Síguenos en Twitter     Síguenos en Facebook     Síguenos en YouTube     Siguenos en Linkedin     Correo Grupsagessa     Gmail     Dropbox     Instagram     Google Drive     StumbleUpon     StumbleUpon     StumbleUpon     StumbleUpon     StumbleUpon     StumbleUpon     StumbleUpon

SOBRE EL AUTOR **

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

WORLD EMERGENCY MEDICINE SOCIETIES & RELATED

COVID-19 Inflammatory Response in Children & Adults. June 03, 2020

Search

Content:

jueves, 4 de junio de 2020

COVID-19 Literature Review

CanadiEM
CanadiEM - By Becky Jones - June 4, 2020
"The Necessity For Knowledge
The COVID-19 pandemic has drastically changed how physicians practice medicine worldwide and has created a wide information gap as clinicians struggle to integrate the immense volume of new research into their practice. Primary literature of varying quality is being published at an accelerated pace, and the lack of strong evidence for diagnostics, treatments, and interventions only further contributes to this uncertainty.
Dr. Mark Crowther, Chair of the Department of Medicine at McMaster University, identified the need for a resource to fill this knowledge gap for frontline clinicians and researchers. Becky Jones, a medical student at McMaster, connected with Dr. Crowther to spearhead the project and subsequently recruited fellow medical students Meghan Glibbery, Hannah Kearney, and Daniel Levin to aid with project coordination and publication review. They were joined by Jasper Ho, another medical student with expertise in programming and website design. Due to the overwhelming volume of literature published daily, four additional medical students were recruited to assist with publication review (Jillian Howden, Maya Amar, Sara Markovic, John Kim)..."

FOAMed SARS CoV-2 / Covid-19

Peripheral Pressors

Logo
R.E.B.E.L.EM - June 4, 2020 - By Salim Rezaie
"Clinical Bottom Line:
  1. Use an antecubital fossa or more proximal vein (Larger diameter)
  2. Use an ultralong catheter (6.35cm or 2.5in — >2.5cm in the vein)
  3. Do not run infusions for >2 – 4hrs
  4. Use as dilute a concentration in as small a volume as possible (4mg/250mL)
  5. Have an IV observation protocol (q15 – q30min)
  6. Have an extravasation protocol (Phentolamine or Terbutaline + Topical NTG + Elevation + Warm Compress)"

Complications of cardiac ablation

Logo
emDocs - June 3, 2020 - By Arnold C and Hamm J 
Reviewed by: Montrief T, Koyfman A and Long B

"Take Home Points:
  • The overall complication rate for cardiac ablation is 6.29%.
  • Atrio-esophageal fistula has up to a 100% mortality without surgery. If considered, emergently consult cardiothoracic surgery.
  • EGD may cause fatal massive air embolism in the setting of atrio-esophageal fistula. Avoid even in the case of gross hematemesis.
  • Delayed cardiac tamponade may occur even up to several weeks out from the ablation.
  • Atypical migraine is a rare post ablation complication and should be considered a diagnosis of exclusion."

martes, 2 de junio de 2020

Charting in the ED

CanadiEM
CanadiEM - By Stella Tung - June 2, 2020
"The Bottom Line:
Tedious as it may be, documentation is a fundamental skill that you will need throughout your career in medicine. After all, if you didn’t write it, it didn’t happen, and it’s your responsibility to capture what happened throughout the patient encounter.
For clinical clerks and even junior residents, using the process of documentation to organize your thoughts is helpful not only for your own understanding, but also for better communication with other providers (e.g. consultants). Think of it as a piece of writing that convinces the reader which diagnosis is most likely using the information you have collected, and use the process to also brainstorm which diagnoses you wouldn’t want to miss. While sometimes it seems easier to write down everything you can think of, I challenge you to continue the pursuit of writing succinct notes throughout your education, which will ultimately make this administrative task an easier one and help you to better enjoy your clinical job as a whole."

lunes, 1 de junio de 2020

Imaging for renal colic

Imaging in renal colic
First 10EM -By Justin Morgenstern - June 1, 2020
"The paper
Moore CL, Carpenter CR, Heilbrun ME, et al. Imaging in Suspected Renal Colic: Systematic Review of the Literature and Multispecialty Consensus. Ann Emerg Med. 2019;74(3):391–399. PMID: 31402153 DOI: 10.1016/j.annemergmed.2019.04.021
Bottom line
The older a patient is, and the less sure you are about the diagnosis of renal colic, the more benefit there will be from CT. In younger patients with a clear diagnosis, no imaging is required at all. For intermediate patients, ultrasound is a great starting point.
I will reiterate my initial thought: imaging for renal colic is pretty easy. It is required if you are searching for an alternative diagnosis. It is required if the patient is septic and needs the OR urgently. It is required if the patient’s pain can’t be controlled and a surgical intervention might be required. Otherwise, it generally isn’t necessary."

jueves, 28 de mayo de 2020

Chest Tubes

REBEL Core Cast 34.0 - May 27, 2020 - By Anand Swaminathan
"Take Home Points
  • Small to Moderate Size Pneumothorax – consider managing conservatively with observation (need to make sure consulting services on same page)
  • Needle aspiration for spontaneous pneumothorax recommend by British Thoracic and European Respiratory Societies
  • 1 in 5 patients requiring a chest tube will suffer complications – many are iatrogenic in nature. Practice procedure via simulation
  • Chest tubes placed for traumatic pneumothoraces should get prophylactic antibiotics
  • When deciding on treatment strategy, discuss with your consultants and make sure you have institutional buy-in."

martes, 26 de mayo de 2020

Disposition Decisions

CanadiEM
CanadiEM - By Rob Woods - May 26, 2020
"Key Takeaways:
  • Tests or imaging studies you would like to order to rule in or out any differential diagnoses on your list.
  • Interventions or therapies you would like to start (remember to reassess your patient to assess for any clinical change).
  • Social factors that would require an admission even if their clinical diagnosis alone would allow the patient to go home.
  • If you are sending a patient home, what do they need to go home with, for what reasons should they return to hospital, and what follow-up do they need?
  • If you believe a patient needs to be admitted to hospital, what service should they be admitted to and with what requirements for their care?"

lunes, 25 de mayo de 2020

Mean Arterial Pressure in Sepsis

PulmCCM
PulmCCM - May 24, 2020 - By Jon-Emile S. Kenny
"What They Did
The 65 Trial was a pragmatic, multi-centre, randomised controlled trial. Patients over the age of 65 were recruited from 65 National Health Service [NHS] adult, general, critical care units. They were with vasodilatory hypotension and having had received vasopressors for at least one hour.
Those randomized to the intervention group received ‘permissive hypotension’ [i.e. mean arterial pressure target range of 60 – 65 mmHg on vasopressors]. Those in the control group received usual care; many different vasoactives were employed.
The primary outcome was 90-day mortality while secondary outcomes were: mortality at hospital discharge, duration of survival to longest available follow-up, duration of advanced respiratory and renal support, days alive and free of advanced respiratory support and renal support, duration of critical care unit and acute hospital stay. They also assessed long-term cognitive function.
What They Found
2600 patients were randomized and 2463 were in the final analysis; the patients were similar at baseline. Mortality in the permissive hypotension group was 41% while it was 43.8 % in the control group; this was not statistically significant. With respect to secondary outcomes, there was a reduction in total vasopressor dose, and no difference in duration of mechanical ventilation or cognitive function..."

Posterior Reversible Encephalopathy Syndrome

Logo
emDocs - May 24, 2020 - By Matlock A and Long B - Reviewed by: Koyfman A
 
"Take Home Points:
  • Emergency physicians should consider PRES in patients presenting with altered mental status, seizures, and neurologic deficits who have risk factors for PRES. Heightened suspicion should be raised in those patients who are on immune-suppressive medications, those with renal disease and acutely elevated blood pressure.
  • While non-contrast CT scan may show signs of vasogenic edema, expeditious MRI should be performed, as this is the most sensitive and specific imaging modality for PRES.
  • Seizures are often the presenting symptom of PRES and occur in a majority of cases.
  • Treatment is focused on seizure management, blood pressure control and removal of offending agents.
  • PRES and eclampsia have significant overlap, and management principles are similar, though magnesium is the preferred agent for treatment of seizures in eclampsia."

Enoxaparin dose for DVT prophylaxis

PulmCrit (EMCrit)
PulmCrit – May 25, 2020 - By Josh Farkas
"Summary: The bullet
  • There is no Level-I evidence regarding the optimal dose of enoxaparin for DVT prophylaxis among critically ill patients. Critical illness increases both the risk of venous thromboembolic disease and resistance to enoxaparin, so these patients may require a more aggressive anticoagulation strategy.
  • The practice of giving patients 40 mg enoxaparin daily is based more on convenience than on evidence. Nearly every study which has evaluated drug levels resulting from this strategy among critically ill patients has found substantial problems with it.
  • Recent studies seem to be converging on a strategy of twice-daily, weight-based enoxaparin (~0.5 mg/kg sq. BID). Given variability in pharmacokinetics between patients, therapeutic drug monitoring may help optimize the dose (especially among patients with unusual weight, renal dysfunction, or extreme illness severity).
  • It’s common for ICU patients to develop thromboembolic disease despite receiving DVT prophylaxis. Rather than patients’ failing to respond to DVT prophylaxis, it’s possible that we’re failing to optimize their dose."

viernes, 22 de mayo de 2020

Thoracic Trauma

Logo
emDocs - May 22, 2020 - Originally posted on Trauma ICU Rounds on April 17, 2020.

Listen to the accompanying podcast by downloading it HERE

"In this episode we review the “lethal 6” and “hidden 6” chest injuries that comprise the deadly dozen of thoracic trauma. Mechanism of injury together with vital signs and findings from the physical exam should provide us with the data needed to identify life-threatening thoracic injuries on our primary survey. For hidden injuries, the diagnostic adjuncts required to identify these injuries are also discussed...
Lethal 6 Table.png     Hidden 6.png
Take Home Points
  • Mechanism of injury together with vitals and a focused physical exam should alert you to the presence of a life-threatening thoracic injury
  • The vast majority of chest injuries can be initially and definitely managed with a well-placed chest tube
  • Hidden injuries require more than a thoughtful physical exam. Common adjuncts or modalities to identify these injuries include CXR, CT scan, EKG, and labs including CK/Tn"

jueves, 21 de mayo de 2020

Endoscopy for UGIB

REBEL Cast Ep82 - May 21, 2020 - By Salim Rezaie
"Clinical Question: In patients admitted with acute UGIB who are predicted to be at high risk (Glasgow-Blatchford score ≥12) for further bleeding or death, does endoscopy performed within 6 hours after gastroenterologic consultation (urgent endoscopy) or endoscopy performed between 6 to 24 hours after consultation (early endoscopy) decrease further bleeding and improve outcomes?
Author Conclusion: “In patients with acute upper gastrointestinal bleeding who were at high risk for further bleeding or death, endoscopy performed within 6 hours after gastroenterologic consultation was not associated with lower 30-day mortality than endoscopy performed between 6 and 24 hours after consultation.”
Clinical Take Home Point: In this RCT of patients with UGIB in patients who are HD stable at high risk of bleeding, this study does not answer the question of <6hrs vs 6 – 24hrs for timing of endoscopy as only ¼ of patients had endoscopy at <6hours. In patients who are hemodynamically unstable (mostly excluded in this study), who are receiving maximal resuscitation and medical therapy and non-responders or transient responders, the optimal time for endoscopy is likely as soon as possible (ASAP)."

The PEGeD Trial

Logo
R.E.B.E.L.EM - May 20, 2020 - By Salim Rezaie
"In this 6:32 min video I review the PEGeD prospective trial using clinical risk adjusted d-dimer to rule out venothromboembolism"

miércoles, 20 de mayo de 2020

SZC for hyperkalemia

PulmCrit (EMCrit)
PulmCrit - May 20, 2020 - By Josh Farkas
"Summary: The Bullet
  • Sodium Zirconium Cyclosilicate (SZC) is an oral potassium binder, essentially an upgrade of sodium polystyrene sulfonate (Kayexalate). Unlike sodium polystyrene sulfonate, SZC doesn’t appear to cause bowel necrosis.
  • SZC is studied predominantly for subacute to chronic reduction in potassium. However, it does appear to cause some reduction in potassium levels acutely (perhaps ~0.2 mM within 4 hours, and ~0.4 mM within 24 hours).
  • The role of SZC for acute management of hyperkalemia is currently unclear. SZC appears to be safe, but it’s debatable whether it is effective enough to cause meaningful patient-centered benefit. SZC may be considered as an adjunctive therapy for the management of moderate hyperkalemia, but it must be used with recognition of its minimal efficacy.
  • SZC may help put the nails in the coffin of sodium polystyrene sulfonate (Kayexalate). Specifically, if there are any residual situations where sodium polystyrene sulfonate may be considered or recommended, these patients can be treated more safely and effectively with SZC."

martes, 19 de mayo de 2020

Feedback in the ED

CanadiEM
CanadiEM - By Arthur Welsher - May 19, 2020
"We’ve all heard the adage that practice makes perfect and to become an expert you must complete 10 000 hours of deliberate practice​​. This involves motivated, goal oriented, purposeful practice with periodic feedback. Feedback is critical to allow for growth from where you currently are as a clinical clerk to where you want to be as future practicing physician​2. Even with extensive deliberate practice, you will plateau without guidance and identification of areas to improve through feedback. However, feedback can be difficult to come by in a busy emergency department. We will break down how to solicit high quality feedback as a clinical clerk on your emergency department shifts."

lunes, 18 de mayo de 2020

Intranasal Midazolam for Seizures

intranasal midazolam in status epilepticus
First10EM - By Justin Morgenster - May 18, 2020
"The paper
Arya R, Kothari H, Zhang Z, Han B, Horn PS, Glauser TA. Efficacy of nonvenous medications for acute convulsive seizures Neurology. 2015; 85(21):1859-1868. PMID: 26511448 
Bottom line
Intramuscular midazolam is probably supported by better evidence than intranasal, is likely more reliable, and considering the patient can’t feel the injection, should be our first line agent if we don’t have an IV in status epilepticus."

Metabolic Cocktail for Sepsis

R.E.B.E.L.EM - May 18, 2020 - By Salim Rezaie
"Paper: Chang P et al. Combined Treatment with Hydrocortisone, Vitamin C, and Thiamine for Sepsis and Septic Shock (HYVCTTSSS): A Randomized Controlled Clinical Trial. CHEST 2020. PMID: 32243943
Clinical Question: Does the “metabolic cocktail” improve 28 day mortality in patients with sepsis and septic shock in comparison to placebo?
Author Conclusion: “Among patients with sepsis or septic shock, the combination of hydrocortisone, vitamin C, and thiamine did not reduce mortality compared with placebo.”
Clinical Take Home Point: This single center, small study doesn’t really add much to our knowledge of the metabolic cocktail in sepsis. The 28-mortality difference goal of 30% was too large and most likely confirms the methodologically flawed before and after Marik study results were overstated."

PCC for emergent VKA reversal

Logo
emDocs - May 17, 2020 - By Moussavi K and Quyen N 
Reviewed by: Lentz S; Koyfman A and Long B
"Take Home Points
  • Patients with urgent or emergent need for VKA reversal require IV vitamin K 5-10 mg and PCC.
  • PCC dosing approved by manufacturers for VKA reversal may be complicated, result in excessive administration of clotting factors, and be more expensive than other dosing strategies.
  • Fixed-dose PCC refers to giving a predetermined dose (e.g. 1500 units) instead of a variable dose based on weight and pretreatment INR (e.g. 25-50 units/kg for INR 2 to >6).
  • There is currently limited evidence to support fixed-dose strategies; however, some studies suggest doses 1500-2000 units can provide similar efficacy and safety when compared to weight/INR-based regimens.
  • Fixed doses ≤1000 units may be insufficient for VKA reversal, especially in patients with intracranial hemorrhage.
  • If a fixed dose strategy is adopted, consider adding a re-dose option (e.g. if INR goal not achieved, give remainder of weight/INR-based dose per package insert)."

domingo, 17 de mayo de 2020

COVID-19 and global health

Coronavirus en el mundo: 4 millones de contagios y 282.000 muertes
St. Emlyn´s - By Anisa Jafar - May 16, 2020
"There are a number of sound-bytes which have been cropping up recently such as “in this together” and “One world: together at home” alongside COVID-19. The irony of course is that there is no more of a universal “seat at the table” than there ever was prior to the pandemic. In fact, it would be fair to say that for some people, who beforehand might at least have been a few proverbial towns away from said “table”, now find themselves (proverbially of course) on a separate continent​1​
In emergency care we, along with our colleagues in the community, have the unique speciality-privilege of seeing the unfettered outside world at our front door​2​. We see the sharp end of social inequality sitting in our waiting rooms as we manage its direct and indirect consequences on both physical and mental health..."

jueves, 14 de mayo de 2020

GEMA 5.0 (ASMA)

Inicio
"La Sociedad Española de Neumología y Cirugía Torácica (SEPAR) ha lanzado GEMA 5.0, la nueva versión de la Guía Española para el Manejo del Asma (GEMA). SEPAR ha liderado y coordinado la elaboración de este nuevo documento, en el que han participado diecisiete sociedades científicas, quince españolas a las que cabe sumar la plena incorporación de ALAT (Asociación Latinoamericana del Tórax) y de la Socieda de Portuguesa de Pneumologia (SPP), y que ha implicado a un total de 110 expertos en asma, representantes acreditados de 21 Sociedades, grupos científicos o asociaciones, en su redacción y revisión. 
La nueva GEMA 5.0 incluye numerosas novedades para el manejo del asma, entre las que destacan un apartado específico de asma y COVID-19, un nuevo algoritmo para el tratamiento del asma grave no controlada (basado en el reciente consenso SEPAR del tema), una nueva definición de asma intermitente más exigente, así como cambios en el tratamiento del asma intermitente y del leve...

miércoles, 13 de mayo de 2020

Needle Decompression

REBEL Core Cast 33.0 - By Anand Swaminathan - May 13, 2020
"Take Home Points
  • Forget the “traditional” needle decompression landmark
  • Decompress at 4th or 5th intercostal space in the anterior axillary line"

martes, 12 de mayo de 2020

Navigating Patient Handovers

CanadiEM
CanadiEM - By Richard Tang - May 12, 2020
...Handovers are well-known to be a potential source of miscommunication that can ultimately lead to medical errors and adverse patient outcomes. Learning to effectively hand over patients is an important skill for both junior residents and medical students who are expected to attend and, on occasion, hand over patients directly to the incoming ED physician. 
Here are some tips for effectively handing over patients in the ED:
  • Be familiar with the local hospital/physician group policy on handovers
  • Hand over in a safe and quiet area with minimal interruptions/distractions
  • Utilize a consistent approach to delivering handovers
  • Provide a clear diagnostic and dispositional algorithm for patients still undergoing workup
  • Tie up any loose ends for the incoming physician"

lunes, 11 de mayo de 2020

Steroids in Septic Shock

R.E:B.E.L.EM - May 11, 2020 - By Salim Rezaie
"Clinical Question:
We tend to think of sepsis as this kind of bag where we throw in fluids, vasopressors and antibiotics early so we can improve outcomes. Should steroids be included? What is the evidence that shows that steroids work in septic shock?...
Conclusion:
“I say: certainly, if the patient has risk of adrenal insufficiency due to chronic steroid therapy, it’s a no brainer, make it happen. If the patient is requiring multiple doses of pressors, you’re starting to max out your norepinephrine and you’re starting to think maybe I should add a second or third pressor. In order to get them off of those pressors faster and out of shock, I would give them a stress dose of steroids. And I am using hydrocortisone and not fludrocortisone”

viernes, 8 de mayo de 2020

Sepsis and Septic Shock

EM Ottawa - By Garrick Mok - May 7, 2020
Sepsis
"Take Home Points
There is no perfect marker for perfusion in sepsis. These patients are complicated to manage, and there are many factors that you have to piece together to improve their perfusion. Some key points to remember include:
  1. MAP ≠ perfusion
    1. Ensure that you’re utilizing other markers to assess perfusion in conjunction with MAP
  2. Lactate ≥2 is a prognosticator of mortality in sepsis
    1. Consider differential for Type A vs. Type B lactic acidosis
  3. Lactate clearance is associated with improved survival
    1. Recommend repeating lactates q2h and targeting 10 – 20% clearance
    2. Goal is normalization at 6hrs
    3. Caution in patients with liver and renal failure
  4. Mottling score is associated with mortality
  5. CRT can be used in conjunction with lactate to guide resuscitation"

lunes, 4 de mayo de 2020

Ogilvie´s Syndrome

Acute colonic pseudo-obstruction
First10EM - By Justin Morgenstern - May 04, 2020
"In the Rapid Review series, I briefly review the key points of a clinical review paper (or two). The topic this time: Acute colonic pseudo-obstruction (Ogilvie’s syndrome)
The papers:
  • Chudzinski AP, Thompson EV, Ayscue JM. Acute colonic pseudoobstruction. Clinics in colon and rectal surgery. 2015; 28(2):112-7. PMID: 26034408 [free full text]
  • Pereira P, Djeudji F, Leduc P, Fanget F, Barth X. Ogilvie’s syndrome-acute colonic pseudo-obstruction. Journal of visceral surgery. 2015; 152(2):99-105. PMID: 25770746"

Refractory Hypoxemia & ARDS

TAMING THE SRU
TAMING THE SRU - By Christopher Shaw - May 04, 2020
"Transport of the ARDS patient is fraught with risk. These patients are at high risk of decompensation, which can be disastrous in the back of an ambulance or helicopter. The primary goal for critical care transport teams should be safe arrival of both the crew and patient to their destination. As such, if patients are achieving an adequate oxygen saturation at the referring facility, the better part of valor is to continue the current course, even if the crew believes that ventilator settings are suboptimal. If ventilator changes need to be made due to inadequate oxygenation, ventilation, or other factors, strong consideration should be given to LPV settings. Of note, ventilator settings utilized in an emergency department setting have been strongly correlated with the settings used in the ICU, and changes designed to encourage adherence to LPV have been associated with reduced incidence of ARDS and even mortality (38). It is reasonable to assume that this therapeutic momentum may apply in the inter-facility setting. Any ventilator changes should be made prior to loading the patient to ensure a period of stability and to ensure the availability of extra staff if decompensation does occur. NMB can be considered for patient who remain dyssynchronous with the ventilator despite appropriate analgosedation. Adjunct therapies, including APRV or proning, should only be considered by appropriately experienced teams after rigorous preparation, including high-fidelity simulation. Given the increasing use of ECMO in the United States, it is reasonable to assume that transport of these patients will become increasingly common. It is imperative that critical care transport teams be familiar with the data informing management of these patients, to ensure that we continue to deliver definitive care outside the walls of the hospital."

domingo, 3 de mayo de 2020

EMS Crash-Related Delays

SGEM#291 - By admin - May 2, 2020 
"CLINICAL QUESTION: WHAT IS THE ASSOCIATION BETWEEN WARNING LIGHTS AND SIRENS USE BY EMS AND CRASH-RELATED DELAYS?
Authors’ Conclusions: “Ambulance use of lights and sirens is associated with increased risk of ambulance crashes. The association is greatest during the transport phase. EMS providers should weigh these risks against any potential time savings associated with lights and sirens use.”
KEY RESULT: THERE WAS A GREATER ODDS RATIO OF CRASHING WITH THE USE OF LIGHTS AND SIRENS.
SGEM BOTTOM LINE: THE USE OF WARNING LIGHTS AND SIRENS WAS ASSOCIATED WITH A SIGNIFICANT INCREASE IN THE RISK OF CRASHING IN THE TRANSPORT PHASE."

Tibial Plateau Fracture

Logo
EM@3AM - May 02, 2020 - By Sumpter R, Bridwell R Reviewed by: Long B ; Koyfman A
"Pearls:
  • High clinical suspicion of acute compartment syndrome in high energy mechanisms, Schatzker VI fractures, and associated fibular fractures requiring frequent compartment checks.
  • At minimum, 4 radiographic views of affected knee are recommended. CT can assist.
  • With the exception of non-displaced or non-depressed fracture without meniscal or ligamentous injury, expect to be calling orthopedics with a well-done exam for surgery.
  • Keep compartment syndrome at the forefront of your thoughts during initial assessment and reevaluations."

viernes, 1 de mayo de 2020

New NICE VTE Guideline

St. Emlyn´s - By Dan Horner - May 1, 2020
..."These recommendations provide some assurance to those already using PERC and age adjusted D-Dimer and outpatient management strategies that they are practicing evidence-based medicine. In addition, they will also gently nudge those not using these strategies towards them. A variety of stipulations in the NHS contract mandate practice to be in line with NICE guidance; this contract can now act as a valuable trigger for change, if you have previously met local resistance while trying to implement any of the above. Finally, these guidelines offer some clarity around the safety and broad clinical application of DOAC agents in VTE. Long live the tablet, down with the needle. There are research recommendations in the detail as well and anyone looking to get funding on VTE research would be sensible to look at these..."

lunes, 27 de abril de 2020

The ISCHEMIA Trial

R.E.B.E.L.EM - April 27, 2020 - By Salim Rezaie
"Paper: Maron D.J et al. Initial Invasive or Conservative Strategy for Stable Coronary Disease. NEJM 2020. PMID: 32227755.
Clinical Question: In patients with stable coronary artery disease and moderate to severe ischemia, does the addition of routine invasive therapy to optimal medical therapy (conservative) alone improve clinical outcomes?
Clinical Take Home Points:
  • There is no need to rush to the cath lab after an abnormal stress test. Optimizing medical therapy and assessing response to therapy does not place patients at greater risk. If the patient’s symptoms and angina do not improve with OMT, then an invasive strategy is appropriate.
  • In patients with stable moderate – severe coronary disease there were no clinically meaningful differences in outcomes over 4 years in those who were randomized to a conservative versus early invasive strategy.
  • Clinicians can use the results of the ISCHEMIA trial in a shared decision–making process with their patients. However, we need additional analyses that enable us to use a risk-score tool in order to provide more precise advice to patients about the relative advantages/ risks of the two strategies.
  • We should wait for a longer-term follow-up to see if any benefits of the invasive strategy become evident over time."

jueves, 23 de abril de 2020

EVALI

E-Cigarette or Vaping Product Use-Associated Lung Injury (EVALI)
R.E.B.E.L.EM - April 23, 2020 - By Borelli C
Article: Layden JE et al. Pulmonary Illness Related to E-Cigarette Use in Illinois and Wisconsin – Final Report. NEJM 2020. PMID: 31491072
"Authors’ Conclusions:
“Case patients presented with similar clinical characteristics. Although the definitive substance or substances contributing to injury have not been determined, this initial cluster of illnesses represents an emerging clinical syndrome or syndromes. Additional work is needed to characterize the pathophysiology and to identify the definitive causes.”
Clinical Take-Home Points:
The clinical presentation of EVALI based on this case series typically occurs in young males with subjective fever, dyspnea, cough, abdominal pain, and diarrhea which overlaps with many respiratory illnesses (including the recent COVID outbreak) and remains a diagnosis of exclusion. Inquiring about vaping is important, and the specific products should be recorded."

IV Corticosteroids + ACLS

CanadiEM
CanadiEM -  April 23, 2020 - By Aida Owlia
"Summary
The addition of intravenous (IV) corticosteroids to the standard Advanced Cardiovascular Life Support (ACLS) algorithm in the resuscitation of adult patients experiencing non-traumatic cardiac arrest may improve the chances of achieving survival to hospital discharge. These findings are based on a small number of studies with diverse methodology, significant variability in patient population, and poor-quality data. The optimal patient population, corticosteroid agent, dose, timing and duration of administration remains unclear and requires further research. Despite limited data, the potential benefits of corticosteroid administration may outweigh the small risks, and physicians should use their clinical judgment when administering this therapy...
Important Key points:
  • Limited data on IV corticosteroids in cardiac arrest with few RCTs to date. Additional RCTs are needed to draw definitive treatment recommendations.
  • There is uncertainty around which steroid formulation is best and what dose provides optimal benefit.
  • The potential benefits of IV corticosteroids may exceed limited harms and warrant consideration in cardiac arrest. Specifically, consider IV corticosteroids early (within 6 minutes of arrival in the ED) and as an adjunct agent in cardiac arrest particularly in patients with COPD, asthma and non-shockable cardiac rhythms"

martes, 21 de abril de 2020

Pain Management

CanadiEM
CanadiEM - April 21, 2020 - By Jana Balakumaran
"Takeaways
  1. The goal of pain-management in the ED is not zero pain, but rather reaching an acceptable level for function.
  2. When choosing route of delivery, oral is often preferred unless the patient cannot tolerate PO meds.
  3. Consider a combination of non-opiates. Starting with 1000 mg Acetaminophen and 400 mg of Ibuprofen is an ED go-to for mild-moderate pain.
  4. Opiates should only be used if non-opiate agents are insufficient to treat the severity of pain that the patient endorses. When using opiates, start low and go slow!
  5. Treat pain before ordering your workup! Do not leave your patient suffering until you get results back."

lunes, 20 de abril de 2020

Canadian Syncope Risk Score

CanadiEM - April 20, 2020 - By Ramzy M
"Clinical Question:
Is the CSRS a valid clinical tool in predicting 30-day serious outcomes not evident during the index ED evaluation of syncope patients?
Author’s Conclusions:
The CSRS was successfully validated and its use is recommended to guide ED management of patients when serious causes are not identified during index ED evaluation. Very-low-risk and low-risk patients can generally be discharged, while brief hospitalization can be considered for high-risk patients. We believe CSRS implementation has the potential to improve patient safety and health care efficiency.
Our Conclusion:
In patient’s presenting to the ED with syncope, the CSRS appears to be a validated and reliable tool in determining the risk of serious outcomes in lower risk patients. Patients who are very low and low risk should still have close outpatient follow-up and given strict return precautions. A lower threshold for admission is warranted when determining the need for hospitalization of high and very high-risk patients. As well any other risk stratification score or clinical decision tool, clinical judgement, patient presentation and shared decision making should be incorporated prior to determining dispositions"