Bloody Hell: GI Bleed Management in the ED at #ACEP21 Upper vs Lower GIB at #ACEP21

Low BP = Assume UGIB
BRBPR w/Clots = LGIB
BUN/Cr >30 = UGIB
NGL = NOT Helpful

Cruising the Literature: Updates in GI Emergencies at #ACEP21

-CODA: Abx 1st vs Surgery 1st for Appendicitis
-HALT-IT: TXA for GIBs
-Timing of Endoscopy in GIBs
-Topical Capsaicin Cream for Cannaboid Hyperemesis
-Inhaled Isopropyl Alcohol for N/V CODA: Abx 1st vs Surgery 1st for Appendicitis

rebelem.com/rebel-cast-ep-…

-Abx non-inferior to surgery BUT...
-Appendectomy in 30% by 90d
-3x more ED visits
-2x more complications
-Appendicoliths higher risk for complications

ECG Indications for Emergent Reperfusion via @amalmattu at #ACEP21

Concerning Symptoms PLUS...
-STE in Contiguous Leads
-Posterior STEMI
-Non STE-ACS WITH...
-Refractory Ischemia
-Developing Acute Heart Failure
-Electrical Instability
-HD Instability Additionally, Increasing Lit BUT NOT YET in the US Guidelines...

-LBBB w/Sgarbossa Criteria(& Modified)
-Pacers w/Sgarbossa Criteria(& Modified)
-de Winter T-Waves
-STE aVR w/Diffuse STD

Serial ECGs if you see...
-Hyperacute Ts in Symptomatic Pts
-STD in aVL in Symptomatic Pts

Great time chatting with @TessaRDavis @VenkBellamkonda @marco_propersi @M_Lin on productivity...here are some thoughts from me...

#MedEd #productivity Email

-Focus on Task Zero NOT Inbox Zero
-Email for me falls into 4 categories:
1 Actionable item (>5min to accomplish)->Task manager
2 Junk->Delete
3 Reference->Evernote
4 Quick action (<5min to accomplish)->Answer right then

Goal isn't zero emails but zero tasks in ur email

CDC Releases Interim Guidance for Those Who Are Fully Vaccinated

cdc.gov/.../fully-vacc…

#COVID19 Fully Vaccinated is ≥2weeks after 2nd dose of Moderna/Pfizer

Fully Vaccinated is ≥2weeks after 1 dose of J&J

COVID-19: An EBM Take Part 2 at #ACOEP20

-Anticoagulation
-Awake Proning
-Invasive Mechanical Ventilation
-ECMO
-Hydroxychloroquine

#FOAMed #FOAMcc @ACOEP Anticoagulation in #COVID19

-Admitted pts = weight based prophylaxis (unless contraindications)
-IMV = therapeutic anticoagulation
-Intermediate dosing has ZERO evidence base
-Thrombolysis --> Only if other indication (i.e. MI, PE, CVA)

#FOAMed #FOAMcc @ACOEP

COVID-19: An EBM Take Part 1 at #ACOEP20

-When to Change Practice
-N95 Reuse
-Corticosteroids
-Remdesivir
-Convalescent Plasma

#FOAMed #FOAMcc When to Change Practice

Expedited thirst for info & rapidity of pandemic lead to abbreviated peer review, publication of unvalidated data, retraction, and dissemination through press release

When to change = multidisciplinary discussion to set standard care at each institution

Fascinating paper shared with me via @DFarcy Preliminary Observations on the Vent Management of ICU #COVID19

sfar.org/preliminary-ob…

COVID-19 ICU pts are NOT similar to ARDS pts. They have profound hypoxia with pulmonary compliance that is generally high

#COVID19FOAM High-Pulmonary Compliance: Hypoxic vasoconstriction. Major issue is lung perfusion. Increasing PEEP and prone positioning are of minimal help with recruitment of collapsed lungs. In these patients high PEEP (>15cmH20) may compromise right cardiac filling

Australian Safe Airway Society Consensus Statement of Airway Management and Tracheal Intubation in COVID19 Adult Patients – Preprint Only

bit.ly/3d4Ud77

#COVID19FOAM Aerosol Generating Procedures

Airway management recs from Hong Kong on #COVID19

Aerosol generating procedures, such as NIV, HFNC, BMV, & intubation all high-risk

≥6L/min of O2 are considered high flow & use should be discouraged if airborne isolation room unavailable

ncbi.nlm.nih.gov/pubmed/32105633 #COVID19FOAM In pts with suspected COVID-19, airborne precautions, hand hygiene, & donning of PPE is recommended

Double gloving, as standard practice might provide extra protection & minimize spreading via fomite contamination to surrounding equipment after intubation

Two major types of COVID-19

L Type (70%): More prevalent; More aggressive & spreads more quickly; Often seen in patients in Wuhan China

S Type (30%): Less aggressive; Strain spreading in countries outside of China

#COVID19FOAM In one study, of 138 hospitalized pts with confirmed novel coronavirus-infected PNA (NCIP), the rate of hospital-associated transmission was:

Active Health Care Professionals: 40 (29%)
Hospitalized Patients: 17 (12.0%)

This suggests a 41% nosocomial spread

#COVID19FOAM