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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

Gastric ultrasound for preoperative assessment

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lunes, 21 de mayo de 2018

ACEP 2018: Acute VTE

R.E.B.E.L.EM - May 21, 2018
ACEP Clinical Policies Subcommittee. Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department with Suspected Acute Venous Thromboembolic Disease. 
Ann Emerg Med 2018; 71(5): e59-109. PMID: 29681319
..."Take Home Points
  1. The PERC risk stratifies low risk PE patients (~10%) to a level low enough (1.9%) as to obviate the need for additional testing.
  2. Age-adjusted D-dimers are ready for use and it doesn’t matter if your assay uses FEU (cutoff 500) or DDU (cutoff 250). For FEU use an upper limit of 10 X age and for DDU use an upper limit of 5 X age.
  3. For now, subsegmental PEs should continue to routinely be anticoagulated even in the absence of a DVT. Keep an eye out for more research on this area.
  4. Although outpatient management of select PE patients (using sPESI or Hestia criteria) may be standard practice, the evidence wasn’t strong enough for ACEP to give it’s support
  5. Patients with DVT can be started on a NOAC and discharged from the ED"

sábado, 19 de mayo de 2018

Lokelma


Resultado de imagen de european medicines agency

"This is a summary of the European public assessment report (EPAR) for Lokelma. It explains how the Agency assessed the medicine to recommend its authorisation in the EU and its conditions of use. It is not intended to provide practical advice on how to use Lokelma.
For practical information about using Lokelma, patients should read the package leafletor contact their doctor or pharmacist.
Lokelma is a medicine used to treat hyperkalaemia (high levels of potassium in the blood) in adults. It contains the active substance sodium zirconium cyclosilicate..."

miércoles, 16 de mayo de 2018

The Abdominal XRay

TAMING THE SRU - April 16, 2018 - By Skrobut T
"The KUB is easy to obtain and commonly used in the Emergency Department despite the advent and ease of higher specificity radiological studies. As these studies are still readily used and in some settings may be the only imaging available, our goals for this post will be to discuss indications for abdominal radiography in the emergency department as well as give examples of normal anatomy, an approach to interpretation, and underlying pathology that can be discovered, including associated sensitivities and specificities. We will not discuss utilization of contrast. Furthermore, we will briefly touch on different abdominal views that can be obtained and their utility but will focus primarily on the KUB since it is the most utilized image obtained in the emergency department..."

lunes, 14 de mayo de 2018

Wernicke Encephalopathy

R.E.B.E.L. EM - Emergency Medicine Blog
R.E.B.E.L.EM - 14 May, 2018 - By Anand Swaminathan
"Definition: Encephalopathy that occurs secondary to thiamine (vitamin B1) deficiency. While Wernicke encephalopathy is reversible with treatment, it can progress to the irreversible Korsakoff’s syndrome if left untreated...
Take Home Points
  • Wernicke encephalopathy is characterized by ataxia, altered mental status and ophthalmoplegia but patients are unlikely to have all these components
  • Suspect Wernicke encephalopathy in any patient that is at risk of malnutrition or malabsorption and has any one of the classic symptoms
  • Prophylactic administration of thiamine 100 mg IV/IM to at risk patients can prevent development of the disease
  • Once Wernicke encephalopathy has developed, it must be treated with high-dose, IV thiamine"

domingo, 13 de mayo de 2018

Abscess Management


R.E.B.E.L.EM - May 12, 2018
..."Take Home Points:
  • There is room for a safe increase in antibiotic use
  • There does not need to be reckless over-use of antibiotics
  • Use ultrasound with any abscess you are unsure of
  • Use a loop vessel rather than packing"

Excited Delirium Syndrome

The Skeptics Guide to Emergency Medicine
SGEM#218 - May 12th
"Clinical Question: What is the definition, epidemiology, pathophysiology and evidence-based management and treatment of excited delirium?
SGEM Bottom Line: The excited delirium syndrome remains a poorly defined disease and is difficult to study because of its inconsistent definition. However, it is a dangerous, high morbidity and mortality condition that requires aggressive management in the emergency department..."

Oxygen in the Acutely Unwell Patient

St Emlyn´s - By Simon Carley - May 13, 2018
"...Does this make sense?
Oxygen is good for you of course. Anyone who has tried to do without it will be fully aware of the challenges of hypoxia, but what’s the problem with 02 excess? This study cannot answer that question, but the discussion explores the pathophysiological argument for why an excess of 02 may be a problem for the critically unwell. In essence we know that 02 levels are a powerful driver in physiology and pathology and we also know that were never designed or evolved to have supra-normal levels as they don’t occur in nature. Vasoconstriction, inflammation and oxiditive stress have all been demonstrated in physiological models and constitute plausible mechanisms for harm. However, the discussion is more nuanced than this and I would recommend you read the full article to understand specific sub groups (e.g. surgical patients where super-oxia may be beneficial).
So what does this mean for my practice?
In Virchester it means that we will carry on as we have done recently. Superoxia is to be avoided. In a small group of patients we will tolerate superoxia (for example in the initial resus phase whilst preparing for advanced airway management, but for the vast majority of our patients an Sa02 of >94% is just fine thanks."

lunes, 7 de mayo de 2018

EM 2018 Match

Resultado de imagen de aliem emergency medicine
ALiEM - May 7th, 2018 - By: Michael Gisondi
"The National Residency Matching Program® (NRMP) recently published its annual Results and Data for the 2018 Main Residency Match®. How competitive was emergency medicine? Spoiler alert: not much changed! But to understand the full picture, we need to dive into the numbers, which look a lot different from last year. Below is a summary of the most pertinent results for emergency medicine, trended from 2011-2018. You will notice some striking differences in the data between the 2017 Match and the 2018 Match."

Chest Trauma

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emDocs - May 7, 2018 - Authors: Ramzy M and R
Edited by: Koyfman A and Long B
"...This post will focus on both threatening and non-threatening pulmonary conditions that may arise from blunt trauma to the chest. Furthermore, it will provide pearls and pitfalls for each condition that will enhance your ability to evaluate a patient with blunt injury to the chest..."

Drowned Airway

PulmCrit (EMCrit)
PulmCrit - May 7, 2018 - By Josh Farkas

"Summary: The Bullet
  • The drowned airway is a rare and uniquely perilous situation were copious regurgitation prevents either intubation or mask ventilation. These patients are at very high risk of aspiration, ARDS, anoxic brain damage, or cardiac arrest.
  • Massive regurgitation may be prevented in some cases by using gastric ultrasonography to detect large volumes of gastric fluid. NG tube drainage before intubation may mitigate risk.
  • Front-line techniques for management of the drowned airway are large-bore catheter suctioning, Seldinger intubation using a large-bore suction catheter, or esophageal diversion with an endotracheal tube.
  • There should be a low threshold to perform surgical cricothyrotomy if other techniques fail or if the patient begins desaturating. Cricothyrotomy is highly effective, but in order to work it must be initiated early (before the patient develops massive aspiration or anoxic brain injury).
  • An airway algorithm is proposed for management of the drowned airway."

Intoxicated Patients

R.E.B.E.L.EM - May 7, 2018 
"Background: Visits to the ED for alcohol intoxication can create quite the clinical conundrum both for acute medical and traumatic reasons. Acutely intoxicated patients, just like young kids, don’t always have the ability to communicate due to sedation, agitation, or some other critical medical/traumatic process that is ongoing. This makes getting a complete history or depending on the physical exam unreliable at best..."

sábado, 5 de mayo de 2018

Obesity Emergency Management

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emDocs - May 4, 2018 - By Anton Helman
Originally published at EM Cases – Visit to listen to accompanying podcast
"Current estimates of the prevalence of obesity are that a quarter of adult Canadians and one third of Americans are considered obese with approximately 3% being morbidly obese. With the proportion of patients with a BMI>30 growing every year, you’re likely to manage at least one obese patient on every ED shift. Obese patients are at high risk of developing a host of medical complications including diabetes, hypertension, coronary artery disease, peripheral vascular disease, biliary disease, sleep apnea, cardiomyopathy, pulmonary embolism and depression, and are less likely compared to non-obese adults to receive timely care in the ED.
Not only are these patients at higher risk for morbidity and mortality, but obesity emergency management is complicated by the patient’s altered cardiopulmonary physiology and drug metabolism. This can make their acute management much more challenging and dangerous. To help us gain a deeper understanding of the challenges of managing obese patients and elucidate a number of important differences as well as practical approaches to obesity emergency management, we welcome Dr. Andrew Sloas, the founder and creator of the fantastic pediatric EM podcast PEM ED, Dr. Richard Levitan, a world-famous airway management educator and innovator and Dr. David Barbic a prominent Canadian researcher in obesity in emergency medicine from University of British Columbia…."

Top 10 Trauma Papers 2017-2018

St Emlyn’s - By Simon Carley - April 18, 2018 
"This week I am at the Trauma Care UK conference. If you’ve not been to this one then you should, it’s friendly, great value and aims to influence and engage with all aspects of trauma care from injury prevention right through to rehab. You can go for just the day if you want to focus on your area of interest or spread out and hear what the other parts of the trauma pathway are up to.
I’m delivering a short talk on the top 10 trauma papers over the last year or so which is always a pleasure to do. It gives me an excuse to go back over the literature and to ask myself if there is anything that we should be adopting in Virchester based on the latest evidence. I did a similar talk a couple of years ago which you can see here,
My usual approach is to search through the literature for those studies that can have an impact at the bedside, for papers that are relevant to the clinician and not just the researcher and if possible for those that might challenge our current practice.
Despite trauma being responsible for an enormous disease burden in our societies I was once again struck by the paucity of clinically relevant papers in the management of major trauma out there. If I was looking for theory or lab-based articles then I would have had no problem at all, there are many papers out there looking at stuff happening in test tubes, but I am naturally wary of these. Far too many therapies look good in the lab, but that does not transfer to clinical practice and so I’ve not really included them (though if you want to see some recommendations from Rich Carden on papers worth reading then I would start with these ones1–6 ).
So, my top 10 is intended to be real world, influential and pragmatic. You will no doubt disagree and I apologise if I have not included your personal favourite (or heaven forbid failed to include the paper you authored  ). If you have better suggestions then please do add them in the comments..."

miércoles, 2 de mayo de 2018

Retire the SSC Guidelines

emupdates

First10EM

Petition to retire the surviving sepsis campaign guidelines

..."We are disseminating an international petition that will allow clinicians to express their displeasure and concern over these guidelines. If you believe that our septic patients deserve more evidence-based guidelines, please stand with us.
Sincerely, 

Scott Aberegg MD MPH
Jennifer Beck-Esmay MD
Steven Carroll DO MEd
Joshua Farkas MD
Jon-Emile Kenny MD
Alex Koyfman MD
Michelle Lin MD
Brit Long MD
Manu Malbrain MD PhD
Paul Marik MD
Ken Milne MD
Justin Morgenstern MD
Segun Olusanya MD
Salim Rezaie MD
Philippe Rola MD
Manpreet Singh MD
Rory Speigel MD
Reuben Strayer MD
Anand Swaminathan MD
Adam Thomas MD
Scott Weingart MD
Lauren Westafer DO MPH

MEDEST Top 2017 (Trauma)

"Welcome to our review of the best articles from the last year.
This will be a weekly (or so..) appointment with the top articles from 2017 divided by topic and chosen by me..."

lunes, 30 de abril de 2018

Goodpasture’s syndrome

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emDocs - April 30, 2018 - By Author: Webb J - Edited by: Koyfman A and Long B
"Key Points:
  • Anti-GBM disease is caused by circulating auto-antibodies to the basement membrane resulting in glomerulonephritis and alveolar hemorrhage.
  • Labwork frequently shows elevated BUN and creatinine; UA with hematuria, proteinuria, and RBC casts.
  • CXR may show bilateral diffuse patchy alveolar infiltrates.
  • Symptoms can progress quickly and often require intubation and dialysis.
  • Empiric treatment with high-dose glucocorticoids (IV Methylprednisolone) can be started with high clinical suspicion."

Stress Tests, PoCUS & ECG

R.E.B.E.L.EM - April 30, 2018 - Expert Peer Review Stephen W. Smith,
"I was working a busy shift in the ED, like many of us do, and the next patient I was going to see was a 57 year old male with no real medical problems complaining of chest pain. I remember thinking as I walked into the room this guy looks ashen and diaphoretic….he doesn’t look well. He is a paramedic telling me how he has been having off and on chest pain for the past several months. He just had a stress test two months ago that was “negative”. Today he was working on his pool and developed the same chest discomfort as he had been having off and on the past several months, but today, the pain would just not go away. In his mind, he thought this might be an ulcer and just needed some Pepcid to help. He got put on the monitor and an ECG was run…
Clinical Bottom Line & Things I Learned from the Case:
  1. A prior “negative” stress test, even if recently done, should not be used to determine the disposition of your patients. If you think they are having ACS, then disposition them appropriately regardless of the prior “negative” stress test.
  2. In patients having chest pain, use POCUS liberally, as this will save patients’ lives
  3. If you are having difficulty differentiating between benign early repolarization vs “subtle” anterior STEMI don’t forget about the Steve Smith equation to help differentiate between the two in the correct clinical setting"

Corticosteroids for Patients with Pneumonia

The Skeptics Guide to Emergency Medicine
SGEM#216 - April 25th, 2018 - By Jake Turnerl
Reference: Stern A et al, Corticosteroids for pneumonia (Review). 
Cochrane Database of Systematic Reviews. December 2017.
..."Clinical Question: Do steroids safely reduce morbidity and mortality in patients with community acquired pneumonia?
SGEM Bottom Line: Corticosteroids appear to improve mortality and/or morbidity in patients admitted to hospital with community acquired pneumonia..."

sábado, 28 de abril de 2018

Emergency Reflex Action Drills

EMCritRACC
EMCrit - April 24, 2018 - By Lauria M, Reid C and Weingart S
Specific ERAD Examples
  1. Response to Grade III or IV Cormack-Lehane View During Intubation – George Kovacs (@kovacsgj) developed an excellent ERAD in response to Grade III/IV view on direct laryngoscopy in three steps: 1) lift the occiput beyond sniffing position and align axes, 2) use external laryngeal manipulation to optimize view, 3) Use Two Hand lifting if unable to manage with one hand. Or as Scott teaches this ERAD, HEAD-NECK-HANDS
  2. Response to Sudden and Profound Hypotension – Scott uses this immediate action in response to a patient whose hemodynamics suddenly deteriorate and is peri-arrest: 1) grab an amp of cardiac epinephrine (100 mcg/cc) from the code cart 2) push 0.5 cc to maintain hemodynamics while you determine the cause for acute decompensation and develop a plan for definitive fix. CART-EPI-HALF
  3. Response to Hypoxia in the Awake Patient – Rich Levitan (@airwaycam) teaches the OOPS mnemonic to address hypoxia: 1) OXYGEN ON via nasal cannula, 2) PULL the jaw forward/jaw thrust 3) SIT patient up.
  4. Response to Cardiovascular Collapse in Patient on ECMO – The @EDECMO team suggest the following as immediate response to blood spraying around the room with a patient on ECMO: 1) clamp the arterial cannula 2) clamp the venous cannula 3) Prepare Epinephrine & Change Vent Settings. CLAMP-CLAMP-RESUSCITATE
  5. Response to Profound Deterioration on a Ventilator – Scott teaches this 3 part ERAD to overcome vent manipulation fixation as the patient crashes: 1) Bag with BVM (ask for a PEEP valve as soon as possible) 2) Call for Help—often fixing this problem is a 2-person job 3) Troubleshoot with DOPES. BAG-HELP-DOPES
  6. Response to Loss of Palpable Pulses in a Blunt Polytrauma Patient – The Sydney HEMS team will 1) Attempt to arrest massive haemorrhage, 2) Perform a ‘cold’ tracheal intubation, 3) Make bilateral open thoracostomy incisions, and 4) infuse packed red blood cells. STOP-TUBE-CUT-INFUSE

Stroke Workflow in 2018

R.E.B.E.L. EM - Emergency Medicine Blog
R.E.B.E.L.EM - April 22, 2018
"With the publication of the DAWN and DEFUSE-3 trials came a new era in stroke management. We have discussed the specific literature pertaining to endovascular therapy on REBEL EM before in our 2hour CME activity HERE. Along with the two new publications came the 2018 AHA/ASA guidelines for endovascular therapy in acute ischemic stroke. Anand Swaminathan and myself wanted to place a stand alone post on the workflow of stroke in 2018..."

miércoles, 25 de abril de 2018

Esophageal Perforation

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emDocs - April 23, 2018 - Authors: DeVivo A and Beck-Esmay J
Edited by: Koyfman A and Long B
"Management and disposition 
The diagnosis of esophageal perforation carries significant mortality, and thus all patients, even if nontoxic appearing upon presentation, should still be considered critically ill. These patients will require early consultation of multiple specialists and should be admitted to an ICU.
Early broad-spectrum IV antibiotics, including anaerobic coverage due to concern for gut flora extravasating into the mediastinum
  • Early IV antifungal therapy should also be considered in esophageal rupture due the commonality of candidal colonization. Patients that are immunocompromised, carry a diagnosis of HIV, or are on a proton pump inhibitor are at particularly increased risk.
  • Appropriate intervention for associated pathologies such as chest tube placement for pneumo or hemothorax.
  • Surgical consultation for primary repair, intervention of pneumothorax, hydrothorax, empyema, or significant pneumomediastinum.
  • Gastroenterology consultation, particularly if perforation was iatrogenic, for possible repair.
  • Medical or surgical intensive care consultation for definitive disposition."

Optimal Energy in Afib

R.E:B.E.L.EM - April 23, 2018 - By Salim Rezaie
Post Peer Reviewed By: Anand Swaminathan
"Clinical Take Home Point: In patients with persistent atrial fibrillation being evaluated for electrical cardioversion, using a non-escalating 200J first shock strategy, with biphasic machines has a higher success at conversion to normal sinus rhythm with no difference in duration of procedure, amount of sedation administered, or post-shock arrhythmias compared to an escalating (100J – 150J – 200J) shock strategy. Persistent atrial fibrillation is much more likely to not respond to electricity at lower doses where as in patients with new onset atrial fibrillation (<48hrs), lower doses may be feasible as these patients are more likely to be electro-sensitive."

Articles of the year (EMU 2018)

Hand out for the articles of the year lecture at EMU 2018
First10EM - By Justin Morgenstern - April 25, 2018PosApril 25, 2018
"I love evidence based medicine, but I definitely understand the criticism that EBM nerds like myself can come across as very negative. Thrombolytics don’t work. BNP isn’t helpful. Stress testing is a sham. Idarucizumab? Yeah right. I think this scientific criticism is crucial, but I understand that it isn’t always fun. So when I was asked to present my favourite articles of the year at the North York General Emergency Medicine Update, I decided to stay entirely positive. I only chose papers that were potentially practice changing, but more importantly, that could have a positive impact on clinical practice. These are the papers I chose..."

miércoles, 18 de abril de 2018

Pulmonary Hypertension and RVF

A guide to the initial emergency department management of patients with 
pulmonary hypertension and right ventricular failure
First10EM - By Justin Morgenstern - April 16, 2018
..."In the setting of pulmonary hypertension, the right ventricle is impaired both mechanically and by ischemia. Increased RV pressure leads to bowing of the septum into the left ventricle, which leads to decreased LV filling and decreased cardiac output. Right ventricular stretching will cause tricuspid regurgitation, which will also result in decreased cardiac output. Any decrease in cardiac output will result in decreased perfusion to the right ventricle. Finally, increased pulmonary pressures increase the RV wall tension and induce RV hypertrophy, which decreases perfusion to the right ventricle, ultimately worsening cardiac output further. (True experts are probably cringing at this over-simplified explanation, but I think it is enough to understand the management, which is my priority.)...."
RV spiral of death FRIST10EM.png

Octreotide and Somastostatin for UUGB

R.E.B.E.L. EM - Emergency Medicine Blog
R.E.B.E.L.EM - April 13, 2018 - Post Peer Reviewed By: Anand Swaminathan
"Recently I was asked to speak at the Texas College of Emergency Physicians (TCEP) conference April 2018. The particulars of this session were, five, 10 minute lectures on new indications for old drugs. My topic was the use of octreotide and somatostatin for undifferentiated upper gastrointestinal bleeding. This is a particular topic I have been getting more and more requests for, but didn’t really know the evidence behind why I was doing it. Does it help my patients or just another expensive medication, that takes up an IV with no clear patient oriented outcome?...
Clinical Bottom Line: Until newer studies are published showing either harm or no clinical benefit, at this time the use of octreotide in non-variceal upper gastrointestinal hemorrhage appears to benefit bleeding and need for surgery (Especially in the sickest patients: Hemodynamically unstable, requiring transfusion, large volume hematemesis). Unfortunately, we just do not have mortality data to help guide this decision nor do we know the optimal length of time to continue the infusion."

Pancreatitis

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emDocs - April 16, 2018 - Author: Waller A -  Edited by: Koyfman A and Long B
"Key Points
  • Diagnosis of pancreatitis: 2 out of 3 criteria met => upper abdominal pain (clinical), serum lipase or amylase >3x upper limit of normal (laboratory), or imaging findings of pancreatic inflammation.
  • CT is not necessary if diagnosis can be made without it and is better obtained later in the disease course if needed.
  • Patients should receive a RUQ US in the ED if it will impact management.
  • Be cautious and avoid normal saline for fluid resuscitation (Lactated Ringer’s likely best).
  • APACHE II and BISAP score are the most useful predictors of mortality in the ED, but keep the entire clinical picture in mind.
  • There is little research to support discharging patients from the ED, but it may be possible in specific circumstances."

miércoles, 11 de abril de 2018

Severely Burned

MCC Project - March 24, 2018 - By Chung K
"Today with have the distinct pleasure to welcome a mentor of mine and a true expert in the field of critical care, Kevin K Chung, MD, FCCM, FACP, Colonel, Army. After finishing a fellowship in Critical Care Medicine at Walter Reed Army Medical Center, Dr. Chung was assigned to the US Army Institute of Surgical Research (USAISR) where he has served in the capacity of Medical Director of the Burn Intensive Care Unit, Task Area Manager of Clinical Trials in Burns and Trauma, and the Director of Research for the USAISR. He is currently the Chief of Medicine at Brooke Army Medical Center. COL Chung holds academic appointments at the Uniformed Services University of the Health Sciences as Professor of Medicine and Professor of Surgery. In his career, COL Chung has authored over 180 peer reviewed papers, authored 13 book chapters, and has been an invited speaker for over 85 lectures internationally..."

Caustic Ingestion

TAMING THE SRU

Taming The SRU - April 10, 2018 - By Scalon M
..."Ingestion of detergent agents, whether intentional or accidental, can cause serious and potentially life-threatening toxicologic disease. While ingestion in the adult population often stems from psychiatric disease or self-injurious behaviors, the advent of water-soluble laundry detergent pods has led to a significant increase in the number of pediatric poisonings, due in part to their bright coloration and pleasant smell.[1] This article will discuss the various manifestations of toxic exposure, pathogenesis, and evidence-based management of detergent poisonings in both the pediatric and adult populations..."
 fIGURE 1.&nbsp; eNDOSCOPIC GRADING SYSTEM FOR CAUSTIC INJURIES.

martes, 10 de abril de 2018

Critical Care Year 2018

Keynotable Blog
Critical Care Year in Review 2018
April 8, 2018 - By Mallemat H

Here’s the handout for the AAEM Year in Review 2018

domingo, 8 de abril de 2018

EM Personality

Jordan J et al. AEM EDUCATION AND TRAINING 2018;00:00–00
"Objectives: This study aimed to understand the personality characteristics of emergency medicine (EM) residents and assess consistency and variations among residency programs...
Conclusions: Our findings suggest that the personality characteristics of EM residents differ considerably from the norm for physicians, which may have implications for medical students’ choice of specialty. Additionally, results indicated that EM residents at different programs are comparable in many areas, but moderate variation in personality characteristics exists. These results may help to inform future research incorporating personality assessment into the resident selection process and the training environment."

Aggressive Management of AF

R.E.B.E.L.EM - February 13, 2018
Article: Stiell IG et al. Outcomes for Emergency Department Patients with Recent-Onset Atrial Fibrillation and Flutter Treated in Canadian Hospitals. Ann Emerg Med 2017. PMID: 28110987
Background: Atrial fibrillation (AF) is one of the most common dysrhythmias encountered in the ED. The management of recent-onset AF and atrial flutter (AFl) in the ED continues to be debated. The discussion centers on whether patients with recent-onset AF should be rhythm controlled (e.g. converted back to sinus rhythm) or rate controlled only. This debate was showcased in a point-counterpoint in Annals of Emergency Medicine in 2011 (Stiell 2011, Decker 2011). The rhythm control supporters argue that AF/AFl is abnormal, worsens quality of life, leads to cardiac remodeling and, in may patients, requires medications for rate control and anticoagulation. The rate control group argues that cardioversion runs the risk of causing a thromboembolic event (i.e. CVA, peripheral arterial occlusion). Thus, it should not be performed until the absence of clot in the left atrium is confirmed (by TEE) or appropriate anticoagulation has occurred. It has long been taught that if the patient has been in AF/AFl for < 48 hours, the risk of developing a clot in the left atrium is negligible and cardioversion may be pursued. However, some recent literature has called this classic teaching into question (Nuotio 2014). Prospective studies looking at outcomes of recent-onset AF/AFl patients after aggressive treatment in the ED are needed to further evaluate the risks of aggressive treatment...
Clinical Bottom Line:
An aggressive approach to the management of recent-onset AF/AFl did not result in an unacceptable rate of adverse events. Adopting a rhythm control approach in these patients appears safe."

miércoles, 4 de abril de 2018

Anticoagulants and surgery

An online community of practice for Canadian EM physicians
CanadiEM - by Kerstin de Wit - April 3, 2018
"Main Messages
  • Always verify the name of the anticoagulant.
  • Always verify the date and time of the last dose of the anticoagulant.
  • Always calculate the creatinine clearance. Do not rely on the lab estimated GFR.
  • Consider the urgency and importance of the surgery.
  • Consider the risk of bleeding associated with surgery.
  • Consider the risk of clotting (venous thrombosis or stroke)."

lunes, 2 de abril de 2018

Abscess Management

R.E.B.E.L.EM - April 02, 2018 - 
Ref: Gottlieb M et al. Systemic Antibiotics for the Treatment of Skin and Soft Tissue Abscesses: A Systematic Review and Meta-Analysis. Ann Emerg Med 2018. [Epub Ahead of Print]
"Background: Skin and soft tissue abscesses are a common emergency department (ED) presentation. The approach to management has changed little in recent decades: incision and drainage (I+D) and then discharge home with follow up. However, increasing rates of methicillin-resistant staph aureus (MRSA) over the last decade have led to further consideration of adjunct therapy with oral antibiotics to improve cure rates. Two recent studies (Talan 2016, Daum 2017) have shown a modest but consistent benefit to oral antibiotics...
Potential to Impact Current Practice: The findings of this systematic review and meta-analysis show strong evidence that antibiotic therapy, in addition to I&D, leads to higher cure rates for small abscesses with overlying cellulitis. These findings should not be taken to mean that all patients with abscesses who are I&D’d in the ED will need antibiotics as the majority of abscesses (84%) will resolve with I&D alone. The increased clinical cure rate must be weighed against the potential risks associated with increase antibiotic use such as adverse medication-related events and increasing antibiotic resistance.
Bottom Line: ED providers should consider adjunctive therapy with oral antibiotics with MRSA coverage after I&D of simple, small (<5cm) abscesses with overlying cellulitis in healthy individuals to increase short-term cure rates. The presence of significant overlying cellulitis continues to warrant adjunctive therapy with antibiotics."

Urine Testing

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emDocs - April 2, 2018 - Author: Long B - / Edited by: Koyfman A
"Key Points
  • UTI is a clinical diagnosis (dysuria, frequency, etc.). Urine that is cloudy or “smelly” is not diagnostic of UTI. LE or nitrites alone without symptoms does not require treatment.
  • Patients with simple, routine UTI do not require urine cultures. Patients with complicated UTI, pyelonephritis, failed treatment, or recent antibiotic therapy should have urine cultures obtained.
  • Bacteriuria in the absence of symptoms defines asymptomatic bacteriuria, which should not be routinely treated.
  • Patients with dementia and falls or those with altered mental status and no ability to provide a history of urinary symptoms can be difficult. Negative nitrite and LE rules out UTI in ASB and in patients for whom exam is challenging.
  • Other markers of systemic inflammation should be used for diagnosis if history or exam are unreliable."

Burns

EMCritRACC
EMCrit RACC Podcast 221 – April 2, 2018 - By Scott Weingart
"Dr. Djogovic completed training in Emergency Medicine and Critical Care Medicine from 1999-2005, and is currently employed at the University of Alberta Hospital as an Emergency Physician, and as an Intensivist in the General Systems Intensive Care Unit and in the Firefighters Burn Treatment Unit..."
Part I

*
EMCrit RACC Podcast 219 - March 5, 2018 - By Scott Weingart

Part II