Author Archive for: srrezaie

September 2016 REBEL Cast: Refractory Ventricular Fibrillation

05 Sep
September 5, 2016

Refractory Ventricular FibrillationBackground: Welcome back to the September 2016 REBEL Cast. We are back with another episode and I am super excited about this episode because we are going to talk about two papers just published in the Resuscitation Journal on management of refractory ventricular fibrillation. It is a well known fact that the cornerstones for survival from Out-Of-Hospital Cardiac Arrest (OHCA) have always been early, high quality CPR and early defibrillation in patients with shockable rhythms (i.e. Ventricular Fibrillation/Ventricular Tachycardia). Some patients with shockable rhythms may be refractory to standard defibrillation therapy (i.e. refractory VF). Even more frustrating, there is truly a dearth of data on what to do with these patients. One strategy that has been reported more and more in the literature is double sequential defibrillation (DSD).

Another issue in cardiac arrest patients is we frequently give boluses of 1mg epinephrine every 3 – 5 minutes as is outlined in the ACLS guidelines.  When patients have minimal cardiac output, the buildup of catecholamines may potentially cause refractory ventricular fibrillation (RVF).  This could be due to an increase myocardial oxygen consumption causing an increase in myocardial ischemia, and ultimately more difficulty in successful defibrillation.  But maybe by blocking the beta-adrenergic receptors in the myocardium, we can block the beta effects of the catecholamines and potentially increase the chances of successful sustained ROSC.

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Upcoming Conferences Presented By The Teaching Institute

02 Sep
September 2, 2016

The Teaching Institute LogoThis year has been an exciting year for us at The Teaching Institute (TTI).  We have had some great medical education conferences at some pretty amazing places, including Cape Town, South Africa and Melbourne, Australia.  The rest of 2016 and 2017 promise to be just as exciting if not more so.  TTI is dedicated to helping others learn how to be better educators and committed to creativity and innovation.  Our motto is simple: better educators equals better patient care. If you haven’t been able to participate in any of our courses, it’s not too late.  You can still sign up for several of our courses that are coming up. Read more →

The Fragility Index: Assessing Usefulness of Randomized Clinical Trials

22 Aug
August 22, 2016

Fragility IndexBackground: In the pyramid of evidence based medicine randomized controlled trials (RCTs) are considered to be one of the most reliable study designs when evaluating the cause and effect of treatment modalities. When evaluating randomized controlled trials, we often look for statistical significance of a study to determine if a treatment has an effect.  Statistical significance means that the result of a study is unlikely to occur by chance alone.  The value assigned to a statistically significant result is typically a p-value less than 0.05. Read more →

Euglycemic DKA: It’s not a Myth

18 Aug
August 18, 2016

Euglycemic DKABackground: Diabetic ketoacidosis (DKA) is traditionally defined as a triad of hyperglycemia (>250mg/dL), anion gap acidosis, and increased plasma ketones. There is another entity that providers must be aware of known as euglycemic DKA (euDKA), which is essentially DKA without the hyperglycemia (Serum glucose <200 mg/dL). Euglycemic DKA is a rare entity that mostly occurs in patients with type 1 diabetes, but can possibly occur in type 2 diabetes as well. The exact mechanism of euDKA is not entirely known, but has been associated with partial treatment of diabetes, carbohydrate food restriction, alcohol intake, and inhibition of gluconeogenesis. euDKA, can also be associated with sodium-glucose cotransporter 2 (SGLT-2) inhibitor medications.  These medications first came onto the market in 2013 and are FDA approved for the treatment of type 2 diabetes, however many physicians use them off-label for type I diabetes due to their ability to improve average glucose levels, reduce glycemic variability without increasing hypoglycemia, and finally promote weight loss. Read more →

REBELCast: The PROCAMIO Trial – IV Procainamide vs IV Amiodarone for the Acute Treatment of Stable Wide Complex Tachycardia

15 Aug
August 15, 2016

The PROCAMIO TrialBackground: In the ACLS guidelines stable Ventricular Tachycardia (VT) can be treated with either IV amiodarone or IV procainamide, as the drugs of choice. This has been given a class II recommendation, but there has not been a controlled prospective trial to base the use of one drug over the other in the clinical setting. Despite both medications having a class II recommendation, both clinically and anecdotally it appears that amiodarone is the preferred agent in clinical practice. Read more →

The POKER Trial: Go All in on Ketofol?

01 Aug
August 1, 2016

The POKER TrialBackground: Procedural sedation and analgesia is a frequently performed procedure in the emergency department to help facilitate care of patients in an effective manner. Our goal should be to minimize pain and anxiety while minimizing adverse effects. We have discussed the complications associated with procedural sedation and analgesia on REBEL EM before HERE.  Ketamine and Propofol are two agents commonly used for this and each agent has its own theoretical advantages and disadvantages. Due to this, it has been hypothesized that the combination of the two agents may result in fewer adverse events because of each agent counteracting the disadvantages of the other. Despite this, to date, no RCTs have really shown a reduction in adverse events with the combination of propofol and ketamine. Read more →

Predicting Fluid Responsiveness by Passive Leg Raise (PLR)

23 Jun
June 23, 2016

passive leg raiseBackground: The best way to resuscitate critically ill patients with fluids has been a hotly debated topic in the FOAMed and Critical Care worlds. Fluids are important to optimize stroke volume and distal tissue perfusion, however, the administration of excessive fluids for shock can increase a patient’s morbidity and mortality by causing volume overload, which may lead to tissue edema and subsequently inadequate blood flow to tissues [1]. Accurately predicting when, whom, and how much fluid to administer remains a very challenging clinical question as only half of critically ill patients increase their cardiac output in response to the administration of fluids (i.e. the patient is preload or fluid responsive) [1].

Clinical signs and pressure/volumetric static variables are unreliable predictors of fluid responsiveness [1]. Ventilator-induced dynamic variables such as stroke volume variation and pulse pressure variation, however, have been shown to be more accurate in predicating fluid responsiveness. These tests can only be applied when several criteria are present (e.g., sinus heart rate, mechanical ventilation with a tidal volume of 8-10cc/kg of ideal body weight).

Passive leg raise (PLR) is another method to assess preload responsiveness. PLR produces a temporary and reversible increase in ventricular preload through an increase in venous return from the lower extremities, which mimics fluid administration without actually having to give exogenous fluids. This sounds great in theory, but PLR requires a hemodynamic assessment to be made during the maneuver to determine if the patient is preload responsive or not. There are multiple techniques for assessing changes in stroke volume but the diagnostic performance of each method still remains unknown. The two most commonly described methods are changes in pulse pressure variation and variables of flow. Read more →

The PATCH Trial: Hold the Platelets in Spontaneous Intracerebral Hemorrhage?

15 Jun
June 15, 2016

PATCH TrialBackground: Hemorrhagic stroke accounts for 11 – 22% of strokes, half of all stroke deaths, and a significant amount of disability in many of the remaining survivors. Spontaneous, non-traumatic, intracerebral hemorrhage (ICH) accounts for 2/3 of hemorrhagic strokes; estimated at > 2 million ICHs each year. To date several studies have suggested that antiplatelet therapy use before ICH might worsen outcomes by increasing the risk of early ICH volume growth, due to platelet dysfunction, and pathophysiologically this makes sense. Platelet transfusion has been used therapeutically in many clinical settings for acute ICH, but there is a paucity of randomized trials investigating its effectiveness for reducing death or dependence.  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 →

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