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

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viernes, 24 de marzo de 2017

Mechanical CPR (out-of-hospital)

R.E.B.E.L.EM - March 23, 2017 - By Salim Rezaie
Ref. Buckler DG et al. Association of mechanical cardiopulmonary resuscitation device use with cardiac arrest outcomes: a population-based study using the CARES registry (Cardiac Arrest Registry to Enhance Survival). Circulation 2016; 134: 2131-33. PMID: 27994028
"Background: The two most important things that we can do in cardiac arrest to improve survival and neurologically intact outcomes is high quality CPR, with limited interruptions and early defibrillation. In the case of the former, the 2015 AHA/ACC CPR updatesrecommended a compression rate of 100 -120/min, a depth of 2 – 2.4in, allowing full recoil, and minimizing pauses. This is a lot to remember during a stressful code situation and one way many providers are offloading themselves cognitively is by the use of mechancical CPR (mCPR) devices. In theory these devices compress at a fixed rate, and depth, with the added benefit that the machine simply does not tire out. Additionally, use of this device allows another provider to be available for other procedures and interventions. A recent systematic review and meta-analysis in looked at five randomized clinical trials with over 10,000 patients with out-of-hospital cardiac arrest (OHCA) (Gates 2015). They concluded that there was no difference in ROSC, survival or survival with good neurological outcomes with the use of these devices compared to manual CPR. It is important to state that none of these studies showed increased harm either. A new paper just published in Circulation however, argues that mCPR during OHCA was associated with lower neurologically intact survival.
Author Conclusion: “In conclusion, the use of mCPR during out-of-hospital cardiac arrest was associated with lower neurologically favorable survival within emergency medical services agencies participating in CARES. Although the use of mCPR devices increased during the study period, deployment rates remained highly variable, and the majority of agencies did not use them. Further research is required to identify circumstances in which mCPR may benefit patients with out-of hospital cardiac arrest; however our data indicate that mCPR for routine cardiac arrest care was associated with worse outcomes.”

jueves, 23 de marzo de 2017

MDCalc for the perfect intubation

PulmCrit (EMCrit)
PulmCrit - March 22, 2017 - By Josh Farkas
"Imagine you went to buy an expensive piece of clothing. Rather than measuring your size, the store owner simply said “well, on average most folks require a medium, so let's try that on, we can always re-size it later.” You would be irritated that they were wasting your time. When you go clothes shopping, you expect measurement to be made so that the clothes fit right the first time. The patients we intubate deserve this same level of consideration.
  • Emerging evidence continues to support the importance of ventilating patients using lung-protective tidal volumes.
  • Height-based estimation of ETT depth may allow for a simple, protocolized approach that avoids right mainstem intubation.
  • A new MDCalc equation may facilitate intubation safety, by simultaneously calculating lung-protective tidal volumes and reasonable ETT depth."

Isolated distal DVT

An online community of practice for Canadian EM physicians
CanadiEM - By David Wonnacott - March 21, 2017
"Clinical Question:
Should we be doing whole-leg ultrasounds to look for isolated distal DVTs (IDDVT), and if we find them, how should we manage them?
Isolated distal DVTs are a controversial clinical entity. The distinction between proximal and distal DVTs is usually made at the level of the trifurcation of the popliteal vein, located at or just below the popliteal fossa.1 While there’s a robust literature and consensus around diagnosing and treating proximal DVTs to reduce the risk of pulmonary embolism, recurrence, and clot extension, the evidence around IDDVT is much murkier. Major guidelines differ significantly in management suggestions, and the objective of this article is to discuss some of the controversies and approaches to IDDVT management. The most commonly used guideline for VTE diagnosis and management in North America is the American Academy of Chest Physicians antithrombotic guidelines, which most recently published recommendations about IDDVT in 2012 and 2016.23 On the other side of the Atlantic, the UK National Institute for Health and Clinical Excellence (NICE) guidelines of 2012 and 2015 are more commonly used.45 Let’s consider how each of these guidelines would inform our management of this case regarding a possible diagnosis of isolated distal DVT."

martes, 21 de marzo de 2017

The Hand: ED Diagnosis

emDocs
emDocs - March 20, 2017 - Authors: Gragossian A and Hamilton R 
Edited by: Simon E & Koyfman A
"Pearls:
  • A rapid hand exam can be performed in the following manner:
  • As the patient make an “OKAY” sign with thumb and first finger (median nerve). Spread the fingers apart maximally (ulnar nerve). Dorsiflex the wrist fully (radial nerve). These can be combined into an OKAY sign with remaining fingers spread apart and the wrist dorsiflexed to get an all-in-one motor exam.
  • Check sensation of the median and ulnar nerve by testing two-point discrimination at the index and small finger pads respectively. Radial nerve sensation can be tested over the dorsum of the thumb.
  • For carpal tunnel syndrome, perform Tinel’s and Phalen’s tests. Remember, a positive test occurs when the patient reports paresthesias in median nerve distribution.
  • Acute compartment syndrome must go to the OR within 8 hours of onset.
  • Kanavel’s Signs are key physical exam findings for flexor tenosynovitis: finger held in flexion, pain with passive extension, pain with palpation of the flexor tendon sheath, and fusiform swelling.
  • Beware of high-pressure injection injuries. They look more benign than they truly are, and warrant a careful physical examination of the hand and consultation."

Tracheostomy and Laryngectomy Emergencies

EM Crit - Podcast 195 - March 20, 2017 - By Scott Weingart
The Best Paper and the most amazing site
from the National Tracheostomy Safety Project (NTSP), the ultimate site for trach emergency management
green-protocol         red-protocol

Heliox & Mechanical Power

PulmCCM
PulmCCM - By Jon-Emile S. Kenny - March 20, 2017
"Of the countless things taught to me by Dr. Chitkara at the Palo Alto VA Health Care System, one that sticks is the difference between density-dependent and viscosity-dependent airflow. He often used the chronic bronchitic suffering through the viscous, humid New York City summers as a teaching example. The importance of gas density and viscosity is also frequently encountered when considering the properties and benefits of helium-oxygen gas mixtures [i.e. ‘Heliox’]. This brief review highlights the viscosity and density characteristics of gas within the context of the mechanical power applied to the lung; as such, roles for Heliox may extend beyond that of a rescue therapy for severe obstructive airways disease... 
Caveats, Concerns, Conclusion 
Lowering gas density has salutary effects on both inspiratory and expiratory phases of the respiratory cycle. By reducing Ppeak, PEEPi and Pplat, dynamic and elastic work is reduced. Accordingly, the total mechanical power applied to the lung skeleton is diminished which may mitigate VILI. Lung units of differing time-constants have been found in ARDS, so this physiology may be germane beyond obstructive airways disease. The obvious drawback is that the density-dependent benefits of Heliox come at the expense of FiO2 and will limit application to severely hypoxemic patients. Accordingly, Heliox as an adjunct to extracorporeal oxygenation may hold clinical merit. Regardless, as a lesson in applied physiology this thought experiment – I think – remains worthwhile; thanks Dr. C!"

lunes, 20 de marzo de 2017

Top trauma papers 2016

St.Emlyn’s - By Simon Carley - March 17, 2017
"This week I am off to one of the most enjoyable conferences I can get to in the UK. The Trauma Care conference is usually held around the Midlands and brings together everyone involved in trauma care for 4 days of learning and fun. My role is usually to go and present the top 10 trauma papers of the year and so it is again this year (2016-17 and a couple sneakingin fom late 2015). In previous years I’ve really enjoyed this1 and I’m looking forward to it again in 2017.
The system is fairly well established now. I use a combination of regular PubMed searches, together with #FOAMed sites such as REBELEM, The Bottom Line, RESUS.ME, EMLitofNote, and of course the wider St.Emlyn’s team to scan the literature from 2016 up until the present day. I look for articles that ideally have three features. I want them to be able to change what we do, be of high quality and tio be interesting to the audience. This is usually an easy tasks as there are lots of papers out there, but not so much this year. I struggled to find those game changing papers around trauma which really surprised me. Trauma is a huge topic, with an enormous societal impact and yet the number of high quality RCTs is pretty damn small, especially so around the initial management and resuscitation of patients. Having said that I think we have found 10 papers that are interesting and useful to know about. If you find some more then let me know. We can always add in some extras.
Here’s my top 10..."

viernes, 17 de marzo de 2017

Posterior Circulation Strokes

emDocs
emDocs - March 15, 2017 - Authors: Pawlukiewicz A and Long D
Edited by: Koyfman A and Long B
"Pearls and Pitfalls
Pearls
  • Clarify what the patient means by dizziness regarding timing and triggers of the onset of symptoms. Distinguish dizziness from syncope or other mimicking conditions, as these will require a different work-up.
  • Suspect a central etiology in patients with acute vestibular syndrome. Evaluate with the HINTS exam.
  • Use the HINTS test in patients presenting with Acute Vestibular Syndrome, as this is more sensitive than both CT and MRI for posterior circulation strokes.
  • Nystagmus is assessed during lateral gaze at 45-60 degrees, not at end-gaze. An abnormal response in a patient with AVS is vertical or torsional nystagmus. 
  • The HINTS exam should only be used in patients presenting with Acute Vestibular Syndrome, not patients with Triggered or Spontaneous Episodic Vertigo Syndrome.
Pitfalls
  • Symptoms that worsen with movement do not confirm a peripheral process. Symptoms with movement may also exacerbate symptoms from a central process.
  • A normal head CT is not sufficient in excluding ischemic stroke.
  • MRI should not be relied upon in the initial 24-48 hours after symptom onset to rule out a posterior circulation stroke, as it may miss up to 10-20% of posterior circulation strokes.
  • Younger age does not exclude central causes of Acute Vestibular Syndrome. A stroke should still be suspected in patients younger than 50 if the physical exam is concerning for a central process.
  • Many of the classic distinguishing features of peripheral lesions are also found in central lesions."

miércoles, 15 de marzo de 2017

Convulsive Status Epilepticus

American Epilepsy Society Guideline
Glauser T et al. Epilepsy Currents 2016; 16 (1): 48–61
"CONTEXT: The optimal pharmacologic treatment for early convulsive status epilepticus is unclear. 
OBJECTIVE: To analyze efficacy, tolerability and safety data for anticonvulsant treatment of children and adults with convulsive status epilepticus and use this analysis to develop an evidence-based treatment algorithm. 
DATA SOURCES: Structured literature review using MEDLINE, Embase, Current Contents, and Cochrane library supplemented with article reference lists. 
STUDY SELECTION: Randomized controlled trials of anticonvulsant treatment for seizures lasting longer than 5 minutes. 
DATA EXTRACTION: Individual studies were rated using predefined criteria and these results were used to form recommendations, conclusions, and an evidence-based treatment algorithm..."

martes, 14 de marzo de 2017

Hypertriglyceridemic pancreatitis

PulmCrit ( EMCrit)
PulmCrit- March 13, 2017 - By Josh Farkas
"Summary: The Bullet
  • Hypertriglyceridemic pancreatitis is common among critically ill pancreatitis patients, but receives little attention.
  • Measuring a triglyceride level should be considered in all patients with pancreatitis.
  • The diagnosis of hypertriglyceridemic pancreatitis is based upon an elevated triglyceride level (typically >1,000 mg/dL) and exclusion of other likely causes.
  • In addition to general therapies for pancreatitis, patients with hypertriglyceridemic pancreatitis may also benefit from treatments targeted at reducing triglyceride levels (either plasmapheresis or insulin infusion).
  • Some recent evidence suggests that insulin infusion may be more effective than plasmapheresis clinically. Insulin infusion is also safer and easier to initiate immediately."

Lung Protective Ventilation

R.E.B.E.L.EM - March 13, 2017
"Background: Intubation and mechanical ventilation are commonly performed ED interventions and although patients optimally go to an ICU level of care afterwards, many of them remain in the ED for prolonged periods of time. It is widely accepted that the utilization of lung protective ventilation reduces ventilator-associated complications, including acute respiratory distress syndrome (ARDS). Additionally, it is believed that ventilatory-associated lung injury can occur early after the initiation of mechanical ventilation thus making ED management vital in preventing this disorder. Despite this, intubated ED patients are not optimally ventilated used lung-protective strategy on a routine basis.
Clinical Question: Can the adoption of an ED lung-protective ventilation protocol decrease the frequency of ventilator associated complications?...
Clinical Bottom Line:
Patients intubated in the ED without reactive airway disease should be ventilated with a lung protect approach. Starting lung protective ventilation in the ED is feasible, it influences ventilator settings in the ICU and reduces pulmonary complications. Implementation includes getting an accurate height to use for the tidal volume, minimal FiO2 to meet an O2 saturation greater than 90%, matching PEEP to the FiO2 according to the ARDSNet protocol, keeping the plateau pressure < 30 mm Hg and keeping the head of the bed at 30 degrees.

Community-Acquired Pneumonia

emDocs
EMDOCS CASES - March 13, 2017 - Authors: Long B and Long D -  Edited by: Koyfman A
"Summary
  • Pneumonia possesses a wide range of presentations.
  • One study shows a prevalence of 2.6% for pneumonia in patients with URI symptoms, while other studies suggest this is closer to 7%.
  • No combination of history, exam, and testing can improve the diagnostic probability of pneumonia to over 50%.
  • Patients younger than 65 years with normal vital signs and normal lung exam may not require a CXR. Patients with URI symptoms, vital sign abnormalities, and abnormal lung findings should have imaging.
  • For imaging, US can be beneficial. Patients with high likelihood of pneumonia and negative CXR, such as those with immunosuppression, dehydration, and older age, may need additional imaging such as CT chest.
  • Clinical scores can assist in risk stratification and disposition, but they should only be used in association with clinical judgment and gestalt.
  • Patient social situation, substance abuse history, and PO tolerance should be taken into consideration."

domingo, 12 de marzo de 2017

Prophylactic hydration to protect renal function

The Bottom Line - March 10, 2017 - By Bradford C
Ref. Nijssen E. The Lancet; published online February 20, 2017 
http://dx.doi.org/10.1016/S0140-6736(17)30057-0
"Clinical Question
In high-risk patients receiving contrast medium, does prophylactic hydration with normal saline compared to no prophylaxis impact the rate of contrast-induced nephropathy?
The Bottom Line
  • Hydration prior to contrast administration may not be necessary in all patients previously thought at risk to develop CIN.
  • However, this trial does not specifically answer the question for my ICU patient. At this stage, intravenous hydration in this population should continue especially if the patient has haemodynamic instability, nephrotoxic drugs and high contrast doses. Patients with GFR < 30 should still receive peri-procedure hydration. With patients at risk of pulmonary oedema, hydration should be used judiciously."

Sudden Arrhythmic Death

Resultado de imagen de emergency medicine news
Roberts, James R. Emergency Medicine News 2017; 39(3): 8-9
doi: 10.1097/01.EEM.0000513577.37092.89
"Some patients suffer sudden arrhythmic death without any prior symptoms, but a relatively large number of young individuals who die suddenly and unexpectedly experience warning symptoms prior to their arrest. Unfortunately, these symptoms are seemingly benign and often not worrisome to the patient or inscrutable to the evaluating clinician, but they nonetheless prognosticate future cardiac arrest. Substernal chest pain with radiation to the arms associated with nausea and vomiting, diaphoresis, and shortness of breath would not be deemed benign by any emergency clinician and at least initially attributed to a cardiac etiology. Likewise, abnormalities on the ECG or cardiac enzymes are also likely to substantiate a cardiac event. Presyncope in a healthy, young individual with normal exam, however, is likely not very concerning.
It would be best to be able to identify patients prior to their sudden arrhythmic death, but so far no study of an unselected population has been able to characterize variables. A nationwide study among young adults in Denmark attempted to clarify symptoms that young individuals experienced prior to a sudden arrhythmic death. Many causes of cardiac death are secondary to coronary artery disease, as discussed in last month's column, but now more causes have been identified with sophisticated DNA analysis."

viernes, 10 de marzo de 2017

Cannabis Use and Dangers

emDocs
emDocs - March 9, 2017 - Authors: Cao D J, MD and Hail S
Edited by: Koyfman A and Long B
"Pearls
  • Cannabis is sold in many forms including marijuana (dried plant product), hashish, and higher concentration products (“dab,” “wax,” “honey,” “shatter,” “butane hash oil”).
  • Acute cannabis intoxication can range from desired psychoactive effects to severe life-threatening respiratory depression with the latter being more common in children.
  • Cannabinoid hyperemesis syndrome, characterized by bouts of intense cyclic nausea/vomiting and relief with hot showers/baths, may be increasing with decriminalization of medical and recreational cannabis.
  • Consider secondary injuries related to cannabis use and production including motor vehicle collisions and severe burns.
  • Average THC concentrations of marijuana in the United States have increased related to the cultivation technique of sinsemilla (seedless female buds), which can yield an average concentration of 14.5% THC."

Triage ECGs

R.E.B.E.L.EM - March 9, 2017
Ref. Hughes KE et al. Safety of Computer Interpretation of Normal Triage Electrocardiograms. 
Acad Emerg Med 2017; 24(1): 120 – 24. PMID: 27519772
"Background: Lets face it. All of us have been interrupted by the onslaught of triage ECGs for interpretation. This constant flow of pink paper with black scribble causes frequent task switching, interrupts train of thought, and ultimately can lead to medical errors, which affects the patients in front of us. On the other hand, it is important to avoid delays in care and, in accordance with the American Heart Association guidelines, ECGs in triage should be obtained and interpreted by an attending emergency physician within 10 minutes of arrival to the emergency department for any patients with concerns of acute coronary syndrome. Is there a way to maybe minimize the number of interruptions?...
Author Conclusion:Our data suggest that triage ECGs identified by the computer as normal are unlikely to have clinical significance that would change triage care. Eliminating physician review of triage ECGs with a computer interpretation of normal may be a safe way to improve patient care by decreasing physician interruptions.”
Clinical Take Home Point: Although this is a small, single center study, who’s results need to be replicated, this seems like a very feasible intervention to try and reduce one of the most common interruptions encountered by EM physicians at the work place."


jueves, 9 de marzo de 2017

Amputations

emDocs
emDocs - March 8, 2017 - Authors: Kanter C and Repanshek Z
 Edited by: Koyfman A and Long B
"Review of the Pearls
  1. ED management is the same for ALL types of traumatic amputation => ALL patients are candidates for reimplantation until a surgeon says otherwise!
  2. ISCHEMIA TIME predicts success for reimplantation!
  3. Don’t forget ATLS => look for other injuries that may kill the patient first!
  4. Life over limb!
  5. Traumatic amputation is a surgical emergency! Get the patient to a surgeon ASAP!"

Renal biomarkers

Critical Care logo
Deng Y et al. Critical Care 2017;21:46 - DOI: 10.1186/s13054-017-1626-0
"Although serum cystatin C (sCysC), urinary N-acetyl-β-d-glucosaminidase (uNAG), and urinary albumin/creatinine ratio (uACR) are clinically available, their optimal combination for acute kidney injury (AKI) detection and prognosis prediction remains unclear. We aimed to assess the discriminative abilities of these biomarkers and their possible combinations for AKI detection and intensive care unit (ICU) mortality prediction in critically ill adults...
Conclusions
The present study shows that the combination of a functional marker (sCysC) and a tubular damage marker (uNAG) at ICU admission had significantly better discriminative performance for AKI detection than either the individual biomarkers or the other two panels, and that combining this panel with a clinical model added significant value for AKI detection. Moreover, this panel also significantly contributed to the accuracy of the clinical model for ICU mortality prediction. This study was conducted in general adult ICUs with a heterogeneous cohort. Thus, our findings could have significant clinical implications for actual heterogeneous ICU patients at risk for AKI."

Rudeness

EM Topics - March 8, 2017 
Ref. Pediatrics 2017;Jan 10. pii: e20162305. doi: 10.1542/peds.2016-2305. [Epub ahead of print]
"CONCLUSIONS:
Rudeness has robust, deleterious effects on the performance of medical teams. Moreover, exposure to rudeness debilitated the very collaborative mechanisms recognized as essential for patient care and safety. Interventions focusing on teaching medical professionals to implicitly avoid cognitive distraction such as CBM may offer a means to mitigate the adverse consequences of behaviors that, unfortunately, cannot be prevented."

miércoles, 8 de marzo de 2017

Serotonin Syndrome

Resultado de imagen de Taming The SRU
Taming The SRU - March 07, 2017 - Authored by Michael Klaszky 
..."Serotonin syndrome is a condition caused by increased serotonergic activity in the central nervous system. Patients may present with a broad range of symptoms such as anxiety and tremor in mild cases, or altered mental status, cardiovascular compromise, and seizures in severe cases. Mild serotonin syndrome can occur as a side effect of normal medication use for depression or anxiety. Moderate to severe cases, however, are often due to medication interactions or intentional overdose, and can quickly become life threatening, making recognition and prompt treatment of this condition important for the emergency physician..."

Disposition of patients with AHF

Resultado de imagen de european journal emergency medicine
Miró O et al. European Journal of Emergency Medicine 2017; 24(1): 2-12
doi: 10.1097/MEJ.0000000000000411
"Summary
Worldwide, the ED is the primary point of contact for most patients with AHF. Yet, during the most acute phase of hospital management, practice varies widely. Much of this is because of variance in patients and practice patterns, along with geographic differences in ED and hospital staffing, training and management capabilities. Achieving equipoise in patient care would require practice standardization but, given such heterogeneity, development of universal recommendations, particularly as they relate to disposition, is challenging. Identification of low-risk patients with AHF who are safe for early discharge continues to be a related and important unmet global need that is driven largely by a lack of prospectively developed risk stratification tools. In this review, we propose an algorithmic approach to patient disposition that is based on existing, albeit limited, evidence and expert consensus. We remain cognizant of the need to carry out further prospective studies and, to help drive this, we also propose a set of postdischarge outcomes that can reasonably be attributed to ED care and provide estimates of potentially acceptable event rates. It is our hope that this review will lead to further study of AHF disposition from the ED and promote change in the long-standing approach to AHF patient care."

lunes, 6 de marzo de 2017

Transfusion Reactions

emDocs
emDocs - March 6, 2017 - Authors: Wroblewski R and Repanshek Z
Edited by: Koyfman A and Long B
Screen Shot 2017-02-20 at 2.58.07 PM
"Pearls and Pitfalls: Approach to Reactions
  • Maintaining high clinical suspicion for reaction will save lives; although rare these are serious reactions.
  • Report any reaction to the blood bank to allow for reporting and monitoring.
  • For any reaction: stop transfusion, call blood bank, and double check that the correct patient received the correct blood.
  • Most reactions with fever will require a full laboratory work-up for signs of hemolysis and infection: CMP, CBC, Haptoglobin, DAT, LDH, PT, PTT, fibrinogen, blood culture, and gram stains from patient and sample, and a type and cross.
  • Any signs of dyspnea require a chest radiograph; if there is a fever and hypotension, it is more likely to be TRALI than TACO.
  • Treatment for all is largely supportive; however, in severe reactions antibiotics can be initiated for any suspicion of septic transfusion."

Ottawa heart failure scale

First10EM - March 6, 2017 - By Justin Morgenstern
"Dr. Stiell thinks this decision tool is ready to be used right now. This is THE Dr. Stiell. You know: Ottawa ankle rule, Canadian CT head rule… a list that doesn’t end. One of the biggest minds in emergency medicine. That guy. So although my take is a little different, you might want to consider the source of your information when deciding for yourself.
This study is a multi-centre prospective observational cohort to validate this previously derived decision tool. They looked at adult patients with acute heart failure in the emergency department. The scale is used to predict serious adverse events. Here is the scale:

jueves, 2 de marzo de 2017

Acute Urinary Retention

emDocs
emDocs - March 1, 2017 - Author: Johnson C - Edited by: Koyfman A and Long B
"Take Home Points
  • Consider all of the possible causes of acute urinary retention, and avoid prematurely anchoring on BPH, even in men with known BPH.
  • If the cause is determined to be BPH, start alpha reductase inhibitor immediately and attempt to arrange 3 day follow up to improve outcomes and reduce complications.
  • In addition to trauma, chronic diseases such as diabetes may cause neurogenic bladder. Patients with peripheral neuropathy are at high risk of developing neurogenic bladder.
  • Antidepressants, over-the-counter cold medicines, and NSAIDS are common pharmacologic causes of urinary retention.
  • Fever and urinary retention in a male should lead to a high suspicion for prostatitis. Treatment should be directed based on risk factors."

Mental health patients

ERCAST.ORG
ERCAST.ORG - March 1, 2017- By Rob Orman
"When you examine a patient who presents with a mental health complaint, let’s say they are depressed and psychotic, how do you do it? Do you listen to their lungs and heart, check for pitting edema? You might, if the history dictates. We are also responsible for a medical screening exam, but regarding the focused mental health part of the exam, what do you look for and how do you document it? There are all sorts of different ways to go about it, but one I find particularly useful is the mental status exam. Not alert and oriented times 3 or GCS 15 mental status exam, but the one that goes by the title Mental Status Exam"... 

miércoles, 1 de marzo de 2017

LVADs in the ED

An online community of practice for Canadian EM physicians
CanadiEM - By Jared Baylis - February 28, 2017
"You may be wondering; why do we need another post on left ventricular assist devices (LVADs) when there are already several phenomenal articles out there in the #FOAMed universe? There are two reasons for this. First, to my knowledge, there has not yet been a #FOAMed article regarding community emergency department (ED) management of LVAD related complications. LVADs are surgically placed in tertiary care, academic centres with specialized LVAD teams. However, the patients who receive LVADs are not confined to those centres. Second, in this article, we have expert contribution from Dr. Gil Kimel, a palliative care physician with fellowship training in palliative management of congestive heart failure, as well as Annemarie Kaan, a masters-prepared nurse, who works as part of the LVAD team at St. Paul’s Hospital in Vancouver.
The purpose of this post is to provide a practical, case based approach to the patient with a LVAD who presents to the ED. This is not intended to be comprehensive as there are already several detailed articles out there [see below]..."

martes, 28 de febrero de 2017

Fluid Responsiveness

R.E.B.E.L.EM - February 27, 2017 - By Christina Chien
Post Peer Reviewed By: Salim Rezaie
"Clinical Take Home Points:
  • Fluid resuscitation is an essential skill in EM and critical care but is poorly understood.
  • Fluid administration should be guided both by the concepts of fluid responsiveness (dictated by the Frank-Starling curve) and fluid tolerance.
  • Because it is difficult to know which patients with sepsis will be fluid responsive, small, frequent boluses may be preferred, and early vasopressor use should be considered.
  • This may difficult to apply in EM as we do not have technologically advanced cardiac output monitoring devices. However, the principles of fluid resuscitation are sound, and should make us think critically on how to manage these patients.
“…in almost half of the patients no hemodynamic variable was used to predict fluid responsiveness – and if used, CVP was used most often.” (Cecconi 2015). Only about 50% of hemodynamically unstable patients are fluid responsive, and only about 50% of those patients are tested for fluid responsiveness; this is a major aspect of emergency and critical care medicine that we can focus on improving."