REBEL Cast

is the blogs audio version. The podcast typically starts by setting a clinical stage with a pertinent clinical question, followed by a discussion of the paper with pertinent results, strengths, limitations, and further discussion. Finally, we end every podcast with clinical take home points from the papers being reviewed. If there are papers you think we should evaluate, email them to srrezaie@gmail.com.

November 27, 2019

Take Home Points   
  • End stage liver disease patients have fragile baseline physiology. Minor insults can have profound effects
  • Always start with the basics - large bore IV lines
  • SBP give 3rd generation cephalosporin + albumin in severe disease
  • Upper GI bleed give appropriate blood products + ceftriaxone
 

October 31, 2019

Take Home Points  
  • Stress cardiomyopathy looks like ACS/STEMI, with patient presenting with chest pain, dyspnea or maybe syncope. It looks like ACS and should be treated as such until you prove to yourself it’s not.
  • Classic patient is an older woman with chest pain or syncope after a stressful event.
  • Bedside echo will show left ventricular dysfunction with one of a variety of patterns of wall motion abnormality. The most common is apical, but there are also variant patterns including mid-ventricular, basal, focal and global.
  • Watch for QTc prolongation as this could precipitate an arrhythmia. Be sure to stop all QT prolonging meds and replete magnesium
  • Consider the differential in the patient who has cardiogenic shock because the treatment differs. Avoid catecholamines and if you need inotropic support use dobutamine or dopamine. Look for evidence of left ventricular outflow tract (LVOT) obstruction, as this should be treated like a hypertrophic cardiomyopathy with beta blockers rather than inotropes.

October 30, 2019

Background: Currently, alteplase is the mainstay of treatment of acute ischemic stroke.  Advocates of alteplase suggest that the benefit of alteplase is greatest when given early and declines with increasing time from stroke symptom onset (i.e. time is brain).  Therefore, the AHA/ASA guidelines recommend intravenous alteplase within 4.5 hours after stroke onset, which is based on very weak evidence (i.e. NINDS & ECASS III). Due to weak evidence in support of it’s use and significant patient risks associated with alteplase, it’s use in acute ischemic stroke remains controversial.  One of the big issues is that by decreasing the time for evaluation and treatment, there is an increased risk of administrating alteplase to patients presenting with noncerebrovascular conditions that can resemble an acute ischemic stroke (i.e. stroke mimics).  This puts patients with no chance of improvement with alteplase at risk for increased mortality and symptomatic ICH.  There is some limited data on the safety of alteplase in stroke mimics and this study adds to that knowledge.

October 9, 2019

Take Home Points 
  • Acute closed angle glaucoma is an ophthalmologic emergency that usually presents with sudden, painful, monocular vision loss.
  • Physical exam will reveal conjunctival redness, corneal haziness or cloudiness due to edema and a pupil that is mid sized and minimally reactive to light, a rock hard globe and IOP >/= 21.
  • These patients require emergent ophthalmology evaluation but treatment should be started empirically while waiting for the evaluation. Initial treatment to decrease IOP usually includes a topical BB such as timolol and topical AB such as apraclonidine and either IV or PO acetazolamide.