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


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viernes, 19 de abril de 2019

VT Storm

PulmCrit (EMCrit)
PulmCrit (EMCrit) - April 18, 2019 by Josh Farkas
"Ventricular tachycardia (VT) storm refers to recurrent episodes of VT. Although any individual episode of VT can be broken, the overall process of recurrent arrests (or ICD shocks) creates a vicious cycle. Aggressive management is required including intubation, deep sedation, antiarrhythmics, and sympatholysis. Given the rarity of this condition, it's difficult to obtain high-level evidence or extensive experience. This chapter attempts to create an organized pathway, incorporating some emerging evidence regarding ultrasound-guided stellate ganglion blocks.
  • The IBCC chapter is located here"

Clamshell Thoracotomy

R.E.B.E.L.EM - April 18, 2019 - By Zaf Qasim
"Every now and again someone raises the issue on social media about resuscitative thoracotomy. What are the indications (we have the EAST guidelines for that), what are the risks (highlighted in this important recent paper), and of course, whether EM or surgery should be doing it in the trauma bay (guess what – it’s in the curriculum for both specialties).
That’s not the point of this post. This post is about how I think you, as the emergency medicine physician (EP), working in a system where your surgeon is not in-house, but is available in a reasonable amount of time, should proceed when faced with the patient who meets the indications. You’ve gone through your HOTTT(T) algorithm and are now at that final “T” – you have to open the chest...
Final Thoughts
The end-point, ideally, is ROSC, when a few things may happen. The patient may wake up and so will require appropriate sedation. The internal mammary arteries may start bleeding and should be controlled with hemostats or tied off. Remember – you need to have a plan to get the patient expediently to surgical care and resuscitation should remain ongoing.
Even if you do not achieve ROSC, at least you will know that when the decision was made to proceed with thoracotomy, you did the best you could for the patient."

lunes, 15 de abril de 2019


R.E.B.E.L.EM - April 15, 2019 - By Salim Rezaie
Ref: Frat JP et al. Non-Invasive Ventilation Versus High-Flow Nasal Cannula Oxygen Therapy with Apnoeic Oxygenation for Preoxygenation Before Intubation of Patients with Acute Hypoxaemic Respiratory Failure: A Randomised, Multicentre, Open-Label Trial. Lancet Respir Med 2019. PMID: 30898520

..."Author Conclusion:“In patients with acute hypoxaemic respiratory failure, preoxygenation with non-invasive ventilation or high-flow oxygen therapy did not change the risk of severe hypoxaemia. Future research should explore the effect of preoxygenation method in patients with moderate-to-severe hypoxaemia at baseline.” 
Clinical Take Home Point: It’s hard to know what to take away from this study, as the comparisons were far from fair or even optimal. As a matter of fact, we are comparing apples to oranges. In a population of patients with severe shunt physiology we are comparing NIV (increased alveolar recruitment through higher levels of PEEP and no nasal/apneic oxygenation) to HFNC (a lower magnitude of alveolar recruitment with lower levels of PEEP + nasal/apneic oxygenation) during laryngoscopy. Essentially, less than optimal pre-oxygenation (NIV alone) with even worse pre-oxygenation (HFNC alone).
In patients with shunt physiology we must optimize pre-oxygenation by recruiting atelectatic alveoli with the best tools we have available:
  1. Increasing PEEP via BVM + PEEP valve with flush rate oxygen AND
  2. Nasal/Apneic oxygenation"

Metformin-induced lactic acidosis

PulmCrit (EMCrit)
IBCC chapter & cast - April 11, 2019 - By Farkas J
"Metformin poisoning and lactic acidosis has always been murky. For years there was debate about whether metformin-induced lactic acidosis exists (short answer: it obviously does). However, for an individual patient, it can still be confusing sorting out the contribution of metformin to their critical illness. A recent re-definition of the condition clarifies things a bit, but substantial confusion persists regarding how to diagnose and treat these patients."
  • The IBCC chapter is located here

Sickle Cell Vaso-occlusive Crises

emDocs - april 15, 2019 - Author: Cisewski D - Edited by: Singh M; Koyfman A and Long B
..."The Upshot
Vaso-occlusive crisis pain is a common, debilitating pathology among sickle cell patients and should not be misinterpreted as drug-seeking behavior. Early recognition and initiation of an analgesic regimen is essential to limiting further sequelae and hospital admission rates/length of stay. Do not rely on abnormal vital signs (or absence of) to guide your management. Oral, intranasal, subcutaneous, nebulized, and intravenous routes of administration should all be considered. Remember that typical pain management regimens are not usually effective in treating a vaso-occlusive crisis. Limit NSAIDS and avoid fluid boluses during acute pain management. Limit oxygen to patients with O2 saturation < 95%. If admission is required, ensure a smooth transition of care that involves a continued analgesic regimen and involvement of the pain management or hematologic consultation service."

Syncope: show me the ECG

Boston City EM
Boston City EM - April 5, 2019
"After each pass, I say to myself:
  • “Short PR, Long QT, High degree and Bundle blocks.
  • Brugada, ARVD.
  • LVH and Cardiomyopathy.
  • Right heart strain and MI.”
Other schemes you may know:
  • WOBBLER – WPW, obstructed AV pathway, Bifascicular Block, Brugada, LVH (HCM and AS), Epsilon wave, Repolarization abnormality. Which has the benefit of being read from left to right on ECG. (pr, qrs, q-t)
  • Can Quick BRAD Walk Home?: Conduction blocks, Long/ short QT, Brugada, RV infarction, ARVD, DCM, WPW, Hypertrophy (HCM or LVH due to AS)
  • 2 more mnemonics, ABCDE-I and “I get my Dairy Queen At HEB” which you can look up. But, these mostly cover the same stuff."

jueves, 11 de abril de 2019

Extracorporeal CO2 removal

PulmCrit (EMCrit)
PulmCrit - April 8, 2019 - By Josh Farkas 
  • "Permissive hypercapnia is a cornerstone of mechanical ventilation in difficult-to-ventilate patients (e.g. ARDS, asthma). However, the optimal degree of permissive hypercapnia is unknown (e.g. the safe pH range).
  • Intravenous bicarbonate can be used to avoid severe acidemia in the context of permissive hypercapnia. This was utilized in the landmark ARDSnet trial and seems reasonable, but it too remains untested by rigorous trials.
  • Extracorporeal CO2 removal is effective at decreasing CO2 levels, and thereby facilitating more gentle ventilation. However, in the absence of any clear therapeutic targets (regarding pH or pCO2), it’s unclear where this technology might fit in our therapeutic armamentarium.
  • Available evidence regarding extracorporeal CO2 removal has failed to show benefit, but has demonstrated potential harms (e.g. increased risk of bleeding, including intracranial hemorrhage). Given that this technology is expensive and invasive, widespread incorporation should await evidence of benefit in RCTs."

Speculum in the ED

emDocs - April 8, 2019 - Authors: Christophe K and Silverberg M 
Edited by: Koyfman A and Long B
"Key points
  • Pelvic exam findings are highly subjective.
  • Accuracy of pelvic exam results may vary depending on patient body habitus.
  • Absence of adnexal mass and/or lack of severe pelvic tenderness does not rule out ovarian torsion.
  • Pelvic exam should not be relied on to rule out sexually transmitted infections.
  • Patient-collected vaginal swabs or urine specimens are acceptable and accurate for STI testing.
  • Pelvic exam cannot reliably rule out ectopic pregnancy.
  • When ultrasound is performed in patients with early pregnancy complaints, the pelvic exam is unlikely to change patient disposition.
  • Engage patients in shared decision making when you are questioning the utility of a pelvic exam."

Reverse anticoagulation with warfarin

CanadiEM -  By Matthew Nicholson - April 2, 2019
"Main Messages
  • In major bleeding or urgent major procedures patients anticoagulated on warfarin the standard of care is co-administration of vitamin K (10 mg IV) and PCCs
  • PCCs are typically dosed based by INR +/- weight. An empiric dose if the INR is not known is typically 2000 IU.
  • Frozen plasma is inappropriate for warfarin reversal unless PCCs are unavailable (which should generally not be the case) or the patient has had a previous reaction to heparin (PCCs contain heparin)"

Endovascular Therapy for AIS

R.E.B.E.L.EM - April 11, 2019 - By Michael Pallaci
"Clinical Bottom Line
  • 8 RCTs have demonstrated the benefit of EST (NNT: 2-12) for a highly selected group of patients: large anterior strokes with a demonstrable clot in a large vessel (distal ICA, ACA, MCA) with a small ischemic core and large salvageable penumbra
  • There are issues with the data, but unlike IV tPA for stroke, the results for EST have been consistently replicated
    • EST benefits only about 1 of every 770 patients with acute ischemic stroke
  • The extended treatment windows resulting from the DAWN and DEFUSE-3 trials may bring that number down
  • Areas for future study:
    • Attempting to identify more patients who benefit
    • EST alone for patients in the window for IV tPA (unlikely in the current climate)
    • Confirming benefit out to 24 hours (i.e., replicating the DAWN trial)
Endovascular stroke therapy will be one of the most hotly debated topics for the next several years. Despite the flaws in the evidence, the reproducibility and wildly positive results of the studies provide some optimism that, for the tiny subset of patients who meet the inclusion criteria, significant benefit is possible. But the societal costs and potential for indication creep are major causes for concern, and will undoubtedly lead to battle lines being drawn and fiercely defended, just as has been the case for IV thrombolysis for stroke for the past two decades."

miércoles, 3 de abril de 2019

Intensive glucose management in Stroke

PulmCCM - March 31, 2019 
..."The SHINE trial may have written the last line of the epitaph on the tombstone of intensive insulin therapy. As a leading stroke researcher put it, the trial leaves "no doubt" as to the lack of benefit in acute stroke, and "now you have a very clear answer. I wouldn't want to mount another trial." How often have you heard those words from an academic?"


Resultado de imagen de british medical journal
Stanley A & Laine L. BMJ 2019; 364: l536 doi: 10.1136/bmj.l536
"Abstract: Upper gastrointestinal bleeding (UGIB) is a common medical emergency, with a reported mortality of 2-10%. Patients identified as being at very low risk of either needing an intervention or death can be managed as outpatients. For all other patients, intravenous fluids as needed for resuscitation and red cell transfusion at a hemoglobin threshold of 70-80 g/L are recommended. After resuscitation is initiated, proton pump inhibitors (PPIs) and the prokinetic agent erythromycin may be administered, with antibiotics and vasoactive drugs recommended in patients who have cirrhosis. Endoscopy should be undertaken within 24 hours, with earlier endoscopy considered after resuscitation in patients at high risk, such as those with hemodynamic instability. Endoscopic treatment is used for variceal bleeding (for example, ligation for esophageal varices and tissue glue for gastric varices) and for high risk non-variceal bleeding (for example, injection, thermal probes, or clips for lesions with active bleeding or non-bleeding visible vessel). Patients who require endoscopic therapy for ulcer bleeding should receive high dose proton pump inhibitors after endoscopy, whereas those who have variceal bleeding should continue taking antibiotics and vasoactive drugs. Recurrent ulcer bleeding is treated with repeat endoscopic therapy, with subsequent bleeding managed by interventional radiology or surgery. Recurrent variceal bleeding is generally treated with transjugular intrahepatic portosystemic shunt. In patients who require antithrombotic agents, outcomes appear to be better when these drugs are reintroduced early"

tPA Window in AIS

R.E.B.E.L.EM - By Salim rezaie - April 01, 2019
..."Author Conclusion: “In patients with acute stroke with an unknown time of onset, intravenous alteplase guided by a mismatch between diffusion-weighted imaging and FLAIR in the region of ischemia resulted in a significantly better functional outcome and numerically more intracranial hemorrhages than placebo at 90 days.” 
Clinical Take Home Point: In this multicenter randomized trial of patients with strokes of unknown time onset, the use of tPA resulted in a 11% improvement in neurologic outcomes at 90 days, and although not statistically significant also resulted in more death and more ICH."

Pulse Checks in Cardiac Arrest

R.E.B.E.L.EM - By Salim Rezaie - March 28, 2019
..."Author Conclusion:“The use of real-time CUSG during resuscitation provides a substantial contribution to the resuscitation team. CUSG will allow earlier and more accurate detection of pulse than manual pulse palpation and DUSG.”
ClinicalTake Home Point: Manual pulse palpation alone can result in incorrect decisions in management of cardiac arrest patients and should stop being used in clinical practice as it is not sensitive or specific for pulses in cardiac arrest. DUSG is a nice secondary modality compared to CUSG but can have false positives and negatives for pulse detection. Some institutions have started using TEE, which would be the optimal tool for the job, however the majority of ED providers do not have access to TEE so it seems, in appropriately trained providers, CUSG > DUSG > Manual Palpation would be the preferred modalities, in descending order, for pulse detection in cardiac arrest."

miércoles, 27 de marzo de 2019


emDocs - March 25, 2019 - Author: Elfatihi M -  Edited by: Koyfman A and Long B
"Take home points
  • Rapid intervention should proceed diagnostic work up in the ill-appearing patient.
  • Intubation for ill-appearing patients should be performed by proficient healthcare clinicians, with ENT and anesthesia consultation recommended.
  • A smaller ETT should be ready for a smaller than anticipated airway due to edema.
  • Stridor, fever, and rapidly progressing symptoms are most likely to be epiglottitis or bacterial tracheitis.
  • In afebrile patient with stridor and progressively worsening symptoms, consider foreign body, anaphylaxis, or thermal epiglottitis in the appropriate clinical setting.
  • A clinician with appropriate airway equipment should accompany stable patients to radiology in case of deterioration.
  • There is a wide differential for stridor, but this can be narrowed based on the timing of stridor in the respiratory cycle, age of patients, and acuity."

martes, 26 de marzo de 2019

Pacemakers malfunction

emDocs - March 26, 2019 - David Bussé D -  Edited by: Santistevan J and Long B
"ED Approach to Pacemaker Malfunction
  • Suspect pacemaker malfunction with complaints of lightheadedness, fatigue, palpitations, hiccups, confusion, dyspnea, muscle twitches, and syncope.
  • The history should elicit whether the patient has any underlying problems leading to pacemaker malfunction. These include ACS, trauma, medication changes, or recent device reprogramming [1, 2].
  • Patients are given cards with the device’s type, model, manufacturer, and the date the device was implanted.
  • Ask patients to provide their pacemaker card.
  • The physical exam should begin with a review of vital signs, mental status, and cardiopulmonary status. Note signs of infection, migration, or trauma at the implant site [2, 7]. Also look for JVD, cannon A waves, pectoral muscle twitching, and new cardiac murmurs/rubs.
  • Obtain an ECG to determine whether an unstable bradycardia is present. Compare it to prior ECGs, looking particularly at axis changes [2].
  • The ECG of a single ventricle-paced patient will show ventricular pacer spikes and a LBBB with left axis deviation due to the placement of the electrode in the RV [7].
  • Biventriculrar pacers capturing the LV free wall demonstrate a dominant R wave in V1 and a QS complex in lead I, indicating a wavefront propagating away from the LV6.
  • ST segments and T-waves should be discordant with the QRS.
  • Obtain PA and lateral chest radiographs to check for lead dislodgement, fracture, or pneumothorax. Should a patient be unable to produce the pacer card, an overpenetrated chest radiograph can be used to determine the device maker by identifying the company symbol [1, 7].
  • Obtain serum measurements of electrolytes and any cardiotoxic drugs in addition to cardiac biomarkers in the appropriate setting. Metabolic derangements including hypothyroidism, acidosis, and hypokalemia can alter the threshold potential required for pacing [2].
  • Management is dictated by the patient’s symptoms and hemodynamic status. Transcutaneous pacing pads should be placed on the patient in an anterior-posterior configuration whenever malfunction is suspected [1, 2, 7]. Apply standard ACLS protocols should a patient be bradycardic with symptoms of hypoperfusion.
  • When hemodynamically stable, interrogate the pacemaker. Interrogation yields information on battery life, sensing and pacing thresholds (under/oversensing), integrity of the lead system (lead fracture), and recordings of cardiac rhythm [1, 6, 7]. Interrogation can indicate proper functioning or presence of arrhythmias that help risk stratify the patient.
  • Interrogation involves radiofrequency communication with the pacemaker by placing a wand over the device. The wand is attached to a programmer that performs the interrogation, and is specific to each device company."

Adjusted DD in Pregnancy PE

the short coat - March 23, 2019 
"The Gist: Use of the YEARS algorithm in pregnant patients with possible pulmonary embolism (PE) appears safe and results in fewer computed tomographic pulmonary angiograms (CTPAs), particularly in low-prevalence testing environments. Given the natural course of d-dimer throughout pregnancy, gestation adjusted versions of this algorithm may better curb overtesting..."

TXA for Everything that Bleeds?

R.E.B.E.L.EM - March 25, 2019 - By Salim Rezaie
"Background: TXA is a synthetic lysine derivative that binds with the lysine site on plasminogen and inhibits fibrinolysis. TXA is not a new drug. Studies from the late 1960s and early 1970s have shown reduced bleeding and need for transfusions in many surgical and medical settings. Fast forward to today and we are finding all kinds of uses for TXA other than trauma including post-partum hemorrhage, epistaxis, hemoptysis, gastrointestinal hemorrhage, and many more..."

viernes, 22 de marzo de 2019

Transfusion for Acute Upper GI Bleeding

CanadiEM - In Infographics - By Alixe Dick - March 22, 2019
...Acute upper gastrointestinal bleeding (UGIB) is a common emergency condition that is associated with a high morbidity and mortality rate.4 Previous to 2013, the guidelines to transfuse this population group were controversial. Villanueva et al. were the first to examine the hemoglobin threshold for transfusion of red cells within this population group.4 They compared the efficacy and safety of a restrictive vs. liberal hemoglobin threshold for red cell transfusion. They determined that a restrictive transfusion strategy with a threshold for transfusion of 70 g/L can decrease mortality at 45 days, rates of further bleeding and rates of transfusion....

ED Stroke

emDocs - March 22, 2019 - By Anton Helman 
Originally published at EM Cases – Visit to listen to accompanying podcast

stroke management update

"Time and image based stroke management algorithm
Activating a “code stroke” on every patient that experiences any acute neurologic event within 24hrs of symptom onset based on the DIFFUSE 3 and DAWN trials may outstrip resources, with only a tiny minority of these patients receiving potential benefit. There is currently an effort to identify those patients clinically who might be most likely to benefit from endovascular therapy so that not all stroke patients require transport to a stroke center with multiple imaging modalities and resource-heavy acute stroke team care..."

jueves, 21 de marzo de 2019


Crit Loud - March 15, 2019

  • It's time to get rid of the classical image of CP radiating only into the left arm. While this might still be the predominant complaint at presentation, it's the right sided shoulder/ arm pain we should keep a close eye on!
  • Chest pain radiating to the right shoulder/ arm is more predicitive of myocardial infarction than left sided chest pain
  • And remember: a positive Troponin alone does not fullfill the diagnostic criteria of AMI!

Early or Delayed Cardioversion in Recent-Onset AF

EM Nerd - March 20, 2019 - By Rory Spiegel
..."Atrial fibrillation is a chronic disease with outcomes measured in years. Constraining its irregularities for the fleeting moments the patient is before us in the Emergency Department has minimal effect on patient outcomes or wellbeing. An immediate cardioversion strategy is a quixotic attempt to check a symptom that is not only incredibly difficult to control, but whose regulation has never been found to improve patient important outcomes. When viewed from this perspective, the futility of ED cardioversion seems obvious. It serves only as a distractor, diverting our attention from rate control and the appropriate use of anticoagulants, interventions that have proven benefits on patients’ downstream health and wellbeing."


R.E.B.E.L.EM - November 05, 2017
"Clinical Take Home Point:
  • The most robust evidence for the increase in adverse events and morphine use evaluates surrogate outcomes (i.e. Effect on platelet reactivity) in healthy volunteers. The findings in these studies should be read as hypothesis generating.
  • When evaluating patient oriented outcomes, there are no randomized studies, but there are several registry level observational trials with differing results associating morphine with increased adverse event making it difficult to draw definitive conclusions.
  • Until further stronger evidence is available it is probably worth erring on the side of safety and reserving morphine in an individualized manner evaluating benefit vs harm and use only when truly necessary in patients with refractory pain
  • One possible alternative for refractory chest pain in ACS is fentanyl, although it would be nice to see studies evaluating the drug-drug interactions between fentanyl and P2Y12 antiplatelet agents
Clinical Take Home Point:
  • To date there is a paucity of high quality randomized clinical trial data to support routine use of supplemental oxygen in normoxemic patients with AMI. It seems reasonable at this time, to withhold oxygen therapy in normoxemic patients
  • It is important to remember that oxygen is a drug, and just like any drug we prescribe to patients it has possible significant side effects.
Clinical Take Home Points:
  • The evidence for SL NTG in acute coronary syndromes appears to be extrapolated from IV nitrate dosing
  • Nitrates studied in most of these trials were IV nitrates and oral long acting nitrates (i.e. isosorbide dinitrate) not SL nitroglycerin
  • In patients with ischemic chest pain, IV nitroglycerin initiated within the first 24 hours of symptom onset reduces overall mortality.
Clinical Take Home Point: 
  • Aspirin at a dose of 162 – 324mg, provides protection against cardiovascular events (reinfarction, cardiac arrest, and stroke) as well as reduce all cause mortality"

jueves, 14 de marzo de 2019

Abdominal Compartment Syndrome

PulmCrit (EMCrit)
PulmCrit (EMCrit) - March 14, 2019 - By Josh Farkas
"Abdominal compartment syndrome can result from primary abdominal pathology (e.g. bowel obstruction), but it can also occur due to systemic inflammation combined with large-volume resuscitation. As such, abdominal compartment syndrome is probably more frequent than generally perceived, functioning as an occult driver of multi-organ failure. Treatment is based upon physiological properties, involving many therapies aside from simply opening the abdomen."
The IBCC chapter is located here.

Predictive Symptoms of AMI

R.E.B.E.L.EM - March 14, 2019 - By Salim Rezaie
"...Author Conclusion:
“In this large multicenter trial, only 4 symptoms were associated with the diagnosis of AMI, and no symptoms that were associated with a non-AMI diagnosis.”
Clinical Take Home Point: 
Pay closer attention to patients with chest pain that radiates to their right arm. In this multicenter study of patients with chest pain presenting to the ED, chest pain radiation to the right arm is more predictive of AMI than chest pain radiating to the left arm."

martes, 12 de marzo de 2019

Subarachnoid Hemorrhage

CanadiEM -  By Michael Kruse - March 12, 2019
  1. What are some common signs and symptoms of subarachnoid hemorrhage (SAH)?
  2. How can pre-hospital providers manage suspected SAH?
  3. How is SAH is diagnosed and managed in the ED?"
SAH Rule


R.E.B.E.L.EM - March 11, 2019 - By Salim Rezaie
"Author Conclusion: 
“Among patients with septic shock a resuscitation strategy targeting normalization of capillary refill time, compared with a strategy targeting serum lactate levels, did not reduce all-cause 28-day mortality.”
Clinical Take Home Point: 
Although the authors conclusion makes it sound like a negative trial, as the gold standard in sepsis is to use lactate and not CRT, this study should be considered a positive trial, as it shows CRT is at least as good as a lactate-guided resuscitation strategy. Using a lactate-guided resuscitation strategy led to more fluid administration, more epinephrine used, and more vasopressors used without improvement in mortality (not statistically significant), compared to normalizing capillary refill time. In other words, with a lactate-guided resuscitation strategy, we are doing more things that don’t make a difference in mortality…Which begs the question…should we be drawing repeat lactates in septic shock?"


PulmCrit (EMCrit)
PulmCrit - March 11, 2019 - By Josh Farkas
"Summary: The Bullet
  • Acetaminophen has previously been shown to be an effective analgesic which can reduce opioid consumption.
  • DEXACET shows that in a cohort of critically ill post-cardiothoracic surgery patients, IV acetaminophen reduced the incidence of delirium. This suggests that acetaminophen use may offer meaningful, patient-oriented benefit.
  • Although DEXACET was performed with IV acetaminophen, other studies have found equivalent efficacy between either oral or intravenous forms.
  • Acetaminophen is probably an under-utilized analgesic among critically ill patients. For maximal efficacy, oral acetaminophen should be given in substantial doses in a scheduled fashion (e.g. 1 gram q6-q8 hours scheduled, not 650 mg q8hr PRN).
  • DEXACET isn’t incredibly robust statistically (fragility index of two). However, it validates longstanding principles of analgesia (specifically, the “analgesic ladder”). Until further evidence is available, it’s sensible to use these principles in clinical practice. This isn’t a revolution, but rather a reminder of first principles."

Hepatic Encephalopathy

emDocs - March 11, 2019 - Authors: Mohammadie S and Zeidan A 
Edited by: Koyfman A and Long B
  1. HE is common in patients with cirrhosis and is the most common reason for readmission. Patients with cirrhosis who experience HE have an increase in mortality demonstrating the seriousness of this common disease.
  2. Clinicians should rely on the history, exam, and clinical suspicion when diagnosing HE, rather than ammonia levels.
  3. Causes of HE are typically due to increased generation of ammonia or decreased clearance. The most common precipitants include infection, GI bleed, dehydration, AKI, lactulose nonadherence, and constipation.
  4. Patients with cirrhosis are more susceptible to developing infections due to a dysfunction of host defense mechanisms as well as dysregulation of inflammatory cytokines.
  5. Diet and hydration status are critical in patients with cirrhosis. Dehydration is a common precipitant of HE due to use of diuretics, lactulose, large volume paracentesis, poor PO intake, and difficult medication titration post TIPS.
  6. Less common precipitants to keep in mind when evaluating for HE include concomitant precipitants, such as infection and
  7. Be wary of new medications in cirrhotic patients. Consider reviewing side effects of all medications used in patients with cirrhosis before prescribing to assess for hepatotoxicity: https://livertox.nlm.nih.gov/."

domingo, 10 de marzo de 2019

Traumatic Arrest

R.E.B.E.L.EM - 06 March, 2019
"Take Home Points:
  • If the patient is a clear traumatic arrest, compressions aren’t indicated and, instead we should focus on the important interventions that need to be done.
  • Ultrasound can be incredibly helpful in traumatic arrest. If you’ve got a traumatic arrest patient with neither pericardial fluid nor cardiac activity, it may be reasonable to stop resuscitation without the thoracotomy.
  • When decompressing the chest, it’s better to place your angiocath in the 5th intercostal space in the anterior axillary line. This helps you avoid the great vessels in the as well as the thick anterior chest wall
  • And last, if you are doing a thoracostomy, you may as well go bilaterally. You are doing invasive things to a dying patient, there is no reason to guess where the problem is. Similarly, if you have to do a thoracotomy, you could consider making it a clamshell as it space to look into and making sure the right side of the chest is accessed."

Methotrexate Failure in Non-Ruptured Ectopic Pregnancy

R.E.B.E.L.EM - march 07, 2019 - By Jessica Pescatore
..."Author Conclusion:
“The proportion of patients failing methotrexate as first-line treatment was higher than previously reported. Further investigation is needed to determine whether methotrexate failure was due to non-adherence to recommended guidelines.”
Clinical Take Home Point: 
Despite the authors quoting a 17.8% failure rate with medical management of non-ruptured, hemodynamically stable, ectopic pregnancy with methotrexate, a more appropriate statement would be that in patients who received methotrexate without relative contraindications (pre-treatment bHCG level >5000mIU/mL, presence of fetal cardiac activity ectopic pregnancy size >4cm), 12 (9.1%), had an ectopic rupture, which is a more accurate estimation."

2018-2019 St. Emlyn´s Top 10 Trauma papers

St. Emlyn´s - By Simon Carley - March 6, 2019
"I’m back in the Midlands at the excellent and great value TraumaUK conference. If you’ve not been to this conference then I’d strongly suggest you do next year. It’s an amazing program and incredible value for money.
As usual I’m in the emergency medicine stream bringing together the top 10 trauma papers from 2018-2019.
As ever it’s a bit disappointing to find relatively few papers to talk about as I try and focus on those papers that might lead to a change in practice. Although there are a lot of publications out there, once you start applying the filters of applicability, quality and interest that number plummets.
So here is my top 10 list based entirely on my own opinion. There is some repetition from past posts, but I’m OK with that as we can call it spaced repetition"

jueves, 28 de febrero de 2019

Early Norepi in Septic Shock

R.E.B.E.L.EM - February 28, 2019 - By Salim Rezaie
"Background: Standard management of septic shock has included, IV fluids until optimal intravascular volume is achieved, appropriate early antibiotics, and source control. Typically, only after all these measures have been undertaken is vasopressor infusion initiated if a MAP of ≥65mmHg is not achieved.
There have been some animal and human studies that have advocated for early norepinephrine administration in septic shock improving hemodynamics and mortality. The issue, with these trials is that they were retrospective which means these studies suffer from the limitations of this type of methodology (i.e. convenience sampling, recall bias, confounding, and ultimately cannot determine causation, only association)...
Author Conclusion: “Early Norepinephrine was significantly associated with increased shock control by 6 hours. Further studies are needed before this approach is introduced in clinical resuscitation practice.”
Clinical Take Home Point: Although, this study confirms my own biases of initiating vasopressor therapy earlier in the course of patients with septic shock, it should be remembered that this study still requires external validation with patient oriented outcomes before implementation into routine clinical practice.
Currently, in my practice, in patients with septic shock, I am starting with a Lactated Ringers bolus and assessing fluid status with RUSH exam. If my patient is euvolemic or hypervolemic, I am beginning my norepinephrine infusion at a much sooner time than waiting for 30cc/kg to be completed"

IV Bolus Epi for Anaphylaxis

EMCrit CQiR - February 27, 2019 by Ashley Mogul
"Take Home Points:
  • Continue giving your initial dose of epinephrine IM
  • In IV bolus epinephrine: low dose, slow push
  • Don’t give dead people doses of epinephrine to alive people
I would like to acknowledge Diane Lum, PharmD and Guang Mei Fung, PharmD for their assistance with my literature review.

Comments from Weingart
There must be an equivalent IV infusion dose to our standard IM dosing! But I'll be damned if I can find out what it is… So my best clinical recs based on experience actual patients we have tried this on.
  • Start at 5 mcg/min
  • this will almost always be too low
  • titrate every couple of minutes up to 10, 15, 20 mcg
  • For a patient that is peri-code, consider 20-40 mcg/min (as best I can tell, the 0.3 mg IM we give is expected to last approx. 10 minutes, so 30 mcg/min is probably the mean over those 10 minutes (though I'm sure there is a peak/trough rather than steady state)). If someone is truly going down the poop shoot, giving half of an ml of cardiac epi (50 mcg) or 5 mls of EMCrit-style push-dose pressors (50 mcg) may be warranted."


PulmCCM - February 23, 2019 - By Jon-Emile S. Kenny
..."Within the 2016 Surviving Sepsis Guidelines lies the following recommendation: ‘normalize lactate in patients with elevated lactate levels as a marker of tissue hypo-perfusion.’ This, however, is graded as a weak recommendation, low quality of evidence. Interestingly, buried within the text, the guideline authors declare – correctly – that ‘serum lactate is not a direct measure of tissue perfusion.’ Could there exist a better indicator of tissue starvation in septic shock?
Almost 40 years ago, Champion introduced the idea of monitoring capillary refill time [CRT] for shock resuscitation. This low-tech metric fell out of favour during the zenith of invasive monitoring and oxygen delivery optimization in the 1980s and ‘90s. However, recent data have shown that CRT: 1. is potentially a more responsive resuscitation sign in sepsis than biochemical guides, 2. spares excessive intravenous fluids and their inherent harms and 3. predicts mortality in septic patients in the ED.
Given the above, the ANDROMEDA-SHOCK trial was released last week at the 48th Critical Care Congress and the caterwauling was recorded immediately across multiple time zones. Do we dare worship this false idol? This Golden Calf called ‘capillary refill time?’..."