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

WORLD EMERGENCY MEDICINE SOCIETIES & RELATED

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Friday, November 12, 2021

Liver Emergencies

emDocs - November 12, 20211 - By Antón Helman
Key Take Home Points for Liver Emergencies: Thrombosis and Bleeding, Portal Vein Thrombosis, Spontaneous Bacterial Peritonitis and Paracentesis
  • Do not assume that the liver patient with a high INR is anticoagulated; they may still be at risk for thrombosis
  • Keep your differential wide in liver patients with abdominal pain, have a low threshold for abdominal imaging, and think specifically about the possibility of portal vein thrombosis and bacterial peritonitis even in the patient with a “benign” abdomen on physical exam
  • IV albumin should be considered in the patient with acute liver failure and/or bacterial peritonitis and/or paracentesis >5L of ascitic fluid
  • Do not forget to order a fibrinogen level in the liver patient with life-threatening bleeding and give cryoprecipitate or fibrinogen to keep the fibrinogen level > 100
  • It is considered generally safe to perform a paracentesis in a liver patient with an INR as high as 8 and a platelet count as low as 20,000
  • Consider use of POCUS, a pigtail catheter, Z-track technique and tissue glue adhesive for paracentesis

Pigtail in haemothorax

St Emlyn’s - By Simon Carley - November 11, 2021
“Back in 2016 we published a blog on chest drains and chest aspiration, in which we argued that the dogma of putting in huge drains for traumatic haemothoraces should be questioned. 
The dogma of using large drains has puzzled me for many reasons. One reason is that I also work in paediatric major trauma and there no way that I’m going to place a 36F drain in a 6 year old. Apart from anything else I’d probably have to remove a rib to do it, and yet the blood and air still comes out. Big drains might appear to be an obviously good choice for big volumes and maybe we think they clot less, but observational studies in trauma patients have suggested that smaller drains (28-32F vs 36-40F) may be just as effective. How small you can go is uncertain but 36-40F are pretty huge and I’ve stopped using them in my patients. Smaller than this and there is little evidence, but having worked in paeds and adults I’m pretty confident blood does come out of smaller tubes. Back in 2016 we found one study by Russo in swine that suggested 14F tubes may be OK, but it was a small animal study and we expressed caution in extrapolating that to clinical practice. 
This month we have new evidence from the US specifically looking at the 14F question in humans. The abstract is below, but as always we want you to read the full paper and make up your own mind.”

POCUS and the JVP

POCUS Med Ed - By Istrail - November 12, 2021
I've spent the last year scanning hundreds of jugular veins and writing a book on point of care ultrasound. It has resulted in this preprint study on a novel method for estimating jugular pressure and right atrial pressure, and a book. The following is a more in-depth, technical deep dive into the internal jugular vein exam expanded from Chapters 14 and 15 of The POCUS Manifesto: Expanding the limits of the physical exam with point-of-care ultrasound…
Concluding Thoughts
This study has been submitted for publication but has yet to be peer reviewed. Overall I found that this method can very accurately estimate right atrial pressure within a couple of millimeters of mercury almost every time. A major limitation of our initial study was the fact that we compared our estimate to a right atrial pressure measured by many different cardiologists with no standard zero-level amongst them. This made it very difficult - or impossible - to say exactly how close our measurements actually were to the actual right atrial pressure. This technique measures the right atrial depth in every patient, which can vary from 5cm to 15cm. Therefore it is not clear if using a right heart cath - which uses a standard measurement on every patient - is even a good comparison to use. We have controlled for these issues and are currently underway with a follow-up study.”

Tuesday, November 9, 2021

Posterior Reversible Encephalopathy Syndrome

emDOCs Podcast – Episode 41- November 08, 2021 - By Brit Long
Take Home Points:
  • Emergency physicians should consider PRES in patients presenting with altered mental status, seizures, and neurologic deficits who have risk factors for PRES. Heightened suspicion should be raised in those patients who are on immune-suppressive medications, those with renal disease and acutely elevated blood pressure.
  • While non-contrast CT scan may show signs of vasogenic edema, MRI is the imaging modality of choice.
  • Seizures are often the presenting symptom of PRES and occur in a majority of cases.
  • Treatment is focused on seizure management, blood pressure control, and removal of offending agents.
  • PRES and eclampsia have significant overlap, and management principles are similar, though magnesium is the preferred agent for treatment of seizures in eclampsia.

Monday, November 8, 2021

Hyperglycemia

TAMING THE SRU
TAMING THE SRU - November 08, 2021 - By Jazmín Shaw
In 2016, a total of 16 million ED visits were reported with diabetes listed as a diagnosis, with 224,000 of these being for hyperglycemic crisis (1). In this post, we will explore the evaluation and treatment of various hyperglycemic etiologies in the ED through a series of clinical scenarios.

TIA

emDocs - NOVember 08, 2021 - By Elizabeth P. Lanata and Matthew S. Siket
Reviewed by: Alexander Y. Sheng; Alex Koyfman; Brit Long
Summary Points
  • Timely workup and treatment can minimize the risk of developing a subsequent stroke following TIA and much of this work up can be initiated from the ED
  • The Canadian TIA Score combines clinical history and exam finding with neuroimaging to risk stratify patients and better predict the probability of stroke occurring within 7 days of TIA; this risk stratification can help to guide the where and when of the TIA work up
  • Risk Stratification scores alone cannot be used to determine disposition and must be utilized within the larger clinical context
  • Regardless of risk stratification score, all patients with TIA should have a front-loaded work up to decrease potential stroke in the subsequent weeks to months following a TIA (know the pros and limitations of the clinical system you work in)
SGEM#349 - By admin - November 06, 2021
Reference: Katsanos et al. Utility of Intravenous Alteplase Prior to Endovascular Stroke Treatment: A Systematic Review and Meta-analysis of RCTs. Neurology 2021
CLINICAL QUESTION: WHAT IS THE BEST STRATEGY FOR TREATING PATIENTS WITH AN ACUTE LARGE VESSEL OCCLUSION STROKE, DIRECT TO MECHANICAL THROMBECTOMY OR A BRIDGING APPROACH WITH TPA FOLLOWED BY MECHANICAL THROMBECTOMY?
KEY RESULTS: NO STATISTICAL DIFFERENCE IN GOOD NEUROLOGIC OUTCOME
SGEM BOTTOM LINE: CURRENTLY THERE IS INSUFFICIENT EVIDENCE TO KNOW WHAT THE BEST STRATEGY FOR PATIENTS WITH LARGE VESSEL OCCLUSIONS IS, DIRECT TO MECHANICAL THROMBECTOMY OR BRIDGING WITH TPA.

Transvenous Pacemakers

EMCrit 310 - November 4, 2021 - By Scott Weingart
“Being able to competently float a transvenous pacemaker is the mark of a resuscitationist. This procedure can be life-saving, but it requires a diligent regime of knowledge retention and a department with good clinical logistics. In this EMCrit Episode, I go through the procedure in intricate detail–by the end of it, you will be exposed to all aspects of pacemaker placement. Being able to competently float a transvenous pacemaker is the mark of a resuscitationist. This procedure can be life-saving, but it requires a diligent regime of knowledge retention and a department with good clinical logistics. In this EMCrit Episode, I go through the procedure in intricate detail–by the end of it, you will be exposed to all aspects of pacemaker placement.”

Tuesday, November 2, 2021

Rabdomiolisis

empills - By Davide Tizzani - 01 Novembre 2021
…”L’incremento dei valori dosabili a livello ematico dell’enzima muscolare CK identifica una condizione medica nota come rabdomiolisi, causata da una rottura/lisi delle cellule muscolari. Tale situazione è potenzialmente pericolosa e richiede un rapido riconoscimento ed una corretta gestione per il rischio di complicanze severe.
Ma sono pochi i dati certi di tale condizione:
  • L’incidenza è poco studiata (uno studio datato 1994 stima una prevalenza nel dipartimento di emergenza di CK > 5000 UI/l dello 0.07%);
  • Non si conosce il preciso valore di CK che determina e predice un possibile danno renale;
  • Non esistono RCT che hanno dimostrato il beneficio sicuro di una determinata terapia.
La rabdomiolisi rimane “un enigma avvolto in un mistero dentro un segreto…”

Saturday, October 30, 2021

Focused Echo for Embolic Source

emDocs
emDocs - October 29, 2021 - By Michael Prats 
Originally published on Ultrasound G.E.L. on 11/23/20 – Visit HERE to listen the PODCAST!
Take Home Points
  1. A focused echo can be sensitive and specific for sources of embolism in ischemic stroke.
  2. It is unclear if this practice could lead to improvements in meaningful patient centered outcomes.

Friday, October 29, 2021

Opioid Use Disorder

TAMING THE SRU
Taming The SRU - October 28, 2021 - By David Jackson
“The opioid crisis has been well-publicized over the last decade. After a brief decrease in opioid related deaths, there has been a sharp increase since the start of the COVID-19 pandemic. (1,2) Chronic opioid use results in the development of tolerance, requiring larger and larger doses of substance to achieve the same effects. Adaptations in cell physiology in the presence of long-term opioid use results in the syndrome of opioid withdrawal when cessation is attempted. Individuals with opioid use disorder (OUD) who attempt cessation without Medication for Opioid Use Disorder (MOUD) are at high risk for subsequent relapse and potentially fatal overdose. (3) One observational study found significant 1-year mortality (5.5%) in individuals presenting to the emergency department with a non-fatal opioid overdose. (3) Patients receiving treatment for OUD with opioid agonists are more likely to stay in treatment than those receiving non-opioid medications as treatment and have significantly reduced overall mortality compared to patients not receiving MOUD. (4,5) Furthermore, initiation of MOUD from the emergency department is associated with increased retention in treatment for OUD. (6) Below, we will review the presentation of patients to the emergency department with OUD and available treatments for these patients. We will explore using MOUD in the emergency department through a series of clinical scenarios.”

Tuesday, October 26, 2021

Pulse Oximetry

emDocs - October 25, 2021 - By Adam Engberg; Robert Brown; Andrew Moore
Reviewed by: Tim Montrief; Alex Koyfman; Brit Long
“Summary
Pulse oximetry is a standard in monitoring the vital signs of emergency department patients around the world. It is imperative to understand how these sensors work. More importantly, though, is anticipating how and when pulse oximetry may mislead us. The cases we chose highlight two significant flaws in peripheral pulse oximetry: latency and ventilation”

Cellulitis & Dalbavancin

SGEM#348 - By admin - October 23, 2021
Reference: Talan et al. Pathway with single-dose long-acting intravenous antibiotic reduces emergency department hospitalizations of patients with skin infections. AEM October 2021
“CLINICAL QUESTION: DOES THE USE OF A CLINICAL PATHWAY, INCLUDING A DOSE OF INTRAVENOUS DALBAVANCIN, IN EMERGENCY DEPARTMENT PATIENTS WITH SKIN AND SOFT TISSUE INFECTIONS REDUCE HOSPITALIZATIONS?
Authors’ Conclusions: “Implementation of an ED SSTI clinical pathway for patient selection and follow-up that included use of a single-dose, long-acting IV antibiotic was associated with a significant reduction in hospitalization rate for stable patients with moderately severe infections.”
KEY RESULT: LESS PATIENTS WERE HOSPITALIZED AFTER THE IMPLEMENTATION OF THE NEW CLINICAL PATHWAY THAT INCLUDED A SINGLE-DOSE, LONG-ACTING IV ANTIBIOTIC.
SGEM BOTTOM LINE: IN HOSPITAL SYSTEMS WITH ACCESS TO IV DALBAVANCIN AND THE ABILITY TO ESTABLISH EXPEDITED TELEPHONE AND IN-PERSON FOLLOW UP, THIS CLINICAL PATHWAY IS ASSOCIATED WITH A DECREASE IN HOSPITALIZATIONS FOR PATIENTS WITH MODERATELY SEVERE CELLULITIS”

Friday, October 22, 2021

High-Sensitivity Troponin

REBEL EM - October 21, 2021 - By Olayode Owoade
Paper: Greenslade JH et al. Diagnostic Accuracy of a New High-Sensitivity Troponin I Assay and Five Accelerated Diagnostic Pathways for Ruling Out Acute Myocardial Infarction and Acute Coronary Syndrome. Ann Emerg Med. 2018. PMID: 29248334
Clinical Question: Do diagnostic chest pain pathways commonly used to rule out AMI and/or ACS remain effective when used with a newer high sensitivity troponin assay (Access hs-TnI)?
Author Conclusion:In this cohort with a low prevalence of acute myocardial infarction and acute coronary syndrome, the use of Access hs-TnI results with either the Vancouver Chest Pain rule or the No Objective Testing Rule enabled approximately one-third of patients to be safely discharged after 2-hour risk stratification with no further testing. The use of this assay within the EDACS, m-ADAPT, or HEART rule pathways enabled more than half of ED patients to be rapidly referred for objective testing.”
Clinical Bottom Line:
The results from retrospective application of the Beckman-Coulter Access high sensitivity troponin assay in the Vancouver Chest Pain rule, NOT, m-ADAPT, EDACS, and HEART pathways were promising. Many of these decision rules have subsequently undergone further validation in prospective trials. In 2017 when this paper was released we would have suggested larger prospective trials be performed for further external validation before the widespread use of these CDI’s with hs-TnI.

Wednesday, October 20, 2021

Sedación Paliativa

El objetivo de esta nueva edición, elaborada por el Observatorio de Atención Médica al Final de la Vida del CGCOM y la Sociedad Española de Cuidados Paliativos (SECPAL) es el de abordar la necesidad de la adecuación de la Medicina científica en expansión y el respeto a la dignidad de los seres humanos, y, además, destaca que la adecuada formación de los médicos en esta práctica será la garantía de que los enfermos no sufran de forma innecesaria al final de su vida…
Enlace a la guía

Monday, October 18, 2021

Hepatic Encephalopathy

First10EM - By Punithan Thiagalingam - October 18, 2021
In the Rapid Review series, we (somewhat) briefly review the key points of a clinical review paper (or three). The topic this time: hepatic encephalopathy.
The papers:

Urolithiasis

emDocs
emDocs - October 18, 2021 - By Eriny Hanna and Aaron Lacy
Reviewed by: Michael J. Yoo, Alex Koyfman and Brit Long
“Pearls
  • Do not forget to consider complications (infection, AKI, obstruction) as well as serious alternative diagnosesin every patient with flank pain.
  • When needing to evaluate for other etiologies of flank pain, a contrasted CT has adequate sensitivity for obstructive stones. Otherwise, low dose and even ultra-low dose non-contrast CT will detect clinically significant (>3mm) stones. Do start with renal ultrasound first if there is low suspicion of complication or serious alternative
  • Disposition bottom line:
    • Infection or AKI due to obstruction: urgent urology consult for drainage + broad spectrum antibiotics + admission (floor vs ICU depending on hemodynamics).
    • Moderate/severe hydronephrosis or >10mm stone: urology consult (or very urgent outpatient urology follow up if young, healthy, uncomplicated). Disposition can vary depending on urology’s plan for intervention.
    • Intractable pain/vomiting/dehydration/revisit for worsening symptoms: admit to floor for symptom control.
    • Presence of risk factors for developing complications/needing intervention: arrange a very urgent urology clinic follow up if discharging. Admit any patient with concerns for loss to follow up or clinical deterioration.
    • Uncomplicated, small, distal stone: Discharge with pain control +/- MET, close PCP follown up and non-urgent urology clinic follow up”

Cauda Equina

St Emlyn's
St Emlyn’s - By Simon Carley - October 17, 2021
“The bottom line.
Patients with atraumatic back pain who are clinically suspected to have cauda equina syndrome following thorough assessment,should undergo MR imaging to evaluate for evidence of radiological compression. Clinicians should not solely rely on the presence or absence of specific clinical symptoms or signs to rule in or rule out CES. 
A key message is that the absence of perineal signs should not be used as a reason to not perform an MR scan.
In addition, these findings suggest EM clinicians should carefully consider how a digital rectal examination on patients with suspected CES will influence clinical decision making. This information should also be discussed with patients, to allow informed consent. In the cohort presented, this invasive aspect of routine assessment appeared to add no additional diagnostic value. If these findings can be replicated and validated through prospective research, routine invasive DRE could potentially be avoided without impact on diagnosis”

Wednesday, October 13, 2021

Barcelona Criteria

emDocs
emDocs - October 13, 2021 - By Brannon Inman and Lloyd Tannenbaum
Reviewed by: Jamie Santistevan; Manpreet Singh; and Brit Long
Main ECG Pointers:
  1. Both the Sgarbossa and Smith criteria are approved for use to diagnose AMI in LBBB
  2. The Barcelona criteria are new (published in 2020)
  3. Unique parts of the Barcelona criteria include applying concordant depression to all leads, and the application of excessive discordance to low voltage leads ≤ 6mm.
  4. The Barcelona criteria have been derived and internally validated with promising results. However, it awaits external validation.
  5. As always, when applying any clinical rules, always consider the patient’s pretest probability.

Monday, October 11, 2021

Intracerebral Hemorrhage

emDocs
emDocs - October 11, 2021 - By Daniel Bak and Matthew Siket 
Reviewed by: Andrew Grock; Alex Koyfman; Brit Long
“Takeaways
Early and aggressive optimization of care can impact outcomes in ICH despite its intimidating prognosis. Initially, key steps include: a primary and secondary survey, identifying patients with potential ICH, and rapidly performing a NCCT brain. Once diagnosed, immediately elevate the head of the bed, keep SBP < 180 mmHg, reverse any coagulopathy, and consult neurosurgery. Surgical intervention, with a few important exceptions, remains reserved for those who have failed medical management, are rapidly deteriorating, or showing signs of obstructive hydrocephalus. Imaging findings and tools like the ICH scorecan aid in prognostication and communication with patients, family members, and colleagues. Maintenance of euglycemia and normothermia, and prevention of aspiration are basic, but meaningful strategies to optimize functional outcome. While treatment options for ICH remain largely conservative, recognizing that we have the power to affect outcomes is critical to ensuring that patients receive optimal care”

Oxygenation Targets for AHRF

EMOttawa - By Hans Rosenberg - October 11, 2021
Question and Methods: Can a lower PaO2 target (i.e., 60mmHg) compared to higher PaO2 target (i.e., 90mmHg) decrease all cause 90 day mortality by more than 5% in patient with acute hypoxemic respiratory failure requiring >10L of O2?
Findings: At 90 days, all-cause mortality between the high and low PaO2 targe\RFt groups was not statistically different (42.4% and 42.9%, respectively) (RR: 1.02; 95% CI 0.94 – 1.11; P=0.64).
Limitations: Major limitations included not meeting the lower PaO2 target and no standard ABG protocol.
Interpretation: It is reasonable to target lower SpO2 (90-96%) for patients with acute hypoxemic respiratory failure requiring oxygenation

Aslanger

empills - Di Francesco Patrone - 11 Ottobre 2021
Pattern di Aslanger
Tutte queste caratteristiche suggeriscono la presenza del pattern di Aslanger, recentemente pubblicato (J Electrocardiology: A new electrocardiographic pattern indicating inferior myocardial infarction). link
Vediamo nel dettaglio di cosa si tratta.
Diciamo subito che circa il 13,3% degli infarti inferiori si presentano con questo pattern elettrocardiografico, che spesso viene refertato come N-STEMI e di conseguenza, i pazienti non vengono inviati in sala di emodinamica, con considerevole impatto sulla mortalità, senza contare che come vedremo si tratta di infarti del miocardio particolarmente gravi.
Nell’aprile 2020, Aslanger e collaboratori, hanno identificato questo pattern ECG specifico, relativo all’infarto miocardico inferiore acuto (OMI), in pazienti con concomitante malattia multivasale, che non mostra un sopraslivellamento del tratto ST in due derivazioni contigue e pertanto non soddisfa i criteri per la diagnosi di STEMI…

Friday, October 8, 2021

Transplant Emergencies

REBEL EM - By Salim Rezaie - October 06, 2021
“In this 22-minute presentation from Rebellion in EM 2021, Dr. Chris Colbert, DO discusses transplant emergencies and how to manage them.”

Tuesday, October 5, 2021

Antibiotics for acute appendicitis

REBEL EM - By Salim Rezaie - October 04, 2021
“In this lecture from Rebellion in EM 2021, Dr. Rob Bryant, MD reviews the recent literature suggesting the possibility of using antibiotics as an alternative to hospital admission and surgery for acute appendicitis.”

CTCA for cardiac chest pain

St Emlyn’s - By Simon Carley - October 5, 2021
Objectives: To establish if the use of early computed tomography (CT) coronary angiography improves one year clinical outcomes in patients presenting to the emergency departen with acute chest pain and at intermediate risk of acute coronary syndrome and subsequent clinical events…
Clinical Bottom Line 
The findings do not support the routine use of early CT coronary angiography in all intermediate risk patients with acute chest pain”

Balanced vs 0.9% Saline Solution

SGEM#347 - By Admin - October 03, 2021
Reference: Zampieri et al. Effect of Intravenous Fluid Treatment With a Balanced Solution vs 0.9% Saline Solution on Mortality in Critically Ill Patients: The BaSICS Randomized Clinical Trial. JAMA 2021
CLINICAL QUESTION: DOES ADMINISTRATION OF A BALANCED SOLUTION (PLASMA-LYTE 148) DURING INTENSIVE CARE UNIT (ICU) STAY, COMPARED WITH SALINE SOLUTION, RESULT IN IMPROVED 90-DAY SURVIVAL IN CRITICALLY ILL PATIENTS?
KEY RESULTS: NO SIGNIFICANT INTERACTION BETWEEN FLUID TYPE OR INFUSION RATE FOR THE PRIMARY OUTCOME OF DEATH AT 90 
SGEM BOTTOM LINE: IN ADULT ICU PATIENTS AT RISK FOR KIDNEY INJURY, ADMINISTERING MODEST VOLUMES OF PLASMALYTE 148 VERSUS NORMAL SALINE, AT FAST OR SLOW INFUSION RATES, DID NOT INFLUENCE 90-DAY MORTALITY.

Canadian TIA Score

EMOttawa - By Hans Rosenberg - October 04, 2021
Question and methods: This multicenter prospective cohort study validates the Canadian TIA Score and compares it to the ABCD2 and ABCD2i score to identify risk of subsequent stroke and carotid revascularization after TIA.
Findings: This study was able to validate the score that risk of stroke, carotid revascularization, or both within 7 days as low, medium, or high risk in a new cohort of patients more accurately than the ABCD2 and ABCD2i score.
Limitations: The score uses 13 clinical variables and needs access to tool for calculation, however, this gives it greater predictive power than the ABCD2 and ABCD2i score.
Interpretation: The Canadian TIA Score shows increased accuracy when stratifying risk after TIA compared to ABCD2 and ABCD2i and further studies once this is implemented into patient care will help evaluate the health system applicability

Severe Pancreatitis

emDocs
emDocs - October 04, 2021 - By Alex Stern 
Reviewed by Michael J. Yoo; Alex Koyfman and Brit Long
“Pearls
  • As with any patient with abdominal pain, always keep a broad differential and include those life-threateningconditions: AAA, bowel ischemia, ectopic, perforated viscus, etc.
  • Ultrasound and CT of the abdomen and pelvis can aid in the etiology of pancreatitis or undifferentiatedabdominal pain.
  • If concerned for concomitant infection or necrotizing pancreatitis, initiate broad-spectrum antibiotics.
  • IVF like in sepsis; avoid overly aggressive fluid resuscitation and start pressors earlier to reduce the risk of iatrogenic volume overload.
  • Aggressive, multimodal pain control.”

Thursday, September 30, 2021

Milrinone vs Dobutamine

of Cardiogenic Shock
REBEL EM - September 30, 2021 - By Mark Ramzy
Paper: Mathew R, et al. Milrinone as Compared with Dobutamine in the Treatment of Cardiogenic Shock. N Engl J Med. 2021 Aug 5. PMID: 34347952
Clinical Question: What is the efficacy and safety of Milrinone compared to Dobutamine in patients with cardiogenic shock?
Clinical Bottom Line:
There was no significant difference in the primary composite outcome between milrinone and dobutamine in patients with classic or deteriorating cardiogenic shock in this single-center trial with a small sample size. The lack of difference found in this trial could simply be because initiation of therapy may have been too late in the clinical course of illness as is seen by the high mortality rates in this population across both groups. The decision on which drug to use should be tailored to institutional availability, cost, nursing familiarity, the individual patient and their clinical condition.

Trauma in pregnancy

St Emlyn’sSt Emlyn´s - By Anisa Jafar - September 28, 2021
One of the problems faced when managing major trauma in pregnancy is that most trauma centres see and treat seriously injured pregnant trauma patients relatively infrequently. So it is really important that the trauma team drill the obstetric trauma scenario both regularly and alongside obstetric, anaesthetic & neonatal friends (might want to make that “best friends” as you’d want them to be in this situation)..

Monday, September 27, 2021

Alteplase for Stroke

REBEL EM / Rebelion21 - September 25, 2021 - By Salim Rezaie
“Bottom Line: This meta-analysis provides level 1a evidence for the use of advanced brain imaging beyond non-contrast CT to help guide treatment with intravenous alteplase in patients with acute ischemic stroke with an unknown time of onset. However, despite a consistently better functional outcome at 90d with alteplase compared to placebo or standard of care there was still an increased risk of symptomatic intracranial hemorrhage and a higher mortality which has also been consistent across all randomized clinical trials.”

Cannabinoid Hyperemesis Syndrome

ALiEM - September 27, 2021 - By: Jason Elzinga and Fareen Zaver / Editors: Moises Gallegos
“What is cannabinoid hyperemesis syndrome?Cannabinoid hyperemesis síndrome (CHS) is a condition in which patients who have been using cannabis or synthetic cannabinoids for a prolonged period of time develop a pattern of episodic, severe vomiting (usually accompanied by abdominal pain) interspersed with prolonged asymptomatic periods…”

Pulmonary embolism

emDocs - Septiember 27, 2021 - By Anita Bhamidipati; Sumaya Mekkaoui
Reviewed by: Courtney Cassella; Alex Koyfman; Brit Long
“Take Home Points
  1. Patients may present with vague symptoms. The most common symptom of PE is dyspnea. This is more common than chest pain or hemoptysis. Pay attention to unexplained dyspnea or breathlessness.
  2. Delayed diagnosis leads to worse outcomes even in patients that are admitted to the hospital.
  3. Physical exam most commonly reveals tachypnea, followed by tachycardia. PE should also be on your differential when you note JVD, tachypnea and tachycardia on exam.
  4. POCUS is a great adjunct to the clinical exam and is helpful in determining if there are signs of right ventricular strain (RV-strain). POCUS can assist in making important decisions regarding diagnosis and treatment sometimes faster than CT scans. Use this to your advantage!
  5. Certain EKG findings may help you to consider the diagnosis in the right clinical context. The most common EKG finding in PE is tachycardia. The most specific EKG finding is anteroinferior TWIs. STE in V1, RBBB and right-axis deviation are among others.
  6. Clinical decision tools are just that: they are “tools,” not “rules” and should not replace clinical judgment. Do not anchor on a diagnosis. Rely on your clinical history and exam and use these as adjuncts.”

Diplopia

First10EM - By Kristine Laing - Published September 27, 2021
… “Diplopia, or double vision, can be a tricky and complicated disorder. There are various forms of double vision and many etiologies, ranging from non-serious to life-threatening. I always felt a little confused and unsure of how to approach someone with Diplopia. So here goes my step-wise approach to optimize the care of a patient with non-traumatic diplopia...
Diplopia can be a clue to many different conditions ranging from benign to very serious and life-threatening conditions. I hope this article helps clarify and organize an approach to diplopia to optimize your patient’s care while in the emergency department”

Thursday, September 23, 2021

Top 10 UK Trauma Papers

St Emyln’sSt Emlyn ´s - By Simon Carley - September 22, 2021
… “Choosing the top 10 is an imprecise and personal decision. I try to pick papers that will either change practice, that will make us challenge current practice or bring in new ideas. I also look for methodological rigour, but in truth it’s my opinion and if your favourite paper is not here I am sorry. If it’s one that you wrote then I am really, really sorry. I’ve taken papers from September 2019-2020 to reflect the timing of the conference...”
3. Emergency Scalpel Cricothyroidotomy use in a prehospital trauma service: a 20-year review.
5. Association of Prehospital Plasma With Survival in Patients With Traumatic Brain Injury. A Secondary
6. Understanding the neuroprotective effect of tranexamic acid: an exploratory analysis of the CRASH-3 randomised trial
7. ITACTIC trial
8. Effect of Continuous Infusion of Hypertonic Saline vs Standard Care on 6-Month Neurological Outcomes in Patients With Traumatic Brain Injury: The COBI Randomized Clinical Trial
10. Emergency Resuscitative Thoracotomy: A Nationwide Analysis of Outcomes and Predictors of Futility