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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, 26 de noviembre de 2020

2020 AHA and Red cross First Aid Update

CanadiEM - By Andrew Tolmie - November 25, 2020
"This year, the American Heart Association released the updated 2020 Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care; the first major update to the internationally recognized guideline in five years. CanadiEM has worked alongside the AHA to produce infographics summarizing these updates. 
Alongside the American Red Cross, the AHA developed a Focused Update for First Aid outlining the “Top 10 Things to Know” for providers. The update used systematic reviews produced by the International Liaison Committee on Resuscitation (ILCOR) to create recommendations for North American First Aid providers. 
The 2020 First Aid update provides new recommendations regarding how to recognize and treat life-threatening bleeding and heatstroke; both topics that were not included in the 2015 update. Furthermore, updates have been made to stroke recognition, and nontraumatic chest pain guidelines, which can potentially improve patient outcomes. Lastly, the 2020 version reiterates the management guidelines of common first aid presentations such as tooth avulsion and hypoglycemia."

IM Tranexamic Acid

REBEL EM - November 26, 2020 - By Shyam Murali
Paper: Grassin-Delyle et al. Pharmacokinetics of intramuscular tranexamic acid in bleeding trauma patients: a clinical trial. British Journal of Anaesthesia 2020. PMID: 330109274
"Clinical Question: In bleeding trauma patients, will intramuscular TXA achieve concentrations sufficient to inhibit fibrinolysis?
Author Conclusions:
“Intramuscular TXA is well tolerated with only mild and transient injection site reactions. Intramuscular TXA is rapidly absorbed, reaching therapeutic concentrations within 15 min. Blood lactate and signs of shock had no apparent impact on the rate of absorption. Our results have major implications for trauma care, particularly in low- and middle-income countries where i.m. TXA could expand access to treatment.”
Clinical Take Home Point:
IM TXA appears to be rapidly absorbed and reaches therapeutic concentrations quickly. While this paper does not change our current clinical practice here in the US, it does open doors for further research and potentially impacts the care of trauma patients in healthcare systems of low- and middle-income countries."

Low Platelets counts

By EMottawa -  Aug 27, 2015
"Platelets: too much, too little, don’t work. The approach to platelet emergencies is perhaps a little bit more complicated than that, so we attempt to breakdown a simplified approach to platelets in the Emergency Department (ED). Patients with various disease processes often present to the emergency department with critically low platelet counts.
When should we consider transfusing these patients prophylactically to prevent bleeding? 
Some of these patients may require a procedure (such as lumbar puncture, central line or paracentesis) in the ED. 
When is it safe to do these procedures? When should we consider transfusing during/prior to these procedures to prevent severe bleeding?
The following should provide a simple guide to some of these platelet-related dilemmas in the ED...

Take Home Points

lunes, 23 de noviembre de 2020

Early Rhythm-Control in AF

REBEL EM - November 23, 2020 - By Benjamin M. Gerretsen
Paper: Kirchhof et al. Early Rhythm-Control Therapy in Patients with Atrial Fibrillation. NEJM 2020. PMID 32865375
"Clinical Question: Does early rhythm-control or rate-control therapy reduce the risk of cardiovascular complications in patients with atrial fibrillation?
Author Conclusion: “Early rhythm-control therapy was associated with a lower risk of adverse cardiovascular outcomes than usual care among patients with early atrial fibrillation and cardiovascular conditions.”
Clinical Take Home Point / What Do I Tell My Patient: An association was found between early rhythm-control and reduction of AF-related adverse clinical outcomes in patients with recent atrial fibrillation diagnosis and cardiovascular disease, without affecting the number of nights spent in hospital. While early rhythm-control was associated with more adverse events, the incidence of the overall safety outcome events was similar in the two groups. The result of this trial support the use of rhythm control to reduce atrial fibrillation–related adverse clinical outcomes when applied early in the treatment of patients with atrial fibrillation."

eCPR

ED ECMO -  November 22, 2020 
"The ARREST Trial is published! Demetris Yannopoulos, Jason Bartos and their army of rockstars have done it! This is the first randomized ECPR trial and it showed tremendous benefit of ECPR compared to traditional therapies. Zack explores this paper and their concurrent publication of process with Demetris. Their two Lancet papers are below..."
  • https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)32338-2/fulltext
  • https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(20)30376-X/fulltext

sábado, 21 de noviembre de 2020

Methemoglobinemia

EM@3AM - emDocs - November 21, 2020 - By Taylor Guinn
Reviewed by: Alex Koyfman, Brit Long & Cynthia Santos
"Pearls:
  • While rare, it is important to be aware of causative factors for methemoglobinemia, with topical anesthetics being the most common precipitant in the ED.
  • Treat with methylene blue if a patient is symptomatic or has a methemoglobin level >25%.
  • Methylene blue dose is 1-2 mg/kg given over a 5 minute slow push.
  • Improvement and disposition should be dictated by clinical examination, not repeat methemoglobin testing."

COVID-19: Thrombosis and Hemoglobin

emDocs – November 20, 2020 - By Salim Rezaie 
(Originally published at R.E.B.E.L. EM on April 9, 2020)
"The Novel Coronavirus 2019, was first reported on in Wuhan, China in late December 2019. The outbreak was declared a public health emergency of international concern in January 2020 and on March 11th, 2020, the outbreak was declared a global pandemic. The spread of this virus is now global with lots of media attention. The virus has been named SARS-CoV-2 and the disease it causes has become known as coronavirus disease 2019 (COVID-19). This new outbreak has been producing lots of hysteria and false truths being spread, however the data surrounding the biology, epidemiology, and clinical characteristics are growing daily, making this a moving target. This post will serve as a summary of thrombosis and hemoglobin in regard to COVID-19..."

lunes, 16 de noviembre de 2020

EM Pharmacist key Articles

emDocs - November 16, 2020 - By Blake Porter
"Have you ever wondered what your emergency medicine (EM) pharmacist is referring to as you discuss a patient case? Well look no further. In 2018, fourteen EM pharmacists convened to update a previously published review of key articles and guidelines relevant for the EM clinical pharmacist (Thomas 2011, Acquisto 2020). This 52-page updated review systematically identifies and summarizes pertinent research studies and guidelines between 2011 and 2018 related to EM pharmacotherapy. The utility of these articles is not limited to the EM pharmacist; they are relevant to EM physicians, physician assistants, nurse practitioners, and other clinical staff. This review should also prove to be useful for those practicing within urgent care sites, prehospital medicine, and especially for students, residents, and new EM clinicians. In this Part 1, a selection of these key articles and the author takeaways are summarized below. A more detailed discussion is available in the full paper (Acquisto 2020). Part 2 will discuss pertinent guidelines..."

Idiopathic Intracranial Hypertension

First 10EM - By Kristine Laing - November 16, 2020
..."IIH is a condition of raised intracranial pressure with no known cause. IIH was previously known as pseudotumor cerebri or benign intracranial hypertension. If left untreated, IIH may lead to permanent vision loss and/or chronic debilitating headaches...
When do we need to think about this in the ED?
IIH is commonly missed because it is rare and the symptoms are non-specific. Given the rise in cases each year, we must consider IIH, especially when a young, overweight female patient presents with any of the above signs/symptoms. The primary driver of further investigation is going to be the identification of papilledema, as papilledema is a major sign of raised intracranial pressure.
Bottom line for the ER
  • If vision is impaired, stat referral to neurosurgery
  • Treat headache with your usual medications
  • Urgent referral to both Ophthalmology and Neurology
  • Rule out life-threatening causes of papilloedema / raised ICP"

domingo, 15 de noviembre de 2020

Covid-19 Update

REBEL.EM - November 13, 2020 - By Salim Rezaie
"Background: There have been lots of trials sitting on my computer desktop awaiting my review, but like many of you time has been thin from clinical work and increasing cases of COVID-19 where I work. I thought it might be more effective to give you the Cliff’s Notes highlights of each since the time for deep dives remains elusive. As always, I urge you to read each of the papers yourselves and come to your own conclusions.
Thus far in the pandemic, there have been few treatment options available to manage COVID-19. Many clinicians have been using repurposed drugs with scant data as well as other non-drug interventions. Let’s get into some recent data behind these interventions.
WHO SOLIDARITY Interim Results [1]
Clinical Question: Does the use of remdesivir reduce mortality in hospitalized patients with COVID-19? (The authors also looked at hydroxychloroquine, lopinavir, and interferon-B1a in this trial, but we are going to focus on remdesivir only)
PLACID Trial [2]
Clinical Question: Is convalescent plasma + standard care more effective than standard care alone in moderate COVID-19?
HESACOVID [3]
Clinical Question: In patients with severe COVID-19 does therapeutic enoxaparin or standard anticoagulant thromboprophylaxis improve gas exchange over time?
COVID-19 Related Organ Dysfunction and Management Strategies Review [4]
Optimal organ support and adjunctive therapies for COVID-19 have not yet been well established by trial-based outcomes thus far. The authors of this paper did a review of relevant pathophysiology and management strategies for critically ill patients with COVID-19 based out of the UK. Of the 100s of papers I have read on COVID-19, this is one of the best reviews I have read to date."

jueves, 12 de noviembre de 2020

Antibiotics vs Appendectomy for Appendicitis

REBEL Cast Ep 89 - November 12, 2020 - By Salim Rezaie
"Background: The well-established, standard treatment for acute appendicitis is surgical appendectomy. However, recent research has challenged the dominance of the surgical approach in looking at antibiotics alone. The available literature on non-operative treatment of appendicitis (NOTA) has important limitations: exclusion of patients with appendicoliths, small sample size and predominance of open appendectomy over laparoscopic appendectomy. While data on NOTA is intriguing, it is clear that additional studies are needed.
Paper: The CODA Collaborative. A Randomized Trial Comparing Antibiotics with Appendectomy for Appendicitis. NEJM 2020. PMID: 33017106
Clinical Question: In adult patients, are antibiotics noninferior to surgery for the treatment of acute appendicitis?
Author Conclusion: “For the treatment of appendicitis, antibiotics were noninferior to appendectomy on the basis of results of a standard health-status measure. In the antibiotics group, nearly 3 in 10 participants had undergone appendectomy by 90 days. Participants with an appendicolith were at a higher risk for appendectomy and for complications than those without an appendicolith.”
Clinical Take Home Point: Although an antibiotic 1st strategy was non-inferior in this trial compared to appendectomy, nearly 3 in 10 patients had undergone appendectomy by 90 days, there were 3x more ED visits, and 2x more complications (This could be balanced with less days of missed work). Patients with an appendicolith are at a much higher risk of complications and need for surgery and in these patients an antibiotic 1st strategy should not be recommended."

Liver Emergencies

Emergency Medicine Cases: Ep 148 - November 10, 2020 By Anton Helman 
...In this podcast on liver emergencies and acute liver failure we answer questions such as: What are the most important causes of acute liver failure that we need to identify in the ED so we can initiate timely treatment? What are some of the common medications we use in the ED that we should avoid in the liver patient? How should we approach the interpretation of liver enzymes and liver function tests? What are the key management steps in treating acute liver and hepatorenal syndrome? Why do liver failure patients become hypoglycemic and how should hypoglycemia in these patients be treated in the ED? How do we diagnose hepatorenal syndrome in the ED? How can the MELD score help us manage liver patients? What are the indications for IV albumin? What is the role of an ammonia level in the diagnosis of hepatic encephalopathy? Is polyethylene glycol a better alternative to lactulose for treating hepatic encephalopathy? and much more…"

miércoles, 11 de noviembre de 2020

Push Th(d)ose Vasopressors

iEM - November 11, 2020 - By Neha Hudlikar
"Since Scott Weingart first advocated for using push-dose pressors in the Emergency Department (ED) over a decade ago(1), push-dose vasopressors, also known as bolus-dose vasopressors have seemingly found their way into many EDs. However, recent studies have sought to ask more questions regarding its use and safety in the Emergency Department...
Conclusion
While the practice of using push-dose pressors has found its way into the Emergency Department, it is crucial to acknowledge that evidence regarding its safety and benefits is limited. However, rather than disregarding the practice, high-quality research should be encouraged, which could potentially be practice-changing. Holden et al. offer a framework of operational and safety considerations for the use of push-dose pressors in the ED and is a must-read for all using push-dose pressors in their current practice."

lunes, 9 de noviembre de 2020

Sodium Bicarbonate in Cardiac Arrest

R.E.B.E.L EM - November 09, 2020 - By Muhammad Durrani
Paper: Wu KH et al. Effectiveness of Sodium Bicarbonate Administration on Mortality in Cardiac Arrest Patients: A Systematic Review and Meta-analysis. J Emerg Med. 2020. PMID: 32978028
"Clinical Question: In adult patients with non-traumatic cardiac arrest, does the administration of sodium bicarbonate improve return of spontaneous circulation (ROSC) and survival to discharge rates?
Clinical Take Home Point:
In this systematic review and meta-analysis, the use of Sodium Bicarbonate in cardiac arrest was not associated with improvements in the rates of ROSC or Survival to Discharge. The findings need to be interpreted in the context of inadequate number of included studies, poor statistical quality with high heterogeneity, and risk of bias/confounders. This is however, an important study that is attempting to clarify the evidence based nature of a routinely used medication during cardiac arrest, and hopefully will serve as a jumping off point for further research into identifying the role of Sodium Bicarbonate in cardiac arrest with special attention to patient oriented outcomes.
The bottom line is that the scales are being tipped towards refuting the use of sodium bicarbonate in cardiac arrest at this time and this is supported by ACLS guidelines except in special circumstances."

domingo, 8 de noviembre de 2020

Extremity Compartment Syndrome

emDocs - By Kim Dennis - November 06, 2020 
Originally posted on Trauma ICU Rounds on October 10, 2020
"What are the 5 or 6 Ps? If you answered Pain, Pain, Pain, Pain, Pain, and Pain, you can go right ahead and skip this episode. Extremity compartment syndrome is an acute surgical emergency and requires a HIGH index of suspicion in order to make the diagnosis. Therapy consists of fasciotomy. If left untreated, numerous complications and sequelae may develop including AKI and even death...
Take Home Points
  • Extremity compartment syndrome is an acute surgical emergency that required a HIGH INDEX OF SUSPICION
  • Although commonly associated with fractures (especially, tib-fib and distal forearm), up to 1/3 of patients have NO LONG BONE FRACTURE
  • Pain out of proportion or on passive stretching of a muscle group and paresthesias are the first signs of extremity compartment syndrome
  • Physical exam, specifically, feeling for the tenseness of a compartment is UNRELIABLE
  • In the leg, the ANTERIOR and DEEP POSTERIOR compartments are the most frequently missed!
  • If you suspect it, DO SOMETHING = either a compartment pressure check OR fasciotomy"

miércoles, 4 de noviembre de 2020

Dental Infections

TAMING THE SRU
Taming The SRU - By Max Kletsel - November 03, 2020 
..."Overall, although our mouths are rich in microorganisms, the irreversible inflammation of the pulp in the setting of a progress dental cavity is considered to be an inflammatory process to the oral environment, rather than an infectious one. Regardless, antibiotics continue to be prescribed for patients presenting with such symptoms, despite little evidence of their efficacy. In 2000, Nagle et al. established a randomized, double-blinded placebo-controlled study to see if oral penicillin versus placebo helps improve pain over a 7-day period in patients presenting with symptoms of irreversible pulpitis. In this study, a total of 40 adult patients were randomly assigned to either receive penicillin VK (500mg QID) or a placebo control, and were asked to keep a daily diary for tracking their symptoms, as well as number of pain medications taken. After a 7-day period, there was no significant difference in pain ratings or need for pain-relief medications between the two groups.
Evidence such as the study listed above shaped the 2019 recommendations from the American Dental Association, who strongly recommended against prescribing antibiotics for otherwise healthy adults presenting with signs of irreversible pulpitis. So as you head back from the exam room of the patient complaining of tooth pain only with cold, sweet drinks, ask yourself if you really need to place an order for an outpatient antibiotic..."

lunes, 2 de noviembre de 2020

The Triple F UTI algorithm

PLOS ONE
Rothe K, Spinner CD, Waschulzik B, Janke C, Schneider J, Schneider H, et al. (2020) PLoS ONE 15(10): e0240981. https://doi.org/10.1371/journal.pone.0240981
For acute medicine physicians, distinguishing between asymptomatic bacteriuria (ABU) and clinically relevant urinary tract infections (UTI) is challenging, resulting in overtreatment of ABU and under-recognition of urinary-source bacteraemia without genitourinary symptoms (USB). We conducted a retrospective analysis of ED encounters in a university hospital between October 2013 and September 2018 who met the following inclusion criteria: Suspected UTI with simultaneous collection of paired urinary cultures and blood cultures (PUB) and determination of Procalcitonin (PCT). We sought to develop a simple algorithm based on clinical signs and PCT for the management of suspected UTI..."

Emerging Tick-Borne Illnesses

R.E.B.E.L.EM - November 02, 2020 - By Muhammad Durrani
"Tick-borne disease surveillance studies have shown increasing prevalence, transmission, and disease burden over the last decade. Tick-borne illnesses remain a public health threat and the true incidence remains unknown and is thought to be underrepresented. Although Lyme Disease is the most frequently reported tick-borne disease in the United States, the incidence of four other tick-borne diseases is noted to be increasing in the United States:
  1. Anaplasmosis (Nov 3rd, 2020)
  2. Ehrlichiosis (Nov 4th, 2020)
  3. Rocky Mountain Spotted Fever (Nov 5th, 2020)
  4. Babesiosis (Nov 6th, 2020)
In this five-part post, we will review the salient features of these other emerging tick-borne illnesses to increase recognition of these disease entities.
This overview will serve to lay a foundation and summarize shared features of tick-borne illnesses prior to diving into each specific disease..."

Neurolisteriosis

TamING THE SRU

Taming The SRU - November 02, 2020 - By Wolochatiul S
..."L. monocytogenes has well-described neuro-invasive potential, also known as neurolisteriosis, most commonly presenting as meningitis.  While L. monocytogenes accounts for only four percent of bacterial meningitis cases in patients aged two to 60, it is responsible for 25% of cases in patients younger than two and older than sixty years. Thus, both neonatal and elderly patients with a high clinical suspicion for meningitis are empirically treated for L. monocytogenes. Unlike meningitis, encephalitis is relatively rare; it is estimated that anywhere from 6-24% of patients with neurolisteriosis exhibit signs of encephalitis presenting as focal neurologic deficits or seizures...

domingo, 1 de noviembre de 2020

Buffered lidocaine

SGEM#307 - October 31, 2020 - By Admin
Reference: Vent et al. Buffered lidocaine 1%, epinephrine 1:100,000 with sodium bicarbonate (hydrogencarbonate) in a 3:1 ratio is less painful than a 9:1 ratio: A double-blind, randomized, placebo-controlled, crossover trial. JAAD (2020)
"CLINICAL QUESTION: 
DOES BUFFERING LIDOCAINE WITH SODIUM BICARBONATE MAKE LOCAL ANESTHETIC LESS PAINFUL?
Authors’ Conclusions: 
“Lido/Epi-NaHCO3 mixtures effectively reduce burning pain during infiltration. The 3:1 mixing ratio is significantly less painful than the 9:1 ratio. Reported findings are of high practical relevance given the extensive use of local anesthesia today.”
SGEM BOTTOM LINE: 
CONSIDER BUFFERING YOUR LIDOCAINE WITH A 3:1 SODIUM BICARBONATE MIXTURE TO DECREASE THE DISCOMFORT OF LOCAL ANESTHETIC INFILTRATION.

sábado, 31 de octubre de 2020

Early plasma in TBI

St. Emlyn´s - By Simon Carley - October 30, 2020
...CRASH 3 was one of the standout papers of the year. It showed that TXA was likely most effective in the group of patients in whom further bleeding (and thus its prevention) was likely. The principle of managing the secondary brain injury by reducing the amount of bleeding from cerebral contusions and blood collections certainly makes pathophysiological sense, with TXA affecting fibrinolysis, but what of other aspects of the clotting mechanism?
Back in 2018 the PAMPER trial reported on the outcome of a prehospital randomised controlled trial of early plasma use in trauma patients. We reviewed the paper on St Emlyn’s here. In brief this was an RCT of 501 patients in whom a 10% benefit in terms of mortality was found. This is a remarkable effect which certainly raised some skeptical eyebrows, but there are plausible reasons why it might be true.
This month we have a secondary analysis of the PAMPER trial with a particular focus on those patients with traumatic brain injury. The abstract is below, but as always we strongly recommend that you read the full paper..."

martes, 27 de octubre de 2020

Abdominal Cutaneous Nerve Entrapment Syndrome

CanadiEm - By Alex Senger - October 27, 2020
"In this article, we will dive into the world of abdominal wall pain – specifically from a condition called Abdominal Cutaneous Nerve Entrapment Syndrome (ACNES) – a diagnosis rarely considered when seeing patients with abdominal pain in the ED...
ACNES has an absolute prevalence estimated at 1/1800 adults​1​ and an unknown prevalence in children.​​ One retrospective study found that 2% of patients presenting with abdominal pain to the ED were eventually diagnosed with ACNES.​​ Other studies show that the prevalence of ACNES or other abdominal wall pain syndromes was 10-30% after patients had a negative diagnostic workup to exclude other causes.​Despite this, ACNES is poorly understood and rarely diagnosed.​.."

Finger on the Pulse?

St. Emlyn´s - By Natalie May - October 26, 2020
"If you’re an avid follower of FOAM, you’ll have seen many assertions that manual pulse checks by healthcare providers during cardiac arrest are pretty unreliable at best.
The most commonly advocated alternatives are EtCO2 increase suggesting perfusion (quick and easy but not particularly sensitive), arterial line waveform assessment (an inevitable intervention once you do achieve ROSC and useful for guiding more nuanced adrenaline dosing, but not always easy to achieve during arrest itself) and various uses of point-of-care-ultrasound (POCUS). It’s the use of POCUS to determine the presence of carotid pulsation (rather than cardiac motion) that has been investigated in this paper published in Resuscitation and written by some of my colleagues out here in Sydney..."

domingo, 25 de octubre de 2020

2020 AHA: RCP y ACE

"En estos aspectos destacados, se resumen los temas y cambios clave realizados en las Guías para reanimación cardiopulmonar (RCP) y atención cardiovascular de emergencia (ACE) de la American Heart Association (AHA) del 2020. Las Guías del 2020 son una revisión completa de las guías de la AHA para los temas relacionados con el soporte vital de adultos, niños y neonatos, la ciencia de la educación para la reanimación y los sistemas de atención sanitaria. Se han desarrollado con el objetivo de que los profesionales encargados de la reanimación y los instructores de la AHA se centren en la ciencia de la reanimación y en las recomendaciones más importantes o controvertidas de las guías, o aquellas que sean susceptibles de modificar la práctica o el entrenamiento de la reanimación, y para brindar los fundamentos que sustentan las recomendaciones. Dado que esta publicación pretende ser un resumen, no se hace referencia a los estudios publicados en los que se basa, y tampoco se incluyen las clasificaciones de recomendaciones (CDR) ni los niveles de evidencia (NDE)..."

miércoles, 21 de octubre de 2020

Adrenalina y antiarritmicos en la PCR

Urgencias y Emergencias - Por Plaza Elena - Julio 02, 2020
¿Cuándo ponemos la adrenalina en la RCP? ¿Tras la segunda descarga? ¿Tras la tercera? ¿Por qué? ¿Y la amiodarona? En este post intento responder a estas preguntas. Vamos a revisar cuándo administrar los antiarrítmicos y la adrenalina en una RCP según las recomendaciones de la AHA, la Asociación Americana del corazón.
Contenidos
  1. Contenido de Adrenalina y antiarrítmicos en la RCP
  2. Introducción de Adrenalina y antiarrítmicos en la RCP
  3. Adrenalina
    1. Adrenalina en ritmos NO desfibrilables (AESP y asistolia)
    2. Adrenalina en ritmos desfibrilables (FV y TV sin pulso)
  4. Antiarrítmicos: amiodarona y lidocaína

martes, 20 de octubre de 2020

Unstable AF & Ablation Complications

emDOCs Podcast – Episode 14 - October 20, 2020 - By Long B & singh M
"Today on the emDocs cast with Brit Long and Manpreet Singh we cover two posts: unstable atrial fibrillation patient and cardiac ablation complications.
  • Key Points from the Podcast and Post (Part 1: Unstable Atrial Fibrillation)
    • Don’t prematurely assume that the hypotension in your patient with a-fib is due to the arrhythmia. Do a thorough evaluation for other causes of shock before lowering the rate.
    • When cardioverting your unstable patient with a-fib, do it right the first time; start out at 200J and consider adding external pressure to the anterior pad.
    • Use push dose vasopressors or a drip to stabilize the BP before trying to control the rate.
    • Consider Amiodarone or Esmolol as the drug of choice for rate control in the crashing patient with a-fib.
  • Key Points from the Podcast and Post (Part 2: Cardiac Ablation Complications)
    • 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.
    • Stroke due to thromboembolic event.
    • Atypical migraine is a rare post ablation complication and should be considered a diagnosis of exclusion."

lunes, 19 de octubre de 2020

Cerebral Venous Thrombosis

First10EM - By Justin Morgenstern - October 19, 2020
"In the Rapid Review series, I briefly review the key points of a clinical review paper (or two). The topic this time: Cerebral venous thrombosis (CVT)
The papers: 
  • Behrouzi R, Punter M. Diagnosis and management of cerebral venous thrombosis. Clin Med (Lond). 2018;18(1):75-79. doi:10.7861/clinmedicine.18-1-75 PMID: 29436443
  • Long B, Koyfman A, Runyon MS. Cerebral Venous Thrombosis: A Challenging Neurologic Diagnosis. Emerg Med Clin North Am. 2017;35(4):869-878. doi:10.1016/j.emc.2017.07.004 PMID: 28987433"


Puncture Wounds

emDocs - October 19, 2020 - By Kaur G, Katirji L 
Reviewed by: Sheng A; Koyfman A; Long B
"Pearls:
  1. Despite their benign initial appearance, puncture wounds should be taken seriously due to risk of infection and potential sequela such as osteomyelitis and deep soft tissue infections.
  2. Consideration of retained foreign bodies and thorough examination and imaging (ultrasound and/or plain films) are the keys to decreasing complications.
  3. Staphylococcus and Streptococcal species are the most common causes of infection. Pseudomonas is an important consideration in plantar puncture wounds and the most common cause of osteomyelitis.
  4. The majority of puncture wounds without retained foreign bodies will have a benign course. Prophylactic antibiotics, high-pressure irrigation, and debridement are unnecessary in most cases. Educate patients re: signs and symptoms to return for."

sábado, 17 de octubre de 2020

Solidarity trial for Covid-19 treatments

WHO - Posted on 16 October 2020
"Solidarity is an international clinical trial to help find an effective treatment for COVID-19, launched by the World Health Organization and partners. It is one of the largest international randomized trials for COVID-19 treatments, enrolling almost 12 000 patients in 500 hospital sites in over 30 countries...
The Solidarity Trial published interim results on 15 October 2020. It found that all 4 treatments evaluated (remdesivir, hydroxychloroquine, lopinavir/ritonavir and interferon) had little or no effect on overall mortality, initiation of ventilation and duration of hospital stay in hospitalized patients.
The Solidarity Trial is considering evaluating other treatments, to continue the search for effective COVID-19 therapeutics.
So far, only corticosteroids have been proven effective against severe and critical COVID-19.

CONCLUSIONS 
These Remdesivir, Hydroxychloroquine, Lopinavir and Interferon regimens appeared to have little or no effect on hospitalized COVID-19, as indicated by overall mortality, initiation of ventilation and duration of hospital stay. The mortality findings contain most of the randomized evidence on Remdesivir and Interferon, and are consistent with meta-analyses of mortality in all major trials. (Funding: WHO. Registration: ISRCTN83971151, NCT04315948)

Dexmedetomidine (Precedex)

EMCrit RACC
EMCrit 283 - October 16, 2020 - By Scott Weingart
"So this episode addresses a big gap in the EMCrit content, namely a discussion of the myriad uses of dexmedetomine. This is one of the primary agents I use for post-intubation sedation (PAD), but also for things like NIPPV sedation and procedural sedation..."

jueves, 15 de octubre de 2020

Resuscitative Thoracotomy

REBEL CRIT - October 15, 2020 - By Zaf Qasim
"Background: A resuscitative thoracotomy is a time-critical high acuity, low occurrence (HALO) procedure – as an emergency physician you need to know how to do it, but depending on your practice environment, it may be a once-in-a-career maneuver. All the more reason that, if you have to do it, you want to make sure your effort counts...
Paper: Newberry R et al. Prospective randomized trial of standard left anterolateral thoracotomy versus modified bilateral clamshell thoracotomy performed by emergency physicians. Annals of Emergency Medicine 2020. PMID: 32807537
Clinical Question: What is the optimal technique for the nonsurgical specialist to perform a resuscitative thoracotomy?
Author Conclusion: “Resuscitative thoracotomy success rates were lower than expected in this capable subject population. Success rates and procedural time for the MCT and LAT were similar. However, the MCT had a higher success rate when performed by staff emergency physicians, resulted in less periprocedural iatrogenic injuries, and was the preferred technique by most subjects. The MCT is a potentially feasible alternative resuscitative thoracotomy technique that requires further investigation.”
Clinical Take Home Point: When faced with a time-critical injury amenable to resuscitative thoracotomy, the emergency physician has precious little opportunity to make a difference in outcome. Therefore, they should adopt the technique that will most likely allow success. This paper shows that for this HALO procedure, the MCT allows timely access to the chest, provides the best exposure to attempt to fix the problem, and decreases the risk of iatrogenic injury. It should be strongly considered by the emergency physician having to perform this while working within the right system to support this procedure."

miércoles, 14 de octubre de 2020

Orbital Compartment Syndrome

REBEL Core Cast 42.0 - By Anand Swaminathan - October 14, 2020
"Take Home Points
  • Trauma resulting in a retrobulbar hemorrhage can lead to orbital compartment syndrome which is a vision threatening injury
  • Diagnosis is made clinically based on the presence of an afferent pupillary defect, vision loss and an intraocular pressure > 40 mm Hg
  • Treatment is with a lateral canthotomy – a simple but mentally daunting procedure"
Resources:

martes, 13 de octubre de 2020

VTE and COVID-19

ST.EMLYN´S
St. Emlyn´s - By Dan Horner - October 12, 2020
That’s a leading question. Of course you would...
And what should we be doing?
I think that’s still tricky. But we are in a better position than last time and I think we can use this new evidence to agree on some issues
  • First, it is clear (and has been for some time) that all patients admitted to hospital who are unwell with COVID-19 should undergo risk assessment for VTE and should receive pharmacological thromboprophylaxis if safe. If community hubs and ‘hospital at home’ services continue to expand, this assessment may need to be extended outside the front door. 
  • Second, in those patients who are prescribed thromboprophylaxis, weight-based dosing algorithms should be strongly considered. There appears to be no clinical evidence of superiority for intermediate dosing strategies over a standard, licensed weight-based approach. I would extend this logic to patients admitted to intensive care. 
  • Third, we should ensure these patients are managed in line with the emerging evidence base outside of anticoagulation. Immunomodulatory agents clearly have face validity in this cohort. Before we weigh up the merits of unproven dose escalations of anticoagulants that we know will cause predictable harm, we must ensure that hypoxaemic patients have received dexamethasone. In the future this will also apply to any other therapies that have been studied and proven effective within the context of large, well conducted randomised controlled trials. 
  • Fourth we must continue to offer research opportunity. All our patients have the right to participate in ongoing studies and potentially benefit from novel therapies..."

Screening per la TVP nel Covid-19

EMPills - Ottobre 12, 2020 - By Paolo Balzaretti
"Una delle caratteristiche più peculiari del COVID-19 è risultata fin da subito l’elevata incidenza di complicanze tromboemboliche e il relativo impatto sulla prognosi del paziente. Secondo alcune casistiche autoptiche, la tromboembolia polmonare è la causa del 10-30% dei decessi dei pazienti con polmonite COVD-19 correlata (Wichmann 2020, Edler 2020).
Questi dati portano a pensare che possa essere importante definire strategie di prevenzione della malattia tromboembolica venosa da associare alla profilassi eparinica, adottata universalmente. In particolare, uno screening per la presenza di trombosi venosa profonda (TVP) con ecografia compressiva potrebbe essere giustificato?
Conclusioni.
  • Nei pazienti ricoverati con Covid-19, la prevalenza di TVP asintomatica è verosimilmente più elevata che nei pazienti ricoverati con altre diagnosi.
  • Le TVP sono più frequentemente distali; per questo motivo, in caso si voglia adottare una strategia di screening basata sull’ecografia compressiva a 2 punti, è opportuno mettere in conto di effettuare controlli seriati a distanza di alcuni giorni, quanto meno nei pazienti a maggior rischio di complicanze.
  • A mia conoscenza, non esistono attualmente studi che confermino che uno screening della TVP asintomatica nel paziente con Covid-19 possa ridurre la mortalità."

Mammalian Bites

emDocs - October 12, 2020 - By Rizzo E and Zummer J
Reviewed by: Koyfman A; Long B; Santistevan J
"Pearls and Pitfalls
  • Clenched fist injuries (“fight bites”) are high risk injuries that require antibiotics and hand surgery consultation.
  • Augmentin is the oral antibiotic of choice for both prophylaxis and treatment of infected mammalian bites.
  • In the United States, bats are the most common cause of rabies while in other countries dogs cause most cases. Patients at risk, including children and intoxicated or mentally disabled adults found in the same room as a bat, should get both rabies immunoglobulin and vaccination.
  • HIV transmission from bites is very rare however if a patient has a significant wound to their hand after a bite from an HIV positive patient, especially one with a lot of bleeding in the mouth, PEP should be discussed."