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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.

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.

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.

A 35-year-old woman presents with 4 days of headache, nasal congestion, ear pain, and mild sore throat. She has been taking an over-the-counter medication for her symptoms, but it doesn’t do anything for her. According to recent FDA news, which medication has she likely been taking? Diphenhydramine Oxymetazoline Phenylephrine Pseudoephedrine FOR THE RIGHT ANSWER CLICK ... Read more The post Rosh Review EM Scholar Monthly Question appeared first on REBEL EM - Emergency Medicine Blog.

Background: Hemmorhage is a major cause of preventable death in trauma patients. Early expeditious definitive hemorrhage control is a major focus in trauma resuscitation. Patients with torso hemorrhage present a clinical conundrum often requiring interventional radiology or surgery, both of which take time to mobilize. Theoretically, the use of REBOA with aortic occlusion should help ... Read more The post UK-REBOA on Trial: Innovative or Over-Inflated? appeared first on REBEL EM - Emergency Medicine Blog.

Take Home Points: Dose your RSI meds correctly.  Reach for post-intubation sedation at the same time you are asking for your induction agent and paralytic.   Propofol is a great choice for post-intubation sedation, and if your patient becomes hypotensive do not be afraid of adding on a pressor!  REBEL Core Cast 112.0 – Awareness During ... Read more The post REBEL Core Cast 112.0 – Awareness During Paralysis appeared first on REBEL EM - Emergency Medicine Blog.

Background Information: Vasoplegic shock is defined as hypotension with normal or increased cardiac output and can commonly occur in post-cardiac surgery patients having received cardiopulmonary bypass. This dysregulation of vasodilation is associated with a mortality of close to 25%. After catecholamine vasopressors, treatment options include angiotensin II, corticosteroids, methylene blue and hydroxocobalamin. The latter two ... Read more The post Hydroxycobalamin vs Methylene Blue for Vasoplegic Shock from Cardiopulmonary Bypass appeared first on REBEL EM - Emergency Medicine Blog.

What is Flow?  Simply put, flow is the peak of human performance, maximum focus with maximum responsiveness, an optimal state of consciousness. This state of mind is accessible to anyone under the right circumstances and has huge implications to how we live, work and train.    REBEL Cast Book Club Episode 4 — The Rise ... Read more The post REBEL Cast Book Club Episode 4 — The Rise of Superman: Decoding the Science of Ultimate Human Performance appeared first on REBEL EM - Emergency Medicine Blog.

Background: Hemorrhage is the leading cause of trauma related mortality. The initial injury is often complicated by multifactorial coagulopathy that can exacerbate bleeding.  Fibrinogen is the precursor to fibrin and a major component of stable clot formation. Fibrinogen and fibrin are often depleted during major trauma as a result of consumption, breakdown, and dilution. Most ... Read more The post CRYOSTAT-2: Early Empiric Cryoprecipitate in Major Trauma appeared first on REBEL EM - Emergency Medicine Blog.

Background: There is a shifting paradigm towards shorter durations of antibiotics in pediatric infections. Conflicting international guidelines recommend treatment of urinary tract infection (UTI) with antibiotic courses ranging from just 3 days to 7–14 days.1–4 Antimicrobial resistance is a global health crisis, underscoring the importance of antibiotic stewardship. Investigators in the SCOUT Trial examine the ... Read more The post Pediatric UTIs: Short-Course vs. Standard-Course Antibiotics — Is It Time for a Change? appeared first on REBEL EM - Emergency Medicine Blog.

Take Home Points: A CCTA is an anatomic test to determine if a patient has normal coronary arteries, non-obstructive disease, or obstructive disease. The warranty period for a CCTA is anywhere from 3-10 years depending on the characteristics of the plaque.  A nuclear stress test is a functional study that allows for ischemia-driven management. The ... Read more The post REBEL Core Cast 111.0 – Cardiac Testing appeared first on REBEL EM - Emergency Medicine Blog.

A 5-year-old boy is brought in by his parent for a dental injury. The patient was walking his dog when it ran after a squirrel. The patient was pulled forward, causing him to hit his tooth on the asphalt. His parent noticed a dental problem and immediately brought the patient to the ED. The physical ... Read more The post Rosh Review EM Scholar Monthly Question appeared first on REBEL EM - Emergency Medicine Blog.

Take Home Points: Patients with recent onset atrial fibrillation can safely be cardioverted if they are 1) on anticoagulation 2) Low risk based on CHADS-VASC with onset < 48 hours or 3) High risk based on CHADS-VASC with onset < 12 hours. In anaphylaxis, think, “If A, B or C, give E.” If the patient ... Read more The post REBEL Core Cast 110.0 – On Shift Learning Pearls appeared first on REBEL EM - Emergency Medicine Blog.

Background: Community-acquired pneumonia (CAP) can lead to pulmonary and systemic inflammation, resulting in impaired gas exchange, sepsis, organ failure, and an increased risk of death. Corticosteroids have excellent anti-inflammatory and immunomodulatory effects that could mitigate some of the inflammation caused by pneumonia. There have been several randomized trials that have shown glucocorticoids have positive effects ... Read more The post Corticosteroids in Severe Community Acquired Pneumonia: Could CAPE COD catalyze a change in critical care management? appeared first on REBEL EM - Emergency Medicine Blog.

Background: DKA is traditionally treated with fluid resuscitation, electrolyte replacement, and intravenous infusions of insulin. However, it is unclear if all degrees (mild, moderate, severe) of DKA require the same intensive treatment. Mild to moderate DKA represents a subgroup of patients that often require admission to the ICU due to hospital policies not allowing insulin ... Read more The post The SQuID Protocol: SQ Insulin in DKA? appeared first on REBEL EM - Emergency Medicine Blog.

Background: Primary PCI is the recommended reperfusion strategy in patients with STEMI and should be initiated within 2 hours after first medical contact.  In non-PCI-capable hospitals this goal is not always achievable due to delays in transfer.  In these cases, thrombolysis is recommended to improve morbidity and mortality. The STREAM-1 trial found that for [2] ... Read more The post STREAM-2: Half-Dose Tenecteplase vs Primary PCI in Older Patients with STEMI? appeared first on REBEL EM - Emergency Medicine Blog.

Take Home Points: In the context of poisoning, a “wide QRS” is anything greater than 100 milliseconds. A newly “wide QRS”, especially with hemodynamic instability, should prompt consideration of sodium channel blockade and not ventricular tachycardia. Treatment is guided by administration of sodium-bicarbonate. Recall that the resultant alkalemia driven by sodium-bicarbonate will shift potassium intracellularly. ... Read more The post REBEL Core Cast 109.0 – Na Channel Blocker Poisoning appeared first on REBEL EM - Emergency Medicine Blog.

Bottom Line Up Top: Troponins should not be routinely sent in patients presenting with SVT. Rarely, they may be necessary if the patient has concerning ischemic symptoms that persist after conversion to sinus rhythm. Clinical Scenario: A 44-year-old man presents with palpitations that started 45 minutes ago. He has no medical problems and denies any ... Read more The post Clinical Conundrum: Should a Troponin Routinely be Ordered in Patients with SVT? appeared first on REBEL EM - Emergency Medicine Blog.

An 85-year-old man presents for evaluation of left wrist pain. Last night, he missed the last step while descending the stairs at his house. He fell and landed on his hands and did not have other injuries. Acetaminophen and ibuprofen have not alleviated his pain. X-ray imaging is shown below. His physical exam reveals limited ... Read more The post Rosh Review EM Scholar Monthly Question appeared first on REBEL EM - Emergency Medicine Blog.

Background: Cardiogenic shock develops in up to 10% of patients with acute myocardial infarction (AMI) and carries a 30 day mortality rate around 50%. Revascularization of the culprit lesion remains one of the few established treatments though there are numerous other unproven modalities including extracorporeal life support (ECLS). Many centers have attempted ECLS to achieve ... Read more The post The ECLS-SHOCK Trial: ECPR in Infarct-Related Cardiogenic Shock appeared first on REBEL EM - Emergency Medicine Blog.

Take Home Points: Airway management is paramount; expect a challenging intubation and consider controlling the airway early if there is apparent airway compromise. Understanding the cause of angioedema (mast cell vs. bradykinin mediated) helps dictate directed management. Urticaria and pruritus = MAST CELL mediated, which is treated like a standard allergic reaction. REBEL Core Cast ... Read more The post REBEL Core Cast 108.0 – Angioedema appeared first on REBEL EM - Emergency Medicine Blog.

Background: Point of care ultrasound (POCUS) has a demonstrated sensitivity of 89.8% and specificity of 88.0% for identification of cholelithiasis and has a proven negative predictive value for ruling out other acute biliary pathology such as acute cholecystitis.1  It is a quickly deployable and easily interpreted study that can be done in real time to ... Read more The post POCUS in the ED: Is Confirmatory RUQ US Still Necessary? appeared first on REBEL EM - Emergency Medicine Blog.

BACKGROUND: intracerebral hemorrhage (ICH) makes up 10-15% of all strokes and significantly contributes to overall stroke-related morbidity and mortality  (Hostettler 2019). Levetiracetam is frequently used to prevent seizures in patients with conditions such as ICH, traumatic brain injury (TBI), supratentorial neurosurgery, and subarachnoid hemorrhage (SAH). However, guidelines offer no strong recommendations for its use, specifically ... Read more The post Unpacking the PEACH Trial: What is Levetiracetam’s Role in Spontaneous Intracerebral Hemorrhage? appeared first on REBEL EM - Emergency Medicine Blog.

Background: Bleeding complications are an uncommon but potentially a significant risk during central venous catheter (CVC) placement. Thrombocytopenia is associated with increased bleeding complications but there is no good-quality evidence showing that prophylactic platelet transfusions decrease that risk. Previous studies were retrospective and current society guidelines have differing thresholds (20,000 – 50,000 per cubic millimeter) ... Read more The post The PACER Trial: Platelet Transfusion before CVC Placement in Patients with Thrombocytopenia appeared first on REBEL EM - Emergency Medicine Blog.

Take Home Points Clinical presentation is very nonspecific; evaluate all patients presenting with back pain for infectious risk factors. Baseline labs should not guide diagnosis, but may assist in later management. MRI is key to diagnosis, obtain this imaging in all patients who raise clinical suspicion Patients with hemodynamic instability and neurologic compromise warrant empiric ... Read more The post REBEL Core Cast 107.0 – Vertebral Osteomyelitis appeared first on REBEL EM - Emergency Medicine Blog.

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 pain is muscular in origin and likely secondary to heavy lifting while moving apartments. You contemplate analgesic options and decide that a NSAID makes sense.  Should you give her PO ibuprofen or IM ... Read more The post Clinical Conundrum: Does IM Ketorolac Provide Superior Pain Relief to PO Ibuprofen? appeared first on REBEL EM - Emergency Medicine Blog.

Background: Sports-related concussions are among the most common injuries in children and adolescents, affecting millions of youth athletes annually.1 Given their prevalence in this population, providers must be up to date on diagnosis and management. Historical practice recommends rest to prevent adverse outcomes; however, evidence suggests strict rest is harmful. Relative rest (activities of daily ... Read more The post Back in the Game: The Effects of Activity on Youth Concussion Recovery appeared first on REBEL EM - Emergency Medicine Blog.

Background Information: Cardiac arrest is a devastating event that imposes considerable human and financial burdens. While it is widely recognized that cardiac arrest leads to brain injury, what is often overlooked is the persistent cerebral hypoperfusion that continues even after circulation is restored. The sustained cerebral hypoperfusion can be attributed to impaired cerebrovascular auto-regulation, which ... Read more The post TAME Trial: Mild Hypercapnia vs Normocapnia in Out-of-Hospital Cardiac Arrest appeared first on REBEL EM - Emergency Medicine Blog.

A 24-year-old woman presents to the emergency department with persistent severe pain in her right thigh following a direct blow during a soccer match 2 weeks ago. She is participating in an important tournament, so she has been attempting to continue playing. However, she reports difficulty and pain with walking and feels a hard lump ... Read more The post Rosh Review EM Scholar Monthly Question appeared first on REBEL EM - Emergency Medicine Blog.

Take Home Points REBEL Core Cast 106.0 – Nerve Block Basics Click here for Direct Download of the Podcast Resources REBEL EM: Local Anesthetic Systemic Toxicity Sono in Staten Blog: https://www.statenislandem.com/sono-in-staten Core Ultrasound: https://www.coreultrasound.com/ POCUS Atlas: https://www.thepocusatlas.com/ Highland Ultrasound: http://highlandultrasound.com/ Post Created By: Billy Caputo MD Post Peer Reviewed By: Anand Swaminathan MD, MPH (Twitter ... Read more The post REBEL Core Cast 106.0 – Nerve Block Basics appeared first on REBEL EM - Emergency Medicine Blog.