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


Noxious or Nociceptive Stimuli in Neurologic Evaluations (The Soto Saline Sign)

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miércoles, 18 de enero de 2017

Modified Centor Score

An online community of practice for Canadian EM physicians
CanadiEm - By Richard Tang - January 18, 2017 
"Upper Respiratory Infection symptoms like cough or sore throat are still some of the top reasons for Canadian emergency department visits, and will likely be even higher in the upcoming months and in Urgent Care Centres. The most common organisms responsible for uncomplicated acute pharyngitis are viral agents at 50-80% and Streptococcal agents, specifically Group A Beta-Hemolytic Strep, at 5-36%. It is clinically significant to differentiate between these two pathogens as patients with the latter would benefit from antibiotic therapy, and patients with the former should not have antibiotic therapy due to deriving no benefit...
The Bottom Line: 
In summary, the Modified Centor Score is a quick, reliable and useful bedside tool to gauge the risk of streptococcal pharyngitis in a patient with sore throat complaints. As a firm believer keeping mnemonics simple, I recommend to just use the name of the score (M-CENTOR) as the mnemonic!"


Autores: Juan José Pajuelo Castro y José Carlos Meneses Pardo
"Los sucesos recientes, ya no solo en países en conflicto, si no en territorio europeo como los acaecidos en Francia, Bélgica o Alemania, nos hacen pensar que debemos adaptarnos a una nueva amenaza creciente y global y, por lo tanto, a un nuevo cambio de paradigma asistencial. Para hacer frente a este tipo de incidentes a nivel asistencial y operativo, el 2 de Abril de 2013 representantes de un grupo selecto de instituciones de seguridad pública incluyendo policía, bomberos, profesionales de asistencia prehospitalaria, asistencia al trauma y militares, se reunieron en Hartford, Connecticut, para llevar a cabo un consenso en relación a las estrategias para mejorar la supervivencia en incidentes con armas de fuego con múltiples víctimas. Esta reunión dio como resultado un documento conocido como Consenso Hartford. Posteriormente, en la última reunión de 2016 presidida por Lenworth M. Jacobs, Jr., MD, MPH, FACS del Colegio Americano de Cirujanos (ACS), se concretaron los pasos para crear una política conjunta sobre formación y el posicionamiento del material necesario para el manejo de la hemorragia masiva en lugares de afluencia masiva de personas y, para establecer un lenguaje común a nivel nacional entre todos los escalones asistenciales. Con esta y otras estrategias, como por ejemplo el proyecto Stop the Bleed del ACS y de la Casa Blanca, se intentan potenciar el papel del “interviniente inmediato” (ciudadano) y del primer interviniente a la hora de controlar la hemorragia de manera precoz en el mismo lugar del incidente. Esta política tiene además como objetivo, disminuir la tasa de mortalidad en todos los escalones asistenciales de aquellos pacientes que presenten una hemorragia masiva. Se espera que las recomendaciones que se presentan a continuación sirvan de guía para todo aquél que se pueda ver involucrado en incidentes intencionados con múltiples víctimas y con tiradores activos, a la hora de enfrentarse al manejo de las principales causas de muerte evitable que se producen en este tipo de circunstancias."

lunes, 16 de enero de 2017

Mg+ for COPD/Asthma

Mizzou EM - January 16, 2017 - By mizzouem 
"In what populations does intravenous or nebulized magnesium sulfate provide benefit?
The research on the benefit of magnesium sulfate- either intravenous or nebulized- for the treatment of acute exacerbations of asthma and COPD are scattered and of varying quality, sample size, and relevance to the US population. However, there does appear to be some support of use of intravenous magnesium in the treatment of asthma and potentially for COPD exacerbations– although the volume data on the latter is even more lacking. There did not, however, appear to be any significant adverse effects of magnesium infusion or inhaled therapy in the studies evaluated, suggesting that it may be worth consideration in patients who do not demonstrate significant improvement with initiation of standard therapy."

sábado, 14 de enero de 2017

Morphine Mortality in APE

Resultado de imagen de emergency medicine news
Runde D. EM News 2016; 38 (11): 31–31
doi: 10.1097/01.EEM.0000508278.78193.16
..."The most compelling and certainly the most cited article on morphine for APE was performed by W. Frank Peacock IV, MD. (Emerg Med J 2008;25[4]:205.) Before looking at the paper, we need to acknowledge how awesome his name is. This was a retrospective analysis of the Acute Decompensated Heart Failure National Registry (ADHERE) that compared the records of 20,782 hospitalizations for APE where the patient received IV morphine with 126,580 hospitalizations where the patient was not given morphine. The quick summary is that the patients who received IV morphine did worse in essentially every way, but I'll summarize the high points here:
  • Need for intubation: 15.4 percent in the morphine group vs. 2.8 percent in the no-morphine group (NNH=8).
  • Need for ICU admission: 38.7 percent in the morphine group vs. 14.4 percent in the no-morphine group (NNH=5).
  • Mortality: 13.0 percent in the morphine group vs. 2.4 percent in the no-morphine group (NNH=10).
... the take-home point should be pretty clear, but just to summarize one more time: Do not give morphine to patients with acute pulmonary edema. Perhaps someday a study will give us cause to revisit this issue, but until then I'll hold the morphine rather than holding my breath."

2016 in Review (MEDEST)

MEDEST - Gen 12, 2017
"2016 has been a great year for Emergency Medicine.
MEDEST on a daily base, via Twitter or Facebook, shared the best (for us) Emergency Medicine articles coming from the net.
At the beginning of a new year we would like to share a collection of those articles (all free full text) organised by topics.You can browse freely for research or educational proposal
I hope you’ll enjoy. 2016 Review by topic
You can also find articles from previous years on this page MEDEST Review’s"

PTSD for Emergency Physicians

EMOttawa - January 12, 2017 - By Valerie Charbonneau
"For many of us in Emergency Medicine, PTSD is something we don’t really think about. We might pause before using ketamine for sedation in a war veteran, or seek psychological support for victims of sexual assault, but it is not a topic that we usually discuss or associate with. It certainly isn’t something that we feel threatens us and our careers.
However studies using standardized and validated tools have shown a point prevalence of PTSD in German and Belgian emergency physicians, Dutch hospital physicians and Vancouver ED staff to be approximately 15%. By comparison, the lifetime prevalence of PTSD in the Canadian population is approximately 2.4% so a point prevalence of 15% is extremely high. 
Though initially surprising, these numbers start to make sense when we think about the types of cases that emergency physicians handle regularly: pediatric injuries and arrests, sexual assaults, graphic traumas, failed resuscitations. We are exposed daily to things that would scar most people. 
And yet we do not talk about occupational stress injuries, do not train for resiliency, and often fail to recognize distress in a colleague and even in ourselves. After all, we are physicians, we should be better and stronger than this right?..."

jueves, 12 de enero de 2017

Olanzapine IV

PulmCrit- January 11, 2017 - By Josh Farkas
"The potential role for IV olanzapine was examined in a post last year. The following conclusions were reached:
  • IV olanzapine appears to be safe.
  • IV olanzapine has equal potency compared to IV droperidol and about twice the potency of IV haloperidol.
  • Olanzapine doesn’t affect QT interval or cause torsade de pointes.
Two articles were just published in the Annals of Emergency Medicine about intravenous olanzapine. What does the new evidence show?
  • These studies validate the safety of IV olanzapine (now demonstrated in four studies including administration to 1,237 patients).
  • IV olanzapine has an efficacy equal to IV droperidol, and probably about twice as potent as IV haloperidol.
  • Addition of IV midazolam to IV droperidol hastens achievement of sedation, but this may come at the cost of increased respiratory suppression."

Acute dyspepsia

An online community of practice for Canadian EM physicians
CanadiEM - By Colin Siu - January 10, 2017
..."While not the sexiest of topics, this post underscores the importance of looking up the literature on the basics. Patients with dyspepsia are not uncommon and, while we must always diligently rule out more dangerous causes (depending on the patient’s age and the particulars of their presentation, things like Acute Coronary Syndrome, Pulmonary Embolism, Pneumothorax, Pericarditis, Pancreatitis, Cholecystitis, and more may be on your list of things to ‘rule out’!), sometimes it is the diagnosis that is most likely at the end (and beginning!) of the work-up. You would think that we have a great evidence-based approach to its management, but as this post shows the treatments that we provide are more often steeped in dogma and tradition than they are evidence...
The Bottom Line
Most of the evidence points towards initial management of acute dyspepsia with an oral antacid. There does not seem to be additional benefits to using a GI cocktail or Pink Lady over antacids alone. If symptom relief is not achieved with an antacid, a trial of intravenous or oral H2-receptor antagonists may be considered. In patients that have not responded to antacids or H2-receptor antagonists in previous dyspeptic episodes, a trial of IV proton-pump inhibitors may be considered. However, intravenous proton-pump inhibitors are not recommended for concurrent use with antacids, given the former is an acid-activated pro-drug."

martes, 10 de enero de 2017

Top 10 Clinical Posts (ALiEM)

ALiEM - January 8th, 2017 - By Bryan D. Hayes
"Seasons greetings from the ALiEM team. We have been publishing so many posts this year that you may have missed a few. Did you catch at least the top 10 most-read ALiEM clinical posts, which were published in 2016? These include some Tricks of the Track pearls and clinical tips in toxicology, orthopedics, and neurology. Check them out."

Sepsis Biomarkers

emDocs - January 9, 2017 - Author: Long B -  Edited by: Koyfman A
"Key Points:
  • Biomarkers cannot replace the bedside clinician, but they may assist clinical decision making, risk stratification, and prognostication. Lactate has the best evidence in sepsis.
  • Lactate is useful for assessing severity, screening, and resuscitation. However, it is not always elevated in sepsis. Venous POC levels are recommended.
  • Procalcitonin is a marker of bacterial versus viral It is not associated with mortality benefit, but may reduce antibiotic usage. PCT requires further study in the ED.
  • Troponin can be elevated in many conditions and is associated with worse prognosis in sepsis. Sepsis cardiomyopathy is more common than many providers realize.
  • Biomarkers on the horizon include endothelial activators, acute-phase reactants, BNP/NT-proBNP, and proadrenomedullin."

Intraosseous in Obese Patients

R.E.B.E.L.EM - January 9, 2017 - By Anand Swaminathan
Peer Reviewed By: Salim Rezaie
Intraosseous (IO) access can play an important role in the resuscitation of the critically ill patient to help expedite delivery of critical medications (i.e. RSI). Much like with peripheral or central access, obesity can present a challenge to placement of an IO as accurate placement relies on use of landmarks which may not be palpable in this group. Additionally, increased soft tissue depth may render standard needles ineffective. IO needles require 5 mm of excess length from skin to bony cortex to ensure successful placement (i.e. maximal depth of 20 mm for a 25 mm needle). Studies investigating these questions are necessary in order to understand how reliable IO access will be in obese patients.
Author’s Conclusions:
“In obese adults with a palpable TT or BMI ≤43 a 25mmIO needle is likely adequate at the proximal and distal tibial insertion sites. Empiric use of an extended 45mmIO needle is advisable at the proximal humeral insertion site in obese patients.”
Potential Impact to Current Practice:
In obese patients, it is reasonable to reach for the 45 mm IO needle instead of the 25 mm needle to ensure adequate length to obtain access. The 45 mm IO needles can be used at any site regardless of depth as long as the provider does not “bury the needle.” Placement until the needle penetrates the cortex (possibly leaving some portion of the needle protruding from the skin) will provide IO access at all three common sites.
Bottom Line:
The 25 mm IO needle may not provide proper length for obtaining IO access in obese patients. Consider reaching for the 45 mm IO needle in these patients particularly if you cannot palpate the tibial tuberosity."

Torsades de Pointes

First10EM - Justin Morgenstern - January 9, 2017
"Torsades de pointes is a ventricular tachycardia. In the unstable patient, cardiovert. In the pulseless, defibrillate. (The polymorphic nature of the rhythm may interfere with the defibrillator’s ability to synchronize, so cardioversion may not be possible. In that case, in the unstable patient, deliver an unsynchronized shock.)
What do you do if the patient is stable? I think it is reasonable to electrically cardiovert stable ventricular tachycardia, but you can also attempt to treat it medically. Torsades de pointes is caused by a prolonged QT. Almost all of the antiarrhythmics that we normally use to treat ventricular tachycardia, such as amiodarone and procainamide, will prolong the QT further, and therefore can make your patient worse. Do not give amiodarone or procainamide. The medical treatment for stable torsades de pointes is magnesium..."

Opioids in the ED

Your Boot Camp Guide to Emergency Medicine
EM Basic - By Dr. Sheyna Gifford
"It’s no secret that we have a major opioid problem in the United States. The number of people addicted to opioids has reached epidemic proportions and we are certainly seeing this everyday in the Emergency Department. In this episode Dr. Sheyna Gifford discusses a few facts about the scope of this epidemic, the basics of recognizing opioid overdose, and initial stabilization and treatment. She’ll discuss the many different ways of using naloxone (aka Narcan) that we can utilize to wake up patients safely and without precipitating acute withdrawal.
In part 2, Dr Sheyna Gifford will discuss the how to differentiate opioid overdose from other causes of altered mental status, some special disposition situations (especially with methadone), and how we can quickly screen for opioid abuse and provide patients compassionate care, treatment, and referral."

lunes, 9 de enero de 2017

Potential spinal injury

Biomed Central
Kornhall D et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2017; 25:2 - DOI: 10.1186/s13049-016-0345-x - Published: 5 January 2017
"The traditional prehospital management of trauma victims with potential spinal injury has become increasingly questioned as authors and clinicians have raised concerns about over-triage and harm. In order to address these concerns, the Norwegian National Competence Service for Traumatology commissioned a faculty to provide a national guideline for pre-hospital spinal stabilisation. This work is based on a systematic review of available literature and a standardised consensus process. The faculty recommends a selective approach to spinal stabilisation as well as the implementation of triaging tools based on clinical findings. A strategy of minimal handling should be observed.
This guideline, based on consensus and the best available evidence, is an attempt to address concerns about over-triage, harms and costs associated with the traditional management of potential spinal injury. The faculty found no reason to abandon the current doctrine of spinal immobilisation in patients with potential spinal injury. We do, however, recommend implementing pre-hospital triaging tools as well as maintaining a selective approach to the use of the various stabilisation devices."

IV Fluis in Trauma

World Journal of Surgery
Robert Wise et al. World Journal of Surgery. Jan 2017 - DOI 10.1007/s00268-016-3865-7
Intravenous fluid management of trauma patients is fraught with complex decisions that are often complicated by coagulopathy and blood loss. This review discusses the fluid management in trauma patients from the perspective of the developing world. In addition, the article describes an approach to specific circumstances in trauma fluid decision-making and provides recommendations for the resource-limited environment
Fluids are drugs and should be managed as such. Appropriate early fluid resuscitation in trauma patients is a challenging task. Care should be taken in selecting both the type and volume to promote appropriate perfusion and oxygen delivery, avoiding the adverse effects seen when giving too little or too much. Ongoing fluid strategies following resuscitation should incorporate dynamic markers of volume status whenever possible. All aspects of fluid administration should be incorporated into daily fluid plans, including feeding and infusions of medications. A sound knowledge of the differences and physiological consequences of specific trauma groups is essential for all practitioners delivering care for trauma patients.

domingo, 8 de enero de 2017

Acute Valvular Emergencies

emDocs - jan 6, 2017 - Authors: Zack J and Long B -  Edited by: Koyfman A
"Key Takeaways:
  • In patients presenting with sudden onset dyspnea, always keep a valvular emergency on the differential.
  • Murmurs may not be audible in the acute setting.
  • Definitive management is surgery more often than not, so get consultants on board early.
  • If you have a sick patient with a native valve emergency consider nitroprusside +/- dobutamine.
  • If present, don’t forget to treat the underlying cause of aortic regurgitation (aortic dissection, endocarditis), mitral regurgitation (ischemia, endocarditis), or prosthetic valve emergency (endocarditis, thrombosis)."

Best of 2016 on PulmCCM

PulmCCM - Jan 06, 2017
"Happy New Year! PulmCCM posts will return soon. In case you missed them, here are some of the top posts of 2016:

viernes, 6 de enero de 2017

Satisfying ED patients

CEP America - January 4, 2017 - By By Charmaine Mislang
"Satisfying ED patients has become a do or die mission for hospitals. Unfortunately, EDs are not naturally satisfying places. Long waits, rushed communications, and multitasking staff tend to be the norm.
But that doesn't mean ED care can't satisfy . . . and even delight. And in the digital age, a little goodwill can spread at the speed of light.
Perspectives recently sat down with Charmaine Mislang, 22, of Redlands, Calif. Her Facebook post about the great care she received at the Redlands Community Hospital ED went viral. Today, she shares her tips on how EDs can connect with patients and cultivate positive social proof..."


R.E.B.E.L.EM - january 5, 2017 - By Salim Rezaie - Peer Reviewed by Astin M
"Background: Anyone who has run a code, knows that pulseless electrical activity (PEA) during cardiac arrest has a worse prognosis compared to patients with shockable rhythms. In patients with suspected massive PE as the cause of their cardiac arrest the Advanced Cardiac Life Support (ACLS) and American Heart Association (AHA) guidelines do recommend consideration of thrombolytics. There is however, no uniform consensus on the type, dose, duration, timing, or method of administration. The current study (PEAPETT Trial) was an attempt to do exactly that...
Author Conclusion: “Rapid administration of 50mg of tPA is safe and effective in restoration of spontaneous circulation in PEA due to massive PE leading to enhanced survival and significant reduction in pulmonary artery pressures.”
Clinical Take Home Point: Although this is not the most robust evidence, it would be reasonable to consider giving 50mg IV tPA in patients with suspected or confirmed PE causing cardiac arrest."

jueves, 5 de enero de 2017

Risk scoring for upper GI Bleeding

Resultado de imagen de BMJ
Stanley A et al. BMJ 2017; 356:i6432 
doi: http://dx.doi.org/10.1136/bmj.i6432 (Published 04 January 2017)

The Glasgow Blatchford score has high accuracy at predicting need for hospital based intervention or death. Scores of ≤1 appear the optimum threshold for directing patients to outpatient management. AUROCs of scores for the other endpoints are less than 0.80, therefore their clinical utility for these outcomes seems to be limited."

Low and Slow Poisoning

low and slow poisoning
Emergency Medicine Cases - By Anton Helman - January 3rd, 2017
"One of the things we need to think about whenever we see a patient who’s going low and slow with hypotension and bradycardia is an overdose. B-blockers, calcium channel blockers (CCB) and digoxin are some of the most frequently prescribed cardiovascular drugs. And inevitably we’re going to be faced with both intentional and unintentional overdoses from these drugs in the ED. On this EM Cases podcast the Medical Director of The Ontario Poison Control Centre and Emergency Physician at St. Michael’s Hospital, Dr. Margaret Thompson, along with Dr. Emily Austin, Emergency Physician and Toxicologist at St. Michael’s Hospital, help us to recognize these overdoses early and manage them appropriately..."

Expanded CURB65 & DRIP score

EM Pills - 4 Gen 2017 - Por Mauro Cardillo
"Oggi vorrei chiacchierare con voi di polmoniti e di due reecenti studi che hanno validato/proposto degli score a mio avviso molto interessanti. Gli assidui lettori di EMpills sapranno già che gli score sono uno degli argomenti più di voga sul nostro blog. Gli score sono uno strumento utile, utilissimo ma a mio modo di vedere un punto di partenza e non di arrivo.
Utili perché:
1. consentono di avere un punto di vista asettico e privo di pregiudizi su di un paziente o una patologia
2. aiutano a mettere ordine nella confusione dell’Area di Emergenza obbligandoci a rivedere dei punti importanti: ci costringono a fare la checklist...

miércoles, 4 de enero de 2017


Heather Kanga H et al. Neuropharmacology 2017; 112; 144-149
  • New ‘legal high’, the dissociative ephenidine, displaces MK-801 binding.
  • Ephenidine, like ketamine, blocks NMDA receptor mediated synaptic potentials and plasticity.
  • Ephenidine, like ketamine, blocks the NMDA receptor in a highly voltage-dependent manner.
  • Ephenidine blocks long-term potentiation, LTP.
  • NMDA receptor antagonism likely underlies the psychoactive effects of ephenidine."

Antimicrobials regimens (Adults)

emDocs - January 3, 2017 - Authors: Boushra M and Bradby C
Edited by: Koyfman A and Long B
..."Bacterial infections are a common diagnosis in the emergency department, and emergency physicians are often tasked with providing antibiotics for outpatient management or beginning antibiotics prior to admission. Antibiotic treatment is not without side effects, and treatment started in the emergency department is frequently empiric. Therefore, an understanding of the most likely causative organisms as well as local patterns of susceptibility and resistance is paramount to adequate treatment, appropriate antibiotic selection, and responsible antibiotic stewardship. Important historical details to elicit include allergies, recent antibiotic use, prior antibiotic failure, dialysis use, use of immunosuppressants or history of immunocompromise, culture results of prior infections, and contact with healthcare facilities, including recent hospitalization, living in a care facility, or recent invasive procedures such as ureteral catheterizations or intubation. These details offer vital information regarding possible bacterial resistance or the presence of opportunistic infection. Because multiple empiric regimens exist for infectious disease in the emergency department, contacting the hospital pharmacy about the local antibiogram may help tailor the empiric regimen to local microbial susceptibilities. Please keep this in mind with the recommendations discussed in each table. The following is a discussion of the most common or most emergent ED-diagnosed bacterial infections, their most likely causative organisms, and current recommendations for empiric treatment..."

Traumatic SAH

"Neurosurgical involvement in the management of simple traumatic brain injury (TBI) has been slowly dwindling over the past several years. This is the result of the general consensus that very few of these patients progress to need neurosurgical procedures.
A group at Wright State University in Dayton sought to define the progression of one specific finding in TBI, the subarachnoid hemorrhage (SAH). Secondarily, the wanted to determine if a neurosurgery consultation was warranted in these patients...
Bottom line: The authors conclude that initial neurosurgical consultation is not needed, since only 9% of patients have worrisome findings on repeat CT. They do, however, recommend that the practice of repeat scanning be continued because of this same number..."
Related posts:

Safe discharge advice

EM Didactic - January 2, 2017 - By Noor M
"A lot of patients come to the emergency department with various issues ranging from a simple fever to other life-threatening conditions like arrhythmias etc. It’s the responsibility of the emergency physician to decide who needs to be admitted and which patients are safe to be discharged home. About 4 out of 5 patients who come to the ED are discharged home. Failure to provide safe discharge advice can have significant clinical as well as medico-legal consequences. A lack of understanding or providing discharge advice can cause avoidable return to the ED within 72 hours or more, medication non-compliance, dissatisfaction with the care, progression of the illness and even unexpected death...
Take home points:
1. Communication is the key.
2. Provide safe discharge advice to all patients getting discharged from the ED.
3. Clear verbal advice that is documented is better that written advice."

martes, 3 de enero de 2017

Glucagon for Food Boluses

R.E.B.E.L.EM - January 2, 2016 - By Salim Rezaie
"Background: How many of you have had this scenario…patient comes into ED, just ate a big steak and now they can’t swallow. You call gastroenterology, who asks… “Did you try glucagon yet?” OK, well maybe not exactly like that, but you get what I am asking. Esophageal foreign body impactions are a rare entity, that cause quite a bit of discomfort to patients and have the potential for esophageal necrosis and perforation. The definitive treatment for removal is endoscopy with direct visualization and removal of the object causing the obstruction. This procedure is invasive, time consuming, requires a gastroenterologist, as well as procedural sedation. Due to the time it takes to set up for this procedure, many consultants will ask to try medical therapy first. There are several options including carbonated beverages, calcium channel blockers, sublingual nitroglycerin, proteolytic enzymes, benzodiazepines, and last but not least intravenous glucagon. This review will focus on the use of glucagon for esophageal foreign bodies....
Clinical Take Home Point: Given the weak evidence for the benefits of glucagon, the potential side effect of nausea/vomiting, and the fact that nearly 1/4th of patients will have an anatomic etiology to their obstruction, avoid the use of glucagon and consult your local gastroenterologist instead."

Seizure mimics

emDocs - January 1, 2017 -Author: Webb J and Long B - Edited by: Simon E & Koyfman A
  • Seizures are caused by abnormal neurologic electrical activity resulting in motor, sensory, and behavioral symptoms.
  • In all patients presenting with AMS or actively seizing: ABCs, accucheck, initiate therapy as appropriate (benzodiazepines first line).
  • For patients presenting after return to baseline mental status: a thorough history and physical examination are key to differentiating between a true seizure and its mimic.
  • If a seizure is not suspected, consider syncope, psychogenic non-epileptic seizures, stroke or TIA, sleep disorders, and migraines."

domingo, 1 de enero de 2017

Toxin-Induced Hyperthermic Disorders

By Traficante D and Kashani J - December 14, 2016
Table 1. Management of Toxin-Induced Hyperthermic Disorders
Management of patients with the described toxin-induced hyperthermic disorders begins with supportive care and focuses on decreasing muscle activity (benzos) and core body temperature (and chill). Benzodiazepines play an important role in decreasing mortality by reducing shivering and muscle breakdown that can lead to rhabdomyolysis, hyperkalemia, and ultimately renal failure. Patients with severe toxicity who do not respond to benzodiazepines may even require chemical paralysis with a non-depolarizing paralytic agent along with mechanical ventilation for better control of their muscle hyperactivity."

IV Nitroglycerin Bolus for APE

The PharmERToxGuy - December 27, 2016
"Nitroglycerin (NTG) is an important preload reducer in acute pulmonary edema, and even modestly reduces afterload with high doses. For pulmonary edema in the ED, NTG is often administered as a sublingual tablet and/or IV infusion. Starting the infusion at ≥ 80 mcg/min produces rapid effects in many patients, and can be titrated higher as needed. Combined with noninvasive positive pressure ventilation (and sometimes IV enalapril), patients often turn around quickly, from the precipice of intubation to comfortably lying in bed. But what about high-dose IV bolus NTG?
In a recent UMEM pearl, Dr. Rory Spiegel highlighted two studies in which patients who received high doses of IV nitrates every 5 minute were intubated less often than patients who received a standard infusion.
A new retrospective study by Wilson and colleagues evaluated the incidence of ICU admission and hospital LOS in acute pulmonary edema patients who received intermittent high-dose NTG bolus vs. standard NTG infusion vs. bolus + infusion. This was actually a follow-up to their previously published study."

viernes, 30 de diciembre de 2016

Pulmonary Hypertension

Emergency Physicians Monthly
EP Monthly - By Long B & Koyfman A - December 23, 2016
"Pulmonary hypertension is a condition with significant morbidity and mortality. Primary pulmonary hypertension (just one group of the condition) is rare with 5 to 15 cases per 1 million adults, though patients with the disease accounted for 64,400 ED visits over a 5-year period in one study. Patients are often on complex medication regimens, and managing these patients is difficult due to the heterogeneous nature of the disease. Unfortunately, despite the potential for severe disease, up to 21% of patients have symptoms over two years before diagnosis. These patients in particular have greater functional disability and risk of mortality...
Pulmonary hypertension is a rare disease with high morbidity and mortality. Five groups are present, based on the underlying disease. Ask the patient about prior pulmonary vasodilator treatment, chest pain, exertional dyspnea, and syncope. Key studies include cardiac biomarkers, electrolytes, and imaging (chest X-ray, bedside US, and chest CT). Management requires focus on treating the underlying cause of the exacerbation, consulting pulmonology, continuing pulmonary vasodilator treatment, optimizing volume, optimizing RV systolic function and perfusion, and rapidly treating dysrhythmias. Patients with negative prior workups for cardiovascular/pulmonary complaints should be referred for pulmonology follow-up and echocardiogram."

miércoles, 28 de diciembre de 2016

Alvarado Score

EBM - Posted on December 26, 2016 - By mizzouem
"Originally described in 1986, the Alvarado score has been the most widely used clinical scoring system for acute appendicitis. It consists of eight predictive factors, each assigned a value of 1 or 2 based on their diagnostic weight. Score of 1 is given for: elevated temperature >37.3C, rebound tenderness, migration of pain to RLQ, anorexia, nausea or vomiting, and leukocyte left shift. Score of 2 is given for RLQ tenderness and leukocytosis >10,000...
It is currently the only clinical scoring system described in ACEP Clinical Policy guidelines (Level C recommendation). Despite its presence over the last 30 years, its diagnostic accuracy remains debatable. 
Can the Alvarado score be used effectively to rule-in or rule-out acute appendicitis?
The Bottom Line:
Low scores with a cutoff of </=3 may be appropriate for excluding appendicitis, while anything above may still need imaging to identify appropriate diagnosis. High Alvarado score with a cutoff of 7 is not predictive enough to rule-in appendicitis; however, likely warrants early surgical consultation."

Gabrahat (Anxiety)

EM Didactic - December 26, 2016 - By Sagar Galwankar
  • Basic Approach should be T/P/R/BP/Pulse Ox
  • I always order a CBC LFT RFT EKG Trop CXR. Looking for Rhythm abnormalities is also important. Fever can also cause Gabrahat.
  • In Females in the Pregnancy Age group a HCG-UA is ordered
  • If Patient has SOB I will R/O Thoracic Causes like Dissection/Pneumothorax and PE.
  • If Patient has a presentation of Altered Mental Status I always order a CT Head.
  • If Toxicology screen is available, I will order one.
  • Co-Symptoms should guide further investigations.
  • Discussing with the Relatives in key to educate them- that this is not Hysteria / Tension / Stress. Those are the diagnosis to be considered once Major Life threatening causes are ruled out.
  • I have often Seen Marital Discord / Intimate Partner Abuse to be causes of GABRAHAT. So Going deeper into the history. Sitting with the patient with Privacy is the key.
  • Anxiety / Panic attack also can be on the differential once Major causes are ruled out.
  • Being a Compassionate Emergency Physician is the key. Communication is the answer and Competency to Care is crucial.

sábado, 24 de diciembre de 2016

Academic Emergency Medicine

emDocs - December 23, 2016 - Authors: Long B, Koyfman A and Robertson J
..."The decision to practice academic or community practice can be a difficult one to make, as there are perks and drawbacks in both settings. This post will evaluate the road to academic emergency medicine, the positives and negatives, and provide tips for success. However, before we start, we need to understand the difference between academic and community EM...
There are many pitfalls in academics. These include not enough protection from other duties (working too many clinical shifts with the expectation for academic productivity), not enough training for an academic career (research focus without training on research question and 
protocol formation), failure to have a mentor (one of the cornerstones of academic success), failure to form a plan/timeline of goals, lack of balance (which leads to burnout), biting off too much, and not listening to feedback.
Importance of Balance – Maintain balance and block off time for your family and hobbies. Success takes time, and it will not occur overnight. Recent years have seen an emphasis on physician health. This really comes down to balancing many aspects of life including your shifts, academics, community activities, exercise, hobbies, family, religious/spiritual concerns, friends, and future plans. Pushing too hard and too fast with too much will lead to burnout.
The Decision – Residency is a great time to explore academics and community practice. Rotations in both settings can help you determine which practice is the best fit for you. You can always switch settings, or in other words, it is never too late to go from community to academic practice. Work on perfecting your clinical skills and management early, as this is essential to both academic and community medicine."

jueves, 22 de diciembre de 2016

Antibiotics vs Surgery for Appendicitis

St.Emlyn's - By Carley S - December 21, 2016
..."A recent paper in the Annals of Emergency Medicine on the use of antibiotics to treat low grade appendicitis in the out patient setting. Now the concept of treating appendicitis with antibiotics is not new and there are RCTs, non randomised trials3–13 and meta-analyses14–16 to support this approach, although antibiotic therapy is not without risks (e.g. recurrent appendicitis). There is little published evidence to date about whether antibiotic therapy can be safely achieved in the outpatient setting which would of course be relevant to emergency physicians. The abstract fornthis weeks paper is below, please have a read but of course we always recommend that you read the whole paper...
What is interesting to me is that outpatient management of appendicitis is already taking place in some places. In hospitals near Virchester the concept of a surgical hot clinic (essentially ambulatory care of adult surgical conditions such as low grade appendicitis, abscesses, biliary colic etc.) has been developed. In the UK these innovations have been borne from the need to reduce hospital admissions as a result of the combination of a declining bed base together with an ageing population. The resultant ED overcrowding is a real problem and any innovation leading to a reduction in the number of patients admitted to hospital is welcome, but we can and should only advocate it if there it’s safe for our patients. On this occasion it looks as though pragmatic clinical change is preceeding the evidential change. Ross Fisher raises some quite real concerns about this in the comment below (please read it). Do we really know the natural history of the disease without conducting well designed trials and might pragmatism without evidence put our patients at risk?