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SOBRE EL AUTOR **

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

WORLD EMERGENCY MEDICINE SOCIETIES

Hypertensive Emergency Treatment

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miércoles, 18 de abril de 2018

Pulmonary Hypertension and RVF

A guide to the initial emergency department management of patients with 
pulmonary hypertension and right ventricular failure
First10EM - By Justin Morgenstern - April 16, 2018
..."In the setting of pulmonary hypertension, the right ventricle is impaired both mechanically and by ischemia. Increased RV pressure leads to bowing of the septum into the left ventricle, which leads to decreased LV filling and decreased cardiac output. Right ventricular stretching will cause tricuspid regurgitation, which will also result in decreased cardiac output. Any decrease in cardiac output will result in decreased perfusion to the right ventricle. Finally, increased pulmonary pressures increase the RV wall tension and induce RV hypertrophy, which decreases perfusion to the right ventricle, ultimately worsening cardiac output further. (True experts are probably cringing at this over-simplified explanation, but I think it is enough to understand the management, which is my priority.)...."
RV spiral of death FRIST10EM.png

Octreotide and Somastostatin for UUGB

R.E.B.E.L. EM - Emergency Medicine Blog
R.E.B.E.L.EM - April 13, 2018 - Post Peer Reviewed By: Anand Swaminathan
"Recently I was asked to speak at the Texas College of Emergency Physicians (TCEP) conference April 2018. The particulars of this session were, five, 10 minute lectures on new indications for old drugs. My topic was the use of octreotide and somatostatin for undifferentiated upper gastrointestinal bleeding. This is a particular topic I have been getting more and more requests for, but didn’t really know the evidence behind why I was doing it. Does it help my patients or just another expensive medication, that takes up an IV with no clear patient oriented outcome?...
Clinical Bottom Line: Until newer studies are published showing either harm or no clinical benefit, at this time the use of octreotide in non-variceal upper gastrointestinal hemorrhage appears to benefit bleeding and need for surgery (Especially in the sickest patients: Hemodynamically unstable, requiring transfusion, large volume hematemesis). Unfortunately, we just do not have mortality data to help guide this decision nor do we know the optimal length of time to continue the infusion."

Pancreatitis

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emDocs - April 16, 2018 - Author: Waller A -  Edited by: Koyfman A and Long B
"Key Points
  • Diagnosis of pancreatitis: 2 out of 3 criteria met => upper abdominal pain (clinical), serum lipase or amylase >3x upper limit of normal (laboratory), or imaging findings of pancreatic inflammation.
  • CT is not necessary if diagnosis can be made without it and is better obtained later in the disease course if needed.
  • Patients should receive a RUQ US in the ED if it will impact management.
  • Be cautious and avoid normal saline for fluid resuscitation (Lactated Ringer’s likely best).
  • APACHE II and BISAP score are the most useful predictors of mortality in the ED, but keep the entire clinical picture in mind.
  • There is little research to support discharging patients from the ED, but it may be possible in specific circumstances."

miércoles, 11 de abril de 2018

Severely Burned

MCC Project - March 24, 2018 - By Chung K
"Today with have the distinct pleasure to welcome a mentor of mine and a true expert in the field of critical care, Kevin K Chung, MD, FCCM, FACP, Colonel, Army. After finishing a fellowship in Critical Care Medicine at Walter Reed Army Medical Center, Dr. Chung was assigned to the US Army Institute of Surgical Research (USAISR) where he has served in the capacity of Medical Director of the Burn Intensive Care Unit, Task Area Manager of Clinical Trials in Burns and Trauma, and the Director of Research for the USAISR. He is currently the Chief of Medicine at Brooke Army Medical Center. COL Chung holds academic appointments at the Uniformed Services University of the Health Sciences as Professor of Medicine and Professor of Surgery. In his career, COL Chung has authored over 180 peer reviewed papers, authored 13 book chapters, and has been an invited speaker for over 85 lectures internationally..."

Caustic Ingestion

TAMING THE SRU

Taming The SRU - April 10, 2018 - By Scalon M
..."Ingestion of detergent agents, whether intentional or accidental, can cause serious and potentially life-threatening toxicologic disease. While ingestion in the adult population often stems from psychiatric disease or self-injurious behaviors, the advent of water-soluble laundry detergent pods has led to a significant increase in the number of pediatric poisonings, due in part to their bright coloration and pleasant smell.[1] This article will discuss the various manifestations of toxic exposure, pathogenesis, and evidence-based management of detergent poisonings in both the pediatric and adult populations..."
 fIGURE 1.  eNDOSCOPIC GRADING SYSTEM FOR CAUSTIC INJURIES.

martes, 10 de abril de 2018

Critical Care Year 2018

Keynotable Blog
Critical Care Year in Review 2018
April 8, 2018 - By Mallemat H

Here’s the handout for the AAEM Year in Review 2018

domingo, 8 de abril de 2018

EM Personality

Jordan J et al. AEM EDUCATION AND TRAINING 2018;00:00–00
"Objectives: This study aimed to understand the personality characteristics of emergency medicine (EM) residents and assess consistency and variations among residency programs...
Conclusions: Our findings suggest that the personality characteristics of EM residents differ considerably from the norm for physicians, which may have implications for medical students’ choice of specialty. Additionally, results indicated that EM residents at different programs are comparable in many areas, but moderate variation in personality characteristics exists. These results may help to inform future research incorporating personality assessment into the resident selection process and the training environment."

Aggressive Management of AF

R.E.B.E.L.EM - February 13, 2018
Article: Stiell IG et al. Outcomes for Emergency Department Patients with Recent-Onset Atrial Fibrillation and Flutter Treated in Canadian Hospitals. Ann Emerg Med 2017. PMID: 28110987
Background: Atrial fibrillation (AF) is one of the most common dysrhythmias encountered in the ED. The management of recent-onset AF and atrial flutter (AFl) in the ED continues to be debated. The discussion centers on whether patients with recent-onset AF should be rhythm controlled (e.g. converted back to sinus rhythm) or rate controlled only. This debate was showcased in a point-counterpoint in Annals of Emergency Medicine in 2011 (Stiell 2011, Decker 2011). The rhythm control supporters argue that AF/AFl is abnormal, worsens quality of life, leads to cardiac remodeling and, in may patients, requires medications for rate control and anticoagulation. The rate control group argues that cardioversion runs the risk of causing a thromboembolic event (i.e. CVA, peripheral arterial occlusion). Thus, it should not be performed until the absence of clot in the left atrium is confirmed (by TEE) or appropriate anticoagulation has occurred. It has long been taught that if the patient has been in AF/AFl for < 48 hours, the risk of developing a clot in the left atrium is negligible and cardioversion may be pursued. However, some recent literature has called this classic teaching into question (Nuotio 2014). Prospective studies looking at outcomes of recent-onset AF/AFl patients after aggressive treatment in the ED are needed to further evaluate the risks of aggressive treatment...
Clinical Bottom Line:
An aggressive approach to the management of recent-onset AF/AFl did not result in an unacceptable rate of adverse events. Adopting a rhythm control approach in these patients appears safe."

miércoles, 4 de abril de 2018

Anticoagulants and surgery

An online community of practice for Canadian EM physicians
CanadiEM - by Kerstin de Wit - April 3, 2018
"Main Messages
  • Always verify the name of the anticoagulant.
  • Always verify the date and time of the last dose of the anticoagulant.
  • Always calculate the creatinine clearance. Do not rely on the lab estimated GFR.
  • Consider the urgency and importance of the surgery.
  • Consider the risk of bleeding associated with surgery.
  • Consider the risk of clotting (venous thrombosis or stroke)."

lunes, 2 de abril de 2018

Abscess Management

R.E.B.E.L.EM - April 02, 2018 - 
Ref: Gottlieb M et al. Systemic Antibiotics for the Treatment of Skin and Soft Tissue Abscesses: A Systematic Review and Meta-Analysis. Ann Emerg Med 2018. [Epub Ahead of Print]
"Background: Skin and soft tissue abscesses are a common emergency department (ED) presentation. The approach to management has changed little in recent decades: incision and drainage (I+D) and then discharge home with follow up. However, increasing rates of methicillin-resistant staph aureus (MRSA) over the last decade have led to further consideration of adjunct therapy with oral antibiotics to improve cure rates. Two recent studies (Talan 2016, Daum 2017) have shown a modest but consistent benefit to oral antibiotics...
Potential to Impact Current Practice: The findings of this systematic review and meta-analysis show strong evidence that antibiotic therapy, in addition to I&D, leads to higher cure rates for small abscesses with overlying cellulitis. These findings should not be taken to mean that all patients with abscesses who are I&D’d in the ED will need antibiotics as the majority of abscesses (84%) will resolve with I&D alone. The increased clinical cure rate must be weighed against the potential risks associated with increase antibiotic use such as adverse medication-related events and increasing antibiotic resistance.
Bottom Line: ED providers should consider adjunctive therapy with oral antibiotics with MRSA coverage after I&D of simple, small (<5cm) abscesses with overlying cellulitis in healthy individuals to increase short-term cure rates. The presence of significant overlying cellulitis continues to warrant adjunctive therapy with antibiotics."

Urine Testing

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emDocs - April 2, 2018 - Author: Long B - / Edited by: Koyfman A
"Key Points
  • UTI is a clinical diagnosis (dysuria, frequency, etc.). Urine that is cloudy or “smelly” is not diagnostic of UTI. LE or nitrites alone without symptoms does not require treatment.
  • Patients with simple, routine UTI do not require urine cultures. Patients with complicated UTI, pyelonephritis, failed treatment, or recent antibiotic therapy should have urine cultures obtained.
  • Bacteriuria in the absence of symptoms defines asymptomatic bacteriuria, which should not be routinely treated.
  • Patients with dementia and falls or those with altered mental status and no ability to provide a history of urinary symptoms can be difficult. Negative nitrite and LE rules out UTI in ASB and in patients for whom exam is challenging.
  • Other markers of systemic inflammation should be used for diagnosis if history or exam are unreliable."

Burns

EMCritRACC
EMCrit RACC Podcast 221 – April 2, 2018 - By Scott Weingart
"Dr. Djogovic completed training in Emergency Medicine and Critical Care Medicine from 1999-2005, and is currently employed at the University of Alberta Hospital as an Emergency Physician, and as an Intensivist in the General Systems Intensive Care Unit and in the Firefighters Burn Treatment Unit..."
Part I

*
EMCrit RACC Podcast 219 - March 5, 2018 - By Scott Weingart

Part II

Down with STEMI

EMCrit RACC
EMCrit RACC - April 1, 2018 - By Pendell Meyers
"The current guideline-recommended paradigm of acute MI management (“STEMI vs. NSTEMI”) is irreversibly flawed, and has prevented meaningful progress in the science of emergent reperfusion therapy over the past 25 years. Dr. Stephen Smith, my mentor and co-editor of this post, has been saying this much more eloquently for many years in his “STEMI/NSTEMI False Dichotomy” lecture series, but this bears repeating and needs to be reiterated as widely as possible.
Deciding which patients need emergent reperfusion therapy is complex, and our current criteria for doing so are not adequate to the task. The patients who benefit from emergent catheterization are those with acute coronary occlusion (ACO) or near occlusion, with insufficient collateral circulation, whose myocardium is at imminent risk of irreversible infarction without immediate reperfusion therapy. This is the anatomic substrate of the entity we are supposed to refer to as “STEMI.” Unfortunately the term “STEMI” restricts our minds into thinking that ACO is diagnosed reliably and/or only by “STEMI criteria” and the ST segments. In reality, the STEMI criteria and widespread current performance under the current paradigm have unacceptable accuracy, routinely missing at least 25-30% of ACO in those classified as “NSTEMI”(1-9) and generating a similar false positive rate of emergent cath lab activations (10-12)..."

sábado, 31 de marzo de 2018

Withdraw resuscitation

St.Emlyn’s - By Richard Taylor - March 13, 2018
..."If confronted with a situation where withdrawal of resuscitation may be considered in the ED also remember the following: Medicine, especially critical care medicine, is a team game. Decisions like these should be taken in concert with other senior (read Consultant) colleagues, and always in discussion with the patient’s family. Further, when considering the management of an incapacitous patient (in England) one must consider the Mental Capacity Act3, taking into account previously expressed wishes, the patient’s values, any Lasting Power of Attorney and so forth. Finally, the clinician in this situation must always explore the possibility of organ or tissue donation, which may provide some solace to relatives, and hope to others..."

DEFUSE 3

The Bottom Line - By Anthony Hackett - March 30, 2018
Albers et Al, N Engl J Med 2018; 378:708-718 DOI: 10.1056/NEJMoa1713973
"Clinical Question
  • In patients with proximal internal carotid (ICA) or middle cerebral artery (MCA) occlusion with likely salvageable ischaemic brain tissue, does thrombectomy, at 6-16 hours post ischaemic stroke, in addition to medical therapy, compared to medical therapy alone, improve functional outcome at 90 days?...
The Bottom Line
  • In patients with large vessel strokes with favourable ischaemic core to penumbra ratios, endovascular therapy at 6-16 hours post stroke onset in addition to medical therapy, improved functional neurological outcome at 90 days, compared with medical therapy alone
  • These are promising results but given the specific selection criteria, and the need for advanced imaging and intervention it is unclear how broad the actual benefit in clinical practice will extend."

miércoles, 28 de marzo de 2018

Emergent Large Vessel Occlusion

R.E.B.E.L.EM - March 27, 2018
"Background: Over the last three years, we have seen the rise of neurointerventional therapies for patients with ischemic strokes due to large vessel occlusions (LVOs). This group of strokes typically includes patients with occlusion of the distal intracranial carotid artery, middle cerebral artery or anterior cerebral artery. Rapid identification of these patients both in the prehospital setting as well as in the emergency department (ED) may be beneficial as it can lead to mobilization of necessary resources and ordering of proper investigations (CT perfusion, MRI/MRA). While there are a number of clinical scoring systems in place to identify patients with LVO, none are ideal. The authors investigate the utility of the vision, aphasia, neglect (VAN) assessment for this purpose.
The VAN assessment (see table below) begins with a simple assessment of upper extremity weakness. If the patient exhibits weakness (minimum is any drift) they then proceed to vision, aphasia and neglect testing. If either vision, aphasia or neglect assessment is abnormal, the patient should be suspected of having a LVO. If there is no weakness, the patient is deemed to not have an LVO and the vision, aphasia and neglect pieces of the assessment are not carried out...
Bottom Line: The VAN assessment is a novel approach to rapid identification of patients with ischemic stroke from potential LVO who may be eligible for endovascular therapy. We await further research prior to making any further recommendations."

martes, 27 de marzo de 2018

VTE and DVT (NICE 2018)

National Institute for Health and Care Excellence (NICE)
NICE guideline [NG89] Published date: March 2018
"This guideline covers assessing and reducing the risk of venous thromboembolism (VTE or blood clots) and deep vein thrombosis (DVT) in people aged 16 and over in hospital. It aims to help healthcare professionals identify people most at risk and describes interventions that can be used to reduce the risk of VTE.
Recommendations
This guideline includes recommendations on:

Syncope (ESC 2018)

European Society of Cardiology
Brignole M et al. European Heart Journal, ehy037, doi.org/10.1093/eurheartj/ehy037
Published: 19 March 2018
...What is new in the 2018 version? 
The changes in recommendations made in the 2018 version compared with the 2009 version, the new recommendations, and the most important new/revised concepts are summarized in Figure 1..."

What is new in the 2018 syncope Guidelines? AA = antiarrhythmic; AF = atrial fibrillation; ARVC = arrhythmogenic right ventricular cardiomyopathy; CSM = carotid sinus massage; ECG = electrocardiogram; ED = emergency department; LVEF = left ventricular ejection fraction; EPS = electrophysiological study; HCM = hypertrophic cardiomyopathy; ICD = implantable cardioverter defibrillator; ILR = implantable loop recorder; OH = orthostatic hypotension; PCM = physical counter-pressure manoeuvres; POTS = postural orthostatic tachycardia syndrome; PPS = psychogenic pseudosyncope; SNRT = sinus node recovery time; SU = syncope unit; SVT = supraventricular tachycardia; VT = ventricular tachycardia.

lunes, 19 de marzo de 2018

Hemorrhagic Shock

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emDocs - March 12, 2018 - Authors: DeVivo A and Beck-Esmay J
Edited by: Koyfman A and Long B
..."The compensatory mechanisms enacted by the body during hemorrhagic shock inevitably fail without intervention. As these mechanisms become overwhelmed, acidosis will begin to worsen due to decreased perfusion. This will be reflected by the progressive increase in lactate and base deficit. These two levels can be evaluated as point-of-care test in the emergency department and may be utilized as rough estimations for impending failure of physiologic compensatory mechanisms, and thus vascular collapse.
The remainder of this article will be focused on resuscitation bay pearls for early detection, intervention, and prevention of rapid deterioration in hemorrhagic shock..."

DD and Pregnancy

R.E.B.E.L.EM - March 19, 2018
..."While the use of the D-dimer in conjunction with a low pre-test probability for pulmonary embolism is well established for ruling out PE in the non-pregnant population, the preponderance of evidence to date suggests significant shortcomings with such a strategy in pregnant patients. Indeed, the American Thoracic Society guidelines recommend specifically against the use of D-dimer to exclude PE in pregnancy. Still, though, many emergency physicians have striven for a rational approach to diagnosis—limiting radiation exposure while ensuring safety and sensitivity. The “Kline Algorithm,” as best described in this 2013 podcast on Rob Orman’s venerable ERCast, draws on physiologic expectations and the expertise of Jeff Kline, MD, an emergency medicine physician and expert in venous thromboembolism, to propose a more sensible approach to diagnosis. Unfortunately, literature to support this approach has been sparse. The DiPEP study, published recently in the British Journal of Haematology, attempted to add to this literature base...
Author Conclusion:
“…D-dimer should not be recommended for use in the diagnostic work-up of PE in pregnancy.”
Clinical Take Home Point: Among pregnant women presenting with concern for pulmonary embolism in pregnancy, there remain no data supporting the use of D-dimer in any diagnostic algorithm."

viernes, 16 de marzo de 2018

Endovascular Therapy for Strokes

R.E.B.E.L.EM - March 15, 2018 - By Salim Rezaie
Clinical Take Home Point: 
  • Systemic IV thrombolysis can have limited responsiveness (13 – 50%) to large thrombi in the central circulation, a narrow time window for administration (4.5hrs), and increases the risk of cerebral/systematic hemorrhage
  • The initial 3 trials showing no difference in 90d mRs scores were most likely due to:
    • Proximal occlusion not radiologically proven with intracranial occlusions (i.e. CTA, MRA)
    • The use of first-generation Merci devices as opposed to retrievable stents
    • It is also important to note that in many of the earlier trials there were more new strokes and vessel dissections compared to systemic therapy
  • In the studies reviewed, recruitment averaged about 1 patient per month, meaning this was a very specific and particular patient that was recruited
  • As more and more trials have been performed, the efficiency, the type of imaging, and technology have all also improved, minimizing complications and improving efficacy of endovascular therapy
  • Endovascular therapy for ischemic stroke is suitable for patients with ischemic stroke within 24hrs of symptom onset, with:
    • Proof of proximal intracranial vessel occlusion
    • Imaging methods to exclude large infarct cores
    • Efficient workflow to achieve fast recanalization and high reperfusion rates
    • Workflow: Ischemic Stroke Symptoms ≤24hrs -> CT/CTA -> If CTA positive for large anterior (ICA/MCA) stroke -> CT or MR Perfusion Scan to determine eligibility for Endovascular Therapy
  • Later trials included patients with “wake up” strokes, which have not previously been included in systemic t-PA trials
  • One final note: It is important to realize that many trials were stopped early, and because of this the magnitude of benefit for endovascular therapy may be over inflated in many of these trials

martes, 13 de marzo de 2018

BNP in the ED

First10EM - By Justin Morgenstern - March 13, 2018
"In the most recent episode of Emergency Medicine Cases Journal Jam, Rory, Anton, and I cover the evidence for (for against) using BNP in the emergency department. These are my notes...
Summary
Looking at observational data, BNP and NT-proBNP both appear to have a good sensitivities for CHF, but only moderate to poor specificities. There are a number of RCTs looking at BNP use in the emergency department setting. Two studies demonstrated a decrease in hospital length of stay and total costs, but 4 other studies showed no difference. Two studies looked at ED length of stay, 1 demonstrating a statistical but clinically insignificant difference and the other showing no difference. None of the studies demonstrated a change in ED treatment, mortality, or hospital readmission. There are a large number of problems with these studies, including the lack of a clear gold standard for CHF, a lack of blinding, incorporation bias, and spectrum bias. These problems are discussed further in the discussion section. I have never worked in an emergency department where BNP testing has been available, and after reviewing this literature I think that is probably a good thing. It is easy to get excited about tests with high sensitivities, but the use of diagnostic tests is complex and fraught with unintended consequences. I think the best evidence to date suggests that BNP testing does not provide any patient important benefit to emergency department patients."

Palliative Care Myths

NUEM Blog
NU-EMBy Zaidi H - March 5, 2018 - Edited by: Marshall A
Expertreview by: Chandrasekaran E
  1. “Palliative care is only for people close to death”
  2. “Palliative care discussions are really just about establishing code status.”
  3. “A patient who is DNR or DNR/DNI should not be admitted to the ICU”
  4. “Having a productive goals of care conversation takes hours; I don’t have that kind of time in the ED”
  5. “When discussing goals of care for a patient with a dire prognosis, I should avoid partiality in treatment options.”

domingo, 11 de marzo de 2018

TXA nebulized for Hemoptysis

The PharmERToxGuy - Creator: Mike O’Brien - Posted March 10, 2018

Pharmacology Infographics
click image to enlarge

Abdominal Cutaneous Nerve Entrapment Syndrome

CORE EM
CORE EM - March 7, 2018 - By Carl Preiksaitis
"Definition: Abdominal cutaneous nerve entrapment syndrome (ACNES) is an under recognized cause of chronic abdominal pain. It results when the cutaneous branches of the lower intercostal nerves become entrapped in the lateral border of the rectus muscle...
Take Home Points
  • ACNES is an under recognized cause of chronic abdominal pain in patients presenting to the ED
  • Consider in patients with localized, positional pain without symptoms suggestive of an intra-abdominal pathology
  • Diagnosis is based on characteristic history and physical exam findings including positive Carnett’s test
  • Trigger point injection with anesthetic and steroid can both confirm the diagnosis and provide symptomatic relief"

Fluids in Burn Patients

EMCrit RACC Podcast 219 - March 5, 2018 - By Scott Weingart 

Dr. Djogovic completed training in Emergency Medicine and Critical Care Medicine from 1999-2005, and is currently employed at the University of Alberta Hospital as an Emergency Physician, and as an Intensivist in the General Systems Intensive Care Unit and in the Firefighters Burn Treatment Unit.

lunes, 5 de marzo de 2018

Ischemic Stroke Updates (2018 AHA/ASA)

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emDocs - March 5, 2018 - Author: Long B - Edited by: Koyfman A
ED Evaluation and Management
  1. "Use of a stroke severity scale (preferably NIHSS) is recommended.
  2. All patients admitted with suspected acute stroke should receive imaging including noncontrast head CT. Although diffusion weighted MRI is more sensitive, routine use in all patients is not recommended as it is not cost effective. If CT is negative and the presentation is unclear, an area of restricted diffusion on MRI may lead to management change.
  3. Imaging should occur within 20 minutes of ED arrival in > 50% of patients who are candidates for tPA and/or mechanical thrombectomy.
  4. There is insufficient evidence to identify a specific amount of acute CT hypoattenuation severity/extent that affects response to tPA. Extent and severity of acute hypoattenuation or early ischemia should not be used to withhold therapy.
  5. The hyperdense MCA sign or loss of gray-white differentiation on CT should not be used to withhold tPA.
  6. Routine MRI for exclusion of cerebral microbleeds before tPA is not recommended.
  7. Using imaging criteria to select patients who woke with stroke symptoms or have unclear time of symptom onset for treatment with tPA is not recommended.
  8. Multimodal CT and MRI (with perfusion imaging) should not delay tPA administration.
  9. For patients meeting criteria for endovascular therapy, noninvasive intracranial vascular imaging is recommended during initial imaging, but this should not delay tPA. Patients who qualify for tPA before vascular imaging should receive tPA before vascular imaging.
  10. For patients who meet criteria for endovascular treatment, CTA is reasonable before obtaining creatinine if there is no history of renal disease and a large vessel occlusion is suspected.
  11. Imaging of the extracranial carotid and vertebral vasculature is reasonable in patients who are candidates for mechanical thrombectomy (evaluate for stenosis, dissection, occlusion).
  12. Additional imaging other than CT and CTA or MRI with MRA such as perfusion studies to select patients for mechanical thrombectomy in < 6 hours is not recommended.
  13. In patients with stroke symptoms within 6-24 hours after last normal with large vessel occlusion in the anterior circulation, CT perfusion, MRI perfusion, DW-MRI is recommended to assist in selecting patients for mechanical thrombectomy (DAWN, DEFUSE 3 trials)..."

Corneal Abrasions

TAMING THE SRU
Taming The SRU - March 05, 2018 - By James Li
"The eye is a complicated organ that is not well understood by many new emergency physicians because it historically has not received much attention during medical school. This makes taking care of these patients challenging. However, eye complaints make up approximately 8% of ED visits and so it is something we will see quite often. In this post we will discuss one of the more common etiologies of "eye pain", corneal abrasions. Corneal abrasions account for 45% of eye complaints in the ED and so are a high yield topic to review. We will start by reviewing some of the anatomy, and then delve into the presentation and management of these patients...
PEARLS
  • Corneal abrasions account for 45% of eye complaints in the ED
  • Use fluoroscein to identify abrasions and a slit lamp to complete a thorough exam
  • Although not evidence based, most patients receive topical antibiotics for 3-5 days
  • Topical tetracaine is likely safe for symptomatic control on discharge, but should be prescribed with caution"

jueves, 1 de marzo de 2018

Penicilin allergy

Emergency Physicians Monthly
EP Monthly - By Serranoo K and Shenvi - January 31, 2018
..."In summary, penicillin allergy is commonly reported but largely overestimated. Questioning your patient about the type of reaction that occurred can help elucidate whether the reaction was an IgE-mediated reaction. Referral for penicillin skin testing is a good option that can lead to better antibiotic stewardship, decreased costs, and better outcomes for your patient. Many cephalosporins can be safely given to patients with penicillin allergy provided they do not share a common side chain."

Normal saline for resuscitation

PulmCrit (EmCrit)
PulmCrit - February 27, 2018 - By Josh Farkas
  • “Normal” saline is a hypertonic, acidotic fluid. There is no physiologic rationale for its use as a resuscitative fluid.
  • There are many potential problems related to saline. These include causing hyperchloremic acidosis, hyperkalemia, hemodynamic instability, renal malperfusion, systemic inflammation, and hypotension.
  • Numerous small RCTs have emerged over the past few years which highlight various problems with saline resuscitation.
  • The SMART and SALT-ED trials are massive, multiple-crossover trials which compare saline versus balanced crystalloids among critically ill and non-critical patients. Both studies found a 1% increase in death or renal failure with the use of saline.
  • The combination of physiology, animal studies, numerous RCTs, SMART, and SALT-ED indicate that it's time to stop resuscitating with saline."

Vasoplejia

Critical Care logo
Levy B . Critical Care 2018; 22:52
"Vasoplegia is a ubiquitous phenomenon in all advanced shock states, including septic, cardiogenic, hemorrhagic, and anaphylactic shock. Its pathophysiology is complex, involving various mechanisms in vascular smooth muscle cells such as G protein-coupled receptor desensitization (adrenoceptors, vasopressin 1 receptors, angiotensin type 1 receptors), alteration of second messenger pathways, critical illness-related corticosteroid insufficiency, and increased production of nitric oxide. This review, based on a critical appraisal of the literature, discusses the main current treatments and future approaches. Our improved understanding of these mechanisms is progressively changing our therapeutic approach to vasoplegia from a standardized to a personalized multimodal treatment with the prescription of several vasopressors. While norepinephrine is confirmed as first line therapy for the treatment of vasoplegia, the latest Surviving Sepsis Campaign guidelines also consider that the best therapeutic management of vascular hyporesponsiveness to vasopressors could be a combination of multiple vasopressors, including norepinephrine and early prescription of vasopressin. This new approach is seemingly justified by the need to limit adrenoceptor desensitization as well as sympathetic overactivation given its subsequent deleterious impacts on hemodynamics and inflammation. Finally, based on new pathophysiological data, two potential drugs, selepressin and angiotensin II, are currently being evaluated."

Syncope

An online community of practice for Canadian EM physicians
CanadiEM - By Shahbaz Syed - February 28, 2018
"Syncope is a common problem encountered in the Emergency Department, and yet despite this there are few strong consensus guidelines, and significant practice variation. Here we seek to explore some of the evidence regarding syncope care. The vast majority of literature and recommendations on syncope in this post, are based upon the well patient who has a syncopal event and is now well again. The differential diagnosis in this scenario is actually fairly limited, as there are not many things that do this beyond cardiac and vasovagal (and potentially GI bleeding, but historical features will aid you there)..."

martes, 27 de febrero de 2018

Alcohol sniffing and nausea

St.Emlyn's
St. Emlyn´s - By Simon Caarley - February 25, 2018
..."So where does that leave us?
Well, we have two recent RCTs that suggest sniffing alcohol swabs works. They both have similar flaws, but they are consistent. Until we know better it seems like a reasonable tool for the ED clinician who wants to reduce nausea quickly.
A second question would be whether this study is robust enough to suggest that we should swap Ondansetron for alcohol swabs. In that regard my answer is no. These are really interesting data, but it’s not robust enough to go that far (and in the authors defence they neither designed this study to do that, nor do they suggest it).
So. Get sniffing. Personally, I’m off to get a whiff of a rather nice Albarino I’ve got chilling in the fridge."

Respiratory Failure and NIV

R.E.B.E.L.EM - By Haney Mallemat - February 26, 2018
"Imagine you have a patient in respiratory failure sitting right in front of you. The patient has an increased work of breathing and obviously in distress. Monitors are beeping, nurses are asking you what you want to do, and if you don’t do something, the patient is going to arrest and potentially die. What is your framework for tackling these patients? Well, I had a chance to sit down with Haney Mallemat and discuss his framework for managing respiratory failure and NIV." 

Reversing DOAC in intracraneal bleeding

An online community of practice for Canadian EM physicians
CanadiEM - By Andrew Shih - February 27, 2018
"Main Messages
  • When managing DOAC-associated bleeding, consider the interventions that you would perform if the patient was not on a DOAC. Tranexamic acid has an excellent safety profile based on RCTs. Definitive procedural intervention remains the cornerstone of therapy.
  • Specific reversal agents should be used whenever possible. PCCs and FEIBA are options in factor Xa inhibitor associated bleeding in the absence of a specific reversal agent, where thrombosis risk is low but should be discussed during consent.
  • Plasma and platelet transfusion should only occur when indicated as if the patient was not on a DOAC."