REBEL Cast Episode 39 – The TOAST Trial: Dexamethasone for Acute Pharyngitis

24 Jul
July 24, 2017

Background: Sore throat is a common presentation to the emergency department as well as primary care clinics.  Corticosteroids inhibit transcription of pro-inflammatory mediators in airway endothelial cells responsible for pharyngeal inflammation and symptoms of pain.  They have been used in other upper respiratory tract infections such as acute sinusitis and croup.  In adults, previous studies with dexamethasone are in combination with antibiotics but studies of children have included dexamethasone without antibiotics.  This study is unique as it is evaluating the benefits of oral corticosteroids for acute sore throat in primary care in the absence of antibiotics Read more →

Perichondritis: Not Just Simple Cellulitis

20 Jul
July 20, 2017

Background: Perichondritis is an infection of the connective tissue of the ear that covers the cartilaginous auricle or pinna, excluding the lobule (Caruso 2014). The term perichondritis is itself a misnomer, as the cartilage is almost always involved, with abscess formation and cavitation (Prasad 2007). Perichondritis can be a devastating disease, and if left improperly treated, the infection can worsen into a liquefying chondritis resulting in disfigurement and/or loss of the external ear (Noel 1989) (Martin 1976). Unfortunately, misdiagnosis and mistreatment is common. In one small retrospective review, the overwhelming majority of patients presenting to a large general hospital were prescribed antibiotics without appropriate antimicrobial coverage, resulting in a significant number of patients developing chondral deformities or “cauliflower ear” (Liu 2013). Read more →

Apneic Oxygenation (ApOx): A Review of the Evidence in Critical Care & Emergency Medicine

17 Jul
July 17, 2017

Background: Apneic oxygenation (ApOx) is the passive flow of oxygen into the alveoli during apnea.  This passive movement occurs due to the differential rate between alveolar oxygen absorption and carbon dioxide excretion producing a mass flow of gas from the upper respiratory tract into the lungs.  Another important component of this maneuver is maintaining a patent airway so that supplemental oxygen administered through the nares is able to be delivered to the alveoli.  This practice has been a game changer in emergency airway management for many providers.  However, there are still some naysayers that believe in the sickest patients ApOx may not be so beneficial. This post is a review of two recent systematic reviews/meta-analyses published in the critical care and ED/retrieval settings on the use of ApOx. Read more →

Occult Causes of Non-Response to Vasopressors

13 Jul
July 13, 2017

Intro: Vasoactive substances are powerful therapeutic medications that can boost a patient’s blood pressure and perfusion to target organs. They are often used in resuscitation to support tissue perfusion though their benefits are mostly unproven and may be harmful in certain circumstances (i.e. hypovolemia, hemorrhage). The cognitive response to hypotension should not be reaching for a pressor. The primary therapy for any sick hypotensive patient is treatment of the underlying pathology.

While many patients will respond to these medications, we occasionally encounter non-responder-patients who despite substantial doses do not show hemodynamic parameter improvements. Absence of response can result from a number of causes including misidentification of the underlying pathology (i.e. I missed the massive PE or pericardial tamponade thinking the patient was in septic shock). Premature diagnostic closure can lead us to simply push on with higher doses of pressors and adding additional pressors. However, there should be a cognitive pause at this point where the clinician reassesses the situation, considers alternate causes and therapeutics. Below is a list of pathologic conditions that complicate other diagnoses and are frequently missed as causes of non-response to vasopressors. This is the list I consider during my cognitive pause. Read more →

The EM Mindset

12 Jul
July 12, 2017

The American College of Emergency Physicians (ACEP) defines Emergency Medicine (EM) as:

“The initial evaluation, diagnosis, treatment, and disposition of any patient requiring expeditious medical, surgical, or psychiatric care.”

I would take this a step further and say these patients are often undifferentiated and come at all hours of the day/night. As the EM physician we are constantly risk stratifying and ruling out life-threatening issues with limited information and time.  So what are the things I think will give you a successful EM mindset? Read more →

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