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SOBRE EL AUTOR **

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

WORLD EMERGENCY MEDICINE SOCIETIES

The Utility of BNP in the Dyspneic Patient (TAMING THE SRU June 03, 2018)

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martes, 19 de junio de 2018

Médico de urgencia

PORROs EM

PorrosEM - June 18, 2018 - By Dr. Po
"Siempre que le contaba a mis amigos y familiares que iba a hacer una residencia de urgencia saltaba un patrón de preguntas similares en cada uno de ellos: ¿Y es una especialidad? ¿Y dónde trabajan? ¿Pero eso no lo hacen los médicos generales?. La verdad es que no me molestaba (no tenían porque saber), pero para ser completamente sincero al principio no tenía del todo claro que significaba ser un médico especialista en medicina de urgencia y menos aún acerca de como piensa uno de ellos.
Hay muchos conceptos dentro de la especialidad que se repiten constantemente, tales como: paciente indiferenciado, toma de decisiones, tiempo-dependiente, evaluación primaria, estratificación de riesgo y un largo etc, cada uno toca tangencialmente características que debería aprender un médico de urgencia a lo largo de su formación.
Les dejo una traducción de una entrada que aborda estos tema sacado del blog http://rebelem.com/the-em-mindset/ del excelentísimo Salim Rezaie
(Traducción autorizada por Salim Rezaie)..."

The EMN Salary Survey

Resultado de imagen de emergency medicine news
Emergency Medicine News: June 19, 2018 - Volume 40 - Issue 6B - p - By Lam, Jackie
doi: 10.1097/01.EEM.0000540078.65056.ba
click image to enlarge
"Emergency physicians board-certified in emergency medicine earn more than their non-EM-certified counterparts, perhaps reflecting a growing appreciation for the education and training found only in emergency medicine residencies. It appears to be no coincidence that as the percentage of board-certified EPs in our 2017 EMN salary survey increased to 85 percent—from 81 percent in 2015—more of them reported salaries in the highest income categories ($300,000 to more than $350,000) last year compared with two years before. And that's not all; fewer board-certified-EP salaries fell in the lower categories of $100,001-$300,000.
The gap between those with and without EM board certification in the highest income category in our survey has widened quite a bit. Close to 30 percent of board-certified EPs v. 18 percent of non-board-certified EPs made more than $350,000 in 2017, a 12-percent disparity, while 20 percent of board-certified EPs v. 16 percent of those not board-certified reported earning that much in 2015, a four-percent difference. The hourly rate data we added this year revealed a much starker reality of the disparity between these two groups. You can find more in our Salary Survey blog at http://bit.ly/EMNSalarySurvey..."

lunes, 18 de junio de 2018

Refractory Status Epilepticus

Logo
emDocs - Jun 18, 2018 - Authors: DeVivo A and Beck-Esmay J
Edited by: Koyfman A and Long B
"Key Points
  • Keep a broad differential in patients who present in refractory status epilepticus and use all modalities of history available to discern and treat the most likely etiology. Small pieces of history can vastly change management.
  • Patients who require intubation and sedation should be frequently re-assessed for signs of persistent seizure activity and an EEG should be obtained as soon as possible in an intensive care setting once the initial ED workup is complete.
  • After the ABCs, one of the initial diagnostics ordered should be a point of care glucose.
  • After initial stabilization, an EKG should be performed on all patients in status epilepticus.
  • A core temperature should always be obtained.
  • Any signs of trauma should raise clinical suspicion for intracranial pathology as the etiology of the seizures.
  • History of recent febrile illness and seizures should prompt all ED staff to take appropriate precautions in order to avoid transmission of communicable disease in the event meningitis is the etiology. Provider and ED staff safety is paramount, regardless of the situation.
  • Patients with a history of seizures can easily lead to anchoring on medication noncompliance as the etiology of their status epilepticus. However, these patients can easily have multifactorial etiologies for their presentation, and caution is warranted when attributing persistent seizures to medication nonadherence."

Bicarbonate in Cardiac Arrest

R.E.B.E.LEM - June 15, 2018
"Author’s Conclusions:
“The use of sodium bicarbonate improved acid-base status, but did not improve the rate of ROSC and good neurologic survival. We could not draw a conclusion, but our pilot data could be used to design a larger trial to verify the efficacy of sodium bicarbonate.”
Our Conclusion:
We agree with the authors conclusions. While the use of NaHCO3 improved the surrogate endpoint of acid-base status, there was no patient centered improvement seen in this study.
Potential to Impact Current Practice:
This small pilot study should not change clinical practice. Indiscriminate use of NaHCO3 in cardiac arrest should not be performed. However, providers should continue to use their judgement as to which patients with arrest may benefit from NaHCO3.
Bottom Line:
The use of NaHCO3 does not appear to improve clinically meaningful outcomes. A larger study should be undertaken to further evaluate this clinical question."

miércoles, 13 de junio de 2018

Airway Update

EMCrit RACC
EMCrit Podcast 226 - June 13, 2018 - By Scott Weingart
Bougie First?"A recent RCT from Hennepin by Driver et al. evaluated the effect of bougie use on first pass success. This adds to a prior retrospective study by the same group. These studies lend support to a practice that many of us have already adapted–bougie first intubation..."

martes, 12 de junio de 2018

PE Decision Rules

EM sandbox - June 8, 2018 - By jfhine
"In this podcasts we review the literature and discuss the decision rules crafted for the work up of pulmonary embolism- Wells, PERC, and the new kid on the block YEARS. It is a lot of content, so we also broke down the talk by decision rule."

lunes, 11 de junio de 2018

Infusions of beta-lactam in sepsis

PulmCCM
PulmCCM - June 7, 2018
"Infusing antipseudomonal beta-lactam antibiotics over longer periods could save lives in sepsis over intermittent bolus dosing, according to a systematic review and meta-analysis of randomized trials.
Vardakas et al aggregated data from studies of patients with sepsis receiving infusions of carbapenems, cephalosporins, and penicillins with antipseudomonal activity. Studies included compared prolonged infusion (over at least three hours), vs. hour-long infusions or shorter. They included 22 randomized trials with 1,876 patients.
Prolonged infusion of antipseudomonal beta-lactams reduced mortality by 30% compared with shorter infusions. Findings were published in Lancet Infectious Diseases..."

Corticoides en el paciente crítico

AnestesiaR -
AnestesiaR - By Isabel de la Calle Gil - 11 Junio 2018
Artículo original: Djillali Annane, Stephen M. Pastores, Bram Rochwerg, Wiebke Arlt, Robert A. Balk, Albertus Beishuizen, et al. Guidelines for the diagnosis and management of critical illness-related corticosteroid insufficiency (CIRCI) in critically ill patients (Part I and II). Society of Critical Care Medicine (SCCM) and European Society of Intensive Care Medicine (ESICM) 2017 (HTML)
...En lo que se refiere al tratamiento, en función de la condición específica por la que se desarrolla el CIRCI:
  • No recomiendan la administración de corticoesteroides en pacientes sépticos en ausencia de shock.
  • Recomiendan el uso de hidrocortisona intravenosa <400 mg/día durante ≥3 días a dosis plenas en pacientes con shock séptico que no responden a fluidoterapia ni a dosis moderadas-elevadas de vasopresores.
  • Recomiendan el uso de metilprednisolona intravenosa 1 mg/kg/día en pacientes con síndrome de distrés respiratorio agudo (SDRA) precoz (hasta el 7º día desde su inicio) moderado-severo (PaO2/FiO2 < 200); y en SDRA tardío (después del 6º día de inicio), metilprednisolona intravenosa 2 mg/kg/día; seguidos ambos de un descenso paulatino durante 13 días. Se recomienda metilprednisolona porque penetra mejor en el tejido pulmonar y permanece más tiempo.
  • No recomiendan el uso de corticoesteroides en pacientes con trauma severo.
  • En neumonía adquirida en la comunidad, recomiendan el uso de corticoides durante 5-7 días a una dosis diaria de menos de 400 mg de hidrocortisona intravenosa.
  • Recomiendan no usar corticoides en la gripe.
  • Recomiendan el uso de corticoides en meningitis bacteriana, en pacientes con circulación extracorpórea y en pacientes que han sufrido parada cardíaca."

lunes, 4 de junio de 2018

Nuclear Attack

Resultado de imagen de aliem academic life in emergency medicine
June 4th, 2018 - By: Tenner A and Reilly A
"Ever wonder what would happen if you were working in the emergency department (ED) when a nuclear attack happens? We’ve all had questions on boards or inservice exams about the long-term effect of radiation exposure, but would you know what to ACTUALLY DO if a nuclear attack happened? What do you do in the first few minutes? First few hours? We know that if you are in the immediate bomb vicinity, there is not much you can do. But what if you are 5 miles away? Or 10 miles?
If you look for information regarding nuclear attacks, there are no great summary resources on what to do in the immediate aftermath if you are in the ED. In order to bring this to you in an easily digestible format, we have broken this post up into a few topic areas: This blog post will cover (1) what physically happens in a nuclear attack and (2) what this means in the ED..."

EXTEND-IA TNK

R.E.B.E.L.EM - June 4, 2018
"Author’s Conclusions: “Tenecteplase before thrombectomy was associated with a higher incidence of reperfusion and better functional outcome than alteplase among patients with ischemic stroke treated within 4.5 hours after symptom onset.”
Our Conclusions: Tenecteplase results in improved perfusion after thrombectomy compared to alteplase but only in patients that undergo endovascular intervention. Additionally, the rates of reperfusion prior to thrombectomy were low in both groups (22% in telecteplase vs 10% in alteplase group). There are no differences in clinically significant outcomes.
Potential Impact to Current Practice: This study only applies to a small subset of patients with strokes (ischemic, large-vessel, undergoing thrombectomy) so there is unlikely to be a difference in large population outcomes. However, hospital stroke outcomes are of increasing importance so if tenecteplase costs less and requires less time to administer, this data may lead to a shift in management.
Bottom Line: Neither alteplase or tenecteplase are very effective in significant vessel reperfusion. Though alteplase is the drug of choice currently in ischemic stroke, tenecteplase may provide more cost-effective and time-efficient option."

Dantrolene

EMCrit
EMCrit - June 4, 2018 - By Sarah Shafer
"Dantrolene is one of the few, true “muscle relaxers”. It was discovered in 1967 and approved by the FDA in 1979. Unlike paralytic neuromuscular blockers, dantrolene works post-synaptically, at the sarcoplasmic reticulum in the myocyte. It binds to the ryanodine receptor in skeletal muscle (RYR1), preventing sarcoplasmic calcium-induced calcium release.
When RYR1 works normally, calcium gets released from the sarcoplasmic reticulum and binds to troponin, exposing actin. This allows myosin to bind with actin to produce muscle contraction. When there is too much calcium, it causes excess muscle contraction. Without enough calcium, myosin is blocked from binding to actin. When dantrolene is at steady-state in healthy human volunteers, it produces a 75% reduction in muscle twitch without full paralysis. It reduces grip strength in volunteer subjects by over 50%, taking 20 hours to return to normal. Residual weakness can persist for up to 48 hours. [Flewellen 1983 PMID: 6614536]..."

jueves, 31 de mayo de 2018

Cauda Equina Syndrome

R.E.B.E.L.EM - May 31, 2018
"Take Home Points
  • Cauda equina syndrome is a rare emergency with devastating consequences
  • Early recognition is paramount as the presence of bladder dysfunction portends bad functional outcomes
  • The presence of bilateral lower extremity weakness or sensory changes should alert clinicians to the diagnosis. Saddle anesthesia (or change in sensation) and any bladder/bowel changes in function should also raise suspicion for the disorder
  • MRI is the diagnostic modality of choice though CT myelogram can be performed if necessary
  • Prompt surgical consultation is mandatory for all patients with cauda equina syndrome regardless of symptoms at presentation"

miércoles, 30 de mayo de 2018

Infections

Logo
emDocs - May 30, 2018 - Author: Nicholas Smith and David Pillus
Edited by: Alex Koyfman and Brit Long
"Key Points
  • In some cases, antibiotics alone are not adequate for infectious source control.
  • Complete exposure and skin examis crucial in making the timely diagnosis of several life-threatening diseases.
  • For many of these infections, getting a surgeon on board as soon as possible is associated with source control and reduction in both morbidity and mortality.
  • Keep a broad differential in patients presenting with apparent infection without a source, and don’t forget the possibility of not readily apparent skin and soft tissue infections."

lunes, 28 de mayo de 2018

Epinephrine in Sepsis

PulmCrit (EMCrit)
April 25, 2016 - By Josh Farkas
"Summary: The Bullet
  • Epinephrine and norepinephrine are both acceptable, evidence-based approaches to hemodynamic support in septic shock.
  • Individual patient responsiveness to vasopressors is variable and unpredictable.
  • Some patients respond better to epinephrine than norepinephrine.
  • For patients who are not responding well to norepinephrine, it is reasonable to empirically trial a low dose of epinephrine (“epinephrine challenge”)."
titralgo

Penetrating Neck Injuries

R.E.B.E.L.EM - May 28, 2018
"Background: Patients with penetrating neck trauma can present with a variety of injury patterns including hemorrhagic shock, airway obstruction and neurologic injury. Serious injuries may not be clinically obvious making diagnosis and prompt treatment challenging. Due to the large number of critical structures in the neck, a clear knowledge of the anatomy is necessary for proper evaluation and management...
Take Home Points
  1. Penetrating injuries to the neck can damage a host of structures. Understanding the zones of the neck and the structures within them can help predict injuries
  2. If the platysma is violated, it should be assumed that deeper structures have been injured until proven otherwise
  3. Early airway management is crucial as injuries can lead to dynamic airway obstruction. Always be prepared for a surgical airway
  4. The presence of any hard signs of aerodigestive/neurovascular injuries (expanding/pulsatile hematoma, active brisk bleeding, hemorrhagic shock, massive subcutaneous emphysema, air bubbling through the wound, neurologic deficit) or violation of platysma, mandates an immediate OR trip. Do not delay the patient getting to the OR for additional studies
  5. Attempt to control vascular injuries with direct pressure and consider balloon tamponade with a foley catheter"

sábado, 26 de mayo de 2018

Surviving Sepsis Update

Written by Thomas Davis
 Intensive Care Med. 2018 Apr 19. doi: 10.1007/s00134-018-5085-0. [Epub ahead of print]

"The Surviving Sepsis Campaign has issued a new 1-hour bundle beginning at the time of triage in the emergency department. This replaces the current 3- and 6-hour bundles...
Why does this matter?
Although the 2016 Surviving Sepsis Campaign guidelines state that “Recommendations from these guidelines cannot replace the clinician’s decision-making capacity when presented with a patient’s unique set of clinical variables,” the regulatory reality is less deferential to your clinical acumen. The Centers for Medicare and Medicaid Services (CMS) has adopted the 3- and 6-hour bundles as rigid core measures, which severely impact hospital reimbursement. Just as you may be getting used to the current bundles, you may want to read the 1-hour bundle summary below as this will likely be the new CMS standard."

 From cited article

Emergency Medicine Day

"27 May is introduced as the Emergency Medicine Day and promoted by the EUSEM globally. The aim of this day is to unite the world population and decision makers to think and talk about emergency medicine and emergency medical care.
We believe it is important to build awareness about the need for well developed, well prepared and well organised emergency medical systems everywhere in the world to increase survival and reduce disability after any kind of urgent or emergent medical situation.
On 27 May, we encourage citizens, patients, health care personnel, and institutions all around the world to talk about emergency medicine and make projects for a year of progress in the discipline.
Where the specialty in emergency medicine is not yet developed, where emergency medical systems are not well structured, where competences are not standardized and certified, where resources for emergency medicine are insufficient, there should be a strong voice to ask and claim for a change, for a better life.
Because “competence makes the difference”.

viernes, 25 de mayo de 2018

Hyponatremia in the ED

An online community of practice for Canadian EM physicians
CanadiEM - By Andrei Smarandache - May 22, 2018
"Electrolyte imbalances like hyponatremia can be the cause of a variety of vague complaints. At the same time, patients may present with electrolyte abnormalities that are asymptomatic and are incidental findings on bloodwork. Here’s an approach to deciding when and how to treat hyponatremia in the emergency department..."
Approach to Hyponatremia

SICKLE CELL IN THE ED

EMOTTAWA
EMOTTAWA - By: Adam Parks - May 24, 2018
"Sickle Cell Disease (SCD) is a complex medical entity, associated with significant morbidity and mortality. Patients with SCD suffer from acute and chronic pain, along with a seemingly endless list of additional complications (from hemolysis and sequestration, to aplastic crises and acute chest syndrome). The associated morbidity of SCD is apparent, but these patients also have an alarming decrease in life expectancy, with recent estimates ranging from 28-49 years. Nationally, there is an estimated 5000 patients who suffer from SCD in Canada, and this number is likely to quickly increase given high rates of immigration from countries with high prevalence of SCD, combined with the increased survival associated with improved medical care.

From an Emergency Department (ED) perspective, many providers find the disease and its associated complications challenging and cumbersome. This summary will provide an abbreviated approach to SCD pathophysiology, vaso-occlusive pain crisis (VOC), and acute chest syndrome (AChS) in the ED..."

Corticosteroids in Pharyngitis

R.E.B.E.L.EM - May 24, 2018 - By Allon Mordel
Clinical Question:
Do single, low dose corticosteroids provide symptomatic relief in undifferentiated pharyngitis without significant adverse effects?
Author’s Conclusions:
“Single low dose corticosteroids can provide pain relief in patients with sore throat, with no increase in serious adverse effects.”
Our Conclusions:
Of all the outcomes, only the complete resolution of symptoms at 48 hours is backed by high quality evidence and a narrow confidence interval. Steroids also appear to provide only a moderate improvement in time to and degree of resolution of symptoms. However, in the setting of severe symptoms, these moderate improvements could make a significant difference.
Potential to Impact Current Practice:
This study validates prior studies suggesting corticosteroids offer therapeutic benefit in the management of sore throat. Clinicians should strongly consider adding a single dose of corticosteroids to their treatment regimen for patients with pharyngitis.
Bottom Line:
In cases of severe pharyngitis, single low dose corticosteroid administration would likely provide symptomatic benefit that outweigh potential adverse effects.

lunes, 21 de mayo de 2018

ACEP 2018: Acute VTE

R.E.B.E.L.EM - May 21, 2018
ACEP Clinical Policies Subcommittee. Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department with Suspected Acute Venous Thromboembolic Disease. 
Ann Emerg Med 2018; 71(5): e59-109. PMID: 29681319
..."Take Home Points
  1. The PERC risk stratifies low risk PE patients (~10%) to a level low enough (1.9%) as to obviate the need for additional testing.
  2. Age-adjusted D-dimers are ready for use and it doesn’t matter if your assay uses FEU (cutoff 500) or DDU (cutoff 250). For FEU use an upper limit of 10 X age and for DDU use an upper limit of 5 X age.
  3. For now, subsegmental PEs should continue to routinely be anticoagulated even in the absence of a DVT. Keep an eye out for more research on this area.
  4. Although outpatient management of select PE patients (using sPESI or Hestia criteria) may be standard practice, the evidence wasn’t strong enough for ACEP to give it’s support
  5. Patients with DVT can be started on a NOAC and discharged from the ED"

sábado, 19 de mayo de 2018

Lokelma


Resultado de imagen de european medicines agency

"This is a summary of the European public assessment report (EPAR) for Lokelma. It explains how the Agency assessed the medicine to recommend its authorisation in the EU and its conditions of use. It is not intended to provide practical advice on how to use Lokelma.
For practical information about using Lokelma, patients should read the package leafletor contact their doctor or pharmacist.
Lokelma is a medicine used to treat hyperkalaemia (high levels of potassium in the blood) in adults. It contains the active substance sodium zirconium cyclosilicate..."

miércoles, 16 de mayo de 2018

The Abdominal XRay

TAMING THE SRU - April 16, 2018 - By Skrobut T
"The KUB is easy to obtain and commonly used in the Emergency Department despite the advent and ease of higher specificity radiological studies. As these studies are still readily used and in some settings may be the only imaging available, our goals for this post will be to discuss indications for abdominal radiography in the emergency department as well as give examples of normal anatomy, an approach to interpretation, and underlying pathology that can be discovered, including associated sensitivities and specificities. We will not discuss utilization of contrast. Furthermore, we will briefly touch on different abdominal views that can be obtained and their utility but will focus primarily on the KUB since it is the most utilized image obtained in the emergency department..."

lunes, 14 de mayo de 2018

Wernicke Encephalopathy

R.E.B.E.L. EM - Emergency Medicine Blog
R.E.B.E.L.EM - 14 May, 2018 - By Anand Swaminathan
"Definition: Encephalopathy that occurs secondary to thiamine (vitamin B1) deficiency. While Wernicke encephalopathy is reversible with treatment, it can progress to the irreversible Korsakoff’s syndrome if left untreated...
Take Home Points
  • Wernicke encephalopathy is characterized by ataxia, altered mental status and ophthalmoplegia but patients are unlikely to have all these components
  • Suspect Wernicke encephalopathy in any patient that is at risk of malnutrition or malabsorption and has any one of the classic symptoms
  • Prophylactic administration of thiamine 100 mg IV/IM to at risk patients can prevent development of the disease
  • Once Wernicke encephalopathy has developed, it must be treated with high-dose, IV thiamine"

domingo, 13 de mayo de 2018

Abscess Management


R.E.B.E.L.EM - May 12, 2018
..."Take Home Points:
  • There is room for a safe increase in antibiotic use
  • There does not need to be reckless over-use of antibiotics
  • Use ultrasound with any abscess you are unsure of
  • Use a loop vessel rather than packing"

Excited Delirium Syndrome

The Skeptics Guide to Emergency Medicine
SGEM#218 - May 12th
"Clinical Question: What is the definition, epidemiology, pathophysiology and evidence-based management and treatment of excited delirium?
SGEM Bottom Line: The excited delirium syndrome remains a poorly defined disease and is difficult to study because of its inconsistent definition. However, it is a dangerous, high morbidity and mortality condition that requires aggressive management in the emergency department..."

Oxygen in the Acutely Unwell Patient

St Emlyn´s - By Simon Carley - May 13, 2018
"...Does this make sense?
Oxygen is good for you of course. Anyone who has tried to do without it will be fully aware of the challenges of hypoxia, but what’s the problem with 02 excess? This study cannot answer that question, but the discussion explores the pathophysiological argument for why an excess of 02 may be a problem for the critically unwell. In essence we know that 02 levels are a powerful driver in physiology and pathology and we also know that were never designed or evolved to have supra-normal levels as they don’t occur in nature. Vasoconstriction, inflammation and oxiditive stress have all been demonstrated in physiological models and constitute plausible mechanisms for harm. However, the discussion is more nuanced than this and I would recommend you read the full article to understand specific sub groups (e.g. surgical patients where super-oxia may be beneficial).
So what does this mean for my practice?
In Virchester it means that we will carry on as we have done recently. Superoxia is to be avoided. In a small group of patients we will tolerate superoxia (for example in the initial resus phase whilst preparing for advanced airway management, but for the vast majority of our patients an Sa02 of >94% is just fine thanks."

lunes, 7 de mayo de 2018

EM 2018 Match

Resultado de imagen de aliem emergency medicine
ALiEM - May 7th, 2018 - By: Michael Gisondi
"The National Residency Matching Program® (NRMP) recently published its annual Results and Data for the 2018 Main Residency Match®. How competitive was emergency medicine? Spoiler alert: not much changed! But to understand the full picture, we need to dive into the numbers, which look a lot different from last year. Below is a summary of the most pertinent results for emergency medicine, trended from 2011-2018. You will notice some striking differences in the data between the 2017 Match and the 2018 Match."

Chest Trauma

Logo
emDocs - May 7, 2018 - Authors: Ramzy M and R
Edited by: Koyfman A and Long B
"...This post will focus on both threatening and non-threatening pulmonary conditions that may arise from blunt trauma to the chest. Furthermore, it will provide pearls and pitfalls for each condition that will enhance your ability to evaluate a patient with blunt injury to the chest..."

Drowned Airway

PulmCrit (EMCrit)
PulmCrit - May 7, 2018 - By Josh Farkas

"Summary: The Bullet
  • The drowned airway is a rare and uniquely perilous situation were copious regurgitation prevents either intubation or mask ventilation. These patients are at very high risk of aspiration, ARDS, anoxic brain damage, or cardiac arrest.
  • Massive regurgitation may be prevented in some cases by using gastric ultrasonography to detect large volumes of gastric fluid. NG tube drainage before intubation may mitigate risk.
  • Front-line techniques for management of the drowned airway are large-bore catheter suctioning, Seldinger intubation using a large-bore suction catheter, or esophageal diversion with an endotracheal tube.
  • There should be a low threshold to perform surgical cricothyrotomy if other techniques fail or if the patient begins desaturating. Cricothyrotomy is highly effective, but in order to work it must be initiated early (before the patient develops massive aspiration or anoxic brain injury).
  • An airway algorithm is proposed for management of the drowned airway."

Intoxicated Patients

R.E.B.E.L.EM - May 7, 2018 
"Background: Visits to the ED for alcohol intoxication can create quite the clinical conundrum both for acute medical and traumatic reasons. Acutely intoxicated patients, just like young kids, don’t always have the ability to communicate due to sedation, agitation, or some other critical medical/traumatic process that is ongoing. This makes getting a complete history or depending on the physical exam unreliable at best..."

sábado, 5 de mayo de 2018

Obesity Emergency Management

Logo
emDocs - May 4, 2018 - By Anton Helman
Originally published at EM Cases – Visit to listen to accompanying podcast
"Current estimates of the prevalence of obesity are that a quarter of adult Canadians and one third of Americans are considered obese with approximately 3% being morbidly obese. With the proportion of patients with a BMI>30 growing every year, you’re likely to manage at least one obese patient on every ED shift. Obese patients are at high risk of developing a host of medical complications including diabetes, hypertension, coronary artery disease, peripheral vascular disease, biliary disease, sleep apnea, cardiomyopathy, pulmonary embolism and depression, and are less likely compared to non-obese adults to receive timely care in the ED.
Not only are these patients at higher risk for morbidity and mortality, but obesity emergency management is complicated by the patient’s altered cardiopulmonary physiology and drug metabolism. This can make their acute management much more challenging and dangerous. To help us gain a deeper understanding of the challenges of managing obese patients and elucidate a number of important differences as well as practical approaches to obesity emergency management, we welcome Dr. Andrew Sloas, the founder and creator of the fantastic pediatric EM podcast PEM ED, Dr. Richard Levitan, a world-famous airway management educator and innovator and Dr. David Barbic a prominent Canadian researcher in obesity in emergency medicine from University of British Columbia…."