Author Archive for: srrezaie

Direct Oral Anticoagulants (DOACs): A Practical Guide for the EM Physician

12 May
May 12, 2016

Direct Oral Anticoagulants (DOACs)Over the past 5 to 6 years we have seen an explosion of new anticoagulant medications.  Since 2010, four new oral anticoagulant medications have arrived on the scene: dabigatran, apixaban, edoxaban, and rivaroxaban.  Their popularity amongst patients is no surprise as they have a fixed dosing, absence of dietary interactions, and a lack of laboratory monitoring unlike warfarin.  As EM physicians we often are the common point of entry into the hospital system.  Therefore, we not only deal with the complications of these medications, but also have to deal with patients with venous thromboembolism (VTE) and atrial fibrillation who may require these medications.  Also, with more and more push to discharge patients from the emergency department and the difficulties in arranging timely follow up (i.e. warfarin clinic), discharging patients with direct oral anticoagulants (DOACs) may be coming more en vogue.  This blog post will focus on three major points:

  1. How to Prescribe DOACs in the ED
  2. What are the Red Flags for not prescribing DOACs in the ED
  3. How to Manage Emergency Bleeding in Patients on DOACs

Read more →

ALPS: Amiodarone, Lidocaine or Placebo Study in OHCA

25 Apr
April 25, 2016

ALPSBackground: Many Out-of-Hospital Cardiac Arrest (OHCA) are attributable to ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT). Both are said to be treatable presentations of OHCA, due to their responsiveness to defibrillation. VF and VT can persist or recur after defibrillation with an inverse relationship between the duration of OHCA, the recurrences of arrhythmias, and ultimately resuscitation outcomes.

Amiodarone and lidocaine are both recommended by the advanced cardiovascular life support (ACLS) guidelines to help promote successful defibrillation in refractory ventricular fibrillation or pulseless ventricular tachycardia and to prevent recurrences. In previous randomized controlled trials patients receiving amiodarone vs placebo or lidocaine in OHCA were more likely to have return of spontaneous circulation (ROSC) and to survive to hospital admission. However the effects of amiodarone on survival to hospital discharge or neurologic outcome still remain uncertain. Should we be using anti-dysrhythmic drugs in out-of-hospital cardiac arrest? Read more →

Advice to the Graduating Resident – Victoria Brazil

18 Apr
April 18, 2016

Advice to the Graduating ResidentSo this is the third installation of Advice to the Graduating Resident. Again, many 3rd year residents will be graduating in just a few short months and taking on their first jobs as attending physicians. I was lucky enough to sit down with the amazing Victoria Brazil and pick her brain. She gave some valuable words of wisdom, which I will try and summarize in this post, but for the full advice, be sure to checkout the podcast. Read more →

Hemophilia: What’s so Bloody Funny?

13 Apr
April 13, 2016

HemophiliaToday, I gave a lecture on Hemophilia to our residents in San Antonio, TX.  Now this was a core content lecture that I have actually never given before. As I was preparing the lecture I realized that this is a diagnosis that comes up frequently enough that it is important to know about, but also so infrequently that I always have to look up the factor replacement options and calculations.  So instead of being our typical evidence based evaluation of literature, this post will serve as a reminder of the basics of hemophilia and what are the essential elements one needs to know to appropriately treat a patient with Hemophilia. Read more →

Is Apneic Oxygenation Overhyped with Scott Weingart

04 Apr
April 4, 2016

Apneic OxygenationWelcome back to the April 2016 edition of REBELCast. For this episode I was lucky enough to get Scott Weingart on the show to talk to us about all things Apneic Oxygenation (ApOx). ApOx is a concept that has been around for some time in the operating room literature, but only recently been gaining acceptance in the ED, especially after the publication of this concept by Scott and Richard Levitan in the Annals of Emergency Medicine in 2011 [1]. Many nay sayers will argue that the OR studies were in controlled settings with elective surgical patients who were not in critical condition. The believers would argue that ApOx makes sense, its low cost,  and low complexity.  To date there has been no randomized controlled trials (RCTs) on ApOx in the ED.  There has been one ICU Trial (i.e. The FELLOW Trial) [2] and an even more recent observational trial in the ED [3] that have been published on the topic of ApOx. So the question remains: Is Apneic Oxygenation Overhyped? Read more →

Advice to the Graduating Resident – Amal Mattu

28 Mar
March 28, 2016

AdviceSo this is the second installation of Advice to Graduating Residents. Again, many 3rd year residents will be graduating in just a few short months and taking on their first jobs as attending physicians. I was lucky enough to sit down with the amazing Amal Mattu and pick his brain. He gave some valuable words of wisdom, which I will try and summarize in this post, but for the full advice, be sure to checkout the podcast.   Read more →

What is the Best Anatomic Location for Needle Thoracostomy?

21 Mar
March 21, 2016

Needle Thoracostomy TitleBackground: Currently the Advanced Trauma Life Support (ATLS) guidelines recommend initial treatment of decompression of a tension pneumothorax, as needle thoracostomy (NT) using a 5cm angiocatheter at the 2nd intercostal space (ICS2) in the mid clavicular line (MCL). With the growth of size in our population worldwide, there has been increasing evidence about two things:

  1. A 5cm angiocatheter may not be long enough to reach the pleural space
  2. The 2nd intercostal space at the mid clavicular line (ICS2-MCL) may not be the ideal location for needle decompression

Read more →

Is ST-Segment Elevation in Lead aVR Getting Too Much Respect? with Amal Mattu

14 Mar
March 14, 2016

aVRLead aVR is a commonly ignored lead and I have even heard of it referred to as the Rodney Dangerfield of ECG leads as it gets no respect. I have anecdotally heard many EM physicians activate the cath lab for STE in lead aVR and many cardiologists say that these are not STEMI patients. So is lead aVR now getting too much respect? Well, I thought it would be a great idea to bring the great Amal Mattu on to the show to answer a few questions for us regarding STE in lead aVR.

If you don’t know Amal Mattu by now, I am not sure where you have been. Currently he is a tenured professor of Emergency Medicine at the University of Maryland School of Medicine in Baltimore. He has presented at numerous national and international conferences on ECG interpretation, published several books on the topic and if you want more from him just checkout his site ecgweekly.comRead more →

Trimethoprim-Sulfamethoxazole for Uncomplicated Skin Abscesses?

10 Mar
March 10, 2016

Trimethoprim-Sulfamethoxazole for Uncomplicated Skin Abscesses?Background: It is well documented that the number of visits to the ED for abscesses is on the rise in the US, with methicillin-resistant Staphylococcus aureus (MRSA) being the most common cause of purulent skin and soft-tissue infections. The primary treatment for cutaneous abscesses is incision and drainage (I&D). The prescription of antibiotics after this procedure is not straightforward. On one hand there is increased cost and possibly increased side effects, but on the other hand maybe antibiotics will increase eradication and improve treatment. What is known is that I&D alone will result in resolution in >80% of cases. So this begs the question, should we be empirically prescribing Trimethoprim-Sulfamethoxazole for uncomplicated skin abscesses after I&D? Read more →

Advice to the Graduating Resident – Anand Swaminathan

29 Feb
February 29, 2016

AdviceWe are getting closer to the end of the year and pretty soon 3rd year residents will be graduating and moving on to their first jobs as attending physicians.  My own residents have been asking for advice, and I thought this would be a great opportunity to ask some EM educators what their advice would be. Essentially, I asked each of them two basic questions and let them steal the show. For our inaugural first episode I asked Anand Swaminathan if he could give us some of his words of wisdom. Read more →

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