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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 & RELATED

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viernes, 11 de octubre de 2019

EuSEM Prague 2019


Lactated Ringers

R.E.B.E.L.EM - October 10, 2019 - By Rezaie S
..."Author Conclusion: “In healthy individuals, a modest but significant rise in mean serum lactate was seen after a 30cc/kg LR bolus. There was no difference in mean serum lactated when comparing a 30mL/kg bolus of NS to LR.”
Clinical Take Home Point: In healthy volunteers the use of 30cc/kg of LR or NS both slightly increase lactate levels, however the duration of this effect, effect on patient oriented outcomes, effect on patients with renal/liver impairment, and the effect on patients with acute illness cannot be generalized based on this study. I will continue to use balanced crystalloids in large volume resuscitations until further evidence indicates that this is causing harm to patients."

Trauma

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emDocs - October 4, 2019 By Helman A
Originally published at EM Cases – Visit to listen to accompanying podcast
"Take Home Points for Trauma – The First and Last 15 Minutes Part 1
  • Prepare your team, your gear and yourself prior to patient arrival with 4 discussion points, assigning specific gear preparation to specific team members and mental preparation
  • Resequence the trauma resuscitation by managing massive external hemorrhage and active/dynamic airway first, then concentrating on hemodynamic optimization before definitive airway management in those patients without active/dynamic airways
  • Identify occult shock using shock index >1, delta shock index ≥0.1, the lowest BP recorded, FAST/IVC, a fluid challenge and clinical exam
  • Consider the patient’s age, blood pressure medications and baseline blood pressure in assessing for occult shock, interpreting the shock index and in deciding to activate massive transfusion protocol
  • Early actions to consider include control of massive external hemorrhage, bilateral finger thoracostomies, pelvic binder, tranexamic acid, activation of massive transfusion protocol and call for help
  • Two large bore IVs are the preferred initial access in most trauma patients
  • Avoid transferring a patient long distances with IO access only
  • Large volumes of crystalloid may lead to the “triangle of death”; your goal should be no crystalloid
  • Controlled resuscitation to a target SBP of ≥70 is reasonable in most young, otherwise healthy trauma patients presumed to be in hemorrhagic shock
  • Use clinical judgement, mechanism of injury, pitfall conditions, shock index and resuscitation intensity to help in decisions to activate massive transfusion protocol"
*
emDocs - October 11, 2019 - By Helman A
Originally published at EM Cases – Visit to listen to accompanying podcast
"In this podcast we answer questions such as: What should your resuscitation targets be in the first 15 minutes for trauma patients with hemorrhagic shock, neurogenic shock, severe head injury? When is a pelvic binder indicated? Is a bedsheet good enough? What are the most common pitfalls in binding the pelvis? What are the best ways to maintain team situational awareness during a trauma resuscitation? Should we rethink patient positioning for the trauma patient? What are the indications for transport to a trauma center? What is the minimal data set required before transfer? Which patients require a pelvic x-ray prior to transfer to a trauma center? What are the key elements of a transport checklist? What does the future hold for trauma care and many more…"

miércoles, 9 de octubre de 2019

Acute Angle Closure Glaucoma

REBEL Core Cast 19.0 - By Anand Swaminathan - OCTOBER 09, 2019
Take Home Points 
  • Acute closed angle glaucoma is an ophthalmologic emergency that usually presents with sudden, painful, monocular vision loss.
  • Physical exam will reveal conjunctival redness, corneal haziness or cloudiness due to edema and a pupil that is mid sized and minimally reactive to light, a rock hard globe and IOP >/= 21.
  • These patients require emergent ophthalmology evaluation but treatment should be started empirically while waiting for the evaluation. Initial treatment to decrease IOP usually includes a topical BB such as timolol and topical AB such as apraclonidine and either IV or PO acetazolamide."

Pulseless Electrical Activity

EMCrit 257 - October 9, 2019 - By Scott Weingart
"Pulseless Electrical Activity ( PEA ) is confusing! The diagnosis and treatment of PEA is bogged down by terminology and misunderstandings. Spurred by a recent interview I did with Anton Helman of EM Cases, I lay down some of my thoughts on PEA here."

martes, 8 de octubre de 2019

2019 GINA Report

Global Initiative for Asthma – GINA
2019 GINA Report, Global Strategy for Asthma Management and Prevention
"The 2019 update of the Global Strategy for Asthma Management and Prevention incorporates new scientific information about asthma based on a review of recent scientific literature by an international panel of experts on the GINA Science Committee. This comprehensive and practical resource about one of the most common chronic lung diseases worldwide contains extensive citations from the scientific literature and forms the basis for other GINA documents and programs."

2019 Appendix to GINA Report
This online appendix contains additional scientific information supporting the recommendations and concepts detailed in the GINA Report, Global Strategy for Asthma Management and Prevention.

martes, 1 de octubre de 2019

Vit C in Sepsis-induced ARDS

PulmCrit (EMCrit)
PulmCrit - October 1, 2019 - By Josh Farkas
"Summary The Bullet: 
  • CITRIS-ALI is a multi-center RCT investigating IV vitamin C in patients with sepsis-induced ARDS. Vitamin C was initiated relatively late in the disease course (up to 48 hours after the development of end-organ failure meeting ARDS criteria).
  • The primary endpoints of this trial were negative (including change in SOFA score over 96 hours and two biomarkers). However, some secondary endpoints suggested benefit from Vitamin C (including improvements in mortality and ICU-free days).
  • It’s possible that mortality differences could have biased the primary endpoint (SOFA score), due to selective elimination of sicker patients from the control group. Thus, it's conceivable that the secondary endpoint staged a coup d’état, overthrowing the primary endpoint.
  • No evidence of harm from IV vitamin C was found (despite use of larger doses than used in Paul Marik’s study)."

Gestalt for ACS

R.E.B.E.L.EM - September 30, 2019 - By Cara Borelli C
"Authors’ Conclusion: “Clinician gestalt is not sufficiently accurate or safe to either “rule in” or “rule out” ACS as a decision-making strategy. This study will enable emergency physicians to understand the limitations of our clinical judgement.”
Clinical Take Home Point: In this study, clinician gestalt was not safe to rule out ACS; however, further research is necessary to more conclusively determine the sensitivity, specificity, positive predictive value, and negative predictive value of clinical gestalt. Furthermore, this study was fundamentally estimating the risk of a positive second troponin or risk of MACE at 30 days in a population of patients already stratified as having suspected cardiac chest pain."

jueves, 26 de septiembre de 2019

Pyomyositis

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emDocs - September 26, 2019 - By Cropano A and Serrano F
Reviewed by Simon E, Koyfman A and Long B
"Take Home Points
  1. In patients presenting with prolonged muscle pain, low-grade fevers, myalgias, and generalized fatigue, PM should be considered.
  2. Immunosuppression is a significant risk factor.
  3. PM most frequently results from aureus infection.
  4. Ultrasound may rapidly identify PM, but MRI is the diagnostic test of choice to determine the extent of the disease.
  5. IV antibiotics and I&D are the mainstays of treatment."

lunes, 23 de septiembre de 2019

Standard vs Modified Valsalva

R.E.B.E.L.EM - September 23, 2019 - By Astin M
"Background: Supraventricular tachycardia (SVT) is not an uncommon condition in the emergency department. Epidemiologically, SVT has an incidence of 35/100,000 person-years in the United States.2That is roughly 89,000 new cases per year. The Valsalva maneuver is a recognized treatment for SVT, but has a low success rate (5-20%). 3,4,5 The REVERT trial showed an increase in cardioversion of SVT using a modified Valsalva maneuver, but this was done with a manometer, and adjustable bed, which may not be available in many settings.
What They Did: The authors conducted a randomized, multicenter parallel group trial in five emergency departments in China. Patients were randomized in a 1:1 fashion to the treatment group or control group.
Author Conclusion: “With this simple modified Valsalva maneuver, the conversion rate of SVT to sinus rhythm was higher than the standard Valsalva maneuver.”
Clinical Take Home Point: Use of a 10 mL syringe and lying the patient supine with 90 degrees of hip flexion can be a useful treatment for SVT, with few adverse effects and no change in ED LOS, if the use of medications or electricity is not desired."

Common Diving Emergencies

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emDocs -  Septiember 23, 2019 - By  Humphrey T., Cirone M
Edited by: Koyfman A and Long B
"Key Points
  • Conditions related to descent are generally treated with symptomatic management.
  • Pulmonary barotrauma of ascent can lead to local pulmonary injury, pneumomediastinum, pneumothorax, or AGE.
  • A chest x-ray should be obtained in all cases of suspected pulmonary barotrauma or AGE.
  • Any neurological symptoms or loss of consciousness upon surfacing is considered AGE until proven otherwise. Treatment is supplemental O2, IV fluids, and most importantly, a hyperbaric chamber.
  • Decompression sickness is more appropriately categorized by the organ system affected, as even minor manifestations can progress to more serious forms.
  • While AGE and neurological DCS may be clinically indistinguishable, both are managed similarly with supplemental oxygen, IV fluids, and hyperbaric oxygen therapy.
  • In general, AGE and DCS are clinical diagnoses. Labs and imaging should not delay transfer to a hyperbaric facility.
  • Consultation with Diver’s Alert Network (919-684-9111; https://www.diversalertnetwork.org) should be performed early in cases of diving emergencies."

sábado, 21 de septiembre de 2019

AF: CHEMICAL VS. ELECTRICAL

SGEM#267:  - Posted by admin - Sep 21, 2019 
"CLINICAL QUESTION: 
IN EMERGENCY DEPARTMENT PATIENTS WITH ATRIAL FIBRILLATION, IS SINUS RHYTHM ACHIEVED MORE RAPIDLY WITH ELECTRICAL-FIRST RHYTHM CONTROL WHEN COMPARED WITH CHEMICAL-FIRST RHYTHM CONTROL?
_____________________________________________________________

1/3 OF PATIENTS WERE DISCHARGED IN FOUR HOURS WITH CHEMICAL-FIRST GROUP COMPARED TO 2/3 IN THE ELECTRICAL-FIRST GROUP.
______________________________________________________________

SGEM BOTTOM LINE: 
CONSIDER IMPLEMENTING AN ELECTRICAL-FIRST RHYTHM CONTROL STRATEGY FOR LOW RISK PATIENTS WITH ATRIAL FIBRILLATION."

martes, 17 de septiembre de 2019

Anti-Coagulation after ICH

ThromboPhonia E02 - CanadiEM - September 16, 2019
Guests: Dr. Ashkan Shoamanesh and Dr. Sunjay Sharma

                 

Wounds and Lacerations

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emDocs - September 16, 2019 - By Bryant J and Thoppil J
Edited By: Montrief T; Koyfman A and Long B
"Take Home Points:
  • Evaluation of the wound begins with the history, continues with full exploration of the wound to assess the extent of repair needed, physical exam to assess structural integrity, and imaging as needed for foreign body/vascular injury.
  • Warming anesthetics to body temperature can reduce pain with injection.
  • LET jelly is another adjunct to avoid pain on injection.
  • Local infiltration of ketamine may be just as efficacious as other topical anesthetics.
  • Important considerations not to miss: open fracture, open joint, tendon injury, vascular injury, nerve injury, muscle injury, compartment syndrome.
  • Update tetanus prophylaxis if >5 years have passed since prior immunization.
  • Irrigation with potable tap water is just as effective as saline irrigation.
  • Antibiotics for higher risk patients (diabetes, poor circulation, HIV/AIDS, immunocompromised), with wounds in higher risk areas (axilla, perineum, hands, feet), and high-risk wounds (human bites anywhere, mammalian bites to hand).
  • If transferring a digit for reimplantation, do not place digit directly on ice! Wrap amputated digit in moist gauze and place in a plastic bag which then goes on ice."

Burn Blisters

First10EM - By Justin Morgenstern - September 16, 2019
..."There is a BestBET review on this topic from 2006, and the only paper they found that matched their search criteria was the paper by Swain. Their conclusion is “based on the current available evidence, blisters should, wherever possible, be left intact to reduce the risk of infection, but if anatomical position necessitates intervention for functional purposes, aspiration appears to result in less pain than deroofing.” (Shaw 2006)..."

sábado, 14 de septiembre de 2019

Vaping Associated Lung Disease

Vaping Associated Lung Disease title image
First 10EM - by Justin Morgenstern - September 11, 2019
"Unfortunately, although the popularity of smoking has been on the decline for decades, vaping is becoming extremely popular, especially among young patients. More than 20% of high-school students and about 5% of middle school students admit to using an e-cigarette in the past 30 days. (Cullen 2018) When compared to smoking – one of the most unhealthy activities known – if would not be surprising if vaping resulted in fewer adverse health effects, although the true effects will not be known until we have long term studies. However, “safer than cigarettes” is not the same as “safe”. When talking about smoking and vaping, we are usually focused on long term health outcomes. However, there has been a recent flood of case reports of young patients with significant lung disease after vaping. What is vaping associated lung disease and what do we need to know in the emergency department?..."

Other FOAMed Resources:
Internet Book of Critical Care: Vaping Associated Pulmonary Injury (VAPI)

Acute Pulmonary Embolism (ESC 2019)

ESC logo
Stavros V Konstantinides, Guy Meyer, Cecilia Becattini et al. 
European Heart Journal, ehz405 - https://doi.org/10.1093/eurheartj/ehz405
Published:  31 August 2019
..."This document follows the previous ESC Guidelines focusing on the clinical management of pulmonary embolism (PE), published in 2000, 2008, and 2014. Many recommendations have been retained or their validity has been reinforced; however, new data have extended or modified our knowledge in respect of the optimal diagnosis, assessment, and treatment of patients with PE. These new aspects have been integrated into previous knowledge to suggest optimal and—whenever possible—objectively validated management strategies for patients with suspected or confirmed PE. To limit the length of the printed text, additional information, tables, figures, and references are available as supplementary data on the ESC website (www.escardio.org)..."

Decompensated Liver Disease

ST.EMLYN'S
St. Emlyn´s -  By Gareth Roberts - September 12, 2019
... Many people with chronic liver disease are asymptomatic. It takes a seriously cirrhosed liver to cause symptoms. If I’ve a patient with an incidental finding of deranged liver function tests in an otherwise well person, other than counselling about lifestyle changes I would refer these people back to primary care for investigation. The patients I’m worried about in the ED are those who have decompensated. They present with deteriorating liver function, jaundice, encephalopathy or renal dysfunction. There’s often a precipitant to the deterioration. GI bleeding (variceal and non-variceal), infection, alcohol and constipation are common but others such as acute portal vein thrombosis, and transformation to hepatocellular carcinoma need to be considered...

martes, 10 de septiembre de 2019

SVT Guidelines 2019

ESC logo
The Task Force for the management of patients with supraventricular tachycardia of the European Society of Cardiology (ESC): Developed in collaboration with the Association for European Paediatric and Congenital Cardiology (AEPC) 
Brugada J, Katritsis D, Arbelo E, et al. European Heart Journal, ehz467, https://doi.org/10.1093/eurheartj/ehz467 - Published: 31 August 2019

US for Vascular Access in Adults

Resultado de imagen de society hospital medicine
Published Online Only September 6, 2019. DOI: 10.12788/jhm.3287
..."The purpose of this position statement is to present evidence-based recommendations on the use of ultrasound guidance for the insertion of central and peripheral vascular access catheters in adult patients. This document presents consensus-based recommendations with supporting evidence for clinical outcomes, techniques, and training for the use of ultrasound guidance for vascular access. We have subdivided the recommendations on techniques for central venous access, peripheral venous access, and arterial access individually, as some providers may not perform all types of vascular access procedures..."

miércoles, 4 de septiembre de 2019

Abdominal Aortic Aneurysm

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emDocs - September 3, 2019 - By Long D - Edited by Koyfman A and Long B
"Pearls
  • Consider symptomatic or ruptured AAA in any patient (especially elderly) with abdominal pain, flank pain, back pain, syncope, especially if he/she is presenting with hypotension.
  • The RUSH exam is key in any hypotensive patient and can rapidly diagnose AAA.
  • Resuscitation of rAAA includes 2 large bore IVs, early blood products, minimizing crystalloid, permissive hypotension, tranexamic acid, and delayed airway management.
  • As soon as a AAA or rAAA is diagnosed or suspected, vascular surgery consultation is recommended. Surgery is required for definitive management.
  • Permissive hypotension is maintaining BP as low as possible to maintain end organ perfusion in an attempt to preserve hemostasis.
  • Vascular surgery guidelines recommend a 90-minute time from first medical contact to definitive operative management for ruptured AAA, with a 30-minute time from first medical contact to transfer to a center with definitive management.
  • REBOA is a potential therapy to attempt in the crashing AAA patient, but should not be used if it delays time to the operating room for definitive management."

martes, 27 de agosto de 2019

Depression

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emDocs - August 26, 2019 - By Pillai S and Desai S 
Edited by: Simon E; Koyfman A; Long B

"Key Points
  • 34% to 50% of patients who present to the ED with psychiatric complaints have a coexisting medical illness.
  • Situations that favor a substance-induced depressive disorder include: absence of depression history, absence of symptoms prior to substance exposure/intoxication /withdrawal, absence of persistent symptoms following substance use or abuse.
  • Seek out an underlying etiology for depression in patients presenting with: new-onset depression with psychotic features, recurrent depression not readily explained by the psycho-social stressors, or treatment-resistant depression.
  • Laboratory studies and imaging should be obtained if indicated by history and physical examination.
  • Antipsychotics or benzodiazepinesmay be administered to the distressed patient with psychotic features during the ED course.Initiation of outpatient anti-depressant therapy from the ED is not advised."

sábado, 24 de agosto de 2019

CRP and ATBs in COPD

R.E.B.E.L.EM - August 22, 2019 - By Salim Rezaie
"Author Conclusion: “CRP-guided prescribing of antibiotics for exacerbations of COPD in primary care clinics resulted in lower percentage of patients who reported antibiotic use and who received antibiotic prescriptions from clinicians, with no evidence of harm.”
Clinical Take Home Point: With an antibiotic prescription rate of almost 80% in the usual care group, just about any intervention that pushes antibiotic stewardship would make a difference in prescribing habits, and therefore there is no surprise that POC CRP reduced the number of antibiotic prescriptions in patients with acute COPD."

miércoles, 21 de agosto de 2019

Decompensated Hypothyroidism

REBEL Core Cast 16.0 - By Anand Swaminathan - August 21, 2019
"Take Home Points
  • Myxedema coma is severe, decompensated hypothyroidism with a very high mortality.
  • Classic features include: decreased mental status, hypothermia, hypotension, bradycardia, hyponatremia, hypoglycemia, and hypoventilation
  • Work up includes looking for and treating precipitating causes, most commonly infection as well as serum levels of TSH, T4 and cortisol
  • Treat for the possibility of adrenal insufficiency with stress dose steroids such as hydrocortisone 100 mg IV
  • The exact means of thyroid replacement is controversial. Definitely given 100-500 mcg levothyroxine and discuss the simultaneous administration of T3 with your endocrine and ICU teams"

Resuscitation Pressure in Polytrauma with TBI

TAMING THE SRU
Taming The SRU - August 19, 2019 - By Rath K., Gottula A
"SUMMARY
  • There is little data to help us in optimal blood pressure targets in patients with both TBI and systemic trauma with hemorrhagic shock, largely because these patients are excluded from the majority of studies. Given the significant evidence that permissive hypotension would be associated with worse TBI related outcomes, we would not recommend prehospital permissive hypotension in the subset of patients with blunt, severe TBI.
  • In the resuscitation of these patients, hypertonic saline offers great promise as a means to resuscitate patients in hemorrhagic shock, while also minimizing intracranial pressure. Mannitol is a less than ideal alternative until more definitive data is obtained on injuries, and the patient is hemodynamically stabilized.
  • Future directions on this topic should include high-quality, high-powered studies investigating the hypotensive strategies to include patients with severe traumatic brain injury with GCS 8 or lower.
  • Finally, a good neurologic exam to more sensitively assess for focal neurologic deficits and signs of intracranial hypertension can assist pre-hospital providers to better determine the likelihood of the presence or absence of traumatic brain injury."

domingo, 18 de agosto de 2019

Intraosseous Access

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emDocs - August 15, 2019 - By Bloom J
Edited by: DeVivo A., Koyfman A., Long B and  Singh M
"Pearls and Pitfalls
  • Patients come in all shapes and sizes. If your patient has excessive subcutaneous or adipose tissue over your preferred site, you may have to choose an alternative site.
  • Position for success! Make sure the extremity or site is visible, angled advantageously, and supported. Use bedrolls/sheets or fellow personnel to assist you with this.
  • Avoid needlestick injuries! IO catheters and stylets/trocars are still sharps and can injure the proceduralist. Make sure your hand is not directly behind the insertion site, as a misplaced IO can bypass or completely penetrate the extremity and cause injury.
  • It is very easy to forget to secure an IO during a busy resuscitation. Although they don’t slip out as easily as an IV, an IO can fall out, and if it does replacement likely needs to be in a different extremity to avoid infiltration. Tape down your IO securely!
  • In a resuscitated patient, make sure that any IO access is clearly indicated and discussed with receiving providers during handoff. When receiving a resuscitated patient, examine carefully for the presence of an IO on the extremities or sternum.
  • Anecdotally the proximal humerus is favored by many practitioners because of its theoretical faster infusion rates and utility in cases of abdominopelvic or lower extremity compromise9,29. The proximal tibia is frequently easier to palpate and available in patients of all ages. You should feel comfortable inserting an IO in at least two different sites and should be familiar with all of them."

Imaging for Appendicitis in Pregnancy

Resultado de imagen de journalfeed
Journalfeed - August 16, 2019 - By Vivian Lei
..."In a pregnant patient presenting with abdominal pain and suspected appendicitis, an initial ultrasound should be performed to exclude obstetric causes for abdominal pain. MRI may be a reasonable next study if it is immediately accessible and radiologists with expertise in MRI interpretation are available. Otherwise, CT should be utilized..."

sábado, 17 de agosto de 2019

CXR for AAS

Resultado de imagen de journal feed
Journalfeed -  August 5, 2019 - By Clay Smith
..."Not the way to screen for this problem
This was a secondary analysis of ADviSED. Use of an aortic dissection detection risk score plus mediastinal enlargement on CXR had sensitivity of 67%, specificity 83%. The risk score plus any sign on CXR had sensitivity 69%, specificity 77%. For CXR alone, without the risk score, sensitivity was 54%, specificity 92% for mediastinal enlargement; sensitivity 60%, specificity 85% for any sign on CXR. Inter-rater agreement between radiologists for mediastinal enlargement was fair to moderate (k = 0.44). What this all means is that a CXR is a poor screening tool for acute aortic syndromes. If mediastinal enlargement or other signs are seen on CXR, this is concerning and needs further workup. If you suspect acute aortic syndrome, it’s best to just get a CTA."

Gestalt for ACS

Gestalt in ACS
First 10EM - By Justin Morgenstern - August 7, 2019
..."So how good is gestalt in the diagnosis of acute coronary syndrome? A lot of people are already talking about this paper. Honestly, I don’t find the results all that exciting. I think it basically tells us what we already knew. It shouldn’t change anyone’s practice. However, I worry that the headlines will be misinterpreted in ways that could ultimately harm our patients. So let’s take a quick look to ensure we all understand what this study really shows.
The paper
Oliver G, Reynard C, Morris N, Body R. Can emergency physician gestalt “rule in” or “rule out” acute coronary syndrome: validation in a multi-center prospective diagnostic cohort study. Academic emergency medicine. 2019; PMID: 31338902 [article]
Bottom line
Don’t believe the rumours you might hear. Clinical judgement is enough to rule out ACS for many patients in the emergency department. Just don’t contradict yourself and try to use gestalt to rule out ACS in patients where your gestalt is that ACS is a possibility. That would be silly."

Mass Casualty Incidents

Trauma System News
By Potter C - July 22, 2016 - Reviewed and updated in April 2018.
"Mass casualty incidents (MCIs) seem to strike at random. That is one reason why these incidents — particularly mass shootings — are so frightening. But while the timing and location of most MCIs are unpredictable, the way these events play out at the scene and the trauma center is not.
Longstanding research shows that no MCI is truly unique — whether it is a natural disaster such as an earthquake, hurricane, flood or tornado, or the result of human violence. At the receiving hospital, an MCI triggers a sequence of disruptions that follow a predictable pattern..."

jueves, 15 de agosto de 2019

Pregnancy-Adapted YEARS Algorithm for PE

R.E:B.E.L.EM - August 15, 2019 - By Anand Swaminathan
"Authors Conclusions: “Pulmonary embolism was safely ruled out by the pregnancy-adapted YEARS diagnostic algorithm across all trimesters of pregnancy. CT pulmonary angiography was avoided in 32 to 65% of patients.” 
Our Conclusions: Overall, we agree with the authors conclusions. The pregnancy-adapted YEARS algorithm safely ruled out PE in this cohort of patients with a small risk of VTE at 3 months if the patient was negative on initial visit. 
Potential to Impact Current Practice: External validation of this approach is needed but, application of the pregnancy-adapted YEARS algorithm has the potential to safely decrease CTPA use in pregnant women in whom the clinician has a concern for PE. 
Bottom Line: The Pregnancy-Adapted YEARS algorithm has both face validity and is pragmatic for clinical practice. However, before implementation of this algorithm into everyday practice, an external validation study would be warranted." 



Magnesium

PulmCrit (EMCrit)
August 15, 2019 - By Josh Farkas
"Magnesium might be the darling ion of critical care. It has an interesting array of therapeutic applications ranging from asthma to Torsade de Pointes to preeclampsia. This pair of chapters discusses the evaluation of both hypomagnesemia and hypermagnesemia."
  • IBCC chapter on hypomagnesemia is located here.
  • IBCC chapter on hypermagnesemia is located here.
  • The podcast & comments are below.
Follow us on iTunes

lunes, 12 de agosto de 2019

Septic Shock

PulmCrit (EMCrit)
August 8, 2019 - By Josh Farkas
"Septic shock is perhaps the defining illness of medical intensive care. As such it is an enormously broad and controversial topic. This chapter attempts to provide a unified and straight-forward approach. However, every physicians has a different approach to septic shock, so it's impossible to claim that this is the best approach.
There will doubtless be vigorous debate about this topic, so I encourage all to leave their questions and comments below. This chapter will be revised on an ongoing basis, so the current form might be most realistically viewed as an outline for future revisions (rather than a final word on the topic)."
  • The IBCC chapter is located here.
  • The podcast & comments are below.
  • Follow us on iTunes

Large pleural effusions

PulmCrit 
PulmCrit - August 12, 2019 - By Josh Farkas
"Summary The Bullet:
  • Large pleural effusions can generally be drained entirely (although the procedure should be stopped if the patient develops vague central chest discomfort).
  • Pleural manometry has not been shown to reduce discomfort or re-expansion pulmonary edema during large volume thoracentesis.
  • The rate of re-expansion pulmonary edema is low, even in large-volume thoracentesis (<1%). When it occurs, this can generally be treated with conservative measures (e.g. supplemental oxygen or noninvasive ventilation).
  • Using multiple small-volume thoracenteses to avoid large-volume thoracentesis is probably a misguided strategy. Multiple small-volume thoracenteses may cause an overall increase in the risk of procedural complications (due to increases in the risk of bleeding, infection, or lung laceration with multiple procedures)."

REstart or STop Antithrombotics

R.E.B.E:L.EM - August 12, 2019 - By Salim Rezaie 
"Author’s Conclusions: “These results exclude all but a very modest increase in the risk of recurrent intracerebral haemorrhage with antiplatelet therapy for patients on antithrombotic therapy for the prevention of occlusive vascular disease when they developed intracerebral haemorrhage. The risk of recurrent intracerebral haemorrhage is probably too small to exceed the established benefits of antiplatelet therapy for secondary prevention.”
Clinical Take Home Point: The established benefits of antiplatelet therapy likely outweigh what may be a small or non-existent increased risk of recurrent bleeding following ICH; however, it is unclear when is the optimal time to restart therapy."