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


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lunes, 18 de febrero de 2019

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


Constipation Mimics

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

Early use of Norepinephrine in Septic Shock

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

jueves, 14 de febrero de 2019


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

Heparin in NSTEMI

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

LUS in acute heart failure

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

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

Salicylate intoxication

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


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

Pelvic Trauma

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

lunes, 4 de febrero de 2019

O2 Sat for acutely ill

SGEM#243 - Posted by admin  - February 02, 2019



Trauma Falls

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

sábado, 2 de febrero de 2019

PoCUS for ET Confirmation

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

Lactate is Not Everything

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

Inhaled NO for submassive PE

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

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

jueves, 24 de enero de 2019

Best of 2018 (LIFT)

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

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

Libsyn podcast LITFL Collection Twitter profile Facebook profile


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


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

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

Lumbar Punctures

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

lunes, 21 de enero de 2019

Rectal Foreign Bodies

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

Opioid Overdose

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

Undifferentiated shock

PulmCrit (EMCrit) 
PulmCrit (IBCC chapter & cast) - January 17, 2019 - By Josh Farkas 
"Shock is the next-door neighbor of death. Shock can present in a myriad of different forms, making early recognition challenging. However, early diagnosis is essential. Shock can be caused by a broad differential of serious illnesses. Unlike most differential diagnosis lists, every item on this differential is life-threatening. Fortunately, many causes of shock are reversible if identified early. Therefore, as soon as shock is identified the cause must be sorted out and treated as rapidly as possible..." 
  • The IBCC chapter is located here

Best 2018 (EMU)

Emergency Medicine Cases Logo
"In this video from North York General’s Emergency Medicine Update Conference 2018, Justin Morgenstern reviews high yield, practice changing articles in emergency medicine including: alternative options to treat nausea or vomiting in the ED, the best method of pre-oxygenation, controversies around post-contrast acute kidney injury, best method of immobilization for pediatric forearm buckle injuries and more"

domingo, 20 de enero de 2019

TIA Update

EM Cases (emDocs) - January 18, 2019 - By Anton Heiman 
Originally published at M Cases – Visit to listen to accompanying podcast
"This is Part 1 of EM Cases two part podcast on TIA and Stroke with Walter Himmel and David Dushenski – TIA Update – Risk Stratification, Workup and Dual Antiplatelet Therapy.

Much has changed in recent years when it comes to TIA risk stratification, workup and antiplatelet therapy. In this podcast we use the overarching theme of timing to elucidate how to distinguish true TIA from the common TIA mimics, the importance of timing in the workup of TIA, why the duration of therapy with dual antiplatelet therapy and timing of starting anticoagulation in patient with atrial fibrillation, contributes to the difference between preventing catastrophic strokes and causing intracranial hemorrhage. Remember that stroke is a leading cause of adult disability and is the third leading cause of death in Canada. It’s time we paid more attention to TIA…"

miércoles, 16 de enero de 2019

Thoracic Aortic Aneurysms

emDocs - January 16, 2019 - Author: Chesnokov F - Edited by: Koyfman A and Long B
"Key Points
  • Most often, patients with TAAs are asymptomatic.
  • Symptoms of TAA are often non-specific and may include cough, shortness of breath, chest pain, dysphagia, voice changes, congestive heart failure, and superior vena cava syndrome.
  • CTA with contrast and MRA with contrast are the imaging modalities of choice for the diagnosis of TAA.
  • Diagnosis of TAA warrants screening for other types of aneurysms such as abdominal aortic aneurysm.
  • Symptomatic TAAs warrant urgent repair regardless of size.
  • Management of asymptomatic aneurysms that do not meet criteria for surgical repair should focus on control of hypertension with beta blockers."

EM Quick Hits

Emergency Medicine Cases Logo
EM Quick Hits - January 15, 2019 - By Anton Helman
Topics in this EM Quick Hits podcast
EM Quick Hits Podcast

Endovascular Stroke Treatment

January 14, 2019 - By Clay Smith
"Spoon Feed
Endovascular therapy (EVT) for acute ischemic stroke can dramatically improve outcome in select patients. This review helps us makes sense of the trials on this topic.
Why does this matter?
So many trials came out in such a short space of time that it can be difficult to keep them all straight in our minds. This is an incredible review that brings all this information together in one place..."
From cited article
The authors proposed a stroke workup algorithm that takes EVT into account

FOAM EMCC Blogs 2018

Life in the Fast Lane
LIFT - By Michael Stirling - January 14, 2019
Review of prospectively collected data pertaining to Emergency Medicine and Critical Care (EMCC) blogs and podcasts providing Free Open Access Medical Education (FOAM) with no barrier to entry (e.g. readers not required to logon to site or pay to read/listen).
A total of 460 EMCC blogs, vlogs and podcasts were identified and reviewed in December 2018. Data was collected relating to platform; content; publication (onset, duration and current activity); country of origin; primary language; social media channel integration; RSS feed; and legal disclaimer. Comparison was then made with the previous census reviews of 2012, 2014 and 2016..."

martes, 15 de enero de 2019


Emergency Physicians Monthly
Emergency Physicians Monthly - December 28, 2018 - By Long B & Koyfman A
..."Almost every emergency physician will face a challenging airway during their career. This may include the patient with severe facial trauma, a patient with severe angioedema or the patient with refractory hypoxia, despite preoxygenation. What about the patient with massive regurgitation and other material in the airway? The majority of the time, vomiting is a minor nuisance, but during intubation with high quantities of vomit or blood, aspiration and failure to obtain a definitive airway are real dangers. This article will discuss the standard Yankauer, the SALAD Park technique and intubation with a suction device..."

Infection & MI

PulmCrit (EMCrit)
PulmCrit - January 14, 2019 - By Josh Farkas 
"Summary The Bullet:
  • Myocardial infarction can be caused by any source of physiologic stress. Infection is no exception to this rule.
  • Myocardial infarction can be commonly diagnosed among patients with acute infection. However, most of these patients likely have type-II MI (demand ischemia), which doesn’t mandate specific therapy (e.g. anticoagulation, cardiac catheterization).
  • For patients presenting with infection, appropriate screening tools to look for myocardial ischemia include a history, physical examination, and EKG. If these tests reveal no evidence of ischemia, there is no indication to check a troponin.
  • Allow me to repeat this for emphasis: Neither influenza nor pneumonia are indications to check a troponin level.
  • Aggressively screening every influenza patient with a troponin will only degrade the positive predictive value of the test, leading to lots of false-positive results. This may trigger a cascade of inappropriate therapies (anticoagulation, beta-blockade, cardiac catheterization) with iatrogenic harm."

Chest Pain Pathway

Emergency Medicine Updates - January 13, 2019 - By Reuben
Full pathway as png and pdf

Influenza Management

R.E.B.E.L.EM - January 14, 2019 - By Anand Swaminathan
Article: Uyeki TM et al. Clinical Practice Guidelines by the Infectious Diseases Society of America: 2018 Update on Diagnosis, Treatment, Chemoprophylaxis, and Institutional Outbreak Management of Seasonal Influenza. Clin Infect Dis 2018. PMID: 30566567
"Background: Influenza is an Emergency Department scourge that we deal with every year. The vast majority of patients recover from uncomplicated influenza without anything more than supportive care but, influenza can cause serious complications. Young children, older adults, pregnant and postpartum women, people with neurologic disorders and patients with certain chronic medical conditions (i.e. COPD, CAD, Diabetes, Immunocompromised states) are at increased risk for these complications. Annual vaccination is the best method to reduce the impact of influenza on morbidity and mortality. Though antiviral medications for influenza are far from perfect, the indications for their use must be understood..."

jueves, 10 de enero de 2019

Valproic Acid Toxicity

emDocs - January 10, 2019 - Author: Yip K
Edited by: Tanen D, Santos C, Koyfman A and Long B
"Take home points
  • Check serial valproic acid levels to make sure it is downtrending.
  • CNS effects (e.g. somnolence, confusion) are most common.
  • Valproic acid induced hyperammonemia encephalopathy may be seen even without hepatotoxicity or elevated VPA levels.
  • Supportive care is key, though L-carnitine may be helpful."