April 17, 2020

The SARS-CoV-2 pandemic has strained our available healthcare resources and caused unprecedented stress in the lives of our healthcare workers.  With the advent of COVID-19 and the resultant deaths of our colleagues, it has become painfully clear that our profession has become inherently dangerous.  It is ethically sound to expect the provision of appropriate personal protective equipment (PPE) before treating patients with infectious diseases.1  To borrow from our pre-hospital counterparts, when responding in dangerous situations the utmost priority is your personal safety and the safety of your teammates, and only once these have been assured are we able to attend to the needs of the victim/patient.  However, we cannot be frozen by fear and through the proper and appropriate use of PPE, clinicians can safely uphold the sacred duty to care for the ill.  Following the 2003 Severe Acute Respiratory Syndrome (SARS) outbreak, a study analyzed the nosocomial infections in Hong Kong healthcare workers.  Standardized PPE contact and droplet precautions included a mask, gloves, gowns, and handwashing.  Notably, none of the personnel who utilized all four measures were infected with SARS.  Contrastingly, all of the healthcare workers with nosocomial infection had failed to implement at least one of the PPE methods.2  We have confidently and effectively employed PPE against airborne, droplet, and contact pathogens for years (e.g. Mycobacterium tuberculosis, H1N1 influenza A, Clostridium difficile).  Now, as we battle COVID-19, similar to lessons learned on the battlefield and taught in Tactical Combat Casualty Care, we must first engage in suppression of the threat prior to initiating patient care.3

REBEL Review 97: Sedation and Analgesia in Drug Shortages

Created April 3, 2020 | Procedures and Skills | DOWNLOAD

April 2, 2020

Background: Peripheral intravenous (PIV) access is one of the most commonly performed invasive procedures in unwell patients.  Although, most patients can have PIVs placed by palpation, there is a subset of patients with difficult vascular access that will require ultrasound-guided peripheral IVs. We have covered this topic before with Jacob Avila (The Ultrasound Podcast, 5 Minute Sono) in REBEL Cast Ep 62. One thing we did not cover was catheter dwell rates.  Catheter dwell rate is an important endpoint as it takes time to perform the procedure, but more importantly for the patient, premature IV failure can include complications such as infiltration, phlebitis, ischemia, necrosis, as well as delays in receiving medications. Therefore, an important concept worth covering is the length of the catheter that is in the vein.

Midline catheters, which we have also covered on REBEL EM are catheters with lengths of 6 to 20cm and represent a potential solution.  These catheters have high success rates and longevity, but insertion requires institutional protocols and specialized training.  A nice go between is the peripheral ultralong catheter (ULC), which is 6.35cm. As with anything new in medicine, it is important to review the evidence to ensure we are performing best practices for our patients.

March 16, 2020

Traditionally, endotracheal intubation has been the gold standard for airway management in cardiac arrest. However, more recent data suggests that maybe less is more (i.e. supraglottic airways and/or bag valve mask ventilation).  The AHA guidelines have also de-emphasized airway management as the old acronym of ABC's has now been changed to CAB's.  In this talk from Rebellion in EM 2019, Dr. Chris Hicks, MD discusses the optimal airway management in OHCA.

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).