The Role of TEE in Cardiac Arrest

04 Jan
January 4, 2016

TEEBackground: Sudden cardiac arrest has very poor outcomes; less than 11% of patients in cardiac arrest in the Emergency Department survive to discharge from the hospital. The management of cardiac arrest is algorithmic because providers have limited tools at their disposal and limited knowledge of the patient’s past medical history. EKG is limited in its evaluation of cardiac function. Pulses are often difficult to palpate. The blood pressure cuff is often unreliable. As a result, there is a sense of futility when running resuscitations.

Transthoracic echocardiography (TTE) in the Emergency Department gave providers another tool to help guide management through direct visualization of cardiac activity, tamponade physiology, right heart strain, etc . It also offers prognostic value if there is no cardiac activity upon arrival to the Emergency Department on TTE, there is a near 0% chance of survival. However, TTE has its limitations: obesity, emphysema, poor windows, interrupts compressions, gel gets everywhere.

Transesophageal echocardiography (TEE) provides significant benefits when compared to TTE in the management of cardiac arrest in the emergency department. Read more →

Reflections on the Closing of a Hospital

17 Dec
December 17, 2015

ReflectionsI know, I know. We here at REBEL EM are normally very clinically oriented. We take recent articles or hot topics and give you the breakdown and clinical take home points. But a recent event happened that made me look at my own practice, and now on the other side, I feel that I am a better doctor. The hospital I was working at as medical director of the Emergency Department (ED) closed its doors. This was a hospital that had been in the community for more than 60 years. I won’t go into the reasons for closure, but rather, I would like to tell the story from the side of the ED provider and what I had to change until the lights were turned out. Read more →

Should We Give Fingertip Amputations with Exposed Bone Prophylactic Antibiotics?

14 Dec
December 14, 2015

FingertipBackground: Fingertip amputations are not an uncommon injury seen in the emergency department. Treatment options range from healing by secondary intention to flap coverage or replantation. Selection of the appropriate treatment modality depends on the nature of the injury, the physical demands of the patient, and the patient’s co-morbidities. Prophylactic antibiotic use in patients with fingertip amputations is controversial. The routine use of prophylactic antibiotics is universally recommended on grossly contaminated wounds, in immunocompromised patients, and in injuries with extensively destroyed/devitalized tissue as it is thought the infection risk is high in these circumstances. However, many reflexively prescribe antibiotics prophylactically in all distal tip amputations. Moreover, there is often an underlying tuft fracture and we reflexively give these patients antibiotics because we were all taught that any open fractures require antibiotics in addition to usual fracture care. Prior studies on distal fingertip amputations and the use of prophylactic antibiotics suggest no change in infection risk with the routine use of antibiotics but these studies were small and have done little to inspire an antibiotic-restrictive approach universally. Read more →

December 2015 All Cardiology REBELCast

10 Dec
December 10, 2015

REBELCastWelcome to the December 2015 REBELCast, where Swami, Matt, and I are going to tackle a couple of topics in the world of Cardiology and Critical Care. First of all, we all know that the optimal treatment for STEMI is getting the patient to the cardiac catheterization lab, and time is muscle, but does it help to get patients to the catheterization lab even faster than 90 minutes? Or does speeding up the time have bad outcomes? Secondly, it has been drilled into our heads that high-quality CPR with minimal to no interruptions is key in OHCA.  This gives our patients the best chance of neurologically intact survival.  But a new study just published might beg to differ. So with that introduction today we are going to specifically tackle:

Topic #1: Reducing Door to Balloon (D2B) Times to <90 Minutes in STEMI
Topic #2: Continuous vs Interrupted CPR in OHCA Read more →

What Is the Role of Muscle Relaxants or Opiates in the Treatment of Acute Non-Traumatic LBP?

07 Dec
December 7, 2015

LBPBackground: Acute, non-traumatic low back pain (LBP) is a common chief complaint and has been estimated to lead to more than 2.7 million ED visits annually nationwide. It affects a broad range of individuals and can be painful and debilitating long after an initial ED visit. Often times in clinical practice, evidence based decisions on medical management of acute lower back pain seem to be thrown out the window; rather medications are prescribed on a gestalt medicament do jour. NSAIDs, muscle relaxants, and opioids have all been used in isolation and in combination for treating acute LBP but trials investigating the efficacy of these medications combined have produced heterogeneous results. Read more →

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