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SOBRE EL AUTOR **

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

WORLD EMERGENCY MEDICINE SOCIETIES

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Contenido:

viernes, 22 de junio de 2018

Mechanical Ventilation

R.E.B.E.L. EM - Emergency Medicine Blog
Simplifying Mechanical Ventilation
REBEL EM - By Frank Lodeserto - March 8-18 & June 18-22

Methemoglobinemia

The Tox and The Hound (EMCrit)
EMCrit - June 22, 2018 - By Steve Curry
..."A 2012 report out of Oregon serves as one of many examples reminding us that some serious cases of methemoglobinemia require more than a single injection of methylene blue in the ED or ICU. I thought this might be a good opportunity to describe our approach to this problem.
This Feb 10, 2012 issue of MMWR describes two men who drank what they believed to be 2C-E, a.k.a. 4-ethyl-2,5-dimethoxyphenethylamine..."

miércoles, 20 de junio de 2018

DOAC Reversal

 R.E.B.E.L. EM - Emergency Medicine Blog
Rebellion in EM - June 20, 2018 - By Scott Wieters
"3 Questions to ask when Dealing with a Patient Bleeding from DOACs:
  1. When was the last time medication was taken?
  2. What is the half-life of the medication?
  3. What is the renal function? – Chronic kidney disease or acute kidney injury may make DOACs more potent
Shape of the TEG + Alcohol Glass = What is Needed:

Brandy Tumbler = Normal (Do Nothing)
Champagne Flute = Give Cryo
Red Wine Glass = Give Platelets
Martini Glass = Give TXA
Test Tube = Give Platelets

Take Home Messages for DOAC Reversal:
  • Xa Reversal Summary: 4 Factor PCC 50U/kg + TXA 1g IV –> Consider Andexanet Alpha when available –> In the Future Ciraparantag
  • IIa Reversal Summary: Idarucizumab 5g IV + TXA 1g –> If no Idarucizumab available, consider FEIBA 50U/kg –> In the Future Ciraparantag"

Button Battery

Resultado de imagen de life in the fast lane
Life in the Fast Lane - By Neil Long - Last updated June 20, 2018
"Button battery ingestion is one of the leading causes of death in paediatric poisoning and this has sharply risen from 2016 despite manufacturing warnings and the addition of tape to cover the negative side (not very useful once you’ve removed that to place it in your device). See Poison.org for more statistics. What makes button battery ingestion more frightening is the fact that the ingestion may go unwitnessed, the child may have vague symptoms like ‘off food’ and later haematemasis can result from erosion of the battery through the oesophagus and into the thoracic aorta..."
Example Algorithm
(from Dr Litovitz who has been monitoring more than 1100 battery ingestion annually):

martes, 19 de junio de 2018

Médico de urgencia

PORROs EM

PorrosEM - June 18, 2018 - By Dr. Po
"Siempre que le contaba a mis amigos y familiares que iba a hacer una residencia de urgencia saltaba un patrón de preguntas similares en cada uno de ellos: ¿Y es una especialidad? ¿Y dónde trabajan? ¿Pero eso no lo hacen los médicos generales?. La verdad es que no me molestaba (no tenían porque saber), pero para ser completamente sincero al principio no tenía del todo claro que significaba ser un médico especialista en medicina de urgencia y menos aún acerca de como piensa uno de ellos.
Hay muchos conceptos dentro de la especialidad que se repiten constantemente, tales como: paciente indiferenciado, toma de decisiones, tiempo-dependiente, evaluación primaria, estratificación de riesgo y un largo etc, cada uno toca tangencialmente características que debería aprender un médico de urgencia a lo largo de su formación.
Les dejo una traducción de una entrada que aborda estos tema sacado del blog http://rebelem.com/the-em-mindset/ del excelentísimo Salim Rezaie
(Traducción autorizada por Salim Rezaie)..."

The EMN Salary Survey

Resultado de imagen de emergency medicine news
Emergency Medicine News: June 19, 2018 - Volume 40 - Issue 6B - p - By Lam, Jackie
doi: 10.1097/01.EEM.0000540078.65056.ba
click image to enlarge
"Emergency physicians board-certified in emergency medicine earn more than their non-EM-certified counterparts, perhaps reflecting a growing appreciation for the education and training found only in emergency medicine residencies. It appears to be no coincidence that as the percentage of board-certified EPs in our 2017 EMN salary survey increased to 85 percent—from 81 percent in 2015—more of them reported salaries in the highest income categories ($300,000 to more than $350,000) last year compared with two years before. And that's not all; fewer board-certified-EP salaries fell in the lower categories of $100,001-$300,000.
The gap between those with and without EM board certification in the highest income category in our survey has widened quite a bit. Close to 30 percent of board-certified EPs v. 18 percent of non-board-certified EPs made more than $350,000 in 2017, a 12-percent disparity, while 20 percent of board-certified EPs v. 16 percent of those not board-certified reported earning that much in 2015, a four-percent difference. The hourly rate data we added this year revealed a much starker reality of the disparity between these two groups. You can find more in our Salary Survey blog at http://bit.ly/EMNSalarySurvey..."

lunes, 18 de junio de 2018

Refractory Status Epilepticus

Logo
emDocs - Jun 18, 2018 - Authors: DeVivo A and Beck-Esmay J
Edited by: Koyfman A and Long B
"Key Points
  • Keep a broad differential in patients who present in refractory status epilepticus and use all modalities of history available to discern and treat the most likely etiology. Small pieces of history can vastly change management.
  • Patients who require intubation and sedation should be frequently re-assessed for signs of persistent seizure activity and an EEG should be obtained as soon as possible in an intensive care setting once the initial ED workup is complete.
  • After the ABCs, one of the initial diagnostics ordered should be a point of care glucose.
  • After initial stabilization, an EKG should be performed on all patients in status epilepticus.
  • A core temperature should always be obtained.
  • Any signs of trauma should raise clinical suspicion for intracranial pathology as the etiology of the seizures.
  • History of recent febrile illness and seizures should prompt all ED staff to take appropriate precautions in order to avoid transmission of communicable disease in the event meningitis is the etiology. Provider and ED staff safety is paramount, regardless of the situation.
  • Patients with a history of seizures can easily lead to anchoring on medication noncompliance as the etiology of their status epilepticus. However, these patients can easily have multifactorial etiologies for their presentation, and caution is warranted when attributing persistent seizures to medication nonadherence."

Bicarbonate in Cardiac Arrest

R.E.B.E.LEM - June 15, 2018
"Author’s Conclusions:
“The use of sodium bicarbonate improved acid-base status, but did not improve the rate of ROSC and good neurologic survival. We could not draw a conclusion, but our pilot data could be used to design a larger trial to verify the efficacy of sodium bicarbonate.”
Our Conclusion:
We agree with the authors conclusions. While the use of NaHCO3 improved the surrogate endpoint of acid-base status, there was no patient centered improvement seen in this study.
Potential to Impact Current Practice:
This small pilot study should not change clinical practice. Indiscriminate use of NaHCO3 in cardiac arrest should not be performed. However, providers should continue to use their judgement as to which patients with arrest may benefit from NaHCO3.
Bottom Line:
The use of NaHCO3 does not appear to improve clinically meaningful outcomes. A larger study should be undertaken to further evaluate this clinical question."

miércoles, 13 de junio de 2018

Airway Update

EMCrit RACC
EMCrit Podcast 226 - June 13, 2018 - By Scott Weingart
Bougie First?"A recent RCT from Hennepin by Driver et al. evaluated the effect of bougie use on first pass success. This adds to a prior retrospective study by the same group. These studies lend support to a practice that many of us have already adapted–bougie first intubation..."

martes, 12 de junio de 2018

PE Decision Rules

EM sandbox - June 8, 2018 - By jfhine
"In this podcasts we review the literature and discuss the decision rules crafted for the work up of pulmonary embolism- Wells, PERC, and the new kid on the block YEARS. It is a lot of content, so we also broke down the talk by decision rule."

lunes, 11 de junio de 2018

Infusions of beta-lactam in sepsis

PulmCCM
PulmCCM - June 7, 2018
"Infusing antipseudomonal beta-lactam antibiotics over longer periods could save lives in sepsis over intermittent bolus dosing, according to a systematic review and meta-analysis of randomized trials.
Vardakas et al aggregated data from studies of patients with sepsis receiving infusions of carbapenems, cephalosporins, and penicillins with antipseudomonal activity. Studies included compared prolonged infusion (over at least three hours), vs. hour-long infusions or shorter. They included 22 randomized trials with 1,876 patients.
Prolonged infusion of antipseudomonal beta-lactams reduced mortality by 30% compared with shorter infusions. Findings were published in Lancet Infectious Diseases..."

Corticoides en el paciente crítico

AnestesiaR -
AnestesiaR - By Isabel de la Calle Gil - 11 Junio 2018
Artículo original: Djillali Annane, Stephen M. Pastores, Bram Rochwerg, Wiebke Arlt, Robert A. Balk, Albertus Beishuizen, et al. Guidelines for the diagnosis and management of critical illness-related corticosteroid insufficiency (CIRCI) in critically ill patients (Part I and II). Society of Critical Care Medicine (SCCM) and European Society of Intensive Care Medicine (ESICM) 2017 (HTML)
...En lo que se refiere al tratamiento, en función de la condición específica por la que se desarrolla el CIRCI:
  • No recomiendan la administración de corticoesteroides en pacientes sépticos en ausencia de shock.
  • Recomiendan el uso de hidrocortisona intravenosa <400 mg/día durante ≥3 días a dosis plenas en pacientes con shock séptico que no responden a fluidoterapia ni a dosis moderadas-elevadas de vasopresores.
  • Recomiendan el uso de metilprednisolona intravenosa 1 mg/kg/día en pacientes con síndrome de distrés respiratorio agudo (SDRA) precoz (hasta el 7º día desde su inicio) moderado-severo (PaO2/FiO2 < 200); y en SDRA tardío (después del 6º día de inicio), metilprednisolona intravenosa 2 mg/kg/día; seguidos ambos de un descenso paulatino durante 13 días. Se recomienda metilprednisolona porque penetra mejor en el tejido pulmonar y permanece más tiempo.
  • No recomiendan el uso de corticoesteroides en pacientes con trauma severo.
  • En neumonía adquirida en la comunidad, recomiendan el uso de corticoides durante 5-7 días a una dosis diaria de menos de 400 mg de hidrocortisona intravenosa.
  • Recomiendan no usar corticoides en la gripe.
  • Recomiendan el uso de corticoides en meningitis bacteriana, en pacientes con circulación extracorpórea y en pacientes que han sufrido parada cardíaca."

lunes, 4 de junio de 2018

Nuclear Attack

Resultado de imagen de aliem academic life in emergency medicine
June 4th, 2018 - By: Tenner A and Reilly A
"Ever wonder what would happen if you were working in the emergency department (ED) when a nuclear attack happens? We’ve all had questions on boards or inservice exams about the long-term effect of radiation exposure, but would you know what to ACTUALLY DO if a nuclear attack happened? What do you do in the first few minutes? First few hours? We know that if you are in the immediate bomb vicinity, there is not much you can do. But what if you are 5 miles away? Or 10 miles?
If you look for information regarding nuclear attacks, there are no great summary resources on what to do in the immediate aftermath if you are in the ED. In order to bring this to you in an easily digestible format, we have broken this post up into a few topic areas: This blog post will cover (1) what physically happens in a nuclear attack and (2) what this means in the ED..."

EXTEND-IA TNK

R.E.B.E.L.EM - June 4, 2018
"Author’s Conclusions: “Tenecteplase before thrombectomy was associated with a higher incidence of reperfusion and better functional outcome than alteplase among patients with ischemic stroke treated within 4.5 hours after symptom onset.”
Our Conclusions: Tenecteplase results in improved perfusion after thrombectomy compared to alteplase but only in patients that undergo endovascular intervention. Additionally, the rates of reperfusion prior to thrombectomy were low in both groups (22% in telecteplase vs 10% in alteplase group). There are no differences in clinically significant outcomes.
Potential Impact to Current Practice: This study only applies to a small subset of patients with strokes (ischemic, large-vessel, undergoing thrombectomy) so there is unlikely to be a difference in large population outcomes. However, hospital stroke outcomes are of increasing importance so if tenecteplase costs less and requires less time to administer, this data may lead to a shift in management.
Bottom Line: Neither alteplase or tenecteplase are very effective in significant vessel reperfusion. Though alteplase is the drug of choice currently in ischemic stroke, tenecteplase may provide more cost-effective and time-efficient option."

Dantrolene

EMCrit
EMCrit - June 4, 2018 - By Sarah Shafer
"Dantrolene is one of the few, true “muscle relaxers”. It was discovered in 1967 and approved by the FDA in 1979. Unlike paralytic neuromuscular blockers, dantrolene works post-synaptically, at the sarcoplasmic reticulum in the myocyte. It binds to the ryanodine receptor in skeletal muscle (RYR1), preventing sarcoplasmic calcium-induced calcium release.
When RYR1 works normally, calcium gets released from the sarcoplasmic reticulum and binds to troponin, exposing actin. This allows myosin to bind with actin to produce muscle contraction. When there is too much calcium, it causes excess muscle contraction. Without enough calcium, myosin is blocked from binding to actin. When dantrolene is at steady-state in healthy human volunteers, it produces a 75% reduction in muscle twitch without full paralysis. It reduces grip strength in volunteer subjects by over 50%, taking 20 hours to return to normal. Residual weakness can persist for up to 48 hours. [Flewellen 1983 PMID: 6614536]..."

jueves, 31 de mayo de 2018

Cauda Equina Syndrome

R.E.B.E.L.EM - May 31, 2018
"Take Home Points
  • Cauda equina syndrome is a rare emergency with devastating consequences
  • Early recognition is paramount as the presence of bladder dysfunction portends bad functional outcomes
  • The presence of bilateral lower extremity weakness or sensory changes should alert clinicians to the diagnosis. Saddle anesthesia (or change in sensation) and any bladder/bowel changes in function should also raise suspicion for the disorder
  • MRI is the diagnostic modality of choice though CT myelogram can be performed if necessary
  • Prompt surgical consultation is mandatory for all patients with cauda equina syndrome regardless of symptoms at presentation"

miércoles, 30 de mayo de 2018

Infections

Logo
emDocs - May 30, 2018 - Author: Nicholas Smith and David Pillus
Edited by: Alex Koyfman and Brit Long
"Key Points
  • In some cases, antibiotics alone are not adequate for infectious source control.
  • Complete exposure and skin examis crucial in making the timely diagnosis of several life-threatening diseases.
  • For many of these infections, getting a surgeon on board as soon as possible is associated with source control and reduction in both morbidity and mortality.
  • Keep a broad differential in patients presenting with apparent infection without a source, and don’t forget the possibility of not readily apparent skin and soft tissue infections."

lunes, 28 de mayo de 2018

Epinephrine in Sepsis

PulmCrit (EMCrit)
April 25, 2016 - By Josh Farkas
"Summary: The Bullet
  • Epinephrine and norepinephrine are both acceptable, evidence-based approaches to hemodynamic support in septic shock.
  • Individual patient responsiveness to vasopressors is variable and unpredictable.
  • Some patients respond better to epinephrine than norepinephrine.
  • For patients who are not responding well to norepinephrine, it is reasonable to empirically trial a low dose of epinephrine (“epinephrine challenge”)."
titralgo

Penetrating Neck Injuries

R.E.B.E.L.EM - May 28, 2018
"Background: Patients with penetrating neck trauma can present with a variety of injury patterns including hemorrhagic shock, airway obstruction and neurologic injury. Serious injuries may not be clinically obvious making diagnosis and prompt treatment challenging. Due to the large number of critical structures in the neck, a clear knowledge of the anatomy is necessary for proper evaluation and management...
Take Home Points
  1. Penetrating injuries to the neck can damage a host of structures. Understanding the zones of the neck and the structures within them can help predict injuries
  2. If the platysma is violated, it should be assumed that deeper structures have been injured until proven otherwise
  3. Early airway management is crucial as injuries can lead to dynamic airway obstruction. Always be prepared for a surgical airway
  4. The presence of any hard signs of aerodigestive/neurovascular injuries (expanding/pulsatile hematoma, active brisk bleeding, hemorrhagic shock, massive subcutaneous emphysema, air bubbling through the wound, neurologic deficit) or violation of platysma, mandates an immediate OR trip. Do not delay the patient getting to the OR for additional studies
  5. Attempt to control vascular injuries with direct pressure and consider balloon tamponade with a foley catheter"

sábado, 26 de mayo de 2018

Surviving Sepsis Update

Written by Thomas Davis
 Intensive Care Med. 2018 Apr 19. doi: 10.1007/s00134-018-5085-0. [Epub ahead of print]

"The Surviving Sepsis Campaign has issued a new 1-hour bundle beginning at the time of triage in the emergency department. This replaces the current 3- and 6-hour bundles...
Why does this matter?
Although the 2016 Surviving Sepsis Campaign guidelines state that “Recommendations from these guidelines cannot replace the clinician’s decision-making capacity when presented with a patient’s unique set of clinical variables,” the regulatory reality is less deferential to your clinical acumen. The Centers for Medicare and Medicaid Services (CMS) has adopted the 3- and 6-hour bundles as rigid core measures, which severely impact hospital reimbursement. Just as you may be getting used to the current bundles, you may want to read the 1-hour bundle summary below as this will likely be the new CMS standard."

 From cited article

Emergency Medicine Day

"27 May is introduced as the Emergency Medicine Day and promoted by the EUSEM globally. The aim of this day is to unite the world population and decision makers to think and talk about emergency medicine and emergency medical care.
We believe it is important to build awareness about the need for well developed, well prepared and well organised emergency medical systems everywhere in the world to increase survival and reduce disability after any kind of urgent or emergent medical situation.
On 27 May, we encourage citizens, patients, health care personnel, and institutions all around the world to talk about emergency medicine and make projects for a year of progress in the discipline.
Where the specialty in emergency medicine is not yet developed, where emergency medical systems are not well structured, where competences are not standardized and certified, where resources for emergency medicine are insufficient, there should be a strong voice to ask and claim for a change, for a better life.
Because “competence makes the difference”.

viernes, 25 de mayo de 2018

Hyponatremia in the ED

An online community of practice for Canadian EM physicians
CanadiEM - By Andrei Smarandache - May 22, 2018
"Electrolyte imbalances like hyponatremia can be the cause of a variety of vague complaints. At the same time, patients may present with electrolyte abnormalities that are asymptomatic and are incidental findings on bloodwork. Here’s an approach to deciding when and how to treat hyponatremia in the emergency department..."
Approach to Hyponatremia

SICKLE CELL IN THE ED

EMOTTAWA
EMOTTAWA - By: Adam Parks - May 24, 2018
"Sickle Cell Disease (SCD) is a complex medical entity, associated with significant morbidity and mortality. Patients with SCD suffer from acute and chronic pain, along with a seemingly endless list of additional complications (from hemolysis and sequestration, to aplastic crises and acute chest syndrome). The associated morbidity of SCD is apparent, but these patients also have an alarming decrease in life expectancy, with recent estimates ranging from 28-49 years. Nationally, there is an estimated 5000 patients who suffer from SCD in Canada, and this number is likely to quickly increase given high rates of immigration from countries with high prevalence of SCD, combined with the increased survival associated with improved medical care.

From an Emergency Department (ED) perspective, many providers find the disease and its associated complications challenging and cumbersome. This summary will provide an abbreviated approach to SCD pathophysiology, vaso-occlusive pain crisis (VOC), and acute chest syndrome (AChS) in the ED..."

Corticosteroids in Pharyngitis

R.E.B.E.L.EM - May 24, 2018 - By Allon Mordel
Clinical Question:
Do single, low dose corticosteroids provide symptomatic relief in undifferentiated pharyngitis without significant adverse effects?
Author’s Conclusions:
“Single low dose corticosteroids can provide pain relief in patients with sore throat, with no increase in serious adverse effects.”
Our Conclusions:
Of all the outcomes, only the complete resolution of symptoms at 48 hours is backed by high quality evidence and a narrow confidence interval. Steroids also appear to provide only a moderate improvement in time to and degree of resolution of symptoms. However, in the setting of severe symptoms, these moderate improvements could make a significant difference.
Potential to Impact Current Practice:
This study validates prior studies suggesting corticosteroids offer therapeutic benefit in the management of sore throat. Clinicians should strongly consider adding a single dose of corticosteroids to their treatment regimen for patients with pharyngitis.
Bottom Line:
In cases of severe pharyngitis, single low dose corticosteroid administration would likely provide symptomatic benefit that outweigh potential adverse effects.

lunes, 21 de mayo de 2018

ACEP 2018: Acute VTE

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

sábado, 19 de mayo de 2018

Lokelma


Resultado de imagen de european medicines agency

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