January 27, 2020

Background: The combination of vitamin C, hydrocortisone and thiamine in sepsis has been a topic of hot debate in the past couple years.  There is a hypothetical pathophysiological basis to make an argument for the use of this combination of medications, but as with anything it is important to ensure there are no untoward effects either. In Dr. Marik’s before and after study [1] we saw some pretty amazing results showing that treatment reduced hospital mortality  by 31.9% (Treatment Group 8.5% vs Control Group 40.4%). Too good to be true?  Well in short, YES…the major issues with this study were it was not a randomized controlled trial, had a small sample size, was a single center study, and had significant selection bias.  Well we finally have our first randomized controlled trial evaluating the “metabolic cocktail” in a general population of septic shock adult patients.

January 15, 2020

Take Home Points 
  • Osteomyelitis is an infection in any part of a bone. It has a varied presentation including acute and chronic forms. Patients can present septic, or rather well appearing.
  • Patients may present with fever, chills, musculoskeletal pain, erythema, swelling or drainage from an ulcer.
  • Lab evaluation includes WBC, ESR and CRP, which we expect to be elevated in acute osteo, but less so in chronic.
  • MRI is the best imaging modality, but XR and CT may have some findings that suggest osteo.
  • Unstable patients should be started on broad spectrum antibiotics, usually vancomycin and cefepime, right away. Stable patients can be started on antibiotics in conjunction with your orthopedic consults.

January 13, 2020

Therapeutic Hypothermia (also called targeted temperature management (TTM)) is a deliberate reduction of the core body temperature to 32 - 34°C, in patients who suffer cardiac arrest with return of spontaneous circulation, but also don't regain consciousness.  In REBEL Crit Cast episode 1, I will go through the evidence for cooling adults and children, potential adverse effects, and what temperature to shoot for.

January 2, 2020

Background: Traditionally, vasopressors have been given through central venous catheters (CVCs) in the critically ill.However, the time it takes to place a CVC is time a patient could potentially remain hypotensive. Early initiation of vasopressors may be associated with reduced mortality by increasing end-organ perfusion. Therefore, there has been a growing trend to use vasopressors through peripheral IVs (PIVs).  Running pressors through a peripheral IV has a couple of important benefits including faster time to pressor initiation and no need for invasive procedures (i.e. CVC). There islittle evidence to support the safety of this practice other than one systematic review which included case reports and small case series. Now we have two more papers that evaluate this very question…are peripheral pressors safe?

December 30, 2019

REBEL EM-ers: Salim & I would like to introduce the launch of a new REBEL EM project. We are adding a podcast focused on a wide variety of resuscitation and critical care topics in both Adult & Pediatric Medicine to the website. The podcast will be called REBEL Crit Cast, and will compliment are already popular REBEL Crit content on our parent site.  This will include blog posts and podcast content with a dedicated place on the parent site. Instead of creating a separate podcast, we’ll be bringing you REBEL Crit Cast as part of REBEL Cast. This way, you won’t need to download another podcast. The format may change over time, and I'd love to know your questions, and ideas for topics so that I can make this as practical and useful to YOU, our audience, as possible.