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




lunes, 10 de agosto de 2020

CT Imaging in Pyelonephritis

emDocs - August 10, 2020 - By Pillai S and Desai S 
Reviewed by: Chavez S; Koyfman A and Long B
  • Acute pyelonephritis (APN) is an infection of the upper urinary tract with a clinical presentation that may be challenging.
  • Uncomplicated pyelonephritis occurs in a non-pregnant, immunocompetent female of reproductive age with previously normal renal function while complicated pyelonephritis occurs in those that do not fit this criterion.
  • The lack of consensus regarding a diagnostic criterion (classic triad of fever, flank pain, and nausea and/or vomiting has a varying prevalence of 35 to 80%) as well as the significant mortality rates (up to 20% in APN) have made CT imaging an integral part of diagnosis and management of complicated APN.
  • There is no role for imaging in management of uncomplicated APN unless there is uncertainty in diagnosis (few leukocytes in urine, vague symptoms, etc.). Imaging may be considered if fever or leukocytosis persist beyond 72 hours.
  • Kidneys in APN may either appear normal or focally edematous in non-contrast CT. Renal calculi (obstructive APN), gas (emphysematous APN), hemorrhage, renal enlargement, inflammatory masses, and non-calculi obstructions can be visualized with a non-contrast CT.
  • CT imaging of the abdomen and pelvis with IV contrast is the modality of choice in APN. It characteristically shows one or more focal or ill-defined wedge-like regions with reduced enhancement and poor corticomedullary differentiation. Other common findings better appreciated compared to non-contrast CT include delayed calyceal opacification, perinephric stranding, inflammatory parenchyma or gas formation. A “striated nephrogram” (alternating cortical radial bands of hyper- and hypo-attenuation) is common but nonspecific.
  • Contrast CT findings in complications of APN include: abscess (sharply marginated area of low attenuation with peripheral enhancing), obstructing APN with pyonephrosis (calculi with dilated calyces, pelvic wall thickening, and gas in the collecting system), and papillary necrosis (poorly marginated hypo-attenuated lesions in papilla).
  • Emphysematous pyelonephritis is an often-fatal necrotizing complication of APN occurring commonly in diabetics and necessitates emergent nephrectomy or percutaneous drainage. Non-contrast CT may demonstrate pararenal or parenchymal gas. In addition to these findings, CT imaging with contrast will also show parenchymal destruction, fluid collections or focal tissue necrosis."


R.E.B.E.L.EM - By Salim Rezaie - August 10, 2020
Paper: Chauvin A et al. Reducing Pain by Using Venous Blood Gas Instead of Arterial Blood Gas (VEINART): A Multicentre Randomised Controlled Trial. EMJ 2020. [Epub Ahead of Print]
"Clinical Question: In non-hypoxemic patients (pulse oximetry >95% on room air), is the maximal pain during sampling less with VBG or ABG?
Author Conclusion: “Venous blood gas is less painful for patients than ABG in non-hypoxaemic patients. Venous blood gas should replace ABG in this setting.”

Clinical Take Home Point: In non-hypoxemic patients requiring acid-base evaluation:
  • VBG is less painful for patients compared to ABG
  • VBG is easier for the healthcare team compared to ABG
  • VBG provides useful information similar to ABG for physicians in regard to treatment decisions"

Lab testing in psychiatric patiens

Back Home
First10EM - By Justin Morgenstern - August 10, 2020
“Medical clearance” for psychiatric patients has long been a problem for emergency medicine. Despite a clear consensus in the medical literature and guidelines that routine laboratory testing is not required for psychiatric patients, many hospitals are still requiring this testing. (I know from first hand experience.) This is harmful to our patients, results in unnecessary delays in care, and is incredibly wasteful. I think we need to stop the practice as soon as possible...
Stop routine testing in psychiatric patients
Bottom Line
There are certainly medical causes of psychiatric issues. Psychiatric patients are at high risk for a number of other medical issues. We need to assess these patients carefully, especially when they are unable to provide us with a clear history. However, there is clearly no role for routine testing. The history and physical will catch almost all important medical issues. Policies that require testing before patients are accepted by psychiatric teams hurt our patients, waste time and money, and take important resources away from other sick patients in the emergency department. This position is supported both by evidence and by guidelines from multiple major medical associations."

jueves, 6 de agosto de 2020

COVID-19 Severity index

R.E.B.E.L.EM - August 06, 2020 - By Anand Swaminathan

Article: Haimovich A et al. Development and validation of the quick COVID-19 severity index (qCSI): a prognostic tool for early decompensation. Ann Emerg Med 2020. Link
Clinical Question: Can an Emergency Department (ED) risk stratification tool be created that predicts respiratory failure within 24 hours of admission in patients with COVID-19?Authors Conclusions: “A significant proportion of admitted COVID-19 patients progress to respiratory failure within 24 hours of admission. These events are accurately predicted using bedside respiratory exam findings within a simple scoring system.”
Our Conclusions: The qCSI is a good initial attempt to derive a CDI to support clinicians in disposition decisions for COVID-19 patients who require hospital admission. However, prospective as well as external validation is necessary prior to widespread use can be recommended.
Potential to Impact Current Practice: While we do not recommend using this tool in lieu of experienced clinician gestalt, there may be a role for its use in less experienced clinicians or, for non-emergency clinicians that support EDs during the pandemic.“

lunes, 3 de agosto de 2020


NERDfacts Folge 7/2020 - 03 August, 2020 - By Martin Fandler
..."Der Tauchunfall umfasst alle tauchassoziierten Erkrankungen und Symptome, die innerhalb 24h nach dem Tauchgang auftreten. Es kann sich um sehr unterschiedliche Symptome handeln, und manchmal liegen mehrere Stunden zwischen dem Tauchgang und dem Auftreten der ersten Symptome. Durch die unterschiedlichen Krankheitsbilder und Zeitdifferenzen ist es nicht immer leicht, den Tauchgang als Ursache in Erwägung zu ziehen. Die Bandbreite reicht dabei von „ein Taucher liegt im nassen Tauchanzug vor euch“ bis zu „ein Passagier in einem Flugzeug hat auf dem Rückflug aus dem Urlaub Symptome eines Herzinfarktes entwickelt“. Welcher von Beiden hatte einen Tauchunfall?.."
Veröffentlicht am

Savage Therapies in ARDS

REBEL CRIT - August 03, 2020 - By Mark Ramzy
..."Alternative or “salvage” therapies are typically implemented to correct refractory hypoxia and used when more conventional therapies fail. Examples of these therapies include proning, inhaled pulmonary vasodilators, extracorporeal membranous oxygenation (ECMO), paralysis, recruitment maneuvers, unconventional ventilator modes and more. The following post and included infographics focus on the following salvage therapies: Proning, Paralytics and (lung) Protection. It is important to note that regardless of the therapy, specializing care on an individual basis with a risk-benefit analysis is required to give patients the best possible chance at survival..."

Salvage Therapies in Acute Respiratory Distress Syndrome Summary

sábado, 1 de agosto de 2020

EM@3AM - August 01, 2020 - By Ediger D and Bridwell R
Reviewed by: Long B and Koyfman A
  • Pyogenic flexor tenosynovitis is a clinical diagnosis requiring a high index of suspicion, especially when patients return after a course of antibiotics
  • Patients who have acute (<5 days) onset of painful extension and flexor sheath tenderness have a high likelihood of having PFT
  • The cornerstones of management are surgical consultation and early empiric antibiotics against MRSA and Streptococcus
  • Consider gonococcal tenosynovitis in sexually active patients with symptoms without antecedent hand injury"

jueves, 30 de julio de 2020

Sternoclavicular Dislocation

emDocs - July 30, 2020 - By Barbour K and Grenga P
Reviewed by: Chavez S; Koyfman A and Long B
"The sternoclavicular joint (SCJ) is an exceptionally stable and rarely dislocated synovial saddle joint required for nearly all shoulder movements It is the only articulation of the shoulder with the axial skeleton. Its strength comes almost entirely from its robust ligamentous attachments, as the manubrium articulates with little of the medial clavicle. Dislocation requires rupture of all these attachments. When dislocated, the medial end of the clavicle can migrate anteriorly or posteriorly, with anterior dislocation far more common. The epiphyseal plate of the medial clavicle is the last ossification center in the body to fuse, doing so as late as the 3rd decade of life. As such, it is easy to misdiagnose younger patients with a Salter I or II medial clavicle fracture-dislocation as a sternoclavicular dislocation. Unlike posterior SCJ dislocations, physeal fracture-dislocations are less likely to require surgery and have a better prognosis..."

COVID-19 Made Simple

CanadiEM - By Vikas Patel - July 30, 2020
..."COVID-19 Made Simple is a grass-roots initiative that was created with the hopes of sharing accurate and reliable information for the community at large. We have managed to partner with over 30 organizations, social media platforms and university groups across Canada, while having obtained the support of 3500 followers across all social media platforms over the last three months. Our resource aims to tackle misinformation and provide accessible information by sharing daily case updates, national and local government recommendations, reliable news coverage, and evidence-based research updates to members of the public without them having to sift through many news sources themselves. It is our hope that through COVID-19 Made Simple, we are able to equip members of the public with the knowledge they need to stay informed in an engaging way throughout the pandemic..."

Hemophagocytic Lymphohistiocytosis

REBEL CRIT - July 30, 2020 - By Frank Lodeserto
"Hemophagocytic Lymphohistiocytosis (HLH) is a rare and often fatal syndrome of uncontrolled and ineffective inflammatory response to a certain trigger. It is characterized by excessive proliferation of lymphocytes and macrophages (histiocytes), hence the name “lymphohistiocytosis”. This results in the overproduction of cytokines, responsible for many of the clinical features present in this syndrome.
Familial, or genetic, HLH occurs as a result of a genetic mutation leading to impaired cytotoxic function. There have been several genetic mutations indicated in the development of HLH, including an association with congenital immunodeficiency syndromes, such as Chediak-Higashi, Griscelli and X-Linked Lymphoproliferative Syndromes. This form most often occurs within the first year of life (median age 8 months), with the majority of pediatric cases occurring <2 years of age, but can range from infancy to adulthood.
Acquired HLH occurs in the setting of an underlying condition, such as immunodeficiency, malignancy, or autoimmune disease. When HLH is secondary to a predisposing autoimmune disease, it is referred to as macrophage activating syndrome (MAS). Acquired HLH is the most common cause of this syndrome in adults, but this form can be seen in all ages. Overall, the syndrome is most often triggered by an infectious agent in an otherwise healthy person..."

lunes, 27 de julio de 2020

Guillain-Barre Syndrome

PulmCrit (EMCrit)
IBCC chapter & cast - July 27, 2020 - By Josh Farkas
"Guillain-Barre Syndrome is the most common cause of acute-onset neuromuscular weakness requiring ICU admission. COVID-19 appears to be one trigger of Guillain-Barre Syndrome, so this might be even more common in the coming months. There isn't much high-quality evidence regarding respiratory support in Guillain-Barre Syndrome, particularly when intubation is indicated. Consequently, it's important to use basic critical care principles and common sense, rather than artificial “rules” which are widely propagated in the literature."

Lidocaine for epigastric pain

Don't use lidocaine for epigastric pain
First10EM -July 27, 2020 - By Justin Morgenstern
The paper: Warren J, Cooper B, Jermakoff A, Knott JC. Antacid monotherapy is more effective in relieving epigastric pain than in combination with lidocaine. A randomized double-blind clinical trial. Acad Emerg Med. 2020;10.1111/acem.14069. doi:10.1111/acem.14069 PMID: 32602148 Australian New Zealand Clinical Trials Registry ACTRN12619000928112
"Bottom line
In this single centre RCT, adding lidocaine to an antacid provided no extra pain relief, but increased adverse events and decreased the palatability of the medication. The trial is imperfect, but there is no reason to prescribe the “GI cocktail” or “pink lady” at this time."

Congestión venosa con PoCUS (VExUS)

AnestesiaR - July 27, 2020 - By Fernando García-Montoto Pérez
Artículo Original: Beaubien-Souligny, W., Rola, P., Haycock, K., Bouchard, J., Lamarche, Y., Spiegel, R., Denault, A. Y. Quantifying systemic congestion with Point-Of-Care ultrasound: development of the venous excess ultrasound grading system. Ultrasound J. 2020; 12: 1-12.DOI: 10.1186/s13089-020-00163-w (HTML)

..."El manejo hemodinámico del paciente crítico se ha enfocado tradicionalmente al mantenimiento de un adecuado gasto cardiaco y de la presión arterial con la administración de fluidos y de vasopresores o inotrópicos. Pero es ya también conocido que una terapia hídrica restrictiva, independientemente de líquido utilizado, tiene un efecto beneficioso sobre la mortalidad y que ha dado lugar a la propuesta del protocolo ROSE. Además, existe consenso en que la sobrecarga hídrica y la insuficiencia del ventrículo derecho se asocian a lesiones en múltiples órganos y efectos adversos. La ecocardiografía como Point-Of-Care es una herramienta que nos permite una valoración funcional de la situación hemodinámica del paciente con shock, que podemos centrar en el cálculo del volumen sistólico, con la integral de la velocidad por el tiempo (IVT). Mercadal et al nos presentan una propuesta que permite realizar una valoración de los diferentes tipos de shock y su abordaje, conjuntamente con la clínica (valoración de la perfusión), intentando diferenciar la patología crónica de la aguda. Con la propuesta de este artículo tenemos la posibilidad de cerrar el sistema de valoración hemodinámica incluyendo la evaluación de la congestión venosa, y así adecuar la necesidad hídrica real y poder ser más restrictivos..."


emDocs - July 27, 2020 - By Cisewski D, Schimmel J
Reviewed by: Koyfman A and Long B

  • Methamphetamine (MA) is a highly addictive substance that has reached epidemic proportions;
  • Unlike opioids, there is no analogous acute reversal agent or Medication-Assisted Treatment to curb cravings.
  • MA is used by individuals of all ages, ethnicities, and socioeconomic classes.
  • Maintain a suspicion for sympathomimetic drug use in patients presenting to the ED with acute psychosis.
  • Benzodiazepines and antipsychotics are first-line treatments for acute MA toxicity.
  • Treat hyperthermia and rhabdomyolysis aggressively to reduce sequelae.
  • While diagnostic testing may be deferred in select low-risk patients, the multiorgan effects of MA should be considered."

Thrombolysis in Acute Ischemic Stroke

R.E.B.E.L.EM - July 27, 2020 - By Salim Rezaie
"Clinical Question: Does removing confounders and effect modifiers in patients from the original NINDS trials change the outcomes of alteplase given within 3 hours of symptom onset for acute ischemic stroke?
Author Conclusion: “Reanalysis of the ECASS III trial data with multiple approaches adjusting for baseline imbalances does not support any significant benefits and continues to support harms for the use of alteplase 3—4.5 hours after stroke onset. Clinicians, patients and policymakers should reconsider interpretations and decisions regarding management of acute ischaemic stoke that were based on ECASS III results.”
Clinical Take Home Point: The re-analysis of ECASS III raises concerns that baseline imbalances create bias and affect the conclusions of efficacy of alteplase given within 3 to 4.5 hours after stroke onset in acute ischemic stroke compared to placebo.
Clinical Bottom Line: There have been only two randomized clinical trials to show benefit of systemic alteplase vs placebo in acute ischemic stroke. After balancing for baseline differences in patients between the two groups, re-analysis of these two trial questions the validity and robustness of alteplase. This means there are now ZERO RCTs supporting the practice of thrombolysis in acute ischemic stroke."

viernes, 24 de julio de 2020

Electrical Injuries

emDocs - July 24th, 2020 - By Helman A. Originally published at EM Cases
"Key Take Home Points for Electrical Injuries
  • Think trauma and tox first. Don’t get distracted by the burns
  • Perform serial examinations of limbs to assess for compartment syndrome and assume rhabdomyolysis if tea colored urine
  • Cardiac complications of electrical injuries are rare with VF occurring immediately after high voltage AC exposure; while ECG is recommended for all patients, only patients with risk factors and/or clinical presentation consistent with cardiac ischemia require troponins
  • Cardiac monitoring is only required for low voltage injured patients with chest pain or syncope and all high voltage injured patients
  • Electrical injured patients generally require more fluid than suggested by The Modified Brooke/Parkland Formula
  • Fluid formulas are starting points only, titrate carefully, assessing urine output and signs of end organ perfusion to avoid over and under resuscitation
  • Consider alkalinizing the urine and forced diuresis after adequate fluid resuscitation for patients with tea colored urine and/or a CK in the thousands
  • Asymptomatic low voltage (<600V) injured patients only require an ECG with no further workup or observation if the ECG is normal
  • Refer all high voltage (>600V) injured patients to a burn center
  • For patients going home with electrical injuries, counsel regarding delayed symptoms including psychological, neurological, limb ischemia and for kids who bite on an electrical cable, delayed bleeding"

jueves, 23 de julio de 2020

Intracranial hemorrhage

IBCC chapter & cast – July 23, 2020 - By Josh Farkas
Intracranial hemorrhage is a fairly common problem, which spans the gamut from mild to life-threatening. Most therapies haven't been shown to work, so management mostly consists of high-quality neuro-supportive care.
  • The IBCC chapter is located here

Traumatic Cardiac Arrest

R.E.B.E.L.EM - July 23 - By Zaf Qasim
Paper: Tran A et al. Pre-arrest and intra-arrest prognostic factors associated with survival following traumatic out-of-hospital cardiac arrest – a systematic review and meta-analysis. Resuscitation 2020. PMID: 32531405
"Clinical Question: What are the prognostic associations of various pre- and intra-arrest factors associated with return of spontaneous circulation (ROSC) and survival in adult patients following a traumatic out-of-hospital cardiac arrest (OHCA)?
Author(s) Conclusion: “This review provides very low to moderate certainty evidence that pre- and intra-arrest prognostic factors following penetrating or blunt traumatic OHCA predict ROSC and survival. This evidence is primarily based on unadjusted data. Further well-designed studies with larger cohorts are warranted to test the adjusted prognostic ability of pre- and intra-arrest factors and guide therapeutic decision-making”
Clinical Take Home Point: In this systematic review and meta-analysis, there was a signal to improved survival from traumatic out-of-hospital arrest with the presence of cardiac motion on ultrasound and a shockable initial rhythm. The findings do need to be taken in the context of the overall poor statistical quality (primarily retrospective and observational) and the significant risk of bias of included studies. While this study, within these limitations, is a valiant attempt to clarify gaps in clinical care around an important pathophysiologic process, it is also a call to arms to improve future research efforts in identifying the best predictors of good outcomes in traumatic arrest."

martes, 21 de julio de 2020

Requesting Consults in the ED

CanadiEM - By Julia Heighton - July 21, 2020
"Key takeaways
Although each of these three approaches are slightly different, they all have a number of core similarities. These similarities provide us with hints as to which elements are especially critical when making a consultation request. Here are key takeaways:
  • Prepare, prepare, prepare: before calling a consultant, make sure that you have a specific clinical question and a one liner prepared to “hook” the consultant. Additionally, ensure that you have all of the patient’s data in front of you, including old charts, lab and imaging results, the names of previous specialists, the dates of previous procedures/important investigations, and any other pertinent clinical information. This will allow you to present a concise clinical story to the consultant and be prepared to answer any questions the consultant may ask.
  • Introductions: when starting the call, introduce yourself, your level of training, your service, and the patient. This will help build familiarity between you and the consultant.
  • Open strong: following introductions, start with the one liner you prepared. Then pose your clear clinical question to the consultant before providing a concise story – this will help the consultant orient themselves and decide which information is most important as they listen to your story.
  • Close the loop: before hanging up the phone, reiterate the plan to ensure that both parties are on the same page with respect to next steps. Closed loop communication is critical in ensuring that everyone leaves the conversation with the same expectations and understanding.
  • Thank the consultant: being polite and providing thanks will go a long way towards improving collegiality and developing a good relationship with the consultant!"

lunes, 20 de julio de 2020


emDocs - July 20, 2020 - By Pederson T, Hagahmed M
Reviewed by: Lew E; Koyfman A and Long B
#1: Utilize prediction scoring tools: AIR score for high risk patients, Alvarado score for dischargeable patients.
These tools can reduce cognitive bias by enabling us to work up the disease objectively using the same criteria for every patient, and they are especially useful for prompting further workup for patients classified as intermediate risk. The AIR score has been shown to outperform Alvarado in identifying high risk patients.

#2: Don’t be afraid to utilize CT imaging for intermediate risk patients, including pregnant women and children.
The overwhelming majority of missed appendicitis is in “intermediate risk” patients. While ultrasound is the appropriate first imaging modality to consider in children and pregnant women, it should not be used to rule out appendicitis, as the sensitivity is only 63% (33). In intermediate risk patients who you still have a high suspicion for appendicitis after negative or inconclusive ultrasound, get the CT. You will “rule-in” appendicitis 9 times out of 10.

#3: Train yourself to consider appendicitis in “outlier” populations: children, pregnant women, older adults, and black patients. 
If we wish to decrease the misdiagnosis rate of appendicitis among “all comers” to the emergency department, then we must remain vigilant for the diagnosis in these populations.

sábado, 18 de julio de 2020

Signs and Symptoms of Pneumonia

SGEM - By admin - July 18, 2020
Reference: Ebell et al. Accuracy of Signs and Symptoms for the Diagnosis of Community‐acquired Pneumonia: A Meta‐analysis. AEM July 2020



Communication During Resuscitation

EMCrit RACC - July 16, 2020 - By Mike Lauria
"Communication During Resuscitation
Communication continues to be a major issue in virtually all high-stress, time-sensitive environments. This has been discussed a number of times on EMCrit, most recently in Podcast 230: Resuscitation Communication. This post reviews some of those key elements and some of the literature to support these concepts.
Failure of communication has been cited as a primary contributor to a number of mishaps and accidents in different industries as well as the world of clinical medicine. In resuscitation, communication is paramount. It is critical to understand important aspects of good communication: what should or should not be said, how it should be said, when it should be said, and who should be saying it..."

lunes, 13 de julio de 2020

Haloperidol for Headache

R.E.B.E.L.EM - July 13, 2020 - By Mark Ramzy
Paper: Treatment of Headache in the Emergency Department: Haloperidol in the Acute Setting (THE-HA Study): A Randomized Clinical Trial. J Emerg Med 2020. PMID: 32402480
"Clinical Question: What is the effectiveness of 2.5mg of IV haloperidol compared to placebo in the treatment of acute headache in ED patients aged 13 to 55 years old?
Author’s Conclusions:
  • This study suggests that 2.5 mg IV haloperidol is a rapid and effective treatment for acute, severe, benign headache in ED patients aged 18 to 55 years. Further study is warranted to confirm these results in adolescents
Our Conclusion:
  • Although a small sample size, the use of low dose IV haloperidol appears to be effective in the acute treatment of benign headaches in the adult emergency department patient. The low adverse effects observed in this study, specifically QT prolongation, suggest that the use of haloperidol may be a safe first line agent in the treatment of benign headache. Given the small sample size of pediatric patients in this study, these findings cannot be applied to patients under the age of 18 years old until additional research has been performed.
Clinical Bottom Line:
  • With a low side-effect profile, emergency physicians should consider the use of 2.5 mg IV haloperidol as a rapid and effective treatment for acute benign headache in adult emergency department patients aged 18 to 55 years old."

sábado, 11 de julio de 2020

Intubation in Trauma

emDocs - July 20, 2020 - By Qasim Z
Originally published at R.E.B.E.L. EM on June 10, 2019

..."Historically there has been concern that by exposing profoundly shocked patients to poorly planned rapid sequence intubation and subsequent positive pressure ventilation, we may incurring more harm than good...
We should strongly consider reordering our approach to resuscitation in the critically ill trauma patient, identifying both overt and covert physiologic threats before proceeding with intubation. When the need for intubation does arise, we need to be optimizing our strategy to ensure both first-pass success and minimal hemodynamic insult...

We need to understand that what we do, despite our best intentions can induce harm if we get it wrong. We should continue to evolve our approach to the physiologically-challenged airway, and that includes the critically injured trauma patient. By paying attention to the order of resuscitation, signs and symptoms of covert shock, and the optimization of our intubation and ventilation strategy, we can minimize any secondary injury to our patients.

jueves, 9 de julio de 2020

COVID Pulmonary Physiology

EMCrit 277 - July 09, 2020 - By Scott Weingart
"Today on the podcast, I interview Martin Tobin on 3 papers he has recently written on COVID pulmonary physiology."

2019-2020 St. Emlyn´s Top 10 Trauma papers

St.Emlyn's, July 9, 2020, By Simon Carley
"My task was to present a short review of important clinical trauma research from the last year. I’ve done a few of these sorts of ‘top-10’ presentations over the years and they roughly follow these principles to get included. Papers have to score at least 2 out of 3 for the following.
  • Methodologically sound
  • Interesting (to me)
  • Practice changing
This is, of course, entirely subjective, so if you disagree I am sorry (not sorry), but if I’ve missed something important please add your suggestions to the comments. In the presentation I will focus on 10 papers, but here in the blog I will add a few more at the end that did not make the cut, but which you will benefit from reading."

Electrical vs Pharmacological Cardioversion (AF)

R.E.B.E.L.EM - July 09, 2020 - By Salim Rezaie
Paper: Stiell IG et al. Electrical Versus Pharmacological Cardioversion for Emergency Department Patients with Acute Atrial Fibrillation (RAFF2): A Partial Factorial Randomised Trial. Lancet 2020. PMID: 32007169
"Clinical Question: Is a pharmacological cardioversion first approach more successful than an electrical cardioversion first approach in acute atrial fibrillation?
Author Conclusion: “Both the drug-shock and shock-only strategies were highly effective, rapid, and safe in restoring sinus rhythm for patients in the emergency department with acute atrial fibrillation, avoiding the need for return to hospital. The drug infusion worked for about half of patients and avoided the resource intensive procedural sedation required for electrical cardioversion. We also found no significant difference between the anterolateral and anteroposterior pad positions for electrical cardioversion. Immediate rhythm control for patients in the emergency department with acute atrial fibrillation leads to excellent outcomes.”
Clinical Take Home Point: Both the drug-shock and shock-only strategies led to similar conversion rates and rates of discharge home. Length of stay was similar between groups; however this doesn’t reflect real-world application where a shock first approach would not get a 30 minute infusion of placebo for the purpose of blinding. Ultimately either approach is fine based on provider comfort, patient preference and departmental considerations."

martes, 7 de julio de 2020

CHEST Guidelines: VTE in COVID-19

emDocs - june 07, 2020 - By Long B -  Reviewed by: Koyfman A and Singh M
"Evidence suggests patients with COVID-19 are at risk of thromboses and coagulopathy. Up to now, there has not been an established set of clear guidelines. CHEST released a guideline and expert panel report on venous thromboembolism in COVID-19 patients in early June 2020.
This post will take you through the relevant ED recommendations on for prevention, diagnosis, and treatment of VTE in these patients."

jueves, 2 de julio de 2020

Ticagrelor vs Prasugrel in ACS

R.E.B.E.L.EM - July 02, 2020 - By Salim Rezaie
Paper: Schupke S et al. Ticagrelor or Prasugrel in Patients With Acute Coronary Syndromes. NEJM 2019. PMID: 31475799
"Clinical Question: Does ticagrelor or prasugrel improve the composite of death, myocardial infarction, or stroke at one year after randomization in patients with ACS?
Author Conclusion: “Among patients who presented with acute coronary syndromes with or without ST-segment elevation, the incidence of death, myocardial infarction, or stroke was significantly lower among those who received prasugrel than among those who received ticagrelor, and the incidence of major bleeding was not significantly different between the two groups.”
Clinical Take Home Point: In this multicenter, international randomized clinical trial of adult patients with ACS undergoing PCI, prasugrel was superior to ticagrelor in the primary outcome. Additionally, a prasugrel-based strategy with deferred loading after knowledge of the coronary anatomy was superior to a ticagrelor-based strategy with routine pretreatment in patients with NSTEMI and UA. Finally, when evaluating the individual results from the composite primary outcome, the findings of this study were driven by reduction in MI, not in death or stroke."


PulmCrit (EMCrit)
IBCC chapter & cast - July 2, 2020 - By Josh Farkas 

"Epiglottitis is often a game of chicken. The great majority of adult patients don't require intubation, so the best management for them is steroid and antibiotic (plus close observation and the ability to intubate if necessary). For these patients, intubation isn't protective – it's dangerous. However, some patients do truly require intubation – which can often be difficult and require cricothyrotomy."

lunes, 29 de junio de 2020

Pyelonephritis disposition

emDocs - June 28, 2020 - By Mishra D and Curato M
Reviewed by: Montrief T; Koyfman A and Long B
"Take Home Points:
  • A diagnosis of pyelonephritis is made through a combination of vital signs, clinical presentation, physical exam, and urinalysis. It is essential to take the entire clinical picture into account when deciding on a disposition for a patient
  • Discharge home with oral antibiotics is an appropriate disposition plan for the majority of mild to moderately ill acute pyelonephritis patients who are able to tolerate oral intake and are not persistently tachycardic, hypotensive, or tachypneic. They should also have stable coexisting medical comorbidities, a reliable psychosocial situation, an appropriate oral antimicrobial regimen, and access to outpatient follow-up.
  • It is important that, regardless of disposition decision, all of your patients have appropriate follow-up to assess for improvement in symptoms"
Further Reading:

domingo, 28 de junio de 2020

TXA in Acute GI Bleeds

"Paper: The HALT-IT Trial Collaborators. Effects of High-Dose 24-h Infusion of Tranexamic Acid on Death and Thromboembolic Events in Patients with Acute Gastrointestinal Bleeding (HALT-IT): An International Randomised, Double-Blind, Placebo-Controlled Trial. Lancet 2020. [Epub Ahead of Print]
Clinical Question: Does IV tranexamic acid reduce 5-day death due to bleeding in adult patients with acute gastrointestinal hemorrhage compared to placebo?
Author Conclusion: “We found that tranexamic acid did not reduce death from gastrointestinal bleeding. On the basis of our results, tranexamic acid should not be used for the treatment of gastrointestinal bleeding outside the context of a randomized trial.” 
Clinical Take Home Point: This is a very well done, large, multicenter randomized controlled trial of TXA vs placebo for acute GIB. The results demonstrate no benefit of giving TXA on 5d mortality in patients with acute GIB and a small signal of harm with increased VTE and seizures. TXA should not be recommended at this time for patients with acute GIB."

sábado, 27 de junio de 2020

Rapid Code Status Disccussions

EMCrit 276 – June 25, 2020 - By Scott Weingart 
"Today, I am joined by Kei Ouchi to disucss rapid code status discussions in Emergency Medicine and Critical Care. I came across Kei after he put up an amazing post on ALIEM with his co-author Naomi George. Conversation is the essence of palliative care–we need to be experts at them..."

jueves, 25 de junio de 2020

Septic Bursitis

emDocs - June 25, 2020 - By Pritchard R, Bodeau H, Bonson P and Borloz M
Reviewed by: Koyfman A and Long B
  • The diagnostic gold standard for septic bursitis is bursal fluid culture
  • Negative bursal fluid culture does not exclude the diagnosis of septic bursitis, especially if due to a fastidious organism or when antibiotics precede culture
  • A number of other signs are associated with septic bursitis (Table 1) and can be used to support the dx
  • Bursal fluid aspiration should be performed prior to antibiotic use