October 2015 REBELCast: The All Thoracotomy Episode

ED ThoracotomyWelcome to the October 2015 REBELCast, where Swami, Matt, and I are going to tackle a couple of topics in the world of Trauma, specifically ED Thoracotomy. Now we all know that ED thoracotomy is a last ditch salvage effort, performed under specific clinical circumstances, during a traumatic arrest. The purpose of the ED thoracotomy is to evacuate pericardial tamponade, control hemorrhage, improve coronary/cerebral blood flow, and if needed internal cardiac massage. The purpose of this podcast is to discuss specific indications where this already low yield procedure may have some benefit.

  • Topic #1: FAST US Examination as a Predictor of Outcomes After Resuscitative Thoracotomy
  • Topic #2: Blunt Trauma Thoracotomy

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Screen Shot 2015-09-26 at 7.29.36 AMI recently gave a talk at my old alma mater (Texas A&M College of Medicine) on creating a Professional and Scholarly Community with FOAM in early September of 2015.  One of the things I was most amazed by was how many people had not heard of the concept of FOAM, but more importantly the number of questions I received after my talk on how to get started and how to consume FOAM.  Now many people in the FOAM world have posted blog posts, videos, and even podcasts on how to do this, but I thought I would write a blog post on how I keep up and stay organized for anyone who is new to the FOAM world or if someone simply asks you how to get started feel free to just refer them here. Continue reading

The Modern Day Superhero

The Modern Day SuperheroI was recently invited by Rick Body and Natalie May to speak at the Royal College of Emergency Medicine (RCEM) Meeting in Manchester, England, September 2015.  The topic was “The Essence of Emergency Medicine.”  I was allotted 20 minutes to give this talk and in my mind I immediately thought about two questions:

  1. How am I supposed to talk about the essence of EM in 20 minutes?
  2. What is it that we really do in the emergency department on a day to day basis?

So instead what I did, was make an executive decision to change the lecture to something slightly different.  I figured we could talk about the modern day superhero.  When you think about it, some of the things we are asked to do in the first 20 minutes of a patients care, truly are superhuman. Now when we were kids, many of us wanted to be superheroes.  How many of us tied a table cloth or towel around our necks like a cape?  Well, to me emergency medicine is one of the closest things to a  modern day superhero.  So instead of the essence of emergency medicine, I gave a talk on the five powers of the modern day superhero.  To me, these are the things that encompass the essence of EM and our initial care of patients.

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Catheter Directed Thrombolysis: The Magic Bullet for Submassive Pulmonary Embolism?

thrombolysisBackground: When evaluating therapeutic options for PE, there are three categories in my mind: Subsegmental, Submassive, and Massive. For simplicity sake lets just say subsegmental PEs get treated with anticoagulation and massive PEs get treated with thrombolysis. The submassive category is a bit trickier. For example the PEITHO trial looked at full dose systemic fibrinolysis, tenecteplace in intermediate-risk pulmonary embolism and found a reduced risk of death or cardiovascular collapse by 56% but this was offset by an almost 5-fold increased risk of major bleeding and 10-fold increased risk of intracranial hemorrhage compared to anticoagulation alone. The MOPETT Trial on the other hand, looked at half dose systemic tPA for submassive PE and found that there was a significant reduction in pulmonary artery systolic pressures at 28 months vs usual care, with no increase in intracranial hemorrhage but failed to show any statistical mortality benefit compared to anticoagulation alone. Maybe a more simple answer to the submassive PE group would be to do catheter directed thrombolysis at lower doses than given with systemic fibrinolysis. Continue reading

Time to Antibiotics in Sepsis: A Metric Not Supported by “High Quality” Evidence

Time to Abx in SepsisBackground: Some of the major take home points from the sepsis trilogy of studies recently published (ProCESS, ARISE, and ProMISe) was that early identification of patients with sepsis, early intravenous fluids, and timely, appropriate broad-spectrum antibiotics is key to decreasing morbidity and mortality. In 2006 a study by Kumar et al [3] showed a 7.6% increase in mortality in patients with sepsis for every hour of delay after the onset of shock, but this finding has not been reproduced. In fact, the results of timing of antibiotic administration on outcomes have been all over the map. Regardless, the Surviving Sepsis Campaign still has very specific recommendations regarding the timing of antibiotics. And even more painful is that metrics for the quality of care of patients with severe sepsis and septic shock are now recognizing these recommendations as core measures. Continue reading