BACKGROUND The management of patients with tricyclic antidepressant drug overdose can be a challenge for the emergency department physician. Tricyclic antidepressants block alpha-adrenergic receptors and the anticholinergic effects may lead to cardiotoxicity, resulting in arrhythmias and hypotension that can lead to patient mortality. This report is of a case of a 28-year-old woman who presented with cardiac arrest due to amitriptyline overdose and who responded to intravenous lipid emulsion (ILE) therapy. CASE REPORT A 28-year-old woman was admitted to the emergency department with amitriptyline overdose. She suffered a cardiac arrest followed by cardiovascular and neurological complications. Hypotension and lack of a pulse did not respond to treatment with high-dose sodium, but she stabilized following treatment with ILE. The prompt response from the emergency team guaranteed rapid intervention that may have influenced the successful results. CONCLUSIONS Despite the frequency and severity of poisoning with tricyclic antidepressants, there is little consensus among physicians regarding patient management. This case showed the successful use of ILE as rescue therapy in a patient in cardiac arrest following amitriptyline overdose. However, the successful outcome obtained in this case is not a recommendation for the use of ILE as a first-line treatment for the management of patients with tricyclic antidepressant drug overdose. Controlled clinical studies are required to evaluate the safety and efficacy of ILE in the management of tricyclic antidepressant drug overdose.

Introduction: Bleeding associated with elevated blood urea nitrogen (BUN) is a known complication. Patients with uremia require a central venous catheter insertion by dialysis. The relation between BUN and bleeding complications during central venous catheter insertion is not yet clear. Objective: We described the frequency of complications associated with central venous catheter implantation in uremic patients and evaluated the statistical relationship between bleeding complications and catheter type, number of punctures, and catheter insertion site. Also, we determined if any value of BUN is associated with bleeding complications. Methods: We included patients with a serum value of BUN > 70 mg/dl that required insertion of a central venous catheter. The quantitative variables were expressed through the measure of central tendency. A bivariate analysis and a ROC curve were performed. Results: A total of 273 catheters were included in this study. Bleeding complications were detected in 69 cases (25.3%), and local bleeding was the most frequent complication in 51/69 cases. Statistically significant association was not established. We did not find a specific cut-off value directly related to BUN levels and the rate of complications. Conclusion: Bleeding complications associated with the insertion of central venous catheter and the suspected disorder of hemostasis given by BUN levels > 70 mg/dl are common. It was not possible to determine a BUN cut-off value to predict complications. The association analysis was not conclusive. High BUN levels should not be considered a high-risk condition for central venous cannulation under ultrasound guidance performed by trained personnel.

Introducción. El trauma es una de las entidades con mayor morbimortalidad en el mundo. Los equipos especializados en la atención del paciente traumatizado son llamados <>. Dichos equipos surgieron de la necesidad de brindar tratamiento oportuno multidisciplinario a individuos con heridas que condicionan gran severidad en la guerra; sin embargo, con el paso del tiempo se trasladaron al ámbito civil, generando un impacto positivo en términos de tiempos de atención, mortalidad y morbilidad. El objetivo de este estudio fue describir el proceso de desarrollo de los equipos de trauma a nivel mundial y la experiencia en nuestra institución en el suroccidente colombiano. Métodos. Se realizó una búsqueda en la base de datos PUBMED, que incluyó revisiones sistemáticas, metaanálisis, revisiones de Cochrane, ensayos clínicos y series de casos. Resultados. Se incluyeron 41 estudios para esta revisión narrativa, y se observó que el tiempo de permanencia en el Emergencias, el tiempo de traslado a cirugía, la mortalidad y las complicaciones asociadas al trauma fueron menores cuando se implementan equipos de trauma. Discusión. El diseño de un sistema de atención y valoración horizontal de un paciente con traumatismos severos produce un impacto positivo en términos de tiempos de atención, mortalidad y morbilidad. Se hace necesario establecer los parámetros operativos necesarios en las instituciones de salud de alta y mediana complejidad en nuestro país para implementar dichos equipos de trabajo.

Traumatic brain injury (TBI) remains a leading cause of mortality and disability in Colombia and other low- and middle-income countries (LMICs), where disparities in resource availability limit implementation of standardized care. The first edition of BOOTStraP (Beyond One Option for Treatment of Traumatic Brain Injury: A Stratified Protocol), published in 2020, provided guidance for TBI management across variable healthcare settings. Advances in neurotrauma care prompted development of an updated protocol. How can TBI management be optimized across prehospital care, emergency care, neurosurgical surgery, and intensive care phases in settings with varying resource availability? A multidisciplinary panel of 17 national experts in prehospital care, emergency medicine, neurosurgery, and intensive care conducted a structured consensus process using Delphi principles and Nominal Group Technique. Eleven predefined clinical questions were addressed. Recommendations were developed through subgroup work, literature review, and iterative voting, requiring ≥70% agreement at subgroup level and ≥90% plenary consensus. Final algorithms were stratified according to resource availability and healthcare complexity. The second BOOTStraP edition produced 9 integrated management algorithms covering prehospital transport, emergency care, neurosurgical decision-making, and critical care. Interventions are stratified and color-coded by resource requirements, enabling feasible actions in low-, intermediate-, and high-resource settings. Algorithms integrate neuroprotection goals, triage criteria, surgical indications, and monitoring strategies. BOOTStraP provides a pragmatic, phase-based, resource-sensitive framework bridging evidence-based recommendations with real-world constraints. This approach supports context-adapted decision-making and may reduce secondary brain injury while improving standardization of TBI care in resource-limited environments.

Methods to guide fluid therapy in spontaneously breathing patients are scarce. No studies have reported the accuracy of end-tidal CO₂ (ET-CO₂) to predict volume responsiveness in these patients. We sought to evaluate the ET-CO₂ gradient (ΔET-CO₂) after a passive leg rise (PLR) maneuver to predict volume responsiveness in spontaneously breathing healthy adults. We conducted a prospective study in healthy adult human volunteers. A PLR maneuver was performed and cardiac output (CO) was measured by transthoracic echocardiography. ET-CO2 was measured with non-invasive capnographs. Volume responsiveness was defined as an increase in cardiac output (CO) > 12% at 90 s after PLR. Of the 50 volunteers, 32% were classified as volume responders. In this group, the left ventricle outflow tract velocity time integral (VTI_LVOT) increased from 17.9 ± 3.0 to 20.4 ± 3.4 (p = 0.0004), CO increased from 4.4 ± 1.5 to 5.5 ± 1.6 (p = 0.0), and ET-CO₂ rose from 32 ± 4.84 to 33 ± 5.07 (p = 0.135). Within the entire population, PLR-induced percentage ∆CO was not correlated with percentage ∆ET-CO₂ (R² = 0.13; p = 0.36). The area under the receiver operating curve for the ability of ET-CO₂ to discriminate responders from non-responders was of 0.67 ± 0.09 (95% CI 0.498–0.853). A ΔET-CO₂ ≥ 2 mmHg had a sensitivity of 50%, specificity of 97.06%, positive likelihood ratio of 17.00, negative likelihood ratio of 0.51, positive predictive value of 88.9%, and negative predictive value of 80.5% for the prediction of fluid responsiveness. ΔET-CO₂ after a PLR has limited utility to discriminate responders from non-responders among healthy spontaneously breathing adults.

An 80-Year-Old Woman with Alzheimer Disease and Accidental Poisoning with Pyrethroid Pesticide Successfully Treated with Intravenous Lipid Emulsion - Article abstract #928420