June 3, 2019

Background: Despite the lack of replication of the NINDS & ECASS-3 trials, guidelines recommend the use of tPA in the ≤4.5hr window after the onset of symptoms of acute ischemic stroke [2]. These recommendations used non-contrast computed tomography (NCHCT) for the selection of patients.  More recent endovascular studies have shown that perfusion-based imaging can show potential viable brain tissue beyond the 4.5 hour mark in patients with large vessel occlusions and result in good neurologic outcomes.  This advance has prompted investigators to look at perfusion-based technology to identify a larger cohort of patients without large vessel occlusion that may be candidates for systemic thrombolysis.  One of the big fears in stroke management is the concept of indication creep: finding more uses for a medication or product without strong evidence to support its use. The bigger question is, does this increase in use help the company’s bottom line or the patient? It is no wonder physicians are skeptical of industry sponsored trials, as we sometimes question the motives behind the study.  Now we have another industry sponsored trial: EXTEND. In this trial.

May 29, 2019

Take Home Points on Tracheostomy Emergencies

  • Track is mature in 7 days - don't blindly replace before then because concern for false track creation
  • All bleeding needs to be taken seriously and should be evaluated by surgery
  • If not ventilating through trach - go through it systematically to find malfunction

May 15, 2019

Take Home Points on Epiglottitis

  • Epiglottitis has demonstrated a resurgence in the adult population. It is no longer a pediatric only disease.
  • The classic presentation of epiglottitis (3Ds of drooling, dysphagia and distress) is uncommon
  • Epiglottitis should be high on your differential for the bounce-back patient who continues to complain of worsening sore throat
  • Definitive diagnosis is made by flexible fiberoptic laryngoscopy
  • Be ready for a difficult airway

May 13, 2019

Background: Post-ROSC care is a multifaceted endeavor that includes targeted temperature management (TTM), vital-organ support, and treatment of the underlying cause of arrest. One of the most common causes of cardiac arrest is acute coronary syndrome.  Current European and American guidelines recommend immediate coronary angiography with PCI in patients who present with cardiac arrest due to STEMI. However, in patients with cardiac arrest who do not have STEMI, the role of immediate coronary angiography is still up for debate.  The ACC/AHA published a statement in July of 2015 (Covered on REBEL EM) that proposed an algorithm to stratify cardiac arrest patients who are comatose on presentation for emergent coronary angiography and possible PCI. 

May 9, 2019

Background Information: The sequential administration of a sedative and neuromuscular blocking agent (NMBA) to facilitate the passage of an endotracheal tube is a common method of intubating in both the emergency department (ED) and intensive care unit (ICU). In fact, 85% of ED intubation and 75% of ICU intubations are performed using RSI. 1 It has been shown that the NMBA not only provides muscle relaxation to improve laryngeal view but has also reduced intubation associated complications, ultimately improving the likelihood of intubation success.2-4 While the early use of a sedative leads to hypoventilation and apnea, the patient has an increased risk of hypoxemia and delaying optimal intubation conditions.1 Use of an NMBA was associated with a lower prevalence of hypoxemia, however the order of its administration before the sedative remains controversial for fear of patient awareness and its use has been limited to the operating room (OR) setting. 1,2 The authors of this study sought to identify whether the order of RSI drugs was associated with increased apnea time during intubation. They defined this interval as the time elapsed from administration of the first RSI drug to the end of a successful first intubation attempt.