Knowledge translation (KT) is the process involved in moving research from the laboratory bench, research journals, and academic conferences to the hands of providers who can put it to practical use at the bedside or in the prehospital environment. REBEL EM has been dedicated to this initiative for several years and is now happy to present

REBEL CME.

The goal is to provide Continuing Medical Education (CME) and Continuing Education Hours (CEH) for a nominal fee to support the blog, on several of these activities.

August 19, 2019

Background: Antibiotics are one of the cornerstones of therapy in the treatment of sepsis/septic shock, however according to the Surviving Sepsis Campaign (SSC) guidelines, time to antibiotics is a core measure, though there is weak evidence in support of this.  Most of the evidence supporting this is based off retrospective studies that showed delays in the administration of antibiotics after the development of septic shock is associated with an increase in mortality of almost 7.6% per hour [3]. The major issues with retrospective studies are that they are uncontrolled, chart quality may be inaccurate, baseline status of patients may be unbalanced and thus allow selection bias that can affect the results. Although, prospective observational studies have failed to consistently show an association between early antibiotics and mortality benefit, the guidelines still recommend early antibiotic administration within an hour of sepsis recognition.

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 27, 2019

Background: In 2000, the U.S. achieved the elimination of measles, defined as the absence of sustained transmission of the virus for more than 12 months [3,7]. Unfortunately, this success was short lived.  According to the CDC, 555 cases of measles have already been confirmed from Jan 1st – April 11th, 2019 [3]. This resurgence in measles is frustrating as it has a safe and highly effective vaccine, and it has no animal reservoir to maintain circulation.  Failure to get vaccinated unfortunately stems from misconceptions about vaccine safety (i.e. the now-debunked claim connecting vaccination to autism [4,5]), poor health education, lack of access to health care, and complacency.  This is now a global epidemic as disease does not respect borders.

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. 

April 25, 2019

Background: Although the debate over balanced (i.e. lactated ringers, PlasmaLyte) vs unbalanced (i.e. 0.9% saline) crystalloids has not been settled, fluid resuscitation continues to be a fundamental therapy given to critically ill patients.  0.9% saline is one of the most common fluids given in resuscitation of patients but the high chloride content may contribute to the development of acute kidney injury (AKI) [1]. Alternatives to 0.9% saline include crystalloids with electrolyte compositions that are more balanced and resemble that of plasma (i.e. Lactated Ringer’s Plasma-Lyte, etc). Theoretically use of more balanced crystalloids would result in less potential side effects when compared to 0.9% saline. The crux of the matter is does fluid choice affect any patient-oriented outcomes?