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Thursday, September 29, 2022

CV Risk in Transgender Persons

EMOttawa - By Rebecca Seliga, Alex Coutin - September 29, 2022
Question:
Are transgender and gender-diverse (TGD) persons on testosterone at a higher risk for acute coronary syndrome (ACS)?
Evidence:
There is very little literature on the topic of TGD persons who take testosterone with regards to cardiovascular risk. We know that the FDA has previously issued a warning for testosterone taken for hypogonadism in cisgender (cis) men as it may increase the risk of myocardial infarction. This warning has been controversial as some subsequent studies have been discordant. However, patients who take testosterone as gender-affirming hormone therapy (GAHT) generally take at minimum two-fold higher doses in the first year of treatment, and may be subject to even higher risks.
One study published in 2019 found that trans men are at a four-fold higher risk of MI than cis women, and a two-fold higher risk of MI than cis men. Possible mechanisms of increased cardiovascular risk for trans men taking GAHT include increases in blood pressure, insulin resistance, changes in lipid profiles (most notably decreases in HDL, increases in triglycerides and LDL), and increased BMI. We do know that TGD persons are at higher risk for venous thromboembolism.

IV Fluids in Pancreatitis

REBEL EM - By Anand Swaminathan - September 29, 2022
Article: de-Madaria E et al. Aggressive or Moderate Fluid Resuscitation in Acute Pancreatitis (WATERFALL). NEJM 2022. PMID: 36103415
Clinical Question: Does the use of moderate fluid resuscitation in acute pancreatitis decrease the rate of progression to moderate/severe pancreatitis in comparison to aggressive fluid resuscitation?
Authors Conclusions: “In this randomized trial involving patients with acute pancreatitis, early aggressive fluid resuscitation resulted in a higher incidence of fluid overload without improvement in clinical outcomes.”
Our Conclusions: We agree with the authors. Aggressive fluid administration results in an increased likelihood of fluid overload. Though not statistically significant, the primary outcome as well as many of the important secondary outcomes favor the moderate fluid group as well.
Potential to Impact Current Practice: The tide has been turning against the use of aggressive fluid resuscitation in acute pancreatitis and this high-quality study should increase the push for a paradigm change. Administer smaller fluid boluses (10 cc/kg) in patients with hypovolemia (and no bolus in those with normovolemia) and start maintenance fluids at 1.5 cc/kg/hour.

TEG-Guided Resuscitation

REBEL Crit, REBEL EM - By Cheng Ng - September 26, 2022 
Article: Kumar M et al. Thromboelastography-Guided Blood Component Use in Patients With Cirrhosis With Nonvariceal Bleeding: A Randomized Controlled Trial. Hepatology. 2020;71(1):235-246. PMID: 31148204
Clinical Question: Does a TEG-guided transfusion strategy lead to lower use of blood products compared with standard practice (guided by PT and INR) in acute non-variceal bleeding among patients with advanced cirrhosis? 
Author’s Conclusion: “Among patients with advanced cirrhosis with coagulopathy and nonvariceal upper GI bleeding, TEG guided transfusion strategy leads to a significant lower use of blood components compared with SOC (transfusion guided by INR and PLT count), without an increase in failure to control bleed, failure to prevent rebleed, and mortality.”
Our Conclusion: Overall, we agree with the authors’ findings. Patients with advanced cirrhosis and nonvariceal upper GI bleeding transfused using a TEG-guided strategy required less FFP, platelets, and cryoprecipitate. In addition, they experienced fewer transfusion-related reactions, with no difference in mortality rates compared to the SOC group. We would advocate for using a TEG-guided transfusion strategy in this patient population as it would conserve precious resources while obtaining similar health outcomes. However, EGD results confirming nonvariceal bleeding would likely be unavailable outside the ICU.

ABCDE Approach

CanadiEM - By Devika Singh - September 27, 2022
The ABCDE approach applies to the initial assessment of critically ill patients. For each step, appropriate treatment should be started regardless if there is a definitive diagnosis.

TNK for AIS

SGEM#37 - By admin - September 24, 2022
Reference: Menon et al. Intravenous tenecteplase compared with alteplase for acute ischaemic stroke in Canada (AcT): a pragmatic, multicentre, open-label, registry-linked, randomised, controlled, non-inferiority trial. The Lancet 2022
CLINICAL QUESTION: IS TENECTEPLASE NON-INFERIOR TO ALTEPLASE IN TREATING ACUTE ISCHEMIC STROKE?
KEY RESULT: TENECTEPLASE WAS NON-INFERIOR TO ALTEPLASE IN STROKE PATIENTS TREATED WITHIN 4.5 HOURS OF SYMPTOM ONSET
SGEM BOTTOM LINE: WE REMAIN SKEPTICAL ABOUT THROMBOLYSIS FOR ACUTE ISCHEMIC STROKE WHETHER IT IS DONE WITH ALTEPLASE OR TENECTEPLASE

Tuesday, September 20, 2022

HINTS Exam

SGEM#376 - September 17, 2022 - By admin
Reference: Gerlier C, et al. Differentiating central from peripheral causes of acute vertigo in an emergency setting with the HINTS, STANDING and ABCD2 tests: A diagnostic cohort study. AEM 2021
The paper we will discuss compares the HINTS exam to the STANDING protocol. STANDING is an algorithm by Dr. Vanni et al. published in Frontiers in Neurology 2017.


"CLINICAL QUESTION: CAN EMERGENCY PHYSICIANS LEARN AND PROPERLY USE VERTIGO PROTOCOLS TO ASSESS PATIENTS WITH ACUTE VESTIBULAR SYNDROME, AND IS ONE PROTOCOL BETTER THAN OTHERS?
KEY RESULT: IN THESE NINE TRAINED EMERGENCY PHYSICIANS, THE HINTS EXAM, AND THE STANDING ALGORITHM OUTPERFORMED ABCD2 IN DIAGNOSING CENTRAL CAUSES OF VERTIGO.
SGEM BOTTOM LINE: THIS STUDY SHOWS THAT EMERGENCY PHYSICIANS CAN USE THE HINTS EXAM TO RULE OUT STROKE ON PATIENTS WITH CONSTANT VERTIGO AND NYSTAGMUS, WHO SCREEN NEGATIVE FOR CENTRAL FEATURES OF VERTIGO, AND HAVE AN OVERALL HINTS PERIPHERAL RESULT"

High-Risk Syncope Mnemonic

emDOCs - September 19, 2022 - By Matthew Christensen and Kristy Schwartz
Reviewed by: Jamie Santistevan; Manpreet Singh and Brit Long
Syncope is a relatively common chief complaint in the emergency department, with a broad differential that ranges from reassuringly benign to acutely life-threatening. While there is no substitute for a thorough history and physical exam, obtaining an electrocardiogram (ECG) is a key aspect of nearly every syncope workup. Prompt recognition of high-risk ECG patterns is a critical skill for emergency medicine attendings, residents, and medical students alike. Here we introduce the mnemonic “ABCDE Left Right”, a memory aid to help EM providers quickly recall seven ECG patterns of high-risk syncope: AV block, Brugada pattern, QTc prolongation, delta waves (Wolff-Parkinson-White), epsilon waves (arrhythmogenic right ventricular cardiomyopathy), left ventricular hypertrophy, and right ventricular strain.
For a refresher on the broader approach to syncope in the emergency department and take a closer look at non-cardiac causes of syncope, see the emDocs article Syncope and Syncope Mimics.
                                                            

Saturday, September 17, 2022

Diltiazem O Metoprololo

empills - 14 September 2022 By Federica Liegi
Lo studio
“DILTIAZEM VS. METOPROLOL IN THE MANAGEMENT OF ATRIAL FIBRILLATION OR FLUTTER WITH RAPID VENTRICULAR RATE IN THE EMERGENCY DEPARTMENT” link
Conclusioni degli autori dello studio:
Il Diltiazem è più efficace del Metoprololo nell’ottenere il rate-control nei pazienti che accedono in Pronto Soccorso con diagnosi di Fibrillazione atriale ad elevata risposta ventricolare nei primi 30 minuti – e ad ogni misurazione della FC (5’-10’-15’-20’-25’-30’) – dalla somministrazione del farmaco, in assenza di un significativo aumento dell’incidenza di eventi avversi, come bradicardia o ipotensione.

Optic Neuritis

emDOCs - September 12, 2022 - By Tallib Karaze and Matt Baluzy
Reviewed by: Courtney Cassella; Alex Koyfman; Brit Long
Take Home Points
  • Optic neuritis is a clinical diagnosis and presents with acute vision change, pain with eye movements, changes in color vision, and an RAPD on exam. Additional studies such as MRI, POCUS, serum, and CSF studies can aid in the diagnosis.
  • Neurology, ophthalmology, or a neuro-ophthalmologist should be consulted to help guide management decisions.
  • Treatment options for typical optic neuritis include three days of either IV methylprednisolone or high dose oral prednisone, followed by low-dose oral prednisone and a steroid taper if needed.

Acetazolamide in ADHF

REBEL CRIT, REBEL EM - September 15, 2022 - By Salim Rezaie
Paper: Mullens W et al. Acetazolamide in Acute Decompensated Heart Failure with Volume Overload. NEJM 2022. PMID: 36027559 [Access on Read By QxMD
Clinical Question: Does the addition of acetazolamide to loop diuretics lead to more and faster decongestion in patients with acute decompensated heart failure with volume overload?
Author Conclusion: “The addition of acetazolamide to loop diuretic therapy in patients with acute decompensated heart failure resulted in a greater incidence of successful decongestion.”
Clinical Take Home Point: In patients with acute decompensated heart failure, and clinical signs of volume overload (i.e. edema, pleural effusion, or ascites) the addition of 500mg of IV acetazolamide to standard loop diuretic therapy resulted in more diuresis, more natriuresis, shorter hospital stay, and an increased likelihood of being discharged without residual signs of volume overload.

Friday, September 9, 2022

HFNC vs NC for RSI

REBEL Cast Ep112 - By Salim Rezaie - September 08, 2022

Paper: Chua MT et al. Pre- and Apnoeic High-Flow Oxygenation for Rapid Sequence Intubation in the Emergency Department (the Pre-AeRATE Trial): A Multicentre Randomised Controlled Trial. Ann Acad Med Singap 2022. PMID: 35373238 [Access on Read by QxMD]
Clinical Question: Does HFNC oxygenation for preoxygenation and apnoeic oxygenation maintain a higher oxygen saturation (SpO2) during RSI in ED patients compared to usual care (Nasal Cannula)?
Author Conclusion: “Use of HFNC for preoxygenation and apnoeic oxygenation when compared to usual care, did not improve lowest SpO2 during the first intubation attempt but may prolong safe apnoea time.”
Clinical Take Home Point: I am not surprised by these results. In a population of predominantly neurologic emergencies, HFNC used for preoxygenation and apneic oxygenation did not show improvement in median lowest SpO2 achieved during the 1st intubation attempt. However, HFNC did seem to prolong safe apnea (≈3min) and decrease the risk of SpO2 falling below 90% compared to NRB + NC. HFNC could be considered as an intermediary step for patients in cardiopulmonary extremis or with perceived difficult airways when not tolerating NIV.

Tuesday, September 6, 2022

New in OCHA

MEDEST - By Mario Rugna - September 06, 2022
Chest compressions alternate to abdominal compression–decompression technique
For prehospital use of combined chest compression and abdominal compression–decompression cardiopulmonary resuscitation we have first of all to account the need of an additional rescuer to perform abdominal compression-decompression. By the way the alternate chest/abdominal compression-decompression method is promising even if we need larger multicenter randomised trial for a more consistent evaluation of its efficacy.
Head and thorax elevation during cardiopulmonary resuscitation
There are still insufficient historical data to understand the benefit of automated controlled elevation (ACE) CPR and this study doesn’t clear any doubt about it’s efficacies on clinical oriented outcomes.
Aortic occlusion during cardiac arrest. Mechanical adrenaline?
REBOA in Cardiac Arrest is potentially useful to increase CPP and less dangerous than epinephrine administration. 
It’s feasibility in emergency (in-hospital and out of hospital) settings in a timely manner and with a small number of medical personnel needs to be demonstrated.

BP & O2 Target with ROSC

REBEL Crit - By Salim Rezaie - September 05, 2022
Clinical Take Home Point: 
In comatose adult patients, with presumed cardiac etiology of their cardiac arrest, with ROSC…
  • There appears to be no difference between a restrictive vs liberal oxygenation target regarding the incidence of death or severe disability or coma at 90 days.
    • will continue to titrate FiO2 to maintain a PaO2 range of 68 to 105mmHg (based on this trial) or an SpO2 of 90 to 95% (my bedside practice) in the post arrest setting.
  • There appears to be no difference between targeting a lower mean arterial pressure (63mmHg) vs a higher mean arterial pressure (77mmHg) regarding the incidence of death or severe disability or coma at 90 days.
    • I will continue to target a mean arterial pressure of ≥65mmHg in the post arrest setting.

Complications of Stroke Therapy

EM Ottawa - By Emma Ferguson & Lucy Karp - September 01, 2022
Acute stroke care is integrated into emergency medicine in many emergency departments across Canada. Whether you are involved in acute stroke care through consultation with neurology or through tele-stroke, understanding the complications of acute stroke therapy and evidence around treatment options is essential. Specifically, in this blog post we will focus on the following:
  • Orolingual angioedema post thrombolysis for acute ischemic stroke
  • Approach to post-thrombolysis intra-cranial hemorrhage (ICH)
  • Approach to seizure in the stroke patient

Thursday, August 25, 2022

REBOA

canadi EM - August 25, 2022 - By Braedon Paul
…Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA)
Traditionally, resuscitative thoracotomy (RT) with aortic cross-clamping has been the intervention of choice for achieving control of non-compressible torso hemorrhage (NCTH) for patients in extremis (i.e., severe hemodynamic compromise). This is, of course, a temporizing measure until definitive surgical management can be obtained.​ Despite what the writers of Grey’s Anatomy or ER want us to think, survival rates following ED thoracotomy for penetrating abdominal trauma are somewhat disheartening (around 9% based on 25 years of data from 2000).​
In more recent literature, resuscitative endovascular balloon occlusion of the aorta (REBOA – not to be confused with country music sensation, Reba) has been suggested as an alternative to RT for achieving NCTH control for life-threatening bleeds.​ As the name suggests, REBOA involves deploying an occluding balloon in the distal thoracic or distal abdominal aorta (depending on the site of injury), typically via the femoral artery, to gain hemorrhage control and thus improve proximal perfusion to the brain and coronaries.​..


A video demonstrating this technique with the ER-REBOA catheter system can be viewed here: ER-REBOA™ Procedure – YouTube

Wednesday, August 24, 2022

Mesenteric Ischemia

emDOCs - August 23, 2022 - By Alex Koyfman
Reviewed by: Brit Long and Manpreet Singh
Welcome back to the EM Educator Series. These posts provide brief mini-cases followed by key questions to consider while working. The featured questions provide important learning points for those working with you, as well as vital items to consider in the evaluation and management of the specific condition discussed.
Considerations:
  • What are the four types of mesenteric ischemia?
  • What are the major risk factors for mesenteric ischemia?
  • How can this disease present, and how does it relate to the pathophysiology of each type?
  • What are pitfalls with laboratory evaluation?
  • What imaging is recommended, and what are pitfalls?
  • What is the ED management?
  • What specialists should be consulted?

Tuesday, August 23, 2022

Ocular PoCUS

EM Ottawa - August 18, 2022 - By Joyes Botros, Wilson Lam, Rajiv Thavanathan
Summary
POCUS can be a useful adjunct to the eye exam when seeing a patient with visual disturbances in the emergency department. It can be useful in detecting increased optic nerve sheath diameter and optic disc elevation suggestive of increased intracranial pressure. It may also be useful in seeing a thick or thin hyperechoic membrane which may suggest retinal detachment or vitreous detachment, respectively. In patients with vitreous hemorrhage, you may see a washing machine sign. Finally, look out for the retrobulbar spot sign indicative of central retinal artery occlusion. On your next shift, try using POCUS to help you gain more information to integrate into your clinical case and help you diagnose your ocular emergencies.

Non-Sterile Gloves for Suturing

REBEL EM - August 22, 2022 - By Salim Rezaie
Paper: Zwaans JJM et al. Non-Sterile Gloves and Dressing Versus Sterile Gloves, Dressings and Drapes for Suturing Traumatic Wounds in the Emergency Department: A Non-Inferiority Multicentre Randomised Controlled Trial. Emerg Med J 2022. PMID: 35882525 [Access on Read by QxMD]
Clinical Question: Is the use of non-sterile materials (gloves, dressings, and drapes) non-inferior to sterile materials in the rate of wound infection after suturing traumatic lacerations?
Author Conclusion: “Although recruitment ceased prior to reaching our planned sample size, the findings suggest that there is unlikely to be a large difference between the non-sterile gloves and dressings for suturing of traumatic wounds and sterile gloves, dressings and drapes for suturing traumatic wounds in the ED.”
Clinical Take Home Point: Although underpowered, this trial suggests that there is no significant difference between non-sterile gloves/dressings compared to sterile gloves/dressings/drapes in the suturing of traumatic wounds and the risk of infection. Due to the small numbers of patients with diabetes mellitus, immunosuppressed and on corticosteroids, caution should be applied to extrapolating these results in those populations.

CCB Intoxication

empills - 22 Agosto 2022 - di Isabelle Piazza
L’intossicazione da CCB causa quindi problematiche con due modalità:
  1. Blocca i canali del Ca nelle cellule miocardiche e muscolari lisce dei vasi
  2. Causa ipoinsulinemia che a sua volta contribuisce alla tossicità diminuendo la quantità di glucosio intracellulare per i cardiomiociti provocando un viraggio del metabolismo verso un maggiore utilizzo di acidi grassi, meno efficienti dal punto di vista energetico
HIET – Hyperinsulinemia Euglycemia Therapy


Monday, August 22, 2022

Nausea and Vomiting

emDOCs - August 22, 2022 - By Marie J. Murphy and Ian S. deSouza
Reviewed by: Marina Boushra; Alex Koyfman
Take Home Points
An accurate history of present illness, a thorough review of systems, and a broad differential diagnosis will help identify the underlying cause of nausea/vomiting

Saturday, August 20, 2022

Agitation in the ED

Canadi EM - By Edward Feng - August 11, 2022
&
Canadi EM - By Edward Feng - August 18, 2022

…We hope to leave readers more comfortable dealing with these common yet extremely important situations in the ED, all while keeping the 4 objectives of the American Association of Emergency Psychiatry (AAEP) at the forefront​: 
  1. Ensure the safety of the patient, staff, and others in the area.
  2. Help the patient manage their emotions and distress and maintain or regain control of their behaviour. 
  3. Avoid the use of restraints when at all possible. 
  4. Avoid coercive interventions that escalate agitation.

N-ATBs in Mild Acute Diverticulitis

REBEL EM - By James C. Fletcher - August 18, 2022
The Paper: Mora-López, L. et al. Efficacy and Safety of Nonantibiotic Outpatient Treatment in Mild Acute Diverticulitis (DINAMO Study). Annals of Surgery, 2021. PMID: 34183510 [Access on Read by QxMD]
Clinical Question: Is it necessary to prescribe antibiotics to all patients undergoing outpatient management for mild diverticulitis as identified on CT scan?
Author Conclusion:Nonantibiotic outpatient treatment of mild AD is safe and effective and is not inferior to current standard treatment.”
Clinical Bottom Line: Otherwise healthy patients presenting to the Emergency Department with mild acute diverticulitis, no signs of severe infection/sepsis, and who achieve good symptom control in the ED may be discharged home with symptomatic management and close follow-up only, and may not require antibiotic therapy.

Tuesday, August 16, 2022

Abscess

emDOCs Podcast Episode 60 - By Brit Long - August 16, 2022
Key Points:
  • S. aureus is the most common cause of abscess.
  • Abscess, like cellulitis, is a clinical diagnosis. Labs and imaging are not usually needed in evaluating or managing an abscess.
  • POCUS can assist with abscess identification and drainage.
  • Incision and drainage is the treatment of choice. Some patients should be treated with antibiotics.
  • Admit the patient for parenteral therapy when not tolerating PO antibiotics, rapid progression of erythema, severe infection, and/or proximity of the lesion to an indwelling medical device.

ECG in Aortic Dissection

Emergency Medicine Cases - ECG  Cases 34 - By Jesse McLaren
Peer Reviewed and edited by Anton Helman - August 2022
Take home points for ECG in aortic dissection
  • The ECG in aortic dissection can range from normal, to chronic LVH, to acute ST/T changes
  • ECGs diagnostic of acute coronary occlusion are unlikely to be secondary to aortic dissection, and CT scans to rule out aortic dissection lead to reperfusion delays
  • Non-diagnostic ECGs require other tests (including POCUS) guided by pre-test probability

Monday, August 15, 2022

Basic EM

REBEL EM - June 01, 2022 - By Ellsworth Wright
Take Home Points
  • Emergency medicine revolves around the differential diagnosis
  • History and physical exam should significantly narrow your differential diagnosis
  • Have an idea of what specific diagnoses are being ruled out when ordering diagnostic tests
  • Always consider the most life-threatening and most common disease processes first – we are a rule out specialty
  • “Red flags” are key historical or physical exam findings that put one at a higher risk for certain conditions
  • You have a finite number of shifts as a learner. Challenge yourself to learn something new every day!

Saturday, August 13, 2022

Viruela del mono

SEMES PARTICIPA EN LA ELABORACIÓN DE LAS NUEVAS GUÍAS DE MANEJO DE CASOS DE VIRUELA DEL MONO DEL MINISTERIOS DE SANIDAD
El Ministerio de Sanidad ha publicado las nuevas Guías de Manejo de casos de Viruela del Mono, en las cuales ha participado la Sociedad Española de Medicina de Urgencias y Emergencias (SEMES). El objetivo de dichos documentos es para mejorar el diagnóstico, tratamiento y prevención entre los diferentes grupos de enfermos: ambulatorios, hospitalarios y pediátricos.
Desde SEMES, compartimos con nuestros socios las diferentes guías:
Acceda a la web del Ministerio de Sanidad

Tuesday, August 9, 2022

Calcium and blood products in trauma

St Emlyn’s - By Simon Carley - August 09, 2022
This week we have a nice paper that highlights some of the ongoing thoughts and controversies about the use of calcium in major haemorrhage protocols. Hopefully you’ve already read Iain’s excellent review of the matter here which is well worth a read together with the links at the end of this article. You should probably also read up on the RePHILL trial of blood in major trauma patients which has it’s own controversies and nuances that are asking questions of those organisations using prehospital blood products…”

Video Laryngoscopy

EemDOCs - August 08, 2022 - By Cameron Jones
Reviewed by: Bryant Allen; Alex Koyfman; Marina Boushra; Brit Long
Take-Home Points
  • Video laryngoscopes include standard-geometry blades (SGVL), hyper-angulated blades (HAVL), and hyper-angulated blades with an ET tube channel.
  • While SGVL involves similar technique to classic DL blades, HAVL requires a specific skill set, particularly when it comes to tube insertion.
  • There is some evidence that VL may increase first-pass and overall intubation-success rate, but the data in ED-based studies is still mixed.
  • The availability of SGVL also makes the “VL vs DL” debate obsolete, and EPs should instead focus on building both HAVL and SGVL into their airway algorithms.
  • There is limited evidence comparing HAVL and SGVL, and future prospective trials may inform selection of specific devices for certain clinical scenarios.

Saturday, August 6, 2022

HIV in the ED

EMOttawa - By Alex Viau, Josee Malette, Alex Coutin - July 28, 2022
EMOttawa - By Alex Viau, Josee Malette, Alex Coutin - August 04, 2022

In this two-part blog series, we hope to outline the following:
  • Part 1: 
    • The UNAIDS 90-90-90 guidelines and the importance of early recognition in order to engage patients with early ART;
    • The 3 phases of HIV infection and the Acute Retroviral Syndrome (ARS);
    • PublicHealth Agency of Canada (PHAC) and Center for Disease Control (CDC) recommendations for testing and how it works at The Ottawa Hospital.
  • Part 2: 
    • Indications for occupational and non-occupational post-exposure prophylaxis (PEP);
    • Indications and resources for pre-exposure prophylaxis (PrEP);
    • Barriers to patient engagement and ways we can overcome them.

Decompression Syndrome

Empills - By Davide Tizzani - 05 Agosto 2022
La malattia da decompressione (DCS) si verifica durante la depressurizzazione quando i gas disciolti durante la discesa (solitamente azoto o elio, utilizzati nelle immersioni) formano bubbles (bolle) a rischio di “intrappolamento” all’interno del singoli tessuti. La DCS si verifica durante la salita nella decompressione subacquea, nel lavoro nei cassoni, in volo in un aereo non pressurizzato, in attività extraveicolare da veicoli spaziali. Una appropriata procedura di decompressione può ridurre l’incidenza di DCS. 
Gli esperti hanno classificato due tipologie di malattia: la tipo 1 con sintomi solamente muscoloscheletrici o cutanei, solitamente di lieve entità; il tipo 2 con sintomi a carico del SNC e manifestazioni cardiopolmonari.

EM Rash

REBEL Core Cast - June 01, 2022 - By Ellsworth Wright
Take Home Points
  • Examine all parts of the body, even inside the mouth – this can be the difference between benign and life threatening rashes
  • Truly emergent causes: meningococcemia, TTP, DIC, TSS, SJS, TEN, and necrotizing fasciitis
  • Toxic appearing patients with petechia/purpura = sepsis until proven otherwise
  • Look for medication reactions: Sulfa, Penicillins, NSAID’s, ABX, Chemo, Anti-epileptic agents
  • It’s ok not to know the cause – know the life threatening rashes and rule them out – refer to dermatology out patient
  • TTP – get smear, heme/onc consult, plasmapheresis, and AVOID giving platelets – they will just get chewed up – fix the underlying issue

Tuesday, August 2, 2022

Syncope

Emergency Medicine Cases (Ep172) - By Helman, A. Carr - August 2022 
In this main episode podcast, Dr. David Carr joins Anton to give us his simplified approach to syncope based solely on history, physical and ECG to help guide disposition decisions. We answer questions such as: What features have the best likelihood ratios to help distinguish syncope from seizure? What key clinical features on history and physical exam can help us distinguish orthostatic and reflex syncope from the more sinister cardiac syncope? What is the best approach to ECG interpretation for the patient who has presents with syncope? Are syncope clinical decision tools any better than physician gestalt? and many more….The ED approach to syncope is almost entirely based on a focused but thorough history, cardiac physical exam and ECG rather than laboratory tests and imaging. The first step is distinguishing syncope from seizure. The next step is distinguishing cardiac from non-cardiac syncope. Our ultimate aim is to make safe disposition decisions based on this approach.

Monday, August 1, 2022

Sciatica Mimics

emDOCs - August 01, 2022 - Authors: Mitchell Blenden and Kelly Williamson
Reviewed by: Alexander Y. Sheng; Alex Koyfman; Brit Long
Key Points
  • Sciatica is a diagnosis of exclusion in the emergency department. It is important to assess for red flag symptoms that should prompt further evaluation.
  • Important diagnoses to consider that may mimic sciatica include spinal cord compression, infectious processes, malignancy, and acute limb ischemia.
  • There is no perfect test for sciatica. History and physical exam should be used together to make this diagnosis.
  • The treatment of sciatica is pain control with NSAIDs. The utility of corticosteroids is controversial. Opioids and benzodiazepines have no proven benefit.

ICH Score

EMCritRACC
NeuroEMCrit - August 1, 2022 - By NeuroEMCrit Team (Casey & Neha)
In summary: 
  • The ICH score is a number that is helpful in conveying disease severity
  • Limitations include that it was determined from a cohort in which early withdrawal of care was allowed which biases towards the self-fufiling prophecy
  • Like many scores, it captures neither the context of injury nor patient specific factors such as frailty and reserve. 
  • Use it as part of the diagnostic evaluation, but not as a determination of who gets maximally aggressive care and who doesn’t!

Sunday, July 31, 2022

US for SBO

SGEM#373 - By admin - July 30, 2022
Reference: Brower et al. Point-of-Care Ultrasound-First for the Evaluation of Small Bowel Obstruction: National Cost Savings, Length of Stay Reduction, and Preventable Radiation Exposure. AEM July 2022

CLINICAL QUESTION: 
DOES USING POINT OF CARE ULTRASOUND FIRST LINE IN SUSPECTED SMALL BOWEL OBSTRUCTION REDUCE COST, LENGTH OF STAY AND RADIATION EXPOSURE?
KEY RESULT: 
USING POCUS AS FIRST-LINE IMAGING IN SUSPECTED SBO COULD AVOID 143,000 CT SCANS ANNUALLY IN THE US POTENTIALLY SAVING MILLIONS OF DOLLARS
SGEM BOTTOM LINE: 
POCUS AS FIRST-LINE IMAGING IN SUSPECTED SBO COULD AVOID SIGNIFICANT NUMBERS OF CT SCANS IN US