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SOBRE EL AUTOR **

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

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Cranial Nerve VI Palsy Emergency

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sábado, 18 de noviembre de 2017

Aortic Dissection

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ACEPNow - By Anton Helman - November 13, 2017
Living Art Enterprises / Science Source
"Take-Home Points
  • Remember the big pain pearls when taking a history:
    • Ask the three important questions.
    • Aortic dissection should be considered the subarachnoid hemorrhage of the torso.
    • Migrating pain, colicky pain, plus need for IV opioids should raise your suspicion.
    • Intermittent pain can still be a dissection.
  • Look for Marfan syndrome, listen for an aortic regurgitation murmur, and feel for a pulse deficit.
  • Think not only about CP +1 but also 1+ CP.
  • Know the radiographic findings of loss or aortic knob/aortopulmonary window and the calcium sign, and use POCUS to look for an intimal flap and pericardial effusion.
  • Don’t be misled by a troponin or D-dimer."

Spontaneous Bacterial Peritonitis

R.E.B.E.L. EM - Emergency Medicine Blog
R.E.B.E.L.EM - Novembre 16, 2017

"Take Home Points:
  • SBP is a difficult diagnosis to make because presentations are variable. Consider a diagnostic paracentesis in all patients presenting to the ED with ascites from cirrhosis
  • An ascites PMN count > 250 cells/mm3 is diagnostic of SBP but treatment should be considered in any patient with ascites and abdominal pain or fever
  • Treatment of SBP is with a 3rd generation cephalosporin with the addition of albumin infusion in any patient meeting AASLD criteria (Cr > 1.0 mg/dL, BUN > 30 mg/dL or Total bilirubin > 4 mg/dL)"

miércoles, 15 de noviembre de 2017

Sepsis interprofessional curriculum

MCC Project - By Jim Lantry
"Please enjoy complimentary access to a sepsis curriculum created by two esteemed faculty members here at the University of Maryland Medical School: Jeffrey P. Gonzales, PharmD, FCCM, BCPS, BCCCP and Nirav G. Shah, MD, FCCP.
Dr. Gonzales is an Associate Professor of Critical Care and a faculty member at the University of Maryland School of Pharmacy where he is the director of the Post-Graduate Year One and Year Two Pharmacotherapy Residency Program. He is a staple on MICU rounds and has been a driving force for pharmacy integration into the critical care fellow’s curriculum.
Dr. Shah is an Associate Professor of Medicine in the Division of Pulmonary & Critical Care Medicine, the Course Director of Pathophysiology & Therapeutics I; and also acts as the Director of the Pulmonary & Critical Care Fellowship Program here at the University of Maryland Medical Center. Despite his many administrative duties, Dr. Shah continues to be rated as one the best MICU educators by the medicine and critical care fellows."

Fluoroquinolonas

Emergency Medicine PharmD - By Tony Mixon - November 15, 2017
"Many institutions have implemented antimicrobial restriction programs where specific agents, based on toxicity, cost, or broad-spectrum of activity, require special permission for use. Often a page is required to initiate the request. During my infectious diseases PGY-2 I carried this antimicrobial approval pager, either approving the use of restricted agents or offering suggesting on alternative therapy. Fluoroquinolones (FQs) were by far, the most requested restricted antimicrobials, and also the most denied. In emergency departments without such programs, pharmacists play a vital role in antimicrobial stewardship, steering therapy to optimize clinical outcomes while minimizing unintended consequences. With their broad spectrum of activity, oral formulation, and seemingly minimal adverse effect profile, FQs were highly touted when originally approved. However, after decades of clinical use and research, is it time we rethink their greatness?"
Take Home Points
  • FQs have been associated with many severe adverse reactions, including but not limited to QT prolongation, CDI, seizures, peripheral neuropathy, hypo/hyper glycemia, GI perforation, tendinopathy, retinal detachment, aortic dissection/aneurysm, as well as causing drug-drug interactions.
  • FQs carry multiple black box warnings surrounding their safety.
  • FQs have a low barrier to resistance.
  • Resistance rates to FQs have increased rapidly. Look at your antibiogram!
  • Ciprofloxacin and levofloxacin are our only oral agents with reliable activity against Pseudomonas spp.
  • FQs should be reserved for a few clinical scenarios where other antibiotics are not safe or feasible.

lunes, 13 de noviembre de 2017

NSTEMI mimics

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emDocs - November 13, 2017 - Author: Folse M - Edited by: Koyfman A and Long B
"Summary
  • Type 1 NSTEMI involves a new, partial occlusion of the cardiac vessel. Type 2 NSTEMI involves a supply-demand deficiency.
  • Always check for reciprocal ST-segment elevation when observing ST-segment depression.
  • Posterior MI diagnosis requires ST-segment elevation of 0.5mm or greater.
  • Upsloping ST-segment depressions with tall T-waves through V1-V6 is a STEMI equivalent.
  • The American Heart Association recognizes aVR ST-segment elevation in the setting of anterolateral ST-segment depression as an indication for emergent cardiac catheterization.
  • PE and dissection are important mimics of NSTEMI.
  • Consider inflammatory markers in suspected cases of myocarditis and pericarditis.
  • Differentiation of NSTEMI-mimics that involve a physiologic increase in post-left/right ventricular afterload (HOCM, AI, AS, PAH, COPD) can generally be made by careful examination of the patient’s medical history and clinical presentation."

Angiography

Resultado de imagen de new england journal of medicine
Weisbord S. et al. New England Journal of Medicine - November 12, 2017
DOI: 10.1056/NEJMoa1710933
"CONCLUSIONS
Among patients at high risk for renal complications who were undergoing angiography, there was no benefit of intravenous sodium bicarbonate over intravenous sodium chloride or of oral acetylcysteine over placebo for the prevention of death, need for dialysis, or persistent decline in kidney function at 90 days or for the prevention of contrast-associated acute kidney injury. (Funded by the U.S. Department of Veterans Affairs Office of Research and Development and the National Health and Medical Research Council of Australia; PRESERVE ClinicalTrials.gov number, NCT01467466.)"

domingo, 12 de noviembre de 2017

CCB Overdose

The Original Kings of County - by kkelson - November 9, 2017
“He took all his medication,” you chuckle to yourself as you read the chief complaint on the board. “Man, isn’t that what we try to get all our patients to do?”
As you open up the patient’s chart, however, your smugness quickly turns to unease when you read through the triage note; “Per wife, patient took a whole month’s supply of his amlodipine.” Oh no. He took ALL his medication. Your grin melts as you see the vitals: bradycardic, mildly hypotensive..."
  • Time to call poison control
  • Mechanism
  • Initial Management
  • High-Dose Insulin
  • The Kitchen Sink
  • We have no idea what we’re doing

Renal colic mimics

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emDocs - November 8, 2017 - Author: Crain N - Edited by: Koyfman A and Long B
"Summary:
  • Flank pain and hematuria are the hallmarks of renal colic, however the presentation is variable.
  • Diagnosis can be confirmed with CT scan, which will show most other potential items in the differential if the scan is negative for a stone.
  • Patients with a good story for stone who are young and healthy at baseline can receive renal US to evaluate for hydronephrosis, rather than CT.
  • Nephrolithiasis and nearly all of its mimics are confirmed with imaging.
  • Some mimics of renal colic that may arrive at the ED include: upper UTI’s, ectopic pregnancies, ovarian torsion, adnexal masses, testicular torsion, acute aortic syndromes, renal artery aneurysms, renal infarction, splenic infarction, bowel obstruction, diverticulitis, appendicitis, biliary colic, cholecystitis, acute intestinal ischemia, pneumonia, pulmonary embolism, retroperitoneal hematoma, iliopsoas abscess.
  • Focused history and physical exam are paramount due to the multitude of structures in the area and potentially dangerous conditions that may mimic renal colic."

ACEP 2017

R.E.B.E.L.EM - November 9, 2017
"This year ACEP 2017 took place in Washington D.C. from Oct. 29th – Nov 1st, 2017. There were lots of amazing speakers and topics as was evidenced by the eruption of everyone’s twitter feeds with the #ACEP17 hashtag. I was fortunate enough to attend this amazing conference and approached by several attendees if I would put together a list of my favorite pearls from this conference. I decided to put a top 10 list together, in no particular order."

Enfermedades tropicales

Resultado de imagen de infurg semes
Fecha: 07-11-2017
"La sección de Medicina Tropical y del viajero del grupo INFURG-SEMES presenta los primeros números de una serie de Protocolos de actuación en urgencias en enfermedades procedentes del trópico.
Puede acceder directamente a los siguientes protocolos (seleccione para poder acceder al contenido): 

martes, 7 de noviembre de 2017

Critical Pulmonary Embolism Patient

R.E.B.E.L.EM - Novemeber 6, 2017 
"Background: Previously, I had given a talk on the use of thrombolytics in submassive PE in 2016. This year, I had the privilege of speaking at ACOEP 2017 again with an update on the critical pulmonary embolism patient. This post will serve as a reference for that talk.
There are many ways to classify pulmonary embolism, but the best clinical definition would depend on the hemodynamic consequences. For example, massive pulmonary embolism can be defined as systemic hypotension (SBP < 90 mmHg or a drop in SBP of at least 40mmHg for at least 15 min) or shock (tissue hypoperfusion, hypoxia, altered mental status, oliguria, or cool clammy extremities.) There is a second subset of patients that also warrant discussion; submassive pulmonary embolism. These patients are defined as lack of systemic hypotension (<90mmHg), but have right ventricular dysfunction/hypokinesis. RV dysfunction tells us that there is severe pulmonary artery obstruction and impending hemodynamic failure..."

Diabetic Ketoacidosis

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emDocs - November 6, 2017 - Authors: Reynolds C and Fairbrother H
Edited by: Koyfman A and Long B
"Key Points
  • Always rule out serious life-threatening conditions that may have precipitated a patient’s DKA. DKA is never simple, and the EM physician’s job is not over with the diagnosis and initiation of the insulin drip.
  • Consider DKA in populations with diabetes risk factors, even in patients with no known history of diabetes; particularly in patients suffering CVAs, pregnant patients, patients on high risk medications (olanzapine, risperidone or clozapine) or substance use disorders.
  • Make sure to consider DKA on the differential even in euglycemic patients, particularly those on the novel SGLT2 inhibitors.
  • Persistent tachycardia in DKA in aseptic patients after adequate volume resuscitation may be due to hyperthyroidism.
  • Make sure to consider possible underlying infections or ischemia in DKA patients who present with diffuse abdominal pain as attributing this pain solely to DKA may mask the underlying pathology.
  • Consider cardiac ischemia as MI can be a trigger of DKA, but DKA can also act as a cardiac stress test.
  • Consider DKA in the setting of natural and manmade disasters where the supply of insulin may become unavailable to patients."

viernes, 3 de noviembre de 2017

Submassive PE

MCC Project - By Scott Michael - November 3, 2017
"Today we welcome back one of our favorite graduates of the EM/IM/CCM residency/fellowship here at University of Maryland, Michael C. Scott, MD. Luckily he stayed local and has been paving his own path across town at St. Agnes Hospital of Baltimore, Maryland. Dr. Scott originally hails from San Antonio Texas, where he graduated from the University of Texas Medical School Medical School before heading up to the North East. Since his arrival to Baltimore, Mike has demonstrated a wide knowledge of modern academic literature and has continued to challenge the status quo in medicine! Dr. Scott has proved time and time again that there are no definitives in medicine and today he tackles a very polarizing topic: what to do with a submassive PE?.."

miércoles, 1 de noviembre de 2017

Damage Control Resuscitation

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emDocs - September 13, 2017 - By McAninch S - Edited by: Koyfman A and Long B
"Trauma patients with significant injuries may arrive at the non-trauma designated hospital by various means: they may check-in through triage, be “dropped off” unexpectedly (in the parking lot), or arrive under the care of pre-hospital providers. Trauma patients with significant injuries and illness have better outcomes if transferred to a designated trauma center. Trauma center transfer guidelines exist to help identify such patients. Additionally, in pediatric patients, a Revised Trauma Score of < 12 or a Pediatric Trauma Score of < 8 are indications for transfer to a pediatric trauma center. If you are working in a non-trauma center, and your trauma patient appears “sick” at any point in care (even if on primary survey), meets any aforementioned criteria for transfer to a trauma center, or may require resources beyond you or your facility, then your priorities are to provide life-stabilizing care and then transfer to the nearest accepting trauma center as soon as possible. In the first of this two-part series, we will discuss personal mental preparation and creating a calm and safe resuscitation environment for the “sick” trauma patient in the non-trauma center. The second part of the series will discuss the clinical aspects of a focused trauma resuscitation in the non-trauma center and process improvement..."
*
emDocs - October 31, 2017 - By McAninch S - Edited by: Koyfman A and Long B
"Part One discussed creating and maintaining a calm, orderly, and relatively quiet resuscitation environment that is goal-oriented to complete life-saving tasks. Part two will discuss the clinical care of the “sick” trauma patient in the non-trauma center and suggestions for trauma process improvement. Clinical care includes early activation of transfer process, prioritized trauma survey physical exam, and application of “damage control resuscitation” treatment principals, as feasible in the non-trauma designated center..."

Emergency vs Internal Medicine

The CurbiderS #65 - October 30, 2017 - By Matthew Watto
"Fighting with Emergency Medicine colleagues is stupid. Learn how EM doctors think and avoid the petty infighting with tips from Dr Scott Weingart, MD FCCM FUCEM DipHTFU, of the EmCrit podcast and Clinical Associate Professor and Chief, Division of Emergency Critical Care at Stony Brook Hospital, NY. We discuss heuristics, how to avoid anchoring bias, the devil of the gaps, why the elderly always get admitted, how to build relationships with the ED, and Scott’s pet peeves..."

Overcrowding in the ED

Medical Bag
Medicalbag - October 31, 2017 - By Joel Cooper
"Emergency departments (EDs) are the Grand Central Station of medicine in this country. Serving an estimated 141.4 million patients a year and providing an average of 47.7% of all medical care delivered in the United States,1EDs are the hub, the core, the main cattle crossing, and the big monkey cage of medicine.
Like giant mirrors, EDs reflect everything good and bad about our nation's healthcare system. And like lightning rods in a raging thunderstorm, they bear the brunt of all negative energy resulting from their often-cited and harshly criticized overcrowding problem.
But the truth is that fierce logjams in the ED, and the resulting plethora of proposed yet often unheeded solutions, are certainly nothing new. In fact, the whole topic of ED overcrowding is newsworthy only because it's pathognomonic of a deeper healthcare delivery system malady, and a failure on society's part to confront and come to grip with the real issues..."

martes, 31 de octubre de 2017

Sepsis

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emDocs - October 30, 2017 - Authors: Boushra M and Miller S
Edited by: Koyfman A and Long B
"Summary
In the acutely ill patient without an apparent source, consider musculoskeletal, cardiac, nervous system, and abdominal sources of sepsis. A thorough physical examination, abdominal CT scan, and lumbar puncture may help reveal the source of sepsis. Keep the differential broad when treating the hyperthermic, tachycardic patient, as many conditions can mimic sepsis. A review of the patient’s medical history and medications may be invaluable in pinpointing the source of the patient’s fever and tachycardia. Summarized below are features of sepsis mimics and their treatment."

NIMV (ERS/ATS) 2017

AnestesiaR -
AnestesiaR - Octubre 30, 2017 - By Vizuete
Artículo original

Bochwerg B, Brochard L, Elliott MW, Hess D, Hill NS, Nava S et al. Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure. Eur Respir J 2017; 50: 1602426 (Pubmed) (HTML) (PDF)
"La insuficiencia respiratoria aguda sigue siendo una patología frecuente en la Unidad de Cuidados Intensivos, teniendo su origen en diversas patologías. El tratamiento de la IRA debe ser el de la causa que lo provoca, siendo la ventilación mecánica el soporte necesario para mantener al paciente oxigenado mientras se curan los daños pulmonares causantes de la misma. El soporte respiratorio puede variar desde la simple aplicación de oxigenoterapia, hasta la intubación orotraqueal y conexión a la ventilación mecánica invasiva, pasando por la ventilación no invasiva en diferentes modalidades."
(AnestesiaR - Oct 30, 2017 - Por Jiménez Vizuete JM, Iñiguez De Onzoño A, Sánchez López)


Tabla 1. Resumen de las recomendaciones ERS/ATS sobre el uso de la VNI en la insuficiencia respiratoria aguda.

NSTEMI

R.E:B.E.L.EM - October 30, 2017
"Author Conclusion: “Our meta-analysis suggests that patients with NSTEMI who demonstrate a totally occluded culprit vessel on coronary angiography are at higher risk of mortality and major adverse cardiac events. Better risk stratification tools are needed to identify such high-risk acute coronary syndrome patients to facilitate earlier revascularization and potentially to improve outcomes.”
Clinical Take Home Point:
Total occlusion of culprit artery in acute NSTEMI have an increased risk of MACE and all-cause mortality compared to non-total occlusion, but unfortunately there are no significant differences in high risk clinical features that can allow us to stratify these patients. If you have a patient with NSTEMI and hemodynamic instability or features of ongoing ischemia, be an advocate for your patient and push for an early invasive strategy."

miércoles, 25 de octubre de 2017

EtOH

THE ORIGINAL KING OF COUNTY
The Original King of County - By Surriya - October 24, 2017 
"Summary:
  • Undress patients completely and perform full head to toe exam; rule out all trauma and infection
  • Get full history to risk stratify
  • Consider other medical emergencies
  • Check glucose. Give thiamine before glucose to [theoretically] prevent Wernicke Encephalopathy (unless the patient has acute symptomatic hypoglycemia, in which case giving dextrose immediately is essential)."

Thiamine Deficiency

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emDocs - October 24, 2017 - Authors: Reyes J and Baker A
Edited by: Singh M and Koyfman A
"...The multi-organ manifestations of thiamine deficiency can be explained by the essential role of thiamine in the body’s most basic metabolic processes. Thiamine pyrophosphate or thiamine diphosphate is a coenzyme in the pyruvate dehydrogenase complex, which accelerates the conversion of pyruvate to acetyl coenzyme A. This process links anaerobic glycolysis to the aerobic Krebs cycle which produces 36 mol of adenosine triphosphate (ATP) from 1 mol of glucose.
When thiamine is not available to facilitate these reactions, energy production is limited to the comparatively paltry 2 mol of ATP produced via anaerobic metabolism. Thiamine is also a cofactor for alpha-ketoglutarate dehydrogenase (also of the Krebs cycle) and transketolase (of the pentose phosphate pathway) in which essential nicotinamide adenine dinucleotide and nicotinamide adenine dinucleotide phosphate (NADH and NADPH) are created for use in energy production and reductive biosynthesis.4,7 Thiamine deficiency therefore results in massive energy deficits and defects in cell synthesis, replication, and repair.
In the central nervous system, decreased acetylcholine synthesis results in impaired conduction, and mitochondrial dysfunction from oxidative stress leads to neurodegeneration. In the peripheral nerve and muscle tissues, this leads to decreased sensorimotor activity, muscle atrophy, and neuropathy. In cardiac muscle, lack of thiamine shifts pyruvate toward increased lactate production, resulting in a dysfunctional myocardium..."

Acyclovir for HSV

PulmCrit (EMCrit)
PulmCrit - October 23, 2017 - By Josh Farkas
"Summary: the Bullet:
  • Acyclovir is nephrotoxic and lowers the seizure threshold. Therefore, universal application of empiric acyclovir to all encephalopathic patients while awaiting an HSV PCR would cause harm.
  • Various decision tools are available in the literature to exclude HSV infection on the basis of CSF chemistries and immunologic status. Although this remains controversial, these tools have been validated and may provide a framework for determining which patients require empiric acyclovir.
  • An algorithm incorporating pre-test probability and published decision tools is proposed":

ADvISED (AA Syndromes)

R.E.B.E.L. EM - Emergency Medicine Blog
R.E.B.E.L.EM - October 23, 2017
Background: Acute Aortic Syndromes (AAS) are life threatening cardiovascular emergencies that are the bane of every emergency physician’s existence. They are diagnostic challenges due to the clinical presentation being highly non-specific. Computed tomography angiography (CTA), Transesophageal Echocardiography (TEE), and Magnetic Resonance Angiography (MRA) can help accurately diagnose AAS. CTA exposes patients to radiation and large doses of intravenous contrast, neither of which is a good enough reason to skip the test in patients you think may have a dissection, but certainly not something we want to do to all patients coming to the ED with chest pain. TEE and MRA may not be available or able to be performed in a timely manner. Having a clinical algorithm that can help physicians reduce misdiagnosis and at the same time avoid over-testing are lacking...
"Author Conclusion: “Integration of ADD-RS (both = 0 or ≤ 1) with DD may be considered to standardize diagnostic rule-out of AAS.”
Clinical Take Home Point:
This is a novel clinical strategy in evaluating patients with the potential of Acute Aortic Syndromes (AAS), but still requires external validation, for reproducibility and comparison to overall clinical gestalt before implementation into clinical practice."

miércoles, 18 de octubre de 2017

Budd Chiari Syndrome

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emDocs - October 18, 2017 - Authors: Balogun R and Oliver J
Edited by: Koyfman A and Long 
"Key Points
  • Budd Chiari is a rare syndrome that is usually associated with a hypercoagulable state.
  • Paracentesis may support diagnosis and be therapeutic to the patient.
  • Treatment of this syndrome can be managed medically but may require surgical intervention.
  • Be wary of other serious conditions that may mimic this syndrome such as: constrictive pericarditis, tricuspid insufficiency, right atrial myxoma, congestive heart failure, hepatitis, and cholecystitis."

Necrotizing fascitis

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emDocs - October 16, 2017 - Authors: Cohen P and Musisca N 
Edited by: Koyfman A and Long B
"Take Home Points
  • Necrotizing fasciitis is a challenging diagnosis as it is exceedingly rare and classic findings are often not seen early in the disease.
  • Laboratory and imaging data may aid the diagnosis but are often neither sensitive nor specific and should never replace clinical suspicion.
  • Early diagnosis is essential but difficult to separate from more common diagnoses such as cellulitis. Key early findings include:
    • Tenderness and edema that spreads beyond the apparent boundaries of infection
    • Pain out of proportion to skin findings
    • Ill-defined margins of involvement
    • Rapid progression of infection
  • If a patient presents with the classic findings (shock, bullae, crepitus, skin necrosis, and skin anesthesia), the infection has likely progressed and they need prompt surgical consultation."

Easy IJ

SJRHEM - October 17, 2017 - B Kavish Chandra - Reviewed by Dr. David Lewis
"The “easy IJ”, a quick solution for difficult intravenous access?
The importance of intravenous (IV) access is something seared in the mind of every practicing emergency department physician. Over the years, central intravenous access for difficult IV access has been obviated by the intraosseous drill and line. Furthermore, we just see and do less central IV lines. The likely reasons for this are that running vasopressors in peripheral intravenous (IV) lines is becoming more accepted as well as the increased time associated with placing a fully sterile central line (draping, etc.) as well as the risks of the over-the-wire procedure (infection, deep vein thrombosis, cardiac arrhythmias).
Enter the internal jugular vein catheterization using a peripheral IV catheter, which is placed under a limited sterile environment. Is the 5 minutes to establish access that “easy” when peripheral access and external jugular catheterization has failed?"

GI Bleed (Part 2)

Emergency Medicine Cases Sticky Logo
"In Part 2 of our two part podcast on GI Bleed Emergencies Anand Swaminathan and Salim Rezaie kick off with a discussion on the evidence for benefit of various medications in ED patients with upper GI bleed. PPIs, somatostatin analogues such as Octreotide, antibiotic prophylaxis and prokinetics have varying degrees of benefit, and we should know which ones to prioritize. We then discuss the usefulness of the Glasgow-Blatchford and Rockall scores for risk stratification and disposition of patient with upper GI bleeds and hit it home with putting it all together in a practical algorithm. Enjoy!"

domingo, 15 de octubre de 2017

CT Angiography for Chest Pain

Medscape Logo
Medscape - By Patrice Wendling - October 11, 2017
"HERSHEY, PA — A new meta-analysis shows that use of coronary computed tomography angiography (CTA) is associated with significantly fewer MIs than standard functional stress testing in patients with suspected CAD and acute or stable chest pain.
CTA, however, is also associated with significantly more downstream invasive coronary procedures, CAD diagnoses, and aspirin and statin prescriptions—all without an overall reduction in mortality or cardiac hospitalizations.
"If you look at the strength and robustness of the individual findings, what my coauthors and I can say with high certainty is that cardiac CT compared with functional testing will lead to a significant increase in downstream procedures, whether that's just catheterization or whether it's also revascularization, and we believe that a lot, if not all, of that excess is unnecessary," corresponding author Dr Andrew J Foy (Penn State College of Medicine, Hershey, PA), told theheart.org | Medscape Cardiology.
The study, with senior author Dr Rita Redberg (University of California, San Francisco), was published October 3, 2017 in JAMA Internal Medicine."

Traumatic Hemothorax

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emDocs - October 13, 2017 - By Anand Swaminathan 
Originally published at CoreEM.net, dedicated to bringing Emergency Providers all things core content Emergency Medicine available to anyone, anywhere, anytime. Reposted with permission.

"Take Home Points

  • Always look for concomitant extra-thoracic trauma in patients with hemothorax
  • Hemothoracies should be emergently drained by performing a tube thoracostomy
  • Tube thoracostomies should be placed in the 4th or 5th intercostal space over the rib with care to ensure entry into the thorax and not the abdomen
  • If initial drainage is > 1000-1500 mL or their is continued brisk output (> 300-500 mL in the first hour or > 200 mL every hour for the next 3 hours) consult trauma surgery for emergent OR management"

SVT AND DOACs

St. Emlyn´s - October 13, 2017 - By Dan Horner
"Been a while since we have had any clotology on here. That is unacceptable. So here we go with another journal club fest on the management of acute VTE.
Now we have improved access to whole leg compression ultrasound, some reliable safety data around the use of this technology and a specialist society for vascular sonographers it is not surprising that we are picking up more and more small clots in an ED setting. Here in both east and west Virchester, we can add to this number an increased rate of confirmed superficial vein thrombosis (SVT), or thrombophlebitis by its old name. Not a bad thing really, when you consider that unprovoked thrombophlebitis can herald fairly nasty thromboembolic disease, or sometimes even malignancy. These clots often extend far more proximal than their symptomatic margin, and sonographic confirmation and characterisation can be useful to guide treatment decisions.
There is evidence (from the STENOX 1 and CALISTO 2 trials) to suggest that treatment of these clots can lead to a reasonable reduction in serious event rates. An alumnus of virchester has also recently looked at the management of superficial vein thrombosis for her FRCEM clinical topic review. Pretty convincing data to treat these patients with prophylactic dose anticoagulation really. This evidence is supported by BMJ best practice and ACCP guidelines, that offer risk stratification criteria so you can perhaps select out those likely to result in higher risk and concentrate on advising those patients carefully regarding treatment options. However, the current evidence base is for fondaparinux treatment and 6 weeks of injections can be a real (and literal) pain. If patients are reluctant to self inject, then it also can come at considerable cost and nursing resource. One wonders if there is another way…."

RCEM 50th. birthday

St. Emlyn´s - October 12, 2017
"The Royal College of Emergency Medicine (RCEM) is celebrating a landmark in is history: its 50th birthday. To mark this event, RCEM has been doing a number of things...
Simon, Laura and I were also asked to write pieces to mark the occasion. I was asked to write some reflections on the progress of EM research. With RCEM’s permission, I’m now publishing that for free below. My contribution is one of 50 special chapters, each written by a different author. There are some real gems in there! You can buy a copy at this link..."

jueves, 12 de octubre de 2017

GI Bleed

Emergency Medicine Cases Sticky Logo
"Join Anand Swaminathan, Salim Rezaie and Jeannie Callum to discuss the management of some of our most challenging GI bleed emergencies. In this Part 1 of our two part podcast on GI bleed emergencies we answer questions such as: How do you distinguish between an upper vs lower GI bleed when it’s not so obvious clinically? What alterations to airway management are necessary for the GI bleed patient? What do we need to know about the value of fecal occult blood in determining whether or not a patient has a GI bleed? Which patients require red cell transfusions? Massive transfusion? Why is it important to get a fibrinogen level in the sick GI bleed patient? What are the goals of resuscitation in a massive GI bleed? What’s the evidence for using an NG tube for diagnosis and management of upper GI bleeds? In which patients should we give tranexamic acid and which patients should we avoid it in? How are the indications for massive transfusion in GI bleed different to the trauma patient? What are your options if the bleeding can’t be stopped on endoscopy? and many more…"

Donación de órganos

Resultado de imagen de semesResultado de imagen de organizacion nacional trasplantes
Documento elaborado por el Grupo Colaborativo ONT-SEMES encuadrado en el Convenio de colaboración entre la Organización Nacional de Trasplantes y la Sociedad Española de Medicina de Urgencias. 
"Los profesionales de urgencias desempeñan un papel relevante en el proceso de donación de órganos y son uno de los pilares fundamentales en la identificación y derivación de posibles donantes a las unidades de cuidados intensivos. La cooperación ONT-SEMES a nivel institucional, y entre los coordinadores de trasplantes y los profesionales de urgencias y emergencias, constituye una de las líneas estratégicas de mejora de la donación de órganos en España al considerarlo un proceso multidisciplinar donde intervienen los servicios de emergencias (SE), urgencias hospitalarios (SHU), de neurología y de cuidados intensivos (UCI). En los últimos años se ha consolidado la integración de la donación en los cuidados al final de la vida como una opción que debe plantearse siempre que sea razonable y factible. Esto ha condicionado un cambio en la secuencia de actuación al plantearse la posibilidad de ingreso para donación en aquellos pacientes que, debido al mal pronóstico vital por la lesión inicial, no son tributarios de tratamiento médico/quirúrgico pero podrían evolucionar a muerte encefálica (ME) y, en consecuencia, ser donantes de órganos si se inician medidas de soporte vital adecuadas. Todo lo anteriormente expuesto hace que sea fundamental elaborar e implementar unas recomendaciones que integren procedimientos basados en la actuación multidisciplinar, toma de decisiones compartida y en la comunicación veraz con los familiares acerca del diagnóstico y pronóstico del paciente y su ingreso en unidad de cuidados intensivos con el propósito de la donación."