November 5, 2018

Background: Care of trauma patients with severe bleeding has advanced in recent years with a focus on damage control resuscitation which includes permissive hypotension, hemostatic resuscitation (blood component resuscitation), and hemorrhage control. Minimizing crystalloids in favor of blood component-based resuscitation in the prehospital setting has the potential to reduce downstream complications by intervening closer to the time of injury before the development of coagulopathy, irreversible shock, and inflammatory response.  There is a paucity of high level evidence showing the efficacy and safety of plasma transfusions in the prehospital setting including retrospective studies which suffered from survivor bias (patients had to survive long enough to receive plasma) and small randomized clinical trials not showing survival benefit.  This has led to the publication of two randomized controlled trials: COMBAT and PAMPer.

November 1, 2018

Background: Keeping up to date with the current literature is no small task.  You may say it is like drinking from a firehose when you’re thirsty;  it can be painful and, at the end, does it really quench our thirst?  The constant influx of new published research makes it difficult to stay current with the latest and greatest (information overload).  At REBEL EM we have been committed to critical appraisal of current research with application at the bedside to improve patient care.  In this post, I hope to give everyone a step by step guide on how to keep up to date in an efficient manner.

October 29, 2018

Background:In the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial [2], there was no difference in MI and death rates between patients with stable coronary artery disease who underwent PCI and controls. In stable angina, the primary goal of percutaneous coronary intervention (PCI) is symptomatic relief of angina, with guidelines recommending its use for those who remain symptomatic despite optimal medical management.  The issue with previous studies is both physicians and patients have not been blinded, therefore the effect size of PCI on symptomatic endpoints can be overestimated due to placebo effect as opposed to true physiological effect.  The Objective Randomized Blinded Investigation with optimal medical Therapy of Angioplasty in stable angina (ORBITA) trial was designed to assess the effect of PCI versus placebo on exercise time in patients with stable ischemic symptoms in a blinded fashion.

October 24, 2018

Background: Establishing IV access has become the norm for patients presenting to the ED.  However with increasing patient volumes, difficulty and delays in acquiring IV access, it seems that anything that could expedite care, reduce pain and suffering, and improve patient care would be welcomed in the ED.  There are several tricks I have learned along the way to achieve just this: No IV access, no problem…performing procedures like a boss…

October 24, 2018

Background:  Oseltamivir (Tamiflu), a neuraminidase inhibitor, was approved by the FDA in 1999.  The majority of the evidence supporting the use of the medication came from trials funded by Roche, the maker of the drug. Safety issues with the drug began sprouting up in 2009, due to case reports in Japan of neuropsychiatric events and these events eventually led to a label warning. The Cochrane collaboration published analyses of the available data in 1999, 2003, and 2006, supporting the use of the drug. However, in 2009, the  Cochrane collaboration began to question Roche about the completeness of the data they were using, which was data from another meta-analysis with 10 RCTs.  Only 2 of those RCTs (Nicholson 2000 and Treanor 2000) were published in peer-reviewed journals.  The other 8 RCTs were presented as proceedings of congress or abstracts in meetings.  Cochrane decided to undertake a complete analysis of full clinical trial data, but had difficulties accessing the data until 2013.  This post will serve as a review of the evidence for and against the use of Oseltamivir (Tamiflu) after the full clinical trial data was finally released.