January 23, 2019

Take Home Points
  1. Single dose oral dexamethasone is an excellent choice for asthma exacerbations. It takes away the compliance issue for patients who have trouble getting medications or filling medications once they leave the ED.
  2. Antibiotics aren’t always indicated in COPD exacerbations, but are used much more frequently than in asthma exacerbations because the structural changes in the patient’s lung lead to increased bacterial colonization. In general, if the patient has increased cough or sputum production, they probably would benefit from a course of antibiotics
  3. In general, azithro alone is no longer a good choice as solo covereage for community acquired pneumonia.  Adding either amoxicillin or cefdinir to you amoxicillin should get you good coverage of both strep pneumo and atypicals.

January 14, 2019

Article: Uyeki TM et al. Clinical Practice Guidelines by the Infectious Diseases Society of America: 2018 Update on Diagnosis, Treatment, Chemoprophylaxis, and Institutional Outbreak Management of Seasonal Influenza. Clin Infect Dis 2018. PMID: 30566567

Background: Influenza is an Emergency Department scourge that we deal with every year. The vast majority of patients recover from uncomplicated influenza without anything more than supportive care but, influenza can cause serious complications. Young children, older adults, pregnant and postpartum women, people with neurologic disorders and patients with certain chronic medical conditions (i.e. COPD, CAD, Diabetes, Immunocompromised states) are at increased risk for these complications. Annual vaccination is the best method to reduce the impact of influenza on morbidity and mortality. Though antiviral medications for influenza are far from perfect, the indications for their use must be understood.

January 9, 2019

Take Homes

  1. Calcium Channel Blocker (CCB) toxicity usually present with bradycardia and hypotension, but with preserved mental status. This can help differential from Beta Blocker (BB) toxicity, where the patients often have altered mental status.
  2. Hyperglycemia is the other hallmark of CCB toxicity, which can help you differentiate from BB. This hyperglycemia may be a harbinger of impending circulatory collapse, so be on guard in a pt with CCB overdose, normal vitals and hyperglycemia
  3. Don’t be afraid to use and infuse hyperinsulinemia-euglycemia therapy for BB and CCB toxicity. Have a frank and open conversation with your team about how it works to get everyone on board before your start.
  4. TCA overdoses present with a a number of signs and symptoms including anticholinergic symptoms, AMS, hypotension and seizures. Once you identify the TCA toxicity, you’re going to start with fluids and pressors and then move on the antidote which is sodium bicarbonate 1-2 mEq/kg as a bolus followed by a drip. You want to keep pushing sodium bicarb until you see the QRS narrow

January 7, 2019

Background: Syncope, defined as a transient loss of consciousness with spontaneous and complete recovery to pre-event status, is a common emergency department (ED) presentation. Near-syncope is frequently seen as well. Unlike syncope, near-syncope has a more nebulous definition often thought of as the feeling of oncoming syncope without a complete loss of consciousness. Regardless of definition, many providers consider syncope and near-syncope as two ends of a spectrum of disease with near-syncope being not as dangerous and syncope being more dangerous. The literature on this, however, is inconsistent with a 2009 study stating that near-syncope was a “low-risk" factor (Sun 2009) and a 2015 study showing the opposite (Thiruganasambandamoorthy 2015). Additional high-quality data in this area is needed to further elucidate the risk of near-syncope presentations in the ED.

December 26, 2018

REBEL EM-ers: Salim, Jenny and I would like to announce the launch of a new REBEL EM project. Beginning in 2019, we'll be adding a core content section to the website. This will include core content blog posts and a core content podcast with a dedicated place on the parent site. Instead of creating a separate podcast, we'll be bringing you REBEL Core Cast as part of REBEL Cast. This way, you won't need to download another podcast. Twice a month, Jenny and I will bring you a podcast based on a core topic in EM or based on pearls from our conferences. See you all in the New Year!