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

  • Damping and Arterial Lines
    by Salim Rezaie on July 4, 2022 at 12:00 pm

    Damping is the influence within a system that is a dissipation of energy during an oscillation.  In other words, think of damping like a shock absorber. Imagine a patient presenting with altered mental status.  All we know about the patient is they have a history of hypertension.  The patient is intubated for airway protection and ... Read more The post Damping and Arterial Lines appeared first on REBEL EM - Emergency Medicine Blog.

  • The ED-AWARENESS Study: Awareness with Paralysis
    by Rob Bryant on June 30, 2022 at 12:00 pm

    ‘He remembered waking up with someone pulling very hard on his injured leg, which caused severe pain. He thinks he was in the ED. The patient said this was the worst pain he had every had and it was unbearable, and said he felt “scarred” by going through such intense pain. Reported that he tried ... Read more The post The ED-AWARENESS Study: Awareness with Paralysis appeared first on REBEL EM - Emergency Medicine Blog.

  • Antibiotics in COPD Exacerbations – 2 days vs 7 days
    by Anand Swaminathan on June 27, 2022 at 12:00 pm

    Background: Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are commonly seen in the ED. AECOPD is characterized by a change in the patient’s baseline dyspnea, cough or sputum purulence. While there are a number of causes for exacerbations, infectious etiologies are one of the most common. Viral and bacterial pathogens are frequently responsible though ... Read more The post Antibiotics in COPD Exacerbations – 2 days vs 7 days appeared first on REBEL EM - Emergency Medicine Blog.

  • The CLASSIC Trial: IV Fluid Restriction in Septic Shock
    by Salim Rezaie on June 23, 2022 at 12:00 pm

    Background: The Surviving Sepsis Campaign guidelines recommend an initial fixed volume of 30mL/kg of IDEAL body weight within the first 3 hours of resuscitation (weak recommendation, low-quality evidence). [2].  Additionally, the Surviving Sepsis Campaign Guidelines state there is insufficient evidence to make a recommendation on the use of restrictive versus liberal fluid strategies in the ... Read more The post The CLASSIC Trial: IV Fluid Restriction in Septic Shock appeared first on REBEL EM - Emergency Medicine Blog.

  • REBEL Core Cast 83.0 – Post-LP Headache
    by Anand Swaminathan on June 22, 2022 at 3:00 pm

    Take Home Points Post dural-puncture headache affects up to 30% of patients after lumbar puncture. Suspect PDPH in all patients who recently underwent an LP or epidural anesthesia regardless of whether they meet the IHS criteria. The best way to treat PDPH is to prevent it from developing. Techniques proven to reduce risk include large ... Read more The post REBEL Core Cast 83.0 – Post-LP Headache appeared first on REBEL EM - Emergency Medicine Blog.

  • REBEL Cast Ep110: The COVI-PRONE Trial – Awake Prone Positioning and COVID-19
    by Salim Rezaie on June 20, 2022 at 12:00 pm

    Background: Early in the COVID-19 pandemic, clinicians were looking for practical, widely available, and low-cost interventions to help patients with hypoxemia.  One of those interventions was awake prone positioning.  Potential mechanisms of benefit in awake proning include more uniform distribution of tidal volume, recruitment of areas in the posterior part of the lung, improved ventilation/perfusion, ... Read more The post REBEL Cast Ep110: The COVI-PRONE Trial – Awake Prone Positioning and COVID-19 appeared first on REBEL EM - Emergency Medicine Blog.

  • Tenecteplase vs Alteplase in Acute Ischemic Stroke
    by Salim Rezaie on June 16, 2022 at 12:00 pm

    Background: At my shop we have changed wholesale to the use of tenecteplase over alteplase for acute ischemic stroke meeting criteria for thrombolytic therapy.  This was based on a systematic review and meta-analysis of 6 RCTs and 2 observational trials showing improved reperfusion and early neurologic improvement with tenecteplase compared to alteplase (Link is HERE).  ... Read more The post Tenecteplase vs Alteplase in Acute Ischemic Stroke appeared first on REBEL EM - Emergency Medicine Blog.

  • EPIC Trial: Electrode Positioning in Cardioverting Atrial Fibrillation
    by Mark Ramzy on June 13, 2022 at 12:00 pm

    Background Information: Electrical cardioversion of atrial fibrillation is regularly performed by emergency physicians, intensivists, and cardiologists. Although many approaches to performing this procedure exist, the most common electrode placement is the anterior-lateral compared to the anterior-posterior positioning.1 The literature backing this up comes from two studies that used monophasic defibrillators.2,3 A more recent meta-analysis that ... Read more The post EPIC Trial: Electrode Positioning in Cardioverting Atrial Fibrillation appeared first on REBEL EM - Emergency Medicine Blog.

  • Traumatic Hemothorax: Pigtail vs Chest Tube
    by Marco Propersi on June 9, 2022 at 12:00 pm

    Background: Optimal management of pneumothorax and hemothorax with chest thoracostomy has been widely debated over the last decade.  We no longer question the utility of pigtail catheters for pneumothorax and now ask whether a catheter has to be placed at all (REBEL EM). We’ve moved towards smaller (28-32 Fr) chest tubes for the management of ... Read more The post Traumatic Hemothorax: Pigtail vs Chest Tube appeared first on REBEL EM - Emergency Medicine Blog.

  • REBEL Core Cast 82.0 – Abdominal Aortic Aneurysm
    by Anand Swaminathan on June 8, 2022 at 3:00 pm

    Take Home Points Consider AAA in patients with acute onset of back or abdominal pain particularly in patients > 50 and in those with a history of hypertension Consider ruptured AAA in patients (especially those > 50 years of age) with unexplained hypotension, back or abdominal pain All ruptured AAAs should be considered unstable regardless ... Read more The post REBEL Core Cast 82.0 – Abdominal Aortic Aneurysm appeared first on REBEL EM - Emergency Medicine Blog.

  • Impella Devices 101
    by Salim Rezaie on June 2, 2022 at 12:00 pm

    Now that I am working up in the ICU, one of the devices that I am frequently coming across is the Impella device.  This is not something we get much training on downstairs in the ED.  Below is a summary of these devices, indications, management, and potential complications. The Impella Pump Setup What is it?: ... Read more The post Impella Devices 101 appeared first on REBEL EM - Emergency Medicine Blog.

  • The Dirty Epi Drip and IV Flow Rates
    by Salim Rezaie on June 2, 2022 at 12:00 pm

    Recently, I put out a video on the dirty epi drip (YouTube and TikTok) and in that video I discuss the use of this modality when in a pinch (i.e. can’t get push-dose pressors and/or a pump is not available as a patient is crashing).  To be clear and explicit, I would prefer vasoactive medications ... Read more The post The Dirty Epi Drip and IV Flow Rates appeared first on REBEL EM - Emergency Medicine Blog.

  • REBEL Core Cast – Basics of EM – Mega Summary – Part 2
    by Ellsworth Wright on June 1, 2022 at 1:01 pm

    Take Home Points Emergency medicine revolves around the differential diagnosis History and physical exam should significantly narrow your differential diagnosis Have an idea of what specific diagnoses are being ruled out when ordering diagnostic tests Always consider the most life-threatening and most common disease processes first – we are a rule out specialty “Red flags” are ... Read more The post REBEL Core Cast – Basics of EM – Mega Summary – Part 2 appeared first on REBEL EM - Emergency Medicine Blog.

  • REBEL Core Cast – Basics of EM – Mega Summary – Part 1
    by Ellsworth Wright on June 1, 2022 at 1:00 pm

    Take Home Points Emergency medicine revolves around the differential diagnosis History and physical exam should significantly narrow your differential diagnosis Have an idea of what specific diagnoses are being ruled out when ordering diagnostic tests Always consider the most life-threatening and most common disease processes first – we are a rule out specialty “Red flags” are ... Read more The post REBEL Core Cast – Basics of EM – Mega Summary – Part 1 appeared first on REBEL EM - Emergency Medicine Blog.

  • REBEL Core Cast – Basics of EM – Syncope
    by Ellsworth Wright on June 1, 2022 at 12:26 pm

    Take Home Points Break the differentials down into bad & painless, bad & painful, and other causes – WOMAN-PE Cardiac causes – mechanical or electrical – look for the obvious and 5 non-obvious causes (WPW, HCOM, ARVD, prolonged QT, and Brugada) Ask the red flag questions – was there a prodrome, signs of seizure activity ... Read more The post REBEL Core Cast – Basics of EM – Syncope appeared first on REBEL EM - Emergency Medicine Blog.

  • REBEL Core Cast – Basics of EM – Weakness
    by Ellsworth Wright on June 1, 2022 at 12:25 pm

    Take Home Points Be prepared to do everything with these cases, if they can’t provide information, dive into their medication list, history, contact whoever you have to to get more information Keep differentials wide – then approach these cases with the mindset of focal vs generalized weakness and work from there Focal – ask about ... Read more The post REBEL Core Cast – Basics of EM – Weakness appeared first on REBEL EM - Emergency Medicine Blog.

  • REBEL Core Cast – Basics of EM – Dizziness
    by Ellsworth Wright on June 1, 2022 at 12:24 pm

    Take Home Points Key point is to discern between central and peripheral causes – become familiar with the nuances of one and concentrate on that Assume central and convince yourself its peripheral in nature, if at the end of the evaluation, you can’t do that, assume a central cause and do a work-up Using timing ... Read more The post REBEL Core Cast – Basics of EM – Dizziness appeared first on REBEL EM - Emergency Medicine Blog.

  • REBEL Core Cast – Basics of EM – Rash
    by Ellsworth Wright on June 1, 2022 at 12:23 pm

    Take Home Points Examine all parts of the body, even inside the mouth – this can be the difference between benign and life threatening rashes Truly emergent causes: meningococcemia, TTP, DIC, TSS, SJS, TEN, and necrotizing fasciitis Toxic appearing patients with petechia/purpura = sepsis until proven otherwise Look for medication reactions: Sulfa, Penicillins, NSAID’s, ABX, ... Read more The post REBEL Core Cast – Basics of EM – Rash appeared first on REBEL EM - Emergency Medicine Blog.

  • REBEL Core Cast – Basics of EM – Fever
    by Ellsworth Wright on June 1, 2022 at 12:22 pm

    Take Home Points Look for the red flags – hypotension, environmental exposures, medications (SS, NMS), SIRS/qSOFA criteria Be on the lookout for neutropenic fever – isolate patients, administer abx early, and admit Sepsis definition is changing all the time – be aware of current guidelines Remove pre-existing indwelling lines/catheters in the setting of sepsis – ... Read more The post REBEL Core Cast – Basics of EM – Fever appeared first on REBEL EM - Emergency Medicine Blog.

  • REBEL Core Cast – Basics of EM – Ankle and Foot Injuries
    by Ellsworth Wright on June 1, 2022 at 12:21 pm

    Take Home Points Sprains need more support than just an ace wrap – place them in an aircast or a splint Perform a thorough physical exam – take off their shoes and socks Lisfranc and Maisonneuve injuries are often missed – make sure to exam the bottom of the foot for echymosis, eval for mid ... Read more The post REBEL Core Cast – Basics of EM – Ankle and Foot Injuries appeared first on REBEL EM - Emergency Medicine Blog.

  • REBEL Core Cast – Basics of EM – Leg Pain
    by Ellsworth Wright on June 1, 2022 at 12:20 pm

    Take Home Points Approach leg pain with the seconds, minutes, hours mindset – think about acute limb ischemia, compartment syndrome, and necrotizing fasciitis Do a thorough physical exam – get their shoes and socks off – you will find crazy stuff when you actually look Palpate and image the joint above and below any injury ... Read more The post REBEL Core Cast – Basics of EM – Leg Pain appeared first on REBEL EM - Emergency Medicine Blog.

  • REBEL Core Cast – Basics of EM – Lacerations
    by Ellsworth Wright on June 1, 2022 at 12:19 pm

    Take Home Points Don’t make bite width to small – look at the curvature of the needle – start the bite at half the curvature of the needle Don’t pull too tight – this will pucker the skin and lead to poor healing due to ischemia at the wound borders Laceration repairs are not sterile! ... Read more The post REBEL Core Cast – Basics of EM – Lacerations appeared first on REBEL EM - Emergency Medicine Blog.

  • REBEL Core Cast – Basics of EM – Back Pain
    by Ellsworth Wright on June 1, 2022 at 12:18 pm

    Take Home Points Ask about the red flags: cancer, fever, IVDA, FND, point tenderness, saddle/perianal anesthesia, trauma, urinary retention, bowel incontinence, weight loss Most don’t need XR’s – set this expectation and advise against bed rest Consider XR’s: h/o cancer, extremes of age, osteoporosis, new back pain in the elderly, trauma Perform POCUS and check ... Read more The post REBEL Core Cast – Basics of EM – Back Pain appeared first on REBEL EM - Emergency Medicine Blog.

  • REBEL Core Cast – Basics of EM – Vaginal Bleeding
    by Ellsworth Wright on June 1, 2022 at 12:17 pm

    Take Home Points Get a upreg on any childbearing age female with vaginal bleeding – this is an ectopic pregnancy until proven otherwise Confirm vaginal vs rectal bleeding – it can be hard for patients to tell, especially the elderly Quantify the amount of blood loss – soaking thru >1 pad/hr is a lot Ask ... Read more The post REBEL Core Cast – Basics of EM – Vaginal Bleeding appeared first on REBEL EM - Emergency Medicine Blog.

  • REBEL Core Cast – Basics of EM – Lower Abdominal Pain
    by Ellsworth Wright on June 1, 2022 at 12:16 pm

    Take Home Points Get a upreg on every female patient of child bearing age with lower abdominal pain – this is an ectopic pregnancy until proven otherwise Always consider ovarian/testicular pathology for lower abdominal pain Always have a chaperone when performing genitourinary physical exams Ovarian cysts >5 cm are at high risk for torsion, consider ... Read more The post REBEL Core Cast – Basics of EM – Lower Abdominal Pain appeared first on REBEL EM - Emergency Medicine Blog.

  • REBEL Core Cast – Basics of EM – Diffuse and Flank Abdominal Pain
    by Ellsworth Wright on June 1, 2022 at 12:15 pm

    Take Home Points Diffuse abdominal pain can be anything – keep a broad differential and work from there Old patient and flank pain = aortic catastrophe – aortic dissections and aneurysms can knock off flow to the kidneys Appendicitis and diverticulitis can presents diffusely early in their clinical presentation before they localize Kidney stones are ... Read more The post REBEL Core Cast – Basics of EM – Diffuse and Flank Abdominal Pain appeared first on REBEL EM - Emergency Medicine Blog.

  • REBEL Core Cast – Basics of EM – Epigastric Pain
    by Ellsworth Wright on June 1, 2022 at 12:14 pm

    Take Home Points Patients don’t necessarily know what’s important – ask lots of questions, find out if they’ve been taking a ton of NSAID’s or Tylenol for their pain and now they have an ulcer or hepatitis Keep a broad differential – the kidneys, the aorta, and consider chest pain differentials in any patient with ... Read more The post REBEL Core Cast – Basics of EM – Epigastric Pain appeared first on REBEL EM - Emergency Medicine Blog.

  • REBEL Core Cast – Basics of EM – Introduction to Abdominal Pain
    by Ellsworth Wright on June 1, 2022 at 12:13 pm

    Take Home Points Go in thinking sick vs not sick – this can take time to develop and that’s ok, this skill will come as you see more patients If you’re thinking about getting a scan or u/s – just get it! You don’t want to go home thinking you should have gotten a scan ... Read more The post REBEL Core Cast – Basics of EM – Introduction to Abdominal Pain appeared first on REBEL EM - Emergency Medicine Blog.

  • REBEL Core Cast – Basics of EM – Vomiting
    by Ellsworth Wright on June 1, 2022 at 12:12 pm

    Take Home Points Think about causes – is it the head, the belly, or something else leading to the vomiting Get a upreg on all females of childbearing age Peritoneal signs – look for rebound/guarding, consider surgery consult prior to imaging if unstable Ask about last BM and if their passing gas – avoid metoclopramide ... Read more The post REBEL Core Cast – Basics of EM – Vomiting appeared first on REBEL EM - Emergency Medicine Blog.

  • REBEL Core Cast – Basics of EM – Chest Pain
    by Ellsworth Wright on June 1, 2022 at 12:11 pm

    Take Home Points Take chest pain seriously – ACS and PE patients don’t always appear ill – look for the silent killer cases Remember 4-2-1 approach to chest pain = 4 chambers, 2 lungs, 1 esophagus EKG’s – get an old one to compare to for every patient and make sure to perform serial EKG’s Concerning ... Read more The post REBEL Core Cast – Basics of EM – Chest Pain appeared first on REBEL EM - Emergency Medicine Blog.

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