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SOBRE EL AUTOR **

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

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Cranial Nerve VI Palsy Emergency

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miércoles, 13 de diciembre de 2017

Antibiotic IV to PO

Resultado de imagen de academic life in emergency medicine
ALiEM - December 13th, 2017 - By: Koehl J and McCreary E - Editors: Monette D, Hayes B
"Hurricane Maria ravaged Puerto Rico almost 3 months ago, destroying factories that manufacture and distribute medications and related supplies. Healthcare facilities across the nation are now experiencing a critical shortage of small-volume intravenous (IV) fluids, which impacts the supply of IV antimicrobials. With no end in sight, ED providers can protect the quality of patient care by considering 2 strategies: IV to PO conversion and first-dose antimicrobials via IV push."

Tramadol

An online community of practice for Canadian EM physicians
CanadiEM  - By Shahbaz Syed - December 13, 2017
"Conclusions
We’re in the midst of an opioid crisis, with increased emphasis on opioid prescribing and the utilization of alternative or adjunctive medications. The emerging evidence against Tramadol should deter us from reaching for this medication as an alternative. While we should be mindful of prescribing opioids in general, Tramadol likely should not be a first line agent for patients, and we need to be very careful prescribing this medication for those who are already on serotonergic agents. Health Canada is apparently looking into the scheduling of this medication, and that would go a long way to increasing awareness about the harms of Tramadol."

New Arrhythmia Guidelines 2017

EmergencyPedia
EmergencyPedia -  December 13, 2017 - By Andrew Coggins

"Summary from Journal Feed
  1. If in doubt with wide complex tachycardia, assume it’s VT (class I).
  2. For hemodynamically stable VT, procainamide is the preferred pharmacologic agent (class IIa). However, cardioversion remains a class I recommendation.
  3. In hemodynamically unstable ventricular arrhythmias, electricity is undoubtedly first priority. If that fails, amiodarone is the preferred pharmacologic agent (class IIa).
  4. IV beta blockers may be useful (class IIa) for patients with:
    1. VT/VF storm despite DCCV and antiarrhythmics
    2. Polymorphic VT due to MI
  5. Adrenaline 1mg every 3-5 minutes “may be reasonable” in cardiac arrest (class IIb).
  6. Consider emergent PCI in all patients after out-of-hospital cardiac arrest, particularly with initial shockable rhythm. Absence of STEMI does not rule out culprit coronary lesion and may be seen in 30% of patients.
  7. Contrary to common teaching, accelerated idioventricular rhythm (AIVR) is not a marker of reperfusion. Instead it is more strongly associated with infarct size.
  8. Some drugs can worsen or unmask Brugada syndrome. (drugs of concern include procainamide (not available in Australia), flecainide, TCAs, lithium, propofol, cocaine, cannabis and alcohol).
  9. Digoxin isn’t the only cause of bidirectional VT. Catecholaminergic polymorphic VT (exercise or stress induced VT) can also cause it.
  10. Long QT syndrome: males in childhood and postpartum females are at greatest risk for ventricular arrhythmia."

lunes, 11 de diciembre de 2017

Chest Pain

Resultado de imagen de academic life in emergency medicine
ALiEM - December 11, 2017 | By: Derek Monette
"Emergency Medicine has made significant contributions to the proliferation of Observation Medicine, an attractive alternative to admission for patients with low- and moderate-risk chest pain. Selecting the right patient, identifying appropriate interventions, and documenting appropriately are just some of the challenges discussed in the latest ACEP E-QUAL Network podcast, a partnership with ALiEM to promote clinical practice improvements. We review highlights from a podcast with experts Dr. Anwar Osborne (Emory University) and Dr. Michael Granovsky (LogixHealth)."

Push vs Short Infusion

The Skeptics Guide to Emergency Medicine
SGEM#198 - November 28, 2017 - By Salim Rezaie
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"Clinical Question: Does increasing the duration of the ketamine from IV push (3 – 5 min) to a slow infusion (10 – 15 min) mitigate some of the untoward side effects, while maintaining analgesic efficacy?
SGEM Bottom Line: Slowing down the rate of low-dose IV ketamine infusion to 15 minutes significantly reduces rates of the feeling of unreality and sedation with no difference in analgesic efficacy when compared to IV push over 3 – 5 minutes."

ROTEM

MCC Project -  December 4, 2017 - By Jim Lantry
"Join me in welcoming Kenichi Tanaka, M.D., MSc., Professor of Anesthesiology and Division Chief Cardiothoracic Anesthesiology at the University of Maryland Medical Center. Dr. Tanaka started his Anesthesia training at Pittsburgh, then specialized in Cardiothoracic Anesthesia at Emory where he also earned a Masters in the Science of Clinical Research. Since joining UMMC in 2014 Dr. Tanaka has raised the bar in regards to academic research by publishing > 100 peer-reviewed journals and serving on the editorial boards of British Journal of Anaesthesia (Associate Editor), Anesthesia & Analgesia (Senior Editor), and Journal of Cardiothoracic Vascular Anesthesia. Today Dr. Tanaka sacrifices time from his busy schedule to delve into the dynamics of Thromboelastometry. I can assure you, if you ever plan to remedy coagulopathy in the ICU you will be glad you took 40 minutes to listen to this lecture!"

Chest compression point

MEDEST - December 8, 2017
Clinical pilot study of different hand positions during manual chest compressions monitored with capnography
Image attribution: Qvigstad E, et al. Clinical pilot study of different hand positions during manual chest compressions monitored with capnography. Resuscitation (2013), http://dx.doi.org/10.1016/j.resuscitation.2013.03.010

"Actual applications for clinical practice
  • The recommended chest compression point can be ineffective to generate enough outflow because the Area of Maximum Compression is not on the Left Ventricle but either on the Aortic Valve or the Ascending tract of the Aorta
  • Emergency providers can adjust the compression point based on EtCO2 values.
  • If, despite technically correct chest compressions, the EtCO2 remains below 10, try to adjust the compression point.
  • In those cases, the Optimal Compression Point is usually positioned caudally to the recommended one on the lower third of the sternum"

lunes, 27 de noviembre de 2017

Sepsis, Diastolic Dysfunction & Hypernatremia

PulmCCM
PulmCCM - November 26, 2017 - By Jon-Emile S. Kenny
..."Diastolic dysfunction complicated by clinical heart failure is a complex interplay between the heart and the vascular system. One may be tempted to be more liberal with intravenous fluids in patients with diastolic dysfunction – with fear allayed by the words ‘preserved ejection fraction.’ However, patients with this form of heart failure are just as insulted by excessive salt and water as their counterparts with reduced ejection fraction..."

iSepsis: bolus? Yes or No

EMCrit - November 26, 2017 - By Paul Marik
"The Current Surviving Sepsis Campaign “recommends that, in the resuscitation from sepsis induced hypoperfusion, at least 30 mL/kg of IV crystalloid fluid be given within the first 3 hours” (with no exceptions) (STRONG RECOMMENDATION).
Do you support/agree with the above recommendation? The answer is a Yes or No (NO conditional answers)
Results from the Surviving Sepsis Campaign Committee members
The number of “NO” votes exceeds the threshold of 20% established by the Guideline Rules and therefore this recommendation must be rejected."

D2F

R.E.B.E.L. EM - Emergency Medicine Blog
R.E.B.E.L.EM - November 27, 2017 
"Clinical Take Home Point: We must be careful in making brash conclusions from this study. Although the authors conclude early treatment with IV loop diuretics is associated with lower in-hospital mortality, it is important to remember, patients in the early treatment group were more likely to arrive by ambulance, have an onset of symptoms that was more abrupt, and have more obvious signs of volume overload. All these confounders, would lead to earlier treatment with IV diuretics, meanwhile the quality of care as well as other treatments not accounted for (i.e. NIPPV and/or nitrates) may be the reason why mortality was improved."

viernes, 24 de noviembre de 2017

Ottawa SAH Rule

EMOttawa - By: Jeffrey Perry - November 13, 2017

"Dr. Perry and Colleagues have previously derived and validated the Ottawa SAH rule for patients with suspected subarachnoid hemorrhage, here we present the multicenter prospective validation of the rule, with some insight on the rule from Dr. Perry himself!"

HIV screening

St.Emlyn’s - By Gareth - November 24, 2017
"So in summary
  • I think these guidelines make a lot of sense.
  • A step wise approach to HIV screening in hospitals depending on local prevalence rates.
  • Embedding HIV screening as a routine part of ED practice may help reduce the stigma associated with testing for the disease.
  • We have a captured audience in the emergency department and are the perfect place for public health initiatives like this.
  • It makes sense because we take blood for lots of things we don’t need (coagulation screen anyone?). Taking a bottle for something we do need is obvious and logical.. I mean, I’d like to know my HIV status far more than I would my PT any day.
  • I know we’re busy and at a time when we’re stretched, asking us to do more and more is probably the last thing a ED clinician wants to hear but if we really think about it.. when we realise it is just one extra bottle of blood, your patients might just that you for saving their life."

jueves, 23 de noviembre de 2017

Running Codes

EMsandox - November 22, 2017 - By jfhine
"In this podcast we discuss coding patients in cardiac arrest and the barriers to a successful resuscitation.
Review Questions:
  1. What are the two interventions shown to improve survival in cardiac arrest?
  2. Define compression fraction.
  3. What are the major barriers we outlined to maintaining a good compression fraction?
  4. In the nurse-led code model, what responsibilities fall on the nurse leader? What ones fall on the doctors?"

Sinusitis Mimics

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emDocs - November 22, 2017 - Author: Cooper J - Edited by: Koyfman A and Long B
"Take home points:
  • Sinusitis symptoms overlap with many other diseases, only some of the prominent diseases were covered here.
  • CTS presents with unilateral retroorbital and frontal headache and cranial nerve deficits. CTS and sinusitis can occur concurrently. Include a detailed ocular and neurologic exam in your assessment to help clue you in.
  • Brain abscesses can result as a direct extension of sinusitis. Headache is a common presenting feature, which may be frontal or retroorbital. Fevers are also common to both. In patients with sinusitis, consider a brain abscess if they have mental status changes, lethargy, or subtle or progressive neurologic deficits.
  • Meningitis presents with headache and fever and can mimic sinusitis. Be wary of sinusitis directly extending to the CNS. Physical exam is unreliable for ruling out meningitis. Maintain a high index of suspicion in sinusitis patients that have other symptoms suggestive of meningitis.
  • Orbital cellulitis often occurs as a direct extension of sinusitis. Be suspicious when patients have vision complaints and ocular findings on exam including proptosis and antalgic eye movements. These often require surgical management
  • Mucormycosis is a surgical emergency! Always do a thorough oral and nasal exam to look for necrotic tissue and black eschar in the immunocompromised and diabetics
  • Think nasal foreign body in a kid with unilateral congestion. Be sure to check all orifices as kids like to put things everywhere.
  • Headache with positional changes or progression can be a brain tumor. Be sure to evaluate for these signs in a sinusitis patient."

miércoles, 22 de noviembre de 2017

ED Temperature and ICU Survival

The Skeptics Guide to Emergency Medicine
SGEM#195 - November 11, 2017
"Clinical Question: Does patient body temperature in the emergency department predict survival of adult patients with severe sepsis and septic shock admitted to the intensive care unit?
Screen Shot 2017-11-10 at 7.08.43 PM
Primary Outcome: In hospital mortality was inversely correlated with body temperature.
SGEM Bottom Line: We should pay greater attention to patients presenting with features of severe sepsis and septic shock that do not have fever in the emergency department as they have an associated high mortality rate."

Pericarditis

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emDocs - November 21, 2017 - Author: Santistevan J - Edited by: Koyfman A
"What are the main ECG pointers for pericarditis?
  • Pericarditis and STEMI can be very difficult to differentiate on ECG!
  • The ST elevation of pericarditis should be concave (smiley-face)
  • The ST elevation should be diffuse, not localized to a single vascular territory
  • In pericarditis, ST depression should only be found in aVR and V1
  • If you’re not sure, get serial ECGs and err on the side of caution!"

martes, 21 de noviembre de 2017

TXA in Massive Hemorrhage

R.E.B.E.L.EM - Nov 20, 2017
Background: Bleeding from massive hemorrhage in trauma and post-partum are a major cause of death worldwide. There have been two large randomized controlled trials, in trauma and post-partum hemorrhage that have shown administration of TXA within 3 hrs of bleeding onset reduces death due to bleeding. The current meta-analysis that we are going to review sought to quantify the effect of treatment delay in acute severe bleeding by analyzing individual patient-level data from the two randomized clinical trials mentioned above...
Clinical Take Home Point: 
  • In patients with massive bleeding from trauma or post-partum hemorrhage, giving TXA as soon as bleeding is suspected, reduces mortality from bleeding.
  • Most deaths, in trauma and postpartum from hemorrhage, occur within hours of bleeding onset
  • The mortality benefit of TXA appears to diminish over time and is lost at 3 hours after major hemorrhage begins
  • In this trial, there was no evidence of adverse effects (vascular occlusive events) associated with TXA treatment"

Headache in the ED

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emDocs - Nov 20, 2017 - Author: Long B - Edited by: Koyfman A
"Key Points:
  • Headache is divided into benign, primary causes and dangerous, secondary etiologies. Focused history and examination are recommended.
  • Benign headaches include migraine, tension, cluster, and several others, but a specific diagnosis is not required in the ED.
  • Management should also focus on symptom treatment for pain and nausea.
  • A combination of medications is advised.
  • Antidopaminergics have the strongest literature support. These should be used with NSAIDs and/or acetaminophen.
  • Steroids likely decrease headache recurrence.
  • Other treatments include ketamine, propofol, and nerve blocks. These are options for refractory headaches to other treatments."

LVH on ECG

JournalFeed
 Peguero J et al. J Am Coll Cardiol. 2017; 69(13):1694-1703. 
doi: 10.1016/j.jacc.2017.01.037. Peer reviewed by Clay Smith, MD.
"The Lo down on the Peguero-Lo Presti criteria for LVH
This study retrospectively evaluated a combined 216 patients in a test cohort and a validation cohort. Using echocardiography as the reference standard, the study compared the Peguero-Lo Presti criteria (SD + SV4) to several other commonly used ECG criteria for LVH. Using cutoffs of >/=2.3mV for females and >/=2.8mV for males, the Peguero-Lo Presti criteria had a far superior sensitivity for LVH (62%) compared to the next highest performer (Cornell voltage criteria, 35%). One millivolt = 10 small vertical boxes, 2 large boxes. The Peguero-Lo Presti criteria maintained specificity at 90%, which was similar to the other criteria evaluated."

The 4AT for delirium detection

4AT - RAPID CLINICAL TEST FOR DELIRIUM

The 4AT is a rapid clinical instrument for delirium detection.
It is a short and practical tool designed for use in busy areas where assessment for delirium is needed.
The 4AT is among the most widely-used clinical tests for delirium internationally.
The 4AT is free to download and use."

sábado, 18 de noviembre de 2017

Aortic Dissection

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ACEPNow - By Anton Helman - November 13, 2017
Living Art Enterprises / Science Source
"Take-Home Points
  • Remember the big pain pearls when taking a history:
    • Ask the three important questions.
    • Aortic dissection should be considered the subarachnoid hemorrhage of the torso.
    • Migrating pain, colicky pain, plus need for IV opioids should raise your suspicion.
    • Intermittent pain can still be a dissection.
  • Look for Marfan syndrome, listen for an aortic regurgitation murmur, and feel for a pulse deficit.
  • Think not only about CP +1 but also 1+ CP.
  • Know the radiographic findings of loss or aortic knob/aortopulmonary window and the calcium sign, and use POCUS to look for an intimal flap and pericardial effusion.
  • Don’t be misled by a troponin or D-dimer."

Spontaneous Bacterial Peritonitis

R.E.B.E.L. EM - Emergency Medicine Blog
R.E.B.E.L.EM - Novembre 16, 2017

"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)"

miércoles, 15 de noviembre de 2017

Sepsis interprofessional curriculum

MCC Project - By Jim Lantry
"Please enjoy complimentary access to a sepsis curriculum created by two esteemed faculty members here at the University of Maryland Medical School: Jeffrey P. Gonzales, PharmD, FCCM, BCPS, BCCCP and Nirav G. Shah, MD, FCCP.
Dr. Gonzales is an Associate Professor of Critical Care and a faculty member at the University of Maryland School of Pharmacy where he is the director of the Post-Graduate Year One and Year Two Pharmacotherapy Residency Program. He is a staple on MICU rounds and has been a driving force for pharmacy integration into the critical care fellow’s curriculum.
Dr. Shah is an Associate Professor of Medicine in the Division of Pulmonary & Critical Care Medicine, the Course Director of Pathophysiology & Therapeutics I; and also acts as the Director of the Pulmonary & Critical Care Fellowship Program here at the University of Maryland Medical Center. Despite his many administrative duties, Dr. Shah continues to be rated as one the best MICU educators by the medicine and critical care fellows."

Fluoroquinolonas

Emergency Medicine PharmD - By Tony Mixon - November 15, 2017
"Many institutions have implemented antimicrobial restriction programs where specific agents, based on toxicity, cost, or broad-spectrum of activity, require special permission for use. Often a page is required to initiate the request. During my infectious diseases PGY-2 I carried this antimicrobial approval pager, either approving the use of restricted agents or offering suggesting on alternative therapy. Fluoroquinolones (FQs) were by far, the most requested restricted antimicrobials, and also the most denied. In emergency departments without such programs, pharmacists play a vital role in antimicrobial stewardship, steering therapy to optimize clinical outcomes while minimizing unintended consequences. With their broad spectrum of activity, oral formulation, and seemingly minimal adverse effect profile, FQs were highly touted when originally approved. However, after decades of clinical use and research, is it time we rethink their greatness?"
Take Home Points
  • FQs have been associated with many severe adverse reactions, including but not limited to QT prolongation, CDI, seizures, peripheral neuropathy, hypo/hyper glycemia, GI perforation, tendinopathy, retinal detachment, aortic dissection/aneurysm, as well as causing drug-drug interactions.
  • FQs carry multiple black box warnings surrounding their safety.
  • FQs have a low barrier to resistance.
  • Resistance rates to FQs have increased rapidly. Look at your antibiogram!
  • Ciprofloxacin and levofloxacin are our only oral agents with reliable activity against Pseudomonas spp.
  • FQs should be reserved for a few clinical scenarios where other antibiotics are not safe or feasible.

lunes, 13 de noviembre de 2017

NSTEMI mimics

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emDocs - November 13, 2017 - Author: Folse M - Edited by: Koyfman A and Long B
"Summary
  • Type 1 NSTEMI involves a new, partial occlusion of the cardiac vessel. Type 2 NSTEMI involves a supply-demand deficiency.
  • Always check for reciprocal ST-segment elevation when observing ST-segment depression.
  • Posterior MI diagnosis requires ST-segment elevation of 0.5mm or greater.
  • Upsloping ST-segment depressions with tall T-waves through V1-V6 is a STEMI equivalent.
  • The American Heart Association recognizes aVR ST-segment elevation in the setting of anterolateral ST-segment depression as an indication for emergent cardiac catheterization.
  • PE and dissection are important mimics of NSTEMI.
  • Consider inflammatory markers in suspected cases of myocarditis and pericarditis.
  • Differentiation of NSTEMI-mimics that involve a physiologic increase in post-left/right ventricular afterload (HOCM, AI, AS, PAH, COPD) can generally be made by careful examination of the patient’s medical history and clinical presentation."

Angiography

Resultado de imagen de new england journal of medicine
Weisbord S. et al. New England Journal of Medicine - November 12, 2017
DOI: 10.1056/NEJMoa1710933
"CONCLUSIONS
Among patients at high risk for renal complications who were undergoing angiography, there was no benefit of intravenous sodium bicarbonate over intravenous sodium chloride or of oral acetylcysteine over placebo for the prevention of death, need for dialysis, or persistent decline in kidney function at 90 days or for the prevention of contrast-associated acute kidney injury. (Funded by the U.S. Department of Veterans Affairs Office of Research and Development and the National Health and Medical Research Council of Australia; PRESERVE ClinicalTrials.gov number, NCT01467466.)"

domingo, 12 de noviembre de 2017

CCB Overdose

The Original Kings of County - by kkelson - November 9, 2017
“He took all his medication,” you chuckle to yourself as you read the chief complaint on the board. “Man, isn’t that what we try to get all our patients to do?”
As you open up the patient’s chart, however, your smugness quickly turns to unease when you read through the triage note; “Per wife, patient took a whole month’s supply of his amlodipine.” Oh no. He took ALL his medication. Your grin melts as you see the vitals: bradycardic, mildly hypotensive..."
  • Time to call poison control
  • Mechanism
  • Initial Management
  • High-Dose Insulin
  • The Kitchen Sink
  • We have no idea what we’re doing

Renal colic mimics

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emDocs - November 8, 2017 - Author: Crain N - Edited by: Koyfman A and Long B
"Summary:
  • Flank pain and hematuria are the hallmarks of renal colic, however the presentation is variable.
  • Diagnosis can be confirmed with CT scan, which will show most other potential items in the differential if the scan is negative for a stone.
  • Patients with a good story for stone who are young and healthy at baseline can receive renal US to evaluate for hydronephrosis, rather than CT.
  • Nephrolithiasis and nearly all of its mimics are confirmed with imaging.
  • Some mimics of renal colic that may arrive at the ED include: upper UTI’s, ectopic pregnancies, ovarian torsion, adnexal masses, testicular torsion, acute aortic syndromes, renal artery aneurysms, renal infarction, splenic infarction, bowel obstruction, diverticulitis, appendicitis, biliary colic, cholecystitis, acute intestinal ischemia, pneumonia, pulmonary embolism, retroperitoneal hematoma, iliopsoas abscess.
  • Focused history and physical exam are paramount due to the multitude of structures in the area and potentially dangerous conditions that may mimic renal colic."

ACEP 2017

R.E.B.E.L.EM - November 9, 2017
"This year ACEP 2017 took place in Washington D.C. from Oct. 29th – Nov 1st, 2017. There were lots of amazing speakers and topics as was evidenced by the eruption of everyone’s twitter feeds with the #ACEP17 hashtag. I was fortunate enough to attend this amazing conference and approached by several attendees if I would put together a list of my favorite pearls from this conference. I decided to put a top 10 list together, in no particular order."

Enfermedades tropicales

Resultado de imagen de infurg semes
Fecha: 07-11-2017
"La sección de Medicina Tropical y del viajero del grupo INFURG-SEMES presenta los primeros números de una serie de Protocolos de actuación en urgencias en enfermedades procedentes del trópico.
Puede acceder directamente a los siguientes protocolos (seleccione para poder acceder al contenido): 

martes, 7 de noviembre de 2017

Critical Pulmonary Embolism Patient

R.E.B.E.L.EM - Novemeber 6, 2017 
"Background: Previously, I had given a talk on the use of thrombolytics in submassive PE in 2016. This year, I had the privilege of speaking at ACOEP 2017 again with an update on the critical pulmonary embolism patient. This post will serve as a reference for that talk.
There are many ways to classify pulmonary embolism, but the best clinical definition would depend on the hemodynamic consequences. For example, massive pulmonary embolism can be defined as systemic hypotension (SBP < 90 mmHg or a drop in SBP of at least 40mmHg for at least 15 min) or shock (tissue hypoperfusion, hypoxia, altered mental status, oliguria, or cool clammy extremities.) There is a second subset of patients that also warrant discussion; submassive pulmonary embolism. These patients are defined as lack of systemic hypotension (<90mmHg), but have right ventricular dysfunction/hypokinesis. RV dysfunction tells us that there is severe pulmonary artery obstruction and impending hemodynamic failure..."

Diabetic Ketoacidosis

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emDocs - November 6, 2017 - Authors: Reynolds C and Fairbrother H
Edited by: Koyfman A and Long B
"Key Points
  • Always rule out serious life-threatening conditions that may have precipitated a patient’s DKA. DKA is never simple, and the EM physician’s job is not over with the diagnosis and initiation of the insulin drip.
  • Consider DKA in populations with diabetes risk factors, even in patients with no known history of diabetes; particularly in patients suffering CVAs, pregnant patients, patients on high risk medications (olanzapine, risperidone or clozapine) or substance use disorders.
  • Make sure to consider DKA on the differential even in euglycemic patients, particularly those on the novel SGLT2 inhibitors.
  • Persistent tachycardia in DKA in aseptic patients after adequate volume resuscitation may be due to hyperthyroidism.
  • Make sure to consider possible underlying infections or ischemia in DKA patients who present with diffuse abdominal pain as attributing this pain solely to DKA may mask the underlying pathology.
  • Consider cardiac ischemia as MI can be a trigger of DKA, but DKA can also act as a cardiac stress test.
  • Consider DKA in the setting of natural and manmade disasters where the supply of insulin may become unavailable to patients."