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





A day in the ED at the largest and busiest hospital in the world (South Africa)

How to Use a Magnet for Pacemakers + ICDs

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sábado, 24 de septiembre de 2016

Massive Hemothorax

emDocs - Septeber 23, 2016 - Author: Simon E - Edited by: Koyfman A and Long B
The emergency physician’s role in addressing a hemothorax is first to make the diagnosis utilizing CXR, US or CT. Hemothoraces should be managed with the placement of a chest tube to avoid the later complications of empyemas and fibrothorax. Massive hemothoraces warrant volume resuscitation, consultation with a trauma surgeon, and performance of a thoracotomy. Early identification and intervention is the key to limiting the morbitidy and mortality associated with hemothoraces.
Key Pearls
  • Hemothorax presentation is variable
  • Step 1: Diagnose the hemothorax with CXR vs. US definitively with CT
  • If the mechanism suggests hemothorax = rule out hemothorax despite CXR findings (CT if patient hemodynamically stable)
  • Hemothorax Treatment = Chest tube
  • Massive Hemothorax Treatment = Transfuse, consult, thoracotomy PRN
  • If the patient is persistently hypotensive despite control of pulmonary bleeding => look for other etiologies
  • Auto-transfusion of unprocessed shed hemothorax blood => additional research needed"

Proning the non-intubated patient

PulmCrit (EMCrit)
PulmCrit Wee - September 21, 2016 - By Josh Farkas
..."Which patients might be candidates for awake proning?
Proning an awake patient may be used only in carefully selected patients with intensive monitoring. This could be considered in the following situations:
(1) Isolated hypoxemic respiratory failure without substantial dyspnea (the “paradoxically well appearing” hypoxemic patient). A reasonable candidate might meet the following criteria:
  • not in multi-organ failure
  • expectation that patient has a fairly reversible lung injury and may avoid intubation
  • no hypercapnia or substantial dyspnea
  • normal mental status, able to communicate distress
  • no anticipation of difficult airway
(2) Patients who do not wish to be intubated (DNI). The main risk of awake proning is that it could cause excessive delays in intubation. In the DNI patient who is failing other modes of ventilation, there is little to be lost by trialing awake proning (1).
(3) This could be attempted as a stop-gap measure for a hypoxemic patient when intubation isn’t immediately available (e.g. desaturation during transportation). Many awake patients are capable of proning themselves, so this could be achievable without any resources.

  • Prone positioning has been shown to improve oxygenation and survival among intubated patients with ARDS.
  • Scaravilli et al. 2015 proves that proning awake patients will similarly improve their oxygenation, although this improvement is only temporary.
  • Proning awake patients may occasionally be a useful technique to recruit the lung bases, improve oxygenation, and promote secretion clearance.
  • Among patients with hypoxemic respiratory failure, it remains unclear which patients could be treated with noninvasive techniques (e.g. high-flow nasal cannula and awake proning) versus which patients should be intubated. If noninvasive techniques are attempted, this should be done with intensive monitoring and the ability to intubate promptly if necessary.

viernes, 23 de septiembre de 2016


"The European Resuscitation Council and The European Board of Anaesthesiology recommend a standard Cardiac Arrest call telephone number in European hospitals. The European Resuscitation Council and the European Board of Anaesthesiology recommend that all European Hospitals standardise the internal telephone number used for a cardiac arrest call* to the number 2222. It makes inherent logical sense that a standard cardiac arrest call number should be engrained in the minds of all doctors and nurses. Confusion by staff trying to summon the resuscitation team can lose precious time and put patients' lives at risk. Since 2004 this standard number has already been successfully adopted in several European countries and because of the increasing free movement of healthcare staff around Europe it will be an extremely low cost measure to increase Patient Safety"

Severe TBI,

Resultado de imagen de brain trauma foundation
September 2016
An Executive Summary of these Guidelines is available in the journal Neurosurgery. Click here to view.
A PDF of the complete Guideline including methods and the detailed evidence review can be downloaded here.

Trauma cranico minore

EM Pills - 22 Set 2016 - By Carlo D´Apuzzo
"Devo ammettere che, anche a seguito dell’opinione di un esperto quale Scott Weingart sull’argomento, da qualche tempo sono solito eseguire la TC nei pazienti con trauma cranico minore che assumono aspirina o altri antiaggreganti. Non tutti i miei colleghi però concordano con questo approccio. In particolare Gianfrancesco qualche tempo fa mi ha fatto notare che le linee guida NICE parlano chiaro:” sebbene i pazienti con sanguinamento intracranico cerebrale che assumevano aspirina abbiamo una prognosi peggiore nel caso sviluppino un’emorragia intracranica, in linea generale non hanno un maggior rischio di sanguinamento in seguito ad un trauma cranico rispetto alla popolazione generale, ergo non necessitano di essere sottoposti in modo indiscriminato alla TC ” Certo un ottimo spunto per approfondire e cercare di fare chiarezza.
Per questo ho dato uno sguardo ai principali database biomedici (Pubmed e Embase) poi ho visto che Dynamed , l’EBM point of care che la BVS mette a disposizione del personale sanitario della regione Piemonte, dedica un intero capitolo proprio al tema trauma cranico e TC: Decision rules for computed tomography in head injury in adults. Vediamo cosa dice..."

jueves, 22 de septiembre de 2016

Intraabdominal catastrophes in the pregnant Patient

emDocs - September 21, 2016 - Author: Liu L - Edited by: Cassella C and Koyfman A
"Take Home Points
  • The gravid uterus can mask the signs of peritoneal irritation (guarding, rigidity and rebound tenderness) by preventing the inflamed organ from contacting the peritoneum.
  • Due to increased white blood cells that naturally occur during pregnancy, leukocytosis is not helpful in identifying acute pathology.
  • A relative increase in blood volume can delay the development of tachycardia and hypotension in the truly ill patient.
  • Consider appendicitis in the patient complaining of typical signs and symptoms of appendicitis even if confounded by right middle and upper quadrant abdominal pain, pyuria, urinary symptoms and subtle signs of peritonitis.
  • HELLP syndrome is managed with blood pressure control, prevention of seizures, correction of coagulopathy, and delivery of the fetus.
  • Radiological investigations, including abdominal plain films, can be safely undertaken during pregnancy and should always be considered so as to avoid delays and failures in diagnosing potentially life-threatening conditions."

Cognitively Offloading During a Cardiac Arrest

Beyond ACLS
R.E.B.E.L.EM - September 22, 2016 - By Salim Rezaie
"Today I am giving a talk at the 25th National Emergency Medicine Symposium by Kaiser Permanente in Maui, HI. The focus of this talk was on how to cognitively offload our minds as we are running a resuscitation. ACLS provides us with a framework in treating adult victims of Cardiac Arrest (CA) or other cardiopulmonary emergencies. This helps get providers who don’t commonly deal with CA, to improve things, such as the quality of CPR, minimizing interruptions during CPR for pulse checks, and the timing/dosing of epinephrine. Emergency Medicine (EM) and the prehospital world are different than many environments in medicine. We get minimal information at the time of patient arrival while at the same time the disease process that is taking place has not quite defined itself. We are constantly expected to acutely manage and resuscitate anyone who comes in our doors 24-7-365, many times without crucial information. Our job therefore should be to ensure coronary and cerebral perfusion are at their highest quality, but also simultaneously putting the pieces of the puzzle together to figure out why our patient is in CA. It can be very difficult to do both and many times we sacrifice one for the other. It is therefore important to cognitively offload ourselves during the resuscitation of our patients in CA and focus our attention on why they are in CA. As a disclosure for this lecture I did state that some of the recommendations made have evidence to support them and others are more theoretical and certainly up for discussion...
Critical Take Home Points to go Beyond ACLS and Cognitively Offload During Resuscitation Efforts of Cardiac Arrest:
  • CPR: Mechanical CPR > Manual CPR
  • Access: IO Access > IV Access
  • Epinephrine: Epinephrine Drip > Epinephrine Bolus
  • PEA Workup: Ultrasound > H’s & T’s
  • Pulse Checks: EtCO2 + Bedside TTE > Manual Pulse Checks"

Coronary CTA Use

emDocs - September 20, 2016 - Authors: Long B and Koyfman A - Edited by: Santistevan J 
"This is the second of a two-part series evaluating chest pain controversies in the ED. The American Heart Association (AHA) supports noninvasive cardiac imaging for further evaluation before or within 72 hours of discharge, which may consist of stress testing, CCTA, or no further testing at all. As discussed previously, a nonischemic ECG with negative cardiac biomarkers at 0 hr and 3 hr is associated with low risk of major cardiac adverse event (MACE). This post will examine the use of CCTA in the ED. Are there benefits? What are the adverse effects? 
  • Missed ACS is a concern for patients and emergency providers. Nonischemic ECG and negative biomarker at 0 and 3 hours reduces risk of MACE to less than 1%.
  • Stress testing and CCTA are commonly used for further evaluation of these patients, but their ability to further risk stratify low risk patients further is controversial.
  • Use of CCTA has increased, with the goal to evaluate anatomical coronary artery disease.
  • CCTA is associated with decreased ED LOS. However, CCTA is also associated with further downstream testing, with no evidence of improved outcome in low risk patients.
  • Intermediate risk patients, or those with difficulty obtaining follow up, may benefit from CCTA, though further studies are required in this patient subset."

martes, 20 de septiembre de 2016

Mesenteric Ischemia

EM Didactic - September 19, 2016 - By Lakshay Chanan
"Mesenteric ischemia (MI) is a frightful pathology due to its variable presentations, time‐ sensitive nature, and high morbidity and mortality. It is quite a rare disease; and as Emergency Physicians we are likely to encounter only a few cases of it in our entire careers. As a consequence of that, it gives a hard time to even the most senior physicians to diagnose mesenteric ischemia. Ischemic bowel can progress to infarction within a matter of hours which gives us a very short window to make the diagnosis. Moreover, Emergency Physicians may be the only early healthcare providers who see these patients within such a narrow time‐frame, which makes it pivotal for us to know about this entity
Lets look at some key questions regarding Mesenteric Ischemia...
Key Points:
  • Whenever you suspect Mesenteric Ischemia, do not dilly-dally – Do a quick assessment and come up with a plan. Get senior help early enough. Involve your Surgical colleagues and Radiologists ASAP.
  • Start suspecting MI despite normal vital signs and laboratory values. Do not overly on White cell count and lactate. Remember, Nothing is 100% in Medicine!
  • X-rays and CT with oral contrast rarely provide any useful information. Use CT with IV contrast in those patients with normal renal function to pick vascular filling defects."

lunes, 19 de septiembre de 2016

Fistula complications

emDocs - September 18, 2016 - Author: Simon E - Edited by: Robertson J and Koyfman A
Nearly 400,000 individuals in the United States are maintained on HD therapy. With incident cases of ESRD reaching nearly 21,000 annually, and vascular access complications accounting for 16 to 25% of hospital admissions, understanding of the appropriate management of AV fistula complications is paramount for the emergency medicine physician..."
Key Pearls

  • Fistula complications = 16-25% of hospital admissions for HD patients
    • DASS => complication of operative creation of a HD fistula
      • Diagnosis based upon presentation and PE
        • Cool/painful limb + diminished or absent distal radial pulse, palpable only with compression of the dialysis access site => Vascular Consult
    • Hemorrhage
      • #1 = direct pressure
      • Gel foam, rhThrombin +/- DDAVP in consultation with a specialist are options
      • Consider protamine for heparin reversal if recently received dialysis
    • Infection
      • Common cause of morbidity = cover for Staph and Strep
      • Use US to differentiate perivascular cellulitis from local abscess, infected hematoma or infected thrombus.
        • Perivascular cellulitis => Vancomycin (+ gentamycin if gram negatives suspected)
        • Abscess, hematoma, thrombus => Antibiotics + vascular consult for possible OR
    • Fistula Stenosis
      • Patients present with extremity pain +/- chest wall edema
        • Order Doppler US
          • Abnormalities = consult vascular => PTCA
        • Fistula Thrombosis
          • Fistula has absent bruit or thrill = vascular consult => thrombectomy vs. thrombolysis
      • Fistula Aneurysm or Pseudoaneurysm
        • Patients present with extremity pain, compression neuropathy, or hemorrhage secondary to skin erosion.
          • Doppler US => vascular consult for abnormalities

Radiocontrast, Iodine, and Seafood Allergies

R.E.B.E.L. EM - Emergency Medicine Blog
R.E.B.E.L.EM - February 4, 2014 - By Salim Rezaie
"Computed Tomography (CT) scan using radiocontrast is one of the most common imaging modalities used in emergency departments today. Several studies and my own anecdotal experiences indicate that both physicians and patients believe that iodine allergies are linked to seafood allergies and that both are related to a disproportionate increased risk of “allergic” reactions to radiocontrast agents. To add further insult to injury, some hospitals have premedication protocols with steroids and antihistamines requiring up to 12 hours before CT scans with intravenous contrast can be performed. So what is the relationship of radiocontrast, iodine, and seafood allergies?
Relationship of Radiocontrast, Iodine, and Seafood Allergies
Take Home Points:
  • Seafood allergy confers the same risk of radiocontrast reaction as:
    • ANY allergies (not just seafood allergies)
    • Having a previous reaction to a contrast agent
    • Evidence of atopy (i.e. asthma)
  • Iodine is NOT an allergen!!!
  • Low-Osmolar Contrast Media (LOCM) has significantly reduced the number of severe reactions to radiocontrast
  • Premedication with steroids has not been shown to decrease the number of severe allergic reactions to radiocontrast

Demyelinating and Movement Disorders

AMP EM - September 16, 2016 - By Gregory Eisinger
  • Describe the pathophysiology and clinical features related to Amyotrophic lateral sclerosis (ALS). What are some of the common complications that may lead to ED presentation?
  • What is myasthenia gravis, and what are some of the typical features? How should acute crises be diagnosed and treated?
  • Describe the pathophysiology behind multiple sclerosis (MS) and how it is typically treated. What is one of the most common initial presentations of MS?
  • What are some of the common features of Parkinson’s disease (PD)? How is it typically treated?

Upper GI Bleeding

St. Emlyn´s - September 17, 2016 - By Chis Gray
"Earlier this week, Simon and Iain released a podcast on the management of acute upper gastrointestinal bleeding. Welcome to the blog post version, for all your textual needs.
Around 60,000 people are admitted into hospital every year with an upper GI bleed. With emergency department attendances in the UK totalling just over 22 million in the last year, this equates to roughly one person in every 300 seen. For those of you who work in bigger departments, on average you’ll refer one patient in every day to be investigated or treated. And this doesn’t take into account the patients you discharge.
It’s an important presentation to be aware of, and with an overall mortality of around 10% (which has remained static for 50 years despite advances in medical management), early recognition and treatment can really make a big difference 1.
NICE guidance for the management of acute upper gastrointestinal bleeding has recently been reviewed and updated 2, with only one difference in the new advice compared with that released in 2012 3. This relates to H2-antagonist and proton-pump inhibitor use for ulcer/GI bleeding prophylaxis in the critically ill. Whilst NICE recommends either can be used, they note that only ranitidine and cimetidine are licensed for this purpose. The use of PPI therapy would be off-licence, and whilst this will not affect the emergency physicians amongst us, it’s something for our critical care colleagues to be aware of..."

sábado, 17 de septiembre de 2016


Resultado de imagen de Maryland cc project
"Today we are excited to present a Pulmonary Grand Rounds presentation from Daniel S. Chertow, M.D., M.P.H. Dr. Chertow is an Assistant Clinical Investigator in the Critical Care Medicine Department of the NIH and a Special Volunteer in the Viral Pathogenesis and Evolution Section, Laboratory of Infectious Diseases, NIAID. Over the last several years he has solidified his role as a world expert in the field of virology and today speaks on a topic he has published a great deal about, Influenza virus. Tis the season for influenza, and if you ever hope to survive it, you will listen to this talk!"
Resultado de imagen de vimeo

Chest Pain Controversies (Part 1)

emDocs - September 14, 2016 - Authors: Brit Long and Alex Koyfman - Edited by: Jamie Santistevan
  • Missed ACS is a concern for patients and emergency providers.
  • Misdiagnosis and mismanagement of ACS accounts for a large percentage of lawsuits. However, the true rate of missing ACS approaches 0.2%.
  • Nonischemic ECG and negative biomarker at 0 hr and 3 hr reduces risk of MACE to less than 1%.
  • Further testing does not provide reassurance. Discussion with the patient of the assessment and follow up plan is needed.
  • Stress testing can be conducted with several modes and modalities which perform similarly, but these evaluations cannot further risk stratify patients to less than 1% risk.
  • Stress testing does not diagnose MI or ACS."

Security in the emergency room

EdwinLeap.com - September 15, 2016 - By Edwin
"Emergency departments come in all shapes and sizes. I recently visited one that treats about 350 patients per day, which comes in around 127,000 per year. That’s a lot of sick people. Some departments see more than that.
Other emergency departments where I have worked in my locums journey see fifteen patients a day, which is about 5,000 patients per year. Some see less that that.
But one thing is certain. All of them are dangerous. And I don’t mean because of medical error or malpractice. They’re dangerous because they are frequently overcrowded and understaffed, to be sure. But what I’m really talking about is the dangerous people who use them.
In addition to the incredible work done in so many ER’s around the country, in addition to the lives saved the suffering alleviated, many of our patients are suffering from mental illness (some violent), many are seeking drugs (and dangerously angry when denied) and others are simply criminals. ER patients are sometimes victims of other ER patients. ER visitors can be as dangerous as the patients, and sometimes claim to be family in order to exact vengeance on the sick and injured..."

viernes, 16 de septiembre de 2016

Air Embolism

Air Embolism (safeinfusiontherapy.com)
"Definition: Entrainment of air into the venous or arterial system as a result of direct communication and a pressure gradient. Venous air can enter from blunt or penetrating trauma, central venous catheter manipulation, intravenous contrast injections, and surgery (e.g., ophthalmologic, neurosurgical, dental procedures and cesarean delivery) (O’Dowd 2013).
Take Home Points

  • Air embolism is a rare but potentially fatal complication of central line placement and specific surgical procedures
  • Recognition can be difficult as initial signs and symptoms are non-specific. Consider the diagnosis in any patient with decompensation after placement of a central line
  • Treatment should focus on supportive care, air embolism aspiration when feasible and consultation for hyperbaric and cardiopulmonary bypass"

New Treatments for Angioedema

Emergency Physicians Monthly
Emergency Physicians Monthly - September 12, 2016 - By Christina Shenvi and Karen Serrano
An in-depth look at the latest medications for this emergency

Gun Shot Wounds

emDocs - September 14, 2016 - Author: Joshua Bucher
Edited by: Alex Koyfman and Brit Long
"Take Home Points
  1. Utilize ketamine for airway management as it is the most hemodynamically neutral agent.
  2. Use traditional large chest tubes for hemothoraces and large pneumothoraces.
  3. Aggressively resuscitate with blood products for the exsanguinating trauma patient."

Hydrogen Sulfide Toxicity

emDocs - eptember 14, 2016 - Authors: Patrick C Ng and Brit Long
Edited by: Alex Koyfman and Stephen Alerhand
  • Hydrogen sulfide exposures can be deadly.
  • Hydrogen sulfide exposures can happen in various industrial settings as well as in the home as a suicide attempt.
  • Removal of the patient from the exposure as soon and as safely as possible is a key initial step.
  • Aggressive supportive care is the mainstay of treatment.
  • Sodium nitrite and other nitrite formulations can be used to induce a methemoglobinemia to treat H2S toxicity. Hyperbaric oxygen, methylene blue, and hydroxocobalamin have also been used.
  • There is no consensus on dosing of sodium nitrite, and one must consider the drug’s side effects including hypotension.
  • Cobinamide, a hydroxocobalamin derivative, may serve as an effective intramuscular antidote for H2S toxicity in the future.

martes, 13 de septiembre de 2016

Antibiotics for Facial Fractures

Resultado de imagen de taming sru
Taming The SRU - September 12, 2016
The orthopedic literature has shown strong evidence that open fractures are at risk for infectious complications (leading to osteomyelitis, deep space infections, and non-union of fractures), and supports the use of antibiotics for open fractures. Theoretically, similar risks exist with facial fractures that extend into adjacent sinus and oral cavities, due to the bacterial flora within these spaces...
Though the literature is mixed, Drs. Hom and Collar would suggest the following, but are happy to talk about things on a case-by-case basis, as every patient is different:
  • Give antibiotics for: 
    • Facial fractures communicating with open wounds of the skin
    • Mandibular fractures that extend into the oral cavity (including the dentoalveolar ridge)
  • Strongly consider antibiotics for:
    • Orbital wall fractures with extension into the maxillary, ethmoid, or frontal sinus
  • Consider antibiotics for:
    • Frontal sinus fractures
    • Nasal bone fractures with mucosal disruption (leading to epistaxis)
    • Orbital wall fractures that do not extend into the sinuses (lateral)
  • No need for antibiotics in isolated:
    • Closed nasal fractures without septal mucosal disruption
    • Closed zygomatic arch fractures
    • Closed mandibular condyle fractures (since these typically do not communicate with the oral cavity)
    Antibiotic of choice: Augmentin BID x 1 week, or Clindamycin for one week in those with penicillin allergies."

Penicillin Allergy

NU-EM Blog - September 12, 2016 - By Andrew Moore A - Edited by: Rusinak T -  Expert Commentary: Allen K>
Citation: [Peer-Reviewed, Web Publication] Moore A, Rusinak T (2016, September 13). The Penicillin Allergy Conundrum [NUEM Blog. Expert Commentary By Allen K]. Retrieved from http://www.nuemblog.com/blog/penicillin-allergy/
"Prevalence of Penicillin Allergy
Penicillin allergy is the most commonly reported allergy in the United States with a prevalence of up to 12.8% of the population. While this may seem inconsequential, recent data suggest patients with reported penicillin allergies have increased hospital length of stay and increased risks of clostridium difficile, vancomycin resistant enterococcus, and MRSA infections. This leads back to our original question, “Are you really allergic to penicillin?”
We know that of patients who report a penicillin allergy, 90% are able to tolerate penicillin. Using these numbers we can extrapolate that only 1/100 patients have a true allergy to penicillin. Furthermore, cross-allergenicity rates are much less common than originally thought. More recent studies demonstrate cephalosporin-penicillin cross-allergenicity rates between 0.1% and 2%, carbapenem-penicillin cross-allergenicity rates less than 1% and aztreonam-penicillin cross-allergenicity rates 0%.
Emergency Department Approach to Patients with a Self-Reported Penicillin Allergy
In most settings a good clinical history of allergy symptoms can appropriately guide antibiotic choice. When obtaining a history, it is important to ask about a patient’s previous reaction to penicillin. A rash is usually IgG mediated and not concerning while hives, angioedema or anaphylaxis are consistent with a true IgE mediated allergy. It is also useful to know if the patient had to previously seek emergency department care for an allergy as this indicates a more serious reaction. Lastly, asking the patient what antibiotics they tolerated in the past (i.e amoxicillin or other beta-lactams) may help you assess for true penicillin allergy. If it is deemed that a patient has an allergy description that is not consistent with an IgE mediated allergy, it is likely safe to attempt use of another beta-lactam such as a cephalosporin. For patients deemed unsafe to attempt alternative beta-lactam treatment, start a non-beta-lactam and refer for allergy testing. In one prevalence study, only 6% of patients reporting penicillin allergy were referred for allergy testing. If the patient is being admitted to the hospital, consider inpatient testing for IgE mediated hypersensitivity as this has been shown to decrease both inpatient complications and cost of care."

Chronic, asymptomatic hyperlithemia

PulmCrit- September 12, 2016 - By Josh Farkas
Factor #1: A single level doesn’t reveal pharmacokinetics
Factor #2: Serum levels don’t predict with brain levels
  • Patients with chronic, asymptomatic elevation of lithium levels are at little acute risk of immediate deterioration: their lithium level should fall over time, and they are tolerating their current lithium level well.
  • There is no evidence to support the use of dialysis in stable patients with chronic asymptomatic hyperlithemia.
  • Some reports suggest that abrupt reduction in lithium levels induced by dialysis may cause neurological deterioration.
  • A sensible approach to chronic asymptomatic hyperlithemia in a patient with adequate renal function might be rehydration with close monitoring of lithium levels and clinical status.
There is no evidence to support dialysis for chronic asymptomatic hyperlithemia.

Procalcitonin and Lower Respiratory Tract Infections

Resultado de imagen de AAEM RSA
AAEM RSA - September 11, 2016 - By Jordan Kaylor
"Procalcitonin (PCT) is a serum biomarker that, when paired with clinical judgment, may help guide management of lower respiratory tract infections (LRTIs) in the emergency department (ED). Procalcitonin levels can help clinicians distinguish between bacterial and viral infections and might subsequently guide decisions to initiate or discontinue antibiotics. Procalcitonin is a prohormone of calcitonin. It is an acute-phase reactant synthesized in many tissues and released in response to cytokines such as interleukin (IL)-1, IL-6, and tumor necrosis factor (TNF)-α.1 Normal serum concentrations are <0.05ng/mL, but in bacterial infections, PCT increases to detectable levels within three to four hours (earlier than ESR or CRP).Elevations are not seen in noninfectious inflammatory conditions or viral infections, but are possible in Addisonian crises, malaria, severe fungal infections and medullary thyroid carcinoma. In viral infections, interferon (INF)-ɣ probably decreases PCT release, leading to lower or undetectable serum levels."

lunes, 12 de septiembre de 2016

Transient Ischemic Attack

ACEP Now - By Bruce M. Lo - September 6, 2016
"In June 2016, the ACEP Board of Directors approved a new clinical policy on the evaluation of adult patients with suspected transient ischemic attack (TIA), which was developed by ACEP’s Clinical Policies Committee. This clinical policy can also be found on ACEP’s website and has been submitted for inclusion on the National Guideline Clearinghouse website.
TIA is part of a spectrum that involves ischemia of the central nervous system, with approximately 240,000 cases a year in the United States. Although most TIAs last less than one to two hours, by definition, TIAs have a resolution of symptoms within 24 hours without evidence of an acute infarction on imaging. Since approximately 15 percent of all ischemic strokes are preceded by a TIA, timely evaluation for high-risk conditions, such as carotid stenosis and atrial fibrillation, is important.
Based on the feedback from the ACEP membership, the committee focused on four clinical questions about the evaluation of TIA in the emergency department. A systematic review of the evidence was conducted, and the committee made recommendations (A, B, or C) based on the strength of evidence (see Table 1). This clinical policy received input and comments from emergency physicians, neurologists, and members of the American Heart Association/American Stroke Association during the 60-day open-comment period. These responses were used to refine and enhance this clinical policy..."

Blast Crisis

emDocs - September 10, 2016 - Authors: Patrick C Ng and Long B -  Editors: Robertson J
  • CML is a myeloproliferative disorder that can present at any age, but typically presents in the 6th decade of life
  • CML has three phases: Chronic(most common), Accelerated, and Blast
  • Blast phase is a poor prognostic factor
  • Blast phase can present in a variety of ways including but not limited to eye pain, vision changes, neurologic complaints, joint pain, and bleeding. The emergency provider must maintain a high suspicion for this diagnosis, particularly in patients that carry a diagnosis of CML, although these can serve as initial presentations of the disease as well
  • Blast phase can present in conjunction with other pathology including but not limited to fractures and infections. The emergency provider must be aware of this key point to properly address these pathologies in the initial resuscitation and management of the patient.
  • Tyrosine kinase inhibitors serve as the first line of treatment for CML, those progressing to later phases may require other specialized therapy such as combination therapy or cell transplantation that will require expert consultation with a hematologist/oncologist."

Severe community-acquired pneumonia

Biomed Central
Jason Phua J et al. Critical Care 2016; 20:237 - DOI: 10.1186/s13054-016-1414-2. Published: 28 August 2016
"Mortality rates for severe community-acquired pneumonia (CAP) range from 17 to 48 % in published studies.
In this review, we searched PubMed for relevant papers published between 1981 and June 2016 and relevant files. We explored how early and aggressive management measures, implemented within 24 hours of recognition of severe CAP and carried out both in the emergency department and in the ICU, decrease mortality in severe CAP.
These measures begin with the use of severity assessment tools and the application of care bundles via clinical decision support tools. The bundles include early guideline-concordant antibiotics including macrolides, early haemodynamic support (lactate measurement, intravenous fluids, and vasopressors), and early respiratory support (high-flow nasal cannulae, lung-protective ventilation, prone positioning, and neuromuscular blockade for acute respiratory distress syndrome).
While the proposed interventions appear straightforward, multiple barriers to their implementation exist. To successfully decrease mortality for severe CAP, early and close collaboration between emergency medicine and respiratory and critical care medicine teams is required. We propose a workflow incorporating these interventions."

Vulnerable Patient Population

emDocs - September 8, 2016 - Authors: Palmer-Smith V and Setrakian A
Edited by: Koyfman A and Alerhand S
"Emergency medicine providers treat patients living under difficult circumstances every day. Patients with limited resources use the ED for emergent and non-emergent conditions because ED’s are always open, reside on a bus route, can be accessed via EMS, do not require health insurance or payment up front, and have resources that free-standing clinics may not. Failure to recognize these circumstances can lead to missed diagnoses, worsening of a patient’s condition, and failure to follow up. For the provider, meanwhile, these issues can prompt bias, dissatisfaction, and burnout. For the health care system it means repeat visits, late diagnoses, and increased costs of care.
It is thus imperative for patient, provider, and population alike to understand the complexity of these cases and address more than just the medical issues at hand. In some cases, it may even make sense to prioritize intervention for social needs over medical therapy. Addressing a patient’s homelessness, for instance, over their more chronic medical concerns, may result in better health outcomes for the patient and lower overall costs for the healthcare system. Limited resources have yet to be published with regard to this topic, providing guidance and a systematic approach to this population. Here, we will discuss individual provider and department/hospital-level recommendations."

domingo, 11 de septiembre de 2016

Fluid management of the neurological patient

Biomed Central
Van der Jagt. Critical Care 2016; 20:126 - DOI 10.1186/s13054-016-1309-2
Maintenance fluids in critically ill brain-injured patients are part of routine critical care. Both the amounts of fluid volumes infused and the type and tonicity of maintenance fluids are relevant in understanding the impact of fluids on the pathophysiology of secondary brain injuries in these patients. In this narrative review, current evidence on routine fluid management of critically ill brain-injured patients and use of haemodynamic monitoring is summarized. Pertinent guidelines and consensus statements on fluid management for brain-injured patients are highlighted. In general, existing guidelines indicate that fluid management in these neurocritical care patients should be targeted at euvolemia using isotonic fluids. A critical appraisal is made of the available literature regarding the appropriate amount of fluids, haemodynamic monitoring and which types of fluids should be administered or avoided and a practical approach to fluid management is elaborated. Although hypovolemia is bound to contribute to secondary brain injury, some more recent data have emerged indicating the potential risks of fluid overload. However, it is acknowledged that many factors govern the relationship between fluid management and cerebral blood flow and oxygenation and more research seems warranted to optimise fluid management and improve outcomes."