Author Archive for: srrezaie

Is it PROPER to PERC it Up?

19 Feb
February 19, 2018

Background: The diagnosis of PE is a tricky thing.  We want to limit over-testing patients and therefore, over-diagnosis. On the other hand, we don’t want to limit testing so much that we miss the diagnosis where treatment would make a difference.  The pulmonary embolism rule-out criteria (PERC) was created to reduce testing in patients who have a low probability of PE (i.e. prevalence of <1.8%) in which further testing would not be necessary.  There have been many observational trials published on this score but until now there has not been a prospective randomized clinical trial (The PROPER Trial). Read more →

Peripheral Vasopressors: Safe or Dangerous?

12 Feb
February 12, 2018

Background: We have discussed the safety of peripheral vasopressors on REBEL EM before. In that review by Loubani et al was a systematic review of 85 articles and 270 patients.  95% of the extravasation events occurred in PIVs with infusions running greater than 4 hours and 85% of extravasation events occurred in PIVs distal to the antecubital fossa.  The major limitation of this systematic review is that the majority of the data was derived from case reports and case series and not prospective trials.  The authors of this current study sought to determine the incidence of complications of running vasopressors through PIVs in patients with circulatory shock in a prospective, observational trial. Read more →

An Emergency Difficult Airway Predictor Would be From HEAVEN

31 Jan
January 31, 2018

Background: Predicting an anatomically and/or physiologically challenging airway is not a straightforward task by any stretch of the imagination.  There are some existing difficult-airway prediction tools available (i.e. LEMON = Look externally, Evaluate 3-3-2 rule, Mallampati score, Obstruction, Neck mobility), but many of them were derived in an elective surgery setting and may not be as applicable to emergency airway management.  Additionally, these prediction models only focus on anatomical challenges and ignore physiologic ones. Several components of the LEMON approach require an awake, cooperative patient. The authors of this paper derived a tool, called the HEAVEN criteria (Hypoxemia, Extremes of size, Anatomic abnormalities, Vomit/blood/fluid, Exsanguination, Neck mobility issues) to address this clinical need. Read more →

The ADRENAL Trial: Steroids in Septic Shock

22 Jan
January 22, 2018

Background: Randomized clinical trials evaluating the efficacy of adjunctive corticosteroids in septic shock have shown conflicting evidence of clinical relevance. Two trials in particular [2][3] looked at lower dose hydrocortisone (200mg/day) and its effect on mortality in patients with septic shock resulting in conflicting results in regards to mortality, but both showing earlier reversal of shock in patients treated with hydrocortisone. The current surviving sepsis guidelines recommend the use of hydrocortisone in patients with septic shock after adequate fluid resuscitation and use of vasopressors who have not achieved hemodynamic stability, but this recommendation is classified as weak evidence (Level 2C). Due to these weak recommendations there has been a variability in use of corticosteroids in septic shock. On Jan 19th, 2018 the ADRENAL Trial results were published trying to once and for all answer the question of adjunctive steroids in septic shock. Read more →

Should we Pump up the Juice (Steroids) in Septic Shock?

18 Jan
January 18, 2018

Background: A Cochrane review was published in 2015 evaluating 33 trials with 4,268 participants to evaluate the effects of corticosteroids on death at one month in patients with sepsis.  In that meta-analysis the authors concluded that despite the overall low quality of evidence, corticosteroids still reduced mortality among patients with sepsis. Corticosteroids in sepsis/septic shock has been a controversial topic as the exact dose, which steroid to use, which patients will benefit and when to start them have all been debated.  Read more →

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