As emergency physicians, we are constantly on the look out for elevated blood pressures and the potential devastating consequences. We are concerned about intracranial bleeds and acute pulmonary edema from heart failure. But what about the patient that comes in with high blood pressures, yet has no symptoms? Do we need to treat the number or the patient? In this post we will tackle this clinical dilemma of elevated asymptomatic hypertension: To treat or not to treat? Read more →
Animal bites are a common cause of injury in the United States. About 4.5 million Americans/year (5% of all traumatic wounds in the ED) will sustain a bite injury. Dog bites compromise a majority of these wounds. The classic teaching is that dog bites should not be closed primarily and they should all be prophylactically treated with antibiotics. When dog bites become infected, Pasteurella species, specifically P. canis, are the most common pathogens. Amoxicillin-clavulanate (AKA “dog-mentin”) is the antibiotic of choice. It’s also important to keep in mind that Emergency Department repaired lacerations (not just dog bites but all comers) have a 3-7% infection rate. As usual, the dogma (pun intended) is based on minimal if any evidence. Additionally, there are some recent articles that are relevant to the discussion that should be discussed.
Recently, there has been a lot of buzz about the use of topical tranexamic acid for epistaxis or oral bleeds on multiple social media platforms. Everyone seems so happy that it works so well, but we thought we would look through the literature and see what the evidence for use of topical tranexamic acid (TXA) is and how best to compound it for these clinical dilemma. We performed a PubMed, and Ovid search using the terms “topical” AND/OR “oral solution” AND/OR “intranasal” PLUS “tranexamic acid” to answer our questions at hand. Read more →
D-dimer has been shown to increase with age, which can cause a lower specificity (i.e. more false positive tests) in older patients. The result of this would be that older patients would often have more diagnostic imaging or downstream testing, but on the other hand, maybe a higher cut-off d-dimer value may lead to increased false negative cases (i.e. missed venothromboembolism) and make this strategy less safe. Recently, I wrote a post on age-adjusted d-dimer testing on REBEL EM, but since that post there was a new article that was published in Chest 2014. This post, will specifically focus on an update of age-adjusted d-dimer testing based on the above article. Read more →
Welcome to REBELCast Episode 1, where Matt, Swami, and I are going to tackle a couple of scenarios to help your clinical practice. Today, we are going to specifically tackle two different topics:
- Topic #1: Clinically Important Biphasic Anaphylaxis
- Topic #2: Total Lymphocyte Count (TLC) as a Surrogate Marker for CD4 Counts
For those who haven’t checked out the site already R.E.B.E.L. EM stands for Rezaie’s Evidence Based Evaluation of Literature in Emergency Medicine. The blog was launched in October 2013, and continues to grow every month, and with that growth we are excited to announce the introduction of REBEL Cast. Read more →
Typically, the initial evaluation of blunt trauma patients involves a supine anteroposterior (AP) chest x-ray (CXR) which has a poor sensitivity for the detection of pneumothorax (PTX), and has been reported as low as 20% - 48%. Following the CXR computed tomography (CT) has been the standard for the diagnosis of pneumothorax. The use of ultrasonography to diagnose pneumothorax was first described in 1986 in animal studies. Since then there have been many studies that have shown bedside ultrasound can rapidly detect pneumothorax, helping avoid serious potential consequences (i.e. tension pneumothorax), especially in patients requiring mechanical ventilation. There are several different sonographic signs that can be used to detect pneumothorax, specifically, sonographic lung sliding. But how good is ultrasound for the detection of pneumothorax?
Please welcome a new development in critical care publishing with the launch of a new open access critical care journal: CRITICAL CARE HORIZONS!!! This will be a fresh, new, original voice in the critical care literature, offering thought provoking, cutting-edge commentary, opinion papers, plus state-of-the art review articles. Read more →
89 year old male with PMH of hypertension, stage 3 chronic kidney disease with chief complaint of shortness of breath. Several days ago patient had a laminectomy for radicular pain. He was doing fine post-operatively and began to develop gradual shortness of breath. He had no complaints of chest pain, nausea/vomiting, fevers, diaphoresis, but did have some weakness. There were no prior ECGs for comparison.
BP: 98/48 HR: 103 RR: 18 O2 on RA: 94% Temp: 38.6
JVD to the angle of the mandible
Bilateral lower extremity pitting edema
Labs: Na 125, K+ 4.2, Creatinine 2, BNP > 2500
ECG from triage is shown… Read more →
The first left ventricular assist device (LVAD) was performed in 1984 and since that time there is an increasingly growing population of patients with LVADs. This means ED physicians will be seeing more and more of these patients in the ED and should have a basic understanding of how these devices work and have an adequate understanding of common complications and an approach to evaluate these patients. LVADs are typically used for end-stage heart failure for both a bridge to transplantion and for long-term quality of life improvement. Most of the information for this post comes from a great review article written by Chris Partyka et al in EMA 2014. Read more →