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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

Is Impella the Future of Mechanical Circulatory Support?

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sábado, 10 de diciembre de 2016

RESPECT-ED (PE)

EM Nerd - December 8, 2016 by Rory Spiegel 
"The existence of overdiagnosis in the pursuit of pulmonary embolism (PE) is undeniable. But the burden of clinically insignificant PEs diagnosed by our current hypersensitive, zero-miss culture is less apparent. The authors of a recent article ironically entitled RESPECT-ED, attempted to quantify the role in which overdiagnosis plays in the current incidence of PE.
The authors conclude that:
Higher CTPA utilization was positively correlated with PE diagnoses, but without evidence of increased proportions of small PE. This suggests that increased diagnoses seem to be of clinically relevant sized PE.
The RESPECT-ED data set is not wrong. Rather our understanding of the clinical importance of anatomic disease burden is incomplete. Such analyses do not account for the physiologic turmoil surrounding the emboli. Without an understanding of the patients who experiences these embolic injuries, it is impossible to assign any clinical weight to their existence. And so the best that can be said from RESPECT-ED is the more PEs one endeavors to find the more one will be rewarded with anatomically definable disease. The clinical relevance of these findings is still unclear."

IRONMAN

ironman-header-image
The Bottom Line - December 9, 2016 - By Duncan Chambler
Ref: Litton. Intensive Care Medicine 2016; First online September 30th, 2016. doi:10.1007/s00134-016-4465-6
"Clinical question
In critically ill patients who are anaemic, does early administration of intravenous iron compared to placebo reduce the requirement for blood transfusion?
tbl-ironman-data-table
Authors’ Conclusions
In anaemic patients who are admitted to ICU, IV iron did not result in a reduction in red blood cell transfusion compared to placebo, however they did leave hospital with a higher haemoglobin level."

PESIT Trial


Citation: [Peer-Reviewed, Web Publication] Kline J , Courtney DM (2016, December 9). The PESIT Trial: Not all first time syncope needs testing for PE [NUEM Blog]. 
Retrieved from http://www.nuemblog.com/blog/the-pesit-trial
"Bottom Line:
In elderly syncope patients with some combination of: tachycardia, tachypnea, hypotension, active cancer, and perhaps especially those without a clear suspected cause of syncope, PE should be a consideration that warrants testing. Perhaps this should be considered even when patients do not have the more traditional symptoms of PE such as dyspnea or chest pain. However, we would caution clinicians NOT to interpret this study as rationale for widespread testing on all or nearly all US ED syncope patients. The outcome of such a simplistic interpretation of this study would undoubtedly result in further radiation and contrast burden and harms for our patients."

viernes, 9 de diciembre de 2016

POCUS in Cardiac Arrest

R.E.B.E.L. EM - Emergency Medicine Blog
R.E.B.E.L.EM - December 8, 2016 - By Salim Rezaie
"Background: For many emergency providers, POCUS has become a critical modality in the resuscitation of patients with cardiac arrest. The authors of this paper (The REASON Trial) state that <8% of all OHCA’s survive to hospital discharge; a dismal number. We already know that shockable rhythms, early defibrillation, early bystander CPR, and ROSC in the field are all associated with increased survival. What we don’t have is large scale evidence that the use of POCUS improves survival with good neurologic outcomes.
Clinical Question: Is detection of cardiac activity on POCUS in patients with PEA or asystole associated with improved survival from cardiac arrest?...
Author Conclusion: “Cardiac activity on ultrasound was the variable most associated with survival following cardiac arrest. Ultrasound during cardiac arrest identifies interventions outside of the standard ACLS algorithm.”
Clinical Take Home Point: The use of bedside ultrasound in PEA/Asystolic cardiac arrest can help identify pathologies that require a specific intervention, used as an adjunct to discontinue resuscitation efforts, and identify cardiac activity that is not appreciated with traditional finger pulse checks. It is unclear from this study whether the use of bedside ultrasound in cardiac arrest is an intervention that improves neurologically intact outcomes."

GOLD 2017

PulmCCM
"The Global Initiative for Obstructive Lung Disease (GOLD - because GIOLD sounded weird) is an international collaboration of experts in chronic obstructive pulmonary disease (COPD). Every so often the GOLD gang releases another update of their standard-setting GOLD guidelines. (Read PulmCCM's 2014 GOLD guideline review and our COPD Review.)
Get the full 2017 GOLD guidelines or the 36 page "pocket" review on the GOLD website for the full details. Following are a few highlights from GOLD 2017."

Management of Hyperkalemia

Emergency medicine PharmD - By Nadia Awad - December 8, 2016
"At the 2016 Midyear Clinical Meeting of the American Society of Health-Systems Pharmacists (ASHP), my colleague Bryan Hayes and I presented a continuing education program on debates in the management of hyperkalemia. 
This blog post serves as a summary of the key points of the presentation, and we created this resource as an active and living reference of the educational material shared in the session that can be shared at any point following the session."

jueves, 8 de diciembre de 2016

Decision Making in EM

Emergency Medicine Cases
Cognitive Debiasing, Situational Awareness & Preferred Error
Emergency Medicine Cases - By Anton Helman - Jan 2016
"While knowledge acquisition is vital to developing your clinical skills as an EM provider, using that knowledge effectively for decision making in EM requires a whole other set of skills. In this EM Cases episode on Decision Making in EM Part 2 – Cognitive Debiasing, Situational Awareness & Preferred Error, we explore some of the concepts introduced in Episode 11 on Cognitive Decision Making like cognitive debiasing strategies, and some of the concepts introduced in Episode 62 Diagnostic Decision Making Part 1 like risk tolerance, with the goal of helping you gain insight into how we think and when to take action so you can ultimately take better care of your patients.
Walter Himmel, Chris Hicks and David Dushenski answer questions such as: How do expert clinicians blend Type 1 and Type 2 thinking to make decisions? How do expert clinicians use their mistakes and reflect on their experience to improve their decision making skills? How can we mitigate the detrimental effects of affective bias, high decision density and decision fatigue that are so abundant in the ED? How can we use mental rehearsal to not only improve our procedural skills but also our team-based resuscitation skills? How can we improve our situational awareness to make our clinical assessments more robust? How can anticipatory guidance improve the care of your non-critical patients as well as the flow of a resuscitation? How can understanding the concept of preferred error help us make critical time-sensitive decisions? and many more important decision making in EM nuggets of wisdom…"

Vasopressin Analogues in Septic Shock

ICM Case Summaries - December 7, 2016 
..."Adjunctive vasopressin infusion is useful in septic shock where target MAP is difficult to achieve without high noradrenaline requirements. There is no clear mortality benefit associated with this, though it may attenuate some potentially harmful consequences seen with high-dose catecholamine use. Conceptually it appears ideally suited to cirrhotic patients with septic shock. Although synthetic vasopressin analogues have theoretical advantages to vasopressin itself, there is not enough evidence to justify their use routinely. Bolus use of vasopressin analogues for septic shock, outside of cirrhotic patients with associated gastrointestinal haemorrhage or hepatorenal syndrome, cannot be recommended at this time."

IV Lidocaine for Renal Colic

renal-colic
IV Lidocaine for Renal Colic: Another Opioid Sparing Option?
R.E.B.E.L.EM - By Salim Rezaie - Peer review by Anand Swaminathan
"Background: For anyone who has taken care of a patient with renal colic, the agony they experience is indelible. I have had several female patients even tell me that the pain is worse than child birth. Treatment of renal colic comes down to two key components: treatment of pain and expediting passage of the stone. Many medications have been tested for the former, and we have discussed the latter on our blog before (HERE and HERE). We had a recent resident journal club discussing a trial comparing IV lidocaine (1.5mg/kg) vs IV morphine (0.1mg/kg) for treatment of pain...
Author Conclusion: “Changing the smooth muscle tone and reducing the transmission of afferent sensory pathways, lidocaine causes a significant reduction in pain.”
Clinical Take Home Point: IV preservative free (cardiac) lidocaine (1.5mg/kg) seems to be another opioid sparing treatment option in our armamentarium to treat renal colic pain in patients without renal, liver, or cardiac disease, however this single study should not change practice of using NSAIDs as first line opioid sparing therapy where available."

Heart Score

December 7, 2016 - Authors: Long B, Oliver J and Streitz M - Edited by: Koyfman A
screen-shot-2016-12-04-at-6-16-20-pm
"Summary and Takeaways:
  • The risk of ACS in patients with negative biomarkers and normal ECGs approaches 0.2%.
  • Prior risk scores, such as TIMI and GRACE, provide little, if any benefit, in risk stratification for ED chest pain patients.
  • The HEART score and pathway can risk stratify patients into three separate categories: low (0-3), moderate (4-6), and high score (> 7).
  • Low risk patients on the HEART pathway demonstrate likelihood of ACS that approaches < 1%, and it is easy to use in the ED.
  • Risk factors, history, ECG, troponin, follow up, gestalt, patients with points 3 or 4, and research design are areas of potential weakness.
  • Further improvement of the HEART pathway at this time is difficult, but in patients at moderate risk, CCTA may hold promise for evaluation of risk. This requires further study."

Impella

EDECMO - December 6, 2017
archimedes-screw
"In this episode we change direction a bit and explore two very different applications of the Impella® device – a percutaneously-placed temporary ventricular assist device (VAD) sold by Abiomed (no financial disclosures). These VADs work by the use of a micro-axillary pump which is typically placed by interventional cardiologists under fluoroscopy. The inlet of the pump is placed in the ventrical while the outlet rests just above the aortic valve..."

miércoles, 7 de diciembre de 2016

Neurologic Emergencies

Logo of wjem
Grock A et al. West J Emerg Med. 2016; 17(6): 726–733.  doi: 10.5811/westjem.2016.9.31010
"The WestJEM Blog and Podcast Watch presents high quality open-access educational blogs and podcasts in emergency medicine (EM) based on the ongoing ALiEM Approved Instructional Resources (AIR) and AIR-Professional series. Both series critically appraise resources using an objective scoring rubric. This installment of the Blog and Podcast Watch highlights the topic of neurologic emergencies from the AIR series..."

PeRRT Score

Mayo Clinic
EM Blog Mayo Clinic - November 29, 2016 - By Daniel CabreraAuthor Shawna Bellew
"What patients admitted from the Emergency Department to a general floor/ward will deteriorate?
Emergency physicians must excel at a variety of skills. In addition to the obvious-evaluating the undifferentiated patient as well as resuscitating the critically ill-we must also be the masters of negotiating with other providers in the best interest of our patient and pertinently determining disposition. Disposition decision-making must account for a dizzying array of factors. In addition to admitting diagnosis, hemodynamics, and respiratory status at the time of admission, more nuanced considerations also come into play such as gut feeling (gestalt), practice setting, co-morbidities, social supports, hospital census, and even the time of day. This type of complex decision-making is characteristic of Emergency Medicine. While not as glamorous as running the perfect code or performing a live-saving ED thoracotomy, great dispositions can save resources and lives..."

Epinephrine in cardiac arrest

MEDEST - December 6, 2016
"Take home points for future improvement.
  1. Train to reach an US guided arterial line in cardiac arrest
  2. Check aortic pressure via peripheral or central (femoral) arterial line
  3. Give Adrenaline intrarterially
  4. Target Adrenaline doses to maintain a good aortic pressure"
Tanks to Jim Manning who inspired this post with his talk Rethinking Adrenaline in Cardiac Arrest

Push Dose Pressors

Mizzou EM - December 6, 2016  - By mizzouem 
neostick  epi
..."Use of push-dose pressors has recently transitioned into the ED setting, despite being used for decades in other practice areas. Its use has gained popularity due to increasing evidence that peri-intubation hypotension is strongly associated with post-intubation cardiac arrest (Heffner 2013, Kim 2014). Push-dose pressors may also provide an important bridge to vasopressor infusion while the medication is being mixed or pump is being set up... 
There is no current standard of care for using push dose pressors in the ED; therefore, its use is still largely dependent on physician discretion and judgment. However, with careful preparation and administration of these agents, correcting transient hypotension can be life-saving in the appropriate clinical circumstances."

martes, 6 de diciembre de 2016

Sepsis-induced DIC

PulmCrit (EMCrit)
PulmCrit - December 5, 2016 by Josh Farkas
 click to enlarge
  • "Sepsis-induced DIC is distinct from other types of DIC.
  • S-DIC doesn’t cause low fibrinogen levels. It is generally noticed due to a thrombocytopenia.
  • Despite thrombocytopenia, most patients with S-DIC are hyper-coagulable or norma-coagulable. The sickest patients are hypocoagulable, indicating poor prognosis.
  • Patients with S-DIC and platelet count >30,000/mm3 should receive DVT prophylaxis.
  • Blood products should generally be avoided in patients with S-DIC who aren’t bleeding.
  • Purpura fulminans is an extreme form of S-DIC which may require more aggressive therapy (e.g. plasma exchange)."

Outpatient Treatment of VTE

venous-thromboembolism

R.E.B.E.L.EM - December 5, 2016 - By Salim Rezaie
"Background: The care of venous thromboembolism (VTE) is currently undergoing a paradigm shift in the US with an increasingly large percentage of patients being discharged home from the Emergency Department (ED). It wasn’t too long ago that all patients diagnosed with deep vein thrombosis (DVT) and pulmonary embolism (PE) would be admitted for anticoagulation. Some of the reasons for this were lack of literature to support outpatient therapy in the US, inability to arrange outpatient follow up, and, of course, medicolegal concerns. Dr. Jeff Kline, one of the thought leaders in VTE, advocates for the outpatient treatment of “low-risk” patients using a modified Hestia criteria supplemented with additional criteria (POMPE-C) for patients with active cancer. This publication is the initial results of his rivaroxaban-based treatment protocol...
Author Conclusion: “Patients diagnosed with VTE and immediately discharged from the ED while treated with rivaroxaban had a low rate of VTE recurrence and bleeding.”
Clinical Take Home Point: This is a nice proof of concept publication that further adds to the evidence for the safety of outpatient treatment of low risk DVT and PE in patients with very low complication rates."

lunes, 5 de diciembre de 2016

Big Trauma: Before the CT

Emergency Medicine Updates - November 28th, 2016 -By reuben
before the CT
"Efforts to standardize the approach to trauma have led to an algorithmic, thoughtless approach to trauma that over-utilizes CT in well patients and delays CT in ill patients. In critically injured blunt trauma patients, CT is a fantastically useful test and should be prioritized as the critical diagnostic step to be taken as quickly as feasible.
Classic teaching is that unstable patients should be stabilized prior to CT, but this is an outdated, dangerous paradigm; optimal care in severe trauma rapidly implements key resuscitative maneuvers so that resuscitation can continuesimultaneously with CT. I have witnessed many cases where persistently hypotensive patients were observed in the trauma bay because “the patient might need to go direct to the OR,” but direct to the OR means direct to the OR; observation of an unstable trauma patient prior to elucidation of the injuries is usually the wrong strategy. Know exactly what the initial resuscitative priorities are in trauma so that as soon as they’re done, the patient can be taken to their next destination (CT, OR, IR). The following are carried out in parallel with universal first steps of resuscitation and the primary survey..:"

Sickle Cell Disease

Logo
ACEPNow - By Anton Helman - November 13, 2016
"Sickle cell disease (SCD) patients are at increased risk for a whole slew of life-threatening problems. One of the many reasons they are vulnerable is because people with SCD are functionally asplenic, so they’re more likely to suffer from serious bacterial infections like meningitis, osteomyelitis, and septic arthritis. For a variety of reasons, they’re also more likely than the general population to suffer from cholecystitis, priapism, leg ulcers, avascular necrosis of the hip, acute coronary syndromes, pulmonary embolism, and even sudden exertional death. Many of these diagnoses present with pain similar to a sickle cell crisis and can be challenging because the presentations of some are less typical than usual..."

Lab in Hepatic Failure

Taming The SRU
Taming The SRU - December 04, 2016 - by Kelli Jarrell

"There are many groups of patients that alter how we must evaluate and interpret our diagnostic studies in the setting of baseline chronic laboratory abnormalities, which is often challenging. One especially challenging patient population are patients with chronic liver disease, and in this post we will look into how their disease process create chronic and acute on chronic derangements of which we need to be aware..."

Hepatic Failure.jpg

Nutritional support

PulmCrit (EMCrit)
PulmCrit - November 7, 2016 - By Josh Farkas 
"Everyone has strong opinions about food. We all feel that we have some special, intuitive understanding of nutrition. Nonsense. Such intuitions have historically created a wide array of dogma regarding nutrition, complicating matters immensely.
Fortunately, the 2016 SCCM/ASPEN guidelines have stripped away much of the nonsense involved in nutritional support. This allows for a simple and effective approach to nutritional support in the ICU. Based on these guidelines, this post will attempt to sort out truth vs. fiction: which nutritional beliefs are valid, and which need to be discarded?
Over time, critical care nutrition is becoming progressively simpler and easier. Take-home messages from the 2016 SCCM/ASPEN guidelines include:
  • Early enteral nutrition should be provided to nearly all intubated patients.
  • The only strong contraindication to enteral nutrition is an intestinal catastrophe. The following are not contraindications: lack of bowel sounds, therapeutic paralysis, vasopressors, pancreatitis, or open abdomen.
  • Don’t check gastric residual volumes.
  • Patients with pancreatitis, septic shock, hepatic failure, or renal failure can all be fed in essentially the same way that you would feed any patient in the ICU.
  • Fancy, designer tube-feed formulations are rarely needed."

domingo, 4 de diciembre de 2016

GI Bleeds

emDocs - December 3, 2016 - By Thorngren C and Welch J. 
Edited by: Simon E and Koyfman A
"Developing a clinical gestalt regarding a patient with a gastrointestinal bleed (GIB) can be challenging even for the seasoned emergency medicine physician. Anecdotally, we’ve all heard of the hemodynamically stable patient with one bloody bowel movement prior to arrival that acutely decompensates in the ED. While the decision to admit these patients to the ward versus the ICU may be clear in the setting of unstable VS or post endotracheal intubation, there are often times when we encounter shades of gray. The following discussion will hopefully shed some light on topic, and offer a quick discussion of risk stratification methods for EM physicians to utilize when addressing upper and lower GI bleeds...
Conclusion
Extensive research has been performed in an attempt to develop clinical decision-making tools for the risk stratification of patients with GI bleeds. Ultimately, patients who are hemodynamically unstable, risk stratify as having a high mortality secondary to GI bleeding, or are at risk for having a severe lower GI bleed, should be admitted to an ICU setting."

Galaxia 2016

Ir al Inicio
SEAIC - 29 de Noviembre 2016
"GALAXIA 2016 es la actualización de la guía consensuada española sobre actuación en anafilaxia.
Para realizar esta guía se ha contando con profesionales con una amplia experiencia en el diagnóstico y tratamiento de la anafilaxia, representando a varias sociedades:
– Sociedad Española de Alergología e Inmunología Clínica
– Asociación Española de Pediatría
– Asociación Española de Pediatría de Atención Primaria
– Sociedad Española de Inmunología Clínica, Alergología y Asma Pediátrica
– Sociedad Española de Médicos de Atención Primaria
– Sociedad Española de Medicina de Emergencias
– Sociedad Española de Medicina de Familia y Comunitaria
– Sociedad Española de Médicos Generales y de Familia
– Sociedad Española de Urgencias Pediátricas
En esta guía se ha realizado un consenso actualizado en el diagnóstico y tratamiento de las reacciones anafilácticas. En su contenido destacan las recomendaciones prácticas sencillas de aprender y fáciles de aplicar en la mayoría de los casos de anafilaxia, contemplando además las peculiaridades en la edad pediátrica de las reacciones anafilácticas."
Descargar documento: GALAXIA 2016 (4012)

jueves, 1 de diciembre de 2016

Surgical Emergencies (Part 2)

emDocs - November 29, 2016 - Authors: Brubaker S and Long B - Edited by: Koyfman A
"This is the second in a two-part series discussing can’t-miss diagnoses that may require emergent surgical intervention. Part 1 included ruptured ectopic pregnancy, ruptured AAA, and aortic dissection. In this article, we will explore three more disease processes that can be easy to miss, though delay in diagnosis and treatment can lead to long-term sequelae and even death. So, without further ado, let’s jump right in to discuss three more surgical emergencies.
  • NECROTIZING FASCIITIS
  • TESTICULAR TORSION
  • OVARIAN TORSION

Approach to Tachypnea

emDosc - December 1, 2016 - Author: Alexander D -  Edited by: Koyfman A and Long B
screen-shot-2016-11-27-at-6-55-42-pm
"Summary & Take Home Points
Tachypnea can be the presentation of multiple different pathologies. A focused history and physical exam, along with an understanding of the pathophysiology of appropriate disease states, can lead to thorough evaluation and management at the bedside. A systematic organ system approach to the patient can quickly lead to bedside diagnosis and initiation of treatment in patients with undifferentiated tachypnea.
As Emergency Physicians we should:
  • Avoid anchoring on the pulmonary system as the only cause of tachypnea
  • Maintain a broad differential for extra-pulmonary causes of tachypnea
  • Use bedside ultrasound in the setting of undifferentiated tachypnea; lung US can reveal pathology of PTX, Asthma, CHF, and PNA effectively and accurately
  • Utilize follow up chest x-ray to improve diagnostic ability
  • Combine EKG findings with bedside ECHO to quickly identify life threatening conditions
  • Remember that metabolic acidosis can present as tachypnea & point of care testing can give clues to an early diagnosis of DKA"

Glucose Levels

R.E.B.E.L.EM - Posted by Salim Rezaie - December 1, 2016

"Background: Anyone who works in the Emergency Department has seen patients brought in by EMS or sent from the clinic with a chief complaint of “high blood sugar.” Now, we are not talking about patients with diabetic ketoacidosis, but just simple hyperglycemia. This is a common complaint with no real consensus on optimal blood glucose levels before safe discharge...
Author Conclusion: “ED discharge glucose in patients with moderate to severe hyperglycemia was not associated with 7-day outcomes of repeat ED visit for hyperglycemia or hospitalization. Attaining a specific glucose goal before discharge in patients with hyperglycemia may be less important than traditionally thought.”
Clinical Take Home Point: A more appropriate approach to simple hyperglycemia, may be ensuring appropriate outpatient follow up for long-term glycemic control, just as we currently do for asymptomatic hypertension, instead of reaching a “safe” glucose threshold before discharge.

Supratherapeutic INR

EVIDENCE BASED MEDICINE
EBM - November 30, 2016 - By mizzouem
warfarin-pills
"In patients on warfarin presenting to the ED with asymptomatic supratherapeutic INR greater than 3.5, is treatment with vitamin K compare to no treatment with vitamin K associated with worse outcomes defined as increased risk of major bleeding?...
Bottom Line
There is low risk of bleeding in patients with supratherapeutic INR. Outpatient management is recommended, but close follow up is key. There should be an emphasis on not creating warfarin resistance or making the patient subtherapeutic. Vitamin K should be used in those with INR>5 and increased risk of bleeding. Higher doses of vitamin K should be used in all patients with INR>9."

martes, 29 de noviembre de 2016

Sexual Assault

emDocs - November 28, 2016 - Author: Simon E and Sessions D
Edited by: Cassella C and Koyfman A
"Key Pearls
  • Stabilize the patient as appropriate – 5% of victims require hospitalization secondary to severe injury5,8,9
  • Understand your options and do what’s in the best interest of the patient:
    • Call the patient advocate (state attorney’s offices will provide a list of resources if needed)
    • Refer as appropriate:
      • If the patient may be better served by an institution with a SANE program, then transfer
    • Provide pregnancy prophylaxis as appropriate
    • Provide STI prophylaxis
    • Provide Hepatitis B vaccination if un-immunized
    • Discuss risk factors for HIV transmission and the risks/benefits of prophylaxis
    • Involve a rape crisis counselor EARLY
      • Many patients experience PTSD, depression, and suicidal ideation post assault13
    • Stress the importance of follow-up for STI monitoring, PEP evaluation as indicated, and continued emotional support"

Targeted Temperature Management

R.E.B.E.L.EM - 28 Nov, 2016 - By Mastin A - Post Peer Reviewed By: Salim R. Rezaie
Ref: Schenone et al. Therapeutic Hypothermia After Cardiac Arrest: A Systematic Review/Meta-Analysis Exploring the Impact of Expanded Criteria and Targeted Temperature. 
Resuscitation 2016; 108: 102 – 110. PMID: 27521472
"The use of therapeutic hypothermia (TH) has become part of the routine care of patients after return of spontaneous circulation (ROSC) from cardiac arrest (Use of the phrase Targeted Temperature Management has become more accepted). It became much more accepted after two separate trials were published in the New England Journal of Medicine in 2002 showing a survival benefit and improved neurologic outcome with use of TH. The use of TH has even been given a Level One recommendation by the American Heart Association for comatose post-arrest patients. Uncertainties still remain, however, such as what optimal temperature to use, and most recommendations on specifics related to TH are based on observational studies and expert opinion. So what is the actual evidence behind the use of TH?
Authors’ conclusions:
  • “Our analysis proves there is a benefit of TH in a much broader spectrum of patients [from the original 2002 trials], and perhaps clinical guidelines need to strongly favor TH in all patients with cardiac arrest.”
  • “At this time there is no evidence to support the use of one temperature level over others across the entire range of included temperatures of 32°C and 36°C during TH after OHCA.”
Take home points:
  • Current evidence does support the use of targeted temperature management in ROSC patients after cardiac arrest
  • The current optimal temperature remains elusive, but what is certain is that the prevention of fever is paramount."

lunes, 28 de noviembre de 2016

Minor Facial Trauma

NUEM Blog
"In the emergency department, we commonly encounter minor injuries to the face and mouth. In a two part series, we provide a short overview of some helpful strategies for dealing with these cosmetically sensitive injuries in an effective manner."
Citation: [Peer-Reviewed, Web Publication] Reuter Q, Macias M (2016, May 24). Quick Guide To Minor Facial Trauma: Part I. [NUEM Blog. Expert Commentary by Levine M]. Retrieved from http://www.nuemblog.com/blog/minor-facial-trauma-1/
*
Citation: [Peer-Reviewed, Web Publication] Reuter Q, Macias M (2016, June 28). Quick Guide To Minor Facial Trauma: Part 2. [NUEM Blog. Expert Commentary by Levine M]. Retrieved from http://www.nuemblog.com/blog/minor-facial-trauma-2/

Non Confirmed Septic Shock

Contou D et al. Critical Care 2016; 20:360
DOI: 10.1186/s13054-016-1537-5 - Published: 6 November 2016
..."The main results of our pragmatic study are as follows: (1) a quarter of patients admitted to ICUs with suspected septic shock had no infection identified at 24 h after onset of shock and almost half of them had a septic shock mimicker; (2) septic shock mimickers were mostly due to acute mesenteric ischemia or adverse effects of drugs; and (3) outcomes did not differ between EC-SS and non EC-SS patients.
Conclusion
Our study showed that using conventional microbiological methods, one quarter of the patients admitted to the ICU with clinical presentation of septic shock had no infection identified 24 h after introduction of vasopressors, and almost half of these patients had a non-infectious diagnosis that mimicked sepsis. We identified several causes of septic shock mimickers for which patients with suspected septic shock of no apparent etiology should be screened. Outcomes did not differ between patients with early-confirmed septic shock and other patients. Seven percent of the patients admitted on suspicion of septic shock had no cause identified by the end of ICU stay. Further studies are needed to assess the diagnostic yield of molecular detection methods in this subgroup of patients."

domingo, 27 de noviembre de 2016

Arrhythmias in Pregnancy

emDocs - November 24, 2016 - Author: Robertson J - Edited by: Koyfman A
"Conclusions
While there are a few differences, the management of tachycardic arrhythmias in pregnancy is quite similar to the non-pregnant patient. DC cardioversion should always be conducted in patients with hemodynamic instability. Pharmacologic cardioversion of supraventricular and ventricular arrhythmias is possible in the stable patient. No drugs are completely safe in pregnancy, but most are rated category C in pregnancy and if the benefit exceeds the risk, then the medication may be given. Amiodarone and atenolol are two medications that should be avoided in the pregnant patient, especially in the first trimester. Rate control with beta blockers or calcium channel blockers is an option in patients with supraventricular tachycardias who are not immediate candidates for cardioversion. Stroke risk should still be accounted for and at risk patients should be anticoagulated with LMWH or vitamin K antagonists (only in the 2nd and 3rd trimesters and not in the last month of pregnancy). Finally, close cardiac monitoring of both the mother and fetus and availability of emergency C section should be available whenever medication or cardioversion is indicated. Finally, but importantly, obstetrics and cardiology consultation is prudent whenever a pregnant patient with an abnormal tachycardic arrhythmia presents to the ED."

IV Fluids and etOH

R.E.B.E.L. EM - Emergency Medicine Blog
01 May - R.E.B.E.L.EM - By Salim Rezaie
"Frequently, patients with acute alcohol intoxication are brought to the emergency department (ED) for evaluation and treatment. Although practice patterns vary, it is not an uncommon practice to give normal saline to these patients in the hopes that the saline will cause a dilution effect on the level of alcohol helping patients sober faster and therefore having a shorter length of stay in the ED. At the end of 2013 a study was published evaluating intravenous fluids and alcohol intoxication...
Take Home Message
There is no evidence that intravenous fluids will expedite sobriety in patients with acute alcohol intoxication"
For more thoughts on intravenous fluids and alcohol intoxication also checkout:

sábado, 26 de noviembre de 2016

The suction catheter

The Resuscitationist
The Resuscitationist - November 23, 2016 - By Jason Bowman
..."Bottom line: The yankauer sucks (or rather doesn’t) and shouldn’t be used, the DuCanto catheter was hand delivered by the Archangel Resusitashunus to Jim DuCanto himself to bestow upon the world a life-saving weapon to fight against the demon Kopeeus Pukeius. And I was paid to say all of that. You should really just read the article this time and not tl;dr me. I write funny stuff, my mom says."

Adverse Drug Events

Nadine Shehab et al. JAMA. 2016; 316(20): 2115-2125. doi:10.1001/jama.2016.16201
"Key Points
Question What are the characteristics of adverse drug events that lead to US emergency department (ED) visits?
Findings Based on 2013-2014 nationally representative surveillance data, an estimated 4 ED visits for adverse drug events occurred per 1000 individuals annually. Among children (aged ≤5 years), antibiotics were most commonly implicated; among older children and adolescents (aged 6-19 years), antibiotics were most commonly implicated, followed by antipsychotics; and among older adults (aged ≥65 years), anticoagulants, diabetes agents, and opioid analgesics were implicated in approximately 60% of ED visits for adverse drug events.
Meaning Adverse drug events from anticoagulants, antibiotics, diabetes agents, opioid analgesics, and antipsychotics are a common reason for ED visits and may benefit from patient safety initiatives.
Conclusions and Relevance 
The prevalence of emergency department visits for adverse drug events in the United States was estimated to be 4 per 1000 individuals in 2013 and 2014. The most common drug classes implicated were anticoagulants, antibiotics, diabetes agents, and opioid analgesics."