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


Emergency Suprapubic Catheter Placement

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viernes, 12 de enero de 2018


emDocs - January 5, 2018 - By Salim Rezaie
Originally published at R.E.B.E.L. EM on February 23, 2017. Reposted with permission.
"Upper gastrointestinal bleeding remains a common reason for emergency department visits and is a major cause of morbidity, mortality, and medical care costs. Often when these patients arrive, the classic IV-O2-Monitor is initiated and hemodynamic stability is assessed. One of the next steps often performed includes the initiation of proton pump inhibitors (PPIs).
The ultimate question however is does initiation of PPIs reduce clinically relevant outcomes (i.e. mortality, rebleeding, need for surgical intervention) in upper gastrointestinal bleeds (UGIB)?"

lunes, 8 de enero de 2018

Pain Control

R.E.B.E.L.EM - January 8, 2017 - By Salim Rezaie
"Background: In the United States we are not only seeing an opioid epidemic but also a shortage of IV opioid agents. For both reasons, it is important to find non-opioid options for common pain complaints seen in the ED. Changing prescribing practices is difficult but an important step in minimizing opioid usage. Current research suggests that even short term opioid use can cause a predisposition to subsequent opioid dependence. In the spirit of doing no harm, we as a healthcare community should look to find other less harmful ways to decrease pain and suffering. In this episode, we will review four randomized clinical trials published in the past year on pain control to see if there is evidence to support other non-opioid options...
Clinical Bottom Lines:
  • IN ketamine 1mg/kg provides effective analgesia in renal colic
  • Ibuprofen 400mg combined with acetaminophen 1000mg can reduce pain in mild to moderate extremity injuries
  • In renal colic, a ketorolac 15mg IV first strategy is still appropriate, with the addition of an IV opioid only if pain is not adequately controlled
  • In patients 60 years of age or older, presenting to the ED with hip fractures, femoral nerve blocks with 20mL of 0.5% bupivacaine not only improves pain, but also increase mobility and functional outcomes with significantly less medication side effects when compared to IV opioid agents"

miércoles, 3 de enero de 2018

Angiotensin II

PulmCrit (EMCrit)
PulmCrit - January 2, 2018 - By Josh Farkas
"...Maybe angiotensin II is a fantastic vasopressor, but currently it's doubtful whether the benefits outweigh the risks. There are several reasons that angiotensin II isn't ready for widespread use:
  1. Angiotensin II has pro-inflammatory effects, causing increased levels of interleukin-6.
  2. Angiotensin II has pro-coagulant effects, which could increase microvascular thrombosis and the risk of DVT/PE.
  3. Angiotensin II inhibition improved survival in an animal model of sepsis, suggesting that excessive angiotensin II activity can be harmful.
  4. Angiotensin II hasn't been shown to improve any outcome other than a minor increase in blood pressure. Full stop.
  5. ATHOS-3 is underpowered to detect uncommon adverse events.
  6. The rationale for using angiotensin II is very similar to the rationale for using vasopressin. Although vasopressin is occasionally quite useful, it hasn't proven to be a wonder drug."

domingo, 31 de diciembre de 2017

Top emDOCs 2017

emDocs - December 25, 2017 - Authors: Long B., Singh M and Koyfman A
"The emDOCs team is incredibly grateful for our readers and our amazing contributing authors. You and your amazing support always keep us going. This past year we saw the development of several new series including Tox Cards, emDocs Cases, Elemental EM, ECG Pointers, and US Probe. Stay tuned for an exciting 2018, and thanks again for your support! Happy Holidays and Happy New Year!..."
  1. emDocs Cases: Updates in Management of Hyperkalemia
  2. Cellulitis Mimics – ED Considerations
  3. High Risk Post Intubation Patients
  4. Neurotrauma Resuscitation: Pearls & Pitfalls
  5. TOXCARD: Alternatives to Sodium Bicarbonate for Alkalinization of a Poisoned Patient
  6. Must Know Antimicrobial Regimens – Adults
  7. Guillain-Barré Syndrome – Third time’s the charm
  8. Treatment of Refractory SVT: Pearls and Pitfalls
  9. Safe & Unsafe Medications in Pregnancy
  10. Is vancomycin/zosyn the answer for everything?
  11. US Probe: Ultrasound for Small Bowel Obstruction
  12. Elemental EM: Eating Disorder
  13. ECG Pointers: Hyperacute T-Waves


PulmCCM - December 22, 2017
"The FDA approved angiotensin-II (Giapreza) as a new intravenous vasopressor for septic shock and other forms of distributive shock. The first new FDA-approved vasopressor in decades, angiotensin-II could significantly change the management of severe septic shock.
FDA based its expedited approval (under priority review) on the ATHOS-3 trial enrolling 321 patients with shock refractory to catecholamines like norepinephrine or epinephrine. At 3 hours, almost 70% of patients with angiotensin II added reached the target blood pressure, compared to 23% receiving placebo and usual vasopressors. The study was not designed to detect a mortality benefit from angiotensin II.
Patients receiving angiotensin II also required lower doses of other vasopressors. The general strategy in the study was to wean off vasopressin first, then catecholamines, while titrating up angiotensin-II.
Angiotensin II patients experienced more thromboses, and FDA advised “Giapreza can cause dangerous blood clots with serious consequences (clots in arteries and veins, including deep venous thrombosis); prophylactic treatment for blood clots should be used.” Similar language will be on the product's label..."

sábado, 30 de diciembre de 2017

TTP: Plasmic Score

Taming The SRU - December 28, 2017 - By Baez J 
figure 3: PLASMIC scoring system. Score 0-4: low risk for ttp. Score 5-6: Intermediate risk, additional testing needed. Score 7: High risk for TTP, may treat empirically.
"In summary, TTP is a diagnosis that can be made using simple laboratory data obtained in the ED. With the advent of the PLASMIC score, emergency providers can expedite treatment in consultation with a specialist. Standard therapy with plasma exchange and steroids leads to clinical response in most patients. Platelet transfusion should be avoided if possible. For patients who do not fully respond or relapse, rituximab should be considered. Through early recognition and treatment, emergency providers can lessen the morbidity and mortality associated with this rare disease process."

Portal Vein Thrombosis

emDocs - December 27, 2017 - Authors: Hanlin E and Kaelin A 
Edited by: Koyfman A and Long B
"Clinical Pearls
  • Patients with PVT are often asymptomatic. Knowledge of risk factors associated with the disease is important to ensure the disease is considered.
  • Abdominal pain in patients with PVT is often associated with mesenteric vein occlusion and subsequent intestinal ischemia.
  • Consider PVT in patients with hematologic cancers or other pro-thrombotic conditions presenting to the ED with abdominal pain or new ascites.
  • Color Dopper US is sufficient for diagnosing PVT in clinically stable patients.
  • Consider contrast-enhanced CT in patients with severe symptoms or those who are clinically deteriorating to look for sequelae of PVT.
  • LFTs are usually normal in patients with PVT.
  • Timely initiation of anticoagulation with heparin or LMWH followed by warfarin is the recommended treatment for acute PVT.
  • Patients with acute PVT should be admitted to surgery or a medicine service with a surgery consult for frequent abdominal checks and initiation of anticoagulation therapy."

MEESI-AHF Risk Model

"MEESSI-AHF is a risk model to predict 30-day mortality in patients attending Emergency Departments (ED) with a diagnosis of Acute Heart Failures (AHF).
The MEESSI-AHF score was derived on 4867 consecutive AHF patients admitted to Spanish ED during 2009-2011, and then validated in 3229 consecutive AHF patients during 2014. (Note patients also with ST elevation myocardial infarction are excluded)
The MEESSI-AHF risk model includes 13 variables readily available on arrival to Emergency Department. The 40% of patients classified as LOW RISK (30-day mortality: <2%) should be considered as potential candidates to be early discharged from Emergency Department without admission after adequate response to initial treatment. The 10% of patients classified as VERY HIGH RISK (30-day mortality: >2%) may clearly benefit from hospital admission.
For some patients troponin, NT-proBNP and/or Barthel index values may be unknown. In such cases we still enable the risk score to be derived."
Reference: Miro O et al. Predicting 30-day Mortality for Patients with Acute Heart Failure Who Are in the Emergency Department: A Cohort Study. Ann Intern Med 2017.

domingo, 17 de diciembre de 2017


R.E.B.E.L.EM - December 14, 2017 - By Anand Swaminathan
"Background: The provision of high-quality compressions with minimal interruptions is central to the management of cardiac arrest. Along with defibrillation, high-quality compressions are the only interventions proven to improve patient-oriented outcomes. Recently, point-of-care ultrasound (POCUS) has gained greater use in cardiac arrest care for determination the cause of arrest as well as guiding the resuscitation and interventions. Performance of POCUS during arrest can be challenging particularly in terms of obtaining cardiac windows. Among these challenges is obtaining images of the heart during compressions. As a result, cardiac POCUS is often performed during rhythm checks when there is a scheduled pause in compressions. Despite the potential benefit from POCUS in cardiac arrest, prolonged interruptions in compressions while attempting to get optimal windows is unlikely to benefit the patient and, may be harmful.
Clinical Question: Does the use of POCUS during cardiac arrest care alter the duration of pauses in compressions?
Authors Conclusions: “In this prospective cohort trial of 24 patients with CA, POCUS during CPR pauses was associated with longer interruptions in CPR.”
Our Conclusions:
The use of intra-arrest POCUS was associated with an increased length of rhythm checks and, thus, an increased length in compression interruptions."

Initial Trauma Assessment

Resultado de imagen de core em
CORE EM - By Carl Preiksaitis
"Background: Addressing traumatic injuries is a major component of Emergency Medicine (EM) practice. Providers are asked to quickly evaluate these patients, address major life threats, and make a full inventory of injuries. Having a systematic approach is essential to a rapid assessment that minimizes the chance of missing injuries. This post will outline a step-by-step approach to evaluation...
Take Home Points
  • Development of a systematic approach is essential to rapidly assessing the wide diversity of trauma patients and minimizes missed injures
  • Prepare with whatever information is available before the patient arrives and remember to get a good handoff from the pre-hospital team
  • Complete the primary survey (ABCDEs) and address immediate life threats
  • Obtain a good medical history and remember to complete a comprehensive head-to-toe exam"

Amyotrophic Lateral Sclerosis

emDocs - December 13, 2017 - By Gipson J - Edited by: Koyfman A and Long B 
"Take Home Points
  • ALS is a progressive, degenerative disease which leads to paralysis and respiratory failure. It inevitably results in death, usually within 3-5 years from the onset of symptoms. 
  • ALS has a variety of phenotypes, and it is important for the emergency physician to recognize the various ways the disease can present and to refer patients with signs/symptoms of the disease to a neurologist for further testing. 
  • Bilevel positive pressure ventilation has been shown to reduce symptoms, prolong life, and improve quality of life in patients with ALS. 
  • Patients with ALS should have relatively normal lung function and generally do not require supplemental oxygen unless a secondary process is present. Supplemental oxygen should be administered concurrently with NIV when it is needed. 
  • ALS treatment strategies should focus on symptomatic treatment and should serve to enhance quality of life while maintaining patient autonomy."

miércoles, 13 de diciembre de 2017

Antibiotic IV to PO

Resultado de imagen de academic life in emergency medicine
ALiEM - December 13th, 2017 - By: Koehl J and McCreary E - Editors: Monette D, Hayes B
"Hurricane Maria ravaged Puerto Rico almost 3 months ago, destroying factories that manufacture and distribute medications and related supplies. Healthcare facilities across the nation are now experiencing a critical shortage of small-volume intravenous (IV) fluids, which impacts the supply of IV antimicrobials. With no end in sight, ED providers can protect the quality of patient care by considering 2 strategies: IV to PO conversion and first-dose antimicrobials via IV push."


An online community of practice for Canadian EM physicians
CanadiEM  - By Shahbaz Syed - December 13, 2017
We’re in the midst of an opioid crisis, with increased emphasis on opioid prescribing and the utilization of alternative or adjunctive medications. The emerging evidence against Tramadol should deter us from reaching for this medication as an alternative. While we should be mindful of prescribing opioids in general, Tramadol likely should not be a first line agent for patients, and we need to be very careful prescribing this medication for those who are already on serotonergic agents. Health Canada is apparently looking into the scheduling of this medication, and that would go a long way to increasing awareness about the harms of Tramadol."

New Arrhythmia Guidelines 2017

EmergencyPedia -  December 13, 2017 - By Andrew Coggins

"Summary from Journal Feed
  1. If in doubt with wide complex tachycardia, assume it’s VT (class I).
  2. For hemodynamically stable VT, procainamide is the preferred pharmacologic agent (class IIa). However, cardioversion remains a class I recommendation.
  3. In hemodynamically unstable ventricular arrhythmias, electricity is undoubtedly first priority. If that fails, amiodarone is the preferred pharmacologic agent (class IIa).
  4. IV beta blockers may be useful (class IIa) for patients with:
    1. VT/VF storm despite DCCV and antiarrhythmics
    2. Polymorphic VT due to MI
  5. Adrenaline 1mg every 3-5 minutes “may be reasonable” in cardiac arrest (class IIb).
  6. Consider emergent PCI in all patients after out-of-hospital cardiac arrest, particularly with initial shockable rhythm. Absence of STEMI does not rule out culprit coronary lesion and may be seen in 30% of patients.
  7. Contrary to common teaching, accelerated idioventricular rhythm (AIVR) is not a marker of reperfusion. Instead it is more strongly associated with infarct size.
  8. Some drugs can worsen or unmask Brugada syndrome. (drugs of concern include procainamide (not available in Australia), flecainide, TCAs, lithium, propofol, cocaine, cannabis and alcohol).
  9. Digoxin isn’t the only cause of bidirectional VT. Catecholaminergic polymorphic VT (exercise or stress induced VT) can also cause it.
  10. Long QT syndrome: males in childhood and postpartum females are at greatest risk for ventricular arrhythmia."

lunes, 11 de diciembre de 2017

Chest Pain

Resultado de imagen de academic life in emergency medicine
ALiEM - December 11, 2017 | By: Derek Monette
"Emergency Medicine has made significant contributions to the proliferation of Observation Medicine, an attractive alternative to admission for patients with low- and moderate-risk chest pain. Selecting the right patient, identifying appropriate interventions, and documenting appropriately are just some of the challenges discussed in the latest ACEP E-QUAL Network podcast, a partnership with ALiEM to promote clinical practice improvements. We review highlights from a podcast with experts Dr. Anwar Osborne (Emory University) and Dr. Michael Granovsky (LogixHealth)."

Push vs Short Infusion

The Skeptics Guide to Emergency Medicine
SGEM#198 - November 28, 2017 - By Salim Rezaie
"Clinical Question: Does increasing the duration of the ketamine from IV push (3 – 5 min) to a slow infusion (10 – 15 min) mitigate some of the untoward side effects, while maintaining analgesic efficacy?
SGEM Bottom Line: Slowing down the rate of low-dose IV ketamine infusion to 15 minutes significantly reduces rates of the feeling of unreality and sedation with no difference in analgesic efficacy when compared to IV push over 3 – 5 minutes."


MCC Project -  December 4, 2017 - By Jim Lantry
"Join me in welcoming Kenichi Tanaka, M.D., MSc., Professor of Anesthesiology and Division Chief Cardiothoracic Anesthesiology at the University of Maryland Medical Center. Dr. Tanaka started his Anesthesia training at Pittsburgh, then specialized in Cardiothoracic Anesthesia at Emory where he also earned a Masters in the Science of Clinical Research. Since joining UMMC in 2014 Dr. Tanaka has raised the bar in regards to academic research by publishing > 100 peer-reviewed journals and serving on the editorial boards of British Journal of Anaesthesia (Associate Editor), Anesthesia & Analgesia (Senior Editor), and Journal of Cardiothoracic Vascular Anesthesia. Today Dr. Tanaka sacrifices time from his busy schedule to delve into the dynamics of Thromboelastometry. I can assure you, if you ever plan to remedy coagulopathy in the ICU you will be glad you took 40 minutes to listen to this lecture!"

Chest compression point

MEDEST - December 8, 2017
Clinical pilot study of different hand positions during manual chest compressions monitored with capnography
Image attribution: Qvigstad E, et al. Clinical pilot study of different hand positions during manual chest compressions monitored with capnography. Resuscitation (2013), http://dx.doi.org/10.1016/j.resuscitation.2013.03.010

"Actual applications for clinical practice
  • The recommended chest compression point can be ineffective to generate enough outflow because the Area of Maximum Compression is not on the Left Ventricle but either on the Aortic Valve or the Ascending tract of the Aorta
  • Emergency providers can adjust the compression point based on EtCO2 values.
  • If, despite technically correct chest compressions, the EtCO2 remains below 10, try to adjust the compression point.
  • In those cases, the Optimal Compression Point is usually positioned caudally to the recommended one on the lower third of the sternum"

lunes, 27 de noviembre de 2017

Sepsis, Diastolic Dysfunction & Hypernatremia

PulmCCM - November 26, 2017 - By Jon-Emile S. Kenny
..."Diastolic dysfunction complicated by clinical heart failure is a complex interplay between the heart and the vascular system. One may be tempted to be more liberal with intravenous fluids in patients with diastolic dysfunction – with fear allayed by the words ‘preserved ejection fraction.’ However, patients with this form of heart failure are just as insulted by excessive salt and water as their counterparts with reduced ejection fraction..."

iSepsis: bolus? Yes or No

EMCrit - November 26, 2017 - By Paul Marik
"The Current Surviving Sepsis Campaign “recommends that, in the resuscitation from sepsis induced hypoperfusion, at least 30 mL/kg of IV crystalloid fluid be given within the first 3 hours” (with no exceptions) (STRONG RECOMMENDATION).
Do you support/agree with the above recommendation? The answer is a Yes or No (NO conditional answers)
Results from the Surviving Sepsis Campaign Committee members
The number of “NO” votes exceeds the threshold of 20% established by the Guideline Rules and therefore this recommendation must be rejected."


R.E.B.E.L. EM - Emergency Medicine Blog
R.E.B.E.L.EM - November 27, 2017 
"Clinical Take Home Point: We must be careful in making brash conclusions from this study. Although the authors conclude early treatment with IV loop diuretics is associated with lower in-hospital mortality, it is important to remember, patients in the early treatment group were more likely to arrive by ambulance, have an onset of symptoms that was more abrupt, and have more obvious signs of volume overload. All these confounders, would lead to earlier treatment with IV diuretics, meanwhile the quality of care as well as other treatments not accounted for (i.e. NIPPV and/or nitrates) may be the reason why mortality was improved."

viernes, 24 de noviembre de 2017

Ottawa SAH Rule

EMOttawa - By: Jeffrey Perry - November 13, 2017

"Dr. Perry and Colleagues have previously derived and validated the Ottawa SAH rule for patients with suspected subarachnoid hemorrhage, here we present the multicenter prospective validation of the rule, with some insight on the rule from Dr. Perry himself!"

HIV screening

St.Emlyn’s - By Gareth - November 24, 2017
"So in summary
  • I think these guidelines make a lot of sense.
  • A step wise approach to HIV screening in hospitals depending on local prevalence rates.
  • Embedding HIV screening as a routine part of ED practice may help reduce the stigma associated with testing for the disease.
  • We have a captured audience in the emergency department and are the perfect place for public health initiatives like this.
  • It makes sense because we take blood for lots of things we don’t need (coagulation screen anyone?). Taking a bottle for something we do need is obvious and logical.. I mean, I’d like to know my HIV status far more than I would my PT any day.
  • I know we’re busy and at a time when we’re stretched, asking us to do more and more is probably the last thing a ED clinician wants to hear but if we really think about it.. when we realise it is just one extra bottle of blood, your patients might just that you for saving their life."

jueves, 23 de noviembre de 2017

Running Codes

EMsandox - November 22, 2017 - By jfhine
"In this podcast we discuss coding patients in cardiac arrest and the barriers to a successful resuscitation.
Review Questions:
  1. What are the two interventions shown to improve survival in cardiac arrest?
  2. Define compression fraction.
  3. What are the major barriers we outlined to maintaining a good compression fraction?
  4. In the nurse-led code model, what responsibilities fall on the nurse leader? What ones fall on the doctors?"

Sinusitis Mimics

emDocs - November 22, 2017 - Author: Cooper J - Edited by: Koyfman A and Long B
"Take home points:
  • Sinusitis symptoms overlap with many other diseases, only some of the prominent diseases were covered here.
  • CTS presents with unilateral retroorbital and frontal headache and cranial nerve deficits. CTS and sinusitis can occur concurrently. Include a detailed ocular and neurologic exam in your assessment to help clue you in.
  • Brain abscesses can result as a direct extension of sinusitis. Headache is a common presenting feature, which may be frontal or retroorbital. Fevers are also common to both. In patients with sinusitis, consider a brain abscess if they have mental status changes, lethargy, or subtle or progressive neurologic deficits.
  • Meningitis presents with headache and fever and can mimic sinusitis. Be wary of sinusitis directly extending to the CNS. Physical exam is unreliable for ruling out meningitis. Maintain a high index of suspicion in sinusitis patients that have other symptoms suggestive of meningitis.
  • Orbital cellulitis often occurs as a direct extension of sinusitis. Be suspicious when patients have vision complaints and ocular findings on exam including proptosis and antalgic eye movements. These often require surgical management
  • Mucormycosis is a surgical emergency! Always do a thorough oral and nasal exam to look for necrotic tissue and black eschar in the immunocompromised and diabetics
  • Think nasal foreign body in a kid with unilateral congestion. Be sure to check all orifices as kids like to put things everywhere.
  • Headache with positional changes or progression can be a brain tumor. Be sure to evaluate for these signs in a sinusitis patient."

miércoles, 22 de noviembre de 2017

ED Temperature and ICU Survival

The Skeptics Guide to Emergency Medicine
SGEM#195 - November 11, 2017
"Clinical Question: Does patient body temperature in the emergency department predict survival of adult patients with severe sepsis and septic shock admitted to the intensive care unit?
Screen Shot 2017-11-10 at 7.08.43 PM
Primary Outcome: In hospital mortality was inversely correlated with body temperature.
SGEM Bottom Line: We should pay greater attention to patients presenting with features of severe sepsis and septic shock that do not have fever in the emergency department as they have an associated high mortality rate."


emDocs - November 21, 2017 - Author: Santistevan J - Edited by: Koyfman A
"What are the main ECG pointers for pericarditis?
  • Pericarditis and STEMI can be very difficult to differentiate on ECG!
  • The ST elevation of pericarditis should be concave (smiley-face)
  • The ST elevation should be diffuse, not localized to a single vascular territory
  • In pericarditis, ST depression should only be found in aVR and V1
  • If you’re not sure, get serial ECGs and err on the side of caution!"

martes, 21 de noviembre de 2017

TXA in Massive Hemorrhage

R.E.B.E.L.EM - Nov 20, 2017
Background: Bleeding from massive hemorrhage in trauma and post-partum are a major cause of death worldwide. There have been two large randomized controlled trials, in trauma and post-partum hemorrhage that have shown administration of TXA within 3 hrs of bleeding onset reduces death due to bleeding. The current meta-analysis that we are going to review sought to quantify the effect of treatment delay in acute severe bleeding by analyzing individual patient-level data from the two randomized clinical trials mentioned above...
Clinical Take Home Point: 
  • In patients with massive bleeding from trauma or post-partum hemorrhage, giving TXA as soon as bleeding is suspected, reduces mortality from bleeding.
  • Most deaths, in trauma and postpartum from hemorrhage, occur within hours of bleeding onset
  • The mortality benefit of TXA appears to diminish over time and is lost at 3 hours after major hemorrhage begins
  • In this trial, there was no evidence of adverse effects (vascular occlusive events) associated with TXA treatment"

Headache in the ED

emDocs - Nov 20, 2017 - Author: Long B - Edited by: Koyfman A
"Key Points:
  • Headache is divided into benign, primary causes and dangerous, secondary etiologies. Focused history and examination are recommended.
  • Benign headaches include migraine, tension, cluster, and several others, but a specific diagnosis is not required in the ED.
  • Management should also focus on symptom treatment for pain and nausea.
  • A combination of medications is advised.
  • Antidopaminergics have the strongest literature support. These should be used with NSAIDs and/or acetaminophen.
  • Steroids likely decrease headache recurrence.
  • Other treatments include ketamine, propofol, and nerve blocks. These are options for refractory headaches to other treatments."


 Peguero J et al. J Am Coll Cardiol. 2017; 69(13):1694-1703. 
doi: 10.1016/j.jacc.2017.01.037. Peer reviewed by Clay Smith, MD.
"The Lo down on the Peguero-Lo Presti criteria for LVH
This study retrospectively evaluated a combined 216 patients in a test cohort and a validation cohort. Using echocardiography as the reference standard, the study compared the Peguero-Lo Presti criteria (SD + SV4) to several other commonly used ECG criteria for LVH. Using cutoffs of >/=2.3mV for females and >/=2.8mV for males, the Peguero-Lo Presti criteria had a far superior sensitivity for LVH (62%) compared to the next highest performer (Cornell voltage criteria, 35%). One millivolt = 10 small vertical boxes, 2 large boxes. The Peguero-Lo Presti criteria maintained specificity at 90%, which was similar to the other criteria evaluated."

The 4AT for delirium detection


The 4AT is a rapid clinical instrument for delirium detection.
It is a short and practical tool designed for use in busy areas where assessment for delirium is needed.
The 4AT is among the most widely-used clinical tests for delirium internationally.
The 4AT is free to download and use."

sábado, 18 de noviembre de 2017

Aortic Dissection

ACEPNow - By Anton Helman - November 13, 2017
Living Art Enterprises / Science Source
"Take-Home Points
  • Remember the big pain pearls when taking a history:
    • Ask the three important questions.
    • Aortic dissection should be considered the subarachnoid hemorrhage of the torso.
    • Migrating pain, colicky pain, plus need for IV opioids should raise your suspicion.
    • Intermittent pain can still be a dissection.
  • Look for Marfan syndrome, listen for an aortic regurgitation murmur, and feel for a pulse deficit.
  • Think not only about CP +1 but also 1+ CP.
  • Know the radiographic findings of loss or aortic knob/aortopulmonary window and the calcium sign, and use POCUS to look for an intimal flap and pericardial effusion.
  • Don’t be misled by a troponin or D-dimer."

Spontaneous Bacterial Peritonitis

R.E.B.E.L. EM - Emergency Medicine Blog
R.E.B.E.L.EM - Novembre 16, 2017

"Take Home Points:
  • SBP is a difficult diagnosis to make because presentations are variable. Consider a diagnostic paracentesis in all patients presenting to the ED with ascites from cirrhosis
  • An ascites PMN count > 250 cells/mm3 is diagnostic of SBP but treatment should be considered in any patient with ascites and abdominal pain or fever
  • Treatment of SBP is with a 3rd generation cephalosporin with the addition of albumin infusion in any patient meeting AASLD criteria (Cr > 1.0 mg/dL, BUN > 30 mg/dL or Total bilirubin > 4 mg/dL)"

miércoles, 15 de noviembre de 2017

Sepsis interprofessional curriculum

MCC Project - By Jim Lantry
"Please enjoy complimentary access to a sepsis curriculum created by two esteemed faculty members here at the University of Maryland Medical School: Jeffrey P. Gonzales, PharmD, FCCM, BCPS, BCCCP and Nirav G. Shah, MD, FCCP.
Dr. Gonzales is an Associate Professor of Critical Care and a faculty member at the University of Maryland School of Pharmacy where he is the director of the Post-Graduate Year One and Year Two Pharmacotherapy Residency Program. He is a staple on MICU rounds and has been a driving force for pharmacy integration into the critical care fellow’s curriculum.
Dr. Shah is an Associate Professor of Medicine in the Division of Pulmonary & Critical Care Medicine, the Course Director of Pathophysiology & Therapeutics I; and also acts as the Director of the Pulmonary & Critical Care Fellowship Program here at the University of Maryland Medical Center. Despite his many administrative duties, Dr. Shah continues to be rated as one the best MICU educators by the medicine and critical care fellows."


Emergency Medicine PharmD - By Tony Mixon - November 15, 2017
"Many institutions have implemented antimicrobial restriction programs where specific agents, based on toxicity, cost, or broad-spectrum of activity, require special permission for use. Often a page is required to initiate the request. During my infectious diseases PGY-2 I carried this antimicrobial approval pager, either approving the use of restricted agents or offering suggesting on alternative therapy. Fluoroquinolones (FQs) were by far, the most requested restricted antimicrobials, and also the most denied. In emergency departments without such programs, pharmacists play a vital role in antimicrobial stewardship, steering therapy to optimize clinical outcomes while minimizing unintended consequences. With their broad spectrum of activity, oral formulation, and seemingly minimal adverse effect profile, FQs were highly touted when originally approved. However, after decades of clinical use and research, is it time we rethink their greatness?"
Take Home Points
  • FQs have been associated with many severe adverse reactions, including but not limited to QT prolongation, CDI, seizures, peripheral neuropathy, hypo/hyper glycemia, GI perforation, tendinopathy, retinal detachment, aortic dissection/aneurysm, as well as causing drug-drug interactions.
  • FQs carry multiple black box warnings surrounding their safety.
  • FQs have a low barrier to resistance.
  • Resistance rates to FQs have increased rapidly. Look at your antibiogram!
  • Ciprofloxacin and levofloxacin are our only oral agents with reliable activity against Pseudomonas spp.
  • FQs should be reserved for a few clinical scenarios where other antibiotics are not safe or feasible.