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






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sábado, 25 de junio de 2016

The Procedural Pause

Resultado de imagen de emergency medicine news

The Procedural Pause
"Renowned emergency physician James R. Roberts, MD, and his daughter, Martha Roberts, ACNP, CEN, are teaming up to create a new EMN blog, The Procedural Pause.
The blog will focus on procedures that emergency medicine residents and midlevel providers are often called on to perform in the ED. Each case will cover the basics, the best approach for treatment, and pearls and pitfalls.
The Procedural Pause publishes anonymous case studies that required an ED procedure. The site welcomes all providers to share their ideas about emergency medicine, procedures, and experience with similar cases. Application of the information in this blog remains the professional responsibility of the practitioner.
Like all texts, manuals, support guides, and blogs, this site conveys personal opinions and experiences. Providers may approach a patient or procedure in many ways, and this blog is not a dictum nor is it meant to dictate standard of care. It is a clinical guide, not a legal document; do not reference this site in court or as a defense. It is your responsibility to follow your hospital’s procedures and protocol and to practice under the guidelines of your professional license.Click here to watch a video of ultrasound-guided intravenous line insertion, and read the first three parts of this series:

Volumetric capnography

Biomed Central logo
Verscheure et al. Critical Care 2016; 20:184 - DOI: 10.1186/s13054-016-1377-3
Dead space is an important component of ventilation–perfusion abnormalities. Measurement of dead space has diagnostic, prognostic and therapeutic applications. In the intensive care unit (ICU) dead space measurement can be used to guide therapy for patients with acute respiratory distress syndrome (ARDS); in the emergency department it can guide thrombolytic therapy for pulmonary embolism; in peri-operative patients it can indicate the success of recruitment maneuvers. A newly available technique called volumetric capnography (Vcap) allows measurement of physiological and alveolar dead space on a regular basis at the bedside. We discuss the components of dead space, explain important differences between the Bohr and Enghoff approaches, discuss the clinical significance of arterial to end-tidal CO2 gradient and finally summarize potential clinical indications for Vcap measurements in the emergency room, operating room and ICU."

ER misuse in our instant gratification society

Resultado de imagen de kevinmd
Kevin MD - By Kenneth Szwak - June 20, 2016
"Those of us who work in emergency medicine have all had these patients. They present with a complaint that started two years ago and for whatever reason now deem it an issue that needs immediate attention in the ER. I had a patient like this recently who not only had the issue for two years, but also had a primary care provider. Not only did the patient have a PCP, they saw their PCP a week before coming to the ER. Their provider also referred the patient for some outpatient studies. The studies were reasonable even though they would unlikely get to the root cause of the patient’s symptoms.
Despite being reasonable, the patient decided to not follow through with the referrals and instead decided to come to the ER demanding the studies be done there because the patient “needed to know today.” I politely went through my normal boundary setting dialogue about how the patient should be getting her outpatient studies done as referred by her PCP and how coming to the ER in lieu of that is an inappropriate use of the ER but it fell on deaf ears as usual..."


EM Resident Magazine
EM Resident - By David Traficante and Anthony Catapano - On 05/26/2016
"Emergency physicians are faced with the task of identifying life-, limb-, and eyesight-threatening diseases on a daily basis. Some of these conditions are more common and obvious than others. Endophthalmitis, although rare, is a vision-threatening disease that cannot be missed. It is an inflammatory condition involving the intraocular cavities of the eye (ie, the aqueous and/or vitreous humors) and is usually caused by infection.
Emergency Department Management
Endophthalmitis is an ophthalmological emergency and treatment is best left in the hands of an ophthalmologist.The mainstay of treatment for all types of endophthalmitis is intravitreal antibiotics +/- vitrectomy.9 For traumatic endophthalmitis, there is some evidence that systemic antibiotics are also indicated.10 For endogenous endophthalmitis, systemic antibiotic treatment is certainly indicated and should be targeted at treating the underlying source of the bacteremia. Fluconazole must be added if there is suspicion for candidal endophthalmitis.Regardless, the best and most efficient action in treating these patients is to involve ophthalmology early on in their care.
Delayed diagnosis of endophthalmitis can be catastrophic, and emergency medicine providers must have a low threshold for consulting ophthalmology as soon as the diagnosis is considered. While the excitement of “eye pain” may pale in comparison to the hustle and bustle that surrounds myocardial infarctions, gunshot wounds, and strokes, the consequences of missing this disease can be just as grave, and the diagnosis just as rewarding."

viernes, 24 de junio de 2016

Approach for Felons

Resultado de imagen de emergency medicine news
June 2, 2016 - By Larry Mellick
"I have serious issues with the current management recommendations for fingertip felons. I hate the thought of blindly "slicing and dicing" fingertips as treatment. I agree that fingertip abscesses should be drained, but I really question whether current approaches are the best. Thankfully, the really aggressive techniques of the past such as the through-and-through, hockey stick, or fish mouth incisions are no longer recommended. Currently, the unilateral longitudinal approach and the volar finger pad longitudinal approaches are recommended in textbooks. Unfortunately, even these recommendations are based purely on consensus and have almost no supporting evidence-based literature. The research is essentially nonexistent, and these treatment recommendations come from consensus opinions based on clinical experience. (J Hand Surg Am 2012;37[12]:2603.) 
It's possible, however, that even these incision and drainage techniques may be unnecessary in a large percentage of these infections. The problem is that ultrasound adapted to avoid near field acoustic distortion is not being used consistently. Documentation of an abscess clearly justifies an intervention. It's entirely possible, however, that a simple large bore needle aspiration of the abscess may be the only intervention needed in addition to appropriate oral antibiotics. I agree that these infections are a compartment syndrome of the finger pad. These fingertip infections are not your typical compartment syndrome, however.
The compartment of the fingertip is actually 15 to 20 small compartments, which means the normal, healthy finger pad is divided into multiple small compartments by 15 to 20 septa that extend from the periosteum to the skin. Consequently, the same 18-gauge needle used to aspirate an abscess can be redirected to decompress these tiny, engorged compartments. It's highly possible that we have accomplished a kinder and gentler compartment release if the fingertip is vigorously massaged after the needle decompression to express fluid from the compartments through the needle tracks.
My agenda for wanting to find something less invasive is because the fingertip is rich with sensory nerves and blood vessels. I could not find a study, but I strongly suspect that the residual morbidity of the current approach with the fingertip incision and drainage procedure is significant and includes finger pad instability, pain, and numbness. We must find a kinder and gentler, evidence-based approach to treating felons."

Predicting Fluid Responsiveness by PLR

passive leg raise

R.E.B.E.L.M EM - Posted by Salim Rezaie - June 23, 2016
"Background: The best way to resuscitate critically ill patients with fluids has been a hotly debated topic in the FOAMed and Critical Care worlds. Fluids are important to optimize stroke volume and distal tissue perfusion, however, the administration of excessive fluids for shock can increase a patient’s morbidity and mortality by causing volume overload, which may lead to tissue edema and subsequently inadequate blood flow to tissues. Accurately predicting when, whom, and how much fluid to administer remains a very challenging clinical question as only half of critically ill patients increase their cardiac output in response to the administration of fluids (i.e. the patient is preload or fluid responsive).
Clinical signs and pressure/volumetric static variables are unreliable predictors of fluid responsiveness. Ventilator-induced dynamic variables such as stroke volume variation and pulse pressure variation, however, have been shown to be more accurate in predicating fluid responsiveness. These tests can only be applied when several criteria are present (e.g., sinus heart rate, mechanical ventilation with a tidal volume of 8-10cc/kg of ideal body weight).
Passive leg raise (PLR) is another method to assess preload responsiveness. PLR produces a temporary and reversible increase in ventricular preload through an increase in venous return from the lower extremities, which mimics fluid administration without actually having to give exogenous fluids. This sounds great in theory, but PLR requires a hemodynamic assessment to be made during the maneuver to determine if the patient is preload responsive or not. There are multiple techniques for assessing changes in stroke volume but the diagnostic performance of each method still remains unknown. The two most commonly described methods are changes in pulse pressure variation and variables of flow...
Author Conclusion: “Passive leg raising retains a high diagnostic performance in various clinical settings and patient groups. The predictive value of a change in pulse pressure on passive leg raising is inferior to a passive leg raising-induced change in a flow variable.”
Clinical Take Home Point: PLR is a clinically reliable predictor of fluid responsiveness and can be used with confidence as long as the PLR effects are assessed by a direct measure of cardiac output.

jueves, 23 de junio de 2016

US for retained radiolucent FB

emDocs - June 22, 2016 - Author: Alerhand S - Edited by: Koyfman A
"How to Perform Ultrasound of Soft Tissue to Visualize A Retained Foreign Body
  • Use linear transducer (7.5 to 10 MHz) to scan in both longitudinal and transverse orientations.
  • Water bath can enhance visualization.
  • The FB appears hyperechoic with surrounding hypoechoic rim (inflammatory reaction if retained for > 24 hours).
  • Wood or plastic FB usually produce posterior shadowing.
  • Metal FB usually produces reverberation or comet tail artifact.
  • Visualization is more difficult if FB is adjacent to bone or deep to subcutaneous tissue
  • False positives: calcification, scar tissue, fresh hematoma, air trapped in soft tissues. However, these can often be correlated clinically.
  • Measure the depth of FB from skin surface.
  • Mark the skin for FB removal if indicated, while noting surrounding vessels and nerves"
water bath
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Abdominal Vascular Graft Complications

emDocs - June 21, 2016 - Author: Slama R - Edited by: Koyfman A and Singh M
"As trainees I think it is beaten into our heads that all males over the age of 50 with new onset hematuria and flank pain should also be screened for AAA. One thing that is not so much beaten into our heads is how we still have to take hematuria and or hematochezia seriously in these same patients even after they receive endovascular repair. There are many complications that can occur from having an aortic graft placed, but for the purpose of this article let’s focus on Aortoenteric fistula and Endoleaks.
  1. Endovascular grafts are often life-saving, but can have disastrous complications
  2. Complications of endovascular grafts can present atypically or silently. Always maintain a high index of suspicion and have a low threshold to perform imaging.
  3. Endoleaks are the most common complication of Endovascular Aortic grafts.
  4. Don’t be hesitant to get a vascular surgeon involved even if your workup is normal."

Medical Assistance in Dying (MAID)

An online community of practice for Canadian EM physicians
 CanadiEM - By Francis Bakewell - June 22, 2016
"After an excellent introduction to Medical Assistance in Dying, and its potential impact upon the Healthcare System, Dr. Francis Bakewell takes a further look at potential implications and ramifications within the Emergency Department (ED). 
Last week, after much review and attempts at amendment by the Senate, the federal government’s legislation on Medical Assistance in Dying (MAID) received royal assent and became law. Bill C14 allows for aid in dying, either through prescription of lethal medication or through administration of medication, to be provided to persons over the age of 18 who meet all of the following criteria:
  • Have a serious and incurable illness, disease, or disability
  • Are in an advanced state of irreversible decline in capability
  • Have enduring physical or psychological suffering as a result of their illness and decline that is intolerable to them and cannot be relieved under conditions they find acceptable
  • Have a reasonably foreseeable death (though a prognosis as to specific length of time remaining does not necessarily need to have been made)
While its exact impact remains to be seen, the legalization of MAID in Canada is likely to have effects throughout medicine, including in the emergency department. We may see it come up in end-of-life discussions, in the care of patients with potential complications, or simply in deciding how to treat a patient who comes in after an attempted suicide. Direct experience with MAID in the ED may turn out to be uncommon, but it is precisely in preparing for the uncommon but complicated that the practice of emergency medicine distinguishes itself. We’d be well served to plan for it now."

Orogastric Lavage

CORE EM - By Anand Swaminathan - Edited by Daniel Lugassy
"Orgastric lavage is a controversial topic. In the past, it was used liberally in patients with a variety of reported toxic exposures. In recent times, it is performed rarely in the developed world, as the benefits are not clear and supportive care has significantly advanced. In spite
of this change, there may still be a role for orogastric lavage in a small subset of patients presenting early after a life threatening toxic ingestion.
Take Home Points
  1. Orogastric lavage may still play an important role in treatment of the overdose patient. Do not perform lavage if the ingestion has limited toxicity at any dose or the ingested dose is unlikely to cause significant toxicity.
  2. Strongly consider orogastric lavage in a patient who has taken an overdose of drugs that are particularly toxic, suspected extreme doses associated with high morbidity/mortality and do not have easily available and effective antidotes.
  3. Secure the airway prior to placing the lavage tube to minimize aspiration risk."

martes, 21 de junio de 2016

Nausea and vomiting in pregnancy

emDocs - June 20, 2016 - Author: Sciano N - Edited by: Koyfman A and Long B
"A woman of reproductive age walks into your Emergency Department with nausea and vomiting. The differential is already broad, but what if she is pregnant? Yes, this may just be “morning sickness”, which can occur in up to 75% of pregnant women. But hey, we’re Emergency Physicians; what else could it be?
We should take into account the whole picture of the patient in front of us including their age, parity, gestational age, body habitus, and ethnicity. If nausea and vomiting have developed after 10 weeks we need to think of non-pregnancy related causes as well. If symptoms occur in the first trimester of pregnancy think of gestational trophoblastic disease (GTD), hyperemesis gravidarum, and multiple gestations. If symptoms occur late in pregnancy our differential should include preeclampsia, HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets), and acute fatty liver of pregnancy (AFLP)...
Key Points
  • Take into account the whole picture including parity, age, gestational age, and previous pregnancy complications.
  • Nausea and vomiting in early pregnancy think molar pregnancy, multiple gestations, and hyperemesis gravidarum.Replete thiamine in hyperemesis.
  • Obtain an ultrasound if there is no documentation of one previously.
  • Nausea and vomiting late in pregnancy think of HELLP, AFLP, and preeclampsia.
  • Check your sixth vital sign: Glucose. This may help differentiate AFLP from HELLP.
  • Onset of nausea and vomiting after 10 weeks may be non-pregnancy related.
  • Remember “Hypertensive Mom’s Love Nifedipine”
  • Magnesium 4-6 grams in 15-20 minutes, followed by maintenance infusion of 1-2 grams/hour."

Common errors during intubation

emDocs - June 19, 2016 - Authors: Bucher J and Cuthbert D
Edited by: Santistevan J, Koyfman A and Long B
"It is vital that emergency physicians are exceedingly skilled at airway management while caring for critical patients in the emergency department (ED). This can be a daunting task due to the variation and complexity of patients that present with critical illness. Problems are frequently encountered in the process of intubation, which can potentially exacerbate a bad situation. Therefore, it is imperative that ED physicians are prepared in dealing with the complications of intubation as with the process in itself.
Current literature reports that up to 12% of intubations will require multiple attempts, leaving surviving patients at an elevated risk of adverse events later on.1 In this post, we will review a case that demonstrates some of the common problems that lead to unsuccessful first-pass intubation attempts. We will then discuss 5 common procedural intubation complications that lead to a failure in proper and timely airway management. A discussion of how to prevent such difficulties while preparing to manage their consequences is provided.
  • Error 1: Failure to appropriately evaluate the airway
  • Error 2: Failure of positioning of the airway
  • Error 3: Failure to prepare a backup plan
  • Error 4: Failure to select appropriate methods and medications
  • Error 5: Failure of decision-making"

Refractory ARDS

PulmCrit (EMCrit)
PulmCrit - June 20, 2016 - By Josh Farkas 
"ARDS causes shunting of deoxygenated blood through the lungs. Most therapies for ARDS naturally combat this shunting (e.g. opening alveoli with PEEP). However, there is often a limit to which pulmonary shunting is treatable.
Jujitsu is a Japanese martial art based on flexibility and technique, rather than a directly confronting an opponent with force. In the spirit of jujitsu, this post explores how to support ARDS patients without directly confronting lung dysfunction. This is useful in refractory ARDS, when frontal assault has failed.
  • Four variables determine systemic oxygen delivery in ARDS:
    • cardiac output
    • hemoglobin concentration
    • systemic oxygen consumption (VO2)
    • fraction of blood shunted through the lungs without being oxygenated
  • Therapies for ARDS focus on reducing the shunt fraction (e.g., PEEP, proning, APRV). Patients with refractory shunting will be refractory to these therapies.
  • Among patients with refractory ARDS, manipulations of other variables could improve systemic oxygen delivery:
    • reduced systemic oxygen consumption (paralysis, temperature control)
    • increased hemoglobin concentration (blood conservation, possibly transfusion)
    • increased cardiac output (inotropes)
  • Arterial oxygen saturation is not a reliable measurement of systemic oxygen delivery (DO2).
  • It’s notable how little we know about oxygenation goals when treating ARDS. Over-emphasis on normalizing arterial oxygen saturation may be leading us astray."

lunes, 20 de junio de 2016

Seizures and respiratory compromise

Resultado de imagen de EMS1
EMS1 - Jun 13, 2016 - By Bob Sullivan
"Understand how respiratory monitoring devices can be used to guide treatment during and after seizures.
Seizures are one of the most common conditions encountered by EMS providers and one where critical interventions can significantly affect patient outcomes. Timely seizure management is a benchmark proposed by a group of metropolitan medical directors and is currently being studied as a performance measure by the EMS Compass initiative.
Oxygenation and ventilation can be compromised during prolonged the seizures, as well as during the postictal phase after seizures. Here are three things you should know about seizures and respiratory compromise..."
  1. Seizures can cause upper airway obstruction and respiratory depression
  2. Waveform capnography can help guide airway management during and after seizures
  3. Definitive airway management for seizures is stopping the seizure

Scheduling Complexity

Lightning Bolt Solutions

2016 Physician scheduling - By Lightning Bolt Solutions
"The first-ever look at physician shift scheduling trends using real data from over 5,500 medical department schedules across the country. This detailed analysis provides actionable findings for hospital operations administrators and physician schedulers in any specialty. From the root causes of staff burnout to the challenges of 24/7 hospital coverage, this is must-read research for healthcare leaders.
Our research on physician shift scheduling trends shows that emergency medicine departments in the U.S. balance the most complex sets of staffing rules and monthly requests of any specialty in the mediector..

“Emergency department scheduling is complex for many reasons, beginning with patient demand and facility configuration.”

5 Things specialties don´t understand about ED

The Rolobot Rambles
The Rolobot Rambles - 67th  #WILTW
Ed appears to be the cause of many problems. He missed the sepsis, the hairline fracture and the pneumonia. All on one shift. To make it worse no-one ever pronounces his name right either. It’s the “E” “D” people say. And then roll their eyes.
My colleagues and I spend a lot of time debugging problems caused by Ed. The last clinical conversation I had before going on leave last week was about Ed and why other specialities seem to dislike him so much. It was with this in mind that I spent a bit of time mulling over what I could do to help him. A few weeks ago I wrote a blog entitled “5 referral tips what won’t annoy a paediatrician.” While it proved popular with paediatricians I realise it was potentially an example of further implicit tribalism against Ed.
  1. Ed is not one person
  2. Ed must be a jack of all trades and is a servant to all
  3. Ed manages unwell patients
  4. Ed likes to learn
  5. Ed manages increasingly, and more often than not, appropriately expectant patients, parents and carers

domingo, 19 de junio de 2016

EM Pharmacotherapy Articles of 2015

ALiEM - By Bryan D. Hayes - February 3rd, 2016
"There is so much literature to sift through each year, it becomes nearly impossible to stay abreast of it. Here is a quick summary of the 10 must-know Emergency Medicine pharmacotherapy articles from 2015, in my humble opinion.
  1. IV Magnesium for Acute Migraine Headache
  2. Ketamine for Alcohol Withdrawal
  3. Vancomycin Loading in Obese Patients
  4. Early Glargine Administration at Start of DKA Treatment
  5. Reversing Dabigatran with Idarucizumab
  6. Blood Glucose Response to Rescue Dextrose
  7. Ketamine vs. Morphine for Analgesia in the ED
  8. Avoid Opioids for Low Back Pain
  9. Andexanet Alfa for the Reversal of Factor Xa Inhibitor Activity
  10. Therapeutic Tramadol Use Significantly Increases Seizure Risk
Bonus Article
Favorite Article of the Year"

Pelvic circumferential compression devices

Biomed Central logo
Peyman Bakhshayesh P, Boutefnouchet T & Tötterman A. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2016; 24:73 - DOI: 10.1186/s13049-016-0259-7

"Pelvic fractures might carry a significant risk of bleeding. A wide variety of pelvic binders together with pelvic sheets are available and offer an adjunct to the initial management of poly-trauma patients with pelvic injuries. These devices are collectively referred to as pelvic circumferential compression devices (PCCDs). The aim of this study was to review the literature for evidence pertinent to the efficacy and safety of PCCDs.
Based on available literature, PCCDs are widely used in the initial management of patients with suspected pelvic bleeding. There is evidence to suggest that external compression reduces disrupted pelvic rings. There are some complications reported following application of PCCDs. Hemorrhagic source and physiological effectiveness of PCCDs needs to be addressed in future studies. In the meantime judicious application of PCCDs will continue to be recommended."

Consenso sobre uso BNP

Logo Sociedad Español de Secardiología
Cardiología hoy - Dra. Nekane Murga Eizagaechevarria - Publicado: 08 Junio 2016 
Revisión del documento de consenso sobre los Péptidos Natriuréticos (PN) que ha sido publicado en la Revista Clínica Española y como editorial en Revista Española de Cardiología. 
"Las Sociedades Españolas de Cardiología, de medicina interna, de Medicina de Familia y Comunitaria y de Medicina de Emergencia han propuesto y han formado un grupo de trabajo, que ha elaborado unas recomendaciones consensuadas sobre el uso los PN en pacientes con sospecha o IC establecida.
Los PN se han convertido en una herramienta que puede ser utilizada en el diagnóstico, pronostico y tratamiento de los pacientes con sospecha o insuficiencia cardiaca (IC) establecida. Su utilización puede realizarse en diversos entornos sanitarios (consultas, urgencias, hospitalización y en laboratorios) y por diversos profesionales, tanto en atención primaria como especializada. Adicionalmente, el uso correcto de los PN tiene implicaciones tanto para el paciente como para el sistema sanitario, teniendo encuentra la presentación epidémica de la IC.
Como recomendación general, como test diagnóstico, recomiendan la utilización de BNP:
  • Racional, basada en su utilidad para tomar decisiones, establecer el diagnóstico y el tratamiento.
  • Basado en protocolos en los que participen todos los departamentos que atienden pacientes con IC.
  • La utilización de BNP para mejorar el diagnóstico de IC se basa en extensos estudios con evidencia. 
Tres aspectos son mencionados:
  • La determinación de BNP de be ser adicional al juicio diagnóstico y debe completarlo.
  • La “disnea” es al síntoma que puede ser aplicable.
  • Su utilidad es superior para excluir IC en pacientes sin IC previa (de novo).
Recomiendan su utilización en todos los escenarios en los que se presenta la IC para su diagnóstico."

viernes, 17 de junio de 2016

US: Alveolar Consolidation and Shred Sign

"Sliding lung, A lines and B lines – easy enough, right? But what about the spectrum of alveolar consolidation and the so called “shred” sign. This review by Yogesh Lala, MD, FRCPC – alumnus of our critical care program, has got YOU covered."