Video 120 – Sindrome Coronario Agudo

Qué llamamos Sindrome Coronario Agudo? Qué es lo que entendemos por Sindrome Coronario Agudo? En este video, el Dr. Carlos Donoso profundiza en la fisiopatología y el diagnóstico de esta patología, que es frecuente y que si no la manejamos bien, el paciente tiene consecuencias graves.
Esta es la parte 1 de 2. En la 2nda parte se profundizará el manejo de esta patología y el tratamiento.
Les recomendamos que vean también la serie: métodos diagnósticos en SCA.
mue.cl/2016/06/19/video-106-metodos-diagnosticos-en-sca/

Guías ACCF/AHA manejo SCA con SDST
onlinejacc.org/content/61/4/e78?_ga=1.78146580.1227970386.1482470542

Esperamos que les sea de utilidad!

Video 119 – Compromiso de conciencia

La evaluación del paciente con compromiso de conciencia es un problema en el servicio de urgencia. En la escuela de medicina nos enseñaron a enfrentarnos al paciente desde los diagnósticos, siendo lo más importante que es lo que el paciente tiene. Pero qué pasa cuando nos enfrentamos a un síntoma que tiene cientos de diagnósticos posibles y varias decenas de diagnósticos probables? Cómo priorizar que hacemos 1ero, que segundo y que después? Como manejamos la ventana de 5 minutos que nos da una neurona sin combustibles antes de entrar en apoptosis?
En este 1er video, nos enfocaremos en por qué debemos considerar este enfrentamiento como un problema. El Dr. Nicolás Pineda nos comparte su visión del enfrentamiento del paciente con este síntoma desde la urgencia.
#ChileEM

That’s not what I meant by that picture

A picture can paint a thousand words. It is important that an image within p2 paints the words the presenter intends the audience to hear. A single image may have multiple meanings. It is essential to consider other possibilities may exist. Make sure the message received is the message sent by the picture.

Athis apple picturen obvious example would be an apple. Just an apple. What else could it possibly mean? It could it be the temptation of the fruit from the tree of life? Or the fruit that encouraged Isaac Newton to consider gravity? Or the record company formed by The Beatles? Once it has a leaf attached it may become rainbow coloured and then grey…in the mind of the audience. Or  is it just a random piece of fruit? Everything has meaning and clearly context of the p1 and the nature of the p2 will affect this meaning but beware the possibilities for an alternative or confused message.

Unfortunately, when searching, it is possible to discover images and unknowingly use them out red coat pictureof context. A cinematographic motif may work appear effective for a presentation but leave confusion or upset. The little girl’s jacket is the only thing of colour within this scene. A striking example of perhaps individuality, of uniqueness, or even beauty? The brutal imagery the film’s producer intended when he shot the scene may be not what the presenter intended in choosing that image.

The value of images in a presentation, rather than text, is clear. One must recognise that meaning is in the eye of the beholder. Implications may be drawn that are different from those intended, even within the context of a presentation. As with words, chose images carefully.

The post That’s not what I meant by that picture appeared first on p cubed presentations.

MOFFITT HOLIDAY PEARLS 12/27/16: Subsegmental PE and Necrotizing Fasciitis!

Thanks to Brad and Scott for presenting two cases today about management of subsegmental PE and a surprising case of necrotizing fasciitis. Here are brief pearls from both cases. Thanks to Brad for sharing these articles with us!

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Top Pearls:

  1. 2016 Chest guidelines suggest surveillance over anticoagulation for patients with subsegmental PE, no proximal DVT, and low risk for recurrence.
  2. Don’t forget to give clindamycin and IVIG if necrotizing fasciitis is suspected! Both interventions have been shown to reduce 30 day mortality.
  3. Misdiagnosis of lower extremity cellulitis (pseudocellulitis) is common (30% of cases), and the most common alternative diagnosis is venous stasis dermatitis.

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Here are some articles from today’s discussion:

In a retrospective cohort study at a single hospital, out of 937 CT scans read as positive for PE, 25% were false positives. Solitary PE and subsegmental PE were more commonly overread. (Hutchinson, AJR, 2015)

Chest guidelines from 2016 state that in patients with subsegmental PE and no proximal DVT in legs who have a low risk for recurrent VTE, clinical surveillance is suggested over anticoagulation (Grade 2C recommendation).

http://journal.publications.chestnet.org/article.aspx?articleid=2479255#WhethertoAnticoagulateSubsegmentalPE

We use clindamycin in necrotizing fasciitis for two reasons:

  1. Eagle Effect: Reduced efficacy of beta-lactam antibiotics in invasive Strep pyogenes infections. When Strep reaches the stationary phase of growth at a high inoculum, there is reduced availability of penicillin binding proteins which reduces susceptibility to beta lactams. Clindamycin effect is not inhibited by inoculum size.
  2. Clindamycin suppresses synthesis of bacterial toxins.

This has borne out in clinical trials; for example, in one study (Carapetis, Clin Infect Dis 2014), 30 day mortality was reduced by 24% in patients with invasive GAS infection treated with clindamycin (15% vs. 39%). Don’t forget to give IVIG which further reduced mortality by another 7%!

Misdiagnosis of lower extremity cellulitis (“pseudocellulitis”) is common (30% of cases in a single hospital cross-sectional study, Weng JAMA Dermatology 2016). The most common alternative diagnoses are vascular (60%, venous stasis dermatitis most common) and inflammatory (20%, gout/pseudogout most common). See table below from the same article for the complete list of alternative diagnoses.

table-1

Evernote: https://www.evernote.com/shard/s272/sh/c042cb31-5649-4694-a339-040b84dee838/fa937673b70c711631f30400bcd2735f

Have a great day everyone!

SamMy


Filed under: Infectious Disease, Morning Report, Pulmonary and Critical Care Medicine

Lipid therapy in oral poisoning: a not-so-systematic review

intralipid-161x3002 out of 5 stars

No support for lipid rescue in oral poisoning: A systematic review and analysis of 160 published cases. Forsberg M et al. Hum Exp Toxicol 2016 Nov 24 [Epub ahead of print]

Abstract

The authors’ goal was “to present a systematic review and case analysis of practically all published reports on humans treated with lipid rescue for LAST [local anesthetic systemic toxicity] or oral poisoning.”

The focus of the paper is on oral poisonings. The authors report that they identified 94 reported cases of oral poisoning with “alleged” positive response to lipid rescue therapy (LRT.) Two authors reviewed each case and rated causality (that is, LRT -> positive response) using a modified WHO-UMC scale. (As the authors note, the WHO-UMC scale was actually designed to determine causality in adverse drug reactions, not antidote response.) If the two authors disagreed as to the causality score, “consensus was obtained through discussion.”

The authors report that all 94 oral poisonings received scores of 2 (probable causality,) 3 (possible causality,) and 4 (unlikely causality.) in fact, 86% received a score of 3 or 4. They note that 91% of these cases received other treatment modalities at approximately the same time they received LRT.

The authors conclude:

“Considering the findings of the present study, the weak and contradictory scientific evidence for lipid rescue being an effective antidote and its increasingly reported adverse effects, it is reasonable to strictly limit its use in clinical practice. We would not recommend its use at all in cases of oral poisoning.”

There are several significant problems with this conclusion:

  1. Because of the nature of case reports, it is most often impossible to determine causality, especially using a scale that was not designed for this purpose. There are few methods describe as to how the authors assigned a score to each case. One could go back to original cases and make one’s own conclusions, but the reference list has only 22 citations and does not include all or most of the relevant papers. The paper says this information is contained in online appendices at http://het.sagepub.com/supplemental, but my efforts to reach that material through the link came back with either a blank page or an error message. This is really inexcusable. While it’s true that this paper was posted online before it appears in print, it should not in my opinion have been posted until the crucial supplemental material was available.
  2. It is completely unclear how the “discussions” of disputed cases were handled. Was one author more pessimistic and more persuasive than the other?
  3. Of course many of these patients received multiple, nearly simultaneous, treatment modalities. This certainly would make determining causality more uncertain, but not to the extent of concluding that LRT should not be used at all in oral poisoning.

I would add that the Cochrane Review states that a systematic review “summarizes the results of available carefully designed healthcare studies (controlled trials) and provides a high level of evidence on the effectiveness of healthcare interventions.” Case reports are not “carefully designed healthcare studies.” This is no systematic review, and this paper totally misappropriates the term.
Related posts:

Effect of lipid rescue therapy on laboratory tests

Excellent review of lipid rescue therapy

Lipid rescue therapy can interfere with critical lab values