Author Archive for: srrezaie

Why we Should Consider Not Using Morphine in Acute Heart Failure

02 Aug
August 2, 2018

Background/Introduction: Acute heart failure is a common diagnosis encountered among patients presenting to the Emergency Department with complaints of shortness of breath. The emergency treatment of these patients has traditionally focused on alleviation of their symptoms of breathlessness and anxiety in addition to optimization of hemodynamics and rapid reduction in both preload and afterload. The treatment of associated symptoms has often included the administration of morphine, which has been posited to have both beneficial physiologic (vasodilation, reduction of preload) and central nervous system (reduction of breathlessness, anxiety, and pain) effects. However, recent experimental and experiential data have pointed to morphine’s potential for effecting negative physiological and CNS responses, thereby raising the possibility of increasing patient morbidity and/or mortality. Additionally, no large randomized controlled trials have been conducted to study the potential risks and benefits of morphine administration in patients presenting with acute heart failure. Despite these factors, a contingent of Emergency Physicians continue to routinely use morphine in the treatment of patients presenting with acute heart failure. Read more →

TICH-2: TXA for Spontaneous ICH?

30 Jul
July 30, 2018

Background: Spontaneous, non-traumatic intracerebral hemorrhage, is one of the only stroke subtypes without a proven treatment. It is not as common as ischemic stroke, representing up to 20% of all strokes, but it accounts for almost half of all stroke deaths worldwide.  Furthermore, about a quarter of intracerebral hemorrhage can be complicated by hematoma expansion which can occur up to 24 hours later and is itself associated with poor outcomes.  There have been only small trials looking at the use of tranexamic acid in this group of patients, until now.  The Tranexamic acid for hyperacute primary IntraCerebral Haemorrhage (TICH-2) trial looked to see if intravenous TXA reduces death and dependence when given within 8 hours of spontaneous ICH. Read more →

REBEL Cast Ep57 – Cardiac Arrest Sonographic Assessment (CASA) with Lead Author Kevin Gardner, MD

25 Jul
July 25, 2018

Background: In the ED, POCUS has become one of the most important tools in discovering both the diagnosis and in the management of critically ill patients.  cardiac arrest, is ultimately as sick as a person can get in the spectrum of critical illness.  I mean how can someone be deader than dead, right?  There has been a slew of literature evaluating the use of POCUS in cardiac arrest and many providers have started to incorporate its use into their practice.  Newer literature, however indicates that the use of POCUS prolongs CPR pauses which ultimately impacts good neurological survival.  POCUS protocols may help decrease cognitive load, but many are too cumbersome and complicated.  Enter the Cardiac Arrest Sonographic Assessment (CASA) exam. Read more →

REBEL Cast Ep56 – PARAMEDIC-2: Time to Abandon Epinephrine in OHCA?

20 Jul
July 20, 2018

Background: Epinephrine(adrenaline) has been used in advanced life support in cardiac arrest since the early 1960s. Despite the routine recommendation for its use, evidence to support administration is less than ideal.  Although it is clear from multiple observational studies that epinephrine improves return of spontaneous circulation (ROSC) and short-term survival, most evidence suggests an absence of improvements in survival with good neurologic outcomes.  In cardiac arrest we want to take advantage of the alpha effects of epinephrine, including peripheral vasoconstriction, and therefore increasing aortic diastolic pressure, which in turn helps augment coronary and cerebral blood flow.  On the other hand, we want to avoid the potentially detrimental beta effects including dysrhythmias, decreased microcirculation, and increased myocardial oxygen demand all of which increase the chances of recurrent cardiac arrest and decreased neurologic recovery.  The only two interventions in cardiac arrest that have shown improve survival with good neurologic outcomes continue to be high-quality CPR and early defibrillation. The debate over the utility of epinephrine in OHCA has been ongoing for several years now and many providers have been awaiting the results of the PARAMEDIC-2 trial that was just published in the NEJM 2018.  Read more →

Rebellion in EM 2018: STEMI Equivalents by Tarlan Hedayati, MD

16 Jul
July 16, 2018

The 1stannual Rebellion in EM Clinical Conference took place in San Antonio, TX on May 11th– 13th, 2018.  If you missed out in 2018, the Rebellion is coming back June 28th – 30th, 2019.  Stay up to date as we plan the conference for this upcoming year at www.rebellioninem.com.

The Missions of Rebellion in EM:

  1. Decrease Knowledge Translation: With 100s of journals and thousands of publications every year, it takes time for research to disseminate to clinical practice. Discussion of current literature and its application to practice is the key to facilitating safe best practices.
  2. Create a Community of Practice: It requires many to take care of the few. Patient care is a team sport that starts pre-hospital, continues through the ED, and finally into the hospital.
  3. Improve Patient Care: Decrease suffering and improve patient oriented outcomes

“Learning is always rebellion…every bit of new truth discovered is revolutionary to what was believed before.” -Margaret lee Runbeck- Read more →