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



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jueves, 13 de diciembre de 2018

Cricoid pressure

Cricoid pressure is dead Title Image
First10EM - By Justin Morgenstern - December 10, 2018
..."Bottom line
Despite the confusing non-inferiority conclusion, this study clearly demonstrates that cricoid pressure causes harm by interfering with intubation without providing any benefit. Until further data becomes available, the practice should be abandoned."

Adrenal crisis

PulmCrit (EMCrit) 
PulmCrit (EMCrit) - December 12, 2018 - By Josh Farkas
"Adrenal crisis is a can't-miss diagnosis. Prompt identification and proper management will generally lead to rapid improvement. The most important aspect is maintaining a high index of suspicion. When in doubt, start empiric therapy first and ask questions later."

Early Sepsis Screening

R.E.B.E.L.EM - December 10, 2018 - By Mark Ramzy
..."Clinical Bottom Line:
In this limited retrospective study, NEWS was more accurate than both SIRS and qSOFA for the early detection of severe sepsis and septic shock. This severity score is calculable at triage, improves in prediction with increasing illness severity, and may better allow for risk stratification, however until prospective performance of the score in the ED can be determined, SIRS remains the most sensitive algorithm for predicting patients at risk for severe sepsis and septic shock."

2018 Guidelines

MEDEST - December 13, 2018
"So 2018 is at the end and we give, as every year, a look back to literature and articles of this finishing year.
This is the first step of 1 YEAR IN REVIEW the classical MEDEST appointment with all that matter in emergency medicine literature.
So let’s start with Guidelines but first I want to cite an important point of view about Clinical practice Guidelines and they future development:
“Clinical practice guidelines will remain an important part of medicine. Trustworthy guidelines not only contain an important review and assessment of the medical literature but establish norms of practice. Ensuring that guidelines are up-to-date and that the development process minimizes the risk of bias are critical to their validity. Reconciling the differences in major guidelines is an important unresolved challenge.”
And now here it is, divided by topics, the most important new 2018 Guidelines. Click on the link to read more..."

domingo, 2 de diciembre de 2018

Guidelines on Venous Thromboembolism

"In 2014, in response to long-standing member interest, ASH initiated an effort to develop evidence-based clinical practice guidelines for hematology that meet the highest standards of development, rigor and trustworthiness. Development of these guidelines, including systematic evidence review, was supported by the McMaster University GRADE Centre, a world leader in guideline development. With their partnership, ASH brought together ten panels of more than 100 thrombosis experts to review evidence and formulate more than 200 recommendations on venous thromboembolism (VTE)."
Click image for video of experts discussing the new guidelines

Acute Coronary Syndrome

SAEM sponsors AIR series
ALiEM - November 30th, 2018 - By Chris Belcher
"Welcome to the Acute Coronary Syndrome (ACS) Module! After carefully reviewing all relevant posts from the top 50 sites of the Social Media Index, the AIR Team is proud to present the highest quality online content related to ACS emergencies. 13 blog posts within the past 12 months (as of July 2018) met our standard of online excellence and were curated and approved for residency training by the AIR Series Board. We identified 2 AIR and 11 Honorable Mentions. We recommend programs give 5.5 hours (about 25 minutes per article) of III credit for this module..."

D-Dimer in Pregnancy

R.E.B.E.L.EM - November 29, 2018 - By Rick Pescatore

..."Authors’ Conclusion:
In pregnant women with suspected PE, a diagnostic strategy involving assessment of pretest clinical probability, D-dimer measurement, bilateral leg CUS, and CTPA can safely rule out the disease, with a 3-month thromboembolic rate of 0.0% (95% CI, 0.0% to 1.0%).
Clinical Take Home Point: Among pregnant women presenting with concern for pulmonary embolism in pregnancy, who have a low or medium pre-test probability of PE, a negative D-dimer can safely rule out the disease, though will only be helpful in a small proportion of patients."

Beyond A(C)LS

#stemlynsLIVE #FOAMed
St.Emlyn´s - By Simon Carley - November 27, 2018
"Ed – This blog is based on the talk Salim gave at #stemlynsLIVE in Manchester back in September 2018. The background and data below was first published on the REBEL EM website and is reproduced here with permission. Please visit that site and subscribe for more evidence based emergency medicine and critical care. Note that in the UK we use the term ALS instead of ACLS.
The focus of this talk is on how to cognitively offload our minds as we are running a resuscitation. ACLS provides us with a framework in treating adult victims of Cardiac Arrest (CA) or other cardiopulmonary emergencies. This helps get providers who don’t commonly deal with CA, to improve things, such as the quality of CPR, minimizing interruptions during CPR for pulse checks, and the timing/dosing of epinephrine. Emergency Medicine (EM) and the prehospital world are different than many environments in medicine. We get minimal information at the time of patient arrival while at the same time the disease process that is taking place has not quite defined itself. We are constantly expected to acutely manage and resuscitate anyone who comes in our doors 24-7-365, many times without crucial information. Our job therefore should be to ensure coronary and cerebral perfusion are at their highest quality, but also simultaneously putting the pieces of the puzzle together to figure out why our patient is in CA. It can be very difficult to do both and many times we sacrifice one for the other. It is therefore important to cognitively offload ourselves during the resuscitation of our patients in CA and focus our attention on why they are in CA. As a disclosure for this lecture I did state that some of the recommendations made have evidence to support them and others are more theoretical and certainly up for discussion."

jueves, 22 de noviembre de 2018

The Sick Kidney Stone Patient

emDocs Cases - November 19, 2018 - Authors: Schmitz G and Hockstein M
Edited by: Koyfman A and Long B
Key Points:
  • The combination of an obstructed stone with a UTI is a urologic emergency. About 8% of patients presenting with acute nephrolithiasis will also have a UTI.
  • Patients with decreased renal function, previous urologic interventions, and symptoms of infection are historical features for poor outcome in patients with stones.
  • The presence of pyuria has only moderate sensitivity in patients with positive urine cultures.
  • Fever was absent in 50% of patients with stone and confirmed UTI.
  • Hydronephrosis and hydroureter may be secondary signs of ureteral obstruction. However, this finding is not specific and can be caused by other things including rapid administration of IV fluids.
  • In a subset of low risk patients, renal ultrasound may be an alternative to CT imaging without exposing patients to ionizing radiation. The absence of hydronephrosis in these patients may predict the spontaneous passage of stone without urologic intervention.
  • Antibiotic penetration in staghorn calculi is poor, the potential for urosepsis is increased until the stone is removed. Surgical treatment is generally required for staghorn calculi.
  • Patients with acute flank pain have many etiologies, including cardiovascular and pulmonary catastrophes. Isolated kidney stones should not cause shock.

domingo, 18 de noviembre de 2018

Severe Hyponatremia

PulmCCM - November 17, 2018
"Severe hyponatremia (often defined as a serum sodium < 120 mEq/L) occurs most often in people with pituitary or lung tumors, those taking antipsychotic or other neuroleptic drugs, heavy beer drinkers, or the elderly. Usually sodium levels decline slowly over weeks or months prior to detection, allowing time for the brain to compensate, with only minor neurologic symptoms.
Sodium levels will often return to normal just as slowly, with minimal intervention by physicians (change in drug therapy, fluid restriction, etc). But new evidence shows that when patients with hyponatremia get admitted to the hospital, their impatient treatment teams often correct sodium levels too quickly, increasing the risk for dangerous complications..."

sábado, 17 de noviembre de 2018


Emergency Medicine PharmD - May 4, 2015 - By Matthew DeLaney
..."Tramadol has been marketed as a novel analgesic that offers pain relief comparable to opioids without the associated risks of abuse or dependency. As its use has increased, there is emerging data to suggest that tramadol is not a medication that should be routinely used in the emergency department. From questionable efficacy, risk of dependency/abuse, to a somewhat unique risk of complications, there are three major reasons why providers should be careful when using tramadol...
Despite its widespread use, there are significant issues that providers should consider before using tramadol. In terms of efficacy tramadol has not been shown to consistently outperform other available analgesics. In addition, tramadol has a set of potential side effects that make it a less than ideal first line analgesics. Finally tramadol does not appear to be a “safe opioid” as there seem to be significant potential for abuse, dependency, and withdrawal."

jueves, 15 de noviembre de 2018

Cricoid Pressure in Airway Management:

R.E.B.E.L.EM - November 15, 2018 - By Anand Swaminathan
..."Potential to Impact Current Practice: Cricoid pressure should not routinely be provided to patients undergoing intubation.
Bottom Line: Occlusion of the esophagus by cricoid pressure appears to be a myth based on MRI and US studies. Previous literature demonstrates that cricoid pressure gives inferior views and no high-quality literature has shown decreased aspiration with application of cricoid pressure.
All of this in conjunction with the numbers seen in this study tells us that pulmonary aspiration is uncommon in the OR setting and isn’t reduced by the application of cricoid pressure. While an ED based study would be nice to have, the current evidence tells us that application of cricoid pressure is unlikely to benefit our patients but is likely to make our intubation more difficult..."

Intracranial Hemorrhage (ECG)

emDocs - November 14, 2018 - Author: Tannenbaum LL
Edited by: Santistevan J; Singh M and Long B
"Take home points:
  • In patients with intracranial hemorrhage, hypertension and bradycardia can be signs that herniation is occurring.
  • There are many nonspecific ECG changes seen in patients with intracranial hemorrhage including ST changes, QT prolongation, and T-wave inversions.
  • Occasionally these changes can mimic acute coronary syndromes including STEMI and can lead to misdiagnosis, unnecessary thrombolytics, or PCI.
  • Sometimes, it isn’t the heart"

martes, 13 de noviembre de 2018

Brain Injury after Cardiac Arrest

Maryland CC Project - By Jim Lantry - November 12, 2018
"Please welcome back an old friend of Baltimore, Karen G. Hirsch, MD. Dr. Hirsch is an Assistant Professor of Neurology and the Director of Neurocritical Care at the Stanford University Medical Center. She is also one of the guru’s and experts in the field of neuroprognostication after cardiac arrest leading to a multitude of publications and numerous grants. Today we are exceedingly fortunate to have her grace the halls of The University of Maryland to give us a crash course on what we SHOULD be doing for our cardiac arrest patients. I assure you, this is a lecture all of us need to hear!"
Resultado de imagen de vimeo

lunes, 12 de noviembre de 2018

Whole blood in the trauma bay

St. Emlyn´s - By Zaf Qasim - November 9, 2018
"One thing is clear from the military and civilian literature – hemorrhage kills1,2. Overall, 40-50,000 deaths per year in the US are preventable with appropriate hemorrhage control and resuscitation. The demographic of these victims is primarily young, healthy individuals who would otherwise have had the chance to live a productive life.
Resuscitation should address the components responsible for hemorrhagic shock – blood loss and systemic injury – while mitigating hemodilution. There has been a concerted push away from using clear fluids for initial resuscitation, with recent evidence pointing to the mortality benefit of using balanced ratios of packed red cells, plasma, and platelets in massive transfusion3.
The aim of balancing components is to approximate reconstituted whole blood – so why not just give whole blood?..."

Ways to Solve ED Boarding

Emergency Physicians Monthly
Emergency Physicians Monthly - By Shah S and Esbenshade A - October 31, 2018
"Strategies to increase efficiency and involvement.
In 2011, nine out of 10 hospitals reported boarding patients in the emergency department while they awaited inpatient beds.
The Joint Commission has since made boarding part of its survey process because it’s a patient care and safety issue. But the negative effects don’t stop at safety and clinical outcomes. There are also the negative downstream effects of boarding, including the inability to treat newly arriving patients, longer cycle times for existing ED patients and poor perception of quality and confidentiality by boarded patients.
With the stakes so high, can you afford to not address this issue? Here are seven ways to solve the ED boarding challenge..."

Angiotensin–Neprilysin Inhibition in ADHF

Velazquez E et al. NEJM - November 11, 2018 - DOI: 10.1056/NEJMoa1812851
Among patients with heart failure with reduced ejection fraction who were hospitalized for acute decompensated heart failure, the initiation of sacubitril–valsartan therapy led to a greater reduction in the NT-proBNP concentration than enalapril therapy. Rates of worsening renal function, hyperkalemia, symptomatic hypotension, and angioedema did not differ significantly between the two groups. (Funded by Novartis; PIONEER-HF ClinicalTrials.gov number, NCT02554890.)"


Urgencias y Emergencias
Urgencias y Emergencias - By Elena Plaza Moreno - November 6, 2018
"Acaba de publicarse la actualización 2018 de AHA de ACLS y PALS (soporte vital avanzado de adultos y pediatría) de AHA.Esto es debido a que desde el 2015, ILCOR comenzó un proceso continuo de revisión de la evidencia. Esto se traduce en la práctica en que las recomendaciones ya no se realizan cada 5 años, sino que se hacen actualizaciones continúas.
El año pasado se actualizaron las recomendaciones sobre Soporte Vital Básico tanto de adultos como de pediatría. Y ayer se actualizaron las recomendaciones sobre Soporte Vital cardiovascular avanzado tanto de adultos como de pediatría.
Os dejo con mi propia traducción del documento de Highlights de los cambios (podéis ver el original en inglés al final de esta entrada). Los cambios ya se han introducido en la web de la AHA, en la parte de las guías integradas (está en inglés): https://eccguidelines.heart.org/index.php/circulation/cpr-ecc-guidelines-2/
Y podéis ver y descargar el documento completo publicado en Circulation para adultos aquí y para pediatría aquí."

miércoles, 7 de noviembre de 2018

Lung Abscess

emDocs - November 7, 2018 - Author: Ramzy M - Edited by: Koyfman A and Long B
  • Obtain sputum cultures in hospitalized or septic patients to better focus antibiotic therapy.
  • Clindamycin is the first line antibiotic of choice; transition from IV to PO when appropriate.
  • Blood cultures are rarely positive in anaerobic lung abscesses.
  • Consider admission and IV antibiotics rather than discharging patients with poor outpatient follow-up or those who may be non-compliant with antibiotics."

Epinephrine in out of hospital cardiac arrest

First 10EM - Justin Morgenstern - November 6, 2018
I am concerned, after reviewing all this data, that we are harming our patients with the routine use of epinephrine in cardiac arrest. I would remove it from the algorithms, but recognize that there are still many questions, and that there may be individual patient circumstances in which a bolus of epinephrine might make sense."

Blunt cerebrovascular injury

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine logo
Tor Brommeland et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2018; 26:90 - https://doi.org/10.1186/s13049-018-0559-1
"Blunt cerebrovascular injury (BCVI) is a non-penetrating injury to the carotid and/or vertebral artery that may cause stroke in trauma patients. Historically BCVI has been considered rare but more recent publications indicate an overall incidence of 1–2% in the in-hospital trauma population and as high as 9% in patients with severe head injury. The indications for screening, treatment and follow-up of these patients have been controversial for years with few clear recommendations. In an attempt to provide a clinically oriented guideline for the handling of BCVI patients a working committee was created. The current guideline is the end result of this committees work. It is based on a systematic literature search and critical review of all available publications in addition to a standardized consensus process. We recommend using the expanded Denver screening criteria and CT angiography (CTA) for the detection of BCVI. Early antithrombotic treatment should be commenced as soon as considered safe and continued for at least 3 months. A CTA at 7 days to confirm or discard the diagnosis as well as a final imaging control at 3 months should be performed."

Troponinas cardiacas en el IAM en emergencias

Colaboración entre la Sociedad Española de Cardiología, la Sociedad Española de Medicina de Urgencias y Emergencias y la SEQC-ML
SEQC - 18/10/2018
"Representada por los Dres. Jordi Ordóñez y Eva Guillén, la SEQCML ha participado en la elaboración de un documento de consenso sobre la utilización de la troponina cardiaca para el diagnóstico del infarto agudo de miocardio en Urgencias, publicado recientemente en la Revista Emergencias. Dicha participación se ha desarrollado en colaboración con la Sociedad Española de Cardiología (SEC) y la Sociedad Española de Medicina de Urgencias y Emergencias (SEMES)...
Además, la SEC ha publicado una completa infografía en la que se muestran las recomendaciones de uso y las conclusiones alcanzadas en el documento de consenso..."

lunes, 5 de noviembre de 2018

Procalcitonin in COPD exacerbations

PulmCCM - November 4, 2018
..." Most of the small studies testing procalcitonin-driven algorithms have shown the method to be generally safe and effective at reducing antibiotic use. But a new study suggests that in patients with COPD exacerbations admitted to the ICU, withholding or stopping antibiotics based on PCT levels could be harmful...
Procalcitonin shouldn't be used as a reason to withhold antibiotics from seriously ill patients with acute exacerbations of COPD, sepsis, or any other potential bacterial infection -- especially early in their clinical course."

Sodium Bicarbonate in Cardiac Arrest

emDocs - November 5, 2018 - Author: Murchison C - Edited by: Koyfman A and Long B
  1. The evidence for acidosis being harmful is primarily based on in vitro studies. Clinical data show acidosis may not be as harmful as we think. 
  2. Sodium bicarbonate therapy creates excess CO2 which must be quickly exhaled. If a patient is not adequately ventilating they will become more acidotic when given sodium bicarbonate therapy. 
  3. There are only two clinical trials on using sodium bicarbonate in cardiac arrest, both show no benefit. The AHA no longer recommends its use in ACLS."

Antipsychotics for delirium

PulmCrit - November 5, 2018 by Josh Farkas
..."Summary: The Bullet
  • MINDS-USA investigated the use of haloperidol or ziprasidone among a group of delirious ICU patients, 89% of whom had hypoactive delirium.
  • Haloperidol and ziprasidone were both ineffective. However, they were both also surprisingly safe (with comparable side-effect rates compared to placebo).
  • This study suggests that haloperidol and ziprasidone are ineffective for hypoactive delirium. This makes sense given the clinical features of hypoactive delirium (somnolence) and the variable neurobiological underpinnings of this disorder (making a single therapy unlikely to work for all patients).
  • All patients in the study were allowed to have open-label PRN antipsychotics for breakthrough agitation. Therefore, this study cannot reveal anything about this utilization of antipsychotics.
  • The receptor targets of atypical antipsychotics are widely variable. Thus, results obtained in this study are not necessarily generalizable to all antipsychotic medications."

Prehospital Plasma in Trauma

REBEL Cast Ep60 - November 5, 2018 - By Ashley Liebig
..."Different Outcomes in COMBAT and PAMPer:
  • Patients slightly older in PAMPer Trial vs COMBAT Trial (40’s vs 30’s)
  • More Crystalloid used in PAMPer Trial vs COMBAT Trial (500 – 900cc vs 150 – 250cc)
  • More Blunt Injury in PAMPer Trial vs COMBAT Trial (>80% vs ≈50%)
  • Transport Times Longer in PAMPer Trial vs COMBAT Trial 39 – 52min vs 16 – 28min
Clinical Take Home Point:
In injured patients at risk for hemorrhagic shock, pre-hospital administration of thawed plasma appears to be a safe and efficacious practice in reducing mortality. The difference in mortality outcomes between the COMBAT and PAMPer trials may simply be the longer transport times and the amount of crystalloids, which begs the question of whether we should be resuscitating these patients with crystalloid fluids at all?..."

domingo, 4 de noviembre de 2018

Hypothermia in brain injury

St. Emlyn´s - November 3, 2018 - By Dan Horner
..."We recently reported on the EuroTHERM trial3,4 that looked at rescue hypothermia in patients with severe traumatic brain injury refractory to standard tier 1 care. We felt the trial showed harm to patients in the hypothermia group, but did not answer the question as to whether hypothermia may be used as a prophylactic therapy in patients who are at the lower end of the severity spectrum, but remain at risk of secondary brain injury.
This month an international group reported the result of a randomised controlled trial in just such a group. The paper is published in JAMA and is (I think) currently open access. The abstract is below, but as we always say it’s vital that you read the full paper..."

Methanol Toxicity

EM@3AM - November 3, 2018 - Author: Bridwell R - Edited by: Long B and Koyfman A
  • Acidemia is greatest predictor of final visual acuity.9
  • Dose to cause permanent visual impairment is approximately 30cc, or a mouthful.
  • Delayed Parkinsonism and polyneuropathy can occur later.
  • John Milton, author of Paradise Lost, went blind from methanol poisoning."

FLORALI trial.

PulmCrit - November 1, 2018 - By Josh Farkas
"Summary The Bullet:
  • Conventional wisdom is that FLORALI is a positive trial, whereas HIGH is a negative trial. As such, these trials are portrayed as contradicting each other.
  • The actual data from FLORALI and HIGH are consistent. FLORALI isn’t quite as optimistic as it is commonly perceived, whereas HIGH isn’t quite as dreary as it has been described. The truth probably lies in between.
  • Evidence doesn’t show a mortality benefit from HFNC. However, combining data from HIGH and FLORALI does suggest a non-significant reduction in intubation rates. Such a reduction has been shown in two RCTs following extubation.4 5
  • HFNC is remarkably safe. None of these trials report any worrisome complications from HFNC.
  • Currently, benefit/risk analysis continues to favor the use of HFNC for hypoxemic respiratory failure. HFNC isn’t a magic bullet for hypoxemic respiratory failure, but it may help some patients and it is extremely safe."

jueves, 1 de noviembre de 2018

Heart Score

Porros EM - November 1, 2018 - By Dr. Po
..."¿Por qué es complejo de evaluar el dolor torácico? Según nuestra alida la Ñora Tintinalli el dolor torácico cuenta con 8 millones de consultas por año (USA), de estas consultas entre en 50 y 70% se estudian en urgencia pero aun así un 5% de los infartos al cuore los damos de alta desde la urgencia. La complejidad de esto es dada su amplia variedad de diferenciales y combinaciones de síntomas en la presentación, haciendo que nuestra toma de decisiones sea mas enredada que los planos del puente Cau-cau*.."

EVLI Airway Incrementalization

EMCrit 236 - October 31, 2018 - By Scott Weingart
"A video lecture from my friend and airway guru, Prof. George Kovacs. He has been obsessed with airway for decades. This lecture discusses breaking down the steps of airway management into chunks."


emDocs - October 31, 2018 - Authors: Toni Riveros and Michael Schindlbeck 
Edited by: Alex Koyfman and Brit Long
"Pearls & Pitfalls
  • Myocarditis remains a challenging diagnosis given its wide range in clinical presentation, from a subtle picture of mild dyspnea and malaise following a recent viral illness to fulminant congestive heart failure and sudden cardiac death.
  • Clinicians should investigate for clues including travel or immigration history, illicit drug use, underlying autoimmune conditions, transplant status, co-infections such as hepatitis or HIV, or treatment with chemotoxic or new antibiotic agents.
  • Physical exam findings may include tachycardia disproportionate to body temperature, a toxic appearance without a clear source of infection, or dyspnea with signs of circulatory overload in a patient with no known cardiac history.
  • Patients with myocarditis should be admitted to a setting capable of cardiac monitoring. Treatment in the ED is mainly supportive with careful attention to airway, breathing, and circulation."

martes, 30 de octubre de 2018

New Oncologic Emergencies

CanadiEM - By Arden Azim - October 30, 2018

Summary of Approach to Patients on Immune 
Checkpoint Inhibitors
In summary, immunotherapy drugs are increasingly used in the treatment of multiple malignancies.1–3 A broad spectrum of immunotherapy-related adverse events exists, with skin, GI tract and lungs most commonly affected.1–3 Immunotherapy is distinct from chemotherapy, and complications require a distinct approach to management. High-dose corticosteroids are the basis of emergency management for severe cases, along with supportive therapy and early consultation to medicine, oncology and other appropriate specialists.1–3 Careful medication reviews (look for drugs ending in “mab”) for oncology patients and a high index of suspicion for immunotherapy-related adverse events are key in the early detection of complications and appropriate management of these patients.
A tool-kit and guidelines by Cancer Care Ontario for management of immunotherapy toxicities can be found at: 

Manual de Urgencias

‘Manual de Urgencias’, tenemos nueva edición (la 3ª) del manual coordinado por Carlos Bibiano Guillén. Ha sido presentado el 22 de octubre en el Hospital Universitario Infanta Leonor, donde Bibiano es Jefe del Servicio de Urgencias."
Tamaño:14 Mb

Critical Care Reviews Book 2018

CCR Logo Promoting OA 080715 opt
"The Critical Care Reviews Book summarises, critiques and puts in context the biggest trials of the year. Five intensivists from Belfast, Northern Ireland, spend a year writing this in their own time. This is available as a free pdf download or at minimum cost for the print version. Critical Care Reviews is a not-for-profit organisation."