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STEMI-equivalent and STEMI-mimic ECGs are among the most difficult tracings to interpret. This study examines how Queen of Hearts AI performed against physicians when accuracy in cath lab activation decisions mattered most. The post The Queen of Hearts Returns: AI vs Physicians in STEMI-Equivalent and STEMI-Mimic ECGs appeared first on REBEL EM - Emergency Medicine Blog.

In the first trimester, fever is associated with increased risk of birth defects such as cleft lip and palate, as well as serious neural-tube defects such as spina bifida and anencephaly. In late pregnancy, fevers can boost the risk of miscarriage, stillbirth, and preterm birth (Antoun 2021). Acetaminophen is the most commonly used antipyretic/analgesic medications with up to 62% of women using it during pregnancy (Bandli 2020). The drug does cross the placenta making it important to research fetal effects, particularly neurodevelopmental disorders (NDDs) including autism, ADHD and intellectual disability. For decades, the American College of Obstetrics and Gynecology (ACOG) has recommended acetaminophen as the safest antipyretic/analgesic during pregnancy (ACOG 2021). The post Clinical Conundrum: Is Acetaminophen Safe in Pregnancy? appeared first on REBEL EM - Emergency Medicine Blog.

POCUS diastology doesn’t diagnose chronic diastolic dysfunction—it estimates left atrial pressure in real time. Learn how to capture E and e’ from an apical 4-chamber view, calculate E/e’, and rapidly distinguish cardiogenic pulmonary edema from other causes of acute dyspnea in the ED. The post Diastology: Use E/e’ to Estimate Left Atrial Pressure appeared first on REBEL EM - Emergency Medicine Blog.

Today we are exploring the imperative topic of rest and why it’s not just about sleeping. The first of a two part series, hosted by Dr. Mark Ramzy with guests Dr. Maureen Aiad and Dr. Amil Badoolah, our discussion sheds light on the multifaceted nature of rest, especially in the demanding field of emergency medicine. The post REBEL MIND – How to Sleep When the World Says You Can’t appeared first on REBEL EM - Emergency Medicine Blog.

The optimal treatment strategy for intermediate-risk (submassive) pulmonary embolism remains controversial. These patients are not in shock, but they have right ventricular (RV) dysfunction and myocardial injury, which are associated with higher risk for clinical decompensation and adverse outcomes. The post The PEERLESS Trial: Large-Bore Mechanical Thrombectomy Versus Catheter-Directed Thrombolysis in Intermediate-Risk PE appeared first on REBEL EM - Emergency Medicine Blog.

Need a quick, reliable coma scale in real ED chaos? SMS simplifies assessment, while FOUR adds brainstem and respiratory data when it matters most. The post MDCalc Wars: GCS Alternatives in the ED: SMS and FOUR Score 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: Is Tamsulosin Effective in Increasing Spontaneous Passage Rate of Ureteral Stones? appeared first on REBEL EM - Emergency Medicine Blog.

In this episode, we're excited to continue collaboration with Arena Labs, where host Dr. Mark Ramzy interviews Allyn Abadie, Arena Labs’ Principal Scientist on how we can apply performance science in and out of the emergency department. The post REBEL MIND: Applying Performance Science In and Out of the Emergency Department appeared first on REBEL EM - Emergency Medicine Blog.

The cornerstone of acute ischemic stroke (AIS) management involves timely reperfusion of the ischemic brain tissue. Intravenous thrombolysis with alteplase has been the standard of care for AIS within 4.5 hours of symptom onset, based on pivotal trials such as NINDS and ECASS III, which demonstrated improved functional outcomes despite an increased risk of intracerebral hemorrhage. However, many patients present outside this narrow therapeutic window, excluding many patients from the potential benefits of thrombolytics. For some, mechanical thrombectomy is an option if their stroke is the result of a medium or large vessel occlusion and is amenable to aspiration or stent retrieval. Recent advances in neuroimaging, particularly perfusion-based techniques, have allowed for the identification of salvageable brain tissue beyond traditional time limits. This imaging-guided approach has spurred clinical trials evaluating the safety and efficacy of thrombolysis in the extended and late time windows. The post The Hope Trial: Alteplase 4.5–24 Hours After Stroke (CT Perfusion Selected) appeared first on REBEL EM - Emergency Medicine Blog.

Consults aren’t a formality—they’re a patient-care intervention. In this post, Swami breaks down how to call a consult in the ED using a simple 4-step framework (introduce yourself, lead with the ask, give a focused summary, and close the loop), plus practical strategies for handling pushback, refusals, and when to escalate to protect patient care. The post REBEL Core Cast 150.0: Emergency Medicine Consults: How to Call a Consult + Handle Pushback (With Scripts) appeared first on REBEL EM - Emergency Medicine Blog.

Prior research has shown that deep tracheal suctioning can result in more rapid development of hypoxemia. It is unclear if continuous suctioning during intubation poses a similar risk. Does the application of continuous suctioning during rapid sequence intubation (RSI) result in more rapid deoxygenation? The post Continuous Suctioning Doesn’t Hasten Hypoxemia appeared first on REBEL EM - Emergency Medicine Blog.

The RENOVATE trial set out to answer a high-impact question across five distinct etiologic groups: Is HFNC non-inferior to BPAP (NIV) for preventing intubation or death in acute respiratory failure? The post REBEL CAST – RENOVATE Trial: HFNC vs BPAP in Acute Respiratory Failure appeared first on REBEL EM - Emergency Medicine Blog.

Today we are exploring the imperative topic of rest and why it’s not just about sleeping. The first of a two part series, hosted by Dr. Mark Ramzy with guests Dr. Maureen Aiad and Dr. Amil Badoolah, our discussion sheds light on the multifaceted nature of rest, especially in the demanding field of emergency medicine. The post REBEL MIND – Rest Is Not Sleep: The Seven Dimensions of True Recovery appeared first on REBEL EM - Emergency Medicine Blog.

Corticosteroids have long sparked debate in the treatment of bacterial pneumonia — once viewed with skepticism, now increasingly supported by high-quality evidence. In this episode, Dr. Alex Chapa joins the REBEL Core Cast team to explore how the 2023 Cape Cod Trial (NEJM) reshaped practice and guideline recommendations for severe community-acquired pneumonia (CAP). The post REBEL Core Cast 149: Review of Corticosteroids in Community-Acquired Pneumonia appeared first on REBEL EM - Emergency Medicine Blog.

Host Dr. Mark Ramzy shines a spotlight on two phenomenal educators: Drs. Sara Crager and Ryan Ernst who shared their expertise and experiences at this transformative gathering last spring. The post REBEL CAST – IncrEMentuM26 Speaker Spotlight : Drs. Sara Crager and Ryan Ernst appeared first on REBEL EM - Emergency Medicine Blog.

In this episode, we're excited to continue collaboration with Arena Labs, where host Dr. Marco Propersi interviews Jackie Pen, Heading of Performance Coaching at Arena Labs. The post REBEL MIND: The Power of Performance Coaching in Medicine appeared first on REBEL EM - Emergency Medicine Blog.

CIWA-Ar breaks down when patients can’t participate. mMINDS offers an objective, ICU-ready approach to scoring severe alcohol withdrawal—especially in delirious, intubated, or critically ill patients. The post MDCalc Wars: Alcohol Withdrawal–When CIWA-Ar Breaks Down, mMINDS Score Still Works appeared first on REBEL EM - Emergency Medicine Blog.

Ketamine was first introduced for human use in 1965 and has been widely utilized as a general anesthetic with an excellent safety profile (Mion 2017, Dorandeu 2013). Ketamine works on several receptors, resulting in various actions such as anesthesia, analgesia, and antidepressant effects. While not widely studied, ketamine has been shown to have antiepileptic properties. In seizures, the excessive release of glutamate leads to the overactivation of N-methyl-D-aspartate (NMDA) receptors, thereby causing neuronal hyperexcitability and seizure-like activity. Ketamine works by regulating neuronal excitability and reducing excessive, synchronized neural activity through non-competitive inhibition of glutamatergic transmission, primarily via NMDA receptor antagonism. More specifically, blocking the NMDA receptor with ketamine decreases neuronal depolarization and excitotoxicity, potentially halting seizure propagation (Tan 2024). The post Seizing the Evidence: Should We Consider Ketamine’s Place in Seizure Protocols? appeared first on REBEL EM - Emergency Medicine Blog.

Welcome back to Rebel MIND, the podcast where we sharpen the person behind the practitioner. In this episode, hosted by Drs. Mark Ramzy and Marco Propersi, we're excited to introduce a collaboration with Arena Labs. Arena Labs is helping us measure healthcare performance through innovative programs designed to combat burnout and enhance personal wellness using data-driven strategies. The post REBEL MIND: Performance Under Pressure – What Medicine Can Learn from Elite Teams appeared first on REBEL EM - Emergency Medicine Blog.

With high flows, modest PEEP, and effective dead-space washout, HFNC can improve oxygenation and decrease work of breathing while preserving the ability to talk, cough, eat, and interact with staff and family. The RENOVATE trial set out to answer a high-impact question across five distinct etiologic groups: Is HFNC non-inferior to BPAP (NIV) for preventing intubation or death in acute respiratory failure? The post RENOVATE Trial: HFNC vs BPAP in Acute Respiratory Failure appeared first on REBEL EM - Emergency Medicine Blog.

Non-invasive ventilation (NIV) refers to respiratory support provided without endotracheal intubation. The most common modalities include continuous positive airway pressure (CPAP), bilevel positive airway pressure (BiPAP), and high-flow nasal cannula (HFNC). These therapies aim to improve oxygenation, reduce the work of breathing, and potentially prevent invasive mechanical ventilation. The post REBEL Core Cast 148.0–Demystifying Non-Invasive Ventilation & HiFlow appeared first on REBEL EM - Emergency Medicine Blog.

Etomidate or ketamine? The debate over the ideal agent for emergency rapid sequence intubation (RSI) has raged for years with no clear winner. Etomidate has been touted in the past for its rapid onset and minimal intrinsic effects on hemodynamics. However, the drug is well known as a transient adrenal suppressant though the impact of this suppression isn’t clear. Ketamine has risen in recent years as an alternative, due to its perceived hemodynamic stability, analgesic properties and absence of adrenal suppression. Additionally, recent data points towards improved mortality when ketamine was selected over etomidate (Kotani 2023). High quality randomized controlled trials are needed to further elucidate which agent should be selected in critically ill patients. The post The RSI Trial: Ketamine vs Etomidate in Rapid Sequence Intubation appeared first on REBEL EM - Emergency Medicine Blog.

In this episode and blog post, hosts Mark Ramzy and Kim Bambach (Assistant Professor of Emergency Medicine, The Ohio State University) explore a deceptively simple question: How accurately can we assess our own performance? The answer hinges on a classic cognitive bias that touches all of us in emergency medicine. The post REBEL MIND – The Dunning Kruger Effect: Why Looking Inward Improves Patient Care appeared first on REBEL EM - Emergency Medicine Blog.

Shock is a life threatening condition that requires rapid resuscitation, and targeted treatment. Due to its complex nature, shock management poses many challenges for physicians in the acute care setting, more specifically, in the emergency department (ED). Point-of-care-ultrasound (POCUS) has emerged as a promising diagnostic and therapeutic clinical tool in this context, allowing ED physicians to assess hemodynamics and guide treatment interventions in real-time at the bedside. The post POCUS Use in Shock Resuscitation: Evidence for Patient and System-Level Benefits appeared first on REBEL EM - Emergency Medicine Blog.

Rib fractures are among the most common injuries in older trauma patients and can look deceptively “benign” early—until pain-limited ventilation, atelectasis, pneumonia, and respiratory failure develop hours to days later. Disposition decisions based on fracture count alone often miss the interaction between anatomic injury burden and physiologic reserve, especially in frail patients with limited pulmonary “margin.” RibScore offers an anatomy/CT-based estimate of pulmonary complication risk, while SCARF captures dynamic bedside physiology and functional respiratory performance that can worsen despite stable imaging. Using both together helps identify who needs earlier admission, aggressive multimodal analgesia, and closer respiratory monitoring—before decompensation declares itself. The post Rib Fracture Risk: Using RibScore + SCARF to Predict Decline appeared first on REBEL EM - Emergency Medicine Blog.

Annual influenza cases exceed one billion worldwide, with the vast majority of patients experiencing mild to moderate severity of illness. This massive health burden explains the extensive research into antivirals, including oseltamivir (Tamiflu). Initial studies supported the utility of oseltamivir for preventing complications, hospitalization and shortening disease course in patients with mild to moderate influenza. However, subsequent analysis determined that Roche (the manufacturer of oseltamivir), purposefully hid data from reviewers, biasing the initial interpretations (Krumholz 2014, Fremantle 2014). Subsequent analysis of the full set of data tempered expected benefits (Jefferson 2014). The post Clinical Conundrum: How Effective is Oseltamivir in Influenza? appeared first on REBEL EM - Emergency Medicine Blog.

This episode reviews essential ventilator pressures and how to interpret them during ICU rounds. The post REBEL Core Cast 147.0–Ventilators Part 5: Key Mechanical Ventilator Pressures & Definitions Made Simple appeared first on REBEL EM - Emergency Medicine Blog.

Antithrombotic therapy is a cornerstone in the treatment of atrial fibrillation (AFib), though it carries a significant risk of bleeding. While Vitamin K antagonists (VKAs), the oldest anticoagulants, were largely supplanted by direct oral anticoagulants (DOACs) following trials like ARISTOTLE and ROCKET AF, the risk of bleeding with these newer agents still exists. Enter Abelacimab, a novel drug designed to provide thrombosis protection while minimizing the impact on hemostasis. Abelacimab is a fully human monoclonal antibody that specifically targets and inhibits both Factor XI (FXI) and its activated form, Factor XIa (FXIa). Its pharmacokinetics suggest complete suppression of FXIa, requiring a single intravenous dose administered once a month. The post Is Abelacimab the Next Step in AF Anticoagulation? Early Signals and Remaining Questions appeared first on REBEL EM - Emergency Medicine Blog.

Nausea with or without vomiting is very common in early pregnancy, affecting approximately 70% of pregnancies (Maisal 2012). Hyperemesis gravidarum is a severe form of nausea and vomiting in pregnancy that can lead to significant maternal dehydration, electrolyte abnormalities, and weight loss if not properly managed. Pharmacologic treatment is crucial to break the cycle of vomiting, restore oral intake, and prevent complications such as Wernicke’s encephalopathy or hospitalization. Timely and effective treatment improves maternal quality of life, prevents adverse fetal outcomes related to malnutrition, and reduces the need for invasive interventions. The post Clinical Conundrum: Pregnant and Puking: What’s Safe and Effective in the ED? appeared first on REBEL EM - Emergency Medicine Blog.

Ventilator management can feel overwhelming—there are so many knobs to turn, numbers to watch, and changes to make. But before adjusting any settings, it’s crucial to understand why the patient is in distress in the first place, because the right strategy depends on the underlying cause. In this episode, we’ll walk through three different cases to see how the approach changes depending on the problem at hand. The post REBEL Core Cast 146.0–Ventilators Part 4: Setting up the Ventilator appeared first on REBEL EM - Emergency Medicine Blog.