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.

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?

March 25, 2019

Background: TXA is a synthetic lysine derivative that binds with the lysine site on plasminogen and inhibits fibrinolysis.  TXA is not a new drug. Studies from the late 1960s and early 1970s have shown reduced bleeding and need for transfusions in many surgical and medical settings.  Fast forward to today and we are finding all kinds of uses for TXA other than trauma including post-partum hemorrhage, epistaxis, hemoptysis, gastrointestinal hemorrhage, and many more.

July 20, 2018

Background: Epinephrine(adrenaline) has been used in advanced life support in cardiac arrest since the early 1960s. Despite the routine recommendation for its use, evidence to support administration is less than ideal.  Although it is clear from multiple observational studies that epinephrine improves return of spontaneous circulation (ROSC) and short-term survival, most evidence suggests an absence of improvements in survival with good neurologic outcomes.  In cardiac arrest we want to take advantage of the alpha effects of epinephrine, including peripheral vasoconstriction, and therefore increasing aortic diastolic pressure, which in turn helps augment coronary and cerebral blood flow.  On the other hand, we want to avoid the potentially detrimental beta effects including dysrhythmias, decreased microcirculation, and increased myocardial oxygen demand all of which increase the chances of recurrent cardiac arrest and decreased neurologic recovery.  The only two interventions in cardiac arrest that have shown improve survival with good neurologic outcomes continue to be high-quality CPR and early defibrillation. The debate over the utility of epinephrine in OHCA has been ongoing for several years now and many providers have been awaiting the results of the PARAMEDIC-2 trial that was just published in the NEJM 2018. 

March 15, 2018

Background: Approximately 80% of strokes are ischemic in origin leading to significant morbidity and mortality worldwide.  In ischemic stroke, there is usually a core infarct and an ischemic penumbra.  The penumbra is the area that we try to salvage with reperfusion therapy. Currently, systematic intravenous alteplase administered within 4.5hrs after symptom onset is the mainstay of therapy, however many question its risk/benefit ratio in ischemic stroke. 4.5 hours is a narrow therapeutic time window and many contraindications such as recent surgery, coagulation abnormalities, and history of intracranial hemorrhage inhibit many patients from receiving systemic thrombolysis.  There have been many studies evaluating endovascular therapy in the management of ischemic stroke published in the past few years.  This post will serve as a review of those studies.

August 7, 2017

Background: It has been common practice in trauma to place patients in cervical collars and on long backboards (LBBs) to achieve spinal immobilization. LBBs are used to help prevent spinal movement and facilitate extrication of patients. Cervical collars (C-Collars) are used to help prevent movement of the cervical spine and often are combined with lateral head blocks and straps. The theory behind this is that spine immobilization prevents secondary spinal cord injury during extrication, transport, and evaluation of trauma patients by minimizing movement.  Most of this information has been passed on from historical teachings, like the Advanced Trauma Life Support (ATLS) courses, and not from scientific research. To date there has been no high-quality evidence that use of spinal immobilization improves patient outcomes. In this post, we will review the evidence associated with spinal immobilization in trauma patients.