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


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martes, 17 de septiembre de 2019

Anti-Coagulation after ICH

ThromboPhonia E02 - CanadiEM - September 16, 2019
Guests: Dr. Ashkan Shoamanesh and Dr. Sunjay Sharma


Wounds and Lacerations

emDocs - September 16, 2019 - By Bryant J and Thoppil J
Edited By: Montrief T; Koyfman A and Long B
"Take Home Points:
  • Evaluation of the wound begins with the history, continues with full exploration of the wound to assess the extent of repair needed, physical exam to assess structural integrity, and imaging as needed for foreign body/vascular injury.
  • Warming anesthetics to body temperature can reduce pain with injection.
  • LET jelly is another adjunct to avoid pain on injection.
  • Local infiltration of ketamine may be just as efficacious as other topical anesthetics.
  • Important considerations not to miss: open fracture, open joint, tendon injury, vascular injury, nerve injury, muscle injury, compartment syndrome.
  • Update tetanus prophylaxis if >5 years have passed since prior immunization.
  • Irrigation with potable tap water is just as effective as saline irrigation.
  • Antibiotics for higher risk patients (diabetes, poor circulation, HIV/AIDS, immunocompromised), with wounds in higher risk areas (axilla, perineum, hands, feet), and high-risk wounds (human bites anywhere, mammalian bites to hand).
  • If transferring a digit for reimplantation, do not place digit directly on ice! Wrap amputated digit in moist gauze and place in a plastic bag which then goes on ice."

Burn Blisters

First10EM - By Justin Morgenstern - September 16, 2019
..."There is a BestBET review on this topic from 2006, and the only paper they found that matched their search criteria was the paper by Swain. Their conclusion is “based on the current available evidence, blisters should, wherever possible, be left intact to reduce the risk of infection, but if anatomical position necessitates intervention for functional purposes, aspiration appears to result in less pain than deroofing.” (Shaw 2006)..."

sábado, 14 de septiembre de 2019

Vaping Associated Lung Disease

Vaping Associated Lung Disease title image
First 10EM - by Justin Morgenstern - September 11, 2019
"Unfortunately, although the popularity of smoking has been on the decline for decades, vaping is becoming extremely popular, especially among young patients. More than 20% of high-school students and about 5% of middle school students admit to using an e-cigarette in the past 30 days. (Cullen 2018) When compared to smoking – one of the most unhealthy activities known – if would not be surprising if vaping resulted in fewer adverse health effects, although the true effects will not be known until we have long term studies. However, “safer than cigarettes” is not the same as “safe”. When talking about smoking and vaping, we are usually focused on long term health outcomes. However, there has been a recent flood of case reports of young patients with significant lung disease after vaping. What is vaping associated lung disease and what do we need to know in the emergency department?..."

Other FOAMed Resources:
Internet Book of Critical Care: Vaping Associated Pulmonary Injury (VAPI)

Acute Pulmonary Embolism (ESC 2019)

ESC logo
Stavros V Konstantinides, Guy Meyer, Cecilia Becattini et al. 
European Heart Journal, ehz405 - https://doi.org/10.1093/eurheartj/ehz405
Published:  31 August 2019
..."This document follows the previous ESC Guidelines focusing on the clinical management of pulmonary embolism (PE), published in 2000, 2008, and 2014. Many recommendations have been retained or their validity has been reinforced; however, new data have extended or modified our knowledge in respect of the optimal diagnosis, assessment, and treatment of patients with PE. These new aspects have been integrated into previous knowledge to suggest optimal and—whenever possible—objectively validated management strategies for patients with suspected or confirmed PE. To limit the length of the printed text, additional information, tables, figures, and references are available as supplementary data on the ESC website (www.escardio.org)..."

Decompensated Liver Disease

St. Emlyn´s -  By Gareth Roberts - September 12, 2019
... Many people with chronic liver disease are asymptomatic. It takes a seriously cirrhosed liver to cause symptoms. If I’ve a patient with an incidental finding of deranged liver function tests in an otherwise well person, other than counselling about lifestyle changes I would refer these people back to primary care for investigation. The patients I’m worried about in the ED are those who have decompensated. They present with deteriorating liver function, jaundice, encephalopathy or renal dysfunction. There’s often a precipitant to the deterioration. GI bleeding (variceal and non-variceal), infection, alcohol and constipation are common but others such as acute portal vein thrombosis, and transformation to hepatocellular carcinoma need to be considered...

martes, 10 de septiembre de 2019

SVT Guidelines 2019

ESC logo
The Task Force for the management of patients with supraventricular tachycardia of the European Society of Cardiology (ESC): Developed in collaboration with the Association for European Paediatric and Congenital Cardiology (AEPC) 
Brugada J, Katritsis D, Arbelo E, et al. European Heart Journal, ehz467, https://doi.org/10.1093/eurheartj/ehz467 - Published: 31 August 2019

US for Vascular Access in Adults

Resultado de imagen de society hospital medicine
Published Online Only September 6, 2019. DOI: 10.12788/jhm.3287
..."The purpose of this position statement is to present evidence-based recommendations on the use of ultrasound guidance for the insertion of central and peripheral vascular access catheters in adult patients. This document presents consensus-based recommendations with supporting evidence for clinical outcomes, techniques, and training for the use of ultrasound guidance for vascular access. We have subdivided the recommendations on techniques for central venous access, peripheral venous access, and arterial access individually, as some providers may not perform all types of vascular access procedures..."

miércoles, 4 de septiembre de 2019

Abdominal Aortic Aneurysm

emDocs - September 3, 2019 - By Long D - Edited by Koyfman A and Long B
  • Consider symptomatic or ruptured AAA in any patient (especially elderly) with abdominal pain, flank pain, back pain, syncope, especially if he/she is presenting with hypotension.
  • The RUSH exam is key in any hypotensive patient and can rapidly diagnose AAA.
  • Resuscitation of rAAA includes 2 large bore IVs, early blood products, minimizing crystalloid, permissive hypotension, tranexamic acid, and delayed airway management.
  • As soon as a AAA or rAAA is diagnosed or suspected, vascular surgery consultation is recommended. Surgery is required for definitive management.
  • Permissive hypotension is maintaining BP as low as possible to maintain end organ perfusion in an attempt to preserve hemostasis.
  • Vascular surgery guidelines recommend a 90-minute time from first medical contact to definitive operative management for ruptured AAA, with a 30-minute time from first medical contact to transfer to a center with definitive management.
  • REBOA is a potential therapy to attempt in the crashing AAA patient, but should not be used if it delays time to the operating room for definitive management."

martes, 27 de agosto de 2019


emDocs - August 26, 2019 - By Pillai S and Desai S 
Edited by: Simon E; Koyfman A; Long B

"Key Points
  • 34% to 50% of patients who present to the ED with psychiatric complaints have a coexisting medical illness.
  • Situations that favor a substance-induced depressive disorder include: absence of depression history, absence of symptoms prior to substance exposure/intoxication /withdrawal, absence of persistent symptoms following substance use or abuse.
  • Seek out an underlying etiology for depression in patients presenting with: new-onset depression with psychotic features, recurrent depression not readily explained by the psycho-social stressors, or treatment-resistant depression.
  • Laboratory studies and imaging should be obtained if indicated by history and physical examination.
  • Antipsychotics or benzodiazepinesmay be administered to the distressed patient with psychotic features during the ED course.Initiation of outpatient anti-depressant therapy from the ED is not advised."

sábado, 24 de agosto de 2019

CRP and ATBs in COPD

R.E.B.E.L.EM - August 22, 2019 - By Salim Rezaie
"Author Conclusion: “CRP-guided prescribing of antibiotics for exacerbations of COPD in primary care clinics resulted in lower percentage of patients who reported antibiotic use and who received antibiotic prescriptions from clinicians, with no evidence of harm.”
Clinical Take Home Point: With an antibiotic prescription rate of almost 80% in the usual care group, just about any intervention that pushes antibiotic stewardship would make a difference in prescribing habits, and therefore there is no surprise that POC CRP reduced the number of antibiotic prescriptions in patients with acute COPD."

miércoles, 21 de agosto de 2019

Decompensated Hypothyroidism

REBEL Core Cast 16.0 - By Anand Swaminathan - August 21, 2019
"Take Home Points
  • Myxedema coma is severe, decompensated hypothyroidism with a very high mortality.
  • Classic features include: decreased mental status, hypothermia, hypotension, bradycardia, hyponatremia, hypoglycemia, and hypoventilation
  • Work up includes looking for and treating precipitating causes, most commonly infection as well as serum levels of TSH, T4 and cortisol
  • Treat for the possibility of adrenal insufficiency with stress dose steroids such as hydrocortisone 100 mg IV
  • The exact means of thyroid replacement is controversial. Definitely given 100-500 mcg levothyroxine and discuss the simultaneous administration of T3 with your endocrine and ICU teams"

Resuscitation Pressure in Polytrauma with TBI

Taming The SRU - August 19, 2019 - By Rath K., Gottula A
  • There is little data to help us in optimal blood pressure targets in patients with both TBI and systemic trauma with hemorrhagic shock, largely because these patients are excluded from the majority of studies. Given the significant evidence that permissive hypotension would be associated with worse TBI related outcomes, we would not recommend prehospital permissive hypotension in the subset of patients with blunt, severe TBI.
  • In the resuscitation of these patients, hypertonic saline offers great promise as a means to resuscitate patients in hemorrhagic shock, while also minimizing intracranial pressure. Mannitol is a less than ideal alternative until more definitive data is obtained on injuries, and the patient is hemodynamically stabilized.
  • Future directions on this topic should include high-quality, high-powered studies investigating the hypotensive strategies to include patients with severe traumatic brain injury with GCS 8 or lower.
  • Finally, a good neurologic exam to more sensitively assess for focal neurologic deficits and signs of intracranial hypertension can assist pre-hospital providers to better determine the likelihood of the presence or absence of traumatic brain injury."

domingo, 18 de agosto de 2019

Intraosseous Access

emDocs - August 15, 2019 - By Bloom J
Edited by: DeVivo A., Koyfman A., Long B and  Singh M
"Pearls and Pitfalls
  • Patients come in all shapes and sizes. If your patient has excessive subcutaneous or adipose tissue over your preferred site, you may have to choose an alternative site.
  • Position for success! Make sure the extremity or site is visible, angled advantageously, and supported. Use bedrolls/sheets or fellow personnel to assist you with this.
  • Avoid needlestick injuries! IO catheters and stylets/trocars are still sharps and can injure the proceduralist. Make sure your hand is not directly behind the insertion site, as a misplaced IO can bypass or completely penetrate the extremity and cause injury.
  • It is very easy to forget to secure an IO during a busy resuscitation. Although they don’t slip out as easily as an IV, an IO can fall out, and if it does replacement likely needs to be in a different extremity to avoid infiltration. Tape down your IO securely!
  • In a resuscitated patient, make sure that any IO access is clearly indicated and discussed with receiving providers during handoff. When receiving a resuscitated patient, examine carefully for the presence of an IO on the extremities or sternum.
  • Anecdotally the proximal humerus is favored by many practitioners because of its theoretical faster infusion rates and utility in cases of abdominopelvic or lower extremity compromise9,29. The proximal tibia is frequently easier to palpate and available in patients of all ages. You should feel comfortable inserting an IO in at least two different sites and should be familiar with all of them."

Imaging for Appendicitis in Pregnancy

Resultado de imagen de journalfeed
Journalfeed - August 16, 2019 - By Vivian Lei
..."In a pregnant patient presenting with abdominal pain and suspected appendicitis, an initial ultrasound should be performed to exclude obstetric causes for abdominal pain. MRI may be a reasonable next study if it is immediately accessible and radiologists with expertise in MRI interpretation are available. Otherwise, CT should be utilized..."

sábado, 17 de agosto de 2019


Resultado de imagen de journal feed
Journalfeed -  August 5, 2019 - By Clay Smith
..."Not the way to screen for this problem
This was a secondary analysis of ADviSED. Use of an aortic dissection detection risk score plus mediastinal enlargement on CXR had sensitivity of 67%, specificity 83%. The risk score plus any sign on CXR had sensitivity 69%, specificity 77%. For CXR alone, without the risk score, sensitivity was 54%, specificity 92% for mediastinal enlargement; sensitivity 60%, specificity 85% for any sign on CXR. Inter-rater agreement between radiologists for mediastinal enlargement was fair to moderate (k = 0.44). What this all means is that a CXR is a poor screening tool for acute aortic syndromes. If mediastinal enlargement or other signs are seen on CXR, this is concerning and needs further workup. If you suspect acute aortic syndrome, it’s best to just get a CTA."

Gestalt for ACS

Gestalt in ACS
First 10EM - By Justin Morgenstern - August 7, 2019
..."So how good is gestalt in the diagnosis of acute coronary syndrome? A lot of people are already talking about this paper. Honestly, I don’t find the results all that exciting. I think it basically tells us what we already knew. It shouldn’t change anyone’s practice. However, I worry that the headlines will be misinterpreted in ways that could ultimately harm our patients. So let’s take a quick look to ensure we all understand what this study really shows.
The paper
Oliver G, Reynard C, Morris N, Body R. Can emergency physician gestalt “rule in” or “rule out” acute coronary syndrome: validation in a multi-center prospective diagnostic cohort study. Academic emergency medicine. 2019; PMID: 31338902 [article]
Bottom line
Don’t believe the rumours you might hear. Clinical judgement is enough to rule out ACS for many patients in the emergency department. Just don’t contradict yourself and try to use gestalt to rule out ACS in patients where your gestalt is that ACS is a possibility. That would be silly."

Mass Casualty Incidents

Trauma System News
By Potter C - July 22, 2016 - Reviewed and updated in April 2018.
"Mass casualty incidents (MCIs) seem to strike at random. That is one reason why these incidents — particularly mass shootings — are so frightening. But while the timing and location of most MCIs are unpredictable, the way these events play out at the scene and the trauma center is not.
Longstanding research shows that no MCI is truly unique — whether it is a natural disaster such as an earthquake, hurricane, flood or tornado, or the result of human violence. At the receiving hospital, an MCI triggers a sequence of disruptions that follow a predictable pattern..."

jueves, 15 de agosto de 2019

Pregnancy-Adapted YEARS Algorithm for PE

R.E:B.E.L.EM - August 15, 2019 - By Anand Swaminathan
"Authors Conclusions: “Pulmonary embolism was safely ruled out by the pregnancy-adapted YEARS diagnostic algorithm across all trimesters of pregnancy. CT pulmonary angiography was avoided in 32 to 65% of patients.” 
Our Conclusions: Overall, we agree with the authors conclusions. The pregnancy-adapted YEARS algorithm safely ruled out PE in this cohort of patients with a small risk of VTE at 3 months if the patient was negative on initial visit. 
Potential to Impact Current Practice: External validation of this approach is needed but, application of the pregnancy-adapted YEARS algorithm has the potential to safely decrease CTPA use in pregnant women in whom the clinician has a concern for PE. 
Bottom Line: The Pregnancy-Adapted YEARS algorithm has both face validity and is pragmatic for clinical practice. However, before implementation of this algorithm into everyday practice, an external validation study would be warranted." 


PulmCrit (EMCrit)
August 15, 2019 - By Josh Farkas
"Magnesium might be the darling ion of critical care. It has an interesting array of therapeutic applications ranging from asthma to Torsade de Pointes to preeclampsia. This pair of chapters discusses the evaluation of both hypomagnesemia and hypermagnesemia."
  • IBCC chapter on hypomagnesemia is located here.
  • IBCC chapter on hypermagnesemia is located here.
  • The podcast & comments are below.
Follow us on iTunes

lunes, 12 de agosto de 2019

Septic Shock

PulmCrit (EMCrit)
August 8, 2019 - By Josh Farkas
"Septic shock is perhaps the defining illness of medical intensive care. As such it is an enormously broad and controversial topic. This chapter attempts to provide a unified and straight-forward approach. However, every physicians has a different approach to septic shock, so it's impossible to claim that this is the best approach.
There will doubtless be vigorous debate about this topic, so I encourage all to leave their questions and comments below. This chapter will be revised on an ongoing basis, so the current form might be most realistically viewed as an outline for future revisions (rather than a final word on the topic)."
  • The IBCC chapter is located here.
  • The podcast & comments are below.
  • Follow us on iTunes

Large pleural effusions

PulmCrit - August 12, 2019 - By Josh Farkas
"Summary The Bullet:
  • Large pleural effusions can generally be drained entirely (although the procedure should be stopped if the patient develops vague central chest discomfort).
  • Pleural manometry has not been shown to reduce discomfort or re-expansion pulmonary edema during large volume thoracentesis.
  • The rate of re-expansion pulmonary edema is low, even in large-volume thoracentesis (<1%). When it occurs, this can generally be treated with conservative measures (e.g. supplemental oxygen or noninvasive ventilation).
  • Using multiple small-volume thoracenteses to avoid large-volume thoracentesis is probably a misguided strategy. Multiple small-volume thoracenteses may cause an overall increase in the risk of procedural complications (due to increases in the risk of bleeding, infection, or lung laceration with multiple procedures)."

REstart or STop Antithrombotics

R.E.B.E:L.EM - August 12, 2019 - By Salim Rezaie 
"Author’s Conclusions: “These results exclude all but a very modest increase in the risk of recurrent intracerebral haemorrhage with antiplatelet therapy for patients on antithrombotic therapy for the prevention of occlusive vascular disease when they developed intracerebral haemorrhage. The risk of recurrent intracerebral haemorrhage is probably too small to exceed the established benefits of antiplatelet therapy for secondary prevention.”
Clinical Take Home Point: The established benefits of antiplatelet therapy likely outweigh what may be a small or non-existent increased risk of recurrent bleeding following ICH; however, it is unclear when is the optimal time to restart therapy."

Peritonsillar abscess drainage

ALiEM Logo
ALiEM - August 9th, 2019 - By Davis M and Alvarez A
"Dr. Michelle Lin and Dr. Demian Szyld have created great guides for the common and important emergency medicine procedure of draining a PTA (laryngoscope lighting and spinal needle for aspiration; ultrasound localization and spinal needle guard; avoiding awkward one-handed needle aspiration). This update reviews these tricks as well as some additional techniques for optimal success in draining a PTA, while avoiding the ultimate feared complication of puncturing the carotid artery."

Varicose Veins

emDocs - August 12, 2019 - Authors: Rusnack F and He C
Edited by: Simon E., Koyfman A & Long B
"Key Points
  • Varicose veins are common in the elderly. Risk factors include obesity, pregnancy, bleeding dyscrasias, prolonged standing, immobility, and cigarette smoking.
  • Complications associated with varicose veins include bleeding, DVT/PE, SVT, and venous ulceration.
  • Bleeding may be managed with direct pressure, pressure dressings, topical TXA, a figure-of-eight suture, and vascular surgery consultation.
  • Varicose veins are associated with DVT: US evaluation is warranted.
  • US may be utilized to evaluate the extent of SVT; proximity to the deep venous system may dictate systemic anticoagulation.
  • Both SVT and venous ulceration require evaluation for cellulitis."

jueves, 1 de agosto de 2019


July 26, 2019
EU Directive update
"On 16 January 2019 a European Commission Delegated Decision (EU) 2019/608 has amended Annex V to Directive 2005/36/EC of the European Parliament and of the Council as regards the evidence of formal qualifications and titles of training courses.
So far 16 European countries have recognised Emergency medicine as s specialty requiring a minimum training period of 5 years.
  • You can find here the text of the Decision."

Head Elevation during Intubation

R.E.B.E.L.EM - August 01, 2019 - By Bryant R
  • Pre-oxygenation and intubation in HOB elevated position makes physiologic sense.
  • Pre-oxygenating obese and non obese patients undergoing elective surgery in HOB elevated position can prolong the non patient oriented outcome of safe apnea duration by over 1 minute. This supports the physiologic plausibility of HOB elevation improving respiratory dynamics.
  • Intubating non trauma and non cardiac arrest patients in a pre-hospital setting in a HOB elevated position is associated with improved first pass success, improved glottic visualization, and a decrease in the presence of airway secretions during laryngoscopy.
  • ED studies show mixed results with one study showing improved first pass success without a difference in peri-intubation hypoxia or rates of post intubation pneumonia. A larger registry-based study showed no difference in first pass success, but a higher incidence of peri-intubation hypoxia in the HOB elevated group that may have been a sicker population.
  • In-hospital studies are split, with one showing a dramatic reduction in peri-intubation adverse events with HOB elevation, and another showing a reduction in first pass success that may be associated with ICU bed design.
  • Equipment / position issues may be overcome with deliberate practice and increased experience.
  • For ED patients requiring intubation HOB elevation makes physiologic sense and is supported by prehospital and ED studies. There is no evidence of harm in the ED setting."

PE and CT in Pregnancy

Blog de Medicina Intensiva

Pulmonary Embolism and Diagnostic CT in Pregnancy

Medicina Intensiva - July 31, 2019 - By Santana L
"Acute pulmonary embolism is a leading cause of maternal death in the Western world. But routine diagnostic use of CT pulmonary angiography or ventilation–perfusion scanning exposes both mother and fetus to radiation. Full study: https://nej.md/2ukleOC "

Furosemide in CHF

The Resuscitationist
The Resuscitationist - July 25, 2019 By Bowman J
..."In June of 2017 the REALITY AHF (Registry Focused on Very Early Presentation and Treatment in Emergency Department of Acute Heart Failure) trial results were published in the Journal of the American College of Cardiology. In short they found a survival benefit (2.3% vs 6% mortality) to giving Lasix in the first 60 minutes of arrival to the ED. That’s an NNT of just 27! Better than aspirin in chest pain (NNT 43). Dun Dun Duuuuuunnnn….. Interesting. Salim Rezaie of RebelEM has a great review of the stats of the article. Essentially, it’s a prospective Japanese article of 20 hospitals looking at ADHF and the survival association of time to treatment with Lasix, excluding prehospital administration of Lasix. This was a pretty big undertaking to set up this registry and end up with something like 1200 patients enrolled, apparently us not giving Lasix early as much as we used to really pissed those medicine docs off. Now really though this is a Japanese study so I don’t know what the climate of Japanese EM Lasix administration was, from this study it seems like they gave it more than I’ve seen here in the US in a while. And this is actually a pretty good study question to answer, before this study we didn’t have any prospective outcome data on the temporal association of Lasix administration. Now this data exists. And apparently we should’ve been giving Lasix in the first 60 minutes. So oops right? Not so fast..."

IV Thiamine

EM PharmD
EM PharmD - July 23, 2019 - By Singh R
..."Bottom Line
The data involving a large number of both IVP doses and patients without adverse reactions to thiamine IVP gathered from decades-old literature, new literature, and recent responses from practitioners around the USA strongly suggests that thiamine 100 mg IVP is reasonably safe, and 200 mg IVP may be considered safe, too. 
Even though publications are in the works, conducting more studies or sharing an MUE abstract is encouraged because people tend to like recent data. Moreover, maybe your hospital has already been doing IVP thiamine for years without issue and it’s not even on your radar, but I’m sure there is another hospital on the cusp to make a decision to change from IVPB to IVP that would benefit from your experience. Never underestimate the power of sharing knowledge, you can literally help change and improve practice."

lunes, 22 de julio de 2019

Framework on Quality and Safety in Emergency Medicine

Resultado de imagen de international federation emergency medicine
2nd Edition | Quality and Safety Special Interest Group | January 2019 
Document Editors: Kim Hansen, Melinda Truesdale,  Adrian Boyle,  Brian Holroyd,  Georgina Phillips,  Jonathan Benger,  Lucas Chartier,  Fiona Lecky,  Ellen Webb,  Samuel Vaillancourt,  Peter Cameron,  Grzegorz Waligora,  Lisa Kurland  
"On behalf of the IFEM Quality and Safety Special Interest Group. 
"The original “Quality Framework” document arose from the sessions and discussions that took place at the International Federation for Emergency Medicine (IFEM) Symposium for Quality and Safety in Emergency Care, hosted by the College of Emergency Medicine (CEM) in the UK in 2011. It was presented and further refined at the 14th International Conference on Emergency Medicine in 2012. After feedback and review, an updated 2nd edition was developed in 2018 by the IFEM Quality and Safety Special Interest Group and associated editors. We would like to acknowledge the editors of the 2012 Framework for Quality and Safety in the Emergency Department: Fiona Lecky, Suzanne Walsh, Jonathan Benger, Peter Cameron, Chris Walsh"

sábado, 20 de julio de 2019

Cannabinoid Hyperemesis Syndrome

EM Pharma D
EM Pharma D - July 19, 2019 - By Evan Mulvihill
"Cannabinoid Hyperemesis Syndrome (CHS) is a sequela of long-term heavy cannabis use that involves cyclic bouts of nausea, vomiting, and diffuse abdominal pain. The treatment of CHS is unique in that your traditional anti-emetics and GI cocktails like Zofran, metoclopramide, and acid reducers, are fairly ineffective in controlling symptoms. CHS patients often receive extensive gastrointestinal (GI) work-ups in the ED, and may even be admitted when there are much simpler treatments to attempt first..."

Hyperthermia & heat stroke

PulmCrit (EMCrit)
PulmCrit (EMCrit) - July 19, 2019 - By Josh Farkas 
"Since it looks like the United States is about to go into total meltdown from a heat wave, I dusted off the hyperthermia chapter. This is a bit of an impromptu post, so we don't have a podcast to go along with it (we will record one eventually – Adam has more experience with the ice tarp taco than I do). So stick some bags of lactated ringers in the refrigerator, get your ice buckets ready, and, well, good luck."
  • The IBCC chapter is located here

jueves, 18 de julio de 2019

Drugs That Work and Drugs That Don’t

EM Cases - June 18, 2019 - By Helman A
"This is EM Cases Episode 126 Emergency Drugs that Work and Drugs that Don’t Part 1 – Analgesics with Dr. Joel Lexchin and Dr. Justin Morgenstern. In this podcast we discuss the key concepts in assessing drug efficacy trials, and provide you with a bottom line recommendation for the use of gabapentinoids, NSAIDs and acetaminophen for low back pain and radicular symptoms, topical NSAIDs and cyclobenzaprine for sprains and strains, caffeine as an adjunct analgesic, why we should never prescribe tramadol, dexamethasone for pharyngitis, calcium channel blockers for hemorrhoids and anal fissures, buscopan for abdominal pain and renal colic and why morphine might be a better analgesic choice than hydromorphone…"
EM Cases - July 02, 2019 - By Heiman A
"In this Episode 127 Drugs that Work and Drugs that Don't Part 2 - Antiemetics, Angioedema and Oxygen, with Justin Morgenstern and Joel Lexchin we discuss the evidence for various antiemetics like metoclopramide, prochlorperazine, promethazine, droperidol, ondansetron, inhaled isopropyl alcohol and haloperidol as well as why should not use an antiemetic routinely with morphine in the ED. We then discuss the evidence for various drugs options for a potpourri of true emergencies like angioedema and hyperkalemia, and wrap it up with a discussion on oxygen therapy..."

The Overdosed Patient

emDocs - July 15, 2019 - Author: Dazhe J
Edited by: Santos C; Koyfman A  and Long B
"...Summary – Key Take Home Points:
  1. Avoid premature closure by verifying through history and exam that the patient’s presentation is consistent with what the reported ingestion was.
  2. A thorough toxicology history with relevant social history elements take time, but learn to start incorporating some of these questions if diagnostic uncertainty is present – i.e. ask if pets are also sick at home.
  3. Manage and stabilize patients as you would any critically ill patient with attention to ABCs and supportive care. Add in considerations of antidote, decontamination, and enhanced elimination based on suspected exposure.
  4. Know your toxicology resources listed above and call your local poison center or medical toxicologist for clinical assistance."