Author Archive for: srrezaie

The ENDAO Trial: Is Apneic Oxygenation a Futile Intervention in ED RSI?

21 Aug
August 21, 2017

Background: One of the most feared complications associated with rapid sequence intubation (RSI) is hypoxemia ultimately leading to cardiac arrest.  The FELLOW Trial, a recent randomized controlled trial demonstrated no difference in hypoxemia rates between patients that received apneic oxygenation and those that did not (i.e. “usual practice”) in the ICU.  What many forget about this trial is 1/3 of the patients were pre-oxygenated with a bag valve mask and another 1/3 of the patients with a BIPAP device, meaning that 2/3rds of these patients were not truly apneic during the period that induction medications were pushed up to laryngoscopy.  Currently, there is a lack of high quality research on the use of apneic oxygenation in the ED setting.  Many still use the intervention as it is cheap, easy to do, with no increase in patient harm, but there are still naysayers that do not feel the intervention is warranted in standard RSI practice. Read more →

Spinal Immobilization in Trauma Patients

07 Aug
August 7, 2017

Background: It has been common practice in trauma to place patients in cervical collars and on long backboards (LBBs) to achieve spinal immobilization. LBBs are used to help prevent spinal movement and facilitate extrication of patients. Cervical collars (C-Collars) are used to help prevent movement of the cervical spine and often are combined with lateral head blocks and straps. The theory behind this is that spine immobilization prevents secondary spinal cord injury during extrication, transport, and evaluation of trauma patients by minimizing movement.  Most of this information has been passed on from historical teachings, like the Advanced Trauma Life Support (ATLS) courses, and not from scientific research. To date there has been no high-quality evidence that use of spinal immobilization improves patient outcomes. In this post, we will review the evidence associated with spinal immobilization in trauma patients. Read more →

Balanced vs Unbalanced Fluids in Pediatric Severe Sepsis

27 Jul
July 27, 2017

Background: Fluid resuscitation with crystalloid is one of the most basic initial management approaches to adult and pediatric patients with severe sepsis and septic shock. However, which fluid should we be giving, and does it matter?  Should we give an unbalanced, chloride rich solution such as normal saline or a balanced, chloride restrictive fluid, such as lactated ringers, Plasma-Lyte, or Normasol? Interestingly, the 2016 Surviving Sepsis Guidelines, added resuscitation with balanced fluids into the guidelines, although a weak recommendation with low quality of evidence.

This recommendation was based on some growing adult data, albeit retrospective, showing that resuscitation strategies using normal saline may be harmful and associated with increased risk of AKI (1), need for CRRT (1) and increased mortality (2-3). The effects of balanced fluids however, have not been studied in the resuscitation of children in severe sepsis and septic shock. Read more →

REBEL Cast Episode 39 – The TOAST Trial: Dexamethasone for Acute Pharyngitis

24 Jul
July 24, 2017

Background: Sore throat is a common presentation to the emergency department as well as primary care clinics.  Corticosteroids inhibit transcription of pro-inflammatory mediators in airway endothelial cells responsible for pharyngeal inflammation and symptoms of pain.  They have been used in other upper respiratory tract infections such as acute sinusitis and croup.  In adults, previous studies with dexamethasone are in combination with antibiotics but studies of children have included dexamethasone without antibiotics.  This study is unique as it is evaluating the benefits of oral corticosteroids for acute sore throat in primary care in the absence of antibiotics Read more →

Apneic Oxygenation (ApOx): A Review of the Evidence in Critical Care & Emergency Medicine

17 Jul
July 17, 2017

Background: Apneic oxygenation (ApOx) is the passive flow of oxygen into the alveoli during apnea.  This passive movement occurs due to the differential rate between alveolar oxygen absorption and carbon dioxide excretion producing a mass flow of gas from the upper respiratory tract into the lungs.  Another important component of this maneuver is maintaining a patent airway so that supplemental oxygen administered through the nares is able to be delivered to the alveoli.  This practice has been a game changer in emergency airway management for many providers.  However, there are still some naysayers that believe in the sickest patients ApOx may not be so beneficial. This post is a review of two recent systematic reviews/meta-analyses published in the critical care and ED/retrieval settings on the use of ApOx. Read more →

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