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Background information: Alcohol has potentiating effects on the inhibitory GABA neurotransmission system and inhibitory effects on the excitatory glutamate neurotransmission system. Chronic alcohol use causes changes to preserve homeostasis, and when the stimulus is removed, alcohol withdrawal results due to decreased inhibition via the GABA system and increased excitation via the glutamate system. Treatment options ... Read more The post REBEL Cast Ep115 – Phenobarbital vs Lorazepam in Alcohol Withdrawal appeared first on REBEL EM - Emergency Medicine Blog.

Take Home Points AVNRT is a common tachydysrhythmia that results from a reentrant loop within the AV node. Unstable patients with AVNRT should be considered for immediate synchronized electrical cardioversion. Stable patients with AVNRT can have a trial of vagal maneuvers followed by chemical cardioversion with adenosine or verapamil and synchronized electrical cardioversion if that ... Read more The post REBEL Core Cast 98.0 – AVNRT appeared first on REBEL EM - Emergency Medicine Blog.

Background: Traumatic cardiac arrest in the prehospital setting carries an extremely high mortality rate. Nevertheless, mortality of prehospital traumatic cardiac arrest (TCA), and survivability with good neurologic outcome, remain the gold standards of trauma care in and out of the hospital and are effectively the criterion by which we measure outcomes in the trauma literature. ... Read more The post Prehospital Traumatic Cardiac Arrest: A Systematic Review and Meta-analysis appeared first on REBEL EM - Emergency Medicine Blog.

Background: Acute alcohol intoxication is often identified early in a patient’s visit by behavioral changes accompanied by slurred speech, ataxia, nystagmus, or the smell of alcohol. However, evaluating and managing patients with acute alcohol intoxication in the emergency department can be challenging. Patients may be agitated or altered, hindering their initial evaluation and diagnostic workup. ... Read more The post Managing the Patient with Alcohol Intoxication appeared first on REBEL EM - Emergency Medicine Blog.

Take Home Points: Assess patients with floaters or flashers for retinal or vitreous detachment. Rapid diagnosis and emergency referral improves outcomes of ophthalmologic interventions. CRAO is a stroke of the eye; patients should be considered for a complete stroke work up. REBEL Core Cast 97.0 – Acute Vision Loss II Click here for Direct Download ... Read more The post REBEL Core Cast 97.0 – Acute Vision Loss II appeared first on REBEL EM - Emergency Medicine Blog.

Background: Historically, we have treated acute coronary syndrome with supplemental oxygen regardless of the patient’s oxygen saturation.  This intervention was based on the belief that pushing the patient’s PaO2 to supra therapeutic levels would increase O2 delivery to ischemic myocardium and help reduce myocardial injury.  More recent evidence, however, demonstrates that too much oxygen could ... Read more The post REBEL Cast Ep114: High Flow O2, Suspected ACS, and Mortality? appeared first on REBEL EM - Emergency Medicine Blog.

Take Home Points: Suspect glaucoma in any patient with an acute change in vision and get an intraocular pressure measurement First line treatment in acute angle closure glaucoma is a topical beta blocker Consider giant cell arteritis in patients with unilateral headache, jaw claudication and change in vision Don’t wait for the biopsy to start ... Read more The post REBEL Core Cast 96.0 – Acute Vision Loss I appeared first on REBEL EM - Emergency Medicine Blog.

Take Home Points: Fluorescein is an essential tool in the diagnosis of HSV keratitis Identifying the type of HSV keratitis is crucial, as it will guide treatment Update tetanus vaccination Consult ophthalmology if there is concern for HSV keratitis as these patients require close and frequent follow-up REBEL Core Cast 95.0 – Herpetic Keratitis Click ... Read more The post REBEL Core Cast 95.0 – Herpetic Keratitis appeared first on REBEL EM - Emergency Medicine Blog.

Background Information: Atrial fibrillation with rapid ventricular rate (RVR) is one of the many tachydysrhythmias we encounter in the Emergency Department (ED). Though consensus has been reached for first-line treatment of ventricular rate control1 with beta blockers (BB) and non-dihydropyridine (non-DHP) calcium channel blockers (CCB), there is still much debate regarding a preferred second-line agent ... Read more The post Amiodarone Versus Digoxin for Acute Rate Control of Atrial Fibrillation in the Emergency Department appeared first on REBEL EM - Emergency Medicine Blog.

Background: Many clinicians have transitioned from procedural sedation and analgesia (PSA) in favor of intra-articular lidocaine (IAL) to manage anterior shoulder dislocation. PSA, also referred to as intravenous sedation in this paper, requires considerable resources, including 1:1 nursing observation, and burdens the emergency department (ED). In addition, many hospitals are still reeling from the COVID-19 ... Read more The post Intra-articular Lidocaine vs Procedural Sedation and Analgesia for Closed Reduction of Acute Anterior Shoulder Dislocation appeared first on REBEL EM - Emergency Medicine Blog.

Take Home Points SBO should be considered in all patients presenting with abdominal pain particularly if they have a prior abdominal surgical history Patients with SBO often have non-specific signs and symptoms. There is no history or physical exam feature that rules out the disease Lactate elevation is a late finding in SBO. A normal ... Read more The post REBEL Core Cast 94.0 – SBO appeared first on REBEL EM - Emergency Medicine Blog.

Background: Diphenhydramine, a first-generation antihistamine, is the most common pharmacologic agent used to treat acute allergic reactions. Despite being highly effective in treating acute allergic reactions, first-generation H1 antihistamines cross the blood-brain barrier and bind to H1 receptors, which can lead to undesirable side effects, including drowsiness, sedation, fatigue, and decreased cognition (Church MK 2010). ... Read more The post Cetirizine Vs Diphenhydramine For the Treatment of Acute Urticaria in the ED appeared first on REBEL EM - Emergency Medicine Blog.

Background: Primary spontaneous pneumothorax, by definition, occurs without trauma or any underlying lung pathology. Often patients are otherwise young and healthy. However, management continues to be debated and may lead to unnecessary hospitalization. Previous studies regarding ambulatory management included randomized trials that lacked adequate power, and recently, a 2013 systematic review that, although showed promise ... Read more The post The RAMPP Trial: Randomised Ambulatory Management of Primary Pneumothorax appeared first on REBEL EM - Emergency Medicine Blog.

Take Home Points Lithium toxicity comes in a three flavors: acute, chronic and acute on chronic. Each form will have a different presentation as well as management. Lithium levels are often unreliable in terms of guiding management and must be taken in context with symptoms and time of ingestion (in acute overdose). IV fluids are ... Read more The post REBEL Core Cast 93.0 – Lithium Toxicity appeared first on REBEL EM - Emergency Medicine Blog.

Background: Urinary tract infection (UTI) is one of the most common reasons for anti-microbial use (Tan, 2016). However, the optimal treatment duration for UTI in men is not well studied, and current practice guidelines are based on historical dogma. One clinical trial demonstrates that afebrile UTI can be treated successfully with antibiotics for seven days ... Read more The post 7d vs 14d of Antibiotics in Afebrile Men with UTI appeared first on REBEL EM - Emergency Medicine Blog.

Background Information:  Double external defibrillation (DED) is an intervention often used to treat refractory ventricular fibrillation (RVF). This procedure involves applying another set of pads attached to a second defibrillator to a patient and shocking them in hopes of terminating the rhythm. At REBEL EM, we’ve done an extensive write up that details some of ... Read more The post REBEL Cast Ep113: Defibrillation Strategies for Refractory Ventricular Fibrillation appeared first on REBEL EM - Emergency Medicine Blog.

Take Home Points Perichondritis is an infection of the cartilage and connective tissue of the ear Perichondritis can be recognized clinically by erythema, swelling and tenderness of the auricle. The most common organism in perichondritis is P. aeruginosa and antibiotics should be tailored to cover this organism REBEL Core Cast 92.0 – Perichondritis Click here ... Read more The post REBEL Core Cast 92.0 – Perichondritis appeared first on REBEL EM - Emergency Medicine Blog.

Background: There is a shifting paradigm with persuasive evidence favoring a shorter duration of antibiotics for outpatient management of community-acquired pneumonia (CAP) in children. The SAFER and CAP-IT trials found that short-course antibiotic therapy was not inferior to standard duration therapy. The SCOUT-CAP Trial found that short-course antibiotic therapy was superior to standard therapy. The pooled ... Read more The post Short Course Antibiotics for Peds CAP: A Systematic Review and Meta-Analysis appeared first on REBEL EM - Emergency Medicine Blog.

Background: Pneumothorax management is a common clinical condition in the emergency department (ED) occurring in patients of varying ages and caused by multiple etiologies, including spontaneous, traumatic, and iatrogenic pneumothorax. Regardless of the cause, a thoracostomy is often required for treatment (Currie 2007). Traditionally, all pneumothoraces were treated with large bore chest tubes (LBCT) defined ... Read more The post Pigtail Catheter vs Large Bore Chest Tube for Pneumothorax appeared first on REBEL EM - Emergency Medicine Blog.

Take Home Points Consider the diagnosis of testicular torsion in all patients with acute testicular pain Testicular torsion is a surgical emergency that requires immediate urologic consultation to increase the rate of tissue salvage. History, physical examination and ultrasound are all flawed in making the diagnosis. The gold standard is surgical exploration. Perform manual detorsion ... Read more The post REBEL Core Cast 91.0 – Testicular Torsion appeared first on REBEL EM - Emergency Medicine Blog.

BACKGROUND: Direct oral anticoagulants (DOACs) such as rivaroxaban [Xarelto] and apixaban [Eliquis] have become more prevalent in the aging population and are associated with intracranial bleeding at rates up to 4.2%. (Xian 2019) 4-Factor Prothrombin Complex Concentrates (4F-PCC), or K-Centra, is a derivative of human plasma and is explicitly used to reverse vitamin K antagonists ... Read more The post Andexxa Vs 4F-PCC in ICH: An Ongoing Debate appeared first on REBEL EM - Emergency Medicine Blog.

Take Home Points Methemoglobinemia can result from exposure to a number of different medications. The most common are dapsone and topical anesthetic agents (i.e. benzocaine) Consider the diagnosis in any patient with cyanosis and hypoxia that doesn’t respond to oxygen administration Administer methylene blue to any patient with abnormal vital signs, metabolic acidosis, end organ ... Read more The post REBEL Core Cast 90.0 – Methemoglobinemia appeared first on REBEL EM - Emergency Medicine Blog.

Background: Rapid sequence intubation (RSI) induction agent selection remains a heavily debated matter. Etomidate causes adrenal suppression in critically ill patients triggering a groundswell of support in favor of ketamine. (Albert 2011, Jabre 2009) However, the existing literature comparing etomidate and ketamine is conflicting. In 2017, a single-centered, retrospective study found a lower incidence of ... Read more The post Etomidate Vs. Ketamine: A Systematic Review and Meta-Analysis appeared first on REBEL EM - Emergency Medicine Blog.

Take Home Points Spontaneous Bacterial Peritonitis (SBP) is a difficult diagnosis to make because presentations are variable. Consider a diagnostic paracentesis in all patients presenting to the ED with ascites from cirrhosis An ascites PMN count > 250 cells/mm3 is diagnostic of SBP but treatment should be considered in any patient with ascites and abdominal ... Read more The post REBEL Core Cast 89.0 – Spontaneous Bacterial Peritonitis appeared first on REBEL EM - Emergency Medicine Blog.

Background: Vitamin C dissociates to ascorbate at physiological pH and is not organically synthesized by the human body. Vitamin C can function as an antioxidant and may mitigate endothelial oxidative stress in sepsis. (Amrein 2018) A small, single-center, before-and-after study utilized a sepsis cocktail consisting of IV thiamine, hydrocortisone, and vitamin C and discovered a ... Read more The post The LOVIT Trial: Orange Crushed appeared first on REBEL EM - Emergency Medicine Blog.

Take Home Points Severe hypocalcemia can cause hypotension and QTc prolongation leading to Torsades de Pointes.  Treat moderate to severe symptoms and any EKG changes with IV calcium salts Always search for and treat the underlying cause of hypocalcemia REBEL Core Cast 88.0 – Hypocalcemia Click here for Direct Download of the Podcast Definition: A ... Read more The post REBEL Core Cast 88.0 – Hypocalcemia appeared first on REBEL EM - Emergency Medicine Blog.

Take Home Points Patients with severe hypercalcemia (> 14 mg/dL) are at risk for severe cardiac dysrhythmias and cardiac collapse Treatment centers on volume repletion with normal saline with consideration for the addition of loop diuretics AFTER volume reexpansion is complete As the patient begins to diurese, continually monitor electrolytes REBEL Core Cast 87.0 – ... Read more The post REBEL Core Cast 87.0 – Hypercalcemia appeared first on REBEL EM - Emergency Medicine Blog.

Background: Standard emergency department management of acute pancreatitis has focused on aggressive hydration, analgesia and investigation for an underlying reversible cause (eg gallstones). Recent evidence has challenged the routine use of aggressive hydration as unnecessary. There are also potential harms to large volume fluid resuscitation including progression of pancreatitis and fluid overload with or without ... Read more The post Less is More . . . Again: Speed of IV Fluid Administration in Pancreatitis (WATERFALL Trial) appeared first on REBEL EM - Emergency Medicine Blog.

Background: Thromboelastography (TEG) is a reliable, comprehensive non-invasive hemostatic assay that measures the ability of whole blood to form a clot. TEG analyzes the interaction between platelets and the coagulation cascade. It provides highly descriptive, real-time information on clot formation, clot strength, platelet function, and fibrinolysis, which is superior to traditional coagulation tests such as ... Read more The post TEG-Guided Resuscitation of Patients with Cirrhosis and Non-Variceal Bleeding appeared first on REBEL EM - Emergency Medicine Blog.

Background: Medical equipment that gives clinicians vital signs or other objective information must be reliable across populations as this data drives medical decisions. Many of these tools were not developed or validated in a racially diverse group of patients.  We have already covered issues with pulse oximetry potentially missing hypoxemia in Black patients on REBEL ... Read more The post Another Piece of Equipment with Racial Bias appeared first on REBEL EM - Emergency Medicine Blog.