July 15, 2021

Background: Transfusion thresholds for anemia have large variations in clinical practice.  This is especially true in patients with acute myocardial infarction (AMI).  Part of the reason for this is the lack of high-quality data.  There was a large, randomized trial looking at restrictive vs liberal transfusion strategies in non-crashing GI bleeding [2] which found a restrictive transfusion strategy was superior, however patients with AMI were excluded.

July 12, 2021

Background: Hypertensive acute heart failure is a subgroup of acute congestive heart failure (CHF) patients.  Physiologically there is increased afterload and decreased venous capacitance both leading to fluid shifts resulting in pulmonary vascular congestion.  Sympathetic crashing acute pulmonary edema (SCAPE) is a severe form of hypertensive acute CHF.  The rapidity and severity of this illness leaves a very narrow period of time for therapeutic intervention before subsequent deterioration. Therapeutic intervention includes vasodilators such as, high-dose nitroglycerin (NTG) and non-invasive ventilation (NIV). Both therapies can result in reduced work of breathing, decreased preload/afterload, and prevention of endotracheal intubation, and ventilation.  There is a paucity of high level literature on this topic. However, many resuscitation-minded clinicians advocate for this therapy.

July 5, 2021

Background: Intravenous sub-dissociative dosed ketamine has gained an expanded role in the management of a variety of acute painful conditions in the ED (REBEL EM).  When IV access is not readily available or unobtainable, sub-dissociative dosed ketamine can be given through the intranasal route as well.  Another non-invasive route of ketamine administration could be the nebulized route.  Inhaled ketamine has a bioavailability of about 20 to 40% (compared to the IV route) and a duration of action of 20 to 40 minutes. There is currently no high-quality literature in the ED that evaluates or compares the analgesic efficacy and safety of nebulized ketamine.

June 28, 2021

58 y/o female with colorectal cancer recently started on continuous 5-FU chemotherapy presents to the ED with chest pain, shortness of breath, and diaphoresis.  The symptoms wax and wane with no specific exacerbating factors.  She has no other past medical history, had a port placed recently for her chemotherapy and not a smoker.  Initial vital signs are shown below… BP: 146/64 HR: 113 RR: 15 Temp: 98.1 O2 Sat on RA: 100%

June 21, 2021

Background: Acute basilary artery occlusion has a high morbidity and mortality.  Treatment strategies for acute basilar artery occlusion are rather sparse.  Endovascular research over the last 5 years (REBEL EM Post) adds little to the conversation of these strokes as very few patients with basilar artery strokes were included. The Basilar Artery International Cooperation Study (BASICS) was a prospective observational registry in which ≈600 patients were divided into three groups: antithrombic treatment only (antiplatelet drugs or systemic anticoagulation), primary intravenous thrombolysis (including subsequent intra-arterial thrombolysis), or intra-arterial therapy (which compromised thrombolysis, mechanical thrombectomy, stenting, or a combination of these approaches) [2].  The majority of patients (68%) received intra-arterial therapy, but the study showed no statistically significant superiority for any treatment strategy.  In a subgroup analysis of the BASICS registry, patients with the most severe neurologic deficits (NIHSS >19) showed a trend toward lower risk of a poor neurologic outcome with endovascular therapy. Clearly, additional data is needed to elucidate the role of endovascular treatment in basilar artery strokes.