More Trials Showing Harm of Opioids in ACS…or do They?

22 Feb
February 22, 2018

Background: Typical medical treatment of ACS patients include dual antiplatelet therapy (DAPT) and revascularization with primary percutaneous coronary intervention (PPCI).  Nitroglycerin is first line therapy in the treatment of pain in ACS with morphine as a common adjunct. Morphine helps relieve pain which decreases catecholamines and oxygen demand.  We have written about the use of Morphine in ACS before on REBEL EM and advocated for fentanyl over morphine for pain control in patients with refractory pain to IV nitroglycerin.  However, two new trials have been published in the past month: An observational trial in 300 patients with STEMI receiving morphine and a randomized trial using fentanyl which requires us to revisit the use of opioids in ACS. Read more →

Is it PROPER to PERC it Up?

19 Feb
February 19, 2018

Background: The diagnosis of PE is a tricky thing.  We want to limit over-testing patients and therefore, over-diagnosis. On the other hand, we don’t want to limit testing so much that we miss the diagnosis where treatment would make a difference.  The pulmonary embolism rule-out criteria (PERC) was created to reduce testing in patients who have a low probability of PE (i.e. prevalence of <1.8%) in which further testing would not be necessary.  There have been many observational trials published on this score but until now there has not been a prospective randomized clinical trial (The PROPER Trial). Read more →

Peripheral Vasopressors: Safe or Dangerous?

12 Feb
February 12, 2018

Background: We have discussed the safety of peripheral vasopressors on REBEL EM before. In that review by Loubani et al was a systematic review of 85 articles and 270 patients.  95% of the extravasation events occurred in PIVs with infusions running greater than 4 hours and 85% of extravasation events occurred in PIVs distal to the antecubital fossa.  The major limitation of this systematic review is that the majority of the data was derived from case reports and case series and not prospective trials.  The authors of this current study sought to determine the incidence of complications of running vasopressors through PIVs in patients with circulatory shock in a prospective, observational trial. Read more →

REBEL Cast Ep 45: How to Build a Great Presentation

05 Feb
February 5, 2018

What’s Wrong With Lectures/Presentations Now?

  • Lecturing style has remained stagnant despite the fact that our understanding of how people learn has changed.
  • Most presentations make the supportive media (i.e. slides) the focus of the presentation without thought about the story or the delivery.
  • Lectures are too focused on the educator instead of focusing on the needs of the learner.

Read more →

An Emergency Difficult Airway Predictor Would be From HEAVEN

31 Jan
January 31, 2018

Background: Predicting an anatomically and/or physiologically challenging airway is not a straightforward task by any stretch of the imagination.  There are some existing difficult-airway prediction tools available (i.e. LEMON = Look externally, Evaluate 3-3-2 rule, Mallampati score, Obstruction, Neck mobility), but many of them were derived in an elective surgery setting and may not be as applicable to emergency airway management.  Additionally, these prediction models only focus on anatomical challenges and ignore physiologic ones. Several components of the LEMON approach require an awake, cooperative patient. The authors of this paper derived a tool, called the HEAVEN criteria (Hypoxemia, Extremes of size, Anatomic abnormalities, Vomit/blood/fluid, Exsanguination, Neck mobility issues) to address this clinical need. Read more →

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