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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.

Bottom Line Up Top: A negative D-Dimer likely excludes significant pulmonary embolism (PE) in all patients but the low chance of getting a negative result makes a D-Dimer first approach of low clinical utility in the high pre-test probability group. Clinical Scenario: A 45-year-old man with malignant melanoma presents with right-sided pleuritic chest pain for ... Read more The post Is the D-Dimer Useful in High-Probabilty Pulmonary Embolism? 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 March 31: Levitan/Rezaie Practical Airway Course appeared first on REBEL EM - Emergency Medicine Blog.

Bottom Line Up Top: Replacing the nail into the eponychial fold doesn’t appear to be critical to nail regrowth and  cosmetic outcomes of finger injuries with nail avulsion. Clinical Scenario: A 6-year-old boy presents to the Peds ED with an injury to their left 2nd digit. The finger was caught in a car door, injuring ... Read more The post Clinical Conundrum: Do I Have to Replace the Nail After an Avulsion? appeared first on REBEL EM - Emergency Medicine Blog.

Background  In 1979, Hiroshi Natori was the first to appreciate the sonographic changes that occur in the inferior vena cava (IVC)’s diameter with ventilation in spontaneously breathing patients, mechanically ventilated patients, and those with carcinogenic and tuberculoid cardiac tamponade.1 They noticed how spontaneously breathing patients had their IVC collapse with inspiration; and ventilated patients had ... Read more The post IVC Distensibility Index vs Collapsibility Index: Using the Correct Index appeared first on REBEL EM - Emergency Medicine Blog.

Background: ST-segment elevation myocardial infarction (STEMI) is a critical condition requiring rapid diagnosis and intervention. While ECGs play a central role in detecting STEMI, misinterpretations often occur, leading to unnecessary catheterization or missed diagnoses. With advancements in artificial intelligence (AI), there is potential for machine learning models to assist in more accurate detection of STEMI. ... Read more The post Balancing Innovation and Reality: Evaluating AI’s Role in STEMI Diagnosis appeared first on REBEL EM - Emergency Medicine Blog.

\Background: The current standard care for evaluating pulmonary embolism (PE) advises against D-dimer testing in patients with a high clinical probability. European and American guidelines emphasize a sequential diagnostic approach based on pretest probability assessment using either a formal clinical decision instrument (e.g., Wells’, Revised Geneva) or clinical gestalt. D-dimer testing is commonly used to ... Read more The post D-Dimer in High-Risk PE: A Gamble Worth Taking? appeared first on REBEL EM - Emergency Medicine Blog.

Bottom Line Up Top: In patients with mild to moderate asthma exacerbations that are stable for discharge home, there is evidence to support discharging patients from the ED with combination Inhaled Corticosteroid/Long-Acting Beta Agonist (ICS-LABA) maintenance therapy. Clinical Scenario: A 21-year-old man with a history of asthma presents with difficulty breathing for the past two ... Read more The post Clinical Conundrum: Should Acute Asthma Exacerbations Be Discharged From the ED With Combination Beta Agonist/Corticosteroid Inhalers? appeared first on REBEL EM - Emergency Medicine Blog.

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.

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.