Background: Alcohol and drug intoxication is common in trauma patients and a significant proportion of cervical spine (c-spine) injuries occur in patients with intoxication. A standard approach to both intoxicated and sober patients with suspected c-spine injury in many trauma centers includes the placement of a rigid cervical collar for spinal immobilization until the c-spine can be “cleared.” Even after a negative CT, intoxicated patients often are immobilized for prolonged periods of time until a reliable exam can be performed due to concern for missed findings on CT scan, specifically unstable ligamentous injuries. This practice is less than ideal, as prolonged c-spine immobilization is associated with DVT, atelectasis, aspiration pneumonia, and elevated intracranial pressures. In 2015, the Eastern Association for the Surgery of Trauma (EAST) demonstrated that CT imaging of obtunded patients due to any cause would miss approximately 9% of cervical spine injuries, most of which are clinically insignificant. They additionally found no benefit to prolonged immobilization. Read more →
Background: Emergency providers frequently care for agitated patients ranging from restlessness to verbally and physically aggressive. Agitation is a symptom, not a diagnosis and these patients require careful evaluation to rule in or out serious medical conditions. Unfortunately, the agitation itself often obstructs this evaluation and places the patient, other patients and staff at risk. While verbal de-escalation can be effective in select cases, administration of medications for behavioral control is often required. Numerous medications are available for this indication, but the optimal approach is still unclear. Read more →
Background: Acute asthma exacerbations are a common presentation to pediatric emergency departments (EDs). Standard treatment with inhaled beta agonists and corticosteroids are often sufficient in mild asthma but can fall short in the treatment of moderate to severe exacerbations. Magnesium sulfate (MgSO4) has long been touted as an adjunct treatment due to its bronchodilatory properties (both in its intravenous (IV) and nebulized form). Despite its routine use, the evidence for its benefit is inconsistent, particularly in the adult population where the most recent large RCT demonstrated modest benefits (Goodacre 2013). Read more →
REBEL Cast Ep58 – Would you be SHoC-ED if POCUS did not Improve Clinical Outcomes in Patients with Undifferentiated Shock?
Background: POCUS has been touted as the stethoscope 2.0, a true game changer in patient care. There is no patient population that this statement should hold more true for, than in patients with undifferentiated shock (SBP <100mmHg or SI > 1). Everyone has a story about how ultrasound changed their management or even saved a patient’s life. Unfortunately, the plural of anecdote is not data. To date, there have not been any prospective randomized controlled trials examining POCUS outcomes on survival in this population. Enter the Sonography in Hypotension and Cardiac Arrest in the Emergency Department (SHoC-ED) trial. Read more →
Background/Introduction: Acute heart failure is a common diagnosis encountered among patients presenting to the Emergency Department with complaints of shortness of breath. The emergency treatment of these patients has traditionally focused on alleviation of their symptoms of breathlessness and anxiety in addition to optimization of hemodynamics and rapid reduction in both preload and afterload. The treatment of associated symptoms has often included the administration of morphine, which has been posited to have both beneficial physiologic (vasodilation, reduction of preload) and central nervous system (reduction of breathlessness, anxiety, and pain) effects. However, recent experimental and experiential data have pointed to morphine’s potential for effecting negative physiological and CNS responses, thereby raising the possibility of increasing patient morbidity and/or mortality. Additionally, no large randomized controlled trials have been conducted to study the potential risks and benefits of morphine administration in patients presenting with acute heart failure. Despite these factors, a contingent of Emergency Physicians continue to routinely use morphine in the treatment of patients presenting with acute heart failure. Read more →