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

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Sunday, May 22, 2022

Monkeypox

First10EM - By Justin Morgenstern - May 19, 2022 / Updated May 18, 2022
In the Rapid Review series, I briefly review the key points of a clinical review paper (or two). With reports of monkeypox cases arising around the world (Canada, United Kingdom, Europe, and United States), I figured we had better do a quick review of the disease, because it was either never taught in my medical school curriculum, or I missed that day.
The papers: 
  • Di Giulio DB, Eckburg PB. Human monkeypox: an emerging zoonosis. Lancet Infect Dis. 2004 Jan;4(1):15-25. doi: 10.1016/s1473-3099(03)00856-9. Erratum in: Lancet Infect Dis. 2004 Apr;4(4):251. PMID: 14720564
  • McCollum AM, Damon IK. Human monkeypox. Clin Infect Dis. 2014 Jan;58(2):260-7. doi: 10.1093/cid/cit703. Epub 2013 Oct 24. Erratum in: Clin Infect Dis. 2014 Jun;58(12):1792. PMID: 24158414


Compartment Syndrome

REBEL Core Cast 80.0 - May 04, 2022 - By Anand Swaminathan
Take Home Points
  • Compartment syndrome is a life and limb threatening emergency that requires early recognition, prompt diagnosis and immediate management with fasciotomy
  • While clinical evaluation is flawed, pain out of proportion to injury and pain with passive stretch of muscles within the compartment are the best screening tools.
  • Do not wait for the development of pallor, absence of pulse or paralysis to consult surgery. These are late findings that may only arise once the limb is non-salvageable. 
  • In unconscious patients, there should be a low threshold to measure compartment pressure in patients who are at risk as clinical signs cannot be evaluated
  • When measuring compartment pressures, look for an absolute pressure > 30 mm Hg and perfusion pressure (DBP – compartment pressure) of < 30 mm Hg. All patients with a clinical suspicion and normal pressures should have repeat pressures measured.

Monday, May 16, 2022

Alcohol Withdrawal Syndrome

emDOCs - May 16, 2022 - By Jack Yancey; Drew Micciche
Reviewed by: Todd Phillips; Alex Koyfman; Brit Long
Summary
  • CNS hyperexcitation is the primary physiological abnormality seen in AWS
  • AWS is a clinical diagnosis, and a diagnosis of exclusion. Consider other disease mimickers and rule them out during your workup
  • Early diagnosis and treatment of AWS prevents symptom progression into life-threatening complications (withdrawal seizures, delirium tremens)
  • Stages of AWS: withdrawal symptoms, hallucinations, withdrawal seizures, delirium tremens
  • Benzodiazepines are the mainstay of treatment
  • Patients with signs of mild withdrawal can be considered for discharge after receiving treatment
  • Treat severe AWS with rapidly escalating doses of benzodiazepines to reduce risk of withdrawal seizures, delirium tremens, and need for intubation. Appropriate level of sedation is drowsy yet arousable
  • Use phenobarbital for benzodiazepine-refractory AWS
Pearls/Pitfalls
  • CIWA scores have questionable utility in the ED setting. They are nursing driven, and are not diagnostic for AWS.
  • Inspect all patients for signs of head trauma and neurological deficits. Have a low threshold for CT head imaging
  • Certain patients may develop withdrawal with mild to modestly elevated ethanol levels, however their clinical presentation and daily alcohol consumption should always be factored into the equation when determining whether the patient is in acute withdrawal.

Thursday, May 12, 2022

In-Flight Emergencies

EM Ottawa - By Steven Sanders, Sam Wilson, Josee Malette - May 12, 2022
To conclude, I leave you with a few general take-home points:
  • Given the growth of air travel, and the aging, generally more comorbid population, in-flight medical emergencies are becoming more common.
  • We are emergency experts. We’re experts in dealing with uncertainty. Experts in working with limited resources. Experts in chaos. These problems fall squarely in our wheelhouse, and we should be ready to deal with them. I hope this blog post helped you feel a little bit more prepared.
  • Trying to navigate the laws is too complicated – don’t worry about it too much. We have ethical and professional duty to help and know that we a well-protected in doing so.
  • This is an austere, uncomfortable environment. As you’ve read, the emergency medical kits are limited and vary by airline. Do what you can with what you have. Know your limitations and accept them.

Saturday, May 7, 2022

AKI ED Management

emDOCs - May 06, 2022 - By Anton Helman
Originally published at EM Cases. Reposted with permission
Listen to accompany podcast HERE
Take Home Points for AKI ED Management
  • First and foremost, rule out immediate life threats – hyperkalemia and severe acidosis
  • Most patients with AKI simply require “fluids and a foley”, however a more nuanced treatment algorithm should be considered in complex cases
  • Have respect for new severe hypertension in the setting of AKI as these patients may have an intrarenal cause that requires urgent BP control and internal medicine consultation for further workup
  • Get help from ICU for patients with AKI, pulmonary edema and cardiogenic shock as these patients are challenging to manage
  • Not all patients with AKI require imaging; bilateral ureteric obstruction is a rare cause of AKI
  • Avoid nephrotoxins in patients with AKI whenever possible (NSAIDs, ACEi/ARBs, gentamicin, amphotericin)
  • The resuscitation fluid of choice in AKI patients is Ringer’s Lactate in small boluses with frequent assessments of volume status
  • Use AEIOU mnemonic for emergency indications for dialysis; for other AKI patients it is generally safe to delay dialysis for 1-2 days
  • IV bicarb is reasonable in AKI patients with refractory severe metabolic acidosis

Sunday, May 1, 2022

Pericarditis and Myocarditis

EM Ottawa - By Maria Doubova & Lucy Karp - April 28, 2022
Chest pain is one of the most common presentations to the emergency department (ED) and includes a wide differential diagnosis. In today’s post, we will review a less common cause of chest pain seen in the ED: pericarditis and myocarditis. We will also review considerations for these disease processes as it pertains to COVID-19…
Take Home Points
  • Keep myocarditis on the differential diagnosis for young patients presenting with chest pain and dyspnea. Have a low threshold to order a troponin in the workup of these patients.
  • The prognosis following a diagnosis of myocarditis is highly dependent on the underlying etiology.
Take Home Points (in the setting of Covid-19)
  • Investigate for post-vaccine myocarditis in patients within 42 days of COVID-19 mRNA vaccination.
  • Most patients have good prognosis following the disease.
  • Fill out the Adverse Events form for these patients.

ED Procedures without an IV

REBEL EM - By WriSalim Rezaie - October 04, 2018
Background: Establishing IV access has become the norm for patients presenting to the ED. However with increasing patient volumes, difficulty and delays in acquiring IV access, it seems that anything that could expedite care, reduce pain and suffering, and improve patient care would be welcomed in the ED. There are several tricks I have learned along the way to achieve just this: No IV access, no problem…performing procedures like a boss…
  • Isopropyl alcohol inhalation for nausea/vomiting is reasonable
  • Sphenopalatine ganglion block for frontal headaches may have a roll
  • Modified valsalva maneuver for stable SVT is superior to standard valsalva techniques
  • Use a spinal needle with sheath (for better visibility and protection) and disposable speculum (to put the light source anteriorly) for peritonsillar abscess drainage
  • Davos and Spaso techniques with intra-articular lidocaine could reduce procedural sedation with anterior shoulder dislocation
  • Nebulized TXA can be a temporizing measure to halt acute bleeding in patients with acute hemoptysis

DKA Myths

REBEL EM - By Salim Rezaie - November 02, 2015
„Recently, I was asked to give a lecture to both my residents and nurses at the University of Texas Health Science Center at San Antonio (UTHSCSA) on some common DKA myths. Now this topic was originally covered by my good friend Anand Swaminathan on multiple platforms and I did ask his permission to create this blogpost with the idea of improving patient care and wanted to express full disclosure of that fact. I specifically covered four common myths that I still see people doing in regards to DKA management…“
Myth #1: We should get ABGs instead of VBGs in DKA
Myth #2: After Intravenous Fluids (IVF), Insulin is the Next Step
Myth #3: Once pH <7.1, Patients Need Bicarbonate Therapy
Myth #4: We Should Bolus Insulin Before Starting the Infusion

Tuesday, April 26, 2022

Gout

emDOCs - April 25, 2022, By Shannon M. Burke and Benjamin H. Schnapp
Reviewed by: Michael J. Yoo, Alex Koyfman and Brit Long

                            
Key Points:
  • It’s possible to diagnose acute gout flares clinically, but the gold standard is arthrocentesis. Use this whenever there is concern for a septic joint or if the clinical picture is not entirely consistent with an acute gout flare.
  • Treatment of gout is anti-inflammatory medications, and this mostly means NSAIDs, corticosteroids, and colchicine.
    • Avoid the combination of NSAIDs and corticosteroids due to additive GI toxicity.
    • Remember there are contraindications to these medications. Pay attention to a patient’s kidney function, liver function, and history of diabetes.
    • Certain patients may also be eligible for initiation of urate-lowering therapy even in an acute gout flare.
  • Opioids are not a first-line treatment for gout, although they may be used if there are significant contraindicationsto anti-inflammatory medications.

Saline or Blood in Trauma

First10 EM - By Justin Morgenstern - April 25, 2022
Trauma patients aren’t bleeding salty water, so why would you give them intravenous salty water? It doesn’t make any sense. Obviously, if they require fluid resuscitation, it should be with the fluid they are losing. So when we compare blood products to normal saline in an RCT (the RePHILL study), we are bound to see a massive benefit, right? RIGHT?!
The paper: The RePHILL trial. Crombie N, Doughty HA, Bishop JRB, Desai A, Dixon EF, Hancox JM, Herbert MJ, Leech C, Lewis SJ, Nash MR, Naumann DN, Slinn G, Smith H, Smith IM, Wale RK, Wilson A, Ives N, Perkins GD; RePHILL collaborative group. Resuscitation with blood products in patients with trauma-related haemorrhagic shock receiving prehospital care (RePHILL): a multicentre, open-label, randomised, controlled, phase 3 trial. Lancet Haematol. 2022 Apr;9(4):e250-e261. doi: 10.1016/S2352-3026(22)00040-0. PMID: 35271808 ISRCTN62326938
Bottom line
Despite some very strong physiologic reasons that blood should be preferred in trauma patients, this RCT failed to demonstrate any benefit over normal saline. I still would never preferentially use saline if I thought a patient needed blood, but this trial should reassure you if you need to give a small crystalloid bolus while waiting for blood to arrive.

HEART Score

EMOttawa - By Graham Mazereeuw - April 25, 2022
Questions and Methods: This study compared agreement in HEART scores derived by ED physicians and those derived by researchers using a prospective cohort study of adults with cardiac chest pain.
Findings: In a sample of 336 patients, HEART score agreement between ED clinicians and researchers was moderate: 78% (Cohen’s Kappa 0.48, 95% confidence interval 0.37 to 0.58).
Limitations: Research-derived HEART scores performed poorly at predicting 30-day MACE, verification bias limited the discovery of MACE in low-risk HEART score patients, and the study was powered for an outcome other than the primary outcome.
Interpretation: HEART scores completed by ED physicians are highly sensitive at ruling out 30-day MACE in patients with chest pain, despite only moderate agreement between clinicians and researchers. HEART scores may be most relevant to the management of patients with a moderate pre-test probability of CAD.


Friday, April 15, 2022

AHF Disposition

emDOCs
emDOCs Podcast: Episode 51 - April 13, 2022 By Brit Long
Welcome back to emDOCs cast with Brit Long, MD. Today we have the last in the podcast series evaluating acute heart failure: disposition.
Introduction:
  • Over 6.2 million patients live with HF in the U.S., and over 8 million cases of HF are projected by 2030.
  • More than 90% of patients in AHF present to the emergency department (ED), and over 80% of these patients are hospitalized in the U.S.
  • Mortality ranges from 4-12% for admitted patients, which may reach 25% in high-risk patients.
  • Disposition can be challenging: multiple comorbidities, different precipitating factors, range of cardiac abnormalities, and presenting signs and symptoms. There are also potential issues with health literacy, self-care, and ability to follow-up for short-term re-evaluation.
  • While discharge rates in the U.S. are low, they are higher in other countries (Canada) for heart failure.

MRI for TGA

SGEM#364 - By admin - April 9, 2022
…Transient global amnesia (TGA) is an idiopathic acute neurological disorder that presents with sudden onset anterograde memory loss. It was first described as a syndrome in 1956 by Courjon and Guyotat and also by Bender. Fisher and Adams formally described as TGA in 1964. The usual presentation is a patient between 50 and 70 years of age who are cognitively and neurologically intact but asking repetitive questions, unable to form new memory. Symptoms do not last very long and resolve within 24 hours. The incidence has been reported as 23.5 per 100,000 people per year and is more common in people who get migraine headaches. TGA is often precipitated by physical or emotional stressors, pain, the Valsalva maneuver, hot or cold-water immersion or sexual intercourse. Diagnosing TGA combines items put forward by Hodges and Warlow and Caplan. This results in seven diagnostic criteria for TGA…
CLINICAL QUESTION: WHAT IS THE SENSITIVITY OF DIFFUSION-WEIGHTED MAGNETIC RESONANCE IMAGING (DW-MRI) AS A FUNCTION OF TIME FROM SYMPTOM ONSET COMPARED TO CLINICAL DIAGNOSIS OF TGA?
SGEM BOTTOM LINE: URGENT DW-MRI FOR PATIENTS MEETING STANDARD DIAGNOSTIC CRITERIA FOR TGA IS A LOW YIELD INTERVENTION.


Sunday, April 10, 2022

Rib Fractures

emDOCs
EM@3AM - April 9, 2022 - By Seth Cohen; Joshua Kern
Reviewed by: Alex Koyfman and Brit Long
Key Points: 
  • Rib fractures can have serious complications including hemo/pneumothorax, aortic injury, and splenic/liver lacerations
  • Adults, especially elderly patients, have a high risk of complications with rib fractures
  • Evaluate with a chest x-ray. Follow up with a CT if there is suspicion for any chest/abdomen injuries that would require a change in management
  • Reinforce the importance of an incentive spirometer and appropriate analgesia

Thursday, April 7, 2022

Bariatric Surgery Complications

EMOttawa - By Renee Bradley, Lucy Karp - April 7, 2022
As emergency physicians, we frequently see patient with metabolic syndromes and obesity. Globally, a significant rise in obesity has been observed over the last 30 years, including a dramatic rise in Canada28,32. From 1985 to 2016, obesity increased by more than 300% in Canada29, and currently 1.2 million Canadians have severe obesity23. It is estimated that 1000 bariatric surgeries were performed in 2017, and these numbers are rising. Although the advancement of modern laparoscopic surgical procedures has decreased the rates of post-operative complications, hospitalizations and death, these risks are still present for patients undergoing bariatric surgery…

Digoxin Toxicity

REBEL EM - Febrero 21, 2022 - By Santiago Lopez, Katrina D’Amore, John Kashani
Post Peer Reviewed By: Anand Swaminathan and Salim R. Rezaie
Take Home Points
  • Although the overall prevalence of digoxin toxicity seems to be decreasing, one must think of this toxicity when facing a patient with bradycardia and “something else”
  • Obtain a 12 lead EKG, serum electrolytes and serum digoxin level initially
  • Digoxin toxicity may mimic several different EKG patterns
  • “Scooped” ST segments signify that the patient is taking digoxin (“dig effect”) and is not an indication of digoxin toxicity
  • Simple doses to remember for Digibind
    • 5 vials in hemodynamically stable patients
    • 10 vials in unstable patients
    • 20 vials in the setting of cardiac arrest
    • Of note: consult your pharmacy to see how many vials are available at your local hospital

Monday, April 4, 2022

Pericardial Effusion

emDOCs
emDOCs - April 4, 2022 - By Taylor Franz, Janet S. Young
Reviewed by: Stephen Alerhand; Alex Koyfman; Brit Long
Pearls:
  • Predictive morbidity of developing tamponade may be dependent upon causative etiology. Malignant and tuberculous/bacterial effusions are more likely to develop cardiac tamponade when compared to viral or iatrogenic causes.
  • Tachycardia is the most common presenting sign for pericardial effusion. EKG findings are tachycardia, low voltage, and electrical alternans. Bedside ultrasound is diagnostic.
  • Hemodynamically stable cardiac tamponade can be managed with pericardiocentesis or pericardial window.
  • Hemodynamically unstable patients need emergent ultrasound-guided pericardiocentesis. Prep a large area of the chest in case you need to change your approach. Keep your needle in-plane at all times to avoid damage to surrounding structures.

Overdiagnosis

First10EM - By Justin Morgenstern - April 4, 2022
The paper: Vigna M, Vigna C, Lang ES. Overdiagnosis in the emergency department: a sharper focus. Intern Emerg Med. 2022 Mar 5. doi: 10.1007/s11739-022-02952-8. Epub ahead of print. PMID: 35249191
…“ The essential basic concept is that sometimes (perhaps often) making a diagnosis can actually cause a patient harm. This might occur with incidental findings, when normal human variation is transformed into disease. It might occur with self resolving illnesses, such that a condition that would have disappeared on its own is medicalized, resulting in side effects from treatment but no chance of benefit. It might occur with very slowly progressive pathology which would have never caused the patient harm, but is now pursued with unnecessary interventions. False positives are technically a different concept, in that they represent an error with no true underlying pathology, but the result is the same: a patient receives an unnecessary or inappropriate label that ends up resulting in harm...“

Sunday, April 3, 2022

Thrombolytics in DOACs

ALiEM - April 2, 2022 - By: Bryan D. Hayes and Mike O'Brien
Bottom Line
  • The management of acute ischemic stroke in patients receiving prior anticoagulation presents a challenging clinical scenario.
  • Studies to date fail to include enough patients to evaluate the true risk of bleeding.
  • This study supports the current guideline recommendation to avoid alteplase in patients receiving a DOAC within 0-48 hours due to the increased risk of intracranial hemorrhage.

Friday, April 1, 2022

PPIs for GI bleeds

First10EM - By Justin Morgenstern - March 30, 2022
“The clinical summary
Although there are still large gaps in this evidence base, I think the clinical conclusion is very clear: PPIs should not be given. Every RCT conducted to date has been negative. There is no indication of clinical benefit, and we should be concerned about the possibility of an increase in mortality. 
Given the (marginal) benefit in patients with known bleeding ulcers, if a patient had a recent endoscopy with known peptic ulcer disease, I will give a single IV bolus of PPI. Given that the largest studies excluded the most critically ill patients, it seems reasonable to run further RCTs focusing specifically on that population. However, without further studies, I think it is very clear that we should not be prescribing PPIs, given their potential for harm and absolute lack of proven benefit“

AHF Management

emDOCs
emDOCs Podcast Episode 50 - March 30, 2022 - By Brit Long
Misconception #1: Diuretics are the mainstay of therapy in all cases of AHF
Pearl #1: In SCAPE, nitroglycerin and noninvasive positive pressure ventilation should be first-line therapies before diuresis.
Pearl #2: Several diuretic strategies can be used in patients with systemic congestion, and ultrafiltration may improve diuresis in patients refractory to IV diuretics.
Misconception #2: The safest way of providing nitroglycerin IV is to begin with small doses and titrate to relief of symptoms to ensure patient safety in those with pulmonary edema.
Pearl #3: Nitroglycerin IV in high bolus doses is safe and effective in SCAPE.
Misconception #3: Morphine is safe in AHF and should be administered in AHF.
Pearl #4: Morphine may be associated with harm in AHF based on observational data.
Misconception #4: In patients with cardiogenic shock and SBP <100 mmHg, dopamine is the best agent to improve cardiac output and perfusion.
Pearl #5 : Norepinephrine should be used instead of dopamine in cardiogenic shock with hypotension

Tuesday, March 29, 2022

Large Vessel Stroke

emdocs
emDocs - March 28, 2023 By Zack Brady; Maggie Moran; Brit Long
Review by: Alex Koyfman
„Pearls
  • Patients who present with symptoms of large vessel occlusion stroke should receive both a non-contrast CT scan of the head and a CT angiogram of the head and neck. CT perfusion imaging, if available, can assist.
  • Mechanical thrombectomy has clear benefit for patients with acute ischemic stroke secondary to a large vessel occlusion in the proximal anterior cerebral artery if treated within 6 hours.
  • Benefit of mechanical thrombectomy is likely in patients with LVOs who present in the 6-24 hour time frame, but should be based on clinical deficits and imaging.
  • Thrombectomy should be pursued if indicated in patients, regardless of tPA status“

Trauma Team Tips

St Emlyn ´s - By Iain Beardsell - March 29, 2022
„Learning points:
  • Think about yourself, the team and the environment. Are you fully rested and fit to fly?
  • Use a script and play a part. Whatever your personality you can be the leder the team needs
  • Thinks ahead; set time targets; don’t get angry and use humour and touch carefully
  • Checklists really aren’t cheating. They just give your brain space to think
  • Practice, practice, practice and be watched whenever possible“

Monday, March 21, 2022

Disposition of Acute Pancreatitis

emDocs 
emDocs - March 21, 2022 - By Jonathan Reeder
Reviewed by: Michael; Alex Koyfman; Brit Long
"Conclusion
Acute pancreatitis is a commonly encountered etiology of abdominal pain in the ED. Despite its ubiquity, the spectrum of disease severity is broad, posing many diagnostic and disposition challenges for the emergency physician. Keep in mind the following:
  • Try to establish the etiology of the pancreatitis. Without this knowledge, our ability to predict the disease course, and therefore disposition may be limited.
  • Imaging is not necessary but may be helpful in a particularly acute patient or in one with high levels of diagnostic uncertainty. Uncovering evidence of necrosis or localized complications will change the disposition.
  • No single scoring tool is perfect. They should not be used in isolation nor override clinical judgement. However, look for key markers that may help predict morbidity/mortality:
    • SIRS criteria
    • Older age
    • Evidence of large-volume fluid shifts, refractoriness to fluid repletion"

Tuesday, March 15, 2022

Acute Heart Failure Misconceptions

emDocs
emDOCs Podcast  Episode 49 - March 15, 2022 - By Brit Long
Misconception #1: Natriuretic peptide testing is always helpful in diagnosing or excluding AHF.
  • Pearl #1: Natriuretic peptides should only be used in conjunction with clinical evaluation, rather than using the test in isolation. There are other causes of elevated BNP.
Misconception #2: Chest radiograph is the go-to imaging test in AHF.
  • Pearl #2: Point of care ultrasound (POCUS) is a reliable too in assessing for pulmonary edema associated with heart failure

Atypical Headaches

TAMING THE SRU
TAMING THE SRU - By Casey Glenn - March 14, 2022 
"So the patient has a headache. How can one risk stratify them into primary or secondary causes? Patients with a secondary cause of their headache will often present with signs or symptoms that will aid in their diagnosis. There are symptoms that are classically referred to as the "red flag symptoms" that, if present, are suggestive of secondary causes of headaches and can be remembered by the SNOOP2 mnemonic:
  • Systemic symptoms: fever, chills, weight loss, HIV+, immunocompromised, or history of cancer
  • Neurologic symptoms: confusion, change in mental status, vision change, seizure, asymmetric reflexes
  • Onset: acute, sudden, or "thunderclap"
  • Older patient: >50 years old with new-onset or progressive headache
  • Previous headache history: first headache or change in character, severity, or frequency
  • Pregnant or postpartum
It is important to remember that patients presenting any "red flag symptom" require thorough workup and assessment, even if their symptoms are alleviated."

Monday, March 14, 2022

Epiglottitis

emDocs
emDocs - March 12, 2022 - By Rachel Bridwell  / Reviewed by: Alex Koyfman; Brit Long
Pearls
  • More common in adults who present with odynophagia, dysphagia, and over a more subacute time frameNormal oropharynx occurs in 90% of adults with epiglottitis
  • Lateral neck radiographs are a screening tool which may show the thumbprint or vallecula sign though have a high false positive rate
  • Factors associated with increased rates of intubation are diabetes mellitus, symptoms over 12-24 hours, stridor, drooling, tachypnea, hypercarbia, epiglottic abscess, and subglottic extension
  • Airway management has shifted from intubation/surgical airway in the operating room to awake fiberoptic intubation
  • Corticosteroids and nebulized epinephrine may assist in decompensating patients, but the literature is controversial

2021 AHA Chest Pain

First 10EM - By Justin Morgenstern - March 14, 2022
The paper: "Writing Committee Members, Gulati M, Levy PD, Mukherjee D, et al. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2021 Nov 30;78(22):e187-e285. doi: 10.1016/j.jacc.2021.07.053. Epub 2021 Oct 28. PMID: 34756653 [free full text]

Some of my key take-aways
This is a very long and dense publication. The majority of their recommendations are not practice changing (things like calling 911 if you have chest pain, or trying to get an ECG done within 10 minutes) and there is a lot that is irrelevant to emergency physicians. I am not going to attempt a comprehensive summary of the guidelines. Some people will want to read them all, and they are available for free online. I am just going to highlight a few points that I found interesting, potentially practice changing, or clearly wrong.
  • No stress tests in low risk patients
  • High sensitivity troponin is preferred
  • They like echo in intermediate risk patients
  • They are stuck in the STEMI/NSTEMI world
  • Share the decision making
  • Forget “atypical”
  • Their text sometimes doesn’t match their recommendations: Should you get a chest x-ray?
  • They really like structured risk assessment and clinical decision pathways
  • They give you a warranty period based on prior test results (which I don’t think is at all evidence based)

Monday, February 28, 2022

Potential Harms of IV fluids

emDOCs - February 28, 2022 - By Adam Lalley
Reviewed by: Mark Ramzy; Alex Koyfman; Brit Long
"Conclusion:
Fluid overload has been associated with increased post-operative complications and can be detrimental to multiple organ systems, with consequences including poor gas exchange, impaired renal function and slower wound healing.
Given that no ideal fluid exists, recent literature has suggested that physicians should treat crystalloids like any other prescribed drug. Some suggest that antibiotic selection might serve as a model. This framework involves considering the “4 D’s”:
  • Drug – consider the side effects of fluids (i.e., hyperchloremic metabolic acidosis) along with their benefits; the patient’s underlying conditions (i.e., kidney disease, heart failure, cirrhosis); the specific use of the fluid (i.e., resuscitation, replacement, maintenance); and the type of fluid that would best suit the patient’s needs.
  • Dosing – consider both the timing and the speed of fluid administration relative to the illness course along with the parameters you might use to monitor the patient’s response.
  • Duration – while the triggers to start fluid therapies are often clear, the triggers to stop them are often less evident. Emergency physicians, especially those in critical care, may benefit from establishing clear goals for fluid tapering.
  • De-escalation – the final step is knowing when to withdraw fluids when resuscitation is no longer required.
Hopefully, the framework above along with a review of the handful of conditions mentioned in this article can help emergency physicians to think more deliberately about resuscitative strategies. Sometimes it’s all too easy to check that box for fluids and risk rubbing salt into wounds."

Monday, February 21, 2022

Digoxin Toxicity

REBEL EM - By Anand Swaminathan - February 22, 2022
Take Home Points
  • Although the overall prevalence of digoxin toxicity seems to be decreasing, one must think of this toxicity when facing a patient with bradycardia and “something else”
  • Obtain a 12 lead EKG, serum electrolytes and serum digoxin level initially
  • Digoxin toxicity may mimic several different EKG patterns
  • “Scooped” ST segments signify that the patient is taking digoxin (“dig effect”) and is not an indication of digoxin toxicity
  • Simple doses to remember for Digibind
    • 5 vials in hemodynamically stable patients
    • 10 vials in unstable patients
    • 20 vials in the setting of cardiac arrest
    • Of note: consult your pharmacy to see how many vials are available at your local hospital

Thursday, February 17, 2022

Hemophilia Management

TAMING THE SRU
Taming The SRU - By Anne Grisoli - February 16, 2022
“Understanding how to acutely manage trauma or hemorrhage in patients with hemophilia is an important role for Emergency Providers. Morbidity and mortality for patients with hemophilia has improved with advanced prophylaxis. However, bleeding-related complications remain a leading cause of death and disability. Patients are generally knowledgeable about their disease and emergency physicians should feel comfortable starting treatment based on patient-reported symptoms and bleeding prior to initiating a diagnostic workup. Early consultation with the patient’s treating hematologist is essential, but should not delay treatment with factor replacement in severe or life-threatening hemorrhage. This post will detail further the pathophysiology and therapies for the bumps, bruises and bleeding of the hemophilias…”

Monday, February 14, 2022

Subarachnoid Hemorrhage

emDocs - February 14, 2022 - By John J. Campo and Manpreet Singh
Reviewed by: Joe Ravera; Alex Koyfman; Brit Long
Take Home Points
  • All patients presenting with a thunderclap headache should undergo evaluation for a SAH starting with a NCCTH.
  • If performed within 6 hours of onset of the headache, a negative NCCTH essentially rules out a SAH.
  • If outside the 6-hour window, further evaluation with an LP (or CTA) should be pursued if the CT is negative.
  • The most common mistake made by providers leading to misdiagnosis is not getting a NCCTH.

Procalcitonin

First10EM - By Justin Morgenstern - February 14, 2022
…”Procalcitonin just isn’t that great. The diagnostic accuracy (sensitivity/specificity) of the test is only moderate at best, and the numbers in these studies can’t be taken at face value. Because the threshold for calling procalcitonin positive or negative was often not prespecified, the authors could choose the threshold that provided the best numbers. Furthermore, most bacterial infections (such as pneumonia) don’t have a perfect gold standard, so there is even more room for bias when assessing the accuracy of procalcitonin.
Even if procalcitonin was very accurate, it shouldn’t be measured in a vacuum. We don’t need to know whether tests work, but rather whether they add anything to what we already have. Not many studies compared procalcitonin directly to physician judgment, but when the comparison is made, judgment appears to outperform procalcitonin. (Maisel 2012)
Either way, the only data supporting procalcitonin appears to be in the inpatient setting. From an emergency department standpoint, there just doesn’t seem to be any role for procalcitonin at this point in time…”

Thursday, February 10, 2022

Atrial Fibrillation/Flutter

EM Ottawa - By Pascale King, Amanda Mattice - February 10, 2022 
Atrial fibrillation (AF) is encountered with significant frequency in the Emergency Department (ED). In fact, atrial fibrillation is the single most common arrhythmia seen in the ED. As per the 2020 CCS review, AF resulted in 8815 same-day procedures, 76 964 ED visits, 25 892 acute care admissions in Canada in a given year.1 The CAEP 2021 guidelines were created in consensus with academic, community ED physicians and cardiologists from multiple sites across Canada. This post will review the literature leading to the new best practice guidelines and highlight major updates since the last management guidelines were posted in 2018 while identifying sources of practice variation.
This blog post will review the following and apply guidelines to common cases seen below:
  • New safe rhythm control timelines
  • Rate control and pitfalls
  • Stroke prevention
TAKE HOME POINTS
  • Refrain from aggressive treatment of secondary AF / AFL
  • Consider WPW in rapid HR for varying management
  • Rate control CHADS-65 positive ( >2 pts) patients at > 12 hrs if no anticoagulation on board
  • Calcium channel blockers and beta blockers are contraindicated in acute heart failure patients
  • Consider anticoagulation x 4 weeks in CHADS-65 negative patients after rhythm control

Wednesday, February 9, 2022

Hyperthermic Conditions

Canadi EM - February 8, 2022 - By Victoria Forcina
Takeaways:
„Both serotonin syndrome and neuroleptic malignant syndrome are key diagnoses to be considered in the differential for the hyperthermic patient. Look for key clues in the history such as medications taken, recent dose changes, and onset of symptoms. An easy way to remember the clinical features for the two syndromes are the mnemonics HARM and MAN. Once diagnosed, treatment revolves around discontinuation of the offending medications and supportive care. On further examination you also notice generalized “lead-pipe rigidity” in the patient. You make the diagnosis of neuroleptic malignant syndrome and ensure that no further doses of anti-psychotics are given; instead, you treat her with fluid resuscitation and continue to monitor her. You treat her agitation with benzodiazepines, but her symptoms persist and eventually admission to hospital is needed“