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


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viernes, 14 de junio de 2019

Unscheduled Procedural Sedation

Journalfeed - By Clay Smith - June 11, 2019
Source: Unscheduled Procedural Sedation: A Multidisciplinary Consensus Practice Guideline.  Ann Emerg Med. 2019 May;73(5):e51-e65.  doi: 10.1016/j.annemergmed.2019.02.022. 
"This guideline for unscheduled sedation is based on good evidence and authoritatively states some key aspects of emergency sedation that apply to our patients and fit the needs of our setting."

jueves, 13 de junio de 2019

ECG Monitoring in Syncope

R.E.B.E.L.EM - By Mark Ramzy - June 13, 2019
..."Clinical Bottom Line:
  • Cardiac monitoring cutoff periods based on patient risk for adverse outcomes are not only clinically sensible but also serve to balance over-testing vs benefit of diagnostic yield. While the risk factors, times and recommended dispositions based off this study are derived below, it is important to recognize that various clinicians in different healthcare systems may have dissimilar thresholds
    • Low Risk (2-hour observation) = Residual 0.2% risk of serious arrhythmic outcome (ZERO of the low risk cohort were ventricular arrhythmias or death) and can be discharged home
    • Medium Risk (6-hour observation) = Residual 5.0% risk of serious arrhythmic outcome (0.9% of the medium risk cohort were ventricular arrhythmias or death) and can most likely be discharged home but requires follow-up within 24-48hours
    • High Risk (6-hour observation) = Residual 18.1% risk of serious arrhythmic outcome (6.3% of the high risk cohort were ventricular arrhythmias or death) and likely need to be admitted if follow-up cannot be arranged before 24-48 hours"

Wolff-Parkinson-White Syndrome

CanadiEM - By Paula Sneath - June 12, 2019
  • Review the physiology of Wolff-Parkinson-White Syndrome (WPW)
  • Review the management of SVT in WPW and consider potential complications
What are WPW and AVRT?
Preexcitation describes the situation in which impulses from the SA node or atrium reach the ventricle through an accessory pathway (a bypass tract) in addition to the AV node. WPW is a type of preexcitation syndrome in which there are ECG findings of an atrial-ventricular bypass tract (often, but erroneously, called Kent bundles) and the patient demonstrates related tachydysrhythmias. The most common tachydysrhythmia seen in WPW is atrioventricular re-entrant tachycardia (AVRT) – this is seen in 80% of patients with WPW and is what paramedics would most commonly be called for..."

martes, 11 de junio de 2019


emDocs Cases - Jun 10, 2019 - Authors: Long B and Gottlieb M -  Edited by: Koyfman A
"Key Points:
  • Transient, non-dependent, non-pitting edema is the most common presentation of angioedema. Commonly involved sites include the face, lips, extremities, and GI system.
  • Two forms include histamine- and bradykinin-mediated forms. Histamine-mediated angioedema presents similarly to anaphylaxis, while bradykinin-mediated angioedema is slower in onset, more severe, and more commonly affects the oropharynx.
  • Management should focus on the airway initially.
  • Histaminergic-mediated angioedema can be treated with medications such as epinephrine, antihistamines, and steroids. However, these medications are not as effective for bradykinin-mediated angioedema.
  • C1-INH protein replacement, kallikrein inhibitor, and bradykinin receptor antagonists are agents that may benefit bradykinin-mediated angioedema.
  • Airway management can be challenging and is improved with fiberoptic or video laryngoscopy, with preparation for cricothyrotomy.
  • Disposition is also challenging, dependent on the involved sites."

PEA after TCA

MEDEST - June 11, 2019 
"On May 2019 was published an article we review today, cause the authors conclusions are pretty astonishing and worth a deeper look.
Authors Conclusions: Following pre-hospital traumatic cardiac arrest, PEA on arrival portends death. Although Cardiac Wall Motion (CWM) is associated with survival to admission, it is not associated with meaningful survival. Heroic resuscitative measures may be unwarranted for PEA following pre-hospital traumatic arrest, regardless of CWM..."

Intubation in Trauma

R.E.B.E.L.EM - By Zaf Qasim - June 10, 2019
... Bring in the New Order!
If anything good has come out of the recent military conflicts, it is our approach to trauma care. We have learnt the benefit of tourniquets and whole blood, and are applying or studying them in civilian practice.
Another important takeaway should be the re-ordering of our approach to resuscitation. Patients who are truly exsanguinating will likely arrest if you attempt to intubate them first. One of the prototypical wartime injuries was the traumatic amputation leading to massive exsanguination. Over time, their management changed and these patients would always have an extremity tourniquet applied before definitive airway management.
This logically leads to the reordering of resuscitation by shifting the initial focus from airway to managing a major insult like this. The ABC mnemonic can be changed to either (C)CAB (Catastrophic hemorrhage; Circulation; Airway; Breathing) or MARCH (Massive hemorrhage; Airway; Respiration; Circulation; Head/Hypothermia)..."


domingo, 9 de junio de 2019

Traumatic Cardiac Arrest

St. Emlyn´s - By Simon Carley - June 7, 2019
"A few weeks ago we reviewed a paper on the management of traumatic cardiac arrest. That paper specifically looked at the role of closed chest compressions in traumatic cardiac arrest (TCA). I recently managed to catch up with the lead author, an old friend of mine and an expert in the management of this complex condition.

In this podcast we discuss the background to Jason’s research and discuss the recent closed chest compression trial in some detail."

jueves, 6 de junio de 2019

Acetaminophen Toxicity

Tox & Hound (EMCrit) - June 6, 2019 - By Diane Calello
..."For starters, let’s establish that the nomogram was developed to predict risk in single, acute APAP overdoses. Not chronic overdoses. Not staggered overdoses. Not repeated supra-therapeutic ingestions. Not the case of “I have no idea what happened because the history is completely unreliable, but I have a detectable level..."

Basilar Skull Fracture

emDocs - June 6, 2019 - Authors: Pillai S and Desai S
Edited by: Koyfman A and Long B
..."Pearls and Pitfalls:
  • Battle sign and raccoon’s eye may be delayed 6-12 hours or not present with BSF.
  • Hemotympanum is typically first finding.
  • Most complications of BSF like CSF leak, cranial nerve deficits, and sequelae of carotid/vertebral artery injury arise late and present after 48 hours.
  • Consider abuse in elderly and children.
  • Consider meningitis if prolonged CSF leak.
  • No evidence for prophylactic antibiotics regardless of CSF leak.
  • Consider CTA to evaluate for carotid artery injury regardless of cervical fracture.
  • Missed CVI can lead to permanent neurologic sequelae or mortality in up to 50% cases.
  • Avoid nasogastric intubation, nasopharyngeal suction / airway, and NIPPV if potential BSF."

martes, 4 de junio de 2019

EXTEND-ing Times for Thrombolysis in AIS?

REBEL Cast Episode 67 - By Salim Rezaie - June 03, 2019
..."Author Conclusion: “Among the patients in this trial who had ischemic stroke and salvageable brain tissue, the use of alteplase between 4.5 – 9.0 hours after stroke onset or at the time the patient awoke with stroke symptoms resulted in a higher percentage of patients with no or minor neurologic deficits than the use of placebo. There were more cases of symptomatic cerebral hemorrhage in the alteplase group than in the placebo group.”
Clinical Take Home Point: This study should in no way change practice and is a ridiculous display of statistical hocus pocus (i.e. multiple regressions ran, and the one that worked for the authors was the one selected for the manuscript). Another example of a small study, stopped early, with frank manipulation of data to help promote one thing…more money in the pockets of the company making the medication."

Fluid boluses

PulmCrit (EMCrit)
PulmCrit - June 3, 2019 - By Josh Farkas 
..."Summary:The Bullet:
  • Fluid boluses don’t necessarily provide reliable information about the patient’s hemodynamics (especially if they are provided casually and without precise hemodynamic monitoring).
  • As shown below, the majority of fluid boluses don’t lead to sustained clinical benefit.
  • Risks of fluid bolus therapy include damage to the endothelial glycocalyx and volume overload.
  • Available RCTs involving fluid bolus treatment suggest that it is harmful.
  • Overall, fluid boluses may lead to transient improvements in hemodynamics, which reinforces the practice of providing them. However, a more detailed evaluation of the evidence and physiology suggests that most fluid boluses probably lead to harm.
  • The widely-recommended practice of treating anyone with potential infection and possible “sepsis” with a 30 cc/kg fluid bolus is likely dangerous and not evidence-based."

Status Epilepticus

Back Home
First10EM - By Justin Morgenstern - June 3, 2019
..."This post is an update of the original status epilepticus post from 2015. The general algorithm is the same, but a few clarifications were added, and the references were updated.
Although older definitions of status epilepticus focused on seizures lasting more than 30 minutes, a more practical definition is any individual seizure lasting more than 5 minutes or 2 seizures without full recovery of consciousness. From an emergency department standpoint, if a patient is still seizing by the time EMS arrives, it is probably status.
I think the described aggressive approach to status epilepticus makes sense in continuous convulsive seizures. However, in patients whose seizures stop with benzos, but simply recur before the patient returns to their baseline neurologic status, a less aggressive approach is probably warranted. (The key distinction is whether you think there is still generalized seizure activity occurring in the brain, which will result in neuronal death). In intermittent seizures, you probably have time to use a conventional anticonvulsant as the second line therapy.
I don’t recommend fosphenytoin. Although it can be given quicker, it doesn’t work any faster or better than phenytoin. Some studies have demonstrated lower side effects with fosphenytoin, but if you look closely, the only side effect that seems to be decreased is pain at the injection site. (Glauser 2016) That doesn’t make sense for patients in status, as they will be unconscious.
I use the same algorithm in both children and adults, as the underlying pathophysiology is the same, and there is little reason to think that the treatment needs to differ. (Glauser 2016) That being said, outcomes tend to be better in children, so a less aggressive approach may be warranted in some circumstances.
Obviously, this aggressive algorithm is not appropriate for non-epileptic spells, or pseudoseizures. Pseudoseizures are usually relatively obvious clinically. Indicators of a non-epileptic spell include maintained consciousness, poorly coordinated thrashing, purposeful movements, back arching, eyes held shut, head rolling, and pelvic thrusting. (Claassen 2017)"
An algorithm for the management of status epilepticus

domingo, 2 de junio de 2019

68 laws of the ER

Resultado de imagen de kevin md.com
KevinMD -  By Rada Jones - January 3, 2019
Resultado de imagen de 68 laws of the ER

Beyond ATLS

St Emlyn’s - By Simon Carley - June 2, 2019
"Another of our videos and podcasts from the #stemlynsLIVE conference. This month it’s Alan Grayson on the role of ATLS in trauma management. If you listen to the twittersphere then ATLS seems to have a terrible reputation, but is that entirely justified?

Perhaps not, and perhaps there are many things that we should be doing ourselves before we criticise a course that was never designed for a major trauma centre setting (although it has been advocated to be so)..."

sábado, 1 de junio de 2019

Overdiagnosis of pericarditis

EMCrit - May 24, 2019 - By Meyers P
"It is my opinion that the medical discovery of pericarditis as a disease entity has actually caused overall net harm to human beings. I see and review so many cases in which the notion of “pericarditis” leads to patient harm that it has become a four-letter diagnosis to me. With the exception of extremely rare cases of significant pericardial effusions made hemorrhagic by thrombolytics (only 2 cases) witnessed in an entire career by one of the world's leading experts who reviews thousands of cases around the world), almost no one has any significant complication of uncomplicated pericarditis (unlike myocarditis, complicated pericarditis with significant pericardial effusions, etc.), and whatever small symptomatic benefit true pericarditis patients receive from NSAIDs and/or colchicine is completely overshadowed by the harms of erroneously diagnosing pericarditis.
Pericarditis is almost a wastebasket diagnosis of exclusion, barely more important than costochondritis (and treated in basically the same way). If I were pericarditis, my only reason to exist would be to trick emergency physicians and cardiologists into missing Occlusion MIs and other real pathologic processes. If you correctly diagnose 99 patients with pericarditis and misdiagnose 1 Occlusion MI as pericarditis, you have failed your goal of protecting patients from emergencies. The harm of missing a single Occlusion MI far outweighs the harms of missing pericarditis.
The simplest solution for Emergency Medicine: Just say no to diagnosing uncomplicated pericarditis in the ED..."

Superficial Venous Thrombosis

emDocs - May 31, 2019 - By Avila J
  • Due to the lack of large clinical trials evaluating the treatment of SVT, much of the literature relies heavily on expert consensus.
  • Traditional treatment involves NSAIDS and stockings. This treatment is still recommended by most for SVT’s <5cm in length and >3cm from the SFJ. (Cosmi 2015)
  • 2012 ACCP guidelines suggest that patients with SVT > 5 cm can be treated with prophylactic dose of fondaparinux or LMWH for 45 days. (Guyatt 2012)
  • This recommendation was largely based on the CALISTO trial, which randomized 3002 patients with SVT to get either fondaparinux or placebo and reported that the rate of PE or DVT was 85% lower in the fondaparinux group (Decousus 2010)
  • SVT within 3 cm of SFJ is considered by some to be equivalent to DVT and can be treated as such (Cosmi 2015)
  • Topical NSAIDS may help symptoms and can be used at the same time as anticoagulation (Kearon 2012)
  • There is no literature supporting or refuting using the same treatment in the evaluation of upper extremity SVT.
  • If an SVT is uncovered in the lower extremity, a bilateral duplex ultrasound evaluating the deep venous system should be considered.
Take Home Points
  • SVT >5cm or <3 cm from the SFJ should be treated with anti-coagulation.
  • The rate of concurrent DVT and PE in patients with SVT is 25% and 5%, respectively.

IV antibiotics for cellulitis

IV antibiotics for cellulitis title image
First10EM - By Justin Morgenstern| - April 2, 2018
Putting this all together, I think it is pretty clear that oral antibiotics should be used for the vast majority of cellulitis patients. Even patients who have already been on oral antibiotics seem to fare great when randomized to cephalexin. (Aboltins 2015) In fact, oral antibiotics seem to be the right choice for almost every infectious disease that has been studied. That makes sense, considering that the bacterium living in your tissues remains ignorant of the antibiotic’s port of entry.
Clearly there are times when intravenous therapy is required. If a patient cannot swallow. If the required dose cannot be tolerated orally. If oral antibiotics cannot be absorbed, either because of the chemical structure of the antibiotic, or because of intestinal problems, which often occur in the critically ill. Or in emergent scenarios, when rapidly achieving peak antibiotic levels might matter. However, these represent a minority of clinical scenarios, especially when discussing cellulitis.
It is time that we dispel the magical thinking that surrounds IV antibiotics."

Acutely Can’t Walk

emDocs  - May 23, 2019 - Authors: Martin K, Uribe J, Waseem M, Gernsheimer J
Edited by: Koyfman A and Long B
"Key Points:
  • “I can’t walk” is an important complaint that has many etiologies, including neurologic, orthopedic, and metabolic.
  • Determining what the patient means by inability to walk is essential (ie, pain vs. weakness vs. focal deficit).
  • While evaluating the patient for the cause of weakness with a good history, physical exam, and appropriate ancillary testing, it is critical to evaluate and stabilize the patient’s ABCs.
  • Determining which part of the nervous system is involved will help make an expeditious and correct diagnosis that will lead to appropriate therapy, which may prevent further mortality and morbidity."

jueves, 30 de mayo de 2019


SGEM#258 - By admin - May 25, 2019
Reference: Joseph et al. Nationwide Analysis of Resuscitative Endovascular Balloon Occlusion of the Aorta in Civilian Trauma. JAMA Surgery March 2019.
  • Authors’ Conclusions: “Placement of REBOA in severely injured trauma patients was associated with a higher mortality rate compared with a similar cohort of patients with no placement of REBOA. Patients in the REOBA group also had higher rates of acute kidney injury and lower leg amputations. There is a need for a concerted effort to clearly define when and in which patient population REBOA has benefit.”

Nebulized TXA for Hemoptysis

Nebulized TXA for hemoptysis WAND 2018
First10EM - May 26, 2019 - By Justin Morgenstern
"Hemoptysis can be scary. I covered the emergency medicine approach to massive hemoptysis in one of the early posts on First10EM. However, even when the hemoptysis is small volume, it can be quite distressing to patients and clinicians alike. This paper asks whether using nebulized tranexamic acid (or TXA) for hemoptysis results in less bleeding.
The paper: Wand O, Guber E, Guber A, Epstein Shochet G, Israeli-Shani L, Shitrit D. Inhaled Tranexamic Acid TXA for Hemoptysis Treatment: A Randomized Controlled Trial. Chest. 2018; 154(6):1379-1384. PMID: 30321510
Bottom line:
This is a small trial with lots of issues, but it hints that in stable inpatients with small volume hemoptysis, the use of nebulized TXA might reduce bleeding. The trial is too small to comment on harms. We need to see this trial replicated, preferable in a larger multicentre RCT, before this becomes standard care, but I think it would be reasonable to use this therapy while waiting for more trials to be completed."

Hepatic Encephalopathy

EMCRIT - May 30, 2019 - By Josh Farkas

"Hepatic encephalopathy is a common cause of ICU admission, as well as a common complication of ICU admission for other indications (e.g. gastrointestinal hemorrhage). At first the intubated patient with hepatic encephalopathy may seem a bit bewildering (will they ever wake up??). However, an organized and aggressive strategy combined with some patience is generally sufficient to obtain an improved mental status and liberation from the ventilator.

Hospitalization in Syncope

R.E.B.E.L.EM - By Anand Swaminathan - May 30, 2019
Article:  Probst MA et al. Clinical Benefit of Hospitalization for Older Adults with Unexplained Syncope: 
A Propensity-Matched Analysis. Ann Emerg Med 2019. PMID: 31080027
"Clinical Question: 
Does hospital admission of ED patients >60 years of age with syncope reduce the rate of serious adverse outcomes?
Authors Conclusions:
“In our propensity-matched sample of older adults with unexplained syncope, for those with clinical characteristics similar to that of the discharged cohort, hospitalization was not associated with improvement in 30-day serious adverse event rates.”
Our Conclusions:
In this propensity-matched sample of prospectively enrolled patients > 60 years of age with syncope or near-syncope, hospitalization was not associated with a decrease in serious adverse events.
Potential to Impact Current Practice: 
While a randomized controlled trial is needed, this information should be used by the clinician to tailor the decision for hospitalization versus discharge for the individual patient.
Bottom Line: 
Hospitalization for patients who are not deemed to be high-risk for a serious cause of syncope, though common in older patients, does not appear to reduce the risk of serious adverse events."

lunes, 27 de mayo de 2019

Cryptococcal Meningitis

emDocs - May 27, 2019 - Authors: Kathryn Fisher and Tim Montrief
Edited by Alex Koyfman and Brit Long
..."Take Home Points:
  • Cryptococcal meningitis (CM) is the most common cause of fungal meningitis and the most common cause of extrapulmonary cryptococcosis worldwide with over 220,000 cases per year, and a mortality of ~30% worldwide.
  • CM occurs primarily in immunocompromised patients. Patients with HIV, cancer, iatrogenic immunosuppression, transplants, drug or alcohol abuse, chronic kidney disease, diabetes and other immunodeficiencies are at high risk.
  • The clinical course of CM is variable, although it typically presents as a subacute meningoencephalitis characterized by an initially indolent course of neurological symptoms including headache, altered mental status, lethargy, fever, meningismus, nausea and vomiting for days to weeks that progressively worsens.
  • CM may be the initial AIDS-defining illness in up to 84% of patients.
  • Emergency providers must have a high index of suspicion for CM in the immunocompromised patient. This is especially true for patients with repeated visits for increasing and atypical neurological symptoms including headache.
  • Initial CSF studies (including India ink stain) may be normal in up to 17% of patients, especially in HIV-positive populations. CSF culture is the current gold-standard for ruling in or out CM, but commonly takes up to 10 days to result.
  • Patients should be treated empirically for bacterial, fungal, and viral meningitis.
  • Initial antifungal regimen for CM includes amphotericin B + flucytosine for 2 weeks"


R.E.B.E.L.EM - By Salim Rezaie - May 27, 2019
..."Take Home Points
  • There is a resurgence of measles worldwide
  • Incubation period is 10 – 14 days
  • Patients are contagious 4 days before rash develops and up to 5 days after
  • Acute treatment is primarily supportive
  • Know the Post Exposure Prophylaxis (PEP) schedules and isolation times of various populations
  • Healthcare workers should wear N95 masks while taking care of patients with suspected measles, and report cases to their local health department."

martes, 21 de mayo de 2019

Beta-lactam allergies

PulmCrit (EMCrit)
PulmCrit - May 20, 2019 - By Josh Farkas
Kimberly Blumenthal and colleagues at the Massachusetts General Hospital have been performing groundbreaking work on beta-lactam allergies. Their work forms the foundation for much of the IBCC chapter on beta-lactam allergies (you might want to read it before this post, but if you don't have time, a one-minute synopsis is below).
One fundamental technique when approaching patients with possible beta-lactam allergy is a “graded challenge” or “test dose.” This may be used when there is some suspicion of a potential allergy. A small dose is provided initially with close supervision, to determine if the patient will react. If this is tolerated, larger doses are subsequently given. 
Historically, there has been little evidence to guide the safety and performance of this strategy. A new publication by the Blumenthal group describes their experience with this...
Summary: The Bullet
  • A test-dose strategy can be used in situations where an allergy is unlikely (yet possible), to help determine the safety of providing a full dose of antibiotic.
  • This is the largest study to validate any specific protocol for challenging patients with possible antibiotic allergy.
  • Within the context of a structured protocol, the test-dose strategy was safe and effective (even without the assistance of an allergist and outside of an ICU).
  • Administration of an advanced-generation cephalosporin using a test dose seems to be safe, even in patients with anaphylaxis to a penicillin."

lunes, 20 de mayo de 2019

Complications of ERCP

EMdOCS - mAY 20, 2019 - Authors: Montrief t and Boin n
Edited by Koyfman a and Long B
"...Take Home Points:
  • The most common post-ERCP complication is acute pancreatitis, followed by gastrointestinal bleeding, viscous perforation, and biliary tract infections.
  • Risk factors for post-ERCP complications include patient factors (aberrant anatomy, renal failure, presence of coagulopathy), provider factors (experience and appropriate endoscope disinfection), and procedure factors (multiple cannulation attempts, contrast injection, intraoperative gallbladder opacification).
  • A transient increase in serum pancreatic enzymes is common following ERCP, found in up to 75% of patients.
  • When evaluating a post-ERCP viscous perforation, the amount of intraperitoneal air does not correlate with the severity of the perforation, but rather reflects the degree of endoscopic insufflation after the perforation occurred.
  • Up to 29% of asymptomatic patients have evidence of retroperitoneal air on CT scan performed 24 hours after ERCP.
  • Most post-ERCP gastrointestinal bleeding is mild, however, severe intra-abdominal hemorrhage can occur.
  • Post-ERCP biliary infections are typically unimicrobial; the most common organisms implicated are Enterobacteriaceae (Escherichia coli and Klebsiella species), Staphylococcus epidermidis, alpha hemolytic streptococci, Enterococcus, and Pseudomonas aeruginosa."

AFib: Wait-and-See or Early Cardioversion

R.E.B.E.L.EM - May 20, 2019 - By Tarlan Hedayati
..."Author Conclusion: 
“In patients presenting to the emergency department with recent-onset, symptomatic atrial fibrillation, a wait-and-see approach was noninferior to early cardioversion in achieving a return to sinus rhythm at 4 weeks.”
Clinical Take Home Point:
Most patients with AF will convert spontaneously to sinus rhythm and, in the absence of hemodynamic compromise, there is no need to rush for rhythm control in the ED. It is difficult to predict which specific patients will convert spontaneously and over what period of time. Providers need to assess severity and duration of symptoms, access to follow-up, risks for CVA, and available anticoagulation strategies, amongst other factors, in the management of patients with AF. Based on this study, a delayed conversion strategy for a specific group of AF patients demonstrates similar rates of sinus rhythm at 4 weeks with no difference in potential risks or patient-reported quality of life as compared to an early cardioversion strategy."

domingo, 19 de mayo de 2019

Lights and Sirens

MEDEST - April 16, 2019
"For who has a multiyear experience in prehospital emergency medicine and deals everyday with emergency transportation of critical patients the sensation is that the use of emergency warning systems are, mostly of times, useless and doesn’t really have any impact on clinical outcomes...
Take home messages for our system and for clinical practice
  • Maybe we need lights and sirens in response phase, cause slightly increase in accident risk corresponds to some gain in arriving time on the scene.
  • Maybe we don’t need lights and sirens in transportation phase cause a great increase in risk of crash do not correspond to a clinical sensitive time gain."

Chest compressions in traumatic cardiac arrest

St. Emlyn´s - Simon Carley - May 19, 2019 
"This is a question that we’ve addressed on the blog before and the evidence has been a little conflicting. From a pathophysiological perspective the logic of using closed chest compressions in a patient who has no circulating volume is clearly pointless. In order for CCC to work, then the patient has to have an intravascular volume to pump around the circulation. However, that’s just a pathophysiological argument and to date there has been little evidence to support it. 
This week there is a paper published which, although an experimental model in pigs, might help enlighten the debate​. 
I actually saw this data at a recent conference but it was (rightly) embargoed and so it’s great to see it in e-print format. The abstract is below, but as always please read the paper yourself and make your own mind up.... 
The bottom line 
If you think that your patient is in hypovolaemic traumatic cardiac arrest then CCC is unlikely to be helpful and may be harmful (but exclude other causes before you abandon them)."

The At-Risk” Applicants’ Emergency Medicine

Cordemblog - May 03, 2019
Authors: Liza Smith, MD; Emily Hillman, MD; Jamie Hess, MD; Seth Kelly, MD; Katelyn Harris, MD; Alexis Pelletier-Bui, MD; and Adam Kellogg, MD on behalf of the CORD Advising Students Committee in EM (ASC-EM)
This applying guide is intended for students interested in applying to emergency medicine (EM) but who have had academic struggles, professionalism concerns, or other potential red flags that may affect their ability to match. 
A printable version of this guide can be found here.

viernes, 17 de mayo de 2019

Cardiovert AF in the ED

St Emlyn’s - By Simon Carley - May 11, 2019
"If I develop AF then I reckon I’d be able to spot it pretty quick, and I’d get myself down to ED pronto so that I could get myself cardioverted having read the excellent work of Stiell et al​1​. Why? Well I quite like to do cardioversions and so it would be nice to give someone else the opportunity, but more than that, it’s because I think it’s a good idea. But is it?
My belief is that the risks of cardioversion are low, and that the risks of complications are higher if we wait to get it done. In other words my ‘belief’ is that earlier is better, but in truth that may not be the case. The data that’s out there suggests that cardioversion is low risk up until 48 hours​2​ and so what’s the rush? Perhaps it’s because of this thought…..
The bottom line
  • In patients who present to the ED within 48 hours there is probably no panic to cardiovert the patient. It’s fine to delay DC cardioversion to try a period of either rate control, or (as we will continue to do) an attempt to pharmacologically cardiovert them.
  • If you want to go straight for a DC cardioversion then that’s probably also fine, but just make sure you balance the risks of the procedure against time, space and convenience."

Speckle Tracking for ACS

emDocs - May 17, 2019 - By Prats M - Originally published on Ultrasound G.E.L. on 11/26/18 - Visit HERE to listen to accompanying PODCAST

"...Take Home Points
  1. Speckle tracking echocardiography is not ready for prime time in the ED. It was not very sensitive or specific for the diagnosis of acute coronary syndrome in this small retrospective study.
  2. More work needs to be done to see how this modality could help with the diagnosis of acute coronary syndrome and other cardiac pathology in the acute care setting."


The Bottom Line - 17 May 2019 - By Daniel Lane
Ref. Bag-Mask Ventilation during Tracheal Intubation of Critically Ill Adults. Casey J. NEJM 2019; 380:811-821 DOI: 10.1056/NEJMoa1812405
"Clinical Question
In adult ICU patients undergoing tracheal intubation, does bag mask ventilation (BMV) between induction and laryngoscopy reduce the risk of hypoxaemia?...
The Bottom Line
  • Within the methodological limitations of this study, bag-mask ventilation (BMV) appears to be a reasonable intervention to prevent hypoxia
  • This study is inadequately powered to determine whether aspiration risk is increased with BMV. Moreover, there are a multitude of cofounders (mask seal, ventilatory volumes and pressure and gastric stasis) which may influence this
  • Mask ventilation (with cricoid pressure) is recommended by the Difficult Airway Society especially when the patient has poor respiratory reserve, sepsis, or high metabolic requirements. It also provides an early indication of the ease of ventilation"