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SOBRE EL AUTOR **

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

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Penetrating Neck Trauma

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jueves, 28 de julio de 2016

Eating for Shift Work

Taming The SRU - July 25, 2016 - By Brittney Bernardoni, MD
"Tips for Eating during Shift Work:
  1. Eat your main meal before work
  2. Bring healthy snacks and a small balanced meal to work
  3. Avoid eating between 0000-0600 especially carb-rich meals (decreased attention, increased risk metabolic synd, possibly insulin-related)
  4. Drink plenty of water, have a water bottle by your workstation
  5. <400mg of caffeine/day (4 c coffee, 4 monsters, 4 mountain dew)
  6. No caffeine in the 4 hours before bedtime
  7. Avoid large meals 1-2 hours before bedtime
  8. Avoid alcohol after work (may disturb sleep)
Remember, these tips are guidelines. We will frequently do the exact opposite of these recommendations, especially during post-overnight breakfasts (aka 7 and 8). Wellness is all about balance. This month, try incorporating 1-2 of these recommendations into your daily shift routine and see what works for you!"

Blunt Trauma

emDocs - July 27, 2016 - Authors: Macdonald C and Waseem M
Edited by: Koyfman A and Alerhand S
"Missed injuries are fortunately rare, yet the injured trauma patient may present a unique diagnostic challenge. Missed injuries and delay in diagnosis remain a concern for ED physicians caring for trauma patients. Delayed diagnosis of intra-abdominal injuries, for instance, results in significantly increased morbidity and mortality. Literature suggests an 8.1% incidence of patients with missed injuries, which may be an underestimation of the true incidence of missed injuries.
Take-home points/Pearls
  • Some missed injuries may be due to inadequate clinical assessment; therefore an accurate assessment is very critical to identify injuries.
  • A false negative FAST examination is NOT sensitive enough to rule out all abdominal injuries.
  • The absence of abdominal pain or tenderness does not rule out significant injury.
  • Following ATLS protocol may be helpful for an adequate assessment."
Go here for further reading related to this topic: http://www.emdocs.net/the-cleared-trauma-patient-what-could-we-be-missing/

Elevated Lactate: Significance and Challenges

Resultado de imagen de SINAIEM
SinAiEM - By Jean Sun - 22 July, 2016
"Given the evolving definition of sepsis and the continual push to report sepsis measures to State Health Departments and CMS, I thought the time is ripe to revisit a popular topic: the significance of elevated lactate in the ED. After all, not all elevated lactate is sepsis, and we may be able to spare some diagnostic errors in the ED by examining this popular lab value more closely."

Postobstructive diuresis

Logo of canfamphys
Halbgewachs C & Domes T. Can Fam Physician. 2015 Feb; 61(2): 137–142. 
"Urinary retention is a common clinical condition encountered by all physicians at some point in their careers. As described above, the initial medical approach involves decompressing the bladder with the placement of a urethral catheter, followed by a workup to identify the underlying cause. However, how often do primary care physicians consider the potential effects of rapidly draining a patient’s bladder on the rest of the body? One might argue there is little effect, as doing so mimics urination, the normal physiologic process that has been perfected over thousands of years of natural selection. However, in some situations, acute drainage of an obstructed urinary tract can unmask deranged renal mechanisms and result in uncontrolled, unregulated urine production known as postobstructive diuresis. Postobstructive diuresis is important because it can occur in up to 50% of patients with substantial urinary tract obstruction and can be life-threatening if it becomes pathologic and is not adequately treated. The goal of this article is to make primary care physicians aware of this clinical entity and help them confidently identify individuals at risk, initiate appropriate monitoring to allow for early diagnosis, and provide adequate treatment to avoid any adverse outcomes.
EDITOR’S KEY POINTS
  • Acute drainage of an obstructed urinary tract can unmask deranged renal mechanisms and result in uncontrolled, unregulated urine production known as postobstructive diuresis (POD).
  • Postobstructive diuresis can occur in up to 50% of patients with substantial urinary tract obstruction and can be life-threatening if it becomes pathologic.
  • Patients with decompressed urinary obstruction might have to be admitted for a 24-hour observation period. If pathologic POD ensues, then polyuria will continue even after a euvolemic state is reached. Patients with pathologic POD require strict monitoring of vital signs, fluid status, and serum electrolyte levels, and benefit from consultation with a nephrologist."

miércoles, 27 de julio de 2016

Auricular Hematoma Drainage

NU EM - Author: Berg A - Edited by: Byrne E - Expert Commentary: Beach C
Citation: [Peer-Reviewed, Web Publication] Berg A, Byrne E (2016, July 26). Simple Steps To Auricular Hematoma Drainage [NUEM Blog. Expert Commentary by Beach C]. Retrieved from http://www.nuemblog.com/blog/auricular-hematoma/
"Pearls
  • The term “cauliflower ear” is based on the fact that the pressure, scarring and neocartilage formation at the site of the clot creates a deformity similar to the appearance of a cauliflower. 
  • It is imperative to recognize an auricular hematoma! Early treatment of this condition will prevent permanent disfigurement and improve cosmetic outcomes. Necrosis begins within 24 hours.
  • Advise your patient to avoid contact sports until the ear has healed completely as the hematoma can reaccumulate if reinjured. 
  • Remember to place dressing both posterior and anterior to the ear to maintain pressure to prevent re-accumulation. 
  • If the injury occurred greater than 7 days after the trauma, refer your patient to an ENT for repair as the patient’s ear may require debridement. 
  • Instruct your patient to inspect the wound frequently to return for signs of vascular compromise or infection."

Occult Sepsis in Traumatic Injuries

emDocs - July 26, 2016 - Author: Long B - Edited by: Koyfman A
..."Sepsis and Trauma patients may both demonstrate positive SIRS criteria. The qSOFA score may also be positive in these patients, which raises questions regarding the use of Sepsis 3.0 to differentiate sepsis and trauma.
The best tools for diagnosis likely include the use of history, vital signs, physical examination, ultrasound, laboratory markers, and clinical gestalt.
One recent review article published in 2015 compares the classic approaches to resuscitation in trauma and sepsis patients.
Management priorities in trauma from Frankel HL, Magee GA, Ivatury RR. Why is sepsis resuscitation not more like trauma resuscitation? Should it be? J Trauma Acute Care Surg 2015 Oct; 79 (4): 669-77.
This diagram reflects the primary strategies for trauma management: (1) fix the problem (often bleeding source), (2) provide fluids (usually blood products), and (3) utilize appropriate tests and monitoring. The authors advocate that sepsis should be cared for similar to trauma, with targeted source control and minimizing “collateral damage,” including over-resuscitation.
The initial management strategy of the patient in extremis for trauma and sepsis is similar. Resuscitate first and ask questions later. As discussed above, go through Airway, Breathing, Circulation, Disability/D-stick, Exposure, E-FAST exam/fetus (is the female patient pregnant?). Obtain IV access, attach monitors, and be prepared to provide supplemental O2.
Finally, when diagnosing sepsis, a potential source needs to be found. The LUCCASSS pneumonic is helpful toward assisting in a search for the source: source: lung (pneumonia), urine (cystitis/pyelonephritis), cardiac (endocarditis), CNS (meningitis, encephalitis), abdominal (abscess, cholecystitis), spine (osteomyelitis, abscess), skin (cellulitis, IV line/PICC infection), and septic arthritis. Fortunately, an accurate history, physical examination, and appropriate laboratory tests and imaging can usually pinpoint the source of sepsis, but a systematic approach should be followed. Look for biomarkers that are not improving, and evaluate for hypotension, altered mental status, and RR ≥ 22/min. These are markers for mortality and should trigger consideration of sepsis."

Acute Lower Gastrointestinal Bleeding

Strate L and Ian M. Gralnek I. Am J Gastroenterol advance online publication, 1 March 2016; doi: 10.1038/ajg.2016.41 
"This guideline provides recommendations for the management of patients with acute overt lower gastrointestinal bleeding. Hemodynamic status should be initially assessed with intravascular volume resuscitation started as needed. Risk stratifi cation based on clinical parameters should be performed to help distinguish patients at highand low-risk of adverse outcomes. Hematochezia associated with hemodynamic instability may be indicative of an upper gastrointestinal (GI) bleeding source and thus warrants an upper endoscopy. In the majority of patients, colonoscopy should be the initial diagnostic procedure and should be performed within 24 h of patient presentation after adequate colon preparation. Endoscopic hemostasis therapy should be provided to patients with high-risk endoscopic stigmata of bleeding including active bleeding, non-bleeding visible vessel, or adherent clot. The endoscopic hemostasis modality used (mechanical, thermal, injection, or combination) is most often guided by the etiology of bleeding, access to the bleeding site, and endoscopist experience with the various hemostasis modalities. Repeat colonoscopy, with endoscopic hemostasis performed if indicated, should be considered for patients with evidence of recurrent bleeding. Radiographic interventions (tagged red blood cell scintigraphy, computed tomographic angiography, and angiography) should be considered in high-risk patients with ongoing bleeding who do not respond adequately to resuscitation and who are unlikely to tolerate bowel preparation and colonoscopy. Strategies to prevent recurrent bleeding should be considered. Nonsteroidal anti-infl ammatory drug use should be avoided in patients with a history of acute lower GI bleeding, particularly if secondary to diverticulosis or angioectasia. Patients with established cardiovascular disease who require aspirin (secondary prophylaxis) should generally resume aspirin as soon as possible after bleeding ceases and at least within 7 days. The exact timing depends on the severity of bleeding, perceived adequacy of hemostasis, and the risk of a thromboembolic event. Surgery for the prevention of recurrent lower gastrointestinal bleeding should be individualized, and the source of bleeding should be carefully localized before resection."

martes, 26 de julio de 2016

BP in Brain Bleeds (ATACH 2)

SCANCRIT - Posted on July 25, 2016 - By K
"A trial called ATACH-2 (Antihypertensive Treatment of Acute Cerebral Hemorrhage II), recently published inNEJM, is likely to temper the enthusiasm for aggressively lowering blood pressure in patients with intracranial bleeds...
Take-home message
ATACH-2 is similar to the previous INTERACT2 trial. INTERACT 2 could display a marginal tendency towards benefit with aggressive treatment. ATACH-2 builds on that as the researchers recruited patients with higher BPs and started treating earlier (4,5 vs 6h), hoping to amplify the trend seen in INTERACT2. Unfortunately, ATACH-2 could demonstrate no incremental benefit.
For me this means I will keep treating high blood pressures in patients with intracranial bleeds, perhaps aiming for the upper normal range. Not because I think it will improve neurological outcome but out of concern for other organ systems. These patients are often old and have comorbidities and might not tolerate high BPs for long."

Chemotherapy Induced Emetogenecity

EM Didactic - July 25, 2016 - By Lakshay Chanana 
"Cancer is one of the top three killers today and Emergency Departments are expected to see more and more Oncological Emergencies in future. CINV i.e. Chemo Induced Nausea and Vomiting is one such complication of chemotherapy...
Key Points
  • First Line for CINV - 5HT3 Antagonists, Steroids, NK1RA
  • Adjuncts - Benzodiazepines, D2 RA, Olanzapine, Anti-Histaminics, Cannabinoids"

Ideal Length of Residency Training in EM

Hopson L et al. Acad Emerg Med. 2016 Jul;23(7): 823-7. doi: 10.1111/acem.12968. Epub 2016 Jun 20.
"CONCLUSIONS: PD opinion on ideal LoT averages between 36 and 48 months, but is longer when the sum of desired clinical rotations is considered. While half of the respondents reported direct experience with both PGY 1-3 and PGY 1-4 training programs, opinions on ideal LoT through both methods corresponded strongly with the length of the program the PDs trained in and the format of the program they currently direct. PD opinions may be too biased by their own experiences to provide objective input on the ideal LoT for EM residency programs."

Evaluación y manejo inicial del trauma grave

IntraMed - 24 Jul 2016
Una síntesis de los cursos de acción para los equipos de trauma recomendados por la nueva Guía NICE
Autor: Jessica Glen, Margaret Constanti, Karim Brohi, Fuente: BMJ 2016;353:i3051 Assessment and initial management of major trauma: summary of NICE guidance
"El trauma es un importante contribuyente a la carga mundial de enfermedad. Las personas que experimentan un trauma mayor tienen lesiones graves y con frecuencia múltiples asociadas con una fuerte posibilidad de muerte o discapacidad.
A nivel nacional existen alrededor de 20 000 casos de traumatismo mayor por año en Inglaterra, y más de una cuarta parte de ellos resultan en muertes. La atención del trauma es un campo en desarrollo y la reciente investigación civil y militar ha llevado a introducir cambios en la evaluación y gestión de los pacientes lesionados graves.
En este artículo se resumen las recomendaciones más recientes del Instituto Nacional de Salud y Cuidado de la Excelencia (NICE) sobre la evaluación y manejo inicial de un trauma mayor. Estas directrices se sientan como parte de un conjunto de directrices sobre manejo de traumatismos junto a las directrices publicadas con anterioridad sobre trauma de cráneo. Están escritas en el contexto de la NHS, donde la atención del trauma se reorganizó en grandes redes de trauma en 2012. Aquí vamos a centrarnos en dos temas centrales de las directrices:
  • La evaluación de un paciente con un traumatismo grave.
  • La gestión de los pacientes que están sangrando activamente."

lunes, 25 de julio de 2016

The TAME Cardiac Arrest Trial

"The TAME Cardiac Arrest Trial is a 1700 patient pragmatic, parallel group, randomised controlled trial evaluating the effect of mild hypercarbia in resuscitated patients post cardiac arrest. This ANZICS Clinical Trials Group investigation is presently recruiting centres and patients - if you would like to take part, please contact Dr Glenn Eastwood at the below email address."

Further Details:

domingo, 24 de julio de 2016

EM docs & burnout

Emergency Physicians Monthly
EP Monthly - July 19, 2016 - By Manfredi R, Hughes D and Jois P
"According to a JAMA Internal Medicine study, emergency physicians are the most burned out specialty in medicine – over 65% of EP respondents reported burnout. But what exactly is burnout, really? And what can emergency physicians do about it?
Burnout is an ancient concept which can be traced back to our oldest stories. William Shakespeare used the phrase “to burn out” in his 16th century poetry to speak of love that has peaked and faded. A more modern definition is “exhaustion of physical or emotional strength usually as a result of prolonged stress or frustration”. For emergency physicians, burnout is an insidious process that can take a doctor down from having an optimistic and idealistic outlook to dreading going to work each day.
Like Justice Stewart, we may ‘know burnout when we see it,’ but often we do not recognize it in ourselves. Many of us have experienced a stressful shift in the ED that is remedied by a vigorous physical workout or a good night’s sleep. We are able to bounce back. The recognition of burnout begins when we realize we are not bouncing back. This lack of resilience prevents us from “re-charging our batteries” and sets the stage for burnout. Picture a spectrum where the lack of resilience at one end leads to burnout at the other.
An emergency physician may find that he or she is far along the path to burnout before taking any steps to remedy it. Some subtle warning signs and symptoms of burnout include affirmative answers to the following:
  • Are you fatigued even with adequate sleep?
  • Do you find that you are more irritable and less satisfied with work?
  • Have you noticed that you seem to have numerous minor physical ailments?
  • Are you sad, more forgetful, or do you find that you are having trouble concentrating?"

Understanding the Heart Failure Population


MD Magazine - HCP Live - July 20, 2016 
"The MD Magazine Peer Exchange “Managing Heart Failure Today: Current Best Practices and New Treatment Options” features a panel of physician experts discussing key factors to consider when making treatment decisions for patients with heart failure and their own clinical experiences with recently approved medications for the treatment of heart failure. This Peer Exchange is moderated by Peter Salgo, MD, professor of medicine and anesthesiology at Columbia University College of Physicians and Surgeons, and an associate director of Surgical Intensive Care at New York-Presbyterian Hospital."

  • Episode 1: Characterizing Heart Failure
  • Episode 2: Understanding the Heart Failure Population

sábado, 23 de julio de 2016

Celulitis Antibiotic Selection

emDocs - July 22, 2016 - Authors: Bucher J and Cuthbert D 
Edited by: Koyfman A and Long B
"Introduction
The treatment of cellulitis has changed tremendously in the last ten years. With the development of community-acquired MRSA infections along with an increasing number of immunocompromised hosts, there is concern about missing MRSA if not treating cellulitis for it. However, the Infectious Disease Society of America (IDSA) released their skin and soft tissue guidelines in 2014, providing clear instructions for both antibiotic choice and who should be treated for suspected MRSA. We will start with four cases and then describe the IDSA recommendations.
These cases will highlight the recent updates to the Infectious Disease Society’s Practice Guidelines for the management of cellulitis and soft tissue infections. It is vital that emergency providers stay current with their clinical judgment in disposition as well as the use of appropriate antibiotic therapy.
Take Home Points
  1. Patients with uncomplicated cellulitis, with no co-morbidities, and without purulence, require coverage for MSSA with penicillins or first-generation cephalosporins.
  2. Patients with non-purulent cellulitis requiring admission only need coverage for MSSA and not MRSA.
  3. Purulent cellulitis requires coverage for MRSA.
  4. Necrotizing fasciitis requires broad-spectrum coverage, and, most importantly, immediate surgical consultation for debridement.
  5. Know your hospital’s antibiogram and availability of timely outpatient follow-up."

ED High-Flow nasal O2 for ARD

hot-er-twitter-image
The Bottom Line - By Duncan Chambler - 5th July 2016 - Peer-review editor: Steve Mathieu 
Ref. Jones. Respiratory Care 2016; 61(3):291-299. doi:10.4187/respcare.04252 
"Clinical Question 
In hypoxic adults presenting to the emergency department, does nasal high-flow oxygen compared to standard oxygen therapy reduce the need for advanced respiratory support? 
Authors’ Conclusions 
Oxygen therapy delivered by high-flow nasal cannulae did not reduce the need for non-invasive or invasive ventilation when compared against standard oxygen therapy 
However, the trial was unexpectedly underpowered and a true, clinically important benefit may exist, therefore this trial should be considered a pilot for a larger (~900 patient) trial 
One in 12 patients are intolerant of oxygen delivery via high-flow nasal cannulae 
The Bottom Line 
This trial did not demonstrate a difference between nasal high-flow oxygen and standard oxygen therapy in hypoxic and dyspneic patients arriving in the Emergency Department 
Significant weaknesses in the methodology mean that no firm conclusion can be drawn, as a false positive result may have occurred"

Profile of wounding in civilian public mass shooting

Trauma and Acute Care Surgery
Smith E, Shapiro G, Sarani B. Journal of Trauma and Acute Care Surgery 2016; 81(1): 86-92 - doi: 10.1097/TA.0000000000001031
"BACKGROUND: The incidence and severity of civilian public mass shootings (CPMS) continue to rise. Initiatives predicated on lessons learned from military woundings have placed strong emphasis on hemorrhage control, especially via use of tourniquets, as means to improve survival. We hypothesize that both the overall wounding pattern and the specific fatal wounds in CPMS events are different from those in military combat fatalities and thus may require a new management strategy.
CONCLUSION: The overall and fatal wounding patterns following CPMS are different from those resulting from combat operations. Given that no deaths were due to extremity hemorrhage, a treatment strategy that goes beyond use of tourniquets is needed to rescue the few victims with potentially survivable injuries."

Testicular Pain

Starter Pack Testicular Pain
PEMBLOG - July 21, 2016 By Brad Sobolewski
"It’s the beginning of a new academic year – and whether or not you are entering the ED for the first time, or returning after a hiatus it’s a good time to catch up on the basics. That’s what these “Starter Packs” are about. I have collated a number of different posts to give you an idea of what I’ve shared over the past few years on a number of common conditions. Though this one only applies to 50% of the population you will not doubt agree that acute testicular pain is a common ED problem worthy of prompt evaluation."

viernes, 22 de julio de 2016

X-ray limitations

AvoidingERrors - By Jesse - July 21, 2016
"Diagnostic errors involving imaging include not ordering appropriate imaging, incorrectly reading imaging, and incorrectly applying the results of diagnostic imaging due to its intrinsic limitations. We can order the right image and correctly read it, but if we don’t consider the inherent test characteristics we can still make a diagnostic error.
This especially applies to X-rays which are simple screening tools with very imperfect sensitivities. Scaphoid fractures, for example, are notorious for being radiographically occult—and we are trained to assess snuffbox tenderness in FOOSH patients and immobilize them even if the X-rays fail to reveal a fracture, because of the poor sensitivity of X-rays.
It’s important to know the limitations of X-rays so we can correctly interpret them in clinical context, and consider better imaging—from Point Of Care UltraSound (POCUS) to CT or MRI. Below is a brief overview of X-ray limitations and considerations for high-risk patients."
xray

jueves, 21 de julio de 2016

Chest VTE Guideline

RCEM - JULY 20, 2016 - By Neil A & Maxwell B
This is the first in a series of monthly Guidelines podcasts. This month @AndyNeill joins @maxirebecca to discuss the recent Chest Guidelines on Antithrombotic Therapy for VTE disease
A summary of discussion points:
  • Choice of anticoagulant: CHEST recommends Direct Oral Anticoagulants (DOACS). NICE currently recommend Warfarin but most centres in UK are already moving towards DOACS. Advantages of DOACS include increasing compliance and convenience for patients and clinicians.
  • Choice of Anticoagulant in patients with active cancer: CHEST and NICE recommend LMWH.
  • Duration of treatment: 3 months – if provoked DVT/PE. If unprovoked consider a longer period of treatment (6 months). CHEST also recommends Aspirin for those who have completed their period of treatment – this is not mentioned in the NICE guidance. The New England Journal of Medicine published two studies in 2012 looking at the benefit of Aspirin in preventing recurrence of VTE ASPIRE trial and WARFASA study
  • Below knee DVT: CHEST recommends not routinely treating below the knee DVTs, if it’s a lower risk patient with no risk factors they recommend repeat scanning as an option rather than treatment with oral anticoagulants. NICE guidelines have no specific recommendation on below knee DVTs.
  • Intervention Radiology: Catheter Directed Thrombolysis for DVTs -Typically done for iliofemeoral clots. CHEST recommends against this. NICE guideline suggest to consider this in ilofemoral DVT with vascular compromise.
  • IVC filters – CHEST advise against use of IVC filters. NICE suggest try a few options first – Increase INR to 3-4 (remember current NICE recommendations are to use Warfarin!) or consider a trial of LMWH before going down the road of IVC filters
  • Compression Stockings: previously there has been a recommendation to put compression stockings on patients with DVTs to prevent post-thrombotic syndromes. Khan et al published RCT in Lancet 2013, which suggested no real benefit. CHEST and NICE no longer recommend this.
  • Sub segmental PE to treat or not to treat?: This is the recommendation most likely to result in debate from the CHEST Guidelines. CHEST state “In patients with subsegmental PE (no involvement of more proximal pulmonary arteries) and no proximal DVT in the legs who have a low risk for recurrent VTE we suggest clinical surveillance over anticoagulation” This is the first time that this has been suggested. This already has provoked a lot of debate – check out EM:RAP for a debate discussing this by Jeff Kline and Tom DeLoghery. The more CTs we do the more of subsegmental PEs we diagnose, some studies have suggested that there is a large proportion of false positives. Hutchinson et al did a large study in Ireland 2015 suggesting that “PEs diagnosed by pulmonary CTA are frequently over diagnosed.”
  • Outpatient Management – CHEST guidelines recommend treating low risk PEs as an outpatient. This is already happening in lots of centres in the UK.
  • Thrombolytics for PE – CHEST recommend we lyse massive PEs, which is pretty straightforward. Submassive PEs are more difficult and CHEST recommend against this. Evidence isn’t really there for this, The PEITHO trial a few years ago demonstrated no mortality benefit. NICE guidelines recommend against it even with RV dilation. N.B. There no mention of half dose lytics in any guideline as suggested by the MOPPET trial
  • Thrombectomy for PEs– CHEST suggest peripheral lytics over thrombectomy
  • Recurrence of VTE: If already on DOAC CHEST recommend switching to LMWH. NICE recommend this as well.

Hemodynamically Unstable PE

CORE EM
CORE EM - By Anand Swaminathan
"Definition: A pulmonary embolism (PE) that results in hemodynamic compromise and end-organ hypoperfusion. The physical size of the PE does not differentiate a PE as massive or submassive but rather it is the patients physiologic response to the clot(s)...
Severe PE Pathophysiology (Wood 2011)
Take Home Points
  • Massive PE is defined as any PE that results in hemodynamic instability.
  • Patients with massive PE will often be too unstable for advanced diagnostic imaging (i.e. CT scan) requiring bedside diagnosis with history, physical examination and POC US
  • Systemic administration of a fibrinolytic drug is a potentially life-saving therapeutic intervention with an NNT for death of 16. However, it comes with the significant risk of intracranial hemorrhage and major bleeding (NNH = 10)"

miércoles, 20 de julio de 2016

Dangerous Rashes

emDocs - July 18, 2016 - Author: Santistevan J - Edited by: Koyfman A
"A wide range of benign and dangerous pathology can present with a rash. It is wise to develop a systematic approach to rashes in the ED, one that helps you recognize the deadly causes of rash while narrowing the differential diagnosis.
Key elements from the history include the distribution and progression of the skin lesions, recent exposures (sick contacts, foreign travel, sexual history and vaccination status), and any new medications. On physical exam, pay specific attention to vital signs. A rash associated with fever or hypotension should make you worry about potentially deadly diagnoses. Perform a careful physical exam, including undressing the patient to fully examine the trunk and the extremities as well as the palms, soles and mucous membranes. Touch the skin with a gloved hand to determine if the lesions are flat or raised and press on lesions to see whether they blanch. Rub erythematous skin to see if it sloughs. Historical and physical “red flags” in a patient with an unknown rash include:
  • Fever
  • Toxic appearance
  • Hypotension
  • Mucosal lesions
  • Severe pain
  • Very old or young age
  • Immunosuppressed
  • New medication"

Whole body CT in trauma?

Do we always need thewhole body CTin trauma_
St. Emlyn´s - Simon Carley - July 19, 2016
"The whole body CT has become a commonplace strategy for trauma in the UK. When a trauma patient is in your emergency room, it’s a quick and accurate detection method for most injuries. The primary survey in the resus room is all well and good for the initially life threatening injury, but the CT detects so much more, and following a number of papers looking at injury detection and survival UK trauma centres are targetted to get patients to the CT scanner within 30 minutes of arrival in the ED (http://stemlynsblog.org/ttl-podcast-1-getting-ct-30-minutes/) This is a hard target to hit with the sick trauma patient, and cna become a bit mechanistic. It’s quite easy to request a whole body scan, but should that be our default position? Could we reduce radiation dose with selective imaging? Will total body CT reduce mortality or is it unnecessary exposure to radiation? Does a total body CT break the first rule of medicine: First do no harm. REACT 2 aims to answer these questions, an RCT of WBCT vs selective imaging. The abstract is below, but as ever we always recommend you read the full paper (sadly it’s not open access)..:
The bottom line
There is no difference in mortality outcome for trauma patients who have a total body CT compared to selective imaging. Total body CT scan does increase the patients exposure to radiation, but by an amount that is surprisingly small (on average). This may be because a large percentage of patients who have selective scans ended up with the equivalent of a total body CT. Total body CT does give the quickest answer but does not ultimately reduce time spent in the emergency department.
In other words it seems that both strategies work."

martes, 19 de julio de 2016

Overview of Therapeutic Hypothermia

Resultado de imagen de SINAIEM
SINAIEM - By Jean Sun - 18 July, 2016
maxresdefault
"If you’ve ever been confused about why cooling matters in post-cardiac arrest, when to do it, how to order it, or what temperature (34C? 36C?) is best, read on.
Why do we do this?
To protect the brain from the effects of poor profusion due to cardiac arrest. There is good evidence that hypothermia slows cerebral metabolism (decreases O2 consumption by 6% for each degree in body temperature reduction), limits cerebral cell death, and lessens cerebral edema. This protective effect of hypothermia is very time-sensitive, however. One study showed that poor neurological outcome increased by 8% with each 5 min delay in initiating hypothermia, and by 17% for every 30 min delay in time to target temperature..."

Fewer Red Cell Transfusions, More IV Iron?

Logo
ACEP Now - By Anton Helman - On July 15, 2016
"You might be surprised to learn that many of the patients who receive red cell transfusions in the emergency department don’t need them. A Canadian study looking at trends in transfusion practice in the emergency department found that about half of transfusions given were deemed unnecessary.
If we think of a blood transfusion as a “blood transplant” similar to an organ transplant, then the potential complications including transfusion-associated circulatory overload (TACO), transfusion-related lung injury (TRALI), and alloimmunization become, perhaps, a bit more understandable. When you give someone a blood transfusion, you’re changing the patient’s immune system for life. Red cell transfusions should not be thought of as a delivery system for iron! While IV iron has been used for years in hematology clinics across the country, the emergency medicine community has been largely unaware of this sensible alternative..."

RBC transfusion in the ED

emDocs - July 18, 2016 - Author: Long B & Koyfman A - Edited by Simon E
"Conclusions
As the AABB guidelines are ambiguous, emergency physicians should consider transfusion thresholds and weigh the risks and benefits of transfusion. If the patient is hemodynamically stable and asymptomatic, a Hgb of 7 g/dL is safe. If the patient is hemodynamically unstable and anemic, transfusion may assist the provider in stabilizing the patient.
Summary
  • The transfusion threshold of 10 g/dL has recently been questioned, as RBC transfusion is not without risks (transfusion reaction, infection, and potentially increased mortality).
  • The AABB currently recommends a transfusion threshold of 7 g/dL Hgb, though studies evaluating transfusion are small in sample size, retrospective, and observational in nature, affecting their applicability.
  • Age of products transfused likely has no effect on products administered prior to 21 days of storage, though further study is required.
  • A hemoglobin level of 7 g/dL is safe in the setting of critical illness, sepsis, gastrointestinal bleeding, and trauma.
  • The clinician at the bedside should evaluate the patient for symptoms associated with anemia and transfuse based on risks and benefits."

Which patients admitted for pneumonia need MRSA coverage

PulmCrit (EMCrit)
PulmCrit (EMCrit) - July 18, 2016 - By Josh Farkas
  • "Current guidelines regarding MRSA coverage are contradictory, leading to confusion. The concept of healthcare-associated pneumonia (HCAP) doesn’t help matters.
  • Four newer tests may help determine if patients have MRSA PNA:
    • (1) The Shorr Score is a MRSA risk-stratification tool, which was empirically derived and validated.
    • (2) Nares PCR is ~90% sensitive for detecting MRSA pneumonia.
    • (3) Throat culture for MRSA may be used as a surrogate for sputum culture in patients who cannot expectorate.
    • (4) Procalcitonin should be elevated in patients with MRSA pneumonia.
  • These tests may be arranged to create an evidence-based algorithm:
algorithm

lunes, 18 de julio de 2016

qSOFA does not replace SIRS

Biomed Central logo
Jean-Louis Vincent J L, Martin G & Levy M - Critical Care 2016; 20:210
DOI: 10.1186/s13054-016-1389-z
...We would like to stress that, although SIRS was part of the definition of sepsis in 1992 [3], the qSOFA is not part of the new sepsis definitions. This important difference is illustrated in Fig. 1, with panel A showing that infection and sepsis (by the 1992 definition) are virtually the same—infection without SIRS can be found, but it is relatively rare. By contrast, panel B shows that sepsis (by the new SEPSIS-3 definition) represents only a minority of cases of infection. Moreover, panel B illustrates important aspects of the sepsis definition vis-à-vis infection and qSOFA. For example, sepsis can be present without a qSOFA score ≥ 2 because different forms of organ dysfunction may be present than are assessed using the qSOFA, such as hypoxemia, renal failure, coagulopathy, or hyperbilirubinemia. In addition, a patient may have a qSOFA ≥ 2 without infection; for example, in other acute conditions, such as hypovolemia, severe heart failure, or large pulmonary embolism. Further work remains to be done to determine the predictive validity of qSOFA in such patients. Finally, infected patients may have a qSOFA ≥ 2 and not be septic because the degree of hypotension, tachycardia, and/or altered mentation needed to fulfill qSOFA criteria is not the same as that needed to meet the SOFA organ dysfunction criteria necessary for a diagnosis of sepsis; the qSOFA criteria are thus clinically valuable but imperfect markers of sepsis. Nevertheless, in an analysis of a database of more than 74,000 patients, Seymour et al. [11] recently reported that 75 % of patients with suspected infection who had two or more qSOFA points also had at least two SOFA points.
https://static-content.springer.com/image/art%3A10.1186%2Fs13054-016-1389-z/MediaObjects/13054_2016_1389_Fig1_HTML.gif
We hope this editorial will clarify that the qSOFA is meant to be used to raise suspicion of sepsis and prompt further action—it is not a replacement for SIRS and is not part of the definition of sepsis."

Elevated LFT: ED Management

emDocs - July 16, 2016 - Authors: Sulava E and Bergin S
Edited by: Koyfman A and Long B
"In today’s medical system, marginal laboratory values can lead to expensive, unnecessary, and potentially harmful further diagnostic evaluations. A 2012 retrospective, multi-center cohort study of patients presenting to the ED showed that laboratory testing has a direct effect on patients’ emergency department (ED) length of stay, with an average increase of 10 minutes for every five individual tests ordered. With routine incorporation of hepatic tests in blood chemical panels, it is crucial to have a detailed understanding of the pathophysiologic basis of liver function tests in order to establish appropriate clinical correlation and patient disposition.
Conclusions
LFT are commonly ordered laboratory tests with a variety of abnormalities in a vast array of disorders. By understanding the biochemical basis of each test, it is possible to correlate laboratory findings to a patient’s clinical presentation. By separating common hepatic disorders into subcategories based on the magnification of transaminase elevation, a more simplistic algorithm like approach can be taken to help narrow the spectrum of a differential diagnosis. This can be used to help eliminate waste in costly and unnecessary follow up studies by maximizing the understanding of what an LFT result represents.
  • LFTs = ‘hepatocellular’ or ‘cholestatic’ arrangement based on the pattern of elevation.
  • Hepatocellular pattern = transaminases > ALP
  • ALT is generally considered to be more specific to liver damage
  • Past medical history and social history are crucial insight to hepatic risk factors (table 3)
  • Magnitude of aminotransferase elevation => guide initial diagnosis: mild (<5x), moderate (5-10x), or marked elevation (>10x)
  • Mild = NAFLD, Drug Induced Liver Injury, Alcohol Induced Liver Injury
  • Moderate = Alcoholic Hepatitis, Biliary Tract Disease
  • Severe = Acute Viral Hepatitis, Ischemic Injury, Acetaminophen Toxicity
  • As always, supportive care is key in the ED!"

What We Can Learn From Resuscitators Around the World

EMOttawa - Emergency Medicine Ottawa 
EMOttawa - July 15, 2016 - By Noam Katz 

"Out-of-hospital cardiac arrest (OHCA) remains a major cause of mortality for which we rely on advanced cardiac life support (ACLS) guidelines to manage within the ED. However, when these guidelines fail, we are left with almost no additional options as lifesaving measures. Worldwide there has been exponential growth in the use of veno-arterial extracorporeal membranous oxygenation (VA ECMO) – a bedside heart-lung bypass modality – in order to take control of the physiology of patients in cardiac arrest in order to perform additional life-saving interventions.
I had the opportunity to attend a conference – Reanimate 2016 – in order to learn more about this modality, how it is being applied in the ED for cardiac arrest patients and how Sharp Memorial Hospital in San Diego, CA, has improved their cardiac arrest survival rates regardless of the use of ECMO..:"

ATACH-2: BP lowering in ACH

atach-2-twitter-image
The Bottom Line - July 15, 2016 - By Adrian Wong
Qureshi et al. NEJM 2016 DOI: 10.1056/NEJMoa1603460
"Clinical Question
In patients with acute intracerebral haemorrhage and who are hypertensive, does rapid lowering of systolic blood pressure compared to standard therapy improve patient outcomes ?
Authors’ Conclusions
The results of the trial do not support the reduction of systolic blood pressure to a target of 110 to 139 mmHg in patients with intracerebral haemorrhage.
The Bottom Line
The results of this trial and that of the INTERACT2 trial do not support an early, intensive control of systolic blood pressure in patients with acute intracranial haemorrhage"

domingo, 17 de julio de 2016

Basis and consequences of fever

Biomed Central logo
Edward James Walter E J et al. Critical Care 2016; 20:200
DOI: 10.1186/s13054-016-1375-5
"There are numerous causes of a raised core temperature. A fever occurring in sepsis may be associated with a survival benefit. However, this is not the case for non-infective triggers. Where heat generation exceeds heat loss and the core temperature rises above that set by the hypothalamus, a combination of cellular, local, organ-specific, and systemic effects occurs and puts the individual at risk of both short-term and long-term dysfunction which, if severe or sustained, may lead to death. This narrative review is part of a series that will outline the pathophysiology of pyrogenic and non-pyrogenic fever, concentrating primarily on the pathophysiology of non-septic causes."

Inutilidad de la PVC

ARTÍCULO ORIGINAL: Systematic review including re-analyses of 1148 individual data sets of central venous pressure as a predictor of fluid responsiveness. Eskesen TG, Wetterslev M, Perner A. Intensive Care Med 2016; 42(3): 324-332. [Resumen] [Artículos relacionados]
"COMENTARIO: Más de 1.000 mediciones publicadas en la literatura indican claramente que la PVC no es útil para predecir la respuesta a volumen. Este re-análisis aporta frente a estudios previos los datos individuales de los pacientes, y el análisis por cada uno de los rangos de PVC, incluyendo un número razonable de mediciones con los valores bajos de PVC. En los valores más altos de PVC hay pocos casos, lo que hace imprecisos los resultados (IC 95% no mostrados). La evidencia por tanto muestra claramente que la PVC no es útil para guiar la fluidoterapia en pacientes críticos con compromiso hemodinámico."

viernes, 15 de julio de 2016

Clinical Pathway Use

emDocs - July  14, 2016 - Authors: Long B and Sheridan B
Edited by: Koyfman A  & Bright J
Background:
Clinical decision rules (CDR) can improve decision-making in specific situations in the ED, potentially decreasing further testing and improving disposition times. This part of the CDR series will look in detail at a current clinically significant CDR and pathway – The HEART pathway.
Part 1 of this series listed the essentials a CDR should possess: answers a relevant question, addresses a common clinical problem, appropriately derived, externally validated, improves clinical practice, applicable to practice and patients, and ease of use. http://www.emdocs.net/clinical-decision-rules-part-1/
Part 2 examined applying a CDR to actual clinical practice, which involved several steps: determining the rule that would most affect patient care in your setting, identify obstacles to implementation (provider and institution), achieving buy-in (from all members of the team including nurses and other specialties/consultants), publicizing pathway use, and monitoring and refinement of the rule once in place. http://www.emdocs.net/clinical-decision-rules-part-2/
Part 3 will evaluate actual risk of missed MI in chest pain patients, followed by a look at several clinical rules and pathways.
Summary
  • Risk stratification in patients with low risk chest pain has significantly evolved over the past decade. Multiple tools have been derived and evaluated for patient disposition decisions.
  • TIMI and GRACE are not sensitive enough to use in the undifferentiated patient in the ED with chest pain.
  • Decision pathways using these scores should be used with caution, though patients with two negative biomarkers and negative ECG for ischemia are at low risk for MACE.
  • The HEART score and pathway provide the best sensitivity and NPV capability, while classifying a large percentage of patients as low risk.
  • By combining the use of this rule with shared decision making, this pathway provides safe, efficient care, protecting the patient and physician.

Intra-abdominal Pressure and Renal Function

PulmCCM
PulmCCM - Jul142016 - By JE
figure1
"An' it ain't no use in turnin' on your light, babe, I'm on the dark side of the road ..."
-Bob Dylan
"A 44 year old man with cryptogenic cirrhosis is admitted with large ascites and acute kidney injury. A 50 mL, diagnostic paracentesis reveals 12 PMNs and he is admitted from the emergency department for further evaluation of his renal dysfunction. On the medical floor, initial urine sodium is < 10 mEq/L and urine osmolality is 1100 mOsm/kg. He is labeled as ‘pre-renal’ and given 3 litres of lactated ringers overnight. The following morning, his urine output is minimal and his creatinine has quintupled..."