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


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martes, 21 de enero de 2020

Research Roundup 01/2020

Research Roundup First10EM best of emergency medicine research
First10EM - By Justin Morgenstern - January 20, 2020
"Time for another semi-regular round-up of the top emergency medicine and critical care articles I have encountered over the last few months. This time we will tackle anti-epileptics, anti-emetics, the word “quiet”, and a whole bunch more…"
  • Our second line agents for status epilepticus all suck
  • Hearts have memory?
  • Peripheral pressor update
  • His arm is bent!! Are you seriously just going to leave it like that!?!?!
  • Using a facemask to blind children (that sounds sort of bad)
  • Are antiemetics useless?
  • Martial arts technique for control of severe external bleeding
  • Could an ED-ICU combination unit save lives?
  • I am sure everyone working over the holidays this year has noticed how quiet it has been

Spontaneous Bacterial Peritonitis

R.E.B.E.L.EM - January 20, 2020 - By Swaminathan A
"Take Home Points:
  • SBP is a difficult diagnosis to make because presentations are variable. Consider a diagnostic paracentesis in all patients presenting to the ED with ascites from cirrhosis
  • An ascites PMN count > 250 cells/mm3 is diagnostic of SBP but treatment should be considered in any patient with ascites and abdominal pain or fever
  • Treatment of SBP is with a 3rd generation cephalosporin with the addition of albumin infusion in any patient meeting AASLD criteria (Cr > 1.0 mg/dL, BUN > 30 mg/dL or Total bilirubin > 4 mg/dL)"

Acute Acalculous Cholecystitis

ED Presentation, Evaluation, and Management
emDocs - January 20, 2020 - By Conte J - Reviewed by: Koyfman A and Long B
"Key Points
  • AAC may have a higher incidence in outpatients than hospitalized, critically ill patients. Maintain a high index of suspicion in patients who present to the ED with right upper quadrant pain even in the absence of a history of cholelithiasis.
  • Men > 60 years old with atherosclerotic cardiovascular disease are the most common outpatient population to develop AAC.
  • The sensitivity of ultrasound for acute acalculous cholecystitis is not well established. If you have a high clinical suspicion and a negative ultrasound, pursue further diagnostic imaging with HIDA scan +/- CT imaging, followed by admission for diagnostic laparoscopy if all noninvasive testing is negative.
  • Acute acalculous cholecystitis follows a more fulminant course than calculous cholecystitis. Broad spectrum antibiotics with gram-negative coverage and fluid resuscitation should be started immediately if the diagnosis is suspected, with an emergent consultation to general surgery."

domingo, 19 de enero de 2020

Severe acute pancreatitis

Joe Hines, Stephen J Pandol. BMJ 2019;367:l6227 | doi: 10.1136/bmj.l6227
The risks, measurements of severity, and management of severe acute pancreatitis and its complications have evolved rapidly over the past decade. Evidence suggests that initial goal directed therapy, nutritional support, and vigilance for pancreatic complications are best practice. Patients can develop pancreatic fluid collections including acute pancreatic fluid collections, pancreatic pseudocysts, acute necrotic collections, and walled-off necrosis. Several randomized controlled trials and cohort studies have recently highlighted the advantage of managing these conditions with a progressive approach, with initial draining for infection followed by less invasive techniques. Surgery is no longer an early intervention and may not be needed. Instead, interventional radiologic and endoscopic methods seem to be safer with at least as good survival outcomes. Newly developed evidence based quality indicators are available to assess and improve performance. Development and clinical testing of drugs to target the mechanisms of disease are necessary for further advancements."


The BREACH, EM research bulletin
The Breach - By Barrie Stevenson - January 16, 2020
The paper: Wardi G, Brice J, Correia M. Demystifying lactate in the Emergency Department. Ann Emerg Med. 2019 [epub ahead of print]
"Take home points
  1. When confronted with a raised lactate, ask yourself: “Does this patient have signs of regional ischaemia or shock?”
  2. If not, consider why their lactate might be raised and whether you have to do something about it
  3. Try to resist the unthinking ‘Lacto-Bolo reflex’ if you can!"

ACS, troponin and the elderly

SGEM#280 - Posted by admin - Jan 18, 2020

viernes, 17 de enero de 2020

MEDEST 2019 Review: ALS

Year in Review 2019 
MEDEST - January 15, 2020

Post Contrast Acute Kidney Injury

R.E.B.EL.EM - January 16, 2020 - By Salim Rezaie
..."Author Conclusion: “Our study findings could serve as useful reference for physicians who are concerned about performing computed tomography pulmonary angiography for fear of renal function deterioration.”
Clinical Take Home Point: This current study shows that the last eGFR prior to CTPA in patients with suspected acute pulmonary embolism in the ED was not associated with occurrence of PC-AKI, even if the eGFR was <30mL/min/1.73m2, but there was certainly a trend toward increased AKI in this patient population. What we need now is not another retrospective observational study, and although a randomized clinical trial would be great, it is unlikely to ever happen. We now have a huge amount of data saying it doesn’t matter what the kidney function of a patient is and we should start to change protocols to allow IV contrast in patients where critical diagnoses need to be made."

martes, 14 de enero de 2020

MEDEST: 2019 Guidelines

MEDEST - January 12, 2020

Critical Hyponatremia

emDocs - January 13, 2020 - By  Desai N and Jang D
Reviewed by: Koyfman A; Montrief T; Long B
  • Rate of serum sodium concentration change is far more important to quantify than the numerical number itself. Rely on symptoms and good history taking skills.
  • Just because you can correct acute hyponatremia quickly does not mean you should. Aim for a 4-6 mEq/L increase in the first six hours of treatment if the patient has signs of CNS dysfunction listed above. Do not correct greater than 6 mEq/L in the first 24 hours to avoid the risk of osmotic demyelination syndrome.
  • If you do not have ready access to hypertonic saline (100 cc of 3% hypertonic saline IV over 10 min), you can substitute with an ampule (50 ml) of bicarbonate (8.4% sodium bicarbonate).
  • Confirm tonicity of fluid (hypo-, iso-, hyper-) prior to initiating treatment in the emergency department.
  • Be comfortable with the use of desmopressin in the case of undifferentiated hyponatremia, severely hypovolemic hyponatremia and rapid overcorrection of hyponatremia. You can administer this concurrently during hypertonic or intravenous fluid administration for prophylactic measures.
  • Be very cautious in administration of intravenous fluids (Lactate preferably over NaCl or 3% hypertonic) in patients with hypovolemic history (poor oral intake, diarrhea, increased NG tube output, vomiting) as they tend to overcorrect rapidly leading to an increased risk of osmotic demyelination syndrome. Be judicious with fluid challenges (250cc – 500cc per bolus).
  • If you administer 3% hypertonic saline, pay close attention to the urine output and consider placing a foley early, urine output >100 cc/hr is an early red flag for overcorrection."

sábado, 11 de enero de 2020

Roc vs Sux

REBEL Crit - January 09, 2020 - By Salim Rezaie
"Author Conclusion: “Among patients undergoing endotracheal intubation in an out-of-hospital emergency setting, rocuronium, compared with succinylcholine, failed to demonstrate noninferiority with regard to first-attempt intubation success rate.”
Clinical Take Home Point: I am not sure why this is still a debate. If dosed appropriately, and the patient is paralyzed, the agent used should have no effect on the success rate of intubation. There are, however, several untoward effects of succinylcholine (i.e. hyperkalemia, shorter safe apnea time, etc) that push me toward using rocuronium."

Colchicine for AMI

EM PharmD Logo
EM PharmD - January 08, 2020
"Role in STEMI
The COLCOT study was a prospective, randomized trial of 4745 patients with a recent MI. Patients were randomized to receive colchicine 0.5 mg daily or placebo within 30 days after MI with the primary outcome of a composite endpoint consisting of death from cardiovascular causes, resuscitated cardiac arrest, myocardial infarction, stroke, or urgent hospitalization for angina leading to coronary revascularization. 
The typical patient enrolled in this study was a 60-year-old male with hypertension who received standard of care treatment (primary PCI) and appropriate secondary prevention drug therapy. Most patients received colchicine or placebo 13 days after the initial MI. The primary outcome occurred in 5.5% of patients receiving colchicine compared to 7.1% receiving placebo (HR 0.77; 95% CI 0.61-0.96; p=0.02). This effect appeared to be driven by the reduction in stroke (HR 0.26, 95% CI 0.1-0.7), and reduction in urgent revascularization (HR 0.5 95% CI 0.31-0.81). More relevant CV related outcomes were not significantly different: CV death (HR 0.84, 0.4-1.52), resuscitated cardiac arrest (HR 0.83, 0.25-2.73), or MI (HR 0.91, 0.68-1.21). From a safety perspective, colchicine was associated with a higher incidence of pneumonia when compared to placebo (p=0.03).
Promising, but still skeptical
While colchicine may hold promise in cardiology, there is sufficient skepticism with this evidence to warrant further study before wide adoption in post-MI care. Aside from the considerably increased cost of care from the drug, it’s not certain what effect the addition to colchicine will have in a larger group of real-world patients."

Burn and Inhalation Injuries

emDocs - January 10, 2020 - By Helman A
"Key Take Home Points for Burn and Inhalation Injuries
  • Think trauma and tox first; don’t get distracted by the burns
  • Debride blisters, cover burns with antibiotic ointment and nonadherent dressings with reassessment within 72 hours
  • For fires in an enclosed space or involving plastics, consider cyanide toxicity in addition to carbon monoxide poisoning and consider treating on speculation
  • Use the Palmar Method for burns <15% and Lund & Browder for burns>15% rather than the Rule of 9s to estimate TBSA
  • Use modified Brooke/Parkland to guide fluid management
  • Fluid formulas are starting points only; titrate to urine output and end organ perfusion to avoid over- and under-resuscitation"


The BREACH, EM research bulletin
The Breach - By Barrie Stevenson - January 7, 2020
"Problem 1: Too much insulin
Take home points
  1. Treating hyperkalaemia with insulin will cause blood glucose levels to fall, even if you co-administer dextrose
  2. The drop in blood glucose is highly variable, but may be as much as 2.9mmol/L (53mg/dL)
  3. The effects of IV dextrose will wear off before those of insulin, so check blood glucose after 1-2 hours
Problem 2: Too little calcium
Take home points
  1. Use 10% calcium gluconate unless you have a central line. Give 3 sequential doses of 10ml until the ECG normalises
  2. Only give calcium if there are ECG changes associated with hyperkalaemia
  3. The duration of action is 30-60min, so be ready to repeat the dose if ECG changes reappear"

MEDEST Year in Review 2019

MEDEST - January 09, 2020
MEDEST - January 08, 2019

St Emlyn’s JC 2019-2020

St. Emlyn´s - By Simon Carley - January 10, 2020
We’re delighted to publish the annual St Emlyn’s critical appraisal book this week. It’s a collection of our best critical appraisal blogs and covers over 30 papers that we have found to be interesting, challenging, useful or just a bit odd.

martes, 7 de enero de 2020

Pacemaker complications

CanadiEM - January 07, 2020 - By Costello L
"Key take away points: 
  1. Never attempt to drain a pocket hematoma in the ED!
  2. Most pocket and systemic infections require intravenous antibiotics and removal of the pacemaker.
  3. Phlebitis and thrombophlebitis are common but usually do not pose a problem due to collateralisation of veins. However, consider DVT in your differential for arm swelling or pain.
  4. Think of pacemaker syndrome whenever someone comes in with vague symptoms or CHF –especially if the pacemaker is new or has been recently adjusted.
  5. An ECG and CXR are always good starting investigations for pacemaker malfunction but findings may be subtle. If you suspect a malfunction, then patients should ultimately undergo a pacemaker interrogation."

lunes, 6 de enero de 2020

Conciliación de la Medicación

Logo del Ministerio de Sanidad, Consumo y Bienestar Social         
"Recomendaciones de Prácticas Seguras en la Conciliación de la Medicación al Alta Hospitalaria en Pacientes Crónicos
La conciliación de la Medicación al alta hospitalaria mejora la seguridad de los pacientes durante las transiciones asistenciales o traslados de pacientes entre diferentes servicios o ámbitos, es una práctica segura que mejorar la comunicación y contribuye a la disminución de incidentes de seguridad, garantizando que el paciente recibe en cada momento la medicación correcta a lo largo de toda su asistencia.
La Estrategia de Seguridad del Paciente 2015-2020 del SNS recoge entre sus objetivos fomentar prácticas para el uso seguro de los medicamentos y la Estrategia de Cronicidad del SNS recoge la necesidad de establecer prácticas de conciliación de la medicación durante las transiciones asistenciales, especialmente en pacientes crónicos polimedicados, por ello se ha considerado conveniente identificar la evidencia científica disponible y establecer recomendaciones dirigidas a establecer un proceso estructurado y multidisciplinar, que implica tanto a los profesionales sanitarios como a los pacientes y sus familiares o cuidadores, para lograr que la información que se transmite sobre la medicación al alta hospitalaria sea precisa y completa."

Respiratory distress

an emergency medicine approach to shortness of breath or dyspnea
First10EM - January 06, 2020 - By Justin Morgenstern
..."My “first 10 minute” approach to a sick patient with undifferentiated difficulty breathing is focused on rapidly finding the right therapy, but not necessarily on finding the right diagnosis. I find that this simplifies my thinking. There are only a limited number of things that I can do to help a patient with dyspnea and I want to quickly pick the best therapies from my menu..."

CBC and Sepsis

PulmCrit (EMCrit)
PulmCrit - January 06, 2020 - By Josh Farkas
"Summary The Bullet:
  • No component of the complete blood cell count is a perfect indicator of septic shock. However, since this data is available to us, we should use it to maximal advantage.
  • White blood cell count is the least useful parameter. Persistent focus on the WBC isn’t evidence-based and should be curtailed.
  • Left-shift is often a delayed finding in septic shock. Measurements of left-shift (bandemia and immature granulocyte count) have substantial drawbacks. However, if a left-shift is found, this is a red flag which warrants further attention.
  • Neutrophil to lymphocyte ratio (NLR) might be the single most useful parameter. NLR responds rapidly to infection and is uniformly available across all laboratories. However, NLR is fundamentally an index of physiologic stress (not septic shock) – so clinical context and judgement are required to interpret this properly."

Interfacility Transfers

emDocs - January 06, 2020 - By Durrani O; Ely R and Kester N
 Reviewed by: Simon E, Koyfman A and Long B
"Take Home Points
  • Emergency medicine transfers are conducted on principles outlined in the 1986 Emergency Medical Treatment and Labor Act, or EMTALA4.
  • Patients must be stabilized to the best of the facility’s ability prior to transfer. Any life-threatening process that requires immediate management must be treated prior to transfer.
  • If specialty consultation is required, it is important that as the ED physician accepting a transfer, you ensure the specialist has agreed to accept and see the patient.
  • As a receiving physician, you have an obligation to report inappropriate transfers (EMTALA violations) within 72 hours8 – not doing may result in facility termination of Medicare participation9.
  • A common pitfall for ED physicians is to perform an extensive evaluation on a trauma patient that requires transfer. Recognize the resource limitations of your facility early. Avoid workups that won’t change patient management17.
  • Frequently, patients are transferred long distances, which may make discharge difficult if there is limited social support. Engage case workers and discharge planners to address these unique situations."


R.E.B.E.L.EM - By Cara Borelli - January 06, 2020
..."Authors’ Conclusion:
“In the general population, BUHE intubation position provides a non-inferior laryngeal view to GLSC intubation. The laryngeal views obtained in both approaches were superior to the laryngeal view obtained in the sniffing position. In view of the many advantages of the BUHE position for intubation, the lack of proven adverse effects, the simplicity, and the cost-effectiveness, we propose that clinicians should consider the BUHE position as the standard intubation position for the general population.”
Clinical Take-Home Point:
Both video-assisted laryngoscopy and elevating the head of the bed with direct laryngoscopy can help improve visualization of the glottis during intubation."

viernes, 3 de enero de 2020

Needle Thoracostomy

Curbside to Bedside Podcast 24 - January 3, 2020 - Andrew Bernard (peer review)
"Important Papers Mentioned in the Podcast:

EMRs for EPs

Resultado de imagen de emergency medicine news
Sandra Scott S; Emergency Medicine News 2020: 42 (1): 9 - Volume 42 - Issue 1 - p 9
"I doubt anyone fully grasped how dangerous the click of a mouse could be back in 2009 when President Obama signed the HITECH Act requiring physicians to abandon paper charts and begin using electronic medical records. The past decade has introduced a whole new world of medical errors by putting EMRs in the hands of fallible humans. Even when computers function flawlessly, the humans using them certainly do not.
Even the brightest physician's working memory can only process a finite amount of new information at a time. Physicians are less efficient at task-switching and less likely to complete tasks when their working memory gets overburdened with competing stimuli. (Ann Emerg Med. 2016;68[2]:189; http://bit.ly/2XkmUW7.) When we are interrupted, our performance suffers. Before EMRs, when we were still using timesheets, physicians were interrupted an average of 31 times in 180 minutes. (Acad Emerg Med. 2000;7[11]:1239; http://bit.ly/2NOaqD9.) Now we are interrupted even more by incessant requests to enter orders..."

jueves, 2 de enero de 2020

EM Cases Best 2019

Emergency Medicine Cases Logo
Emergency Medicine Cases - By Anton Helman- December 31st, 2019
EM Cases 2019 Top 10
..."Based on a blend of the number of podcast downloads, webpage views, social media engagement, number of positive emails and comments that I received, and my own favs, I’m pleased to bring you the EM Cases Best of 2019 Top 10. Many huge thanks to the entire EM Cases team, Advisory Board, SREMI, the amazing guest experts and you, the listeners of the podcasts, readers of the blogs, viewers of the videos and participants in the courses, for making 2019 another successful year for EM Cases!..."

EM Podcasts

Resultado de imagen de player FM

Top EM Blogs

Resultado de imagen de feedspot
Last Updated Jan 1, 2020
"Feedspot has a team of over 25 experts whose goal is to discover and rank popular blogs, podcasts and youtube channels in several niche categories. With millions of blogs on the web, finding influential bloggers in a niche industry is a hard problem to address. Our experience leads us to believe that a thoughtful combination of both algorithmic and human editing offers the best means of curation..."

Hyperglycemic Hyperosmolar State

emDocs - January 2, 2020 - Authors: De Andrande Pereira R; Waseem M; Godil M
Reviewed by: Lew E; Koyfman A; Long B
"Take Home Points
  • HHS is a medical emergency and therefore early recognition and aggressive resuscitation with fluids are critical for survival. It is important that physicians have a high index of suspicion particularly with obese patients presenting with altered mental status and hyperglycemia. Beware that there can be overlap between DKA and HHS. Consequently, patients may present with features of both conditions.
  • HHS is driven by osmotic diuresis with an overwhelming dehydration. Fluid replacement with Normal saline is an important initial step.
  • Insulin is more effective following fluid replacement and decreases osmolality and plasma glucose continually.
  • Monitor and replace electrolyte as necessary.
  • Continuous monitoring of vital signs and mental status are important."

A Decade of Diagnostics in Emergency Care

St. Emlyn´s - By Rick Body - January 1, 2020
"When we saw in the last decade, I’d just finished my PhD looking to discover the ‘new troponin’. At the time, patients with suspected acute coronary syndromes (ACS) were routinely admitted to hospital to undergo serial troponin testing with the second test being run at least 12 hours after peak symptoms. Troponin was a ‘late marker’ of myocardial injury, and in my PhD I’d been looking to discover an ‘early marker’ that could be used to ‘rule out’ the diagnosis with one test in the ED..."

lunes, 30 de diciembre de 2019

Imaging for suspected renal colic

SGEM XTRA - December 28, 2019 - By admin

  1. Younger Patients (~35 years old): Even without a history of stones, CT may be avoided as long as pain is controlled (perfect consensus).
  2. Middle-Aged Patients (~55 years old): We recommend CT if there is no history of kidney stones.
  3. Older Patients (~75 years old): We recommend CT regardless of history.
  4. Pregnant and Pediatric Patients: With a typical presentation they should undergo ultrasonography and do not require initial CT if symptoms are relieved.
  5. Radiation Dose: We recommend reduced-radiation-dose CT whenever CT is used for suspected renal colic.
Were there any limitations you identified?
There are many more 29 clinical scenarios. We chose this number because it seemed to be the best balance of major factors with the least number of scenarios. The scenarios are also skewed toward those in which the clinical likelihood of a kidney stone is high according to objective criteria. Although we did include scenarios with stone being less likely and found that in these scenarios practitioners were more likely to request CT, there may have been a bias toward assuming these scenarios represented kidney stone and no other diagnosis."