO..."

    Acute Mesenteric Ischemia

    Emergency Physicians Monthly
    Emergency Physicians Monthly - By Long B and Koyfman A - May 19, 2016
    "80% of acute mesenteric ischemia cases result in mortality because of missed diagnosis. Here’s how to recognize the signs...
    Abdominal vascular catastrophes are uncommon but can be fatal. Acute mesenteric ischemia (AMI) is one abdominal catastrophe of great interest to emergency physicians in that rapid diagnosis and initiation of treatment can prevent mortality and reduce long-term morbidity. The often quoted “Time is bowel” is a sentiment that speaks to the danger of this disease and need for diagnosis.
    The annual incidence of this disease is 0.09-0.2% per year and ~1% of acute abdomen hospitalizations, but this rarity is offset with a 60-80% mortality within the first 24 hours especially if the disease is missed. With the population around the world growing older, this incidence is increasing. Unfortunately this disease presents with a variety of nonspecific symptoms that overlap with other diseases, creating challenges even for the most astute clinician..."

    domingo, 22 de mayo de 2016

    TEE in the Emergency Department

    Resultado de imagen de society academic emergency medicine
    Lecture presented at the 2016 Society of Academic Emergency Medicine Conference 
    held in New Orleans, USA, on May 11th, 2016.
    "Focused transthoracic echocardiography (TTE) to determine prognosis and uncover reversible etiologies during resuscitation has been recommended by the American Heart Association and the International Liaison Committee on Resuscitation (ILCOR) guidelines. Additionally, TTE has allowed Emergency Physicians (EPs) to identify the subgroup of patients in whom the absence of cardiac activity predicts an extremely low chance of survival indicating that resuscitative efforts should be discontinued. The main limitation of TTE is the difficulty of obtaining adequate views due to anatomic and technical factors. Transesophageal echocardiography (TEE) provides numerous benefits compared to TTE and has been used by cardiologists and anesthesiologists to assess patients during hemodynamic decompensation and during resuscitation of cardiac arrest. While the 2008 ACEP Emergency Ultrasound Guidelines consider TEE as an emerging ultrasound application, several factors have precluded the widespread uptake of this intervention. These factors include cost of transducers, perceived risks and training difficulties. Eight years after this first report we believe we have achieved a point where we can provide effective solutions to all these issues in order to pioneer the advance of this application. Once considered part of the future of advanced resuscitation, TEE is today a reality, and has tremendous potential to improve resuscitation care. In the current presentation, I describe our experience at the Mount Sinai Resuscitative TEE program, a multidisciplinary collaboration that successfully implemented the use of TEE performed by Emergency Physicians. By sharing this experience, I aim to encourage and inspire others to join us in the advancement of this field."