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

WORLD EMERGENCY MEDICINE SOCIETIES & RELATED

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Monday, April 12, 2021

Upper Airway Foreign Bodies

emDocs - Abril 12, 2021 - By Joshua White, J.D. Cambron and Craig Pedersen
Reviewed by: Alex Koyfman; Brit Long; Alexander Y. Sheng
...”Foreign body aspiration is a common complaint when presenting to the ED. In the United States from 2001-2009 an average of 12,435 children/year with ages ranging from 0-14 years presented to the ED with this complaint. Aspiration of a foreign body is the 3rd most common cause of death due to unintentional injury in children less than 1 year old in the United States. Although children account for most of foreign body aspiration cases, adults make up to 25% of these incidents. Developmentally delayed individuals are at a higher risk to aspirate foreign bodies. Those with impaired swallowing, chronic sedative, alcohol use and the elderly are at increased risk. Of aspirated foreign bodies approximately 20% affect the upper airway which includes the nasopharynx, oropharynx, laryngopharynx and also the trachea according to some sources. The remainder are lodged in mainstem or lobar bronchus. Children are more likely to have upper airway foreign bodies due to relative anatomical narrowing of the tracheobronchial tree...”

Saturday, April 10, 2021

Hypertonic saline for Hyponatremia

SGEM#326 - By admin - Apr 10, 2021
Reference: Risk of Overcorrection in Rapid Intermittent Bolus vs Slow Continuous Infusion Therapies of Hypertonic Saline for Patients With Symptomatic Hyponatremia: The SALSA Randomized Clinical Trial. JAMA Intern Med 2021
“CLINICAL QUESTION: WHEN TREATING SYMPTOMATIC HYPONATREMIA WHAT ARE THE RISKS OF OVERCORRECTION IN PATIENTS USING EITHER A SLOW CONTINUOUS INFUSION VS. A RAPID INTERMITTENT BOLUS OF HYPERTONIC SALINE STRATEGY?
Authors’ Conclusions: “This randomized clinical trial found that both RIB and SIC therapies of hypertonic saline for treating hyponatremia were effective and safe, with no difference in the overcorrection risk. However, RIB had a lower incidence of therapeutic relowering treatment and tended to have a better efficacy in achieving sNa within 1 hour than SCI. RIB could be suggested as the preferred treatment of symptomatic hyponatremia, which is consistent with the current consensus guidelines.” 
KEY RESULT: NO STATISTICAL DIFFERENCE IN OVERCORRECTION BETWEEN THE RAPID INTERMITTENT BOLUS GROUP AND SLOW CONTINUOUS INFUSION GROUP.
SGEM BOTTOM LINE: BOTH RAPID INTERMITTENT BOLUSES OF HYPERTONIC SALINE AND SLOW CONTINUOUS INFUSIONS APPEAR EFFICACIOUS STRATEGIES WITH NO STATISTICAL DIFFERENCE IN SAFETY.”

Pack Abscesses?

PEMBLOG - By Brad Sobolewski - April 7th, 2021
So, in conclusion…
These three studies seem to suggest that in smaller abscesses there is probably no definite benefit to packing, and patients may have more pain. It is also important to accurately assess the size of the diameter of the abscess. It is the actual size of the cavity – not just the redness on the surface of the skin. We can only assess the size in many cases during exploration of the cavity and with ultrasound. I cannot conclude that all abscesses should not be packed. I think that those greater than 5cm may still benefit, especially if the patient has good follow up. And, of course, pilonidal abscesses are their own special thing. I stopped packing most all of my abscesses 7-8 years ago and have noted no significantly increased rate of return to the ED or complications from patients. I do call families after select procedures to see how they are doing – this is a great way to improve your practice by the way.
Also loop drainage is great… Learn how to do it.”

Headache post Covid vaccine

St Emlyn’sSt Emlyn´s By Dan Horner - April 9, 2021
“I am sure you all saw the recent MHRA press release and guidance, discussing the issue of a possible link between the AstraZeneca COVID19 vaccine and a rare type of thrombotic condition of Vaccine induced thrombocytopenic thrombosis (VITT). This is a good example of why it is important to use the yellow card reporting system and a reminder to us all why we ideally need phase 4 research studies (post marketing surveillance) in non-pandemic times.
This statement was a helpful conclusion to the developing concerns around thrombosis and vaccination. There have been several anecdotal cases reported of unusual site thrombosis following vaccination in otherwise healthy adults. We have seen a few of these potential cases locally and it is good to get timely access to national data when you have local concerns.
Bringing together all the yellow card reports and known cases, the MHRA describe the risk of serious harm with the vaccine of around 1:250,000. Unfortunately, this risk seems higher in younger patients – reported at 1:100,000 by the BBC on this nice comparative 

Thursday, April 1, 2021

SB for Arrest

CRITICALCARENOW
CRITICACARENOW - By Jeff Pepin - March 30, 2021
“The Debrief
  • There is no definitive evidence that SB works to improve outcomes in cardiac arrest
  • If a TCA overdose is suspected, then SB should be administered
  • Another potential harm of SB administration is it adds a cognitive load to the team leader, distracting them from interventions that could improve survival.”

Anorexia Nervosa

EM Ottawa - By Tetyana Maniuk - Abril 01, 2021
“In this comprehensive guide, Dr. Tetyana Maniuk, a third-year FRCPC Ottawa Emergency Medicine resident summarizes the existing evidence on anorexia and eating disorders specific to the emergency department. Highlighting everything from signs and symptoms to watch out for, to associated complications, and a list of patient and parent resources, this is an invaluable post to reference for your next shift...”

Wednesday, March 31, 2021

Gastric Volvulus

Taming The SRU
Taming The SRU - March 31, 2021 - By Stephanie Winslow
“SUMMARY
Acute gastric volvulus occurs due to an abnormal rotation of the stomach given gastric ligament or other anatomic abnormalities within the abdomen. Patients typically present with abdominal pain and vomiting due to complications of obstruction, ischemia, or perforation. Plain radiography is the initial test of choice, although CT studies are frequently required. Most patients will require open surgical reduction and fixation; however, initial management should include decompression of the stomach with a nasogastric tube. Laparoscopic and endoscopic options have become more common due to the benefit of decreased length of hospitalization, especially in patients who are at high risk for complication from open operative intervention.”

Tuesday, March 30, 2021

Jaundice

emDOCs Podcast – Episode 25 - March 30, 2021 - By Brit Long
“Background
  • Jaundice is due to elevated serum bilirubin and yellow bilirubin pigment deposition. Patients often present with symptoms due to the underlying cause of the jaundice.
  • Frequency and etiology of the condition varies, with over 52,000 ED visits per year for jaundice.
  • Literature suggests the most frequent causes are ischemic liver injury, pancreatic/biliary carcinoma, gallstones, and alcoholic cirrhosis.
  • Viral-induced and drug-related causes (acetaminophen) also account for a significant number.
  • Normal serum bilirubin concentration is < 1 mg/dL, and jaundice is not usually detectable until 2.5 mg/dL”

Monday, March 29, 2021

Corneal Abrasions

REBEL EM - March 29, 2021 - By Mark Ramzy 
Paper: Yu CW, et al. Topical Pain Control for Corneal Abrasions: A Systematic Review and Meta-Analysis. Acad Emerg Med. 2021 Jan 28. PMID: 33508879
“Clinical Question:
Whats are the healing rates, pain control and complications between all topical pain management and control for patients presenting with traumatic corneal abrasions?
Clinical Bottom Line:
Topical NSAIDs when used in the first 48 hours may help reduce pain with no significant complications and, alongside with diluted proparacaine, may be considered an alternative therapeutic option in patients presenting to the emergency department with corneal abrasions.”

Oliguria y Anuria

EmDocs - March 29, 2021 By Daniel A. Weidner and Michael J. Yoo
Reviewed by Alex Koyfman and Brit Long
“Take Home Points
  • Oliguria has a broad differential: rule out obstruction first.
  • Consider neurogenic causes of acute urinary retention such as cauda equina syndrome.
  • Search for and avoid nephrotoxins if possible: NSAIDs, ACEi/ARB, antibiotics, antivirals, diuretics, and drugs of abuse.
  • Prerenal etiologies are the most common cause of oliguria and are often caused by hypovolemia or infection; however, can’t miss causes include cardiorenal syndrome, hepatorenal syndrome, and abdominal compartment syndrome.
  • Relieve obstructions with a Foley catheter, and consider a Coude catheter in patients with large prostates and a three-way catheter in patients with bleeding and clots.”

Saturday, March 27, 2021

Spirometry and Rib Fractures

SGEM#324 - By admin - March 27, 2021
Reference: Schuster et al. Spirometry not pain level predicts outcomes in geriatric patients with isolated rib fractures. J Trauma Acute Care Surg. 2020
“CLINICAL QUESTION: CAN SPIROMETRY TESTING IDENTIFY PATIENTS 60 YEARS AND OLDER WITH AT LEAST THREE RIB FRACTURES WHO CAN SAFELY BE DISCHARGED HOME FROM THE ED?
KEY RESULTS: HIGHER SPIROMETRY VALUES AND GRIP-STRENGTH WERE ASSOCIATED WITH EARLY DISCHARGE FROM HOSPITAL
SGEM BOTTOM LINE: SPIROMETRY REPRESENTS AN INTERESTING PROGNOSTIC TOOL FOR OLDER PATIENTS WITH MULTIPLE RIB FRACTURES, BUT WE DO NOT HAVE ENOUGH HIGH-QUALITY EVIDENCE FOR IT TO GUIDE US IN DISCHARGING PATIENTS HOME DIRECTLY FROM THE ED.”

Fomepizol for APAP

CRITICALCARENOW
CriticalCareNow- By Ruben Santiago - March 25, 2021
The Debrief:
  • Acetaminophen overdose is a common presentation to the emergency department
  • NAC is the only FDA approved agent for APAP overdose and works primarily by providing GSH stores to detoxify NAPQI
  • There are instances when, despite therapy with NAC, hepatotoxicity still occurs
  • Fomepizole inhibits NAPQI through CYP2E1 inhibition and prevents further hepatotoxicity through JNK inhibition
  • For massive APAP overdoses, fomepizole may be considered as an adjunct to NAC to combat hepatotoxicity 
  • Always consult your poison control center at 1-800-222-1222 when these patients present”

Thursday, March 25, 2021

Airway Choices

Emergen y Medicine Updates - March 24, 2021 - By Reuben
...” Recent years have brought incredible advances in emergency airway management that have made intubation easier to learn and less dangerous. Take a critical look at the devices you stock in your department, what you shouldstock in your department, and how you can best take advantage of many choices to improve airway outcomes...”

New 2021 ERC Guidelines

The ERC Guidelines 2021 are now available
*

Monday, March 22, 2021

The HEAR Score


REBEL EM - March 22, 2021 - By Jonathan Gravel
Article: Smith LM et al. Identification of very low-risk acute chest pain patients without troponin testing. Emerg Med J 2020. PMID: 32753395.
“Clinical Question: When using the HEART Pathway to risk stratify patients, is there a group of very low-risk chest pain patients (HEAR score ≤ 1) that does not require troponin testing to achieve a MACE miss rate <1%?
Author Conclusion: These data suggest that patients with HEAR scores of 0 and 1 represent a very low-risk group that may not require troponin testing to achieve a missed MACE rate <1%”
Clinical Take Home Point: Using a HEAR score ≤1 without troponin testing to safely disposition patients is certainly interesting, has face validity, and worth validating. However, with 95% CI crossing >2% for MACE at 30d, I am not sure we are at a place where potentially missing this many events would be considered standard care or even safe from a medicolegal perspective.”

Sunday, March 21, 2021

Outpatient treatment of PE

The Skeptic Guide to EM - By admin - March 20, 2021
Reference: Westafer et al. Outpatient Management of Patients Following Diagnosis of Acute Pulmonary Embolism. AEM March 2021
“CLINICAL QUESTION: WHAT ARE THE CURRENT DISPOSITION PRACTICES, AND OUTCOMES, FOR PATIENTS WITH PE IN US HOSPITALS?
KEY RESULT: THE VAST MAJORITY OF PATIENTS DIAGNOSED WITH PE WERE ADMITTED TO HOSPITAL.
SGEM BOTTOM LINE: PATIENTS WITH PE, GIVEN THE RIGHT CRITERIA, CAN BE DISCHARGED HOME FROM THE ED. US HEALTHCARE SYSTEMS SHOULD CONSIDER DECREASING THE NUMBER OF PATIENTS WHO ARE ADMITTED, WITH THE UNDERSTANDING THAT THE RISK OF RETURN VISITS IS HIGH.”

Friday, March 19, 2021

Anaphylaxis Management

EM Ottawa - By Alex Coutin - March 18, 2021
...”Within the last year, 2 major anaphylaxis organizations – the Canadian Society of Allergy and Clinical Immunology (CSACI) and the World Allergy Organization (WAO) – updated their anaphylaxis guidelines with the most up-to-date evidence, even proposing new, simpler diagnostic criteria.
There are 4 take home points from this post:
  1. The World Allergy Organization has developed new anaphylaxis diagnostic criteria.
  2. There is little to no evidence to support the routine administration of steroids in the acute phase of anaphylaxis, nor in the mitigation or prevention of biphasic reactions.
  3. Antihistamines should never come before, delay or replace the administration of epinephrine for anaphylaxis.
  4. In patients with high-risk features, extended observation (≥6h) is reasonable. In patients without high-risk features, early discharge may be appropriate (<2h)...”

High Sensitivity Cardiac Troponin T

REBEL EM - March 19, 2021 - By Benjamin M. Gerretsen,
Paper: Allen et al. Diagnostic Performance of High Sensitivity Cardiac Troponin T Strategies and Clinical Variables in a Multisite United States Cohort. Circulation 2021. PMID 33474976
“Clinical Questions: 
  • What is the diagnostic performance (safety and efficacy) of the Roche hs-cTnT assay for the detection of 30-day MACE (plus the composite of cardiac death or MI) at 30 days using an initial hs-cTnT below the limit of quantification (LOQ) and a 0/1-h algorithm?
  • Same question as above both with and without the inclusion of ECG interpretation and HEART score?
Author Conclusion: “In a prospective multisite US cohort, an initial hs-cTnT <LOQ combined with a low-risk HEART score was 99% NPV for 30-day MACE. The 0/1-h hs-cTnT algorithm did not achieve a NPV >99% for 30-day MACE when used alone or with a HEART score.”
Clinical Take Home Point: Addition of the HEART score to an initial hs-TnT below the limit of quantification improves sensitivity and NPV for cardiac events increasing patient safety, but this strategy does rule-out fewer patients.”

Posterior Reversible Encephalopathy Syndrome

EmDocs - May 24, 2021 - By Aaron G. Matlockm and Brit Long. Reviewed by: Alex Koyfman
“Take Home Points:
  • Emergency physicians should consider PRES in patients presenting with altered mental status, seizures, and neurologic deficits who have risk factors for PRES. Heightened suspicion should be raised in those patients who are on immune-suppressive medications, those with renal disease and acutely elevated blood pressure.
  • While non-contrast CT scan may show signs of vasogenic edema, expeditious MRI should be performed, as this is the most sensitive and specific imaging modality for PRES.
  • Seizures are often the presenting symptom of PRES and occur in a majority of cases.
  • Treatment is focused on seizure management, blood pressure control and removal of offending agents.
  • PRES and eclampsia have significant overlap, and management principles are similar, though magnesium is the preferred agent for treatment of seizures in eclampsia.”

Thursday, March 18, 2021

Systemic Thrombolysis Prior to Endovascular Treatment

REBEL EM - March 18, 2021 - By Anand Swaminathan

“Clinical Question: Is endovascular mechanical thrombectomy alone non-inferior to endovascular therapy + systemic thrombolytics in the treatment of patients with large vessel occlusion (LVO) strokes presenting within 4.5 hours of onset?
  • The DEVT Trial
    • Authors Conclusions: “Among patients with ischemic stroke due to proximal anterior circulation occlusion within 4.5 hours from onset, endovascular treatment alone, compared with intravenous alteplase plus endovascular treatment, met the prespecified statistical threshold for noninferiority for the outcome of 90-day functional independence. These findings should be interpreted in the context of the clinical acceptability of the selected noninferiority threshold.”
    • Our Conclusions: Endovascular therapy alone met the non-inferiority threshold when compared to combination therapy. However, this was a small trial that was stopped early and should be taken in context with all the available literature on the subject.
  • The SKIP Trial
    • Authors Conclusions: “Among patients with acute large vessel occlusion stroke, mechanical thrombectomy alone, compared with combined intravenous thrombolysis plus mechanical thrombectomy, failed to demonstrate noninferiority regarding favorable functional outcome. However, the wide confidence intervals around the effect estimate also did not allow a conclusion of inferiority.”
    • Our Conclusions: The authors did not demonstrate non-inferiority for thrombectomy alone in comparison to combination treatment.”

Wednesday, March 17, 2021

Tóxicos dializables

AnestesiaR - Por Delia Parreño Buedo - 15 de marzo de 2021
"Decidir qué modalidad de terapia extracorpórea (TE) es la más apropiada para eliminar de forma aguda una determinada sustancia requiere de una buena comprensión de las propiedades fisicoquímicas y farmacocinéticas del fármaco, además de un conocimiento práctico de las TE; particularidades técnicas, ventajas y limitaciones. La presente revisión tiene como objetivo sintetizar los conocimientos sobre las diferentes TE y su utilidad en las intoxicaciones agudas, junto con una descripción de las características de las sustancias potencialmente dializables. Se realizó una búsqueda bibliográfica en Pubmed y Medline con la siguiente estrategia: (Intoxication OR poisons OR overdose) AND (extracorporeal therapy OR extracorporeal treatment OR hemodialysis OR hemofiltration OR haemodialysis OR CRRT). Se completó la búsqueda de información revisando las publicaciones del grupo de trabajo EXTRIP."

AnestesiaR - Por Delia Parreño Buedo - 17 de marzo de 2021
"Aunque las maniobras de estabilización inicial son el pilar fundamental en el tratamiento del paciente intoxicado, las terapias extracorpóreas (TE) juegan un papel fundamental en un subconjunto de intoxicaciones, para prevenir o revertir una toxicidad grave. La presente revisión tiene como objetivo describir aspectos relacionados con el tratamiento de las intoxicaciones agudas causadas por las sustancias dializables mas frecuentes; en base a los aspectos farmacológicos que presentan este tipo de tóxicos. Se realizó una búsqueda bibliográfica en Pubmed y Medline con la siguiente estrategia: (Intoxication OR poisons OR overdose) AND (extracorporeal therapy OR extracorporeal treatment OR hemodialysis OR hemofiltration OR haemodialysis OR CRRT). Se completó la búsqueda de información revisando las publicaciones del grupo de trabajo EXTRIP."

Tuesday, March 16, 2021

TXA for SAH

The Skeptics Guide to EM - By admin - March 13, 2021
Reference: Post et al. Ultra-early tranexamic acid after subarachnoid haemorrhage (ULTRA): a randomised controlled trial. Lancet 2021
“CLINICAL QUESTION: DOES RAPID ADMINISTRATION OF TRANEXAMIC ACID IN PATIENTS WITH CT CONFIRMED SAH IMPROVE CLINICAL OUTCOME?
KEY RESULT: NO SUPERIORITY OF TXA COMPARED TO USUAL CARE FOR PATIENTS WITH A SUBARACHNOID HEMORRHAGE.
SGEM BOTTOM LINE: TXA USE IN SUBARACHNOID HEMORRHAGE DOES NOT PRESENTLY HAVE SUFFICIENT EVIDENCE OF IMPROVING PATIENT OUTCOMES TO RECOMMEND ITS ROUTINE USE.”

Elder Abuse in The ED

Canadi EM - By Miriam Armanious - March 16, 2021
“Studies suggest that the prevalence of elder abuse in high-incoe countries sits at around 7.6-10%.​1​ As individuals age, there can be a decline in social connections and even primary care visits. ED visits can be one of the only points of contact outside their immediate living environment, making this a crucial setting for identification of elder abuse.​2​It’s a statistical certainty that anyone working in health care has encountered several victims of elder abuse, particularly in the ED. Yet, when is the last time you identified a case of elder abuse? How would you know to recognize it in the future? And what would you do about it? If you’re not happy with your answers to some of these questions, you’re not alone. Evidence suggests ED clinicians do a poor job of recognizing and reporting elder abuse.​3​ 
In this post, we present the Top 5 Things You Should Know About Elder Abuse. We hope it will give you the chance to be the one to break the pattern of abuse for the vulnerable patient you are certain to meet on one of your next shifts...”
  1. Elder abuse takes many forms.
  2. Elder abuse is associated with adverse health outcomes
  3. ED visits are an opportunity to detect and act upon elder abuse.
  4. Certain exam findings are consistent with elder abuse
  5. You may have a duty to report

Saturday, March 13, 2021

Serotonin Syndrome

EmDocs - March 13, 2021 - Andrea Nillas
Reviewed by: Kerollos Shaker, Nancy Onisko, Alex Koyfman, Brit Long
“Pearls:
  • Consider with history of polypharmacy, antidepressant, or opioid use
  • Presentation has fast onset and resolution
  • Clonus is a key physical exam finding
  • Hyperthermia, seizures, and rhabdomyolysis indicate severe serotonin syndrome
  • Treatment is supportive, targeting hyperthermia and agitation”


Thursday, March 11, 2021

Canadian TIA Score vs ABCD2

REBEL EM - March 11, 2021 - By Salim Rezaie 
Paper: Perry JJ et al. Prospective Validation of Canadian TIA Score and Comparison with ABCD2 and ABCD2i for Subsequent Stroke Risk After Transient Ischaemic Attack: Multicentre Prospective Cohort Study. BMJ 2021. [Link is HERE][Access on Read by QxMD]
“Clinical Question: Does the Canadian TIA Score perform better than the ABCD2 score in stratifying subsequent stroke risk in patients with TIAs?
Author Conclusion: “The Canadian TIA Score stratifies patients’ seven day risk for stroke, with or without carotid endarterectomy/carotid artery stenting, and is now ready for clinical use. Incorporating this validated risk estimate into management plans should improve early decision making at the index emergency visit regarding benefits of hospital admission, timing of investigations, and prioritization of specialist referral.”
Clinical Take Home Point: As they always do, Perry and colleagues have done an amazing job deriving and validating the Canadian TIA Score. This score is certainly better than ABCD2 and ABCD2i in risk stratification of patients with suspected TIAs. However, risk stratification is one thing, and the resources available, follow up available, and the health system in which one works may make risk stratification a moot point.”

Tuesday, March 9, 2021

Chest-CT and Occult Injuries

The Trauma Pro - March 09, 2021 - By The Trauma Pro
There are major belief systems when it comes to the use of trauma CT: selective scan vs pan scan. The selective scanners believe that too much radiation can be bad, and that the risk of excess exposure outweighs the value of scanning everything. The pan scanners believe that valuable information might be missed unless they routinely image everything.Who is right? There’s probably value in each side of the argument. But do we have data? Good data? Two emergency medicine groups from UC-Irvine and UC-San Diego tried to answer this question via a prospective study involving 10 Level I trauma center EDs in California. They tagged onto data collection underway for the NEXUS chest and chest CT studies from 2009-2012...
The authors concluded that occult injuries were found in 71% of their patients, with the majority of those “requiring” chest tubes. They recognized some of the shortcomings in their study and stopped short of recommending a pan-scan type approach to major chest trauma...”

Monday, March 8, 2021

St. Emlyn´s - By Simon Carley - March 08, 2021
“Cricothyroidotomy is a procedure that worried many emergency physicians. Partly because it’s a rare procedure, but also because we are likely to embarking on it at a time when things are ‘going wrong’. The most likely time will be during a failed intubation when stress levels will be high, the patient will be seriously unwell and time will be running out. The fear that many of us feel about this procedure are therefore quite understandable and similar to other immediate life saving interventions such as thoracotomy. 
How many cricothyroidotomies have you performed or seen in your clinical practice?”

Anorectal Abscesses

EmDocs - March 08, 2021 - By Kristina Eastman; Eva Ryder; Scarlet Benson
Reviewed by: Andrew Grock; Alex Koyfman; Brit Long
“Pearls
  • Suspect anorectal abscesses in patients with severe anorectal pain, especially when accompanied by fever or malaise.
  • Superficial anorectal abscesses can be diagnosed on physical examination by perianal erythema and a palpable, fluctuant, tender mass.
  • Perirectal abscesses can occasionally present with a tender, fluctuant mass on DRE, but may have limited physical exam findings and require imaging to diagnose.
  • For patients with evidence of deep infection, CT is the imaging modality of choice. Transperineal ultrasound has recently been recognized as a quick, easy, noninvasive, and cost-effective technique to diagnose and monitor for resolution of anorectal abscesses.
  • Perianal abscesses can be drained at the bedside in the ED while perirectal abscesses require surgical intervention in the operating room.
  • Immunocompromised patients can rapidly decompensate secondary to severe infection from anorectal abscesses. They require urgent surgical intervention.
  • After I&D of anorectal abscesses, immunocompromised patients require antibiotics.”

Lower vs Higher O2 Target for AHRF

REBEL CRIT - March 08, 2021 - By Salim Rezaie
Article: Schjorring O et al. Lower or Higher Oxygenation Targets for Acute Hypoxemic Respiratory Failure. NEJM. Jan 2021. PMID 33471452 [Access on Read by QxMD]
“Clinical Question: Does lower oxygenation with PaO2 60 mmHg reduce 90-day mortality compared to higher oxygenation with PaO2 90 mmHg in patients admitted to ICU with acute hypoxemic respiratory failure?
Author’s Conclusion: “Among adult patients with acute hypoxemic respiratory failure in the ICU, a lower oxygenation target did not result in lower mortality than a higher target at 90 days.”
Clinical Take Home Point: This study adds very little new information into clinical practice and does not provide a definite answer for specific oxygenation parameters. Current evidence shows we should embrace lower PaO2 and SaO2 and continue to wean FiO2 as quickly and safely as possible while ensuring to not expose patients with suboptimal oxygen saturations. While we await the results of larger trials like MEGA-ROX, targeting an SpO2 of 92 to 96% (PaO2 60 to 90) is the ideal target.”Lotería vs Higuera O2”

ATBs for Open Fractures

Taming The SRU
Taming The SRU - March 08, 2021 - By Kelly Tillotson
“Open fractures are a common pathology seen in emergency departments, especially in trauma centers. In open fractures, the skin barrier has been compromised, exposing sterile bone to the environment. Considered a true orthopedic emergency, these fractures have high morbidity due to osteomyelitis, with infection rates up to 55%.  Appropriate and timely intervention in the emergency department with proper antibiotic therapy, wound care, and early orthopedic surgery involvement dramatically reduces the risk of developing osteomyelitis. In this post we will discuss antibiotic recommendations for osteomyelitis prophylaxis for open fractures. Initial management of open fractures is discussed in another post...”



Sunday, March 7, 2021

Adenosine or CCBs for SVT

First10EM EM - By Justin Morgenstern - September 5, 2017
... Bottom line: The studies aren’t huge, but calcium channel blockers seem to be a better choice than adenosine as a first line agent in the management of SVT...
A couple practical points
  • Hypotension seems to be more common with verapamil than with diltiazem (although I have not seen a head to head comparison). I tend to stick with diltiazem. 
  • Go low and go slow. Although the diltiazem dose used in the Lim study was 2.5 mg/min to a maximum of 50 mg, 75% of patients had converted by 18mg. I tend to give 15 mg of diltiazem over 10 minutes. It almost always works, but when it doesn’t I just repeat the dose. 
  • Always be prepared. Although SVT patients almost never crash, you should always be prepared to cardiovert any emergency department patient with an arrhythmia. At the doses I use, calcium channel blocker induced hypotension is almost never a problem. However, I am always prepared for clinically significant hypotension. My first step here would be to simply cardiovert the patient out of SVT. If that was not enough, I would start a fluid bolus with or without a dose of IV calcium, or in the worst case scenario, start a vasopressor. (This is not like the dreaded calcium channel blocker overdose.)

Friday, March 5, 2021

Guillain-Barre Syndrome

Tasty Morsels of Critical Care 030 - March 4, 2021 - By Andy 
“GBS is a clinically important diagnosis for both the emergency department and the ICU. Its rareish but common enough that you will at least suspect it often enough in the ED and many ICUs will have one long stay ICU patient with GBS every few years and a short stay one more often. It has the right mix of just enough clinical findings to diagnose from clinical exam but also has some novel test characteristics and some lovely management options and discussion points making it all very examinable...”

Thursday, March 4, 2021

Open fractures

Taming The SRU
Taming The SRU - March 04, 2021 - By Kelly Tillotson
“Open fractures are a common pathology seen in emergency departments, especially in trauma centers. In open fractures, the skin barrier has been compromised, exposing sterile bone to the environment. Considered a true orthopedic emergency, these fractures have high morbidity due to osteomyelitis, with infection rates up to 55%. Appropriate and timely intervention in the emergency department with proper antibiotic therapy, wound care, and early orthopedic surgery involvement dramatically reduces the risk of developing osteomyelitis. In this post, we will review the management of open fractures and address additional complications from open fractures. Fractures of the axial skeleton (skull, facial bones, spine, ribs, and pelvis) will not be discussed in this post. Antibiotic recommendations for osteomyelitis prophylaxis are discussed in another post..”

Functional Heuristics in Resus

EMCrit RACC
EMCrit 293 - March 03, 2021 - By Scott Weingart
...”What is a Heuristic?
A short cut to extended, analytical thinking that when functional provides a solution that may not be optimal but will be sufficient. When based on cognitive biases, heuristics may be dysfunctional. Wikipedia has a fairly good discussion of heuristics...
Functional Heuristics in Resuscitation
  • Flank Pain in Elderly is AAA until the Ultrasound
  • Severe Bradycardia/Heart Block = Hyperkalemia until you see the K
  • Slovis' Hypokalemia = Hypomagnesemia (Hypok=HypoMAG)
  • Unexplained Hypotension gets antibiotics
  • Hypotension and Abdominal Pain in Child-Bearing Age Female is Ectopic
  • Chest Pain Plus
  • Tamponade is dissection until it is not
  • Old stay, young go
  • Err towards Young D/C and Old Stay and then check
  • Think LP/do LP
  • The diagnoses of costochondritis and gastroenteritis do not exist
  • What is going to kill this patient? (Pre-Mortem)Functional Heuristics in Resus

ECMO + Angio/Cath for RVF

REBEL EM - March 04, 2021 - By Matt Astin
Paper: Yannopoulos et al. Advanced Reperfusion Strategies for Patients with Out-of-Hospital-Cardiac Arrest and Refractory Ventricular Fibrillation (ARREST): A Phase 2, Single Centre, Open-Label, Randomised Control Trial. Lancet. PMID: 33197396
“Clinical question: Does extracorporeal membrane oxygenation (ECMO) resuscitation coupled with immediate coronary angiography/catheterization improve survival compared to standard ACLS in the emergency department?
Author Conclusión: “Early ECMO-facilitated resuscitation for patients with OHCA and refractory ventricular fibrillation significantly improved survival to hospital discharge and functional status compared with patients receiving standard ACLS resuscitation.”
Clinical Take Home Point: ECMO provides a promising opportunity to increase meaningful survival for OHCA patients with refractory VF or VT. However, this is a time- and resource-intensive modality that is not available in all settings. Continue to provide high-quality CPR, defibrillate early, and search for reversible causes. If ROSC is achieved, evaluate for evidence of acute coronary occlusion and the need for emergent coronary revascularization.”