Background: In 2011, we saw 7 million patients in the emergency department (ED) complaining of chest pain. Most of these patients did NOT have an acute coronary syndrome (ACS) or an acute myocardial infarction (AMI). Missing an AMI is one of the biggest fears we have in the ED. By using validated risk scores, we can help decrease the risk of missing AMI and the resultant adverse events. There are multiple scores available for our use. Thrombolysis in Myocardial Infarction (TIMI) predicts risk of adverse outcomes in the next 14 days. Global Registry of Acute Coronary Events (GRACE) predicts outcomes at 6 months. ED specific scores include HEART and Emergency Department Assessment of Chest Pain (EDACS). But, how well do these scores actually perform? Are we missing AMIs by using these clinical risk scores? Read more →
Author Archive for: mastinmd
The use of therapeutic hypothermia (TH) has become part of the routine care of patients after return of spontaneous circulation (ROSC) from cardiac arrest (Use of the phrase Targeted Temperature Management has become more accepted). It became much more accepted after two separate trials were published in the New England Journal of Medicine in 2002 showing a survival benefit and improved neurologic outcome with use of TH. (1,2) The use of TH has even been given a Level One recommendation by the American Heart Association for comatose post-arrest patients. (3) Uncertainties still remain, however, such as what optimal temperature to use, and most recommendations on specifics related to TH are based on observational studies and expert opinion. So what is the actual evidence behind the use of TH? Read more →
The subclavian route is known to be the site for central line placement with the lowest risk of infection, but can also lead to many mechanical complications . The biggest risk of subclavian line placement is an iatrogenic pneumothorax. The use of ultrasound for subclavian line placement can greatly reduce this risk by watching the needle enter the vein. But does arm position matter for ultrasound guided subclavian central lines? Read more →
I know, I know. We here at REBEL EM are normally very clinically oriented. We take recent articles or hot topics and give you the breakdown and clinical take home points. But a recent event happened that made me look at my own practice, and now on the other side, I feel that I am a better doctor. The hospital I was working at as medical director of the Emergency Department (ED) closed its doors. This was a hospital that had been in the community for more than 60 years. I won’t go into the reasons for closure, but rather, I would like to tell the story from the side of the ED provider and what I had to change until the lights were turned out. Read more →
There has been a lot of debate over the recent years about the safety of crystalloid fluid therapy in acutely ill patients. Several observational studies have shown an increased risk of acute kidney injury (AKI) with the use of normal saline (NS). Other observational studies have shown a decreased risk of AKI when using a buffered solution (Hartmann’s solution, Plasma-Lyte (PL)). What is the best fluid to give to our patients who need fluid resuscitation? The answer to this question is not known, but another step in finding the answer was taken with the release of the SPLIT trial online by JAMA on October 7, 2015.