January 7, 2016

Background: The traditional standard workup for ruling out subarachnoid hemorrhage (SAH) has been a non-contrast head CT and, if negative, a lumbar puncture. The thought behind this is that the sensitivity of head CT to rule out SAH is not 100% and declines over time and missing a SAH is potentially devastating. There has been a series of studies published in the past few years looking at the value of a negative head CT scan performed within 6 hours of headache onset in ruling out SAH. I have heard many say that if they have a negative Head CT at 6 hours or less in a neurologically intact patient they would not perform a lumbar puncture.

December 10, 2015

Welcome to the December 2015 REBELCast, where Swami, Matt, and I are going to tackle a couple of topics in the world of Cardiology and Critical Care. First of all, we all know that the optimal treatment for STEMI is getting the patient to the cardiac catheterization lab, and time is muscle, but does it help to get patients to the catheterization lab even faster than 90 minutes? Or does speeding up the time have bad outcomes? Secondly, it has been drilled into our heads that high-quality CPR with minimal to no interruptions is key in OHCA.  This gives our patients the best chance of neurologically intact survival.  But a new study just published might beg to differ. So with that introduction today we are going to specifically tackle:

Topic #1: Reducing Door to Balloon (D2B) Times to <90 Minutes in STEMI Topic #2: Continuous vs Interrupted CPR in OHCA

November 30, 2015

Background: As emergency providers we must be smarter than our ECG machines. Many times subtle findings on ECGs are not read by the machine, but we must be the experts at making the distinction between findings that require emergent treatment versus more benign etiologies. One specific set of diagnoses that can be very difficult to distinguish from each other is inferior STEMI vs Pericarditis. ECG experts discuss strategies such as looking at morphology of ST-segments (i.e. concavity or convexity), but this is not always accurate. Another, frustrating fact is that ST-elevation in the inferior leads (II, III, aVF) is typically seen with inferior STEMI and pericarditis. We therefore need a finding that has both a high sensitivity and specificity for MI.

November 23, 2015

Background: We have already discussed the value of a good history in assessing patients with chest pain on REBEL EM. What is known about chest pain is that it is a common complaint presenting to EDs all over the world, but only a small percentage of these patients will be ultimately diagnosed with Acute Coronary Syndrome (ACS). This complaint leads to prolonged ED length of stays, provocative testing, potentially invasive testing, and stress for the patient and the physician. For simplicity sake, we will say that, looking at the ECG can make the diagnosis of STEMI. What becomes more difficult is making a distinction between non-ST-Elevation ACS (NSTEMI/UA) vs non-cardiac chest pain. ED physicians have different levels of tolerance for missing ACS with many surveys showing that a miss rate of <1% is the acceptable miss rate, but some have an even lower threshold, as low as a 0% miss rate. Over testing however, can lead to false positives, which can lead to increased harms for patients. In November 2015, a new systematic review was published reviewing what factors could help accurately estimate the probability of ACS.

November 12, 2015

Welcome to the November 2015 REBELCast, where Swami, Matt, and I are going to tackle a couple of topics in the world of Vascular Access. Peripheral intravenous (PIV) access is one of the most common procedures we perform in the emergency department (ED) and central venous catheter (CVC), although decreasing in frequency, has some very real complications associated with it. It is always good to question clinical practice, especially in procedures that we perform on a daily basis.  IV access is important to patient care for things that we may take for granted such as lab work and initiation of treatment. So with that introduction today we are going to specifically tackle: Topic #1: Intravascular Complications of Central Venous Catheter (CVC) Access Topic #2: US vs Landmark Technique for Peripheral IV Access