RSS Feed

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

  • 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 Salim Rezaie 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.

  • The NICO Trial: NIV in Comatose Patients with Acute Poisoning
    by Salim Rezaie on February 15, 2024 at 1:00 pm

    Background:  Patients with decreased level of consciousness due to alcohol, drugs, or medications commonly present to the ED. These patients can be at risk of vomiting and aspiration and often prompts clinicians to pursue definitive airway management to avoid pneumonia and other complications. It is unclear, though, if the risks of intubation (including ventilator associated ... Read more The post The NICO Trial: NIV in Comatose Patients with Acute Poisoning appeared first on REBEL EM - Emergency Medicine Blog.

  • Clinical Conundrums: Do We Need to Order a CT for Every Patient with Renal Colic?
    by Abbas Husain MD on February 12, 2024 at 4:00 pm

    Bottom Line Up Top: In selective patients presenting with flank pain, we can diagnose renal colic without a CT scan. There is also a subset of patients that would benefit from IV contrast enhanced CT scanning. Clinical Scenario: A 35-year-old man with no PMH presents with left flank pain, hematuria and history of kidney stones. ... Read more The post Clinical Conundrums: Do We Need to Order a CT for Every Patient with Renal Colic? appeared first on REBEL EM - Emergency Medicine Blog.

  • Non-Invasive Blood Pressure Monitoring in Critically Ill Adults?
    by Salim Rezaie on February 8, 2024 at 1:00 pm

    Background: Patients with shock frequently present with hypotension.  Many of these patients are started on vasopressor and inopressor medications to assist in efforts to normalize blood pressure to help improve organ perfusion. In shocky patients, arterial lines are often used to monitor hemodynamic parameters and inform treatment decisions.  However, there is limited data on the ... Read more The post Non-Invasive Blood Pressure Monitoring in Critically Ill Adults? appeared first on REBEL EM - Emergency Medicine Blog.

  • REBEL Core Cast 117.0 – Infections of Pregnancy
    by Jenny Beck-Esmay, MD on February 7, 2024 at 5:00 pm

    Take Home Points Infections are a leading cause of maternal mortality worldwide. Prompt recognition is critical in management. Most infectious processes will require admission and close observation for improvement or decompensation. REBEL Core Cast 117.0 – Infections of Pregnancy Click here for Direct Download of the Podcast Urinary Tract Infection/Pyelonephritis Epidemiology: Occurs in as many ... Read more The post REBEL Core Cast 117.0 – Infections of Pregnancy appeared first on REBEL EM - Emergency Medicine Blog.

  • The Needle Vs. The Knife for Spontaneous Pneumothorax: A Closer Look at the EXPRED Study
    by Bryan Tiernan, DO on February 5, 2024 at 1:00 pm

    Background:  The optimal management of primary, spontaneous pneumothorax (sPTX) remains an area of active debate. The British Thoracic Society recommends the least invasive approach possible. In contrast, the American College of Chest Physicians favors first-line chest tube drainage for any sPTX with an estimated volume of over 20%.(3) A Cochrane systematic review comparing simple aspiration ... Read more The post The Needle Vs. The Knife for Spontaneous Pneumothorax: A Closer Look at the EXPRED Study appeared first on REBEL EM - Emergency Medicine Blog.

  • The AcT Trial: Tenecteplase vs Alteplase for Acute Ischemic Stroke
    by Muhammad Durrani on February 1, 2024 at 1:00 pm

    Background: Alteplase, a class of medication that converts plasminogen to plasmin leading to fibrin degradation and subsequent clot lysis, has been the standard of care for acute ischemic stroke (AIS) patients that meet eligibility criteria. Tenecteplase, a modified version of alteplase, is being increasingly utilized for AIS due to its favorable pharmacological profile, ease of ... Read more The post The AcT Trial: Tenecteplase vs Alteplase for Acute Ischemic Stroke appeared first on REBEL EM - Emergency Medicine Blog.

  • REBEL Cast Ep123: Reduced-Dose Systemic Peripheral Alteplase in Massive PE?
    by Salim Rezaie on January 29, 2024 at 1:00 pm

    Background: Massive pulmonary embolism  defined as sustained hypotension (SBP <90mmHg)  has a high mortality which is why early recognition and thrombolytic therapy is typically recommended (AHA Class IIA; ESC Class IB) [1]. However, full-dose thrombolytic therapy (Alteplase 100mg (IV) is  associated with an increase in bleeding [2]. Because the lungs receive 100% of cardiac output, it has ... Read more The post REBEL Cast Ep123: Reduced-Dose Systemic Peripheral Alteplase in Massive PE? appeared first on REBEL EM - Emergency Medicine Blog.

  • Serial PoCUS for ED Patients with Acute Dyspnea: Is More Actually Better?
    by Jenna LaColla, MS3 on January 25, 2024 at 1:00 pm

    Background: Point-of-care ultrasound (PoCUS) is a valuable clinical tool in the assessment of acute dyspnea. It can be used to distinguish between various conditions, including chronic obstructive pulmonary disease (COPD) exacerbation, acute heart failure (AHF), pleural effusion, pulmonary edema, pericardial effusion, pneumothorax, and pneumonia [2,3]. A 2018 systematic review and meta-analysis of 25 studies focusing ... Read more The post Serial PoCUS for ED Patients with Acute Dyspnea: Is More Actually Better? appeared first on REBEL EM - Emergency Medicine Blog.

  • REBEL Core Cast 116.0 – Achilles Tendon Rupture
    by Anand Swaminathan on January 24, 2024 at 4:00 pm

    Take Home Points Achilles tendon rupture is a clinical diagnosis. The Thompson Test should be applied in all suspected cases. Remember to brace or splint a rupture, even if suspected, in the resting equinus position for optimal healing and prevention of further injury. Schedule follow up with orthopedics within 1 week for discussion of operative ... Read more The post REBEL Core Cast 116.0 – Achilles Tendon Rupture appeared first on REBEL EM - Emergency Medicine Blog.

  • Rosh Review MyEMCert Question
    by ROSH Review Author Team on January 22, 2024 at 1:00 pm

    A 46-year-old woman with a history of borderline high cholesterol levels presents with acute-onset chest pain 2 days ago with progressively worsening shortness of breath. Her only medication is an oral contraceptive pill that she has taken for over 20 years. Vital signs show HR of 121 bpm, BP of 124/80 mm Hg, RR of ... Read more The post Rosh Review MyEMCert Question appeared first on REBEL EM - Emergency Medicine Blog.

  • Pre-Hospital Antibiotics in Sepsis?
    by Salim Rezaie on January 18, 2024 at 1:00 pm

    Background: Sepsis remains one of the leading causes of morbidity and mortality. It is well-established that earlier recognition and treatment can lead to better outcome for these patients .  Time to antibiotic therapy (from triage, not from onset of infection) has become a quality metric to improve the time to administration of these medications. In an ... Read more The post Pre-Hospital Antibiotics in Sepsis? appeared first on REBEL EM - Emergency Medicine Blog.

  • Clinical Conundrums: Should You Give the First Dose of Antibiotics IV Before Discharging Home on Oral Antibiotics?
    by Anand Swaminathan on January 9, 2024 at 4:30 pm

    Bottom Line Up Top: In patients with infectious processes that are stable for discharge home, there is no role for giving a first dose of antibiotics IV in the ED. Clinical Scenario: A 45-year-old woman with hypertension presents with a productive cough and fever. Her vitals are: HR 115, BP 120/80, Temp 102.8, O2 Sat ... Read more The post Clinical Conundrums: Should You Give the First Dose of Antibiotics IV Before Discharging Home on Oral Antibiotics? appeared first on REBEL EM - Emergency Medicine Blog.

  • REBEL Core Cast 115.0 – Cardiogenic Shock
    by Anand Swaminathan on December 27, 2023 at 6:00 pm

    Take Home Points: Know clinical (cold extremities, oliguria, confusion, dizziness, narrow pulse pressure) and laboratory markers (metabolic acidosis, elevated creatinine, lactic acidosis) of hypoperfusion. An elevated lactate is a danger sign and requires explanation. Norepinephrine is a great first line vasopressor in Cardiogenic shock. Dobutamine is useful for inotropic support in Cardiogenic shock. Use POCUS ... Read more The post REBEL Core Cast 115.0 – Cardiogenic Shock appeared first on REBEL EM - Emergency Medicine Blog.

  • Rosh Review EM Scholar Monthly Question
    by ROSH Review Author Team on December 18, 2023 at 1:00 pm

    A 55-year-old woman with a history of end-stage kidney disease on peritoneal dialysis presents due to abdominal pain. She has had pain and redness at the site of her catheter exit site. Physical examination is notable for 3 cm of erythema around the catheter exit, located in the lateral left lower quadrant, along with tenderness ... Read more The post Rosh Review EM Scholar Monthly Question appeared first on REBEL EM - Emergency Medicine Blog.

  • REBEL Core Cast 114.0 – Carbon Monoxide Toxicity
    by Anand Swaminathan on December 13, 2023 at 5:00 pm

    Take Home Points: Carbon monoxide is a colorless, odorless, and tasteless gas that results from incomplete combustion of any carbon containing product. Exposure often occur unintentionally from indoor use of gas powered generators, camp stoves, or faulty home heaters. The symptoms of mild, acute exposure are non-specific and can be confused with a variety of ... Read more The post REBEL Core Cast 114.0 – Carbon Monoxide Toxicity appeared first on REBEL EM - Emergency Medicine Blog.

  • Don’t Believe the Headline: Ultrasound vs CXR in Traumatic Pneumothorax Diagnosis
    by Nicole Yuzuk DO on December 10, 2023 at 4:00 pm

    Background:           The use of ultrasound is well established for trauma patients in the emergency department, with almost every patient receiving a FAST (Focused Assessment with Sonography in Trauma) examination as part of the “ABC’s” of trauma. Though the initial focus of the FAST exam was for detection of abdominal free fluid, the eFAST (Extended ... Read more The post Don’t Believe the Headline: Ultrasound vs CXR in Traumatic Pneumothorax Diagnosis appeared first on REBEL EM - Emergency Medicine Blog.

  • Clinical Conundrums: How Long Should We Monitor After Giving IM Epinephrine for Anaphylaxis?
    by Akash Bhatnagar MD on December 5, 2023 at 4:00 pm

    How Long Should We Monitor After Giving IM Epinephrine for Anaphylaxis? Bottom Line Up Top: After prompt recognition and appropriate treatment with IM epinephrine, the risk of biphasic reactions are exceedingly low. There is no set observation time to monitor patients as long as their symptoms have resolved. At the time of discharge, appropriate patient ... Read more The post Clinical Conundrums: How Long Should We Monitor After Giving IM Epinephrine for Anaphylaxis? appeared first on REBEL EM - Emergency Medicine Blog.

  • Congestive Heart Failure and Sepsis: A Closer Look at Fluid Management
    by Imogene Kane, DO on November 30, 2023 at 1:00 pm

    Background: In medicine, guidelines are valuable tools that help guide care. However, they are not rigid rules that must be strictly followed. Clinicians often find themselves grappling with the challenge of balancing the demands of meeting Center for Medicaid & Medicare (CMS) requirements while also addressing the unique needs of each individual patient. For those ... Read more The post Congestive Heart Failure and Sepsis: A Closer Look at Fluid Management appeared first on REBEL EM - Emergency Medicine Blog.

  • REBEL Core Cast 113.0 – ACS Therapies and Management
    by Anand Swaminathan on November 29, 2023 at 6:00 pm

    Take Home Points: All STEMIs should be loaded with dual antiplatelet therapy. Prasugrel (Effient) is avoided as there is an increase in bleeding complications if the patient requires a CABG. NSTEMI cases can be challenging to manage. Consult Cardiology early and use all available data. The appropriate medical treatment for ACS patients is as important ... Read more The post REBEL Core Cast 113.0 – ACS Therapies and Management appeared first on REBEL EM - Emergency Medicine Blog.