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


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miércoles, 11 de diciembre de 2019

Pseudo PEA in the ED

St Emlyn's - December 10, 2019 - By pete Hulme
..."What is Pseudo-PEA and how does it differ from ‘true’ PEA?
-True PEA is the presence of organized electrical activity on cardiac monitor without a palpable pulse and no cardiac motion on POCUS.
-Pseudo-PEA is organized electrical activity on cardiac monitor without a pulse but with cardiac motion on point of care ultrasound (POCUS).
What’s the bottom line?
It’s really important to differentiate pseudo-PEA from true-PEA because ROSC and survival rates are higher in pseudo-PEA.
The evidence for the different management options vasopressin and CPR synchronised to systole are limited but make sense physiologically and would be important areas for future research. Indeed a further paper looking at synchronous CPR in pigs has just been published showing further promise.
POCUS should be a core skill for all emergency physicians and will help us make a diagnosis of pseudo-PEA.
True PEA has a worse prognosis than pseudo-PEA so diagnosing that may aid decision making in cessation of cardiac arrest.
42-86% of all PEA is pseudo-PEA. As this is more common than people probably realise more research should be done in this area to try to improve outcomes for patients. (Salen et al)"


ALiEM Logo
ALiEM - December 09, 2019 - By Andrew Grock
"Enormous practice variability exists in syncope medical decision making among emergency medicine physicians, perhaps due to a lack of externally validated clinical decision rules (CDR).​Even worse, the literature is rife with conflicting evidence over specific syncope features such as the age cut-off that confers an elevated risk, or the risk of near syncope versus syncope.​ Following is a 3-step, evidence-based framework for the evaluation and workup of syncope...
Summary: Syncope in 3 Easy Steps
  1. Make sure it’s syncope
  2. Consider true syncope versus symptom syncope
  3. Assess the patient’s dysrhythmia risk – “FA HE HE” and Canadian Syncope score"

Vasopressin for Acute Hemorrhage

R.E.B.E.L.EM - December 09, 2019 - By Rob Bryant
"The AVERT-Shock trial: This was a single center Randomized Clinical Trial examining the effects of Low Dose Vasopressin (LDV) on the early resuscitation of patients with trauma and hemorrhagic shock...
Clinical Bottom Line:
  • The use of Vasopressin as an effective adjunct to the resuscitation of hemorrhagic shock is physiologically plausible
  • The optimal dose and timing of LDV administration is still not clear based off this one single center study.
  • The AVERT-Shock trial demonstrates that the use of Low Dose Vasopressin (LDV) in hemorrhagic shock was not associated with complications or increased mortality. However, AVERT-Shock was underpowered to detect a number of clinically significant secondary outcomes. Larger studies are needed to determine the effect of LDV on these outcomes.
  • In a level one trauma center with access to a massive transfusion protocol, the addition of low dose vasopressin to a patient with continued hypotension despite aggressive administration of blood products is reasonable.
  • The AVERT-Shock trial does not inform our practice in resource limited environments that do not have access to massive transfusion. There is no data currently available to show any benefit / harm of using Vasopressin earlier in the resuscitation of trauma patients prior to resuscitation with blood products."


PulmCrit (EMCrit)
PulmCrit - December 09, 2019 - By Josh Farkas
"Summary Th Bullet:
  • Hyperdiuresis involves the combination of large doses of furosemide plus hypertonic saline to facilitate diuresis. Theoretically, the two agents may function synergistically to achieve decongestion while preserving renal function.
  • Hyperdiuresis remains a counterintuitive and controversial therapy. However, it is supported by a moderate amount of clinical evidence. Studies reviewed above suggest that hyperdiuresis is safe and effective across a variety of different contexts.
  • Additional evidence is needed to clarify the value of this therapy. In the interim, attempting hyperdiuresis may be reasonable for patients who have failed conventional therapies and don't have other great treatment options (e.g. hyperdiuresis versus ultrafiltration/hemodialysis versus palliative care). If hyperdiuresis is attempted, it must be monitored carefully and discontinued if patients don't respond favorably."

Risk scores for cardiac chest pain

St. Emlyn´s - December 08, 2019 - By  Charlie Reynard 
"Suspected cardiac chest pain: everyone sees it, everyone has a different clinical pathway, and everyone has a different risk score for it.
This week the Emergency Medicine Journal published our paper “Comparison of four decision aids for the early diagnosis of acute coronary syndromes in the emergency department” headed by Rick Body, directly comparing different risk scores for acute myocardial infarction...
Bottom line
For me this study supports strategies using T-MACS, hsTnI <3ng/l strategy or EDACS. It also reaffirms that troponin-only strategies can be enhanced by risk scores."

domingo, 8 de diciembre de 2019

Abscess Management

emDocs - December 06, 2019 - By Bryant R 
(Originally published at R.E.B.E.L. EM on May 12, 2018)
"Abscess management has evolved somewhat in the 14 years since my residency graduation. The point at which antibiotics are likely to be more helpful than harmful is not always easy to assess, and evidence based expert opinion has flip flopped impressively.
Based on current evidence, I would like to answer 3 big questions that every clinician may have when confronted with an abscess:
-Who needs antibiotics?

-Which abscesses need to be drained?

-How should abscesses be drained?
Take Home Points:
  • There is room for a safe increase in antibiotic use
  • There does not need to be reckless over-use of antibiotics
  • Use ultrasound with any abscess you are unsure of
  • Use a loop vessel rather than packing"

Cognitively Offloading During a Cardiac Arrest

R.E.B.E.L.EM - September 22, 2016 - By Salim Rezaie
..."Critical Take Home Points to go Beyond ACLS and Cognitively Offload During Resuscitation Efforts of Cardiac Arrest:
  • CPR: Mechanical CPR > Manual CPR
  • Access: IO Access > IV Access
  • Airway: SGA > BVM > ETI
  • Epinephrine: Epinephrine Drip > Epinephrine Bolus
  • PEA Workup: POCUS (CASA Exam) > H’s & T’s
  • Pulse Checks: EtCO2 + Bedside TTE > Manual Pulse Checks"

Intubate like a Boss

R.E.B.E.L.EM - By Salim Rezaie - May 03, 2019
"Despite decades of experience with endotracheal intubation, we continue to find approaches to improving the process of how we intubate. In today’s post we are not only going to talk about how to avoid post intubation cardiac arrest, but we are also going to cover 5 rather controversial topics in airway management including: Apneic oxygenation (ApOx), use of video laryngoscopy (VL) compared to direct laryngoscopy (DL), bougie 1st intubation, back up head elevated (BUHE) intubation, and finally bag valve mask ventilation (BVM) prior to intubation...
  • Clinical Bottom Line:
  • ApOx in the ED: Just do it. No cost, no cognitive load, and not been shown to be harmful
  • VL vs DL: Train in both VL and DL. There is a reason we have multiple tools at our disposal when it comes to airway management.
  • Bougie 1st Intubation: Train in both Bougie 1st and standard ETT + Stylet intubation as every airway is unique
  • Back Up Head Elevated Intubation: Decreases intubation-related complications in comparison to standard supine intubation
  • BVM Prior to Intubation: Consider BVM in patients who do not reach appropriate preoxygenation (>95%) despite the use of non-rebreather and nasal cannula at >15LPM"

viernes, 6 de diciembre de 2019

Crystalloids vs Saline in Sepsis

R.E.B.E.L.EM - By Salim Rezaie - Deceember 05, 2019
..."Author Conclusion: “Among patients with sepsis in a large randomized trial, use of balanced crystalloids was associated with a lower 30-day in-hospital mortality compared to use of saline.”
Clinical Take Home Point: We have stated before on the blog that it makes more physiological sense to use balanced crystalloids in large volume (>2L) resuscitation, and given the weight of evidence if you are using NS or a balanced crystalloid as your resuscitation fluid of choice keep using your fluid of choice. It appears now in this secondary analysis of the SMART trial there appears to be a lower 30d in-hospital mortality with the use of lactated Ringer’s solution vs saline which pushes the needle even further to support use of balanced crystalloids over saline in patients with sepsis."

Procainamide for VT

Resultado de imagen de emergency medicine news
Emergency Medicine News - December 2019;  41 (12): 16
doi: 10.1097/01.EEM.0000616476.30357.18
..."Contrary to widespread belief, IV procainamide is more effective and safer than IV amiodarone for the acute conversion of VT. (Am J Emerg Med. 2019;37[7]:1340; Acad Emerg Med. 2019;26[9]:1099, http://bit.ly/2p6hz7Y; Eur Heart J. 2017;38[17]:1329, http://bit.ly/2Vx0Nuw; Emerg Med J. 2015;32[2]:161.)
IV procainamide is the only agent that carries a class IIA indication for the pharmacologic conversion of VT, and it is listed ahead of IV amiodarone (class IIB) in the ACLS guidelines. (Am J Emerg Med. 2019;37[7]:1340; Acad Emerg Med. 2019;26[9]:1099, http://bit.ly/2p6hz7Y; Eur Heart J. 2017;38[17]:1329, http://bit.ly/2Vx0Nuw; Emerg Med J. 2015;32[2]:161; Circulation. 2010;122[16 Suppl 2]:S345; http://bit.ly/2nEfks4.)..."

Ketamine for Trauma Analgesia

Canadi EM - By Casey Petrie - December 5, 2019
"Research Question:
For emergency department trauma patients, is ketamine a safe and effective option for analgesia when compared to current standard practice?...
Key Points:
  • When combined with opioids, sub-dissociative dose ketamine has been shown to be more effective at providing analgesia for trauma patients than opioids alone.
  • The hemodynamic properties of sub-dissociative dose ketamine make it a relatively safe choice for analgesia in trauma patients
  • Ketamine is being used effectively as first-line analgesia for trauma patients by multiple military organizations.
  • The current literature is limited in terms of methodological quality, small sample sizes, and concern for bias (particularly selection and misclassification bias) making it difficult to recommend its’ use on a wide scale.
  • A large randomized controlled trial to evaluate the effectiveness of ketamine compared with opioids on pain scores and hemodynamic outcomes is needed."

miércoles, 4 de diciembre de 2019

Strep Throat & Rheumatic Fever

emDocs - December 02, 2019 - Author: Cisewski D - Reviewed by: Long B and Koyfman A
"The Upshot
The majority of sore throat is viral. Although the historical incidence of ARF and its correlation to strep pharyngitis has led many to believe an antibiotic regimen is necessary to prevent consequential sequelae, no definitive community-based data has ever supported this claim. Unfortunately due to the rarity of ARF in the United States it seems unlikely that such a study will ever be formally conducted. However, correlative data leaves us with an NNT that many would argue does not justify the added risks associated with an antibiotic regimen. For patients in whom symptoms remain the major concern, consider a cocktail of dexamethasone, acetaminophen/ibuprofen, and buckwheat honey instead."

Lefamulin vs Moxifloxacin for CAP

LEAP 2: Lefamulin vs Moxifloxacin for CAP
R.E.B.E.L.EM - By Salim Rezaie - December 02, 2019
"Background: Recently there have been some observed trends in decreasing susceptibility among Strep pneumoniae isolates to antimicrobials used to treat community acquired pneumonia (CAP) (Resistance to oral penicillin and macrolides for Strep pneumoniae & macrolides and fluoroquinolones for Staph aureus). New antibacterials are therefore needed to treat CAP because of growing antibacterial resistance.
Lefamulin is the first pleuromutilin antibiotic approved for intravenous and oral use in humans. Both the intravenous and oral formulations were approved in August 2019 by the US Food and Drug Administration (FDA) to treat CAP. It is active against the most common CAP-causing pathogens, including bacteria resistant to other antimicrobial classes. Lefamulin Evaluation Against Pneumonia 1 (LEAP 1) looked at IV Lefamulin vs IV Moxifloxacin in adult patients with moderate to severe CAP and demonstrated noninferiority in that trial. Given those results, LEAP 2 was performed to compare oral Lefamulin to oral Moxifloxacin in adult patients with moderate to severe CAP.
Author Conclusion: “Among patients with CABP, 5-day oral lefamulin was noninferior to 7-day oral moxifloxacin with respect to early clinical response at 96 hours after first dose.”
Clinical Take Home Point: Both Lefamulin and Moxifloxacin had a high cure rate in the ITT population with CAP, however given the cost of Lefamulin and greater GI side effects compared to Moxifloxacin, unless there is known bacterial resistance, or a good reason to use this antibiotic, the antibiotic to choose is still Moxifloxacin or a penicillin + macrolide for CAP."

Geriatric Emergency Medicine

HealthLeaders - By Christopher Cheney - November 25, 2019
"The four different approaches to establishing geriatric emergency department services vary in the amount of resources required.
  • In 2014, guidelines were established for the formation of geriatric emergency departments.
  • The geriatric ED unit model features a dedicated space within an ED and is relatively resource intense.
  • The geriatrics champion model features care coordination with outpatient geriatricians and requires relatively low resources."

Nausea and vomiting

Nausea and vomiting in the emergency department
First10 EM - By Justin Morgenstern - December 2, 2019
"The paper
Meek R, Mee MJ, Egerton-Warburton D, et al. Randomized Placebo-controlled Trial of Droperidol and Ondansetron for Adult Emergency Department Patients With Nausea. Academic emergency medicine. 2019; 26(8):867-877. PMID: 30368981 Australian New Zealand Clinical Trials Registry ACTRN12617000224325
Bottom line
This study demonstrated no improvement in nausea with droperidol and ondansetron. There were some secondary outcomes suggesting a treatment effect from droperidol, but there were also side effects. It is very hard to know what to do with this information. We probably need to use these medications less often, but relieving suffering is a huge part of our job, and nausea is a significant cause of suffering. I don’t think I am changing my practice significantly yet."

US & ECG in Cardiac Arrest

Canadi EM - By Simon Huang - December 3, 2019
..."The results are highlighted in our visual abstract. The use of PoCUS alone in predicting futility in non-shockable cardiac arrest was found to have a sensitivity of 96% and specificity of 34%5. By contrast, using ECG alone had a sensitivity of 83% and specificity of 47%. For patients with asystole on ECG, PoCUS had a sensitivity of 98% and specificity of 16%. In patients with PEA on ECG, PoCUS had a sensitivity of 87% and specificity of 55%.
Collectively, these results suggest the absence of cardiac activity on both ultrasound and ECG better predicts poor outcomes in non-shockable cardiac arrest."
To read the full article, visit https://doi.org/10.1017/cem.2019.397.

viernes, 29 de noviembre de 2019

2019 AHA Update on ACLS

Circulation logo
Ashish R. Panchal, Katherine M. Berg, Karen G. Hirsch, Peter J. Kudenchuk, Marina Del Rios, José G. Cabañas, Mark S. Link, Michael C. Kurz, Paul S. Chan, Peter T. Morley, Mary Fran Hazinski, Michael W. Donnino
Originally published14 Nov 2019 - Circulation. ;0:CIR.0000000000000732
"The fundamentals of cardiac resuscitation include the immediate provision of high-quality cardiopulmonary resuscitation combined with rapid defibrillation (as appropriate). These mainstays of therapy set the groundwork for other possible interventions such as medications, advanced airways, extracorporeal cardiopulmonary resuscitation, and post–cardiac arrest care, including targeted temperature management, cardiorespiratory support, and percutaneous coronary intervention. Since 2015, an increased number of studies have been published evaluating some of these interventions, requiring a reassessment of their use and impact on survival from cardiac arrest. This 2019 focused update to the American Heart Association advanced cardiovascular life support guidelines summarizes the most recent published evidence for and recommendations on the use of advanced airways, vasopressors, and extracorporeal cardiopulmonary resuscitation during cardiac arrest. It includes revised recommendations for all 3 areas, including the choice of advanced airway devices and strategies during cardiac arrest (eg, bag-mask ventilation, supraglottic airway, or endotracheal intubation), the training and retraining required, the administration of standard-dose epinephrine, and the decisions involved in the application of extracorporeal cardiopulmonary resuscitation and its potential impact on cardiac arrest survival."

jueves, 28 de noviembre de 2019

Brain death

IBCC chapter & cast – November 28, 2019 - By Josh Farkas

"Brain death determination and support of a potential organ donor are core topics in critical care. These topics aren't particularly uplifting or glamorous, so they often are overlooked. Consultants who don't spend a lot amount of time in the ICU may be uncomfortable with them. This makes it even more important that we have a firm grasp of these issues."
  • The IBCC chapter is located here.
  • Podcast:

Adjusted D-Dimer

Th Short Coat - November 28, 2019 - By Lauren Westafer
..."Unfortunately, the lack of specificity of the D-Dimer renders many patients who are low or intermediate risk requiring imaging. Literature has increasingly supported elevated D-Dimer thresholds in certain patients (such as those > 50 years old) and in pregnant patients [2-4, 6, 7]. However, studies have recently examined, with success, risk adjusting the D-dimer to use higher thresholds in low probability patients. 
This study is an evaluation of a modified Wells + D-dimer pathway, allowing for patients with a Wells score of ≤4 to have a D-dimer threshold of 1000 ng/mL..."

Click images to enlarge

martes, 26 de noviembre de 2019

DRESS syndrome

DRESS syndrome title image
First10EM blog - November 25, 2019 - By Justin Morgenstern
"In the Rapid Review series, I briefly review the key points of a clinical review paper. (Well, this time it is a combination of 2 papers. The topic: DRESS syndrome (drug reaction with eosinophilia and systemic symptoms)."
The papers: 
  • Husain Z, Reddy BY, Schwartz RA. DRESS syndrome: Part I. Clinical perspectives. Journal of the American Academy of Dermatology. 2013; 68(5):693.e1-14. PMID: 23602182
  • Husain Z, Reddy BY, Schwartz RA. DRESS syndrome: Part II. Management and therapeutics. Journal of the American Academy of Dermatology. 2013; 68(5):709.e1-9. PMID: 23602183

Controlled aquaresis

PulmCrit (EMCrit)
PulmCrit- November 26, 2019 - By Josh Farkas
View image on Twitter

"Summary The Bullet:

  • Oral urea therapy is finally available in the United States. Urea functions as an osmotic diuretic (a.k.a. aquaretic), with potential use in euvolemic or hypervolemic hyponatremia.
  • No RCTs exist comparing oral urea to alternative therapies (e.g. vaptans). However, oral urea is widely regarded as very safe (it’s classified by the FDA as a “medicinal food”). An emerging body of evidence suggests that oral urea is a safe and effective therapy for many forms of hyponatremia.
  • Although oral urea is perceived as a “new” therapy in the United States, it has been used for decades in Europe. For example, urea was recommended for management of SIADH in the 2014 European guidelines.​
  • Oral urea has important advantages compared to vaptans: it is cheaper and will not cause uncontrolled excretion of free water (thus, urea is unlikely to cause osmotic demyelination syndrome and requires less intensive monitoring than vaptans)."

domingo, 24 de noviembre de 2019


SGEM#276 - By admin - Nov 23, 2019 

SGEM#276: FOCUS on PE in Patients with Abnormal Vital Signs


lunes, 18 de noviembre de 2019

Complications of Nephrostomy

emDocs - November 11, 2019 - Authors: Yoo M., Bridwell R and Sletten Z
Reviewed by Koyfman A and Long B
"Key Points
  • The majority of nephrostomy tubes are placed for relief of urinary obstruction, and failure of catheters manifest with symptoms similar to what led to nephrostomy tube placement.
  • Treat nephrostomy tube infections as complicated cystitis or complicated pyelonephritis, but avoid treating asymptomatic bacteriuria, which is common.
  • Be mindful that nephrostomy tubes are often placed for obstructions caused by cancers—make sure the patient is not neutropenic if on chemotherapy.
  • Obtain fresh urine from the nephrostomy tube to send off for studies, rather than obtaining urine from the collection bag.
  • If an obstruction is suspected, try bedside troubleshooting with gentle irrigation of the catheter.
  • Hematuria is common in the first 2 days, but always consider a vascular injury or hematoma formation if hematuria persists or re-occurs after the urine initially clear.
  • In patients with decreased breath sounds or pleuritic chest pain ipsilateral to a recently placed nephrostomy tube, always consider pleural injury in your differential diagnosis."

Fluid Bolus on CV Collapse During RSI

R.E.B.E.L.EM - By Anand Swaminathan - November 11, 2019
"Authors Conclusions:
“Administration of an intravenous fluid bolus did not decrease the overall incidence of cardiovascular collapse during tracheal intubation of critically ill adults compared with no fluid bolus in this trial.”
Our Conclusions: 
In this mixed etiology, primarily ICU trial, initiation of a fluid bolus did not appear to decrease the risk of cardiovascular collapse peri-intubation. However, this data is not conclusive due to methodological issues.
Potential to Impact Current Practice: 
Our prior understanding of the physiology of intubation and peri-intubation decompensation tells us that universal administration of a fluid bolus is unlikely to benefit patients. This study does not change this understanding.
Bottom Line: 
It is unlikely that universal fluid bolus administration prior to induction of anesthesia for intubation would benefit patients. However, there is likely a group that will benefit. The administration of fluids peri-intubation should continue to be based upon the clinician’s assessment of the individual patient"

Management STEMI Threshold

Treatment threshold in STEMI
FIRST 10EM - By Justin Morgenstern - November 11, 2019
"By now, I think everyone has heard of the test threshold. It is most often discussed in the context of the workup for pulmonary embolism. (I think it is an important concept that we probably need to employ more widely in emergency medicine, but that is the topic of a future post.) At the opposite end of the spectrum, there is an equally important concept called the treatment threshold, which gets far less attention. In this post, I discuss how thinking about the treatment threshold made me more comfortable managing STEMI with thrombolytics..."

Temperature Management in Cardiac Arrest Patients

R.E.B.E.L.EM - By Mark Ramzy - November 18, 2019
"Clinical Question: 
Does moderate therapeutic hypothermia at 33oC or normothermia at 37oC improve the neurologic outcome in patients who have been successfully resuscitated out of cardiac arrest with a non-shockable rhythm?
Author’s Conclusions:
Among patients with coma who had been resuscitated from cardiac arrest with non-shockable rhythm, moderate therapeutic hypothermia at 33°C for 24 hours led to a higher percentage of patients who survived with a favorable neurologic outcome at day 90 than was observed with targeted normothermia.
Our Conclusion:
This study emphasizes the importance of using definitive temperature control using an adaptive-control device. However, it provides no information about whether 33oC vs 36oC is preferable. Lastly, additional studies are needed to investigate more of the body’s effect at a temperature of 33oC and whether this or the avoidance of fever leads to better neurologic outcomes.
Clinical Bottom Line
Therapeutic hypothermia may be neurologically beneficial for post-cardiac arrest patients with non-shockable rhythms however efforts should be directed at avoiding fevers in these patients."

domingo, 10 de noviembre de 2019

RCEM Wellness Compendium

St Emlyn’s - November 10, 2019 - By Simon Carley
"Back in April 2018 the St Emlyn’s team developed and published ‘The Resuscitionist’s guide to Health and Wellbeing”. That represented the work of the team in addressing how we can look after ourselves and others in emergency medicine. We’re proud to say that it’s had thousands of downloads and (we think) it’s been helpful.
However, you will almost certainly also want to download a new open access publication from the Royal College of Emergency Medicine. This week they launched the “Wellness Compendium iBook”. It’s a practical guide across a range of issues which should be relevant to all clinicians.
RCEM have taken a slightly different approach to us, focusing more on brief outlines to topics with links to further resources, which is great as the two documents compliment each other well with the St Emlyn’s blogs offering an expansion to the core content. We would encourage you to disseminate them to all staff in your departments, and even if you don’t agree with everything in them there is no doubt that many in your department will.
How to download

PoCUS for Appendicitis

SGEM#274 - November 9, 2019 - By admin
Reference: Lee and Yun. Diagnostic Performance of Emergency Physician-Performed Point-of-Care Ultrasonography for Acute Appendicitis: A Meta-Analysis. AJEM 2019.




ATBs after cardiac arrest

PulmCrit (EMCrit)
PulmCrit Wee - November 9, 2019 - By Josh Farkas

"Summary the Bullet:
  • Among patients revived from shockable out-of-hospital arrest, a two-day course of amoxicillin-clavulanate reduced the rate of ventilator-associated pneumonia.
  • This is a multi-center, placebo-controlled RCT with no major methodological flaws. It’s not statistically unassailable, but it represents the best available evidence on the topic.
  • It is reasonable to change practice based on this study (while simultaneously maintaining an open mind on the topic and awaiting additional data)."

Grand Rounds Recap 11.6.19

TAMING THE SRU - November 09, 2019 - By Kathryn Banning
"This week Dr. Irankunda and Dr. Berger took us through their excellent QIKT on strangulation and asphyxiation. Dr. Knight walked us through the initial ventilator management in the ED. Dr. Habib talked about some common mythology and Dr. Makinen lead us through a physiologically challenging airway in a sick trauma patient. Ended with a thrilling R4 sim focusing on altitude illnesses."

EM Quick Hits 10

Emergency Medicine Cases Logo
EM Quick Hits 10 - November 2019

Topics in this EM Quick Hits podcast

Bag-Mask Prior to Intubation

R.E.B.E.L.EM - March 21, 2019 - By Anand Swaminathan
"Authors Conclusions: “Among critically ill adults undergoing tracheal intubation, patients receiving bagmask ventilation had higher oxygen saturations and a lower incidence of severe hypoxemia than those receiving no ventilation.”
Our Conclusions: The use of BMV after induction resulted in improved oxygen saturation with a lower incidence of severe hypoxemia in comparison to no BMV in the ICU. However, there were some important limitations that may overstate the benefit including underlying pathophysiology, pre-oxygenation and apneic oxygenation approach.
Potential to Impact Current Practice: This study should not result in widespread adoption of BMV after induction of the critically ill patient. However, its use should be considered in patients where clinicians perceive there to be inadequate oxygenation due to shunting and where regurgitation risk isn’t increased. Use of BMV must be properly taught to avoid aggressive, high-volume BMV which will likely insulate the stomach leading to regurgitation.
Bottom Line: Though it is unlikely to be necessary in all cases of intubation of critically ill patients, BMV can be considered on a case by case basis and may be particularly useful in patients who are unable to reach appropriate pre-oxygenation (> 95%) despite non-rebreather and nasal cannula at > 15 L."

jueves, 7 de noviembre de 2019

Alcohol Use and the ED

CanadiEM - By Gaibrie Stephen - November 5, 2019
"Think back to your last three shifts. Did you see an alcohol related condition? You might even notice a pattern— the same patient, the “regular” who returns time and time again with the same presentation. You may even find yourself writing “discharge home when ambulatory” as you’ve “reached your wits end” and don’t know what to do anymore. 
The use of alcohol is common and the emergency department is often where we see many of alcohol’s complications. Interestingly, despite alcohol’s massive impact and frequency, anti-craving medications for alcohol which are safe and effective are notoriously underprescribed and alcohol use disorder frequently goes untreated.
The emergency department may be a novel setting to intervene in alcohol use disorders..."

Acalculous cholecystitis

IBCC chapter & cast - November 7, 2019 by Josh Farkas
"Acalculous cholecystitis is a slippery beast. It's pretty uncommon, lurking among the myriad of sick ICU patients with moderately abnormal gallbladders. It is likely both under-diagonsed and over-diagonsed at various times. Indeed, since surgical cholecystectomy is currently rare, it is frequently unclear whether a patient ever had acalculous cholecystitis! (For example, if a cholecystostomy drain is placed and the patient recovers, it may remain murky whether the drain was truly required.) This chapter attempts to sift through the confusion."

sábado, 2 de noviembre de 2019

Spinal Immobilization

R.E.B.E.L.EM - By Salim Rezaie - August 07, 2019
  • There is no high-level evidence that prehospital spinal immobilization positively impacts patient oriented outcomes
  • Spinal Immobilization Does NOT Help Immobilize the Cervical Spine
  • Spinal Immobilization Does NOT Decrease Rates of Spinal Cord Injury
  • Spinal Immobilization Increases the Difficulty of Airway Management
  • Spinal Immobilization Can Cause Pressure Ulcers
  • Spinal Immobilization Changes the Physical Exam
  • Spinal Immobilization Worsens Pulmonary Function
  • Spinal Immobilization Increases Intracranial Pressure
  • There is no evidence that immobilizing awake, alert patients without deficits/complaints provides benefit
  • Selective spinal immobilization protocols can help identify patients at low risk for injury and avoid immobilization"