Author Archive for: srrezaie

Update on Age-Adjusted D-Dimer

11 Jul
July 11, 2014

Update on Age-Adjusted D-DimerD-dimer has been shown to increase with age, which can cause a lower specificity (i.e. more false positive tests) in older patients. The result of this would be that older patients would often have more diagnostic imaging or downstream testing, but on the other hand, maybe a higher cut-off d-dimer value may lead to increased false negative cases (i.e. missed venothromboembolism) and make this strategy less safe. Recently, I wrote a post on age-adjusted d-dimer testing on REBEL EM, but since that post there was a new article that was published in Chest 2014. This post, will specifically focus on an update of age-adjusted d-dimer testing based on the above article. Read more →

REBELCast Episode 1

01 Jul
July 1, 2014

REBELCast LogoWelcome to REBELCast Episode 1, where Matt, Swami, and I are going to tackle a couple of scenarios to help your clinical practice.  Today, we are going to specifically tackle two different topics:

  • Topic #1: Clinically Important Biphasic Anaphylaxis
  • Topic #2: Total Lymphocyte Count (TLC) as a Surrogate Marker for CD4 Counts

Read more →

Introduction of REBEL Cast

19 Jun
June 19, 2014

REBEL Cast LogoFor those who haven’t checked out the site already R.E.B.E.L. EM stands for Rezaie’s Evidence Based Evaluation of Literature in Emergency Medicine. The blog was launched in October 2013, and continues to grow every month, and with that growth we are excited to announce the introduction of REBEL Cast.  Read more →

Critical Care Horizons

11 Jun
June 11, 2014

Critical Care Horizones

Please welcome a new development in critical care publishing with the launch of a new open access critical care journal: CRITICAL CARE HORIZONS!!!  This will be a fresh, new, original voice in the critical care literature, offering thought provoking, cutting-edge commentary, opinion papers, plus state-of-the art review articles. Read more →

R.E.B.E.L. ECG of the Week: LBBB and STEMI

09 Jun
June 9, 2014

R.E.B.E.L. ECG of the Week

89 year old male with PMH of hypertension, stage 3 chronic kidney disease with chief complaint of shortness of breath. Several days ago patient had a laminectomy for radicular pain. He was doing fine post-operatively and began to develop gradual shortness of breath.  He had no complaints of chest pain, nausea/vomiting, fevers, diaphoresis, but did have some weakness.  There were no prior ECGs for comparison.

BP: 98/48 HR: 103 RR: 18 O2 on RA: 94% Temp: 38.6

JVD to the angle of the mandible
Bibasilar Crackles
Sinus Tachycardia
Bilateral lower extremity pitting edema

Labs: Na 125, K+ 4.2, Creatinine 2, BNP > 2500

ECG from triage is shown… Read more →

Left Ventricular Assist Device

29 May
May 29, 2014

Left Ventricular Assist Device (LVAD)The first left ventricular assist device (LVAD) was performed in 1984 and since that time there is an increasingly growing population of patients with LVADs.  This means ED physicians will be seeing more and more of these patients in the ED and should have a basic understanding of how these devices work and have an adequate understanding of common complications and an approach to evaluate these patients. LVADs are typically used for end-stage heart failure for both a bridge to transplantion and for long-term quality of life improvement. Most of the information for this post comes from a great review article written by Chris Partyka et al in EMA 2014. Read more →

Rivaroxaban for Treatment of Symptomatic Pulmonary Embolism

26 May
May 26, 2014

Pulmonary EmbolismTypically, the treatment of acute pulmonary embolism consists of administration of unfractionated heparin or low molecular weight heparin (i.e. enoxaparin) overlapped with vitamin K antagonists (i.e. warfarin).  This can be a very effective treatment regimen, but also very complex.  New direct Xa inhibitors are being used more and more in clinical practice with prevention of venothromboembolism (EINSTEIN-DVT Trial), after major orthopedic surgery (RECORD1 Trial), prevention of stroke in patents with atrial fibrillation (ROCKET-AF Trial) , and in the treatment of acute coronary syndromes.  Recently, the EINSTEIN-PE Trial evaluated oral rivaroxaban for treatment of symptomatic pulmonary embolism. Read more →

Intravenous Fluids and Alcohol Intoxication

01 May
May 1, 2014

Intravenous Fluids and Alcohol IntoxicationFrequently, patients with acute alcohol intoxication are brought to the emergency department (ED) for evaluation and treatment.  Although practice patterns vary, it is not an uncommon practice to give normal saline to these patients in the hopes that the saline will cause a dilution effect on the level of alcohol helping patients sober faster and therefore having a shorter length of stay in the ED.  At the end of 2013 a study was published evaluating intravenous fluids and alcohol intoxication. Read more →

Age Adjusted D-Dimer Testing

28 Apr
April 28, 2014

ThromboembolismD-dimer testing is sensitive for thrombus formation, and in patients who are not high risk, this test is used to rule-out venous thromboembolism. D-dimer has been shown to increase with age, which can cause a lower specificity (i.e. more false positive tests) in older patients.  Specificity can range from 49 – 67% in patients ≤ 50 years of age, but in older patients (i.e. ≥ 80 years of age) the specificity is quoted as 0 – 18%. The result of this is, older patients often have more diagnostic imaging, but a higher cut-off may lead to increased false negative cases (i.e. missed VTE) and make this strategy less safe. So could age adjusted d-dimer testing increase specificity without affecting sensitivity?

Read more →

Topical Anesthetic Use on Corneal Abrasions

21 Apr
April 21, 2014

Corneal AbrasionPatients with corneal abrasions typically come to the emergency department for eye pain.  Most physicians treat these with topical antibiotics, oral analgesia, and for those who are lucky enough 48 – 72 hour follow up with ophthalmology. Oral analgesia does a poor job of controlling these patients pain. Tetracaine is an esterase type anesthetic with a onset of action of 10 – 20 seconds and a duration of action of 10 – 15 minutes.  Use of topical anesthetics are very effective at reducing pain, but there use is discouraged secondary to poor wound healing of the corneal epithelium.  So what is the evidence for topical anesthetic use on corneal abrasions? Read more →

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