Author Archive for: srrezaie

April 2015 “Skeptical Edition” REBELCast

20 Apr
April 20, 2015

April 2015 "Skeptical Edition" REBELCastWelcome back to a special edition, or should I say “skeptical edition” of REBELCast. We have started to do something new by inviting guests onto the show to discuss papers in the literature they find interesting.  This month I had the pleasure of working with Ken Milne, an emergency room physician in Canada. Today, Ken and I are going to specifically discuss a new device that recently got FDA approval for CPR in Out of Hospital Cardiac Arrest (OHCA), and the question we are trying to answer is:

Is active Compression Decompression CPR with Augmentation of Negative Intrathoracic Pressure for Treatment of Out-of-Hospital Cardiac Arrest superior to standard CPR?

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Accelerated Diagnostic Protocol for Chest Pain Not Useful in a US Population?

16 Apr
April 16, 2015

Accelerated Diagnostic ProtocolThere are approximately 8 to 10 million patients coming to Emergency Departments (EDs) in the United States annually. In the US, we use a very liberal testing strategy in order to avoid acute coronary syndrome (ACS) in patients presenting with chest pain. This results in over 50% of ED patients with acute chest pain receiving serial cardiac biomarkers, stress testing, and cardiac angiography at an estimated cost of $10 to $13 billion annually and yet fewer than 10% of these patients are diagnosed with ACS.

The 2-hour accelerated diagnostic protocol (ADAPT) combines  0 and 2 hour cardiac troponin (cTn), electrocardiograms (ECGs), and an adapted Thrombolysis in Myocardial Infarction (TIMI) score to help identify ED patients safe for early discharge. Previous studies show that this strategy can identify as many as 20% of patients for early discharge with a high sensitivity of 97.9% to 99.7% for major adverse cardiac events (MACE) at 30 days. This ADP has yet to be tested in a US population until now.

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April 2015 REBELCast

06 Apr
April 6, 2015

April 2015 REBELCastWelcome to the April 2015 REBELCast, where Swami, Matt, and I are going to tackle a couple of articles just published this year. Today we are going to specifically tackle:

  • Topic #1: Basic Life Support (BLS) vs Advanced Cardiac Life Support (ACLS) in Out of Hospital Cardiac Arrest (OHCA)
  • Topic #2: PROMISE Trial – Anatomic vs Functional Testing for Coronary Artery Disease (CAD)

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The Protocolised Management in Sepsis (ProMISe) Trial

17 Mar
March 17, 2015

ProMISeSince 2002, the surviving sepsis campaign (SSC) has stated that best practice in sepsis care includes: early recognition, source control, appropriate/timely antibiotic therapy, resuscitation with intravenous fluids (IVF) and vasoactive medications. Resuscitation of the septic patient in the emergency department has been largely based off the 2001 Rivers trial. This single center study’s focus was to optimize tissue oxygen delivery following several parameters including, central venous pressure (CVP), mean arterial pressure (MAP), and central venous oxygen saturation (SCVO2) to guide IVF, vasoactive medications, and packed red blood cell (PRBC) transfusions. Well today, part 3 of the sepsis trilogy was published in the saga of Early Goal Directed Therapy (EGDT) versus “usual” care. The 3 parts to this saga consist of:

  1. Protocolized Care for Early Septic Shock (ProCESS) – 31 Emergency Departments in the United States
  2. Australasian Resuscitation in Sepsis Evaluation (ARISE) – 51 Emergency Departments in Australia, New Zealand, Finland, Hong Kong, and Ireland
  3. The Protocolised Management in Sepsis (ProMISe) Trial – 56 Emergency Departments in the United Kingdom Read more →

The New Age of Sepsis Management

16 Mar
March 16, 2015

SepsisThere are more than 750,000 cases of severe sepsis and septic shock in the US each year.  Most patients who present with sepsis receive their initial care in the emergency department.  In 2001, there was a landmark study by Rivers et al that reported that among patients with severe sepsis or septic shock mortality was significantly lower among those who received a 6 hour protocol of Early Goal-Directed Therapy (EGDT) (i.e. 30.5% vs 46.5%). The premise of EGDT was that “usual care” lacked aggressive, timely assessment and treatment. The EGDT protocol used central venous catheterization (CVC) to monitor central venous pressure (CVP) and central venous oxygen saturation (SCVO2) to guide the use of intravenous fluids (IVFs), vasopressors, packed red blood cell (PRBC) transfusions, and dobutamine in order to achieve pre-specified physiological targets.  Since the publication of this landmark article, physicians have become more aggressive in the management of sepsis which raises the question of whether all elements of the protocol are still necessary.  Read more →

Epinephrine in Out-of-Hospital Cardiac Arrest Poll

15 Mar
March 15, 2015

epinephrineRecently, I wrote a post on the use of epinephrine in out-of-hospital cardiac arrest (OHCA) and this triggered some interesting discussion on twitter. Are we at a point that we can just stop using epinephrine in OHCA?  Has anyone stopped actually using epinephrine in OHCA and if so, why or why not? The evidence seems to point to no “good” neurologic benefit over basic life support (BLS).  I would love to hear more peoples thoughts on this. Read more →

Is It Time to Abandon Epinephrine in Out-Of-Hospital Cardiac Arrest?

11 Mar
March 11, 2015

epinephrineEpinephrine is widely used and recommended by Advanced Cardiovascular Life Support (ACLS) in out-of-hospital cardiac arrest (OHCA), but its effectiveness in neurologic outcomes has never been truly established.  To verify effectiveness of epinephrine confounders, such as patients, CPR quality, CPR by bystanders, time from call to arrival at scene or hospital, and much much more, must be controlled for in a trial. This type of study is not easily performed due to ACLS being the current standard of care. Read more →

March 2015 REBELCast

09 Mar
March 9, 2015

REBELCastWelcome to the March 2015 REBELCast, where Swami, Matt, and I are going to tackle a couple of topics that come up frequently in clinical practice in the emergency department. Today we are going to specifically tackle:

  • Topic #1: Oseltamivir (Tamiflu) in the Treatment of Influenza
  • Topic #2: Use of the HEART Score in Low Risk Chest Pain Patients Read more →

Video Laryngoscopy or Direct Laryngoscopy for Trainees

05 Mar
March 5, 2015

Glidescope Video LaryngoscopyAccording to a 2012 meta-analysis difficult and failed intubations in the operating room occur 1.8 – 5.8% and 0.13 – 0.30% of the time respectively. Emergent intubation, outside of this environment (i.e emergency department, ICU, and medical ward) is typically associated with a much higher risk of difficulty and complications due to many patients rapidly deteriorating. Recently, I had a discussion on twitter with Jeffrey Hill (@_drjeffy) and Taylor Zhou (@canibagthat) about what is the best way to teach trainees to intubate: Video Laryngoscopy (VL) or Direct Laryngoscopy (DL) for Trainees?

PLEASE BE SURE TO VOTE AT THE BOTTOM OF THIS POST!!!

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How Long Does a Cough From Respiratory Illness Last?

02 Mar
March 2, 2015

Cough and VirusCough from respiratory illness is one of the most common reasons that patients seek care in both the outpatient primary care setting and the emergency department (ED).  Cough due to respiratory illness is a self-limited condition in the majority of cases, but patients still seek care at clinics and EDs seeking relief or their symptoms. Maybe the reason for this is patients’ expectations of duration of cough and the actual natural history of cough from respiratory illness are mismatched. So how long does a cough from respiratory illness last? Read more →