By Salim R. Rezaie, MD
Rational Evidence-Based Evaluation of Literature
Take Home Points Acute rhinosinusitis is a clinical diagnosis The vast majority of acute rhinosinusitis cases are viral in nature and do not require antibiotics Consider the use of antibiotics in select groups with severe disease or worsening symptoms after...
Podcast Direct Download: Link Release Date: April 16th, 2024 Show Notes The Visible Voices Podcast Dr. Glaucomflecken: Power of Ultrasound with Emergency Medicine Dr. Resa Lewiss Adaira I Landry MD Resa E Lewiss MD is a Professor of Emergency Medicine...
REBEL Cast – EMTALA + Reproductive Health Click here for Direct Download of the Podcast. Dr. Dara Kass is a practicing emergency medicine physician who was most recently as the Regional Director of Region 2 for the US Department of...
Background: The mainstay of treatment for symptomatic pulmonary embolism (PE) is anticoagulation (AC). Patients with higher-risk PE may require advanced interventions such as thrombolytic therapy, surgical thrombectomy, or even extracorporeal membrane oxygenation (ECMO). Because of its short half-life and availability...
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...
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...
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...
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...
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...
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...
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...
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...
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...
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...
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...
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 <...
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...
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...
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...
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/...
Background: Getting a definitive airway in a critically ill trauma patient can be a stressful situation. The potential for soiled airways, cervical spine injuries, maxillofacial injuries and head injuries combined with agitation/delirium, altered mental status and hypoxemia can make securing...
Background: The ongoing debate between video laryngoscopy (VL) and direct laryngoscopy (DL) has ignited intense debate within the emergency medicine and critical care communities. A recent pragmatic, randomized, multicenter trial (The DEVICE Trial) compared the two techniques to determine if...
Take Home Points Methylxanthines are a drug class that includes caffeine, theophylline, and theobromine. The three main mechanisms that account for the clinical presentation of methylxanthine toxicity are: catecholamine release, adenosine antagonism, and phosphodiesterase inhibition. Beta agonism will lead to...
Background: Standard rapid sequence intubation (RSI) in the emergency department involves administration of an induction agent and a neuroblocking agent in quick succession. RSI inherently carries with it risks of complications such as post-intubation hypotension and cardiac arrest in the...
Take Home Points Provider assessment of how the patient looks is extremely important. If it looks and feels like a STEMI clinically, get serial ECGs and consult Cardiology immediately. POCUS has been a phenomenal tool in the management and early...
Back on June 1st, 2023, Swami wrote a blog post on REBEL EM titled, The CT FIRST Trial, Should We Pan-CT After ROSC?. This stemmed a lot of discussion in the background between Swami, myself, and Scott. We felt it...
Background: Hemorrhage is the leading cause of mortality in trauma patients. Interventions such as early application of hemorrhage control, tranexamic acid, reduction of crystalloid fluid administration and balanced ratio blood product transfusion have improved many patients’ outcomes. However, mortality still...
Take Home Points Caustics are substances that injure tissue upon physical contact. Caustic potential is not purely a function of pH. The decision to admit is dependent on the history and physical. Vomiting, drooling, and stridor are concerning. Stridor alone...
Background Information: Opioid overdose deaths have been increasing in the past twenty years. The national number of overdose deaths from any opioid has increased 62.5% from 2019 to 2021 (from 48,000 to 81,400 annual deaths), which includes prescription opioids (natural and...
Take Home Points The Parkland formula can be used to be a guide for initial fluid resuscitation. This is based on second- and third-degree burns (not first-degree). Utilize response to treatment as a guide to continue fluid resuscitation. Patients in...
Background: IV fluids are part of the standard resuscitation bundle in septic shock, however it is unclear if they provide a significant benefit. These patients can have a vasodilated vascular bed and the initial use of fluids is hypothesized to...
Take Home Points Many patients with renal colic require a CT scan. Diagnostic imaging should focus on eliminating concerning mimics; not on clinching the diagnosis of renal colic. POCUS and radiology department US are important modalities in evaluation of renal...
Take Home Points Alcoholic Ketoacidosis (AKA) can present with significant acidemia (pH < 7.00). Despite the significant acidemia, patients with AKA can remain alert and lucid despite their severe metabolic derangement. Relying on urine ketones for diagnosis can be misleading,...
REBEL Core Cast 99.0 – Bundle Branch Blocks Click here for Direct Download of the Podcast Definition: Interruption of the normal conduction system leading to aberrant conduction and an abnormal QRS morphology Anatomy: At the AV node, conduction splits into...
Background information: Alcohol has potentiating effects on the inhibitory GABA neurotransmission system and inhibitory effects on the excitatory glutamate neurotransmission system. Chronic alcohol use causes changes to preserve homeostasis, and when the stimulus is removed, alcohol withdrawal results due to...
Take Home Points AVNRT is a common tachydysrhythmia that results from a reentrant loop within the AV node. Unstable patients with AVNRT should be considered for immediate synchronized electrical cardioversion. Stable patients with AVNRT can have a trial of vagal...
Take Home Points: Assess patients with floaters or flashers for retinal or vitreous detachment. Rapid diagnosis and emergency referral improves outcomes of ophthalmologic interventions. CRAO is a stroke of the eye; patients should be considered for a complete stroke work...
Background: Historically, we have treated acute coronary syndrome with supplemental oxygen regardless of the patient’s oxygen saturation. This intervention was based on the belief that pushing the patient’s PaO2 to supra therapeutic levels would increase O2 delivery to ischemic myocardium...
Take Home Points: Suspect glaucoma in any patient with an acute change in vision and get an intraocular pressure measurement First line treatment in acute angle closure glaucoma is a topical beta blocker Consider giant cell arteritis in patients with...
Take Home Points: Fluorescein is an essential tool in the diagnosis of HSV keratitis Identifying the type of HSV keratitis is crucial, as it will guide treatment Update tetanus vaccination Consult ophthalmology if there is concern for HSV keratitis as...
Take Home Points SBO should be considered in all patients presenting with abdominal pain particularly if they have a prior abdominal surgical history Patients with SBO often have non-specific signs and symptoms. There is no history or physical exam feature...
Take Home Points Lithium toxicity comes in a three flavors: acute, chronic and acute on chronic. Each form will have a different presentation as well as management. Lithium levels are often unreliable in terms of guiding management and must be...
Background Information: Double external defibrillation (DED) is an intervention often used to treat refractory ventricular fibrillation (RVF). This procedure involves applying another set of pads attached to a second defibrillator to a patient and shocking them in hopes of terminating...
Take Home Points Perichondritis is an infection of the cartilage and connective tissue of the ear Perichondritis can be recognized clinically by erythema, swelling and tenderness of the auricle. The most common organism in perichondritis is P. aeruginosa and antibiotics...
Take Home Points Methemoglobinemia can result from exposure to a number of different medications. The most common are dapsone and topical anesthetic agents (i.e. benzocaine) Consider the diagnosis in any patient with cyanosis and hypoxia that doesn’t respond to oxygen...
Take Home Points Spontaneous Bacterial Peritonitis (SBP) is a difficult diagnosis to make because presentations are variable. Consider a diagnostic paracentesis in all patients presenting to the ED with ascites from cirrhosis An ascites PMN count > 250 cells/mm3 is...
Take Home Points Severe hypocalcemia can cause hypotension and QTc prolongation leading to Torsades de Pointes. Treat moderate to severe symptoms and any EKG changes with IV calcium salts Always search for and treat the underlying cause of hypocalcemia REBEL...
Take Home Points Patients with severe hypercalcemia (> 14 mg/dL) are at risk for severe cardiac dysrhythmias and cardiac collapse Treatment centers on volume repletion with normal saline with consideration for the addition of loop diuretics AFTER volume reexpansion is...
REBEL Core Cast 86.0 – Hand Nerve Blocks Click here for Direct Download of the Podcast References: Core Ultrasound: Median Nerve Block Core Ultrasound: Radial Nerve Block Core Ultrasound: Ulnar Nerve Block Post Peer Reviewed By: Salim R. Rezaie, MD...
Background: Hypoxemia is a commonly encountered adverse event during rapid sequence intubation (RSI) in the ED. Critically ill patients in the ED often have a lack of physiologic reserve, decreased cardiac output, increased shunting, and reduced pulmonary reserves. Therefore, a...
