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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

EMCrit Podcast 208 – Felipe Teran on Why We are Doing CPR Wrong

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miércoles, 20 de septiembre de 2017

Psychosis Mimics

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emDocs - September 18, 2017 - Authors: Cisewski D and Cassella C
Edited by: Koyfman A and Long B
"Summary
In the absence of a previous history or psychiatric condition, a nonorganic cause of acute symptoms is a diagnosis of exclusion. In addition, one must never assume factitious disorder or malingering until other conditions are ruled out. When psychosis is prematurely assumed to be related to psychiatric condition versus organic cause, delay in failure to treat can be deadly. Hence, the importance of a proper review. Look for signs of organic causes, and be sure to gather a proper history. Most importantly, beware of your cognitive bias during certain patient presentations, and ensure you’re covering all possibilities before making a final diagnosis."

lunes, 18 de septiembre de 2017

Hyperlactatemia

Taming The SRU
Taming The SRU - September 17, 2017
"Since the turn of the century, lactate has become a mainstay in emergency medicine and critical care laboratories. Some clinicians may hate it, others may love it, but very few can feign apathy on the subject. The utility of lactate in the emergency department and the ICU in guiding resuscitations, predicting mortality, or identifying occult critical illness continues to be discussed in the literature, most fervently in the realm of sepsis. But what are the humble beginnings of this molecule? Most fundamentally, how is lactate generated in the setting of critical illness? And how did it come to be so firmly embedded in our understanding of the pathophysiology of critically ill patients?"

Table 1 - Classification of lactic acidosis, adapted from Cohen and Woods [7], with examples.

Cardiac Standstill

R.E.B.E.L.EM - September 18, 2017
"Clinical Question: How much variability exists in the interpretation of cardiac standstill on POCUS amongst physicians? (
Article: Hu K et al. Variability in Interpretation of Cardiac Standstill Among Physician Sonographers. Ann Emerg Med 2017. PMID: 28870394)
Authors Conclusions: “According to the results of our study, there appears to be considerable variability in interpretation of cardiac standstill among physician sonographers. Consensus definitions of cardiac activity and standstill would improve the quality of cardiac arrest ultrasonographic research and standardize the use of this technology at the bedside.”
Our Conclusions: We agree with the authors that this study, though limited by it’s methodology and convenience sample, demonstrates significant disagreement between providers as to the interpretation of cardiac standstill on POCUS.
Potential to Impact Current Practice: This study cannot be used to impact clinical practice but should cause some pause for thought for providers who are currently using POCUS in cardiac arrest as part of their protocol for termination based on cardiac standstill.
Bottom Line: The use of POCUS to declare death and stop resuscitation is predicated on a clear ability to establish the presence of cardiac standstill. The low level of agreement of providers likely reflects the absence of a single definition of standstill as well as calls for increased training and assessment. A unified definition of standstill would be extremely helpful not only in future research but in cardiac arrest care as well."


domingo, 17 de septiembre de 2017

NRB-Flush

R.E.B.E.L.EM - Setember 14, 2017
"Author Conclusion: “Preoxygenation with NRB-Flush was noninferior to BVM-15. NRB with flush rate oxygen may be a reasonable preoxygenation method for spontaneously breathing patients undergoing emergency airway management.”
Clinical Take Home Point: Although the results of this study need to be confirmed in a critically ill patient population, it appears that flush rate oxygen via a NRB mask is non-inferior to BVM mask at 15L/min."

How to Fix the ER

The Wall Street Journal

The Wallstreet Journal - By Ellie Kincaid - September 12, 2017
"ERs are notorious for long waits, endless forms and inconsistent care. Now researchers and hospitals are rethinking the ways they work—with impressive results.
Long wait times in the emergency room have bad effects for patient outcomes and satisfaction.
Hospitals are making a push to fix one of the most irritating issues in health care: the emergency room.
Armed with new research and strategies borrowed from the business world, some facilities are trying to ease the frustrating experience of waiting, filling out forms, explaining a problem—and then waiting some more..."

TB in the ED

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emDocs - September 6, 2017 - Authors: Belle T and Wise - Editors: Koyfman A and Long B
"Key points 
  • TB remains a devastating and fairly ubiquitous disease throughout several parts of the world despite recent downward trends in incidence. 
  • It can present in a variety of ways so a high index of suspicion is needed when evaluating patients with signs and symptoms suggestive of possible infection. 
  • Patients co-infected with HIV or otherwise immunosuppressed tend to present more atypically. 
  • Effective management relies on prompt recognition 
  • Diagnosis relies on a combination of adequate history and clinical, radiographical and microbiological data. 
  • Treatment should be started only after consultation with Infectious Disease specialists at your institution. 
  • Strict adherence to isolation precautions is paramount in preventing the spread of infection in the ED." 



60/60 for PE

The Bottom Line - September 15, 2017 - By David Slessor
"Clinical Question
In patients with suspected acute pulmonary embolism, do echo features of disturbed right ventricular ejection allow accurate diagnosis?...
The Bottom Line
  • In patients seen at a tertiary referral centre with a high pre-test probability of acute pulmonary embolism, the McConnell Sign had a very high positive likelihood ratio. In patients without previous cardiorespiratory disease the 60/60 sign also demonstrated a very high positive likelihood ratio. A negative McConnell or 60/60 sign added little diagnostic information
  • In patients presenting to the ED/ICU with a high probability of acute pulmonary embolism who cannot immediately undergo CT, I will use bedside echo to assess the 60/60 and McConnell’s signs. A positive test result will give me greater confidence for the diagnosis of acute pulmonary embolism, where as a negative result will neither help confirm or repute the diagnosis of acute pulmonary embolism"

lunes, 11 de septiembre de 2017

Dysrhytmias after Syncope

R.E.B.E.L.EM - September 11, 2017 - By Swaminathan A
"Authors Conclusions:
“The Canadian Syncope Arrhythmia Risk Score can improve patient safety by identification of those at-risk for arrhythmias and aid in acute management decisions. Once validated, the score can identify low-risk patients who will require no further investigations.”
Our Conclusions:
This prospectively derived decision instrument may be helpful in stratifying syncope patients to high or low risk for dysrhythmia but requires external validation prior to consideration for implementation.
Potential to Impact Current Practice:
Because dysrhythmia is a common reason for admission to hospital and further workup of patients presenting with syncope, this decision tool has the potential to be used to support a decision of discharge and follow up and avoid low yield inpatient evaluations if externally validated.
Clinical Bottom Line:
The prospective derivation of this decision instrument is a positive step towards risk stratification of syncope patients for subsequent dysrhythmias. It is critical to remember that there are numerous other causes of syncope (ectopic pregnancy, PE, ACS, aortic dissection, GI bleeding etc) that should be considered in patients as well. Additionally, because the population in this study was relatively young and healthy, evaluation of a higher risk cohort would be useful in future studies."

Future of Troponin

St.Emlyn's - By Rick Body - September 8, 2017
"As I’m writing this, I’m travelling back from an excellent conference in London. The BioRemarkable Symposium was sponsored by a company called Singulex. The team at Singulex had decided to hold the event to showcase some of the recent research involving its troponin assay and to bring together some opinion leaders from around the world to discuss the future of troponin testing. I was privileged to be involved and to present the breaking findings of our latest research using the Singulex troponin assay. But the data aren’t published yet – so I won’t discuss that here. Instead, I’d like to pass on details of some of the really exciting discussions we had at the conference. The future of troponin testing could be pretty amazing..."

Angiotension II for Septic Shock

PulmCCM
Angiotensin II, a new vasopressor for septic shock, coming soon (probably)
PulmCCM - September 8, 2017

"La Jolla Pharmaceutical Company, makers of LJPC-501 (no trade name yet), announced the FDA has begun reviewing their fast-track application for approval of angiotensin II. The proposed indications are septic shock and other vasodilatory shock despite provision of fluids and other vasopressors."

Sepsis with Comorbidities

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emDocs - September 4, 2017 - Author: Fox W - Edited by: Koyfman A and Long B
"Conclusion
The understanding and adoption of fluid resuscitation in patients with sepsis has improved outcomes and the level of care so much so that provider compensation may now be tied to meeting certain metrics guiding resuscitation. Though providers may find solace in the relative simplification of sepsis treatment regimens, adopting therapies as a panacea without critical thought and applicability will inevitably doom complicated or outlier patients to substandard or dangerous care. The goal of this review is to understand the implications of chronic physiologic abnormalities that can confound providers and limit the effectiveness of the “standard of care”. An understanding of these nuances of end-organ disease can give providers a general framework to approach the care of complicated sepsis cases in an intelligent, methodical, and patient-centered manner.
Take Home Points
  • Despite comorbidities, sepsis is the primary threat to the life of the patient and must be treated
  • SBP should not be overlooked in cirrhotic, and valuable culture data can be gleaned from inoculating culture bottles immediately after sample collection
  • Early vasopressor usage in pulmonary hypertension and avoidance of positive pressure ventilation can preserve compromised right ventricular function
  • Congestive heart failure patients, conversely, may benefit from positive pressure ventilation used judiciously during resuscitation"

jueves, 31 de agosto de 2017

Alcohol Intoxication Mimics

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emDocs - August 30, 2017 - Authors: Bennett J and Fairbrother H
Edited by: Koyfman A and Long B
"Take Home Points
  • Keep a broad differential in mind for any patient with AMS, even if the patient smells like alcohol and intoxication seems likely
  • Check a POC blood glucose level on arrival
  • Undress patients suspected of alcohol intoxication and fully examine
  • Re-assess every 1-2 hours. If your patient doesn’t improve as expected, reexamine and broaden the differential
  • Don’t ignore abnormal vitals
  • Get a head CT if you see or suspect head trauma in the intoxicated patient
  • Consider checking an alcohol level if you’re unsure. If negative, investigate further. However, remember that a positive EtOH level does not preclude other problems also being present and should not be falsely reassuring."

PE Treatment with Rivaroxaban

R.E.B.E.L.EM - August 31, 2017
"Clinical Question:
What is the safety and efficacy of rivaroxaban in patients with a range of sPESI scores in comparison to standard treatment with enoxaparin/VKA?...
Authors’ Conclusions:
“The findings support using risk stratification with the simplified PESI score to identify low risk patients with PE.”
Our Conclusions:
In this post hoc analysis, a higher sPESI correlated with a higher rate of adverse events, thereby corroborating previous validation studies. Furthermore, when stratified by sPESI, the safety and efficacy outcomes for patients treated with rivaroxaban versus standard therapy were similar.
Potential impact to Current Practice:
DOACs are a simple, effective, safe, and cost-effective treatment for acute PE. The sPESI is a validated tool for identifying low-risk acute PEs for possible outpatient treatment. However, is it possible to combine these two concepts? Can low-risk PE patients be safely treated by initiating a DOAC in the ED and then discharging the patient to outpatient follow-up? This study provides further support towards the momentum that is already headed in that direction..."

miércoles, 30 de agosto de 2017

MM Emergencies

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emDocs - August 29, 2017 - Authors: Xiao J and Todd B
Edited by: Koyfman A and Long B
"Takeaway points
  • Multiple myeloma is difficult to diagnose. Elderly patients with unremitting back pain or pathologic fractures of the axial skeletonshould be considered for multiple myeloma evaluation. Emergency department X-rays may clinch the diagnosis with punched out lytic bone lesions.
  • Cord compression is the most important emergency diagnosis. The absence of neurologic symptoms does not preclude cord compression.
  • The two most common causes of death in multiple myeloma patients are frequent infections, usually respiratory, and renal failure. Their disease process and medications make them immunocompromised.
  • Renal failure in multiple myeloma patients is multifactorial and has a poor prognosis. Treat acute kidney injury aggressively and contact oncology early.
  • Electrolyte abnormalities should be treated by managing the underlying disease process. Multiple myeloma patients are especially prone to hypercalcemia due to osteoclastic bone activity. Treat with generous fluid hydration, and consider loop diuretics (controversial), calcitonin, bisphosphonates in conjunction with their oncologist.
  • Multiple myeloma medications may cause venous thromboembolism and neuropathy."

O2 in MI

SCANCRIT - August 30, 2017 - By Thomas D
"There’s not much left of poor MONA. We’ve written on unnecessary O2 treatment before, ie the AVOID trial. And now, one of the large RCTs on the subject is out. The DETO2X-SWEDEHEART investigators (love the acronym) have published their findings in NEJM: Routine oxygen therapy gave no advantage over breathing ambient air..."

martes, 29 de agosto de 2017

Tracheostomies

TAMING THE SRU
TAMING THE SRU - August 29, 2017
"Troubles with tracheostomy tubes can be some of the most anxiety provoking complaints we see in the Emergency Department. Airway master and Dr. IC Cordes himself, Dr. Steven Carleton, MD PhD joined me on the podcast to help demystify 2 common tracheostomy related complaints - the bleeding trach site and the displaced tracheostomy tube..."

Brain death

PulmCrit (EMCrit)

PulmCrit - August 28, 2017 - By Josh Farkas
"There is no room for error when diagnosing brain death. Incorrect diagnosis causes inappropriate withdrawal of care. However, delayed or missed diagnoses lead to futile care and lost opportunities for organ donation...
Summary The Bullet:
  • Brain death diagnosis should be considered only after patient stabilization and evaluation for other possible causes of coma.
  • Spinal reflexes may produce strange movements among brain dead patients, often causing confusion.
  • The most concerning mimics of brain death are missed alternative diagnoses (e.g. intoxication, C-spine injury), because these may be treatable.
  • Radionuclide flow scan may be used in confusing situations. The scan isn't entirely sensitive, because limited flow may continue in the early phases of brain death. However, lack of blood flow allows for a confident diagnosis of brain death (high specificity)."

ESC guidelines 2017 (STEMI)

ESC logo
European Heart Journal (2017) 00, 1–66 ESC GUIDELINES doi:10.1093/eurheartj/ehx393
"Barcelona, Spain – 26 Aug 2017: European Society of Cardiology (ESC) Guidelines on the management of acute myocardial infarction in patients with ST-segment elevation are published online today in European Heart Journal, (1) and on the ESC website. (2)
The document provides recommendations on topics not covered by the 2012 Guidelines and changes some previous recommendations following new evidence..."

Ventolin in HF

An online community of practice for Canadian EM physicians
CanadiEM - By Ponn Benjamin - August 29, 2017
"Can Ventolin improve wheeze in heart failure?
Breathlessness in heart failure patients led James Hope to coin the term “cardiac asthma” in 18331, and by 1854 cardiac asthma was considered a disease state. Sir William Osler’s classic description (1897) has withstood the test of time: “In the case of advanced arteriosclerosis, there are often attacks of dyspnea of great intensity recurring in paroxysms, often nocturnal. The patient goes to bed feeling quite well, and in the early morning hours wakes in an attack which, in its abruptness of onset and general features, resembles asthma"...
In conclusion, the current evidence does not support or refute the use of ventolin in cardiac asthma. Identifying the etiology behind CHF decompensation will determine the appropriate therapeutic interventions. The patient’s medical history, vital signs, and physical exam may determine whether it should be used. It is reasonable to consider Ventolin therapy in patients with CHF who have a past medical history of asthma or COPD."

lunes, 28 de agosto de 2017

Rapid detection of bacterial meningitis

Rousseau G, et al. Eur J Emerg Med. 2017. -  
doi: 10.1097/MEJ.0000000000000495. [Epub ahead of print]
"CONCLUSION: A glucometer accurately detects an abnormal CSF/blood glucose ratio immediately after the lumbar puncture. This cheap point-of-care method has the potential to speed up the diagnostic process of patients with bacterial meningitis."

Pacemaker Basics

R.E.B.E.L.EM - August 24, 2017
"Have you ever been confused by the alphabet soup of pacemakers? This post will serve as a pacemaker basics reference."

Benzodiazepine Withdrawal Syndrome

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emDocs - August 23, 2017 - Authors: Donepudi M and Carlson A
 Edited by: Koyfman A and Long B
"Key Points:
  1. Given the increase in benzodiazepine prescription rates in the last decade, it is important to recognize the signs and symptoms of benzodiazepine withdrawal syndrome to allow for prompt treatment and stabilization.
  2. While symptoms of benzodiazepine withdrawal typically peak by the second week after abrupt cessation, patients with history of chronic benzodiazepine use can present to the emergency department even months later.
  3. Pay careful attention to other causes for the patient’s acute presentation; eliminate organic causes before attributing symptoms solely to withdrawal.
  4. While withdrawal can and should be managed long term on an outpatient basis, patients presenting with acute withdrawal syndrome are best managed with hospitalization, especially if they have a history of high-dose benzodiazepine use. Patients manifesting severe withdrawal symptoms are best managed in an intensive care setting due to heightened risk of delirium tremens or convulsive status epilepticus.
  5. There is no consensus on a treatment protocol for benzodiazepine withdrawal but it is beneficial to place patients on a CIWA protocol to allow for symptom-triggered treatment with long-acting benzodiazepines as tolerated with slow tapers over time as well as other adjunctive therapies such as phenobarbital, propranolol, haloperidol, and carbamazepine"

sábado, 19 de agosto de 2017

Malignant Otitis Externa

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emDocs - August 16, 2017 - Authors: Yetter E, Isaksen L and Mulvey L
Edited by: Koyfman A and Singh M
"Take Home Points
  • Consider MOE if someone treated for Otitis Externa is not improving and/or they have fever and tenderness to palpation of the mastoid.
  • Pseudomonas is the most common etiology and coverage should be directed appropriately. However in rare cases fungal infections may also be the cause, such as in AIDS patients.
  • Obtain CT and/or MRI imaging of the mastoid.
  • Consult ENT."

DRESS

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emDocs - August 15, 2017 - Authors: Nemero M and Oliver J
Edited by: Koyfman A and Long B
"Key Points
  • DRESS syndrome should be suspected whenever a patient presents with a fever, morbilliform rash, and lymphadenopathy following a medication change.
  • Liver failure is the leading cause of mortality in DRESS syndrome
  • Frequently co-exists with herpesvirus, CMV, or EBV reactivation
  • The mainstay of treatment is stopping the offending agent
  • DRESS without severe organ involvement is treated outpatient with topical steroids
  • DRESS with severe organ involvement warrants hospitalization and the use of systemic corticosteroids"

Acute Heart Failure

Current Heart Failure Reports
Sameer Kurmani & Iain Squire. Curr Heart Fail Rep - DOI 10.1007/s11897-017-0351-y
Open Access - First Online: 07 August 2017
"Summary
We provide an introduction to AHF and discuss its definition, causes and precipitants. We also present epidemiological and demographic data to suggest that there is significant patient heterogeneity and that AHF is not a single pathology, but rather a range of pathophysiological entities. This poses a challenge when designing clinical trials and may, at least in part, explain why the results in this area have been largely disappointing."

Apnoeic Oxygenation

St.Emlyn’s - August 16, 2017 - By Simon Carley
..."This is a randomised controlled trial which is spot on for a therapeutic trial. Patients were randomised either to having 15L/min through nasal canullae or not. Pretty simple design in all honesty, which is great. Oxygen sats were meaured throughout with apnoea time being measured from the point of the laryngoscope entering the mouth to ETCO2 being seen on the monitor. That all seems fair enough to me.
Cleverly they recorded all O2 sats using a remote observer as a way of introducing a degree of blinding into the study as it was clearly impossible to blind the clinicians at the bedside..."

martes, 15 de agosto de 2017

Amiodarone in Cardiac Arrest

R.E.B.E.L.EM - August 14, 2017 - By Alicia Skelton
"Authors Conclusions:
“Amiodarone significantly improves survival to hospital admission. However, amiodarone does not improve survival to discharge or neurological outcomes compared to placebo or other antidysrhythmics.”
Our Conclusions: 
This systematic review and meta-analysis demonstrates that while amiodarone significantly increased survival to hospital to admission compared with placebo or other antidysrhythmics for OHCA, it does not significantly improve favorable neurological outcome or survival to hospital discharge. Ultimately, these outcomes are more meaningful from both a cost and quality of life perspective.
Potential to Impact Current Practice: 
 Given this review and analysis, providers should consider removing amiodarone from their routine cardiac arrest algorithm and focus on interventions that have the ability to improve survival such as high quality chest compressions and defibrillation.
Clinical Bottom Line: 
Based on the available evidence, amiodarone does not appear to be associated with any meaningful clinical outcome in cardiac arrest including neurological outcome or survival to hospital discharge."

Osmolal gap

PulmCrit
PulmCrit- August 14, 2017 - By Josh Farkas
..."This raises the question: What is the performance of the serum osmolal gap? Is this an evidence-based test for intoxicated patients?
  • There is disagreement regarding the best formula to calculate the osmolal gap, and what the appropriate cutoff value should be.
  • Most patients with an elevated osmolal gap don’t have toxic alcohol poisoning. Osmolal gap may be increased by numerous factors including renal failure, ketoacidosis, shock, electrolyte abnormalities, and contrast dye.
  • Performance of the osmolal gap to detect toxic alcohols varies widely depending on the equation used and laboratory techniques. A recent study suggests that it might have a positive likelihood ratio of ~1.2-1.7 and a negative likelihood ratio of ~0.3-0.45.
  • These performance characteristics are inadequate for broad clinical use, with the potential for frequent false-positive and false-negative results.
  • The use of osmolal gap as a diagnostic test for toxic alcohols is poorly supported by available evidence. If a new test were developed with this level of evidentiary support, there is no way it would gain FDA approval."

The expert patient in the ED

the expert patient in the ED St.Emlyn's
St. Emlyn´s - By Simon Carley - August 11, 2017
"Conclusions
  • No matter how good a department is, and I love mine with a passion (told you I am a dinosaur) it can always be better.
  • The ‘expert patient’ can be dangerous but simple safe processing reduces that danger.
  • Do not take the “expert’s diagnosis” for granted, no matter how senior, always do the simple skills we were taught in medical school.
  • No one else noticed my low sodium on my first visit, yet roughly a third (32%) of acute head injuries may have low sodium with ADH secretion believed to be the cause (so any FRCEM candidates might want to look out for a question on this soon).
  • Have systems set up in your department to counter the real problems that VIPs can encounter. It’s pretty simple in theory but does demand a tight team who trust each other and look after each other."

martes, 8 de agosto de 2017

Perichondritis

R.E.B.E.L.EM - July 20, 2017
"Take-Home Points:
  • Perichondritis is a pseudomonal infection of the outer ear marked by tenderness and erythema and distinguished by a spared lobule.
  • Misdiagnosis or mistreatment can result in devastating patient outcomes.
  • Treatment of perichondritis includes a foundation of anti-pseudomonal antibiotic therapy with or without surgical intervention.
  • Urgent specialist evaluation and hospital admission should be considered when abscess or necrosis are suspected or patient follow-up may be challenging.
  • Fluoroquinolone therapy appears safe in pediatric populations in the context of appropriate monitoring and follow-up."


lunes, 7 de agosto de 2017

Spinal Immobilization

R.E.B.E.L.EM - August 07, 2017
"THE BOTTOM LINE:
  • There is no high-level evidence that prehospital spinal immobilization positively impacts patient oriented outcomes
    • Spinal Immobilization Does NOT Help Immobilize the Cervical Spine
    • Spinal Immobilization Does NOT Decrease Rates of Spinal Cord Injury
    • Spinal Immobilization Increases the Difficulty of Airway Management
    • Spinal Immobilization Can Cause Pressure Ulcers
    • Spinal Immobilization Changes the Physical Exam
    • Spinal Immobilization Worsens Pulmonary Function
    • Spinal Immobilization Increases Intracranial Pressure
  • There is no evidence that immobilizing awake, alert patients without deficits/complaints provides benefit
  • Selective spinal immobilization protocols can help identify patients at low risk for injury and avoid immobilization"

The SPARK Study

The Bottom Line - August 4, 2017 - By Celia Bradford
(Bagshaw. J Crit Care 2017;epublished July 12th)
"Clinical Question
In critically ill patients, with mild renal failure, does furosemide infusion compared to placebo worsen kidney function?
Authors’ Conclusions
A furosemide infusion compared to placebo did not change the incidence of progression to a worse degree of kidney injury"

miércoles, 2 de agosto de 2017

A Year at Sydney HEMS

St. Emlyn´s - August 2, 2017
"This post, detailing my reflections on clinical retrieval medicine, is the fifth in a series recording my reflections on the twelve months I spent working for Sydney HEMS in prehospital and retrieval medicine. The first post covers medical education – you can find it here. The second covers human factors – you can find it here. The third covers clinical lessons from retrieval medicine – you can find it here. The fourth covers more clinical lessons – you can find it here.
This post is about the leadership lessons I’ve learned during my year of prehospital and retrieval medicine. As a registrar in the service, much like in Emergency Medicine in the UK, the day-to-day clinical work was the same irrespective of whether you were a consultant or registrar..."

martes, 1 de agosto de 2017

Articles of the Month (July 2017)

First10EM - By Justin Morgenstern - July 31, 2017
"Welcome back to another edition of the articles of the month. I am considering changing the format of my article reviews going forward. Because multiple articles are grouped together in a single post, I frequently have a hard time finding articles I have reviewed when I am looking for them. I might start posting each article as its own blog post, with 8-10 posts over the course of a month. I’d love to hear what people think of that idea – whether it would be better or worse for your reading habits. Either way, Casey and I will still discuss the best articles each month on the Broome Docs podcast."

viernes, 28 de julio de 2017

Extremity Hematoma

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emDocs - Jul 26, 2017 - Authors: Morales J and Williams M
Edited by: Koyfman A and Long B
"Pearls:
  • Most extremity hematomas can be managed conservatively without the need for imaging studies.
  • Consider imaging if the patient is not improving as expected or concerned for other complicating injury such as fracture, tumor, or arterial vascular injury. Musculoskeletal ultrasound has been found to be a useful tool in evaluating hematomas, muscle contusions and other muscle injuries but is operator dependent. Soft tissue MRI generally not indicated in the ED setting.
  • Myositis ossificans takes approximately 6 weeks to be visualized on plain film.
  • Have a low threshold to evaluate for developing compartment syndrome if suspicious based on clinical findings.
  • Know potential indications for emergent surgical evacuation and admission.
  • Antithrombotic/anticoagulant reversal generally not indicated unless compartment syndrome or hemodynamic instability. Specialist consultation advised to assist with risk/benefit assessment."