We believe that critical care is not simply a location or a unit in a hospital, but the practice of providing care to those who need urgent support to treat or prevent a life-threatening illness. Whether you’re a paramedic, nurse, EM, IM, CCM doc, etc…

REBEL Crit

will help you critically appraise the literature so that you can deliver the highest quality, evidence based and compassionate care to your patients.

REBELCrit not only review’s recent publications, but has many review article’s, on often complex topics, to help you, the busy provider, continue to provide the best care possible. Soon, REBELCrit will be launching a critical care podcast through our already popular REBELCast!

REBELCrit strives to give you the most up to date and timely information so that you can be the best provider you can be and deliver the best care to your critically ill patients!

April 8, 2021

Background: Since the publication of the before and after Marik trial [1] published in 2016, there have been six randomized clinical trials trying to answer the question of the utility of the metabolic cocktail (Vitamin C, thiamine, and hydrocortisone) in septic shock (See table below). Although, each was of various methodological rigor only one had a positive primary outcome (i.e. ORANGES). It is important to note that the primary outcome of the ORANGES trial was changed after full data collection (and likely analysis) was complete (See the REBEL EM analysis HERE). We now have our 7th RCT on this topic.

March 8, 2021

Background: Though oxygen is fundamental for life, supra-physiological levels can be deleterious. Several randomized controlled trials and meta-analyses have been conducted in the critically ill to determine whether a conservative oxygenation approach compared to a liberal oxygenation approach is beneficial. The OXYGEN-ICU trial was one of the first trials to explore this issue in 2016. It was a small, single centered trial with 434 ICU patients that showed a significantly lower ICU mortality in the conservative oxygenation group with an ARR 8.6%1. ICU-ROX (Mechanically ventilated patients) and LOCO2 (ARDS patients) were two more randomized trials that explored critically ill patients in the ICU with conflicting evidence on oxygen targets. There was no mortality benefit or ventilator free days in either study2,3. Although in the LOCO2 trial there was a clinically relevant excess mortality in the conservative group of 14 percentage points higher than in the liberal group at 90 days (not statistically significant) Additionally, the LOCO2 trial found a higher rate of intestinal ischemia in patients with a conservative oxygenation strategy3. Based on these three trials it can be stated that both hyperoxia (SpO2 >97%) and hypoxemia (SpO2 <90%) should be avoided.  An SpO2 of 92 to 96% (PaO2 60 to 90) would be the ideal target in these patients. Until now, there has not been any good data regarding oxygenation parameters in patients with acute hypoxemic respiratory failure.

March 4, 2021

Background:  Despite medical advances, survival after out of hospital cardiac arrest (OHCA) is still largely dependent on high-quality CPR. Many of these events are due to a primary cardiac event, likely coronary artery occlusion. Current guidelines recommend reperfusion therapy following cardiac arrest with signs of acute coronary occlusion on EKG. But this only applies when return of spontaneous circulation (ROSC) is achieved. What about those in refractory arrest? Is there a way to increase survival in those patients? Keeping in mind that achieving ROSC may be impossible without reperfusion and reperfusion will likely not occur without ROSC.

February 1, 2021

Background: It has well been established that low tidal volume ventilation minimizes potentially iatrogenic harms of mechanical ventilation.  What is less clear is the use of higher positive end expiratory pressure (PEEP) in patients without acute respiratory distress syndrome (ARDS). Use of PEEP helps prevent alveolar collapse and maintains recruitment of atelectatic and diseased alveoli.  This improves the distribution of lung aeration over a more homogenously inflated lung surface which in turn may improve oxygenation. Although PEEP reduces cyclical opening and closing of alveoli during ventilation, a higher PEEP could also lead to new lung injury (ventilator-induced lung injury), impair hemodynamics (reducing venous return) and could delay weaning/extubation.

January 14, 2021

Background Information: Out-of-hospital cardiac arrest (OHCA) remains a diagnostic challenge to providers and a significant burden on healthcare systems globally. Despite the advancement of invasive medical therapies such as percutaneous coronary intervention (PCI) and extracorporeal membranous oxygenation (ECMO) at designated cardiac catherization centers, the majority of these patients sustain poor outcomes due to hypoxic brain injury. Clinical features of neurologic injury are typically delayed until 72 hours after admission. As a result, many neuro-prognostication tools have been developed to assist with clinical decision making as well as reduce expensive futile interventions.1 Some of these neuroprognostication tools include the Cardiac Arrest Hospital Prognosis (CAHP), OHCA and Targeted Temperature Management (TTM) risk tools. Unfortunately, these are complex and time consuming, thus limiting their use in the emergency department (ED). The authors of the following study sought out to develop and validate a point-based risk score to support clinical decision making and predict neurologic outcomes using the cerebral performance category (CPC) scale (Figure 1)