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SOBRE EL AUTOR **

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

WORLD EMERGENCY MEDICINE SOCIETIES & RELATED

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jueves, 9 de julio de 2020

COVID Pulmonary Physiology

EMCrit (RACC)
EMCrit 277 - July 09, 2020 - By Scott Weingart
"Today on the podcast, I interview Martin Tobin on 3 papers he has recently written on COVID pulmonary physiology."

2019-2020 St. Emlyn´s Top 10 Trauma papers

St.Emlyn's, July 9, 2020, By Simon Carley
"My task was to present a short review of important clinical trauma research from the last year. I’ve done a few of these sorts of ‘top-10’ presentations over the years and they roughly follow these principles to get included. Papers have to score at least 2 out of 3 for the following.
  • Methodologically sound
  • Interesting (to me)
  • Practice changing
This is, of course, entirely subjective, so if you disagree I am sorry (not sorry), but if I’ve missed something important please add your suggestions to the comments. In the presentation I will focus on 10 papers, but here in the blog I will add a few more at the end that did not make the cut, but which you will benefit from reading."

Electrical vs Pharmacological Cardioversion (AF)


R.E.B.E.L.EM - July 09, 2020 - By Salim Rezaie
Paper: Stiell IG et al. Electrical Versus Pharmacological Cardioversion for Emergency Department Patients with Acute Atrial Fibrillation (RAFF2): A Partial Factorial Randomised Trial. Lancet 2020. PMID: 32007169
"Clinical Question: Is a pharmacological cardioversion first approach more successful than an electrical cardioversion first approach in acute atrial fibrillation?
Author Conclusion: “Both the drug-shock and shock-only strategies were highly effective, rapid, and safe in restoring sinus rhythm for patients in the emergency department with acute atrial fibrillation, avoiding the need for return to hospital. The drug infusion worked for about half of patients and avoided the resource intensive procedural sedation required for electrical cardioversion. We also found no significant difference between the anterolateral and anteroposterior pad positions for electrical cardioversion. Immediate rhythm control for patients in the emergency department with acute atrial fibrillation leads to excellent outcomes.”
Clinical Take Home Point: Both the drug-shock and shock-only strategies led to similar conversion rates and rates of discharge home. Length of stay was similar between groups; however this doesn’t reflect real-world application where a shock first approach would not get a 30 minute infusion of placebo for the purpose of blinding. Ultimately either approach is fine based on provider comfort, patient preference and departmental considerations."

martes, 7 de julio de 2020

CHEST Guidelines: VTE in COVID-19

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emDocs - june 07, 2020 - By Long B -  Reviewed by: Koyfman A and Singh M
"Evidence suggests patients with COVID-19 are at risk of thromboses and coagulopathy. Up to now, there has not been an established set of clear guidelines. CHEST released a guideline and expert panel report on venous thromboembolism in COVID-19 patients in early June 2020.
This post will take you through the relevant ED recommendations on for prevention, diagnosis, and treatment of VTE in these patients."

jueves, 2 de julio de 2020

Ticagrelor vs Prasugrel in ACS

R.E.B.E.L.EM - July 02, 2020 - By Salim Rezaie
Paper: Schupke S et al. Ticagrelor or Prasugrel in Patients With Acute Coronary Syndromes. NEJM 2019. PMID: 31475799
"Clinical Question: Does ticagrelor or prasugrel improve the composite of death, myocardial infarction, or stroke at one year after randomization in patients with ACS?
Author Conclusion: “Among patients who presented with acute coronary syndromes with or without ST-segment elevation, the incidence of death, myocardial infarction, or stroke was significantly lower among those who received prasugrel than among those who received ticagrelor, and the incidence of major bleeding was not significantly different between the two groups.”
Clinical Take Home Point: In this multicenter, international randomized clinical trial of adult patients with ACS undergoing PCI, prasugrel was superior to ticagrelor in the primary outcome. Additionally, a prasugrel-based strategy with deferred loading after knowledge of the coronary anatomy was superior to a ticagrelor-based strategy with routine pretreatment in patients with NSTEMI and UA. Finally, when evaluating the individual results from the composite primary outcome, the findings of this study were driven by reduction in MI, not in death or stroke."

Epiglottitis

PulmCrit (EMCrit)
IBCC chapter & cast - July 2, 2020 - By Josh Farkas 

"Epiglottitis is often a game of chicken. The great majority of adult patients don't require intubation, so the best management for them is steroid and antibiotic (plus close observation and the ability to intubate if necessary). For these patients, intubation isn't protective – it's dangerous. However, some patients do truly require intubation – which can often be difficult and require cricothyrotomy."

lunes, 29 de junio de 2020

Pyelonephritis disposition

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emDocs - June 28, 2020 - By Mishra D and Curato M
Reviewed by: Montrief T; Koyfman A and Long B
"Take Home Points:
  • A diagnosis of pyelonephritis is made through a combination of vital signs, clinical presentation, physical exam, and urinalysis. It is essential to take the entire clinical picture into account when deciding on a disposition for a patient
  • Discharge home with oral antibiotics is an appropriate disposition plan for the majority of mild to moderately ill acute pyelonephritis patients who are able to tolerate oral intake and are not persistently tachycardic, hypotensive, or tachypneic. They should also have stable coexisting medical comorbidities, a reliable psychosocial situation, an appropriate oral antimicrobial regimen, and access to outpatient follow-up.
  • It is important that, regardless of disposition decision, all of your patients have appropriate follow-up to assess for improvement in symptoms"
Further Reading:

domingo, 28 de junio de 2020

TXA in Acute GI Bleeds

"Paper: The HALT-IT Trial Collaborators. Effects of High-Dose 24-h Infusion of Tranexamic Acid on Death and Thromboembolic Events in Patients with Acute Gastrointestinal Bleeding (HALT-IT): An International Randomised, Double-Blind, Placebo-Controlled Trial. Lancet 2020. [Epub Ahead of Print]
Clinical Question: Does IV tranexamic acid reduce 5-day death due to bleeding in adult patients with acute gastrointestinal hemorrhage compared to placebo?
Author Conclusion: “We found that tranexamic acid did not reduce death from gastrointestinal bleeding. On the basis of our results, tranexamic acid should not be used for the treatment of gastrointestinal bleeding outside the context of a randomized trial.” 
Clinical Take Home Point: This is a very well done, large, multicenter randomized controlled trial of TXA vs placebo for acute GIB. The results demonstrate no benefit of giving TXA on 5d mortality in patients with acute GIB and a small signal of harm with increased VTE and seizures. TXA should not be recommended at this time for patients with acute GIB."

sábado, 27 de junio de 2020

Rapid Code Status Disccussions

EMCritRACC
EMCrit 276 – June 25, 2020 - By Scott Weingart 
"Today, I am joined by Kei Ouchi to disucss rapid code status discussions in Emergency Medicine and Critical Care. I came across Kei after he put up an amazing post on ALIEM with his co-author Naomi George. Conversation is the essence of palliative care–we need to be experts at them..."

jueves, 25 de junio de 2020

Septic Bursitis

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emDocs - June 25, 2020 - By Pritchard R, Bodeau H, Bonson P and Borloz M
Reviewed by: Koyfman A and Long B
"Pearls
  • The diagnostic gold standard for septic bursitis is bursal fluid culture
  • Negative bursal fluid culture does not exclude the diagnosis of septic bursitis, especially if due to a fastidious organism or when antibiotics precede culture
  • A number of other signs are associated with septic bursitis (Table 1) and can be used to support the dx
  • Bursal fluid aspiration should be performed prior to antibiotic use

Spinal Epidural Abscess

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REBEL CORE - By Anand Swaminathan - June 25, 2020

"Take Home Points
  • Spinal Epidural Abscess may present insidiously and patients often lack the classic triad of fever, back pain and neurologic symptoms
  • Empiric Antibiotics should cover Staphylococcus (including MRSA) and Gram negative Bacilli
  • All patients with clinical suspicion require rapid evaluation with MRI as the diagnostic study of choice
  • Although not all patients will go to the operating room, surgical consult (Neurosurgery or Orthopedics) should be obtained immediately"

Environmental Hyperthermia

REBEL Core Cast 35.0 - By Anand Swaminathan - June 24, 2020
"Take Home Points
  • Heat stroke is a life-threatening disorder characterized by elevated core temperature, compromise to neurologic function and multi-system organ dysfunction
  • The keystone of treatment is rapid cooling within 30 minutes of presentation preferably with ice water immersion
  • Patients with heat stroke should be investigated for rhabdomyolysis, AKI, liver failure and concomitant infection"

miércoles, 24 de junio de 2020

Dexamethasone & COVID

PulmCrit (EMCrit)
PulmCrit – June 23, 2020 - By Josh Farkas
"Summary: The Bullet
  • Dexamethasone is now the standard of care for COVID-19 patients with acute hypoxemic respiratory failure (i.e., requiring oxygen or mechanical ventilation).
  • Available evidence does not support the use of dexamethasone in COVID-19 patients who are not requiring oxygen. Using dexamethasone too early is potentially harmful.
  • Optimal management of patients with COVID-19 might involve close monitoring of oxygenation (e.g., with home pulse oximetry). Dexamethasone should be initiated if patients become hypoxemic and require supplemental oxygen.
  • When dexamethasone supplies are exhausted, equivalent doses of other steroid may be used (e.g., methylprednisolone)."

martes, 23 de junio de 2020

Dexamethasone in Patients with COVID-19

medRxiv
By Horby P et al.  RECOVERY Collaborative Group. medRxiv preprint doi: https://doi.org/10.1101/2020.06.22.20137273. This version posted June 22, 2020
"Abstract
Background: Coronavirus disease 2019 (COVID-19) is associated with diffuse lung damage. Corticosteroids may modulate immune-mediated lung injury and reducing progression to respiratory failure and death. Methods: The Randomised Evaluation of COVID-19 therapy (RECOVERY) trial is a randomized, controlled, open-label, adaptive, platform trial comparing a range of possible treatments with usual care in patients hospitalized with COVID-19. We report the preliminary results for the comparison of dexamethasone 6 mg given once daily for up to ten days vs. usual care alone. The primary outcome was 28-day mortality. Results: 2104 patients randomly allocated to receive dexamethasone were compared with 4321 patients concurrently allocated to usual care. Overall, 454 (21.6%) patients allocated dexamethasone and 1065 (24.6%) patients allocated usual care died within 28 days (age-adjusted rate ratio [RR] 0.83; 95% confidence interval [CI] 0.74 to 0.92; P<0.001). The proportional and absolute mortality rate reductions varied significantly depending on level of respiratory support at randomization (test for trend p<0.001): Dexamethasone reduced deaths by one-third in patients receiving invasive mechanical ventilation (29.0% vs. 40.7%, RR 0.65 [95% CI 0.51 to 0.82]; p<0.001), by one-fifth in patients receiving oxygen without invasive mechanical ventilation (21.5% vs. 25.0%, RR 0.80 [95% CI 0.70 to 0.92]; p=0.002), but did not reduce mortality in patients not receiving respiratory support at randomization (17.0% vs. 13.2%, RR 1.22 [95% CI 0.93 to 1.61]; p=0.14). 
Conclusions: In patients hospitalized with COVID-19, dexamethasone reduced 28-day mortality among those receiving invasive mechanical ventilation or oxygen at randomization, but not among patients not receiving respiratory support."

lunes, 22 de junio de 2020

Research Roundup – June 2020

Research Roundup First10EM best of emergency medicine research
First10 EM - By Morgenster J - June 22, 2020
"After two editions focused on COVID, it’s time to get back to some standard emergency medicine topics. (Yes, there are many more COVID papers to cover, but I am sort of sick of reading them.) This time we cover dog therapy in the ED, imaging for renal colic, hypothermia, vitamin C in sepsis, Achilles tendon ruptures, and much more…"

viernes, 19 de junio de 2020

TXA for GI bleeds

TXA for GI Bleeds
First 10EM - By Justin Morgenstern - June 19, 2020
"The paper
Brenner, A., Afolabi, A., Ahmad, S.M. et al. Tranexamic acid for acute gastrointestinal bleeding (the HALT-IT trial): statistical analysis plan for an international, randomised, double-blind, placebo-controlled trial. Trials 20, 467 (2019). https://doi.org/10.1186/s13063-019-3561-7 PMID: NCT01713101
Bottom line
This is a very high quality RCT that demonstrated no benefit from TXA in GI bleeding, and a small increase in venous thromboembolism. TXA should not be routinely used for GI bleeding."

jueves, 18 de junio de 2020

NMDA Encephalitis

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emDocs - June 18, 2020 - By Furmick J, Murphy C
Reviewed by: Santos C; Koyfman A and Long B
"Anti-NMDA receptor encephalitis is a very specific autoimmune mediated reaction against the NMDA receptor that leads to down regulation of the receptor presenting as a variety of psychiatric and neurologic symptoms. Originally described as a paraneoplastic syndrome and seen exclusively in women with ovarian teratomas, it has since been described in those without tumors...

"Key points:

  • Anti-NMDA receptor encephalitis is an autoimmune reaction targeting the NMDA receptor.
  • Patients present with both psychiatric and neurologic symptoms.
  • 50% of cases are associated with ovarian teratomas.
  • Labs and imaging can be normal.
  • Treatment includes steroids + IVIG or plasmapheresis."

Time is Brain

REBEL Cast Ep84 - By Salim Rezaie - June 18, 2020
Paper: Man S et al. Association Between Thrombolytic Door-to-Needle time and 1-Year Mortality and Readmission in Patients with Acute Ischemic Stroke. JAMA 2020. PMID: 32484532
"Clinical Question: Is shorter door-to-needle times with tPA for acute ischemic stroke in patients ≥65 years associated with improved long-term outcomes?
Author Conclusion: “Among patients aged 65 years or older with acute ischemic stroke who were treated with tissue plasminogen activator, shorter door-to-needle times were associated with lower all-cause mortality and lower all-cause readmission at 1 year. These findings support efforts to shorten time to thrombolytic therapy.”
Clinical Take Home Point: I disagree with the authors conclusions of this trial. It is essentially impossible to draw any conclusions from this observational trial. Pushing for more rapid administration of tPA will include more stroke mimic cases making the earlier times look better and the more difficult patients with more comorbid disease (HTN) look worse in the later times of administration. Additionally, all the long-term outcomes were barely statistically significant, almost crossing"

martes, 16 de junio de 2020

Hiperkalemia

Emergency Medicine Cases Logo
Emergency Medicine Cases - By McLaren J
Peer Reviewed and edited by Helman A. June 2020
"In this ECG Cases blog we learn from 9 patients with potential hyperkalemia...
Take home points on ECG findings in hyperkalemia
  • The ECG cannot rule out hyperkalemia, but significant hyperkalemia often produces multiple changes: survey every aspect of the ECG, especially heart rate (bradycardia, junctional rhythm), electrical conduction (PR prolongation or loss of P waves, QRS prolongation, pacemaker delays), and ST/T waves (Brugada phenocopy, peaked T waves that are narrow/pointy)
  • Consider empiric calcium for multiple signs of hyperkalemia, especially unstable bradycardia, slow or regular “AF”, or “VT” which is slow or very wide"

lunes, 15 de junio de 2020

Observation for ACS

Observation for ACS title image
First10EM - June 15, 2020 - By Murchison C
..."One topic that I have never covered is the role of observation units for low risk chest pain (mostly because we don’t use these in Canada; we just send patients home). Therefore, I am thrilled to host a guest post by Dr. Charles Murchison, modified from an original series of blogs on the County EM blog, addressing the question: Does Observation for ACS Make Sense?...
Observation units were developed in the 1990s to help hospitals save money. We did not have the sophisticated scoring systems or lab tests that we have today, therefore we needed 12 to 24 hours to rule out MI in patients presenting with chest pain, and we needed somewhere to do this outside of a CCU. This is no longer the case. We can safely rule out MI in 3-4 hours in the ED with contemporary troponin testing..."

PCCs for Xa inhibitor ICH

R.E.B.E.L.EM - June 15, 2020 - By Salim Rezaie
"Paper: Panos NG et al. Factor Xa Inhibitor-Related Intracranial Hemorrhage: Results From a Multicenter, Observational Cohort Receiving Prothrombin Complex Concentrates. Circulation 2020. PMID: 32264698
Clinical Question: What is the safety and efficacy of prothrombin complex concentrates (PCCs) for factor Xa inhibitor related intracranial hemorrhage (ICH)?
Author Conclusion: “Administration of PCCs after apixaban- and rivaroxaban-related ICH provided a high rate of excellent or good hemostasis (81.8%) coupled with a 3.8% thrombosis rate. Randomized, controlled trials evaluating the clinical efficacy of PCCs in patients with factor Xa inhibitor-related ICH are needed.”
Clinical Take Home Point: There is a true lack of prospective randomized clinical trials with respect to apixaban- and rivaroxaban-related ICH. This observational trial unfortunately doesn’t give us any real clinical guidance as there is no comparator arm and we simply don’t know what patient-oriented outcomes would be. Additionally, although the study tells us there is a low rate of VTE, we have no idea how robustly the authors screened for VTE (i.e. if you don’t look, you may not find VTE). Finally, physicians should be cautious of thromboembolic events out to 14 days after using PCCs."

Posterior Circulation Strokes

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emDocs - June 15, 2020 - By Pierce A -  Edited by: Koyfman, A and Long B
"Take Home Points
  • Consider stroke at the most likely diagnosis for abrupt onset of neurologic symptoms
  • The timing and triggers diagnostic approach for patients with dizziness is helpful in reducing misdiagnosis and decreasing diagnostic test overuse.
  • Fewer than 20% of stroke patients that present with AVS have focal neurological signs
  • NIH stroke scales of 0 occur with posterior circulation strokes. Performing the HINTS exam and targeted neurologic exam of the visual fields, cranial nerves, and cerebellar function including and evaluation of gait and truncal ataxia can help reduce misdiagnosis.
  • Early brain imaging is frequently non-diagnostic
  • Findings that suggest Central Causes of Dizziness:
    • Nystagmus that is dominantly vertical or torsional or dominantly horizontal, direction changing on left/right gaze
    • Test of Skew with skew deviation
    • Head Impulse Test – bilaterally normal (no corrective saccade)
    • Limb ataxia, dysarthria, diplopia, ptosis, anisocoria, facial sensory loss (pain/temperature), unilateral decreased hearing
    • Ataxia
    • Dix-Hallpike test findings that suggest a central cause
      • Variable direction
      • Variable duration
    • Supine roll test findings that suggest a central cause
      • Variable direction
      • Variable duration
    • Abnormal cranial nerve or cerebellar function
    • Diplopia
    • Headache"

viernes, 12 de junio de 2020

Low Risk Chest Pain

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emDocs - June 12, 2020 - By Helman A. Originally published at EM Cases.  
Listen to accompany podcast HERE
"Take home points for low risk chest pain and high sensitivity troponins
  • Missed ACS is more often a result of a failure to consider the diagnosis in patients with atypical symptoms rather than a failure to interpret troponin or use a clinical decision tool properly.
  • Classic cardiac risk factors may be more useful in shifting pretest probability for ACS in younger patients; ask about non-traditional risk factors in young patients.
  • A single undetectable hs-troponin after 3 hours of symptom onset or a delta 2-hr hs-troponin T <4ng/L plus normal serial ECGs and a HEART score of 0-3 rules out acute MI and lowers 30-day MACE to well below 1%, a threshold below which admission and/or ancillary testing may cause more harm than benefit.
  • An absolute change in hs-troponin is recommended rather than relative percentage change to rule in acute MI
  • The HEART pathway is the best clinical decision tool for ED low risk chest pain patients but has several limitations that are important to understand when applying the tool
  • Ancillary testing including stress testing and CCTA in low risk chest pain patients should not be done routinely during/after an ED visit"

martes, 9 de junio de 2020

Left-Sided Colonic Diverticulitis

Hall J et Al. Prepared on behalf of the Clinical Practice Guidelines Committee of the American Society of Colon and Rectal Surgeons. Diseases of the Colon & Rectum; June 2020: 63 (6): 728-747 doi: 10.1097/DCR.0000000000001679
..."This publication summarizes the changing treatment paradigm for patients with left-sided diverticulitis. Although diverticular disease can affect any segment of the large intestine, we will focus on left-sided disease. Bowel preparation, enhanced recovery pathways, and prevention of thromboembolic disease, while relevant to the management of patients with diverticulitis, are beyond the scope of these guidelines and are addressed in other ASCRS clinical practice guidelines..."

lunes, 8 de junio de 2020

Stab Wounds

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emDocs - June 8, 2020 - By Kieffer C, Doucette R, Rubenstein S, Louthan F
Reviewed by Lew E, Koyfman A and Long B
"Pearls and Pitfalls
  1. Recognize that wounds within the thoracoabdominal cavity need to be evaluated for both chest and abdominal wounds due to diaphragm movement
  2. Patients who are stable with a negative FAST may be candidates for local wound exploration and discharged home if the abdominal fascia is not violated. Those with violation of the fascia will require CT imaging.
  3. Complete a secondary examination of every patient with a stab wound to evaluate for multiple penetrating sites.
  4. For needle thoracostomy, consider entry at the mid-axillary line at the 5th intercostal space as the chest wall is thinner."

Metabolic cocktail for Sepsis

vitamin c in sepsis
Fist 10Em - By Justin Morgenstern - June 8, 2020
"Bottom line
Based on the available evidence, there is no reason to believe that a metabolic cocktail of vitamin C, thiamine, and steroids improve outcomes in sepsis, but a benefit cannot be completely excluded. There is really no role for this therapy in current clinical practice, but future research may be warranted."

domingo, 7 de junio de 2020

Early Norepi in Septic Shock

SGEM#294 - By Ken W - Jun 6, 2020
Reference: Permpikul et al. Early Use of Norepinephrine in Septic Shock Resuscitation (CENSER): A Randomized Trial. Respir Crit Care Med 2019.

"CLINICAL QUESTION: DOES STARTING NOREPINEPHRINE EARLIER IN SEPTIC SHOCK LEAD TO EARLIER SHOCK CONTROL?
Authors’ Conclusions: “Early norepinephrine was significantly associated with increased shock control by 6 hours. Further studies are needed before this approach is introduced in clinical resuscitation practice.” 
SGEM BOTTOM LINE: EARLY NOREPINEPHRINE CAN CHANGE SOME MOOS (MAP, LACTATE, URINARY OUTPUT) BUT DOES NOT SEEM TO CHANGE ANY POOS (IN-HOSPITAL OR 28-DAY MORTALITY) IN ADULT PATIENTS WITH SEPTIC SHOCK."

jueves, 4 de junio de 2020

COVID-19 Literature Review

CanadiEM
CanadiEM - By Becky Jones - June 4, 2020
"The Necessity For Knowledge
The COVID-19 pandemic has drastically changed how physicians practice medicine worldwide and has created a wide information gap as clinicians struggle to integrate the immense volume of new research into their practice. Primary literature of varying quality is being published at an accelerated pace, and the lack of strong evidence for diagnostics, treatments, and interventions only further contributes to this uncertainty.
Dr. Mark Crowther, Chair of the Department of Medicine at McMaster University, identified the need for a resource to fill this knowledge gap for frontline clinicians and researchers. Becky Jones, a medical student at McMaster, connected with Dr. Crowther to spearhead the project and subsequently recruited fellow medical students Meghan Glibbery, Hannah Kearney, and Daniel Levin to aid with project coordination and publication review. They were joined by Jasper Ho, another medical student with expertise in programming and website design. Due to the overwhelming volume of literature published daily, four additional medical students were recruited to assist with publication review (Jillian Howden, Maya Amar, Sara Markovic, John Kim)..."

Peripheral Pressors

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R.E.B.E.L.EM - June 4, 2020 - By Salim Rezaie
"Clinical Bottom Line:
  1. Use an antecubital fossa or more proximal vein (Larger diameter)
  2. Use an ultralong catheter (6.35cm or 2.5in — >2.5cm in the vein)
  3. Do not run infusions for >2 – 4hrs
  4. Use as dilute a concentration in as small a volume as possible (4mg/250mL)
  5. Have an IV observation protocol (q15 – q30min)
  6. Have an extravasation protocol (Phentolamine or Terbutaline + Topical NTG + Elevation + Warm Compress)"

Complications of cardiac ablation

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emDocs - June 3, 2020 - By Arnold C and Hamm J 
Reviewed by: Montrief T, Koyfman A and Long B

"Take Home Points:
  • The overall complication rate for cardiac ablation is 6.29%.
  • Atrio-esophageal fistula has up to a 100% mortality without surgery. If considered, emergently consult cardiothoracic surgery.
  • EGD may cause fatal massive air embolism in the setting of atrio-esophageal fistula. Avoid even in the case of gross hematemesis.
  • Delayed cardiac tamponade may occur even up to several weeks out from the ablation.
  • Atypical migraine is a rare post ablation complication and should be considered a diagnosis of exclusion."

martes, 2 de junio de 2020

Charting in the ED

CanadiEM
CanadiEM - By Stella Tung - June 2, 2020
"The Bottom Line:
Tedious as it may be, documentation is a fundamental skill that you will need throughout your career in medicine. After all, if you didn’t write it, it didn’t happen, and it’s your responsibility to capture what happened throughout the patient encounter.
For clinical clerks and even junior residents, using the process of documentation to organize your thoughts is helpful not only for your own understanding, but also for better communication with other providers (e.g. consultants). Think of it as a piece of writing that convinces the reader which diagnosis is most likely using the information you have collected, and use the process to also brainstorm which diagnoses you wouldn’t want to miss. While sometimes it seems easier to write down everything you can think of, I challenge you to continue the pursuit of writing succinct notes throughout your education, which will ultimately make this administrative task an easier one and help you to better enjoy your clinical job as a whole."

lunes, 1 de junio de 2020

Imaging for renal colic

Imaging in renal colic
First 10EM -By Justin Morgenstern - June 1, 2020
"The paper
Moore CL, Carpenter CR, Heilbrun ME, et al. Imaging in Suspected Renal Colic: Systematic Review of the Literature and Multispecialty Consensus. Ann Emerg Med. 2019;74(3):391–399. PMID: 31402153 DOI: 10.1016/j.annemergmed.2019.04.021
Bottom line
The older a patient is, and the less sure you are about the diagnosis of renal colic, the more benefit there will be from CT. In younger patients with a clear diagnosis, no imaging is required at all. For intermediate patients, ultrasound is a great starting point.
I will reiterate my initial thought: imaging for renal colic is pretty easy. It is required if you are searching for an alternative diagnosis. It is required if the patient is septic and needs the OR urgently. It is required if the patient’s pain can’t be controlled and a surgical intervention might be required. Otherwise, it generally isn’t necessary."

jueves, 28 de mayo de 2020

Chest Tubes

REBEL Core Cast 34.0 - May 27, 2020 - By Anand Swaminathan
"Take Home Points
  • Small to Moderate Size Pneumothorax – consider managing conservatively with observation (need to make sure consulting services on same page)
  • Needle aspiration for spontaneous pneumothorax recommend by British Thoracic and European Respiratory Societies
  • 1 in 5 patients requiring a chest tube will suffer complications – many are iatrogenic in nature. Practice procedure via simulation
  • Chest tubes placed for traumatic pneumothoraces should get prophylactic antibiotics
  • When deciding on treatment strategy, discuss with your consultants and make sure you have institutional buy-in."

martes, 26 de mayo de 2020

Disposition Decisions

CanadiEM
CanadiEM - By Rob Woods - May 26, 2020
"Key Takeaways:
  • Tests or imaging studies you would like to order to rule in or out any differential diagnoses on your list.
  • Interventions or therapies you would like to start (remember to reassess your patient to assess for any clinical change).
  • Social factors that would require an admission even if their clinical diagnosis alone would allow the patient to go home.
  • If you are sending a patient home, what do they need to go home with, for what reasons should they return to hospital, and what follow-up do they need?
  • If you believe a patient needs to be admitted to hospital, what service should they be admitted to and with what requirements for their care?"