Author Archive for: srrezaie

Industry Sponsored Trials and  Entresto in CHF

23 May
May 23, 2018

Background: Congestive Heart Failure (CHF) is one of the leading causes of hospitalization among adults over the age of 65 years of age. Despite improvement in outcomes with optimal medical treatment, admission rates still remain high with many patients requiring rehospitalization.  The staples of CHF management include ACE inhibitors, ARBs, beta blockers, diuretics, aldosterone antagonists, hydralazine/nitrates, and digoxin. Recently, I have seen an increase of patients with CHF on a new medication called Entresto (Valsartan-Sacubitril or LCZ696)  I did not know much about this medication, or the evidence base for it.

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RSI, Predictors of Cardiac Arrest Post-Intubation, and Critically Ill Adults

10 May
May 10, 2018

Background:Intubation is a commonly performed procedure in the ED and ICU. We have discussed the physiologically difficult intubation before on REBEL EM.  One of the tenants in managing these patients is “resuscitate before you intubate.”  Two publications in the past [1][2] discussed the incidence and risk factors associated with cardiac arrest complicating RSI.  In the first study [1], 542 patient underwent emergency intubation, 4.2% had a cardiac arrest, meaning nearly 1 in 25 intubations were associated with cardiac arrest.  In the second study [2], 2,403 patients underwent emergency tracheal intubation, and 1.7% had a cardiac arrest, meaning nearly 1 in 60 intubations were associated with cardiac arrest.  A new study in Critical Care Medicine was just published looking at the prevalence and risk factors associated with intubation (RSI) in 64 ICUs in France. Read more →

REBEL Cast Episode 50 – Intoxicated Patients can Equal Badness

07 May
May 7, 2018

Background: Visits to the ED for alcohol intoxication can create quite the clinical conundrum both for acute medical and traumatic reasons.  Acutely intoxicated patients, just like young kids, don’t always have the ability to communicate due to sedation, agitation, or some other critical medical/traumatic process that is ongoing.  This makes getting a complete history or depending on the physical exam unreliable at best. Read more →

Dosing Sedatives Low and Paralytics High in Shock Patients Requiring RSI

06 May
May 6, 2018

Background: A series of tweets I sent out recently generated a visceral response from critical care clinicians the world over. I summarized my strategy of shock dose RSI as sedatives low and paralytics high (low dose ketamine, high dose rocuronium along with cardiovascular resuscitative strategies of push dose pressors and peripheral vasopressors). It seems that the visceral response and argument stems from EM’s desire to avoid peri-intubation arrest, and anesthesia’s equally strong desire to avoid awareness/suffering in the peri-intubation period.  Typically ketamine is dosed at 1 – 2mg/kg IV followed by a paralytic agent prior to RSI. I have written a blog post on how to manage hypotension prior to RSI in shock patients HERE, but I wanted to write a separate post on this topic as it is difficult to carry on a meaningful conversation with the character limitations of twitter. Read more →

Getting Things Done in a Hyperdistracted World

03 May
May 3, 2018

I have been accused by many of my colleagues and friends as being hypomanic.  They always wonder how I get so much done.  Do I function on 4 – 5 hours of sleep?  Is it the fact that I am not married or don’t have kids?  Well those things definitely help, but I think it’s because I have a rigorous structure in my daily life, that allows me to get so much done.  Before we get into the post, I want to recommend two books to read that were recommended to me by my friend Scott Weingart: Getting Things Done by David Allen and Deep Work by Cal Newport.  There are some pretty extreme ideas in both of these books, but if you can get past that, you can find truth in each of their arguments.  These two books have changed the way I structure my daily life and have increased not only my productivity, but the quality of my productivity (i.e. Getting Things Done). Read more →

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