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





High Altitude Illness

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domingo, 23 de octubre de 2016


R.E.B.E.L.EM - October 8, 2015
"Welcome to the October 2015 REBELCast, where Swami, Matt, and I are going to tackle a couple of topics in the world of Trauma, specifically ED Thoracotomy. Now we all know that ED thoracotomy is a last ditch salvage effort, performed under specific clinical circumstances, during a traumatic arrest. The purpose of the ED thoracotomy is to evacuate pericardial tamponade, control hemorrhage, improve coronary/cerebral blood flow, and if needed internal cardiac massage. The purpose of this podcast is to discuss specific indications where this already low yield procedure may have some benefit.
  • Topic #1: FAST US Examination as a Predictor of Outcomes After Resuscitative Thoracotomy
  • Topic #2: Blunt Trauma Thoracotomy"

sábado, 22 de octubre de 2016

Furosemide in APE

emDocs - January 22, 2014 - By Anand Swaminathan
"Take-Home Messages
  1. There’s minimal or no role for the administration of loop diuretics early in the management of APE. The majority of patients aren’t volume overloaded.
  2. Immediate care should focus on NIPPV and administration of nitroglycerin.
  3. In patients with ESRD, dialysis is what’s ultimately going to fix the patient."

SLE complications

emDocs - October 13, 2016 - Authors: Kaufman R and Reed K
Edited by: Koyfman A and Long B
..."SLE Pearls and Pitfalls
  • Consider MRI for patients with lupus and severe hip pain with a negative x-ray as they are more susceptible to avascular necrosis that may be early, reversible, and not seen on plain radiographs.
  • Patient with fevers, evidence of immune-compromise (such a herpes zoster), and neutropenia warrant admission.
  • Otherwise low-risk chest pain in patients with SLE is never to be considered low risk. These patients have a much higher rate of CAD and an earlier age onset of CAD.
  • Be cautious about holding back on imaging for patients with SLE with headaches as well as for vague neurologic complaints. See neurologic complications above.
  • GI vasculitis is devastating and a patient must appear extremely well so as not to require some form of imaging when complaining about vague abdominal distress.
  • Patients with SLE on chronic steroids and sepsis or shock require stress-dose steroids (hydrocortisone 100 mg IV) and broad-spectrum antibiotics. Adrenal insufficiency from abrupt discontinuation of steroids should be highly considered, especially in the patient whose blood pressure is not fluid responsive."

Mechanical Circulatory Support Devices

The Rise of Mechanical Circulatory Support Devices
What Critical Care Physicians Need to Know
PulmCCM - October 20, 2016 - By Teran-Merino F
  • I. The failing pump and hemodynamic rationale for the use of MCS devices
    • Understanding the vicious cycle of pump failure
    • The role and hemodynamic effects of MCS
    • Why is it important that acute care physicians are familiar with the field of MCS?
    • Indications for Mechanic Circulatory Support
The Rise of Mechanical Circulatory Support Devices
What Critical Care Physicians Need to Know
PulmCCM - October 20, 2016 - By Teran-Merino F
  • II. Main MCS devices used for emergency and short-term support
    • Intra-Aortic Balloon Pump
    • Impella®
    • LVADs
    • CentriMag® and Rotaflow®

viernes, 21 de octubre de 2016

52 Articles in 52 Weeks

ALiEM - By Junk E et al - October 19th, 2016
"Maintaining lifelong learning is challenging, especially when trying to keep up with all of the journal publications in emergency medicine (EM). In 2013, we published a compilation of 52 journal articles, which interns could read over a 52-week period, at an average pace of 1 journal article per week. In the list below, we present an updated compilation for the “52 Articles in 52 Weeks” initiative...
Evaluations were summarized descriptively, then used to rank the order of most essential knowledge for EM interns. The top-ranked articles are provided below to be consumed throughout the EM intern year."

Syncope and Pulmonary Embolism

Prandoni P et al - N Engl J Med 2016; 375:1524-1531 - October 20, 2016
DOI: 10.1056/NEJMoa1602172
..."Although pulmonary embolism is included in the differential diagnosis of syncope in most textbooks, rigorously designed studies to determine the prevalence of pulmonary embolism among patients hospitalized for syncope are lacking. Indeed, current international guidelines, including those from the European Society of Cardiology and the American Heart Association, pay little attention to establishing a diagnostic workup for pulmonary embolism in these patients. Hence, when a patient is admitted to a hospital for an episode of syncope, pulmonary embolism — a potentially fatal disease that can be effectively treated — is rarely considered as a possible cause.
In this study, we used a systematic diagnostic workup to assess the prevalence of pulmonary embolism in a large number of patients who were hospitalized for a first episode of syncope, regardless of whether there were potential alternative explanations for the syncope...
In conclusion, among patients who were hospitalized for a first episode of syncope and who were not receiving anticoagulation therapy, pulmonary embolism was confirmed in 17.3% (approximately one of every six patients). The rate of pulmonary embolism was highest among those who did not have an alternative explanation for syncope."

ACEP Conference 2016

R.E.B.E.L. EM - Emergency Medicine Blog
R.E.B.E.L.EM - October 20, 2016 - By Salim Rezaie
"This years ACEP 2016 conference took place in Las Vegas, NV from Oct 16th – 19th. There was greater than 350 courses, labs, and workshops given throughout the week. It was impossible to make all of these great lectures, but I was able to take away some very important clinical pearls that I wanted to share with our readers..."

Rheumatoid Arthritis in the ED

emDocs - October 19, 2016 - Authors: Berman S and Bucher J 

Edited by: Koyfman A and Long B
"Rheumatoid arthritis is a progressive systemic polyarticular inflammatory arthritis of unclear etiology. Its prevalence in the U.S. is about 1%, and it affects women roughly twice as often as men. While not fatal itself, complications of the disease make it the most common rheumatic disease requiring ICU admission. Understanding of this disease is necessary for the emergency medicine physician to improve patient morbidity and mortality.
Admission to the hospital follows either an infection or a disease flare. Typical disease presentation includes severe joint pain with symmetric synovial joint involvement. If left untreated, patients have a risk of deformity and disability. However, with the advent of disease modifying anti-rheumatic drugs (DMARDs) and newer biologic agents, the disease course has changed dramatically.
So what can we as EM docs do? Being armed with the knowledge of this disease and its complications can lead to earlier recognition and diagnosis as well as optimal outcomes...
Rheumatoid arthritis, a seemingly benign disease entity itself, carries a host of anxiety-inducing complications that every ED doc should be able to address. While RA is largely a clinical diagnosis in the ED, prompt recognition of its complications can lead to decreases in morbidity and mortality down the road for these patients."

Oxygen-ICU trial

PulmCrit (EM Crit)
PulmCrit Wee - October 19, 2016 - By Josh Farkas
"Among intubated patients, we can often control the pO2, pCO2, and pH. Sounds great. Unfortunately, we also have no idea which numbers we should be targeting. Should we target a normal pH, or permissive hypercapnia? Should we shoot for a normoxia, try to maximize the oxygen delivery (hyperoxia), or allow for permissive hypoxemia? Nobody knows. We check ABGs and tweak the ventilator, but it’s often dubious whether this helps our patients.
Although oxygen is necessary for life, it’s also involved in burning stuff (whether that may be a forest fire or oxidative tissue damage). There is increasing recognition that hyperoxia may be harmful, particularly following cardiac arrest and myocardial infarction (e.g., the AVOID trial). This leads to the current study: is targeting a high oxygen saturation harmful in critically ill patients?..
  • The Oxygen-ICU trial found benefit from a conservative (94-98%) oxygen target when compared to a liberal (97-100%) oxygen target.
  • It is conceivable that targeting a lower oxygen saturation led to lower PEEP and FiO2 levels, facilitating earlier extubation.
  • This study suggests that targeting a saturation of 97-100% may be too high. However, most clinicians may already targeting levels lower than this."

miércoles, 19 de octubre de 2016

Nitrous Oxide Abuse

ALiEM - By Vo K and Smollin C - October 17th, 2016

"Case: A 39-year-old man, with no significant past medical history, was brought to the emergency department by family members, over three consecutive days, for anxiety, confusion, and ataxia. In the first two visits, his laboratory work-up, including complete blood cell count, chemistry panel, liver function tests, urine drug screen, and non-contrast head CT, were unremarkable. On his third visit, he was profoundly encephalopathic with confusion and poor concentration. He had bilateral lower extremity weakness and ataxia. He was admitted to the neurology service for further work up. Additional history revealed that hundreds of empty canisters of whipped cream chargers were found in his house..."

Intra-Abdominal Hypertension

ICM Cases Summaries - October 17, 2016
The measurement of IAP in all at-risk critically ill patients is probably unnecessary and burdensome in resource terms. Critical care practitioners should have a low index of suspicion for ACS in their patients; if this develops then decompressive laparotomy is the treatment of choice (unless there is a large extra-luminal collection amenable to urgent drainage), particularly since modern laparostomy management appears to be associated with an increasingly low complication rate, if the abdomen cannot be closed.
The consensus guidelines for IAH/ACS remind us that attention to detail; such as ensuring that enteral nutrition is succeeding, that bowel care is optimal and that fluid balance is tightly controlled, may prevent numerous serious ICU-associated syndromes from ever developing."

martes, 18 de octubre de 2016

Peritonsillar abscess

EMBlog Mayo Clinic - By Cabrera D - Author: Dante LS Souza - October 11, 2016 
"Peritonsillar abscess (PTA) is a collection of pus between the capsule of the palatine tonsil and the pharyngeal muscles. It is the most common deep neck space infection, both in children (49%) and adults (30%), representing the most frequent indication for non-elective otolaryngological hospital admissions... 
Thus, our findings support previous studies that initial medical management should be considered in certain scenarios. Noninvasive approach can be considered as initial management of patients with less-advanced symptoms or smaller abscesses without compromising outcome and it can be an alternative first-line treatment in resource-limited or austere environments or in populations where surgical approach can be challenging or unfeasible, such as small children or when it is the patient’s preference. Patients with drooling, trismus, muffled voice, and uvular deviation or large abscess size may benefit from surgical drainage..."

Hyperthermia Syndromes

R.E.B.E.L.EM - By Swaminathan A - October 17, 2016
"Definition: A life-threatening emergency in which there is a failure of the body’s thermoregulatory mechanisms to handle extrinsic and intrinsic heat. The failure of thermoregulation leads to multi-system organ dysfunction characterized by alteration of neurologic function. Unlike in fever, hyperthermia is not caused by endogenous pyrogens that change the thermoregulation set point in the brain. Hyperthermia results from excessive heat production and/or inadequate heat dissipation...
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"

lunes, 17 de octubre de 2016

Pip-Taz dosing

PulmCCM - October 14, 2016 By JE
..."There is surprisingly little data pertaining to the pharmacokinetics of pip-tazo in the critically-ill patient population. In one small investigation, trough levels of pip-tazo demonstrated significant variability in those with normal renal function. Further, in critically-ill patients with normal renal function and moderately-impaired renal function, the administration of pip-tazo 4.5 grams every 6 hours and every 8 hours, respectively, lead to insufficient plasma levels.
Pip-tazo, like other beta-lactam antibiotics, exhibit time-dependent antibacterial activity; that is, efficacy is related to the absolute duration that the antibiotic remains above the minimum inhibitory concentration [MIC] of the pathological organism of interest.
In the critically-ill, there are multiple mechanisms by which pip-tazo [and beta-lactams, in general] can fall below the MIC when dosing is intermittent. These alterations includean increase in both the apparent volume of distribution, as well as, clearance of the antibiotic. Consequently, administering beta-lactams as a continuous infusion has been shown to increase time above the MIC and amplify bacterial annihilation. Nevertheless, in ameta-analysis which included patients with non-severe sepsis [i.e. patients likely not labeled as septic by the new definition], no significant difference in mortality was found between patients who received continuous infusion versus intermittent beta-lactam dosing..."

Trendelenburg Position

Resultado de imagen de life in the fast lane
Life in the Fast Lane - By Kane Guthrie
Current data to support the use of the Trendelenburg position during shock are limited and do not reveal any beneficial or sustained changes in systolic blood pressure or cardiac output.
Complications of the Trendelenburg position in the hypotensive patient
  • Anxiety and restlessness
  • Progressive dyspnea
  • Hypoventilation and atelectasis caused by reduced respiratory expansion
  • Altered ventilation/perfusion ratios from gravitation of blood to the poorly ventilated lung apices
  • Increasing venous congestion within and outside the cranium leading to increased intracranial pressure
  • Pressure from abdominal organs is transmitted into the thoracic cavity, which can impair venous return to the heart, leading to a further decreased cardiac output and hypotension
  • Increase risk of aspirating gastric contents"

Liver Disease and Hemostasis

emDocs - October 16, 2016 - Author: Robertson J - Edited by: Koyfman A
..."Given the large number of components of hemostasis that are produced by the liver, it is not surprising that patients with cirrhosis are considered to have abnormal hemostasis. However, the pathophysiology is complicated and patients with cirrhosis may actually be prone to clotting just as much as bleeding. In fact, patients with cirrhosis may even be slightly more at risk for clotting than those without liver disease... 
While more studies need to be conducted on bleeding and clotting risk in patients with cirrhosis, especially with newer, more sensitive tests for the coagulation system, the point of this review is that patients with cirrhosis CAN form clots. Thus, if there are any signs and/or symptoms of a blood clot in your next patient with cirrhosis, then adequate workup should be obtained."

Hydrocortisone and Severe Sepsis

The Bottom Line - October 14, 2016 - By Celia Bradford
Ref. Keh. JAMA 2016. Published online October 3, 2016.doi:10.1001/jama.2016.14799
"Clinical Question
In patients with severe sepsis does hydrocortisone compared to placebo prevent the development of septic shock?
Authors’ Conclusions
Administration of hydrocortisone did not prevent the development of shock in patients with severe sepsis.
The Bottom Line
As a non-believer in the use of steroids in sepsis and septic shock I will continue my current practice of not using steroids in this setting.
I am working at a hospital actively recruiting for the ADRENAL trial. 3800 patients with septic shock are being recruited in a placebo-controlled trial to assess 90 day mortality. I keenly await these results which may put this question to rest forever!"

miércoles, 12 de octubre de 2016

Post-Intubation Analgesia/Sedation

emDocs - October 11, 2016 - Authors: Birnbaum K and Willis J
Edited by: Cassella C and Koyfman A
Intubation is an important intervention in the ED. We see a critical or impending airway problem and we secure the airway with intubation–very satisfying! Yet our job does not stop there. In addition to maintaining an appropriate ventilation strategy after intubation, it is crucial that we use appropriate post-intubation sedation and analgesia regimens for the continued care of these critical patients. This post will review sedation and analgesia regimens for different clinical scenarios after intubation, as well as some common pitfalls that we must be diligent to avoid...
Conclusion / Take-Home Points
  • Don’t forget about post-intubation sedation/analgesia. Order these medications with your RSI meds and communicate with your nurses.
  • Mechanical ventilation hurts and pain control is always primary. Every intubated patient should have adequate analgesia. An objective scale like RASS should be used to assess additional sedation needs after primary analgesia is started.
  • Nonbenzodiazepines like ketamine, propofol, and dexmedetomidine are first-line recommendations for sedation over benzodiazepines and are associated with better outcomes.
  • Consider the hemodynamic profile when choosing medications and don’t neglect analgesia/sedation out of fear for hypotension. Use ketamine for sedation and analgesia in patients with persistent hypotension. Use propofol for hypertensive patients and primary neurological problems (seizures, delirium tremens, hemorrhagic stroke, head trauma)."

Acute Angle Closure Glaucoma

An online community of practice for Canadian EM physicians
CanadiEM - By Stephanie Cargnelli - October 11, 2016
..."Acute angle closure glaucoma is a condition characterized by raised intraocular pressure due to impaired outflow of aqueous humor from the posterior chamber of the eye. In a normal eye, the aqueous humor is produced in the posterior chamber by the ciliary process and proceeds to flow through the pupil to the anterior chamber and out through the trabecular meshwork into Schlemm’s canal. In acute angle closure glaucoma, the flow to the trabecular meshwork is blocked by contact between the lens and the iris resulting in accumulation of aqueous humor in the posterior chamber. This is referred to as “pupillary block.” As pressure in the posterior chamber rises, the iris is pushed further forward and causes the angle between the peripheral iris, trabecular meshwork, and cornea to close, hence the name acute angle closure glaucoma..."

Coagulation Studies

Taming The SRU - October 11, 2016 - By Murphy-Crews A
Peer Review and Editing by R LaFollette R
Coagulation Cascade - licensed for reuse by CC SA-3.0 - original available at https://commons.wikimedia.org/wiki/File:Coagulation_full.svg
..."Now that we have a brief refresher on what the body is doing, let’s delve into the mechanism of our coagulation assays.
Coagulation studies need to be collected in a tube with sodium citrate (light blue top). The citrate in the tube binds calcium, which inactivates the clotting potential. Tubes need to be adequately filled, since an excessive amount of citrate/blood can further inhibit coagulation and skew results- so this isn’t a test we can accurately run with that tiny drop we get before a line blew.
The standard coag panel provides three variables: PT, aPTT and INR..."

martes, 11 de octubre de 2016

Joint Fluid Analysis in the ED

Taming The SRU - October 10, 2016 - By Shaun Harty, MD

  • For primarily inflammatory findings, keep in mind both crystal-induced arthropathies as well as other potential autoimmune causes like RA or SLE
  • Septic arthritis is NOT defined by >50,000/mm3 WBCs in the synovial fluid; use your clinical gestalt and the entire picture to define your diagnosis
  • Crystals in the synovial fluid does not preclude the joint from being septic
  • If a septic arthritis diagnosis cannot be reliably excluded after clinical evaluation, including arthrocentesis, admit the patient for IV antibiotics and pain control until culture results are available
  • Based on clinical suspicion, additional testing may be pursued including serum Borrelia burgdorferi DNA PCR and special staining and culturing for TB or fungal organisms"

Corticosteroids in Sepsis

emDocs - October 10, 2016 - Author: Long B - Edited by: Santistevan J and Koyfman A
  • Sepsis management requires early recognition, fluid resuscitation, source control, broad spectrum antimicrobials, and vasopressors for those not responsive to IV fluids.
  • Patients with septic shock unresponsive to fluid and vasopressor resuscitation warrant further management and consideration of other disease states.
  • The pathophysiology of sepsis may include loss of vasomotor tone and relative adrenal insufficiency.
  • High-dose corticosteroids may result in patient harm, but physiologic, or low-dose, corticosteroids may be used to decrease the need for vasopressors.
  • Most current meta-analyses do not demonstrate a mortality benefit with steroids. The Surviving Sepsis Guidelines advise consideration of corticosteroids in patients with vasopressor and fluid resistant septic shock.
  • Corticosteroids may decrease need for vasopressors and improve perfusion."

lunes, 10 de octubre de 2016

¿Rocuronio o succinilcolina?

AnestesiaR - 10 octubre 2016 - Por Patricia Peralta Rodríguez
REFERENCIA: Naquib M, Brewer L, La Pierre C, Kopman AF, Johnson KB. The Myth of Rescue Reversal in “Can´t intubate, can´t ventilate” scenarios. Anesth Analg 2016 Jul; 123(1):82-92. PMID 27140684 (PubMed)
En la situación “no intubable, no ventilable” se precisa una rápida recuperación de la ventilación espontánea. Usando modelos de simulación, se compara el resultado de distintos regímenes de inducción en relación con distintos pesos corporales.
.."Este artículo nos hace reflexionar principalmente sobre dos aspectos principales. El primero, el gran impacto sobre el manejo anestésico en particular sobre el de la vía aérea que tiene la existencia de un IMC elevado en nuestros pacientes. El paciente obeso tiene una disminución en volúmenes pulmonares con reducción de la capacidad residual funcional, lo que provocará un menor tiempo de resistencia a la apnea. Esto cobra especial relevancia en la situación “no intubable, no ventilable”, quedando nuestro margen de maniobra muy reducido en cuanto a tiempo y produciéndose la desaturación a pesar de una adecuada preoxigenación en menos de 4 minutos con el riesgo de daño hipóxico que conlleva.
El segundo aspecto que nos planteamos es la eterna pregunta ¿succinilcolina o rocuronio? A pesar de la evidente ventaja que ha supuesto la aparición del reversor sugammadex, su uso no nos va a garantizar una solución a situaciones complicadas como la que se analiza en este estudio. En primer lugar, se necesita tiempo para cargar esta medicación en una situación de urgencia (especialmente si sólo están disponibles los viales de 200 mg. y el paciente tiene un IMC elevado). Además, existen publicados casos de complicaciones intraoperatorias (2) en probable relación con la administración de sugammadex, en particular de dificultad en la ventilación secundaria a broncoespasmo o rigidez muscular por opioides sin oposición del relajante muscular. Evidentemente como cualquier otro fármaco no está exento de la posibilidad de provocar reacciones adversas..."

Acutely Confused Elderly Patient

EM Didactic - By Lakshay Chanana - October 10, 2016
"Patients presenting to the ED with an Altered Mental Status (AMS) require a thorough history and an extensive work-up leading to time consuming evaluation, talking with families and caregivers, reviewing old records, labs and radiologic studies. Even after an broad work up, occasionally a diagnosis is not reached. It becomes a challenge for emergency physicians to work with limited history and examination findings. Therefore, adopting an organized approach to the evaluation of mental status would result in increased clinician comfort while taking care of elderly, better ability to communicate with other physicians, and improved patient and family satisfaction...

Take Home: 
  • When evaluating delirium, do a through history and physical and ask for medications and also over the counter prescriptions. 
  • Identify and treat life threats first. 
  • Do not underestimate the role of family or nursing home staff who can better detect a change in the patient’s cognition. Be extremely sensitive while dealing with the family."

IDSA Pneumonia Update

R.E.B.E.L.EM - Posted by Anand Swaminathan
"Every few years we get updates in the guidelines based on new evidence. Guidelines give us a framework to work with in the treatment of disease processes, such as pneumonia. The last Infectious Disease Society of America (IDSA) guidelines update on the treatment of pneumonia came from 2005, but recently, the new 2016 guidelines were just published. This was a massive 51 page summary that starts off by saying:
“It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. IDSA considers adherence to these guidelines to be VOLUNTARY, with the ultimate determination regarding their application to be made by the physician in the light of each patient’s individual circumstances.”...
Clinical Bottom Line:
Where does this leave us in terms of HCAP, a more relevant area in Emergency Medicine than HAP and VAP. The truth is that we don’t know. As mentioned in the podcast, many of us see patients who were recently admitted for unrelated issues who now return with pneumonias but are very well appearing and without significant comorbid conditions. Uniformly, admitting these patients and treating them with broad spectrum antibiotics never made sense. It will be interesting to see what subsequent IDSA recommendations are for the treatment of HCAP and how this affects our treatment decisions. For now, in well appearing patients who are otherwise healthy with unremarkable vital signs, we are recommending treating HCAP in the same way we treat community acquired pneumonia and ensuring close follow up and giving explicit return precautions."

USS in cardiac arrest

JC: Is this the REASON to use USS in cardiac arrest?
St. Emlyn´s - By Simon Carley - October 9, 2016
"This month the emergency department point of care ultrasound in out-of-hospital and in-ED cardiac arrest trial from the REASON1 trial is published in the journal Resuscitation. This has been rumoured for some time in the #FOAMed world as patient outcome related evidence for the use of ultrasound in cardiac arrest is not yet definitive.
So, the REASON1 trial is a protocol driven observational trial of the use of point of care ultrasound in the management of cardiac arrest patients in the ED. The aim is stated as looking at the association between cardiac activity on ultrasound and outcome...
What are the main results?
Importantly the main findings of ROSC, admission, and survival to hospital discharge are associated with the finding of cardiac activity on that initial ultrasound. This is arguably unsurprising as a heart which is moving intuitively feels easier to resuscitate than one that is at standstill. Patients with cardiac activity on the initial USS survived to hospital discharge on 3.8% of occasions vs 0.6% where it was absent. For ROSC the difference is even greater – 51% vs 14.3%. So the association appears to be there, and with statistical analysis using a multivariate model, cardiac activity was the single most important factor in survival, although factors such as downtime, rhythm and location of arrest were similarly important..."

domingo, 9 de octubre de 2016

Propofol Infusion Syndrome (PRIS)

emDocs - October 9, 2016 - Authors: Cole S and Velez L
Edited by: Simon E and Koyfman A
..."What is Propofol Infusion Syndrome (PRIS)?
Propofol (2,6-diisopropylphenol), an intravenous sedative-hypnotic approved by the FDA for the induction and maintenance of sedation and anesthesia, is one of the most commonly utilized medications in the ICU setting secondary to its anti-epileptic and neuro-protective properties. Propofol infusion syndrome (PRIS) is a rare, but potentially fatal, adverse effect of propofol administration. First described in children in 1992, and subsequently named by Bray in 1998, PRIS was classically defined as acute bradycardia progressing to asystole status post propofol administration; occurring in the setting of one of the following:
  • metabolic acidosis (base excess > 10 mmol · 1-1)
  • myoglobinuria
  • rhabdomyolysis
  • renal failure
  • lipemic plasma
  • fatty liver enlargement
  • Brugada-type patterns on ECG
Table 1. Risk Factors for the development of PRIS
Key Points:
  1. Prevention of PRIS is best: limit the maximum dose of propofol and the duration of the infusion.
  2. Have a high index of suspicion: pay attention to the development of acute kidney injury, rhabdomyolysis, hyperkalemia, and bradycardia
  3. Immediately discontinue propofol if there is suspicion of PRIS.
  4. Renal replacement therapy (RRT) and Extracorporeal Membrane Oxygenation (ECMO) have been utilized with success in reported cases of PRIS."

Levosimendan in Sepsis

The Bottom Line - October 7, 2016- By Steve Mathieu
Gordon. NEJM 2017; October 5. DOI: 10.1056/NEJMoa1609409
"Clinical Question
  • In adult patients who have sepsis, does levosimendan reduce the incidence and severity of acute organ dysfunction compared with placebo?
Authors’ Conclusions
  • The addition of levosimendan to standard treatment in adults with sepsis was not associated with less severe organ dysfunction or lower mortality. Levosimendan was associated with a lower likelihood of successful weaning from mechanical ventilation and a higher risk of supraventricular tachyarrhythmia
The Bottom Line
  • In adults with sepsis, a 24 hour infusion of levosimendan, in addition to standard treatment, was not associated with less severe organ dysfunction or mortality compared with placebo and standard treatment. There may be associated harm from levosimendan given the higher incidence of haemodynamic instability and the longer duration of mechanical ventilation."

jueves, 6 de octubre de 2016

Posterior Epistaxis Management

emDocs - October 6, 2016 - Author: Simon E - Edited by: Koyfman A and Singh M
"Epistaxis is one of the most commonly encountered ear, nose, and throat (ENT) emergencies in the US.1-4 It is estimated that up to 60% of the population will experience an episode of epistaxis throughout their lifetime; with approximately 10% having a bleeding source localized to the posterior nares. Current data demonstrate a bimodal age distribution of epistaxis with the majority of cases occurring amongst those aged 2-10 years and 50-80 years. Despite this reported prevalence of epistaxis, epidemiologic data cite only 6% of individuals as presenting to healthcare providers for anterior epistaxis treatment, and only 5% for posterior epistaxis treatment.
Seasonal variation in the rates of epistaxis have been described in temperate and tropical climates. The majority of epistaxis episodes in the US occur during the winter months, a finding thought secondary to a decrease in ambient humidity and increase in concomitant upper respiratory infections. In tropical climates, epistaxis occurs frequently during dry seasons...
The Evaluation of a Patient Presenting with Epistaxis
Evaluation should begin with an assessment of the ABCs. If the patient is actively bleeding, but protecting his airway and hemodynamically stable, he should be placed in a seated position (leaning forward so as to avoid increasing the flow of blood to the posterior oropharynx), and instructed on the application of direct pressure to the bilateral nares for approximately 5-10 minutes. Expectoration of blood residing in the oropharynx should be encouraged so as to reduce the risk of aspiration or emesis..."

wounding Patterns of Blast Injury

TacMed Australia
TacMed - 04 OCT 2016 - By Dan Pronk
"The wounding patterns of blast injuries are well known to any military medic who has served recently on operations, with Improvised Explosive Devices (IEDs) constituting a significant proportion of the casualties on the battlefields of Iraq and Afghanistan. Sadly the IED threat is no longer confined to war zones, with a series of high profile, mass-casualty IED terror events occurring in places of mass gathering in first-world countries in recent years.
Terrorists have come to favour explosives because of their proven ability to inflict mass casualties, cause fear and disruption in the community and attract media interest (ANZCTC 2016).
Recent mass-casualty events of international significance include the Boston Marathon bombing of April 2013, the Charlie Hebdo shootings of January 2015 and the November attacks in Paris the same year. More recently we have seen the airport bombings in Brussels and Istanbul, and once again another mass-casualty terrorist attack in France when a truck bomb exploded on 14 July 2016, killing 84 people and injuring in excess of 300 more.
Turkish President Recep Tayyip Erdogan made the following poignant statement on the day of the Istanbul Airport bombing:
“The bombs that exploded in Istanbul today could have gone off at any airport in any city around the world” (bbc.com, 2016)
With that thought in mind it is important that first responders and civilian medical staff have an understanding of the patterns of injury associated with blast, as to be best prepared for the very real possibility that a mass-casualty incident occurs in their city. There are some outstanding lessons to be learned from the experiences of the French medical responders in the wake of the multisite terror attacks around Paris in November 2015 (Hirsch M 2015), and I encourage readers to pursue that reference. This article presents an overview of the specific wounding patterns of blast to better inform medical responders of the constellations of injury patterns following blast, as to be able to manage not only the obvious, but also the unseen life-threatening injuries..."

Reading a Head CT

Emergency Physicians Monthly
Emergency Physicians Monthly - By Broder J - September 30, 2016
"CT signs of elevated intracranial pressure
Unenhanced or noncontrast brain CT is commonly performed in the Emergency Department to evaluate patients with complicated headache, head trauma, or altered mental status. Emergency Physicians must recognize CT findings of elevated intracranial pressure (ICP) to facilitate appropriate treatment and to avoid contraindicated procedures and therapies. It is important to recognize that CT is an imperfect surrogate for elevated intracranial pressure, which may exist in the absence of radiographic signs. However, when CT findings point to elevation of ICP, the condition should be strongly suspected...

miércoles, 5 de octubre de 2016

Motorcycle Accident Patient

emDocs - October 4, 2016 - Author: Patti L - Edited by: Koyfman A and Long B 
  • Motorcyclists are at high risk of injury because riding a motorcycle is inherently riskier than a car. 
  • Helmets decrease injuries. 
  • Older riders are more likely to have more severe thoracic injury. 
  • Be aware of the OMGs in your area, but don’t think that every motorcyclist is in one."


Taming The SRU - October 04, 2016 - By Teuber J, Shah A, Hill J
Ortiz M et al. Randomized Comparison of Intravenous Procainamide vs. Intravenous Amiodarone for the Acute Treatment of Tolerated Wide QRS Tachycardia: the PROCAMIO Study. Eur Heart J 2016. PMID: 27354046
...While it is a bit of a stretch to conclude procainamide should be first line instead, it may be worthy of consideration as another tool in your armamentarium of antiarrhythmics. Still, all of these patients are quick to decompensate, so you will want to prepare for the worst- always keep the defib pads on the patient and have a backup plan in place!

Kudenchuk, P. J., Brown, S. P., Daya, M., Rea, T., Nichol, G., Morrison, L. J., et al. (2016). Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest. New England Journal of Medicine, 374(18), 1711–1722. http://doi.org/10.1056/NEJMoa1514204
...Strictly speaking, amiodarone and lidocaine don’t improve survival to discharge from the hospital but do result in better survival to hospital admission. This isn’t the final word on this subject. Because they improve survival to hospital admission, as in-hospital patient treatments continue to improve, anti-arrhythmic medications may be found, in the future, to improve survival to discharge.
Ageliki Laina et al. Amiodarone and cardiac arrest: Systematic Review and meta-analysis. International Journal of Cardiology. 2016. PMID: 27434349
  1. The researchers did so a sub-analysis that only included randomized control studies that did show a statistically significant improvement in ROSC prior to hospital admission.
  2. Amiodarone was shown to improve the incidence of survival to hospital admission compared to other interventions (placebo, lidocaine, nifekalant)
  3. There was no improvement in survival noted at 24 hour post ROSC in patients that received amiodarone. 
  4. When the data was analyzed, there appeared to be no improvement in survival to hospital discharge in patients that received amiodarone.
  5. Amiodarone was not associated with improved neurologic status at the time of hospital discharge.