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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

"The Asthma Cocktail"

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martes, 25 de abril de 2017

The Easy IJ

R.E.B.E.L.EM - April 24, 2017 - Post Peer Reviewed By: Anand Swaminathan
"Background: We have all taken care of patients in whom IV access is difficult due to a multitude of reasons including repeated prior IV access, advanced vascular disease and shock. This often creates delays in patient care, increases ED length of stay, and uses up ED staff that have other patients to care for. Many providers have resorted to using IO access, particularly in critically ill patients due to speed of establishing access. In stable patients, however, this may be a less desirable. Ultrasound guidance has been a great addition in these patients. Ultrasound guided peripheral IVs and external jugular access would probably be the next “go to options” in these patients. The authors of this paper evaluate yet another option: The Easy IJ...
Author Conclusion: “The Easy IJ was inserted successfully in 88% of cases, with a mean time of 4.4 min. Loss of patency, the only complication, occurred in 14% of cases.”
Clinical Take Home Point: In stable patients, who have had failed attempts at establishing peripheral or external jugular vein access, the Easy IJ is a rapid method of achieving short-term IV access with no major adverse patient oriented outcomes."

lunes, 24 de abril de 2017

Diarrhea

EM Didactic - April 24, 2017 - By Chanana L 
(Originally posted by EM Lyceum on 2/11/2015)
"Acute gastrointestinal disorders are some of the most frequent problems evaluated by ED physicians. Complaints of diarrhea account for almost 5% of visits to the emergency departments. Although the disease entity is extremely prevalent and current evidence on the subject is nothing short of “voluminous,” practice differences among ED physicians in its evaluation and management are as varied and inconsistent as the stools themselves...
  1. When do you send stool cultures, stool ovum and parasites, and/or fecal WBC? How do you use the results in diagnosis and management?
  2. When do you get bloodwork? When do you pursue imaging?
  3. Which patients do you treat with antibiotics?
  4. What other medications do you use? Loperamide, Lomotil, Pepto? What about probiotics?"

sábado, 22 de abril de 2017

PROcalcitonin?

St.Emlyn's

St. Emlyn´s - April 21, 2017 - By Chris Gray
"At work the other day, someone mentioned that we could use procalcitonin to distinguish between viral and bacterial infections, particularly in the paediatric population. It was touted as the answer to that age-old question, “should I prescribe antibiotics for this sore throat/cough/[insert other symptom here]?”. Now, the ED wasn’t the first place I’d heard about this strange test. A year ago, on an intensive care rotation, they were regularly using procalcitonin levels to make decisions on when antibiotics should be stopped. It’s not a test that I’ve seen used since then though, certainly no surgical registrar has insisted on a procalcitonin level before they’ll see my patient with right iliac fossa tenderness, and I’ve not had any complaints from the medics or paediatricians that it hasn’t been added to the routine bloods. It’s definitely not become the new CRP (yet)!
But what is procalcitonin, and should we be using it more? Is it the miracle test that’s going to bring an end to those viral/bacterial conundrums? Is it just another fad that we’ll all use for a few years before replacing it with something else?..."


procalcitonin use

Mentoring Process in EM

emDocs - March 23, 2017 - Authors: Long B and Koyfman A - Edited by: Garmel G and  Runyon M 
*
emDocs - April 20, 2017 - Authors: Long B and Koyfman A - Edited by: Garmel G

"Key Points
  • Mentoring includes several stages: prescriptive, persuasive, collaborative, and confirmative, though these often overlap and are not always clear cut or linear.
  • The mentor and mentee must devote time and energy to the relationship.
  • Listening skills are essential for the mentor and mentee.
  • Each meeting is best having an agenda. The meeting should be scheduled in advance with a plan, a location and time, and a set amount of time set aside.
  • Coaching may be needed for mentees with less experience. Counseling and guidance are important through all stages.
  • Advising is one of the predominant components of the mentoring relationship. The mentee should identify his/her interests, skills, knowledge, and goals. Targeting areas for development, plan creation, indicators of success, and continual reassessment of progress are vital.
  • Mentors should seek to promote the interests of the mentee. Guidance and support may be needed if the mentee feels overwhelmed or experiences difficulty."

viernes, 21 de abril de 2017

Ketamine for sickle cell pain

The Original Kings of County - By kkelson • April 20, 2017
..."There are many alternatives for acute pain control: IV lidocaine, IV acetaminophen, propofol, and even dexmedetomidine (See Dr. Nguyen’s excellent lecture). One emergency department in New Jersey has even employed “energy healing and a wandering harpist” to avoid opioid prescriptions. Although these are all reasonable regimens, the medications listed above are administered intravenously, which may be a challenge in sickle cell patients with notoriously difficult venous access. (And there’s a certain lack of evidence that energy healing and the harp are effective as monotherapy.)
Ketamine, however, has been tested intranasally (IN) and found to be effective. One double-blinded RCT on 90 trauma patients in the ED compared either 1 mg/kg IN ketamine, 0.1 mg/kg IV morphine, or 0.15mg/kg IM morphine and found that the three regimens had similar onset and effectiveness at relieving pain. No adverse events were reported. Although a small study, IN ketamine’s utility in treating acute pain in the ED has been corroborated by other observational studies..."

Fluid Choice in DKA

The Original Kings of County - By Hernandez R - April 19, 2017
..."Diabetic ketoacidosis is one of the diseases for which emergency physicians are expected to have a plan to quickly put into action. The basics should be familiar: Manage the patient’s ABCs, place an IV, put the patient on a monitor to check vitals frequently, and start with an intravenous fluid bolus. There are nuances beyond what is described here, of course (frequent glucose monitoring, adding dextrose once the patient’s blood glucose reaches 200-250 mg/dl, and the like). But our focus will be on that critical first intervention: The choice of IV fluid.
There is a consensus among endocrinologists and emergentologists that the first and most critical intervention in DKA is fluid resuscitation. Different guidelines point to normal saline (0.9% saline solution, aka NS) as the initial fluid of choice. Hydration should initially proceed rapidly at a rate of 1-1.5 liters over the first hour to support hemodynamic functions (e.g., kidney and brain perfusion). The rest of the fluid is meant to replace what was lost from the intracellular and interstitial compartments and should be given over the next 24 hours. [ Lately, some researchers have sought to compare balanced saline solutions (Plasma-Lyte, lactated Ringer’s, and others) to normal saline in DKA, because there is no data showing that NS is truly the best choice. This is an especially salient issue if you are managing DKA patients who are boarding in the Emergency Department. We will not be discussing colloids and hypertonic solution..."

The Mathematics of Syncope

Emergency Physicians Monthly
Emergency Physicians Monthly - April 19, 2017 - By Pines J and Rezaie S
"The PESIT trial deconstructed
Syncope is a familiar complaint for emergency physicians, accounting for 1-3% of ED visits. In general, the causes are mostly benign and self-limited; however, sometimes syncope can be a symptom of a more serious condition, such as acute coronary syndrome, malignant arrhythmia, or even pulmonary embolism (PE). Nevertheless, the ED diagnostic evaluation of syncope is often less than gratifying. A small percentage are diagnosed with something serious, while a larger group with negative ED work-ups are still thought to be high-risk and admitted for further observation and work-up. Unfortunately, there is no real gold standard test or validated decision instruments for syncope..."

Post Intubation Hypotension

R.E.B.E.L. EM - Emergency Medicine Blog
R.E.B.E.L.EM - April 20, 2017 - By Rob Bryant - Post Peer Reviewed By: Salim Rezaie
"Summary:
Anticipate that intubation can worsen underlying physiologic parameters, and can cause some intubation specific causes of hypotension. Anticipating post intubation hypotension and being ready to correct specific causes is an essential part of any intubation.
Transform your mantra for post intubation hypotension evaluation from Resuscitate, Intubate, Panic like #$@#, to Resuscitate, Intubate, Anticipate.
Remember this sage advice from Louis Pasteur: ‘Fortune favors the prepared mind’. The better you plan your intubation (see Salim’s HOP killer series) the less likely you will be dealing with post intubation hypotension."

jueves, 20 de abril de 2017

New drugs, new toxicities

Biomed Central
Kroschinsky et al. Critical Care (2017) 21:89 - DOI 10.1186/s13054-017-1678-1
"Abstract 
Pharmacological and cellular treatment of cancer is changing dramatically with benefits for patient outcome and comfort, but also with new toxicity profiles. The majority of adverse events can be classified as mild or moderate, but severe and life-threatening complications requiring ICU admission also occur. This review will focus on pathophysiology, symptoms, and management of these events based on the available literature. While standard antineoplastic therapy is associated with immunosuppression and infections, some of the recent approaches induce overwhelming inflammation and autoimmunity. Cytokine-release syndrome (CRS) describes a complex of symptoms including fever, hypotension, and skin reactions as well as lab abnormalities. CRS may occur after the infusion of monoclonal or bispecific antibodies (MABs, BABs) targeting immune effectors and tumor cells and is a major concern in recipients of chimeric antigen receptor (CAR) modified T lymphocytes as well. BAB and CAR T-cell treatment may also be compromised by central nervous system (CNS) toxicities such as encephalopathy, cerebellar alteration, disturbed consciousness, or seizures. While CRS is known to be induced by exceedingly high levels of inflammatory cytokines, the pathophysiology of CNS events is still unclear. Treatment with antibodies against inhibiting immune checkpoints can lead to immune-related adverse events (IRAEs); colitis, diarrhea, and endocrine disorders are often the cause for ICU admissions. Respiratory distress is the main reason for ICU treatment in cancer patients and is attributable to infectious agents in most cases. In addition, some of the new drugs are reported to cause non-infectious lung complications. While drug-induced interstitial pneumonitis was observed in a substantial number of patients treated with phosphoinositol-3-kinase inhibitors, IRAEs may also affect the lungs. Inhibitors of angiogenetic pathways have increased the antineoplastic portfolio. However, vessel formation is also essential for regeneration and tissue repair. Therefore, severe vascular side effects, including thromboembolic events, gastrointestinal bleeding or perforation, hypertension, and congestive heart failure, compromise antitumor efficacy. The limited knowledge of the pathophysiology and management of life-threatening complications relating to new cancer drugs presents a need to provide ICU staff, oncologists, and organ specialists with evidence-based algorithms"

miércoles, 19 de abril de 2017

European Curriculum of EM


April 19, 2017 
"A small committee from the EUSEM Education committee and the EMERGE on behalf of the UEMS Section and Board of Emergency medicine has revised the European Curriculum of Emergency medicine to align it to the recent developments of the discipline. The core curriculum exists to identify the knowledge, skills and behaviors that the physician must possess. This naturally changes as the specialty evolves and in the light of experience of using the curriculum to guide training and assessment. This updated curriculum includes new topics or clarifies existing topics where they are relevant or pertinent to current emergency medicine practice.
This allows alignment of the curriculum to the topics tested in the EBEEM (European Board Examination in Emergency Medicine) and ensures that the developing emergency physician knows all the competences required for the scope of practice of emergency medicine.
See the revised curriculum here."

Sonography in Hypotension and Cardiac Arrest

An online community of practice for Canadian EM physicians
CanadiEM -  By David Lussier - April 18, 2017
"Cardiac arrest and hypotension are synonymous with emergency medicine. Over the years, point of care ultrasound (PoCUS) has become an extension of our stethoscope. The recently published consensus statement from the International Federation for Emergency Medicine (IFEM) aims to provide guidance for PoCUS use in these situations, and describes the Sonography in Hypotension and Cardiac Arrest (SHoC Consensus) protocols.
The guidelines were developed based upon expert consensus formulated using three rounds of a modified Delphi approach. Recommendations were based on existing protocols and relevant literature. Disease incidence was also considered, and scanning is to be prioritized based on clinical probability.
Ultimately, two protocols were developed, one for cardiac arrest and one for undifferentiated hypotension. Each protocol included core views, which are performed routinely for all patients; supplementary views, which are only performed on a case by case basis; and additional scans, which are performed when additional investigation is required. When interpreting each view, it is important to investigate each of the “4 Fs”: fluid, form, function, and filling. This approach is illustrated below using two cases."

martes, 18 de abril de 2017

Resuscitate Before You Endoscopate?

R.E.B.E.L.EM Episode 36 – April 17, 2017
"Clinical Take Home Point:
In HD unstable patients the triage point to deciding on how early to perform endoscopy is response to resuscitation. If they stabilize, they can go to the ICU with frequent assessments with a courtesy call to our GI colleagues. The patients who transiently stabilize or don’t stabilize at all despite resuscitation (i.e. Already doing everything that we can from a medical standpoint: blood products, pressors, intubation, PPI, Octreotide, etc.) need hemostasis and the only way this is going to happen is with endoscopy. For these patients, we need to get GI in at whatever time of the day it is. So you still resuscitate before endoscopy (or as I like to say resuscitate before you endoscopate), but the response to that resuscitation is what determines who should get scoped sooner (i.e <2hrs, <3hrs, <6hr etc…)"

domingo, 16 de abril de 2017

Urinary tract infections

First10EM
First10EM - By Justin Morgenstern - April 15, 2017
"For this month’s Emergency Medicine Cases, Anton kindly asked me to act as a guest expert on the topic of urinary tract infections. The episode, which I think is fantastic, can be found here. In preparing for the episode, I ended up reading a lot, learning a lot, and taking relatively extensive notes. Although it doesn’t fit with the usual content of First10EM, I decided to share my notes, as I think some people might find them interesting, and they also provide links to all the literature we mention in the podcast..."

Synthetic Cannabinoids

St Emlyn´s - By Richard Carden - April 15, 2017
..."SCRAs are common, and becoming increasingly so globally. Acute specialties are switched on and are becoming increasingly aware of the burden of this problem. In the UK, the IONA study and the WEDINOS project are aiming to further characterise the problem and the agents at play. An important document to read, if you are interested, was published in 2009 by the European Monitoring Centre for Drugs and Drug Addiction can be found here.
Vulnerable groups are especially likely to affected by the availability of SCRAs, especially the homeless, adolescents and prisoners. Bear that in mind when confronted with unexplainable physiology. It is often largely irrelevant to ask what an individual has taken, but as the signs and symptoms do not fit any one particular toxidrome, it may help make a diagnosis.
Without wanting to precipitate a debate; the now-illegality of these substances mean even less quality control in their production. We really don’t know how or where they are being prepared, or what other ingredients are being added. All these factors create a perfect storm for overdose and emergent toxicological presentations. Treatment remains a very grey area – so please read the articles for yourself and contact your local poisons information service if you find yourself needing to treat one of these patients in real life."

viernes, 14 de abril de 2017

Missing Acute MIs with Clinical Risk Scores

R.E.B.E.L.EM - April 13, 2017
"Background: In 2011, we saw 7 million patients in the emergency department (ED) complaining of chest pain. Most of these patients did NOT have an acute coronary syndrome (ACS) or an acute myocardial infarction (AMI). Missing an AMI is one of the biggest fears we have in the ED. By using validated risk scores, we can help decrease the risk of missing AMI and the resultant adverse events. There are multiple scores available for our use. Thrombolysis in Myocardial Infarction (TIMI) predicts risk of adverse outcomes in the next 14 days. Global Registry of Acute Coronary Events (GRACE) predicts outcomes at 6 months. ED specific scores include HEART and Emergency Department Assessment of Chest Pain (EDACS). But, how well do these scores actually perform? Are we missing AMIs by using these clinical risk scores?...
Author Conclusion: “Using their recommended cutpoints and non-high sensitivity cTn, TIMI and unstructured clinical impression were the only scores with no missed cases of AMI. Using lower cutpoints (GRACE ≤48, TIMI = 0, EDACS ≤11, HEART ≤2) missed no case of AMI, but classified less patients as low-risk.”
Clinical Take Home Point: Clinical gestalt remains the most useful tool for assessment of risk of ACS/AMI. The use of risk assessment tools should be regarded as just that, tools. Keep in mind the limitations of each as you are taking care of patients."

Transgender Patients

emDocs - April 13, 2017 - Authors: Condino A and Riddell J 
Edited by: Koyfman A and Long B
"Key Points
  • Many transgender people are on hormone therapy to promote gender-affirming secondary sex characteristics. Be aware that trans women may be at an increased risk of VTE and migraine.
  • Be aware of binding and tucking and how this may relate to chest and genital complaints, respectively.
  • It is important to know the timing and type of Gender-Affirming surgeries to accurately assess for potential complications, if this is relevant to the chief complaint."

jueves, 13 de abril de 2017

The (real) battle against strep throat

An online community of practice for Canadian EM physicians
CanadiEM - By Edmund Kwok - April 12, 2017
"In the past week, there has been some national buzz around: “Why strep throat is causing serious complications, from amputations to death”. This is quite a headline, especially for those in the emergency medicine community who are moving more and more towards a practice of not routinely treating strep pharyngitis with antibiotics. I can already picture some of our patients rushing to the ER at the first sign of a sore throat, with a copy of this article in hand.
Can you blame them?..."

miércoles, 12 de abril de 2017

3SITES: Position for safest central line placement

PulmCCM
PlmCCM - April 12, 2017
"Where to place a central venous catheter is a decision driven mainly by individual experience and preference. The limited evidence available has not established any site as superior; the subclavian position has been reported as being less infection-prone, but more likely to cause pneumothorax, compared to other sites. A large French randomized trial adds significantly to the evidence base.
Authors of the 3SITES study randomized more than 3,000 patients in France requiring central venous catheterization to have their line placed in either the internal jugular, subclavian, or femoral position..."

March 2017 EM Articles

EM Topics
EM Topics - April 10, 2017
*NNR THIS MONTH = 141
You'd have to read 3100 articles to find these 22 riveting reads.
*NNR - number needed to read

martes, 11 de abril de 2017

Low-Dose Ketamine for Acute Pain

R.E.B.E.L.EM -10 April, 2017 - Post Peer Reviewed By: Rob Bryant
"Background: Ketamine’s role in the ED has expanded in recent years. The clinical reasons for this make it easy to understand why, and include analgesia, amnesia, and anesthesia. Amazingly, ketamine does not only reduce acute pain, but it also decreases persistent chronic and neuropathic pain as well. More importantly, use of low-dose ketamine (0.1 – 0.3 mg/kg IV) has been demonstrated to be opioid sparing. Some of the major issues with IV push low-dose ketamine include its adverse effects, such as feelings of unreality, nausea/vomiting, and dizziness. Many emergency medical providers have anecdotally noticed a decrease in adverse effects when ketamine is given slowly. In the paper we are reviewing today, the authors tried to see if increasing the duration of the ketamine from IV push (3 – 5 min) to a slow infusion (10 – 15 min) could mitigate some of these effects, while maintaining analgesic efficacy...
Author Conclusion: “Low-dose ketamine given as a short infusion is associated with significantly lower rates of feeling of unreality and sedation with no difference in analgesic efficacy in comparison to intravenous push.”
Clinical Take Home Point: Low dose ketamine of 0.3mg/kg, mixed into 100mL of Normal Saline given over slow infusion (15 minutes) has a decreased side effect (i.e hallucinations or dizziness) and equal analgesic profile when compared to IV push (5 minutes) low dose ketamine."

Diabetic Foot Infection

emDocs - April 10, 2017 - Authors: Phelps J and Doty C - Edited by: Koyfman A and Long B
Screen Shot 2017-04-07 at 4.42.39 PM
"Key Pearls for treatment diabetic foot infection
  • Inspect all diabetic patients for foot ulcers and infections.
  • Do not culture uninfected diabetic ulcers.
  • Swab and wound drainage cultures are not recommended.
  • Choose antibiotic treatment based on wound severity.
  • Diabetic care is complicated and requires multidisciplinary approach."

Submassive PE 2017

PulmCrit (EMCrit)
PulmCrit - April 10, 2017 - By Josh Farkas
  • "Long-term outcomes of patients in the PEITHO trial indicate that thrombolysis doesn't affect chronic pulmonary morbidity. This simplifies the approach to submassive PE, by making the primary goal of thrombolysis to avoid PEA arrest.
  • Patients with low-risk submassive PE who are less likely to arrest probably don't benefit from thrombolysis. However, high-risk submassive patients may still benefit from thrombolysis.
  • If our goal from thrombolysis is merely to avoid PEA arrest, all we need to do is reduce the pulmonary pressures somewhat (not normalize them). This may be achievable with lower doses of alteplase than have been used historically, with a superior safety profile."

The Post-ROSC Checklist

ALiEM Logo
ALiEM - April 10th, 2017 - By: Sean Kivleha
"In emergency medicine, we are so heavily trained in resuscitation that any senior resident could recite the ACLS algorithm to you after being woken up at 3 am. However, the real work begins after the pulse return. Up to two-thirds of patients with return of spontaneous circulation (ROSC) will not survive to discharge. This approach, modeled after the 2015 American Heart Association Guidelines3 and an excellent review article by Dr. Jacob Jentzer et al,4 can help guide you through the chaos to stabilize your next post-ROSC patient..."

domingo, 9 de abril de 2017

Vía aérea en transportes aéreos

AnestesiaR -
Manejo de la Vía Aérea en el Paciente Crítico en el Transporte Aéreo Medicalizado
AnestesiaR - Por José Ramón Cabañas - 31/3, 03/4, 05/4 2017
"La mayoría de los sistemas de emergencias médicas han ido introduciendo en los últimos años medios aéreos para la resolución de emergencias y para el transporte interhospitalario. El manejo de la vía aérea en transportes aéreos de pacientes críticos constituye una de las situaciones más comprometidas para el equipo responsable..."

sábado, 8 de abril de 2017

A “Cure” for Severe Sepsis and Septic Shock?

R.E.B.E.L.EM - April 7, 2017 - Expert Peer Review Haney Mallemat
Background: The overall mortality in sepsis has decreased quite a bit in the last decade or so, however for a subset of patients, like those with Septic Shock, the mortality still remains high (as high as 50%). There have been hundreds of studies trying to identify the holy grail to decrease mortality further, but one has not been found thus far. Marik PE et al published a study in Chest 2016 that has found a potential front runner. In addition, the authors go on to say, in order to have an impact on a global scale, treatments would not only need to be effective, but also cheap, safe, and readily available; the authors of the following paper may have found just that..
Author Conclusion: “Our results suggest that the early use of intravenous vitamin C, together with corticosteroids and thiamine may prove to be effective in preventing progressive organ dysfunction including acute kidney injury and reducing the mortality of patients with severe sepsis and septic shock. Additional studies are required to confirm these preliminary findings.”
Clinical Take Home Point: Although the results of this study are very promising, it is important to remember that this was only a hypothesis generating study. We still need an external validation before implementation (How many other treatments in sepsis have been touted as a “cure” and not panned out in subsequent studies?).

viernes, 7 de abril de 2017

Non-Invasive Hemodynamic Monitoring

R.E.B.E.L.EM - April 6, 2017 - Post Peer Reviewed By: Anand Swaminathan
"Background: Many physicians struggle with monitoring accurate continuous blood pressures, cardiac output, and response to fluids in patient resuscitation. Also, due to the invasive nature of most methods presently available (i.e. arterial lines, etc) few patients get this monitoring. Ultrasound has been an amazing addition to our armamentarium, but many, I am sad to say, still don’t feel comfortable with this modality. Recently, finger cuff, non-invasive technology was brought to my attention by Bob Frolichstein, one of my colleagues in San Antonio, TX. Specifically, it has been stated that, finger cuff technology, allows hemodynamic monitoring with both BP and CO continuously available in patients without the need for an arterial line.
Author Conclusion: “Presenting ED noninvasive HD data has not been previously reported in any large patient population. Our data suggest a potential role for early noninvasive HD assessments aiding in diagnosing of patients, individualizing therapy based on each person’s unique HD values and predicting 30-day mortality. Further studies and analyses are needed to determine how HD assessments should be best used in the ED.”
Clinical Take Home Point: At this time, finger cuff non-invasive hemodynamic monitoring devices are not ready for primetime. There is no strong evidence that they are accurate in a sick ED population, or that using them affects outcomes of our patients. This just appears to be a very expensive toy, that has not proven that it can do better than what we already do."

Temperature of Sepsis

SCANCRIT - March 25, 2017 - By K
"We know that hypothermia in sepsis is associated with increased mortality but other than that we tend to see fever in sepsis as something bad. We tend to perceive sepsis patients as more sick the more the temperature is elevated. We then tend to treat that hyperthermia with paracetamol, ibuprofen or external cooling.
A large Swedish study in Crit Care Med suggests that increasing temperatures might actually be a good thing. Increasing body temperatures on sepsis recognition is associated with improved outcomes..."
images

The paper lives here:
The editorial:

jueves, 6 de abril de 2017

CO Toxicity

emDocs - April 5, 2017 - Author: Patrick C. Ng - Edited by: Koyfman A and Long B
"Key points
  • Carbon monoxide poisoning can be an elusive diagnosis.
  • Headache, nausea, fatigue, and chest pain are non-specific, but common complaints in patients poisoned with CO.
  • Historical clues such as high risk exposure environments (garages, heaters) and multiple family members with the same symptoms can narrow the differential to CO poisoning.
  • Management can include supportive care, normobaric and hyperbaric oxygen."

EGDT for sepsis is unhelpful (PRISM)

PulmCCM
PulmCCM - April 5, 2017 
"Three large, well-conducted randomized trials around the world (ProCESSARISE, and ProMISe) all agreed: use of early goal-directed therapy (EGDT) for sepsis does not improve mortality or any other important clinical outcome. The Big Three sepsis trials were a death knell for the formerly ubiquitous "sepsis bundles," protocols based on the single-center 2001 Rivers trial of EGDT for sepsis.
Evidence this convincing is rare in critical care, but experts at some centers noted the relatively low mortality (~25%) in the Big Three trials and continued advocating EGDT, believing it might help the sickest patients with sepsis. Each of the three trials individually could have been underpowered to find this benefit, went the argument.
As it turns out, the clever designers of ProCESS, ARISE, and ProMISe thought of this ahead of time. They synchronized entry criteria, treatment protocols, outcomes, and data collection -- so they could pool their data into a meta-analysis, gaining increased power for their conclusions.
That meta-analysis, called PRISM and published in the New England Journal of Medicine, concludes that EGDT did not improve survival from sepsis, even in the sickest patients, but did increase use of intensive care, vasoactive infusions, and overall costs."

Evidence-Based Trauma Resuscitation

EMCrit
EMCrit - April 4, 2017 - By Scott Weingart
"The science of trauma resuscitation has undergone a fairly massive evolution in the past decade. This talk was our attempt to summarize the best-of-the-best in trauma literature from the past several years, and package it into a series of clinically useful recommendations (i.e., our evidence-based opinions). This talk was live peer reviewed by trauma surgery deity Karim Brohi, who gave us a thumb’s up (although you kind of had to be there)."

miércoles, 5 de abril de 2017

Urinary Retention

R.E.B.E.L.EM - April 4, 2017 - Post Peer Reviewed By: Anand Swaminathan
"Background: The treatment of urinary retention is pretty straightforward; place either a Foley catheter or suprapubic catheter to decompress the bladder. What is less clear, and more often debated, is if we need to clamp the catheter after 200 – 1000mLs of urine output or just allow complete drainage. Historic teaching has been to do intermittent volume drainage to avoid complications such as hematuria, circulatory collapse, and worsening renal failure. I distinctly remember being taught this as a resident, but not sure that I ever evaluated the literature until recently...
Author Conclusion: “In this first randomized trial, no statistically significant difference was noted between gradual and rapid emptying of the bladder for urinary retention. Gradual emptying did not reduce the risk of hematuria or circulatory collapse. Therefore, there is no need to prefer gradual over rapid emptying, which is both easy and safe.”
Clinical Take Home Point: Rapid drainage of the bladder in urinary retention does not cause more hematuria requiring intervention, renal failure, or hemodynamic collapse compared to gradual drainage of the bladder."

martes, 4 de abril de 2017

Celulitis mimics

emDocs - April 3, 2017 - Author: Blumberg G - Editors: Koyfman A and Long B
"SUMMARY
  • Cellulitis and many of its mimics are characterized by rubor, tumor, calor, and dolor.
  • Location of infection and mechanism of injury often provides clues as to the diagnosis and what bacteria are implicated.
  • Cellulitis mimics include: septic bursitis, septic joint, deep vein thrombosis, phlegmasia cerulea dolens, necrotizing fasciitis, flexor tenosynovitis, fight bite, orbital cellulitis, and toxic shock syndrome. Less emergent cellulitis mimics include: erysipelas, abscess, felon, paronychia, and gouty arthritis.
  • Remember to involve your surgeon early if considering necrotizing fasciitis, septic arthritis, phlegmasia cerulea dolens, flexor tenosynovitis, fight bite, or orbital cellulitis."

US for ACPE

EMOttawa
EMOttawa - By Rob Suttie - April 03, 2017
"Point-of-Care Ultrasonography (POCUS) is a valuable tool in the diagnostic armamentarium of the emergency physician. We have been successfully using it to the place lines, diagnose AAAs and assess the cardiac function of our dyspnea patients for awhile now. But what about the lungs? Typically air is thought of as the enemy of ultrasound, but can we successfully use it to diagnose acute respiratory conditions despite this? In this Grand Rounds review, Dr. Elizabeth Lalande goes through the use of POCUS in the diagnosis of Acute Cardiogenic Pulmonary Edema in the undifferentiated, dyspneic patient. 
The objectives are as follows:
1. Definitions in lung ultrasound (US)
2. The role of POCUS in diagnosing acute cardiogenic pulmonary edema
Conclusions:
1. Lung US is a great tool to diagnose ACPE, with excellent test characteristics.
2. An eight zone protocol can be used at the bedside to look for the B-profile in your patients with undifferentiated dyspnea. Remember a B-profile consists of at least 3 B-lines in one intercostal space.
3. Don’t forget to look at the heart as well, to increase your post-test probability of finding the right diagnosis for your patient!"

Non Operative Treatment of Appendicitis

R.E.E.B.E.L.EM - April 3, 2017 - Post Peer Reviewed By: Matt Astin
"Background: Historically the treatment of uncomplicated appendicitis has been appendectomy. The first appendectomy performed dates back to 1735 done by Claudius Amyand. Appendectomy has been the standard treatment for acute appendicitis every since Charles McBurney described it in 1889. However, studies have shown that an antibiotic first strategy may be feasible without increased risk of perforation, sepsis, and/or death. This other approach is called NOTA (Non-Operative Treatment of Appendicitis). Past RCTs were from Europe and this is the first NIH grant study to question this in the US. Antibiotic first strategies are used for uncomplicated diverticulitis, but have not been used in uncomplicated appendicitis. Several reasons why this strategy may be preferred include fewer complications, less pain, and less disability than an appendectomy first strategy. There have been a couple of systematic reviews on the issue of NOTA that came to different conclusions (Varadhan et al. BMJ 2012 and Kirby et al. J of Infection 2015). To date, no US randomized trial has evaluated an antibiotics-first approach in uncomplicated appendicitis until now.
Comment on author’s conclusion compared to REBEL Cast Conclusion: In this small pilot study, it seems reasonable to treat uncomplicated appendicitis as we would with uncomplicated diverticulitis.
REBEL Cast Bottom Line: Even though the results are very promising for using an antibiotic first strategy in acute uncomplicated appendicitis, a much larger trial would need to be performed before generalizability. Even so, this trial did show that outpatient ED management of uncomplicated appendicitis is feasible."

lunes, 3 de abril de 2017

Anemia


emDocs - April 2, 2017 - Author: Simon E - Edited by: Koyfman A and Long B
"Pearls:
  • Patients receiving transfusions require frequent reassessment: be mindful of transfusion reactions and their management.
  • Question females of childbearing age regarding menorrhagia.
  • Bleeding lesions of the GI tract are identified in up to 50% of patients with iron deficiency anemia.
  • A negative FOBT can not rule out the GI tract as the source of an iron deficiency anemia: a loss of 10 ml of blood QD is commonly required for a positive result."
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emDocs - August 19, 2016 - Authors: Robertson J, Brem E, Koyfman A - Editor: Long B
Hemolytic anemia is the premature destruction of RBCs, which can be classified as extrinsic or intrinsic, as well as acute or chronic. In particular, several conditions associated with these anemias can cause significant morbidity and mortality. The ED provider must focus on resuscitation, followed by recognition of the hemolytic process and initiation of appropriate therapy. This post will highlight an approach to evaluation and management of hemolytic anemias.
"Conclusions
Hemolytic anemias are rare and many present with gradual onset of symptoms. However, some can cause rapid hemolysis and contribute to high morbidity and mortality. The primary goal for the EM physician is, of course, resuscitation. However, recognizing that a hemolytic process is present is also very important, as this will guide workup and occasionally, specific treatments."