Intraosseous (IO) Needle Length in Obese Patients

09 Jan
January 9, 2017

intraosseousBackground: Intraosseous (IO) access can play an important role in the resuscitation of the critically ill patient to help expedite delivery of critical medications (i.e. RSI). Much like with peripheral or central access, obesity can present a challenge to placement of an IO as accurate placement relies on use of landmarks which may not be palpable in this group. Additionally, increased soft tissue depth may render standard needles ineffective. IO needles require 5 mm of excess length from skin to bony cortex to ensure successful placement (i.e. maximal depth of 20 mm for a 25 mm needle). Studies investigating these questions are necessary in order to understand how reliable IO access will be in obese patients. Read more →

The PEAPETT Trial: Half Dose tPA for PEA due to Massive Pulmonary Embolism

05 Jan
January 5, 2017

peapett-trialBackground: Anyone who has run a code, knows that pulseless electrical activity (PEA) during cardiac arrest has a worse prognosis compared to patients with shockable rhythms.  In patients with suspected massive PE as the cause of their cardiac arrest the Advanced Cardiac Life Support (ACLS) and American Heart Association (AHA) guidelines do recommend consideration of thrombolytics.  There is however, no uniform consensus on the type, dose, duration, timing, or method of administration.  The current study (PEAPETT Trial) was an attempt to do exactly that. Read more →

Question Tradition: Glucagon for Food Boluses

02 Jan
January 2, 2017

glucagon-and-esophageal-foreign-bodiesBackground: How many of you have had this scenario…patient comes into ED, just ate a big steak and now they can’t swallow.  You call gastroenterology, who asks… “Did you try glucagon yet?” OK, well maybe not exactly like that, but you get what I am asking.  Esophageal foreign body impactions are a rare entity, that cause quite a bit of discomfort to patients and have the potential for esophageal necrosis and perforation.  The definitive treatment for removal is endoscopy with direct visualization and removal of the object causing the obstruction.  This procedure is invasive, time consuming, requires a gastroenterologist, as well as procedural sedation.  Due to the time it takes to set up for this procedure, many consultants will ask to try medical therapy first.  There are several options including carbonated beverages, calcium channel blockers, sublingual nitroglycerin, proteolytic enzymes, benzodiazepines, and last but not least intravenous glucagon. This review will focus on the use of glucagon for esophageal foreign bodies. Read more →

December 2016 REBEL Cast: Obstructive Left Main Coronary Artery Disease

19 Dec
December 19, 2016

obstructive-left-main-coronary-artery-diseaseThe standard treatment for patients with obstructive left main coronary artery disease has typically been coronary-artery bypass grafting (CABG), however some newer trials have suggested that maybe drug-eluting stents may be an acceptable alternative to CABG in select patients. In this episode we will be reviewing the two most recent publications on this topic:

  1. The EXCEL Trial
  2. The NOBLE Trial

Read more →

Cardiac Arrest, Return of Spontaneous Circulation (ROSC) With No ST-Segment Elevation on ECG. Now What?

15 Dec
December 15, 2016

cardiac-arrestBackground: The American Heart Association/American College of Cardiology (AHA/ACC) give a Class I recommendation for activation of the cardiac catheterization lab in patients with out-of-hospital cardiac arrest (OHCA) whom ST-segment elevation myocardial infarction (STEMI) is present.  The evidence for early cardiac catheterization in patients after cardiac arrest, with ROSC and no STEMI is a bit more controversial.  The most recent 2015 AHA/ACC guidelines recommend, “it may be reasonable,” to perform an emergent cardiac catheterization in select patients without STEMI. Read more →

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