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


Calabadions: New Broad-Spectrum Agents to Reverse Neuromuscular Blockade

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martes, 23 de mayo de 2017

Drug-induced anaphylaxis

Acute Medicine & Surgery
Takazawa T., Oshima K., Saito S. Acute Medicine and Surgery. DOI: 10.1002/ams2.282
(First published: 15 May 2017)
The initial treatment strategy, followed by correct diagnosis, in the emergency room is critical for preventing fatal anaphylaxis. Despite the therapeutic benefits of adrenaline and the recommendations for its use, adrenaline injection rates to treat anaphylaxis remain low in many ERs. Emergency room physicians should have proper knowledge regarding the diagnosis and treatment of anaphylaxis."

lunes, 22 de mayo de 2017


AnestesiaR - Por Robert Blasco Mariño - 22 mayo 2017
"Todavía no comercializado, Calabadion; un nuevo reversor de los bloqueantes neuromusculares. Se une al rocuronio con una afinidad 89 veces mayor que el Sugammadex..."
Fig 1. Fuente: Expert Opin Pharmacother. 2016;17(6):819-33.

domingo, 21 de mayo de 2017

Damage Control Resuscitation Principles

Resultado de imagen de journal of emergency medical services
JEMS - Apr 1, 2017 - By William Selde
..."Trauma remains a major cause of death and disability globally. Damage control resuscitation is a strategy that focuses on attempting to maintain or restore homeostasis in 
trauma patients.
The name "damage control" references the naval tactics employed to keep a damaged ship as combat-capable as possible until definite repair can take place. The concept goes hand in hand with damage control surgery. However, for prehospital care, surgery is clearly beyond the scope of practice and won't be discussed here.
First described in the late 1970s and early 1980s, damage control resuscitation has continued to evolve and is primarily focused on mitigating the life threats of trauma.
The main threats concentrated on in damage control resuscitation are acidosis, coagulopathy and hypothermia. Ideally, these pathologies are all addressed in a simultaneous and balanced manner. These three abnormalities form a forward feedback loop that leads to progressive worsening of a patient's hemodynamic status and will eventually lead to death..."

sábado, 20 de mayo de 2017

Reducing brain injury following CP resuscitation

Report of the Guideline Development, Dissemination, and Implementation Subcommittee 
of the American Academy of Neurology
Published Ahead of Print on May 10, 2017. Neurology® 2017; 88:1–9
..."For patients who are comatose in whom the initial cardiac rhythm is either pulseless ventricular tachycardia (VT) or ventricular fibrillation (VF) after out-of-hospital cardiac arrest (OHCA), therapeutic hypothermia (TH; 32–34ºC for 24 hours) is highly likely to be effective in improving functional neurologic outcome and survival compared with non-TH and should be offered (Level A). For patients who are comatose in whom the initial cardiac rhythm is either VT/VF or asystole/pulseless electrical activity (PEA) after OHCA, targeted temperature management (36ºC for 24 hours, followed by 8 hours of rewarming to 37ºC, and temperature maintenance below 37.5ºC until 72 hours) is likely as effective as TH and is an acceptable alternative (Level B). For patients who are comatose with an initial rhythm of PEA/asystole, TH possibly improves survival and functional neurologic outcome at discharge vs standard care and may be offered (Level C). Prehospital cooling as an adjunct to TH is highly likely to be ineffective in further improving neurologic outcome and survival and should not be offered (Level A). Other pharmacologic and nonpharmacologic strategies (applied with or without concomitant TH) are also reviewed..."

Oxygen Guidelines

"Oxygen is probably the drug that we give the most but possibly has the least governance over. More has got to be good except in those at high risk of type II respiratory failure right?? Well as we know the evidence base has swung to challenge that idea in recent years and the new BTS guidelines for Oxygen use in Healthcare and Emergency Settings has just been published with a few things that are worth reviewing since the original publication in 2008. No apologies that this may be predominantly old ground here, this is an area we’re all involved with day in and day out that is simple to correct and affects mortality..."

Medications in Pregnancy

emDocs - May 15, 2017 - Authors: Hahn  and Riddell J -  Edited by: Koyfman a and Long B
  • Treat the emergency: Sick mom = sick baby therefore BENEFIT >> RISK
  • Have your “GO-TO” and “AVOID” meds memorized or easily accessible (Table 2, above)
  • Strongly consider pregnancy testing of reproductive age women before administering meds or writing new prescriptions when possible and practical. 
  • When in doubt, consult a pharmacist or specialist for more complicated medications and imaging decisions."

viernes, 19 de mayo de 2017

Local Anesthetic Systemic Toxicity

R.E.B.E.L.EM - May 18, 2017 - By  Anand Swaminathan
Post Peer Reviewed By: Salim Rezaie
Definition: A life-threatening adverse reaction resulting from local anesthetic reaching significant systemic circulating levels. Local Anesthetic Systemic Toxicity (LAST) is rare and almost always occurs within minutes of injection of the local anesthetic...
Take Home Points
  • The key in managing LAST is prevention. Know your dose, know your maximum dose, always aspirate prior to injection and ask patient about symptoms
  • Lidocaine toxicity CV complications are typically preceded by neurological signs/symptoms. If these develop, stop administration, place patient on monitor and ready your antidote
  • Bupivacaine toxicity can be sudden and catastrophic. If you are using the drug, undershoot your max dose and know where your antidote is
  • Intralipid has been shown to be effective in LAST. Administer the drug anytime there are signs of hemodynamic compromise"

martes, 16 de mayo de 2017

Massive Hemoptysis

EMCrit Podcast 199 - May 14, 2017 by Scott Weingart

lunes, 15 de mayo de 2017

Submasive PE-s

R.E.B.E.L. EM - Emergency Medicine Blog
R.E.B.E.L.EM - Episode 38 - May 15, 2017 - By Salim Rezaie
Post Peer Reviewed By: Anand Swaminathan
Ref.  Konstantinides SV et al. Impact of thrombolytic Therapy on the Long-Term Outcome of Intermediate-Risk Pulmonary Embolism. J Am Coll Cardiol 2017; 69: 1536 – 44. PMID: 28335835
"Clinical Take Home Point: In the current trial, long-term mortality rates and long-term morbidity (residual dyspnea, functional limitations, and persistent RV dysfunction) were not affected by the use of systemic thrombolysis in unstratified patients with submassive PE. Thrombolysis in submassive PE should now only be considered in patients with signs of submassive PE and either at risk of throwing additional emboli to the lungs (proximal DVT or clot in transit on echo) or patients who appear to be at the brink of massive PE (pale, diaphoretic)."

sábado, 13 de mayo de 2017

POCUS for Pneumonia

EDE Blog
The EDE Blog - May 11, 2017 - Presented by TJ
"There is more and more research looking at the utility of POCUS for diagnosing pneumonia, both in adults and pediatrics. At the EDE 3 journal club, Dr Tom Jelic presented a meta-analysis on the topic published by Alzahrani et al in CUJO, Critical Ultrasound Journal. The title is “Systematic review and meta-analysis for the use of ultrasound versus radiology in diagnosing of pneumonia“."


St. Emlyn´s - By Simon Carley - May 12, 2017
..."ReSPECT (no not Aretha) stands for Recommended Summary Plan and Emergency Care Treatment. It is a process (rather than just a form) in which a personalised recommendation of treatment has been made with the agreement of the patient. It’s designed to be used at the time of an emergency when the patient may be unable to express their wishes. ReSPECT is not just about death and dying but it appears to be a truly holistic approach to healthcare with decisions about many aspects of care being made. It has the backing of the Resuscitation Council UK, and our own Royal College of Emergency Medicine. In fact pretty much anyone who is involved with the care of patients from Macmillan to the Intensive Care Society has given their backing to the project..."

viernes, 12 de mayo de 2017

Tox Silent Killers

emDocs - May 10 2017 - Authors: Wong  and Riddell J - Edited by: Koyfman A and Singh M
  • Acetaminophen Toxicity
  • Salicylate Toxicity
  • Tricyclic Antidepressant (TCA) Toxicity
  • Iron Toxicity

jueves, 11 de mayo de 2017

D-dimer Cutoffs

EM Topics
EM Topics - May 10, 2017
Ref. Kohn MA, Klok FA, van Es N. Acad Emerg Med. 2017 Apr 1. doi: 10.1111/acem.13191. [Epub ahead of print] D-Dimer Interval Likelihood Ratios for Pulmonary Embolism.
"Short Attention Span Summary
Fun with D-dimer
If you have a lower pretest probability for PE (5%), e.g. by Wells' Criteria, you can accept a higher D-dimer cutoff (up to 999 ng/mL) and still consider PE ruled out. If you have a higher pretest probability (15%), you need a lower D-dimer (<500 ng/mL) to consider PE ruled out; "ruled out" meaning < 3% posttest probability, which many consider below the threshold to obtain CTPA..."

miércoles, 10 de mayo de 2017

PE in syncope: PESIT update

Fist10EM - By Justin Morgenstern - May 9, 2017
"By now, everyone has (unfortunately) heard about the PESIT trial. Given the many commentaries in the FOAM community, we are all familiar with the many reasons that the widely quoted 1 in 6 figure probably does not apply to our patients. If you need a reminder, I summarize the paper as part of this post, or you can read a more elegant post by Rory Spiegel here. For me, the biggest issue was that PESIT never passed the sniff test. We see a ton of syncope patients. There are massive syncope databases. And nowhere have we seen massive numbers of patients returning with PE.
A research letter was just published yesterday in JAMA that gives us another take on the issue:
Verma AA, Masoom H, Rawal S, Guo Y, Razak F, for the GEMINI Investigators. Pulmonary Embolism and Deep Venous Thrombosis in Patients Hospitalized With Syncope: A Multicenter Cross-sectional Study in Toronto, Ontario, Canada. JAMA Intern Med. Published online May 08, 2017. doi:10.1001/jamainternmed.2017.1246..."


An online community of practice for Canadian EM physicians
CanadiEM - By Richard Tang - May 9, 2017
"Chest Pain? Better check out the HEART (Score)!
Chest pain suspected to be of cardiac origin is a common presentation in the first-world Emergency Department, but trying to decide the appropriate level of care of these patients can often be challenging. What if the chest pain is not a straight-forward STEMI that needs to be sent to the cath lab? What do we say when the troponin levels are not high enough to impress the seasoned (and disgruntled) cardiologist at 2 am in the morning? Worse yet, what if the ECG and troponin levels are both normal in a person with a very suspicious history and multiple risk factors?
HEART Score – A Tool For the ED
The HEART score is an excellent tool that can be used in the ED setting to prognosticate and triage patients with possible Acute Coronary Syndrome (ACS) for admission for further workup and treatment versus safely discharging home with follow-up instructions. The scoring system is based on expert opinion and validated in several ED populations worldwide. Most importantly, the scoring system focuses on disposition via calculating the risk of a Major Adverse Cardiac Event (MACE) within 6 weeks. The HEART score is highly practical for the ED to help focus on identifying low risk as well as high risk patients, in order to offer appropriate care and disposition as early as possible..."


martes, 9 de mayo de 2017

Peri-Intubation Anaphylaxis

R.E.B.E.L.EM - May 8, 2017 - By Rob Bryant - Peer reviewed by Salim Rezaie
"Background: Peri-operative anaphylaxis is an unexpected complication of intubation. The major life threat in anaphylaxis is typically loss of airway, however profound hypotension and circulatory collapse are still possible life threats even in the setting of a protected airway. Peri-operative anaphylaxis is considered an important enough issue to be the subject of the NAP 6 (National Audit Project) audit this year in Great Britain. (Reporting period November 2015 – November 2016)...
Clinical Take Home Points:
  • Be aware of anaphylaxis to NMB as a cause of post intubation hypotension.(1:2000-1:2500)
  • Sugammadex is unlikely to reverse rocuronium induced anaphylaxis.
  • If a patient has a neuromuscular blocking agent listed on their allergy list, this is a real entity, and cross reactivity to other agents can exist: proceed with caution, and consider a KSI (Ketamine Sequence Intubation)"

Status epilepticus

PulmCrit (EMCrit)
PulmCrit - May 8, 2017 - By Josh Farkas
  • "Ongoing generalized convulsive seizures are an immediate life-threat that may cause brain damage, aspiration, rhabdomyolysis, hyperkalemia, arrhythmia, and hyperthermia.
  • A streamlined algorithm is proposed to achieve rapid seizure control using immediately available medications.
  • Patients who fail to respond to benzodiazepine will frequently require intubation and sedative infusion to control their seizures. Early intubation in these patients may expedite seizure control and avoid complications.
  • Propofol and ketamine are powerful anti-epileptic agents. Emerging evidence suggests that they work synergistically by affecting GABA and NMDA receptors, respectively.
  • The best conventional anti-epileptic agent is unknown and currently under investigation in the ESSET trial. Fosphenytoin has the most side-effects, so for now  evtiracetam or valproic acid seem like the best choices."

lunes, 8 de mayo de 2017

Zika Virus

EM Ottawa - By Rob Suttie - May 11, 2017 
"The Zika Virus exploded onto the international health scene in the last several months. It was first discovered in humans in 1951 and remained limited to Africa and Asia until the first major outbreak in Micronesia in 2007. Since then the virus has continued to evolve and spread from the Pacific Islands and French Polynesia to the main major outbreak in South America in early 2015 and finally to the US in January 2016..."

sábado, 6 de mayo de 2017

Fibrinolisis en EVT

Medcriturg - Mayo 4, 2017 - Por wrojewski
"El embolismo pulmonar es la consecuencia más temida del tromboembolismo venoso. En la Unión Europea el número anual de muertes relacionadas con tromboembolismo venoso sobrepasa las 500.000. En Estados Unidos esta cifra ronda los 200.000.
Hasta un 30% de los pacientes que sufren embolismo pulmonar agudo pueden morir en el primer mes. El 30% de los que sobreviven pueden desarrollar síntomas discapacitantes o recurrencias amenazantes para la vida.
Del 1 al 9% de los pacientes con embolismo pulmonar desarrollarán a largo plazo hipertensión pulmonar tromboembólica crónica (HPTC), que es una condición devastadora. La enfermedad tromboembólica supone una carga económica sustancial sobre el sistema de salud. El gasto de un paciente con hipertensión pulmonar crónica es 10 veces más alto que tratar el síndrome postrombótico.."
Medcriturg - Mayo 5, 2017 - Por wrojewski
La base para la selección de la terapia de reperfusión es la estratificación del riesgo, en función de la mortalidad.
La mayoría de las contraindicaciones deberán ser consideradas relativas en embolismo pulmonar de alto riesgo vital.
Hay indicación formal de reperfusión inmediata usando trombolisis sistémica en el grupo de pacientes con embolismo pulmonar de alto riesgo o masivo."

jueves, 4 de mayo de 2017

Procedural sedation and analgesia

Taming The SRU - Originally Written and Posted by: Isaac Shaw, MD 12/30/2016
Last edited: Jeffery Hill 1/3/2017
"Procedural sedation and analgesia (PSA) is the practice of administering sedative or dissociative agents to induce a depressed level of consciousness in order to facilitate painful but necessary procedures. As emergency practitioners are trained to manage airway issues through all levels of sedation, the Center for Medicaid and Medicare Services (CMS) as well as the American College of Emergency Physicians (ACEP) has deemed them as being capable of safely performing PSA."

Sepsis 2.0 vs Sepsis 3.0

R.E.B.E.L.EM - May 1, 2017
"Background: Just a few months ago the surviving sepsis campaign published their international guidelines for management of sepsis and septic shock. There has been a lot of talk in the FOAM world about sepsis 3.0 and this is the first update since the introduction. This was a 67 page document that made a total of 93 statements on the early management and resuscitation of patients with sepsis or septic shock. 1/3 of the statements were strong recommendations and just over 1/3 were weak recommendations. Instead of going through every component of this document, we thought we would discuss one of the potentially biggest components of sepsis care that would affect clinical practice for those of us on the front lines.
One of the main reasons we have seen a mortality decrease in sepsis overtime is due to the proactive nature health care professionals have taken in sepsis management. The so called ABC’s of sepsis management: Early identification, Early fluids, and Early antibiotics. One of the biggest components of this is early identification of these patients...
Clinical Bottom Line: Neither score is perfect. On one hand, Sepsis 2.0 has a better sensitivy for screening but at the cost of specificity as so many other things can cause SIRS. On the other hand, Sepsis 3.0 has a better specificity for prediciton of mortality when compared to Sepsis 2.0, but there maybe other scores out there that may do a better job."

Duke Criteria for Infective Endocarditis

The Original Kings of County - By Derick • May 2, 2017 
  • How do we use the history, exam, lab, and radiologic findings to diagnose infective endocarditis (“IE”)?
  • What are the components of the Duke Criteria?
  • How do we use the Duke Criteria to diagnose IE?
  • What are the unique physical exam findings included in the Duke Criteria for IE?How good are the Duke Criteria?

The Dichotomies of EM Practice

emDocs - May 2, 2017 - Author: Nouhan P - Edited by: Koyfman A and Long 
"What is the most accurate description of an Emergency Medicine persona? Is there a pattern to the skills that strong EM physicians bring to their practice? When I started many years ago as a young resident, the EM doc was cartooned as a less learned, procedure-hungry, loud, risk-taking cowboy who was destined to burn out. I was questioned as to why I would want to pursue that career as a more introverted person. I found my strongest EM teachers, however, were quick-witted, calm, observant resuscitalogists who could juggle many simultaneous, difficult tasks. I wanted to be like them. EM physicians were the MacGyvers of the House of Medicine. Some of them were even loud cowboys who suggested I needed a megaphone in resuscitation upon graduation! Still, I knew I could manage resuscitation confidently without maximum volume because of my strong training. Over the multiple years of my EM career in a busy, urban center in Detroit, I have observed many dichotomies that coexist in the practice of Emergency Medicine and in those who are drawn to EM. What are the qualities of the best Emergency Medicine physicians who deal with the changing complexities of our practice? The EM mindset is complex, fluid, and dynamic..."

Acute respiratory distress syndrome

European Respiratory Society
Marco Confalonieri, Francesco Salton, Francesco Fabiano
European Respiratory Review 2017 26: 160116; DOI: 10.1183/16000617.0116-2016
"In the past year, several interesting papers were published on epidemiology, novel risk factors, prevention and treatment of ARDS. Despite the well-established advances in its supportive treatment, ARDS remains an oftentimes misdiagnosed syndrome, carrying a high burden in terms of patient morbidity and mortality, as well as healthcare costs. Even if plentiful literature exists on the pathophysiology and treatment of this syndrome in human and animal models, implications in clinical practice are still poor. Future directions of research should focus on identification of the mechanisms of susceptibility, primary prevention and early treatment, as well as on targeted pharmacological therapies for this devastating condition."

martes, 2 de mayo de 2017

Infection in the Splenectomy Patient

emDocs - May 1, 2017 - Authors: Weerasuriya D and Stettner E
Edited by: Koyfman A and Long B
"Pearls and Pitfalls
  • Ask all patients with a surgical scar near their spleen if they had a splenectomy.
  • Consider treating patients who are at risk for functional asplenia as if they are asplenic (for example, patients with hemoglobinopathies or bone marrow transplants).
  • Ask what antibiotics, steroids, and vaccines they have received recently.
  • Even if an asplenic patient is afebrile in the emergency department, but reports a fever at home, consider performing a complete sepsis work up in the emergency department.
  • Asplenic patients are at increased risk for encapsulated organisms, parasites, DIC, and meningitis.
  • Evaluate for DIC prior to performing a lumbar puncture, if one is indicated.
  • Streptococcus pneumoniae is still the most common cause of sepsis and death in these patients.
  • Asplenic patients have little reserve and high mortality. Give antibiotics and start aggressive hypotension management early."

Ecocardiography and Lung US for AHF

 Resultado de imagen de nature review cardiology
Price S et al.  Acute Heart Failure Study Group of the European Society of Cardiology. Acute Cardiovascular Care Association 
Echocardiography is increasingly recommended for the diagnosis and assessment of patients with severe cardiac disease, including acute heart failure. Although previously considered to be within the realm of cardiologists, the development of ultrasonography technology has led to the adoption of echocardiography by acute care clinicians across a range of specialties. Data from echocardiography and lung ultrasonography can be used to improve diagnostic accuracy, guide and monitor the response to interventions, and communicate important prognostic information in patients with acute heart failure. However, without the appropriate skills and a good understanding of ultrasonography, its wider application to the most acutely unwell patients can have substantial pitfalls. This Consensus Statement, prepared by the Acute Heart Failure Study Group of the ESC Acute Cardiovascular Care Association, reviews the existing and potential roles of echocardiography and lung ultrasonography in the assessment and management of patients with acute heart failure, highlighting the differences from established practice where relevant."

sábado, 29 de abril de 2017

Acute Retroviral Syndrome In The ED

NU.EM Blog - By Caffrey C - Edited by McCloskey C - Expert Reviewer Angarone M
Citation: [Peer-Reviewed, Web Publication] Caffrey C, McCloskey C (2016, April 5). Acute Retroviral Syndrome In The ED. [NUEM Blog. Expert Peer Review by Angarone M]. Retrieved from http://www.nuemblog.com/blog/acute-retroviral-syndrome/
"HIV testing does not get a lot of love in your average emergency department. Since 2006, the CDC has recommended HIV screening in all adult patients in high prevalence areas, ditching lengthy “opt-in” style consenting and counseling in the process [1]. However, despite these clear consensus recommendations, we are bad at them. Surveys have shown that in areas of relatively high HIV prevalence, less than 10% of hospitals report complying with screening guidelines [2].
This post is not to rail against the missed opportunity of failing to implement widespread routine HIV testing or the innumerable stresses that make such compliance impossible for many departments. Rather, it is to focus on the recognition and diagnosis of acute retroviral syndrome, an area in which we as diagnosticians can have a tremendous benefit."

viernes, 28 de abril de 2017

In-Hospital Cardiac Arrest

R.E.B.E.L. EM - Emergency Medicine Blog
R.E.B.E.L.EM - April 27, 2017
"Background: Over the past few years there has been a shift in cardiac arrest from the mantra of ABC (Airway, Breathing, Circulation) to CAB (Circulation, Airway, Breathing). There has been increased emphasis on circulation and a de-emphasis of airway management in cardiac arrest. Physiologically, this makes sense as the only two interventions in cardiac arrest that have been shown to make a difference in neurological outcomes are early, high quality CPR and defibrillation. The reason for this is increased coronary and cerebral perfusion pressure, which improve oxygenation to ischemic tissue. The less ischemic cardiomyocytes are the more likely they will convert to a perfusing rhythm. Similarly, the less ischemic neurons are, the more likely we will have a better neurologic outcome for our patients. It has been fairly well established in the peer reviewed literature that advanced airway management in the prehospital setting is associated with decreased survival with good neurologic outcome. There is considerably less literature exploring this area in in-hospital cardiac arrest...
Author Conclusion: “Among adult patients with in-hospital cardiac arrest, initiation of tracheal intubation within any given minute during the first 15 minutes of resuscitation, compared with no intubation during that minute, was associated with decreased survival to hospital discharge. Although the study design does not eliminate the potential for confounding by indication, these findings do not support early tracheal intubation for adult in-hospital cardiac arrest.”
Clinical Take Home Point: As there are currently no RCTs evaluating intubation during the first 15 minutes of an in-hospital cardiac arrest, this study may be some of the current best evidence that supports focusing on the interventions that matter most early on: High-Quality CPR and Defibrillation."

jueves, 27 de abril de 2017

Updated Definition of EM in Europe

APRIL 26, 2017 
The EUSEM Professional Committee has redefined the definition of Emergency Medicine in Europe.
"Emergency Medicine is a primary specialty established using the knowledge and skills required for the prevention diagnosis and management of urgent and emergency aspects of illness and injury, affecting patients of all age groups with a full spectrum of undifferentiated physical and behavioral disorders.
This includes organizing the proper medical response for patients looking for urgent medical care.
Time and timing in this setting may be critical either from a medical or from the patient’s point of view.
The practice of Emergency Medicine encompasses the in-hospital as well as out-of-hospital triage, resuscitation, initial assessment, telemedicine and the management of undifferentiated urgent and emergency patients until discharge or transfer to the care of another health care professional."

Is Head CT Needed Before LP

emDocs - April 24, 2017 - Authors: April M and Long B - Edited by: Koyfman A
"Key Takeaways:
  • The best available evidence suggests some association between LP and brainstem herniation in patients with intracranial mass effect lesions.
  • However, this risk is small, and there is no evidence that deferring LP prevents herniation in patients with these lesions.
  • Decision rules that attempt to identify patients most likely to have intracranial lesions with risk for post-LP herniation have several limitations and have not been validated.
  • Patients with significant pre-test probability for intracranial mass effect lesion or bacterial meningitis based on clinical assessment should receive head CT.
  • Antimicrobials are required if meningitis is suspected.
  • Concern for meningitis warrants antibiotics before CT if imaging will be obtained."

martes, 25 de abril de 2017

The Easy IJ

R.E.B.E.L.EM - April 24, 2017 - Post Peer Reviewed By: Anand Swaminathan
"Background: We have all taken care of patients in whom IV access is difficult due to a multitude of reasons including repeated prior IV access, advanced vascular disease and shock. This often creates delays in patient care, increases ED length of stay, and uses up ED staff that have other patients to care for. Many providers have resorted to using IO access, particularly in critically ill patients due to speed of establishing access. In stable patients, however, this may be a less desirable. Ultrasound guidance has been a great addition in these patients. Ultrasound guided peripheral IVs and external jugular access would probably be the next “go to options” in these patients. The authors of this paper evaluate yet another option: The Easy IJ...
Author Conclusion: “The Easy IJ was inserted successfully in 88% of cases, with a mean time of 4.4 min. Loss of patency, the only complication, occurred in 14% of cases.”
Clinical Take Home Point: In stable patients, who have had failed attempts at establishing peripheral or external jugular vein access, the Easy IJ is a rapid method of achieving short-term IV access with no major adverse patient oriented outcomes."

lunes, 24 de abril de 2017


EM Didactic - April 24, 2017 - By Chanana L 
(Originally posted by EM Lyceum on 2/11/2015)
"Acute gastrointestinal disorders are some of the most frequent problems evaluated by ED physicians. Complaints of diarrhea account for almost 5% of visits to the emergency departments. Although the disease entity is extremely prevalent and current evidence on the subject is nothing short of “voluminous,” practice differences among ED physicians in its evaluation and management are as varied and inconsistent as the stools themselves...
  1. When do you send stool cultures, stool ovum and parasites, and/or fecal WBC? How do you use the results in diagnosis and management?
  2. When do you get bloodwork? When do you pursue imaging?
  3. Which patients do you treat with antibiotics?
  4. What other medications do you use? Loperamide, Lomotil, Pepto? What about probiotics?"

sábado, 22 de abril de 2017



St. Emlyn´s - April 21, 2017 - By Chris Gray
"At work the other day, someone mentioned that we could use procalcitonin to distinguish between viral and bacterial infections, particularly in the paediatric population. It was touted as the answer to that age-old question, “should I prescribe antibiotics for this sore throat/cough/[insert other symptom here]?”. Now, the ED wasn’t the first place I’d heard about this strange test. A year ago, on an intensive care rotation, they were regularly using procalcitonin levels to make decisions on when antibiotics should be stopped. It’s not a test that I’ve seen used since then though, certainly no surgical registrar has insisted on a procalcitonin level before they’ll see my patient with right iliac fossa tenderness, and I’ve not had any complaints from the medics or paediatricians that it hasn’t been added to the routine bloods. It’s definitely not become the new CRP (yet)!
But what is procalcitonin, and should we be using it more? Is it the miracle test that’s going to bring an end to those viral/bacterial conundrums? Is it just another fad that we’ll all use for a few years before replacing it with something else?..."

procalcitonin use

Mentoring Process in EM

emDocs - March 23, 2017 - Authors: Long B and Koyfman A - Edited by: Garmel G and  Runyon M 
emDocs - April 20, 2017 - Authors: Long B and Koyfman A - Edited by: Garmel G

"Key Points
  • Mentoring includes several stages: prescriptive, persuasive, collaborative, and confirmative, though these often overlap and are not always clear cut or linear.
  • The mentor and mentee must devote time and energy to the relationship.
  • Listening skills are essential for the mentor and mentee.
  • Each meeting is best having an agenda. The meeting should be scheduled in advance with a plan, a location and time, and a set amount of time set aside.
  • Coaching may be needed for mentees with less experience. Counseling and guidance are important through all stages.
  • Advising is one of the predominant components of the mentoring relationship. The mentee should identify his/her interests, skills, knowledge, and goals. Targeting areas for development, plan creation, indicators of success, and continual reassessment of progress are vital.
  • Mentors should seek to promote the interests of the mentee. Guidance and support may be needed if the mentee feels overwhelmed or experiences difficulty."

viernes, 21 de abril de 2017

Ketamine for sickle cell pain

The Original Kings of County - By kkelson • April 20, 2017
..."There are many alternatives for acute pain control: IV lidocaine, IV acetaminophen, propofol, and even dexmedetomidine (See Dr. Nguyen’s excellent lecture). One emergency department in New Jersey has even employed “energy healing and a wandering harpist” to avoid opioid prescriptions. Although these are all reasonable regimens, the medications listed above are administered intravenously, which may be a challenge in sickle cell patients with notoriously difficult venous access. (And there’s a certain lack of evidence that energy healing and the harp are effective as monotherapy.)
Ketamine, however, has been tested intranasally (IN) and found to be effective. One double-blinded RCT on 90 trauma patients in the ED compared either 1 mg/kg IN ketamine, 0.1 mg/kg IV morphine, or 0.15mg/kg IM morphine and found that the three regimens had similar onset and effectiveness at relieving pain. No adverse events were reported. Although a small study, IN ketamine’s utility in treating acute pain in the ED has been corroborated by other observational studies..."