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

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Tuesday, August 3, 2021

NG tubes for SBO

First10EM - By Justin Morgenstern. August 2, 2021
“Bottom Line
This is clearly a harmful procedure. Patients consider it more painful than almost anything else we do in medicine. That harm means that we must have evidence of benefit before we can consider this practice ethical. At this point, there is no evidence, and therefore NG tubes absolutely should not be placed routinely in patients with small bowel obstructions.
That conclusion doesn’t mean that NG tubes don’t provide any benefit. Evidence on the topic is essentially non-existent. We just don’t know. But we know the tubes cause harm, and therefore the burden of proof lies without those who want to subject patients to that harm. Before NG tubes are used, we must demonstrate that there is a benefit that outweighs the known harm. If NG tubes are as important as surgeons seem to think – if there is a huge absolute benefit – then it should be very easy to demonstrate that benefit in an RCT. However, until we see that RCT, it is unfair to patients to subject them to this unproven, painful procedure.”

Sunday, August 1, 2021

Peritoneal Dialysis Emergencies

EemDocs - July 31, 2021 - By Rachel Bridwell - Reviewed by: Alex Koyfman; Brit Long
Pearls:
  • Peritonitis is common, occurring nearly annually for PD patients
  • Peritonitis predisposes PD patients to a myriad of further infections and mechanical complications
  • Catheter complications may present with edema and/or reduced dialysate yield
  • Sclerosing Encapsulating Peritonitis carries a high mortality and can be prevented with early recognition and cessation of PD

Friday, July 30, 2021

E/e’ for Acute Heart Failure

emDocs - July 30, 2021 - By Michael Prats
Originally published on Ultrasound G.E.L. on 3/26/18 - Visit HERE to listen to accompanying PODCAST!
Take Home Points
  1. Measuring the left atrial pressure with E/e’ ratio may improve accuracy of ultrasound diagnosis of acute heart failure.
  2. The combined lung and echo protocol in this small study had 100% sensitivity and 98.5% specificity for diagnosing acute heart failure, but limitations include a poor gold standard and lack of blinding.

Thursday, July 29, 2021

Metemoglobinemia

EM Pills - Isabelle Piazza - 29 Luglio 2021
“Take home messages:
  1. La metemoglobinemia può derivare dall’esposizione ad una serie di farmaci o tossicidiversi. I più comuni sono il dapsone e gli anestetici topici (es. benzocaina)
  2. L’aumentato utilizzo di droghe (es. popper) deve essere un campanello d’allarme 
  3. Considerare tale diagnosi in caso di cianosi e ipossia che non risponde alla somministrazione di ossigeno
  4. Somministrare blu di metilene in caso di paziente con segni vitali anormali, acidosi metabolica, disfunzione d’organo terminale o un livello sierico > 25%”

Wednesday, July 28, 2021

Piperacillin-tazobactam and penicillin allergy

PulmCrit (EMCrit)
PulmCrit - July 28, 2021 - By Josh Farkas
  • Allergy to beta-lactam antibiotics is mediated by the R side chain, rather than the core structure. Thus, patients are not allergic to all beta-lactams, nor all penicillins. Rather, patients tend to be allergic to a select group of antibiotics with similar R side-chain structure.
  • The side-chain structures of piperacillin and nafcillin are quite dissimilar from other penicillins, so they wouldn’t be expected to be cross-allergic with other penicillins.
  • Recent studies show that most patients who are allergic to piperacillin-tazobactam do not demonstrate allergic cross-reaction with either natural penicillins or amoxicillin. 
  • Occasional patients do have allergy to both piperacillin-tazobactam and to penicillin. This may reflect that some patients have a hyperallergic phenotype, with the development of numerous unrelated drug allergies.
  • The label of “penicillin allergy” is not an absolute contraindication to using piperacillin-tazobactam or nafcillin. Patients should be carefully considered on an individual basis.

Epididymitis to Pyocele

TAMING THE SRU
Taming The SRU - July 28, 2021 - By Laura Frankenfeld
“Summary
Scrotal pyoceles are rare but important considerations when presented with acute to subacute cases of scrotal pain. Management includes urologic evaluation, with antibiotics as a mainstay of therapy, although many progress to requiring surgical intervention. Ultrasound is helpful in confirming diagnosis and ruling out additional causes such as torsion, hematocele, and isolated abscesses. If the patient appears toxic, more advanced imaging such as CT scans may be needed to assess for Fournier’s gangrene”

Monday, July 26, 2021

AF After Stroke

REBEL EM - July 26, 2021 - By Thomas del Ninno
Papers: Effect of Long-term Continuous Cardiac Monitoring vs Usual Care on Detection of Atrial Fibrillation in Patients with Stroke Attributed to Large- or Small-Vessel Disease: The STROKE-AF Randomized Clinical Trial
AND
Effect of Implantable vs Prolonged External Electrocardiographic Monitoring on Atrial Fibrillation Detection in Patients with Ischemic Stroke: The PER DIEM Randomized Clinical Trial11
Clinical Question: What is the rate of atrial fibrillation (AF) detection in patients with an implantable cardiac monitoring (ICM) device compared to external cardiac monitoring in patients with a previous ischemic stroke (PER DIEM) or stroke due to large- or small-vessel disease (STROKE-AF)?
Clinical Take Home Point:
An implanated cardiac monitoring device designed to detect atrial fibrillation is able to diagnose atrial fibrillation at a higher rate when compared to standard of care (STROKE-AF) or 30 days of external cardiac monitoring (PER DIEM) at one year. I agree with the authors of both the STROKE-AF and PER DIEM trial, more research is needed to determine the clinical significance of long-term monitoring in the detection of atrial fibrillation using an implanted cardiac monitor when compared to standard of care.

Obstructive Uropathy

emDocsJuly 26, 2021 - By Andrew Kuschnerait
Reviewed by: Andy Grock; Alex Koyfman; Brit Long
Summary
  • Obstructive uropathy is a complication of many conditions.
  • POCUS is crucial in decreasing time to diagnosis and definitive management.
  • AKI, infection in the urinary tree, and bilateral obstructions need drainage as soon as possible.

High flow nasal oxygen

First 10EM - By Justin Morgenstern - July 26, 2021
The paper
Ruangsomboon O, Dorongthom T, Chakorn T et al. High-Flow Nasal Cannula Versus Conventional Oxygen Therapy in Relieving Dyspnea in Emergency Palliative Patients With Do-Not-Intubate Status: A Randomized Crossover Study. Ann Emerg Med. 2020 May;75(5):615-626. doi: 10.1016/j.annemergmed.2019.09.009. PMID: 31864728
Bottom line
There are significant limitations to a small, unblinded, single centered study. However, the expected costs (assuming you already have these devices) and harms are very low, and the benefits can be immediately assessed for the patient in front of you. Therefore, this is enough evidence to support using high flow humidified nasal cannula for palliative care patients, if that is not already your practice..

Monday, July 19, 2021

Hand Infections

emDocs - July 19, 2021 - By Sarah Brubaker / Reviewed by Alex Koyfman and Brit Long
Clinical Pearls
  1. Use ultrasound and your physical exam to distinguish between superficial and deep-space infection. If you have high concern for deep-space infection, consult your orthopedist, regardless of lab values.
  2. If you discharge the patient, remember to consider MRSA coverage, soft-tissue immobilization, and 48-hour re-check. If you performed an I&D, regular warm water soaks will probably be useful to ensure proper continued drainage.
  3. Don’t forget to ask about recent exposures and injuries; human bites, animal bites, and other zoonotic exposures require specific antibiotic coverage.
  4. If there is an associated wound, check the patient’s tetanus immunization status, and give the patient a tetanus booster if it was not updated in the last 5 years.
  5. Make sure a paronychia is NOT herpetic whitlow, because attempting to I&D herpetic whitlow will only make matters worse

Low-Risk Chest Pain

REBEL EM - July 19, 2021 - By Marco Propersi
Paper: Musey PI Jr, Bellolio F, Upadhye S, et al. Guidelines for reasonable and appropriate care in the emergency department (GRACE): Recurrent, low-risk chest pain in the emergency department [published online ahead of print, 2021 Jul 6]. Acad Emerg Med. 2021. [PMID: DISCUSSION
These guidelines are comprehensive and pragmatic. However, they highlight how little evidence exists on recurrent low-risk chest pain and patient values and preferences for low-risk recurrent chest pain treatment. This lack of data represents an opportunity for future research to illuminate some gaps in knowledge. Also, of worthy discussion, some hospitals do not have high-sensitivity troponins. Therefore, some guidelines may not be applicable in all clinical settings. Likewise, expedited outpatient follow-up may also be difficult for some. Underinsured and uninsured patients are particularly vulnerable to follow-up loss. Accordingly, we often practice more cautiously with patients with limited resources. Moreover, the recommendations are based on derivative, indirect evidence stressing the importance of shared-decision making with our patients. 
Clinical Bottom Line: 
GRACE guidelines offer a pragmatic, evidence-based framework for shared-decision making in patients with recurrent low-risk chest pain.

Cancer associated thromboembolism

empills - By Andrea Milani - 19 Luglio 2021
…”Se il trattamento del VTE nella popolazione generale non lascia molto spazio a discussioni, nella popolazione affetta da VTE cancro-relata (e non è certo una quota trascurabile di casi) vi sono molte meno certezze.
Se da un lato i DOAC sarebbero certamente preferibili nel trattamento del CAT per la facilità di assunzione, il loro utilizzo “sul campo” cela qualche difficoltà. Mi stupiva che i colleghi oncologi non li prescrivessero estesamente, ma leggendo con attenzione la letteratura ho capito perché.
L’eparina rimane probabilmente il “backbone”, i DOAC sono utilizzabili in una minoranza di pazienti perché non sono così “semplici”. Molti fattori, anche piuttosto complessi, vanno sui piatti della bilancia e spesso non è così semplice trarne conclusioni…”

Friday, July 16, 2021

Activated Charcoal

EM Ottawa - By Alexandra Hamelin - Juyl 15, 2021
TAKE HOME POINTS:
  1. The appropriate dosing of AC is an AC-to-drug ratio of 10:1. This strategy works especially well for smaller ingestions. If the amount that the patient ingested is unknown, a 1g/kg dose of AC is appropriate.
  2. AC can be given up to 2-4 hours post-ingestion if the benefits outweigh the risks. Later administration beyond 4 hours can be considered if other factors exist such as serious toxicity, modified-release product, and delayed gastric emptying.
  3. MDAC should be considered if a patient has ingested a life-threatening amount of drug known to undergo enterohepatic circulation (i.e. carbamazepine, phenobarbital, theophylline)
  4. AC can be considered up to 2 hours after acetaminophen overdose. AC should be more strongly considered in polypharmacy ingestions, and especially in massive acetaminophen ingestion.
  5. The combined approach of AC and WBI is still often employed in dangerous overdoses of sustained-release medications. One approach, based largely on expert opinion, is to give a first dose of AC, wait for the AC to act alone, administer WBI, and then give a second dose of AC 1-2 hours later.

Monday, July 12, 2021

Disposition of Pneumonia

EmDocs - July 12, 2021 - By Trevor Cerbini and Richard Sinert
Reviewed by: Andrew Grock, Alex Koyfman, Brit Long
Take Home Points:
  • ACEP and the IDSA/ATS guidelines recommend a clinical prediction rule in combination with clinician judgement to determine patient disposition for adults with CAP.
  • The PSI score identifies a large portion of low-risk patients potentially suitable for outpatient care, but should be used with clinical judgment! Be aware of excluded populations that the PSI score should not be used in.
  • Consider admitting patients with significant hypoxia, hypotension, tachycardia, or renal failure, regardless of PSI score.
  • Likewise, patients demonstrating an inability to comply with an outpatient antibiotic regimen (psychosocial factors, substance use, cognitive deficiencies, or PO intolerance) should also be considered for inpatient care.
  • ED admission to a higher-level care setting should be considered for patients with 3 or more IDSA/ATS 2007 minor criteria

Sunday, July 11, 2021

High-Dose Nitroglycerin for APE

ALiEM - Jul 10, 2021 - By: Bryan D. Hayes / Editors: Mike O'Brien
Bottom Line
  • A few small ED studies support the use of an initial IV NTG bolus followed by an infusion compared to the infusion alone [1, 2]
  • There is a low risk of hypotension following a single IV NTG bolus
  • Consider using the following protocol to identify which doses may be best for specific patients based on initial systolic blood pressure

Thursday, July 8, 2021

Methoxyflurane

CanadiEM - By Jeremi Laski - July 8, 2021
Conclusion
Methoxyflurane, despite its volatile history as an anesthetic (pun intended), has a promising future as an analgesic agent both in the pre-hospital and ED setting. While research is still emerging, including Health Canada trials for use in Canada, many studies have demonstrated both its effectiveness as an analgesic and the added advantages of its portability and non-invasive administration. 
N.B. There is a lack of evidence for whether methoxyflurane inhaler use is an aerosol generating medical procedure; clinicians should consider methoxyflurane use in the broader context of COVID-19 and potential aerosol generation with inhaler use.
Key Takeaways 
Methoxyflurane is a promising non-opioid, non-invasive analgesic that can effectively reduce mild to severe pain in an ED setting. Administer via MDI up to 3 puffs. Care should be taken to avoid giving it to patients with pre existing renal conditions.

Tuesday, July 6, 2021

Pulmonary Hypertension

emDOCs Podcast Episode 32 - July 06, 2021 - By Brit Long and Rachel Bridwell
Key Points:
  • Myriad of chief complaints can be pulmonary hypertension; try to determine what is triggering the acute decompensation.
  • Elevations in troponin and liver function tests portend a poor prognosis.
  • Point of care ultrasound may be useful in guiding acute resuscitation, though evaluation of IVC may not reflect intravascular volume.
  • Avoid hypoxemia and hypercarbia and maintain right ventricular preload support.
  • Most patients will be admitted.
  • Avoid intubating these patients if at all possible.
  • Restart PAH meds if discontinued.

Low Risk Chest Pain

Taming The SRU
Taming The SRU - July 06, 2021 - By Jeff Hill
SUMMARY
The GRACE guidelines for the evaluation of recurrent, low-risk chest pain offer an excellent summary of the available literature addressing a particularly challenging patient population we see in the ED. We approach these patients balancing concern for hidden disease, morbidity, and mortality against concern for harms from diagnostic evaluation and concerns for resource utilization. The amount of evidence available to directly answer the important questions posed by the panel is, at this time, disappointingly lacking. As with any research endeavor however, the asking of, framing of, and publication of these important questions could spur new research in the years to come. For now, we can evaluate these complex patients with a bit more clarity than before.

Monday, July 5, 2021

Nebulized Ketamine

REBEL EM - July 05, 2021 - By Salim Rezaie
Paper: Dove D et al. Comparison of Nebulized Ketamine at Three Different Dosing Regimens for Treating Painful Conditions in the Emergency Department: A Prospective, Randomized, Double-Blind Clinical Trial. Ann Emerg Med 2021. [Epub Ahead of Print]
Clinical Question: What is the analgesic effectiveness and safety of nebulized ketamine at 3 different doses for ED patients presenting with acute and chronic painful conditions?
Author Conclusion: “We found no difference between all 3 doses of ketamine administered through breath-actuated nebulizer for short-term treatment of moderate to severe pain in the emergency department.”
Clinical Take Home Point: 0.75mg/kg of nebulized ketamine was both efficacious and safe in the control of acute pain in the ED. Additionally, compared to previous evidence looking at IV sub-dissociative ketamine there appears to be a signal of decreased levels of psycho-perceptual effects and need for rescue analgesia. However, these last two findings would need to be studied in a trial comparing nebulized vs IV ketamine.

New-Onset Hyperglycemia

EmDocs - July 05, 2021 - By Xavier Schwartz; Alison Sullivan
Reviewed by: Andrew Grock; Alex Koyfman; Brit Long
Take-Home Points
  • Type 1 (autoimmune) diabetes can present in adults.
  • Consider type 1 diabetes in adult patients with hyperglycemia and severe weight loss, polyuria, or polydipsia. This mandates an ED endocrinology consult or hospital admission.
  • For hyperglycemic, stable patients without concern for type 1 diabetes:
    • If asymptomatic with random BG >126 mg/dL (7.0 mmol/L), outpatient follow-up for diabetes screening is appropriate.
    • If symptomatic with a BG between 200 mg/dL (11.1 mmol/L) and 300 mg/dL (16.7 mmol/L), Metformin 500 mg once a day can be safely started in the ED and is usually well tolerated.
    • For severe hyperglycemia (BG >300 mg/dL or 16.7 mmol/L), the patient will likely require long-term insulin therapy. Disposition of these patients will vary by practice environment. Consider initiation of long-acting glargine at 0.1-0.2 units/kg/day on discharge for reliable patients in well-resourced settings with established hospital support.

Decompensated hypothyroidism

First10EM - By Justin Morgenstern - July 5, 2021
  • Follow your approach to altered mental status (check a glucose)
  • Manage the airway
  • Manage the hemodynamics
  • Give Steroids
  • Give levothyroxine (+/- T3)
  • Identify the underlying cause
  • Supportive care is very important

Saturday, July 3, 2021

Atrial Flutter

EmDocs - July 03, 2021 - By Katherine M. Buckley
Reviewed by: Alex Koyfman and Brit Long
Pearls:
  • A regular, narrow-complex tachycardia with a rate of 150 beats/min (+/- 5 beats/min) strongly suggests atrial flutter with 2:1 conduction2
  • CCB and beta-blockers for rate control in the stable patient
  • Synchronized cardioversion (25-50J) in the unstable patient
  • Adenosine can slow down rate long enough to expose flutter waves
  • Flutter also requires thromboembolic risk stratification for anticoagulation


Thursday, July 1, 2021

Thromboembolic Events After Cardioversion

REBEL EM - Written July 01, 2021 - By Miguel Reyes
Paper: Wong BM et al. Thromboembolic Events Following Cardioversion of Acute Atrial Fibrillation and Flutter: A Systematic Review and Meta-Analysis. CJEM 2021. PMID: 33715143.
Clinical Question: What is the effect of oral anticoagulation use on thromboembolic events at 30 days following cardioversion of acute atrial fibrillation and flutter?
Author’s Conclusion: Primary analysis revealed insufficient evidence regarding the effect of oral anticoagulation use on thromboembolic events post-cardioversion of low-risk acute atrial fibrillation and flutter, though the vent rate is low in contemporary practice. Our finding can better inform patient-centered decision-making when considering 4-week oral anticoagulation use for acute atrial fibrillation and flutter patients.”
Clinical Bottom Line:
This systematic review and meta-analysis tells us that thromboembolic events in patients with acute onset atrial fibrillation and flutter post-cardioversion are exceedingly low at 30 days. There is insufficient evidence regarding the value of oral anticoagulation in low-risk acute afib and aflutter patients post-cardioversion. However, based on this limited evidence it does appear as though the event rate in those not receiving oral anticoagulation post-cardioversion is very low. More importantly, I’m reluctant to deviate from the recommendations from both the American and European guidelines and will continue to anticoagulant those with higher risk (CHADS2 ≥1 and CHA2DS2-VASc ≥2).

Monday, June 28, 2021

eFAST-PS

eFAST-PS: proposta eretica?
empills - By Giuseppe Sfuncia - 28 Giugno 2021
..."Avevo già accennato qualcosa in un mio vecchio post eFAST e il Mito del Morison… Nella scansione della pelvi Bauman ha suggerito l’applicazione del FAST-PS ovvero valutazione delle Pubic Symphysis, come strumento per identificare le disastrose “fratture a libro aperto del bacino” ( Ultrasonographic determination of pubic symphyseal widening in trauma: the FAST-PS study JEmerg Med. 2011 May;40(5):528-33 ). Si tratta di una pubblicazione con pochi casi 23 ma la procedura è veloce, semplice ed accurata con 100% sensibilità e specificità se si pone il cut-off >25mm della diastasi della sinfisi pubica valutata in eco..."

Hyperthyroidism

emDocs - June 28, 2021 - By Leah M. Bralow
Reviewed by: Jay Khadpe; Alex Koyfman; Brit Long
"Take Home Points:
  • Hyperthyroidism represents a broad spectrum of disease from subclinical, which requires no ED intervention, to thyroid storm, a life-threatening medical emergency.
  • There are no specific laboratory “cutoffs” that define thyroid storm. This is a clinical diagnosis. The Burch-Wartofsky score can help support clinical gestalt.
  • There are a myriad of Thyroiditis syndromes which are caused by a destructive process to the thyroid gland. These diseases are self-limited and are not associated with true hyperthyroidism. As such, treatment focuses on symptom management with β-blockers and pain control with NSAIDs.
  • Thyroid storm treatment can be remembered as “ABC WI”: Antithyroid Drugs, β-Blockers, Corticosteroids, Wait 1 hour, Iodine.
  • The first step in managing a patient with thyroid storm is aggressive supportive care"

TXA

First10EM - By Justin Morgenster - June 28, 2021
"Summary
Taken together, I think these studies make it clear that TXA is not a miracle cure. It might have a small physiologic effect, but there are more negative trials than there are positive. With the sole exception of CRASH-2, the high quality studies are all negative. The rest of the benefit is seen in disease oriented outcomes in small, low quality studies. That really makes me wonder whether CRASH-2 represents a false positive, outlying result. The only way to know would be a repeat study, which seems unlikely, but – although we tend to ignore the fact in medicine – replication is the foundation of science.
My personal feeling, informed by the totality of the TXA literature, is that a CRASH-2 replication has a high probability of being negative – that there is still equipoise. If such a study were done in a country with an advanced trauma system, it is even more likely to be negative. However, the best available evidence at this point supports TXA in bleeding trauma patients.
Clinically speaking, I use TXA in bleeding trauma patients. I don’t use it in isolated traumatic brain injury. I don’t use it in spontaneous intracranial hemorrhage or subarachnoid hemorrhage. I don’t use it in postpartum hemorrhage. I don’t use it for gastrointestinal bleeding. I have been using it in epistaxis, but should probably stop.
For most other indications, the science is too uncertain to make strong conclusions. In totality, TXA seems to have a very small effect (if any). It probably shouldn’t be used routinely for any indication. Harms are probably small, and probably even smaller when used topically, but shouldn’t be overlooked. For select patients with bleeding issues, especially those uncontrolled by other means, it may still be reasonable to try TXA while waiting for more research to be done."

Sepsis

iEM - June 28, 2021 - By Kohylah Piper
"Key Points
  1. Sepsis is a clinically heterogeneous syndrome, which has a progression that can lead to severe cellular, metabolic, and overall hemodynamic dysfunction.
  2. If left un-recognized or, if it is not treated aggressively, the patient outcomes may be dim.
  3. The SOFA score is a criteria that is used in-depth and in a quick overview to assess the level of organ dysfunction in suspected or confirmed sepsis.
  4. Patients should be consistently monitored while exploring for the possible primary source.
  5. Sepsis is treated with rapid infusion of intravenous fluids and by using broad-spectrum antibiotics"

Sunday, June 27, 2021

Ihnalant Induced Dysrhythmias

ALiEM - June 26, 2021 - By: Bryan D. Hayes and Mike O'Brien
„Bottom Line
  • Patients presenting to the ED with cardiopulmonary manifestations of inhalant use should have routine electrolytes and an ECG to assess cardiac status
  • A quiet environment is important to decrease stimulation and minimize catecholamine surges
  • For both stable and non-perfusing dysrhythmias, propranolol or esmolol are reasonable choices to counteract the catecholamine effects, in addition to standard care
    • Consider avoiding epinephrine and other catecholamines unless necessary, as they may worsen the dysrhythmia“

Monday, June 21, 2021

Excited Delirium

emDocs - June 21, 2021 - By Gabrielle Bunney and Dana Loke 
Reviewed by: Cynthia Santos; Tim Montrief; Alex Koyfman; Brit Long
„Take-home points
  • Safety of patients and staff takes precedent in the setting of excited delirium and may warrant the use of restraints and chemical sedation.
  • Supportive care is paramount, as these patients can be incredibly sick. Assess for electrolyte abnormalities, rhabdomyolysis, and hyperthermia, and treat accordingly.
  • First line agents are benzodiazepines.
  • Ketamine is an appropriate second line medication in the ED, although its use in the prehospital setting is still controversial“

Endovascular Therapy for ABAO

REBEL EM - By Salim Rezaie - June 21, 2021
Paper: Langezaal LCM et al. Endovascular Therapy for Stroke Due to Basilar-Artery Occlusion. NEJM 2021. PMID: 34010530[Access on Read by QxMD
Clinical Question: In patients with acute basilar artery occlusion is favorable functional outcome at 90 days improved with endovascular therapy vs standard medical care?
Author Conclusion: “Among patients with stroke from basilar-artery occlusion, endovascular therapy and medical therapy did not differ significantly with respect to a favorable functional outcome, but as reflected by the wide confidence interval for the primary outcome, the results of this trial may not exclude a substantial benefit of endovascular therapy. Larger trials are needed to determine the efficacy and safety of endovascular therapy for basilar-artery occlusion.”
Clinical Take Home Point: In patients with basilar artery occlusion, endovascular therapy compared to medical therapy alone was not significantly different with respect to a favorable functional outcome. Although, benefit cannot be excluded based on this trial, a much larger trial would be needed to determine the efficacy and safety of endovascular therapy in these patients. Additionally, the use of advanced imaging (i.e CT perfusion) will most likely be needed to select the appropriate patients for endovascular therapy going forward.

Therapeutic hypothermia

First10EM - By Justin Morgenstern - June 21, 2021
The paper
Dankiewicz J, Cronberg T, Lilja G, et al: TTM2 Trial Investigators. Hypothermia versus Normothermia after Out-of-Hospital Cardiac Arrest. N Engl J Med. 2021 Jun 17;384(24):2283-2294. doi: 10.1056/NEJMoa2100591. PMID: 34133859 NCT02908308
„Bottom line
This large RCT demonstrated no benefit from ‘therapeutic’ hypothermia as compared to managed normothermia. To date, there is no evidence that managed normothermia is any better than no temperature management at all. That study probably needs to be done, but until then, temperature should not be a priority in post-arrest care“

Sunday, June 20, 2021

ARDs

EmDocs EM@3AM - June 19, 2021 By Davin Brar
Reviewed by: Alex Koyfman and Brit Long
„Pearls:
  • Patients with ARDs are some of the sickest we see in the ED. Timely recognition and intervention are essential.
  • ARDS is not a primary disorder but instead secondary to other illnesses.
  • Treatment is focused on supportive care and limiting lung injury.
  • Use lung protective ventilation with low tidal volumes.“

Thunderstorm Asthma

St. Emlyn ´s - By Sophie Farooque - June 19, 2021
„In the UK this weekend there are warnings out regarding Thunderstorm Asthma. This is a rare but well described phenomena when patients who are previously known to be grass pollen allergic (e.g. hayfever) suffer asthma like symptoms as a result of thunderstorm activity in the area.
It can take patients and physicians by surprise and can have catastrophic consequences. The most significant episode of thunderstorm asthma on record was in Melbourne in 2016 when A&E asthma-related hospital admissions rose by almost 1000% during a 12 hour storm…“

Tuesday, June 15, 2021

Urine drug screens

emDocs - June 15, 2021 - By Andrew and Ann-Jeannette Geib
Reviewed by: Cynthia Santos; Alex Koyfman; and Brit Long
    “Introduction
  • Many studies have argued against the benefit of urine drug screens (UDS) in the emergency department, and in the setting of emergent psychiatric evaluation. These studies cite high costs associated with the UDS, increased length of stay (LOS), and lack of alteration in patient management. Additionally, the interpretation of the typical UDS, an immunoassay of typical drugs of abuse, is fraught with a high potential for false positives and false negatives1.
  • The immunoassay is a bioanalytical method that uses the reaction of an antigen (analyte) with an antibody, and is used in the typical point of care UDS to determine the presence or absence of a drug in the urine. Each immunoassay tests for a specific analyte, and has a set cutoff above which a concentration of said analyte will yield a positive result. Because of either limited or cross-reactivity, immunoassays are subject to a large number of false positives and false negatives2.
  • A number of substances can cross-react with structurally related and unrelated compounds in the system to produce a positive result.
  • False negatives occur due to a variety of reasons, including antibody interference, a high concentration cutoff for a positive result, and duration between drug dosing and the time the sample is obtained for analysis…“

Dyspepsia in the ED

TAMING THE SRU
TAMING THE SRU - June 15, 2021 - By Justine Milligan
“FIRST OFF, SOME TAKE HOME POINTS…
  • For acute management of dyspepsia in the emergency department, antacids alone may provide the fastest relief, but it is short-lived. 
  • The addition of lidocaine (“the GI cocktail”) does not an additional clinical benefit and has risks of harm. 
  • For longer-term relief of symptoms, consider a dose of an H2RA or PPI. 
  • When sending a patient home with a short-term script of acid suppressants, determine the frequency of their symptoms. If they are occurring >1 time per week, a PPI may be more useful. For more occasional symptoms, an H2RA may be sufficient. If symptoms have been persistent for >1 month despite empiric treatment, further evaluation is recommended“