May 31, 2020

I am fortunate to work in a hospital system that is very forward thinking.  We have a phenomenal relationship with our intensivists, and I have been fortunate enough to have several discussions with them about how we are managing COVID-19 in our ICUs.  For full transparency, I don’t work up in the ICU, but had the opportunity to discuss what we are doing in our ICUs with one of our intensivists (ECMO, steroids, Remdesivir, etc...).  We are doing something different in San Antonio that I thought was worth discussing on this podcast that may be a feasible option for some institutions and some patients, but not all. If there is one thing this disease has taught me, that is one size does not fit all.

May 30, 2020

Background: One of the hot topics in COVID-19 care is the mortality rate associated with invasive mechanical ventilation (IMV). There have been early reports of IMV having mortality rates ranging from 50 to 90%.  These high rates are concerning but, context is important; many of the reports emerged from areas with large surges where hospital systems were overwhelmed. Additional data looking at outcomes of critical patients is important particularly within systems that were able to maintain baseline critical care provisions despite surges.

May 19, 2020

While the rate of prepublications on COVID19 continue to be cranked out, we at REBEL EM have reduced our blog post production. It’s not because we’re reading less, but  we’ve reported enough on small, retrospective, observational studies that don’t tell us anything more than we already know.  At this point in time we know enough about what does and doesn’t work, so we wanted to focus on important literature that may affect practice. Going forward that will be our focus with updates in a less rapid-fire rate and more useful way to digest the information. For this COVID-19 update we have picked four papers that are we thought are worthy of mention.

May 17, 2020

There is a lot we still do not know when it comes to COVID-19 pathophysiology. We are learning every day, and as we navigate the waters of the unknown, there are a few that boldly dare to try and understand what is happening in this disease process that may go against mainstream thinking. COVID-19 is new and therefore will require new thinking and new questions but should also be balanced with not grasping for straws and randomly doing things that could be deleterious. Below is a proposed lung injury model that may be right or could be wrong. However, the only way we can further understanding is by feedback and edits until we can get to the right answer. The purpose of this post is not to tell you what you are doing is wrong, but instead putting a model out there so that we can work on this together to find an answer. This is not a recommendation on how to treat patients, but a proposal that needs feedback and work. We felt it was a good starting place for all of us to work together to figure this thing out. Thank you to Dr. Farid Jalali, MD for putting his thoughts down on COVID-19 acute lung injury to help as a starting point.

May 8, 2020

Background: Although Helmet CPAP is not something commonly used in the US, I think its nice to know what other potential options there are to help patients in the midst of a COVID-19 pandemic. Hypoxemic acute respiratory failure (hARF) is a well-known complication that can occur in patients with pneumonia.  This has a high morbidity and mortality associated with it.  An intermediary step prior to intubation is the use of noninvasive positive pressure ventilation (NIPPV) to stave off intubation. A more important question is does NIPPV in patients with pneumonia and hARF improve clinical outcomes? There have been no randomized clinical trials that have evaluated the clinical efficacy of helmet CPAP in patients with pneumonia suffering from hARF to date Helmet CPAP has also gained recent attention as an oxygenation tool for COVID19 pneumonia. The authors of this trial wanted to compare helmet CPAP vs oxygen therapy delivered by Venturi mask to reduce the proportion of patients requiring ETI in hARF due to pneumonia.
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