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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

HEMORRHAGIC SHOCK THE THOR WAY

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sábado, 20 de octubre de 2018

Cricoid Pressure and RSI

St Emlyn’s - By Simon Carley - October 20, 2018
"...This month we have the publication of the larget trial to date on the use of cricoid pressure in emergency patients4. You can read the paper here and it appears to be open access at the moment...
What’s the clinical bottom line?
On the basis of this and other trials there is no compelling evidence for the use of cricoid pressure in operating department patients, but there is no real evidence of serious harm either. It looks likely that laryngoscopy may be easier without it in place.
So on balance, and arguably not on the strongest of evidence cricoid pressure is probably not doing a great deal in this group of patients.
What we don’t know is whether we can directly transfer that opinion to other groups, notably those in the ED. However, other studies, albeit smaller and less rigorous ones also question the effectiveness of cricoid in emergency patients8–11. In Virchester I’ll carry on not using it, but I accept that this is an evidence light decision."

ACEP 2018 Favorite pearls

R.E.B.E.L. EM - Emergency Medicine Blog
R.E:B.E.L.EM - October 18, 2018 - By Salim Rezaie
"This year ACEP 2018 took place in San Diego, CA from Oct 1st– 4th, 2018. There were lots of amazing speakers and topics as was evidenced by the eruption of everyone’s twitter feeds with the #ACEP18 hashtag. I was fortunate enough to not only attend, but also speak at this amazing conference. I was approached by several attendees requesting that I put together a list of my favorite pearls from this conference, as I have done in years past on REBEL EM. Below is my top 10 list, in no particular order..."

Hypoglycemia

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EM@3AM - October 20, 2018 - Author: Thrasher S, Sulava E
Edited by: Long B and Koyfman A
"Pearls
  • Occurs in insulin-dependent diabetes > non-insulin-dependent diabetes late > non-insulin-dependent diabetes early > Non Diabetic
  • POC Glucose should be part of initial altered mental status work-up
  • Causes: Lifestyle, drugs, alcohol, infection, autoimmune/neoplasm
  • D10 vs D50 for severely hypoglycemic patient? Remember D50 can cause rebound hypoglycemia
  • Glucagon can be used as a temporizing measure if no IV access
  • Sulfonylurea has specific treatment (+/- activated charcoal and octreotide)
  • Involve the specialists for further diagnostics and assistance"

Corticosteroides for COPD

PulmCCM
PulmCCM - October 17, 2018
..."Most patients with severe COPD exacerbations should be treated with seven days or fewer of systemic corticosteroids. There is no reason to believe that longer steroid courses are helpful in patients with mild or moderate COPD either, although evidence is lacking for that conclusion. Some patients are exceptions and may require longer steroid courses to regain symptom control and functional status."

miércoles, 17 de octubre de 2018

Intranasal Analgesics

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emDocs - October 17, 2018 - By Cisewski D
Edited by: Singh M, Alex Koyfman A  and Long B
"Last week on Pain Profiles we discussed a feasibility trial assessing the use of intranasal ketamine for pediatric musculoskeletal pain. A few weeks ago I had the pleasure of talking to Dr. Stacy Reynolds regarding her research with intranasal ketamine pediatric analgesia. [Recall: In 2017, Dr. Reynolds was the lead author on a landmark study presented at the SAEM Annual Conference assessing the feasibility of intranasal ketamine use among pediatric patients with extremity injuries. The results of this study provided supporting evidence for a large-scale, multi-center pediatric trial to assess the safety and efficacy of intranasal ketamine among pediatric population with extremity injuries.] The following is a re-print of an SAEM Pulse interview I did with Dr. Reynolds regarding her research, career interests, and advice for future research-driven students and residents interested in following in her footsteps."
*
emDocs - September 19, 2018 - By Cisewski D
Edited by: Singh M, Alex Koyfman A  and Long B
"So what’s the upshot?
IN ketamine resulted in an acceptable (tolerable) increase in side effects over IN fentanyl, and neither drug proved more efficacious in pain reduction. Having met each of these threshold criteria, the authors confirm that a larger pediatric trial to assess efficacy and safety of IN ketamine for acute extremity pain management is needed. IN administration is already a well-established technique, and this study is a further step toward a promising opioid-sparing analgesic alternative and delivery for pain management."

Cricothyrotomy

TAMING THE SRU
TAMING THE SRU - October 17, 2018 - By Cathers Andrew
Highlighted Article: High, K., Brywczynski J., Han J. Cricothyrotomy in Helicopter Emergency Medical Service Transport. Air Medical Journal , Volume 37 , Issue 1 , 51 – 53
LEARNING POINTS
Overall, I think this article provides further support of the importance of cricothyrotomy skills and maintenance in our environment. I think the biggest takeaway for me (as well as the authors) was the potential weakness of having two different methods of cricothyrotomy. This requires providers to learn and maintain both, and also requires additional decision-making in high-stress, time-critical situations. In addition, each provider also has to learn how to assist the other provider in performing either of the procedures. Many experts advocate for the superiority of the surgical (scalpel-finger-bougie) method of cricothyrotomy over the percutaneous approach, and I would have to agree. In this very small study this method did seem more effective, as well. It should always be a goal to look for the most reproducible and effective method of performing a procedure, and then train that exact way as much as possible. Not only will this reduce cognitive load during these situations, it will also lead to a higher level of proficiency in this procedure for all crew members.
Bougie Aided Cric Video from UC EM on Vimeo.

lunes, 15 de octubre de 2018

Airway Decontamination

SCANCRIT - October 14, 2018 - By Thomas D
...SALAD is DuCanto’s project of Suction Assisted Laryngoscopy Airway Decontamination, and is the focus of both his talk and the workshop they had later in the day..."

sábado, 13 de octubre de 2018

Making Resus Better

St. Emlyn´s - By Simon Carley - October 12, 2018
"This week we are hosting the #stemlynsLIVE conference here in Manchester. We are so excited to be bringing together an amazing faculty for a day of talks, workshops, panel discussions and skill stations designed to improve our lives as critical care and emergency clinicians.
This blog supports my presentation on ‘Making Resus Better’, a title that evolved from Cutting Edge evidence in resuscitation. I’ve changed the title after discovering that this is all being covered by other speakers. What do you do when that happens? You ask the best in the business for help. I reached out to Scott Weingart, Chris Hicks, Cliff Reid, Ken Milne, Youri Yourdanov and the St Emlyn’s team with the simple question….
If you could change one thing in resus to make resuscitation better what would it be?

viernes, 12 de octubre de 2018

Functional Neurological Disorder

EMOttawa
EMOttawa - By: Miguel Cortel - October 11, 2018
"Definitions:

  1. Medically Unexplained Physical Symptoms (MUPS)
    1. Patient complaints and symptoms for which no medical etiology is identified
  2. Somatic Symptom Disorder
    1. Somatic symptoms that are distressing to a patient for at least 6 months
    2. Importantly, patients have disproportionate and excessive thoughts and behaviours towards these symptoms
  3. Functional Symptom
    1. Another term for MUPS commonly used in all specialties
    2. Every specialty sees patients with functional symptoms, for example:
      1. Cardiology – non-cardiac chest pain
      2. Gastroenterology – IBS
      3. Rheumatology – fibromyalgia
  4. Functional Neurological Disorder (FND)
    1. Previously conversion disorder
    2. Term for a constellation of functional symptoms that are neurologic in nature
    3. DSM 5 updated criteria will be explained below"

CPR IN TCA

The Collective - October 11, 2018
‘Don’t compress the chest in traumatic arrest…’ That’s the narrative. But Alan Garner has questions.
Do you do chest compressions in traumatic cardiac arrest (TCA)?
Don’t be dopey, right? Compressions are not important compared with seeking and correcting reversible causes. Indeed you can just omit the compressions altogether and transport the patient without them as they are detrimental in hypovolaemia and obstructive causes of arrest, right?
I would like to work through the logic of this. I think the nidus of an idea got dropped into a super saturated FOAMEd solution and Milton the Monster* precipitated out. The end result might be an approach that got extrapolated way beyond the biologically plausible..."

jueves, 11 de octubre de 2018

CCTA in Chest Pain Evaluation?

R.E.B.E.L.EM - October 11, 2018 - By Salim Rezzaie
"Author Conclusion: “Compared with other SOC approaches use of CCTA is associated with similar major adverse cardiac events but higher rates of revascularization in patients with acute chest pain.”
Clinical Take Home Point: In patients that are deemed “low risk” for atherosclerotic disease, with no previous diagnosis of coronary artery disease the use of CCTA compared to standard of care physiologic testing decreases length of stay, increases downstream testing (invasive coronary angiography and revascularization), without any patient oriented benefit all-cause mortality, MI, MACE) and should not be used in this patient population."

Lemierre’s Syndrome

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emDocs - October 10, 2018 - Author: Pickens A - Edited by: Koyfman A, Long and Singh M

  

miércoles, 10 de octubre de 2018

Chronic heart failure in adults

Resultado de imagen de british medical journal
BMJ 2018;362:k3646 doi: https://doi.org/10.1136/bmj.k3646 
(Published 24 September 2018)
"What you need to know
  • Refer people with suspected heart failure and N-terminal pro B-type natriuretic peptide (NT-proBNP) greater than 400 ng/L for specialist assessment and transthoracic echocardiography within 6 weeks.
  • Offer angiotensin converting enzyme (ACE) inhibitors and beta blockers as first line treatment for heart failure with reduced ejection fraction, and add mineralocorticoid receptor antagonist (MRA) if symptoms continue.
  • Offer exercise based cardiac rehabilitation therapy to people with stable heart failure in a format and setting that is easily accessible.
  • Provide management in primary care once the person’s condition is stable, with advice from specialist heart failure teams (MDTs).
  • People with heart failure do not routinely need to restrict their sodium or fluid consumption.
What’s new in this guidance
  • Clearer advice on managing the care of people with heart failure, including a greater emphasis on multidisciplinary working, shared decision making, care planning, lifestyle advice and interventions, co-morbidities, and end-of-life care.
  • N-terminal pro-B-type natriuretic peptide (NT-proBNP) specified as the biomarker to be used in the diagnosis (and, if relevant, the monitoring) of people with heart failure.
  • Mineralocorticoid receptor antagonist (MRA) to be offered (in addition to an ACE inhibitor (or angiotensin receptor blocker, ARB) and beta blocker) in people with heart failure with reduced ejection fraction who remain symptomatic."

martes, 9 de octubre de 2018

Accidental Hypothermia

R.E.B.E.L.EM - October 08, 2018 - By Johnson L
"Take Home Points:
  • Hypothermia is neuroprotective and patients can survive prolonged periods of cardiac arrest. Termination of resuscitative efforts in cardiac arrest should not considered until the patient is >32°C or has a K > 12 mEq/L
  • Active internal rewarming is the keystone of treatment for unstable hypothermic patients. Utilize available resources including ECMO to effectively warm your patient
  • Consider alternate causes for hypothermia, especially in patients who fail to respond to warming"

Exacerbación EPOC

Resultado de imagen de spanish society of chemotherapy
Juan González del Castillo. Rev Esp Quimioter 2018;31(5): 461-484
Documento de Consenso
1-Sociedad Española de Medicina de Urgencias y Emergencias. 
2-Grupo de Estudio de Infecciones en el Paciente Crítico de la Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica. 
3-Sociedad Española de Medicina Interna. 
4-Sociedad Española de Medicina Intensiva Crítica y Unidades Coronarias. 
5-Sociedad Española de Geriatría y Gerontología. 
6-Sociedad Española de Neumología y Cirugía Torácica. 
7-Sociedad Española de Hospitalización a Domicilio. 
8-Sociedad Española de Quimioterapia.
"Denominamos enfermedad pulmonar obstructiva crónica a un conjunto de procesos clínicos que tienen en común una obstrucción crónica y progresiva al flujo aéreo, salpicada de episodios de reagudización (exacerbaciones o brotes). Estas exacerbaciones se hacen con el tiempo más frecuentes e intensas deteriorando la función pulmonar. La principal causa de estas agudizaciones es la infección bacteriana. Existen múltiples guías y documentos que abordan el manejo de esta patología. Sin embargo, se centran fundamentalmente en el tratamiento durante la fase estable. Este documento realiza un abordaje del problema de la exacerbación aguda con origen infeccioso desde una perspectiva multidisciplinar, centrándonos en el abordaje integral del proceso, y aborda la etiología, resistencias a los antimicrobianos, estudios microbiológicos, la estratificación del riesgo y el manejo terapéutico empírico inicial, antibiótico y concomitante. Además, incluye una aproximación frente aspectos más complejos como son el manejo de poblaciones especiales (ancianos, inmunodeprimidos) o del fracaso terapéutico ante el tratamiento instaurado. Por último, se discuten específicamente temas más controvertidos como la profilaxis de la infección o el tratamiento paliativo."

lunes, 1 de octubre de 2018

Cardiac Arrest Sonographic Assessment

R.E.B.E.L. EM - Emergency Medicine Blog
R.E.B.E.L.EM - October 01, 2018  - By Salim Rezaie
Author Conclusion:
“In this pre and post-intervention study, the implementation of a structured algorithm for ultrasound use during cardiac arrest significantly reduced the duration of CPR interruptions when ultrasound was performed.”
Clinical Take Home Point: 
Having a scripted protocol for POCUS in cardiac arrest, and placing the probe on the chest during compressions are associated with shorter duration of CPR pulse checks, but even with the CASA exam, CPR pulse checks are still longer than without the use of POCUS. Having a dedicated counter can ensure that pauses with POCUS do not last longer than 10 seconds.

For More Thoughts on This Topic Checkout:

Acute Compartment Syndrome

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emDocs - October 01, 2018 - Authors: Long B and Gottlieb M. Edited by: Koyfman A
"Key Points
  • Compartment syndrome is a time-sensitive surgical emergency caused by increased pressure within a closed compartment.
  • ACS is associated with a number of risk factors but occurs most frequently after a fracture or trauma to the involved area.
  • Pain out of proportion to the injury, paresthesias, pain with passive stretch, tense compartment, focal motor or sensory deficits, or decreased pulse or capillary refill time are signs and symptoms concerning for ACS.
  • Pain is the earliest finding in patients with ACS, but findings on history and exam cannot rule out the diagnosis.
  • Measurement of intracompartmental pressures using a pressure monitor is the most reliable test.
  • Treatment involves analgesia, removing constrictive dressing, placing the limb at heart level, and surgical consultation for emergent fasciotomy."

domingo, 30 de septiembre de 2018

The Zero Point Survey

St. Emlyn´s  Blog - By Simon Carley - September 30, 2018
St Emlyn's

sábado, 29 de septiembre de 2018

Supraglottic vs Tracheal Intubation in OHCA

REBEL Cast Ep 59: AIRWAYS-2 - September 27, 2018
..."Author Conclusion: 
“Among patients with out-of-hospital cardiac arrest, randomization to a strategy of advanced airway management with a supraglottic airway device compared with tracheal intubation did not result in a favorable functional outcome at 30 days.”
Clinical Take Home Point: 
In patients with OHCA, there was no difference in survival with good neurologic outcome regardless of supraglottic airway or tracheal intubation, however the supraglottic airway is easier to place, more likely to be successful, not more likely to lead to more regurgitation/aspiration, and allows for more focus on high quality CPR and should be used as the primary advanced airway technique in OHCA."

Clostridium Difficile Infection (2018 IDSA Guidelines)

PulmCCM
PulmCCM - September 28, 2018 - By Kenny Jon-Emile

...In general I find the IDSA guidelines to be of excellent quality with fair and reasonable assessment of the evidence. I find their approach to diagnosis – which is inherently Bayesian – to be an admirable synthesis of the current literature. It seems prudent to set forth institutional guidelines for C. difficile testing bearing in mind the inherent imperfection of recipe-based medicine – especially in the immunocompromised. Equally important is to know the diagnostic characteristics of the bioassays employed in one’s hospital.

The previous guidelines also relied upon risk assessment to guide treatment of C. difficile. While the 2018 approach follows suit, treatment is now the same for mild and severe disease. This follows – since publication of the last guidelines – the observed superiority of vancomycin in all disease severities; accordingly, oral metronidazole should rarely be considered..."

miércoles, 26 de septiembre de 2018

tPA dose for PE

PulmCrit (EMCrit)
PulmCrit - September 24, 2018 by Josh Farkas
..."Summary: The Bullet
  • The optimal dose of tPA for PE remains unknown. No RCT has been able to demonstrate any difference in efficacy when comparing different doses. This is perhaps most notable within the recent OPTALYSE trial, which found equivalent results when using either ~24 mg, ~12 mg, or ~8 mg tPA.
  • Most studies use fixed-dose tPA dosing. This fails to account for differences in patient weight or the patient’s balance between fibrinolysis versus fibrin generation. Failure to account for these variables could make fixed-dose tPA a shot in the dark: some patients will receive an excessive dose while other patients receive an inadequate dose.
  • tPA should arguably be provided using weight-based dosing with titration to physiologic effect. It’s possible that dosing tPA in a precise fashion could allow for optimization of the risk/benefit ratio for each individual patient (rather than guessing a dose which will work OK across a diverse population of patients).
  • The optimal dose of tPA for massive PE is unknown. 100 mg is the traditional dose, but 50 mg may be reasonable for patients at increased risk of bleeding who aren't acutely unstable."

Ottawa SAH Rule

R.E:B.E:L.EM - September 24, 2018 - By Devivo A
..."Author’s Conclusion:
We found that the Ottawa SAH Rule had excellent sensitivity for identifying subarachnoid hemorrhage in a new consecutive cohort of patients with acute headache. Patients who are neurologically intact with a new rapidly peaking headache and who lack each of the 6 elements of the rule do not need further investigation to rule out subarachnoid hemorrhage. Instead, other diagnoses should be considered and managed accordingly in these patients...
Clinical Bottom Line:
The Ottawa Subarachnoid Hemorrhage Rule is a high sensitivity screening tool that may be applied to the aforementioned patient population, in conjunction with a complete history and physical exam, in order to clinically rule out a subarachnoid hemorrhage. However as a one sided rule, with poor specificity, if a patient is not ruled out, clinical decision making and shared decision making must be used to determine which patients would need further workup."

viernes, 21 de septiembre de 2018

Troponina cardiaca para IAM (consenso)

SEC - 17 de Septiembre 2018
"La SEC participa en el documento de consenso sobre la utilización de la troponina cardiaca para el diagnóstico del infarto agudo de miocardio en Urgencias publicado en la Revista Emergencias.
El documento se ha realizado en colaboración con la Sociedad Española de Medicina de Laboratorio y la Sociedad Española de Medicina de Urgencias y Emergencias.
La introducción de la troponina ha supuesto un gran avance para el diagnóstico del infarto agudo de miocardio (IAM) al permitir la detección de cualquier mínima cantidad de daño miocárdico. Sin embargo, el Dr. Sanchis Forés apunta que el uso excesivo de la troponina en los servicios de urgencias puede generar confusión en determinadas circunstancias.
Como explica Jordi Ordóñez, bioquímico clínico en el Hospital de la Santa Creu i Sant Pau, “es evidente que los métodos de alta sensibilidad están representando un reto pero también una gran ayuda para la práctica clínica”. Por ello, uno de los motivos de realizar este documento es aclarar las diferencias entre los métodos de empleo contemporáneos y los de alta sensibilidad y su papel en la práctica clínica diaria.
A la hora de descartar de forma segura un síndrome coronario agudo, el Dr. Aitor Alquézar (Servicio de Urgencias del Hospital de la Santa Creui Sant Pau) matiza que con los algoritmos propuestos de determinación de troponina de alta sensibilidad “se facilita el descarte del infarto agudo de miocardio” pero es importante conocer el método de troponina disponible en el centro, así como valorar la historia clínica y el ecocardiograma.
¿Cómo se interpreta la troponina elevada fuera del contexto del dolor torácico agudo? ”Este es el dilema clínico diario en un servicio de urgencias”, afirma el cardiólogo del Hospital Universitario de Tarragona Joan XXIII, Alfredo Bardají. Puesto que el IAM no siempre presenta los síntomas clásicos, la troponina positiva se tiene que interpretar en el contexto de la clínica, para determinar si se trata de un infarto de miocardio tipo 1 o 2 o lesión miocárdica aguda, y asignar el tratamiento adecuado. De este modo, es vital realizar una cuidadosa evaluación clínica antes de tomar decisiones y asignar diagnóstico."
ACCEDE AL DOCUMENTO EN 'REVISTA EMERGENCIAS' con el código CONSENSO:

Lung US

MarylandCC Project - September 13, 2018 - By Jim Lantry
"Today we are fortunate to welcome Sam Hsu, MD, RDMS, Assistant Professor for the University of Maryland Medical School. Dr. Hsu is the acting Emergency Department Ultrasound Director at one of the UMMC satellite centers her in Baltimore, Mercy Medical Center. He also takes on command of medical student emergency ultrasound education for the medical school. I guess you could say, he lives and breaths ED ultrasound! Today he takes us through his algorithm on how to approach ultrasonography of the lungs. I have attending many lectures on the topic and have even performed lung US research, but this lecture is the best presentation I have ever seen on the topic. You NEED to watch this lecture."

High Sensitivity Troponin Protocols in the ED

Dr. Smith's ECG Blog

Dr. Smith´s ECG Blog - September 21, 2018 - By Steve Smith
High Sensitivity Troponin; Considerations for Implementing ED protocols.
"There is a huge amount of new data since 2015, and it will keep accumulating.
I have tried to distill a huge literature down to fewer important studies, and I give my bottom line summary, but there is still a huge amount of data. This is my reading of the literature. It is not peer-reviewed. I'm sure there are many who would disagree with my summary slides. But I present a lot of data so that you can make your own decision. A file of the outline of the slides can be accessed on my Google Drive via the link.
The purpose of this lecture is to expose you to the broad spectrum of high sensitivity based protocols that your ED might choose from. You will not be able to use it on your next patient, but use it to institute a protocol that works for your institution. So just sit back and listen.
One thing I forgot to address in the lecture: Acute Occlusion Myocardial infarction (OMI). There is no evidence that hs troponin will help in the early diagnosis of acute coronary occlusion vs. non-occlusive MI. It does help in early diagnosis of MI (of OMI/NOMI), but does not differentiate.
Thanks to Scott Joing for recording this. Scott is our tech wizard and fine emergency physician, and co-editor of Ma and Mateer's standard EM ultrasound textbook. He is the creator of www.hqmeded.com.
Also thanks to my incredibly bright and knowledgeable troponin research partners, both of whom know much more about troponin than I do. They are Fred Apple and Yader Sandoval (https://twitter.com/yadersandoval), and also to the Cardiac Biomarkers Research Lab, especially Karen Schulz, at Hennepin and Minneapolis Medical Research Foundation.
High Sensitivity Troponin; Considerations for Implementing ED protocols."
The text of the slides can be seen here in .rtf format:
High Sensitivity Troponins from HQMedEd on Vimeo.

Failed Airway Algorithm 2018

EMCritRACC
EMCrit 233  - September 19, 2018 - By Scott Weingart


sábado, 15 de septiembre de 2018

EuSEM 2018

St.Emlyn’s at #EuSEM18 (Glasgow)

EuSEM day 1


EuSEM 3

EuSEM 4

Pacemaker Basics

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emDocs - September 14, 2018 - By Anand Swaminathan 
Originally published at R.E.B.E.L. EM on Aug 24, 2017. Reposted with permission 
"Have you ever been confused by the alphabet soup of pacemakers? This post will serve as a pacemaker basics reference..."

jueves, 13 de septiembre de 2018

NY Style Resuscitation

Intensive Care Network
DASS SMAC Berlin 2017
"What is New York City style resuscitation? Reuben Strayer and Scott Weingart honed their chops in public hospitals in America’s largest city, where patients come from every country, speak every language, and manifest every physiologic derangement on earth. Preferring to ask neither permission nor forgiveness, Reuben and Scott have long challenged emergency medicine and critical care orthodoxy and developed lateral (though sometimes divergent) strategies in their approach to problems that arise in the care of the sometimes unwashed masses who tend to avoid presenting to medical attention until they’ve fallen off the Frank-Starling curve. Topics that may be discussed (or argued) include the use of epinephrine, the use of noninvasive ventilation, the management of recently intubated patients, the use of ketamine as an induction agent with and without a paralytic, and decision-making in badly injured trauma patients. Ad hominem attacks will be defined and probably employed. Though Weingart has a physical and intellectual disadvantage against the bigger, stronger, quicker, younger, and better-looking Strayer, these disparities will be muted by Natalie May’s capable moderation"
.

HFO2 in COPD

PulmCCM
PulmCCM - Sep 08, 2018 - By Jon-Emile S. Kenny
..."As a fussy physiologist, I frequently find myself deciphering literature on hemodynamics and respiratory mechanics – not because of their complexity, but rather their inconsistent nomenclature. A recent report by Di mussi et al. multiplies my frustrations.
I have previously posted on the mechanisms of carbon dioxide excretion with oxygen delivered by nasal high flow [NHF], as well as on the important distinction between respiratory work and power. A fresh publication addressing the beneficial effects of NHF in patients with chronic obstructive pulmonary disease [COPD] focuses these erstwhile ruminations and further informs on the subtle disparities between respiratory work, effort and efficiency. Without jest, I invite you to travel back in physiological time with me … you must bring your own weapons of critical appraisal; your safety is not guaranteed..."

Sodium Bicarbonate in Cardiac Arrest

The Original Kings of County - September 12, 2018 - By Charles
"This article will not attempt to wade into the pathophysiology of acid-base disorders. From reading the nephrology literature, it seems that this topic is more closely akin to theoretical physics than the sturdy biochemistry I learned in college. Researchers can’t even agree on how to define acidosis, much less what causes it or how to measure or name it. Is it just HCO3 and CO2? Were Henderson and Hasselbach wrong, and it’s actually a strong…
Summary:
  1. Acidosis itself is likely not as harmful as we think.
  2. Sodium bicarbonate therapy works by changing a metabolic acidosis to a respiratory acidosis, so you must be able to ventilate off the extra CO2 to raise the pH.
  3. There are several negative effects of sodium bicarbonate therapy, including worsening intracellular acidosis and increased extracellular volume.
  4. The literature behind using sodium bicarbonate in undifferentiated cardiac arrest clearly shows it does not work and may even be harmful. The AHA recommends against its routine use. So stop using it."

miércoles, 5 de septiembre de 2018

NIV in acute hypercapnic respiratory failure

European Respiratory Society
Schreiber A, Fusar B, Lieuwe D. Bos D, Nenna R - Breathe 2018 14: 235-237
DOI: 10.1183/20734735.018918
..."In this article, we attempt to present a chronological account of what we consider to have been some of the most significant research on NIV in acute hypercapnic respiratory failure over recent decades, determining a radical change or breakthrough in the approach to the various aetiologies of this condition..."

Refractory migraines (GONB)

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emDocs - September 05, 2018 - Author: Cisewski D - Edited by: Singh Mand Long B
Last month, a long-anticipated research trial on ED migraine treatment came out of Bronx, NYC, looking at the use greater occipital nerve blocks (GONB) in the ED setting for the treatment of refractory migraines. That makes this a great opportunity to talk about migraines, what we know migraine treatment, and what nerve blocks bring to the table.
A Randomized, Sham-Controlled Trial of Bilateral Greater Occipital Nerve Blocks With Bupivacaine for Acute Migraine Patients Refractory to Standard ED Treatment With Metoclopramide 

4th Definition of MI (2018)

European Society of Cardiology
Kristian Thygesen K et al.  European Heart Journal, ehy462. Published: 25 August 2018
...Studies have shown that myocardial injury, defined by an elevated cardiac troponin (cTn) value, is frequently encountered clinically and is associated with an adverse prognosis. Although myocardial injury is a prerequisite for the diagnosis of MI, it is also an entity in itself. To establish a diagnosis of MI, criteria in addition to abnormal biomarkers are required. Non-ischaemic myocardial injury may arise secondary to many cardiac conditions such as myocarditis, or may be associated with non-cardiac conditions such as renal failure. Therefore, for patients with increased cTn values, clinicians must distinguish whether patients have suffered a non-ischaemic myocardial injury or one of the MI subtypes. If there is no evidence to support the presence of myocardial ischaemia, a diagnosis of myocardial injury should be made. This diagnosis can be changed if subsequent evaluation indicates criteria for MI. The current Fourth Universal Definition of Myocardial Infarction Consensus Document reflects these considerations through adhering to the clinical approach of the definition of MI..."
Spectrum of myocardial injury, ranging from no injury to myocardial infarction. Various clinical entities may involve these myocardial categories, e.g. ventricular tachyarrhythmia, heart failure, kidney disease, hypotension/shock, hypoxaemia, and anaemia. cTn = cardiac troponin; URL = upper reference limit. aNo myocardial injury = cTn values ≤ 99th percentile URL or not detectable. bMyocardial injury = cTn values > 99th percentile URL. cMyocardial infarction = clinical evidence of myocardial ischaemia and a rise and/or fall of cTn values > 99th percentile URL.

lunes, 3 de septiembre de 2018

Genitourinary Trauma

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emDocs - September 03, 2018 - By Arthur J.,  Chadwick S & Ellington C
Edited by Koyfman A and Long B
"Key points
  • GU trauma is common, occurring in 10% of traumas.
  • The classic teaching of high riding prostate, perineal hematoma, and pain with or inability to urinate is not sensitive for GU trauma.
  • Gross hematuria should prompt consideration of GU trauma.
  • Timing of contrast is critical to assessing the GU system for injury.
  • Conventional cystography is equally as sensitive as CT cystography.
  • A RUG should be performed prior to catheterization among patients with gross hematuria, inability to void, or a high index of suspicion for urethral injury.
  • Ultrasound is the primary imaging modality for the penis and scrotum."