REBEL Cast

By Salim R. Rezaie, MD

Rational Evidence-Based Evaluation of Literature... more

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FAQs about REBEL Cast:

How many episodes does REBEL Cast have?

The podcast currently has 341 episodes available.

REBEL Cast episodes:

August 30, 2023REBEL Core Cast 107.0 – Vertebral Osteomyelitis
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 antibiotics. The initiation of empiric antibiotics in hemodynamically stable, neurologically intact patients should be done on a case-by-case basis.
REBEL Core Cast 107.0 – Vertebral Osteomyelitis
Click here for Direct Download of the Podcast
Definition
Inflammation of the vertebrae due to a pyogenic, fungal or mycobacterial organism.
Classified as either acute (days), subacute (weeks) or chronic (months)
Spondylodiscitis: a term encompassing osteomyelitis, spondylitis and discitis. Often used interchangeably with osteomyelitis.
Epidemiology
1 to 2.4 cases per 100,000 people (Zimmerli 2010)
More common in males with M:F of 3:1
Rate is also increasing due to increased number of spinal procedures
Typically affects adults, with most cases occurring in patients over 50 years old.
Pathogenesis
Infection occurs by three routes:
Hematogenous spread – secondary to infections of the GU, skin, soft tissue and respiratory system, indwelling catheters or endocarditis
Due to the bifurcated structure of the arterial supply, generally presents as infection of 2 contiguous vertebrae and the intervertebral disc
Direct inoculation during trauma or spinal surgery
Spread from adjacent soft tissue infection
Organism
Most cases in the United States are pyogenic.
Most common organism is Staph Aureus (36-67% of cases) (Boody 2015).
Other pathogens include: E. Coli, Pseudomonas Aeruginosa and Group B and G hemolytic Strep
Other pathogens to consider:
Fungal – blastomycosis, coccidiomycosis, histoplasmosis, aspergillosis
Brucellosis
Mycobacterial
Location: lumbar (48%) most common, followed by thoracic (35%) and cervical (6.5%)
History and Physical
Symptoms
Back pain – often described as dull, may be present for weeks to months
Neurologic symptoms (paresthesias, weakness or radiculopathy) present in approximately one-third of patients
Most patients lack systemic symptoms
Exam
Tenderness over affected vertebrae
Paraspinal tenderness or spams may be present which may mislead the clinician towards a musculoskeletal diagnoses
Risk Factors:
Diabetes Mellitus (most common)
Immunosuppression: HIV, Malignancy, chronic steroids or immunosuppressant medication use
Spinal fracture, trauma or recent procedure
Substance Abuse: Alcoholism and IVDU
Presence of an indwelling vascular device
Elderly
Diagnosis
Labs
Leukocytosis and Neutrophilia are poorly sensitive and highly non-specific (Gouliouris 2010). The degree of elevation does not predict disease severity.
ESR and CRP are sensitive, yet not specific.
CRP concentration rise and fall quicker than ESR, often used to guide treatment
Blood Cultures – an important element in management and treatment
Blood culture positivity often decides whether a patient will require a bone biopsy.
Cultured specimen narrows antibiotic coverage
Urinalysis/Urine Culture –UTI is a frequent missed source of bacteremia (especially in diabetic patients).
Imaging
Gadolinium enhanced MRI – modality of choice, highly sensitive and specific (Mylona 2009).
Although MRI with and without contrast is preferred, a non-contrast MRI can evaluate for inflammatory processes.
If a patient requires premedication or has renal failure, obtain the non-contrast MRI first. A contrast MRI can be done later to delineate subtle findings.
Findings include: enhancement (hypointense on T1 and hyperintense on T2) of vertebral endplates and adjacent disc space (Image 1)
CT Scan with IV contrast – use only of MRI contraindicated
Inferior in evaluation of disc spaces and neural tissues
Less sensitive than MRI and may be falsely negative in early disease
Used primarily by surgeons for biopsy of spine
Findings include loss of end plate definition and narrowing of disc space (Image 2)
Previously used CT Myelogram now out of favor due to potential for intradural spread of infection.
Plain Radiographs – often done to evaluate other causes (masses, fracture) however not recommended for diagnosis
Poorly sensitive and findings typically present in advanced disease (10-14 days after onset), once significant bone demineralization has already occurred
Radionuclide studies – (including: Tech 99m Bone scan, Gallium -67)
Sensitive but not specific, long acquisition time and difficult to obtain in the emergent setting
Management
Pathogen directed therapy – Antibiotics tailored towards cultured organism
Given the dependence on blood culture results to guide therapy, current recommendations (IDSA 2015 Guidelines) suggest holding empiric antibiotics in medically stable patients (non-septic, hemodynamically stable, neurologically intact) until cultures grow out.
Note: this is a weak recommendation based on low quality evidence and patients should be managed on a case by case basis in conjunction with the inpatient treatment team
Empiric coverage:
Vancomycin 15-20 mg/kg/dose every 8-12 hrs
PLUS
3rd Generation Cephalosporin: Cefotaxime (2 g IV every 6 hrs), Ceftriaxone (1 to 2 g IV daily) or Ceftazidime (1 to 2 g IV every 8 -12 hrs)
OR
Cefepime 2 g IV every 12 hours
Duration: 6 weeks (occasionally 12 weeks if advanced disease) of IV antibiotics followed by 1-2 months of oral antibiotics
Surgical Consult – although most patients are successfully treated with antibiotics alone, some may require surgical intervention if there is concern for vertebral instability or spinal cord compromise.
Indications for surgical intervention include: associated abscess formation, spinal cord compression, progression of disease despite antimicrobial treatment
Obtain consult (Neurosurgery or Orthopedics) early, since patients may require bone biopsy for detection of organism
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 antibiotics. The initiation of empiric antibiotics in hemodynamically stable, neurologically intact patients should be done on a case-by-case basis.
Graphics
Image 1: http://www.mghradrounds.org/clientuploads/nov_dec_2006/figure2.jpg
Image 2: http://www.thelancet.com/cms/attachment/2000991969/2003662063/gr3.jpg
References
Berbari EF, Kanj SS, et al. Executive Summary: 2015 Infectious Disease Society of America (IDSA) Clinical Practice Guidelines for the Diagnosis and Treatment of Native Vertebral Osteomyelitis in Adults. Clin Infect Dis 2015 Sept 15;61(6):859-63. PMID: 26316526
Boody B, et al. Vertebral Osteomyelitis and Spinal Epidural Abscess: An Evidence-based Review. J Spinal Disord Tech. 2015 Jul;28(6):E316-27 PMID: 26079841
Chowdhury V, Gupta A, Khandelwal N. Diagnostic Radiology: Musculoskeletal and Breast Imaging. 3rd ed. New Delhi: JP Brothers Medical Ltd; 2012
Della-Guistina, D. Evaluation and Treatment of Acute Back Pain in the Emergency Department. Orthopedic Emergencies 2015 May; 33(2) 311-26. PMID: 25892724
Gouliouris T, et al. Spondylodiscitis: update on diagnosis and management. J Antimicrob Chemother. 2010 Nov;65 Suppl 3:iii 11-24 PMID: 20876624
Mylona E, et al. Pyogenic Vertebral Osteomyelitis: A Systematic Review of Clinical Characteristics. Semin Arthritis Rheum. 2009 Aug; 39(1):10-7. PMID: 18550153
Pruitt CR, Perron AD. Specific Disorders of the Spine. In: Sherman SC eds. Simon’s Emergency Orthopedics. 7th ed. New York, NY: McGraw-Hill; 2014
Winters ME, Kluetz P et al. Back Pain Emergencies. Med Clin North Am, 2006 May;90(3):505-23. PMID: 16473102
Zimmerli W. Vertebral Osteomyelitis. N Engl J Med 2010 Mar; 362(11)1022-9. PMID: 20237348
Post Created By: Anand Swaminathan MD, MPH (Twitter @EMSwami)
Post Peer Reviewed By: Salim Rezaie MD (Twitter @SRRezaie)
The post REBEL Core Cast 107.0 – Vertebral Osteomyelitis appeared first on REBEL EM - Emergency Medicine Blog.
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8min
August 16, 2023 REBEL Core Cast 106.0 – Nerve Block Basics
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.
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27min
August 07, 2023 REBEL Cast Ep122 – Delayed vs Rapid Sequence Intubation in Agitated Trauma Patients
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 a definitive airway both an anatomic and physiologic challenge. Traditional RSI entails preoxygenation followed by ... Read more
The post REBEL Cast Ep122 – Delayed vs Rapid Sequence Intubation in Agitated Trauma Patients appeared first on REBEL EM - Emergency Medicine Blog.
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20min
July 31, 2023 REBEL Cast Ep121: The Battle of the Blades – Video Laryngoscopy vs. Direct Laryngoscopy
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 VL outperformed DL in first-pass success (FPS). In this blog post, we explore the study’s ... Read more
The post REBEL Cast Ep121: The Battle of the Blades – Video Laryngoscopy vs. Direct Laryngoscopy appeared first on REBEL EM - Emergency Medicine Blog.
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27min
July 26, 2023 REBEL Core Cast 105.0 – Methylxanthine Toxicity
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 hyperlactatemia, hypokalemia, hyperglycemia, and tachycardia. Adenosine antagonism may lead to seizures and/or supraventricular tachycardia that ... Read more
The post REBEL Core Cast 105.0 – Methylxanthine Toxicity appeared first on REBEL EM - Emergency Medicine Blog.
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10min
July 17, 2023 REBEL Cast Ep120: Etomidate vs Ketamine for RSI in the ED?
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 most extreme cases. It is possible that the induction agent used could play an important ... Read more
The post REBEL Cast Ep120: Etomidate vs Ketamine for RSI in the ED? appeared first on REBEL EM - Emergency Medicine Blog.
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18min
July 05, 2023 REBEL Core Cast 104.0 – Subtle ECGs in Acute Coronary Occlusion
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 diagnosis of a lot of abnormal ECG and chest pain presentations. Isolated elevation in aVR ... Read more
The post REBEL Core Cast 104.0 – Subtle ECGs in Acute Coronary Occlusion appeared first on REBEL EM - Emergency Medicine Blog.
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34min
June 29, 2023 REBEL Cast Ep119: A Discussion with Scott Weingart on the CT FIRST Trial
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 was worthwhile to record this as a podcast to better flush out some nuanced points. ... Read more
The post REBEL Cast Ep119: A Discussion with Scott Weingart on the CT FIRST Trial appeared first on REBEL EM - Emergency Medicine Blog.
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34min
June 26, 2023 REBEL Cast Ep 118: The PROCOAG Trial – 4F-PCC for Trauma Patients?
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 remains high due to trauma-induced coagulopathy. Some clinicians have advocated for early administration of 4-factor ... Read more
The post REBEL Cast Ep 118: The PROCOAG Trial – 4F-PCC for Trauma Patients? appeared first on REBEL EM - Emergency Medicine Blog.
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17min
June 07, 2023 REBEL Core Cast 103.0 – Caustic Ingestions
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 or 2/3 symptoms should warrant admission and gastroenterology consultation for potential endoscopy. The lack of ... Read more
The post REBEL Core Cast 103.0 – Caustic Ingestions appeared first on REBEL EM - Emergency Medicine Blog.
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13min

FAQs about REBEL Cast:

How many episodes does REBEL Cast have?

The podcast currently has 341 episodes available.

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