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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 & RELATED

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sábado, 15 de febrero de 2020

MAP: >65 mm or >60 mm ?

PulmCrit (EMCrit)
PulmCrit - February 15, 2020 - By Josh Farkas
"The 65 trial compares MAP targets of >65 mm to >60 mm in treating vasodilatory hypotension. This trial challenges decades of protocols which have targeted a MAP >65 mm. As such, it is a courageous and practice-changing study. However, we need to be realistic about the study’s limitations...
Summary The Bullet: 
  • The 65 trial randomized ICU patients over 65 years old with vasodilatory shock admitted to ICU to target a MAP of 60-65 versus conventional therapy.
  • Patients in the 60-65 mm arm on average had MAPs ~6 mm below the conventional arm. Fluid utilization was not different between the two groups.
  • Targeting lower MAPs didn’t have a statistically significant effect on mortality, renal function, respiratory function, ICU length of stay, or 90-day cognitive outcomes. Targeting a lower MAP accelerated liberation from vasopressors by an average of 5 hours.
  • This study demonstrates that targeting a MAP >60 mm in ICU patients over age 65 is safe and potentially beneficial within the context of an RCT. However, as with any hemodynamic intervention, careful monitoring is likely important to ensure that patients are responding favorably.·

viernes, 14 de febrero de 2020

Sepsis and Septic Shock

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emDocs - February 14, 2020 - By Helman A
"Take home points on sepsis and septic shock
  • Calculate NEWS to detect subtle cases of occult septic shock.
  • Less saline, more Ringer’s, even if acute heart failure, especially in renal failure and severe acidosis.
  • Norepinephrine whenever MAP <65 – earlier rather than later.
  • Early antibiotics (within 1hr of the diagnosis rather than 1 hour of arrival at ED), given over 5 minutes (except vancomycin over 30 minutes), chosen wisely according to local antibiograms.
  • Use a combination of MAP, GCS, urine output, initial lactate, capillary refill time, POCUS IVC to guide initial fluid resuscitation, individualized to each patient.
  • If the lactate is rising despite resuscitative efforts call your intensivist. Early to ICU is preferable, but remember that capillary refill time may be as good, or even better than lactate at guiding resuscitation.
  • Consider vasopressin and hydrocortisone if a MAP of 65 cannot be maintained with 35mcg/min norepinephrine and ongoing fluid resuscitation."

jueves, 13 de febrero de 2020

CVC placemet

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emDocs - February 13, 2020 - By DeVivo A 
Reviewed by: Koyfman A, Long B and  Singh M
"Introduction
The ability to obtain rapid IV access in any patient, regardless of the clinical scenario, is a quintessential skill practiced by emergency physicians. While most patients in the ED will simply require peripheral IV access, the vignettes above present two critically-ill patients in very different circumstances, both of whom will likely require central venous catheter (CVC) placement. While the location of insertion is vital in certain scenarios, it does not define a CVC. A CVC is actually defined as a catheter whose tip resides within the superior vena cava, inferior vena cava, or at the junction between the vena cava and the right atrium (cavoatrial junction). Central venous access is obtained via the readily utilized Seldinger technique, in which a catheter is placed over a guidewire that has been threaded into a vessel through an introducer needle. The Seldinger technique is the foundation of most intravascular procedures and can be utilized for both peripheral and central venous catheters. The methodology has evolved over the past several decades and is now performed with or without ultrasound guidance, both of which techniques we will discuss below. This article will focus on the placement of CVCs including indications, contraindications, site choice, and complications. In addition, we will discuss the current literature behind the insertion site options and when pathophysiology should play a role in this decision. Since there are a variety of approaches and subtypes of catheters that can be placed depending upon the clinical scenario, the conclusion of this article will specifically review the placement of an internal jugular triple lumen catheter. Further posts under this broad overview will continue to discuss alternative approaches and catheter subtypes..."

Midline IV Catheters

R.E.B.E.L.EM - February 13, 2020 - By Salim Rezaie
Background: In critically ill patients needing IV access, ultrasound has helped improve gaining access to a set of peripheral veins, located deeper in the arm. The time it takes to do this however is not insignificant but even more importantly is that once you achieve success, the line can fail due to a short catheter length. Central venous catheters, often seen as a solution to this latter issue, are not without their own risks and complications. Therefore, a nice alternative option may be a midline catheter. These catheters are not meant for fast, large volume resuscitations because they also take time to place, but also have a longer catheter length which slows down infusion rates. Midline catheters are really about having safe access that is unlikely to be dislodged. This is a great option when you have medications you want to give but not have extravasation occur (i.e. vasopressors, hypertonic saline, calcium chloride, etc.)...
Author Conclusion: “Midline catheters may present a feasible alternative to central venous access in certain critically ill ED patients.”
Clinical Take Home Point: Midline catheter placement is feasible in the ED as an alternate approach to central lines or standard US guided lines. Further research is needed to look at generalizability of placement at other institutions, time to placement and complication rates in comparison to central venous catheters."

miércoles, 12 de febrero de 2020

Steroid for ARDS?

PulmCrit (EMCrit)
PulmCrit - February 12, 2020 - By Josh Farkas 
"Summary The Bullet:
  • There is considerable overlap between ARDS, severe pneumonia, and intubated patients with septic shock. Studies regarding these conditions may be best understood in the greater context of all three conditions (otherwise we are continually re-designing the wheel).
  • Prior evidence shows that steroid reduces duration of ventilation in ARDS and in intubated septic patients. Likewise, steroid may decrease ICU length of stay and the likelihood of requiring intubation in severe pneumonia. Some studies suggest mortality benefit, whereas others don’t.
  • DEXA-ARDS is a new, multi-center RCT investigating dexamethasone for patients with ARDS (77% of whom had pneumonia or sepsis as the cause of ARDS). Dexamethasone both accelerated liberation from ventilation and reduced mortality.
  • This study provides further support for the use of steroid in patients with both ARDS and either pneumonia or sepsis. It remains unclear whether steroid could benefit other subsets of ARDS patients (e.g. ARDS following trauma).
  • Since dexamethasone is a pure glucocorticoid (with no mineralocorticoid activity), it could act as a cleaner anti-inflammatory agent than most steroids. Its ability to auto-taper is also convenient."

Endocarditis

REBEL Core Cast 27.0 – February 12, 2020 - By Anand Swaminathan
"Take-Home Points
  1. Endocarditis can have vague and varied presentations and has high morbidity and mortality. Be on the lookout in patients with risk factors including:
    1. Congenital heart disease
    2. Cardiac prosthesis or devices
    3. Immunocompromise
    4. IV drug use
    5. Recent invasive procedure
    6. Hx of prior IE
  2. Patients may present with fever, sepsis of unclear source or may have manifestations of emboli to the skin, eyes, brain, lungs, spleen or kidney.
  3. Diagnosis is based on the modified Duke Criteria and workup should include THREE good sets of blood cultures.
  4. ED management includes consultation with ID and cardiothoracic surgery and starting antibiotics based on whether the patient has a native or prosthetic valve. Basic starting antibiotic regimen includes:
    1. For patients with native valve disease a good starting regimen is:
      1. Vancomycin 25-30 mg/kg IV loading dose followed by 15-20 mg/kg twice daily AND
      2. Cefepime 2 g IV TID
    2. For patients with prosthetic valve disease, we have to go a bit bigger:
    3. Vancomycin 25-30 mg/kg IV loading dose followed by 15-20 mg/kg IV twice daily AND
    4. Rifampin 300 mg PO/IV TID AND
    5. Gentamicin 1 mg/kg IV TID AND
    6. Some recommendations include the Cefepime 2 g IV TID"

martes, 11 de febrero de 2020

Extending Thrombolysis time in AIS

R.E.B.E.L.EM - February 06, 2020 - By Mark Ramzy
"Author’s Conclusions:
Patients with ischaemic stroke 4.5 – 9 h from stroke onset or wake-up stroke with salvageable brain tissue who were treated with alteplase achieved better functional outcomes than did patients given placebo. The rate of symptomatic intracerebral haemorrhage was higher with alteplase, but this increase did not negate the overall net benefit of thrombolysis.
Our Conclusion:
For patients without large vessel occlusion, this data pushes to expand the number of patients with AIS who may benefit from systemic alteplase. (ie. 4.5 – 9 hour window + wake up strokes). Functional independence is a subjective outcome that varies from patient to patient and is difficult to categorize with a single scoring system. Furthermore, not all institutions have access to the advanced neuroimaging modalities used in this study which limits its utility in more rural and community facilities. Lastly the overall application of this study may be further limited by the very select population of AIS patients. These AIS patients must have a small core infarct and larger ischemic penumbra to gain potential benefit, all while the risk of intracerebral hemorrhage remains the same as previous studies (i.e. 5-6%).
Clinical Bottom Line:
We should no longer be using the paradigm “Time is Brain” in AIS. The advancement of neuroimaging and perfusion-based imaging in an extended stroke window is the future of stroke care by helping identify a limited population of patients that would benefit from systemic alteplase vs those with no chance to benefit at all. The difficult decision to administer systemic alteplase should be based on the individual patient’s overall clinical picture and come following an in-depth shared-decision making discussion with the patient, and/or their family, explicitly stating the benefits and risks, including those of death and further hemorrhage."

Hyperdiuresis

PulmCrit(EMCrit)
PulmCrit Wee - February 11, 2020 by Josh Farkas 
Ref: Griffin M, Soufer A, Goljo E, et al. Real World Use of Hypertonic Saline in Refractory Acute Decompensated Heart Failure. JACC: Heart Failure. February 2020. doi:10.1016/j.jchf.2019.10.012

..."Summary The Bullet: 
  • Hyperdiuresis involves a combination of hypertonic saline and loop diuretic, for management of refractory volume overload.
  • This retrospective cohort study describes 58 episodes of hyperdiuresis among a cohort of profoundly ill patients with decompensated heart failure and diuretic resistance (most of whom had severely impaired cardiac and renal function).
  • Hyperdiuresis was successful in achieving volume removal, with a simultaneous improvement in renal function. 
  • Hyperdiuresis was well tolerated. There was no signal of increasing pulmonary edema. Hyperdiuresis did tend to increase the sodium and chloride levels, but these shifts were moderate (and tended to push patients towards normal values). 
  • Further investigation of hyperdiuresis is needed (ideally in the form of a RCT). In the interim, this seems to be a very reasonable treatment consideration for patients who are refractory to other therapies."
going further

lunes, 10 de febrero de 2020

Pleural effusions

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emDocs - February 10, 2020 - Authors: Peta N and Avila J
Reviewed by: Montrief T; Koyfman A; Long B
"Pearls
  • A diagnostic thoracentesis can be performed in patients with new pleural effusions or in patients with known but worsening pleural effusions.
  • A therapeutic thoracentesis should be performed in unstable patients, patients with complicated parapneumonic effusions, or in patients with empyemas.
  • Listen to your patients during the thoracentesis; if they complain of chest discomfort or worsening dyspnea… stop the procedure.
Pitfalls
  • Typically, you should not drain more than 1 liter of fluid. Draining more than 1 liter of fluid can cause re-expansion pulmonary edema (patient becomes unstable and has frothy sputum).
  • Your patient develops a cough during the thoracentesis. Should you be worried? Not really. This cough is probably a sign of physiologic lung re-expansion or pleural irritation from the tube.
Take Home Points
  • There are a lot of causes for pleural effusions, but CHF is the most common precipitant seen in patients with bilateral pleural effusions. Malignancy is the most common cause of unilateral pleural effusions.
  • You may not be able see a pleural effusion on a CXR unless there is at least 175mL of fluid present.
  • If the effusion’s fluid is > 1.5cm in thickness (from parietal to visceral pleura) and covers at least 3 rib spaces, then it may be safe to tap.
  • A great guide on thoracentesis, using ultrasound, can be found here: http://www.emdocs.net/ultrasound-guided-thoracentesis/
  • Use an ultrasound to locate the effusion and decrease the risk of bleeding complications and pneumothorax.
  • Patients with parapneumonic effusions or hemodynamic instability will need prompt initiation of antibiotics and a tube thoracostomy"

Pneumothorax: conservative management

St Emlyn´s JC - By Simon Carley - February 10, 2020
..."This month we have a paper in the NEJM​ that may help answer that question. It’s received quite a bit of interest in the #FOAMed world already, but as it’s directly relevant to our day to day practice it’s worth a look from the St Emlyn’s team.
You can read the abstract of the N​​EJM paper below, but as we always say PLEASE read the full paper yourself and make up your own mind before changing practice...
The bottom line
Conservative management of moderate and large spontaneous pneumothoraces is an option, but we will wait for changes to the BTS guidelines before changing our regular practice."

High Flow Nasal Cannula


REBEL Crit Cast Episode 2.0 - February 10, 2020 -By Frank Lodeserto
"The use of heated and humidified high flow nasal cannula (HFNC) has become increasingly popular in the treatment of patients with acute respiratory failure through all age groups. Over the past several years, many studies have come out reviewing the mechanisms of action as well as its use in a variety of conditions. In this episode, I will summarize how it works and for part 2, I will discuss the main indications for its use in both adult and pediatric patients and practical tips on how to use it...
Clinical Bottom Line:
In summary, these different mechanisms described above may all benefit patients in different ways. We are not sure which mechanism is the most important or if they are all helpful. Perhaps, depending on your patient’s condition, one of the mechanisms may be predominate at certain times. One mechanism may be more important in certain disease processes. We will discuss the adult & pediatric indications as well as some practical tips for it’s use in our next podcast!"

martes, 4 de febrero de 2020

Fluid administration for CoV

PulmCrit (EMCrit)
PulmCrit - February 4, 2020 - By Josh Farkas
...An aggressive fluid resuscitation strategy in viral pneumonia is especially misguided. The primary life-threat facing these patients is ARDS (not hypoperfusion, and certainly not hypovolemia). Perfusion can generally be easily maintained with early administration of low-dose vasopressors and a conservative fluid strategy if necessary (although most patients with viral pneumonia have adequate perfusion to begin with). Notably, if hyperlactatemia is being driven by dyspnea causing sympathetic activation, this will only be exacerbated by fluid (which will worsen the respiratory failure)..." 
Summary The Bullet:
  • The Surviving Sepsis Campaign has recommended an aggressive fluid-first resuscitation strategy, despite mounting evidence that fluid boluses are dangerous and usually don’t cause sustained clinical benefit.
  • The Surviving Sepsis guidelines have been applied to coronavirus. In the context of viral pneumonia, large-volume fluid resuscitation may be particularly misguided (since the primary life-threat facing these patients is ARDS).
  • In the event of a pandemic of viral pneumonia, any treatment strategy which increases the number of ventilated patients could exhaust available ICU beds (even in well-resourced countries).

lunes, 3 de febrero de 2020

Tamiflu

Tamilfu doesn't work
First10EM - By Justin Morgenstern - February 3, 2020
"The paper: Butler CC, van der Velden AW, Bongard E, et al. Oseltamivir plus usual care versus usual care for influenza-like illness in primary care: an open-label, pragmatic, randomised controlled trial. Lancet. 2020; 395(10217):42-52. PMID: 31839279 ISRCTN27908921
Bottom line
The positive findings in this unblinded trial are completely unconvincing. Based on plaebo controlled studies, we know that tamiflu doesn’t change any important, objective outcomes. It may decrease the length of illness slightly, although the studies that report than benefit have a high risk of bias. However, it causes side effects that patients tend to find worse than the flu itself. Personally, I do not and will not prescribe Tamiflu."
*
Other FOAMed

Resuscitative Hysterotomy

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Rebellion in EM 2019 - February 3, 2020 - By Salim Rezaie
"The perimortem cesarean section, or better named the resuscitative hysterotomy, is a procedure that is performed at or near death of a pregnant patient. Most experts agree that this procedure should be performed in a maternal arrest with a pregnancy ≥24 weeks of gestation. Although there is no real data regarding the optimal time to delivery post-arrest, survival drastically decreases when the time from maternal death to delivery reaches 5 minutes (ie. Therefore a 4 minute rule has become standard). In this talk from Rebellion in EM 2019, Dr. Jaime Hope, MD walks us through the steps of performing this stressful procedure..."

Cardiogenic Shock

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emDocs - February 3, 2020 - Authors: Daly M and Lentz s
Reviewed by: Montrief T; Koyfman A and Long B
"Take home points:
  • CS is primarily caused by an acute MI (~70%) and is the focus of most studies but other causes should also be considered (see full list in Figure 1).
  • Mortality secondary to CS remains high (~60%), although early identification and intervention improves survival.
  • Perform a careful physical exam looking for hypoperfusion and congestion. JVP is an important physical exam component for the diagnosis of CS and is associated with increased mortality (RR = 1.52).
  • The RUSH exam is both sensitive and specific (0.89 and 0.97, respectively) in the diagnosis of CS. Bedside ultrasound should be repeated frequently as most patients do not initially present in CS.
  • Using LVOT VTI is a simple and noninvasive method for evaluating CO with low measurements associated with adverse outcomes.
  • A suggested approach for evaluating patients with suspected CS with focus on its heterogeneous pathology and presentation is summarized in Figure 5."

sábado, 1 de febrero de 2020

Myths about Lactate

R.E.B.E.L.EM - By Salim Rezaie - January 31, 2020
"The REBEL EM/EEM 2020 Fellowship Competition involved creating an infographic about a myth in Emergency Medicine. An important element of the design was the ease of sharing through social media to increase the reach and exposure of the educational content. The piece was supposed to be creative, demonstrate visual impact in communication of the topic, showcase educational prowess, and teach us all something about a topic that the registrants were passionate about!...
A big thank you to everyone who submitted for this competition. There were 12 submissions from all over the world, as you can see from above. It was tough making a decision, but ultimately, following the rubric, once all the votes were tallied…drum roll please…

DD at Intermediate Risk of PE

The Short Coat - by Lauren Westafer - January 31, 2020

...Risk stratification of pulmonary embolism is complex, partially due to the presence of several cut-offs in Wells, one of the most popular risk stratification scores in the United States...
In the US, we have a problem with overtesting for PE, and the use of the D-dimer in the intermediate-risk group, in addition to clinically adjusted D-dimer thresholds, may help improve the quality of care we deliver to patients"

martes, 28 de enero de 2020

2019-nCoV

St Emlyn´s - By Ashley Liebig - January 27, 2020
"Thursday afternoon, I brazenly told my director that the coronavirus needn’t warrant immediate concern. I didn’t want to add to the typical hysteria that leads to people purchasing too many medical supplies that then results in a supply chain shortage. After all, it seemed well contained in China and the case in Washington State was so far away. I went on to ensure him that I would keep an eye on things. Exactly six minutes later, news broke of a suspected case in College Station, Texas, which was just 100 miles away (face in palm). Since then, three more US cases have been confirmed in the Chicago area and Southern California with more around the world. This is clearly not entirely confined to China and therefore it was time to do some further investigation. 
An outbreak of a 2019 novel coronavirus (2019-nCoV) in Wuhan City, Hubei Province, China began in the final days of 2019. Patients afflicted with the virus have been linked to a seafood and animal market in Wuhan. Recent reports indicate the virus has made its way out of China and into multiple countries..."

Neuraxial procedures in anticoagulated patient

CanadiEM
CanadiEM -  By Tobias Tritschler - January 28, 2020
"Main Messages
  • A pharmacokinetic-based approach to interruption of DOAC intake for neuraxial procedures appears to be safe.
  • Coagulation tests are best reserved for situations in which the timing of last intake of DOAC is unclear or if an urgent procedure is required, or in case the patient is on warfarin."

The EXTEND trial

The EXTEND trial
First10EM - By Justin Morgenstern - January 28, 2020
The paper: The EXTEND Trial: Ma H, Campbell BCV, Parsons MW, et al. Thrombolysis Guided by Perfusion Imaging up to 9 Hours after Onset of Stroke. The New England journal of medicine. 2019; 380(19):1795-1803. PMID: 31067369 [full text] Clinicaltrials.gov: NCT00887328 and NCT01580839
"Bottom line
In this small trial that was stopped early, the small improvement in neurologic outcomes seen with tPa was probably not statistically significant, and only applies to a very small number of patients. This approach probably also increases mortality. I think the use of advanced imaging to guide tPa is promising (especially among patients presenting in the first 3 hours), but we clearly need more research."

Heparin for ACS and STEMI

Heparin for ACS and STEMI
Podcast production by Justin Morgenstern, Rory Spiegel and Anton Helman.
Podcast editing and sound design by Katrina D’Amore & Anton Helman. 
Blog summary by Anton Helman, January 2020.
"Where I work, when a 60 year old man rolls into the resuscitation room with crushing chest pain and diaphoresis and I get handed the EMS ECG showing an obvious anterior STEMI, it’s kind of a no-brainer: Call a “Code STEMI” and tick off a bunch of boxes so that the nurses can go ahead a give a bunch of meds before the patient is whisked off to the cath lab. On that tick box list is ASA, with a NNT of 42 to prevent death [1]. Next on the list is heparin. I’ve been ticking that box for just about every patient with a STEMI, but now that I’ve reviewed the literature, I’m not so sure I should always be ticking that box – especially in the patient with more than a zero HAS-BLED score. What about NSTEMI or unstable angina? Does heparin – LMWH or unfractionated heparin – benefit the patient with, say, a pretty good story for angina with a bump in their troponin and some ST depression in the lateral leads? I think we’re expected to routinely give heparin for all these NSTEMI and unstable angina patients with any ischemic changes seen on the ECG, right? But should we?….
Take home message for heparin in ACS and STEMI
Heparin should not be considered as routine therapy for ACS and STEMI. Based on lack of clear benefit in the literature, it is not unreasonable to withhold heparin for both ACS and STEMI patients, especially in patients who are at moderate or high risk for bleeding complications."

The Rothman Index

PulmCrit(EMCrit)
PulmCrit - January 25, 2020 - By Josh Farkas
"Summary: The Bullet
  • The Rothman Index is an early warning system which is integrated into the electronic medical record. It is similar to prior paper-based early warning systems designed to detect instability (e.g. NEWS), albeit with the addition of information from labs and nursing assessments.
  • The Rothman Index works well on paper as a predictive tool. However, recent evidence suggests that the Rothman Index fails to add true value in practice, for several reasons:
    • The Rothman Index often provides clinicians with information which is redundant to what they already know (e.g. alerts commonly occur after the treating team has already realized the patient is deteriorating).
    • The Rothman Index has limited predictive ability. In one study, the Rothman Index was no better than an intern at predicting patient deterioration. In another, only 29% of patients with cardiac arrest had a RI alert that day.
  • The Rothman Index does fill a void in the healthcare system, which is caused by lack of physician attention to nursing assessments. This is a problem, but there are better ways to fix it. The answer is probably for all of us to spend less time looking at computers – and more time talking with each other."

lunes, 27 de enero de 2020

The WAKE UP trial

WAKE UP Trial
First 10EM - By Justin Morgenstern - January 27, 2020
The paper: The WAKE UP Trial: Thomalla G, Simonsen CZ, Boutitie F, et al. MRI-Guided Thrombolysis for Stroke with Unknown Time of Onset. The New England journal of medicine. 2018; 379(7):611-622. PMID: 29766770 [free full text] ClinicalTrials.gov: NCT01525290

"There have been a few new thrombolytic RCTs since I published my review of the stroke literature, and it is probably about time that I got around to writing about them. On the one hand, I think it is exciting that we are moving past the flawed time-based selection of patients, and exploring other options for deciding who might benefit from thrombolytics. On the other hand, the trials are flawed and don’t really provide any answers, so there isn’t much to be excited about. Tomorrow I will review a group of trials that uses perfusion based imaging to select patients with salvageable brain tissue. In my mind, that is the most promising approach. This review looks at the WAKE-UP trial, which uses an MRI technique that can identify strokes that are less than 4.5 hours old, regardless of the timing of the symptoms...
Bottom line
In this trial, which has significant risk of bias, using MRI to select patients with an unknown time of stroke onset and giving them alteplase resulted in an 11% improvement in 90 day neurologic outcomes, but also probably increased mortality. Using advanced imaging to select stroke patients for thrombolytic therapy is promising, but should be considered unproven at this point. (Thrombolytic therapy in general is unproven, as we still await the necessary NINDS replication study.)"

domingo, 26 de enero de 2020

BMV during RSI

SGEM#281 - By admin - January 25, 2020
SGEM#281: EM Docs Got an AmbuBag – The PreVent Trial
"CLINICAL QUESTION: IS BAG-MASK VENTILATION (BMV) PERFORMED DURING THE APNEIC PERIOD OF RSI (DEFINED AS THE TIME BETWEEN ADMINISTRATION OF RSI MEDICATIONS AND INTUBATION) IN CRITICALLY ILL ADULTS SAFE AND EFFECTIVE?

BAG-MASK VENTILATION GROUP HAD HIGHER OXYGEN SATURATIONS AND LESS SEVERE HYPOXEMIA COMPARED TO THE CONTROL GROUP.

SGEM BOTTOM LINE: IT IS UNCLEAR IF BAG-MASK VENTILATION IN CRITICALLY ILL ADULT PATIENTS REQUIRING INTUBATION PROVIDES A CLINICALLY IMPORTANT BENEFIT OR IS SAFE."

Coronavirus 2019-nCoV

Resultado de imagen de johns hopkins university logo
By Lauren Gardner, January 23, 2020
The Center for Systems Science and Engineering (CSSE) at JHU

GIS Dashboard
..."In response to this ongoing public health emergency, we developed an online dashboard (static snapshot shown below) to visualize and track the reported cases on a daily timescale; the complete set of data is downloadable as a google sheet. The case data visualized is collected from various sources, including WHO, U.S. CDC, ECDC China CDC (CCDC), NHC and DXY. DXY is a Chinese website that aggregates NHC and local CCDC situation reports in near real-time, providing more current regional case estimates than the national level reporting organizations are capable of, and is thus used for all the mainland China cases reported in our dashboard (confirmed, suspected, recovered, deaths). U.S. cases (confirmed, suspected, recovered, deaths) are taken from the U.S. CDC, and all other country (suspected and confirmed) case data is taken from the corresponding regional health departments. The dashboard is intended to provide the public with an understanding of the outbreak situation as it unfolds, with transparent data sources..."

martes, 21 de enero de 2020

Research Roundup 01/2020

Research Roundup First10EM best of emergency medicine research
First10EM - By Justin Morgenstern - January 20, 2020
"Time for another semi-regular round-up of the top emergency medicine and critical care articles I have encountered over the last few months. This time we will tackle anti-epileptics, anti-emetics, the word “quiet”, and a whole bunch more…"
  • Our second line agents for status epilepticus all suck
  • Hearts have memory?
  • Peripheral pressor update
  • His arm is bent!! Are you seriously just going to leave it like that!?!?!
  • Using a facemask to blind children (that sounds sort of bad)
  • Are antiemetics useless?
  • Martial arts technique for control of severe external bleeding
  • Could an ED-ICU combination unit save lives?
  • I am sure everyone working over the holidays this year has noticed how quiet it has been

Spontaneous Bacterial Peritonitis


R.E.B.E.L.EM - January 20, 2020 - By Swaminathan A
"Take Home Points:
  • SBP is a difficult diagnosis to make because presentations are variable. Consider a diagnostic paracentesis in all patients presenting to the ED with ascites from cirrhosis
  • An ascites PMN count > 250 cells/mm3 is diagnostic of SBP but treatment should be considered in any patient with ascites and abdominal pain or fever
  • Treatment of SBP is with a 3rd generation cephalosporin with the addition of albumin infusion in any patient meeting AASLD criteria (Cr > 1.0 mg/dL, BUN > 30 mg/dL or Total bilirubin > 4 mg/dL)"

Acute Acalculous Cholecystitis

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ED Presentation, Evaluation, and Management
emDocs - January 20, 2020 - By Conte J - Reviewed by: Koyfman A and Long B
"Key Points
  • AAC may have a higher incidence in outpatients than hospitalized, critically ill patients. Maintain a high index of suspicion in patients who present to the ED with right upper quadrant pain even in the absence of a history of cholelithiasis.
  • Men > 60 years old with atherosclerotic cardiovascular disease are the most common outpatient population to develop AAC.
  • The sensitivity of ultrasound for acute acalculous cholecystitis is not well established. If you have a high clinical suspicion and a negative ultrasound, pursue further diagnostic imaging with HIDA scan +/- CT imaging, followed by admission for diagnostic laparoscopy if all noninvasive testing is negative.
  • Acute acalculous cholecystitis follows a more fulminant course than calculous cholecystitis. Broad spectrum antibiotics with gram-negative coverage and fluid resuscitation should be started immediately if the diagnosis is suspected, with an emergent consultation to general surgery."

domingo, 19 de enero de 2020

Severe acute pancreatitis

Joe Hines, Stephen J Pandol. BMJ 2019;367:l6227 | doi: 10.1136/bmj.l6227
"Abstract
The risks, measurements of severity, and management of severe acute pancreatitis and its complications have evolved rapidly over the past decade. Evidence suggests that initial goal directed therapy, nutritional support, and vigilance for pancreatic complications are best practice. Patients can develop pancreatic fluid collections including acute pancreatic fluid collections, pancreatic pseudocysts, acute necrotic collections, and walled-off necrosis. Several randomized controlled trials and cohort studies have recently highlighted the advantage of managing these conditions with a progressive approach, with initial draining for infection followed by less invasive techniques. Surgery is no longer an early intervention and may not be needed. Instead, interventional radiologic and endoscopic methods seem to be safer with at least as good survival outcomes. Newly developed evidence based quality indicators are available to assess and improve performance. Development and clinical testing of drugs to target the mechanisms of disease are necessary for further advancements."

Lactate


The BREACH, EM research bulletin
The Breach - By Barrie Stevenson - January 16, 2020
The paper: Wardi G, Brice J, Correia M. Demystifying lactate in the Emergency Department. Ann Emerg Med. 2019 [epub ahead of print]
"Take home points
  1. When confronted with a raised lactate, ask yourself: “Does this patient have signs of regional ischaemia or shock?”
  2. If not, consider why their lactate might be raised and whether you have to do something about it
  3. Try to resist the unthinking ‘Lacto-Bolo reflex’ if you can!"

ACS, troponin and the elderly

SGEM#280 - Posted by admin - Jan 18, 2020

viernes, 17 de enero de 2020

MEDEST 2019 Review: ALS

Year in Review 2019 
MEDEST - January 15, 2020

Post Contrast Acute Kidney Injury

R.E.B.EL.EM - January 16, 2020 - By Salim Rezaie
..."Author Conclusion: “Our study findings could serve as useful reference for physicians who are concerned about performing computed tomography pulmonary angiography for fear of renal function deterioration.”
Clinical Take Home Point: This current study shows that the last eGFR prior to CTPA in patients with suspected acute pulmonary embolism in the ED was not associated with occurrence of PC-AKI, even if the eGFR was <30mL/min/1.73m2, but there was certainly a trend toward increased AKI in this patient population. What we need now is not another retrospective observational study, and although a randomized clinical trial would be great, it is unlikely to ever happen. We now have a huge amount of data saying it doesn’t matter what the kidney function of a patient is and we should start to change protocols to allow IV contrast in patients where critical diagnoses need to be made."

martes, 14 de enero de 2020

MEDEST: 2019 Guidelines

MEDEST - January 12, 2020

Critical Hyponatremia

Logo
emDocs - January 13, 2020 - By  Desai N and Jang D
Reviewed by: Koyfman A; Montrief T; Long B
"Pearls:
  • Rate of serum sodium concentration change is far more important to quantify than the numerical number itself. Rely on symptoms and good history taking skills.
  • Just because you can correct acute hyponatremia quickly does not mean you should. Aim for a 4-6 mEq/L increase in the first six hours of treatment if the patient has signs of CNS dysfunction listed above. Do not correct greater than 6 mEq/L in the first 24 hours to avoid the risk of osmotic demyelination syndrome.
  • If you do not have ready access to hypertonic saline (100 cc of 3% hypertonic saline IV over 10 min), you can substitute with an ampule (50 ml) of bicarbonate (8.4% sodium bicarbonate).
  • Confirm tonicity of fluid (hypo-, iso-, hyper-) prior to initiating treatment in the emergency department.
  • Be comfortable with the use of desmopressin in the case of undifferentiated hyponatremia, severely hypovolemic hyponatremia and rapid overcorrection of hyponatremia. You can administer this concurrently during hypertonic or intravenous fluid administration for prophylactic measures.
Pitfalls:
  • Be very cautious in administration of intravenous fluids (Lactate preferably over NaCl or 3% hypertonic) in patients with hypovolemic history (poor oral intake, diarrhea, increased NG tube output, vomiting) as they tend to overcorrect rapidly leading to an increased risk of osmotic demyelination syndrome. Be judicious with fluid challenges (250cc – 500cc per bolus).
  • If you administer 3% hypertonic saline, pay close attention to the urine output and consider placing a foley early, urine output >100 cc/hr is an early red flag for overcorrection."