July 2015 REBELCast

06 Jul
July 6, 2015

July 2015 REBELCastWelcome to the July 2015 REBELCast, where Swami, Matt, and I are going to talk oxygen. It is important to remember that oxygen is a drug, and just like any drug we prescribe to patients it has potential side effects.  Although there is a paucity of clinical trial data to support routine use of supplemental oxygen, most health care providers still put oxygen on patients for possible physiological benefits.  So with that introduction today we are going to specifically tackle:

  • Topic #1: The AVOID Trial – Supplemental O2 vs Room Air for STEMI
  • Topic #2: The FLORALI Trial – High Flow Nasal Cannula (HFNC) for Acute Hypoxemic Respiratory Failure Read more →

SMACC Chicago

29 Jun
June 29, 2015

SMACC ChicagoThis year I was fortunate enough to attend the 3rd annual Social Media And Critical Care (SMACC) conference from June 23rd – 26th, 2015 in Chicago, IL. This year the conference was dubbed as SMACC Chicago and followed by the hashtag #smaccUS on twitter. I tried to keep track of all the great take home messages while at the conference for those not lucky enough to make it or who have not heard of it. For those of you who have not heard of SMACC, it is a modern, academic meeting, mixed with on-line technologies to deliver innovation in education in the fields of emergency medicine and critical care. This conference addresses important clinical issues in a format that is energetic, cutting edge, and yet reputable. If you wanna see what the conference was about last year checkout this link: smaccGOLD. So what did I learn this year? Well, a lot more than one post can give justice to, but some of the highlights are listed below. Read more →

REBELCast Bootcamp Edition

15 Jun
June 15, 2015

REBELCast Bootcamp EditionWelcome back to a special edition, or should I say “bootcamp edition” of REBELCast. We have started to do something new by inviting guests onto the show to discuss papers in the literature they find interesting. This month I had the pleasure of working with Steve Carroll, an emergency room physician in my neck of the woods, down in San Antonio, TX. Today, Steve and I are going to specifically discuss how to manage the hypoxic and agitated patient, and the topic we are discussing:

Delayed Sequence Intubation (DSI) of the Hypoxic and Agitated Patient

Read more →

Morphine Kills in Acute Decompensated Heart Failure

08 Jun
June 8, 2015

Morphine Kills in Acute Decompensated Heart FailureBackground: Intravenous morphine use has been reported in nearly one of seven patients hospitalized with acute decompensated heart failure (ADHF). I have anecdotally, even seen physicians giving morphine as a “first-line” agent: Nitroglycerine, Non-Invasive Positive Pressure Ventilation (NIPPV), and Morphine. There is surprisingly little evidence supporting routine use of morphine in ADHF, and no major American cardiology or emergency medicine society has really endorsed or published any recommendations on the treatment of ADHF with morphine.

Most of us were taught the acronym “MONA,” Morphine, Oxygen, Nitroglycerin, and Aspirin for treatment of acute pulmonary edema and commonly, quoted physiologic/clinical beliefs for the use of morphine in ADHF are: beneficial hemodynamic effects, managing anxiety/agitation in air hunger, reduction in preload, and maybe to a lesser extent, afterload, and finally, decreasing heart rate. We should also consider the use of morphine in a framework of risk and benefit. For example intravenous morphine can also have some deleterious effects like causing central nervous system suppression, ventilatory depression, and hypotension.

The Acute Decompensated Heart Failure National Registry (ADHERE) is a large multicenter registry that records data from patients hospitalized with ADHF with more than 175,000 hospitalizations from over 250 hospitals across America. To be included in this registry patients must be >18years of age, admitted to an acute care hospital and receive a discharge diagnosis of ADHF. Data for this registry are collected by retrospective chart review and entered via an electronic web-based case report form for all consecutive eligible patients. Read more →

Low Risk Chest Pain and Clinically Relevant Adverse Cardiac Events (CRACE)

04 Jun
June 4, 2015

CRACE v2Background: In 2010, 5.4% of all emergency department (ED) visits in the United States were for chest pain. Admission or observation of such patients cost about $11 billion dollars in the United States in 2006. The majority of these admissions are commonly determined to be non-cardiac in etiology. Many physicians and patients believe that a hospital admission or extended observation after a “negative” ED workup has a safety benefit for patients. Previous studies have looked at 30-day mortality, but no current large trials have looked the short-term risk for clinically relevant adverse cardiac events, including inpatient STEMI, life-threatening arrhythmias, cardiac or respiratory arrest, or death. Other things to keep in mind is that one of the pitfalls of hospitalization of chest pain patients can lead to false-positive testing, hospital-acquired infections, venous thromboembolism, and other iatrogenic events, and can have greater than a 2% rate of adverse events at 30 days often cited as the upper boundary estimate for low-risk chest pain patients.

The purpose of the current study was to quantify the incidence of short-term clinically relevant adverse cardiac events (CRACE), or more simply put, life-threatening events  in patients admitted to the hospital after a “negative” ED evaluation of ischemia. The definition of “negative” was negative serial cardiac biomarkers, normal vital signs, and non-ischemic electrocardiograms (ECGs).

And by the way, checkout the authors: Scott Weingart and David Neman…. Read more →

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