Author Archive for: srrezaie

Endovascular Therapy for Acute Ischemic Stroke

15 Mar
March 15, 2018

Background: Approximately 80% of strokes are ischemic in origin leading to significant morbidity and mortality worldwide.  In ischemic stroke, there is usually a core infarct and an ischemic penumbra.  The penumbra is the area that we try to salvage with reperfusion therapy. Currently, systematic intravenous alteplase administered within 4.5hrs after symptom onset is the mainstay of therapy, however many question its risk/benefit ratio in ischemic stroke. 4.5 hours is a narrow therapeutic time window and many contraindications such as recent surgery, coagulation abnormalities, and history of intracranial hemorrhage inhibit many patients from receiving systemic thrombolysis.  There have been many studies evaluating endovascular therapy in the management of ischemic stroke published in the past few years.  This post will serve as a review of those studies. Read more →

REBEL Cast Ep 46b: Vent Management in the Crashing Patient with Haney Mallemat

12 Mar
March 12, 2018

In Episode 46a we discussed respiratory failure and NIV.  In episode 46b we are going move on to the patient where you have tried NIV and your patient just doesn’t seem to be improving.  You decide to intubate your patient and connect them to the ventilator.  Now the ventilator starts beeping and your patient begins to decompensate.  What are the steps you use to assess the problem and fix it? Read more →

Milk of Amnesia (Propofol) for Pediatric Migraines?

01 Mar
March 1, 2018

Background: There are several classes of medications available to treat pediatric migraines and because of this many providers have different combinations that they like to use.  Typically, NSAIDs, anticholinergics, and dopamine antagonists are used with varying degrees of success.  There is little evidence to guide providers if these agents fail in terms of which medications would be helpful for further abortive therapy.  There have been several trials published in the adult population regarding the use of low dose propofol (LDP) for acute migraines.  Propofol is great in the ED setting due to its short acting duration of action, as well as its anti-emetic properties.  Many things done in pediatrics are extrapolated from adult literature, however the authors of this paper wanted to see if LDP was any better than standard therapy (ST) in the treatment of acute pediatric migraines. Read more →

Is the Great Debate Between Balanced vs Unbalanced Crystalloids Finally Over?

28 Feb
February 28, 2018

Background:  Normal Saline (NS) is one of the most commonly used IVFs in resuscitation today.  The use of balanced vs unbalanced crystalloids has been one of the biggest debates in resuscitation of the critically ill in recent history due to concerns of unbalanced fluids causing acute kidney injury, hyperchloremic metabolic acidosis,  and worsened mortality.  In 2015, we saw the publication of the SPLIT trial, which we covered on REBEL EM. This was a randomized clinical trial of over 2200 patients in 4 ICUs in New Zealand comparing 0.9% Saline (NS) vs Plasma-Lyte.  This trial had many issues including, >70% of patients coming from the OR, only 15% came from the ED, only 4% had sepsis, and the biggest issue with this trial was that the majority of patients only received 1 – 2L of NS, making it unclear if larger volumes of unbalanced crystalloid would have worsened morbidity and mortality.  Since the publication of this study, two more trials have been published: The SALT-ED Trial and The SMART trial (Both Just published in the NEJM Feb 27th, 2018). Read more →

REBEL Cast Ep 46a – Respiratory Failure and NIV with Haney Mallemat

26 Feb
February 26, 2018

Imagine you have a patient in respiratory failure sitting right in front of you. The patient has an increased work of breathing and obviously in distress.  Monitors are beeping, nurses are asking you what you want to do, and if you don’t do something, the patient is going to arrest and potentially die.  What is your framework for tackling these patients?  Well, I had a chance to sit down with Haney Mallemat and discuss his framework for managing respiratory failure and NIV. Read more →

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