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SOBRE EL AUTOR **

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

WORLD EMERGENCY MEDICINE SOCIETIES

SALAD Demonstration w the SSCOR DuCanto Catheter

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Contenido:

domingo, 15 de octubre de 2017

CT Angiography for Chest Pain

Medscape Logo
Medscape - By Patrice Wendling - October 11, 2017
"HERSHEY, PA — A new meta-analysis shows that use of coronary computed tomography angiography (CTA) is associated with significantly fewer MIs than standard functional stress testing in patients with suspected CAD and acute or stable chest pain.
CTA, however, is also associated with significantly more downstream invasive coronary procedures, CAD diagnoses, and aspirin and statin prescriptions—all without an overall reduction in mortality or cardiac hospitalizations.
"If you look at the strength and robustness of the individual findings, what my coauthors and I can say with high certainty is that cardiac CT compared with functional testing will lead to a significant increase in downstream procedures, whether that's just catheterization or whether it's also revascularization, and we believe that a lot, if not all, of that excess is unnecessary," corresponding author Dr Andrew J Foy (Penn State College of Medicine, Hershey, PA), told theheart.org | Medscape Cardiology.
The study, with senior author Dr Rita Redberg (University of California, San Francisco), was published October 3, 2017 in JAMA Internal Medicine."

Traumatic Hemothorax

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emDocs - October 13, 2017 - By Anand Swaminathan 
Originally published at CoreEM.net, dedicated to bringing Emergency Providers all things core content Emergency Medicine available to anyone, anywhere, anytime. Reposted with permission.

"Take Home Points

  • Always look for concomitant extra-thoracic trauma in patients with hemothorax
  • Hemothoracies should be emergently drained by performing a tube thoracostomy
  • Tube thoracostomies should be placed in the 4th or 5th intercostal space over the rib with care to ensure entry into the thorax and not the abdomen
  • If initial drainage is > 1000-1500 mL or their is continued brisk output (> 300-500 mL in the first hour or > 200 mL every hour for the next 3 hours) consult trauma surgery for emergent OR management"

SVT AND DOACs

St. Emlyn´s - October 13, 2017 - By Dan Horner
"Been a while since we have had any clotology on here. That is unacceptable. So here we go with another journal club fest on the management of acute VTE.
Now we have improved access to whole leg compression ultrasound, some reliable safety data around the use of this technology and a specialist society for vascular sonographers it is not surprising that we are picking up more and more small clots in an ED setting. Here in both east and west Virchester, we can add to this number an increased rate of confirmed superficial vein thrombosis (SVT), or thrombophlebitis by its old name. Not a bad thing really, when you consider that unprovoked thrombophlebitis can herald fairly nasty thromboembolic disease, or sometimes even malignancy. These clots often extend far more proximal than their symptomatic margin, and sonographic confirmation and characterisation can be useful to guide treatment decisions.
There is evidence (from the STENOX 1 and CALISTO 2 trials) to suggest that treatment of these clots can lead to a reasonable reduction in serious event rates. An alumnus of virchester has also recently looked at the management of superficial vein thrombosis for her FRCEM clinical topic review. Pretty convincing data to treat these patients with prophylactic dose anticoagulation really. This evidence is supported by BMJ best practice and ACCP guidelines, that offer risk stratification criteria so you can perhaps select out those likely to result in higher risk and concentrate on advising those patients carefully regarding treatment options. However, the current evidence base is for fondaparinux treatment and 6 weeks of injections can be a real (and literal) pain. If patients are reluctant to self inject, then it also can come at considerable cost and nursing resource. One wonders if there is another way…."

RCEM 50th. birthday

St. Emlyn´s - October 12, 2017
"The Royal College of Emergency Medicine (RCEM) is celebrating a landmark in is history: its 50th birthday. To mark this event, RCEM has been doing a number of things...
Simon, Laura and I were also asked to write pieces to mark the occasion. I was asked to write some reflections on the progress of EM research. With RCEM’s permission, I’m now publishing that for free below. My contribution is one of 50 special chapters, each written by a different author. There are some real gems in there! You can buy a copy at this link..."

jueves, 12 de octubre de 2017

GI Bleed

Emergency Medicine Cases Sticky Logo
"Join Anand Swaminathan, Salim Rezaie and Jeannie Callum to discuss the management of some of our most challenging GI bleed emergencies. In this Part 1 of our two part podcast on GI bleed emergencies we answer questions such as: How do you distinguish between an upper vs lower GI bleed when it’s not so obvious clinically? What alterations to airway management are necessary for the GI bleed patient? What do we need to know about the value of fecal occult blood in determining whether or not a patient has a GI bleed? Which patients require red cell transfusions? Massive transfusion? Why is it important to get a fibrinogen level in the sick GI bleed patient? What are the goals of resuscitation in a massive GI bleed? What’s the evidence for using an NG tube for diagnosis and management of upper GI bleeds? In which patients should we give tranexamic acid and which patients should we avoid it in? How are the indications for massive transfusion in GI bleed different to the trauma patient? What are your options if the bleeding can’t be stopped on endoscopy? and many more…"

Donación de órganos

Resultado de imagen de semesResultado de imagen de organizacion nacional trasplantes
Documento elaborado por el Grupo Colaborativo ONT-SEMES encuadrado en el Convenio de colaboración entre la Organización Nacional de Trasplantes y la Sociedad Española de Medicina de Urgencias. 
"Los profesionales de urgencias desempeñan un papel relevante en el proceso de donación de órganos y son uno de los pilares fundamentales en la identificación y derivación de posibles donantes a las unidades de cuidados intensivos. La cooperación ONT-SEMES a nivel institucional, y entre los coordinadores de trasplantes y los profesionales de urgencias y emergencias, constituye una de las líneas estratégicas de mejora de la donación de órganos en España al considerarlo un proceso multidisciplinar donde intervienen los servicios de emergencias (SE), urgencias hospitalarios (SHU), de neurología y de cuidados intensivos (UCI). En los últimos años se ha consolidado la integración de la donación en los cuidados al final de la vida como una opción que debe plantearse siempre que sea razonable y factible. Esto ha condicionado un cambio en la secuencia de actuación al plantearse la posibilidad de ingreso para donación en aquellos pacientes que, debido al mal pronóstico vital por la lesión inicial, no son tributarios de tratamiento médico/quirúrgico pero podrían evolucionar a muerte encefálica (ME) y, en consecuencia, ser donantes de órganos si se inician medidas de soporte vital adecuadas. Todo lo anteriormente expuesto hace que sea fundamental elaborar e implementar unas recomendaciones que integren procedimientos basados en la actuación multidisciplinar, toma de decisiones compartida y en la comunicación veraz con los familiares acerca del diagnóstico y pronóstico del paciente y su ingreso en unidad de cuidados intensivos con el propósito de la donación."

Wegener in the ED

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emDocs - October 11, 2017 - Authors: Hadley N and Powell J
Edited by: Koyfman A and Long B
Background
Granulomatosis with Polyangiitis (GPA, formerly Wegener’s granulomatosis) is a rare vasculitis affecting both arterial and venous small vessels. Incidence is estimated at 12 cases per 1 million individuals per year. GPA, along with microscopic polyangiitis and Churg-Strauss syndrome, is a vasculitis associated with antineutrophil cytoplasmic antibodies. GPA, as the name indicates, is characterized by granulomatous formation of lesions in the upper and lower respiratory tract along with glomerular nephritis. Onset of disease is usually gradual over the course of 4-12 months. The disease affects men and women equally, has a Caucasian predominance, and almost never affects African American males. It most commonly occurs in the 4th and 5th decade, but the disease may occur at any age with 15% of patients diagnosed <19 years of age. Prior to development of effective treatment, GPA was universally fatal from a couple months to a year after diagnosis. GPA is also associated with a 7% annual risk for venous thromboembolism...
Summary
  • Granulomatosis with polyangiitis is classically a triad of:
    • Upper respiratory symptoms
    • Lower respiratory symptoms
    • Renal involvement
  • Complaints are commonly non-specific so look for refractory upper and lower respiratory symptoms with or without renal involvement
  • Most common in 4th and 5th decade but can occur at any age
  • Respiratory collapse can occur quickly
  • GPA associated with 7% annual risk for VTE
  • Previous GPA frequently have relapses

lunes, 9 de octubre de 2017

Steroids for respiratory Infection

Resultado de imagen de jama
 Hay AD et al. JAMA. 2017 Aug 22;318(8):721-730. doi: 10.1001/jama.2017.10572.
"IMPORTANCE:
Acute lower respiratory tract infection is common and often treated inappropriately in primary care with antibiotics. Corticosteroids are increasingly used but without sufficient evidence.
OBJECTIVE:
To assess the effects of oral corticosteroids for acute lower respiratory tract infection in adults without asthma...
CONCLUSIONS AND RELEVANCE:
Oral corticosteroids should not be used for acute lower respiratory tract infection symptoms in adults without asthma because they do not reduce symptom duration or severity."

Aortic Dissection

Emergency Medicine Updates - October 5th, 2017 - By reuben

"KEY POINTS
  • Aortic dissection is an uncommon disease that often presents with varied and atypical findings suggestive of more frequently encountered conditions; therefore, it poses an exceptional diagnostic challenge to emergency providers.
  • Mortality associated with aortic dissection is significant at presentation and advances with every hour the lesion is left untreated.
  • Although almost all patients who have symptoms possibly caused by aortic dissection will not have aortic dissection, key features of the disease, including risk factors, pain characteristics, physical examination findings, and routine ancillary studies, allow clinicians to develop a rational approach to diagnostic testing.
  • When the diagnosis is sufficiently likely to indicate definitive testing, computed tomography angiography is the advanced imaging test of choice in most centers, but transesophageal echocardiography and MRI may be appropriate alternatives in certain circumstances.
  • Patients with diagnosed or strongly suspected aortic dissection require expeditious surgical evaluation, aggressive analgesia and anxiolysis, and treatment with rapid-acting, titratable agents to first lower heart rate, and then blood pressure, to specific targets."

WMD

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emDocs - October 3, 2017 - Authors: Roe B, Whitworth K and Long J
Edited by: Singh M and Koyfman A
"Key Points
  • Weapons of Mass Destruction include: Chemical, Biologic, Radiologic, Nuclear, and Explosive (CBRNE).
  • Recognizing patterns of symptoms or groups of patients with similar symptoms will help you identify when a WMD has been used.
  • Early identification is key in limiting the spread of exposure when dealing with WMD.
  • Decontamination is priority in order to limit further exposure and protect you and your hospital staff.
  • Periodically take time to review signs, symptoms, and treatments so you will be prepared to take care of patients affected by WMD."

ICP with ocular sonography

EMCrit
PulmCrit - October 9, 2017 - By Josh Farkas
"Summary: The Bullet
  • Although papilledema is traditionally considered a finding on opthalmoscopy, it can also be easily observed with point-of-care ultrasonography.
  • Sonographic papilledema appears to have good performance for detection of ICP elevation.
  • Papilledema can be observed with the same ultrasound views that are used to measure optic nerve sheath diameter, so looking for papilledema requires no additional work.
  • Ultrasonographic papilledema may be combined with measurement of the optic nerve sheath diameter to evaluate for elevated intracranial pressure."

lunes, 2 de octubre de 2017

Hemorragia masiva

AnestesiaR -
AnestesiaR - By Amparo Belltall Olmos - October 2, 2017
"La hemorragia masiva, continúa teniendo una elevada morbimortalidad en los pacientes sometidos a procedimientos quirúrgicos y obstétricos. El análisis de las reclamaciones interpuestas por este motivo puede ayudarnos a esclarecer los principales factores de riesgo y patrones de comportamiento relacionados con la severidad del daño..."

Procalcitonin

Taming The SRU
Taming The SRU - October 2, 2017 - By Bennet Lane
"Procalcitonin was reviewed on Taming the SRU in the context of other biomarkers (ESR, CRP) last year with a grand rounds discussion of its utility in the setting of a febrile 7 week old. As procalcitonin has continued to gain traction in the world of pediatric EM – receiving evaluation as part of proposed protocols for management of febrile infants (1) and for its utility as an aid to diagnosis of Serious Bacterial Infection (2,3) – we turned our attention this year to procalcitonin’s use in adults. Procalcitonin testing has been studied and available for decades (as St. Emlyn’s noted in an update earlier this year), but has not really established itself in widespread use in adults (as EMDocs noted in a sepsis update in 2014). In this blog post, we take the approach of going back to what is known (and is NOT known) about the biochemical basics of this molecule to give context to the sometimes confusing smorgasbord of proposed applications for procalcitonin testing that exists in the literature..."

YEARS Study (PE)

R.E.B.E.L.EM - September 28, 2017
"Background: The clinical diagnosis of pulmonary embolism (PE) can be challenging given its variable presentation, requiring dependence on objective testing. Decision instruments such as PERC and the Wells’ score help stratify patients to low or high probability, enabling focused use of CT pulmonary angiography (CTPA) for diagnosis. However, despite these algorithms, there is evidence of increasing use of CTPA along with diminishing diagnostic rate (less than 10%). This combination results in the overdiagnosis of subsegmental PEs, unnecessary exposure to radiation, false positive results and the potential for contrast-induced nephropathy. The YEARS study aims to present a simplified algorithm for evaluation with a two-tiered D-dimer threshold to reduce the numbers of CTPA in all age groups..."

miércoles, 27 de septiembre de 2017

Multiple Sclerosis

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emDocs - September 20, 2017 - Authors: William G & Riehle C
 Edited by: Koyfman A and Long B
"Take Home Points
  • History and presentation are perhaps the most important and may provide you with enough evidence of disease progression “through time and space” to reach a diagnosis.
  • MRI will be needed at some point to look for asymptomatic lesions and establish a baseline for future monitoring.
  • LPs can be used if an MRI is unavailable or unequivocal, but sensitivity is often low in CIS, and specificity is only high when you can rule out other causes of an elevated Ig Index.
  • Treatment consists of high dose steroids +/- β Interferon if you have reason to believe this is a CIS."

Contrast Nephropathy (CIN)

R.E.B.E.L.EM - September 25, 2017
"Background: One of the most common imaging modalities used in the emergency department (ED) today is computed tomography (CT) scans using intravenous radiocontrast agents. Use of IV contrast can help increase visualization of pathology as compared to non-contrast CTs. However, many patients do not get IV contrast due to fear of contrast induced nephropathy. Furthermore, waiting for renal function values delays the care of patients and prolongs time spent in the ED with a potential to increase adverse effects on patient centered outcomes due to delays...
Author Conclusion: “We found no significant differences in our principal study outcomes between patients receiving contrast-enhanced CT versus those receiving noncontrast CT. Given similar frequencies of acute kidney injury in patients receiving noncontrast CT, other patient- and illness-level factors, rather than the use of contrast material, likely contribute to the development of acute kidney injury.”
Clinical Take Home Point: While a prospective, multi center RCT would put this question to rest, it’s unlikely to be feasible to perform. Based on the best available evidence, use of IV low- and iso-osmolar contrast media does not appear to be associated with increased risk of AKI, need for renal replacement therapy, or mortality."

Hemostasia en el hepatópata

AnestesiaR -
AnestesiaR - By Patricia Duque González - 27 Septiembre 2017

"En el paciente hepatópata se produce un equilibrio inestable, que se ha denominado hemostasia “rebalanceada” a nivel de la hemostasia primaria, secundaria y de la fibrinólisis. Su traducción clínica es que el paciente hepatópata está más expuesto tanto a episodios de sangrado agudo como de trombosis..."

miércoles, 20 de septiembre de 2017

Psychosis Mimics

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emDocs - September 18, 2017 - Authors: Cisewski D and Cassella C
Edited by: Koyfman A and Long B
"Summary
In the absence of a previous history or psychiatric condition, a nonorganic cause of acute symptoms is a diagnosis of exclusion. In addition, one must never assume factitious disorder or malingering until other conditions are ruled out. When psychosis is prematurely assumed to be related to psychiatric condition versus organic cause, delay in failure to treat can be deadly. Hence, the importance of a proper review. Look for signs of organic causes, and be sure to gather a proper history. Most importantly, beware of your cognitive bias during certain patient presentations, and ensure you’re covering all possibilities before making a final diagnosis."

lunes, 18 de septiembre de 2017

Hyperlactatemia

Taming The SRU
Taming The SRU - September 17, 2017
"Since the turn of the century, lactate has become a mainstay in emergency medicine and critical care laboratories. Some clinicians may hate it, others may love it, but very few can feign apathy on the subject. The utility of lactate in the emergency department and the ICU in guiding resuscitations, predicting mortality, or identifying occult critical illness continues to be discussed in the literature, most fervently in the realm of sepsis. But what are the humble beginnings of this molecule? Most fundamentally, how is lactate generated in the setting of critical illness? And how did it come to be so firmly embedded in our understanding of the pathophysiology of critically ill patients?"

Table 1 - Classification of lactic acidosis, adapted from Cohen and Woods [7], with examples.

Cardiac Standstill

R.E.B.E.L.EM - September 18, 2017
"Clinical Question: How much variability exists in the interpretation of cardiac standstill on POCUS amongst physicians? (
Article: Hu K et al. Variability in Interpretation of Cardiac Standstill Among Physician Sonographers. Ann Emerg Med 2017. PMID: 28870394)
Authors Conclusions: “According to the results of our study, there appears to be considerable variability in interpretation of cardiac standstill among physician sonographers. Consensus definitions of cardiac activity and standstill would improve the quality of cardiac arrest ultrasonographic research and standardize the use of this technology at the bedside.”
Our Conclusions: We agree with the authors that this study, though limited by it’s methodology and convenience sample, demonstrates significant disagreement between providers as to the interpretation of cardiac standstill on POCUS.
Potential to Impact Current Practice: This study cannot be used to impact clinical practice but should cause some pause for thought for providers who are currently using POCUS in cardiac arrest as part of their protocol for termination based on cardiac standstill.
Bottom Line: The use of POCUS to declare death and stop resuscitation is predicated on a clear ability to establish the presence of cardiac standstill. The low level of agreement of providers likely reflects the absence of a single definition of standstill as well as calls for increased training and assessment. A unified definition of standstill would be extremely helpful not only in future research but in cardiac arrest care as well."


domingo, 17 de septiembre de 2017

NRB-Flush

R.E.B.E.L.EM - Setember 14, 2017
"Author Conclusion: “Preoxygenation with NRB-Flush was noninferior to BVM-15. NRB with flush rate oxygen may be a reasonable preoxygenation method for spontaneously breathing patients undergoing emergency airway management.”
Clinical Take Home Point: Although the results of this study need to be confirmed in a critically ill patient population, it appears that flush rate oxygen via a NRB mask is non-inferior to BVM mask at 15L/min."

How to Fix the ER

The Wall Street Journal

The Wallstreet Journal - By Ellie Kincaid - September 12, 2017
"ERs are notorious for long waits, endless forms and inconsistent care. Now researchers and hospitals are rethinking the ways they work—with impressive results.
Long wait times in the emergency room have bad effects for patient outcomes and satisfaction.
Hospitals are making a push to fix one of the most irritating issues in health care: the emergency room.
Armed with new research and strategies borrowed from the business world, some facilities are trying to ease the frustrating experience of waiting, filling out forms, explaining a problem—and then waiting some more..."

TB in the ED

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emDocs - September 6, 2017 - Authors: Belle T and Wise - Editors: Koyfman A and Long B
"Key points 
  • TB remains a devastating and fairly ubiquitous disease throughout several parts of the world despite recent downward trends in incidence. 
  • It can present in a variety of ways so a high index of suspicion is needed when evaluating patients with signs and symptoms suggestive of possible infection. 
  • Patients co-infected with HIV or otherwise immunosuppressed tend to present more atypically. 
  • Effective management relies on prompt recognition 
  • Diagnosis relies on a combination of adequate history and clinical, radiographical and microbiological data. 
  • Treatment should be started only after consultation with Infectious Disease specialists at your institution. 
  • Strict adherence to isolation precautions is paramount in preventing the spread of infection in the ED." 



60/60 for PE

The Bottom Line - September 15, 2017 - By David Slessor
"Clinical Question
In patients with suspected acute pulmonary embolism, do echo features of disturbed right ventricular ejection allow accurate diagnosis?...
The Bottom Line
  • In patients seen at a tertiary referral centre with a high pre-test probability of acute pulmonary embolism, the McConnell Sign had a very high positive likelihood ratio. In patients without previous cardiorespiratory disease the 60/60 sign also demonstrated a very high positive likelihood ratio. A negative McConnell or 60/60 sign added little diagnostic information
  • In patients presenting to the ED/ICU with a high probability of acute pulmonary embolism who cannot immediately undergo CT, I will use bedside echo to assess the 60/60 and McConnell’s signs. A positive test result will give me greater confidence for the diagnosis of acute pulmonary embolism, where as a negative result will neither help confirm or repute the diagnosis of acute pulmonary embolism"

lunes, 11 de septiembre de 2017

Dysrhytmias after Syncope

R.E.B.E.L.EM - September 11, 2017 - By Swaminathan A
"Authors Conclusions:
“The Canadian Syncope Arrhythmia Risk Score can improve patient safety by identification of those at-risk for arrhythmias and aid in acute management decisions. Once validated, the score can identify low-risk patients who will require no further investigations.”
Our Conclusions:
This prospectively derived decision instrument may be helpful in stratifying syncope patients to high or low risk for dysrhythmia but requires external validation prior to consideration for implementation.
Potential to Impact Current Practice:
Because dysrhythmia is a common reason for admission to hospital and further workup of patients presenting with syncope, this decision tool has the potential to be used to support a decision of discharge and follow up and avoid low yield inpatient evaluations if externally validated.
Clinical Bottom Line:
The prospective derivation of this decision instrument is a positive step towards risk stratification of syncope patients for subsequent dysrhythmias. It is critical to remember that there are numerous other causes of syncope (ectopic pregnancy, PE, ACS, aortic dissection, GI bleeding etc) that should be considered in patients as well. Additionally, because the population in this study was relatively young and healthy, evaluation of a higher risk cohort would be useful in future studies."

Future of Troponin

St.Emlyn's - By Rick Body - September 8, 2017
"As I’m writing this, I’m travelling back from an excellent conference in London. The BioRemarkable Symposium was sponsored by a company called Singulex. The team at Singulex had decided to hold the event to showcase some of the recent research involving its troponin assay and to bring together some opinion leaders from around the world to discuss the future of troponin testing. I was privileged to be involved and to present the breaking findings of our latest research using the Singulex troponin assay. But the data aren’t published yet – so I won’t discuss that here. Instead, I’d like to pass on details of some of the really exciting discussions we had at the conference. The future of troponin testing could be pretty amazing..."

Angiotension II for Septic Shock

PulmCCM
Angiotensin II, a new vasopressor for septic shock, coming soon (probably)
PulmCCM - September 8, 2017

"La Jolla Pharmaceutical Company, makers of LJPC-501 (no trade name yet), announced the FDA has begun reviewing their fast-track application for approval of angiotensin II. The proposed indications are septic shock and other vasodilatory shock despite provision of fluids and other vasopressors."

Sepsis with Comorbidities

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emDocs - September 4, 2017 - Author: Fox W - Edited by: Koyfman A and Long B
"Conclusion
The understanding and adoption of fluid resuscitation in patients with sepsis has improved outcomes and the level of care so much so that provider compensation may now be tied to meeting certain metrics guiding resuscitation. Though providers may find solace in the relative simplification of sepsis treatment regimens, adopting therapies as a panacea without critical thought and applicability will inevitably doom complicated or outlier patients to substandard or dangerous care. The goal of this review is to understand the implications of chronic physiologic abnormalities that can confound providers and limit the effectiveness of the “standard of care”. An understanding of these nuances of end-organ disease can give providers a general framework to approach the care of complicated sepsis cases in an intelligent, methodical, and patient-centered manner.
Take Home Points
  • Despite comorbidities, sepsis is the primary threat to the life of the patient and must be treated
  • SBP should not be overlooked in cirrhotic, and valuable culture data can be gleaned from inoculating culture bottles immediately after sample collection
  • Early vasopressor usage in pulmonary hypertension and avoidance of positive pressure ventilation can preserve compromised right ventricular function
  • Congestive heart failure patients, conversely, may benefit from positive pressure ventilation used judiciously during resuscitation"

jueves, 31 de agosto de 2017

Alcohol Intoxication Mimics

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emDocs - August 30, 2017 - Authors: Bennett J and Fairbrother H
Edited by: Koyfman A and Long B
"Take Home Points
  • Keep a broad differential in mind for any patient with AMS, even if the patient smells like alcohol and intoxication seems likely
  • Check a POC blood glucose level on arrival
  • Undress patients suspected of alcohol intoxication and fully examine
  • Re-assess every 1-2 hours. If your patient doesn’t improve as expected, reexamine and broaden the differential
  • Don’t ignore abnormal vitals
  • Get a head CT if you see or suspect head trauma in the intoxicated patient
  • Consider checking an alcohol level if you’re unsure. If negative, investigate further. However, remember that a positive EtOH level does not preclude other problems also being present and should not be falsely reassuring."

PE Treatment with Rivaroxaban

R.E.B.E.L.EM - August 31, 2017
"Clinical Question:
What is the safety and efficacy of rivaroxaban in patients with a range of sPESI scores in comparison to standard treatment with enoxaparin/VKA?...
Authors’ Conclusions:
“The findings support using risk stratification with the simplified PESI score to identify low risk patients with PE.”
Our Conclusions:
In this post hoc analysis, a higher sPESI correlated with a higher rate of adverse events, thereby corroborating previous validation studies. Furthermore, when stratified by sPESI, the safety and efficacy outcomes for patients treated with rivaroxaban versus standard therapy were similar.
Potential impact to Current Practice:
DOACs are a simple, effective, safe, and cost-effective treatment for acute PE. The sPESI is a validated tool for identifying low-risk acute PEs for possible outpatient treatment. However, is it possible to combine these two concepts? Can low-risk PE patients be safely treated by initiating a DOAC in the ED and then discharging the patient to outpatient follow-up? This study provides further support towards the momentum that is already headed in that direction..."

miércoles, 30 de agosto de 2017

MM Emergencies

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emDocs - August 29, 2017 - Authors: Xiao J and Todd B
Edited by: Koyfman A and Long B
"Takeaway points
  • Multiple myeloma is difficult to diagnose. Elderly patients with unremitting back pain or pathologic fractures of the axial skeletonshould be considered for multiple myeloma evaluation. Emergency department X-rays may clinch the diagnosis with punched out lytic bone lesions.
  • Cord compression is the most important emergency diagnosis. The absence of neurologic symptoms does not preclude cord compression.
  • The two most common causes of death in multiple myeloma patients are frequent infections, usually respiratory, and renal failure. Their disease process and medications make them immunocompromised.
  • Renal failure in multiple myeloma patients is multifactorial and has a poor prognosis. Treat acute kidney injury aggressively and contact oncology early.
  • Electrolyte abnormalities should be treated by managing the underlying disease process. Multiple myeloma patients are especially prone to hypercalcemia due to osteoclastic bone activity. Treat with generous fluid hydration, and consider loop diuretics (controversial), calcitonin, bisphosphonates in conjunction with their oncologist.
  • Multiple myeloma medications may cause venous thromboembolism and neuropathy."