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SOBRE EL AUTOR **

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

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jueves, 19 de julio de 2018

Metabolic resuscitation for Pneumonia

Pulm (EMCrit)
PulmCrit Wee – July 19, 2018 - By Josh Farkas
"Summary: The Bullet
  • The use of steroid for community-acquired pneumonia is supported by several RCTs and currently recommended by SCCM/ESICM guidelines. However, metabolic resuscitation with hydrocortisone, ascorbate, and thiamine remains quite controversial.
  • Kim 2018 performed a before/after study evaluating metabolic resuscitation for patients admitted to an ICU with severe pneumonia. Various analyses suggest a mortality benefit, particularly among the sickest patients. However, this study is far from definitive due to numerous limitations.
  • A multi-center RCT is needed to address this question. In the interim, outcomes from this hospital suggest that metabolic resuscitation is currently a reasonable treatment option for severe community-acquired pneumonia admitted to the ICU."

Articles of the month (07/2018)

A monthly (ish) summary of the emergency medicine literature
First10EM - By Justin Morgenstern - July 19, 2018
"You will probably notice a new format to the articles of the month. I was getting sick of not being able to find papers that I knew I had previously commented upon. Having them listed as one 10 papers in the articles of the month made them very difficult to search for. Therefore, on bigger, more important papers, I have started writing stand alone blog posts. I will still include those papers in the articles of the month, but the summary will be truncated, with a link to the blog for all the details. The articles of the month will probably still contain extra articles, including papers that don’t warrant their own post and my usual “just for fun” kind of papers. Let me know what you think..."
  • TXA is not magical?
  • Bougie is better
  • Interesting airway hack
  • Medical management of peritonsillar abscess?
  • Does ED physician speed affect patient experience?
  • Once again: tamsulosin doesn’t help with kidney stones
  • IV fluids DO NOT cause cerebral edema in pediatric DKA
  • Best medical care in the world
  • Best ever cure for hiccups

Epinephrine in Cardiac Arrest

St Emlyn’s - By Simon Carley - july 19, 2018
"Epinephrine use in cardiac arrest is controversial. Despite patho-physiological arguments3 that it can improve brain perfusion and even that it may improve the rate of ROSC (Return of Spontaneous Circulation) many have expressed the concern that this does not then translate into real survivors to hospital discharge or to those who have survived WITH a good neurological outcome...
There is uncertainty then in whether we should continue to use Epinephrine in cardiac arrest, and so we are delighted to see that the long awaited PARAMEDIC-2 trial is published today which will hopefully answer the question (Ed – which is a surprise in some ways that we’ve never really tested this before).
The abstract is below, but as we always say, please read the full paper (which is open access at NEJM for the moment). You should also read the excellent editorial by Callaway and Donnino..."

miércoles, 18 de julio de 2018

Airway Sans Hypotension

Taming The SRU - By Renne C - July 18, 2018

"WRAPPING UP:
Insofar as Dr. Bill Hinckley has wisely coined the term "Definitive Airway Sans Hypoxia on the 1st Attempt" (DASH-1A). I humbly submit a similar goal in terms of hemodynamics: "Definitive Airway Sans Hypotension on the 1st Attempt." While tongue-in-cheek, it is a somber reminder of the dangers of definitive airway management. If done carelessly in shocked patients, intubation can become an iatrogenic catastrophe. However, performed carefully and with a comprehensive approach, even a shocked patient can be intubated safely:
  1. Resuscitate before you intubate: fluids, products, ino/pressors as needed
  2. Induce with ketamine 0.5-1 mg/kg to avoid sympatholysis, or forego an induction agent if the patient is truly obtunded
  3. Minimize positive pressure and extrinsic PEEP while watching for intrinsic PEEP
  4. Preserve the ventilatory compensation of metabolic acidosis to avoid dropping the pH and causing hemodynamic collapse
Through a deep respect for its perils and a thoughtful deployment of the above strategies, you can successfully circumnavigate the hemodynamic storm clouds of intubation. In doing so, know that you have accomplished one of the greatest challenges of Emergency Medicine and Critical Care: not harming patients in an attempt to save them!"

Sinus Tachycardia

R.E.B.E.L. EM - Emergency Medicine Blog
R.E.B.E.L.EM - July 18, 2018
"Have you ever heard an entire lecture on sinus tachycardia? Neither have I. It is the most common cardiac dysrhythmia seen in critically ill adults and kids, but it is the least frequently talked about. Sinus tachycardia may not be the sexiest rhythm and we don’t think of cardioverting it or giving some new anti-arrhythmic drug, but it is a sign that something may be seriously wrong. To be fair, it’s not the sinus tachycardia we are really worried about, but rather what’s causing the sinus tachycardia that should be our main concern..."

Pseudo PEA

MEDEST - July 17, 2018
"In a recent trial (Focused echocardiographic evaluation in life support and peri-resuscitation of emergency patients: a prospective trial link in the references) evaluating the use of POCUS in extreme shock and cardiac arrest in prehospital setting the investigators found that, examining with ultrasound patients in cardiac arrest, 74,5% and 35% of PEA and Asystole respectively had cardiac wall motion and a rate of survival significatively higher than “no cardiac activity patients” (55% vs 8% in PEA and 24% vs 11% in Asystole)...
Take home points about pseudo PEA:

  1. ALWAYS use ultrasound to determine cardiac activity in cardiac arrest patients
  2. Don’t trust central pulse palpation
  3. Pseudo PEA is an ultrasound evident cardiac activity without carotid pulse
  4. Pseudo PEA is a big clinical reality beyond ACLS mantras
  5. Use ultrasound to look for reversible causes of pseudo PEA.
  6. Use waveform EtCO2 and waveform Pulse Oximetry to monitor perfusion
  7. Continue CHEST COMPRESSIONS in pseudo PEA with bad perfusionstate indicators:
    1. Wide bradycardic electric activity
    2. Low EtCO2 (below 20 mmHg)
    3. No waveform on Pulse ox
  8. Use VASOPRESSORS in pseudo PEA with good perfusion state indicators:
    1. Narrow normofrequent electric activity
    2. EtCO2 above 35-40
    3. Good waveform on Pulse ox

martes, 17 de julio de 2018

ATBs for CAP

header
Suk Lee Mi et al. Infect Chemother. 2018 Jun; 50(2):160-198.
Published online Jun 26, 2018. https://doi.org/10.3947/ic.2018.50.2.160
"Community-acquired pneumonia is common and important infectious disease in adults. This work represents an update to 2009 treatment guideline for community-acquired pneumonia in Korea. The present clinical practice guideline provides revised recommendations on the appropriate diagnosis, treatment, and prevention of community-acquired pneumonia in adults aged 19 years or older, taking into account the current situation regarding community-acquired pneumonia in Korea. This guideline may help reduce the difference in the level of treatment between medical institutions and medical staff, and enable efficient treatment. It may also reduce antibiotic resistance by preventing antibiotic misuse against acute lower respiratory tract infection in Korea."

lunes, 16 de julio de 2018

Core EM Clerkship Topics

Core EM Clerkship Topics
iEM - July 16, 2018
International Emergency Medicine Education Project

"Core EM clerkship topics recommended by SAEM are ready for students. Feel free to read or listen. And, do not forget to share with your colleagues or students. Sharing is caring!"
  • Shock
  • Chest Pain
  • Gastrointestinal Bleeding
  • Headache
  • Respiratory Distress
  • Multiple Trauma
  • Poisoning
  • Cardiac Arrest
  • Altered Mental Status
  • Abdominal Pain


Massive transfusion protocol

An online community of practice for Canadian EM physicians
CanadiEM - By Matthew Nichols - July 16, 2018
"Main Messages 
  • MTP is indicated for patients with prior or ongoing major hemorrhage. MTPs can prevent dilutional coagulopathy and the deleterious effects of large volume crystalloid administration. Fibrinogen, INR, and platelets should be targeted to levels shown to promote hemostasis.
  • Crucial adjunctive measures include administration of tranexamic acid and prevention of hypothermia including the use of a blood warmer, bair hugger, and warmed ambient room temperature.
  • Monitor calcium, magnesium, and potassium to prevent complications of MTP including arrhythmia and death."

All the content from the Blood & Clots series can be found here

Infinite Game Theory in EM

St. Emlyn´s - July 15, 2018 - By Craig Ferguson
"Summary
It’s very understandable that people want to be able to measure outcomes in health-care. It is a really, really expensive business and people want to ensure that they use precious resources wisely. But it is also extremely difficult to translate diffuse concepts such as quality into short-term, quantitive outcomes.
The National Health Service in the UK was set up almost exactly seventy years ago. The Health Minister instrumental in introducing this, Aneurin Bevan stated, ‘..no society can legitimately call itself civilised if a sick person is denied medical aid because of lack of means.’ This is an admirable, infinite goal: the provision of universal health care regardless of means. Many of the indicators, targets or measurements in healthcare introduced since then are less aspirational.
As healthcare professionals we should be aware of the type of game that we are playing and why we are playing it. We should be wary of attempts to construct a finite game out of an infinite pursuit. Healthcare leaders should be aiming to ensure the healthcare system endures for future generations."

Furosemide Stress Test

PulmCrit (EMCrit)
PulmCrit - July 16, 2018 - By Josh Farkas
"Summary The Bullet:
  • The furosemide stress test (FST) is a protocolized furosemide challenge, which has been shown to predict whether patients are likely to progress towards advanced AKI and dialysis.
  • Critically ill patients commonly develop oliguria due to severe intrinsic AKI. In this situation, ongoing efforts to elicit urine output through repeated fluid boluses or other hemodynamic manipulations is generally futile and potentially harmful.
  • FST could conceivably be utilized among patients with persistent oliguria despite initial resuscitation, to facilitate early identification of patients with severe intrinsic renal failure in whom urine output is an unreliable measurement of tissue perfusion."

Tracheostomy Emergencies

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emDocs - July 16, 2018 - Authors: Schwartz J., Lentz S., Roginski M. 
Edited by: Koyfman A and Long B
"Take Away Points
  • Differentiate simple tracheostomy versus total laryngectomy patients by ETCO2at the nose. 
  • Simple tracheostomy patients are (potentially) intubatable from the oropharynx. Total laryngectomy patients are not. 
  • Mucus plugging is common. Attempt suction and replace the tracheostomy tube’s inner cannula. 
  • Let down the cuff, if present, to reposition a tracheostomy tube. 
  • Use caution when replacing dislodged trach tubes in fresh tracheostomies. Consider orotracheal intubation instead. 
  • Bougie, Cook, and Aintree catheters can assist with tracheostomy tube exchange. 
  • Always confirm position of the exchanged tracheostomy tube by direct fiberoptic visualization or ETCO."

Heart Failure Pathway

By Cheney C - July 9, 2018
"Compared to a control group of patients, acute heart failure patients in an emergency department's clinical pathway program had a 13.1% lower readmission rate.
Enrolling acute heart failure patients in a clinical pathway program reduces hospital readmissions from emergency departments without increasing time spent in the ED, researchers say.
The research, which was published this month in the American Journal of Emergency Medicine, found patients in an Acutely Decompensated Heart Failure Clinical Pathway (ADHFCP) program experienced a 13.1% decrease in hospital admission from the ED compared to a control group of patients..."

domingo, 15 de julio de 2018

Reducing missed ACS

AvoidingERrors - July 14, 2018 - By Jesse
"Patients with Acute Coronary Syndrome (ACS) are discharged from the Emergency Department with missed diagnosis at a relatively low rate. But because ACS is a leading cause of death, this translates into a major medico-legal concern for Emergency Physicians. While it is impossible to reduce the miss rate to zero without admitting every patient, many cases of missed ACS are preventable...
1. ACS IS NOT ACUTE CHEST PAIN SYNDROME. CONSIDER ALL SYMPTOMS OF ACS
2. ECGs ARE DYNAMIC AND CHALLENGING. COMPARE ECGs AND KEEP LEARNING
3. TROP NEGATIVE DOES NOT RULE OUT ACS. STRATIFY PATIENTS"

Hypernatremia

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emDocs - July 14, 2018 - Author: Ramzy M - Edited by: Koyfman A and Long B

Pearls:
  1. Resuscitate: Correct volume deficits and hypoperfusion. Do not lower more than 0.5 mEq/L/h or 10 to 12 mEq over 24 hours. If the patient is not hypovolemic, use D5W.
  2. Investigate: Address the underlying cause of hypernatremia. Consider electrolyte imbalances, sarcoidosis, nephrogenic or central diabetes insipidus.
  3. Rehydrate: Use Adrogue Madias’ formula to understand how much each infusate affects the patient’s sodium and adjust treatment course with frequent checks.

Can’t Miss ECG Findings

Resultado de imagen de academic life in emergency medicine
ALiEM - July 11th, 2018 - By Rose C, MD and Goodnough R
"Sudden cardiac death accounts for almost 400,000 deaths per year in the United States, and EM providers must be adept at discerning subtle, high-risk ECG findings. With the advent of triage ECG protocols, one of the most common interruptions in the ED is a request to “sign off” on an ECG. We present a reference of some of the most important high-risk ECG findings, intended to help ED providers systematically screen patients in triage and the waiting room..."

sábado, 14 de julio de 2018

Echo in Cardiac Arrest

R.E.B.E.L.EM - July 13, 2018
Background: Focused use of ultrasound in resuscitation of patients with shock and cardiac arrest has become increasingly embraced in both the emergency department (ED) as well as in the prehospital setting. Application of ultrasound, particularly of echocardiography, has the potential to identify treatable causes of shock and arrest, identify shockable rhythms and identify the presence of mechanical activity. All of these can affect management decisions and, potentially effect outcomes. Recent studies have led to concerns that integration of point of care ultrasound (POCUS) in cardiac arrest increases pauses in compressions. Thus, it is important to establish what POCUS adds to shock and arrest management...
Bottom Line:
POCUS is a powerful tool in cardiac arrest care but is only useful if the information obtained from it is acted upon. In a small number of cases, cardiac ultrasound will reveal potentially reversible pathology in the cardiac arrest patient. Lastly, it is clear that fingers are not accurate in assessing the presence or absence of a pulse in patients in extremis. It’s time to abandon fingers for the pulse check and embrace more advanced technology."

Optimal-pre-oxygenation

PatientSafe Network on April 2, 2017
"Pre-oxygenation is a vital part of airway management immediately prior to intubation and any situation where airway control is taken away from a patient.
We often overestimate our ability to predict airway difficulty – in one study of 3991 difficult intubations 93% were unanticipated (see here). Further the NAP4 study has revealed that airway difficulty is encountered 60 times more frequently in critical care environments than in anaesthesia (see here).
Pre-oxygenation should be performed in the best way possible to provide the greatest time for successful airway control before a patient suffers hypoxic tissue damage.
The Difficult Airway Society have generated guidelines discussing pre-oxygenation in detail (see here).
The DAS guidelines stipulate the requirement for a face mask seal: ‘De-nitrogenation can be achieved with an appropriate flow of 100% oxygen into the breathing system, maintaining an effective face-mask seal’.
Non-rebreather masks (NRM) do not provide a face mask seal. The use of NRM for pre-oxygenation appears to be a culture in some emergency departments. In changing this culture we may provide our patients with a significant increase in the safety of their care..."


miércoles, 11 de julio de 2018

Stress Echo

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ACEP Now - By Lorraine L. Janeczko - July 5, 2018
"Stress echocardiography (SE) may be a good alternative to coronary computed tomography angiography (CCTA) when triaging patients with chest pain in the emergency department, a new study suggests.
“When we compared stress echocardiography and CCTA, we saw that stress echocardiography was able to discharge more patients who came to the emergency department for chest pain and in a faster timeframe,” Dr. Jeffrey M. Levsky of Montefiore Medical Center and Albert Einstein College of Medicine in New York City told Reuters Health by phone.
“Triage and fast decision-making are the order of the day, so it was surprising that stress echo, which is sometimes considered slower, was so good in this role,” he added..."

Cardiac Arrest Management

EMCrit RACC
EMCrit RACC 228 - July 11, 2018 - By Scott Weingart


click image to enlarge

"The slide above is from an SCCM talk by Robert Sutton. Dr. Sutton is a pediatric intensivist at CHOP in Philadelphia. His research interests include pediatric CPR quality research with a focus on evaluating novel interventions, both educational and technological, with the overall goal to improve care delivered to children during resuscitation attempts.
What We Spoke About…
We went box by box through the algorithm above. Note, very little of this is supported by high level evidence. However, neither is anything we are doing now–so be wary of staus quo bias."

lunes, 9 de julio de 2018

Hyperoxia

R.E.B.E.L. EM - Emergency Medicine Blog
REBEL Cast Ep 55 - July 9, 2018
"Background: Critically ill patients come to the ED all the time and it is almost reflexive to liberally administer oxygen in these acutely ill patients. Many providers may consider supplemental oxygen a harmless and potentially beneficial therapy in these patients, irrespective of the presence or absence of hypoxemia (i.e. hyperoxia). There have been several trials (Stroke Oxygen Study, Oxygen in AMI, & Oxygen in the ICU) that have shown harm with hyperoxia in the critically ill. This paper is a systematic review and meta-analysis evaluating the evidence base for liberal versus conservative oxygen therapy in this patient population...
Author Conclusion: “In acutely ill adults, high-quality evidence shows that liberal oxygen therapy increases mortality without improving other patient-important outcomes. Supplemental oxygen might become unfavorable above and SpO2 range of 94 – 96%. These results support the conservative administration of oxygen therapy.”
Clinical Take Home Point: In critically ill adults we should avoid hyperoxia as this increases mortality. Instead we should aim for a target SpO2 of 94 – 96% in these patients."

Manejo del Asma en Urgencias

Resultado de imagen de revista emergencias
Pascual Piñera Salmerón P et al. Emergencias 2018; 30:268-277
"El presente documento de consenso se ha desarrollado con el objetivo de facilitar una herramienta para el manejo del paciente asmático en los servicios de urgencias españoles y mejorar la calidad asistencial. Un equipo multidisciplinar formado por tres especialistas en medicina de urgencias, tres especialistas en neumología y tres especialistas en alergología elaboró un listado de preguntas clínicas y utilizó cuatro guías de práctica clínica sobre el manejo del asma para responderlas. Después de un periodo de trabajo individual, se discutieron y consensuaron en una reunión los contenidos del presente documento. Las recomendaciones y los algoritmos incluidos en él van dirigidos a detectar al paciente asmático a su llegada al servicio de urgencias, establecer un diagnóstico correcto, unificar los criterios terapéuticos y realizar posteriormente una correcta derivación al neumólogo, alergólogo o al médico de atención primaria, según proceda. Las definiciones que se ofrecen en el presente documento proporcionan un lenguaje común que puede ayudar a unificar la actividad asistencial en los servicios de urgencias. Los criterios diagnósticos, las pautas de tratamiento y los criterios de alta y hospitalización recogidos en esta guía pueden ser de utilidad para el manejo del paciente asmático en los servicios de urgencias españoles."

sábado, 7 de julio de 2018

CAP Treatment

R.E.B.E.L.EM - July 6, 2018
Article: Haran JP et al. Macrolide resistance in cases of community-acquired bacterial pneumonia in the emergency department. J Emerg Med 2018.
"Background: Community acquired pneumonia (CAP), defined as lower bronchial tree infection in a patient that has not been hospitalized in the last 90 days is a commonly diagnosed disease. There are between 2-4 million episodes per year in the US with roughly 500,000 hospital admissions (Rosen’s). Most outpatients are treated with azithromycin (or another macrolide antibiotic) as this drug gives a simple treatment regimen (single drug, simple dosing, short course). However, the efficacy of this regimen has been questioned in recent years as resistance patterns shift..."

Huntington’s disease

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emDocs - July 4, 2018 - By: McGurk K & Dyer S - Edited by: Koyfman A & Long B
Take Home Points
  • The clinical effects of HD are progressive but develop slowly. New or rapid changes in a patient’s motor function or cognition should prompt consideration of alternative etiologies or concurrent illness.
  • HD patients may present with acute psychiatric symptoms even before the development of motor symptoms. Risperidone is the med of choice for acute psychosis in HD.
  • Patients with HD need to be carefully screened for suicidal ideation. Their risk of suicide is significantly higher than the general population.
  • Use caution before administering succinylcholine as there may be an increased risk of prolonged apnea and muscle paralysis in this patient population. Certain medications, including anticholinergics and metoclopramide, may contribute to worsened chorea.
  • Consider awake fiberoptic intubation when appropriate. Patients with advanced HD have a high risk of aspiration.

martes, 3 de julio de 2018

Toxic alcohol ingestion / KULTS

The Tox and The Hound (EMCrit)
Tox and Hound - July 2, 2018 - By Meghan Spyres
..."Toxic alcohols are a perfect example of the type of diagnostic challenge that drives us. Ethylene glycol (EG), methanol (MeOH), and isopropanol levels are almost universally unavailable in real time. The differential diagnosis for a toxic alcohol ingestion is huge, and although the alternative diagnoses are much more common, missing the diagnosis can sentence a patient to renal failure, permanent blindness, or death. Even more, toxic alcohol ingestions are accompanied by a great nemesis, a persistent villain that haunts nearly every consult: the osmol gap (OG).
But can’t we use the OG to make (or exclude) the diagnosis of toxic alcohols? Haven’t we been ordering this lab test for years, cognitively offloading any worry about tox as soon as the low OG results? Am I really going to ruin this for you? Yes, of course I am. Far from a quick fix solution, the OG remains one of the more misunderstood tests in medicine...

lunes, 2 de julio de 2018

Heart Failure Triggers

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emDocs - July 2, 2018 - By Karz J & Bucher J-  Edited by Koyfman A & Long B

"...Key Points:
  • Always address ABCs.
  • Rule out more common causes of acute decompensated heart failure first (respiratory illnesses, arrhythmias, renal failure, ACS, uncontrolled HTN, medication non-compliance, and dietary indiscretions).
  • Consider reversible causes of HF (e.g., NSAIDs, alcohol) and stop the offending agent.
  • There may be more than one precipitant leading to acute decompensated heart failure.
  • Always evaluate for ACS."

Torsade de Pointes

PulmCrit
PulmCrit - July 2, 2018 - By Josh Farkas


..."Summary: The Bullet
  • Magnesium is the naloxone of TdP: it works great temporarily, but TdP may recur after magnesium is excreted by the kidneys.
  • After an episode of TdP, the optimal magnesium level seems to be ~3.5-5 mg/dL (not the traditional target of Mg >2 mg/dL).
  • Initiation of a protocolized magnesium infusion immediately following the first episode of TdP may prevent recurrence and thereby avoid complications (e.g. cardiac arrest, rib fractures). This is part of textbook management of TdP, but it is underutilized because the nuts & bolts of running an infusion are unclear.
  • A standardized, evidence-based magnesium infusion protocol may increase the ease and safety of magnesium infusions. This translates magnesium infusion into something which is reproducibly achievable at the bedside.
  • Patients with impaired renal function (GFR<30 ml/min) may be treated with repeated measurement of magnesium levels and PRN boluses, with a target magnesium level of 3.5-5 mg/dL."

domingo, 1 de julio de 2018

Drowning

The Trauma Professional´s Blog - June 29, 2018 - By Michael McGonigal
"This 10 minute video was developed with prehospital providers in mind, but all trauma professionals will find some tidbits of interest. 
Pay no attention to the hideous screenshot, though. I was not trying to look like House."


iEM

International Emergency Medicine Education Project
Free, reusable education resources for medical trainees and teachers/educators 
in the world of emergency medicine
"International Emergency Medicine (iEM) Education Project is an international, non-profit project, supported by emergency medicine professionals from all around the world. It aims to provide free, reusable educational materials for medical trainees, educators, clerkship and program directors.
The project focuses mainly on undergraduate curriculum, but learners from all levels (medical students, interns, residents) and their educators may benefit from it. It is targeted at all learners around the globe, however, learners from areas with limited resources have a special place in mind.
The content is entirely free and available in various formats including website, iBook, eBook, pdf, image, video, and audio. Clinical image and video archives are accessible in Flickr and YouTube accounts. The audio chapters and podcasts are available via SoundCloud. Please visit the”blog” for up-to-date posts (testing phase July – September, active phase from October 15, 2018). The website is mobile-friendly to maximize accessibility. We support free open access medical education (FOAM). All materials are free to use, download and share..."

sábado, 30 de junio de 2018

Poisonings caused by ICU

MCC Project - By Jim Lantry - June 28, 2018
"Today we welcome Josh D King, MD, Assistant Professor of Medicine at the University of Virginia School of Medicine where he also serves as the associate program director for the nephrology fellowship program. Dr. King is a rare specimen, with board certifications in both Nephrology and Toxicology he focuses on critical care nephrology, acute treatment of drug overdoses, and addressing acute poisoning and envenomation. In addition to his clinical work, Dr King is a prolific academician, publishing numerous journal articles on the topic of acute care toxicology. Today he was kind enough to travel up Interstate 95 and donate an hour of his time to explain what we HAVE TO KNOW if we plan to work in the modern ICU!..."

Tamsulosine for KS

R.E.B.E.L.EM - June 29, 2018
..."Authors Conclusions:
“Tamsulosin did not significantly increase the stone passage rate compared with placebo. Our findings do not support the use of tamsulosin for symptomatic urinary stones smaller than 9 mm. Guidelines for medical expulsive therapy for urinary stones may need to be revised.”
Our Conclusions: We agree with the authors conclusions. This well-done, RDCT did not demonstrate an advantage to medical expulsion therapy with tamsulosin in comparison to placebo at 28 days.
Potential to Impact Current Practice: Current urology guidelines recommend the addition of tamuslosin in the treatment of ureteral colic mainly based on poor quality studies and systematic reviews and meta-analyses including these poorly done studies. This study adds to the growing, high-quality evidence that tamsulosin offers no significant benefit and further challenges current practices.
Bottom Line: Tamsulosin should not routinely be prescribed to patients with ureteral colic and, at this point, it is unclear if there is any subgroup that may benefit. There will be continued conjecture that larger stones may benefit due to inconsistency in the literature and the absence of a RDCT primarily looking at passage of larger stones..."

NOACs in the ED


Emergency Medicine PharmD
EM PharmD - June 29, 2018 - By Dietrich Scott
..."Several points must be considered when choosing between rivaroxaban and apixaban. Both agents appear to be equally efficacious, but from a safety standpoint, apixaban is the winner in my book. Renal disease may preclude NOAC use, but for some patients rivaroxaban has a lower CrCl cutoff when used for AF than apixaban, so potentially slight advantage there. Cost considerations are very patient- and location-specific. Not mentioned thus far, but worth considering is the BID dosing of apixaban vs daily dosing with rivaroxaban. If patient compliance is a major concern, rivaroxaban will likely be preferred..."

viernes, 29 de junio de 2018

Brain death / COWS

The Dantastic Mr. Tox & Howard - Season 2 Episode 1 – June 27, 2018 - By Tox & Hound
"Activate your cerebral cortex exploring the determination of brain death with the world’s greatest neurotoxicologist!
Join Dan & Howard as they chat with Dr. Laura Tormoehlen about her experience as a neurologist and toxicologist. Dispel the myths and common misperceptions about the determination of brain death in the toxicology patient and learn the mimics that you need to look out for. Beware the oculovestibular reflex and welcome to Season 2!..."

Delicious Links
  1. ACMT Position Statement: Determining Brain Death in Adults After Drug Overdose.
  2. American Academy of Neurology. Evidence-based guideline update: Determining brain death in adults.
  3. Pediatric determination of brain death. Guidelines for the determination of brain death in infants and children: an update of the 1987 task force recommendations.
  4. Know your local regulations. Organ donation legislation and policy
  5. Scary. Baclofen overdose mimicking brain death.
  6. Grab your copy of Dr. Schaumburg’s excellent textbook. Experimental and Clinical Neurotoxicology.
  7. A video demonstrating cold calorics in an awake patient. Nauseating.
  8. Fascinating article from the New Yorker. What Does It Mean to Die?

Weakness in the Elderly

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emDocs - June 28, 2018 - By Kim J and Dyer S - Edited by: Koyfman A and Long B
..."Regardless of experience, the complaint of weakness in an elderly patient proves challenging, as it is a vague and non-focal complaint that takes time to tease out the nuances. Nemec et al. reviewed 218 elderly patients presenting to the ED with a non-specific complaint and evaluated their 30 day outcomes. Nearly 60% of the population had a serious condition, defined as potentially life-threatening or those requiring early intervention to prevent health status deterioration within 30 days. Nemec consequently found a median of 4 comorbidities (most common were hypertension, coronary artery disease, and dementia) as well as a 6% mortality rate within 30 days. Thus, this article seeks to aid in the evaluation of the elderly patient with generalized non-focal weakness to help you determine who is at higher risk of having one of these serious conditions...
Take Home Points 
  • As mentioned, a thorough history and physical exam are crucial to the evaluation of elderly patients with non-focal generalized weakness. 
  • A CBC, BMP, Accucheck, and ECG are always warranted in the evaluation of generalized weakness in the elderly. 
  • Use your clinical history and exam to guide further lab testing and imaging as appropriate in each individual patient."

Pseudo-PEA

REBEL Cast Ep 54 (mp3) - June 27, 2018 - By Bellezzo J
"Background: Pulseless electrical activity (PEA) is an organized electrical activity without a palpable pulse. 1/3 of cardiac arrest cases will be pulseless electrical activity and the overall prognosis of these patients is worse than patients who have shockable rhythms (ventricular fibrillation or pulseless ventricular tachycardia). It can be a challenge to decide when to terminate or continue resuscitation efforts in PEA arrest. Palpating pulses is difficult in the setting of a code situation, neither sensitive nor specific based on current literature. The use of POCUS could help split PEA patients into Pseudo-PEA (cardiac activity on US = profound shock) vs True-PEA (no cardiac activity on US) in determining the potential for ROSC..."