No More Heparin for NSTEMI?

14 Feb
February 14, 2019

Background: The 2014 AHA guidelines for the management of NSTEMI, recommend unfractionated heparin with an initial loading dose of 60IU/KG (maximum 4,000 IU) with an initial infusion of 12 IU/kg/hr (maximum 1,000 IU/hr) adjusted per active partial thromboplastin time to maintain therapeutic anticoagulation according to the specific hospital protocol, continued for 48 hours or until PCI is performed (Level of Evidence B) [2]. With even a higher level of evidence the 2014 AHA guidelines for the management of NSTEMI, also recommend enoxaparin 1mg/kg subcutaneously every 12 hours with reduced dosing to 1mg/kg subcutaneously in patients with a creatinine clearance <30mL/min) (Level of Evidence A) [2].  The studies supporting this therapy were performed primarily on patients with a diagnosis of unstable angina and in the era before dual anti platelet therapy and early catheterization/revascularization. Therefore, the authors of this paper looked to evaluate the clinical outcomes associated with parenteral anticoagulation therapy (Heparin) in the era of dual anti-platelet therapy in patients with NSTEMI. Read more →

FOAM Impact Study

13 Feb
February 13, 2019

Online educational resources, social media, and asynchronous education increasingly dominate innovation and continuing medical education for practicing emergency physicians. The “Free Open-Access Medical Education” (FOAM) movement has utilized the power of global connectivity to drive narrowing of the knowledge translation window, however critics have urged caution and warned of error, as many of these resources lack peer review or quality control.REBEL EM is an online educational resource widely used throughout the FOAM community, garnering an average of 3,000 – 30,000 views/engagements per educational post, and satisfying all quality indicators that have been previously identified as markers of reliability and usability for digital scholarship.To this end, we at REBEL EM are conducting a survey looking at rates of certain medication usage in the treatment of renal colic.

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The True Prevalence of PE in ED Syncope Patients

11 Feb
February 11, 2019

Background: Syncope, defined as a transient loss of consciousness with a complete recovery, is a common ED presentation. There are numerous causes of syncope ranging from the relatively benign (eg vasovagal syncope) to the potentially life-threatening (eg dysrhythmia, ectopic pregnancy, aortic dissection). Among the life-threatening diagnoses is pulmonary embolism (PE). PE is a common cause of sudden, unexpected, non-traumatic death and, syncope in the setting of PE portends poor 30-day outcomes (Roncon 2018). What is not well known is how often ED presentations of syncope are the result of PE. A study in 2016 demonstrated a 17.3% rate of PE in first time syncope presenting to the ED but, had numerous significant biases and limitations (Prandoni 2016). Ultimately, this study is unlikely to reflect the reality of ED syncope cases and lacks external validity. Incorporating the PESIT trial data into clinical assessment would lead to a profound increase in PE evaluation without adding significant benefit. Additional clinical data demonstrating the true prevalence of PE in syncope patients is needed to confirm these suspicions. Read more →

REBELCast Ep62 – US Guided PIVs with Jacob Avila, MD

07 Feb
February 7, 2019

Welcome back to REBELCast.  In this episode we talked with Jacob Avila about US guided PIVs. Difficult IV access in an already busy department can be a frustrating thing, but it doesn’t have to be.  Patients and providers are often frustrated for different reasons.  Patients for multiple IV attempts and providers because of the time it can take to perform the procedure, delays in care, or lack of success. If you want to get better at this all-important procedure, read/listen on. Read more →

REBEL Core Cast 4.0 – RSI Cheat Codes

06 Feb
February 6, 2019

Take Home Points

  1. Bed Up Head Elevated (BUHE) position is a simple intervention that can reduce the rate of intubation-related complications.
  2. The bougie should be considered standard practice in all intubations and has an NNT = 11 for 1st pass success.
  3. Consider using Suction Assisted Laryngoscopy for Airway Decontamination (SALAD) for all intubations to avoid the failed airway due to contamination.

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