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Background: Sickle cell disease (SCD) affects an estimated 300,000 infants born worldwide each year and has a total estimated prevalence of 100,000 in the United States alone (Piel 2017). Within this population, over 90% of healthcare encounters are due to painful vaso-occlusive episodes (VOE) (Kidwell 2021). VOE is often complicated by hypovolemia, making fluid administration ... Read more The post Rethinking Fluid Resuscitation in Vaso-Occlusive Crisis: Is Lactated Ringer’s the Superior Choice? appeared first on REBEL EM - Emergency Medicine Blog.

Take Home points: Atraumatic TMJ dislocations are typically anterior in nature and can be reduced by a variety of techniques in the ED Traumatic TMJ dislocations often involve mandible fractures and typically require open reduction and fixation in the operating room Consider using the syringe, gag and extraoral reduction techniques first line as they frequently ... Read more The post REBEL Core Cast 133.0 – TMJ Dislocation appeared first on REBEL EM - Emergency Medicine Blog.

Bottom Line Up Top: There doesn’t appear to be a morbidity or mortality benefit to treating fever in sepsis and fever may have a protective effect. Only treat fever if it causes the patient distress. Clinical Scenario: A 45-year-old woman presents with cough and shortness of breath. Vitals are BP 114/42, HR 138, T 102.1, ... Read more The post Clinical Conundrum: Should We Always Treat Fever in Patients with Sepsis? appeared first on REBEL EM - Emergency Medicine Blog.

Take Home points: If the patient is low risk with CHA2DS2-VASc (men < 2, women < 3), cardioversion is safe up to 48 hours from onset. In higher risk patients, we should reserve cardioversion unless there is clear onset less than 12 hours or the patient has been anticoagulated for 3 weeks. Consider anticoagulation in ... Read more The post REBEL Core Cast 132.0 – Recent-Onset AFib appeared first on REBEL EM - Emergency Medicine Blog.

Background: In 2018, the BEAM Trial, a small single-center randomized clinical trial, conducted in the emergency department at Hennepin County Medical Center, demonstrated that bougie use significantly increased the first-attempt intubation success rate compared to the endotracheal tube with stylet (98% vs 87% (absolute difference, 11% [95% CI, 7% to 14%]).1 Conversely, the 2021 BOUGIE ... Read more The post Threading the Needle: Bougie-First Intubation appeared first on REBEL EM - Emergency Medicine Blog.

A parent presents to the ED with their 6-week-old infant for evaluation of a fever. The infant was born full term and has no other symptoms. Physical exam is normal and vital signs are HR is 150 bpm, SpO2 is 99%, and a rectal T is 101.4°F (38.6°C). Blood cultures are sent and lab results ... Read more The post Rosh Review My EMCert Monthly Question appeared first on REBEL EM - Emergency Medicine Blog.

View Course Dates This 2-day course provides an in-depth look at effective surgical airway management techniques that you will actually use in your next emergency airway. There is a unique focus on airway anatomy and imaging combined with one-of-a-kind opportunity to practice the techniques on a large variety of non-embalmed, specially prepared cadavers. This is ... Read more The post Levitan/Rezaie Practical Airway Course appeared first on REBEL EM - Emergency Medicine Blog.

Take Home points: Always suspect an open joint if there is a laceration, regardless of size, the lies over joint CT scan of the affected joint is widely considered to be the standard approach to evaluation but the saline load test may be useful in certain circumstances. Obtain emergency orthopedics consultation for all open joints ... Read more The post REBEL Core Cast 131.0 – Traumatic Arthrotomy appeared first on REBEL EM - Emergency Medicine Blog.

Background: Patients with sepsis are routinely treated with empiric broad-spectrum antibiotics while awaiting source identification, as recommended by the surviving sepsis campaign.2 Vancomycin, in combination with either piperacillin-tazobactam or cefepime, is commonly used for empiric treatment in these cases. Literature comparing the two regimens has largely focused on the adverse effects of each medication, rather ... Read more The post Is Pip-Tazo Harming Sepsis Patients? appeared first on REBEL EM - Emergency Medicine Blog.

Elbow Dislocation Definition:  Disarticulation of the proximal radius & ulna bones from the humerus Epidemiology:  Incidence Second most common joint dislocation (after shoulder) in adults  Most commonly dislocated joint in children Accounts for 10-25% of all injuries to the elbow (Cohen 1998)   Posterolateral is the most common type of dislocation (80%)            Demographics  Most commonly affects ... Read more The post Elbow Dislocations appeared first on REBEL EM - Emergency Medicine Blog.

Take Home Points Early diagnosis: erythema and warmth of the skin surrounding the umbilicus isn’t normal. Get labs, start abx and get the patient admitted Consult peds surgery on all of these patients as progression to nec fast, while uncommon, is devastating If the patient appears toxic or has systemic symptoms, the simply omphalitis has ... Read more The post REBEL Core Cast 130.0 – Omphalitis appeared first on REBEL EM - Emergency Medicine Blog.

Take Home Points Orogastric lavage may still play an important role in treatment of the overdose patient.  Do not perform lavage if the ingestion has limited toxicity at any dose or the ingested dose is unlikely to cause significant toxicity. Strongly consider orogastric lavage in a patient who has taken an overdose of drugs that ... Read more The post REBEL Core Cast 129.0 – Gastric Lavage appeared first on REBEL EM - Emergency Medicine Blog.

Take Home Points Toxic alcohols generally refer to methanol and ethylene glycol as these substances pose significant metabolic derangement and end-organ damage. Patient who present shortly after ingestion will simply look inebriated – no different than ethanol intoxication. At this point, patients will have an elevated osmolar gap and little to no anion gap. Patient ... Read more The post REBEL Core Cast 128.0 – Toxic Alcohols appeared first on REBEL EM - Emergency Medicine Blog.

Bottom Line Up Top: Based on the available evidence, we should strongly consider ketamine over etomidate as our default induction agent in critically ill patients. Clinical Scenario: A 48 year old man presents with fever, hypotension, hypoperfusion and hypoxemia. Workup reveals multifocal pneumonia and oxygenation only marginally improves with non-invasive ventilation. You decide to intubate ... Read more The post Clinical Conundrums: Should Ketamine be Preferred Over Etomidate in RSI? appeared first on REBEL EM - Emergency Medicine Blog.

Take Home Points Anticipate anatomically challenging airways and consider early intubation prior to loss of airway anatomy. Skip the zones of the neck and focus on hard signs of vascular (Shock w/o another source, Pulsatile bleeding, Expanding hematoma, Audible bruit, Signs of stroke) or aerodigestive (Airway compromise, Bubbling wound, Extensive SubQ air, Stridor, Significant hemoptysis/hematemesis). ... Read more The post REBEL Core Cast 127.0 – Penetrating Neck Injuries appeared first on REBEL EM - Emergency Medicine Blog.

A newborn boy presents to the emergency department shortly after a home delivery. The mother had routine prenatal care and reports that he was due in 2 days. The patient appears term and vigorous but is in respiratory distress and gasping for air. His heart rate is 80 bpm. What percent of oxygen should you ... Read more The post Rosh Review My EMCert Monthly Question appeared first on REBEL EM - Emergency Medicine Blog.

Background: Emergency intubations present a unique set of challenges, particularly when dealing with heavily contaminated airways. Anesthesiologist, Dr. James DuCanto, developed the DuCanto catheter to enhance airway management in these high-stakes situations. The commonly used 14 Fr Yankauer catheter, with its smaller bore, may struggle to clear heavily contaminated airways effectively. In contrast, the 28 ... Read more The post The Ducanto Catheter—It Sucks! appeared first on REBEL EM - Emergency Medicine Blog.

Background: The clinical burden of severe COVID-19 triggered a pharmaceutical race to find effective, easily accessible, oral treatments that could decrease the morbidity and mortality associated with the disease. Nirmatrelvir is an oral antiviral agent that inhibits the SARS-CoV2 main protease involved in viral replication. It is administered with ritonavir, which inhibits the cytochrome P450-3A4 ... Read more The post Nirmatrelvir for Vaccinated or Unvaccinated Adult Outpatients with COVID-19 appeared first on REBEL EM - Emergency Medicine Blog.

Background:  Retinal artery occlusion (RAO) is a time-sensitive ophthalmic emergency that demands rapid diagnosis and intervention. Administration of intravenous tissue plasminogen activator (IVtPA) within 4.5 hours of symptom onset appears to be the most promising approach for improving visual outcomes, supported by multiple studies and meta-analyses.1,2 Intra-arterial (IA) tPA has also shown benefit but is less ... Read more The post Remote Consult Protocols for Retinal Artery Occlusion: A Visionary Approach in Emergency Care? appeared first on REBEL EM - Emergency Medicine Blog.

Background Information: Acute kidney injury (AKI) is one of the most frequent complications of cardiac surgery and the cause is complex. Renal hypoperfusion from decreased glomerular filtration rate after cardiopulmonary bypass is a major contributor.1 This in combination with exogenous toxins, endogenous metabolites, oxidative stress, bleeding and reperfusion injury can all lead to the patient ... Read more The post The PROTECTION Trial – A Randomized Trial of Intravenous Amino Acids for Kidney Protection appeared first on REBEL EM - Emergency Medicine Blog.

Do you know the latest evidence in critical care/resuscitation?  If this question makes you uncomfortable or you just don’t have time to keep up with the literature, you should sign up for the REBEL Lit Distillery at the ResusX Conference in Philly. Let us help you keep up to date. -Workshop: Sept 17th, 2024 -Location: ... Read more The post The REBEL Lit Distillery at ResusX appeared first on REBEL EM - Emergency Medicine Blog.

Background: Cath lab activation based on ST-elevation myocardial infarction (STEMI) criteria is founded on aging data and requires evolution. In the “Occlusive Myocardial Infarction (OMI) Manifesto,” emergency physicians Dr. Steve Smith, Dr. Pendell Meyers, and Dr. Scott Weingart introduced a new paradigm —OMI vs. non-occlusive myocardial infarction (NOMI). The OMI/NOMI paradigm focuses on the presence ... Read more The post A Winning Hand in Cardiology: Queen of Hearts AI Model Enhances OMI Detection appeared first on REBEL EM - Emergency Medicine Blog.

Background: Ultrasound-guided nerve blocks have become appealing for pain management in the emergency department (ED). The adoption and expansion of ultrasound, coupled with the precise delivery route and low complication rates, facilitated the transition of nerve blocks from the operating room to the ED. However, some blocks, like the brachial plexus blocks, can cause significant complications, ... Read more The post Navigating Nerve Blocks: US-Guided Nerve Blocks Vs. Sub-Dissociative Ketamine appeared first on REBEL EM - Emergency Medicine Blog.

Bottom Line Up Top: A peripheral venous blood lactate can reliably be used instead of an arterial blood lactate as a marker of systemic tissue hypoperfusion and to measure response to treatment.  Clinical Scenario: A 63 year old woman with diabetes, hypertension and rheumatoid arthritis presents with fever, back pain and dysuria. Vitals are HR ... Read more The post Clinical Conundrums: Is an Arterial Lactate Necessary? appeared first on REBEL EM - Emergency Medicine Blog.

Take Home Points Early administration of antibiotics (within 60 min) in patients with fever and neutropenia is life saving. Fever in sickle cell is an emergency and always requires cultures and antibiotics even if the child appears well. Avoid sedation and lying supine and steroids in patients with mediastinal masses. Red flags in patients with ... Read more The post REBEL Core Cast 126.0 – Peds Hem Onc Emergencies appeared first on REBEL EM - Emergency Medicine Blog.

A 45-year-old man presents to the ED with shortness of breath that began 4 hours ago. He reports 2 days of cough, fever, and pleuritic chest pain. He is speaking in 3–4 word phrases, breathing at 33 breaths/minute, and appears in mild to moderate respiratory distress. He has right middle lobe crackles on auscultation. An ... Read more The post Rosh Review My EMCert Monthly Question appeared first on REBEL EM - Emergency Medicine Blog.

Background: Non-invasive positive pressure ventilation (NIPPV) is an effective treatment modality for patients with both hypoxemic or hypercapnic respiratory failure and has been shown to decrease the need for intubation [2].  Continuous positive airway pressure (CPAP) provides a constant positive pressure support throughout the breathing cycle, while bilevel positive airway pressure (BPAP) provides different levels ... Read more The post BPAP vs AVAPS for Hypercapnic Respiratory Failure in the ED appeared first on REBEL EM - Emergency Medicine Blog.

Background: Tracheal intubation is frequently performed in critically ill patients.  Hypoxemia is one of the major adverse events that can occur during intubation and it increases the risk of morbidity and mortality. Preoxygenation before induction of anesthesia increases the amount of oxygen in the lungs and decreases the risk of hypoxemia by prolonging the safe ... Read more The post The PREOXI Trial: Pre-Oxygenation with NIV vs Facemask appeared first on REBEL EM - Emergency Medicine Blog.

Background: Procedural sedation and analgesia (PSA) is a frequently employed in the emergency department (ED) to facilitate painful procedures. Some of the potential untoward effects of PSA include cardio-respiratory depression and/or airway compromise.  Standard practice in many parts of the world includes non-invasive pulse oximetry as well as end-tidal capnometry (ETC) for patient monitoring. ETC ... Read more The post Should End-Tidal Capnometry (ETC) During ED Procedural Sedation/Analgesia (PSA) Not Be Standard Care? appeared first on REBEL EM - Emergency Medicine Blog.

Take Home Points Always obtain an EKG in patients with ESRD upon presentation Always obtain an EKG in patients with hyperkalemia as pseudohyperkalemia is the number one cause If the patient with hyperkalemia is unstable or has significant EKG changes (wide QRS, sine wave) rapidly administer calcium salts In patients who are anuric, early mobilization ... Read more The post REBEL Core Cast 125.0 – Hyperkalemia appeared first on REBEL EM - Emergency Medicine Blog.