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

WORLD EMERGENCY MEDICINE SOCIETIES & RELATED

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lunes, 28 de septiembre de 2020

TXA in TBI

First 10EM - September 28, 2020 - By justin Morgenstern
The paper
Rowell SE, Meier EN, McKnight B, et al. Effect of Out-of-Hospital Tranexamic Acid vs Placebo on 6-Month Functional Neurologic Outcomes in Patients With Moderate or Severe Traumatic Brain Injury. JAMA. 2020 Sep 8;324(10):961-974. doi: 10.1001/jama.2020.8958. PMID: 32897344. ClinicalTrials.gov Identifier: NCT01990768

...There was no difference in the primary outcome of favourable neurologic outcome on the GOSE score. 58% of the bolus/infusion group, 62% of the bolus only group, and 60% of the placebo group had a favourable outcome...

Bottom line
This is a large, double-blind RCT that demonstrated no benefit from giving TXA in the prehospital setting for traumatic brain injury. The trial is not definitive, but I believe the results.

BRASH syndrome

Internet Book of Critical Care (IBCC) - September 26, 2020 - By Josh Farkas



"BRASH syndrome is defined as a combination of the following:
  • Bradycardia
  • Renal failure (either acute or acute-on-chronic)
  • AV node blocker
    • Usually due to a beta blocker, verapamil, or diltiazem.
    • A recent case report suggested that ranolazine may act similarly)(31975993)
  • Shock
  • Hyperkalemia

Emphysematous Pyelonephritis

emDocs - September 28, 2020 - By Rusnack F 
Reviewed by: Chavez S; Koyfman A; Long B

"Key Points:
  • Suspect EPN in patients with risk factors (DM, immunocompromised, female sex) who present with fever/dysuria/abdominal pain or who do not respond to usual pyelonephritis treatment.
  • CT imaging of the abdomen and pelvis with contrast is the imaging modality of choice to identify gas. KUB or US may be used to aid in early recognition.
  • EPN has a high mortality rate. Start resuscitation measures early including empiric antibiotic therapy such as third-generation cephalosporins with aminoglycosides, fourth-generation cephalosporins, carbapenems, combination beta-lactamase inhibitors, or fluoroquinolones depending on patient risk factors (note: take into account local antibiogram).
  • Consult urology emergently to determine the need for further procedural interventions such as PCD or if severe/nonfunctioning, emergent nephrectomy."

sábado, 26 de septiembre de 2020

Antiacid monotherapy in epigastric pain

SGEM#302 - B admin - September 26, 2020 
Reference: Warren et al. Antacid monotherapy is more effective in relieving epigastric pain than in combination with lidocaine. A randomized double-blind clinical trial. AEM Sept 2020

"CLINICAL QUESTION: IS ANTACID MONOTHERAPY MORE EFFECTIVE IN RELIEVING EPIGASTRIC PAIN THAN IN COMBINATION WITH LIDOCAINE?

ALL THREE TREATMENTS (VISCOUS, SOLUTION OR ANTACID MONOTHERAPY) WORKED AND THERE WAS NO STATISTICAL DIFFERENCE BETWEEN GROUPS.

SGEM BOTTOM LINE: CONSIDER USING ANTACID MONOTHERAPY IN PLACE OF LIDOCAINE/ANTACID COMBINATION THERAPY FOR PATIENTS WITH DYSPEPSIA."

Marine Animal Bites and Stings

EM@3AM (emDocs) - September 26, 2020 
By Taliaferro D - Reviewed by: Santos C; Koyfman A; Long B
"Background: Human contact with species of venomous marine life are relatively common especially in tropical and coastal regions of the world. Common organisms include spiny fish, cone snails, jelly fish, sea snakes, octopi and stingrays. There is an estimated 10 million envenomations worldwide, most being caused by jellyfish. Most of these animals do not inhabit US waters. It is important to know what the common organisms are based on region to determine if an envenomation can be potentially fatal. While most of these envenomations are relatively mild, there are fatal organisms that are most commonly in Australian and Pacific waters."

miércoles, 23 de septiembre de 2020

Electrocution

Taming The SRU
Taming The SRU - September 22, 2020 - By Ijaz Hamza

"CONCLUSION 
The evaluation and management of patients who have suffered electrocution is challenging, as presentations range from asymptomatic to refractory cardiac arrest. Important historical features include type of current (AC or DC), voltage, and duration of exposure. Electrocuted patients are especially susceptible to cardiac arrhythmias, neurologic injury, rhabdomyolysis, and compartment syndrome. Even in the well-appearing patient, a thorough evaluation and high index of suspicion for injury is paramount, as electrocuted patients often have atypical injury patterns."

martes, 22 de septiembre de 2020

Hemophagocytic LymphoHistiocytosis

PulmCrit(EMCrit)
IBCC chapter & cast - September 21, 2020 - By Josh Farkas
"Intensivists have long been struggling with the enigma of hemophagocytic lymphohistiocytosis (HLH). For example, this post from 2016 explores the challenge of dissecting HLH away from septic shock. The COVID pandemic has drawn some attention to the topic, although it's not clear to what extent COVID might truly reflect HLH. This chapter attempts to lay out the fundamental groundwork of HLH. Please note that the treatments for adult secondary HLH are not based on any strong evidence, so considerable controversy surrounds the entire topic..."
  • The IBCC chapter is located 👉 here.

Usual Care +/- Oseltamivir

R.E.B.E.L.EM - By Salim Rezaie - September 21, 2020
Paper: Butler CC et al. Oseltamivir Plus Usual Care Versus Usual Care for Influenza-Like Illness in Primary Care: An Open-Label, Pragmatic Randomised Controlled Trial. Lancet 2020. PMID: 31839279
"Clinical Question: Does adding antiviral treatment to usual primary care for patients with influenza-like illness reduce the time to recovery?
Author Conclusion: “Primary care patients with influenza-like illness treated with oseltamivir recovered one day sooner on average than those managed by usual care alone. Older, sicker patients with comorbidities and longer previous symptom duration recovered 2 – 3 days sooner.”
Clinical Take Home Point: This study should not change practice. In a non-blinded study with a subjective outcome, we would expect patients who are getting the “fancy pill” to feel better faster. Additionally…
  • Oseltamivir works on neuraminidase. This enzyme is not found on other viruses, and there is no biological mechanism for it to have an effect in these patients
  • Objective outcomes of hospitalization and x-ray confirmed pneumonia showed no benefit with oseltamivir
  • There is an increase in nausea/vomiting in the patients taking oseltamivir"

Subarachnoid Hemorrhage

First10 EM - By Justin Morgenstern - September 21, 2020
"Summary
A plain CT head misses very few cases of subarachnoid hemorrhage, even if that CT was done more than 6 hours after symptom onset. The miss rate of a CT done within 6 hours is close to 2 in 1,000. Even if the CT was done after 6 hours, post-test probability is less than 1%. Considering the harms of lumbar puncture, it is clear that the test should not be performed routinely if subarachnoid hemorrhage is the only concern. Of course, there is a much broader differential for a patient with a severe headache, so lumbar puncture will remain a part of the work-up for many patients, based on physician judgement, and hopefully involving patients as part of shared decision making"

miércoles, 16 de septiembre de 2020

Airway in Penetrating Neck Trauma

CanadiEM - September 15, 2020 - By Will Wu

..."Lady Sansa Stark and Lord Petyr Baelish’s relationship goes back to the beginning of King Joffrey Baratheon’s rule in King’s Landing (his death was covered previously – link). It was there where he told Sansa “Look around you. We’re all liars here – and every one of us is better than you”. Unfortunately for him, his lies led him to suffer a brutal execution in Winterfell with Lady Arya slitting his throat with a dagger. Penetrating neck trauma account for 5-10% of all trauma cases and is the leading cause of death under the age of 46 in the USA.​1​ Complex vascular, nervous, and respiratory/GI anatomy in the neck underly the challenges of managing these patients. In this article, we will give a brief overview of clinical considerations in these patients, while delving deeper into airway management..."

Ovarian Torsion

Taming The SRU
Annals of B Pod - September 15, 2020 - Urbanowicz O

"SUMMARY
Ovarian torsion remains a highly morbid disease process that is difficult to diagnose. Emergency physicians need to have a high clinical suspicion of ovarian torsion in women of reproductive age. Appropriate use of imaging will lead to an expedited diagnosis and subsequently decrease the risk of infectious and fertility complications."

lunes, 14 de septiembre de 2020

Gastrointestinal hypomotility

PulmCrit (EMCrit)
IBCC chapter & cast – September 14, 2020 - By Josh Farkas

"Critical illness leads to a variety of gastrointestinal motility problems (largely due to the constellation of immobility, medications, and metabolic abnormalities). Although these topics don't generally attract much interest, maintaining adequate bowel motility is essential to avoid iatrogenic harm."

  • The chapter on gastroparesis is located 👉 here.

  • The chapter on ileus is located 👉 here.

  • The chapter on colonic pseudo-obstruction is located 👉 here.

Pericarditis treatment

Taming The SRU
Taming The SRU - September 14, 2020 - By Stevens E
"BACKGROUND 
Pericarditis is inflammation of the pericardial sac. Classically, pericarditis presents with sharp and pleuritic chest pain which is relieved by sitting up and forward. Pericarditis has multiple etiologies, but is most commonly idiopathic, assumed to be viral, in developed countries. Treatment of pericarditis should be targeted to the underlying etiology if possible. For presumed viral, idiopathic causes, most patients are treated with non-steroidal anti-inflammatory drugs (NSAIDs) and colchicine..."

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Mesenteric Ischemia

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emDocs - September 14, 2020 - By Cai A and deSouza I 
Reviewed by Ramzy M; Koyfman A and Long B
"Take-aways for your practice
Mesenteric ischemia continues to challenge emergency physicians with its subtle and variable presentations. Accurate and timely diagnosis significantly improves mortality in this deadly disease. Strategies to avoid missing the diagnosis include recognizing the presentations of the four main etiologies (arterial embolism, arterial thrombosis, nonocclusive, venous thrombosis), maintaining a high index of suspicion and communicating this to the radiologist, raising your clinical suspicion in the elderly, and relying only on CTA to rule out the diagnosis."

TXA in severe head injury

St Emlyn’s - By Simon Carley - September 13, 2020
“ Our post on the CRASH-3 trial, an RCT examining the use of TXA in head injury, was arguably our most controversial of 2019. Our view was that the evidence was not entirely definitive, but on the balance of probabilities TXA should be given to patients with moderate head injury, although it was probably of little use amongst those who had severe injury.
We are of course always open to the opportunity to change our views and therefore it’s good to see another RCT of TXA in head injury published in JAMA...
The bottom line.
  • The evidence for or against TXA in head injury remains uncertain. On the balance of probabilities my view remains unchanged from our previous CRASH3 conclusions.
  • TXA has been shown to reduce bleeding related deaths in a variety of settings suggesting that it fundamentally improves outcomes for patients with life threatening bleeding.
  • TXA should be given to all mild/moderate head injured patients with evidence of bleeding on CT scan.
  • TXA should be given to all patients who have bilaterally reactive pupils and blood on CT scan.
  • Patients with head injury PLUS extra-cranial injury TXA should be given to patients within 3 hours.“

viernes, 11 de septiembre de 2020

Ketamine in the ED

Taming The SRU
Taming The SRU - September 09, 2020 - By Hill J
Soundcloud-podcast - Soundcloud Podcast Logo Transparent PNG - 676x221 -  Free Download on NicePNG
"In our most recent journal club, we took a look at 3 articles focused on the use of ketamine in the Emergency Department. When treating pain with ketamine, does a rapid administration of ketamine result in more dysphoria? When used for RSI, is ketamine more hemodynamically stable than etomidate? When using ketamine for procedural sedation in adult patients, does pre-treatment with versed or haldol decrease clinically significant emergence agitation?...
Take-homes
  • Ketamine is not necessarily superior to etomidate to prevent peri-intubation hypotension
  • Large incidence of ketamine-related hypotension in medical patients (more likely to be catecholamine depleted) fits with prior data demonstrating benefit of catecholamine release
  • Not practice changing, but provides counterpoint to recent trend toward increasing ketamine use in patients expected to become hypotensive"

jueves, 10 de septiembre de 2020

In the ED after the Beirut Blast

Emergency Physicians Monthly
EP Monthly - September 09, 2020 - By Amin Antoine Kazzi/Interviewed by Logan Plaster
“Even when you think you know what to do after a blast, there will always be another one to push your technical, logistic and emotional boundaries.”
Kazzi is an internationally recognized expert in mass casualty management in the emergency department. He has published and lectured internationally on the topic and is the former president of the American Academy of Emergency Medicine. But none of this experience fully prepared him for this scene.

miércoles, 9 de septiembre de 2020

Abdominal Pain Mimics

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emDocs - September 07, 2020 - By Schandel C, Chrabaszcz S and Clinton M
Reviewed by Boushra M, Koyfman A and Long B
"Summary
  • Undifferentiated abdominal pain presents a unique diagnostic challenge to emergency medicine physicians due to the breadth of potential pathology. Risk stratification of the differential diagnosis through focused history and physical examination is of utmost importance.
  • Expand the differential diagnosis as appropriate based on the patient’s risk factors and history, especially if the patient is presenting multiple times for similar complaints. Organize the differential diagnoses into several categories: cannot miss, common diagnoses, and zebras."

martes, 8 de septiembre de 2020

Crash VV ECMO

ED ECMO Podcast - September 07, 2020 
"Have you ever wondered how you would crash someone onto VV ECMO? Have you ever wondered where is the best place to put the cannulas? Have stayed up late at night wondering which patients in your department could benefit from VV rather than VA ECMO? Then this is the episode for you!! After a few recent cases of crash VV ECMO in our hospital, we have decided to focus on the subject. Zack gets critical care physician and ECMO director Dr. David Willms to answer from a very practical standpoint the who, what, where of crash VVECMO."

Priapism

CanadiEM
CanadiEM - September 08, 2020 - By Anna Black
..."Priapism is defined as a pathological erection lasting or more hours in the absence of sexual desire or stimulation.​ In these presentations, it is important to distinguish ischemic (low-flow) priapism from non-ischemic (high-flow), as the former is a medical emergency. While ischemic priapism is more common and associated with a variety of triggers, non-ischemic priapism almost always occurs after penile or perineal trauma, or a needle injury of the cavernosal artery.​ In both types of priapism, the corpora cavernosa appear engorged but the corpus spongiosum and glans remain flaccid. The corpora cavernosa are fully rigid and painful in ischemic priapism, while they are less painful and not fully rigid in non-ischemic priapism.​​ A doppler ultrasound can aid with the diagnosis by demonstrating decreased blood flow in ischemic priapism and normal or increased blood flow in non-ischemic priapism. A cavernosal blood gas is the most definitive diagnostic test for priapism, with dark, crankcase oil-like blood with a high CO2 content, low O2 content, and low pH indicating ischemic priapism. Ischemic priapism must be treated immediately to preserve erectile function as microscopic tissue damage begins to develop in 4-6 hours, while significant structural damage to smooth muscle occurs after approximately 12 hours.​​ Almost all patients with ischemic priapism lasting >36 hours have erectile dysfunction.​ Non-ischemic priapism, on the other hand, can generally be managed conservatively as it does not result in tissue damage..."

lunes, 7 de septiembre de 2020

Conservative Treatment of Pneumothorax

SGEM#300 - September 06, 2020 - By admin
Reference: Brown et al. Conservative versus Interventional Treatment for Spontaneous Pneumothorax. NEJM 2020
"CLINICAL QUESTION: DOES EVERYONE WITH A LARGE FIRST-TIME SPONTANEOUS PNEUMOTHORAX NEED A CHEST TUBE?
Authors’ Conclusions: “Although the primary outcome was not statistically robust to conservative assumptions about missing data, the trial provides modest evidence that conservative management of primary spontaneous pneumothorax was noninferior to interventional management, with a lower risk of serious adverse events.”
SGEM BOTTOM LINE: IT IS REASONABLE TO PROVIDE CONSERVATIVE MANAGEMENT IN A PATIENT WITH LARGE FIRST-TIME SPONTANEOUS PNEUMOTHORAXES AS LONG AS YOU CAN ENSURE CLOSE FOLLOW-UP."

Ticagrelor and Aspirin for Ischemic Stroke

R.E.B.E.L.EM - September 03, 2020 - By Benjamin M. Gerretsen
Paper: Claiborne Johnston S et al. Ticagrelor and Aspirin or Aspirin Alone in Acute Ischemic Stroke or TIA. NEJM 2020. PMID 32668111
"Clinical Question: Does the addition of ticagrelor to aspirin for 30 days aid in reducing the risk of subsequent stroke or death among patients with acute non-cardioembolic cerebral ischemia?
Author Conclusion: “Among patients with mild-to-moderate ischemic stroke (NIHSS score ≤5) or TIA who were not undergoing intravenous or endovascular thrombolysis, the risk of the composite of stroke or death within 30 days was lower with ticagrelor-aspirin than with aspirin alone, but the incidence of disability did not differ significantly between the two groups. Severe Bleeding was more frequent with ticagrelor.”
Clinical Take Home Point: A benefit was observed with ticagrelor + aspirin with respect to the incidence of the secondary outcome of subsequent ischemic stroke, which was lower than with aspirin alone; however, a benefit was not observed with respect to the incidence of overall disability, and additionally there was increase in severe bleeding and intracranial hemorrhage."

miércoles, 2 de septiembre de 2020

Present a case in the ED

CanadiEM
CanadieEM - September 01, 2020 - By Sophie Ramsden
"Presenting a case in the ED is important for a number of reasons. Not only does better communication result in better patient care, but it’s also a great learning opportunity and your chance as a clerk to impress your attending. Presenting a case well conveys your level of knowledge and understanding to an attending, which allows them to accurately assess and teach to your weaknesses. It also illustrates that you can create a complete diagnostic and management plan for a patient, while prioritizing dangerous diagnoses and critical next steps. Even if you know everything there is to know about abdominal pain and asked all of the right questions, if you can’t present a case thoroughly but concisely, your attending won’t be able to appreciate that. 
Whether you’re brand new to the ED or a well-oiled emergency medicine machine, check out our essential resources for key tips on presenting a case. If you’re interested in a deeper dive into case presentations and some of the evidence supporting different teaching styles, scroll a little further...

martes, 1 de septiembre de 2020

Methemoglobinemia

First 10EM - August 31, 2020 - By Justin Morgenstern
"A 45 year old brought in by EMS after being found unconscious and cyanotic. She has Celiac disease, and was started on dapsone for dermatitis herpetiformis yesterday. She doesn’t have any other health problems, and aside from the rash, has been healthy recently. She is afebrile and her blood glucose is normal. She looks blue, and her oxygen saturation is reading 85% despite the nonrebreather placed by EMS. Her working of breathing appears normal and her lung exam is unremarkable. The nurse doing blood work notes that her blood looks funny – a chocolate brown colour. Could this be methemoglobinemia?..."

Acute Low Back Pain

Taming The SRU
Taming The SRU - August 31, 2020 - By Gillespie L
"Take away points
  • Nonspecific, acute low back pain can be thought of as a diagnosis of exclusion and other etiologies should be considered first.
  • The majority of people at some point in their lives experience low back pain, although it often improves significantly over the 1-3-month period that ensues. Unfortunately, there are high recurrence rates.
  • Treatment of acute low back pain in the ED is different than treatment of chronic low back pain.
  • Pharmacologic therapy can be combined with non-pharmacologic therapy for improved outcomes (ex. patient education).
  • NSAIDs show some mild benefit for analgesia and disability reduction. Acetaminophen has no recent, strong evidence supporting its use in acute low back pain.
  • Muscle relaxants have mixed results for treatment of acute low back pain, and have significant side effect profiles.
  • Lidocaine patches may provide significant benefit without burden of systemic adverse effects although there is not enough evidence to strengthen the argument for its routine use yet.
  • Treatment-focused patient education, especially regarding prognosis and expectations, is an essential component of nonpharmacological therapy for acute low back pain."

lunes, 31 de agosto de 2020

GBL Overdose

St. Emlyn´s - August 30, 2020 By Gareth Roberts 
..."Classically GHB/GBL overdose is characterised by a rapid onset of CNS and respiratory depression. Occasionally we find patients arriving by ambulance disinhibited and acting bizarrely often with hyper sexualised behaviour including touching, exhibitionism and attempting to perform sexual acts in the department. With an increasing dose they will often have ataxic movements and then move through into a state of cataplexy. With further increased dosage the patient develops an almost absence seizure type picture with reduced movement, staring into the distance and they may become non communicative. At higher doses the patient will present in a coma.
Classically the hallmark of GHB/GBL overdose is a rapid onset of CNS and respiratory depression. On blood gas analysis you may find a wide anion gap acidosis. This is due to the dissociation of GHB in to its anion plus a H+. From a physiological point of view in low dose there may be tachycardia and hypertension. This is sometimes confounded by the alcohol, ketamine or other stimulants such as a cathinone or amphetamine being used, however in severe overdose the patient may be bradycardic.."

Red Eye

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emDocs - August 31, 2020 - By manasco C & McIntosh B
Reviewed by: Koyfman A & Long B
"Key Takeaways:
  • Always have a broad differential on evaluation of the red eye (HCG FUNKS). A detailed history may help you diagnose the pathology and the cause behind it, which can save time and effort.
  • Consider autoimmune disease in patients with systemic complaints or unclear etiology when diagnosing eye pathology.
  • The importance of a complete eye exam cannot be understated. This includes visual acuity, pupil exam, intraocular pressure, fundoscopy, and slit lamp exam with fluorescein if not contraindicated.
  • Delayed treatment/consultation with ophthalmology can lead to serious morbidity.
  • Use of the slit lamp is vital to diagnosing many emergent causes of red eye and is expected of us from our ophthalmology colleagues."

jueves, 27 de agosto de 2020

Spinal Epidural Abscess

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emDocs- August 27, 2020 - By Pilcher C
"Takeaways:
  • A simple ESR or CRP can assist in evaluating for SEA patients, especially in drug seekers and malingerers. The test is almost universally “shockingly elevated” (an ID colleague’s words) in SEA patients.
  • Doing the test is evidence that one is thinking of SEA, and if normal, is an effective defense should one later be found.
  • Those with a high ESR or CRP, risk factors, or a high level of suspicion should have a COMPLETE spine MRI, because the abscess is often found to be distant from the point of pain or be present at multiple levels.
  • Missed SEA’s number in the dozens each year nationwide. Making the diagnosis in time to prevent disability could avoid tens of millions of dollars in settlements and years of stressful litigation. Hopefully no emDocs reader will ever miss one.
  • The reference below is excellent but glosses over one of the major signs of SEA: frequent or escalating visits for back pain, even in chronic opioid users."

PE in Covid-19

CanadiEM
CanadiEM / Blood & Clots Series - By Zachary Liederman - August 27, 2020
"Main Messages
  1. COVID-19 is a prothrombotic disorder and PE should be considered for sudden or unexplained respiratory changes.
  2. For most cases, no single clinical or laboratory feature (e.g. D-Dimer) is enough to rule in or rule out PE in COVID-19 by itself
  3. When PE is considered, diagnosis should be based on the standard of care imaging test (positive CTPA or doppler ultrasound) whenever possible. If imaging is not accessible a presumptive diagnosis can be made (and anticoagulation started) taking into consideration ancillary findings, clinical stability and bleeding risk."

ATM in Covid-19

REBEL Covid-19 - August 27, 2020 - By Salim Rezaie
"The Coronaviridae family and its genera coronaviruses have been implicated as having neurotropic and neuroinvasive capabilities in human hosts (Bohmwald 2018). They have been associated with the development of neuropsychiatric symptoms, seizure activity, encephalomyelitis, acute flaccid paralysis, cerebral venous sinus thrombosis, Guillain-Barré syndrome, as well as cerebrovascular disease (Bohmwald 2018, St Jean 2004).
Recently, there has been a growing body of evidence supporting the association of SARS-CoV2 with neurological abnormalities. A systematic review looking at the incidence of secondary neurological disease in patients diagnosed with SARS-CoV2 found rates to vary from 6-36.4% (Herman 2020).
At the time of this submission, there have been ten reports of acute transverse myelitis (ATM) attributed to SARS-CoV2, and others are currently being submitted or are in pre-print at this time..."

lunes, 24 de agosto de 2020

Chronic Spinal Cord Injury

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emDocs - August 24, 2020 - By Lynn R and Scott K
Review by Lentz S, Koyfman A and Long B
"Take Home Points
  • As an emergency medicine physician, it is imperative to be able to anticipate, understand, recognize and treat common conditions that bring patients with SCI to the emergency department.
  • Patients with chronic SCI often present atypically due to alterations in normal physiology.
  • For all patients with SCI, complete a thorough physical exam, including disrobing and rolling the patient for a complete examination of the skin.
  • The most common sources of infection among patients with chronic SCI are UTIs and skin/soft tissue infections; review historical data when possible to inform treatment decisions and antimicrobial selection.
  • Chronic pain and psychiatric co-morbidities are common among patients with SCI. Perform screening for these issues as part of your overall assessment of the patient with chronic SCI."

MgSO4 y catéter vesical

AnestesiaR -
AnestesiaR - Agosto 24, 2020 - Por M Carmen Iribarren
Ref: Magnesium and Bladder Discomfort after Transurethral Resection of Bladder Tumor: A Randomized, Double-blind, Placebo-controlled Study. Park JY, Hong JH, Kim DH, Yu J, Hwang JH, Kim YK. Anesthesiology. 2020;133(1):64-77.doi:10.1097/ALN.0000000000003309 
"El disconfort vesical relacionado con el catéter es un síndrome que se observa con frecuencia en pacientes sometidos a cateterismo urinario. Los factores de riesgo principales son el sexo masculino, diámetro del catéter y el tipo de intervención quirúrgica...
Hay una gran variedad de fármacos disponibles para el tratamiento y prevención de este síndrome. Los más clásicos son los antimuscarínicos, que ya se utilizaban en el tratamiento de la vejiga hiperactiva. Estos tienen la desventaja de producir efectos adversos molestos como rubor facial y sequedad bucal. Se ha observado y estudiado que otros fármacos, como antiepilépticos y analgésicos, también tienen cabida en esta patología. La última novedad en cuanto al manejo del disconfort relacionado con el cateterismo urinario es el sulfato de magnesio. Además de su utilidad para tratar diferentes patologías, resulta eficaz en disminuir la incidencia y severidad de la DVRC, por lo que podría empezar a implementarse en esta patología."

Timing of Renal Replacement Therapy

REBEL CRIT - August 24, 2020 -  By Mark Ramzy
Paper: The STARRT-AKI Investigators. Timing of Initiation of Renal-Replacement Therapy in Acute Kidney Injury. N Engl J Med. 2020; PMID: 32668114
Clinical Question:
Does initiation of an accelerated or standard renal replacement therapy result in lower risk of death from any cause at 90 days in critically ill patients with acute kidney injury?
Author’s Conclusions:
Among critically ill patients with acute kidney injury, an accelerated renal-replacement strategy was not associated with a lower risk of death at 90 days than a standard strategy.
Our Conclusion:
With this being yet another RCT, the decision to initiate early RRT versus a standard therapy in critically ill patients with acute kidney injury has not shown any mortality benefit at 90 days. Patients in the accelerated arm were more dependent on RRT at 90 days and had more adverse events. Multiple studies have validated these findings and short of acute indications for RRT, medically managing these patients appears to be the best strategy in an effort to delay RRT.