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

WORLD EMERGENCY MEDICINE SOCIETIES & RELATED

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Thursday, March 4, 2021

Open fractures

Taming The SRU
Taming The SRU - March 04, 2021 - By Kelly Tillotson
“Open fractures are a common pathology seen in emergency departments, especially in trauma centers. In open fractures, the skin barrier has been compromised, exposing sterile bone to the environment. Considered a true orthopedic emergency, these fractures have high morbidity due to osteomyelitis, with infection rates up to 55%. Appropriate and timely intervention in the emergency department with proper antibiotic therapy, wound care, and early orthopedic surgery involvement dramatically reduces the risk of developing osteomyelitis. In this post, we will review the management of open fractures and address additional complications from open fractures. Fractures of the axial skeleton (skull, facial bones, spine, ribs, and pelvis) will not be discussed in this post. Antibiotic recommendations for osteomyelitis prophylaxis are discussed in another post..”

Functional Heuristics in Resus

EMCrit RACC
EMCrit 293 - March 03, 2021 - By Scott Weingart
...”What is a Heuristic?
A short cut to extended, analytical thinking that when functional provides a solution that may not be optimal but will be sufficient. When based on cognitive biases, heuristics may be dysfunctional. Wikipedia has a fairly good discussion of heuristics...
Functional Heuristics in Resuscitation
  • Flank Pain in Elderly is AAA until the Ultrasound
  • Severe Bradycardia/Heart Block = Hyperkalemia until you see the K
  • Slovis' Hypokalemia = Hypomagnesemia (Hypok=HypoMAG)
  • Unexplained Hypotension gets antibiotics
  • Hypotension and Abdominal Pain in Child-Bearing Age Female is Ectopic
  • Chest Pain Plus
  • Tamponade is dissection until it is not
  • Old stay, young go
  • Err towards Young D/C and Old Stay and then check
  • Think LP/do LP
  • The diagnoses of costochondritis and gastroenteritis do not exist
  • What is going to kill this patient? (Pre-Mortem)Functional Heuristics in Resus

ECMO + Angio/Cath for RVF

REBEL EM - March 04, 2021 - By Matt Astin
Paper: Yannopoulos et al. Advanced Reperfusion Strategies for Patients with Out-of-Hospital-Cardiac Arrest and Refractory Ventricular Fibrillation (ARREST): A Phase 2, Single Centre, Open-Label, Randomised Control Trial. Lancet. PMID: 33197396
“Clinical question: Does extracorporeal membrane oxygenation (ECMO) resuscitation coupled with immediate coronary angiography/catheterization improve survival compared to standard ACLS in the emergency department?
Author Conclusión: “Early ECMO-facilitated resuscitation for patients with OHCA and refractory ventricular fibrillation significantly improved survival to hospital discharge and functional status compared with patients receiving standard ACLS resuscitation.”
Clinical Take Home Point: ECMO provides a promising opportunity to increase meaningful survival for OHCA patients with refractory VF or VT. However, this is a time- and resource-intensive modality that is not available in all settings. Continue to provide high-quality CPR, defibrillate early, and search for reversible causes. If ROSC is achieved, evaluate for evidence of acute coronary occlusion and the need for emergent coronary revascularization.”

Wednesday, March 3, 2021

Single Troponin Testing

REBEL EM - March 03, 2021 - By Benjamin M Gerretsen
Paper: Wassie et al. Single versus serial measurements of cardiac troponin in the evaluation of emergency department patients with suspected acute myocardial infarction. JAMA Network Open 2021. [Link is HERE]
“Clinical Question: Do emergency department patients discharged after a single negative troponin test have similar outcomes to patients receiving multiple tests?
Author Conclusion:When compared to serial troponin testing, discharge after a single negative conventional troponin is routinely done among ED patients, and appears safe based on current physician decision-making with no difference in rates of 30-day cardiac mortality and AMI.”
Clinical Take Home Point: Discharging patients presenting to the ED with chest pain after a single negative conventional troponin and proper risk stratification with the HEART score can be considered to be as safe as serial troponin testing while being less time consuming, less costly and therefore more patient oriented.”

Tuesday, March 2, 2021

Adjunctive therapies for Acute migraine

Taming The SRU
Taming The SRU - March 02, 2021 - By Díaz Martina
Acute migraine causes 1.2 million visits to the US emergency departments annually. Headache is the fifth leading cause of patients presenting to the emergency department (ED) in the United States. We have previously discussed evidence behind the traditional ‘Migraine Cocktail’ here. In this post, we will address adjunctive therapies when the first-line treatments haven’t broken your headache...”

Monday, March 1, 2021

Haloperidol vs Ondasentron for CHS

EM Ottawa - By Hans Rosenberg - March 01, 2021
“Question and Methods: Randomized control trial in which cannabis users with active emesis received either haloperidol (0.05mg/kg or 0.1 mg/kg IV) or ondansetron 8mg IV for symptomatic relief.
Findings: 33 patients were enrolled and randomized, and for the primary outcome haloperidol (either dose) was superior to ondansetron [Difference 2.3 cm (95% confidence 0.6-4.0cm); P=0.01].
Limitations: This study had several limitations including complex design, enrollment difficulties, unplanned interim analyses, and unclear presentation of results.
Interpretation: In patients with suspected CHS, lower dose haloperidol (0.05 mg/kg) can be considered as first line supportive therapy in the ED.”

Spinal Epidural Abscess

EmDocs - March 01, 2021 - By Della Porta A; Bryant J-P; Bornstein K; Montrief T
Reviewed by: Manny Singh; Alex Koyfman and Brit Long
“Take home points

  • Why is spinal epidural abscess a challenging diagnosis? 
  • Back pain is a common chief complaint, while SEA is a rare condition.
  • SEA presents with non-specific symptoms and infrequently with the classic triad.
  • Diagnosis requires expensive and time-consuming imaging (MRI).
  • Coexisting infections or risk factors are common in the ED setting.
How can we improve diagnostic delay of SEA? 
  • Implementation of decision-making algorithms can reduce time intervals of ED presentation to diagnosis.
  • Statistical models have accurately discriminated cases from non-cases of SEA.
  • Focused exam, such as the PVR, can detect subtle neurologic deficits and increase our assessment sensitivity.
  • When indicated, early whole spine imaging can detect skip lesions and prevent delays in diagnosing multiple abscess locations.”

TXA for SAH

FIRST10EM - By Justin Morgenstern - March 1, 2021
“The paper
Post R, Germans MR, Tjerkstra MA, et al; ULTRA Investigators. Ultra-early tranexamic acid after subarachnoid haemorrhage (ULTRA): a randomised controlled trial.Lancet. 2021 Jan 9;397(10269):112-118. doi: 10.1016/S0140-6736(20)32518-6. Epub 2020 Dec 23. PMID: 33357465 NCT02684812
Bottom line
This is the largest RCT to date looking at TXA in subarachnoid hemorrhage, and based on these results, it should not be prescribed routinely.”

Saturday, February 27, 2021

Methoxyflurane for short-term analgesia

SGEM#320 - By admin - Feb 27, 2021
... Recently, there has been increased interest in using methoxyflurane (Penthrox), an inhaled non-opioid analgesic, to provide rapid short-term analgesia (23, 24). In Australia, Methoxyflurane has been widely used at sub-anesthetic doses for analgesia in the pre-hospital setting since 1975. Its use has become more global in recent years and at low doses, it has a very reassuring safety profile...
CLINICAL QUESTION: WHAT IS THE EFFECTIVENESS OF METHOXYFLURANE VERSUS STANDARD CARE FOR THE INITIAL MANAGEMENT OF SEVERE PAIN AMONG ADULT ED PATIENTS?

THERE WAS NO STATISTICAL DIFFERENCE IN THE PRIMARY OUTCOME BETWEEN METHOXYFLURANE AND STANDARD CARE.

SGEM BOTTOM LINE: CONSIDER USING METHOXYFLURANE FOR RAPID ANALGESIA AT TRIAGE IN THE ED.”

Tympanic Membrane Rupture

EmDocs EM@3AM - February 26, 2021 - Brit Long / Reviewed by: Alex Koyfman
“Key Points:
  • TM rupture is divided into simple/isolated versus complicated large.
  • Hearing loss, vertigo/nystagmus, ataxia, and/or facial weakness are complicated.
  • Assess for other injuries, but diagnosis is clinical.
  • Those with complicated injuries or retained FB need ENT consultation”

Friday, February 26, 2021

Bougie-Assisted Cricothyrotomy

REBEL EM - February 26, 2021 - By Salim Rezaie
“Background: Cricothyrotomy is a high acuity low occurrence (HALO) procedure that is time critical. It is the common final step in the cannot intubate cannot oxygenate (CICO) and/or cannot intubate cannot ventilate (CICV) situation. Due to the time critical nature of the procedure, any approach must include three facets:

Clostridium Difficile

Tasty Morsels of Critical Care 029 - February 25, 2021 - By Andy Neill
“We see C. Diff in the ICU in a couple of contexts. Firstly the poor unfortunate soul who starts with a benign illness and gets some antibiotics and develops a fulminant colitis and shock needing colectomy and an ICU admission. Secondly we have the frequent dilemma of the prolonged ICU patient who is collecting complications like they’re merit badges. They’ve developed new shock and there’s some diarrhoea and you’re worried about c. diff...”

Wednesday, February 24, 2021

Superficial Venous Thrombosis

REBEL Core Cast 50.0 - February 24, 2021 - By Anand Swaminathan
"Management:
  • Due to the lack of large clinical trials evaluating the treatment of SVT, much of the literature relies heavily on expert consensus.
  • Traditional treatment involves NSAIDS and stockings. This treatment is still recommended by most for SVT’s <5cm in length and >3cm from the SFJ. (Cosmi 2015)
  • 2012 ACCP guidelines suggest that patients with SVT > 5 cm can be treated with prophylactic dose of fondaparinux or LMWH for 45 days. (Guyatt 2012)
    • This recommendation was largely based on the CALISTO trial, which randomized 3002 patients with SVT to get either fondaparinux or placebo and reported that the rate of PE or DVT was 85% lower in the fondaparinux group (Decousus 2010)
  • SVT within 3 cm of SaphenoFemoralJunction is considered by some to be equivalent to DVT and can be treated as such (Cosmi 2015)
  • Topical NSAIDS may help symptoms and can be used at the same time as anticoagulation (Kearon 2012)
  • There is no literature supporting or refuting using the same treatment in the evaluation of upper extremity SVT.
  • If an SVT is uncovered in the lower extremity, a bilateral duplex ultrasound evaluating the deep venous system should be considered.
"Take Home Points
  1. SVT >5cm or <3 cm from the SFJ should be treated with anti-coagulation.
  2. The rate of concurrent DVT and PE in patients with SVT is 25% and 5%, respectively."

Monday, February 22, 2021

Anemia in the ED

EmDocs - February 22, 2021 - By Brandon M. Carius
Reviewed by: Alex Koyfman and Brit Long
Background Pearls
Anemia is common, with some studies finding prevalence in up to one-third of the global population.
Much literature cites WHO anemia standards of a hemoglobin <12 g/dL in females and <13 g/dL in males, but baselines can vary between demographics.
Outward signs of anemia on initial evaluation (such as tachycardia and hypoxia) may be tempered by chronic compensatory mechanisms of increased plasma volume and RBC production.
Classification Pearls
Anemia can be subclassified between acute and chronic, although stringent time thresholds are not often mentioned. Other classifications include “blood loss” vs. “non-blood loss” anemia and sub-classifications based on RBC indices.
Assessment Pearls
Initial evaluation should focus on patient hemodynamics. When anemia is suspected, crystalloids should be avoided if possible.
Stable vital signs should not be used to exclude the diagnosis of anemia, given early onset with compensation in acutely anemic patients and long-term adaptation measures in those with chronic anemia.
Laboratory Evaluation Pearls
Anemia differential primarily utilizes MCV, however there is some overlap of etiologies between these categories and further laboratory evaluation is generally required.
While IDA is common, its presence should not be presumed to be isolated, and further evaluation is recommended for causes of occult bleeding.
Peripheral blood smears can help recognize specific RBC dysmorphia that can identify anemia etiologies.
Management Pearls
Outpatient management for anemic patients with stable vital signs centers on iron supplementation with encouraged follow-up. Vitamin C may help with absorption.
In patients with gastrointestinal comorbidities or who may not tolerate oral iron supplementation can be considered for IV iron ‘loading’ in the emergency department prior to discharge.
Emergent transfusion with O-negative whole blood should be used for the reproductive age female who is unstable and O-positive for all others
Previously-universal transfusion thresholds of hemoglobin < 10 g/dL have been superseded by a 7 g/dL cut-off in most situations
.”

TXA in epistaxis

First10EM - February 22, 2021 - By Justin Morgenstern
... “The NoPAC trial is the highest quality trial to date looking at TXA for epistaxis, but before diving into that trial, I thought I would share what I had previously written about this literature. My bottom line for the Journal Jam Episode was: The level of evidence is weak, and so I wouldn’t be surprised if it was overturned in the future, but the current evidence does support the use of TXA (either topical or oral) to reduce the risk of rebleeding. There is no evidence that it reduces more important outcomes like transfusions, need for interventions, or surgery...
The paper
Reuben A, Appelboam A, et al. The use of tranexamic acid to reduce the need for Nasal Packing in Epistaxis (NoPac): randomised controlled trial. Annals of Emergency Medicine. 2021. 10.1016/j.annemergmed.2020.12.013
Bottom line
In the highest quality trial to date, there was absolutely no value in using topical TXA in the management of epistaxis.”

Saturday, February 20, 2021

5 Medical Myths in EM

SGEM XTRA - By admin - Feb 20, 2021
This is an SGEM Xtra episode. I had the honour of presenting at the Lehigh Valley Health Network Grand Rounds on February 4th, 2021. The title of the talk “Dogmalysis: Five Medical Myths in Emergency Medicine”. The presentation is available to listen to on iTunes and GooglePlay and all the slides can be downloaded using this LINK.

FIVE MEDICAL MYTHS IN EMERGENCY MEDICINE
  • Myth #1: The use of non-selective NSAIDs will cause a nonunion in long bone fractures
  • Myth #2: Topical anesthetics will cause blindness if used in simple corneal abrasions for less than 48 hours
  • Myth #3: Mild paediatric gastroenteritis is best treated with expensive oral electrolyte solutions
  • Myth #4: Tranexamic acid (TXA) has been proven to saves lives and results in good neurologic function in patients with isolated traumatic brain injuries (TBI)
  • Myth #5: Epinephrine in adult out-of-hospital cardiac arrests (OHCA) results in better patient-oriented outcomes (POOs)”

Friday, February 19, 2021

Blunt Cerebrovascular Injury

TRAUMA ICU ROUDS
Trauma ICU Rouds Episode 32 - December 17, 2020 - By Dr. Walt Biffl
"Take-Home Points
  • BCVI are much more common than originally described; the more you look, the more you find!
  • In general, it’s better to have a high-index of suspicion and low threshold to screen for BCVI
  • Universal screening of blunt polytrauma patients using high-resolution CT is an attractive option for patients already deemed to require a contrast-enhanced CT
  • In patients with competing injuries that could be worsened with the start of antithromobtic therapy (i.e., TBI, solid organ or spine injuries) EARLY multidisciplinary consultation regarding risks and benefits are paramount to optimal patient outcomes"

Thursday, February 18, 2021

IV Fluids in Benign Headaches

REBEL EM - February 18, 2021 - By Jenny Beck-Esmay
Article: Zitek T et al. I-FiBH Trial: Intravenous Fluids in Benign Headaches – A Randomised, Single-Blinded Clinical Trial. Emerg Med J. 2020. PMID: 32620543.
“Clinical Question: In patients presenting to the emergency department for a benign headache, do IV fluids help reduce pain or improve outcomes?
Author’s Conclusion: “Though our study lacked statistical power to detect small but clinically significant differences, ED patients who received an intravenous fluid bolus for their headache had similar improvements in pain and other outcomes compared with those who did not.”
Clinical Take Home Point: In the absence of historical or clinical dehydration, there is little evidence to support the routine use of IV fluids for the treatment of benign headaches in the ED”

Tuesday, February 16, 2021

Intraosseous Myths

ACEP Now - January 22, 2021 - By Christopher Sampson
"When you’re in an adult code and intravenous (IV) access can’t be obtained, the first option we reflexively go to is intraosseous (IO) access. Anyone who has practiced emergency medicine for more than a decade knows that was not always the case. In the 1980s, IO access was introduced as a standard of care by the American Heart Association as a component of pediatric advanced life support. During the decade or two that followed, IO access was mainly reserved for use in the pediatric population as an alternative to IV access. But in the early 2000s, its use in the adult population began to rise. The introduction of IO drills and use by the military helped increase adult use...
Myth 1: The proximal tibia is the only location for insertion.
Myth 2: Only medications and crystalloid solutions can be infused through an IO.
Myth 3: IO infusions are too slow, and pressure bags can’t be used.
Myth 4: IO access is hard to obtain.
Myth 5: There are no complications to placement of an IO.
Myth 6: IO doesn’t hurt."

Monday, February 15, 2021

Stevens-Johnson Syndrome

iEM - February 15, 2021 - By Sumaiya Hafiz
 vs  

..."Stevens-Johnsons Syndrome is a rare type 4 hypersensitivity reaction which affects <10% of body surface area. It is described as a sheet-like skin loss and ulceration (separation of the epidermis from the dermis).
Toxic epidermal necrosis and Stevens-Johnsons Syndrome can be mixed. However, distinguishing between both disease can be done by looking at % of body surface area involvement..."

Syncope: discharge or admit ?

emDocs - February 14, 2021 - By  Aaron Blau
Reviewed by: Mark Ramzy; Alex Koyfman; Brit Long,
"Question: For patients presenting with syncope of unknown etiology, who needs to be admitted and who can go home?
Pearls
  • Many patients with syncope can go home after evaluation for etiology, assessment of risk factors, and obtaining a reassuring EKG.
  • Clinical judgment alone often tends to err on the side of conservative dispositions and can lead to higher admission rates.
  • Decision-making tools, despite their varying level of external validation, can be used to reassure clinicians and assist in shared decision-making when considering safe discharge of syncopal patients.
  • The SFSR requires only basic labs (CBC, BMP) and a standard workup, and is the easiest to remember at the bedside, but sensitivity for adverse events was much lower in external validation studies. The CSRS requires more extensive laboratory testing but has proven more reliable in external validation. The FAINT score appears promising for older patients who present with syncope, but requires external validation before widespread clinical use."

Tecnecteplase for AIS

REBEL EM - February 15, 2021 - By Salim Rezaie
Paper: Oliveira M et al. Tenecteplase for Thrombolysis in Stroke Patients: Systematic Review With Meta-Analysis. AJEM 2021. [Link is HERE]
"Clinical Question: What is the efficacy/safety of tenecteplase vs alteplase in the treatment of acute ischemic stroke?
Author Conclusion:Tenecteplase is an alternative to alteplase for stroke thrombolysis, with lower cost and a more favourable pharmacokinetic profile.”
Clinical Take Home Point: Tenecteplase appears to be a reasonable alternative to alteplase with a similar safety profile but with the added benefits of helping improve early neurologic improvement and recanalization (surrogates of neurologic outcomes). The 0.2 to 0.25mg/kg dose of Tenecteplase in particular appeared to have the highest early neurological improvement rates and a trend for better functional outcomes at 3 months, however this latter outcome was not statistically significant."

Friday, February 12, 2021

Toci + Dexa for COVID

PulmCrit (EMCrit)
PulmCrit - February 12, 2021 - By Josh Farkas
“Summary: The Bullet
  • Among hypoxemic COVID patients with CRP >75 mg/L, adding tocilizumab on top of dexamethasone 6 mg/day improves mortality and other important endpoints (e.g., reductions in intubation and hemodialysis).
  • Evidence suggests that tocilizumab monotherapy is ineffective, but tocilizumab provides benefit when added to steroid. This may explain the success of RECOVERY and REMAP-CAP, in comparison to prior studies of tocilizumab which didn’t detect benefit.
  • The key factor in selecting patients who may benefit from tocilizumab seems to be the presence of systemic inflammation (CRP >75 mg/L), rather than illness severity or timing. 
  • If tocilizumab is unavailable, other immunomodulators may be considered in its place. Higher doses of steroid, or JAK-inhibitors combined with steroid are supported by some evidence in COVID and might be rational therapies here (albeit with less robust evidentiary support). 
  • 6 mg dexamethasone daily is inadequate for sicker patients with COVID pneumonia”

Thursday, February 11, 2021

Uncomplicated Acute Appendicitis

REBEL EM - February 11, 2021 - By Salim Rezaie
Paper: Sippola S et al. Effect of Oral Moxifloxacin vs Intravenous Ertapenem Plus Oral Levofloxacin for Treatment of Uncomplicated Acute Appendicitis: The APPAC II Randomized Clinical Trial. JAMA 2021. PMID: 33427870
"Clinical Question: In acute uncomplicated appendicitis, is treatment with oral antibiotics alone non-inferior to a combination of IV followed by oral antibiotics?
Author Conclusion: “Among adults with uncomplicated acute appendicitis, treatment with 7 days of oral moxifloxacin compared with 2 days of intravenous ertapenem followed by 5 days of levofloxacin and metronidazole resulted in treatment success rates greater than 65% in both groups, but failed to demonstrate noninferiority for treatment success of oral antibiotics compared with intravenous followed by oral antibiotics.”
Clinical Take Home Point: Non-operative management of uncomplicated appendicitis is a feasible option in patients based on good evidence from the APPAC and CODA trials. Further defining optimal treatment strategies to minimize need for hospitalization should be the focus of future research in this area. Questions that remain include antibiotic duration, mode of antibiotic delivery, and the need for in-patient observation. The APPAC II trial is a nice start to answer some of these more nuanced questions. As we see more evidence and gain more experience with the management of uncomplicated acute appendicitis, this will help guide the optimal operative and non-operative management pathways. At this time PO only antibiotics for uncomplicated acute appendicitis appear to be promising, but not non-inferior with no discernible advantage."

Wednesday, February 10, 2021

AAA

REBEL Core Cast 49.0 - February 10, 2021 - By Anand Swaminathan
“Take Home Points
  • Consider ruptured AAA in patients (especially those > 50 years of age) with unexplained hypotension, back or abdominal pain
  • All ruptured AAAs should be considered unstable regardless of vital signs as rapid deterioration is common
  • A ruptured AAA is 100% fatal without surgical or endovascular intervention. Mobilize your surgical colleagues early”

Skin Cancer

EmDocs - February 10, 2021 - By Evelyn Huang and Kelly
Reviewed by: Arianne Chavez-Frazier; Summer Chavez; Alex Koyfman and Brit Long
“Conclusion and Take-Home Points
In the emergency department, you will see many skin lesions that may or may not relate to the patient’s presenting complaint. As seen in the presenting case of melanoma with metastasis to the brain, a thorough skin exam may even help with the diagnosis. Since the emergency department may be the only interaction that a patient has with the healthcare system, it is incredibly important to offer referrals and consultations when discovering lesions concerning for skin cancer. Do not forget to risk stratify your patients by asking pertinent history questions such as sun/UV exposure, family history, and immunosuppression.”

Tuesday, February 9, 2021

Accidental Hypothermia

TAMING THE SRU
Taming The SRU - By Katherine Connelly - February 09, 2021

"CONCLUSION
Accidental hypothermia may occur as a result of environmental exposure or an underlying medical condition, and ranges in severity from mild to profound. The safety of responders is paramount during rescue of a hypothermic patient, and management priorities should include gentle handling with avoidance of rescue collapse, afterdrop, and ongoing heat loss. Patients with HT I can typically be treated in the field with self-rewarming, calories to support shivering, and external rewarming with hot packs or heated blankets. Stable HT II - III patients warrant hospital evaluation with active external rewarming as the mainstay of therapy. Extracorporeal rewarming should be strongly considered for HT II - III patients with hemodynamic instability, core temperature <28°C, or who fail to improve with less invasive measures. Resuscitation should be attempted for all patients in hypothermic cardiac arrest, with the exception of those who are frozen solid or have injuries obviously incompatible with life, as good neurologic survival is possible even with prolonged down times. VA-ECMO is the rewarming strategy of choice for patients in hypothermic arrest, and the HOPE score can be used to guide resuscitation decisions in such patients."

Finger injuries

Canadi EM - By Alkarim Velji - February 9, 2021
..."Let’s be honest, finger injuries can be complicated, and the consequences of inappropriate treatment can be significant. The various pathologies can be hard to remember and differentiate when you don’t see them every day. When given the task of creating an online resource for our yearly Resident Research Day, this topic quickly came up as an area of interest for our team members. At one time or another, most of us have found ourselves looking through multiple wordy resources, attempting to ensure we are employing the right treatment and haven’t missed something that could potentially affect future hand function. The need for a simple, reliable, and succinct resource is why we created the website “Ten Fingers, Ten Problems”..."

Anticoagulation in Covid-19 (2021 ASH)

American Society of Hematology. February 08, 2021 - By Cuker A et al.
The American Society of Hematology (ASH) guideline panel suggests using prophylactic-intensity over intermediate-intensity or therapeutic-intensity anticoagulation for patients with coronavirus disease 2019 (COVID-19)–related critical illness who do not have suspected or confirmed venous thromboembolism (VTE) (conditional recommendation based on very low certainty in the evidence about effects
The ASH guideline panel suggests using prophylactic-intensity over intermediate-intensity or therapeutic-intensity anticoagulation for patients with COVID-19–related acute illness who do not have suspected or confirmed VTE (conditional recommendation based on very low certainty in the evidence about effects

Monday, February 8, 2021

OMI-NOMI

REBEL EM - By Shyam Murali - February 08, 2021
Paper: Myers HP et al. Comparison of the ST-Elevation Myocardial Infarction (STEMI) vs. NSTEMI and Occlusion MI (OMI) vs. NOMI. Paradigms of Acute MI. Journal of Emergency Medicine 2020. PMID: 33308915
“Clinical Question: What differences exist between STEMI(+) OMI patients and STEMI(-) OMI patients in terms of time to catheterization and outcomes?
Author Conclusions:
“STEMI(-) OMI patients had significant delays to catheterization but adverse outcomes more similar to STEMI(+) OMI than those with no occlusion. these data support the OMI/NOMI paradigm and the importance of further research into emergent repercussion for STEMI(-) OMI.”
Clinical Take Home Point:
The STEMI-NSTEMI paradigm still misses a significant number of actúe coronary occlusion events that could benefit from emergent invasive intervention and a new model could improve our ability to identify them more accurately. Additionally, the OMI-NOMI paradigm would move us away from depending solely on ST elevation millimeter criteria for rapid treatment.
These results support that OMI-NOMI (rather than STEMI-NSTEMI) criteria can identify more patients with ACS that have emergently salvageable myocardium that would benefit from emergent invasive intervention and at the same time identify patients where emergent invasive intervention is of minimal benefit. STEMI(-) OMI are an under identified subgroup of ACS patients and this is now the second paper published that really helps push the needle to a OMI-NOMI paradigm shift.”

Sunday, February 7, 2021

Canadian TIA risk score

St Emlyn’s - February 06, 2021 - By Simon Carley
We see a lot of patients in the ED with a history of what sounds very much like a transient ischaemic event (TIA). By definition the patient will have had resolution of their symptoms/signs and so there is no apparent need for immediate intervention, but we also know that a TIA may be precursor to a larger and thus more serious stroke. In some settings the ABCD2 score is used to risk stratify patients into those who are safe to go home and to those requiring urgent investigation or even admission. However, the ABCD2 score is not perfect and in 2014 a Canadian group prospectively derived a risk score that hoped to improve on current models. This Canadian TIA score has now been validated in a paper published in the BMJ this week...
The bottom line
The Canadian TIA score offers advantages over current ABCD scoring systems. We should consider how this might affect patient management pathways with colleagues in related specialities.”

Saturday, February 6, 2021

Care of Older People in the ED

IFEM Geriatric Emergency Medicine Special Interest Group 
December 2020
“Conclusion
Aging of populations around the world will continue in the coming decades. Improvements in their care are possible, most of them occurring at the local ED level. However, they require leadership and direction from national and international organisations. The IFEM Geriatric Emergency Medicine Special Interest Group calls on the institutions of international emergency medicine to ensure that emergency health services are designed to optimally manage the health and social care needs of older people during and after acute illness or injury. IFEM encourages its member organisations to recognise and address the needs of this core user group, and to engage and collaborate across disciplines and across systems. Creating change and driving improvement will benefit patients, staff, health care systems, economies and our societies.”

Tuesday, February 2, 2021

PEEP without ARDS

REBEL EM - February 01, 2021 - By Frank Lodeserto
Paper: Writing Committee and Steering Committee for the RELAx Collaborative Group. Effect of a Lower vs Higher Postive End-Expiratory Pressure Strategy on Ventilator-Free Days in ICU Patients Without ARDS: A Randomized Clinical Trial. JAMA 2020. PMID: 33295981
"Clinical Question: For patients in the ICU who received invasive ventilation for reasons other than ARDS, is a ventilation strategy with lower PEEP noninferior to a strategy using higher PEEP with respect to the number of ventilator-free days at day 28?
Author conclusion: “Among patients in the ICU without ARDS who were expected not to be extubated within 24 hours, a lower PEEP strategy was noninferior to a higher PEEP strategy with regard to the number of ventilator-free days at day 28. These findings support the use of lower PEEP in patients without ARDS.”
Take-home point: In this trial a lower PEEP strategy was shown to be noninferior to higher PEEP in non-ARDS patients (i.e. as good as). However, there are some concerning findings of increased rates of severe hypoxemia, need for rescue strategies, decreased P/F ratios, and increased driving pressures in the lower PEEP group compared to the higher PEEP group. Finding the optimal PEEP can be challenging, and likely tied to the degree of recruitable alveoli. In some patient populations, particularly obese patients (which were excluded from this trial), for example, this will require applying clinical judgement and understanding the benefit vs the harm of PEEP which depends on the balance of alveolar recruitment vs overdistention (i.e. the sweet spot)"

Monday, February 1, 2021

Ostomy complications

EmDOCs  - February 01, 2021 - By Jonathan Bornstein; Jennifer Liao; Marzena Sroczynski; Carlos Rodriguez. Reviewed by: Alex Koyfman; Brit Longnand Caitlyn Costanzo
“Pearls:
  • Ileostomies tend to be on the right side of the abdomen and have loose liquid stool; colostomies tend to be on the left side of the abdomen and have more formed stool; urostomies tend to be on the right side of the abdomen and produce urine.
  • High output failure
    • Be aware of this in the dehydrated patient with a new gastrointestinal ostomy who is putting out 1.5-2 L fluid/day.
    • IV fluid resuscitation and electrolyte replacement are essential. Pay particular attention to signs of severe hyponatremia, hypokalemia, and hypomagnesemia.
    • Consider adv anced imaging to assess for complications such as anastomotic leak, obstruction, or paralytic ileus.
  • Stomal necrosis, incarcerated parastomal hernias, and internal reservoir ruptures are surgical emergencies – do not delay in resuscitating your patient and calling your surgical consultants early.
  • Not all patients with urostomies and evidence of bacteriuria require antibiotics – it is common for their urine to be colonized with bacteria from the ileal conduit. Reserve antibiotics for patients with systemic signs of infection”

Friday, January 29, 2021

Refractory V fib or V Tac

Taming The SRU
Taming The SRU - January 27, 2021 - By Jeffery Hill
“Anyone who’s faced a patient with refractory V fib or V Tac, knows the certain pang of hopelessness that strikes when round and round of epi, CPR, and shocks fails to deliver a return to organized rhythm. ECMO is an option. Baring the availability of perhaps one of the most resource-intensive procedures in medicine, what option does one have? If nothing is working what do you change? Beta blockers? Change up the shocks? Is that bicarb you’re giving doing any good? This post and the affiliated podcast will cover 3 articles looking at the evidence for these new and old treatments for. cardiac arrest