Síguenos en Twitter     Síguenos en Facebook     Síguenos en YouTube     Siguenos en Linkedin     Correo Grupsagessa     Gmail     Dropbox     Instagram     Google Drive     StumbleUpon     StumbleUpon     StumbleUpon     StumbleUpon     StumbleUpon     StumbleUpon     StumbleUpon     StumbleUpon

SOBRE EL AUTOR **

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

WORLD EMERGENCY MEDICINE SOCIETIES & RELATED

Search

Content:

Monday, September 13, 2021

Acute Compartment Syndrome

emDocs - September 13, 2021 - By Martin Yang
 Reviewed by: Courtney Cassella; Alex Koyfman; Brit Long
Take Home Points:
  • 5 Ps = PAIN, pallor, paresthesia, paralysis, pulselessness
  • Increasing pain despite analgesia should increase suspicion for ACS.
  • Passive stretch of compartment thought to be most sensitive exam finding.
  • Compartment pressures: <10 mmHg normal, >30 mmHg concerning for ACS
  • Consider use of delta pressure for monitoring in equivocal exams.
  • Special consideration with hypotensive patients, lower pressures required to overcome arterial pressures.
  • Treat associated rhabdomyolysis, hyperkalemia, and acute kidney injury.

Ketamine for agitation

First10EM - By Justin Morgenstern - September 13, 2021
Paper #1
Lin J, Figuerado Y, Montgomery A, Lee J, Cannis M, Norton VC, Calvo R, Sikand H. Efficacy of ketamine for initial control of acute agitation in the emergency department: A randomized study. Am J Emerg Med. 2021 Jun;44:306-311. doi: 10.1016/j.ajem.2020.04.013. PMID: 32340820
Paper #2
Barbic D, Andolfatto G, Grunau B, Scheuermeyer FX, Macewan B, Qian H, Wong H, Barbic SP, Honer WG. Rapid Agitation Control With Ketamine in the Emergency Department: A Blinded, Randomized Controlled Trial. Ann Emerg Med. 2021 Aug 2:S0196-0644(21)00433-9. doi: 10.1016/j.annemergmed.2021.05.023 PMID: 34353650
Bottom line
There are now 2 RCTs that demonstrate that ketamine will result in more rapid sedation than haloperidol plus a benzodiazepine, but that seems to come at the cost of an increase in adverse events. Ketamine makes sense in carefully selected patients, and may be particularly helpful in the prehospital setting. Regardless of sedative choice, agitated delirium is an emergency that warrants our full attention.

Sunday, September 12, 2021

Disfagia

empills - By Davide Tizzani - 9 Settembre 2021
…” La prevalenza stimata della disfagia è circa fra il 7 ed il 22%, con una forte prevalenza età-relata, con una percentuale del 50% nelle persone anziane residenti in casa di cure. Una persona su 17 svilupperà una forma di disfagia nella sua vita. La disfagia correla ovviamente con disidratazione, malnutrizione, aspirazione, infezione respiratorie, depressione, peggioramento della qualità di vita, ostruzione delle vie aeree, morbidità e mortalità…”

Saline vs Balance

St Emlyńs - By Simon Carley - September 7, 2021
… “The headline figures suggest that there was no significant difference in terms of outcome between the two fluids, or the speed of administration.
90 day Mortality occurred in 1381/5230 (26.4%) of the balanced solution group vs. 1439/5290 in the saline group (adjusted HR, 0.97 [95% CI, 0.90-1.05]; P = .47…
Bottom Line.
It probably does not matter whether you choose balanced solutions or normal saline for the majority of patients who require volume expansion in an ICU setting.”

Electrical cardioversion

EemDocs - September 06, 2021 - By Rachel Lynn Graves and Gillian Bach
Reviewed by: Edward Lew; Alex Koyfman; Brit Long
“Take Home Points:
  • Patients with pre-existing cardiovascular disease, particularly structural heart disease and older patients (defined as age 65 and older, to error on the side of inclusion) are at risk for life-threatening complications following cardioversion. Be prepared to manage complications when cardioverting these patients.
  • Patients with pre-excitation syndromes may have bizarre QRS complexes that are difficult to distinguish from T waves, which can lead to asynchronous shock delivery and the development of VF.
  • All but the lowest risk patients should be anticoagulated prior to and following cardioversion unless they have a direct contraindication”

Tuesday, August 31, 2021

ESC 2021 Insuficiencia cardíaca

Urgencias y Emergencias - 29/08/2021 - Por Elena Plaza Moreno
“Acaba de publicarse (27 de agosto de 2021) la nueva Guía de la ESC 2021 para el diagnóstico y tratamiento de la insuficiencia cardíaca aguda y crónica. Podéis verlas aquí y si usáis el traductor de Google, traducir la página entera. O podéis descargar las guías en formato pdf aquí.
Estas guías ocupan 128 páginas y recogen absolutamente todo sobre la insuficiencia cardíaca. Lo que yo os presento en este post es un resumen traducido de la parte de insuficiencia cardíaca aguda (apartado 11 de las guías), en concreto el manejo del edema agudo de pulmón y el shock cardiogénico, lo que veo más “aplicable” al ámbito de las urgencias y emergencias, y un resumen del manejo de fármacos de la insuficiencia cardiaca aguda.”

First-time seizures

canadiEM - By Michael Verdirame - August 31, 2021
Take Home
While the Pizza SLICES approach is not an exhaustive list, hopefully it will assist you in recalling the essential work-up and management priorities in resolved, first-time seizures. Additional items not covered in the above mnemonic are “can’t miss” seizure mimics such as stroke and TIA. It is intended to be applied once insidious causes have already been considered. 
Next time you are about to discharge someone home after their first seizure, stop and ask yourself – have you served them all of their Pizza SLICES… SSS SSS?

Monday, August 30, 2021

Agitation Control With Ketamine

REBEL EM - August 30, 2021 - By Muhammad Durrani
Paper: Barbic D et al. Rapid Agitation Control With Ketamine in the Emergency Department: A Blinded, Randomized Controlled Trial. Ann Emerg Med. 2021. PMID: 34353650
Clinical Question: Does ketamine 5mg/kg IM or midazolam 5mg plus haloperidol 5mg IM result in more rapid sedation of acutely agitated patients in the ED?
Author Conclusion: 
“Ketamine achieves faster sedation of severely agitated ED patients while maintaining a similar safety profile.”
Clinical Take Home Point:
In this small randomized clinical trial of patients with severe psychomotor agitation, the use of ketamine was associated with a significantly shorter time to adequate sedation versus a combination of midazolam and haloperidol. The findings need to be interpreted in the context of an inadequate number of enrolled patients, early termination of the trial, and single center setting.
The bottom line is that the use of ketamine appears to be a safe and attractive alternative with a good safety profile for severe psychomotor agitation in the emergency department.

LR vs NS

emDocs - August 30, 2021 - By Gabrielle Leonard and Aaron Lacy
Reviewed by: Alex Koyfman; Brit Long
Pearls:
  • LR composition is more similar to human plasma than NS.
  • LR is preferred to NS in select ED presentations, such as DKA.
  • LR will not worsen hyperkalemia and the acidosis from NS may in fact be more detrimental.
  • LR does contain sodium lactate but will not contribute to clinically significant worsening lactic acidosis.
  • NS is preferred to plasma-lyte in patients with TBI.
  • Consider NS when mixed with certain medications such as ceftriaxone or blood transfusions to avoid precipitation when only a single IV access site it available.

The FAST exam

First10EM - By Justin Morgenstern - August 30, 2021
Bottom line for the FAST Exam
The evidence of benefit is non-existent, but I think there is clearly a role for the FAST exam in hemodynamically unstable patients. However, even among the hemodynamically unstable, the role may be more limited than you think. It is essential to consider your resources, and how the test will change your management. In a trauma center, when you are deciding between the operating room and interventional radiology, the FAST exam may provide invaluable information. In the community, where most of us work, such treatment options don’t exist, and the FAST exam may just be delaying the transfer the patient needs.
In hemodynamically stable patients, I think the available data is pretty clear: the FAST exam shouldn’t be used. The sensitivity is not high enough to rule out intra-abdominal injuries. If you are concerned about a patient, CT is the imaging of choice, and a negative ultrasound may just falsely reassure you. The specificity of the FAST exam is excellent, but many hemodynamically stable patients will be managed non-operatively, so essentially all of these patients are going for CT as well. In other words, whether your FAST exam is positive or negative, the patient still needs a CT, which is the definition of a useless test.

Subtle T waves

REBEL EM - By Salim Rezaie - August 29, 2021
“This 28-minute lecture from Rebellion in EM 2021, Dr. Amal Mattu, MD goes over several cases of ECGs and subtle T waves you can’t afford to miss.”

Friday, August 27, 2021

ILCOR 2020

EMOttawa - By Renee Bradley - August 26, 2021
Take Home Points
In summary, review of the current literature surrounding three aspects of the new ILCOR 2020 Guidelines, has led us to draw the following conclusions: 
  1. Dual Sequential Defibrillation (DSD): According to ILCOR, DSD is not recommended due to poor evidence on the subject. However, preliminary data from the DOSE-VF trial demonstrates that DSD is likely safe, and possibly more effective than standard defibrillation when used early in shock refractory VF.
  2. PoCUS during Cardiac Arrest: Although not recommended for use by ILCOR guidelines for prognostication during CPR, evidence suggests that POCUS is quite reliable in predicting likelihood of death. It could play a role as an additional data point to assist risk stratification during cardiac arrest. 
  3. Epinephrine use in PEA/Asystole: Early epinephrine use is most beneficial in the non-shockable subgroup. Overall excessive use of epinephrine should be done with caution, as poor neurological outcomes may be encountered.

Tuesday, August 24, 2021

L’ileo biliare

empills - By Isabelle Piazza - 24 Agosto 2021
Take home messages:
  • L’ileo biliare è una rara causa di occlusione meccanica che colpisce solitamente gli anziani ed è causata da un calcolo biliare che, passando attraverso una fistolabiliodigestiva, si incunea a livello dell’ ileo terminale
  • Il gold standard per la diagnosi è la TC addominale che mostra l’ostruzione intestinale e il calcolo incuneato
  • Il trattamento è chirurgico e consiste in enterolitomia per il trattamento dell’occlusione e colecistectomia e chiusura della fistola.

Splenic Infarction

emDocs - August 23, 2021 - By Marshall Howell and Eliot Blum
Reviewed by: Alex Koyfman and Brit Long
Clinical Pearls
  • The classical presentation of splenic infarction is a patient with left-sided abdominal pain, nausea, vomiting, and fever, but actual presentations are often ambiguous and mimic other pathologies.
  • In patients under 40, the most common cause of infarction is a hematologic or hypercoagulable disorder. In those over 40, most infarctions are the result of thromboembolic disease.
  • The gold standard for diagnosis is abdominal CT with contrast. Ultrasound may be useful in the unstable patient to distinguish infarction from splenic rupture or subcapsular hemorrhage.
  • ~38% of splenic infarctions are the first presentation of an underlying disorder. Begin the investigation in the ED with an EKG, blood cultures, and echo (if possible).
  • Stable patients with controlled pain may be admitted or observed with symptomatic care and appropriate consults based upon the most likely etiology. Unstable patients or those with signs of abscess or hemorrhage require admission with surgical and possible IR consultation

Ludwig’s Angina

Fist10EM - By Punithan Thiagalingam - August 23, 2021
The paper: 
Bridwell R, Gottlieb M, Koyfman A, Long B. Diagnosis and management of Ludwig’s angina: An evidence-based review. Am J Emerg Med. 2021 Mar;41:1-5. doi: 10.1016/j.ajem.2020.12.030. Epub 2020 Dec 23. PMID: 33383265
…”What is the initial ED management?
  1. Airway assessment and management
  2. Broad Spectrum Antibiotics
  3. Dexamethasone (to reduce edema and improve antibiotic penetration)
  4. Surgical debridement of any necrotic tissue and drainage of any abscess 
Swabs of the involved area are low yield and likely to have multiple contaminants. There is limited evidence for nebulized epinephrine…”

Necrotizing Fasciitis

TAMING THE SRU
TAMING THE SRU - By Logan Ramsés - August 23, 2021

SUMMARY
Necrotizing soft tissue infection is a rare, aggressive, and life-threatening disease with high mortality unless extensive surgical intervention is performed. Diagnosis can be challenging in the emergency department due to similarity to more innocuous infections such as cellulitis, but NSTI should be suspected in the case of pain out of proportion to exam, crepitus, bullae, or signs of systemic illness. Diagnosis in the ED is primarily clinical, but diagnostic imaging such as CT scan and ultrasound can be helpful, and the final diagnosis is made after surgical debridement. The mainstays of NSTI treatment in the ED are early surgical consultation and empiric antibiotic therapy for gram positive, gram negative, and anaerobic bacteria. Catfish-associated infections, including NSTI, have been reported in the literature and can be life-threatening.

Saturday, August 21, 2021

Ipertermia

EMPills - By Davide Tizzani - 19 Agosto 2021
La sindrome serotoninergica (SS) è una patologia potenzialmente letale, determinata dalla assunzione di uno o più farmaci ad azione serotoninergica. La maggior parte sono forme lieve-moderate che rispondono alla semplice interruzione del farmaco in questione e migliorano in un giorno. Tuttavia le forme severe spesso richiedono il ricovero in terapia sub/intensiva…
In sintesi
In sintesi per la SS pensa FAST: veloce insorgenza, movimenti veloci (agitazione, iperreflessia), risoluzione veloce; per la NMS pensa SLOW: insorgenza lenta, movimenti lenti (ed iporeflessia) e lenta risoluzione.
Nei pazienti con incapacità alla distinzione fra SS e NMS la letteratura raccomanda la sola terapia con bezodiazepine, dato che la bromocroptina può peggiorare una eventuale SS e gli antipsicoti possono peggiorare ovviamente una NMS.

INR reduction with FFP

ALiEM - Aug 21, 2021 - By: Mike O'Brien and Bryan D. Hayes
Bottom Line
  • A unit of FFP has an INR of ~1.1, but this doesn’t mean it can easily normalize the INR.
  • There is a non-linear relationship between percentage of clotting factors and the INR, resulting in diminishing returns from each unit of FFP as the INR decreases.
  • Very large doses of FFP may be required to fully correct an elevated INR, which frequently precludes its use.
  • Complete normalization of the INR is not required to achieve hemostasis or prevent bleeding from a procedure.

Tuesday, August 17, 2021

Cannabinoid Hyperemesis Syndrome

canadiEM - By Harrish Gangatharan - August 17, 2021
Take Home Points
  1. Think of marijuana use when seeing young adults with abdominal pain. Majority of marijuana related hospitalizations exclusively occur in the young adult population 15-25 years old. 
  2. Significant stigma and reluctance to admit any cannabinoid use is a common characteristic of cannabinoid hyperemesis syndrome.
  3. Cannabinoid hyperemesis syndrome and cyclical vomiting syndrome are similar and sometimes temporally linked syndromes.
  4. Edible cannabis products can still be associated with cannabinoid hyperemesis syndrome. 
  5. Low dose haloperidol < 2 mg IV can be safely used with cannabinoid hyperemesis syndrome.

Acute Compartment Syndrome

emDOCs Podcast Episode 35 – August 17, 2021 - By Brit Long
Key Points
  • Compartment syndrome is a time-sensitive surgical emergency caused by increased pressure within a closed compartment. 
  • ACS is associated with a number of risk factors but occurs most frequently after a fracture or trauma to the involved area.
  • Pain out of proportion to the injury, paresthesias, pain with passive stretch, tense compartment, focal motor or sensory deficits, or decreased pulse or capillary refill time are signs and symptoms concerning for ACS.
  • Pain is the earliest finding in patients with ACS, but findings on history and exam cannot rule out the diagnosis.
  • Measurement of intracompartmental pressures using a pressure monitor is the most reliable test.
  • Treatment involves analgesia, removing constrictive dressing, placing the limb at heart level, and surgical consultation for emergent fasciotomy.

Monday, August 16, 2021

emDocs - August 16, 2021 - By Timothy Wong and Linda Katirji
Reviewed by: Alex Koyfman; Brit Long; Summer Chavez
Main Points:
  1. Patients who have non-improving symptoms despite treatment, persistent abnormal vitals including SpO2 <88% (in COPD) or <93-94% (in asthma), or a new dysrhythmia should be admitted. Those with worsening hypoxia, respiratory acidosis, severe dyspnea requiring assisted ventilation, mental status changes, or hemodynamic instability requiring vasopressors should be admitted to the ICU.
  2. History of any asthma exacerbation within the last 1 year predicts need for MV in acute asthma exacerbation. GCS<8, acidemia (pH<7.2), and APACHE II score >23 predicts need for MV in AECOPD.
  3. Patients with concurrent pneumonia or cardiac disease should be considered for admission. Consider a patient’s understanding of their own illness and ability to access medications and follow-up prior to discharge even if he or she improves in the ED.
  4. Provide counseling on smoking cessation and offer nicotine-replacement therapy to patients in the ED with acute COPD to reduce the risk for future exacerbations and to reduce mortality.

Sunday, August 15, 2021

Compartment Syndrome Diagnostics

TAMING THE SRU
Taming The SRU - August 15, 2021 - By Tianna Negron
SPECIAL CONSIDERATIONS
  • Open fractures DO NOT exclude the possibility of compartment syndrome
  • Reversal or factor replacement should be considered for patients on anticoagulants, and factor replacement for patients with Hemophilia; Hematology should also be consulted for these patients
  • In patients who are obtunded, cognitively impaired, intoxicated, or otherwise unable to give reliable history, there should be much lower threshold to check pressures when there are concerning physical exam findings or clinical suspicion
  • Consider this diagnosis in patients with increasing analgesic requirements who have had extremity trauma, injury, or recent surgery
  • In patients who have borderline elevated compartment pressures with high clinical suspicion based on history / mechanism, consider hourly serial examinations to observe for increasing versus decreasing pressures

Thursday, August 12, 2021

Normal saline and balanced IV fluids

First10EM - By Justin Morgenstern - August 11, 2021
Do you have strong opinions about normal saline? If so, you might need a hobby, but also this paper is for you. The BaSICS trial is a massive RCT with more than 10,000 patients comparing normal saline to a balanced crystalloid IV fluid.
The paper
Zampieri FG, Machado FR, et al. Effect of Intravenous Fluid Treatment With a Balanced Solution vs 0.9% Saline Solution on Mortality in Critically Ill Patients: The BaSICS Randomized Clinical Trial. JAMA. 2021 Aug 10. doi: 10.1001/jama.2021.11684. PMID: 34375394 [free full text]
Bottom line
This is the best and largest study of normal saline and balanced IV fluids to date, and it is pretty clear that normal saline is as safe as the balanced fluid. (Whether providing either IV fluid to these patients is beneficial is a completely different question.) Continue to use whatever is easiest for your team. I still almost always use saline myself.

Monday, August 9, 2021

Nailbed Injuries

emDocs - August 09, 2021 - By Erik Sherman and Chen He
Reviewed by: Edward Lew; Alex Kaufman; Brit Long
Clinical Pearls:
  • For all nailbed injuries, perform a thorough exam to assess neurovascular status and identify involved tissue, and obtain an X-ray to rule out underlying phalanx fractures.
  • Consider trephination alone instead of nail removal – even for large subungual hematomas – so long as the nail fold edges are intact and there is no underlying displaced phalanx fracture.
  • Lacerations to the nailbed can be repaired effectively with similar outcomes using either absorbable sutures or tissue adhesive.
  • Replacement of the nail or use of another material to splint the nail fold after repair remains controversial, and ongoing studies hope to provide a clearer management plan.
  • Antibiotic prophylaxis is not generally indicated in patients with nailbed trauma with simple open distal phalanx fractures (of note: controversial).

Multiple myeloma

First10EM - By Justin Morgenstern - August 9, 2021
In the Rapid Review series, I briefly review the key points of a clinical review paper or two. The topic: Multiple Myeloma
The papers: 
  • Nau KC, Lewis WD. Multiple myeloma: diagnosis and treatment. Am Fam Physician. 2008 Oct 1;78(7):853-9. PMID: 18841734
  • Eslick R, Talaulikar D. Multiple myeloma: from diagnosis to treatment. Aust Fam Physician. 2013 Oct;42(10):684-8. PMID: 24130968
There is not much to do in the emergency department, aside from treating the patient’s presenting complaint and managing hypercalcemia or acute renal failure (if present). Renal impairment is very common, and so NSAIDs should be avoided (which is important as pain is the most common presenting complaint). Patients will get an oncology referral. Many patients (those without symptoms) are not treated at all, as earlier treatment does not improve mortality but does increase the risk of acute leukemia.

Thursday, August 5, 2021

Cerebral Venous Thrombosis

EMCritRACC
EMCritRACC - August 5, 2021 - By Scott Weingart
“You are going to see it referred to by many names: Cerebral Venous Thrombosis (CVT), Venous Sinus Thrombosis (VST), Cavernous Sinus Venous Thrombosis (CSVT)–all a little bit different but within a spectrum of disease we will talk about today. This is a rare cause of headache, but if you do not have a disease script for this diagnosis, you will miss it! Without the right treatment the patient will get much worse, but if you do think about it and diagnose it, these patients can do very well.To talk about CVT, I have brought on new EMCrit Team Member, Casey Albin…”

NMS

EMPills - By Davide Tizzani - 5 Agosto 2021
…”La sindrome maligna da neurolettici (NMS) è un condizione medica potenzialmente letale, generalmente correlata all’utilizzo di agenti antidopaminerigici (in primis Neurolettici) o all’improvvisa sospensione di agenti dopaminergici.
Virtualmente tutti gli antipsicotici (i tipici di prima generazione o gli atipici di seconda generazione), in range terapeutico, possono determinare un tale quadro clinico caratterizzato da alterazioni dello stato mentale, ipertermia, rigidità e disfunzione autonomica. La NSM può avvenire in qualsiasi momento della terapia, senza necessaria overdose acuta del farmaco.
Perchè conoscerla?
La NMS Rappresenta una reale emergenza medica life-threatening ed è spesso una sfida diagnostica a causa della sua relativa rarità (0.01-0.04% fra le persone esposte a neurolettici), dell’assenza di veri e propri criteri diagnostici e della eterogeneità della presentazione clinica (insorgenza, decorso ed outcome). Per tale motivo la NMS è, infine, una diagnosi di esclusione…”

Wednesday, August 4, 2021

Cardiac Tamponade

TAMING THE SRU
TAMING THE SRU - August 04, 2021 - By Anita Goel
… “This question of tamponade or no tamponade can be answered through the use of more comprehensive transthoracic echocardiography (TTE) with 2D images obtained in standard parasternal long and short axis, subcostal, and apical four chamber views, as well as using M-mode and Doppler analysis of blood flow. Bedside echocardiography for pericardial effusions should include a comprehensive evaluation in all 4 standard views. Specifically, the provider should evaluate for size of the effusion, location of the effusion (global vs localized), and signs of cardiac tamponade (1). Echocardiographic findings of cardiac tamponade include:
  • Diastolic collapse of the right atrium and right ventricle
  • Excessive respiratory variation of the inflow velocities over the mitral and tricuspid valves
  • Lack of respiratory variation of the IVC diameter.
For a complete review of how to obtain these types of images, please see Dr. Murphy’s post from February of 2018 discussing cardiac tamponade…”

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.