REBEL Cast Ep 61: Diagnostic Questions in Urinary Tract Infections in the Elderly

03 Jan
January 3, 2019

Introduction: Beyond the Data

The evolution from eminence-based to evidence-based care has come to define bedside emergency medicine, with rigorous skepticism and scholarly consideration accelerated by the power of global connectivity. Where anecdote and opinion once drove therapy, clinicians now approach clinical conundrums with deliberate reflection, expecting—and at times demanding–ever-higher proof of perfection prior to implementing or incorporating therapies, tests, or approaches into their own practice. Such cogitation ensures excellence and safety and avoids pitfalls of over-adoption or confounding. Unfortunately, so many of our daily decisions are made in a space devoid of definitive data, and require a synthesis of relevant literature with our accumulated knowledge and experience—a departure from evidence-based medicine into the pragmatic world of evidence-informed medicine. It is only at this precipice—where studies and statistics simply don’t exist—that we change, where we push forward the boundaries of care, and develop not only experience, but the very questions which will define the next advances in emergency medicine. It’s with this in mind that we present this REBEL post, an entry not so much a look back on manuscripts which dictate our practice, but a treatise to help us look forward. To not inform, but to inspire thought and inquiry.   Read more →

REBEL Core Cast 1.0 – The Intro

26 Dec
December 26, 2018

REBEL EM-ers:

Salim, Jenny and I would like to announce the launch of a new REBEL EM project. Beginning in 2019, we’ll be adding a core content section to the website. This will include core content blog posts and a core content podcast with a dedicated place on the parent site.

Instead of creating a separate podcast, we’ll be bringing you REBEL Core Cast as part of REBEL Cast. This way, you won’t need to download another podcast. Twice a month, Jenny and I will bring you a podcast based on a core topic in EM or based on pearls from our conferences.

See you all in the New Year! Read more →

Early Sepsis Screening in the Emergency Department

10 Dec
December 10, 2018

Background Information: Sepsis is a complex syndrome frequently encountered in the ED. This infection-triggered, multifaceted disorder of life-threatening organ dysfunction is due to the body’s dysregulated response to pathologic and biochemical abnormalities.2-4 There has been significant debate regarding the use of clinical decision tools such as Systemic Inflammatory Response Syndrome (SIRS) and quick Sepsis-related Organ Failure Assessment (qSOFA) in the early recognition of sepsis.2,5-7­ Multiple studies have shown SIRS to not be specific enough for the early detection of sepsis as many non-infectious processes, including exercise, can often meet many of its criteria.8-10 On the other hand, qSOFA has been criticized as having poor sensitivity and moderate specificity for short-term mortality.11,12 Furthermore, qSOFA  has been described as clinically valuable but an imperfect marker of sepsis as some forms of organ dysfunction, such as hypoxemia and renal failure, are not assessed using qSOFA.5 Another severity score known as the National Early Warning Score (NEWS) focuses on inpatient deterioration in detecting patients with increased risk of early cardiac arrest, unanticipated ICU admission and death.13 One study showed that utilization of NEWS in the emergency department (ED) has been shown to be effective in recognizing patients with sepsis who are at a higher risk of adverse outcomes.14  The authors of this study sought to review the use of NEWS as an early sepsis screening score, a predictor of severe sepsis/septic shock, and compare it to SIRS and qSOFA in an ED triage setting. Read more →

Blunt Cardiac Injury (BCI)

06 Dec
December 6, 2018

Friday, 2300 hours:

A 24 year-old woman presents to your Emergency Department after a motor vehicle collision. She was the restrained driver of a car that collided head-on with another vehicle. She is complaining only of chest pain and appears uncomfortable and anxious.  The monitor shows sinus tachycardia and you spot a sternal fracture on her chest x-ray.  After IVF and Fentanyl, she remains slightly tachycardic and you wonder:

  • Do I need to send a troponin?
  • If the troponin is negative does this patient need to be admitted?
  • What other testing should I consider in the Emergency Department?

Read more →

TXA for Everyone: Inhaled TXA for Hemoptysis

03 Dec
December 3, 2018

Background: Use of tranexamic acid (TXA), an antifibronlytic medication,  has certainly become popular for numerous indications (i.e. trauma, uterine bleeding, epistaxis).  Patients with hemoptysis, frequently come through EDs, and as an ED healthcare provider, I am unable to provide the definitive therapies of bronchial artery embolization and bronchoscopy for these patients at many of the institutions in which I work.  And, of course, it’s not like I can just put my finger on the bleeder. There is no real effective medical therapy for hemoptysis, other than antibiotics for infection.  I often find myself helpless with these patients as all I can do is transfer them to larger institutions where definitive therapies can be done.  Well hold on…It turns out inhaled TXA may be an option to reduce bleeding in patients with hemoptysis.  Thus far the evidence for this has  only been from small case series.  There have been no prospective studies evaluating nebulized TXAs effectiveness as an inhaled treatment for hemoptysis.  I have certainly used this treatment for post-tonsillectomy bleeding and have at times used it for hemoptysis, with great success, but it would be nice to see some evidence to support this practice. Read more →