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

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martes, 19 de enero de 2021

Non-Pregnant Vaginal Bleeding

emDocs - January 18, 2021 - By Emily Guy, Julie T. Vieth
Reviewed by: Marina Boushra; Alex Koyfman; Brit Long
"Takeaways:
  • Initial evaluation should assess for hypovolemia and hemodynamic instability. If the patient is unstable, follow the tried-and-true tenants: large bore IVs, monitors, resuscitation with blood products.
  • Perform a focused gynecologic history and physical examination, including a chaperoned pelvic examination, to assess for the underlying cause of heavy vaginal bleeding.
  • Initial treatment should focus on medical management:
    • Massive bleeding: conjugated estrogen 25mg IV +/- TXA 1300mg PO or 10mg/kg IV
    • Stable bleeding: OCPs, progestin-only pills, NSAIDs, oral TXA
  • The need for surgical treatment depends on the patient’s stability, severity of bleeding, response to medical management, or contraindication to medical management.
    • Consult gynecology early in patients with severe bleeding.
    • Attempt tamponade with a 26F foley inflated with 30ml saline.
  • May pack the vagina with betadine-soaked gauze as a temporizing measure. Close follow-up with gynecology is recommended even for stable patients."

Tracheoinnominate Artery Fistula

EM SIM CASES
EM SIM CASES - January 19, 2021 - By Jared Baylis
..."Tracheostomy patients are infrequently seen in the emergency department, leading to an unfamiliarity around important anatomical considerations and tracheostomy hardware management. These individuals can harbour acutely life-threatening pathology, with the most feared being the tracheoinnominate artery fistula. This diagnosis requires a high level of suspicion and a sequence of rapid interventions to protect the airway from on-going hemorrhage, temporize the bleeding via a HALO procedure (Utley maneuver), and stabilize the patient for definitive OR management. The team leader’s crisis resource management skills will be strained in this case given the multitude of serious competing life-threats, navigation of unfamiliar and complex airway anatomy, and the utilization of a HALO procedure..."

sábado, 16 de enero de 2021

TRALI

EM@3AM - January 16, 2021- By Rachel Bridwell
Reviewed by: Brit Long and Alex Koyfman
"Pearls:
  • Underrecognized in population receiving transfusion has presents similarly to ARDS
  • Common in cardiac surgery patients
  • More common in donor products from parous female donor in apheresis components
  • Occurs within 6 hours of transfusion, pulmonary infiltrates in the absence of cardiac dysfunction
  • High rates of intubation in this population, requiring barotrauma mitigation
  • Potential benefit with steroids"
Further Reading (FOAM resources)

miércoles, 13 de enero de 2021

Drowning and Submersion Injuries

emDocs - January 13, 2021 - By Morgan McCarthy and Emilie Powell
Reviewed by: Edward Lew; Alex Koyfman and Brit Long
"Clinical Pearls:
  • Resuscitation focus should be on ventilation due to loss of surfactant.
  • Hypothermia can be neuroprotective: hours of resuscitation may still lead to complete recovery.
  • Antibiotics should only be given if water was grossly contaminated, glucocorticoids are not recommended, and there is no strong data on the use of surfactant.
  • Symptomatic patients, those with shortness of breath, chest pain, cough, nausea or vomiting, should be monitored in the ED for a minimum for 6 hours and should be counseled on prevention and risk factors for drowning."

Fall from Height

CanadiEM - By Denise Wooding - January 12, 2021
"Pearls
  • Workplace accidents and suicide attempts are common causes of falls from height, and should generally be approached using ATLS guidelines
  • Factors like height of the fall, age, surface landed on, and body positioning at landing affect morbidity, mortality and injury pattern
  • Vertebral fractures are the most common injury, are frequently asymptomatic, and must be carefully excluded
  • If it is appropriate to apply the Canadian C-spine rules, imaging will be recommended due to dangerous mechanism
  • Consider psychiatric assessment in intentional falls"

lunes, 11 de enero de 2021

Pulmonary Hypertension

emDocs - January 11, 2021 - By  Rachel Bridwell
Reviewed by: Brit Long; Skyler Lentz; Alex Koyfman
"Key Points:
  • Myriad of chief complaints can be pulmonary hypertension; try to determine what is triggering the acute decompensation.
  • Elevations in troponin and liver function tests portend a poor prognosis.
  • Point of care ultrasound may be useful in guiding acute resuscitation, though evaluation of IVC may not reflect intravascular volume.
  • Avoid hypoxemia and hypercarbia and maintain right ventricular preload support.
  • Most patients will be admitted.
  • Avoid intubating these patients if at all possible.
  • Restart PAH meds if discontinued."

Working night shifts

First 10EM - By Justin Morgenstern - January 11, 2021
The Paper
Wallace PJ, Haber JJ. Top 10 evidence-based countermeasures for night shift workers. Emerg Med J. 2020 Sep;37(9):562-564. doi: 10.1136/emermed-2019-209134. PMID: 32332056
"Bottom line
Looking after ourselves on night shifts is essential. It is essential because we will be doing these shifts throughout our careers, and our personal well being needs to be a priority. It is also essential for our patients, because we cannot not provide our patients with optimal care if we are not alert on shift. This article was a great summary of the available evidence, and therefore a worthwhile read for all nightshift workers."

ITACTIC

REBEL Cast Ep94 - By Salim Rezaie - January 11, 2021
Paper: Badsaas-Aasen K et al. Viscoelastic Haemostatic Assay Augmented Protocols for Major Trauma Haemorrhage (ITACTIC): A Randomized, Controlled Trial. Intensive Care Med 2020. PMID: 33048195
"Clinical Question: Does augmenting massive transfusion protocols using viscoelastic hemostatic assays (VHAs) decrease mortality and massive transfusion at 24 hours compared to conventional coagulation tests (CCTs)?
Author Conclusion: “There was no difference in overall outcomes between VHA- and CCT-augmented-major haemorrhage protocols.”
Clinical Take Home Point: It is unsurprising that coagulation monitoring did not alter clinical outcomes in this study as there was a high prevalence of patients who never had or developed coagulopathy. This RCT does not provide evidence to support using VHA to guide resuscitation in adult trauma patients"

sábado, 9 de enero de 2021

Ludwig’s Angina

St. Emlyn´s - January 09, 2021 - By  Pete Hulme
..."Ludwig’s angina is a cellulitis of the floor of the mouth and soft tissues of the neck. If left untreated it can rapidly lead to an airway obstruction and death with an untreated mortality as high as 50% and mortality 8% for treated disease. The condition is named after the German physician Karl Freidrich Wilhelm von Ludwig who first described the disease in 1836. The angina part of the name comes from the latin word angere which means ‘to strangle’ which is appropriate as the airway swelling would certainly feel like strangulation..."

jueves, 7 de enero de 2021

Ceftriaxone for gonorrhea

PemBlog - January 06, 2021 - By Brad Sobolewski
"The Bottom Line – A single 500mg IM dose of ceftriaxone is effective for treating uncomplicated urogenital, anorectal, and pharyngeal gonorrhea infections
Citing increasing resistance and antibiotic stewardship the CDC has revised its recommendations for the treatment of gonorrhea. Recall that the previous treatment recommendation from 2010 included a dose of 250mg ceftriaxone given as an intramuscular injection and a single 1g oral doze of azithromycin for the treatment of gonorrhea. N. gonorrhoeae continues to be highly susceptible to ceftriaxone – but azithromycin resistance is increasing. There are some updated recommendations which I’ll briefly discuss below. You can read the full report in the MMWR..."

Haloperidol vs Ondansetron for Cannabis Hyperemesis

Paper: Ruberto KH et al. Intravenous Haloperidol Versus Ondansetron for Cannabis Hyperemesis Syndrome (HaVOC): A Randomized, Controlled Trial. Ann Emerg Med. 2020. PMID: 33160719
"Clinical Question: Is haloperidol superior to ondansetron in the treatment of abdominal pain and nausea in adult emergency department patients with cannabis hyperemesis syndrome?
Author Conclusion: “In this clinical trial, haloperidol was superior to ondansetron for the acute treatment of cannabis-associated hyperemesis. The efficacy of haloperidol over ondansetron provides insight into the pathophysiology of this now common diagnosis in many EDs.”
Clinical Take Home Point: In this small randomized controlled trial of patients with cannabis hyperemesis syndrome, the use of haloperidol was associated with improvement in the rates of acute (less than 120 minutes) nausea and abdominal pain, shorter emergency departments length of stay, shorter time to discharge, and less use of rescue medications over the commonly used antiemetic ondansetron. The findings need to be interpreted in the context of inadequate sample size, narrow inclusion and exclusion criteria, as well as unpaired analysis due to low crossover rates.

The bottom line is that only cannabis cessation at this time appears to be the most effective treatment modality but supportive care with intravenous fluids, topical capsaicin cream, avoidance of narcotic medications, and the use of dopamine antagonists such as haloperidol (at a lower dose of 0.05mg/kg) are potentially promising adjunct modalities based on the level of evidence that we have to date."

Tumor Lysis Syndrome

emDocs Visual Wednesdays - January 06, 2021 - By Walid Malki
Reviewed by: Manny Singh; Brit Long; Elizabeth Brem; Sarah Dubbs
Further Resources:

miércoles, 6 de enero de 2021

Cocaine Aortic Dissection

EM SIM CASES
EM SIM Cases - January 5, 2021 - By Chris Heyd
This case was written by Dr Suha Alshambari (Emergency Resident) and Dr Shaza Aouthmany (Attending Physician) at the University of Toledo Medical Center.
"WHY IT MATTERS
Aortic dissection is a catastrophic illness with high mortalities rates. There are significant complications that can arise acutely and require close monitoring and prompt treatment in the emergency department while activating resources for definitive surgical management.
CLINICAL VIGNETTE
A 49-year old man arrives to the emergency department looking unwell. He had sudden onset of abdominal pain two hours earlier that moved up to his chest. He is anxious, distressed and feels like he could die..."

domingo, 3 de enero de 2021

REGN-COV2 (Regeneron)

REBEL EM - January 02, 2020 - By Anand Swaminathan
Paper: Weinreich DM et al. REGN-COV2, a Neutralizing Antibody Cocktail, in Outpatients with COVID-19. NEJM 2020. PMID: 33332778 Free Link Clinical Trials Listing
"Clinical Question: Does REGN-COV2 reduce viral loads, lead to improvements and reduce medical attendance in outpatients with COVID19?
Author Conclusion: “In this interim analysis, the REGN-COV2 antibody cocktail reduced viral load, with a greater effect in patients whose immune response had not yet been initiated or who had a high viral load at baseline. Safety outcomes were similar in the combined REGN-COV2 dose groups and the placebo group.”
Our Conclusions: No conclusions can be drawn from a study published with no hypothesis. Our stance is that this cocktail, as with other monoclonal antibodies, should ONLY be given to patients in the setting of a clinical trial. On a related note, the NEJM is no longer a reliable, trusted source of high-quality clinical information.
Clinical Take Home Point: There is no role for the use of REGN-COV2 outside of a clinical trial. A large, well-done, preferably non-industry sponsored trial is necessary prior to this drug being used outside of this setting."

Aortic Dissection in Pregnancy

EM: RAP - January 2021 - By Rebecca Bavolek and Mel Herbert
"PEARLS
  • Aortic dissection in pregnancy is rare, and often accompanied by traditional risk factors such as hypertension, collagen vascular disease or bicuspid aortic valve.
  • In pregnancy, Stanford Type A dissection is more common.
  • The incidence increases throughout pregnancy; it is most common in the 3rd trimester and the postpartum period
  • Clinical features of the presentation are no different than in non-pregnant patients.
  • Diagnosis is by CT or transesophageal echocardiography (TEE).
  • Management consists of heart rate and blood pressure control. Surgical consultation may also be advised depending on type of dissection."
Related Links

Transfusion Associated Circulatory Overload

emDocs EM@3AM - January 02, 2021 - By Rachel Bridwell
Reviewed by: Brit Long and Alex Koyfman
"Pearls:
  • Special care given to rate of transfusion in those especially with reduced left ventricular dysfunction as 73% of TACO patients have underlying LV dysfunction
  • In these patients, slowing rate of transfusion and limiting volume may reduce TACO2
  • Pre and post transfusion BNP helps distinguish from TRALI
  • Responds well to acute CHF management, early diuretics
  • Requires ICU management"

jueves, 31 de diciembre de 2020

Top 2020 RSA/AAEM

RSA - Decemebre 31, 2020 - By Alex Gregory
"As 2020 comes to an end, we look forward to recognizing the year’s top 10 articles! Join me in congratulating this amazing group of authors at all levels of training and from across the United States! Additionally, I would like to thank each of the AAEM/RSA Modern Resident Blog authors, reviewers, mentors, and editorial staff members for their tireless contributions to the blog. Without all of them, the blog would not be what it is today. Thanks for a successful 2020!"
Top 10 Most Read Posts of 2020
  1. Should ST elevation in lead aVR with concern for acute coronary syndrome prompt emergent coronary angiography?
  2. Tranexamic Acid (TXA) in Obstetric Hemorrhage
  3. Sex Sent Her to the Emergency Department: A Rare Case of Postcoital Hemoperitoneum
  4. Intractable hiccups: a presentation of COVID-19
  5. Board Review: Debunking Dysbarism
  6. New Florida Law Requiring Written Consent for Pelvic Exams: Stumbling Towards Trauma-Informed Care
  7. Lightning Strike Emergencies Part 1: Triage and Cardiac Emergency
  8. Lightning Strike Emergencies Part 2: Trauma Approach
  9. Resuscitation Guidelines Updates: What You Need to Know
  10. Nine Steps to The Best Medical Notebook You'll Ever Use

Top 2020 emDocs

emDocs - December 30, 2020 - By Brit Long; Manpreet Singh and Alex Koyfman

lunes, 28 de diciembre de 2020

Hydrofluoric Acid Exposure

Taming The SRU
Taming The SRU - December 28, 2020 - By Gottula A & Lane B
"Emergency departments in the United States treat nearly 3.5 million upper extremity injuries annually, with 38% involving the fingers [1]. Frequently, hand and finger injuries are triaged to the fast track area: fingertip injuries, lacerations, paronychias…. Many of these patients present with self-evident exams and injury patterns. A few serious hand injuries, though, can present with subtle findings on the initial exam — emergency physicians must beware the missed diagnosis, because those exams will evolve and worsen: high-pressure injection injuries were recently reviewed in Nov 2020 by Life in the Fast Lane, and below we review hydrofluoric (HF) acid exposures. HF exposures present as hand/digit injuries in more than half of cases [2,3]. In this article we review the epidemiology, mechanisms of injury, and therapy for hydrofluoric (HF) acid exposures..."

BC or NS for DKA

PHARMACY JOE Episode 568 - December 24, 2020
..."Researchers from Vanderbilt University Medical Center published a post-hoc subgroup analysis of 2 previously reported companion trials—Saline Against Lactated Ringer’s or Plasma-Lyte in the Emergency Department (SALT-ED) and the Isotonic Solutions and Major Adverse Renal Events Trial (SMART) to examine the difference between the two fluids when treating patients with DKA...
The authors “believe that the results of this study add to the accumulating evidence suggesting balanced crystalloids are better resuscitation fluids than saline for many patients and may have particular benefits for patients with DKA.”

domingo, 27 de diciembre de 2020

Spontaneous pneumothorax

Shaw, Gina. Emergency Medicine News 2020; 42 (12): 26-27
doi: 10.1097/01.EEM.0000724564.10452.46
"Spontaneous pneumothorax is a common presentation in the emergency department, but controversy persists around its management. For small primary spontaneous pneumothoraces—less than 3 cm— the American College of Chest Physicians guidelines recommend observation in the ED for three to six hours followed by a repeat chest x-ray and discharge if the imaging excludes progression.
But for pneumothoraces of 3 cm or greater, the college has long recommended chest tube placement regardless of symptoms or clinical stability, while its European counterparts, the British Thoracic Society and the Belgian Society of Pneumology, recommend simple aspiration as the first-line treatment for primary spontaneous pneumothoraces requiring intervention...
And smaller retrospective studies have suggested that conservative management, regardless of size, leads to no complications, an equal recurrence rate, and a significantly shorter length of stay. (Acute Med Surg. 2014;1[4]:195; https://bit.ly/2IT7Vzn.)..."

PoCUS4COVID

Hussain, A., Via, G., Melniker, L. et al. Crit Care 24, 702 (2020)
"COVID-19 has caused great devastation in the past year. Multi-organ point-of-care ultrasound (PoCUS) including lung ultrasound (LUS) and focused cardiac ultrasound (FoCUS) as a clinical adjunct has played a significant role in triaging, diagnosis and medical management of COVID-19 patients. The expert panel from 27 countries and 6 continents with considerable experience of direct application of PoCUS on COVID-19 patients presents evidence-based consensus using GRADE methodology for the quality of evidence and an expedited, modified-Delphi process for the strength of expert consensus. The use of ultrasound is suggested in many clinical situations related to respiratory, cardiovascular and thromboembolic aspects of COVID-19, comparing well with other imaging modalities. The limitations due to insufficient data are highlighted as opportunities for future research..."

  

JAMA 2020 most Viewed

Best of 2020

viernes, 25 de diciembre de 2020

Necrotizing Pancreatitis

emDocs - December 23, 2020 - By Stephanie Costa, Courtney Cassella
Reviewed by: Skyler Lentz; Brit Long; Alex Koyfman
"Key Points
  • If a patient was previously diagnosed with pancreatitis and is now presenting with clinical worsening, consider necrotizing pancreatitis.
  • CT or MRI with contrast at least 3 days after symptom presentation will give highest yield images for necrotizing pancreatitis diagnosis.
  • Heterogeneous fluid collections and gas within necrotic pancreatic collections may indicate infected necrotizing pancreatitis.
  • Mainstay of management is targeted fluid resuscitation, electrolyte repletion, and analgesia. Vigilance for development of complications and organ failure is paramount.
  • Antibiotics should not be routinely used for sterile necrotizing pancreatitis, but if there is suspicion for infection development, metronidazole, quinolones and carbapenems, specifically imipenem, may be used, but there is limited evidence. Antibiotic usage should be guided by aspiration cultures."

Acute Kidney Injury

Tasty Morsels of Critical Care 015 - December 24, 2020 - By Andy Neill
...This is a somewhat basic and general episode, even for this podcast which indulges in frequent generalisation and summaries of pre existing summaries.
It covers Oh’s Manual Chapter 47 looking at Acute Kidney Injury. While hardly the most exciting topic in the world, there a few important pearls here perhaps worth emphasising.
Oh leads with KDIGO as the AKI classification of choice. The KDIGO classification splits you into 3 stages based on changes in creatinine and urine output over specified time periods. When you compare it with older definitions like AKIN and RIFLE you can see that not a great deal has changed. KDIGO maintains its importance as the one used in most of the recent CRRT trials..."

FAST Exam

Emergency Medicine News: December 2020 - Volume 42 - Issue 12 - p 16 - By Butts, Christine
doi: 10.1097/01.EEM.0000724584.25628.c9
"I review all FAST exams done at our Level I trauma center—thousands and thousands of scans over the years. I've seen a lot of good ones, some bad, and some very ugly, which led me to come up with these ten commandments of FAST..."

martes, 22 de diciembre de 2020

Ultrasound RUSH

Taming The SRU
Taming The SRU - December 21, 2020 - By Meaghan Frederick
"Ultrasound in Undifferentiated Hypotension
Point of care ultrasound (POCUS) can be a life saving, management changing tool in the care of critically ill patients. Multisystem POCUS can help emergency physicians quickly and accurately identify categories of shock, leading to more timely and more focused treatment(1, 2, 3). A multisystem study can be performed in a matter of minutes and help ED physicians distinguish between cardiogenic, obstructive, hypovolemic, and distributive shock.
While multiple variations of whole body ultrasound in shock have been proposed, The RUSH exam (Rapid Ultrasound for Shock and Hypotension) is commonly used. This includes evaluation of the heart, inferior vena cava (IVC), aorta, FAST abdominal views, and lung sliding (4). It is essentially the medical analog to the FAST exam (Focused abdominal sonography in trauma). The Mnemonic HI-MAP can help you remember the necessary views: Heart, IVC, Morrison’s pouch/FAST views, Aorta, and Pneumothorax. Remember, the goal of these views is to help you determine the category of shock, so that you can rapidly move to targeted treatment..."

Peripheral Vasopressors

REBEL EM - December 21, 2020 - By Matt Astin
Paper: Tran et al. Complication of Vasopressor Infusion Through Peripheral Venous Catheter: A Systematic Review and Meta-analysis. Am J Emer Med. PMID: 33039229
"Clinical Question: What is the prevalence of complications from infusing vasopressors through PIVs?
Author Conclusion: “There was low prevalence of complications as a direct result from infusing vasopressors through PIVs. Studies with safety guidelines were associated with significantly lower prevalence of complications. Further studies are needed to confirm our observations.”
Clinical Take Home Point: Infusion of vasopressors through PIV is a safe practice with an overall complication rate of 7%. The majority of these complications are minor in nature (i.e. Extravasation, infiltration, cellulitis, and thrombophlebitis). If infusing vasopressors through a PIV a safety/observation/extravasation guideline should be established as this associated with significantly lower incidence of adverse events."

O2 Sat in dark skin

PulmCrit (EMCrit)
PulmCrit - December 21, 2020 - By Josh Farkas 
"Summary: The Bullet
  • Pulse oximetry may overestimate oxygen saturation among patients with dark skin, often by ~2% when using hospital bedside monitors. This may have substantial treatment implications for patients with borderline oxygen saturation (e.g., saturation ~90%).
  • Bias in pulse oximeters varies substantially between different devices. Available evidence suggests that Nonin clip-on pulse oximeters seem to be accurate regardless of skin color.
  • Trending pulse oximetry over time should remain an accurate tool to monitor clinical progress.
  • Further studies defining the performance of different devices among diverse populations are urgently needed.
  • It is possible to design pulse oximeters which function well regardless of skin color. Fully dismantling the systemic racism of pulse oximetry will require demanding devices which are universally accurate."

domingo, 20 de diciembre de 2020

Hypothermia

EM@3AM - December 19, 2020 - By McKenna Furgurson
Reviewed by: James Cao; Alex Koyfman; Brit Long

"Pearls:
  • Consider the broad differential for hypothermia if it is not an obvious environmental cold exposure.
  • Continue with prolonged CPR, hypothermia is neuroprotective, and patients can have good outcomes despite long resuscitative measures.
  • ECMO is the best method for rewarming – consider transfer to ECMO facility in prehospital setting and even afterwards if ECMO facility is within 6 hours away."

Syncope Workup

The Trauma Pro - December 18, 2020 - By The Trauma Pro
"Syncope accounts for 1-2% of all ED visits, and is a factor in some patients with blunt trauma, especially the elderly. If syncope is suspected, a “syncope workup” is frequently ordered. Just what this consists of is poorly defined. Even less understood is how useful the syncope workup really is.
Researchers at Yale retrospectively looked at their experience doing syncope workups in trauma patients. They were interested in seeing what was typically ordered, if it was clinically useful, and if it impacted length of stay...
Important! Of the patients who underwent an intervention after workup, 69% could have been identified based on history, physical exam, or EKG and did not depend on any of the other diagnostic tests.
Bottom line: Don’t just reflexively order a syncope workup when there is a question of this problem. Think about it first, because the majority of these studies are nonproductive. They are not needed routinely in trauma patients with “syncope” as a contributing factor. Obtain a good cardiac history, and if indicated, order an EKG and go from there. See the practice guideline proposed by the Temple group below. And be sure to include the patients primary doctor in the loop!"

martes, 15 de diciembre de 2020

Appendicitis

emDOCs Podcast Episode 18 - December 15, 2020 - By  Brit Long and Manpreet Singh

  • "For every 100 return visits to the ED for abdominal pain, one-third of them will be due to diagnostic error, and 2 will be for missed appendicitis. Once appendicitis begins, given time, it invariably leads to perforation which can be complicated by peritonitis or sepsis.
  • Lowering the rate of missed appendicitis in the ED can be accomplished through improving our awareness of cognitive biases that affect our medical decision making, being mindful of the populations especially at risk for this missed diagnosis, and utilizing all labs and imaging at our disposal when suspicion for appendicitis is high...
Pearls
  • #1: Utilize prediction scoring tools: AIR score for high risk patients, Alvarado score for dischargeable patients.
  • #2: Don’t be afraid to utilize CT imaging for intermediate risk patients, including pregnant women and children.
  • #3: Train yourself to consider appendicitis in “outlier” populations: children, pregnant women, older adults, and black patients."

lunes, 14 de diciembre de 2020

ECMO CPR

First 10EM - December 14, 2020 - By Justin Morgenstern
The paper
The ARREST trial Yannopoulos D, Bartos J, Raveendran G, Walser E, et al. Advanced reperfusion strategies for patients with out-of-hospital cardiac arrest and refractory ventricular fibrillation (ARREST): a phase 2, single centre, open-label, randomised controlled trial. 
Lancet. 2020 Nov 12:S0140-6736(20)32338-2. doi: 10.1016/S0140-6736(20)32338-2. 
Epub ahead of print. PMID: 33197396 NCT03880565
"The Results
They included 30 patients, with a mean age of 59 years, 83% of whom were men.
The results were pretty dramatic. There was a large improvement in the primary outcome of survival to hospital discharge (43% versus 7%, ARR 36%, 95% CI 3.7-59.2%). Survival to 3 and 6 months was also better in the ECMO CPR group (43% vs 0%, p=0.006). 
Bottom line
This is a promising early study of ECMO in the management of out of hospital cardiac arrest with a shockable rhythm. That being said, this is a small study with many potential sources of bias. Larger studies will be needed to confirm the dramatic benefits seen here."

Renal and Perinephric Abscesses

emDocs - December 13, 2020 - By Christian Capanna
Reviewed by: Edward Lew; Alex Koyfman; Brit Long
"Take Home Points
  • Renal and perinephric abscesses are serious, often missed diagnoses in the emergency department that are important for emergency clinicians to keep on their differential, as only 35% of renal and perinephric abscesses are correctly diagnosed in the emergency department.
  • UA is not necessarily consistent with these infections unless the abscess involves the collecting system.
  • Mortality of renal and perinephric abscesses can be as high as 14%.
  • CT scan is the single best way to diagnosis these disease processes, but bedside ultrasound can offer a quicker diagnosis in some.
  • Broad-spectrum antibiotics are the mainstay of treatment for all confirmed diagnoses and the size of the abscess (>5cm) will determine need for drainage.
  • All patients with confirmed diagnosis should be admitted for continued antibiotics, culture results and urology consultation."

jueves, 10 de diciembre de 2020

Cocaine and ST Elevation

emDocs - December 10, 2020 - By Brannon Inman and Lloyd Tannenbaum
Reviewed by: Jamie Santistevan; Manpreet Singh and Brit Long
"Cocaine causes a huge catecholaminergic surge. All those catecholamines cause vessels to clamp down (vasoconstriction). They also make the heart pump harder (inotropy) and faster (chronotropy). So, you have coronary vessels getting smaller and cardiac muscle working harder. This sounds bad. To make it even worse, the chronotropic effects of cocaine are increased when alcohol is used on top of the cocaine...
In 1994 a group of EM physicians (and cardiologists) wanted to determine which patients coming to the ED with chest pain after cocaine use were having a true MI (in this study, MI is defined as having elevated CK-MB). They enrolled 246 patients over 46 months and looked at ECGs, cardiac biomarkers, echocardiograms and catheterization reports. This study, known as COCHPA or the Cocaine Associated Chest Pain Study, enrolled 246 patients, 14 of which had an MI based on elevated CK-MB level (5.7%; 95% confidence interval [CI], 2.7-8.7%). In this study, an ECG revealing ischemia or infarction had a 35.7% sensitivity for predicting a true MI. This low sensitivity would mean that you cannot exclude acute MI just based on the absence of ischemic changes on the ECG..."