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


The new approach to Glasgow Coma Scale assessment

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miércoles, 22 de febrero de 2017

Submassive Pulmonary Embolism

stemlyns submassive pulmonary embolism smacc
Swami at St.Emlyn’s - February 21, 2017
..."The central theme in pulmonary embolism or, honestly, any disorder we look after is time. Time is the speciality of the Emergentologist. How much time does the patient have? How much time do I have to make the diagnosis? All ED interventions are there to buy the patient time. This idea rings true for the submassive PE: how much time does the patient have to break that clot down on their own? Do I need to simply watch and wait or do I need to help the process along?..."

martes, 21 de febrero de 2017


R.E.B.E.L.EM - February 20, 2017
"Background: Many providers and health care workers place oxygen on patients as a way to overcome hypoxemia or for patient comfort. Also in STEMI patients, many of us have learned the mnemonic “MONA” to remember the treatments for acute coronary syndrome. MONA stands for morphine, oxygen, nitroglycerin, and aspirin. It is however important to remember that oxygen is a drug; just like any other drug, there are side effects. Some of the best known side effects of hyperoxia are direct lung toxicity, peripheral vasoconstriction, and increase in production of reactive oxygen species. The PROXI Trial (Perioperative Oxygen Fraction-Effect on Surgical Site Infection and Pulmonary Complications After Abdominal Surgery) and the AVOID Trial (Air Versus Oxygen in Myocardial Infarction) showed increased long-term mortality and larger myocardial infarction size respectively in patients with supra-normal oxygen levels (hyperoxia)..."

Perils of Intravenous Fluids

PulmCCM - February 13, 2017 - By Jon-Emile S. Kenny 
"The provision of intravenous fluids is no trivial intervention. Indeed, one eminent nephrologist has called for medical students to receive, not a ‘white coat ceremony’ at the outset of their education, but instead a ‘normal saline ceremony.’ This pomp is an occasion whereby the fledgling physician imbibes a reverence for sodium chloride. To hold a bag of resuscitation fluid should rouse veneration no different than grasping an ampule of morphine or vial of piperacillin-tazobactam. Thus, a zealous awareness of the balance between therapy and toxicity is required for all things we inject into another beings’ veins.
Yet, the administration of intravenous fluid is so ubiquitous and commonplace that we take the aforementioned for granted; it certainly isn’t – emotionally – on par with mixing mannitol or readying dantrolene. We ‘bolus’ and ‘challenge’ patients continuously with crystalloid so much so that these terms lose meaning; what, exactly, is indicated when one says ‘bolus’ or ‘challenge?’..."
PulmCCM - February 14, 2017 - By Jon-Emile S. Kenny 
"Fluids and the Glycocaylx
Critically-ill patients all likely have endothelial dysfunction to some degree. This perturbation in microvascular physiology may be underpinned by abnormal glycocalyx structure and function. Sepsis, trauma, surgery and ischemic insults are all known to disrupt the glycocalyx which will increase vascular fluid capacitance. Indeed, at 90 minutes, 20% of crystalloid volume remains within the vascular space, while in sepsis only 5% does. Further, in sepsis, precapillary arteriolar dilation increases capillary filtration pressure which favours interstitial edema. Thus, the use of alpha agonists such as norepinephrine may protect the microvascular beds from excessive filtration pressure..."

domingo, 19 de febrero de 2017

Temperature taking

EM Ireland - February 18, 2017 - By  Andy Neill
..."So what are the diagnostic characteristics of the non-invasive thermometers then?
Well, according to one of the most recent systematic reviews and meta analyses on the subject the sensitivity is 64% and the specificity is 96%. The reported range of inaccuracy was plus or minus 1.5 degrees...
This was actually a fairly nicely done study, with a well defined search strategy and appropriate inclusion and exclusion criteria (prospective studies only, all had to have a clear “gold standard” comparator, ie rectal, oesophageal, endovascular temp etc…) and it’s by no means the first paper to question the use of non invasive techniques for measuring temperatures..."

Large Vessel Occlusion Acute Stroke

Resultado de imagen de Emergency MEdicine news
Marcolini E. Emergency Medicine News 2017; 39(2): 10
doi: 10.1097/01.EEM.0000512770.00506.95
CT perfusion, stroke...
..."The recent groundbreaking trials (MR CLEAN, REVASCAT, ESCAPE, SWIFT PRIME, AND EXTEND-IA) showed us that endovascular therapy can improve outcomes in patients with anterior large vessel occlusion acute stroke. How did they do this? They used better tools (stent retrieval devices), for one thing, but they also used functional imaging technology to figure out which patients would benefit most from revascularization. After years of failing to show that thrombectomy can improve outcomes, these tools helped us by narrowing the studied patient population with practice-changing results..."

Abdominal Pain in the Geriatric Patient

EM Resident Magazine
EM Resident - By Carpenter C, Nagurney J and Tyler K - 02/02/2017
"Geriatric patients, generally defined as persons age 65 and older, comprise a specific, vulnerable, and ever-growing population within the emergency department. Frequently, care of these patients requires modification of existing diagnostic and treatment paradigms.
In particular, older patients presenting with abdominal pain can be challenging for a few reasons. First, the physical exam may be falsely reassuring. For example, older patients with infections do not necessarily have fevers
Even in the face of a serious intra-abdominal pathology, they are equally as likely to be normothermic or hypothermic as hyperthermic.
Second, medications such as beta-blockers or calcium channel blockers may mask tachycardia.
Third, peritoneal symptoms are much less common, possibly because aging changes the way elderly patients experience pain.3 In one study of older patients, 80% of geriatric patients with perforated peptic ulcers did not have peritonitis.
Finally, older patients often have multiple comorbidities, which can complicate diagnostic processes..."

External bleeding control

Trauma System News
TSN - By Catherine Musemche - February 9, 2017 
Forward Surgical Team and bleeding control
"UP TO 16 PERCENT of patients who die from hemorrhage might have been saved if bleeding had been recognized earlier and treated effectively.[4] Undetected internal bleeding into the abdomen or pelvis usually accounts for most of these preventable deaths. But a trauma victim can also bleed to death from external hemorrhage, like bleeding from an arm or leg that no one manages to control in time. Applying a tourniquet, a ten-second procedure, might have saved him...
The military’s MARCH protocol (Massive Hemorrhage, Airway, Respirations, Circulation, and Hypothermia) now instructs army medics to stop external bleeding before doing anything else. Direct pressure is applied first. If the bleeding continues and the source is an extremity, a tourniquet is applied above the site of bleeding..."

sábado, 18 de febrero de 2017

Critical Incident Stress Management

CanadiEm - February 17, 2017 - By Andrew Dixon
"In Emergency Medicine, unexpected tragedies are an expected part of our specialty, and a skilled debrief session can be as important for the team as the patient care delivery itself. This Feature Educational Innovation (FEI), titled “Critical Incident Stress Management – TASK Defusion” on May 15, 2015 and answers the question: “Can we develop a practical debriefing tool to help structure team debriefing after a critical incident?” A PDF version is available here. A CAEP cast is available here."

MRI in the ED

emDocs - February 17, 2017 - Author: Long A -  Edited by: Koyfman A and Long B
"Bottom line:
An MRI should only be ordered in the ED when the patient’s treatment and/or management will be affected.
The misuse of MRIs in the ED generates unnecessary costs to patients and increased time in the department. It is essential to weigh the risk(s) of ordering an MRI for your patient in the ED.
The indications for emergency MRI Brain include clinical concern for acute ischemic stroke, particularly wherein the management may differ with possible intervention versus less aggressive treatment plans.If there is clinical concern for new spinal cord compression from disease or injury, an emergency MRI evaluation is necessary. 
The indications for emergency spinal MRI include suspicion for:
  • Spinal cord compression (herniated disc, burst fracture, tumors, etc)
  • Spinal infection (i.e. abscess)
  • Spinal trauma (epidural hemorrhage, etc)
  • Demyelination with acute neurologic changes
Additionally, emergency MRIs may be considered if there is concern for:
  • Appendicitis in the pregnant or pediatric patient
  • Hip fracture not detected on plain film or CT"

The ED Transfer

emergency department patient transfer St.Emlyn's
St.Emlyn's - By Natalie May - February 17, 2017
"Depending on your department the frequency with which you are faced with the need to transfer a critically ill intubated patient may vary but it is something we think all departments face at some point.
Common examples might be:
  • The intubated major trauma patient, needing to be transferred to radiology for imaging
  • The intubated post-cardiac arrest patient, needing to be transferred to an intensive care setting.
While chatting about my experiences in prehospital and retrieval medicine at Sydney HEMS, Simon and I realised that we were both in the position of having undertaken these transfers at various stages of seniority in our careers and that now, with greater experience, wisdom and hindsight (!) we have an awareness that we could have done a much better job of it, particularly when we were relatively junior.
We put together the podcast below to outline our experiences and thoughts on how we would now approach this potentially very risky clinical undertaking and we would love to hear your thoughts on what we had to say..."

jueves, 16 de febrero de 2017

Sincope (WOBBLER)

RESUS.ME - February 15, 2017 - By Cliff
"Syncope is a common ED presentation. An ECG is a critical investigation in syncope to look for causes which include some rare causes of sudden cardiac death.
So we should be really grateful when we are invited to interpret an ECG while we’re in the middle of six other tasks.
The problem with syncope is that some of the important life-threatening causes have fairly obscure ECG features that might be hard to remember. Some of these causes and their ECG features are not entirely familiar to the clinicians who first screen the ECG.
When you’re busy and cognitively stretched you can save time and reduce the risk of missing important findings by having a structured, memorable checklist. I use the acronym WOBBLER, because you don’t want these people to wobble and kiss the dirt again.
The nice thing about WOBBLER is that it uses the sequence that you follow when you look at an ECG, ie from left to right, or from P wave to T wave..."

miércoles, 15 de febrero de 2017

O2 Sat in Critical illness

PulmCrit - February 15, 2017
Ref. Effect of Conservative vs Conventional Oxygen Therapy on Mortality Among Patients in an Intensive Care Unit. The Oxygen-ICU Randomized Clinical Trial. JAMA. 2016 Oct 18;316(15):1583-1589.
"Oxygen is essential for life, but by forming superoxides and free radicals, supplemental oxygen can also inflict damage on lung and other body tissues.
The sweet spot for oxygen delivery in critically ill patients is unknown, but increasing evidence suggests that when it comes to blood oxygen saturation during critical illness, "normal" levels might actually be harmful...
...this is not a conclusive study by any stretch of the imagination. But given the mounting suggestion of possible harm from high normal or supranormal arterial oxygen levels, and the apparent absence of harm from low-normal oxygenation, it seems prudent to target oxygen saturation in the mid-90s percent for many, if not most critically ill patients."

Shared Decision Making In The ED

Health Affairs Blog
Health Affairs Blog - Melnick E, Hess E - February 7, 2017

..."As our health care system continues to test new ways to deliver value-based health care, there is a growing recognition of the important role of shared decision making. Policymakers are actively creating ways to incentivize providers to build these tools into their routine practice through new Medicare payment models. To date, these efforts have primarily focused on decision making in the physician office. Research like ours shows tremendous potential for driving value-based care in the emergency setting through shared decision making. As we continue to build incentives for value-based care into our health care system, we should not leave the ED out..."

martes, 14 de febrero de 2017

Assessment of bendopnea

European Journal of Heart Failure
Baeza-Trinidad R, Mosquera-Lozano J, El Bikri L. 
Hearth Failure 2017; 19 (1): 111-115 - DOI: 10.1002/ejhf.610
"Bendopnea is related to NYHA functional class III–IV, orthopnoea, PND, EJVP, and abdominal fullness, but not to BMI or cardiomegaly and hepatomegaly. Our study showed that bendopnea is an advanced HF symptom and it is related to mortality in the short term (6 months), particularly in those with advanced NYHA functional class (III–IV) and in those with HFrEF. Finally, bendopnea results in moderate to severe limitation in patients' QoL, which is also related to BMI."

Innovation in EM

Resultado de imagen de emergencias semes revista
Innovation in emergency medicine: 5 operational initiatives that could change our practice 
Lobón L, Anderson P. Emergencias 2017;29:61-64
"La gestión de los SUH es complicada y requiere, además de una observación constante, la capacidad de adaptación a necesidades emergentes y la superación de obstáculos inesperados. Esta capacidad de adaptación es única entre el personal de los SUH dentro del sistema sanitario. Nuestro enfoque y el objetivo en el IEDLI es apoyar la gestión de los SUH por los especialistas de urgencias, siempre considerando como prioridad el trato al paciente, que es sin duda alguna nuestro mejor aliado. Nuestra capacidad de crear y adaptarnos a nuevos procesos de organización y gestión se traducirá en una mejora de la calidad asistencial y del servicio comunitario que nuestros SUH aportan a la sociedad en general."

Aggresive Management of AF

R.E.B.E.L.EM - February 13, 2017
Ref. 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
"Clinical Question:
What is the rate of adverse events occurring within 30 days of ED presentation for recent-onset AF/AFl in a system that utilizes an aggressive approach to management?
Author’s Conclusions:
“Although most recent-onset atrial fibrillation and flutter patients were treated aggressively in the ED, there were few 30-day serious outcomes. Physicians underprescribed oral anticoagulants. Potential risk factors for adverse events include longer duration from arrhythmia onset, previous stroke or transient ischemic attack, pulmonary congestion on chest radiograph, and not being in sinus rhythm at discharge. An ED strategy of sinus rhythm restoration and discharge in most patients is effective and safe”...
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."

Top 10 Articles 2016 (EMOttawa)

EMOttawa - February 13, 2017 - By Hans Rosenberg
"This is a summary of a talk given by Drs. Krishan Yadav and Maggie Kisilewicz at the National Capital Conference in Emergency Medicine. Below are brief summaries and a bottom line, but of course you'll have to read the literature yourself to make your own decisions!"
1) Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage ATACH-2 
2) An Age-Adjusted D-dimer Threshold of Emergency Department patients with Suspected Pulmonary Embolus: Accuracy and Clinical Implications. 
3) Discharge Glucose Is Not Associated With Short-Term Adverse Outcomes in Emergency Department Patients With Moderate to Severe Hyperglycemia. 
4) Air Versus Oxygen in ST-Segment–Elevation Myocardial Infarction. 
5) Randomized Clinical Trial of Observation versus Antibiotic Treatment for a First Episode of CT Proven Uncomplicated Acute Diverticulitis (DIABOLO). 
6) Characteristics and Outcomes of Patients Presenting With Hypertensive Urgency in the Office Setting. 
7) Immediate Total-Body CT Scanning Versus Conventional Imaging and Selective CT Scanning in Patients with Severe Trauma (REACT-2): A Randomized Controlled Trial. 
8) Immediate Discharge and Home Treatment With Rivaroxaban of Low Risk Venous Thromboembolism Diagnosed in Two U.S. Emergency Departments: A One-year Preplanned Analysis. 
9) A randomized trial of intraarterial treatment for acute ischemic stroke. 
10) Prevalence of Pulmonary Embolism Among Patients Hospitalized for Syncope (PESIT).

lunes, 13 de febrero de 2017

Management of elderly major trauma patients

London Major Trauma System - February 2017
"This policy applies to adult patients aged 70 years and over (but this could be younger if frailty is deemed an issue in patients younger than 70) who are admitted to an MTC following traumatic injury. This policy also applies to the early identification of elderly trauma patients admitted to critical care...
A pan London elderly trauma group, comprising of multi-disciplinary professionals with interest and expertise in managing older injured patients, convened in 2016 to develop clinical guidelines and commissioning standards specifically for elderly major trauma. This report summarises the work of the group and aims to improve recognition of injury, clinical management, outcomes and the patient and family experience. Admission pathways for MTCs and TUs are supplemented with ageing-specific suggestions for the clinical management of elderly major trauma. Guidance in this report should be used in conjunction with the existing local policies, NICE guidance NG39, Major trauma: Assessment and initial management and Trauma Quality Improvement Network System (TQuINS) standards . A clear message from the group was that elderly trauma patients with multiple injuries are often only identified retrospectively and that prospective recognition of multiple injuries is key to improving overall care and outcomes. To this end, a suggested ED screening tool (which will require validation) is attached as Appendix 1 (page 26)."

Epinephrine vs. atropine for bradycardic periarrest

PulmCrit - February 13, 2017 - By Josh Farkas
  • "It may be useful to make a distinction between patients with stable, symptomatic bradycardia versus patients who are actively dying from bradycardia (bradycardic periarrest). The best approach to these situations is different.
  • Epinephrine may be superior for patients with bradycardic periarrest for three reasons:
    • (1) It works in a broader range of bradycardias.
    • (2) It provides more powerful hemodynamic support (chronotropy, inotropy, and vasoconstriction).
    • (3) It doesn't cause paradoxical bradycardia.
  • The best initial medical therapy for bradycardic periarrest may be push-dose epinephrine, followed by an epinephrine infusion. However, this shouldn't delay efforts to perform electrical pacing as well."

domingo, 12 de febrero de 2017

Parkinson´s in the ED

Resultado de imagen de RCEM
RCEM - September 26, 2016 - By Jones 
"...People with PD rarely present purely because of PD itself. However, patients may attend ED with complications of their PD (for example falls, delirium, severe constipation or aspiration). In addition, PD may complicate the presentation and treatment of any emergency – for example pre-existing autonomic instability will make sepsis or hypovolaemia more difficult to assess, and the requirement to take regular time critical medications makes managing reduced conscious level or need for sedation/anaesthesia more difficult. Patients in ED may delay/miss their PD medication since this may not be seen as the immediate priority by ED staff. This can cause life threatening complications..."
Postural hypotension is common in PD. This may be the presenting complaint or can complicate any condition causing haemodynamic compromise.-2

Acute angle closure Glaucoma

emDocs - February 10, 2017 - Authors: Langridge C and Williams D
Edited by: Koyfman A and Long B

  • Consider AACG in all patients presenting with headache and visual changes, especially if associated with nausea and vomiting.
  • AACG occurs more frequently in females and those of Asian descent.
  • Early and effective therapy is vital in reducing optic nerve ischemia and vision loss. Time is optic nerve.
  • Be aware of the patient’s comorbidities and allergies before treating (i.e. be aware of the risks of topical β blockers in COPD/asthma, sulfa allergy with acetazolamide use)
  • Consider corneal indentation as a temporizing maneuver if IOP is not satisfactorily lowered in a reasonable amount of time.
  • There is no emergent treatment that an ophthalmologist can offer that an emergency physician cannot. Definitive treatment is with LPI, however this is frequently delayed until corneal clearing occurs. Thus topical and IV agents are paramount in early treatment of AACG."

sábado, 11 de febrero de 2017

Methylene blue vs Vasopresin

The Bottom Line - February 10, 2017 By Duncan Chambler
Ref. El Adawi. Ain-Shams J Anaesthesiol 2016;9:319-24. doi:10.4103/1687-7934.189091
"Clinical Question
In adult patients with severe sepsis, does methylene blue compared to vasopressin reduce noradrenaline requirement and increase blood pressure?
Authors’ Conclusions
In sepsis-induced refractory vasoplegia methylene blue may be more effective than vasopressin but further studies are required
The Bottom Line
Although an exciting and relevant clinical question, the methodological flaws in this study potentially introduce far too many biases for the conclusion to be accepted
Further patient-centred trials are required before I will be reaching for the methylene blue"

Postpartum Cardiomyopathy

The Original Kings of Country - By bobakzonnoor • November 22, 2016
You suspect Postpartum Cardiomyopathy
  • What is your top differential diagnosis?
  • What is Postpartum Cardiomyopathy?
  • What are the diagnostic criteria for Postpartum Cardiomyopathy?
  • What are the most common signs and symptoms of postpartum cardiomyopathy?
  • What are some diagnostic challenges in patients with postpartum cardiomyopathy?
  • What are risk factors for postpartum cardiomyopathy?
  • Is the management of postpartum cardiomyopathy different from management of other causes of heart failure?
  • What is the prognosis of postpartum cardiomyopathy?

jueves, 9 de febrero de 2017

Thrombocytosis in the ED

emDocs - February 9, 2017 - Authors: Fujimoto J and Repanshek Z
Edited by: Koyfman A and Long B
"Pearls and Pitfalls
  1. In the ED, we must try to differentiate myeloproliferative/clonal thrombocytosis from secondary/reactive thrombocytosis.
  2. Reactive thrombocytosis may be secondary to trauma/surgery, splenectomy, infection or inflammation, blood loss, malignancy, medication use, etc. Reactive thrombocytosis tends to be transient, whereas clonal thrombocytosis is sustained. Platelet count does NOT help distinguish the two!
  3. Even in cases of extreme thrombocytosis, treatment of reactive thrombocytosis with antiplatelets or cytoreductive agents is NOT recommended.
  4. Given the relatively high incidence of thrombotic complications in essential thrombocythemia, high-risk, asymptomaticpatients should be treated prophylactically with antiplatelet agents + cytoreductive agents.
  5. Essential thrombocythemia patients with acute thrombotic complications require treatment with a cytoreductive agent, anticoagulation, aspirin, and possibly apheresis."

Vital Signs and PE

R.E:B.E:L.EM - By Beck-Esmay J - February 9, 2017
..."Clinical Question:
Does the normalization of initially abnormal vital signs change to probability of pulmonary embolism in symptomatic patients being evaluated for pulmonary embolism in the emergency department?...
Author’s Conclusions:
“Clinicians should not use the observation of normalized vital signs as a reason to forego objective testing for symptomatic patients with a risk factor for PE.”
Our Conclusions:
If you have a patient in whom you suspect PE, the normalization of their vital signs during their time in the ED should not reassure you that they do not have a PE.
Potential Impact To Current Practice:
This study suggests that when formulating clinical gestalt or when applying vital signs to a clinical decision making rule, the most abnormal vital sign should be used.
Clinical Bottom Line:
For patients in whom you suspect PE, normalization of vital signs should not be used as a rationale to lower your pretest probability for the disease. The best approach is to use the most abnormal vital sign measurement when determining the pre-test probability of a PE in the patient."

martes, 7 de febrero de 2017

The future of EM Education

St.Emlyn’s - By Simon Carley - February 7, 2017
"It’s a special year for UK Emergency Medicine. 2017 is the 50th anniversary of our speciality and the RCEM is planning a series of events to celebrate this. It’s also the 30th anniverary of the EM section at the Royal Society of Medicine in London, and arguably the RSM is kicking off a year of reflection with their 30th anniversary meeting in London that took place earlier this month.
Peter Williams, section president, put together a great program highlighting the past, present and future of EM with speakers from the UK, North America and South Africa. My contribution was to talk around the social future of emergency medicine education and to illustrate how technology and social interaction is disrupting the traditional education model.
There are 3 key messages in the talk linked to past blog posts and presentations. I’ve collated them here as a record for the day and as a way of sharing the message as far as we can.
  1. Techology, Memory and Processing
  2. The social age
  3. Impact and engagement"

Staphylococcal Toxic Shock

emDocs - February 7, 2017 - By Gettel C, Smith J - Edited by: Koyfman A and Long B
"Key Points for the ED provider
  • TSS is often a late diagnosis, and there have been many unfortunate cases, which were initially given a more benign diagnosis.
  • Systemic illness plus blanchable, diffuse rash or ‘pain out of proportion’ should clue the clinician into TSS, either from aureus or S. pyogenes.
  • Half of the cases are from tampon use, while other common precipitants include nasal packing and surgical wound infections.
  • Resuscitation efforts should be initiated by the ED provider, including source control and supportive care with IV fluids, vasopressors, and appropriate antibiotics."

Death after discharge

avoidingERrors - By Jesse - February 7, 2017
“Over 10,000 Medicare beneficiaries die each year across US within 7 days of discharge from emergency departments, despite mean age of 69 and no obvious life limiting illnesses.”
This finding from a new study in the BMJ underscores the importance of disposition and discharge planning in the emergency department. Death after discharge is rare but devastating for patients, families and health providers, and carries a high medico-legal cost. It also includes potentially preventable errors and opportunities to improve patient care.
Here’s a brief summary of five articles on this topic, in chronological order, followed by a summary and safe discharge checklist..."

lunes, 6 de febrero de 2017

Glucagon for FB Impaction

The Skeptics Guide to Emergency Medicine
SGEM - February 2, 2017 - By Meghan Groth
Ref: Bodkin et al. Effectiveness of glucagon in relieving esophageal foreign body impaction: a multicenter study. AJEM June of 2016
"Clinical Question: Is glucagon safe and effective for the management of esophageal foreign body impaction?...
SGEM Bottom Line: Glucagon has a low success rate for EFBI, does not seem to offer much benefit over observation alone and is associated with adverse events like vomiting."

Neurotrauma Resuscitation

emDocs - February 6, 2017 - Author: Long B - Edited by: Koyfman A
"Key points
  • Neurotrauma is common, as it is the leading cause of death in North America in those between ages 1 year to 45 years. Primary and secondary injuries result in severe morbidity and mortality.
  • Neurotrauma includes head contusion, epidural hematoma, subdural hematoma, subarachnoid hemorrhage, diffuse axonal injury, skull fracture, and traumatic spinal cord injury.
  • Cerebral perfusion pressure requires adequate cerebral blood flow.
  • Evaluation and management in the emergency department entails initial stabilization and resuscitation while assessing neurologic status.
  • Targeting mean arterial pressure, oxygen levels, and neurologic status are key components. ICP management should follow a tiered approach.
  • Intubation of the patient with neurotrauma should be completed with several considerations.
  • Hyperosmolar treatments include HTS and mannitol."