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

  • Pigtail Catheter vs Large Bore Chest Tube for Pneumothorax
    by Jessica DiPeri, MD on December 1, 2022 at 2:00 pm

    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.

  • REBEL Core Cast 91.0 – Testicular Torsion
    by Anand Swaminathan on November 30, 2022 at 5:00 pm

    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.

  • Andexxa Vs 4F-PCC in ICH: An Ongoing Debate
    by Carlton C.L. Watson, MD on November 28, 2022 at 2:00 pm

    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.

  • REBEL Core Cast 90.0 – Methemoglobinemia
    by Anand Swaminathan on November 16, 2022 at 4:00 pm

    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.

  • Etomidate Vs. Ketamine: A Systematic Review and Meta-Analysis
    by Anthony Ascione, DO on November 3, 2022 at 12:00 pm

    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.

  • REBEL Core Cast 89.0 – Spontaneous Bacterial Peritonitis
    by Anand Swaminathan on November 2, 2022 at 4:00 pm

    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.

  • The LOVIT Trial: Orange Crushed
    by Wilson Smith, MD on October 31, 2022 at 12:00 pm

    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.

  • REBEL Core Cast 88.0 – Hypocalcemia
    by Anand Swaminathan on October 19, 2022 at 3:00 pm

    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.

  • REBEL Core Cast 87.0 – Hypercalcemia
    by Anand Swaminathan on October 5, 2022 at 3:00 pm

    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.

  • Less is More . . . Again: Speed of IV Fluid Administration in Pancreatitis (WATERFALL Trial)
    by Anand Swaminathan on September 29, 2022 at 12:00 pm

    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.

  • TEG-Guided Resuscitation of Patients with Cirrhosis and Non-Variceal Bleeding
    by Cheng Ng, MD on September 26, 2022 at 12:00 pm

    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.

  • Another Piece of Equipment with Racial Bias
    by Salim Rezaie on September 22, 2022 at 12:00 pm

    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.

  • REBEL Core Cast 86.0 – Hand Nerve Blocks
    by Anand Swaminathan on September 21, 2022 at 5:00 pm

    REBEL Core Cast 86.0 – Hand Nerve Blocks Click here for Direct Download of the Podcast References: Core Ultrasound: Median Nerve Block Core Ultrasound: Radial Nerve Block Core Ultrasound: Ulnar Nerve Block Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie) The post REBEL Core Cast 86.0 – Hand Nerve Blocks appeared first on REBEL EM - Emergency Medicine Blog.

  • Heads Up! There is No Association with Improved Outcomes for Head Up CPR: Why We Must Read Past the Abstract
    by Anand Swaminathan on September 19, 2022 at 12:00 pm

    Background: There are only two interventions that have been proven in the medical literature to improved outcomes in cardiac arrest: high-quality CPR and early defibrillation. Over the years, we as a scientific community have worked extensively to find other interventions that improve outcomes. Some look promising (ie eCPR and application of US) while others have ... Read more The post Heads Up! There is No Association with Improved Outcomes for Head Up CPR: Why We Must Read Past the Abstract appeared first on REBEL EM - Emergency Medicine Blog.

  • The ADVOR Trial: Acetazolamide in Acute Decompensated Heart Failure
    by Salim Rezaie on September 15, 2022 at 10:00 am

    Background: Patients presenting with acute exacerbations of congestive heart failure are frequently treated with intravenous loop diuretics.  Despite being treated with loop diuretics, the problem is many are discharged from the hospital with residual clinical signs of volume overload despite optimal treatment.  One option to improve diuresis may be the addition of acetazolamide, however evidence ... Read more The post The ADVOR Trial: Acetazolamide in Acute Decompensated Heart Failure appeared first on REBEL EM - Emergency Medicine Blog.

  • The REVIVED Trial: PCI in Patients with Severe Ischemic Left Ventricular Systolic Dysfunction?
    by Salim Rezaie on September 12, 2022 at 12:00 pm

    Background: Coronary artery disease can result in hibernating myocardium (chronic myocardial contractile dysfunction) due to ischemia.  The theory is that there is reduced coronary blood flow and increased myocardial demand resulting in impaired contractility. Whether reversal of myocardial hibernation by coronary revascularization is possible and can improve outcomes is debatable.  The STICH trial [2] compared ... Read more The post The REVIVED Trial: PCI in Patients with Severe Ischemic Left Ventricular Systolic Dysfunction? appeared first on REBEL EM - Emergency Medicine Blog.

  • REBEL Cast Ep112: The Pre-AeRATE Trial – HFNC vs NC for RSI
    by Salim Rezaie on September 8, 2022 at 12:00 pm

    Background: Hypoxemia is a commonly encountered adverse event during rapid sequence intubation (RSI) in the ED.  Critically ill patients in the ED often have a lack of physiologic reserve, decreased cardiac output, increased shunting, and reduced pulmonary reserves.  Therefore, a strategy that safely avoids desaturation and prolongs safe apnea times would be beneficial. There are ... Read more The post REBEL Cast Ep112: The Pre-AeRATE Trial – HFNC vs NC for RSI appeared first on REBEL EM - Emergency Medicine Blog.

  • The BOX Trial: BP & O2 Targets in Comatose Survivors of Cardiac Arrest
    by Salim Rezaie on September 5, 2022 at 12:00 pm

    Background: Hypoxemia and hypoperfusion are important factors in outcomes after ROSC.  While hypoxemia (SpO2 <90%) is clearly deleterious, it is unclear if hyperoxia is beneficial.  Recent studies on patients requiring critical care have demonstrated that hyperoxia is harmful and instead we should be targeting normoxia (SpO2>93%). Similarly, while it is clear hypotension/hypoperfusion will result in ... Read more The post The BOX Trial: BP & O2 Targets in Comatose Survivors of Cardiac Arrest appeared first on REBEL EM - Emergency Medicine Blog.

  • COCA Trial Follow-Up: Calcium vs Placebo on Long-Term Outcomes of OHCA
    by Salim Rezaie on September 1, 2022 at 12:00 pm

    Background: The Calcium for Out-of-Hospital Cardiac Arrest (COCA) trial was a randomized, placebo-controlled, double-blind trial of calcium compared to placebo in OHCA.  COCA found no improvement in sustained ROSC but, rather, a trend towards harm for their primary outcome. Additionally, there were non-statistically significant trends toward lower survival and lower survival with good neurologic outcomes ... Read more The post COCA Trial Follow-Up: Calcium vs Placebo on Long-Term Outcomes of OHCA appeared first on REBEL EM - Emergency Medicine Blog.

  • The EvK Trial: Ketamine vs Etomidate for Rapid Sequence Intubation
    by Shahrukh Syed, MD on August 29, 2022 at 12:00 pm

    Background: The use of ketamine and etomidate for induction in rapid sequence intubation is heavily debated. The Ketased Trial (Jabre 2009) reported no significant difference between the two induction agents. However, recently the National Emergency Airway Registry reported ketamine is associated with more-frequent hypotension than etomidate in critically ill patients (Mohr 2020). Another study reported ... Read more The post The EvK Trial: Ketamine vs Etomidate for Rapid Sequence Intubation appeared first on REBEL EM - Emergency Medicine Blog.

  • Non-Sterile Gloves for Suturing Traumatic Lacerations?
    by Salim Rezaie on August 22, 2022 at 12:00 pm

    Background: Traumatic lacerations presenting to the emergency department are, by definition, contaminated (ie non-sterile).  Standard management involves irrigation, local anesthesia, closure and tetanus update if required. The existing literature has never shown benefit to sterile gloves in these types of injuries if we irrigate and clean the site appropriately.  Not using a full sterile prep ... Read more The post Non-Sterile Gloves for Suturing Traumatic Lacerations? appeared first on REBEL EM - Emergency Medicine Blog.

  • The DINAMO Study: Efficacy and Safety of Non-Antibiotic Outpatient Treatment in Mild Acute Diverticulitis
    by James C. Fletcher, MD, FACEP, FAAEM on August 18, 2022 at 12:00 pm

    The DINAMO Study: Efficacy and Safety of Non-Antibiotic Outpatient Treatment in Mild Acute Diverticulitis James C. Fletcher, MD, FACEP and Nicholas Slattery, MD Background: Diverticulitis is a common finding amongst Emergency Department patients, accounting for more than 360,000 visits in 2013 alone1. Additionally, the rate of diverticulitis appears to be increasing among both patients presenting ... Read more The post The DINAMO Study: Efficacy and Safety of Non-Antibiotic Outpatient Treatment in Mild Acute Diverticulitis appeared first on REBEL EM - Emergency Medicine Blog.

  • VTE Recurrence in Subsegmental PE: What’s the Risk?
    by Fang Zhou Yu, MBChB on July 28, 2022 at 12:00 pm

    Background: The overall mortality and case-fatality rate for pulmonary embolism (PE) are decreasing. Yet reporting is increasing, suggesting we are overdiagnosing PE. Furthermore, management with anticoagulation is not entirely benign and places a potential risk of bleeding upon the patient. However, when the threat of disease outweighs the risk from any possible complication, the decision ... Read more The post VTE Recurrence in Subsegmental PE: What’s the Risk? appeared first on REBEL EM - Emergency Medicine Blog.

  • REBEL Cast Ep111: The PREPARE II Trial – Fluid Bolus Prior to Intubation?
    by Salim Rezaie on July 25, 2022 at 12:00 pm

    Background:  Some of the feared complications of endotracheal intubation include hypotension, cardiac arrest, and death (cardiovascular collapse).  These complications can result from numerous causes including medication-induced vasodilation and decreased venous return to the heart due to increased intrathoracic pressure from positive pressure ventilation. In recent years there has been an increased focus on resuscitation prior ... Read more The post REBEL Cast Ep111: The PREPARE II Trial – Fluid Bolus Prior to Intubation? appeared first on REBEL EM - Emergency Medicine Blog.

  • Topical TXA in Atraumatic Anterior Epistaxis Yet Again
    by Salim Rezaie on July 21, 2022 at 12:00 pm

    Background: The use of topical tranexamic acid (TXA) for anterior epistaxis has been studied in many trials with conflicting results. The largest and most methodologically rigorous study to date on the use of topical TXA in epistaxis has been the NoPAC trial (Link is HERE), published in 2021. In that trial there was no difference ... Read more The post Topical TXA in Atraumatic Anterior Epistaxis Yet Again appeared first on REBEL EM - Emergency Medicine Blog.

  • REBEL Core Cast 85.0 – Superficial Venous Thrombosis
    by Anand Swaminathan on July 20, 2022 at 3:00 pm

    Take Home Points SVT >5cm or <3 cm from the SFJ should be treated with anti-coagulation.  The rate of concurrent DVT and PE in patients with SVT is 25% and 5%, respectively.  REBEL Core Cast 85.0 – Superficial Venous Thrombosis Click here for Direct Download of the Podcast Definition: The presence of a clot in ... Read more The post REBEL Core Cast 85.0 – Superficial Venous Thrombosis appeared first on REBEL EM - Emergency Medicine Blog.

  • Classic Journal Club: TXA for Epistaxis
    by Amanda Hall, DO on July 18, 2022 at 12:00 pm

    Background: Epistaxis is a common ailment experienced by millions worldwide. While most of these cases can be managed by patients at home, some will require medical attention. Initial interventions include local pressure, ice, and forward head positioning for persistent bleeds. When simple maneuvers fail, we proceed to topical agents such as lidocaine with epinephrine, oxymetazoline, anterior ... Read more The post Classic Journal Club: TXA for Epistaxis appeared first on REBEL EM - Emergency Medicine Blog.

  • External Validation of Pittsburgh Cardiac Arrest Category (PCAC) Illness Severity Score
    by Mark Ramzy on July 14, 2022 at 12:00 pm

    Background Information: Multiple illness severity scores have been developed for use after out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA). Unfortunately, these rely on information that is not immediately available to providers in the early hours following return of spontaneous circulation (ROSC).1 The Pittsburgh Cardiac Arrest Category (PCAC) Score (Figure 2) was derived from ... Read more The post External Validation of Pittsburgh Cardiac Arrest Category (PCAC) Illness Severity Score appeared first on REBEL EM - Emergency Medicine Blog.

  • Gun Laws and Mass Shootings: A Call to Action
    by Sarah Aly, DO on July 11, 2022 at 2:00 pm

    Background: Rob Elementary. Columbine. Sandy Hook. Pulse Night Club. Tops Grocery Store. Irvine Taiwanese Presbyterian Church. Virginia Beach. The Tree of Life Synagogue. Santa Fe High School. The New York City Subway. The Las Vegas Harvest Music Festival. Aurora Movie Theater. The El Paso Walmart. Tulsa. The list goes on. The United States has a ... Read more The post Gun Laws and Mass Shootings: A Call to Action appeared first on REBEL EM - Emergency Medicine Blog.

  • The FIRST-ABC Step Up Trial: HFNC vs CPAP for Liberation of Respiratory Support in Children?
    by Salim Rezaie on July 7, 2022 at 12:00 pm

    Background: Respiratory support is a common intervention in pediatric ICUs and can include HFNC and CPAP/BPAP to avoid invasive mechanical ventilation.  HFNC has become more popular due to its ease of use, perceived patient comfort, and the ability to discharge patients still receiving HFNC out of the ICU.  Despite its growing popularity there is limited ... Read more The post The FIRST-ABC Step Up Trial: HFNC vs CPAP for Liberation of Respiratory Support in Children? appeared first on REBEL EM - Emergency Medicine Blog.

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