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

WORLD EMERGENCY MEDICINE SOCIETIES & RELATED

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martes, 31 de marzo de 2020

LVA post MI

Logo
emDocs - March 31, 2020 - By Bridwell R and Tannenbaum LL
Reviewed by: Santisteva J; Singh M and Long B

"The main pointers:
  1. Acquiring an old ECG is key to differentiating LV aneurysm from anterior STEMI, with a T-wave amplitude:QRS amplitude assisting in differentiation
  2. STEMI can be superimposed on LV aneurysm, and in this case the T-wave again becomes upright with higher amplitude.
  3. LV aneurysm patients are at very high risk of dysrhythmias and thromboembolic events"

domingo, 29 de marzo de 2020

COVID19 CC PROJECT

Maryland CCP Network
  • Biomarkers and Scoring Systems
    • As more patients are reported, this information is likely to change. The following is mainly based on the case reports mostly from the Chinese data that has been published so far in the literature. Key Points Lymphopenia has been the most prevalent and consistent finding in both severe and non-severe …
  • Vent Management for COVID-19 Patients
    • Below is a summary of ventilator management for patients with COVID-19 infection.
  • Imaging in the Age of COVID-19
    • This post summarizes the role of chest x rays and CT scans in patients with COVID-19 infections.
  • Ultrasound in the Age of COVID-19
    • Ultrasound is likely to play a great role in managing patients with COVID-19 infections, given that it can be done at bedside avoiding transportation, and exposing additional staff members.
  • Helpful Links and Resources
    • Below is a list of helpful resources.
  • Complications – References
    • Annotated List of Sources Reviewed for Complications.

sábado, 28 de marzo de 2020

jueves, 26 de marzo de 2020

The DOSE VF Pilot RCT

REBEL Crit - By Ramzy M - March 26, 2020
Paper: Cheskes S et al. Double Sequential External Defibrillation for Refractory Ventricular Fibrillation: The DOSE VF Pilot Randomized Controlled Trial. Resuscitation 2020. PMID: 32084567

"Clinical Question: How feasible and safe is a full scale RCT of alternate defibrillation strategies in treating refractory ventricular fibrillation?
Author’s Conclusions:
Our findings suggest the DOSE-VF protocol is feasible and safe. Rates of VFT and ROSC were higher in the VC and DSED than standard defibrillation. The results of this pilot trial will allow us to inform a multicenter cluster RCT with crossover to determine if alternate defibrillation strategies for refractory VF may impact clinical outcomes.
Our Conclusion:
Although a pilot study, the findings of this RCT are promising regarding the role of VC and DSED on VF termination and achieving ROSC. Unfortunately, several methodological flaws still leave many questions unanswered regarding DED. More importantly the impact DED has on patient centered outcomes (ie. mortality, survival to discharge, return to functional activities of daily living, etc) is not addressed and is unclear if it will be in the main RCT. The authors have successfully displayed that a double defibrillation RCT is safe and feasible, however they should consider limiting the number of confounding variables and adding a follow-up component to identify DED’s role in patient centered outcomes.
Clinical Bottom Line:
Emergency physicians should continue to consider the use of a second defibrillator when treating refractory ventricular fibrillation. It isn’t clear from this study if increased ROSC will translate into improve neurologically intact survival. In settings where a second defibrillator is not available or not feasible, changing pad placement from anterolateral to anteroposterior when performing defibrillation may help improve VF termination and achievement of ROSC."

martes, 24 de marzo de 2020

Acute Aortic Occlusion

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emDocs - March 24, 2020 - By: Adibi S  - Reviewed by: Lew E; Koyfman A; Long B
"Pearls
  • A high index of suspicion should be maintained for sudden onset of bilateral lower extremity paresthesias/pain/weakness in combination with signs of diminished flow (mottling, decreased peripheral pulses, etc).
  • CT is imaging modality of choice, but US is a rapid bedside assessment you can use.
  • Definitive treatment lies with consultation in vascular surgery for OR. Consider anticoagulation to prevent propagation of clot."

lunes, 23 de marzo de 2020

EXTEND-IA TNK

Logo
R.E.B.E.L.EM - March 23, 2020 - By Anand Swaminathan
Article: Campbell BCV et al. Effect of intravenous tenecteplase dose on cerebral repercussion before thrombectomy in patient with large vessel occlusion ischemic stroke: The EXTEND-IA TNK Part 2 Randomized Clinical Trial. JAMA 2020. PMID: 32078683
"Clinical Question: Does higher dose tenecteplase (0.40 mg/kg) result in improved cerebral reperfusion when administered prior to endovascular therapy in LVO ischemic stroke?
Authors Conclusions:
“Among patients with large vessel occlusion ischemic stroke, a dose of 0.40mg/kg, compared with 0.25mg/kg, of tenecteplase did not significantly improve cerebral reperfusion prior to endovascular thrombectomy. The findings suggest that the 0.40-mg/kg dose of tenecteplase does not confer an advantage over the 0.25-mg/kg dose in patients with large vessel occlusion ischemic stroke in whom endovascular thrombectomy is planned.”
Our Conclusions: A higher dose of tenecteplase did not result in an improvement of the disease centered primary outcome of improved perfusion. Additionally, there was no difference in patient centered outcomes that were investigated as secondary outcomes. Though not clinically significant, there was a 3-fold increase in intracranial hemorrhage with the higher dose.
Potential to Impact Current Practice: Standard doses of systemic lytics should be continued to be used in patients presenting with LVO acute ischemic strokes who present within established timelines and are eligible for EVT. The bigger question is whether future research will show that systemic thrombolytics are unnecessary in these patients all together."

COVID-19 Resource Center

"What's New
New info is coming out daily. We’ll do our best to update this page as we learn more. To start, we launched two critical reviews about recommended calcs for resource-limited situations and odds ratios for mortality."

domingo, 22 de marzo de 2020

Covid19 PoCUS

"A resource of the best in #POCUS ultrasound resources from the best in #POCUS providers around the world - dedicated to the fight against Covid19
Thank you to everyone who has poured their passion, time and energy into each and every one of these resources."

sábado, 21 de marzo de 2020

Biomarkers for CAP

SGEM#287 - By admin - Mar 21, 2020
Reference: Ebell et al. Accuracy of Biomarkers for the Diagnosis of Adult Community-Acquired Pneumonia: A Meta-analysis. AEM March 2020

"CLINICAL QUESTION: 
WHAT IS THE ACCURACY OF BIOMARKERS FOR THE DIAGNOSIS OF COMMUNITY ACQUIRED PNEUMONIA?


SGEM BOTTOM LINE: 
DO NOT RELY ONLY UPON A BIOMARKER IN THE EMERGENCY DEPARTMENT TO RULE IN OR RULE OUT COMMUNITY ACQUIRED PNEUMONIA."

martes, 17 de marzo de 2020

COVID-19 and O2 therapy

MEDEST - March 16, 2020 - 
..."So when dealing with O2 therapy in the potentially infected patients we need to consider the relationship between risk of contamination and clinical efficacy of any device...
Utilising a different device than nasal cannula plus medical mask on the patient mouth and nose (simple, non rebreather or Venturi face mask) to deliver oxygen therapy all healthcare professionals need to be aware that the risk infection increases and the patient has no barriers and so they have to consider improving his own self protection level (N95, FPP2 mask at least)

Chest CT in COVID-19

PulmCCM
PulmCCM - March 16, 2020 -  Jon-Emile S. K with illustrations by Canepa C
"Thoughts
Overall, it looks certain that the diagnosis of COVID-19 will initially present challenges as North America begins to grapple with SARS-CoV-2 in a way that other continents and countries, particularly China, already have. Nevertheless, it may be wise to follow the screening strategy adopted in China as their approach appears to have been quite successful. ‘Fever clinics’ established in China embraced aggressive use of both PCR and chest CT to help catch all possible infections. Given the early and sensitive findings of viral pneumonia detected by CT, its role as a screening adjunct seems clear. Nevertheless, chest CT is a limited resource and this may open the door for other, more available, modalities [e.g. point-of-care ultrasound, POCUS] to aide in the rapid diagnosis of viral pneumonia. Thus, intensivists may ultimately need to find POCUS love in the time of coronavirus."

CPAP and COVID-19

PulmCrit (EMCrit)
PulmCrit Wee - March 17, 2020 by Josh Farkas
"Summary The Bullet
  • COVID-19 appears to cause an unusual form of hypoxemic respiratory failure, with profound hypoxemia but normal lung compliance. This might be due to diffuse atelectasis.
  • CPAP could be a desirable mode of noninvasive support for these patients. CPAP is the modality which provides the most powerful lung recruitment (highest mean airway pressure). It also has the advantage of avoiding injuriously large tidal volumes.
  • The optimal role of noninvasive support modes in COVID-19 is currently unknown. CPAP could be a rational selection for some patients with moderate hypoxemia and single-organ failure. As always, further evidence is needed."

domingo, 15 de marzo de 2020

COVID-19 Drug Interactions

Resultado de imagen de university of liverpool
Prescribing Resources
The Liverpool Drug Interaction Group (based at the University of Liverpool, UK), in collaboration with the University Hospital of Basel (Switzerland) and Radboud UMC (Netherlands), have produced various materials in PDF format to aid the use of experimental agents in the treatment of COVID-19.
Please check this site regularly for updates and additional information.

sábado, 14 de marzo de 2020

COVID19 Intubation Packs

EMCrit RACC
EMCrit RACC - March 13, 2020 - By Scott Weingart
The video contains what I feel is the safest, most effective way to preoxygenate a COVID19 patient. Safe for them, but especially safe for your team.

Covid-19 from Italy

St Emlyn’s - By Simon Carley - March 14, 2020
"Dr Roberto Cosentini is an old friend of St Emlyn’s who works in Bergamo, in Northern Italy. He is right at the heart of the recent Covid19 outbreak. He kindly found an hour to record a podcast with us on his experiences. Click on the link below to listen
There are so many essential lessons in this podcast. Please share with clinical and non-clinical colleagues, as we need to plan NOW. Roberto is quite clear that if we don’t train and get plans into place before the wave of cases hit us then both ourselves and our patients will suffer."

jueves, 12 de marzo de 2020

Spontaneus Pneumothorax

R.E.B.E.L.EM - March12, 2020 - By Tarlan Hedayati 
"Paper: Brown SGA et al. Conservative Versus Interventional Treatment for Spontaneous Pneumothorax. NEJM 2020. PMID: 31995686
Clinical Question: Is conservative management an acceptable alternative to invasive management for uncomplicated, moderate to large primary spontaneous pneumothorax?
Author Conclusion:“Although the primary outcome was not statistically robust to conservative assumptions about missing data, the trial provides modest evidence that conservative management of primary spontaneous pneumothorax was noninferior to interventional management, with a lower risk of serious adverse events.”
Clinical Take Home Point: In a select and carefully identified subset of patients with large primary spontaneous pneumothorax in a clinical setting that can accommodate both observation and potential emergent intervention, a conservative management approach of observation may obviate the need for chest tubes. For many clinicians, this strategy may not be feasible. The authors of this trial have posed a critical question and laid the foundation for a shift in the management of larger primary spontaneous pneumothoraces."

miércoles, 11 de marzo de 2020

Vascular Disasters

REBEL Core Cast 29.0 - March 11, 2020 - By Anand Swaminathan
"Vascular Disasters Take Home Points
  1. Consider vascular pathologies in all of your patients with atraumatic limb pain – especially those with typical and atypical risk factors
  2. Early diagnosis is imperative. Time is tissue. Catch this as early as possible. Pain is the earliest symptom. First presents with pain then paresthesia then paralysis
  3. Perform vascular exam on every patient with pain
  4. If concerned for ischemic limb, call the vascular surgeon and get patient to CT for imaging of aorta and affected limb."
More Reading/Listening

martes, 10 de marzo de 2020

Coding for Coronavirus

Medscape - Betsy Nicoletti - March 4, 2020
The CDC guidance provides specific examples for patients with conditions caused by the coronavirus. Notice that all of these examples are for conditions confirmed as due to COVID-19.
  • Pneumonia, confirmed as due to COVID-19
    • J12.89: other viral pneumonia
    • B97.29: other coronavirus as the cause of diseases classified elsewhere
  • Acute bronchitis, confirmed as due to COVID-19
    • J20.8: acute bronchitis due to other specified organisms
    • B97.29: other coronavirus as the cause of diseases classified elsewhere
  • Bronchitis, not specified as chronic or acute, confirmed as due to COVID-19
    • J40: bronchitis, not specified as acute or chronic
    • B97.29: other coronavirus as the cause of diseases classified elsewhere
  • Lower respiratory infection, confirmed as due to COVID-19
    • J22: unspecified acute lower respiratory infection
    • B97.29: other coronavirus as the cause of diseases classified elsewhere
    • or
    • J98.8: other specified respiratory infection
    • B97.29: other coronavirus as the cause of diseases classified elsewhere
  • Cases with acute respiratory distress syndrome (ARDS), confirmed as due to COVID-19

lunes, 9 de marzo de 2020

10 FAST mistakes

THAMING THE SRU
Taming The SRU - By Susan Owens - March 09, 2020
"FAST - Focused Assessment with Sonography in Trauma. A tool used daily by emergency medicine providers to assess the unstable trauma patient. While touted as an easy and quick way to look for hemorrhagic causes of instability in the trauma patient, the FAST exam can be deceptively tricky. The exam has many pitfalls that can cloud the picture or make image acquisition difficult. When doing a time sensitive exam in high stakes situations there are opportunities for interpretation errors. We all love the FAST – it helps us expedite dispositions, activate resources quickly, and provide better care for our patients; but when it all doesn’t come up roses the FAST exam can really drive you nuts.
Below is a list of 10 common mistakes that occur while performing the FAST exam, along with quick tips to mitigate these errors…"

HFNC vs COT vs NIV

R.E.B.E.L.EM - March 9, 2020 - By Jenny Beck-Esmay
Article: Tinelli V et al. High Flow Nasal Cannula Oxygen Vs. Conventional Oxygen Therapy and Noninvasive Ventilation in Emergency Department Patients: A Systematic Review and Meta-Analysis. JEM 2019. PMID: 31421952
"Clinical Question: In patients with acute respiratory failure in the ED, does conventional oxygen therapy vs high flow nasal cannula vs noninvasive ventilation reduce intubation requirements?
Author Conclusion: “We did not find any benefit of HFNC compared with COT and NIV in terms of intubation requirement, treatment failure, hospitalization, and mortality; COT was better tolerated.”
Clinical Take Home Point: This meta-analysis does not answer the primary question of COT vs HFNC in acute respiratory failure in the ED, due to the small number of trials, the methodological issues mentioned above, and the heterogeneity in the causes of acute respiratory failure, which are not defined in the review. The best we can say, is use the oxygen delivery device that improves oxygen saturation, ventilation where needed, and most comfortable for the patient. This will most likely vary depending on the cause and severity of acute respiratory failure."

TXA for GI bleeds

TXA for GI Bleeds
First10EM - By Justin Morgenstern - March 9, 2020
"Bottom line for TXA in GI bleeds
Small trials with high risk of bias leave us unsure. The Cochrane review says “this review found no evidence that tranexamic acid offers benefit to patients with upper gastrointestinal bleeding, in terms of mortality, bleeding, surgery, or transfusion requirements.” However, their results do show a statistical significant reduction in mortality. (Bennett 2014) Hopefully the large RCT currently underway will settle the issue.
Given the potential reduction in mortality, if you have an IV free and it won’t delay more important therapies, I think giving a bolus of TXA while waiting for definitive management is completely reasonable. However, I also won’t be surprised when the HALT-IT trial is negative (and then we have a another big debate about the meaning of secondary outcomes)."

domingo, 8 de marzo de 2020

The Novel Coronavirus 2019

R.E.B.E.L.EM - March 01, 2020 - By Salim Rezaie
"The Novel Coronavirus 2019, was first reported on in Wuhan, China in late December 2019. The outbreak was declared a public health emergency of international concern in January 2020. The spread of this virus is now global with lots of media attention. The virus has been named SARS-CoV-2 and the disease it causes has become known as coronavirus disease 2019 (COVID-19). This new outbreak has been producing lots of hysteria and false truths being spread, however the data surrounding the biology, epidemiology, and clinical characteristics are growing daily, making this a moving target. This post will serve as a summary of what is currently known, how to screen, when to test, and how to prevent spread of COVID-19..."

sábado, 7 de marzo de 2020

Influenza vs. Coronavirus

MarylandCCP - March 06, 2020 - By Deming M and Williams S
Resultado de imagen de vimeo

jueves, 5 de marzo de 2020

Alteplase for Stroke

EM PharmD Logo
By EM PharmD - March 4th, 2020
Ditch Alteplase for Stroke. It’s the easiest way to save $250,000/year.
For almost 25 years, rt-PA (Alteplase) has been the exclusive drug therapy for acute ischemic stroke. Despite the availability of other fibrinolytics that have established roles in cardiology by maintaining therapeutic benefits while improving safety (bleeding), agents like TNKase (aka tenecteplase) have not been a real consideration. But that has been changing over the past few years. 
In fact, a recent meta-analysis of 5 RCTs demonstrated the noninferiority of TNKase when compared to rt-PA in mRS of 0-1 at 3 months [n=1585, 57.9% vs 55.4%, respectively with a random-effect informal risk difference of 4% (95% CI -1% to 8%) meeting non-inferiority margin of -1.3%]. When extending the mRS scale to 0-2 at 3 months, the results were similar, however, the lower end of the 95% CI of -4% was within 2 of the 3 non-inferiority margins (-6.5%, -5% but not -1.3%). Furthermore, there were similar rates of symptomatic ICH between groups of 3% in each group (95% CI -1% to 2%)...
..."The findings suggest that the 0.40 mg/kg dose of tenecteplase does not confer an advantage over the 0.25 mg/kg dose in patients with large vessel occlusion ischemic stroke in whom endovascular thrombectomy is planned.
What’s left unanswered from this study is whether patients not undergoing planned endovascular thrombectomy would see a similar benefit. Based on all the available data, I would estimate that if a difference in efficacy did exist, it would be small and not significant..."

References for Ditch Alteplase for Stroke:
  • Burgos AM, Saver JL. Evidence that Tenecteplase Is Noninferior to Alteplase for Acute Ischemic Stroke Meta-Analysis of 5 Randomized Trials. Stroke. 2019;50:2156–2162
  • Campbell BCV, Mitchell PJ, Churilov L, et al. Effect of Intravenous Tenecteplase Dose on Cerebral Reperfusion Before Thrombectomy in Patients With Large Vessel Occlusion Ischemic Stroke: The EXTEND-IA TNK Part 2 Randomized Clinical Trial. JAMA. Published online February 20, 2020.

COVID-19 Intubation

CanadiEM
CanadiEm -  By Patrick Boreskie - March 5, 2020
Intubation and the steps leading up to it are some of the highest-risk moments for COVID-19 spread to healthcare workers and other patients.​ In Wuhan, “intubation teams” were established to perform multiple intubations per hour while maintaining strict protocols to limit viral exposure. Who is going to be part of your intubation team? What gear and approach will you use? How will this differ from the average intubation? This infographic was created as a visual reminder of the emerging best practices for intubating a COVID-19 suspect, based on current evidence from China and prior understanding of SARS. Recommendations may evolve with further research.

Download Infographic

lunes, 2 de marzo de 2020

Scores and Rules for ED

iEM - March 2, 2020 - By Kaushila Thilakasiri
Useful scores and rules for ED

The DOSE VF trial

double sequential defibrillation
First 10EM - By Justin Morgensten - Published March 2, 2020
"Double sequential defibrillation has been all the rage over the last few years in emergency medicine. If one shock isn’t enough, use two. (By that logic, I am sort of surprised that no one has moved on to triple sequential defibrillation yet, but there is still time.) There has never been great evidence for the practice, and actually some observational data suggesting it might not be helpful. (Mapp 2019; Emmerson 2017; Cheskes 2019) However, we now have the first proper randomized trial looking at the practice, and the results aren’t bad.
The paper:  Cheskes S, Dorian P, Feldman M, et al. DOuble Sequential External Defibrillation for Refractory Ventricular Fibrillation: The DOSE VF Pilot Randomized Controlled Trial. Resuscitation. 2020; PMID: 32084567 [article] NCT03249948
Bottom line
This small pilot study suggests that ROSC may be improved with double sequential defibrillation (and also with vetor change defibrillation) for patients with refractory ventricular fibrillation. It isn’t clear if this will translate into improved neurologically intact survival, but I think it is enough to support the practice while waiting for more data."

Blood Culture in Sepsis

R.E.B.E.L.EM - March 2, 2020 - By Salim Rezaie
"Background: The cornerstones of sepsis management include early identification, early antimicrobial administration, and source control. The Surviving Sepsis Campaign guidelines recommend that blood cultures be drawn before starting antimicrobial therapy, however, obtaining cultures prior to antibiotics may be challenging due to shorter time windows (i.e. 1hr from identification) to initiate antibiotics. Some may prioritize administering antimicrobial agents before obtaining blood cultures to ensure they meet this core measure. This study (The FABLED Trial) tried to determine the sensitivity of blood cultures obtained both before and after initiation of antimicrobial therapy in patients with severe manifestations of sepsis.
Author Conclusion: “Among patients with severe manifestations of sepsis, initiation of empirical antimicrobial therapy significantly reduces the sensitivity of blood cultures drawn shortly after treatment initiation.” 
Clinical Take Home Point: In a relatively sick septic patient population, drawing blood cultures after administration of antibiotic treatment reduces culture sensitivity which could affect downstream optimization of treatment as well as safe de-escalation of treatment."

Unstable AF

Logo
emDocs - March 2, 2020 - Authors: Blackmon M and Kester N
Reviewed by: Lentz S; Koyfman A; Long B
"Take Home Points
  • Don’t prematurely assume that the hypotension in your patient with a-fib is due to the arrhythmia. Do a thorough evaluation for other causes of shock before lowering the rate.
  • When cardioverting your unstable patient with a-fib, do it right the first time; start out at 200J and consider adding external pressure to the anterior pad.
  • Use push dose phenylephrine or a drip to stabilize the BP before trying to control the rate.
  • Consider Amiodarone or Esmolol as the drug of choice for rate control in the crashing patient with a-fib."

AVP in Haemorrhagic Shock

St Emlyn’s - Craig Ferguson - March 2, 2020
"Blood product transfusion can be lifesaving for patients who have suffered major trauma, but the associated side-effects and risks, mean that most people would agree that less is more. This paper by Sim et al examines whether giving arginine vasopressin (AVP) can reduce blood product requirements in patients receiving massive transfusions following trauma. 
Effect of Low-Dose Supplementation of Arginine Vasopressin on Need for Blood Product Transfusions in Patients With Trauma and Hemorrhagic Shock. A Randomized Clinical Trial. JAMA Surg. 2019;154(11):994-1003. doi:10.1001/jamasurg.2019.2884
Bottom Line?
This paper suggests that the use of AVP did reduce the administration of blood products in major trauma patients requiring transfusion of more than six units; however, this failed to translate into any measurable clinical outcome, other than the unexpected reduction in DVT incidence, so I don’t think I’m ready to change my practice yet. 
The authors suggest a further, larger study is required to demonstrate the true effect but given the lack of demonstrated clinical benefit, and the small number of patients that this is applicable to, it may be some time before this is completed."

miércoles, 26 de febrero de 2020

REBEL Core Cast 28.0

REBEL Core Cast 28.0 - February 26, 2020 - By Anand Swaminathan 
"Take Home Points 
  • No palpable pulse does not equal no perfusion. We aren’t great at feeling pulses
  • Patients with moderate to severe signs and symptoms of lithium toxicity should be considered for hemodialysis
  • Always consider serious causes of back pain before simply treating with analgesics
  • Consider trauma as well as other toxic exposures (I.e. CO and CN) in patients with major burns"

martes, 25 de febrero de 2020

20 abstracts from SCCM

PulmCrit (EMCrit)
PulmCrit-  February 25, 2020 - By Josh Farkas
"The Society of Critical Care Medicine published over 1,800 abstracts to go along with their latest conference. I sifted through them to come up with my favorite 20. Kudos to all the authors on creating diverse and thoughtful work – the future of critical care is indeed bright!
The abstracts are divided into six groups: cardiology, hematology, pulmonology, nephrology, neurology, and miscellaneous. No matter what your interests are, there's probably something here for you."

Stress Ulcer Prophylaxis

R.E.B.E.L.EM - February 24, 2020 - By Zaf Qasim
"Clinical Take Home Point:
  • This is a good attempt at trying to answer a clinically-relevant question for intensivists (and ED physicians who are having to manage ICU boarders for a longer period of time). The authors attempted to achieve statistical power through a huge number of included patients, and generalizability by recruiting across many nations in multiple ICUs. Ultimately, the interpretation of the data was limited due to the nonadherence to the study protocol and the use of registry data for their analysis.
  • Even though there may be lower rates of gastrointestinal bleeding in the PPI group, there is no statistically significant reason in terms of mortality to use PPI over H2RB (and there may in fact be some more harm in using PPIs).
  • For the time being, we should continue to use H2RBs as the primary agent for stress ulcer prophylaxis in mechanically ventilated ICU patients."

domingo, 23 de febrero de 2020

EM Right Care Top 10 List

The Skeptic´s Guide to EM - By admin - February 22, 2020
"EM RIGHT CARE TOP 10 LIST:
Listen to the SGEM podcast to hear Dr. Dorsett and Cooper expand on each of these items.
  1. Avoid further testing beyond history, physical exam, clinical gestalt and ECG in patients who are at minimal risk of an acute coronary syndrome (ACS).
  2. Avoid further testing beyond history, physical exam and clinical gestalt in patients who are at minimal risk of pulmonary embolus (PE).
  3. Be judicious with the use of imaging, especially advanced imaging, in trauma patients.
  4. Avoid routine laboratory testing.
  5. Consider non-medical reasons for a patient’s presentation to the ED.
  6. Tailor the intensity of care to the goals of the patient.
  7. Employ shared decision-making (SDM) where appropriate.
  8. When prescribing an intervention, make an effort to ensure that the patient is capable of accomplishing what is recommended.
  9. Tailor discharge instructions and follow-up recommendations to the individual patient.
  10. Be an advocate.
Conclusion: “The RCA is working to change the conversation about American healthcare, advocating for access for all individuals to high-quality care without financial hardship, eliminating overuse and underuse, and championing the partnership between the patient and clinician. The EM Council’s top 10 list seeks to serve as a starting point to focus ED clinicians in achieving the goals of the RCA. While other lists exist, and we agree with many Choosing Wisely areas of focus, we seek to move the needle even further. In what is ultimately an impossible attempt never to miss a single case with a life-threatening diagnosis, we paradoxically cause a great deal of harm to the overall population through over-testing and contribute to the untenable rising cost of healthcare...”

sábado, 22 de febrero de 2020

Acute kidney injury calculator

Clinical Kidney Journal
CMartin-Cleary C, Molinero-Casares L, Ortiz A, Arce-Obieta J
Clinical Kidney Journal, sfz139, https://doi.org/10.1093/ckj/sfz139
Published: 07 November 2019
"Conclusions
MAKIPS is a new risk score to predict the risk of hospital-acquired AKI, based on variables present at admission in the electronic clinical records. This may help to identify patients who require specific monitoring because of a high risk of AKI." 

"Disclaimer:
The AKI Risk Calculator estimates the probability of acute kidney injury based upon baseline characteristics of the patient (previous co-morbidities the patient has been diagnosed with or has disclosed), laboratory values, and, if applicable, the invasive procedures and surgeries the patient may be subjected to.
Please note the risk percentages provided to you by the AKI Risk Calculator are only estimates. The risk estimate only takes certain information into account. There may be other factors that are not included in the estimate which may increase or decrease the risk of acute kidney injury. These estimates are not a guarantee of results. AKI Risk Calculator is not responsible for medical decisions that may be made based on the risk calculator estimates, since these estimates are provided for informational purposes."