REBELCast: The Crashing Asthmatic

01 Jun
June 1, 2015

The Crashing AsthmaticAcute severe asthma, formerly called status asthmaticus, is defined as severe asthma unresponsive to repeated courses of beta-agonist therapy or subcutaneous epinephrine. It is a medical emergency that requires immediate recognition and treatment. Recently, Anand Swaminathan (Twitter: @EMSwami) gave a lecture to the residents at the University of Texas Health Science Center at San Antonio (UTHSCSA) February 2015. This post is a summary of that lecture on how to manage the crashing asthmatic. Read more →

Mythbuster: Administration of Vasopressors Through Peripheral Intravenous Access

28 May
May 28, 2015

VasopressorsBackground: Vasopressors are frequently used in critically ill patients with hemodynamic instability both in the emergency department (ED) as well as intensive care units (ICUs). Typically, vasopressors are given through central venous catheters (CVCs) as opposed to peripheral intravenous (PIV) access due to the concerns about adverse events (i.e. tissue ischemia/necrosis) associated with extravasation through PIVs. In a truly hypotensive, critically ill patient the use of a PIV to administer vasopressors will allow the medication to stabilize the patient sooner and reduce the time to hemodynamic stability. The requirement to start vasopressors through a CVC may delay administration of pressors. Also, performing the insertion of a CVC in a hypotensive patient in an emergency circumstance versus an elective circumstance may increase the risk of adverse events from the procedure itself (i.e. bacteremia, pneumothorax, arterial puncture). Finally, most of the evidence cited for avoiding PIV administration of pressors is a sparse collection of case studies and expert opinion. Read more →

Cardiogenic Shock

25 May
May 25, 2015

Cardiogenic ShockAuthor’s Note: This post is one of the first written for a new site sponsored by the NYU/Bellevue Emergency Department called Core EM. This is a FOAM site dedicated to core content Emergency Medicine featuring a blog, podcast and procedure video section. The Core EM Project launches on June 15th, 2015. Thanks to Salim and the REBEL EM editorial staff for posting this here. We’ll make sure to let you all know when Core EM is up and running at www.coreem.net

Definition: Tissue hypoperfusion that is primarily attributable to damage to the heart.

Criteria: The cardiology literature focuses diagnostic criteria based on systolic blood pressure (SBP) (Gowda 2008)

  • SBP < 90 mm Hg
  • Decrease in MAP by 30 mm Hg

It is more important, however, to look for evidence of hypoperfusion. In the acute setting, this will typically manifest as a change in mental status (lethargy, decreased responsiveness, agitation, decreased cap refill, cool extremeties etc.). Read more →

7 Pediatric Hacks for Your ED

21 May
May 21, 2015

7 Pediatric Hacks for Your EDHacks are all the rage! There is even a current television show dedicated to “life hacks”. While the following may not be as cool as cutting cake with dental floss or cooking a pizza on your dash board (these were actually on that show) what I have learned from my training and experience in Pediatric Emergency Medicine (and my own 5 children) is that there are some hacks that can make things much easier for you, the kid, and the parents. The hacks presented here range from treatment for common (and often benign) conditions to serious situations. Read more →

Beyond ACLS: A New Pulseless Electrical Activity Algorithm

18 May
May 18, 2015

Pulseless Electrical ActivityPatients with pulseless electrical activity (PEA) account for almost 1/3 of cardiac arrest and even more troublesome is that the survival rate is significantly worse than patients with shockable rhythms. Both the European and American ACLS guidelines stress the importance of quickly finding and addressing the cause of PEA. This is traditionally done with recalling the 5 to 6 H’s and T’s, but during cardiopulmonary resuscitation it is difficult to recall all 13 causes of PEA by trying to recall this list. In 2014 a review article was published that was developed by several departments from the Carolinas Medical Center in Charlotte, NC that tried to simplify the diagnostic approach to PEA. Read more →

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