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SOBRE EL AUTOR **

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

WORLD EMERGENCY MEDICINE SOCIETIES & RELATED

EMERGENCY MEDICINE DAY: May 27

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martes, 21 de mayo de 2019

Beta-lactam allergies

PulmCrit (EMCrit)
PulmCrit - May 20, 2019 - By Josh Farkas
"Background
Kimberly Blumenthal and colleagues at the Massachusetts General Hospital have been performing groundbreaking work on beta-lactam allergies. Their work forms the foundation for much of the IBCC chapter on beta-lactam allergies (you might want to read it before this post, but if you don't have time, a one-minute synopsis is below).
One fundamental technique when approaching patients with possible beta-lactam allergy is a “graded challenge” or “test dose.” This may be used when there is some suspicion of a potential allergy. A small dose is provided initially with close supervision, to determine if the patient will react. If this is tolerated, larger doses are subsequently given. 
Historically, there has been little evidence to guide the safety and performance of this strategy. A new publication by the Blumenthal group describes their experience with this...
Summary: The Bullet
  • A test-dose strategy can be used in situations where an allergy is unlikely (yet possible), to help determine the safety of providing a full dose of antibiotic.
  • This is the largest study to validate any specific protocol for challenging patients with possible antibiotic allergy.
  • Within the context of a structured protocol, the test-dose strategy was safe and effective (even without the assistance of an allergist and outside of an ICU).
  • Administration of an advanced-generation cephalosporin using a test dose seems to be safe, even in patients with anaphylaxis to a penicillin."

lunes, 20 de mayo de 2019

Complications of ERCP

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EMdOCS - mAY 20, 2019 - Authors: Montrief t and Boin n
Edited by Koyfman a and Long B
"...Take Home Points:
  • The most common post-ERCP complication is acute pancreatitis, followed by gastrointestinal bleeding, viscous perforation, and biliary tract infections.
  • Risk factors for post-ERCP complications include patient factors (aberrant anatomy, renal failure, presence of coagulopathy), provider factors (experience and appropriate endoscope disinfection), and procedure factors (multiple cannulation attempts, contrast injection, intraoperative gallbladder opacification).
  • A transient increase in serum pancreatic enzymes is common following ERCP, found in up to 75% of patients.
  • When evaluating a post-ERCP viscous perforation, the amount of intraperitoneal air does not correlate with the severity of the perforation, but rather reflects the degree of endoscopic insufflation after the perforation occurred.
  • Up to 29% of asymptomatic patients have evidence of retroperitoneal air on CT scan performed 24 hours after ERCP.
  • Most post-ERCP gastrointestinal bleeding is mild, however, severe intra-abdominal hemorrhage can occur.
  • Post-ERCP biliary infections are typically unimicrobial; the most common organisms implicated are Enterobacteriaceae (Escherichia coli and Klebsiella species), Staphylococcus epidermidis, alpha hemolytic streptococci, Enterococcus, and Pseudomonas aeruginosa."

AFib: Wait-and-See or Early Cardioversion

R.E.B.E.L.EM - May 20, 2019 - By Tarlan Hedayati
..."Author Conclusion: 
“In patients presenting to the emergency department with recent-onset, symptomatic atrial fibrillation, a wait-and-see approach was noninferior to early cardioversion in achieving a return to sinus rhythm at 4 weeks.”
Clinical Take Home Point:
Most patients with AF will convert spontaneously to sinus rhythm and, in the absence of hemodynamic compromise, there is no need to rush for rhythm control in the ED. It is difficult to predict which specific patients will convert spontaneously and over what period of time. Providers need to assess severity and duration of symptoms, access to follow-up, risks for CVA, and available anticoagulation strategies, amongst other factors, in the management of patients with AF. Based on this study, a delayed conversion strategy for a specific group of AF patients demonstrates similar rates of sinus rhythm at 4 weeks with no difference in potential risks or patient-reported quality of life as compared to an early cardioversion strategy."

domingo, 19 de mayo de 2019

Lights and Sirens

MEDEST - April 16, 2019
"For who has a multiyear experience in prehospital emergency medicine and deals everyday with emergency transportation of critical patients the sensation is that the use of emergency warning systems are, mostly of times, useless and doesn’t really have any impact on clinical outcomes...
Lights-and-Sirens-Graphic-Red-Ambo
Take home messages for our system and for clinical practice
  • Maybe we need lights and sirens in response phase, cause slightly increase in accident risk corresponds to some gain in arriving time on the scene.
  • Maybe we don’t need lights and sirens in transportation phase cause a great increase in risk of crash do not correspond to a clinical sensitive time gain."

Chest compressions in traumatic cardiac arrest

St. Emlyn´s - Simon Carley - May 19, 2019 
"This is a question that we’ve addressed on the blog before and the evidence has been a little conflicting. From a pathophysiological perspective the logic of using closed chest compressions in a patient who has no circulating volume is clearly pointless. In order for CCC to work, then the patient has to have an intravascular volume to pump around the circulation. However, that’s just a pathophysiological argument and to date there has been little evidence to support it. 
This week there is a paper published which, although an experimental model in pigs, might help enlighten the debate​. 
I actually saw this data at a recent conference but it was (rightly) embargoed and so it’s great to see it in e-print format. The abstract is below, but as always please read the paper yourself and make your own mind up.... 
The bottom line 
If you think that your patient is in hypovolaemic traumatic cardiac arrest then CCC is unlikely to be helpful and may be harmful (but exclude other causes before you abandon them)."

The At-Risk” Applicants’ Emergency Medicine

Cordemblog - May 03, 2019
Authors: Liza Smith, MD; Emily Hillman, MD; Jamie Hess, MD; Seth Kelly, MD; Katelyn Harris, MD; Alexis Pelletier-Bui, MD; and Adam Kellogg, MD on behalf of the CORD Advising Students Committee in EM (ASC-EM)
This applying guide is intended for students interested in applying to emergency medicine (EM) but who have had academic struggles, professionalism concerns, or other potential red flags that may affect their ability to match. 
A printable version of this guide can be found here.

viernes, 17 de mayo de 2019

Cardiovert AF in the ED

St Emlyn’s - By Simon Carley - May 11, 2019
"If I develop AF then I reckon I’d be able to spot it pretty quick, and I’d get myself down to ED pronto so that I could get myself cardioverted having read the excellent work of Stiell et al​1​. Why? Well I quite like to do cardioversions and so it would be nice to give someone else the opportunity, but more than that, it’s because I think it’s a good idea. But is it?
My belief is that the risks of cardioversion are low, and that the risks of complications are higher if we wait to get it done. In other words my ‘belief’ is that earlier is better, but in truth that may not be the case. The data that’s out there suggests that cardioversion is low risk up until 48 hours​2​ and so what’s the rush? Perhaps it’s because of this thought…..
The bottom line
  • In patients who present to the ED within 48 hours there is probably no panic to cardiovert the patient. It’s fine to delay DC cardioversion to try a period of either rate control, or (as we will continue to do) an attempt to pharmacologically cardiovert them.
  • If you want to go straight for a DC cardioversion then that’s probably also fine, but just make sure you balance the risks of the procedure against time, space and convenience."

Speckle Tracking for ACS

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emDocs - May 17, 2019 - By Prats M - Originally published on Ultrasound G.E.L. on 11/26/18 - Visit HERE to listen to accompanying PODCAST


"...Take Home Points
  1. Speckle tracking echocardiography is not ready for prime time in the ED. It was not very sensitive or specific for the diagnosis of acute coronary syndrome in this small retrospective study.
  2. More work needs to be done to see how this modality could help with the diagnosis of acute coronary syndrome and other cardiac pathology in the acute care setting."

PreVent

The Bottom Line - 17 May 2019 - By Daniel Lane
Ref. Bag-Mask Ventilation during Tracheal Intubation of Critically Ill Adults. Casey J. NEJM 2019; 380:811-821 DOI: 10.1056/NEJMoa1812405
"Clinical Question
In adult ICU patients undergoing tracheal intubation, does bag mask ventilation (BMV) between induction and laryngoscopy reduce the risk of hypoxaemia?...
The Bottom Line
  • Within the methodological limitations of this study, bag-mask ventilation (BMV) appears to be a reasonable intervention to prevent hypoxia
  • This study is inadequately powered to determine whether aspiration risk is increased with BMV. Moreover, there are a multitude of cofounders (mask seal, ventilatory volumes and pressure and gastric stasis) which may influence this
  • Mask ventilation (with cricoid pressure) is recommended by the Difficult Airway Society especially when the patient has poor respiratory reserve, sepsis, or high metabolic requirements. It also provides an early indication of the ease of ventilation"

jueves, 16 de mayo de 2019

Dissociated Awake Intubation

EMCrit RACC
EMCrit Podcast 247 - May 16, 2019 - By Scott Weingart
..."What is Dissociated Awake Intubation?
I coined this term to describe the administration of a dissociating dose of ketamine to allow a patient to be intubated for many of the same circumstances as the traditional topical awake approach.
This is theoretically distinct from the idea of using ketamine in a sedative-only intubation. The two ideas are separated by the intent, with the former subbing for a topical awake and the latter for a RSI, in systems where for whatever reason, paralytic can be used. In practice, they look the same–it is often the users that look different. 
Kovacs has used the term ketamine facilitated intubation to encompass both uses. This post and podcast only deal with dissociated awake..."


Essentials of EM 2019

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The REBEL at Essentials of Emergency Medicine 2019 
R.E.B.E.L.EM - By Salim Rezaie - May 14, 15, 16 2019 
"Essentials of Emergency Medicine 2019 is taking place at the Cosmopolitan Hotel/Casino in Las Vegas, NV. I was asked to give five lectures on varying topics and wanted to share what I discussed at each of these sessions. If you haven’t been to Essentials of Emergency Medicine, you need to add this conference to your list of conferences to attend. The organizers pride themselves in discussing the latest practice-changing research and have meticulously designed content to maximize enjoyment and retention. In my humble opinion this conference is the quintessential medutainment extravaganza that applies learning theory principles, with amazing speakers, to provide you with the latest and greatest for clinical practice."

Rhabdomyolysis

PulmCrit (EMCrit)

IBCC chapter & cast - May 16, 2019 - By Josh Farkas 
"Before writing this chapter I though I understood rhabdomyolysis fairly well. I had treated many cases, read about it in a few books, and heard a lecture or two on it. However, writing this chapter has forced me to realize that I didn't really understand rhabdo well at all. This disease is generally poorly understood, with almost no high-quality evidence available. Most of the conventional teaching on rhabdomyolysis is based on assumptions and dogma. This chapter attempts to make sense of the topic, but many questions remain." 
  • The IBCC chapter is located here

miércoles, 15 de mayo de 2019

Epiglottitis

REBEL Core Cast 11.0 – By Swaminathan A - May 15, 2019
..."Take Home Points on Epiglottitis
  • Epiglottitis has demonstrated a resurgence in the adult population. It is no longer a pediatric only disease.
  • The classic presentation of epiglottitis (3Ds of drooling, dysphagia and distress) is uncommon
  • Epiglottitis should be high on your differential for the bounce-back patient who continues to complain of worsening sore throat
  • Definitive diagnosis is made by flexible fiberoptic laryngoscopy
  • Be ready for a difficult airway"

Risk of reversing anticoagulation

CanadiEM
CanadiEM - May 14, 2019 - By Andrew Shih
"...Main Messages
  • The main risk of reversing anticoagulant is typically thrombosis, where much of the risk is due to the underlying prothrombotic state rather than the reversal agent itself
  • Thrombosis risks in different meta-analyses for warfarin reversal with PCCs +/- vitamin K are reported to be < 5%
  • The thrombosis risk after use of TXA is likely minimal, though most studies assessing its use in bleeding excluded patients with risk factors for thrombosis"
All the content from the Blood & Clots series can be found here.

lunes, 13 de mayo de 2019

The COACT Trial

REBEL Cast Episode 66 - Written by Salim Rezaie - May 13, 2019
Author Conclusion: “Among patients who had been successfully resuscitated after out-of-hospital cardiac arrest and had no signs of STEMI, a strategy of immediate angiography was not found to be better than a strategy of delayed angiography with respect to overall survival at 90 days.”
Clinical Take Home Point: We agree with the authors conclusions that immediate vs delayed angiography does not affect 90 day mortality in patients with cardiac arrest without STEMI. It is important to note that the majority of patients who had cardiac arrest in this study did not have unstable coronary lesions as the cause of their cardiac arrest (which is the probable reality of this group of patients) therefore the majority of patients who had angiography did not even require PCI. This study is the best evidence we have to date that shows not all cardiac arrests , even those with shockable rhythms need a heart catheterization. So the bottom line for us is:
  • Cardiac Arrest + STEMI on ECG = Cath Lab
  • Cardiac Arrest + No STEMI on ECG = Dependent on patient factors + conversation with interventional cardiologist (It may be reasonable to not cath immediately and wait 24 – 48hrs before doing a heart cath, if at all)

Tramadol

First 10EM - By Justin Morgenstern - May 13, 2019
...I came to New Zealand to learn; to see how medicine was practiced in a different country. I was hoping see different practices, which could open my eyes to dogma that may have found its way into the way that I practice medicine. These differences will probably prompt a number of blog posts over the coming year. However, after reviewing the literature around tramadol, I have to say that my initial teaching was correct. Tramadol is a horrible drug that I will probably never prescribe...
Conclusion
There is really no logical reason to prescribe tramadol. It is an unpredictable medication. Some patients will get no pain relief at all. Others will get much higher opioid concentrations than you expect. It results in dependence, addiction, and abuse like all opioids, but seems to cause more adverse events that other opioids because of its SNRI actions.
If your patient needs an opioid, there is no reason to choose tramadol over morphine.

Neutropenic fever

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emDocs - May 13, 2019 - Author: Long B - Edited by: Koyfman A
"Key Points
  • Fever with neutropenia is an emergency. Neutropenic fever is defined by the IDSA as oral temperature > 38.3o C or temperature >38.0oC for 1 hour with neutropenia.
  • In patients who are risk stratified as low risk, outpatient therapy is safe when compared to inpatient therapy.
  • Oncology consultation is recommended for patients with neutropenic fever, especially with the decision regarding discharge.
  • While several risk scores can be used with oncology consultation, including the MASCC and CISNE scores, clinical judgment should overrule clinical scores.
  • If the patient is appropriate for outpatient therapy following IV antibiotics and observation in the ED, an oral fluoroquinolone (ciprofloxacin or levofloxacin) plus amoxicillin/clavulanate is recommended."

EM Medicine as Speciality 2019

iEM - May 13, 2019 - By Sarbay I
"As health care professionals working on Emergency medicine, our history is still being written. Let’s say you would like to learn which countries officially recognize Emergency Medicine (EM) as a specialty, and want to make a beautiful interactive infographic depicting these countries with their official EM recognition years (Because, why not?). It should be an easy task, right? WRONG..."

jueves, 9 de mayo de 2019

Whole Blood for Massive Transfusion

The Trauma Pro
The Trauma Pro - May 08, 2019
"We’ve been using fractionated blood components in medicine, and trauma specifically, for over 50 years. So why doesn’t component therapy work so well for trauma? Refer to the following diagram. Although when mixed together the final unit of reconstituted blood looks like whole blood, it’s not. Everything about it is inferior.
Then why can’t we just switch back to whole blood? That’s what our trauma patients are losing, right? Unfortunately, it’s a little more complicated than that. The military has been able to use fresh warm whole blood donated by soldiers which has been stored for just a few hours. That is just not practical for civilian use. We need bankable blood for use when the need arises.
This ultimately means that we need to preserve the blood, and this requires a combination of preservatives to prevent clotting and keep the cellular components fresh, and refrigeration to avoid bacterial growth. This is not as simple as it sounds. Adding such a preservative to whole blood dilutes it by about 12%. And there are concerns that cooling it may have effects on platelet function. Recent data suggests that platelet function in cooled whole blood is preserved, but platelet longevity is decreased..."

Ludwig's Angina

TAMING THE SRU
TAMING THE SRU - May 08, 2019 - By Shawn Hassani
Fig. 2  “Brawny” swelling involving submandibular space typical of Ludwig’s Angina.  [Image from medical-dictionary.thefreedictionary.com/]
..."Ludwig’s angina is a diffuse, rapidly expanding infection of the submandibular space. The submandibular space is subdivided by the mylohyoid muscle into the sublingual space superiorly and the submaxillary space inferiorly. These areas communicate freely without the aid of lymphatics, therefore once an infection is present, it can disseminate quickly. To complicate things further, the spaces of the neck also communicate freely with one another making it easy for infection to spread over a wide area. This gives the potential for submandibular infections to involve the pharyngomaxillary and retropharyngeal spaces with minimal resistance. 
Most cases of Ludwig’s angina are due to dental infections, with the second mandibular molar being the most common site. Other causes include: sialadenitis, injury to the floor of the mouth (ex: frenulum or tongue piercings), peritonsillar abscess, lymphadenitis, infected mandibular fractures, infected abscess of the chin, and oral lacerations..."

Top 10 Poscast 2019

TOTAL EM
TOTAL EM - Podcast #146 - 5/7/2019

miércoles, 8 de mayo de 2019

Massive Transfusion and TXA

The Trauma Pro
The Trauma Pro - May 03, 2019
"Tranexamic acid has been in use for decades, just not for trauma. The CRASH-2 trial was a massive multi-country study showed that there was a slight mortality reduction from 16% to 14.5% in trauma patients who had or were at risk for “significant hemorrhage.” Moreover, there was no difference in vascular occlusive events, blood product transfusions, or need for surgery. Sounds great, right?
The MATTERs trial was initiated by the US military and tried to address some of the perceived shortcomings of CRASH-2 and found an absolute mortality reduction of 6.7%. But it also showed DVT rates that were 12x higher and PE rates 9x higher when this drug was given...
The trauma group at Denver Heath published a study of 232 patients with a 20% mortality rate from their injuries. They identified three subsets of patients based on their fibrinolytic response upon presentation to the hospital: physiologic fibrinolysis (49% of patients), hyperfibrinolysis (28%), and fibrinolytic shutdown (23%).
They found that mortality significantly increased in those receiving TXA who were physiologic or hyperfibrinolytic, but unchanged in those in shutdown. They cautioned that giving this drug before the patient’s fibrinolytic status was known could contribute to mortality.
Bottom line: So confusing! And many centers already include TXA in their massive transfusion protocol. Most have not seen unexpected mortality after giving the drug, so the jury is not in yet. Each trauma center should weigh the currently known pros and cons, and decide whether they are “believers” or not. Carefully review all mortalities and thrombotic complications after administration to see if there was any relation to the use of TXA."

Manejo del Paciente con síncope

Resultado de imagen de semes
Basado en las Guías ESC 2018 sobre el diagnóstico y el tratamiento del síncope
Michele Brignole, Angel Moya, Frederik J de Lange, Jean-Claude Deharo, Perry M Elliott, Alessandra Fanciulli, Artur Fedorowski, Raffaello Furlan, Rose Anne Kenny, Alfonso Martín, Vincent Probst, Matthew J Reed, Ciara P Rice, Richard Sutton, Andrea Ungar, J Gert van Dijk, ESC Scientific Document Group; 2018 ESC Guidelines for the diagnosis and management of syncope, European Heart Journal 2018: 39 (21) 1: 1883–1948.
Autores:
  • Alfonso Martín Martínez. Jefe Servicio de Urgencias, Hospital Universitario Severo Ochoa, Madrid. Miembro Grupo de Trabajo Guías Síncope ESC 2018 
  • Ángel Moya Mitjans. Servicio de Cardiología, Hospital Universitario Dexeus, Barcelona. Coordinador Grupo de Trabajo Guías Síncope ESC 2018 
  • Francisco Moya Torrecilla. Director de Servicios Médicos Internacionales, Hospital Vithas Xanit Internacional, Málaga, Coral Suero Méndez. Directora de Unidad de Gestión Clínica de Cuidados Intensivos y Urgencias, Hospital de la Axarquía, Málaga.

Top 5 of 2018 (NU.EM)

NUEM_blog logo_top5.png
NU.EM - April 22, 2019 - By Seth Trueger
"As the long and cold Chicago winter wanes and Spring begins, let’s take a look at the most popular NUEM blogs from 2018. While we value all of our residents’ and experts’ hard work, we are highlighting these 5 posts which earned the most pageviews in calendar year 2018:
1) HiNTS Exam
2) Migraine Cocktail
3) Beta Blocker Toxicity
4) Hand Exam
5) Auricular Hematoma Drainage"

PERCs of the Wells Score

TAMING THE SRU
Taming The SRU - May 04, 2019 - By Christina Pulvino
Screen Shot 2019-05-04 at 8.21.06 AM.png
"Pulmonary embolism (PE) is one of the big “can’t miss” diagnoses in the emergency department. Unfortunately, presenting symptoms are often vague, and definitive diagnostic testing is expensive and comes with risks of radiation and contrast to the patient. In order to avoid missing a PE while mitigating the risks associated with overtesting, some clinical decision tools have been created to aid in the diagnostic process. We will focus on two of these commonly used decision tools: the PERC rule and the WELLS score for PE..."

SHoC-ED 3

The Bottom Line - 3 May 2019 - By Adrian Wong
Does Point-of-care Ultrasound Use Impact Resuscitation Length, Rates of Intervention, and Clinical Outcomes During Cardiac Arrest? Atkinson RP et al. Cureus 11(4): e4456. DOI 10.7759/cureus.4456

"Clinical Question
In patients presenting to the Emergency Department (ED) in cardiac arrest, does a standardised point-of-care ultrasound protocol, compared with usual care, affect the length of resuscitation, frequency of interventions, and clinical outco
mes?
Authors’ Conclusions
Patients with cardiac activity on PoCUS received increased resuscitative effort and had improved clinical outcomes as compared to those with negative findings or when no PoCUS was performed.
The Bottom Line

  • The fact that pts with cardiac activity visualised on POCUS received longer resuscitation attempts, more interventions and had a higher rate of ROSC is unsurprising
  • The reverse is also unsurprising as the decision to terminate or stop intervention is a self-fulfilling prophecy
  • Despite higher rates of ROSC in pts with cardiac activity on POCUS, the rate of survival to hospital discharge falls to that of pts who received no POCUS
  • I will continue to use POCUS during the management of cardiac arrest but priority remains good quality chest compressions and resuscitation
  • Further testing by prospective trial as this study is a) hypothesis generating b) has biological plausibility and c) health economics and d) safety relevance"

martes, 30 de abril de 2019

Managing pH in Salicylate Overdoses

Tox and Hound (EMCrit) - April 30, 2019 -By Dan Rusyniak
...In animal studies, small decreases in serum pH cause big increases in brain aspirin concentrations.
So, what do you do if you need to intubate a sick aspirin patient? First, don’t intubate them. But, if you must, my recommendation is to push bicarb (1-2 mEq/kg), use rapid sequence induction, and hyperventilate (rate and depth) when you bag them, intubate them (hopefully in one quick pass), push more bicarb, set the ventilation rate higher than normal, and keep your bicarb drip running. As for the vent settings, I am not going to pretend I know anything about ventilators – consult your intensivist. But, consider high respiratory rates in the beginning with a goal of getting PCO2 < 20 mmHg until you can get serum pH under control with bicarb. It should also be evident now that if you are intubating a salicylate overdose you need to closely monitor pH. These patients need repeated checks of arterial pH (not a bad indication for an arterial line). And after you have intubated a bad salicylate overdose, you should start pacing nervously while you check your watch asking “when is renal going to get here?” And, although I haven’t mentioned it (and a topic worthy of its own post), if you have a bad salicylate overdose they need emergent hemodialysis.

lunes, 29 de abril de 2019

Mild TBI Transfer?

The Trauma Pro - April 29, 2019
"One of the more common reasons for transfer to a higher level trauma center these days is the “mild or minimal TBI.” Technically, this consists of any patient with a Glasgow Coma Scale score of 14 or 15. A transfer is typically requested for observation or neurosurgical consultation, or because the clinicians at the initial hospital are not comfortable looking after the patient.
Is this really necessary? With the number of ground level falls approaching epidemic proportions, transferring all these patients could begin to overwhelm the resources of high level trauma centers. The surgical group at Carolinas Medical Center examined their experience with a simple scoring system they designed to predict high risk minor TBI patients, and thus suitability for transfer..."

Influenza in the ED

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emDocs - April 29, 2019 - Authors: Mendoza C and Fairbrother H
Edited by: Koyfman A and Long B
"Summary
  • Influenza can present with wide variety of symptoms and can lead to multiple complications.
  • Be aware of your local seasonal prevalence of influenza and specific strains, as it will help limit inappropriate testing and lead to timely therapy (https://www.cdc.gov/flu/weekly/fluactivitysurv.htm)
  • Risk stratify patients depending on their comorbidities and previous medical problems
  • A negative rapid antigen test does not rule out influenza, particularly when prevalence is high
  • A purely clinical diagnosis of influenza (i.e. no confirmatory testing) during high influenza season is reasonable for low-risk patients who are likely to be discharged.
  • For low risk patients with mild to moderate illness, treat as outpatients with oral antiviral if presenting within 48 hours of illness onset, otherwise supportive treatment is recommended.
  • Hospital admission should be based on patient’s risk factors, age, respiratory status, clinical presentation, comorbidities, and access to outpatient follow up.
  • Treatment with antiviral medications is recommended for all patients who are severely ill, have complicated illness, are at high risk for complications, or are hospitalized.
  • Be aware that pneumonia (bacterial, CA-MRSA, viral), pediatric myositis/rhabdomyolysis, and MI in elderly patients are possible contributors to why your influenza patient may be so sick."

jueves, 25 de abril de 2019

Endocarditis

PulmCrit (EMCrit)
PulmCrit - April 25, 2019 - By Josh Farkas
"Endocarditis is a classic disease of emergency medicine, inpatient medicine, and critical care. The opioid epidemic has caused a surge of endocarditis diagnoses, reminding us of the myriad ways that this disease can present itself. However, diagnosis remains challenging, as patients with endocarditis may manifest with wholly different presentations (e.g. one patient with a stroke, another patient with cardiogenic pulmonary edema, and a third with septic shock). This chapter focuses a bit on the selection of empiric antibiotic therapies, which is admittedly a grey area (one which most guidelines tend to shy away from)."
  • The IBCC chapter is located here.
  • The podcast & comments are below.

Balanced crystalloids vs NS

R.E.B.E.L.EM - By Salim Rezaie - April 25, 2019
..."Meta-analysis of randomized controlled trials comparing balanced crystalloids vs NS in critically ill patients...
Author Conclusion: “Among critically ill patients receiving crystalloid fluid therapy, use of a balanced crystalloid compared with normal saline did not reduce the mortality, risk of severe AKI, or RRT use rate. Further large randomized clinical trials are needed to confirm or refute this finding.”
Clinical Take Home Point: This meta-analysis contributes very little to the current discussion mainly because of the heterogeneity of included studies. The use of fluid type in different pathologies isn’t really what we need, but rather tailored use of fluids with patient-oriented outcomes. It appears the debate over balanced crystalloids and normal saline in the resuscitation of the critically ill will continue. Although it makes more physiological sense to use balanced crystalloids in large volume (>2L) resuscitation, at this point in time it appears if you are using NS or a balanced crystalloid as your resuscitation fluid of choice keep using your fluid of choice, and don’t worry about changing your practice, although some individual studies have shown advantages in some clinical situations, until more robust evidence pushes you to do so."

miércoles, 24 de abril de 2019

Adult Congenital Heart Disease

St. Emlyn´s - By Simon Carley - March 3, 2019
"Virchester is recognised as a specialist centre for patients with adult congenital heart disease (ACHD). This is an interesting and occasionally challenging group of patients who may require some modifications in your approach to referral, management and resuscitation. We also know that the success and progress in the management of children with CHD is leading to an increase in the number of survivors and therefore an increase in the number of adult patients attending the ED1. This blog outlines some of the key questions we should be asking when an ACHD patient attends the ED and links to some open access learning resources for those of you who want to know more. When we started looking at this it became clear that although there is a fair amount of guidance out there about the management of patients in the surgical and out-patient setting there is relatively little published that is aimed at the Emergency Medicine community..."

Tension Pneumothorax

EMCrit Podcast 245 - April 24, 2019 - By Scott Weingart
  "Today, a topic about which you may already believe you know all you need to know–chances are you don't. What we were taught about tension pneumo by textbooks and trauma courses may not be right. To discuss tension pneumothorax, there is no better guest than… 
Dr. Simon Leigh-Smith, Consultant in Emergency Medicine, Defence Medical Services & NHS Lothian, Surgeon Commander Royal Navy, Clinical Lead for Pre-Hospital Care and Medic..."

martes, 23 de abril de 2019

Occipital Neuralgia

CanadiEM
CanadiEM - April 23, 2019 - By Tam V
..."The condition is attributed to nerve compression caused by sub-occipital muscle hypertrophy, tensing, or spasm. Approximately 90% of cases of occipital neuralgia involve the greater occipital nerve (GON), while the remaining 10% of cases are thought to be attributable to lesser occipital nerve (LON) pathology...
We propose the following useful mnemonic to assist in making a diagnosis ("STAB"):
Occipital neuralgia

Canadian C-Spine Rule

Taming The SRU
Taming The SRU - April 22, 2019 - By Gawron D

..."Since the creation of both the NEXUS and Canadian clinical decision rules, only one study has directly compared the accuracy of the rules against one another. This study was published in 2003 by the same authors of the Canadian C-Spine Rule.  They applied the same methods as their validation study in 2001 to a population of 8,283 blunt trauma patients, and ultimately had 169 patients (2%) with clinically important cervical spine injuries. 
So in this study, the Canadian C-Spine Rule performed better than NEXUS. One interesting finding, however, was for 845 (10.2%) of the patients, physicians did not evaluate range of motion as required by the CCR algorithm. This may suggest that there is some physician discomfort and decreased compliance when it comes to applying the CCR rule, perhaps due to concern that range of motion testing may exacerbate an injury. An additional 2012 systematic review was published in the Canadian Medical Association Journal to investigate the diagnostic accuracy of the two rules. However, all of the studies included in the review besides the one discussed above were validation studies and did not directly compare the two rules against each other. The review found a combined sensitivity of NEXUS to be 83-100% and Canadian to be 90-100% and the authors concluded that the Canadian C-Spine rule appears to have a better diagnostic accuracy."

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