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SOBRE EL AUTOR **

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

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jueves, 14 de marzo de 2019

Abdominal Compartment Syndrome

PulmCrit (EMCrit)
PulmCrit (EMCrit) - March 14, 2019 - By Josh Farkas
"Abdominal compartment syndrome can result from primary abdominal pathology (e.g. bowel obstruction), but it can also occur due to systemic inflammation combined with large-volume resuscitation. As such, abdominal compartment syndrome is probably more frequent than generally perceived, functioning as an occult driver of multi-organ failure. Treatment is based upon physiological properties, involving many therapies aside from simply opening the abdomen."
The IBCC chapter is located here.

Predictive Symptoms of AMI

R.E.B.E.L.EM - March 14, 2019 - By Salim Rezaie
"...Author Conclusion:
“In this large multicenter trial, only 4 symptoms were associated with the diagnosis of AMI, and no symptoms that were associated with a non-AMI diagnosis.”
Clinical Take Home Point: 
Pay closer attention to patients with chest pain that radiates to their right arm. In this multicenter study of patients with chest pain presenting to the ED, chest pain radiation to the right arm is more predictive of AMI than chest pain radiating to the left arm."

martes, 12 de marzo de 2019

Subarachnoid Hemorrhage

CanadiEM
CanadiEM -  By Michael Kruse - March 12, 2019
"Objectives:
  1. What are some common signs and symptoms of subarachnoid hemorrhage (SAH)?
  2. How can pre-hospital providers manage suspected SAH?
  3. How is SAH is diagnosed and managed in the ED?"
SAH Rule

ANDROMEDA-SHOCK

R.E.B.E.L.EM - March 11, 2019 - By Salim Rezaie
"Author Conclusion: 
“Among patients with septic shock a resuscitation strategy targeting normalization of capillary refill time, compared with a strategy targeting serum lactate levels, did not reduce all-cause 28-day mortality.”
Clinical Take Home Point: 
Although the authors conclusion makes it sound like a negative trial, as the gold standard in sepsis is to use lactate and not CRT, this study should be considered a positive trial, as it shows CRT is at least as good as a lactate-guided resuscitation strategy. Using a lactate-guided resuscitation strategy led to more fluid administration, more epinephrine used, and more vasopressors used without improvement in mortality (not statistically significant), compared to normalizing capillary refill time. In other words, with a lactate-guided resuscitation strategy, we are doing more things that don’t make a difference in mortality…Which begs the question…should we be drawing repeat lactates in septic shock?"

DEXACET

PulmCrit (EMCrit)
PulmCrit - March 11, 2019 - By Josh Farkas
"Summary: The Bullet
  • Acetaminophen has previously been shown to be an effective analgesic which can reduce opioid consumption.
  • DEXACET shows that in a cohort of critically ill post-cardiothoracic surgery patients, IV acetaminophen reduced the incidence of delirium. This suggests that acetaminophen use may offer meaningful, patient-oriented benefit.
  • Although DEXACET was performed with IV acetaminophen, other studies have found equivalent efficacy between either oral or intravenous forms.
  • Acetaminophen is probably an under-utilized analgesic among critically ill patients. For maximal efficacy, oral acetaminophen should be given in substantial doses in a scheduled fashion (e.g. 1 gram q6-q8 hours scheduled, not 650 mg q8hr PRN).
  • DEXACET isn’t incredibly robust statistically (fragility index of two). However, it validates longstanding principles of analgesia (specifically, the “analgesic ladder”). Until further evidence is available, it’s sensible to use these principles in clinical practice. This isn’t a revolution, but rather a reminder of first principles."

Hepatic Encephalopathy

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emDocs - March 11, 2019 - Authors: Mohammadie S and Zeidan A 
Edited by: Koyfman A and Long B
"Takeaways
  1. HE is common in patients with cirrhosis and is the most common reason for readmission. Patients with cirrhosis who experience HE have an increase in mortality demonstrating the seriousness of this common disease.
  2. Clinicians should rely on the history, exam, and clinical suspicion when diagnosing HE, rather than ammonia levels.
  3. Causes of HE are typically due to increased generation of ammonia or decreased clearance. The most common precipitants include infection, GI bleed, dehydration, AKI, lactulose nonadherence, and constipation.
  4. Patients with cirrhosis are more susceptible to developing infections due to a dysfunction of host defense mechanisms as well as dysregulation of inflammatory cytokines.
  5. Diet and hydration status are critical in patients with cirrhosis. Dehydration is a common precipitant of HE due to use of diuretics, lactulose, large volume paracentesis, poor PO intake, and difficult medication titration post TIPS.
  6. Less common precipitants to keep in mind when evaluating for HE include concomitant precipitants, such as infection and
  7. Be wary of new medications in cirrhotic patients. Consider reviewing side effects of all medications used in patients with cirrhosis before prescribing to assess for hepatotoxicity: https://livertox.nlm.nih.gov/."

domingo, 10 de marzo de 2019

Traumatic Arrest

R.E.B.E.L.EM - 06 March, 2019
"Take Home Points:
  • If the patient is a clear traumatic arrest, compressions aren’t indicated and, instead we should focus on the important interventions that need to be done.
  • Ultrasound can be incredibly helpful in traumatic arrest. If you’ve got a traumatic arrest patient with neither pericardial fluid nor cardiac activity, it may be reasonable to stop resuscitation without the thoracotomy.
  • When decompressing the chest, it’s better to place your angiocath in the 5th intercostal space in the anterior axillary line. This helps you avoid the great vessels in the as well as the thick anterior chest wall
  • And last, if you are doing a thoracostomy, you may as well go bilaterally. You are doing invasive things to a dying patient, there is no reason to guess where the problem is. Similarly, if you have to do a thoracotomy, you could consider making it a clamshell as it space to look into and making sure the right side of the chest is accessed."

Methotrexate Failure in Non-Ruptured Ectopic Pregnancy

R.E.B.E.L.EM - march 07, 2019 - By Jessica Pescatore
..."Author Conclusion:
“The proportion of patients failing methotrexate as first-line treatment was higher than previously reported. Further investigation is needed to determine whether methotrexate failure was due to non-adherence to recommended guidelines.”
Clinical Take Home Point: 
Despite the authors quoting a 17.8% failure rate with medical management of non-ruptured, hemodynamically stable, ectopic pregnancy with methotrexate, a more appropriate statement would be that in patients who received methotrexate without relative contraindications (pre-treatment bHCG level >5000mIU/mL, presence of fetal cardiac activity ectopic pregnancy size >4cm), 12 (9.1%), had an ectopic rupture, which is a more accurate estimation."

2018-2019 St. Emlyn´s Top 10 Trauma papers

St. Emlyn´s - By Simon Carley - March 6, 2019
"I’m back in the Midlands at the excellent and great value TraumaUK conference. If you’ve not been to this conference then I’d strongly suggest you do next year. It’s an amazing program and incredible value for money.
As usual I’m in the emergency medicine stream bringing together the top 10 trauma papers from 2018-2019.
As ever it’s a bit disappointing to find relatively few papers to talk about as I try and focus on those papers that might lead to a change in practice. Although there are a lot of publications out there, once you start applying the filters of applicability, quality and interest that number plummets.
So here is my top 10 list based entirely on my own opinion. There is some repetition from past posts, but I’m OK with that as we can call it spaced repetition"
.

jueves, 28 de febrero de 2019

Early Norepi in Septic Shock

R.E.B.E.L.EM - February 28, 2019 - By Salim Rezaie
"Background: Standard management of septic shock has included, IV fluids until optimal intravascular volume is achieved, appropriate early antibiotics, and source control. Typically, only after all these measures have been undertaken is vasopressor infusion initiated if a MAP of ≥65mmHg is not achieved.
There have been some animal and human studies that have advocated for early norepinephrine administration in septic shock improving hemodynamics and mortality. The issue, with these trials is that they were retrospective which means these studies suffer from the limitations of this type of methodology (i.e. convenience sampling, recall bias, confounding, and ultimately cannot determine causation, only association)...
Author Conclusion: “Early Norepinephrine was significantly associated with increased shock control by 6 hours. Further studies are needed before this approach is introduced in clinical resuscitation practice.”
Clinical Take Home Point: Although, this study confirms my own biases of initiating vasopressor therapy earlier in the course of patients with septic shock, it should be remembered that this study still requires external validation with patient oriented outcomes before implementation into routine clinical practice.
Currently, in my practice, in patients with septic shock, I am starting with a Lactated Ringers bolus and assessing fluid status with RUSH exam. If my patient is euvolemic or hypervolemic, I am beginning my norepinephrine infusion at a much sooner time than waiting for 30cc/kg to be completed"

IV Bolus Epi for Anaphylaxis

EMCrit RACC
EMCrit CQiR - February 27, 2019 by Ashley Mogul
"Take Home Points:
  • Continue giving your initial dose of epinephrine IM
  • In IV bolus epinephrine: low dose, slow push
  • Don’t give dead people doses of epinephrine to alive people
I would like to acknowledge Diane Lum, PharmD and Guang Mei Fung, PharmD for their assistance with my literature review.

Comments from Weingart
There must be an equivalent IV infusion dose to our standard IM dosing! But I'll be damned if I can find out what it is… So my best clinical recs based on experience actual patients we have tried this on.
  • Start at 5 mcg/min
  • this will almost always be too low
  • titrate every couple of minutes up to 10, 15, 20 mcg
  • For a patient that is peri-code, consider 20-40 mcg/min (as best I can tell, the 0.3 mg IM we give is expected to last approx. 10 minutes, so 30 mcg/min is probably the mean over those 10 minutes (though I'm sure there is a peak/trough rather than steady state)). If someone is truly going down the poop shoot, giving half of an ml of cardiac epi (50 mcg) or 5 mls of EMCrit-style push-dose pressors (50 mcg) may be warranted."

ANDROMEDA-SHOCK


PulmCCM - February 23, 2019 - By Jon-Emile S. Kenny
..."Within the 2016 Surviving Sepsis Guidelines lies the following recommendation: ‘normalize lactate in patients with elevated lactate levels as a marker of tissue hypo-perfusion.’ This, however, is graded as a weak recommendation, low quality of evidence. Interestingly, buried within the text, the guideline authors declare – correctly – that ‘serum lactate is not a direct measure of tissue perfusion.’ Could there exist a better indicator of tissue starvation in septic shock?
Almost 40 years ago, Champion introduced the idea of monitoring capillary refill time [CRT] for shock resuscitation. This low-tech metric fell out of favour during the zenith of invasive monitoring and oxygen delivery optimization in the 1980s and ‘90s. However, recent data have shown that CRT: 1. is potentially a more responsive resuscitation sign in sepsis than biochemical guides, 2. spares excessive intravenous fluids and their inherent harms and 3. predicts mortality in septic patients in the ED.
Given the above, the ANDROMEDA-SHOCK trial was released last week at the 48th Critical Care Congress and the caterwauling was recorded immediately across multiple time zones. Do we dare worship this false idol? This Golden Calf called ‘capillary refill time?’..."

Non-Infectious Causes of Fever

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emDocs - February 25, 2019 - Author: Brubaker S
Edited by: Koyfman A; Long B and Montrief T
"Summary
  • Most fevers are caused by infection. However, in fever of unknown origin, up to 70% of fevers have non-infectious etiology.
  • Some common medications that can cause fever: beta-lactam antibiotics, antiepileptics (phenytoin, carbamazepine), chemotherapeutic agents (paclitaxel, docetaxel), thyroxine.
  • Toxidromes with fever: anticholinergic, sympathomimetic, hallucinogenic.
  • Withdrawal syndromes with fever: alcohol, opioid, and barbiturate.
  • NMS (most common offending agent: 1st generation antipsychotics) and serotonin syndrome are associated with high mortality; have high suspicion for these diagnoses in patients with hyperpyrexia (temperature greater than 41°C (105.8°F)).
  • Workup for autoimmune disease can often be deferred to the outpatient setting; patients with known chronic inflammatory conditions are often immunocompromised, and infection must be ruled out before assuming a non-infectious fever.
  • “B symptoms” (fever, night sweats, weight loss) may indicate the presence of a neoplastic process; hematologic cancers (both lymphoma and leukemia) are more likely to cause fever than solid cancers.
  • Although infectious causes must be excluded first, non-infectious fevers are common in patients with intracranial pathology (hemorrhage, ischemia, hydrocephalus).
  • Thyroid storm and adrenal insufficiency are two metabolic conditions that can lead to fever. They have very high morbidity and mortality when they are not promptly recognized. They often co-occur with infective processes, so have a low threshold to administer antibiotics.
  • Other possible causes: environmental exposure (e.g. heat exhaustion, heat stroke), as well as thromboembolism (e.g. myocardial infarction, deep venous thrombosis, pulmonary embolism).
  • In the correct setting, fever can also be caused by transplant rejection (both acute and chronic) as well as transfusion reaction."

viernes, 22 de febrero de 2019

PoCUS for Retinal Detachments

SGEM#245 - By admin - February 16, 2019
  • "CLINICAL QUESTION: WHAT ARE THE TESTING CHARACTERISTICS OF OCULAR POINT OF CARE ULTRASOUND WHEN ATTEMPTING TO DIAGNOSE RETINAL DETACHMENT AMONG A GROUP OF PATIENTS PRESENTING WITH VISION COMPLAINTS?
  • SGEM BOTTOM LINE: EARLY ON IN YOUR POCUS TRAINING IF YOU IDENTIFY A RETINAL DETACHMENT MAKE THE CALL. BE WARY IF YOU DON’T SEE ANY PATHOLOGY AND MAKE SURE THE PATIENT HAS IMMEDIATE CONSULTATION OR IMMEDIATE FOLLOW-UP. AS YOU PROGRESS IN YOUR POCUS TRAINING YOU MAY BE MORE CONFIDENT WITH CASES THAT YOU CAN RULE OUT."

Sepsis Update 2019

 EMCrit RACC
EMCrit Podcast 241 - February 21, 2019 - By Scott Weingart


lunes, 18 de febrero de 2019

MEDEST - February 18, 2019
"Non traumatic Transitory Lost Of Consciousness (TLOC) is a common cause of medical emergency call. Among TLOC Syncope is the most common cause. So the first challenge for an emergency professional is discerning from Syncope and non syncope situations (seizures, psychogenic, other rare causes)..."

Syncope.001

Constipation Mimics

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emDocs - February 18, 2019 - Authors: Farney R and Schmitz G
Edited by: Koyfman A and Long B
"Summary
  • A patient presenting with constipation will often have a chief complaint of abdominal pain.
  • Constipation itself is not life-threatening; however, it can lead to or represent a life-threatening disease. An emergency physician must have a wide differential diagnosis to avoid misdiagnosis or attribution of symptoms to functional causes.
  • It is up to the emergency physician to look for red flags. Weight loss, rectal bleeding, peritoneal signs, fever, neurological signs, and history of constipation that requires regular use of enemas are some of the red flags that can be obtained in a good history and physical exam.
  • Non-organic constipation should be treatable with dietary changes, increase in fiber and water intake, and short courses of medications such as polyethylene glycol after other causes have been ruled out."

Early use of Norepinephrine in Septic Shock

The Bottom Line - February 15, 2019 - By Celia Bradford
Ref. Permpikul C, AJRCCM, 2019. Published online February 1. doi:10.1164/rccm.201806-1034OC
"Clinical Question
In adult patients presenting to the emergency department with septic shock, does early low-dose norepinephrine compared with standard care increase shock control at six hours?
Authors’ Conclusions
  • Early norepinephrine was associated with increased shock control at 6 hours
The Bottom Line
  • Overall the results seem encouraging and would certainly provide a basis to conduct a larger, multi-centre trial to explore the important question of timing of initiation of vasopressor therapies in septic shock
  • Low-dose, dilute norepinephrine was given safely through a peripheral line in more than half the patients, without adverse effect. This is reassuring that this practice is safe in time-poor or resource-poor environments
  • This is a well-conducted trial that really adds to the literature base for management of septic shock"

jueves, 14 de febrero de 2019

MAGNESIUM AF

SGEM#244 - February 09, 2019
SGEM#244: Magnesium AF

Heparin in NSTEMI

R.E.B.E.L.EM - February 14, 2019
"Author Conclusion: “In the patients undergoing percutaneous coronary intervention for non-ST-segment elevation acute coronary syndrome, parenteral anticoagulation therapy was not associated with a lower risk of all-cause death or myocardial infarction but was significantly associated with a higher risk of major bleeding. These findings raise important safety questions about the current practice of routine parenteral anticoagulation therapy while we await randomized trials of this practice.”
Clinical Take Home Point: Parenteral anticoagulation therapy did not decrease mortality in patients with NSTEMI undergoing PCI but did have more bleeding events compared to non-parenteral anticoagulation therapy. As this is a retrospective review, which has methodological limitations, the findings of this study should be considered hypothesis generating, urging the need for RCTs.
At this point in time, with no mortality benefit and increased bleeding risk, I would recommend holding off on parenteral anticoagulation therapy in UA/NSTEMI until I have had a discussion with my consultant about their preference of anticoagulation prior to PCI."

LUS in acute heart failure

The Bottom Line - February 8, 2019 - ByAdrian Wong
Ref. Lung ultrasound integrated with clinical assessment for the diagnosis of acute decompensated heart failure in the emergency department: a randomized controlled trial. Pivetta et al. Eur J Heart Failure 2019, doi:10.1002/ejhf.1379

"The Bottom Line
  • The addition of LUS to clinical evaluation improved the diagnostic accuracy of ADHF whereas the addition of CXR and NT-proBNP did not. NT-proBNP is not routinely used in my practice and this paper would support this. My current practice is to evaluate patients who present with acute dyspnoea with ultrasound examination of the lung AND heart – I will continue to do so."

Salicylate intoxication

PulmCrit (EMCrit)
February 14, 2019 - By Josh Farkas 
"Of all intoxications, salicylate is one of the most important to understand. These patients can unravel rapidly, with fatal outcome. However, with prompt management most patients will do fine. Treatment depends on a solid grasp of the underlying chemistry and renal physiology."
  • The IBCC chapter is located here.

RUSH Exam

February 12, 2019 - By Jason Bowman
"Today, in homage to our friend Scott, we want to show you our take on the RUSH exam. This is a great place to start as it’s virtually the one stop shop of things that are gonna kill your patient dead right now. If you’ve never seen this exam before, have no fear, our book still has the soul of one that started off life as a field guide for medics to reference at 2:00 am. Each view is only 1-2 pages and packed with visuals. But this book isn’t limited to just medics. We sought out feedback from medical students, nurses, residents and even physician attendings, ranging in specialties from emergency medicine to critical care and internal medicine. In response, we crammed each page full of widely applicable tips and tricks for both the novice and advanced user. This book is designed to grow with you, in a package small enough to fit in your pocket. While this isn’t meant to be your primary textbook, having it available for quick reference every day is the best way to maximize your incidental learning, which happens to be one of the most powerful methods of adult learning. There’s even a quick reference of measurements on the back cover so you don’t even have to open it to use it, plus we’ve added pages for notes throughout so you can make it your own.
Please, enjoy our RUSH exam section; we hope you find it useful."
click

Pelvic Trauma

EMOttawa
EM Ottawa - By Julie Kim - January 4, 2018
"Unstable pelvic fractures have high mortality rates, particularly with patients who are hemodynamically unstable, due to difficulty in achieving hemostasis and other associated injuries. At present, there is no standard guideline that has been published and universally accepted in the management of pelvic trauma. These patients should have integrated management between ED physicians, trauma surgeons, orthopedic surgeons and interventional radiologists. In the words of Scott Weingart, “If you don’t have an institutional protocol, you are going to fail… this needs to be worked out before the crashing patient comes in!”
pelvic trauma

lunes, 4 de febrero de 2019

O2 Sat for acutely ill

SGEM#243 - Posted by admin  - February 02, 2019
"CLINICAL QUESTION: IS LIBERAL OXYGEN THERAPY VS. CONSERVATIVE OXYGEN THERAPY FOR ACUTELY ILL ADULTS EFFECTIVE AND SAFE?

A LIBERAL OXYGEN STRATEGY INCREASED THE RISK OF DEATH COMPARED WITH A CONSERVATIVE STRATEGY IN HOSPITAL, AT 30-DAYS, AND AT LONGEST REPORTED FOLLOW-UP.

SGEM BOTTOM LINE: THE GOAL OF OXYGEN THERAPY SHOULD NOT USUALLY BE 100% IN CRITICALLY ILL PATIENTS BUT RATHER AIM FOR THE MID 90’S%."

Trauma Falls

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emDocs - February 04, 2019 - Authors: Neofitidis D, Uribe J and Waseem M
Edited by: Koyfman A and Long B
"Pearls
  1. Begin with ABCs, bedside glucose level and possibly Naloxone if overdose suspected, expose patient for complete evaluation.
  2. Remember there are both medical and trauma chameleons to alcohol intoxication.
  3. Obtain alcohol level if diagnosis of alcohol intoxication is in question or if mental status is not improving after a few hours of observation.
  4. If head trauma is minor, deferring CT brain may be reasonable with frequent monitoring, but use your clinical gestalt.
  5. If CT C-spine is negative and no gross motor deficit on exam, cervical collar can be cleared.
  6. Look to the hospital policy regarding disposition of intoxicated patients."

sábado, 2 de febrero de 2019

PoCUS for ET Confirmation

REBEL EM - Emergency Medicine Blog
R.E.B.E.L.EM - January 31, 2019
"Author’s Conclusions:
Transtracheal sonography is a valuable adjunct with an acceptable degree of sensitivity and specificity for ETT confirmation. It should be considered when quantitative capnography is unavailable or unreliable.
Our Conclusion:
Confirmation of the ETT should be done using multiple techniques as no one singular method is perfect. With that said, Ultrasonography is another useful tool for confirming ETT placement when used in the hands of an experienced and well-trained sonographer. Judicious use is required as it may not be appropriate for all intubations and more importantly should not add to the difficulty of placing an ETT. The use of ultrasound should be considered in conjunction with other confirmatory methods such as but not limited to the following: chest and epigastric auscultation, end-tidal capnography, ETT condensation, visualization of chest expansion, clinical improvement, and chest x-ray."

Lactate is Not Everything

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emDocs - January 28, 2019 - Authors: Camacho-Ruiz C and Silverberg M
Edited by: Koyfman A and Long B
"Take Home Points
  • The exact pathophysiology of an elevated lactate is likely multifactorial, patient-specific, and disease-specific.
  • The patient can be extremely sick but not yet in multi-organ failure. Their kidneys and liver can be working to their maximum potential to clear the lactate but this will probably eventually fail. Be ready.
  • Clinical judgment is not a number, and sepsis is not equal to elevated lactate. Our goal should be to treat the primary disease instead of a number which is a marker of multiple metabolic reactions, not only oxidative stress secondary to hypoxia.
  • Beta blockers can decrease lactate production in septic patients. Beware."

Inhaled NO for submassive PE

PulmCrit (EMCrit)
PulmCrit - January 28, 2019 - By Josh Farkas


"Summary: The Bullet:
  • The use of an inhaled pulmonary vasodilator is a logical strategy for stabilization of PE patients (especially nitric oxide, which may be depleted in this situation). Previously inhaled nitric oxide has only been supported by case series.
  • iNOPE is a multi-center placebo-controlled RCT which demonstrated that iNO is safe and that it improved hemodynamics (causing improved RV function). The study was too small to determine whether this translated into an improvement in clinical endpoints (e.g. fewer episodes of hemodynamic deterioration).
  • iNOPE utilized a strange composite primary endpoint, which was not different between both groups. For this reason, it may technically be regarded as a “negative” trial.
  • Inhaled nitric oxide may be a very useful therapy to stabilize the crashing PE patient and bridge them to further therapies. Although proving this in an RCT may be nearly impossible, iNOPE provides some evidence to support this therapy."

jueves, 24 de enero de 2019

Best of 2018 (LIFT)

Life in the Fast Lane
LIFT - January 22, 2019 - By Dr Andrew Davies




"Happy New Year. Here’s hoping 2019 is a great one for you.
Mastering Intensive Care is aimed to inspire and empower you, as an intensive care clinician, to bring your best self to the ICU, through conversations with thought-provoking guests. I think there’s a gap in education on the topics we cover on this show and hopefully you find my guests useful..."


Libsyn podcast LITFL Collection Twitter profile Facebook profile

FOAMed

REBEL EM - Emergency Medicine Blog
R.E.B.E.L.EM - January 24, 2019 - By Jenny Beck-Esmay
"Background: This is a guest post from two of our friends all the way in Italy. They have actually sent several revisions of this post as a way to help learners focus on different aspects of FOAMed. One of the major caveats the authors mentioned is that FOAM covers most of the coolest parts of EM, but there are other topics that are important as well. The authors advocate for a compilation of resources into a simple syndication reader (i.e. Feedly) and podcast application (i.e. Downcast, Overcast, etc). When searching for topics consider using FOAM search. Finally, study and focus on FOAM topics that you like and need:
  1. Like = your passions, what you’re best at
  2. Need = what you’re worst at or scared of..."

Leadership

REBEL EM - Emergency Medicine Blog
R.E.B.E.L.EM - January 23, 2019 - By Salim Rezaie
..."Recently, I also read a book called Multipliers, by Liz Wiseman who does an absolutely amazing job talking about the attributes of successful leaders. I began to think about the ideas in this book and the analogies that could be made to the pieces on a chess board. From this combination, I developed a talk on leadership : “Titles Don’t Make Leaders.”...

If your actions inspire others to dream more, learn more, do more, and become more, you are a leader.” John Quincy Adams..."

Lumbar Punctures

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emDocs - January 24, 2019 - Author: DeVivo A
Edited by: Koyfman A; Long B; and Singh M
"Pearls and Pitfalls
Positioning is vital to the success of any procedure, but particularly in the performance of a lumbar puncture. Both the patient and provider must be appropriately positioned and comfortable before starting.
  • Take as much time as needed to become comfortable with the anatomic landmarks of the patient. If you are unable to consistently find an adequate space for the procedure, try using a marking pen.
  • Having an assistant hold the patient in position during the needle insertion can help maintain ideal procedure conditions and assuring the patient stays adequately flexed in an attempt to widen the intervertebral spaces.
  • If your first attempt is unsuccessful, reassess your plan, and try something different. This may be as simple as a slight repositioning of the patient, or attempting the procedure at a different intervertebral space.
  • If you feel as if you are hitting bone, slightly withdraw the needle and redirect superiorly towards the umbilicus, as you’re likely hitting the vertebral spinous process.
  • If there is any concern for elevated ICP, space occupying intracranial lesion, or abnormalities in the neurologic exam, a CT scan of the brain should be performed first.
  • When a lumbar puncture is being performed due to concern for meningitis, a CT and/or lumbar puncture should not delay antibiotic administration."

lunes, 21 de enero de 2019

Rectal Foreign Bodies

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emDocs - January 21, 2019 - Authors: Barrineau T, Davee D, Mosley C
Edited by: Koyfman A and Long B
"Key Points
  • Patients may not initially volunteer information.
  • Maintain nonjudgmental attitude and professionalism.
  • Labs/Imaging may potentially not provide any insight to problem; history is key!
  • Predictors of failure include sharp or hard objects, longer than 10cm, located in the sigmoid colon, and those objects that have been retained for more than 2 days.
  • Set a time limit and use a stepwise approach in management:
    1. Imaging
    2. Lubrication/DRE
    3. Perianal block/DRE
    4. Speculum/Grasping tools/Foley catheter placement
    5. Avoid pushing the object deeper
    6. Do not blindly grab with instrument, can lead to perforation
    7. Do not attempt to remove sharp objects or objects that may be sharp if they break
    8. General Surgery consult
  • If the object is unreachable or sharp consult surgery.
  • If the patient has peritoneal signs consult surgery immediately, administer antibiotics, and resuscitate."

Opioid Overdose

R.E.B.E.L.EM - January 21, 2019 - By Mark Ramzy
"Author’s Conclusions:
The St. Paul’s Early Discharge Rule appears to be useful for identifying suspected opioid overdose patients treated with naloxone who are safe for discharge one hour after administration. This prediction rule works when naloxone is administered intra-nasally in a population where synthetic opioids are more common than the original study. Further studies are needed to determine the rule’s performance in the context of drug combinations and different routes of opioid administration.
Our Conclusion:
The St. Paul Early Discharge Rule has very limited utility and was found to be no better than clinical gestalt at detecting adverse effects in overdose patients who received intranasal naloxone. We do not recommend the use of this rule as it may be harmful to the patient and implies a focus on throughput and disposition. Opiate overdose patients should be observed for 4-6 hours to allow for safe disposition. The additional time should be used to counsel patients on safe use, referral for treatment, distribution of naloxone to them or their friends, opiate education, risk modification, safe-injection site locations and other patient-centered factors."