November 19, 2018

Background: On October 24th, 2018, Roche, the maker of oseltamivir, announced that the US Food and Drug Administration (FDA) approved Xofluza (baloxavir marboxil) for the treatment of acute, uncomplicated influenza in people 12 years of age and older. Historically, there have been two classes of influenza treatment, the M2 ion-channel inhibitors, and the neuraminidase inhibitors, however circulating influenza viruses have become largely resistant to M2 ion-channel inhibitors and the emergence of newer strains of influenza (H1N1) could threaten the utility of neuraminidase inhibitors as well. I have written previously about the Tamiflu Debacle and why this is a medication we should not prescribe to immunocompetent patients. In this post, we attempt to answer a different question: Is baloxavir approval another debacle or does it actually improve patient oriented outcomes?

November 8, 2018

Background: In the United States 424,000 out of hospital cardiac arrests occur per year with a 10.4% overall survival rate.1 Refractory Ventricular Fibrillation (RVF) is a complication of cardiac arrest and has varying definitions in the literature but is commonly defined as ventricular fibrillation that does not respond to, or resists, three or more defibrillation attempts.2,3Although the estimated incidence of refractory ventricular fibrillation is 0.5-0.6 per 100,000 of the population, some authors report that 10-25% of cardiac arrest cases could develop RVF or recurrent VF.3-5 Patients who experience RVF during their cardiac arrest have a mortality of up to 97%.6,7 Several case reports have shown success with excellent neurologic outcomes in terminating RVF using dual defibrillation after failure of traditional Advance Cardiac Life Support (ACLS) measures.8-12 It is important to note and distinguish that dual defibrillation can either be simultaneous or sequential depending on the duration of the defibrillation potential as well as the intershock interval between the two defibrillator shocks.9-13 The terms “sequential” and “simultaneous” are often used interchangably due to the lack of accurately measuring pulse intervals when performing dual defibrillation in the actual clinical environment. The authors of this review utilize the term dual sequential defibrillation (DSD). They present a case of RVF in a patient with cardiac arrest, on whom DSD was successful in reversion to sinus rhythm and provide a thorough review of similar cases in the literature.

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.