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


Here is a great video summarizing hemodynamic issues in airway management

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lunes, 22 de julio de 2019

Framework on Quality and Safety in Emergency Medicine

Resultado de imagen de international federation emergency medicine
2nd Edition | Quality and Safety Special Interest Group | January 2019 
Document Editors: Kim Hansen, Melinda Truesdale,  Adrian Boyle,  Brian Holroyd,  Georgina Phillips,  Jonathan Benger,  Lucas Chartier,  Fiona Lecky,  Ellen Webb,  Samuel Vaillancourt,  Peter Cameron,  Grzegorz Waligora,  Lisa Kurland  
"On behalf of the IFEM Quality and Safety Special Interest Group. 
"The original “Quality Framework” document arose from the sessions and discussions that took place at the International Federation for Emergency Medicine (IFEM) Symposium for Quality and Safety in Emergency Care, hosted by the College of Emergency Medicine (CEM) in the UK in 2011. It was presented and further refined at the 14th International Conference on Emergency Medicine in 2012. After feedback and review, an updated 2nd edition was developed in 2018 by the IFEM Quality and Safety Special Interest Group and associated editors. We would like to acknowledge the editors of the 2012 Framework for Quality and Safety in the Emergency Department: Fiona Lecky, Suzanne Walsh, Jonathan Benger, Peter Cameron, Chris Walsh"

sábado, 20 de julio de 2019

Cannabinoid Hyperemesis Syndrome

EM Pharma D
EM Pharma D - July 19, 2019 - By Evan Mulvihill
"Cannabinoid Hyperemesis Syndrome (CHS) is a sequela of long-term heavy cannabis use that involves cyclic bouts of nausea, vomiting, and diffuse abdominal pain. The treatment of CHS is unique in that your traditional anti-emetics and GI cocktails like Zofran, metoclopramide, and acid reducers, are fairly ineffective in controlling symptoms. CHS patients often receive extensive gastrointestinal (GI) work-ups in the ED, and may even be admitted when there are much simpler treatments to attempt first..."

Hyperthermia & heat stroke

PulmCrit (EMCrit)
PulmCrit (EMCrit) - July 19, 2019 - By Josh Farkas 
"Since it looks like the United States is about to go into total meltdown from a heat wave, I dusted off the hyperthermia chapter. This is a bit of an impromptu post, so we don't have a podcast to go along with it (we will record one eventually – Adam has more experience with the ice tarp taco than I do). So stick some bags of lactated ringers in the refrigerator, get your ice buckets ready, and, well, good luck."
  • The IBCC chapter is located here

jueves, 18 de julio de 2019

Drugs That Work and Drugs That Don’t

EM Cases - June 18, 2019 - By Helman A
"This is EM Cases Episode 126 Emergency Drugs that Work and Drugs that Don’t Part 1 – Analgesics with Dr. Joel Lexchin and Dr. Justin Morgenstern. In this podcast we discuss the key concepts in assessing drug efficacy trials, and provide you with a bottom line recommendation for the use of gabapentinoids, NSAIDs and acetaminophen for low back pain and radicular symptoms, topical NSAIDs and cyclobenzaprine for sprains and strains, caffeine as an adjunct analgesic, why we should never prescribe tramadol, dexamethasone for pharyngitis, calcium channel blockers for hemorrhoids and anal fissures, buscopan for abdominal pain and renal colic and why morphine might be a better analgesic choice than hydromorphone…"
EM Cases - July 02, 2019 - By Heiman A
"In this Episode 127 Drugs that Work and Drugs that Don't Part 2 - Antiemetics, Angioedema and Oxygen, with Justin Morgenstern and Joel Lexchin we discuss the evidence for various antiemetics like metoclopramide, prochlorperazine, promethazine, droperidol, ondansetron, inhaled isopropyl alcohol and haloperidol as well as why should not use an antiemetic routinely with morphine in the ED. We then discuss the evidence for various drugs options for a potpourri of true emergencies like angioedema and hyperkalemia, and wrap it up with a discussion on oxygen therapy..."

The Overdosed Patient

emDocs - July 15, 2019 - Author: Dazhe J
Edited by: Santos C; Koyfman A  and Long B
"...Summary – Key Take Home Points:
  1. Avoid premature closure by verifying through history and exam that the patient’s presentation is consistent with what the reported ingestion was.
  2. A thorough toxicology history with relevant social history elements take time, but learn to start incorporating some of these questions if diagnostic uncertainty is present – i.e. ask if pets are also sick at home.
  3. Manage and stabilize patients as you would any critically ill patient with attention to ABCs and supportive care. Add in considerations of antidote, decontamination, and enhanced elimination based on suspected exposure.
  4. Know your toxicology resources listed above and call your local poison center or medical toxicologist for clinical assistance."


Some Hints About Airway!
iEM - July 17, 2019 - By Alqahtani A
"The airway is one of the most critical topics in the ER. Read everything about the airway; it is not a waste of time. Even if you have to spend one year just for airway, it is worth it. You will always be confident in dealing with whatever situation that might come to you. Although reading is essential, practicing and getting experience on airway issues is essential too. So, reading along with exposing many patients is a great combination to achieve good skills.
Build your own skills by reading then summarizing your own words. As long as it is correct and safe, the way accomplishing or securing the airway may not be important in many patients.
Here are some tips in airway management at the Emergency Department (ED)
I will mention some points that might help in the management of typical scenarios at the ED. They might look random, but trust me, it is the real deal..."

Topical lidocaine

ALiEM Logo
ALiEM - July 17th, 2019 - By: Bragg K and Fox H
"Severe constipation, requiring fecal disimpaction and rectal enemas, can be excruciatingly painful for patients. Administering sedatives and opioids to help alleviate this pain poses a challenge, because many of the patients are elderly and tend to be more sensitive to these medications. Furthermore, there may be increased vagal tone when straining, leading to hypotension and bradycardia and which can result in defecation-related syncope. Also, opioids can exacerbate constipation. Herein we present 2 cases and tricks on achieving better pain control..."

sábado, 6 de julio de 2019

Managing Hyperkalemia with Insulin/Glucose

JournalFeed - June 27, 2019 - By Alex Chen, MD
Source: Management of Hyperkalemia With Insulin and Glucose: Pearls for the Emergency Clinician. J Emerg Med. 2019 May 11. pii: S0736-4679(19)30250-1. doi: 10.1016/j.jemermed.2019.03.043. [Epub ahead of print]
"Spoon Feed
Use of insulin/glucose to treat hyperkalemia works, but hypoglycemia is a common side effect. Here are some pearls to give this treatment more safely. 
Why does this matter?
Hyperkalemia is a life-threatening condition that requires prompt management in the ED. One of the most common treatment options is the administration of insulin and glucose to help shift potassium into the cell temporarily. Usually this is ordered as 10 units of regular insulin IV and 1 ampule of D50. This article explores some common myths and debunks them..."

Massive Transfusion

CanadiEM MVP Infographic Series - By Lauren Beals - July 5, 2019
Transfusion of Plasma, Platelets, and Red Blood Cells in a 1:1:1 vs a 1:1:2 Ratio: The PROPPR Randomized Clinical Trial​
"20-40% of trauma deaths after hospital admission involve massive hemorrhage, a devastating outcome potentially avoided with good rapid hemorrhage control. Rapid hemorrhage control is best achieved by the timely delivery of plasma, platelets, and packed red blood cells in a balanced ratio, to replace ongoing losses without encouraging coagulopathy. This is most often seen in the context of a massive transfusion protocol activation. 
For a quick refresher on MTP check out Blood and Clots here..."

viernes, 5 de julio de 2019

GI Emergencies

StEmlynsLIVE - By Chris Gray - July 5, 2019
"I was really privileged to give a talk on upper GI/gastrointestinal emergencies last year at St Emlyn’s LIVE. You can read more on the overwhelming impostor syndrome I felt standing there not only with, but also in front of and talking to, such a wealth of experience in emergency medicine and critical care, echoed in Nat’s post from a few years ago. You can watch the talk below or listen to the podcast on our iTunes channel. This blog is designed to give you the background behind the talk.
However, this post isn’t about impostor syndrome, and we’ve got no time to worry about that anyway. The bat phone has just gone off. It’s a red standby..."

Peripartum Cardiomyopathy

emDocs - July 4, 2019 - By Rometti M and Patti L
Edited by: Montrief T, Koyfman A and Long B
"Take Home Points
  • The highest risk for PPCM is in the month prior and the five months following delivery. Diagnosis includes heart failure within this timeframe with no other known underlying etiologies.
  • Consider this diagnosis in patients who are presenting with dyspnea on exertion or other signs of heart failure. Be wary of confusing these with common symptoms of late pregnancy.
  • Initial management should evaluate and support the patient’s respiratory status, with oxygen supplementation and consideration of non-invasive or invasive ventilation as dictated by the stability of the patient, as well as consideration of nitroglycerin (preload) and diuretics (systemic congestion). Patients in cardiogenic shock require resuscitation with vasopressors, inotropes, and consideration of ventricular assist devices.
  • In the still pregnant patient, consider early fetal monitoring in order to evaluate for uterine perfusion.
  • In the pregnant patient, avoidACE-Is, ARBs, warfarin, and DOACs for concern for teratogenicity. These are acceptable in the post-partum patient."

Autoantibody-Mediated Encephalitis

ACEP Now - By Ryan Patrick Radecki - June 19, 2019
"A few years ago, a best-selling autobiographical work, Brain on Fire, chronicled one of the first instances of diagnosis for N-methyl-D-aspartate (NMDA) encephalitis. The story depicted by the author is one of a young woman’s descent into madness caused by encephalitis before its relatively novel cause is determined by a New York neurologist. The book details her recovery, and the story has even been developed into a feature film on Netflix..."

lunes, 1 de julio de 2019

Superficial Venous Thrombosis

REBEL Core Cast 14.0 - June 26, 2019 - By Anand Swaminathan
"Take Home Points on SVT
  • Superficial venous thrombosis refers to a clot and inflammation in the larger, or “axial” veins of the lower extremities and superficial thrombophlebitis refers to clot and inflammation in the tributary veins of the lower extremities. While we previously thought of this as a benign entity, we actually found the superficial venous thrombosis has been associated with concomitant DVT and PE.
  • Small, superficial clots can be treated with compression, NSAIDs, and elevation. These patients should be seen for follow up within 7-10 days to make sure the clot has not progressed.
  • Clots that are longer than 5 cm should be treated with prophylactic dosing of anticoagulation: fondaparinux 2.5mg subq once daily for 45 days or enoxaparin 40 mg subq once daily for 45 days.
  • Clots that are within 3 cm of the sapheno-femoral junction should be treated the same as a DVT.
  • A superficial thrombus could mean there is a deeper clot elsewhere, even in the other leg! Take a good history, perform a thorough physical exam and consider a bilateral lower extremity DVT study in concerning patients."

Fournier’s Gangrene

emDocs - July 1, 2019 - Authors: Montrief T; Auerbach J. Edited by: Koyfman A and Long B
"Take Home Points
  • Fournier’s gangrene is most likely to present in an obese male patient between the ages of 50 and 79 years of age, with one or more risk factors –immunosuppression, alcohol use disorder, or diabetes.
  • Fascial anatomy plays an important role in the pathophysiology of Fournier’s gangrene. The Colles fascia remains continuous with other surrounding fascial planes, facilitating rapid spread towards the abdomen and thorax (via Scarpa’s fascia), as well as the scrotum (via Buck’s and Dartos fascia).
  • The most common sources of Fournier’s gangrene arise from the gastrointestinal tract (30-50%), genitourinary tract (20-40%), and cutaneous injuries (20%).
  • Up to 80% of FG cases are polymicrobial, with an average of four organisms per patient.
  • FG is often misdiagnosed as cellulitis or abscess in 75% of cases, and any crepitus, pain out of proportion, or ecchymosis should clue you in to possible FG.
  • The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score may suggest the presence of NSTI, however, it should not be used to exclude the diagnosis of FG.
  • CT has a sensitivity of 88.5% and specificity of 93.3% for the diagnosis of Fournier’s gangrene. MRI is more sensitive but may not be available and takes longer to obtain.
  • The cornerstones of treatment of FG include emergent surgical debridement of all necrotic tissue, broad-spectrum antibiotics, and hemodynamic resuscitation with intravenous fluids as well as vasoactive medications as needed."

lunes, 24 de junio de 2019

IO Blood for analysis

St. Emlyn´s - By Simon Carley - June 22, 2019
..."The clinical bottom line.
Unless someone out there can find better evidence (I could not) then we should not rely on bone marrow analysis in critically unwell patients. Although the only paper in critically unwell humans suggests that it might have a role for some variables I am unwilling to rely on a study of just 17 patients​​.
Having been told (and taught) hundreds of times that we can use IO samples in resuscitation I think this paper is #dogmalysis​​, and we love that here at St Emlyn’s. Next month I’m teaching APLS in Virchester and I suspect that I might be struggling in the IO practical session..."

Emergency Medicine Apps

EFFICIENT MD - December 28, 2018
"I surveyed a bunch of EM physicians on Facebook, Reddit, and in person, asking them their favorite apps to use in the emergency department. This list is a compilation of the replies that I received. Most of the apps are available for both Android and iOS but a handful are exclusive to just one platform. If there are others worth mentioning, please let me know.

jueves, 20 de junio de 2019

Basics of Mechanical Ventilation

R.E.B.E.L.EM - June 6, 2019 - By Frank Lodeserto

R.E.B.E.L.EM - June 17, 2019 - By Frank Lodeserto


PulmCrit (EMCrit)
IBCC chapter & cast - June 20, 2019 - By Josh Farkas
"Hypercalcemia isn't a particularly common cause of critical illness, but when encountered this requires immediate treatment. Fortunately, advances in the management of hypercalemia have clarified how to control this safely and definitively. Forced diuresis with furosemide has largely fallen by the wayside, simplifying fluid and electrolyte management. The cornerstone of therapy is generally simultaneous initiation of calcitonin and an IV bisphosphonate."
  • The IBCC chapter is located here

Monitorización hemodinámica

AnestesiaR -
anestesiaR - Junio 17, 2019 - Por José LLagunes Herrero
"Para la comprensión del paciente hemodinámicamente inestable y su tratamiento se requiere un conocimiento de la propia fisiología cardiovascular y los métodos de monitorización hemodinámica disponibles. En esta revisión se debatirá el papel de la circulación sanguínea tanto venosa como arterial y la monitorización del gasto cardiaco, en especial mediante ecocardiografía. La revisión se estructura en los apartados siguientes: la fisiología venosa, la arterial y la monitorización hemodinámica..."
anestesiaR - Junio 19, 2019 - Por José LLagunes Herrero
Segunda parte del artículo “Monitorización hemodinámica, de la fisiología a la práctica clínica”...
Es fundamental una buena comprensión de la fisiología cardiovascular para poder aplicar la monitorización adecuada y valorar los cambios a lo largo del tiempo. Es necesario incluir conceptos ya conocidos como la PMS y la E, tanto aortica como dinámica, para poder evaluar y tratar mejor a nuestros pacientes. En un futuro próximo los algoritmos de los monitores hemodinámicos incluirán estas variables y otras muchas que nos proporcionarán herramientas más precisas para el manejo del paciente hemodinámicamente inestable."

lunes, 17 de junio de 2019

mCPR Devices

Curbside to Bedside - June 16, 2019
  • Consider applying your mCPR device later in the arrest, rather than sooner
  • When performing manual chest compressions, monitoring ETCO2 can help ensure proper hand positioning
  • Perform post event reviews using manufacturer software to measure CPR fraction and pauses associated with mCPR application"


emDocs - June 17, 2019 - Author: Montrief T - Edited by: Koyfman A and Long B
"Pearls and Pitfalls
  • Post-CABG patients most commonly present to the ED for post-operative infections, CHF, and chest discomfort.
  • DSWIs occur in 1–2% of all patients undergoing cardiac surgery, but have up to a 30% mortality rate.
  • Ultrasound is an invaluable tool to evaluate for a pericardial effusion, but a retrocardiac clot is difficult to see on either transthoracic echo or X-ray and may be missed.
  • Acute resuscitation of the hemodynamically unstable post-CABG patient includes optimizing preload, rate, rhythm, contractility, and afterload.
  • Early surgical consultation can help guide the diagnostic and therapeutic management."

TEG for Ci coagulopathy

PulmCrit (EMCrit)
PulmCrit - June 17, 2019 - By Josh Farkas
"Traditional coagulation studies (especially the INR) fail miserably in cirrhosis. Thromboelastography (TEG) is a superior approach for understanding the global balance of pro-coagulants versus anti-coagulants in these patients. This isn’t anything particularly new – for example, it was explored in this post from 2015 (if you're not familiar with this concept already, it's explained in that post)...
Summary The Bullet:
  • Problems with standard coagulation tests in cirrhosis (especially INR) are well known.
  • Four RCTs show benefit of blood product administration guided by thromboelastography (TEG), compared to traditional coagulation tests. These are all single-center studies, but they seem to give a coherent message: use of traditional coagulation tests leads to over-transfusion.
  • The optimal TEG-based transfusion algorithm is unclear. The studies above showed benefit from two very different TEG-based strategies. It's likely that any reasonable TEG-based strategy will represent an improvement over strategies using traditional coagulation tests.
  • An approach to TEG-based transfusion in cirrhosis is provided, which is based upon these RCTs:

viernes, 14 de junio de 2019

Unscheduled Procedural Sedation

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

jueves, 13 de junio de 2019

ECG Monitoring in Syncope

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

Wolff-Parkinson-White Syndrome

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

martes, 11 de junio de 2019


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

PEA after TCA

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

Intubation in Trauma

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


domingo, 9 de junio de 2019

Traumatic Cardiac Arrest

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

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

jueves, 6 de junio de 2019

Acetaminophen Toxicity

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

Basilar Skull Fracture

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

martes, 4 de junio de 2019

EXTEND-ing Times for Thrombolysis in AIS?

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

Fluid boluses

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

Status Epilepticus

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

domingo, 2 de junio de 2019

68 laws of the ER

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