Does My Patient with Chest Pain Have Acute Coronary Syndrome?

23 Nov
November 23, 2015

Acute Coronary SyndromeBackground: We have already discussed the value of a good history in assessing patients with chest pain on REBEL EM. What is known about chest pain is that it is a common complaint presenting to EDs all over the world, but only a small percentage of these patients will be ultimately diagnosed with Acute Coronary Syndrome (ACS). This complaint leads to prolonged ED length of stays, provocative testing, potentially invasive testing, and stress for the patient and the physician. For simplicity sake, we will say that, looking at the ECG can make the diagnosis of STEMI. What becomes more difficult is making a distinction between non-ST-Elevation ACS (NSTEMI/UA) vs non-cardiac chest pain. ED physicians have different levels of tolerance for missing ACS with many surveys showing that a miss rate of <1% is the acceptable miss rate, but some have an even lower threshold, as low as a 0% miss rate. Over testing however, can lead to false positives, which can lead to increased harms for patients. In November 2015, a new systematic review was published reviewing what factors could help accurately estimate the probability of ACS. Read more →

November 2015 REBELCast: All Vascular Access Episode

12 Nov
November 12, 2015

Vascular AccessWelcome to the November 2015 REBELCast, where Swami, Matt, and I are going to tackle a couple of topics in the world of Vascular Access. Peripheral intravenous (PIV) access is one of the most common procedures we perform in the emergency department (ED) and central venous catheter (CVC), although decreasing in frequency, has some very real complications associated with it. It is always good to question clinical practice, especially in procedures that we perform on a daily basis.  IV access is important to patient care for things that we may take for granted such as lab work and initiation of treatment. So with that introduction today we are going to specifically tackle:

Topic #1: Intravascular Complications of Central Venous Catheter (CVC) Access
Topic #2: US vs Landmark Technique for Peripheral IV Access

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Ischemic Stroke Treatment Archive

09 Nov
November 9, 2015

Ischemic Stroke Treatment ArchiveI recently returned from the American College of Emergency Physicians (ACEP) Conference which took place from Oct. 26th – 29th, 2015 in Boston, MA.  There were really a lot of amazing talks by so many amazing speakers but one lecture in particular by David Newman, of SMART EM and The NNT fame, made me realize that there is just so much research on treatment of ischemic stroke, that I can’t even keep them straight.  So what I thought I would do is create an archive of all that research and continue to add to the list as more research is released.  I don’t know about you, but I find myself spending lots of time looking this information up every time I need it.  Read more →

Noreversaban?

05 Nov
November 5, 2015

Noreversaban?We have written about the new Non-Vitamin K Oral Anti Coagulants (NOACs). Many have jokingly referred to them as the “Noreversabans.” Taking these drugs is a high risk, high reward type of decision. While we recognize the benefits of quick anticoagulation without a need to bridge, as well as being more stable and having less interactions than Coumadin, these drugs are dangerous with serious bleeding concerns. Recently, Dabigatran was likened to “Dancing with the Devil”. For those of us in EM and Critical Care practice, there are no good options for reversing these agents. Once taken there is no turning back… until now?

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Diabetic Ketoacidosis (DKA) Myths

02 Nov
November 2, 2015

DKARecently, I was asked to give a lecture to both my residents and nurses at the University of Texas Health Science Center at San Antonio (UTHSCSA) on some common DKA myths. Now this topic was originally covered by my good friend Anand Swaminathan on multiple platforms and I did ask his permission to create this blogpost with the idea of improving patient care and wanted to express full disclosure of that fact. I specifically covered four common myths that I still see people doing in regards to DKA management:

  1. We should get ABGs instead of VBGs
  2. After Intravenous Fluids (IVF), Insulin is the Next Step
  3. Once pH <7.1, Patients Need Bicarbonate Therapy
  4. We Should Bolus Insulin before starting the infusion

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