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


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sábado, 24 de agosto de 2019

CRP and ATBs in COPD

R.E.B.E.L.EM - August 22, 2019 - By Salim Rezaie
"Author Conclusion: “CRP-guided prescribing of antibiotics for exacerbations of COPD in primary care clinics resulted in lower percentage of patients who reported antibiotic use and who received antibiotic prescriptions from clinicians, with no evidence of harm.”
Clinical Take Home Point: With an antibiotic prescription rate of almost 80% in the usual care group, just about any intervention that pushes antibiotic stewardship would make a difference in prescribing habits, and therefore there is no surprise that POC CRP reduced the number of antibiotic prescriptions in patients with acute COPD."

miércoles, 21 de agosto de 2019

Decompensated Hypothyroidism

REBEL Core Cast 16.0 - By Anand Swaminathan - August 21, 2019
"Take Home Points
  • Myxedema coma is severe, decompensated hypothyroidism with a very high mortality.
  • Classic features include: decreased mental status, hypothermia, hypotension, bradycardia, hyponatremia, hypoglycemia, and hypoventilation
  • Work up includes looking for and treating precipitating causes, most commonly infection as well as serum levels of TSH, T4 and cortisol
  • Treat for the possibility of adrenal insufficiency with stress dose steroids such as hydrocortisone 100 mg IV
  • The exact means of thyroid replacement is controversial. Definitely given 100-500 mcg levothyroxine and discuss the simultaneous administration of T3 with your endocrine and ICU teams"

Resuscitation Pressure in Polytrauma with TBI

Taming The SRU - August 19, 2019 - By Rath K., Gottula A
  • There is little data to help us in optimal blood pressure targets in patients with both TBI and systemic trauma with hemorrhagic shock, largely because these patients are excluded from the majority of studies. Given the significant evidence that permissive hypotension would be associated with worse TBI related outcomes, we would not recommend prehospital permissive hypotension in the subset of patients with blunt, severe TBI.
  • In the resuscitation of these patients, hypertonic saline offers great promise as a means to resuscitate patients in hemorrhagic shock, while also minimizing intracranial pressure. Mannitol is a less than ideal alternative until more definitive data is obtained on injuries, and the patient is hemodynamically stabilized.
  • Future directions on this topic should include high-quality, high-powered studies investigating the hypotensive strategies to include patients with severe traumatic brain injury with GCS 8 or lower.
  • Finally, a good neurologic exam to more sensitively assess for focal neurologic deficits and signs of intracranial hypertension can assist pre-hospital providers to better determine the likelihood of the presence or absence of traumatic brain injury."

domingo, 18 de agosto de 2019

Intraosseous Access

emDocs - August 15, 2019 - By Bloom J
Edited by: DeVivo A., Koyfman A., Long B and  Singh M
"Pearls and Pitfalls
  • Patients come in all shapes and sizes. If your patient has excessive subcutaneous or adipose tissue over your preferred site, you may have to choose an alternative site.
  • Position for success! Make sure the extremity or site is visible, angled advantageously, and supported. Use bedrolls/sheets or fellow personnel to assist you with this.
  • Avoid needlestick injuries! IO catheters and stylets/trocars are still sharps and can injure the proceduralist. Make sure your hand is not directly behind the insertion site, as a misplaced IO can bypass or completely penetrate the extremity and cause injury.
  • It is very easy to forget to secure an IO during a busy resuscitation. Although they don’t slip out as easily as an IV, an IO can fall out, and if it does replacement likely needs to be in a different extremity to avoid infiltration. Tape down your IO securely!
  • In a resuscitated patient, make sure that any IO access is clearly indicated and discussed with receiving providers during handoff. When receiving a resuscitated patient, examine carefully for the presence of an IO on the extremities or sternum.
  • Anecdotally the proximal humerus is favored by many practitioners because of its theoretical faster infusion rates and utility in cases of abdominopelvic or lower extremity compromise9,29. The proximal tibia is frequently easier to palpate and available in patients of all ages. You should feel comfortable inserting an IO in at least two different sites and should be familiar with all of them."

Imaging for Appendicitis in Pregnancy

Resultado de imagen de journalfeed
Journalfeed - August 16, 2019 - By Vivian Lei
..."In a pregnant patient presenting with abdominal pain and suspected appendicitis, an initial ultrasound should be performed to exclude obstetric causes for abdominal pain. MRI may be a reasonable next study if it is immediately accessible and radiologists with expertise in MRI interpretation are available. Otherwise, CT should be utilized..."

sábado, 17 de agosto de 2019


Resultado de imagen de journal feed
Journalfeed -  August 5, 2019 - By Clay Smith
..."Not the way to screen for this problem
This was a secondary analysis of ADviSED. Use of an aortic dissection detection risk score plus mediastinal enlargement on CXR had sensitivity of 67%, specificity 83%. The risk score plus any sign on CXR had sensitivity 69%, specificity 77%. For CXR alone, without the risk score, sensitivity was 54%, specificity 92% for mediastinal enlargement; sensitivity 60%, specificity 85% for any sign on CXR. Inter-rater agreement between radiologists for mediastinal enlargement was fair to moderate (k = 0.44). What this all means is that a CXR is a poor screening tool for acute aortic syndromes. If mediastinal enlargement or other signs are seen on CXR, this is concerning and needs further workup. If you suspect acute aortic syndrome, it’s best to just get a CTA."

Gestalt for ACS

Gestalt in ACS
First 10EM - By Justin Morgenstern - August 7, 2019
..."So how good is gestalt in the diagnosis of acute coronary syndrome? A lot of people are already talking about this paper. Honestly, I don’t find the results all that exciting. I think it basically tells us what we already knew. It shouldn’t change anyone’s practice. However, I worry that the headlines will be misinterpreted in ways that could ultimately harm our patients. So let’s take a quick look to ensure we all understand what this study really shows.
The paper
Oliver G, Reynard C, Morris N, Body R. Can emergency physician gestalt “rule in” or “rule out” acute coronary syndrome: validation in a multi-center prospective diagnostic cohort study. Academic emergency medicine. 2019; PMID: 31338902 [article]
Bottom line
Don’t believe the rumours you might hear. Clinical judgement is enough to rule out ACS for many patients in the emergency department. Just don’t contradict yourself and try to use gestalt to rule out ACS in patients where your gestalt is that ACS is a possibility. That would be silly."

Mass Casualty Incidents

Trauma System News
By Potter C - July 22, 2016 - Reviewed and updated in April 2018.
"Mass casualty incidents (MCIs) seem to strike at random. That is one reason why these incidents — particularly mass shootings — are so frightening. But while the timing and location of most MCIs are unpredictable, the way these events play out at the scene and the trauma center is not.
Longstanding research shows that no MCI is truly unique — whether it is a natural disaster such as an earthquake, hurricane, flood or tornado, or the result of human violence. At the receiving hospital, an MCI triggers a sequence of disruptions that follow a predictable pattern..."

jueves, 15 de agosto de 2019

Pregnancy-Adapted YEARS Algorithm for PE

R.E:B.E.L.EM - August 15, 2019 - By Anand Swaminathan
"Authors Conclusions: “Pulmonary embolism was safely ruled out by the pregnancy-adapted YEARS diagnostic algorithm across all trimesters of pregnancy. CT pulmonary angiography was avoided in 32 to 65% of patients.” 
Our Conclusions: Overall, we agree with the authors conclusions. The pregnancy-adapted YEARS algorithm safely ruled out PE in this cohort of patients with a small risk of VTE at 3 months if the patient was negative on initial visit. 
Potential to Impact Current Practice: External validation of this approach is needed but, application of the pregnancy-adapted YEARS algorithm has the potential to safely decrease CTPA use in pregnant women in whom the clinician has a concern for PE. 
Bottom Line: The Pregnancy-Adapted YEARS algorithm has both face validity and is pragmatic for clinical practice. However, before implementation of this algorithm into everyday practice, an external validation study would be warranted." 


PulmCrit (EMCrit)
August 15, 2019 - By Josh Farkas
"Magnesium might be the darling ion of critical care. It has an interesting array of therapeutic applications ranging from asthma to Torsade de Pointes to preeclampsia. This pair of chapters discusses the evaluation of both hypomagnesemia and hypermagnesemia."
  • IBCC chapter on hypomagnesemia is located here.
  • IBCC chapter on hypermagnesemia is located here.
  • The podcast & comments are below.
Follow us on iTunes

lunes, 12 de agosto de 2019

Septic Shock

PulmCrit (EMCrit)
August 8, 2019 - By Josh Farkas
"Septic shock is perhaps the defining illness of medical intensive care. As such it is an enormously broad and controversial topic. This chapter attempts to provide a unified and straight-forward approach. However, every physicians has a different approach to septic shock, so it's impossible to claim that this is the best approach.
There will doubtless be vigorous debate about this topic, so I encourage all to leave their questions and comments below. This chapter will be revised on an ongoing basis, so the current form might be most realistically viewed as an outline for future revisions (rather than a final word on the topic)."
  • The IBCC chapter is located here.
  • The podcast & comments are below.
  • Follow us on iTunes

Large pleural effusions

PulmCrit - August 12, 2019 - By Josh Farkas
"Summary The Bullet:
  • Large pleural effusions can generally be drained entirely (although the procedure should be stopped if the patient develops vague central chest discomfort).
  • Pleural manometry has not been shown to reduce discomfort or re-expansion pulmonary edema during large volume thoracentesis.
  • The rate of re-expansion pulmonary edema is low, even in large-volume thoracentesis (<1%). When it occurs, this can generally be treated with conservative measures (e.g. supplemental oxygen or noninvasive ventilation).
  • Using multiple small-volume thoracenteses to avoid large-volume thoracentesis is probably a misguided strategy. Multiple small-volume thoracenteses may cause an overall increase in the risk of procedural complications (due to increases in the risk of bleeding, infection, or lung laceration with multiple procedures)."

REstart or STop Antithrombotics

R.E.B.E:L.EM - August 12, 2019 - By Salim Rezaie 
"Author’s Conclusions: “These results exclude all but a very modest increase in the risk of recurrent intracerebral haemorrhage with antiplatelet therapy for patients on antithrombotic therapy for the prevention of occlusive vascular disease when they developed intracerebral haemorrhage. The risk of recurrent intracerebral haemorrhage is probably too small to exceed the established benefits of antiplatelet therapy for secondary prevention.”
Clinical Take Home Point: The established benefits of antiplatelet therapy likely outweigh what may be a small or non-existent increased risk of recurrent bleeding following ICH; however, it is unclear when is the optimal time to restart therapy."

Peritonsillar abscess drainage

ALiEM Logo
ALiEM - August 9th, 2019 - By Davis M and Alvarez A
"Dr. Michelle Lin and Dr. Demian Szyld have created great guides for the common and important emergency medicine procedure of draining a PTA (laryngoscope lighting and spinal needle for aspiration; ultrasound localization and spinal needle guard; avoiding awkward one-handed needle aspiration). This update reviews these tricks as well as some additional techniques for optimal success in draining a PTA, while avoiding the ultimate feared complication of puncturing the carotid artery."

Varicose Veins

emDocs - August 12, 2019 - Authors: Rusnack F and He C
Edited by: Simon E., Koyfman A & Long B
"Key Points
  • Varicose veins are common in the elderly. Risk factors include obesity, pregnancy, bleeding dyscrasias, prolonged standing, immobility, and cigarette smoking.
  • Complications associated with varicose veins include bleeding, DVT/PE, SVT, and venous ulceration.
  • Bleeding may be managed with direct pressure, pressure dressings, topical TXA, a figure-of-eight suture, and vascular surgery consultation.
  • Varicose veins are associated with DVT: US evaluation is warranted.
  • US may be utilized to evaluate the extent of SVT; proximity to the deep venous system may dictate systemic anticoagulation.
  • Both SVT and venous ulceration require evaluation for cellulitis."

jueves, 1 de agosto de 2019


July 26, 2019
EU Directive update
"On 16 January 2019 a European Commission Delegated Decision (EU) 2019/608 has amended Annex V to Directive 2005/36/EC of the European Parliament and of the Council as regards the evidence of formal qualifications and titles of training courses.
So far 16 European countries have recognised Emergency medicine as s specialty requiring a minimum training period of 5 years.
  • You can find here the text of the Decision."

Head Elevation during Intubation

R.E.B.E.L.EM - August 01, 2019 - By Bryant R
  • Pre-oxygenation and intubation in HOB elevated position makes physiologic sense.
  • Pre-oxygenating obese and non obese patients undergoing elective surgery in HOB elevated position can prolong the non patient oriented outcome of safe apnea duration by over 1 minute. This supports the physiologic plausibility of HOB elevation improving respiratory dynamics.
  • Intubating non trauma and non cardiac arrest patients in a pre-hospital setting in a HOB elevated position is associated with improved first pass success, improved glottic visualization, and a decrease in the presence of airway secretions during laryngoscopy.
  • ED studies show mixed results with one study showing improved first pass success without a difference in peri-intubation hypoxia or rates of post intubation pneumonia. A larger registry-based study showed no difference in first pass success, but a higher incidence of peri-intubation hypoxia in the HOB elevated group that may have been a sicker population.
  • In-hospital studies are split, with one showing a dramatic reduction in peri-intubation adverse events with HOB elevation, and another showing a reduction in first pass success that may be associated with ICU bed design.
  • Equipment / position issues may be overcome with deliberate practice and increased experience.
  • For ED patients requiring intubation HOB elevation makes physiologic sense and is supported by prehospital and ED studies. There is no evidence of harm in the ED setting."

PE and CT in Pregnancy

Blog de Medicina Intensiva

Pulmonary Embolism and Diagnostic CT in Pregnancy

Medicina Intensiva - July 31, 2019 - By Santana L
"Acute pulmonary embolism is a leading cause of maternal death in the Western world. But routine diagnostic use of CT pulmonary angiography or ventilation–perfusion scanning exposes both mother and fetus to radiation. Full study: https://nej.md/2ukleOC "

Furosemide in CHF

The Resuscitationist
The Resuscitationist - July 25, 2019 By Bowman J
..."In June of 2017 the REALITY AHF (Registry Focused on Very Early Presentation and Treatment in Emergency Department of Acute Heart Failure) trial results were published in the Journal of the American College of Cardiology. In short they found a survival benefit (2.3% vs 6% mortality) to giving Lasix in the first 60 minutes of arrival to the ED. That’s an NNT of just 27! Better than aspirin in chest pain (NNT 43). Dun Dun Duuuuuunnnn….. Interesting. Salim Rezaie of RebelEM has a great review of the stats of the article. Essentially, it’s a prospective Japanese article of 20 hospitals looking at ADHF and the survival association of time to treatment with Lasix, excluding prehospital administration of Lasix. This was a pretty big undertaking to set up this registry and end up with something like 1200 patients enrolled, apparently us not giving Lasix early as much as we used to really pissed those medicine docs off. Now really though this is a Japanese study so I don’t know what the climate of Japanese EM Lasix administration was, from this study it seems like they gave it more than I’ve seen here in the US in a while. And this is actually a pretty good study question to answer, before this study we didn’t have any prospective outcome data on the temporal association of Lasix administration. Now this data exists. And apparently we should’ve been giving Lasix in the first 60 minutes. So oops right? Not so fast..."

IV Thiamine

EM PharmD
EM PharmD - July 23, 2019 - By Singh R
..."Bottom Line
The data involving a large number of both IVP doses and patients without adverse reactions to thiamine IVP gathered from decades-old literature, new literature, and recent responses from practitioners around the USA strongly suggests that thiamine 100 mg IVP is reasonably safe, and 200 mg IVP may be considered safe, too. 
Even though publications are in the works, conducting more studies or sharing an MUE abstract is encouraged because people tend to like recent data. Moreover, maybe your hospital has already been doing IVP thiamine for years without issue and it’s not even on your radar, but I’m sure there is another hospital on the cusp to make a decision to change from IVPB to IVP that would benefit from your experience. Never underestimate the power of sharing knowledge, you can literally help change and improve practice."

lunes, 22 de julio de 2019

Framework on Quality and Safety in Emergency Medicine

Resultado de imagen de international federation emergency medicine
2nd Edition | Quality and Safety Special Interest Group | January 2019 
Document Editors: Kim Hansen, Melinda Truesdale,  Adrian Boyle,  Brian Holroyd,  Georgina Phillips,  Jonathan Benger,  Lucas Chartier,  Fiona Lecky,  Ellen Webb,  Samuel Vaillancourt,  Peter Cameron,  Grzegorz Waligora,  Lisa Kurland  
"On behalf of the IFEM Quality and Safety Special Interest Group. 
"The original “Quality Framework” document arose from the sessions and discussions that took place at the International Federation for Emergency Medicine (IFEM) Symposium for Quality and Safety in Emergency Care, hosted by the College of Emergency Medicine (CEM) in the UK in 2011. It was presented and further refined at the 14th International Conference on Emergency Medicine in 2012. After feedback and review, an updated 2nd edition was developed in 2018 by the IFEM Quality and Safety Special Interest Group and associated editors. We would like to acknowledge the editors of the 2012 Framework for Quality and Safety in the Emergency Department: Fiona Lecky, Suzanne Walsh, Jonathan Benger, Peter Cameron, Chris Walsh"

sábado, 20 de julio de 2019

Cannabinoid Hyperemesis Syndrome

EM Pharma D
EM Pharma D - July 19, 2019 - By Evan Mulvihill
"Cannabinoid Hyperemesis Syndrome (CHS) is a sequela of long-term heavy cannabis use that involves cyclic bouts of nausea, vomiting, and diffuse abdominal pain. The treatment of CHS is unique in that your traditional anti-emetics and GI cocktails like Zofran, metoclopramide, and acid reducers, are fairly ineffective in controlling symptoms. CHS patients often receive extensive gastrointestinal (GI) work-ups in the ED, and may even be admitted when there are much simpler treatments to attempt first..."

Hyperthermia & heat stroke

PulmCrit (EMCrit)
PulmCrit (EMCrit) - July 19, 2019 - By Josh Farkas 
"Since it looks like the United States is about to go into total meltdown from a heat wave, I dusted off the hyperthermia chapter. This is a bit of an impromptu post, so we don't have a podcast to go along with it (we will record one eventually – Adam has more experience with the ice tarp taco than I do). So stick some bags of lactated ringers in the refrigerator, get your ice buckets ready, and, well, good luck."
  • The IBCC chapter is located here

jueves, 18 de julio de 2019

Drugs That Work and Drugs That Don’t

EM Cases - June 18, 2019 - By Helman A
"This is EM Cases Episode 126 Emergency Drugs that Work and Drugs that Don’t Part 1 – Analgesics with Dr. Joel Lexchin and Dr. Justin Morgenstern. In this podcast we discuss the key concepts in assessing drug efficacy trials, and provide you with a bottom line recommendation for the use of gabapentinoids, NSAIDs and acetaminophen for low back pain and radicular symptoms, topical NSAIDs and cyclobenzaprine for sprains and strains, caffeine as an adjunct analgesic, why we should never prescribe tramadol, dexamethasone for pharyngitis, calcium channel blockers for hemorrhoids and anal fissures, buscopan for abdominal pain and renal colic and why morphine might be a better analgesic choice than hydromorphone…"
EM Cases - July 02, 2019 - By Heiman A
"In this Episode 127 Drugs that Work and Drugs that Don't Part 2 - Antiemetics, Angioedema and Oxygen, with Justin Morgenstern and Joel Lexchin we discuss the evidence for various antiemetics like metoclopramide, prochlorperazine, promethazine, droperidol, ondansetron, inhaled isopropyl alcohol and haloperidol as well as why should not use an antiemetic routinely with morphine in the ED. We then discuss the evidence for various drugs options for a potpourri of true emergencies like angioedema and hyperkalemia, and wrap it up with a discussion on oxygen therapy..."

The Overdosed Patient

emDocs - July 15, 2019 - Author: Dazhe J
Edited by: Santos C; Koyfman A  and Long B
"...Summary – Key Take Home Points:
  1. Avoid premature closure by verifying through history and exam that the patient’s presentation is consistent with what the reported ingestion was.
  2. A thorough toxicology history with relevant social history elements take time, but learn to start incorporating some of these questions if diagnostic uncertainty is present – i.e. ask if pets are also sick at home.
  3. Manage and stabilize patients as you would any critically ill patient with attention to ABCs and supportive care. Add in considerations of antidote, decontamination, and enhanced elimination based on suspected exposure.
  4. Know your toxicology resources listed above and call your local poison center or medical toxicologist for clinical assistance."


Some Hints About Airway!
iEM - July 17, 2019 - By Alqahtani A
"The airway is one of the most critical topics in the ER. Read everything about the airway; it is not a waste of time. Even if you have to spend one year just for airway, it is worth it. You will always be confident in dealing with whatever situation that might come to you. Although reading is essential, practicing and getting experience on airway issues is essential too. So, reading along with exposing many patients is a great combination to achieve good skills.
Build your own skills by reading then summarizing your own words. As long as it is correct and safe, the way accomplishing or securing the airway may not be important in many patients.
Here are some tips in airway management at the Emergency Department (ED)
I will mention some points that might help in the management of typical scenarios at the ED. They might look random, but trust me, it is the real deal..."

Topical lidocaine

ALiEM Logo
ALiEM - July 17th, 2019 - By: Bragg K and Fox H
"Severe constipation, requiring fecal disimpaction and rectal enemas, can be excruciatingly painful for patients. Administering sedatives and opioids to help alleviate this pain poses a challenge, because many of the patients are elderly and tend to be more sensitive to these medications. Furthermore, there may be increased vagal tone when straining, leading to hypotension and bradycardia and which can result in defecation-related syncope. Also, opioids can exacerbate constipation. Herein we present 2 cases and tricks on achieving better pain control..."

sábado, 6 de julio de 2019

Managing Hyperkalemia with Insulin/Glucose

JournalFeed - June 27, 2019 - By Alex Chen, MD
Source: Management of Hyperkalemia With Insulin and Glucose: Pearls for the Emergency Clinician. J Emerg Med. 2019 May 11. pii: S0736-4679(19)30250-1. doi: 10.1016/j.jemermed.2019.03.043. [Epub ahead of print]
"Spoon Feed
Use of insulin/glucose to treat hyperkalemia works, but hypoglycemia is a common side effect. Here are some pearls to give this treatment more safely. 
Why does this matter?
Hyperkalemia is a life-threatening condition that requires prompt management in the ED. One of the most common treatment options is the administration of insulin and glucose to help shift potassium into the cell temporarily. Usually this is ordered as 10 units of regular insulin IV and 1 ampule of D50. This article explores some common myths and debunks them..."

Massive Transfusion

CanadiEM MVP Infographic Series - By Lauren Beals - July 5, 2019
Transfusion of Plasma, Platelets, and Red Blood Cells in a 1:1:1 vs a 1:1:2 Ratio: The PROPPR Randomized Clinical Trial​
"20-40% of trauma deaths after hospital admission involve massive hemorrhage, a devastating outcome potentially avoided with good rapid hemorrhage control. Rapid hemorrhage control is best achieved by the timely delivery of plasma, platelets, and packed red blood cells in a balanced ratio, to replace ongoing losses without encouraging coagulopathy. This is most often seen in the context of a massive transfusion protocol activation. 
For a quick refresher on MTP check out Blood and Clots here..."

viernes, 5 de julio de 2019

GI Emergencies

StEmlynsLIVE - By Chris Gray - July 5, 2019
"I was really privileged to give a talk on upper GI/gastrointestinal emergencies last year at St Emlyn’s LIVE. You can read more on the overwhelming impostor syndrome I felt standing there not only with, but also in front of and talking to, such a wealth of experience in emergency medicine and critical care, echoed in Nat’s post from a few years ago. You can watch the talk below or listen to the podcast on our iTunes channel. This blog is designed to give you the background behind the talk.
However, this post isn’t about impostor syndrome, and we’ve got no time to worry about that anyway. The bat phone has just gone off. It’s a red standby..."

Peripartum Cardiomyopathy

emDocs - July 4, 2019 - By Rometti M and Patti L
Edited by: Montrief T, Koyfman A and Long B
"Take Home Points
  • The highest risk for PPCM is in the month prior and the five months following delivery. Diagnosis includes heart failure within this timeframe with no other known underlying etiologies.
  • Consider this diagnosis in patients who are presenting with dyspnea on exertion or other signs of heart failure. Be wary of confusing these with common symptoms of late pregnancy.
  • Initial management should evaluate and support the patient’s respiratory status, with oxygen supplementation and consideration of non-invasive or invasive ventilation as dictated by the stability of the patient, as well as consideration of nitroglycerin (preload) and diuretics (systemic congestion). Patients in cardiogenic shock require resuscitation with vasopressors, inotropes, and consideration of ventricular assist devices.
  • In the still pregnant patient, consider early fetal monitoring in order to evaluate for uterine perfusion.
  • In the pregnant patient, avoidACE-Is, ARBs, warfarin, and DOACs for concern for teratogenicity. These are acceptable in the post-partum patient."

Autoantibody-Mediated Encephalitis

ACEP Now - By Ryan Patrick Radecki - June 19, 2019
"A few years ago, a best-selling autobiographical work, Brain on Fire, chronicled one of the first instances of diagnosis for N-methyl-D-aspartate (NMDA) encephalitis. The story depicted by the author is one of a young woman’s descent into madness caused by encephalitis before its relatively novel cause is determined by a New York neurologist. The book details her recovery, and the story has even been developed into a feature film on Netflix..."

lunes, 1 de julio de 2019

Superficial Venous Thrombosis

REBEL Core Cast 14.0 - June 26, 2019 - By Anand Swaminathan
"Take Home Points on SVT
  • Superficial venous thrombosis refers to a clot and inflammation in the larger, or “axial” veins of the lower extremities and superficial thrombophlebitis refers to clot and inflammation in the tributary veins of the lower extremities. While we previously thought of this as a benign entity, we actually found the superficial venous thrombosis has been associated with concomitant DVT and PE.
  • Small, superficial clots can be treated with compression, NSAIDs, and elevation. These patients should be seen for follow up within 7-10 days to make sure the clot has not progressed.
  • Clots that are longer than 5 cm should be treated with prophylactic dosing of anticoagulation: fondaparinux 2.5mg subq once daily for 45 days or enoxaparin 40 mg subq once daily for 45 days.
  • Clots that are within 3 cm of the sapheno-femoral junction should be treated the same as a DVT.
  • A superficial thrombus could mean there is a deeper clot elsewhere, even in the other leg! Take a good history, perform a thorough physical exam and consider a bilateral lower extremity DVT study in concerning patients."

Fournier’s Gangrene

emDocs - July 1, 2019 - Authors: Montrief T; Auerbach J. Edited by: Koyfman A and Long B
"Take Home Points
  • Fournier’s gangrene is most likely to present in an obese male patient between the ages of 50 and 79 years of age, with one or more risk factors –immunosuppression, alcohol use disorder, or diabetes.
  • Fascial anatomy plays an important role in the pathophysiology of Fournier’s gangrene. The Colles fascia remains continuous with other surrounding fascial planes, facilitating rapid spread towards the abdomen and thorax (via Scarpa’s fascia), as well as the scrotum (via Buck’s and Dartos fascia).
  • The most common sources of Fournier’s gangrene arise from the gastrointestinal tract (30-50%), genitourinary tract (20-40%), and cutaneous injuries (20%).
  • Up to 80% of FG cases are polymicrobial, with an average of four organisms per patient.
  • FG is often misdiagnosed as cellulitis or abscess in 75% of cases, and any crepitus, pain out of proportion, or ecchymosis should clue you in to possible FG.
  • The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score may suggest the presence of NSTI, however, it should not be used to exclude the diagnosis of FG.
  • CT has a sensitivity of 88.5% and specificity of 93.3% for the diagnosis of Fournier’s gangrene. MRI is more sensitive but may not be available and takes longer to obtain.
  • The cornerstones of treatment of FG include emergent surgical debridement of all necrotic tissue, broad-spectrum antibiotics, and hemodynamic resuscitation with intravenous fluids as well as vasoactive medications as needed."

lunes, 24 de junio de 2019

IO Blood for analysis

St. Emlyn´s - By Simon Carley - June 22, 2019
..."The clinical bottom line.
Unless someone out there can find better evidence (I could not) then we should not rely on bone marrow analysis in critically unwell patients. Although the only paper in critically unwell humans suggests that it might have a role for some variables I am unwilling to rely on a study of just 17 patients​​.
Having been told (and taught) hundreds of times that we can use IO samples in resuscitation I think this paper is #dogmalysis​​, and we love that here at St Emlyn’s. Next month I’m teaching APLS in Virchester and I suspect that I might be struggling in the IO practical session..."