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In this episode of REBEL Cast, we dive into part one of our Diabetic Ketoacidosis (DKA) series with a twist—subcutaneous insulin instead of the traditional IV drip. We explore the SQuID Protocol (Subcutaneous Insulin in DKA), which could potentially shift how we manage mild to moderate DKA—from the ICU to the general floor. The post REBEL Core Cast – DKA: Beyond the Basics Part 1 – The SQuID Protocol appeared first on REBEL EM - Emergency Medicine Blog.

Emergency medicine physicians were trailblazers during the opioid epidemic, and now we have the same opportunity with alcohol use disorder (AUD). Treating AUD deserves the same attention we give to opioid overdose, diabetic ketoacidosis, or hypertensive emergencies. Even when alcohol use doesn’t present as an immediate crisis, each ED encounter is a chance to intervene—one that could help prevent future withdrawal, traumatic injury, or upper gastrointestinal bleed. Naltrexone and other Medications for Alcohol Use Disorder (MAUD) can reduce alcohol use, and just 12 patients need to be treated to prevent one from returning to heavy drinking. By recognizing alcohol use disorder as a critical health issue and leveraging simple, evidence-based tools, emergency physicians can transform routine encounters into life-changing opportunities. Initiating MAUD in the Emergency Department (ED) is feasible and impactful. Even a single dose of naltrexone in the ED can jump-start treatment and is generally safe and well-tolerated. However, MAUD has rarely been offered in the ED, but the growing evidence suggests it increases treatment engagement and reduces drinking. Many of these medications have been thoroughly investigated, are safe to administer, and are effective at reducing alcohol consumption. Furthermore. In 2024, the Society for Academic Emergency Medicine (SAEM) published Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE-4) on alcohol use disorder and recommend prescribing MAUD. Many patients with alcohol use disorder face numerous societal obstacles and are less likely to access follow-up care. Therefore, initiating MAUD in the emergency department might be the only opportunity to start treatment. The post Treatment for Alcohol Use Disorder appeared first on REBEL EM - Emergency Medicine Blog.

Each year, about 1 in 7 men and 1 in 11 women in the United States meet criteria for alcohol use disorder (AUD)—affecting nearly 29 million people, roughly the entire population of Texas. Patients with AUD face staggering health risks: they are 3.5 times more likely to die than the general population, and their life expectancy is up to 25 years shorter. Over the past decade, alcohol-related emergency department (ED) visits have climbed by nearly 50%. Between 2021 and 2023 alone, alcohol accounted for approximately 8.6 million substance use-related ED visits—double the number linked to opioids. Effective treatments and resources for AUD are underutilized and screening rates in the ED are as low as 8%, leaving millions of high-risk patients unidentified and untreated. This mismatch between disease burden and screening represents a critical missed opportunity. Closing this gap is possible. Naltrexone, for example, has a number needed to treat of just 12 to prevent relapse into heavy drinking. It is widely available, easy to prescribe, and can be life-altering—even life-saving. This post highlights practical screening tools for identifying it in the ED, and offers recommendations for seamlessly integrating these approaches into everyday workflow to deliver more comprehensive patient-centered care. The post Screening for Alcohol Use Disorder appeared first on REBEL EM - Emergency Medicine Blog.

When you take the airway, you take the wheel and you now control the patient’s oxygenation and ventilation. In this REBEL Crit episode, Dr. Lodeserto and Dr. Acker walk through the physiology, ventilator strategies, and clinical curveballs that separate calm control from chaos at the bedside. The post REBEL Core Cast 143.0–Ventilators Part 3: Oxygenation & Ventilation — Mastering the Balance on the Ventilator appeared first on REBEL EM - Emergency Medicine Blog.

PECARN has been THE  decision rule for guidance on management of kids with head injuries, but the Infant Scalp Score dives even deeper—built just for babies with scalp hematomas.  Which rule is best in this situation? The post MDCalc Wars – Tiny Patient, Big Decision: Head CT or no Head CT? appeared first on REBEL EM - Emergency Medicine Blog.

Procalcitonin is a protein that is upregulated during inflammatory states. An elevation in procalcitonin should be specific to bacterial infections. Viral infections should result in decreased procalcitonin levels thus allowing us to differentiate bacterial from viral and help guide antibiotic prescription. However, this differentiation isn’t what we see in real life data. The post Clinical Conundrum: What is the Utility of Procalcitonin in the ED? appeared first on REBEL EM - Emergency Medicine Blog.

Mechanical ventilation can feel overwhelming, especially when faced with a sea of ventilator modes and unfamiliar terminology. In Part 2 of the series, we go beyond breath types and delivery mechanics to explore the most used modes in the ICU. We will break down each one; explaining how it works, when to use it, and why the goal isn’t the “best mode” but the most comfortable one for the patient. The post REBEL Core Cast 142.0–Ventilators Part 2: Simplifying Mechanical Ventilation – Most Common Ventilator Modes appeared first on REBEL EM - Emergency Medicine Blog.

In this special episode of Rebel Cast, we spotlight the Incrementum Conference in Spain, a significant event in emergency medicine. Hosts welcome Dr. Francisco 'Paco' Campillo Palma and Dr. Carmen Maria Cano, founders of Incrementum, to discuss the recognition of emergency medicine as a specialty in Spain. They share their journey of creating the conference, emphasizing the importance of education, collaboration, and growth. The discussion also touches on this year's conference highlights, including sessions on mental health and evidence-based medicine, and the exceptional lineup of speakers. Listeners are encouraged to attend the conference in April 2026 for an enriching experience. The post Incrementum Conference 2026: Revolutionizing Emergency Medicine in Spain appeared first on REBEL EM - Emergency Medicine Blog.

For many medical residents, the ICU can feel like stepping into a pressure cooker. At the heart of that stress often lies one intimidating machine: the ventilator. Rather than diving headfirst into complex ventilator modes, this episode lays a critical foundation by breaking down the basic building blocks of mechanical ventilation, something every clinician should master before moving on to more advanced concepts. Once you know the 3 types of breaths and how those breaths are delivered, you can more easily understand most of the mechanical ventilator modes. The post REBEL Core Cast 141.0–Ventilators Part 1: Simplifying Mechanical Ventilation — Types of Breathes appeared first on REBEL EM - Emergency Medicine Blog.

Hemoptysis is a potentially life-threatening emergency that can lead to airway compromise and hemorrhagic shock. While definitive treatments like bronchoscopy, bronchial artery embolization (BAE), and surgery can be effective, they often require significant time and specialized resources—capabilities not universally available in all hospitals or emergency departments. Tranexamic acid (TXA), an antifibrinolytic agent, has emerged as both an adjunctive and potentially definitive therapy in the acute management of hemoptysis. A 2020 systematic review by Tsai et al. analyzed 617 studies and found that TXA—whether administered intravenously or via inhalation—was associated with reduced bleeding volume, decreased need for invasive interventions, and shorter hospital stays. A small RCT by Wand et al. demonstrated that nebulized TXA significantly reduced expectorated blood volume compared to placebo by day two of admission. Inhaled medications are well-established in pulmonary medicine for delivering rapid, localized effects in conditions such as asthma, COPD, bronchiectasis, and even lung cancer. This targeted delivery to the lung parenchyma may offer advantages over systemic therapy in conditions like hemoptysis. While there is growing evidence for the role of TXA in hemoptysis, no prior study has directly compared the efficacy of different routes of administration in this setting. The study reviewed here is the first randomized controlled trial to directly compare intravenous versus nebulized TXA in patients presenting to the emergency department with hemoptysis. The post TXA for Hemoptysis: We Put That $#!t on Everything (That Bleeds) appeared first on REBEL EM - Emergency Medicine Blog.

The sicker the patient, the more likely an IO line is the right choice. In emergencies such as cardiac arrest or hemorrhagic shock, the speed and reliability of IO access outshine traditional intravenous (IV) or central line placements. There's virtually no resuscitation medication or blood product that cannot be administered through an IO, making it indispensable in life-threatening scenarios. The post REBEL Core Cast 140.0: The Power and Limitations of Intraosseous Lines in Emergency Medicine appeared first on REBEL EM - Emergency Medicine Blog.

Syncope is one of the most common complaints we face in the ED. Most patients do well, yet a small subset are harboring serious cardiac or neurologic disease. Admit everyone, and we waste beds and resources; discharge everyone, and we risk missing life-threatening disease. As always in emergency medicine, we’re searching for the needle in the haystack—the one patient out of hundreds who’s truly at risk. You may have heard of the San Francisco Syncope Rule, but have you met its worthy opponent, the Canadian Syncope Risk Score? When syncope isn’t straightforward, which tool should you trust to guide disposition? Could these decision aids reveal risks you might otherwise miss? The post MDCalc Wars: Sorting Out Syncope – Which Rule Should You Trust? appeared first on REBEL EM - Emergency Medicine Blog.

On this episode of the Rebel Core Cast, Swami takes a deep dive into pneumothorax decompression, focusing on the need for improvements beyond the classic teachings. Covering scenarios where immediate decompression is critical, particularly in tension pneumothorax, Swami discusses the limitations of needle decompression, especially in the second intercostal space at the midclavicular line. He highlights the importance of using POCUS for diagnosis and recommends skipping needle decompression in favor of finger thoracostomy for a more reliable and effective treatment. Key takeaways emphasize recognizing tension pneumothorax in various clinical situations and the advantages of finger thoracostomy over traditional techniques. The post REBEL Core Cast 139.0: Pneumothorax Decompression appeared first on REBEL EM - Emergency Medicine Blog.

Sepsis is one of the most common emergencies we encounter, yet despite decades of research, it still carries a high burden of morbidity and mortality. Over the years, our attempts to improve outcomes have spanned the spectrum—from clearly lifesaving (like timely antibiotics) to largely discredited (like high-dose vitamin C). On paper, treatment with albumin makes sense: it’s a large protein that can boost oncotic pressure and theoretically counteract sepsis-induced capillary leak. But when tested in clinical trials—most of which were conducted in ICU settings—albumin hasn’t delivered. No improvement in mortality, no game-changing results. The ICARUS-ED trial set out to explore whether 20% albumin given during the earliest phase of sepsis care could improve systolic blood pressure at 24 hours. Let’s dive into the study. The post ICARUS ED Trial: Concentrated Albumin for Undifferentiated Sepsis in the Emergency Department appeared first on REBEL EM - Emergency Medicine Blog.

In this episode, we will dive into a simple yet effective bedside approach to a patient in shock. By using quick physical exam findings and bedside vitals (particularly pulse pressure), you can form a quick assessment of the likely underlying etiology of a critically ill patient. The post REBEL Core Cast 138.0: A Simple Bedside Approach to Shock appeared first on REBEL EM - Emergency Medicine Blog.

Diagnosing PE in the emergency department is tricky. The symptoms—chest pain, shortness of breath, tachycardia—are nonspecific and overlap with many other conditions. But missing a PE can have devastating consequences, so there’s often a low threshold to order a CTA. Resulting in over-testing, radiation exposure, contrast risk, increased length of stay, and unnecessary healthcare costs. Wells Criteria and PERC help clinicians safely and systematically identify which patients actually need further workup. These tools reduce cognitive load, provide a standardized approach, and—when used appropriately—minimize unnecessary testing without missing clinically significant PEs. The post MDCalc Wars: Stop Before the CT! — Are You Using PERC or Wells Correctly appeared first on REBEL EM - Emergency Medicine Blog.

Sinus tachycardia is the most prevalent cardiac dysrhythmia in critically ill patients, yet it often receives less attention than it warrants. While the rhythm itself is not inherently dangerous, it serves as a crucial indicator of underlying physiological disturbances that require prompt evaluation and management. The post REBEL Core Cast 137.0: A Simple Approach to Sinus Tachycardia appeared first on REBEL EM - Emergency Medicine Blog.

Managing patients with suspected occult scaphoid fractures and normal X-rays presents a common clinical dilemma. About 1 in 10 of these patients will have an occult fracture, and roughly 10% of all scaphoid fractures result in nonunion. However, the risk of nonunion among patients with MRI-confirmed occult fractures is much lower—around 3.5%. Guidelines recommend immobilization with a thumb spica cast or splint when clinical suspicion is high. But that threshold is subjective, and snuffbox tenderness alone has poor specificity (48%). As a result, many patients without a fracture are unnecessarily immobilized, often leading to repeat imaging, follow-up visits, and added cost and inconvenience. The SUSPECT Trial set out to challenge this reflexive approach—examinig whether simple bandaging could safely replace casting in patients with suspected occult scaphoid fractures and normal X-rays. The post Casting Doubt: The SUSPECT Trial — Bandaging Vs. Casting for Suspected Occult Scaphoid Fracture appeared first on REBEL EM - Emergency Medicine Blog.

In this episode, we focus on the bedside evaluation of the tachypneic patient. Tachypnea (increased respiratory rate) can be an early indicator of serious illness, but not every tachypneic patient is on the verge of arrest. The key is honing your bedside assessment to recognize who is at risk for rapid deterioration and why. We break down a practical approach you can use immediately at the bedside. The post REBEL Core Cast 136.0: A Simple Approach to the Tachypneic Patient appeared first on REBEL EM - Emergency Medicine Blog.

Chest pain is one of the most common—and anxiety-inducing—presentations in the Emergency Department. With millions of visits each year, clinicians face the constant challenge of identifying who is having a major cardiac event and who can safely go home. While most of these patients won’t have acute coronary syndrome, the stakes for missing it are high. That’s where clinical decision rules like the HEART Score and EDACS can help. The post MDCalc Wars: HEART Score Vs. EDACS appeared first on REBEL EM - Emergency Medicine Blog.

🧭 REBEL Rundown 📌 Key Points 💨 Most asthma patients still leave the ED with a SABA alone—time for an upgrade. 📉 SABA/ICS combo inhalers cut severe exacerbations compared to SABA alone. 🏥 Study excluded typical ED patients—few had recent exacerbations. 💰 New combo inhaler costs ~$500 and was compared to a weaker treatment. 💡 ... Read more The post Combination Inhalers in Asthma: Time to Switch? appeared first on REBEL EM - Emergency Medicine Blog.

In this episode, we break down a practical bedside approach to hypoxemia. We clarify the difference between hypoxemia (low oxygen in the blood) and hypoxia (low oxygen at the tissue level), and walk through the major causes of hypoxemia that you need to recognize quickly at the bedside. The post REBEL Core Cast 135.0: A Simple Approach to Hypoxemia (vs. Hypoxia) appeared first on REBEL EM - Emergency Medicine Blog.

Antibiotic stewardship entails delivering the most appropriate antimicrobial therapy for the most appropriate duration of time to help provide the best outcome for patients with sepsis. An unnecessarily extended course of antibiotics leads to adverse effects, greater cost, medication utilization and most importantly antimicrobial resistance. However, too short of a course could lead to failure to treat and clinical deterioration. The optimal duration of antibiotics in sepsis remains uncertain and several biomarkers such as C-reactive protein (CRP) and procalcitonin (PCT) have been studied to help clinicians reduce overtreatment and preserve antibiotic effectiveness. The authors of this 3-group multicenter randomized control trial sought to investigate whether biomarker-guided protocols could safely assist in the decision to discontinue antibiotics. The post The ADAPT-Sepsis Trial: Biomarker-Guided Antibiotic Duration for Hospitalized Patients with Suspected Sepsis appeared first on REBEL EM - Emergency Medicine Blog.

Acetaminophen (APAP) overdose remains one of the most common causes of acute liver failure in the United States. While its therapeutic use is widespread and generally safe, unintentional overdoses and delayed presentations can lead to devastating outcomes. In this episode of REBEL Cast, we break down the pathophysiology, clinical course, diagnostic approach, and evidence-based management ... Read more The post REBEL Core Cast 134.0 – Acetaminophen Toxicity appeared first on REBEL EM - Emergency Medicine Blog.

Over 1 million blunt trauma patients visit US emergency departments each year for possible c-spine injuries. Yet, 98% of c-spine imaging shows no fracture. Using clinical decision tools can safely and significantly reduce unnecessary imaging. The post MDCalc Wars: NEXUS Criteria Vs Canadian C-Spine Rules appeared first on REBEL EM - Emergency Medicine Blog.

Current IDSA guidelines for sepsis recommend individualized durations of antibiotic therapy based on source control and clinical response, but definitive guidance remains limited. Three small noninferiority RCTs suggested that 7 days of antibiotics may be sufficient for patients with gram-negative bacteremia—but these trials had notable limitations: they excluded ICU patients, included only clinically improving individuals, and did not assess gram-positive infections. The BALANCE trial, a large multicenter RCT, aimed to address these gaps and strengthen the evidence base for shorter-course antibiotic strategies in a broader sepsis population. But does The BALANCE Trial tip the scales in favor of 7 days of antibiotics for sepsis? Let’s break it down. The post Is 7 Days Enough? Rethinking Antibiotic Duration in Sepsis — The BALANCE Trial appeared first on REBEL EM - Emergency Medicine Blog.

The American Heart Association and the European Stroke Organization have updated their guidelines to recommend TNK as an alternative to tPA in patients eligible for thrombolysis. TNK, a bioengineered variant of tPA, has some advantages, including its single-dose administration, fibrin specificity, and longer half-life. Several studies have demonstrated the safety and efficacy of TNK as an alternative to tPA The post TNK vs tPA — The ORIGINAL Trial appeared first on REBEL EM - Emergency Medicine Blog.

Bottom Line Up Top: Blood gas electrolytes closely correlate with serum measurements and can be used under most circumstances to guide clinical care. Clinical Scenario: A 62 year old woman with a history of HTN, ESRD on MWF dialysis presents to the Emergency Department with generalized weakness. Her vital signs are HR = 82, BP ... Read more The post How Accurate are Blood Gas Electrolyte Measurements? appeared first on REBEL EM - Emergency Medicine Blog.

Background: Accurate blood pressure (BP) measurement is essential in the emergency department (ED), where it serves as a key marker of hemodynamic stability and informs critical management decisions. Improper technique and incorrect cuff sizing can lead to falsely high or low readings, impacting patient care. The issue of BP cuff size has been studied in ... Read more The post Size Matters: The Impact of Cuff Size on Blood Pressure appeared first on REBEL EM - Emergency Medicine Blog.

Introduction: In this episode of Rebel Cast, host Marco Propersi, along with co-hosts Steve Hochman and Kim Baldino, delve into the practice and importance of street medicine—the direct delivery of healthcare to homeless and unsheltered individuals. Special guests Dr. Jim O’Connell, a pioneer of street medicine, and Dr. Ed Egan, a recent street medicine fellowship ... Read more The post Street Medicine: Compassionate Care for the Unhoused appeared first on REBEL EM - Emergency Medicine Blog.