August 5, 2019

Background Information: Non-steroidal Inflammatory drugs (NSAIDs) such as Ibuprofen are of the one of the most commonly used oral analgesics in the emergency department. 1 These medications work by inhibiting the enzymes cyclooxygenase-1 (COX-1) and cyclooxygenase-2 (COX-2). These are two enzymes which lead to prostaglandin production and ultimately promote pain, fever and inflammation. Prostaglandins also serve to line the stomach epithelium and protect it from the digestive acids. The COX-1 enzyme also plays a role in platelet activation through the production of Thrombaxane-2. Understanding the physiology behind these important enzymes helps us better anticipate the expected adverse effects that may occur when prescribing NSAIDs, especially at higher doses or over an extended period of time. Due to its linear kinetic effects, higher doses of ibuprofen results in longer duration of analgesia and not necessarily more effective pain control. 3, 4 The authors of this study sought to identify the analgesic effects of three different doses of ibuprofen. Furthermore, they hypothesized that a lower dose had comparable analgesic effects when compared to higher doses.

August 5, 2019

Background: Epinephrine (adrenaline) remains a central part of management of OHCA in ACLS guidelines. Recent studies (i.e. PARAMEDIC-2) have raised concerns about the efficacy and possible deleterious effects of epinephrine on both overall survival and long-term neurological outcomes. Other observational trials have suggested that there may be a time dependent effect of epinephrine on survival, with earlier timing of epinephrine improving outcomes, and later timing of epinephrine causing deleterious effects[2]. This trial attempts to analyze the association between timing and dose of epinephrine given on survival and neurologic outcomes of patients with OHCA.

August 1, 2019

You are working an ED shift with an experienced EM resident. As the resident prepares to intubate a 100kg patient with pneumonia you suggest that the head of the bed be elevated to aid in first pass success and avoidance of peri-intubation hypoxia. The resident thanks you for your kind suggestion and states ‘I just read an article in Annals of EM suggesting there was no benefit to non-supine position in ED patients.’ This is news to you. You give the resident the benefit of the doubt and ask them to send you a copy of their evidence.

July 29, 2019

This is a special edition REBEL Cast done by my good friend Andy Little, DO (Twitter: @andylittle).  As I was busy running the 2nd annual Rebellion in EM clinical conference, Andy was able to sit down with the speakers to summarize their main take away messages from each of their talks.  This post is a summary of day 3.