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

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martes, 20 de octubre de 2020

Unstable AF & Ablation Complications

emDOCs Podcast – Episode 14 - October 20, 2020 - By Long B & singh M
"Today on the emDocs cast with Brit Long and Manpreet Singh we cover two posts: unstable atrial fibrillation patient and cardiac ablation complications.
  • Key Points from the Podcast and Post (Part 1: Unstable Atrial Fibrillation)
    • Don’t prematurely assume that the hypotension in your patient with a-fib is due to the arrhythmia. Do a thorough evaluation for other causes of shock before lowering the rate.
    • When cardioverting your unstable patient with a-fib, do it right the first time; start out at 200J and consider adding external pressure to the anterior pad.
    • Use push dose vasopressors or a drip to stabilize the BP before trying to control the rate.
    • Consider Amiodarone or Esmolol as the drug of choice for rate control in the crashing patient with a-fib.
  • Key Points from the Podcast and Post (Part 2: Cardiac Ablation Complications)
    • The overall complication rate for cardiac ablation is 6.29%.
    • Atrio-esophageal fistula has up to a 100% mortality without surgery. If considered, emergently consult cardiothoracic surgery.
    • EGD may cause fatal massive air embolism in the setting of atrio-esophageal fistula. Avoid even in the case of gross hematemesis.
    • Delayed cardiac tamponade may occur even up to several weeks out from the ablation.
    • Stroke due to thromboembolic event.
    • Atypical migraine is a rare post ablation complication and should be considered a diagnosis of exclusion."

lunes, 19 de octubre de 2020

Cerebral Venous Thrombosis

First10EM - By Justin Morgenstern - October 19, 2020
"In the Rapid Review series, I briefly review the key points of a clinical review paper (or two). The topic this time: Cerebral venous thrombosis (CVT)
The papers: 
  • Behrouzi R, Punter M. Diagnosis and management of cerebral venous thrombosis. Clin Med (Lond). 2018;18(1):75-79. doi:10.7861/clinmedicine.18-1-75 PMID: 29436443
  • Long B, Koyfman A, Runyon MS. Cerebral Venous Thrombosis: A Challenging Neurologic Diagnosis. Emerg Med Clin North Am. 2017;35(4):869-878. doi:10.1016/j.emc.2017.07.004 PMID: 28987433"


Puncture Wounds

emDocs - October 19, 2020 - By Kaur G, Katirji L 
Reviewed by: Sheng A; Koyfman A; Long B
"Pearls:
  1. Despite their benign initial appearance, puncture wounds should be taken seriously due to risk of infection and potential sequela such as osteomyelitis and deep soft tissue infections.
  2. Consideration of retained foreign bodies and thorough examination and imaging (ultrasound and/or plain films) are the keys to decreasing complications.
  3. Staphylococcus and Streptococcal species are the most common causes of infection. Pseudomonas is an important consideration in plantar puncture wounds and the most common cause of osteomyelitis.
  4. The majority of puncture wounds without retained foreign bodies will have a benign course. Prophylactic antibiotics, high-pressure irrigation, and debridement are unnecessary in most cases. Educate patients re: signs and symptoms to return for."

sábado, 17 de octubre de 2020

Solidarity trial for Covid-19 treatments

WHO - Posted on 16 October 2020
"Solidarity is an international clinical trial to help find an effective treatment for COVID-19, launched by the World Health Organization and partners. It is one of the largest international randomized trials for COVID-19 treatments, enrolling almost 12 000 patients in 500 hospital sites in over 30 countries...
The Solidarity Trial published interim results on 15 October 2020. It found that all 4 treatments evaluated (remdesivir, hydroxychloroquine, lopinavir/ritonavir and interferon) had little or no effect on overall mortality, initiation of ventilation and duration of hospital stay in hospitalized patients.
The Solidarity Trial is considering evaluating other treatments, to continue the search for effective COVID-19 therapeutics.
So far, only corticosteroids have been proven effective against severe and critical COVID-19.

CONCLUSIONS 
These Remdesivir, Hydroxychloroquine, Lopinavir and Interferon regimens appeared to have little or no effect on hospitalized COVID-19, as indicated by overall mortality, initiation of ventilation and duration of hospital stay. The mortality findings contain most of the randomized evidence on Remdesivir and Interferon, and are consistent with meta-analyses of mortality in all major trials. (Funding: WHO. Registration: ISRCTN83971151, NCT04315948)

Dexmedetomidine (Precedex)

EMCrit RACC
EMCrit 283 - October 16, 2020 - By Scott Weingart
"So this episode addresses a big gap in the EMCrit content, namely a discussion of the myriad uses of dexmedetomine. This is one of the primary agents I use for post-intubation sedation (PAD), but also for things like NIPPV sedation and procedural sedation..."

jueves, 15 de octubre de 2020

Resuscitative Thoracotomy

REBEL CRIT - October 15, 2020 - By Zaf Qasim
"Background: A resuscitative thoracotomy is a time-critical high acuity, low occurrence (HALO) procedure – as an emergency physician you need to know how to do it, but depending on your practice environment, it may be a once-in-a-career maneuver. All the more reason that, if you have to do it, you want to make sure your effort counts...
Paper: Newberry R et al. Prospective randomized trial of standard left anterolateral thoracotomy versus modified bilateral clamshell thoracotomy performed by emergency physicians. Annals of Emergency Medicine 2020. PMID: 32807537
Clinical Question: What is the optimal technique for the nonsurgical specialist to perform a resuscitative thoracotomy?
Author Conclusion: “Resuscitative thoracotomy success rates were lower than expected in this capable subject population. Success rates and procedural time for the MCT and LAT were similar. However, the MCT had a higher success rate when performed by staff emergency physicians, resulted in less periprocedural iatrogenic injuries, and was the preferred technique by most subjects. The MCT is a potentially feasible alternative resuscitative thoracotomy technique that requires further investigation.”
Clinical Take Home Point: When faced with a time-critical injury amenable to resuscitative thoracotomy, the emergency physician has precious little opportunity to make a difference in outcome. Therefore, they should adopt the technique that will most likely allow success. This paper shows that for this HALO procedure, the MCT allows timely access to the chest, provides the best exposure to attempt to fix the problem, and decreases the risk of iatrogenic injury. It should be strongly considered by the emergency physician having to perform this while working within the right system to support this procedure."

miércoles, 14 de octubre de 2020

Orbital Compartment Syndrome

REBEL Core Cast 42.0 - By Anand Swaminathan - October 14, 2020
"Take Home Points
  • Trauma resulting in a retrobulbar hemorrhage can lead to orbital compartment syndrome which is a vision threatening injury
  • Diagnosis is made clinically based on the presence of an afferent pupillary defect, vision loss and an intraocular pressure > 40 mm Hg
  • Treatment is with a lateral canthotomy – a simple but mentally daunting procedure"
Resources:

martes, 13 de octubre de 2020

VTE and COVID-19

ST.EMLYN´S
St. Emlyn´s - By Dan Horner - October 12, 2020
That’s a leading question. Of course you would...
And what should we be doing?
I think that’s still tricky. But we are in a better position than last time and I think we can use this new evidence to agree on some issues
  • First, it is clear (and has been for some time) that all patients admitted to hospital who are unwell with COVID-19 should undergo risk assessment for VTE and should receive pharmacological thromboprophylaxis if safe. If community hubs and ‘hospital at home’ services continue to expand, this assessment may need to be extended outside the front door. 
  • Second, in those patients who are prescribed thromboprophylaxis, weight-based dosing algorithms should be strongly considered. There appears to be no clinical evidence of superiority for intermediate dosing strategies over a standard, licensed weight-based approach. I would extend this logic to patients admitted to intensive care. 
  • Third, we should ensure these patients are managed in line with the emerging evidence base outside of anticoagulation. Immunomodulatory agents clearly have face validity in this cohort. Before we weigh up the merits of unproven dose escalations of anticoagulants that we know will cause predictable harm, we must ensure that hypoxaemic patients have received dexamethasone. In the future this will also apply to any other therapies that have been studied and proven effective within the context of large, well conducted randomised controlled trials. 
  • Fourth we must continue to offer research opportunity. All our patients have the right to participate in ongoing studies and potentially benefit from novel therapies..."

Screening per la TVP nel Covid-19

EMPills - Ottobre 12, 2020 - By Paolo Balzaretti
"Una delle caratteristiche più peculiari del COVID-19 è risultata fin da subito l’elevata incidenza di complicanze tromboemboliche e il relativo impatto sulla prognosi del paziente. Secondo alcune casistiche autoptiche, la tromboembolia polmonare è la causa del 10-30% dei decessi dei pazienti con polmonite COVD-19 correlata (Wichmann 2020, Edler 2020).
Questi dati portano a pensare che possa essere importante definire strategie di prevenzione della malattia tromboembolica venosa da associare alla profilassi eparinica, adottata universalmente. In particolare, uno screening per la presenza di trombosi venosa profonda (TVP) con ecografia compressiva potrebbe essere giustificato?
Conclusioni.
  • Nei pazienti ricoverati con Covid-19, la prevalenza di TVP asintomatica è verosimilmente più elevata che nei pazienti ricoverati con altre diagnosi.
  • Le TVP sono più frequentemente distali; per questo motivo, in caso si voglia adottare una strategia di screening basata sull’ecografia compressiva a 2 punti, è opportuno mettere in conto di effettuare controlli seriati a distanza di alcuni giorni, quanto meno nei pazienti a maggior rischio di complicanze.
  • A mia conoscenza, non esistono attualmente studi che confermino che uno screening della TVP asintomatica nel paziente con Covid-19 possa ridurre la mortalità."

Mammalian Bites

emDocs - October 12, 2020 - By Rizzo E and Zummer J
Reviewed by: Koyfman A; Long B; Santistevan J
"Pearls and Pitfalls
  • Clenched fist injuries (“fight bites”) are high risk injuries that require antibiotics and hand surgery consultation.
  • Augmentin is the oral antibiotic of choice for both prophylaxis and treatment of infected mammalian bites.
  • In the United States, bats are the most common cause of rabies while in other countries dogs cause most cases. Patients at risk, including children and intoxicated or mentally disabled adults found in the same room as a bat, should get both rabies immunoglobulin and vaccination.
  • HIV transmission from bites is very rare however if a patient has a significant wound to their hand after a bite from an HIV positive patient, especially one with a lot of bleeding in the mouth, PEP should be discussed."

Diverticulitis and antibiotics

First10EM - By Justin Morgensten - October 12, 2020
"We have discussed evidence that antibiotics may not help diverticulitis multiple times on this blog (for example here and here). After another negative RCT, it is time to tackle the difficult question of how much evidence we need to overturn long standing medical practices.
The paper
The STAND trial: Jaung R, Nisbet S, Gosselink MP, Di Re A, Keane C, Lin A, Milne T, Su’a B, Rajaratnam S, Ctercteko G, Hsee L, Rowbotham D, Hill A, Bissett I. Antibiotics Do Not Reduce Length of Hospital Stay for Uncomplicated Diverticulitis in a Pragmatic Double-Blind Randomized Trial. Clin Gastroenterol Hepatol. 2020 Mar 30:S1542-3565(20)30426-2. doi: 10.1016/j.cgh.2020.03.049. PMID: 32240832
The Results
Out of 459 patients screened for eligibility, 180 were randomized in the trial. 
There was no statistical difference in the primary outcome of hospital length of stay. Median length of stay was 40 hours in the antibiotic group (95% CI 24-58) and 46 hours in the placebo group (95% CI 27-60).
There also weren’t any differences in the secondary outcomes. 2 patients needed procedural interventions in the antibiotic group, as compared to 0 in the placebo group. 1 patient in the antibiotic group died as compared to 0 in the placebo group. Readmission within 1 week occurred in 6% of the antibiotic group as compared to 1% of the placebo group. Overall adverse events were exactly equal."

domingo, 11 de octubre de 2020

Hyperosmolar agents for ICP and Cerebral Edema

EMCrit RACC
 NeuroEMCrit - October 11, 2020 - By Neha Dangayach
...“So, let’s get started. You’ve probably taken care of a patient with suspected raised intracranial pressure (ICP) and cerebral edema recently. Cerebral edema-simply speaking is an abnormal increase in the fluid content of brain parenchyma. Cerebral edema could be cytotoxic, vasogenic or interstitial or a combination of these different types of edema. You might have suspected raised ICP and cerebral edema either because of their clinical presentation, radiographic imaging or by invasive measurement of their ICP via an External ventricular drain (EVD) or fiber optic parenchymal probe or via a non-invasive surrogate measure of ICP such as Optic nerve sheath diameter (ONSD). In various stepwise protocols described in literature for treating raised ICP, hyperosmolar therapies have been included as first line treatments to prevent herniation and death.
In this blog post, let’s review hyperosmolar therapies for management of raised ICP and cerebral edema, key mechanisms of action for mannitol and hypertonic saline (HTS) and what do some recent guidelines say about using hyperosmolar therapies...“

viernes, 9 de octubre de 2020

Antibiotics or Surgery for appendicitis

St. Emlyn´s - By Simon Carley - October 9, 2020
..."There is certainly evidence around that we can treat a proportion of patients with antibiotics, that seems to be well established, but there is also a significant rate of recurrence and so there are still some doubts amongst clinicians as to whether it is a sensible strategy...



STEMI/NSTEMI to OMI/NOMI

R.E.B.E.L.EM - By Leen Alblaihed - October 08, 2020
Paper: Aslanger EK et al.Diagnostic Accuracy of Electrocardiogram for Acute Coronary Occlusion Resulting in Myocardial Infarction (DIFOCCULT Study). Int J Cardiol Heart Vasc 2020. PMID: 32775606
"Clinical Question: Does shifting from a STEMI/NSTEMI paradigm to a new approach (ACO-MI/ non-ACO-MI) result in better identification of the patients who need acute reperfusion therapy?
Author Conclusion: “We believe that it is time for a new paradigm shift from the STEMI/non-STEMI to the ACOMI/non-ACOMI in the acute management of MI.”
Clinical Take Home Points:
  • The title of this study was appropriate (The DIFOCCULT Trial) as the there were lots of stats that were difficult to read through
  • We agree with the author’s conclusion that a new paradigm shift should be used when considering taking patients with ischemic myocardium to the cath lab, or when considering reperfusion therapy
  • The current STEMI / non-STEMI approach is highly insensitive and has a weak evidence base. It implies that only certain ECG criteria (ST elevations) should be intervened on immediately, missing ⅓ of ACOs that would benefit from such therapy.
  • The ACOMI/ non-ACOMI approach was found to improve long term mortality and has higher sensitivity, PPV and NPV when compared to the standard STEMI/ non-STEMI approach
  • Various ECG findings (not just STE) showed correlation with ACO and should be used clinically to change the course of management for our patients from observation and troponin trending to the deserved intervention and emergent reperfusion"

miércoles, 7 de octubre de 2020

Subungual Hematomas

CanadiEM - By Levi Johnston - October 6, 2020
  1. What is the medical name for this injury?
  2. What are the clinically relevant features of nail anatomy?
  3. What other injuries are important to rule out that are commonly associated with this injury?
  4. Does this patient need an X-ray of the affected digit?
  5. Some subungual hematomas will require a procedure called nail trephination. What is nail trephination? Describe the indications, contraindications, potential complications, and procedure.​
  6. Does the fingernail need to be removed to rule-out a nail bed laceration?
  7. If the patient has an associated distal phalanx fracture, what is the management?
  8. What would your discharge instructions be?

lunes, 5 de octubre de 2020

Be a better Resuscitationist

iMEDconference12 - By Simon Carley - October 4, 2020
"...This blog supports my presentation on ‘Making Resus Better’, a title that evolved from Cutting Edge evidence in resuscitation. I’ve changed the title after discovering that this is all being covered by other speakers. What do you do when that happens? You ask the best in the business for help. I reached out to Scott Weingart, Chris Hicks, Cliff Reid, Ken Milne, Youri Yourdanov and the St Emlyn’s team with the simple question….

If you could change one thing in resus to make resuscitation better what would it be?

Stop for a second and ponder that question for yourself. What would you do to improve resus outcomes for your patients. I suspect that your first thought would be around what evidence or devices have come out recently that we all need to introduce to save lives. Are you ECMO or ECNO? What about REBOA and TEG testing in the resus room? Have you introduced or changed your management of catecholamines in cardiac arrest patients?..."

Disposition in Heart Failure

emDocs - October 05, 2020 - By Rider I ; Benson S
Reviewed by Lew E; Koyfman A; Long B
"Question: Which heart failure patients need to be admitted, and which patients can be discharged home?
Conclusion: Acute heart failure is a presentation commonly seen in the ED that carries high morbidity and mortality. The emergency physician’s role involves rapid identification, management and disposition of these patients based on clinical presentation, response to therapy and risk of adverse events. Several risk stratification tools can be used to risk stratify patients. A wide majority of AHF patients require admission and all require close follow-up with cardiology and primary care.
Pearls:
  • High risk features in AHF are hypotension, elevated BNP, troponin, Cr, and hyponatremia.
  • Patients who require continuous infusions, NIPPV, or are initially treatment-resistant generally require ICU admission.
  • New onset HF patients should be admitted for a broader workup.
  • Patients with OHFRS less than 1 can be discharged.
  • Patients with OHFRS above 1 or 2 require admission (at the EP’s discretion regarding which score to use based on comorbidities and follow-up).
  • Patients with OHFRS of 1 due to O2 saturation <90% on arrival to ED should be admitted.
  • EHFMRG is an externally validated tool to predict a % risk in 7-day mortality for AHF patients.
  • Low-risk MEESSI patients carry a <2% mortality and may be appropriate to discharge home from the ED.
  • Some patients in AHF will be in the MEESSI higher risk categories with a significant increase in 30-day mortality compared to the low-risk groups.
  • Observation units are appropriate for hemodynamically stable patients with good response to therapy who are in very low-risk categories and are reliable to follow-up."

Delayed antibiotics

First10EM - By Justin Morgenstern -  October 5, 2020
"Either a patient needs antibiotics or they don’t. If a patient needs antibiotics, a delayed prescription is harmful. If a patient doesn’t need antibiotics, a delayed prescription is harmful. Thus, delayed antibiotics are dumb.
That paragraph could have stood alone as my shortest (and perhaps best) blog post ever. However, the practice of providing patients with a prescription for delayed antibiotics has become so popular, I should probably expand on my thinking a little more. Like anything in medicine, there is likely some grey area to explore..."

domingo, 4 de octubre de 2020

Magnesium AF

The PharmERToxGuy - By Bryan D. Hayes - September 24, 2020
Today’s pearl is a continuation of Pearl 42: Medication Pearls for Atrial Fibrillation Management in the ED and reviews the role of magnesium for the treatment of atrial fibrillation.

Does magnesium reduce HR? How much and how fast to administer?

"Key teaching point: Magnesium sulfate for rapid AF needs to be administered over 10-20 minutes (rather than 1-2 hours) to achieve an effect.
Bottom Line: Magnesium seems to be safe and moderately effective for reducing heart rate in rapid AF. Even in the studies where magnesium was less effective than an active comparator, it still demonstrated some reduction in HR. Therefore, it seems reasonable to consider administering magnesium 2-4 gm IV as an adjunctive therapy while you are choosing between a calcium channel blocker or beta blocker as the primary rate-control agent. In some cases, you may find magnesium is enough to achieve lenient HR goals (ie, < 110 bpm). Monitor HR and BP appropriately.

Ticagrelor + ASA in AIS/TIA

SGEM#303 - By admin - October 03, 2020 
Reference: Claiborne Johnston S et al. Ticagrelor and Aspirin or Aspirin Alone in Acute Ischemic Stroke or TIA. NEJM July 2020

"CLINICAL QUESTION: IS THE COMBINATION OF TICAGRELOR AND ASPIRIN SUPERIOR TO ASPIRIN ALONE IN REDUCING THE RISK OF SUBSEQUENT STROKE OR DEATH AMONG PATIENTS WITH ACUTE NON-CARDIOEMBOLIC CEREBRAL ISCHEMIA?

LESS STROKES AND MORE BLEEDS IN THE COMBINATION GROUP WITH NO STATISTICAL DIFFERENCE BETWEEN THE TWO GROUPS FOR A GOOD NEUROLOGIC OUTCOME.

SGEM BOTTOM LINE: TICAGRELOR IN COMBINATION WITH ASPIRIN CANNOT BE ROUTINELY RECOMMENDED AT THIS TIME. THE DECREASE IN SUBSEQUENT STROKES COMES AT A COST OF INCREASED SERIOUS BLEEDING AND NO INCREASE IN A GOOD NEUROLOGIC OUTCOME. A RISK ASSESSMENT AND SHARED DECISION MAKING IS ENCOURAGED."

viernes, 2 de octubre de 2020

ROTEM in Trauma

 
EMOttawa - By Richard Hoang - September 24, 2020
In this post, we’ll discuss viscoelastic hemostatic assays (VHAs), namely ROTEM (Rotational Thromboelastometry), and how we can use this tool to enhance the care of traumatically injured patients. This is the first in a two-part series. This part reviews the Evidence for VHAs in Trauma, while Part 2, reviews the practical aspects of using ROTEM in trauma.

EMOttawa - By Richard Hoang - September 24, 2020
In Part 2 of ROTEM for Trauma: Blood is Thicker with Wine – we will review the approach to interpreting ROTEM and how it can guide massive transfusion in the injured and bleeding patient. We will also touch on the practical considerations for starting a ROTEM program at your centre.

Capsaicin & Cannabinoid Hyperemesis Syndrome

R.E.B.E.L.EM - October 01, 2020 - By Mark Ramzy

Paper: Dean D, et al. A Pilot Trial of Topical Capsaicin Cream for Treatment of Cannabinoid Hyperemesis Syndrome. Academic Emergency Medicine. 2020. PMID: 32569429
"Clinical Question:
What is the safety and efficacy of topical capsaicin cream for vomiting from suspected cannabinoid hyperemesis syndrome in the emergency department?
Author’s Conclusions:
In this pilot trial, the application of topical capsaicin cream was associated with a significant reduction in nausea at 60 minutes but not at 30 minutes and provided more complete relief of nausea.
Clinical Bottom Line:
Widespread availability, low cost, low adverse effect profile and ability to reduce nausea at 60 minutes are all factors that favor the use of capsaicin cream in the treatment of patients with CHS. Although not statistically significant, there were trends toward higher proportion of patients with complete nausea relief, overall rates of vomiting and need for rescue medications again favoring the capsaicin arm. Due to this study being underpowered, major conclusions cannot be drawn however this pilot trial provides direction for planning larger scale, adequately powered, clinical trials on this topic."

jueves, 1 de octubre de 2020

TXA vía IM

 
St. Emlyn´s - By Simon Carley - October 1, 2020
"This week the British Journal of Anaesthesia published a paper on the use of IM TXA, and whilst this is an early and relatively small trial it’s worthy of a look as it may be the beginning of a change in trauma care...
The headline data is that all the patients showed effective absorbtion of TXA through the IM route. The authors state that the time to reach therapeutic concentrations (5 or 10 mg L1) after a single intramuscular TXA 1 g injection are 4 or 11 min, with the time above these concentrations being 10 or 5.6 h, respectively..."

lunes, 28 de septiembre de 2020

TXA in TBI

First 10EM - September 28, 2020 - By justin Morgenstern
The paper
Rowell SE, Meier EN, McKnight B, et al. Effect of Out-of-Hospital Tranexamic Acid vs Placebo on 6-Month Functional Neurologic Outcomes in Patients With Moderate or Severe Traumatic Brain Injury. JAMA. 2020 Sep 8;324(10):961-974. doi: 10.1001/jama.2020.8958. PMID: 32897344. ClinicalTrials.gov Identifier: NCT01990768

...There was no difference in the primary outcome of favourable neurologic outcome on the GOSE score. 58% of the bolus/infusion group, 62% of the bolus only group, and 60% of the placebo group had a favourable outcome...

Bottom line
This is a large, double-blind RCT that demonstrated no benefit from giving TXA in the prehospital setting for traumatic brain injury. The trial is not definitive, but I believe the results.

BRASH syndrome

Internet Book of Critical Care (IBCC) - September 26, 2020 - By Josh Farkas



"BRASH syndrome is defined as a combination of the following:
  • Bradycardia
  • Renal failure (either acute or acute-on-chronic)
  • AV node blocker
    • Usually due to a beta blocker, verapamil, or diltiazem.
    • A recent case report suggested that ranolazine may act similarly)(31975993)
  • Shock
  • Hyperkalemia

Emphysematous Pyelonephritis

emDocs - September 28, 2020 - By Rusnack F 
Reviewed by: Chavez S; Koyfman A; Long B

"Key Points:
  • Suspect EPN in patients with risk factors (DM, immunocompromised, female sex) who present with fever/dysuria/abdominal pain or who do not respond to usual pyelonephritis treatment.
  • CT imaging of the abdomen and pelvis with contrast is the imaging modality of choice to identify gas. KUB or US may be used to aid in early recognition.
  • EPN has a high mortality rate. Start resuscitation measures early including empiric antibiotic therapy such as third-generation cephalosporins with aminoglycosides, fourth-generation cephalosporins, carbapenems, combination beta-lactamase inhibitors, or fluoroquinolones depending on patient risk factors (note: take into account local antibiogram).
  • Consult urology emergently to determine the need for further procedural interventions such as PCD or if severe/nonfunctioning, emergent nephrectomy."

sábado, 26 de septiembre de 2020

Antiacid monotherapy in epigastric pain

SGEM#302 - B admin - September 26, 2020 
Reference: Warren et al. Antacid monotherapy is more effective in relieving epigastric pain than in combination with lidocaine. A randomized double-blind clinical trial. AEM Sept 2020

"CLINICAL QUESTION: IS ANTACID MONOTHERAPY MORE EFFECTIVE IN RELIEVING EPIGASTRIC PAIN THAN IN COMBINATION WITH LIDOCAINE?

ALL THREE TREATMENTS (VISCOUS, SOLUTION OR ANTACID MONOTHERAPY) WORKED AND THERE WAS NO STATISTICAL DIFFERENCE BETWEEN GROUPS.

SGEM BOTTOM LINE: CONSIDER USING ANTACID MONOTHERAPY IN PLACE OF LIDOCAINE/ANTACID COMBINATION THERAPY FOR PATIENTS WITH DYSPEPSIA."

Marine Animal Bites and Stings

EM@3AM (emDocs) - September 26, 2020 
By Taliaferro D - Reviewed by: Santos C; Koyfman A; Long B
"Background: Human contact with species of venomous marine life are relatively common especially in tropical and coastal regions of the world. Common organisms include spiny fish, cone snails, jelly fish, sea snakes, octopi and stingrays. There is an estimated 10 million envenomations worldwide, most being caused by jellyfish. Most of these animals do not inhabit US waters. It is important to know what the common organisms are based on region to determine if an envenomation can be potentially fatal. While most of these envenomations are relatively mild, there are fatal organisms that are most commonly in Australian and Pacific waters."

miércoles, 23 de septiembre de 2020

Electrocution

Taming The SRU
Taming The SRU - September 22, 2020 - By Ijaz Hamza

"CONCLUSION 
The evaluation and management of patients who have suffered electrocution is challenging, as presentations range from asymptomatic to refractory cardiac arrest. Important historical features include type of current (AC or DC), voltage, and duration of exposure. Electrocuted patients are especially susceptible to cardiac arrhythmias, neurologic injury, rhabdomyolysis, and compartment syndrome. Even in the well-appearing patient, a thorough evaluation and high index of suspicion for injury is paramount, as electrocuted patients often have atypical injury patterns."

martes, 22 de septiembre de 2020

Hemophagocytic LymphoHistiocytosis

PulmCrit(EMCrit)
IBCC chapter & cast - September 21, 2020 - By Josh Farkas
"Intensivists have long been struggling with the enigma of hemophagocytic lymphohistiocytosis (HLH). For example, this post from 2016 explores the challenge of dissecting HLH away from septic shock. The COVID pandemic has drawn some attention to the topic, although it's not clear to what extent COVID might truly reflect HLH. This chapter attempts to lay out the fundamental groundwork of HLH. Please note that the treatments for adult secondary HLH are not based on any strong evidence, so considerable controversy surrounds the entire topic..."
  • The IBCC chapter is located 👉 here.

Usual Care +/- Oseltamivir

R.E.B.E.L.EM - By Salim Rezaie - September 21, 2020
Paper: Butler CC et al. Oseltamivir Plus Usual Care Versus Usual Care for Influenza-Like Illness in Primary Care: An Open-Label, Pragmatic Randomised Controlled Trial. Lancet 2020. PMID: 31839279
"Clinical Question: Does adding antiviral treatment to usual primary care for patients with influenza-like illness reduce the time to recovery?
Author Conclusion: “Primary care patients with influenza-like illness treated with oseltamivir recovered one day sooner on average than those managed by usual care alone. Older, sicker patients with comorbidities and longer previous symptom duration recovered 2 – 3 days sooner.”
Clinical Take Home Point: This study should not change practice. In a non-blinded study with a subjective outcome, we would expect patients who are getting the “fancy pill” to feel better faster. Additionally…
  • Oseltamivir works on neuraminidase. This enzyme is not found on other viruses, and there is no biological mechanism for it to have an effect in these patients
  • Objective outcomes of hospitalization and x-ray confirmed pneumonia showed no benefit with oseltamivir
  • There is an increase in nausea/vomiting in the patients taking oseltamivir"

Subarachnoid Hemorrhage

First10 EM - By Justin Morgenstern - September 21, 2020
"Summary
A plain CT head misses very few cases of subarachnoid hemorrhage, even if that CT was done more than 6 hours after symptom onset. The miss rate of a CT done within 6 hours is close to 2 in 1,000. Even if the CT was done after 6 hours, post-test probability is less than 1%. Considering the harms of lumbar puncture, it is clear that the test should not be performed routinely if subarachnoid hemorrhage is the only concern. Of course, there is a much broader differential for a patient with a severe headache, so lumbar puncture will remain a part of the work-up for many patients, based on physician judgement, and hopefully involving patients as part of shared decision making"

miércoles, 16 de septiembre de 2020

Airway in Penetrating Neck Trauma

CanadiEM - September 15, 2020 - By Will Wu

..."Lady Sansa Stark and Lord Petyr Baelish’s relationship goes back to the beginning of King Joffrey Baratheon’s rule in King’s Landing (his death was covered previously – link). It was there where he told Sansa “Look around you. We’re all liars here – and every one of us is better than you”. Unfortunately for him, his lies led him to suffer a brutal execution in Winterfell with Lady Arya slitting his throat with a dagger. Penetrating neck trauma account for 5-10% of all trauma cases and is the leading cause of death under the age of 46 in the USA.​1​ Complex vascular, nervous, and respiratory/GI anatomy in the neck underly the challenges of managing these patients. In this article, we will give a brief overview of clinical considerations in these patients, while delving deeper into airway management..."

Ovarian Torsion

Taming The SRU
Annals of B Pod - September 15, 2020 - Urbanowicz O

"SUMMARY
Ovarian torsion remains a highly morbid disease process that is difficult to diagnose. Emergency physicians need to have a high clinical suspicion of ovarian torsion in women of reproductive age. Appropriate use of imaging will lead to an expedited diagnosis and subsequently decrease the risk of infectious and fertility complications."

lunes, 14 de septiembre de 2020

Gastrointestinal hypomotility

PulmCrit (EMCrit)
IBCC chapter & cast – September 14, 2020 - By Josh Farkas

"Critical illness leads to a variety of gastrointestinal motility problems (largely due to the constellation of immobility, medications, and metabolic abnormalities). Although these topics don't generally attract much interest, maintaining adequate bowel motility is essential to avoid iatrogenic harm."

  • The chapter on gastroparesis is located 👉 here.

  • The chapter on ileus is located 👉 here.

  • The chapter on colonic pseudo-obstruction is located 👉 here.