Time to Antibiotics in Sepsis: A Metric Not Supported by “High Quality” Evidence

21 Sep
September 21, 2015

Time to Abx in SepsisBackground: Some of the major take home points from the sepsis trilogy of studies recently published (ProCESS, ARISE, and ProMISe) was that early identification of patients with sepsis, early intravenous fluids, and timely, appropriate broad-spectrum antibiotics is key to decreasing morbidity and mortality. In 2006 a study by Kumar et al [3] showed a 7.6% increase in mortality in patients with sepsis for every hour of delay after the onset of shock, but this finding has not been reproduced. In fact, the results of timing of antibiotic administration on outcomes have been all over the map. Regardless, the Surviving Sepsis Campaign still has very specific recommendations regarding the timing of antibiotics. And even more painful is that metrics for the quality of care of patients with severe sepsis and septic shock are now recognizing these recommendations as core measures. Read more →

The REVERT Trial: A Modified Valsalva Maneuver to Convert SVT

14 Sep
September 14, 2015

SVT - The REVERT TrialBackground: In patients with cardiovascularly stable supraventricular tachycardia (SVT), the valsalva maneuver is recommended as an initial maneuver to help with cardioversion. The success rate of the valsalva maneuver alone is documented at 5 – 20%. The next option for patients who still remain in SVT is intravenous adenosine. Adenosine briefly stops all conduction through the AV node, which causes patients to feel a sense of doom or like they are about to die. Increasing venous return and vagal stimulation by laying patients supine and elevating their legs may increase the rate of conversion and is simple, safe, and cost effective. Read more →

Ten (Trauma Resuscitation) Commandments

10 Sep
September 10, 2015

Commandments1“I’ve been in this game for years, it made me an animal
There’s rules to this sh*t; I wrote me a manual”
— Notorious BIG

You know, whether you sling crack rocks or not, there are some sage words of wisdom in the late Notorious BIG’s Ten Crack Commandments. Life pearls like “Never let ‘em know your next move” and “Never keep no weight on you” have helped guide me through some challenging life decisions.

1. Never let no one know how much dough you hold
2. Never let ‘em know your next move
3. Never trust nobody
4. Never get high on your own supply
5. Never sell no crack where you rest at
6. That Goddamn credit, forget it
7. Keep your family and business completely separated
8. Never keep no weight on you
9. If you ain’t getting bags stay the f*ck from police
10. A strong word called consignment; If you ain’t got the clientele say hell no

Table 1. The ten crack commandments.

While not much is new in the world of hustlin’, when it comes to trauma resuscitation, the game done changed*. It was easier in the old days: 2L of crystalloid for a hypotensive patient, and then blood. While new science on trauma resuscitation has helped us understand how flawed that paradigm is, the new school can be some tricky water to navigate. From damage control to fibrinogen, from TXA to thromboelastometry, there is no doubt that resuscitating a bleeding trauma patient is a more nuanced endeavor than we originally envisioned it.

So, inspired by Biggie’s Descartesian ten-point discourse on method, I present the ten rules of the contemporary trauma resuscitation game as I see them – backed by science, and occasionally editorialized with personal opinion.

* Some academics have argued that the game has in fact not changed, but has just become more fierce; see Slim Charles vs. Cuddy Read more →

September 2015 REBELCast

07 Sep
September 7, 2015

September 2015 REBELCastWelcome to the September 2015 REBELCast, where Swami, Matt, and I are going to tackle a couple of topics in the world of Venous Thromboembolism (VTE). Seems like we are hearing more and more about VTE in terms of workup, management, etc. Lets face it, diagnosing someone with a pulmonary embolism (PE) is no longer as simple as checking a d-dimer or just doing a CT Pulmonary Angiogram.  There is so much more to it and to frustrate physicians even more there is so much research coming out on this topic alone, even I am having a hard time keeping up.  Swami, Matt, and I thought it might be good to tackle a couple of articles from he world of VTE that have implications for clinical practice and patient care. So with that introduction today we are going to specifically tackle:

  • Topic #1: Home Treatment of Low Risk Venous Thromboembolism with Rivaroxaban
  • Topic #2: RV Dilation on Bedside Echo Performed by ED Physicians

Read more →

More Dogma: Epinephrine in Digital Nerve Blocks

03 Sep
September 3, 2015

Digital Nerve BlocksYou are working as an EM resident and have just evaluated a patient with a right long finger DIP joint dislocation. You perform a digital nerve block with 1% lidocaine with 1:100,000 epinephrine, and go to present to your attending before attempting the reduction. Your attending, on hearing about the epinephrine use goes berserk, and says “don’t you know that you shouldn’t use epi in fingers, noses, ears and toes?”.

When confronted with this situation we all like to have a one stop valid literature review to produce that validates our practice. Several social media authors have weighed in on this topic, however blogs sometimes don’t cut it for those unfamiliar with the current quality of peer reviewed online content.

The use of epinephrine in digital nerve blocks has been shown to increase duration of action for the anesthetic, and to allow the avoidance of bupivacaine, thereby decreasing the pain of the injection. (REBEL flashback) Read more →

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