Síguenos en Twitter     Síguenos en Facebook     Síguenos en Google+     Síguenos en YouTube     Siguenos en Linkedin     Correo Grupsagessa     Gmail     Yahoo Mail     Dropbox     Instagram     Pinterest     Slack     Google Drive     Reddit     StumbleUpon     Print


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


Direct vs. Video Laryngoscopy in 10 Minutes

Buscar en contenido


lunes, 19 de marzo de 2018

Hemorrhagic Shock

emDocs - March 12, 2018 - Authors: DeVivo A and Beck-Esmay J
Edited by: Koyfman A and Long B
..."The compensatory mechanisms enacted by the body during hemorrhagic shock inevitably fail without intervention. As these mechanisms become overwhelmed, acidosis will begin to worsen due to decreased perfusion. This will be reflected by the progressive increase in lactate and base deficit. These two levels can be evaluated as point-of-care test in the emergency department and may be utilized as rough estimations for impending failure of physiologic compensatory mechanisms, and thus vascular collapse.
The remainder of this article will be focused on resuscitation bay pearls for early detection, intervention, and prevention of rapid deterioration in hemorrhagic shock..."

DD and Pregnancy

R.E.B.E.L.EM - March 19, 2018
..."While the use of the D-dimer in conjunction with a low pre-test probability for pulmonary embolism is well established for ruling out PE in the non-pregnant population, the preponderance of evidence to date suggests significant shortcomings with such a strategy in pregnant patients. Indeed, the American Thoracic Society guidelines recommend specifically against the use of D-dimer to exclude PE in pregnancy. Still, though, many emergency physicians have striven for a rational approach to diagnosis—limiting radiation exposure while ensuring safety and sensitivity. The “Kline Algorithm,” as best described in this 2013 podcast on Rob Orman’s venerable ERCast, draws on physiologic expectations and the expertise of Jeff Kline, MD, an emergency medicine physician and expert in venous thromboembolism, to propose a more sensible approach to diagnosis. Unfortunately, literature to support this approach has been sparse. The DiPEP study, published recently in the British Journal of Haematology, attempted to add to this literature base...
Author Conclusion:
“…D-dimer should not be recommended for use in the diagnostic work-up of PE in pregnancy.”
Clinical Take Home Point: Among pregnant women presenting with concern for pulmonary embolism in pregnancy, there remain no data supporting the use of D-dimer in any diagnostic algorithm."

viernes, 16 de marzo de 2018

Endovascular Therapy for Strokes

R.E.B.E.L.EM - March 15, 2018 - By Salim Rezaie
Clinical Take Home Point: 
  • Systemic IV thrombolysis can have limited responsiveness (13 – 50%) to large thrombi in the central circulation, a narrow time window for administration (4.5hrs), and increases the risk of cerebral/systematic hemorrhage
  • The initial 3 trials showing no difference in 90d mRs scores were most likely due to:
    • Proximal occlusion not radiologically proven with intracranial occlusions (i.e. CTA, MRA)
    • The use of first-generation Merci devices as opposed to retrievable stents
    • It is also important to note that in many of the earlier trials there were more new strokes and vessel dissections compared to systemic therapy
  • In the studies reviewed, recruitment averaged about 1 patient per month, meaning this was a very specific and particular patient that was recruited
  • As more and more trials have been performed, the efficiency, the type of imaging, and technology have all also improved, minimizing complications and improving efficacy of endovascular therapy
  • Endovascular therapy for ischemic stroke is suitable for patients with ischemic stroke within 24hrs of symptom onset, with:
    • Proof of proximal intracranial vessel occlusion
    • Imaging methods to exclude large infarct cores
    • Efficient workflow to achieve fast recanalization and high reperfusion rates
    • Workflow: Ischemic Stroke Symptoms ≤24hrs -> CT/CTA -> If CTA positive for large anterior (ICA/MCA) stroke -> CT or MR Perfusion Scan to determine eligibility for Endovascular Therapy
  • Later trials included patients with “wake up” strokes, which have not previously been included in systemic t-PA trials
  • One final note: It is important to realize that many trials were stopped early, and because of this the magnitude of benefit for endovascular therapy may be over inflated in many of these trials

martes, 13 de marzo de 2018

BNP in the ED

First10EM - By Justin Morgenstern - March 13, 2018
"In the most recent episode of Emergency Medicine Cases Journal Jam, Rory, Anton, and I cover the evidence for (for against) using BNP in the emergency department. These are my notes...
Looking at observational data, BNP and NT-proBNP both appear to have a good sensitivities for CHF, but only moderate to poor specificities. There are a number of RCTs looking at BNP use in the emergency department setting. Two studies demonstrated a decrease in hospital length of stay and total costs, but 4 other studies showed no difference. Two studies looked at ED length of stay, 1 demonstrating a statistical but clinically insignificant difference and the other showing no difference. None of the studies demonstrated a change in ED treatment, mortality, or hospital readmission. There are a large number of problems with these studies, including the lack of a clear gold standard for CHF, a lack of blinding, incorporation bias, and spectrum bias. These problems are discussed further in the discussion section. I have never worked in an emergency department where BNP testing has been available, and after reviewing this literature I think that is probably a good thing. It is easy to get excited about tests with high sensitivities, but the use of diagnostic tests is complex and fraught with unintended consequences. I think the best evidence to date suggests that BNP testing does not provide any patient important benefit to emergency department patients."

Palliative Care Myths

NU-EMBy Zaidi H - March 5, 2018 - Edited by: Marshall A
Expertreview by: Chandrasekaran E
  1. “Palliative care is only for people close to death”
  2. “Palliative care discussions are really just about establishing code status.”
  3. “A patient who is DNR or DNR/DNI should not be admitted to the ICU”
  4. “Having a productive goals of care conversation takes hours; I don’t have that kind of time in the ED”
  5. “When discussing goals of care for a patient with a dire prognosis, I should avoid partiality in treatment options.”

domingo, 11 de marzo de 2018

TXA nebulized for Hemoptysis

The PharmERToxGuy - Creator: Mike O’Brien - Posted March 10, 2018

Pharmacology Infographics
click image to enlarge

Abdominal Cutaneous Nerve Entrapment Syndrome

CORE EM - March 7, 2018 - By Carl Preiksaitis
"Definition: Abdominal cutaneous nerve entrapment syndrome (ACNES) is an under recognized cause of chronic abdominal pain. It results when the cutaneous branches of the lower intercostal nerves become entrapped in the lateral border of the rectus muscle...
Take Home Points
  • ACNES is an under recognized cause of chronic abdominal pain in patients presenting to the ED
  • Consider in patients with localized, positional pain without symptoms suggestive of an intra-abdominal pathology
  • Diagnosis is based on characteristic history and physical exam findings including positive Carnett’s test
  • Trigger point injection with anesthetic and steroid can both confirm the diagnosis and provide symptomatic relief"

Fluids in Burn Patients

EMCrit RACC Podcast 219 - March 5, 2018 - By Scott Weingart 

Dr. Djogovic completed training in Emergency Medicine and Critical Care Medicine from 1999-2005, and is currently employed at the University of Alberta Hospital as an Emergency Physician, and as an Intensivist in the General Systems Intensive Care Unit and in the Firefighters Burn Treatment Unit.

lunes, 5 de marzo de 2018

Ischemic Stroke Updates (2018 AHA/ASA)

emDocs - March 5, 2018 - Author: Long B - Edited by: Koyfman A
ED Evaluation and Management
  1. "Use of a stroke severity scale (preferably NIHSS) is recommended.
  2. All patients admitted with suspected acute stroke should receive imaging including noncontrast head CT. Although diffusion weighted MRI is more sensitive, routine use in all patients is not recommended as it is not cost effective. If CT is negative and the presentation is unclear, an area of restricted diffusion on MRI may lead to management change.
  3. Imaging should occur within 20 minutes of ED arrival in > 50% of patients who are candidates for tPA and/or mechanical thrombectomy.
  4. There is insufficient evidence to identify a specific amount of acute CT hypoattenuation severity/extent that affects response to tPA. Extent and severity of acute hypoattenuation or early ischemia should not be used to withhold therapy.
  5. The hyperdense MCA sign or loss of gray-white differentiation on CT should not be used to withhold tPA.
  6. Routine MRI for exclusion of cerebral microbleeds before tPA is not recommended.
  7. Using imaging criteria to select patients who woke with stroke symptoms or have unclear time of symptom onset for treatment with tPA is not recommended.
  8. Multimodal CT and MRI (with perfusion imaging) should not delay tPA administration.
  9. For patients meeting criteria for endovascular therapy, noninvasive intracranial vascular imaging is recommended during initial imaging, but this should not delay tPA. Patients who qualify for tPA before vascular imaging should receive tPA before vascular imaging.
  10. For patients who meet criteria for endovascular treatment, CTA is reasonable before obtaining creatinine if there is no history of renal disease and a large vessel occlusion is suspected.
  11. Imaging of the extracranial carotid and vertebral vasculature is reasonable in patients who are candidates for mechanical thrombectomy (evaluate for stenosis, dissection, occlusion).
  12. Additional imaging other than CT and CTA or MRI with MRA such as perfusion studies to select patients for mechanical thrombectomy in < 6 hours is not recommended.
  13. In patients with stroke symptoms within 6-24 hours after last normal with large vessel occlusion in the anterior circulation, CT perfusion, MRI perfusion, DW-MRI is recommended to assist in selecting patients for mechanical thrombectomy (DAWN, DEFUSE 3 trials)..."

Corneal Abrasions

Taming The SRU - March 05, 2018 - By James Li
"The eye is a complicated organ that is not well understood by many new emergency physicians because it historically has not received much attention during medical school. This makes taking care of these patients challenging. However, eye complaints make up approximately 8% of ED visits and so it is something we will see quite often. In this post we will discuss one of the more common etiologies of "eye pain", corneal abrasions. Corneal abrasions account for 45% of eye complaints in the ED and so are a high yield topic to review. We will start by reviewing some of the anatomy, and then delve into the presentation and management of these patients...
  • Corneal abrasions account for 45% of eye complaints in the ED
  • Use fluoroscein to identify abrasions and a slit lamp to complete a thorough exam
  • Although not evidence based, most patients receive topical antibiotics for 3-5 days
  • Topical tetracaine is likely safe for symptomatic control on discharge, but should be prescribed with caution"

jueves, 1 de marzo de 2018

Penicilin allergy

Emergency Physicians Monthly
EP Monthly - By Serranoo K and Shenvi - January 31, 2018
..."In summary, penicillin allergy is commonly reported but largely overestimated. Questioning your patient about the type of reaction that occurred can help elucidate whether the reaction was an IgE-mediated reaction. Referral for penicillin skin testing is a good option that can lead to better antibiotic stewardship, decreased costs, and better outcomes for your patient. Many cephalosporins can be safely given to patients with penicillin allergy provided they do not share a common side chain."

Normal saline for resuscitation

PulmCrit (EmCrit)
PulmCrit - February 27, 2018 - By Josh Farkas
  • “Normal” saline is a hypertonic, acidotic fluid. There is no physiologic rationale for its use as a resuscitative fluid.
  • There are many potential problems related to saline. These include causing hyperchloremic acidosis, hyperkalemia, hemodynamic instability, renal malperfusion, systemic inflammation, and hypotension.
  • Numerous small RCTs have emerged over the past few years which highlight various problems with saline resuscitation.
  • The SMART and SALT-ED trials are massive, multiple-crossover trials which compare saline versus balanced crystalloids among critically ill and non-critical patients. Both studies found a 1% increase in death or renal failure with the use of saline.
  • The combination of physiology, animal studies, numerous RCTs, SMART, and SALT-ED indicate that it's time to stop resuscitating with saline."


Critical Care logo
Levy B . Critical Care 2018; 22:52
"Vasoplegia is a ubiquitous phenomenon in all advanced shock states, including septic, cardiogenic, hemorrhagic, and anaphylactic shock. Its pathophysiology is complex, involving various mechanisms in vascular smooth muscle cells such as G protein-coupled receptor desensitization (adrenoceptors, vasopressin 1 receptors, angiotensin type 1 receptors), alteration of second messenger pathways, critical illness-related corticosteroid insufficiency, and increased production of nitric oxide. This review, based on a critical appraisal of the literature, discusses the main current treatments and future approaches. Our improved understanding of these mechanisms is progressively changing our therapeutic approach to vasoplegia from a standardized to a personalized multimodal treatment with the prescription of several vasopressors. While norepinephrine is confirmed as first line therapy for the treatment of vasoplegia, the latest Surviving Sepsis Campaign guidelines also consider that the best therapeutic management of vascular hyporesponsiveness to vasopressors could be a combination of multiple vasopressors, including norepinephrine and early prescription of vasopressin. This new approach is seemingly justified by the need to limit adrenoceptor desensitization as well as sympathetic overactivation given its subsequent deleterious impacts on hemodynamics and inflammation. Finally, based on new pathophysiological data, two potential drugs, selepressin and angiotensin II, are currently being evaluated."


An online community of practice for Canadian EM physicians
CanadiEM - By Shahbaz Syed - February 28, 2018
"Syncope is a common problem encountered in the Emergency Department, and yet despite this there are few strong consensus guidelines, and significant practice variation. Here we seek to explore some of the evidence regarding syncope care. The vast majority of literature and recommendations on syncope in this post, are based upon the well patient who has a syncopal event and is now well again. The differential diagnosis in this scenario is actually fairly limited, as there are not many things that do this beyond cardiac and vasovagal (and potentially GI bleeding, but historical features will aid you there)..."

martes, 27 de febrero de 2018

Alcohol sniffing and nausea

St. Emlyn´s - By Simon Caarley - February 25, 2018
..."So where does that leave us?
Well, we have two recent RCTs that suggest sniffing alcohol swabs works. They both have similar flaws, but they are consistent. Until we know better it seems like a reasonable tool for the ED clinician who wants to reduce nausea quickly.
A second question would be whether this study is robust enough to suggest that we should swap Ondansetron for alcohol swabs. In that regard my answer is no. These are really interesting data, but it’s not robust enough to go that far (and in the authors defence they neither designed this study to do that, nor do they suggest it).
So. Get sniffing. Personally, I’m off to get a whiff of a rather nice Albarino I’ve got chilling in the fridge."

Respiratory Failure and NIV

R.E.B.E.L.EM - By Haney Mallemat - February 26, 2018
"Imagine you have a patient in respiratory failure sitting right in front of you. The patient has an increased work of breathing and obviously in distress. Monitors are beeping, nurses are asking you what you want to do, and if you don’t do something, the patient is going to arrest and potentially die. What is your framework for tackling these patients? Well, I had a chance to sit down with Haney Mallemat and discuss his framework for managing respiratory failure and NIV." 

Reversing DOAC in intracraneal bleeding

An online community of practice for Canadian EM physicians
CanadiEM - By Andrew Shih - February 27, 2018
"Main Messages
  • When managing DOAC-associated bleeding, consider the interventions that you would perform if the patient was not on a DOAC. Tranexamic acid has an excellent safety profile based on RCTs. Definitive procedural intervention remains the cornerstone of therapy.
  • Specific reversal agents should be used whenever possible. PCCs and FEIBA are options in factor Xa inhibitor associated bleeding in the absence of a specific reversal agent, where thrombosis risk is low but should be discussed during consent.
  • Plasma and platelet transfusion should only occur when indicated as if the patient was not on a DOAC."

Intubation in critically ill

First10EM - By Justin Morgenstern - February 26, 2018
"Just as I set the last blog post in the airway series to post, a fantastic guideline was published on intubation in critically ill adult patients. It covers most of the content I tried to cover in those posts, and probably does a much better job. I recommend that everyone take the time to read it. I have already covered a lot of this information in the airway series, but as a way of reinforcing the lessons from those posts, I thought I would go through my personal takeaways from this document.
Higgs A, McGrath BA, Goddard C. Guidelines for the management of tracheal intubation in critically ill adults. British journal of anaesthesia. 2018; 120(2):323-352. PMID: 29406182 [free full text]"

sábado, 24 de febrero de 2018

Opioids in ACS

R.E.B:E:L.EM - February 22, 2018
"Background: Typical medical treatment of ACS patients include dual antiplatelet therapy (DAPT) and revascularization with primary percutaneous coronary intervention (PPCI). Nitroglycerin is first line therapy in the treatment of pain in ACS with morphine as a common adjunct. Morphine helps relieve pain which decreases catecholamines and oxygen demand. We have written about the use of Morphine in ACS before on REBEL EM and advocated for fentanyl over morphine for pain control in patients with refractory pain to IV nitroglycerin. However, two new trials have been published in the past month: An observational trial in 300 patients with STEMI receiving morphine and a randomized trial using fentanyl which requires us to revisit the use of opioids in ACS..."

ATLS 10th Edition

emDocs - February 21, 2018 - Author: Long B - Edited by: Koyfman A
"Advanced Trauma Life Support (ATLS) has formed the backbone of trauma evaluation and management. However, in recent years, literature has outpaced the ability of ATLS to remain current with best practice. Controversies such as IV fluids, TXA, chest tube placement position, etc. have brought to the forefront the need to remain up to date with the most recent evidence and literature.
The 10th edition of ATLS has several changes in store for you based on recent literature updates. This post will provide you with several quick hits of the updates."

Emergency Radiology

emDocs - February 23, 2018 - By Anton Helman
..."So, with the help of ‘the walking encyclopedia of EM’ Dr. Walter Himmel and North York General’s Deputy Chief of Radiology Dr. Ryan Margau, we’ll discuss a few emergency radiology controversies, pearls and pitfalls: Which patients with chest pain suspected of ACS require a CXR? What CXR findings do ED docs tend to miss? How should we workup solitary pulmonary nodules found on CXR or CT? Is the abdominal x-ray dead or are there still indications for it’s use? Which x-ray views are preferred for detecting pneumoperitoneum? When should we consider ultrasound as a screening test instead of, or before, CT? What are the true indications for contrast in abdominal and head CT? How should we manage the patient who has had a previous CT contrast reaction or “allergy” who really needs a CT with contrast? What is the truth about CT radiation for shared decision making? And many more emergency radiology controversies…"

martes, 20 de febrero de 2018

C.difficile - New Guidelines

Emergency Medicine PharmD - February 19, 2018
By Mixon T - Peer reviewed by: Cocchio C & Dietrich S
"The Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) convened a group of experts to publish an update to their 2010 C.difficile infection (CDI) guidelines. Below is a summary of the new guidelines from the perspective of an emergency medicine (EM) pharmacist...
Take Home Points
  • IDSA/SHEA have released new CDI guidelines.
  • Emergency medicine pharmacists should play a huge role in antimicrobial stewardship, which is a key component in minimizing the occurrence of CDI.
  • Vancomycin PO or fidaxomicin are now the recommended first line agents for CDI, however, the high cost associated with these therapies may prohibit their use in some patients.
  • Metronidazole should only be considered when vancomycin PO or fidaxomicin are unavailable for adults. It is still a first line option for children.
  • Vancomycin PO therapy may be extended in patients with active CDI, or used prophylactically in patients with previous CDI episodes to prevent recurrent infection while on systemic antibiotics.
  • FIRVANQTM, a new oral liquid vancomycin formation, will soon be available, but cost information is currently unknown."


R.E.B.E.L.EM - February 19, 2018
"Background: The diagnosis of PE is a tricky thing. We want to limit over-testing patients and therefore, over-diagnosis. On the other hand, we don’t want to limit testing so much that we miss the diagnosis where treatment would make a difference. The pulmonary embolism rule-out criteria (PERC) was created to reduce testing in patients who have a low probability of PE (i.e. prevalence of <1.8%) in which further testing would not be necessary. There have been many observational trials published on this score but until now there has not been a prospective randomized clinical trial (The PROPER Trial)...
Author Conclusion: “Among very low-risk patients with suspected PE, randomization to a PERC strategy vs conventional strategy did not result in an inferior rate of thromboembolic events over 3 months. These findings support the safety of PERC for very low-risk patients presenting to the emergency department.”
Clinical Take Home Point: In a “low risk” patient population, use of PERC over usual care, was non-inferior in both diagnosis and mortality associated with PE. An added benefit of using PERC over usual care in this study was a 10% decrease in imaging and 40min decrease in ED LOS."

Circulation first

World Journal of Emergency Surgery logo
Ferrada P et al.  World Journal of Emergency Surgery 2018; 13:8
The current study highlights that many trauma centers are already initiating circulation first prior to intubation when treating hypovolemic shock (CAB), even in patients with a low GCS. This practice was not associated with an increased mortality. Further prospective investigation is warranted."

domingo, 18 de febrero de 2018

Ketamine for Analgesia

Approved by the Emergency Nurses Association January 2018
Approved by the Society of Emergency Medicine Physician Assistants December 2017
Approved October 2017
As an adjunct to this policy, ACEP has prepared a Policy Resource Education Paper (PREP) titled, “Sub-dissociative Dose Ketamine for Analgesia.” 
A joint policy statement of the American College of Emergency Physicians, the Emergency Nurses Association, and the Society of Emergency Medicine Physician Assistants

Ruling Out PE

PulmCCM -  Feb 16, 2018 - By Scott Aberegg
"This post is going to be an in-depth "journal club" style analysis of the PROPER trial.
In this week's JAMA, Freund et al report the results of the PROPER randomized controlled trial of the PERC (pulmonary embolism rule -out criteria) rule for safely excluding pulmonary embolism (PE) in the emergency department (ED) among patients with a "low clinical gestalt" of having PE. All things pulmonary and all things noninferiority being pet topics of mine, I had to delve deeper into this article because frankly the abstract confused me..."

Travel History

St. Emlyn´s - September 22, 2017 - By Janos Baombe
"Why is this important for the EP?
Global international travel has exponentially risen in the past decades and a large proportion of the destinations include tropical and subtropical countries.
The importance of taking a travel history to establish the possibility of an imported infection has been emphasised over half a century ago by Maegraith in his publication “Unde Venis?“1 (where are you coming from? – in Latin)
Most post-travel illnesses can be managed on an out-patient basis with appropriate follow-up. Some patients, especially those with systemic febrile illnesses, or those who are clinically unwell may however need hospital admission. Furthermore, potentially severe, transmissible infections require enhanced infection control measures and may require higher levels of care.
Emergency physicians (and other admitting clinicians!) are unfortunately often omitting to include a full travel history in their medical history taking for a variety of reasons (lack of knowledge, time pressures, volume of patients etc). The absence of a travel history in a patient with potential imported illness can affect not only clinical care but also have some severe public health implications..."

miércoles, 14 de febrero de 2018

Managing Chaos

AM Rounds
AM Round - By: Teresa Chan - February 13, 2018
...The skill of managing the multiplicity of patients in a single ED, however, was a bit of a mystery to me. To be honest, I still recall one day in my final year of residency training when I looked at the ED tracker board and was struck by the realization that I knew all the details and plans for all 16 patients listed..."

Outpatient PE

Emergency Physicians Monthly
Emergency Physicians Monthly - By Long B and Koyfman A - January 22, 2018
"Treatment options, management approach, and bleeding risks for the outpatient handling of pulmonary embolism"

martes, 13 de febrero de 2018

Deep Vein Thrombosis

An online community of practice for Canadian EM physicians
CanadiEM - By Kerstin de Wit - February 13, 2018
"Main Messages
  1. Physicians cannot correctly diagnose or exclude DVT without having measured pretest probability of DVT.
  2. Pretest probability of DVT is accurately and reliably measured using the Wells score for DVT.
  3. D-dimer and ultrasound results should always be reviewed in the context of the patient’s Wells score.
  4. Always record the Wells score and D-dimer in the patient chart for better between-physician communication and for medicolegal reasons.
  5. Know which type of ultrasound is performed by your lab (proximal or complete), and know how to interpret the results."


PulmCrit (EMCrit)
PulmCrit - February 12, 2018 - By Josh Farkas 
"Skillful use of BiPAP and high-flow nasal cannula (HFNC) can avoid intubation and improve outcomes. However, there isn't comprehensive evidence about the nitty-gritty details of these techniques. In this post I will use my opinions to fill some gaps in the evidence (1). Noninvasive respiratory support remains more of an art than a science, perhaps a dark art at that...

  • The role of noninvasive respiratory support is generally to reduce the patient's work of breathing, thereby avoiding diaphragmatic exhaustion.
  • The goal of noninvasive respiratory support isn't to immediately normalize the ABG.
  • Serial evaluation by experienced practitioners is generally far more useful than monitoring ABG values.
  • The choice of BiPAP vs. HFNC may be made on the basis of the patient's diagnosis (e.g. pneumonia vs. heart failure), not the ABG values.
  • BiPAP should never be used to “blow off” CO2 in a patient with hypoventilation due to drug intoxication."

Peripheral Vasopressors

R.E.B.E.L.EM - February 12, 2018
"Background: We have discussed the safety of peripheral vasopressors on REBEL EM before. In that review by Loubani et al was a systematic review of 85 articles and 270 patients. 95% of the extravasation events occurred in PIVs with infusions running greater than 4 hours and 85% of extravasation events occurred in PIVs distal to the antecubital fossa. The major limitation of this systematic review is that the majority of the data was derived from case reports and case series and not prospective trials. The authors of this current study sought to determine the incidence of complications of running vasopressors through PIVs in patients with circulatory shock in a prospective, observational trial.
Author Conclusion: “The incidence of complications from the administration of vasopressors through a PVC is small and did not result in significant morbidity in this study. Larger prospective studies are needed to better determine the factors that are associated with these complications, and identify patients in whom this practice is safe.”
Clinical Take Home Point: In patients with shock, use of peripheral vasopressors (Norepinephrine and Dopamine) in a large bore IV (18 – 20g) at a proximal site (antecubital fossa or more proximal) run for ≤4hrs or less is a safe option until more central access can be achieved."

AHF in the ED

Academic Emergency Medicine
Martindale J et al. Academic Emergency Medicine 2016; 23(3): 223-242
DOI: 10.1111/acem.12878
"Acute heart failure (AHF) is one of the most common diagnoses assigned to emergency department (ED) patients who are hospitalized. Despite its high prevalence in the emergency setting, the diagnosis of AHF in ED patients with undifferentiated dyspnea can be challenging.
Bedside lung US and echocardiography appear to the most useful tests for affirming the presence of AHF while NPs are valuable in excluding the diagnosis..."

domingo, 11 de febrero de 2018

Scoop & Run

Emergency Physicians Monthly
Emergency Phhysicians Monthly - By Menes K - February 5, 2018 

"When it comes to mass casualty planning, it’s not a game—it’s a philosophy.
When a mass casualty incident occurs, emergency physicians are quickly thrust onto the front lines. That is precisely what happened on October 1st at Sunrise Emergency Department in Las Vegas the night Stephen Paddock opened fire on a music concert, killing 58 people and injuring more than 500. This article, the first in a series on mass casualty incident (MCI) strategies, takes lessons learned from that event in order to highlight tough questions that your institution will need to answer to be prepared for the worst case scenario..."

AF and OAC in the ED

Resultado de imagen de canadian journal cardiology
Atzema C. Canadian Journal of Cardiology 2018, 34 (2): 125-131
"Atrial fibrillation is a frequent reason for presentation to an emergency department (ED), and the number of these visits are increasing. This creates an opportunity to improve the suboptimal rate of oral anticoagulation (OAC) use in patients with atrial fibrillation who are at high risk of stroke. However, there are very few data on whether OAC initiation in the ED, compared with referral to the longitudinal health care provider to initiate it, results in better long-term use. Moreover, for ethical and medicolegal reasons, physicians who initiate a chronic medication are obliged to reassess the patient at a later date, to check for medication side effects and the need for dose adjustment. More research is needed to determine whether OAC should be prescribed in the ED, by a physician who will never see the patient again. Patients who are cardioverted in the ED might be an exception, secondary to the increased risk of stroke after cardioversion. If ED OAC prescribing is associated with better outcomes, these results must be placed into context with the care and outcomes of the other patients in the ED. If there is a net benefit, the findings should be disseminated to practicing emergency physicians, preferably via emergency physician opinion leaders. An implementation science-based approach, which addresses the barriers to ED OAC prescribing (eg, the competing demands of running an ED and lack of guaranteed follow-up care after discharge from an ED), should be used to support prescribing of OAC in the ED. Potential solutions are described."