April 26, 2021

In emergency medicine, the standard of care is to place an advanced airway for ventilatory or oxygenation failure, impending airway compromise, or inability to protect the airway. A patient with significant cognitive impairment may have depressed gag and/or cough reflexes, putting them at risk for aspiration. The evaluation of a patient’s risk for aspiration can be highly subjective. One common adage states: “If the GCS is less than 8, then intubate”, offering a seemingly simple and more objective standard to guide airway management. Using the Glasgow Coma Scale (GCS) score of 8 or below to evaluate the need for intubation is promoted by the ATLS course and the East Association for the Surgery of Trauma (EAST) practice management guidelines.[1][2] This practice is also commonly applied to patients with non-traumatic causes of obtundation. However, the evidence behind this practice is not clear, prompting many to re-examine this oft-repeated lesson.

December 3, 2015

Background: It’s common practice to give carefully titrated supplemental oxygen therapy for patients in COPD exacerbation. We give enough O2 to prevent hypoxemia, but not so much that it causes hypoventilation or dangerous hypercarbia. If you’re like me then you’ve probably heard a number of conflicting theories as to WHY overzealous supplemental oxygen leads to bad outcomes in these patients. Does hyperoxia suppress a COPD patient’s respiratory drive? Does it cause V/Q mismatching? Does it change the chemistry of the patient’s blood through the Haldane effect? It’s enough to make you want to give up and page respiratory therapy. Well lucky for you we sifted through the primary literature to bring you the myths and facts, and the short answer is…it's complicated.

September 3, 2015

You are working as an EM resident and have just evaluated a patient with a right long finger DIP joint dislocation. You perform a digital nerve block with 1% lidocaine with 1:100,000 epinephrine, and go to present to your attending before attempting the reduction. Your attending, on hearing about the epinephrine use goes berserk, and says “don’t you know that you shouldn’t use epi in fingers, noses, ears and toes?”. When confronted with this situation we all like to have a one stop valid literature review to produce that validates our practice. Several social media authors have weighed in on this topic, however blogs sometimes don’t cut it for those unfamiliar with the current quality of peer reviewed online content. The use of epinephrine in digital nerve blocks has been shown to increase duration of action for the anesthetic, and to allow the avoidance of bupivacaine, thereby decreasing the pain of the injection. (REBEL flashback)