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SOBRE EL AUTOR **

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

WORLD EMERGENCY MEDICINE SOCIETIES & RELATED

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sábado, 6 de julio de 2019

Managing Hyperkalemia with Insulin/Glucose

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JournalFeed - June 27, 2019 - By Alex Chen, MD
Source: Management of Hyperkalemia With Insulin and Glucose: Pearls for the Emergency Clinician. J Emerg Med. 2019 May 11. pii: S0736-4679(19)30250-1. doi: 10.1016/j.jemermed.2019.03.043. [Epub ahead of print]
"Spoon Feed
Use of insulin/glucose to treat hyperkalemia works, but hypoglycemia is a common side effect. Here are some pearls to give this treatment more safely. 
Why does this matter?
Hyperkalemia is a life-threatening condition that requires prompt management in the ED. One of the most common treatment options is the administration of insulin and glucose to help shift potassium into the cell temporarily. Usually this is ordered as 10 units of regular insulin IV and 1 ampule of D50. This article explores some common myths and debunks them..."

Massive Transfusion

CanadiEM
CanadiEM MVP Infographic Series - By Lauren Beals - July 5, 2019
Transfusion of Plasma, Platelets, and Red Blood Cells in a 1:1:1 vs a 1:1:2 Ratio: The PROPPR Randomized Clinical Trial​
"20-40% of trauma deaths after hospital admission involve massive hemorrhage, a devastating outcome potentially avoided with good rapid hemorrhage control. Rapid hemorrhage control is best achieved by the timely delivery of plasma, platelets, and packed red blood cells in a balanced ratio, to replace ongoing losses without encouraging coagulopathy. This is most often seen in the context of a massive transfusion protocol activation. 
For a quick refresher on MTP check out Blood and Clots here..."

viernes, 5 de julio de 2019

GI Emergencies

StEmlynsLIVE - By Chris Gray - July 5, 2019
"I was really privileged to give a talk on upper GI/gastrointestinal emergencies last year at St Emlyn’s LIVE. You can read more on the overwhelming impostor syndrome I felt standing there not only with, but also in front of and talking to, such a wealth of experience in emergency medicine and critical care, echoed in Nat’s post from a few years ago. You can watch the talk below or listen to the podcast on our iTunes channel. This blog is designed to give you the background behind the talk.
However, this post isn’t about impostor syndrome, and we’ve got no time to worry about that anyway. The bat phone has just gone off. It’s a red standby..."

Peripartum Cardiomyopathy

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emDocs - July 4, 2019 - By Rometti M and Patti L
Edited by: Montrief T, Koyfman A and Long B
"Take Home Points
  • The highest risk for PPCM is in the month prior and the five months following delivery. Diagnosis includes heart failure within this timeframe with no other known underlying etiologies.
  • Consider this diagnosis in patients who are presenting with dyspnea on exertion or other signs of heart failure. Be wary of confusing these with common symptoms of late pregnancy.
  • Initial management should evaluate and support the patient’s respiratory status, with oxygen supplementation and consideration of non-invasive or invasive ventilation as dictated by the stability of the patient, as well as consideration of nitroglycerin (preload) and diuretics (systemic congestion). Patients in cardiogenic shock require resuscitation with vasopressors, inotropes, and consideration of ventricular assist devices.
  • In the still pregnant patient, consider early fetal monitoring in order to evaluate for uterine perfusion.
  • In the pregnant patient, avoidACE-Is, ARBs, warfarin, and DOACs for concern for teratogenicity. These are acceptable in the post-partum patient."

Autoantibody-Mediated Encephalitis

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ACEP Now - By Ryan Patrick Radecki - June 19, 2019
"A few years ago, a best-selling autobiographical work, Brain on Fire, chronicled one of the first instances of diagnosis for N-methyl-D-aspartate (NMDA) encephalitis. The story depicted by the author is one of a young woman’s descent into madness caused by encephalitis before its relatively novel cause is determined by a New York neurologist. The book details her recovery, and the story has even been developed into a feature film on Netflix..."

lunes, 1 de julio de 2019

Superficial Venous Thrombosis

REBEL Core Cast 14.0 - June 26, 2019 - By Anand Swaminathan
"Take Home Points on SVT
  • Superficial venous thrombosis refers to a clot and inflammation in the larger, or “axial” veins of the lower extremities and superficial thrombophlebitis refers to clot and inflammation in the tributary veins of the lower extremities. While we previously thought of this as a benign entity, we actually found the superficial venous thrombosis has been associated with concomitant DVT and PE.
  • Small, superficial clots can be treated with compression, NSAIDs, and elevation. These patients should be seen for follow up within 7-10 days to make sure the clot has not progressed.
  • Clots that are longer than 5 cm should be treated with prophylactic dosing of anticoagulation: fondaparinux 2.5mg subq once daily for 45 days or enoxaparin 40 mg subq once daily for 45 days.
  • Clots that are within 3 cm of the sapheno-femoral junction should be treated the same as a DVT.
  • A superficial thrombus could mean there is a deeper clot elsewhere, even in the other leg! Take a good history, perform a thorough physical exam and consider a bilateral lower extremity DVT study in concerning patients."

Fournier’s Gangrene

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emDocs - July 1, 2019 - Authors: Montrief T; Auerbach J. Edited by: Koyfman A and Long B
"Take Home Points
  • Fournier’s gangrene is most likely to present in an obese male patient between the ages of 50 and 79 years of age, with one or more risk factors –immunosuppression, alcohol use disorder, or diabetes.
  • Fascial anatomy plays an important role in the pathophysiology of Fournier’s gangrene. The Colles fascia remains continuous with other surrounding fascial planes, facilitating rapid spread towards the abdomen and thorax (via Scarpa’s fascia), as well as the scrotum (via Buck’s and Dartos fascia).
  • The most common sources of Fournier’s gangrene arise from the gastrointestinal tract (30-50%), genitourinary tract (20-40%), and cutaneous injuries (20%).
  • Up to 80% of FG cases are polymicrobial, with an average of four organisms per patient.
  • FG is often misdiagnosed as cellulitis or abscess in 75% of cases, and any crepitus, pain out of proportion, or ecchymosis should clue you in to possible FG.
  • The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score may suggest the presence of NSTI, however, it should not be used to exclude the diagnosis of FG.
  • CT has a sensitivity of 88.5% and specificity of 93.3% for the diagnosis of Fournier’s gangrene. MRI is more sensitive but may not be available and takes longer to obtain.
  • The cornerstones of treatment of FG include emergent surgical debridement of all necrotic tissue, broad-spectrum antibiotics, and hemodynamic resuscitation with intravenous fluids as well as vasoactive medications as needed."

lunes, 24 de junio de 2019

IO Blood for analysis

St. Emlyn´s - By Simon Carley - June 22, 2019
..."The clinical bottom line.
Unless someone out there can find better evidence (I could not) then we should not rely on bone marrow analysis in critically unwell patients. Although the only paper in critically unwell humans suggests that it might have a role for some variables I am unwilling to rely on a study of just 17 patients​​.
Having been told (and taught) hundreds of times that we can use IO samples in resuscitation I think this paper is #dogmalysis​​, and we love that here at St Emlyn’s. Next month I’m teaching APLS in Virchester and I suspect that I might be struggling in the IO practical session..."

Emergency Medicine Apps

EFFICIENT MD - December 28, 2018
"I surveyed a bunch of EM physicians on Facebook, Reddit, and in person, asking them their favorite apps to use in the emergency department. This list is a compilation of the replies that I received. Most of the apps are available for both Android and iOS but a handful are exclusive to just one platform. If there are others worth mentioning, please let me know.
Categories

jueves, 20 de junio de 2019

Basics of Mechanical Ventilation

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R.E.B.E.L.EM - June 6, 2019 - By Frank Lodeserto

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R.E.B.E.L.EM - June 17, 2019 - By Frank Lodeserto

Hypercalcemia

PulmCrit (EMCrit)
IBCC chapter & cast - June 20, 2019 - By Josh Farkas
"Hypercalcemia isn't a particularly common cause of critical illness, but when encountered this requires immediate treatment. Fortunately, advances in the management of hypercalemia have clarified how to control this safely and definitively. Forced diuresis with furosemide has largely fallen by the wayside, simplifying fluid and electrolyte management. The cornerstone of therapy is generally simultaneous initiation of calcitonin and an IV bisphosphonate."
  • The IBCC chapter is located here

Monitorización hemodinámica

AnestesiaR -
anestesiaR - Junio 17, 2019 - Por José LLagunes Herrero
"Para la comprensión del paciente hemodinámicamente inestable y su tratamiento se requiere un conocimiento de la propia fisiología cardiovascular y los métodos de monitorización hemodinámica disponibles. En esta revisión se debatirá el papel de la circulación sanguínea tanto venosa como arterial y la monitorización del gasto cardiaco, en especial mediante ecocardiografía. La revisión se estructura en los apartados siguientes: la fisiología venosa, la arterial y la monitorización hemodinámica..."
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anestesiaR - Junio 19, 2019 - Por José LLagunes Herrero
Segunda parte del artículo “Monitorización hemodinámica, de la fisiología a la práctica clínica”...
Conclusión
Es fundamental una buena comprensión de la fisiología cardiovascular para poder aplicar la monitorización adecuada y valorar los cambios a lo largo del tiempo. Es necesario incluir conceptos ya conocidos como la PMS y la E, tanto aortica como dinámica, para poder evaluar y tratar mejor a nuestros pacientes. En un futuro próximo los algoritmos de los monitores hemodinámicos incluirán estas variables y otras muchas que nos proporcionarán herramientas más precisas para el manejo del paciente hemodinámicamente inestable."

lunes, 17 de junio de 2019

mCPR Devices

Curbside to Bedside - June 16, 2019
"Conclusion
  • Consider applying your mCPR device later in the arrest, rather than sooner
  • When performing manual chest compressions, monitoring ETCO2 can help ensure proper hand positioning
  • Perform post event reviews using manufacturer software to measure CPR fraction and pauses associated with mCPR application"

Post-CABG

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emDocs - June 17, 2019 - Author: Montrief T - Edited by: Koyfman A and Long B
"Pearls and Pitfalls
  • Post-CABG patients most commonly present to the ED for post-operative infections, CHF, and chest discomfort.
  • DSWIs occur in 1–2% of all patients undergoing cardiac surgery, but have up to a 30% mortality rate.
  • Ultrasound is an invaluable tool to evaluate for a pericardial effusion, but a retrocardiac clot is difficult to see on either transthoracic echo or X-ray and may be missed.
  • Acute resuscitation of the hemodynamically unstable post-CABG patient includes optimizing preload, rate, rhythm, contractility, and afterload.
  • Early surgical consultation can help guide the diagnostic and therapeutic management."

TEG for Ci coagulopathy

PulmCrit (EMCrit)
PulmCrit - June 17, 2019 - By Josh Farkas
"Traditional coagulation studies (especially the INR) fail miserably in cirrhosis. Thromboelastography (TEG) is a superior approach for understanding the global balance of pro-coagulants versus anti-coagulants in these patients. This isn’t anything particularly new – for example, it was explored in this post from 2015 (if you're not familiar with this concept already, it's explained in that post)...
Summary The Bullet:
  • Problems with standard coagulation tests in cirrhosis (especially INR) are well known.
  • Four RCTs show benefit of blood product administration guided by thromboelastography (TEG), compared to traditional coagulation tests. These are all single-center studies, but they seem to give a coherent message: use of traditional coagulation tests leads to over-transfusion.
  • The optimal TEG-based transfusion algorithm is unclear. The studies above showed benefit from two very different TEG-based strategies. It's likely that any reasonable TEG-based strategy will represent an improvement over strategies using traditional coagulation tests.
  • An approach to TEG-based transfusion in cirrhosis is provided, which is based upon these RCTs:

viernes, 14 de junio de 2019

Unscheduled Procedural Sedation

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Journalfeed - By Clay Smith - June 11, 2019
Source: Unscheduled Procedural Sedation: A Multidisciplinary Consensus Practice Guideline.  Ann Emerg Med. 2019 May;73(5):e51-e65.  doi: 10.1016/j.annemergmed.2019.02.022. 
"This guideline for unscheduled sedation is based on good evidence and authoritatively states some key aspects of emergency sedation that apply to our patients and fit the needs of our setting."

jueves, 13 de junio de 2019

ECG Monitoring in Syncope

R.E.B.E.L.EM - By Mark Ramzy - June 13, 2019
..."Clinical Bottom Line:
  • Cardiac monitoring cutoff periods based on patient risk for adverse outcomes are not only clinically sensible but also serve to balance over-testing vs benefit of diagnostic yield. While the risk factors, times and recommended dispositions based off this study are derived below, it is important to recognize that various clinicians in different healthcare systems may have dissimilar thresholds
    • Low Risk (2-hour observation) = Residual 0.2% risk of serious arrhythmic outcome (ZERO of the low risk cohort were ventricular arrhythmias or death) and can be discharged home
    • Medium Risk (6-hour observation) = Residual 5.0% risk of serious arrhythmic outcome (0.9% of the medium risk cohort were ventricular arrhythmias or death) and can most likely be discharged home but requires follow-up within 24-48hours
    • High Risk (6-hour observation) = Residual 18.1% risk of serious arrhythmic outcome (6.3% of the high risk cohort were ventricular arrhythmias or death) and likely need to be admitted if follow-up cannot be arranged before 24-48 hours"

Wolff-Parkinson-White Syndrome

CanadiEM
CanadiEM - By Paula Sneath - June 12, 2019
"Objectives
  • Review the physiology of Wolff-Parkinson-White Syndrome (WPW)
  • Review the management of SVT in WPW and consider potential complications
What are WPW and AVRT?
Preexcitation describes the situation in which impulses from the SA node or atrium reach the ventricle through an accessory pathway (a bypass tract) in addition to the AV node. WPW is a type of preexcitation syndrome in which there are ECG findings of an atrial-ventricular bypass tract (often, but erroneously, called Kent bundles) and the patient demonstrates related tachydysrhythmias. The most common tachydysrhythmia seen in WPW is atrioventricular re-entrant tachycardia (AVRT) – this is seen in 80% of patients with WPW and is what paramedics would most commonly be called for..."

martes, 11 de junio de 2019

Angioedema

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emDocs Cases - Jun 10, 2019 - Authors: Long B and Gottlieb M -  Edited by: Koyfman A
"Key Points:
  • Transient, non-dependent, non-pitting edema is the most common presentation of angioedema. Commonly involved sites include the face, lips, extremities, and GI system.
  • Two forms include histamine- and bradykinin-mediated forms. Histamine-mediated angioedema presents similarly to anaphylaxis, while bradykinin-mediated angioedema is slower in onset, more severe, and more commonly affects the oropharynx.
  • Management should focus on the airway initially.
  • Histaminergic-mediated angioedema can be treated with medications such as epinephrine, antihistamines, and steroids. However, these medications are not as effective for bradykinin-mediated angioedema.
  • C1-INH protein replacement, kallikrein inhibitor, and bradykinin receptor antagonists are agents that may benefit bradykinin-mediated angioedema.
  • Airway management can be challenging and is improved with fiberoptic or video laryngoscopy, with preparation for cricothyrotomy.
  • Disposition is also challenging, dependent on the involved sites."

PEA after TCA

MEDEST - June 11, 2019 
"On May 2019 was published an article we review today, cause the authors conclusions are pretty astonishing and worth a deeper look.
Authors Conclusions: Following pre-hospital traumatic cardiac arrest, PEA on arrival portends death. Although Cardiac Wall Motion (CWM) is associated with survival to admission, it is not associated with meaningful survival. Heroic resuscitative measures may be unwarranted for PEA following pre-hospital traumatic arrest, regardless of CWM..."

Intubation in Trauma

R.E.B.E.L.EM - By Zaf Qasim - June 10, 2019
... Bring in the New Order!
If anything good has come out of the recent military conflicts, it is our approach to trauma care. We have learnt the benefit of tourniquets and whole blood, and are applying or studying them in civilian practice.
Another important takeaway should be the re-ordering of our approach to resuscitation. Patients who are truly exsanguinating will likely arrest if you attempt to intubate them first. One of the prototypical wartime injuries was the traumatic amputation leading to massive exsanguination. Over time, their management changed and these patients would always have an extremity tourniquet applied before definitive airway management.
This logically leads to the reordering of resuscitation by shifting the initial focus from airway to managing a major insult like this. The ABC mnemonic can be changed to either (C)CAB (Catastrophic hemorrhage; Circulation; Airway; Breathing) or MARCH (Massive hemorrhage; Airway; Respiration; Circulation; Head/Hypothermia)..."

     

domingo, 9 de junio de 2019

Traumatic Cardiac Arrest

St. Emlyn´s - By Simon Carley - June 7, 2019
"A few weeks ago we reviewed a paper on the management of traumatic cardiac arrest. That paper specifically looked at the role of closed chest compressions in traumatic cardiac arrest (TCA). I recently managed to catch up with the lead author, an old friend of mine and an expert in the management of this complex condition.



In this podcast we discuss the background to Jason’s research and discuss the recent closed chest compression trial in some detail."

jueves, 6 de junio de 2019

Acetaminophen Toxicity

EMCrit
Tox & Hound (EMCrit) - June 6, 2019 - By Diane Calello
..."For starters, let’s establish that the nomogram was developed to predict risk in single, acute APAP overdoses. Not chronic overdoses. Not staggered overdoses. Not repeated supra-therapeutic ingestions. Not the case of “I have no idea what happened because the history is completely unreliable, but I have a detectable level..."

Basilar Skull Fracture

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emDocs - June 6, 2019 - Authors: Pillai S and Desai S
Edited by: Koyfman A and Long B
..."Pearls and Pitfalls:
  • Battle sign and raccoon’s eye may be delayed 6-12 hours or not present with BSF.
  • Hemotympanum is typically first finding.
  • Most complications of BSF like CSF leak, cranial nerve deficits, and sequelae of carotid/vertebral artery injury arise late and present after 48 hours.
  • Consider abuse in elderly and children.
  • Consider meningitis if prolonged CSF leak.
  • No evidence for prophylactic antibiotics regardless of CSF leak.
  • Consider CTA to evaluate for carotid artery injury regardless of cervical fracture.
  • Missed CVI can lead to permanent neurologic sequelae or mortality in up to 50% cases.
  • Avoid nasogastric intubation, nasopharyngeal suction / airway, and NIPPV if potential BSF."

martes, 4 de junio de 2019

EXTEND-ing Times for Thrombolysis in AIS?

REBEL Cast Episode 67 - By Salim Rezaie - June 03, 2019
..."Author Conclusion: “Among the patients in this trial who had ischemic stroke and salvageable brain tissue, the use of alteplase between 4.5 – 9.0 hours after stroke onset or at the time the patient awoke with stroke symptoms resulted in a higher percentage of patients with no or minor neurologic deficits than the use of placebo. There were more cases of symptomatic cerebral hemorrhage in the alteplase group than in the placebo group.”
Clinical Take Home Point: This study should in no way change practice and is a ridiculous display of statistical hocus pocus (i.e. multiple regressions ran, and the one that worked for the authors was the one selected for the manuscript). Another example of a small study, stopped early, with frank manipulation of data to help promote one thing…more money in the pockets of the company making the medication."

Fluid boluses

PulmCrit (EMCrit)
PulmCrit - June 3, 2019 - By Josh Farkas 
..."Summary:The Bullet:
  • Fluid boluses don’t necessarily provide reliable information about the patient’s hemodynamics (especially if they are provided casually and without precise hemodynamic monitoring).
  • As shown below, the majority of fluid boluses don’t lead to sustained clinical benefit.
  • Risks of fluid bolus therapy include damage to the endothelial glycocalyx and volume overload.
  • Available RCTs involving fluid bolus treatment suggest that it is harmful.
  • Overall, fluid boluses may lead to transient improvements in hemodynamics, which reinforces the practice of providing them. However, a more detailed evaluation of the evidence and physiology suggests that most fluid boluses probably lead to harm.
  • The widely-recommended practice of treating anyone with potential infection and possible “sepsis” with a 30 cc/kg fluid bolus is likely dangerous and not evidence-based."

Status Epilepticus

Back Home
First10EM - By Justin Morgenstern - June 3, 2019
..."This post is an update of the original status epilepticus post from 2015. The general algorithm is the same, but a few clarifications were added, and the references were updated.
Although older definitions of status epilepticus focused on seizures lasting more than 30 minutes, a more practical definition is any individual seizure lasting more than 5 minutes or 2 seizures without full recovery of consciousness. From an emergency department standpoint, if a patient is still seizing by the time EMS arrives, it is probably status.
I think the described aggressive approach to status epilepticus makes sense in continuous convulsive seizures. However, in patients whose seizures stop with benzos, but simply recur before the patient returns to their baseline neurologic status, a less aggressive approach is probably warranted. (The key distinction is whether you think there is still generalized seizure activity occurring in the brain, which will result in neuronal death). In intermittent seizures, you probably have time to use a conventional anticonvulsant as the second line therapy.
I don’t recommend fosphenytoin. Although it can be given quicker, it doesn’t work any faster or better than phenytoin. Some studies have demonstrated lower side effects with fosphenytoin, but if you look closely, the only side effect that seems to be decreased is pain at the injection site. (Glauser 2016) That doesn’t make sense for patients in status, as they will be unconscious.
I use the same algorithm in both children and adults, as the underlying pathophysiology is the same, and there is little reason to think that the treatment needs to differ. (Glauser 2016) That being said, outcomes tend to be better in children, so a less aggressive approach may be warranted in some circumstances.
Obviously, this aggressive algorithm is not appropriate for non-epileptic spells, or pseudoseizures. Pseudoseizures are usually relatively obvious clinically. Indicators of a non-epileptic spell include maintained consciousness, poorly coordinated thrashing, purposeful movements, back arching, eyes held shut, head rolling, and pelvic thrusting. (Claassen 2017)"
An algorithm for the management of status epilepticus

domingo, 2 de junio de 2019

68 laws of the ER

Resultado de imagen de kevin md.com
KevinMD -  By Rada Jones - January 3, 2019
Resultado de imagen de 68 laws of the ER

Beyond ATLS

St Emlyn’s - By Simon Carley - June 2, 2019
"Another of our videos and podcasts from the #stemlynsLIVE conference. This month it’s Alan Grayson on the role of ATLS in trauma management. If you listen to the twittersphere then ATLS seems to have a terrible reputation, but is that entirely justified?

Perhaps not, and perhaps there are many things that we should be doing ourselves before we criticise a course that was never designed for a major trauma centre setting (although it has been advocated to be so)..."

sábado, 1 de junio de 2019

Overdiagnosis of pericarditis

EMCRIT
EMCrit - May 24, 2019 - By Meyers P
"It is my opinion that the medical discovery of pericarditis as a disease entity has actually caused overall net harm to human beings. I see and review so many cases in which the notion of “pericarditis” leads to patient harm that it has become a four-letter diagnosis to me. With the exception of extremely rare cases of significant pericardial effusions made hemorrhagic by thrombolytics (only 2 cases) witnessed in an entire career by one of the world's leading experts who reviews thousands of cases around the world), almost no one has any significant complication of uncomplicated pericarditis (unlike myocarditis, complicated pericarditis with significant pericardial effusions, etc.), and whatever small symptomatic benefit true pericarditis patients receive from NSAIDs and/or colchicine is completely overshadowed by the harms of erroneously diagnosing pericarditis.
Pericarditis is almost a wastebasket diagnosis of exclusion, barely more important than costochondritis (and treated in basically the same way). If I were pericarditis, my only reason to exist would be to trick emergency physicians and cardiologists into missing Occlusion MIs and other real pathologic processes. If you correctly diagnose 99 patients with pericarditis and misdiagnose 1 Occlusion MI as pericarditis, you have failed your goal of protecting patients from emergencies. The harm of missing a single Occlusion MI far outweighs the harms of missing pericarditis.
The simplest solution for Emergency Medicine: Just say no to diagnosing uncomplicated pericarditis in the ED..."

Superficial Venous Thrombosis

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emDocs - May 31, 2019 - By Avila J
..."Management:
  • Due to the lack of large clinical trials evaluating the treatment of SVT, much of the literature relies heavily on expert consensus.
  • Traditional treatment involves NSAIDS and stockings. This treatment is still recommended by most for SVT’s <5cm in length and >3cm from the SFJ. (Cosmi 2015)
  
  • 2012 ACCP guidelines suggest that patients with SVT > 5 cm can be treated with prophylactic dose of fondaparinux or LMWH for 45 days. (Guyatt 2012)
  • This recommendation was largely based on the CALISTO trial, which randomized 3002 patients with SVT to get either fondaparinux or placebo and reported that the rate of PE or DVT was 85% lower in the fondaparinux group (Decousus 2010)
  • SVT within 3 cm of SFJ is considered by some to be equivalent to DVT and can be treated as such (Cosmi 2015)
  • Topical NSAIDS may help symptoms and can be used at the same time as anticoagulation (Kearon 2012)
  • There is no literature supporting or refuting using the same treatment in the evaluation of upper extremity SVT.
  • If an SVT is uncovered in the lower extremity, a bilateral duplex ultrasound evaluating the deep venous system should be considered.
Take Home Points
  • SVT >5cm or <3 cm from the SFJ should be treated with anti-coagulation.
  • The rate of concurrent DVT and PE in patients with SVT is 25% and 5%, respectively.

IV antibiotics for cellulitis

IV antibiotics for cellulitis title image
First10EM - By Justin Morgenstern| - April 2, 2018
..."Summary
Putting this all together, I think it is pretty clear that oral antibiotics should be used for the vast majority of cellulitis patients. Even patients who have already been on oral antibiotics seem to fare great when randomized to cephalexin. (Aboltins 2015) In fact, oral antibiotics seem to be the right choice for almost every infectious disease that has been studied. That makes sense, considering that the bacterium living in your tissues remains ignorant of the antibiotic’s port of entry.
Clearly there are times when intravenous therapy is required. If a patient cannot swallow. If the required dose cannot be tolerated orally. If oral antibiotics cannot be absorbed, either because of the chemical structure of the antibiotic, or because of intestinal problems, which often occur in the critically ill. Or in emergent scenarios, when rapidly achieving peak antibiotic levels might matter. However, these represent a minority of clinical scenarios, especially when discussing cellulitis.
It is time that we dispel the magical thinking that surrounds IV antibiotics."

Acutely Can’t Walk

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emDocs  - May 23, 2019 - Authors: Martin K, Uribe J, Waseem M, Gernsheimer J
Edited by: Koyfman A and Long B
"Key Points:
  • “I can’t walk” is an important complaint that has many etiologies, including neurologic, orthopedic, and metabolic.
  • Determining what the patient means by inability to walk is essential (ie, pain vs. weakness vs. focal deficit).
  • While evaluating the patient for the cause of weakness with a good history, physical exam, and appropriate ancillary testing, it is critical to evaluate and stabilize the patient’s ABCs.
  • Determining which part of the nervous system is involved will help make an expeditious and correct diagnosis that will lead to appropriate therapy, which may prevent further mortality and morbidity."

jueves, 30 de mayo de 2019

REBOA

SGEM#258 - By admin - May 25, 2019
Reference: Joseph et al. Nationwide Analysis of Resuscitative Endovascular Balloon Occlusion of the Aorta in Civilian Trauma. JAMA Surgery March 2019.
  • "CLINICAL QUESTION: WHAT ARE THE OUTCOMES OF TRAUMA PATIENTS AFTER REBOA PLACEMENT?
  • Authors’ Conclusions: “Placement of REBOA in severely injured trauma patients was associated with a higher mortality rate compared with a similar cohort of patients with no placement of REBOA. Patients in the REOBA group also had higher rates of acute kidney injury and lower leg amputations. There is a need for a concerted effort to clearly define when and in which patient population REBOA has benefit.”
  • SGEM BOTTOM LINE: REBOA IS CURRENTLY AN INTERVENTION OF UNCERTAIN BENEFIT. ALTHOUGH IT HAS SHOWN PROMISE IN SOME STUDIES, THIS INVESTIGATION LEAVES ITS THERAPEUTIC POTENTIAL IN QUESTION, AND ARGUABLY DEMONSTRATES HARM. THERE MAY BE SUBSTANTIAL BENEFIT IN SELECT GROUPS OF TRAUMA PATIENTS, BUT THESE GROUPS ARE NOT YET KNOWN."