March 12, 2020

Background: Most published clinical guidelines on the management of primary spontaneous pneumothorax (PSP) advocate for a conservative approach of observation for small asymptomatic pneumothoraces (PTX).(1,2) However, procedural re-expansion with a catheter or chest tube is recommended for all large pneumothoraces, regardless of symptomatology or clinical stability.(1) More recently, smaller chest tubes (i.e. pigtail catheters) have been used as this can potentially cause less pain. Typically, patients who get chest tubes or pigtail catheters require hospitalization for management of the tube. But, chest tubes are not without risk: there are multiple reports in the literature describing terrible consequences of chest tubes including bleeding, infections and empyemas, and misplacement into vital organs like the liver, spleen, and heart.(3-5) An alternative approach to this invasive procedure is to do nothing, unless the pneumothorax becomes physiologically significant. In an effort to reduce these risks and discomfort to the patient, the clinical quandary becomes: can a large pneumothorax be managed using a conservative observation-only approach, without placement of catheters or chest tubes? To date there have been no randomized clinical trials comparing these two polar opposite management strategies until now (The PSP Trial).

March 11, 2020

Vascular Disasters Take Home Points
  1. Consider vascular pathologies in all of your patients with atraumatic limb pain - especially those with typical and atypical risk factors
  2. Early diagnosis is imperative. Time is tissue. Catch this as early as possible. Pain is the earliest symptom. First presents with pain then paresthesia then paralysis
  3. Perform vascular exam on every patient with pain
  4. If concerned for ischemic limb, call the vascular surgeon and get patient to CT for imaging of aorta and affected limb. 

March 9, 2020

Background: Oxygen therapy is frequently used in the emergency department for the treatment of hypoxia and respiratory failure and can be delivered in a variety of ways. Conventional oxygen therapy (COT) via nasal cannula is often a first line treatment, but has some drawbacks, including inability to deliver a precise concentration and volume of oxygen, inability to deliver high enough concentration and volume of oxygen, inability to heat and humidify, and poor tolerance.  While it is able to deliver more precise, high flow oxygen, noninvasive ventilation (NIV) also presents a comfort challenge for many patients. High flow nasal cannula (HFNC) has been introduced as an alternative to COT and NIV. It can be used to deliver heated, humidified oxygen at high rates (up to 60 L/min) and maintain a set oxygen fraction. Prior randomized controlled trials (RCTs) and meta-analysis comparing HFNC to COT and NIV have demonstrated conflicting results. Additionally, none of these previous meta-analyses have evaluated emergency department (ED) patients.

March 5, 2020

Welcome back to REBEL Cast, I am your host Salim Rezaie.  In this episode we are going to review a recent focused 2019 update to the American Heart Association (AHA) pediatric advanced life support (PALS) guidelines from 2018-19. This 2019 PALS Update addresses 3 concerns:
  1. Pediatric advanced airway management in pediatric cardiac arrest
  2. Extracorporeal cardiopulmonary resus (ECPR/ECMO) in pediatric cardiac arrest
  3. Pediatric targeted temperature management (TTM) during post-arrest care

March 2, 2020

Background: The cornerstones of sepsis management include early identification, early antimicrobial administration, and source control.  The Surviving Sepsis Campaign guidelines recommend that blood cultures be drawn before starting antimicrobial therapy, however, obtaining cultures prior to antibiotics may be challenging due to shorter time windows (i.e. 1hr from identification) to initiate antibiotics.  Some may prioritize administering antimicrobial agents before obtaining blood cultures to ensure they meet this core measure. This study (The FABLED Trial) tried to determine the sensitivity of blood cultures obtained both before and after initiation of antimicrobial therapy in patients with severe manifestations of sepsis.