January 19, 2017

Background: Ketorolac is a commonly used parenteral analgesic in the Emergency Department (ED) for a variety of indications ranging from musculoskeletal injuries to renal colic. This non steroidal anti-inflammatory drug (NSAID) is available in oral, intranasal and parenteral routes. Ketorolac has a number of side effects including nausea, vomiting, gastrointestinal bleeding and renal insufficiency. The risk of GI bleeding appears to be related to the use of higher doses and prolonged use. As with all NSAIDs, the drug has an analgesic ceiling - the dose at which additional dosing will not provide additional analgesia but can lead to more side effects. The current FDA dosing is 30 mg intravenously and 60 mg intramuscularly for patients < 65 years of age. However, the necessity of these doses is unclear and prior studies have demonstrated efficacy of considerably lower doses. The use of lower doses, if effective, may mitigate the potential for harm.

October 20, 2016

This years ACEP 2016 conference took place in Las Vegas, NV from Oct 16th - 19th.  There was greater than 350 courses, labs, and workshops given throughout the week.  It was impossible to make all of these great lectures, but I was able to take away some very important clinical pearls that I wanted to share with our readers. 

REBEL Review 73: Intranasal (IN) Medications

Created May 4, 2016 | Trauma | DOWNLOAD

April 21, 2016

Background: Airway management is a critical part of the management of patients presenting with traumatic brain injury (TBI). Emergency Physicians (EPs) have no ability to change the primary injury once it has occurred and so our focus is on preventing secondary brain injury. Hypoxemia and hypercarbia are major contributors to morbidity and mortality and management must focus on preventing them. Patients with TBI and depressed mental status frequently require definitive airway management in order to avoid these secondary insults. Rapid sequence intubation (RSI) with serial administration of a neuromuscular blocking agent (NMBA) and an induction agent is common practice. The most commonly used NMBAs are the depolarizing agent succinylcholine and the non-depolarizing agent rocuronium. There are strong proponents arguing for the dominance of one agent over the other based on qualities of the drugs but scant data investigating the question has led to clinical equipoise.

March 21, 2016

Background: Currently the Advanced Trauma Life Support (ATLS) guidelines recommend initial treatment of decompression of a tension pneumothorax, as needle thoracostomy (NT) using a 5cm angiocatheter at the 2nd intercostal space (ICS2) in the mid clavicular line (MCL). With the growth of size in our population worldwide, there has been increasing evidence about two things:
  1. A 5cm angiocatheter may not be long enough to reach the pleural space
  2. The 2nd intercostal space at the mid clavicular line (ICS2-MCL) may not be the ideal location for needle decompression