Emergency medicine in practice

Chest pain algorithm

042030006.pdf https://cdn.mdedge.com/files/s3fs-public/Document/September-2017/042030006.pdf

https://trekk.ca/

https://www.rcemlearning.co.uk/reference/fascia-iliaca-block/

https://emergencymedicinecases.com/wp-content/uploads/2025/03/Intermediate-Risk-PE-Algorithm-EM-Cases-1.png

https://www.pcds.org.uk/general-dermatology-table

https://emergencymedicinecases.com/congenital-heart-disease-emergencies-2/

https://www.rcemlearning.co.uk/foamed/metabolic-babies-in-the-ed-easy-as-1-2-3/

Another evidence based information 🚨 TXA in Acute GI Bleeding: No Mortality Benefit (HALT-IT Trial) 🚨 🔍 Study: HALT-IT Trial (Lancet, 2020) 📌 Question: Does tranexamic acid (TXA) reduce mortality in patients with acute gastrointestinal (GI) bleeding? 👥 Population: 12,009 patients with upper or lower GI bleeding 💊 Intervention: TXA (1g IV over 10 min, then 3g over 24h) ⚖️ Comparison: Placebo 📉 Primary Outcome: 28-day mortality from bleeding Key Findings: ❌ No significant reduction in 28-day mortality (TXA 3.7% vs. placebo 3.8%) ❗ Higher risk of venous thromboembolism (VTE) in TXA group (0.8% vs. 0.4%) EM Takeaway: 🚫 TXA should NOT be routinely used for GI bleeding ⚠️ Increased thrombotic risk → Use with caution in high-risk patients ✅ Prioritize early resuscitation, PPI, and source control (endoscopy/intervention) #نسولف_طوارئ

Anticoagulation in ischemic stroke and TIA 1. Anticoagulation in Acute Ischemic Stroke (AIS) ■Routine anticoagulation is NOT recommended in the acute phase of ischemic stroke due to the risk of hemorrhagic transformation. ■AHA/ASA 2019 Guidelines: Anticoagulation should not be started within the first 24 hours of intravenous thrombolysis (IV tPA). ■Cochrane Review (Sandercock et al., 2015): Early anticoagulation did not significantly reduce stroke recurrence but increased the risk of symptomatic intracranial hemorrhage. Specific Indications for Anticoagulation in AIS ■Atrial Fibrillation (AF): DOACs (e.g., apixaban, rivaroxaban, dabigatran, edoxaban) are preferred over warfarin for secondary prevention in patients with AF. Timing: Small infarcts: Start after 3 days Moderate infarcts: Start after 6-7 days Large infarcts: Start after 12-14 days (ESC 2023, "1-3-6-12 rule"). ■Mechanical Heart Valves: Warfarin remains the standard, targeting INR based on valve position/type. Bridge with heparin if needed, but avoid in acute stroke. ■Cerebral Venous Sinus Thrombosis (CVST): Anticoagulation with LMWH or warfarin is recommended, even in the presence of hemorrhagic infarction (ESO 2021). 2. Anticoagulation in TIA If TIA is due to AF , oral anticoagulation should be initiated as secondary prevention. DOACs are preferred over warfarin unless contraindicated. ■No role for acute anticoagulation in TIA due to non-cardioembolic causes (e.g., large artery atherosclerosis). Key Trials & Meta-Analyses ■NAVIGATE-ESUS (2018): Rivaroxaban did not reduce recurrent stroke compared to aspirin in embolic stroke of undetermined source (ESUS) but increased bleeding risk. ■RE-SPECT ESUS (2019): Dabigatran also showed no benefit over aspirin for ESUS. ■WARSS Trial (2001): Warfarin was not superior to aspirin for secondary prevention in non-cardioembolic stroke. Summary ■Acute phase: Avoid anticoagulation in most cases due to bleeding risk. ■Secondary prevention: For AF or cardioembolic stroke → DOACs or warfarin (based on CHA₂DS₂-VASc). ■For non-cardioembolic stroke (e.g., atherosclerosis) → Antiplatelets, not anticoagulation. #نسولف_طوارئ

Steroids & Mannitol in Ischemic Stroke: What Does the Evidence Say? 1. Corticosteroids in Ischemic Stroke ■Traditional Practice: Steroids were historically considered to reduce cerebral edema in ischemic stroke. Current Evidence: ■No proven benefit in improving outcomes. ■The Cochrane Review (2009) found no reduction in mortality or disability and potential harm from hyperglycemia and infections. ■AHA/ASA Guidelines (2021): Do not recommend corticosteroids for ischemic stroke-related cerebral edema. ✅ Take-Home: Steroids should not be used for routine management of ischemic stroke. 2. Mannitol in Ischemic Stroke ■Traditional Practice: Mannitol was widely used for stroke-related brain swelling. Current Evidence: ■May provide temporary reduction in intracranial pressure (ICP), but does not improve long-term outcomes. ■INTERACT trial & other studies: Aggressive osmotherapy does not significantly improve functional recovery. ■AHA/ASA Guidelines: Reserve mannitol (or hypertonic saline) for patients with severe cerebral edema causing herniation or neurological deterioration. ✅ Take-Home: Mannitol is not routinely recommended in ischemic stroke but may be used in malignant cerebral edema with herniation risk. Bottomline: ❌ Steroids - No role in ischemic stroke. ⚠️ Mannitol - Limited role, only for life-threatening cerebral edema. #نسولف_طوارئ

TXA in Trauma: Does It Really Save Lives? Evidence-Based: ■CRASH-2 Trial (Lancet, 2010): TXA reduces mortality in trauma patients with significant bleeding if given within 3 hours of injury. ■MATTERS Study (J Trauma, 2012): TXA reduced mortality in military trauma, even with massive transfusions. ■CRASH-3 Trial (Lancet, 2019): TXA in traumatic brain injury (TBI) reduced head injury-related deaths, especially in mild to moderate TBI (GCS 9–15). Current Best Practice: ■Give TXA (1g IV over 10 min, then 1g IV over 8 hours) ASAP in trauma patients with suspected bleeding. ■Avoid delays—benefit is greatest within 3 hours; later administration may increase mortality. Take-Home Message: ■TXA is a life-saving, low-cost intervention in trauma. Give it early! #نسولف_طوارئ

Tranexamic Acid (TXA) in Non-Traumatic Subarachnoid Hemorrhage (SAH): A Paradigm Shift? A recent randomized controlled trial (ULTRA trial, JAMA 2021) investigated early TXA use in spontaneous SAH to reduce rebleeding before definitive aneurysm treatment. The study found no significant reduction in poor neurological outcomes but confirmed TXA significantly reduced early rebleeding without increasing thrombotic complications. 💡 Key Takeaway for EM Physicians: ✅ If there’s a delay to aneurysm treatment (e.g., transfer to neurosurgical care), consider giving TXA early (1g IV bolus, then 1g over 8 hours). ✅ TXA does not worsen long-term neurological outcomes, so early administration may help bridge patients to definitive care. 🔗 Reference: ULTRA Trial, JAMA 2021 #نسولف_طوارئ

Coagulation studies should not be ordered in patients with epistaxis unless there is a personal or family history of a coagulation disorder. #نسولف_طوارئ

A mnemonic to remember management of mammalian bites .. ●HELICOPTER.. History Examination Liberal cleansing Irrigation Closure & Culture consideration Operative cleansing & closure Prophylactic antibiotics Tetanus immunization Elevation Rabies risk ■Indications for Primary Closure of Mammalian Bites... ◇Consider primary closure in face bites if all of the following are true: •Repair can occur within 6hr of injury (time dependent upon individual judgment) •Repair only requires single-layer closure; no devitalized tissue •No underlying fracture •No systemic immunocompromising conditions ◇Large gaping wounds outside the face may also require closure with loose approximation ◇Consider antibiotics in patients who are primarily closed #نسولف_طوارئ

Spinal shock vs Neurogenic shock.. Spinal shock is not a true ‘physiologic shock’, and should be thought of more as a ‘spinal concussion’. It is manifested by a flaccid areflexia post spinal cord injury. As edema around the cord resolves, symptoms will improve over a period of days to months, noted by return of the bulbocavernosus reflex (anal sphincter contraction in response to tugging on a foley catheter). Neurogenic shock is a true distributive shock, in which the patient becomes hypotensive and bradycardic, usually noted with lesions above T6. It is typically a manifestation of decreased vascular resistance and increased vagal tone secondary to autonomic disruption. #نسولف_طوارئ

In ischemic stroke Do not give aspirin until 24 hours after giving tPA, as ASA with tPA does not improve outcomes and increases bleed risk. Do not give acutely heparin (or any anticoagulation) if giving tPA #نسولف_طوارئ