May 17, 2021

Background: A patient presents to the emergency department (ED) for medical treatment. After comprehensive evaluation and management, the patients condition improves and you prepare to discharge the patient home. The nurse notifies you the blood pressure (BP) is 185/105 and asks if you are comfortable discharging the patient in light of the abnormal vital signs. 

This clinical scenario happens regularly in the ED. Our training in emergency medicine has always been: We do not treat asymptomatic hypertension in the ED.” In fact, ACEPs 2013 Clinical Policy statement recommends referring patients with asymptomatic hypertension for outpatient follow-up and NOT starting antihypertensive therapy in the ED. However, this tends to be a controversial topic with various clinical opinions and practices. Ask ten emergency medicine physicians: What BP value would make you uncomfortable when discharging a patient? You may get ten different answers.

Patient safety is paramount. Furthermore, individual physicians have varying levels of risk tolerance and aversion which contribute to treatment decisions. This paper attempts to address concerns in patients with elevated blood pressure readings in the ED.

REBEL REVIEW 102: Confusion Assessment Method Algorithm (CAM-ICU)

Created March 27, 2021 | Neurology | DOWNLOAD

March 18, 2021

Background: The publication of the MR CLEAN trial in January 2015 changed the face of ischemic stroke care. This was the first study demonstrating a benefit to endovascular treatment of a specific subset of ischemic stroke patients: those with a large vessel occlusion (LVO) presenting within 6 hours of symptom onset. MR CLEAN was followed by a flurry of publications seeking to replicate and refine treatment as well as expand the window for treatment. The REBEL EM team reviewed this literature back in 2018 and, with the help of Dr. Evie Marcolini, created a workflow (see CVA Workflow below).

One major component of LVO management is the use of systemic thrombolytics in patients presenting within the current thrombolytic treatment window prior to endovascular intervention. However, it’s unclear if systemic thrombolytic administration results in better outcomes or if it simply exposes the patient to increased risks at a higher cost. Limited evidence questions the utility of the current approach with lytics + endovascular therapy (Phan 2017, Rai 2018).  In 2020, we reviewed an article by Yang and colleagues that demonstrated non-inferiority to an endovascular intervention only approach (with a 20% non-inferiority lower limit) (REBEL EM). Recently, two more studies have been published on this topic.

March 11, 2021

Background: Patients who present with a transient ischemic attack (TIA) are at higher risk of subsequent stroke, especially in the short term (< 7 days). However, the majority of these patients do not experience strokes which leads to a clinical conundrum; should all TIAs be admitted for evaluation? Comprehensive investigation, aggressive treatment, and/or hospital admission is not feasible for all patients and being able to risk stratify these patients to those who would most likely benefit is crucial.

February 18, 2021

Background:  Headache was the 5th most common reason for patients to present to the emergency department in the US in 2016.  Often ED providers include IV fluid boluses in their headache treatment cocktail, with prior research demonstrating IV fluids are included approximately 40% of the time (Jones).  While dehydration may precipitate some headaches, there is little evidence to support the use of IV fluids for their treatment.