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REBEL EM – Emergency Medicine Blog Rational Evidence-Based Evaluation of Literature

  • ANNEXA-1: Andexanet Alfa Associated with Harm in DOAC Reversal
    by Anand Swaminathan on May 23, 2024 at 12:00 pm

    Background: In May of 2018, Andexanet alfa gained accelerated approval by the FDA for the reversal direct oral anticoagulants (DOACs) despite a lack of robust evidence for use. The 2022 AHA/ASA guidelines give the drug a level 2A recommendation and recommend it over the use of 4F-PCC (Greenberg 2022). FDA approval alongside guideline endorsement has ... Read more The post ANNEXA-1: Andexanet Alfa Associated with Harm in DOAC Reversal appeared first on REBEL EM - Emergency Medicine Blog.

  • Automated vs Manual Chest Compressions in Out-of-Hospital Cardiac Arrest
    by Ravali Kundeti on May 20, 2024 at 12:00 pm

    Background Information: Out of hospital cardiac arrest (OHCA) is a medical emergency that requires immediate intervention to increase the chance of survival. The global survival rate of OHCA patients who received CPR has increased in the past 40 years [1]. However, CPR related rib and sternal injuries are observed more frequently in OHCA and are ... Read more The post Automated vs Manual Chest Compressions in Out-of-Hospital Cardiac Arrest appeared first on REBEL EM - Emergency Medicine Blog.

  • Rosh Review My EMCert Monthly Question
    by ROSH Review Author Team on May 20, 2024 at 12:00 pm

    A 67-year-old woman with a history of atrial fibrillation on apixaban presents to the ED for epistaxis that began 30 minutes ago. Her bleeding is difficult to control with direct nasal pressure and topical agents but resolves with silver nitrate cauterization. Her vital signs are within normal limits. How should this patient’s apixaban be managed? ... Read more The post Rosh Review My EMCert Monthly Question appeared first on REBEL EM - Emergency Medicine Blog.

  • Sub-Dissociative IV vs Nebulized Ketamine to Treat Pain
    by Salim Rezaie on May 16, 2024 at 12:00 pm

    Background: IV subdissociative ketamine at a dose of 0.1 to 0.3mg/kg is increasingly being used as an opioid sparing option for short-term acute pain relief. Alternatively, nebulized ketamine can be used for this indication and may have a benefit as it does not require IV access. In the KetaBAN trial, authors randomized 120 patients to ... Read more The post Sub-Dissociative IV vs Nebulized Ketamine to Treat Pain appeared first on REBEL EM - Emergency Medicine Blog.

  • REBEL Core Cast 122.0 – Neutropenic Fever
    by Anand Swaminathan on May 15, 2024 at 3:30 pm

    Take Home Points: There are many causes of neutropenia, chemotherapy being by far the most dangerous. Febrile neutropenia is a condition conveying high mortality. Early administration of antibiotics is the only factor known to reduce this mortality. For a patient with neutropenic fever, remember that the body’s own flora is the greatest danger. Isolate, but ... Read more The post REBEL Core Cast 122.0 – Neutropenic Fever appeared first on REBEL EM - Emergency Medicine Blog.

  • REBEL Cast Ep126: Should We Not Be Recommending Small Adult BVMs in OHCA?
    by Salim Rezaie on May 13, 2024 at 12:00 pm

    Background: The holy grail of outcomes in OHCA is survival with good neurologic outcome.  The only interventions proven to increase this outcome are high quality CPR and defibrillation in shockable rhythms.  Ventilation is also an important component of resuscitation in OHCA.  Excess minute ventilation can adversely affect hemodynamics due to increased intrathoracic pressure (i.e. decreased ... Read more The post REBEL Cast Ep126: Should We Not Be Recommending Small Adult BVMs in OHCA? appeared first on REBEL EM - Emergency Medicine Blog.

  • DanGer Shock Trial: Microaxial Flow Pump or Standard Care in Infarct-Related Cardiogenic Shock
    by Salim Rezaie on May 2, 2024 at 12:00 pm

    Background: STEMI can be complicated by cardiogenic shock and this complication is associated with a high morbidity and mortality rate. Decreased cardiac output  results in inadequate perfusion and subsequent end-organ damage. Mechanical circulatory support can improve perfusion and, in theory, result in better outcomes. The ECLS-Shock trial did not demonstrate improved mortality with ECMO compared ... Read more The post DanGer Shock Trial: Microaxial Flow Pump or Standard Care in Infarct-Related Cardiogenic Shock appeared first on REBEL EM - Emergency Medicine Blog.

  • REBEL Core Cast 121.0 – Acute Sinusitis
    by Anand Swaminathan on May 1, 2024 at 3:00 pm

    Take Home Points Acute rhinosinusitis is a clinical diagnosis The vast majority of acute rhinosinusitis cases are viral in nature and do not require antibiotics Consider the use of antibiotics in select groups with severe disease or worsening symptoms after initial improvement. REBEL Core Cast 121.0 – Acute Sinusitis Click here for Direct Download of ... Read more The post REBEL Core Cast 121.0 – Acute Sinusitis appeared first on REBEL EM - Emergency Medicine Blog.

  • Don’t Forget About the IO in the Critically Ill Patient
    by Kristin Wiley, DO on April 29, 2024 at 12:00 pm

    Critically ill patients requiring resuscitation often present with many challenges including the ability to secure safe, sterile, fast, and reliable intravenous (IV) access. Over the years emergency and critical care physicians have tried many ways to establish IV access in emergencies including the “crash” or “dirty” central line. If you are not familiar with this ... Read more The post Don’t Forget About the IO in the Critically Ill Patient appeared first on REBEL EM - Emergency Medicine Blog.

  • The ACORN Trial: Battle of the Gorilla-Cillins (Cefepime vs Piperacillin-Tazobactam)
    by Salim Rezaie on April 25, 2024 at 12:00 pm

    Background: Acutely ill adults presenting to the hospital with suspected infection commonly receive empiric, broad-spectrum antibiotics as part of their initial management including coverage of both MRSA and pseudomonas species.  MRSA coverage includes the use of vancomycin while anti-pseudomonal coverage is often with cefepime or piperacillin-tazobactam. Both cefepime and piperacillin-tazobactam have similar gram-negative bacterial coverage ... Read more The post The ACORN Trial: Battle of the Gorilla-Cillins (Cefepime vs Piperacillin-Tazobactam) appeared first on REBEL EM - Emergency Medicine Blog.

  • Clinical Conundrums: Should I Provide Patients with Pharyngitis a Dose of Corticosteroids
    by Anand Swaminathan on April 24, 2024 at 3:45 pm

    Bottom Line Up Top: Steroids provide modest improvement in time to resolution and degree of resolution of symptoms in pharyngitis. They should be considered in patients presenting to the ED after weighing potential benefits and risks. Clinical Scenario: A 22-year-old man with a history of poorly controlled diabetes presents with 3 days of sore throat. ... Read more The post Clinical Conundrums: Should I Provide Patients with Pharyngitis a Dose of Corticosteroids appeared first on REBEL EM - Emergency Medicine Blog.

  • How Much O2 Is Right in COVID?
    by Anand Swaminathan on April 22, 2024 at 12:00 pm

    Background: Hypoxemic respiratory failure is a frequent complicating feature of severe COVID-19 infection. Early in the pandemic, extensive efforts were made to identify the best approach to oxygenation in this group of patients. Best practices settled on aggressive use of non-invasive ventilation (NIV) and delaying invasive mechanical ventilation (IMV) where feasible. Advanced interventions include proning ... Read more The post How Much O2 Is Right in COVID? appeared first on REBEL EM - Emergency Medicine Blog.

  • From Debate to Data: Emerging Insights into RSI Induction with Ketamine vs Etomidate
    by Marco Propersi on April 18, 2024 at 12:00 pm

    Introduction: Resuscitationists continue to debate the choice of induction agents in rapid sequence intubation (RSI). Critics of etomidate highlight its link to adrenal suppression in critically ill patients (Albert 2011), while critics of ketamine highlight the higher incidence of post-intubation hypotension (Mohr 2020). Amidst the debate, the Ketased Trial (Jabre 2009), a large multicenter prospective, ... Read more The post From Debate to Data: Emerging Insights into RSI Induction with Ketamine vs Etomidate appeared first on REBEL EM - Emergency Medicine Blog.

  • Intubation in Surgical Patients: VL vs DL
    by Salim Rezaie on April 15, 2024 at 12:00 pm

    Background: Although most intubations are typically successful there is still a portion of patients that may require multiple intubation attempts.  Repeated intubation attempts could lead to respiratory and hemodynamic complications. We recently covered the DEVICE trial on REBEL EM which compared a standard geometry video laryngoscopy approach vs a standard geometry direct laryngoscopy approach in ... Read more The post Intubation in Surgical Patients: VL vs DL appeared first on REBEL EM - Emergency Medicine Blog.

  • Hematologic Emergencies in the Critical Care Setting Part 2
    by Shoon Oo, MD on April 11, 2024 at 12:00 pm

    Background: Hematologic emergencies in the critical care setting are rare but deadly complications that can often be managed appropriately if identified early on and received prompt intervention. In this 2-part review, we will discuss several hematologic emergencies and discuss the literature on current guidelines and principles of management. Shoon Oo MD1 , Vinh Dao MD1, ... Read more The post Hematologic Emergencies in the Critical Care Setting Part 2 appeared first on REBEL EM - Emergency Medicine Blog.

  • REBEL EM Book Club – MicroSkills
    by Anand Swaminathan on April 9, 2024 at 3:30 pm

    Podcast Direct Download: Link Release Date: April 16th, 2024 Show Notes The Visible Voices Podcast Dr. Glaucomflecken: Power of Ultrasound with Emergency Medicine Dr. Resa Lewiss Adaira I Landry MD Resa E Lewiss MD is a Professor of Emergency Medicine at the University of Alabama at Birmingham. A TEDMED speaker and TimesUp Healthcare founder, she’s ... Read more The post REBEL EM Book Club – MicroSkills appeared first on REBEL EM - Emergency Medicine Blog.

  • Hematologic Emergencies in the Critical Care Setting Part 1
    by Vinh Dao, MD on April 8, 2024 at 12:00 pm

    Background: Hematologic emergencies in the critical care setting are rare but deadly complications that can often be managed appropriately if identified early on and received prompt intervention. In this 2 part review, we will discuss several hematologic emergencies and discuss the literature on current guidelines and principles of management. Vinh Dao MD1, Shoon Oo MD1, ... Read more The post Hematologic Emergencies in the Critical Care Setting Part 1 appeared first on REBEL EM - Emergency Medicine Blog.

  • REBEL Cast – EMTALA + Reproductive Health Rights
    by Anand Swaminathan on April 3, 2024 at 3:00 pm

    REBEL Cast – EMTALA + Reproductive Health Click here for Direct Download of the Podcast. Dr. Dara Kass is a practicing emergency medicine physician who was most recently as the Regional Director of Region 2 for the US Department of Health and Human Services. She currently works with organizations and institutions to advance and implement ... Read more The post REBEL Cast – EMTALA + Reproductive Health Rights appeared first on REBEL EM - Emergency Medicine Blog.

  • REBEL Cast Ep125: 1st 48 Hours of PE Management – How Good Is Unfractionated Heparin?
    by Salim Rezaie on April 1, 2024 at 12:00 pm

    Background: The mainstay of treatment for symptomatic pulmonary embolism  (PE) is anticoagulation (AC).  Patients with higher-risk PE may require advanced interventions such as thrombolytic therapy, surgical thrombectomy, or even extracorporeal membrane oxygenation (ECMO). Because of its short half-life and availability of a reversal agent, unfractionated heparin (UFH) is commonly used when percutaneous or surgical interventions ... Read more The post REBEL Cast Ep125: 1st 48 Hours of PE Management – How Good Is Unfractionated Heparin? appeared first on REBEL EM - Emergency Medicine Blog.

  • REBEL Core Cast 120.0 – Salicylate Toxicity
    by Anand Swaminathan on March 20, 2024 at 4:00 pm

    Take Home Points Salicylates are a commonly used and widely prescribed xenobiotic due to their analgesic, anti-inflammatory, and anti-pyretic properties. Common preparations include aspirin, methyl-salicylate (Oil of Wintergreen), and bismuth-subsalicylate (Pepto-Bismol). Salicylate toxicity should be considered in the patient with tachypnea, clear lungs, and some degree of acid-base disturbance. Mainstays of management include: GI decontamination, ... Read more The post REBEL Core Cast 120.0 – Salicylate Toxicity appeared first on REBEL EM - Emergency Medicine Blog.

  • REBEL Cast Ep124: Nitrates in Right Sided MIs?
    by Salim Rezaie on March 18, 2024 at 12:00 pm

    Background: Nitrates can help improve symptoms and ischemia in the setting of acute myocardial infarction. Current teaching holds that nitrates should be avoided in patients with potential right ventricular myocardial infarction (RVMI), due to the risk of decreasing preload and precipitating hypotension. This belief is based on a single 1989 study of 40 patients with ... Read more The post REBEL Cast Ep124: Nitrates in Right Sided MIs? appeared first on REBEL EM - Emergency Medicine Blog.

  • Let’s Get Salty: Hypertonic 3% Saline Through Peripheral IVs in Adult Patients with Traumatic Brain Injury
    by Salim Rezaie on March 14, 2024 at 12:00 pm

    Background: Elevated intracranial pressure in patients with acute brain injury is a neurologic emergency requiring early recognition and early aggressive treatment to prevent progression to cerebral ischemia, brain herniation, and ultimately death.  There are two primary options for treatment in terms of hyperosmolar agents: mannitol and hypertonic saline (HTS). Both agents have pros and cons, ... Read more The post Let’s Get Salty: Hypertonic 3% Saline Through Peripheral IVs in Adult Patients with Traumatic Brain Injury appeared first on REBEL EM - Emergency Medicine Blog.

  • REBEL Reflections Episode 5: Thinking in Bets – Making Better Decisions When You Don’t Have All the Facts
    by Will Smith on March 13, 2024 at 10:00 am

    How sure are you? Think back to the last time someone asked you a difficult question regarding a patient on shift. How sure were you about your decision? Was there a clear-cut right or wrong answer? And after making your decision, how sure were you that the answer you made was the correct one?   ... Read more The post REBEL Reflections Episode 5: Thinking in Bets – Making Better Decisions When You Don’t Have All the Facts appeared first on REBEL EM - Emergency Medicine Blog.

  • Clinical Conundrums: Should I Pretreat Patients with Contrast Allergy Prior to IV Contrast Administration?
    by Brendan Freeman DO on March 12, 2024 at 4:00 pm

    Bottom Line Up Top: Pretreatment is ineffective and unnecessary as it does not significantly reduce the risk of serious adverse reactions to contrast. Pretreatment should not delay imaging required for definitive diagnosis.  Clinical Scenario: A 65 year-old woman presents with shortness of breath. Her vitals are notable for tachycardia and mild hypoxia, but she is ... Read more The post Clinical Conundrums: Should I Pretreat Patients with Contrast Allergy Prior to IV Contrast Administration? appeared first on REBEL EM - Emergency Medicine Blog.

  • Rosh Review MyEMCert Question
    by ROSH Review Author Team on March 11, 2024 at 12:00 pm

    A 42-year-old man presents to the emergency department after a motor vehicle collision. He has no medical problems. He sustained a crush injury to his left leg and a prolonged extraction time. He is agitated and reporting significant pain. His left leg is mottled with significant ecchymoses and gross deformity below the left knee. Pulses ... Read more The post Rosh Review MyEMCert Question appeared first on REBEL EM - Emergency Medicine Blog.

  • REBEL Core Cast 119.0 – Sleep Hygiene
    by Brendan Freeman DO on March 6, 2024 at 5:00 pm

    REBEL Core Cast 119.0 – Sleep Hygiene Click here for Direct Download of the Podcast Employ sleep strategies: Anchor sleep: a period of sleep that overlaps each day regardless of your night shift schedule to provide a guidepost for your body clock. Ideally would overlap with when you would normally be asleep if you were ... Read more The post REBEL Core Cast 119.0 – Sleep Hygiene appeared first on REBEL EM - Emergency Medicine Blog.

  • The PROPHY-VAP Trial: Ceftriaxone to Prevent VAP in Patients with Acute Brain Injury
    by Kelly Sandall, DO on February 29, 2024 at 1:00 pm

    Background:  Ventilator-associated pneumonia (VAP), or what the CDC recently renamed infection-related ventilator-associated complication (IVAC),  is defined as a nosocomial pneumonia occurring on day 3 of mechanical ventilation that was preceded by 2 days of stable or decreasing ventilator requirements.1, 2  Its occurrence often portends worse outcomes in intubated patients, whose projected hospital course was already ... Read more The post The PROPHY-VAP Trial: Ceftriaxone to Prevent VAP in Patients with Acute Brain Injury appeared first on REBEL EM - Emergency Medicine Blog.

  • Restrictive or Liberal Transfusion Strategy in Myocardial Infarction and Anemia (MINT Trial)
    by Clifford Chang, Muhammad Durrani on February 22, 2024 at 1:00 pm

    Background: Concurrent anemia worsens outcomes in patients that present with acute myocardial infarctions. Transfusions increase the oxygen carrying capacity of blood which can improve the perfusion of at-risk cardiac tissue. However, transfusions are also associated with immunosuppression, thrombotic phenomena, volume overload, and inflammatory reactions. An optimal transfusion hemoglobin cutoff has not yet been established in ... Read more The post Restrictive or Liberal Transfusion Strategy in Myocardial Infarction and Anemia (MINT Trial) appeared first on REBEL EM - Emergency Medicine Blog.

  • REBEL Core Cast 118.0 – IM vs PO NSAIDs
    by Anand Swaminathan on February 21, 2024 at 5:00 pm

    REBEL Core Cast 118.0 – IM vs PO NSAIDs Click here for Direct Download of the Podcast Bottom Line Up Top: There is no difference in analgesic efficacy between oral and intramuscular NSAIDs. Clinical Scenario: A 34-year-old woman presents to the ED with back pain. After your history and physical, you conclude that the patient’s ... Read more The post REBEL Core Cast 118.0 – IM vs PO NSAIDs appeared first on REBEL EM - Emergency Medicine Blog.

  • Another Study on Peripheral Vasopressors
    by Salim Rezaie on February 19, 2024 at 1:00 pm

    Background: Use of vasopressors is a common practice to support hemodynamics and optimization of tissue perfusion in patients presenting with shock.  Historically the administration of vasopressors was restricted to central venous catheters (CVC) due to concerns for local tissue injury resulting from vasoconstriction if extravasation occurred from a peripheral IV. The placement of CVCs, however, ... Read more The post Another Study on Peripheral Vasopressors appeared first on REBEL EM - Emergency Medicine Blog.