Top 10 Emergency Medicine Updates

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Top 10 Emergency Medicine Updates

17 Oct, 1:30 PM

welcome good evening everyone this is Dr vrushali and I welcome you all on behalf of Netflix for this session so for today's session that's the top 10 emergency medicine update we have with us Dr Ashima Sharma she is the professor in hod emergency medicine names Hyderabad she completed her post graduation MD in anesthesiology in critical care and has about 25 years of teaching experience after finishing MD she received her education and work experience from prestigious medical schools in India like kjmu Lucknow and mamc Delhi uh she also has a book that's called as current practice updates and emergency medicine so I'm sure all of you must be interested in knowing the emergency updates from her uh basically because medicine is an uh ever growing specialty you always have updates and resource that come up and it becomes very tough to keep up to date with them so that's where Netflix steps in and that's where ma'am Has Come Today and joined us to tell you the top 10 emergency updates I'll just start off with your presentation right away thank you so much I I believe that the audience out here must be curious about emergency medicine if they are young boys and girls if they are students who are supposed to write for post graduation then this is one of the branch which has started in on a country started some 15 years back did not pick up a lot of takers in medical colleges had some takers in DNB uh developed over there and from there this year last year it was decided that it is mandatory for all medical colleges who teach mdbs and therefore by the time if you all are the ones who are sitting forever need to propose graduation then there are many seats of emergency medicine have a look out for it the reason why this branch is so thrilling is because you get all undifferentiated cases over here it is always you don't know what comes next the through the door and that is where you have that entire knowledge right from you and not in physiology uh pathophysiology lab medicine all has and obviously the medicine surgery Pediatrics of stratex knowledge all combined together to come down on few differentials for every case remember it is that our first hour of trauma which started this Branch but the same are the same early Platinum 15 minutes 30 minutes and a golden hour is also very important for the medical emergencies what I come to you is to bring to you what is happening presently as updates in emergency medicine so let us go ahead and see what is happening in EM Cardiology you must have come across uh that there is an apart from having an invasive angiography there is a possibility of doing a coronary City and geography which is non-invasive and many places many Radiology departments have initiated uh doing uh this with the help of cardiologists now what is the uh what does the evidence say so in May 2022 it was seen that those patients where the chest pain is stable you can understand that unstable chest pains are over stemi St elevation Mis or the patients with high probability of risk factors on hard school or team score they would be immediately taken up for pcis by cardiologists but those who have stable chest pain and intermediate immediate probability of coronary artery disease the diagnostic approach which is still not uncertain so this was a trial which was done in more than 3 500 such patients and they found out that if they were if the patients were randomized to have a coronary City NGO the non-invasive arm the procedure related complications were less frequent even the rates of cardiovascular elements like certain Cardiac Arrest non-fetal myocardial infarctions and non-fetal strokes to an extent after three and a half years of follow-up and rates of patient reported angina during the last four weeks of the trial that is last four weeks last one month of the three and a half years only that that was similar between the two groups how uh however because of less procedure related complications it is now suggested that this group of patients it is better to do a non-invasive coronary City NGO rather than having doing a in invasive and geography okay now coming to a next group of drugs why I am you may say that this is not emergency medicine exactly it is there there is a lot of use of more status with LDL cholesterol lowering drugs in your patients and do you know how they present the the most common complication of high dose statins is muscle pain Rhabdomyolysis they come with Aki okay and they come with the severe headaches and all those non um uh specific symptoms and when once you are taking the history of drug use they tell that they are on high dostations for cardiac illness or for uh as a uh as a drug therapy to decrease the cholesterol levels here it is all pertinent for an Emergency Physician to know that there are possibilities of drugs like acetamide which can help in for lowering the LDL cholesterol for decreasing the absorption of that cholesterol from the food now this was a racing trial which again randomized approximately 1300 patients with cardiovascular disease existing to either a combination therapy with a moderate dose of a Statin that is 20 milligram plus acetamide uh or a high dose 40 milligrams monotherapy and they found they try to find out what is the rate of composite cardiovascular that major events non-fetal stroke at three years interval reforms the rate was similar between the treatment groups so they say that those who are receiving combination therapy they are more likely to have LDL cholesterol less than 70 which is a good cholesterol level and those even the dose discontinuation in this of uh of Statin monotherapy because the side effects are untolderable to the patient is found less with this combination therapy my idea to you is that there might be walk-in emergencies to your ER room with a drug uh secondary to Statin use please do not just stop it you have an opportunity make sure if your card if your Cardiology friend uh is worried of stopping it because of cholesterol uh this lipidemia please discuss about the use of drugs like acetamine with him okay now this is something which is also new July 2022 what does it say it says that those patients who come to you and you treat them with hypertensive emergencies and urgencies in emergency department assess these patients whether they whether they are they have there is a possibility that they can be trained for measuring their blood pressures themselves at home it improve it is seen in 18 random maestros the evidence is very significant that self measurement of blood pressure combined with mobile or web-based telemonitoring has led to a greater decrease in systolic and diastolic blood pressures compared with usual care and what is the usual care most of the time you say that please go twice to uh GP and get your blood pressure measured uh once you are discharging those patients whether you discharge it from directly from ER or you discharge it after a medicine Ward admission uh patients who are and so it is important to for us to understand that patients who are interested in self-monitoring should be supported should be empowered if and provided with adequate training in the machine use and the device should be obviously you should be checking the device for accuracy and tell them that at least once a year it needs to be checked and not more than that this is again very important you in emergency department we do get patients who have rheumatic heart disease you just as a had a question also in rheumatic heart disease and those patients who are with atrial fibrillation now you may understand that those who are in atrial fibrillation and have a rhombus in the left atrium these are the patients who would have stroke and therefore it is important that they should be anticoagulated okay even before the AF is taken care of I would give you an example like this that if a person comes to if a patient comes to you with acute onset atrial fibrillation that is within last 24 hours it is okay to do a rhythm conversion but if the person comes to you with a long-standing AF more than 48 24 to 48 hours have passed then do not do Rhythm conversion only correct his rate from the past ventricular rate bring down the rate for a better cardiac output why because otherwise the thrombus which is present in the left atrium can embolize and cause stroke now what is the drug used for uh this anticoagulation age old therapy used to be the vitamin K antagonist which was Warfarin with the introduction of newer oral anticoagulants that is especially the direct and a email editor like River of Saban it was seen that this various trials have used regular Saban and compared the effect with uh keeping Warfare in as the uh in the second arm and they realize that it is always better old is gold they realize that it is vka that is warfarin which has which is better than this drug so uh this is very important for you to understand do not fall in the Trap of prescribing a newer drug look out for evidence and this is as new as September 2022. now again I come with a very important pertinent topic for you that is that you who or who all I hope all of you know how to do a basic CPR okay sudden cardiac arrest in the community community CPR plus being doctors it is very important to understand basic life support or and also Advanced cardiac life support now most of the time when the patient is regains you the return of spontaneous circulation then after that what happens after that we tend to keep him on a hundred percent oxygen we tend to maintain very high blood pressures by pushing in vasopresses the nylotropes because what we are thinking a back of our mind is that we will improve the perfusion to the brain so there are certain some people who looked into this by to by a trials something like 7 189 patients with sudden Cardiac Arrest they were randomly assigned to High versus low mean arterial pressures well what is in one group the pressures were somewhere like more than 75 and in the other group it was just below the uh 65 that is 63 millimeters of mercury at the same time they are what two into two factorial that is a 77 volt could have been combined with the po2 which was less that is between 68 to 75 but or a po2 which was more 98 to 105 millimeters of mercury now partial pressure of oxygen means that they were controlling the fractional inspiration oxygen to control this partial pressure now what did they do they followed these patients for three months 90 days and what did they realize that rates of death severe disability comma if the patient was getting discharged to Rehabilitation it was similar across all group so it is not it what does it mean it means that aggressively supporting mean arterial pressure measure up to a higher Supra normal levels and same a Supra normal oxygen tension levels does not mean that the patient would have a better outcome after a sudden cardiac arrest after rosk is achieved and that is very important however the authors have have said that let us wait for future future studies before a concrete decision is made this wraps up my thought process of what has happened over the last six months in EM Cardiology and now I am with you to em pulmonology so what do you think is new over there there is something which is happening these days in our country and what is it rains rains everywhere and this these are not seasonal race not at all everywhere it is raining and what happens to asthmatics so there is something which is a newer trunk term and that is called as a thunderstorm asthma which happens because in because after in in hours after a thunderstorm especially those rupture of water lock pollen brains a lot of allergic debris swept by strong cross currents and especially especially that is deposited in concentrated form at ground level and those there was a multi-centered trial which was done for it and they thought that that these are the patients who are coming exactly after after a thunderstorm with an acute excessive severe attack of asthma and this was given a new name they they confirmed it by doing the immunoglobulin E levels is novel counts fractional exhale nitric oxide levels or and and they said that uh sort of they give uh um information to the pass on the information to asthmatics not to venture out if it is a thunderstorm because there is a new entity of asthma which can be uh life threatening for them again as well very important now uh we are still reeling under the effect of covet 19. uh when the initial studies if you people are interested in evidence base which I'm sure each and every doctor should be interested in evidence-based medicine and especially when it comes to emergency medicine so they said initially that it is not that only those who have pulmonary disease have were outcome when they get infected with covid-19 virus uh anyone rather they were saying more for patients who had renal diseases or who who had a neurological insult immediately with covid-19 infection however now it has been seen by United States CDC that asthma is a risk factor for severe covid-19 infection they say with several studies uh uh initially where patients with well-controlled asthma do not indicate increased risk in this population however higher risk of intubation prolonged mechanical ventilations are seen in patients with asthma and that is especially so in those patients who had poorly control asthma at the Baseline so what they say prioritize these patients for antiviral therapies it is very very important to initiate and what are the antivirus most of the time we started with Fabi Praveen we went up to morning praveer and uh and so on so forth so if I what is the take-home message with this slide which is evidence as early as June 2022 that if a patient comes is positive for covid-19 infection and the comorbid illness is asthma even if he is not showing severe signs I will sit and discuss with the pulmonologist and I would like to initiate antiviral therapy in this patient I go ahead and we talk a little about uh inhalers so this is May 2022 and it talks about partics partex is nothing but patient activated reliever trickled inhaled glucocorticoid therapy nowadays again asthma those patients who are poorly controlled moderate severe asthma they've said that it is a early use of inhale inhale nebulized glucorticoid strategy especially these inhalers would help to decrease at least annular annual rate of exacerbations by 0.15 percent this is good the only thing which they felt was there is all the patient has to carry multiple rescue inhalers may look unattractive to many patients however inhaled glucocorticoids as a rescue therapy is a gaining a lot of evidence in preventing asthma exercise and can be useful used as an alternative reliever regime now this is COPD so asthma had Whenever there is acute severe asthma there was always a possibility that when it is not getting relieved uh the bronchospasm is not getting relieved by the first line treatment we were using intravenous magnesium therapy as well as recent as August 2022 the same intravenous magnesium sulfate therapy two grams over 10 minutes has been initiated for uh use of COPD patients especially those who have not who have severe exacerbations and are not improving with inhaled bronchodilator therapy this is a very important point this you those who are preparing for post graduate entrance remember these are the questions recent advances where questions would be asked on you for you interstitial lung disease after covid-19 vaccination well it looks tough it looks sounds sad because all of us know that it was a a very very important uh point to get ourselves vaccinated it saved us saves us from severe infection however somewhere there were some reports it is not it is not in our city it is impossible to do our cities in this so these are only some four patients case series with interstitial pulmonary fibrosis and where would you find these ipf patients you find these patients in uh patients who have vasculitis patients who have rheumatoid arthritis so most of the Rheumatology cases who have arrived with underlying lung disease they were the ones who these four patients did not do very good after covid-19 vaccination uh however they say that still because we especially the MRNA vaccine Still They said that because is the benefits outweigh the risk in a larger section of population we will still recommend covid-19 vaccination in patients with interstitial lung disease however be cautious admit them do not discharge them just after vaccination so that they can remain under direct observation at early initiation of life-saving therapy can be taken care of another very interesting thing which happens in pulmonary medicine and that is Osa that is obstructive sleep apnea now we are especially in patients with COPD now this is something very different copds are supposed to be the thin ones you know the ones where you can see between the ribs they are they are not the ones who who would be having the Osa not the obese kinds but these there is some group of patients which have underlying COPD being a smokers all throughout their life greater smoking pack uh cigarette pack your smoking pack years of smoking now these are the patients whether they were saying whether they are really benefiting with positive Airway pressures uh which was supposed to be Mainstay of therapy or not so they saw they studied from the database of health insurance about 6810 patients and they said yes even if it is COPD with Pap that is positive airway pressure uh who who use positive airfare pressures if they adhere to what was the written instructions for positive we have a pressure CPAP therapy they definitely showed a lower risk of uh of reductions in emergency department visits lower uh inpatient hospitalizations and also subsequent less severe acute exacerbations now what does it mean it means that if your patience has Osa and there is underlying COPD you can initiate in your emergency department uh bipack therapy CPAP therapy with great confidence that there is an Evidence which backs it long covert syndrome now this is also uh happening coming to your notice to everyone notice um what do you call it sometimes long Kuwait kovid hall or Post Acute sequeline of SARS gov2 infection well they have studied some people who had just do Who had who had them some mild infection but still they found out that if these patients uh let's say 2560 patients they said let us see these mild patients if they got three doses or two doses of vaccine or just one dose of vaccine did it differ their uh probability of getting long covet and yes it is a good number of cases believe me 20 22 560 mild cases it it says that those who are unvaccinated had 42.8 percent chances of long covet and now long covet is not just pulmonary I am sure you understand that long covered is right from the brain neurological symptoms to non-specific symptoms of weakness including cardiac palpitations including pulmonary symptoms and also Dermatology symptoms so with this uh uh if the if the this particular patient has taken one dose 30 percent uh still there are chances of him to get a long covet another dose chances decrease by all another 15 person uh approximately that is 17.4 percent and the third dose is only as we have all known that it was so all to be told To Us by the government by the CDC that it will just help us to keep our immunity strong and therefore it is not shown to decrease the incidence of long covet to a greater extent than what a second dose was doing okay this these are very important recent advances for you people Delta versus amicron wire and variant well that is also is it affecting the risk of long covet yes in June 2022 about 97 000 think of it almost a lack of vaccinated individuals in United Kingdom they were studied and it was published that these patients who had subsequent infection with Omicron variant after they were vaccinated they had lower risk of developing persistent symptoms that is long covet compared with Delta and this is something a difference is 4.5 versus 10.8 percent they understood that yes these are these things are reported there is certain self-reporting some app reporting and sometimes there is a loss to follow up in uh covet cases and these are the limitations of their study however it is said that vaccination does uh help in prevention of long covet in the Omicron wire variant uh letter lesser than what it does for a Delta variant this brings me to critical care what is new in EM Critical Care let me talk about it with you okay now this topic is very near to my heart why because in emergency department if the patient is not Delirious it is the attendant who is Delirious agitated delirious and what we think because we are so tired we are always so tired of the work workload that we we just want to him to be out of the doors as soon as possible remember if you delirium is the worst killer you may leave the patient today evening tomorrow by tomorrow morning he may be dead if you don't take care of delirium and especially taking care of just putting physical restraints is not is worser than not taking care yes I do understand that it is uh that is at times to restrain the patient so that he does not harm doesn't does allows you to give him medications um especially antipsychotics or benzodiazepine one has to restrain the patient but however apart from this there is one beautiful drug if you you people have gone through your pharmacology which is a I would say a sister of clonidine which is Dex medicomidine okay and that is the central Alpha Agnes that is the one which has reduced the incidence of delirium with a relative risk of 0.67 in Us in in almost 12 000 patients it's good number very good number and this all these all were randomized control trials the evidence is level one that is uh and the only thing where that's mandatory Dean is that it causes bradycardia and hypertension so what I do I'll tell you I never give a loading dose of this matter to Medina or it is supposed to be started with a loading dose of 0.5 to 1 mic per kg and directly I start the infusion of Dex medicity yes it takes time for the plasma level stool like it takes almost two to three hours for the plasma levels to reach I covered that part with a benzodiazepine but uh and by decreasing by eliminating the loading dose I have I take care of not get uh giving this these patients bradycardia and hypotension um now one thing you have to understand that more than 24 for 48 hours of continuous infusion will definitely cause the same effect as to how you have as to the fact that same thing which our loading dose could have given so be very careful and get a psych uh psychiatrist in involved in the treatment of delirium as soon as possible the good antipsychotic agents the typical the atypical agents are very good in controlling the agitation of patients fluid therapy uh someone someone very good person or a very good doctor has said fluids is a drug it is no longer that it is not to be taken as IV fluids on this it is it is supposed to be a therapy it is like a drug therapy and it is very important for you to understand when to de-escalate especially in sepsis isn't it I have you must have heard about it that whenever there is hypertension give a bolus to fill the system those vessels so that because an empty heart what will it pump out so to keep the system full so that cardiac pumping is good one tries to give fluids but as when sepsis sets in it does a place a Havoc with the endothelial system and so whatever fluid you are giving it might not stay intra vascularly it will go into the uh in in the third space and third space the the best absorbers the best absorber is the lung it takes all the fluid and then it becomes very difficult a lot of um help is done is needed for biomechanical ventilation so what they said was that they did a 1500 patients of sepsis who receive achieved at least a liter of fluid and then they were almost 12 bars within 12 hours of the shop and then the doctor decided I will assign him either to a restrictive fluid therapy and stop the infusion I will only give small boluses uh if I feel that there is a low blood pressure urine output has fallen or there are more insensible losses insensible losses means patient is febrile and is losing through by sweating or there is another the other limb was the standard IV fluid therapy where all of us have a nature of writing uh 125 ml per hour 100 ml per hour something like this fluid ongoing fluid and what then they followed these patients for 90 days and they saw that at 90 days what were the is what was the incidence of mortality or adverse effect they said it was very very safe in the for the patient in a restrictive fluid therapy what does that mean it means that within 12 hours of concept of sepsis try to reassess your patient uh for uh fluid requirement do not just use fluid as a exactly as you use your antibiotic as you know I have to de-escalate my antibiotic remember to de-escalate your fluid therapy also at the same time okay how many of us those who have done critical care or those who are doing Critical Care must have used vitamin C for sepsis and would have loved it and published it also and believe me I have also done I mean I must have assessed and cleared three Theses on between therapy uh for by my by students DNB students or some MD students if it has come across me as a external examiner now you what happened in 2022 June the evidence came no longer alone it is effective in sepsis and we were just pushing vitamin C inside with uh to the in our patients they said yes initially when we started we started it we see with I mean and hydrocortisone now the there are almost quite good number of randomized control trials they say no this is the combination does not work it does not work by itself there has to be something more to it so what they did was they started they they they started doing a trial using about 872 patients those who had septic shock so already shock was there I understand you people know that by shock I mean the mean arterial pressure was less than 65 millimeters of mercury and they and these patients were already on one vasopressor at least that is not adrenaline was already going through and they started IV vitamin C alone okay obviously antibiotic was going but not hydrocortisone not thymine and they saw so there is no effect at 28 days their mortality or persistent organ dysfunction was almost similar between the group which got it and with the group which did not get there on the other hand they realized that almost one patient had severe hypoglycemia which is a side effect of vitamin C therapy and one had anaphylaxis as a response to between C so they say ah now we are against the use routine user between C in combination or alone in patients of sepsis now this is something for those people who are regularly working in ER Critical Care units on all three other Critical Care uh rooms where they have they know that those patients who whom they have to put in a tube and initiate endotracial tube and initiate mechanical ventilation you know positive pressure ventilation will definitely decrease BP because our heart does not like the pressure and whenever you will give a positive pressures into the lungs there would definitely be a pressure over the heart and that is why those patients who are hypertensive critically ill they said that uh let us give them a bolus of a fluid and then intubate okay a 500 mL of a fluid were given in more than thousand critically ill patients before into trickle intubation was done did it decrease the incidence of cardiovascular collapse amazingly no it was it did not they said that no it does not work the fluid because it is already these patients are critically ill the fluid does not stay in the venous system it goes into the third space there is rather try to use drugs which are safer do not cause Fallen blood pressures like etominate or ketamine or use more more better use a vasopressor initiate nor epinephrine therapy or push those vasopressors push back push those vessel presses I mean a drug by name phenylephrine I think so you must be knowing it and in addition you can use intravenous fluid therapy but by itself an IV fluid bolus will not be helping you to um to save these patients from further hypertension I am sure all of you must have also heard awake pronation okay go with me okay so we will lie on our stomach if we have covered I have I had it twice and um I I also did it before I before I got this evidence and this is limited data obviously potential benefit is definitely there because it was told it is a strategy to avoid intubation especially when already acute hypoxemic respiratory failure has already settled okay not those who are mild coverage saturation since 96 97 when already hypoxemic respiratory failure means what it means a PO to less than 60 millimeters of mercury these these patients will would were supposed to be were included at least two recent trials and the two arms of the study were awake pronation or standard care and they said that the intubation rate with renovation was 32 percent 34 percent whereas those with standard care was 41 percent yes they said that there is a decrease but it is not that it has a completely uh completely removed the potential of the patients deteriorating if the patient is lying on his stomach so there are certain imperfections in these two trials um and that is why the authors have uh have requested people to do research on this awake promulation in mild in patients with acute respiratory uh failures in covid-19 infections with awake uh pronation okay those patients in ICU who have admitted with stroke stroke is one case that if it goes bad uh then there is they will be intubated and went ventilated for a long time early versus late tracheostomy now this is one thing which has been researched uh many times in previous years also they say that early tracheostomy is something which is done within five days and uh later is one after 10 days within between five to ten days is the gray zone of going to cost me they say that individual individualize your approach see if you feel you will be able to extubate your stroke cases between the fifth and seventh day do not go in foreign but if you know that there is a possibility that this patient would be ventilated for long uh and who are those those who have already aspirated before they came to you please do early tracheostomy it helps in meaning the patients from ventilator okay and there is a and they have said that [Music] um this uh this should be done this this is the practice which should be taken between the 7th and the 21st day of a prince of show okay I'll go ahead and just talk to you about high flow oxygen therapy in covid-19 in fiction now in during covet times we get we all got to see a newer therapy which was hfnc all many of us who never knew what hfnc was there why because our flow meters regular flow meters give no more than 15 liters per minute of oxygen but here we were getting something like 60 liters per minute of oxygen they say that and it was supposed to what was initially published was that this is one commonly used strategy to reduce the risk feed for incubation that these authors whose work I am quoting they randomize some 220 such patients and they found that the mortality difference was not statistically significant whether you give 15 liters or whether you are doing 60 liters now why this is happening as tell you why I personally experienced that when you are using higher flows you get Supra normal oxygen levels in your egg RTA blood gas sample and that makes us so happy 200 pu choose wow we have achieved but this does not mean at all that the condition of lung has improved you are giving more you are getting more and and that is a for sometimes a false reassurance and that is why a lot many patients have had to be intubated at uh um after the initial um um use of hfnc now another one is corticosteroid regimes with 19 related organizing pneumonia now these all patients come to you in ER Department please do not think it has nothing to do with ER all because covid-19 has was Emergency Physician was standing at the door of your on the gates of the hospitals taking in all the covet patients so I should know a new youngster should know what can he do in the initial time frame for these patients would steroids help or would they immunocompromise the patient to Upward outcome in covid-19 and this was reported uh including their respiratory symptoms lung Imaging and Pulmonary functions in patients who develop organ developed organizing pneumonia high and low dose prednisone wall therapy was compared and 40 milligram daily for one week then 30 ml that per day and then 20 milligrams per day and then 10 milligram for two weeks which is a six week therapy and it was the other group had received only 10 milligram per day for six feet and they said the efficacy is better if you keep the single dose 10 milligram per day of uh prednisolone rather than going high and slowly tapering down the dose over six months and this is what their study has taught us okay uh if if build the time permit for me to do the EM neurology can can someone tell me please yes ma'am we can go ahead yeah okay okay so I'll just do a little about new em neurology which is very very recent September we are in October and this this was uh published in September 2022 and uh this is uh when um are one of a very common emergencies for us and that is intracerebral hemorrhage uh a thousand patients who had come to the ER 72 percent patients had poor functional outcome at one month and is it a lot of financial uh and uh you know uh finances go in treating these patients it is a loss GDP lost so is there a possibility that right at the start when the patient comes to you we can assess that these are the patients who will have more acute ich complications so it may be futile to treat them because they may not end up having a good quality of uh life and they realize that in in uh in these patients when they they studied some thousand nearly thousand patients they realize that those patients who had sepsis new ischemic stroke prolonged mechanical ventilations hydrocephalus and move on on Rise to feeding for a long time they did not do well they were they had very poor uh poor quality of life and therefore it friends it important that one should keep a vigil of understanding the futility of treatment also and making your patient attendance understand that the emotions and signs will not go hand in hand in certain cases this is also a neurology update which is from June 2002 we know there is uh intravenous connector plays and we know that there is ultiplase ultiplase which is used for which has been used in all previous acute stroke trials uh but the neck to place has an optic place is cheaper okay a therapy what what lack versus a therapy worth 30 000. obviously will have a better uh acceptability in a country where um earnings are poor and has not yet there are there everyone is insured and some insurances do not support the use of uh very high uh costly highly costly drugs so this not as true trial part a trial they said a close of technical place of 0.4 milligram per kg was his healthy place which is a regular dose of 0.9 milligram per kg and yes and we know that as far as the drug pharmacology is concerned we know technical place is more fibrin specific and therefore it also showed a physical outcome and uh in in the early Place more favorable outcome and are significantly lower mortality rate rather than the nectar place and so the trial was stopped early however uh although these results are not definite and it is just said that present at present in a place 0.4 milligram per kg should not be used for intravenous thrombolysis however these uh a dose of 0.25 milligram per kg is going ongoing for the safe testing for the safety and efficacy what I want to convey to you is that as in healthy place the dose is already there dosing schedule is already known to you it is in the dosing of the nectar place is still getting decided and there is still uh ongoing trials however in India uh this trial is not from our country but we are still we have started using the elective place at a dose of 0.25 milligram per kg okay uh same and intracranial hemorrhage very important when to restart anticoagulation especially profile acting anticoagulation and why not because all these patients would be bedridden and we know that the well score for DVT bad written patients will have DVT and with DVT they may have pulmonary thrombolism so therefore so it is a double-edged sword you start anticoagulation early the bleed increases you don't start patient develops DVT so therefore it is suggested that you can resume that after four to eight weeks of ich in most of the cases but again individualize your patient individualize the patient on the uh or based on the amount of intracranial bleed something which is uh common uh nowadays that is cerebral sinus Venous Thrombosis why it is common because it is seen in summers A Lot Indian summer is very hot dehydrations and they come with small venous Strokes uh to the emergency department and this is it was seen that uh most of the time but we were giving these patients were clexane injections okay low molecular weight appearance would a direct oral anticoagulants work that is a factor 10 a Inhibitors like uh we um the study was done action CBT study ate 45 patients were anticoagulated either by a Warfarin or Apex band or sometimes both at different time intervals and we they try to see how many of the saviness sinuses recanalyzed it's based on Imaging death of the patient or recurrent thrombosis at one year they saw that there is a lower risk of major Hemorrhage with blue acts and therefore it is a reasonable treatment option for uh CVT it what does it mean it has uh direct uh oral anticoagulants have started to be used in uh situations like cyber sinus Venous Thrombosis most common in summer Summers and also in postpartum pregnant uh postpartum females there are other reasons also I'll just tell you two these two reasons because these are the times when you will think it is a heat stroke uh in summers your differential will go more in heat stroke rather than a csvt in postpartum uh patient it goes most as septic encephalopathy thinking of perennial substance rather than csvpd and that is why this is a very important information which you should know last but not the least physician burnout September 2022 it is very very important that and these are these meta-analysis was done for 170 observation studies and see how many of us participated 2 lakh 30 000 Physicians participated and they said that yes we are burnt out three times as likely we are dissatisfied with the carrier Sometimes some have regretted their career choice and think about leaving the job well I would not suggest it but I would definitely say that there it has to be a support system for all the young doctors the the senior should there has always been uh sort of uh what I went through my junior should well go through the same that will make him a more sturdy doctor now we are not cultivating horses out there or so do not make them study make them happy and so your professionalism should be good uh you should re you should not be receiving low patient satisfaction ratings and there should be many interventions will not go into the details of it but if you are in a position where you can help to prevent a burnout of your colleague or a friend or your Junior please go ahead and do that these are the guidelines which were published in 2022 for patients with low risk frequent abdominal pain now what does it say please Google for Grace two guidelines I cannot put all of them together but it says that use or those patients who are coming again and again for some chronic abdominal pain with the start with opioid with lowest effective dose shortest possible time because we know of we have heard about it but and it is uh it is important to understand the opioid crisis yes I do agree that pain is the fifth Vital sign but how much one can go ahead and render the patient addict of opioid is something we have not yet come out in open still in our country so please please be careful uh read these guidelines which will suggest an opioid minimizing approach in patients especially who are younger that is between 80 to 18 to 65 years of age remember it is only for those uh who have who come with chronic abdominal pains multiple times and it is not for those who are pregnant with pain and active cancers recent abdominal surgeries immunosuppressed or severe active psychiatric illness because their differences would be obviously different so many times without even thinking that there could be a transfusion reaction we would have been told if we have been interns if we are young doctors to initiate a blood transfusion only thing we were told warmed the blood check the label and the page which is there in the file make sure the blood group and is checked and matched but is that a complete um is that so that if we check this all there is no way that transmission reaction will not occur no so there is a recent meta-analysis published in August 2022 and this is very important for a in emergency medicine because lot of patients who have a long-standing anemia or who are private sector doctor tells that uh you should take one blood transfusion they turn up in emergency room asking for a blood transfusion and you also think okay the they are they have yes the HB is seven or eight let us go ahead and give a transfusion uh without so please understand that more uh more than 1.3 million transfusion reactions was documented and they and twofold higher frequency of acute transfusion reactions occurred when they were children rather than adults so it is more common in children who have smaller lungs more labile hearts developing brains and at that time having a bad transfusion reaction will have a longer side effect so they these are more to a more with red blood cells and platelets platelets again Dengue is uh Dengue is happening it is ongoing and patients do come young adults do come for platelet transmission to you children so please be very very careful that to always to look out for serious in uh events and remember that whatever is the symptomatology it is potentially serious and it should be evaluated do not think that I have given a steroid and an anti-stemming stop the blood or a plantar transfusion report it let the sample of from that bag and the patient sample go back to the transfusion medicine Department because you might have saved him but next he goes to another hospital and that person might not be able to recognize him and we he this poor patient may lose his life something which is very common you would be as we are all of you are budding doctors or doc already into this system for a long period of time appendicitis diagnosis is the most common diagnosis in children and it is not that all of them need to be operated as in adults it has now it is now very well studied that non-operative uh um is non-operative management of appendicitis was is also uh accepted uh at four children till recent past now what does these people do they studied some 73 000 uh patients children from 2011 to 2020 that is almost like 10 years 9 to 10 years and we saw that these patients they had higher rates of perforations higher rates of sepsis if um in children Wonder went early surgery so appendectomy for early appendicitis remains uh uh though it remains a treatment of choice for most children but it is the non-operative management which appears to be more increasing it is a more safer option for older children with early appendicitis and the only thing they have said it is it is better to do a non-operative management if you are able to visualize on the CT scan that the diameter of the appendix is less than or equal to 1.1 centimeter and there is no appendicular inside so this is so beautiful two criterias diameter of appendix absence perpendicular if it is there prefer a non-uh operative management for children okay so I thank you all for a patient listening and I would like to um introduce to you my book which is uh um a current practice updates in emergency medicine uh the slide has gone but I'm sure yes thank you so much so this I will pick up all these from my book so I wish uh you there is lot more into it but I can't cover all that so I wish you people buy it read it and keep yourself updated with the management of patients in emergency hours thank you thank you so much man I must say you've covered the points so well you divided it into specialty is the critical care of pulmonology neurology it was very interesting and I must say this such kind of presentation it's done when the doctor actually loves teaching as well it shows your love for teaching the way I I mean I enjoyed it it wasn't just a point to point notifications over there it was divided properly explained very well thank you so much ma'am I am sure our doctors have enjoyed it all for all our doctors please make sure if you have any questions for ma'am please type out in the comment section I'll just take up the questions and we have many many many comments today that have enjoyed the session it was amazing uh Dr rajat Rani has a question in children with Dengue which is preferred uh in children with Dengue which should be preferred single donor platelet or pooled platelets okay so I would probably go with a single donor platelet to decrease the possibility of transfusion reactions uh yes singletonal batteries thank you next question by Dr Chandra shekhar is what is the role of mannitol in acute stroke okay the acute Strokes which are big Strokes with the raised ICP uh definitely uh especially hemorrhagic Strokes manitol is a osmotic agent um because there is a pressure inside the brain there we use many tall to decrease that pressure till decompression craniectomy has been taken because uh that pressure would be killing the nerves you can think of something like Umbra and penumbra so we have to save the penumbra so that we save more neurons and that is why we use uh osmotic agents nowadays apart from many tall we use hypertonic cell line which is available three person infusions because many tall causes as you know many tall has its own side effects also so a three most of the neurologists are preferring three person normal saline okay great other than that lot many positive comments amazing informative they've learned a lot yes uh any more questions audience you can also click on raise hand option and I'll be able to accept your request and you can ask ma'am directly a question so in the meanwhile like I said at this start the session that was planned for tomorrow that's the makers of modern medicine with Dr V Mohan who's known as the father of diabetology it has been postponed the new date will be updated on the app soon all of you have already registered will get a rescheduled evil SMS from our site for a notification from our site and those who have not please do reserve the seat uh just the thing is that instead of tomorrow it would be some some time down the line uh Dr basava Raju I am accepting your request kindly turn on your audio and video yeah we can hear you howling this long uh term covet will last longer madam how long this long this is your question sir am I yes Madam yes so I was going through this particular studies while uh and they it is written over there that when they were following this uh 24 000 patients it was a year but it does um they said that the car it is the cardiac myocarditis which takes um somewhere like seven to eight months to start uh like palpitations that um to stop happenings so I think so one year is the answer from that study uh but but there there is another case reports sir wherein patients have told about one more than one year one and a half year um I think so we are in the that times when we do not know because the covet is also not that old so if someone says one and a half years uh it is like uh we have to wait for this answer but it's a good thing sir that uh um we have to keep an eye on this and most of those patients who pass this one year are the ones who are going for lung transplants at different uh centers I I yes in America I'm a professor in a Medical College Madam we have got some students who are having long term what is the what are the precautions we have to take uh precautions for long coveted what I have uh I see I am an Emergency Physician you are you are the best one for that but I I would suggest um vaccination sir we have seen that uh we have listened to the evidence published in August 2022 where a 17 2.2 percent uh patients even if out of hundreds 83 people would be saved from long covet if they had taken uh two doses and um 84 would be saved if they have taken a third dose so one is vaccination and second is if the patients have underlying uh asthma or copd's use of antivirals early antivirals that also prevents long covet this is what the evidence our cities have given evidence sir um I'm not very sure of whether steroids would prevent long covet I am not sure thank you very much thanks a lot thank you Chandra I am accepting your request kindly please turn on your audio and video hello hello what is the rule in COPD can we can you elaborate I am working as a medical specialist in District Hospital foreign thought to be um a drug which is more for asthmatics especially the severe acute asthma but the uh here in the after now sir if we see to uh the present status of use of magnesium sulfate for copds for those patients who have not improved or inhaled bronchodilator therapy the effect size statistically they have it has shown the drug has shown a good effect in uh in uh almost as similar to exacerbation of asthma so it is now suggested sir it is already there in uh in certain uh websites of COPD management that magnesium sulphate is the new drug for severe COPD accessor patients it is short ending of totalitative activity uh which is helpful it is a short acting law good all interactivity where it should be repeated after how much time in America we can repeat the dose sir the time of bronchodilation uh um you want to uh I want to know we have given the first dose two gram in 10 minutes where should when we can repeat it okay okay how much time how much time it one should wait before the bronchodilation occurs yes sir yes sir I think so it is 30 minutes which is written in the in that this particular paper same pattern as we do in eclampsia yes sir yes sir okay same pattern we should follow sir in my personal practice I feel magnesium is a ubiquitous drug anywhere everywhere it can help sir and I am sure you must be also uh feeling the same sir yes in various conditions so that other can get the knowledge we are using it inclusive we are using it in public we were not using it foreign thank you so much thank you so much Dr Chandra shekhar um and there are a few more questions uh Dr Syed is asking what is the best dose for opioid in appendicitis in children okay uh appendicitis the dose of opioid for relief of pain okay um uh I would I'm not very sure if I would use an opioid for a child for appendicitis you have to understand what is the role of uh why where how does opioid works when the pain is somatic or the pain is visceral so if the pain is visceral it won't work when the pain is somatic uh it would probably uh sorry I would say Versa when the pain is visceral it may work but it will also cause you a lot of its side effects um in severe pain scores that is above 7 out of 10 pain scores I would probably use a morphine 0.1 milligram per kg IV single dose I may use based or a fentanyl dose of 1 mics per kg which is easily available short action but I have to be very worried that these patients will vomit more will uh so more than that I would probably use something like Tramadol in uh appendicitis which is also an opioid uh however it is not that uh opioid which has a similar efficacy as morphine and okay great thank you man uh next question by Dr Carver is in septic shock which is the best vasopressor without further choice not epinephrine if you even if you have any question wherein you don't know there are many given please choose nor epinephrine nowadays it is it is not epinephrine everywhere be it cartagenic uh uh later phases of hypovolemic or distributive shock next question by Dr Chetan is when can we restart anti-platelet agents in patients with hemorrhagic stroke who have cve risk in patients with hemorrhagic stroke hemorrhagic stroke platelets yeah when can we restart anti-platelet agents anti-platelet agents for patients in hemorrhagic stroke okay so that is what we were just discussing uh the same thing that okay you are talking of starting and low dose ecosprint of in the patients same thing four to eight weeks individualize your patient there is nothing like I would start in four weeks or you would start in six weeks see if this really does not come under my purview because by this time patient would not be with me but I would say that when patients come to us who have had stroke uh six months six weeks back and they there are normally who have hemorrhagic Strokes they are not to be started as such but I think so you are talking of patients who had an ischemic stroke and underwent a hemorrhagic conversion or something or it is a low dose aspirin for some cardiac event uh that is what you are asking for but whatever it is individualization of your patient therapy is very important and there are certain lab indices which can help you to do so okay great thank you uh last question by Dr ratus bansod what is your opinion regarding immunotherapy foreign I can talk from my knowledge but I would really leave it to the pulmonologist or a physician to really answer it because this is not when patient comes to me and I this is not my drug so my uh I'm very sorry Dr rupesh I will not answer it why because I choose to remain with those acute minutes one 15-20 minutes um uh please look into evidence what we all but I just want to convey to you is many things look very promising many things look very attractive but finally if you use something which which support you with rcts it you would never fall in the Trap of one uh legal hassles number two are patients have become much more intelligent they Google Google has taught them lot of this so they know which therapy works and which does not work it is very unfortunate but it is true so I would I do not think so there are cities yet on that topic so I'll reserve my answer on this I'm sorry all right yes great so those were the questions for today thank you so much ma'am thank you for joining me uh coming on Netflix and sparing some time for us and for our doctors you can see the Emojis flowing on the screen our doctors have enjoyed this session it was amazing to have you here thank you thank you so much and for all our audience members thank you for joining


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