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R.E.B.E.L. EM | Emergency Medicine Blog - Health
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TNK vs tPA — The ORIGINAL Trial - REBEL EM - Emergency Medicine Blog
The American Heart Association and the European Stroke Organization have updated their guidelines to recommend TNK as an alternative to tPA in patients eligible for thrombolysis. TNK, a bioengineered variant of tPA, has some advantages, including its single-dose administration, fibrin specificity, and longer half-life. Several studies have demonstrated the safety and efficacy of TNK as an alternative to tPA
How Accurate are Blood Gas Electrolyte Measurements? - REBEL EM - Emergency Medicine Blog
Bottom Line Up Top: Blood gas electrolytes closely correlate with serum measurements and can be used under most circumstances to guide clinical care. Clinical Scenario: A 62 year old woman with a history of HTN, ESRD on MWF dialysis presents to the Emergency Department with generalized weakness. Her vital signs are HR = 82, BP ... Read more
Size Matters: The Impact of Cuff Size on Blood Pressure - REBEL EM - Emergency Medicine Blog
Background: Accurate blood pressure (BP) measurement is essential in the emergency department (ED), where it serves as a key marker of hemodynamic stability and informs critical management decisions. Improper technique and incorrect cuff sizing can lead to falsely high or low readings, impacting patient care. The issue of BP cuff size has been studied in ... Read more
Street Medicine: Compassionate Care for the Unhoused - REBEL EM - Emergency Medicine Blog
Introduction: In this episode of Rebel Cast, host Marco Propersi, along with co-hosts Steve Hockman and Kim Baldino, delve into the practice and importance of street medicine—the direct delivery of healthcare to homeless and unsheltered individuals. Special guests Dr. Jim O’Connell, a pioneer of street medicine, and Dr. Ed Egan, a recent street medicine fellowship ... Read more
Is the D-Dimer Useful in High-Probabilty Pulmonary Embolism? - REBEL EM - Emergency Medicine Blog
Bottom Line Up Top: A negative D-Dimer likely excludes significant pulmonary embolism (PE) in all patients but the low chance of getting a negative result makes a D-Dimer first approach of low clinical utility in the high pre-test probability group. Clinical Scenario: A 45-year-old man with malignant melanoma presents with right-sided pleuritic chest pain for ... Read more
Clinical Conundrum: Do I Have to Replace the Nail After an Avulsion? - REBEL EM - Emergency Medicine Blog
Bottom Line Up Top: Replacing the nail into the eponychial fold doesn’t appear to be critical to nail regrowth and cosmetic outcomes of finger injuries with nail avulsion. Clinical Scenario: A 6-year-old boy presents to the Peds ED with an injury to their left 2nd digit. The finger was caught in a car door, injuring ... Read more
IVC Distensibility Index vs Collapsibility Index: Using the Correct Index - REBEL EM - Emergency Medicine Blog
The use of point-of-care ultrasonography (POCUS) to evaluate the IVC as a marker for fluid responsiveness has spread from cardiology and nephrology into critical care and emergency medicine, transforming medical practice.
Balancing Innovation and Reality: Evaluating AI's Role in STEMI Diagnosis - REBEL EM - Emergency Medicine Blog
Background: ST-segment elevation myocardial infarction (STEMI) is a critical condition requiring rapid diagnosis and intervention. While ECGs play a central role in detecting STEMI, misinterpretations often occur, leading to unnecessary catheterization or missed diagnoses. With advancements in artificial intelligence (AI), there is potential for machine learning models to assist in more accurate detection of STEMI. ... Read more
D-Dimer in High-Risk PE: A Gamble Worth Taking? - REBEL EM - Emergency Medicine Blog
Background: The current standard care for evaluating pulmonary embolism (PE) advises against D-dimer testing in patients with a high clinical probability. European and American guidelines emphasize a sequential diagnostic approach based on pretest probability assessment using either a formal clinical decision instrument (e.g., Wells’, Revised Geneva) or clinical gestalt. D-dimer testing is commonly used to ... Read more
Clinical Conundrum: Should Acute Asthma Exacerbations Be Discharged From the ED With Combination Beta Agonist/Corticosteroid Inhalers? - REBEL EM - Emergency Medicine Blog
Author: Steven Orellana DO Bottom Line Up Top: In patients with mild to moderate asthma exacerbations that are stable for discharge home, there is evidence to support discharging patients from the ED with combination Inhaled Corticosteroid/Long-Acting Beta Agonist (ICS-LABA) maintenance therapy. Clinical Scenario: A 21-year-old man with a history of asthma presents with difficulty breathing ... Read more
Rethinking Fluid Resuscitation in Vaso-Occlusive Crisis: Is Lactated Ringer’s the Superior Choice? - REBEL EM - Emergency Medicine Blog
Background: Sickle cell disease (SCD) affects an estimated 300,000 infants born worldwide each year and has a total estimated prevalence of 100,000 in the United States alone (Piel 2017). Within this population, over 90% of healthcare encounters are due to painful vaso-occlusive episodes (VOE) (Kidwell 2021). VOE is often complicated by hypovolemia, making fluid administration ... Read more
REBEL Core Cast 133.0 - TMJ Dislocation - REBEL EM - Emergency Medicine Blog
Take Home points: Atraumatic TMJ dislocations are typically anterior in nature and can be reduced by a variety of techniques in the ED Traumatic TMJ dislocations often involve mandible fractures and typically require open reduction and fixation in the operating room Consider using the syringe, gag and extraoral reduction techniques first line as they frequently ... Read more
Clinical Conundrum: Should We Always Treat Fever in Patients with Sepsis? - REBEL EM - Emergency Medicine Blog
Bottom Line Up Top: There doesn’t appear to be a morbidity or mortality benefit to treating fever in sepsis and fever may have a protective effect. Only treat fever if it causes the patient distress. Clinical Scenario: A 45-year-old woman presents with cough and shortness of breath. Vitals are BP 114/42, HR 138, T 102.1, ... Read more
REBEL Core Cast 132.0 - Recent-Onset AFib - REBEL EM - Emergency Medicine Blog
Take Home points: If the patient is low risk with CHA2DS2-VASc (men < 2, women < 3), cardioversion is safe up to 48 hours from onset. In higher risk patients, we should reserve cardioversion unless there is clear onset less than 12 hours or the patient has been anticoagulated for 3 weeks. Consider anticoagulation in ... Read more
Threading the Needle: Bougie-First Intubation - REBEL EM - Emergency Medicine Blog
Background: In 2018, the BEAM Trial, a small single-center randomized clinical trial, conducted in the emergency department at Hennepin County Medical Center, demonstrated that bougie use significantly increased the first-attempt intubation success rate compared to the endotracheal tube with stylet (98% vs 87% (absolute difference, 11% [95% CI, 7% to 14%]).1 Conversely, the 2021 BOUGIE ... Read more
Rosh Review My EMCert Monthly Question - REBEL EM - Emergency Medicine Blog
A parent presents to the ED with their 6-week-old infant for evaluation of a fever. The infant was born full term and has no other symptoms. Physical exam is normal and vital signs are HR is 150 bpm, SpO2 is 99%, and a rectal T is 101.4°F (38.6°C). Blood cultures are sent and lab results ... Read more
Levitan/Rezaie Practical Airway Course - REBEL EM - Emergency Medicine Blog
View Course Dates This 2-day course provides an in-depth look at effective surgical airway management techniques that you will actually use in your next emergency airway. There is a unique focus on airway anatomy and imaging combined with one-of-a-kind opportunity to practice the techniques on a large variety of non-embalmed, specially prepared cadavers. This is ... Read more
REBEL Core Cast 131.0 - Traumatic Arthrotomy - REBEL EM - Emergency Medicine Blog
Take Home points: Always suspect an open joint if there is a laceration, regardless of size, the lies over joint CT scan of the affected joint is widely considered to be the standard approach to evaluation but the saline load test may be useful in certain circumstances. Obtain emergency orthopedics consultation for all open joints ... Read more
Is Pip-Tazo Harming Sepsis Patients? - REBEL EM - Emergency Medicine Blog
Background: Patients with sepsis are routinely treated with empiric broad-spectrum antibiotics while awaiting source identification, as recommended by the surviving sepsis campaign.2 Vancomycin, in combination with either piperacillin-tazobactam or cefepime, is commonly used for empiric treatment in these cases. Literature comparing the two regimens has largely focused on the adverse effects of each medication, rather ... Read more
Elbow Dislocations - REBEL EM - Emergency Medicine Blog
Elbow Dislocation Definition: Disarticulation of the proximal radius & ulna bones from the humerus Epidemiology: Incidence Second most common joint dislocation (after shoulder) in adults Most commonly dislocated joint in children Accounts for 10-25% of all injuries to the elbow (Cohen 1998) Posterolateral is the most common type of dislocation (80%) Demographics Most commonly affects ... Read more
REBEL Core Cast 130.0 - Omphalitis - REBEL EM - Emergency Medicine Blog
Take Home Points Early diagnosis: erythema and warmth of the skin surrounding the umbilicus isn’t normal. Get labs, start abx and get the patient admitted Consult peds surgery on all of these patients as progression to nec fast, while uncommon, is devastating If the patient appears toxic or has systemic symptoms, the simply omphalitis has ... Read more
REBEL Core Cast 129.0 - Gastric Lavage - REBEL EM - Emergency Medicine Blog
Take Home Points Orogastric lavage may still play an important role in treatment of the overdose patient. Do not perform lavage if the ingestion has limited toxicity at any dose or the ingested dose is unlikely to cause significant toxicity. Strongly consider orogastric lavage in a patient who has taken an overdose of drugs that ... Read more
REBEL Core Cast 128.0 - Toxic Alcohols - REBEL EM - Emergency Medicine Blog
Take Home Points Toxic alcohols generally refer to methanol and ethylene glycol as these substances pose significant metabolic derangement and end-organ damage. Patient who present shortly after ingestion will simply look inebriated – no different than ethanol intoxication. At this point, patients will have an elevated osmolar gap and little to no anion gap. Patient ... Read more
REBEL Core Cast 127.0 - Penetrating Neck Injuries - REBEL EM - Emergency Medicine Blog
Take Home Points Anticipate anatomically challenging airways and consider early intubation prior to loss of airway anatomy. Skip the zones of the neck and focus on hard signs of vascular (Shock w/o another source, Pulsatile bleeding, Expanding hematoma, Audible bruit, Signs of stroke) or aerodigestive (Airway compromise, Bubbling wound, Extensive SubQ air, Stridor, Significant hemoptysis/hematemesis). ... Read more
Rosh Review My EMCert Monthly Question - REBEL EM - Emergency Medicine Blog
A newborn boy presents to the emergency department shortly after a home delivery. The mother had routine prenatal care and reports that he was due in 2 days. The patient appears term and vigorous but is in respiratory distress and gasping for air. His heart rate is 80 bpm. What percent of oxygen should you ... Read more
The Ducanto Catheter—It Sucks! - REBEL EM - Emergency Medicine Blog
Background: Emergency intubations present a unique set of challenges, particularly when dealing with heavily contaminated airways. Anesthesiologist, Dr. James DuCanto, developed the DuCanto catheter to enhance airway management in these high-stakes situations. The commonly used 14 Fr Yankauer catheter, with its smaller bore, may struggle to clear heavily contaminated airways effectively. In contrast, the 28 ... Read more
Nirmatrelvir for Vaccinated or Unvaccinated Adult Outpatients with COVID-19 - REBEL EM - Emergency Medicine Blog
Background: The clinical burden of severe COVID-19 triggered a pharmaceutical race to find effective, easily accessible, oral treatments that could decrease the morbidity and mortality associated with the disease. Nirmatrelvir is an oral antiviral agent that inhibits the SARS-CoV2 main protease involved in viral replication. It is administered with ritonavir, which inhibits the cytochrome P450-3A4 ... Read more
Remote Consult Protocols for Retinal Artery Occlusion: A Visionary Approach in Emergency Care? - REBEL EM - Emergency Medicine Blog
Can a remote consult protocol using point-of-care OCT improve the time to diagnosis and treatment of retinal artery occlusions in patients presenting with painless monocular vision loss?
The PROTECTION Trial - A Randomized Trial of Intravenous Amino Acids for Kidney Protection - REBEL EM - Emergency Medicine Blog
PROTECTION Trial: In patients undergoing cardiac surgery with cardiopulmonary bypass, does the administration of intravenous amino acid therapy lead to lower occurrence of postoperative AKI when compared to placebo?
A Winning Hand in Cardiology: Queen of Hearts AI Model Enhances OMI Detection - REBEL EM - Emergency Medicine Blog
Background: Cath lab activation based on ST-elevation myocardial infarction (STEMI) criteria is founded on aging data and requires evolution. In the “Occlusive Myocardial Infarction (OMI) Manifesto,” emergency physicians Dr. Steve Smith, Dr. Pendell Meyers, and Dr. Scott Weingart introduced a new paradigm —OMI vs. non-occlusive myocardial infarction (NOMI). The OMI/NOMI paradigm focuses on the presence ... Read more
Navigating Nerve Blocks: US-Guided Nerve Blocks Vs. Sub-Dissociative Ketamine - REBEL EM - Emergency Medicine Blog
In adult trauma patients with isolated extremity injuries, do peripheral nerve blocks, compared to sub-dissociative ketamine, result in a reduction of pain by the numerical scale rating of at least 3 points?
REBEL Core Cast 126.0 - Peds Hem Onc Emergencies - REBEL EM - Emergency Medicine Blog
Take Home Points Early administration of antibiotics (within 60 min) in patients with fever and neutropenia is life saving. Fever in sickle cell is an emergency and always requires cultures and antibiotics even if the child appears well. Avoid sedation and lying supine and steroids in patients with mediastinal masses. Red flags in patients with ... Read more
Should End-Tidal Capnometry (ETC) During ED Procedural Sedation/Analgesia (PSA) Not Be Standard Care? - REBEL EM - Emergency Medicine Blog
Does end-tidal capnometry (ETC) plus usual care in patients undergoing procedural sedation and analgesia (PSA) in the emergency department (ED) decrease respiratory adverse events compared to usual care alone?