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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.

Background: Sympathetic Crashing Acute Pulmonary Edema (SCAPE) results from an increased systemic vascular resistance and activation of the Renin-Angiotensin-Aldosterone System (RAAS), which causes increased sodium/water reabsorption and worsening cardiac function. Additionally, sympathetic activation shifts fluid from splanchnic beds into the systemic circulation. The fluid build-up in the lungs causes hypoxia, dyspnea, and further sympathetic surge. ... Read more The post Sympathetic Crashing Acute Pulmonary Edema: High-Dose Vs. Low-Dose Nitro appeared first on REBEL EM - Emergency Medicine Blog.

Take Home Points Management of severe beta-blocker and calcium-channel blocker toxicity should occur in a stepwise fashion: potential gastric decontamination, multiple lines of access, judicious fluids, calcium, glucagon, and vasopressors as needed. Initiation of high dose insulin therapy requires a tremendous amount of logistical and cognitive resources as it requires cross-disciplinary collaboration and is prone ... Read more The post REBEL Core Cast 124.0 – Hyperinsulinemia Euglycemia Therapy appeared first on REBEL EM - Emergency Medicine Blog.

Background: Hemorrhage remains as one of the biggest causes of death in trauma patients. Strategies such as permissive hypotension, massive transfusion protocols, avoidance of crystalloids, TXA, and definitive hemorrhage control help decrease mortality in these patients. Empiric component blood transfusion (RBCs, plasma, & platelets) in a 1:1:1 ratio is considered the gold standard of resuscitation ... Read more The post Should We Be Switching to Whole Blood Instead of Component Therapy in Hemorrhagic Shock? appeared first on REBEL EM - Emergency Medicine Blog.

Take Home Points: Posterior epistaxis is a rare, life-threatning presentation. The key is in identifying and rapidly gaining control with a posterior pack or foley catheter. These patients often require surgical intervention so get ENT to the bedside and admit to a place with a higher level of monitoring. REBEL Core Cast 123.0 – Posterior ... Read more The post REBEL Core Cast 123.0 – Posterior Epistaxis appeared first on REBEL EM - Emergency Medicine Blog.

Background: The REVERT Randomized Controlled Trial demonstrated the superiority of the modified valsalva maneuver (MVM) over the standard valsalva maneuver (VM) in re-establishing normal sinus rhythm (NSR) in patients with PSVT (Appelboam 2015). MVM exaggerates venous return to the heart and increases vagal outflow by elevating the patient’s legs. However, the success rate of the ... Read more The post The Modified Valsalva Maneuver: Practical Treatment or Pointless Trick? appeared first on REBEL EM - Emergency Medicine Blog.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.