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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

Nosebleed Emergency and Tranexamic Acid Treatment

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domingo, 26 de febrero de 2017

Regains Lost Patient Flow Efficiencies

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ACEPNow - By Shari Welch - February 13, 2017
"The Miriam Hospital is a 247-bed community hospital affiliated with the Warren Alpert School Medical School of Brown University in Providence, Rhode Island. The emergency department sees 68,000 visits annually in its 61 treatment spaces, which include 21 lounge chairs for vertical flow. The emergency department has had a long reputation for efficiency and service quality. The ED physicians and staff have always been proud of their performance metrics and empty waiting room. However, after crossing the 60,000-visit volume band, the department began to falter operationally, and its wait times increased. The new normal included an often full waiting room. The emergency department, which effectively operates as a geriatric emergency department (more than 30 percent of its patients being older than age 65), often found itself with Emergency Severity Index (ESI) 2 patients being placed back in the waiting room, a situation that did not please staff...
(click for larger image)

Opioid-Prescribing Patterns of EP

Emergency Medicine Updates - February 23rd, 2017 - By reuben
"Barnett and his colleagues demonstrated that opioid-naive patients who presented to an emergency department and were treated by a high opioid prescriber were more likely to become long term opioid users than those who were treated by a low opioid prescriber...
Apart from the strength of the correlation between one opioid prescription and long-term use, it’s hard to imagine that more than 1 in 7 patients discharged from the emergency department should walk out with vicodin, as was found in this study. If you’re looking for resources to help you prescribe more judiciously, readers can start here and listeners/watchers can start here."

sábado, 25 de febrero de 2017

Procalcitonina and respiratory infections

Resultado de imagen de fda
FDA News Release - February 23, 2017
"The U.S. Food and Drug Administration today cleared the expanded use of the Vidas Brahms PCT Assay to help health care providers determine if antibiotic treatment should be started or stopped in patients with lower respiratory tract infections, such as community-acquired pneumonia, and stopped in patients with sepsis. This is the first test to use procalcitonin (PCT), a protein associated with the body’s response to a bacterial infection, as a biomarker to help make antibiotic management decisions in patients with these conditions.
“Unnecessary antibiotic use may contribute to the rise in antibiotic-resistant infections,” said Alberto Gutierrez, Ph.D., director of the Office of In Vitro Diagnostics and Radiological Health at the FDA’s Center for Devices and Radiological Health. “This test may help clinicians make antibiotic treatment decisions.”...
The Vidas Brahms test is intended to be used in the hospital or emergency room."

REBOA

EMOttawa
EMOttawa - February 23, 2017 - By Noam Katz
"The use of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) has become a topic of considerable interest as of late, primarily to treat non-compressible truncal hemorrhage (NCTH). However, it is beginning to expand into other causes of non-compressible bleeding...
Summing it all up
REBOA has proven itself to likely be a true player in the management of NCTH in trauma with the potential for use in other pathologies requiring urgent hemorrhage control. It has shown itself to seemingly be at least as effective as resuscitative thoracotomy (perhaps better?) and certainly creates much less of a secondary iatrogenic injury. Burgeoning advances in catheter technology, increasing utilization in major international trauma centres and considerations of altering balloon inflation characteristics all lend themselves to an exciting time in the treatment of one of the most lethal problems we face as physicians, with the real potential to vastly improve patient outcomes."

viernes, 24 de febrero de 2017

The Normalization Fallacy

PulmCCM
PulmCCM - Feb23, 2017 - By Scott Aberegg
...Several years ago we coined the term the “normalization heuristic” (we should have called it the “normalization fallacy”) to describe our tendency to view abnormal laboratory values and physiological parameters as targets for normalization. This approach is almost reflexive for many values and parameters but on closer reflection it is based on a pivotal assumption: that the targets for normalization are causally related to bad outcomes rather than just associations or even adaptations..."

Proton Pump Inhibitors in UGIB

R:E:B:E:L:EM - February 23, 2017
"Upper gastrointestinal bleeding remains a common reason for emergency department visits and is a major cause of morbidity, mortality, and medical care costs. Often when these patients arrive, the classic IV-O2-Monitor is initiated and hemodynamic stability is assessed. One of the next steps often performed includes the initiation of proton pump inhibitors (PPIs).
The ultimate question however is does initiation of PPIs reduce clinically relevant outcomes (i.e. mortality, rebreeding, need for surgical intervention) in upper gastrointestinal bleeds (UGIB)?...
Clinical Bottom Line:
PPI bolus treatment in undifferentiated UGIB DOES NOT improve mortality,* but in the subcategory of proven PUD may improve clinically relevant outcomes such as rebleeding and need for surgical intervention.
* Interestingly, The NNT did a review of this meta-analysis and found that PPIs may have a mortality benefit in the Asian populations and more harmful (or unhelpful) in the European studies."

Bowel obstruction

emDocs
emDocs - February 23, 2017 - Authors: Mancuso N and Sweeney M 
Edited by: Koyfman A and Long B
"Pearls
  • For the unstable patient with bowel obstruction early surgical consultation and laparotomy are crucial. Manage ABCs, administer resuscitative IV fluids, and place a nasogastric tube to decrease chance of aspiration and for pain control. Abdominal upright x-ray is not as sensitive as CT; if x-ray unremarkable and clinical concern still exists, obtain CT. CT first may be warranted.
  • Ultrasound is a viable newer alternative that appears to take place between X-ray and CT in sensitivity and specificity, is faster, but will be difficult to convince surgeons for now.
  • If peritonitic or septic, cover with antibiotics (institution-specific, not a lot of evidence).
  • Be wary of nonspecific findings in early presentations of bowel obstruction. Labwork directed to detect signs of ischemia (lactate, blood gas). Ongoing passage of stools or flatus does not rule out an obstruction.
  • Closed loop obstruction represents both a diagnostic challenge and a complication with high morbidity and mortality. These patients may present with very little distention but can be very ill. Look for C or U signs, whirl sign, or beak sign on CT.
  • For LBOs, most common cause is by far malignancy (~60%). Sigmoid volvulus shows up as the “coffee-bean” sign, more common in elderly and nursing home patients. Cecal volvulus points to the left upper quadrant and is typically seen in a younger patient (20-60 years old)."

jueves, 23 de febrero de 2017

Aortic Dissection

Emergency Medicine Cases
Emergency Medicine Cases - February 2017 - By Anton Helman
Aortic Dissection Live from The EM Cases Course  aortic dissetion live at the em cases course
"Take Home Points for Aortic Dissection Diagnosis and Management
  • Remember the big pain pearls when taking a history: The 3 important questions, aortic dissection is the subarachnoid hemorrhage of the torso, migrating pain, colicky pain + opioids = badness and pain that comes and goes can still be a dissection.
  • Look for Marphan’s, listen for an aortic regurgitation murmur and feel for a pulse deficit.
  • Think not only about CP +1 but also 1+ CP
  • Know the CXR findings of loss or aortic knob/aortopulmonary window and the calcium sign, use POCUS to look for an intimal flap and pericardial effusion
  • Don’t be misled by a positive troponin
  • When it comes to management, treat pain first, then HR and then BP"

miércoles, 22 de febrero de 2017

Submassive Pulmonary Embolism

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

martes, 21 de febrero de 2017

Hyperoxia

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

Perils of Intravenous Fluids

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

domingo, 19 de febrero de 2017

Temperature taking

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

Large Vessel Occlusion Acute Stroke

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

Abdominal Pain in the Geriatric Patient

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

External bleeding control

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

sábado, 18 de febrero de 2017

Critical Incident Stress Management

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

MRI in the ED

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

The ED Transfer

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

jueves, 16 de febrero de 2017

Sincope (WOBBLER)

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

miércoles, 15 de febrero de 2017

O2 Sat in Critical illness

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

Shared Decision Making In The ED

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

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

martes, 14 de febrero de 2017

Assessment of bendopnea

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

Innovation in EM

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

Aggresive Management of AF

R.E.B.E.L.EM - February 13, 2017
Ref. Stiell IG et al. Outcomes for Emergency Department Patients with Recent-Onset Atrial Fibrillation and Flutter Treated in Canadian Hospitals. Ann Emerg Med 2017. PMID: 28110987
"Clinical Question:
What is the rate of adverse events occurring within 30 days of ED presentation for recent-onset AF/AFl in a system that utilizes an aggressive approach to management?
Author’s Conclusions:
“Although most recent-onset atrial fibrillation and flutter patients were treated aggressively in the ED, there were few 30-day serious outcomes. Physicians underprescribed oral anticoagulants. Potential risk factors for adverse events include longer duration from arrhythmia onset, previous stroke or transient ischemic attack, pulmonary congestion on chest radiograph, and not being in sinus rhythm at discharge. An ED strategy of sinus rhythm restoration and discharge in most patients is effective and safe”...
Clinical Bottom Line:
An aggressive approach to the management of recent-onset AF/AFl did not result in an unacceptable rate of adverse events. Adopting a rhythm control approach in these patients appears safe."

Top 10 Articles 2016 (EMOttawa)

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

lunes, 13 de febrero de 2017

Management of elderly major trauma patients

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

Epinephrine vs. atropine for bradycardic periarrest

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

domingo, 12 de febrero de 2017

Parkinson´s in the ED

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

Acute angle closure Glaucoma

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

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