November 7, 2019

Background: Despite minimal high-quality supporting evidence (Seymour 2017, Liu 2017, Ferrer 2014, Sterling 2015), regulatory bodies have pushed for benchmark times for administration of antibiotics in patients with sepsis. While most clinicians would agree that in patients with septic shock antibiotics should be given as quickly as possible, the same does not hold true for those patients with less severe infections. In the US, the Centers for Medicare and Medicaid Services (CMS) currently mandates that antibiotics be started in patients within 3 hours of onset of new organ dysfunction in patients with systemic inflammatory response syndrome and documented infection. The Surviving Sepsis Campaign (SSC) has even more extreme recommendations stating that antibiotics should be started within 1 hour from triage in septic patients (Levy 2018). Based on prior experience with arbitrary time to antibiotic administration (see community acquired pneumonia), such draconian recommendations are likely to increase inappropriate use of antibiotics, distract clinicians from more important tasks and have minimal effect on patient outcomes. This is likely why the Infectious Disease Society of America (IDSA) declined endorsement of the SSC guidelines. The ridiculous nature of these recommendations has been discussed elsewhere.

Even if the recommendation had some merit, it’s important to ask whether it’s even possible to implement. None of those on the SSC committee work in emergency departments and their understanding of the logistical challenges of such a policy is limited.

November 5, 2019

APPLY NOW: REBEL EM’s 2020 Infographic Competition for Essentials of Emergency Medicine Education Fellowship Program The Essentials of Emergency Medicine (EEM) conference is in May 2020, but the opportunities to attend start NOW. This conference is one of the largest live EM educational conferences in the world with over 2,000 attendees. The conference organizers, led by Dr. Paul Jhun, are again offering an amazing opportunity for EM residents anywhere in the world to serve as an EEM Fellow for the next EEM conference May 21 - 23, 2020.

November 4, 2019

Background: Despite decades of experience with endotracheal intubation, we continue to find approaches to improving the process of how we intubate. In this talk at Rebellion in EM 2019, Rob J. Bryant, MD gave a 14 minute 12 second talk on 3 things that have changed the way he intubates (Back Up Head Elevated - BUHE, Bougie 1st Intubation, & Team Management).  

October 31, 2019

Take Home Points  
  • Stress cardiomyopathy looks like ACS/STEMI, with patient presenting with chest pain, dyspnea or maybe syncope. It looks like ACS and should be treated as such until you prove to yourself it’s not.
  • Classic patient is an older woman with chest pain or syncope after a stressful event.
  • Bedside echo will show left ventricular dysfunction with one of a variety of patterns of wall motion abnormality. The most common is apical, but there are also variant patterns including mid-ventricular, basal, focal and global.
  • Watch for QTc prolongation as this could precipitate an arrhythmia. Be sure to stop all QT prolonging meds and replete magnesium
  • Consider the differential in the patient who has cardiogenic shock because the treatment differs. Avoid catecholamines and if you need inotropic support use dobutamine or dopamine. Look for evidence of left ventricular outflow tract (LVOT) obstruction, as this should be treated like a hypertrophic cardiomyopathy with beta blockers rather than inotropes.

October 30, 2019

Background: Currently, alteplase is the mainstay of treatment of acute ischemic stroke.  Advocates of alteplase suggest that the benefit of alteplase is greatest when given early and declines with increasing time from stroke symptom onset (i.e. time is brain).  Therefore, the AHA/ASA guidelines recommend intravenous alteplase within 4.5 hours after stroke onset, which is based on very weak evidence (i.e. NINDS & ECASS III). Due to weak evidence in support of it’s use and significant patient risks associated with alteplase, it’s use in acute ischemic stroke remains controversial.  One of the big issues is that by decreasing the time for evaluation and treatment, there is an increased risk of administrating alteplase to patients presenting with noncerebrovascular conditions that can resemble an acute ischemic stroke (i.e. stroke mimics).  This puts patients with no chance of improvement with alteplase at risk for increased mortality and symptomatic ICH.  There is some limited data on the safety of alteplase in stroke mimics and this study adds to that knowledge.