REBEL EM

FEBRUARY 15, 2024

Background: Patients with decreased level of consciousness due to alcohol, drugs, or medications commonly present to the ED. These patients can be at risk of vomiting and aspiration and often prompts clinicians to pursue definitive airway management to avoid pneumonia and other complications. Paper: Freund Y et al.

ICU 141

ICU ALS ED OR 141

REBEL EM

MAY 25, 2023

mental status, urine output, capillary refill) is more important than an actual goal PERMISSIVE HYPOTENSTION IN PTS WITH TBI Brotfain E et al. mental status, urine output, capillary refill) is more important than an actual goal PERMISSIVE HYPOTENSTION IN PTS WITH TBI Brotfain E et al. Richards JE et al. NEJM 1994. [2]

E-9-1-1 145

E-9-1-1 Plasma ALS OR 145

The Skeptics' Guide to EM

JULY 25, 2020

Reference: Carley et al. The bottom line from that episode on skin glue for peripheral intravenous lines was: “Skin glue does appear to decrease the failure rate of IVs in patients admitted to hospital from the ED at 48 hours. It was great that it started with a definition of evidence-based medicine (EBM).

ED 130

ED ALS OR 130

EMS 12-Lead

APRIL 2, 2022

1, 2] The most clinically useful definition to account for this entire constellation is intraventricular conduction delay. You will see that they were initially ischemic, by definition, because of the subsequent voltage attenuation. Additional findings include a patently leftward frontal plane axis, an intriniscoid deflection (i.e.,

ALS 130

ALS STEMI Coronary OR 130

REBEL EM

JUNE 22, 2023

However, the medical community is only just starting to understand long-COVID (WHO Definition: the continuation or development of new symptoms 3 months after the initial SARS-CoV-2 infection, with these symptoms lasting for at least 2 months with no other explanation). Article: Bramante CT et al. References: Bramante CT et al.

ALS 145

ALS OR EMS ED 145

The Skeptics' Guide to EM

NOVEMBER 1, 2022

Date: October 27th, 2022 Reference: Hayashi et al. Date: October 27th, 2022 Reference: Hayashi et al. There have been a few randomized control trials (RCTs) of peripheral nerve blocks for shoulder dislocation, but without definitive results (Raeyat Doost 2017; Blaivas 2011).

ALS 118

ALS Emergency Department OR ED 118

ACEP Now

JULY 7, 2023

emergency departments (EDs), with statistics reporting more than 356,000 out-of-hospital cardiac arrests per year. References Tsao CW, et al. Benjamin EJ, et al. Kimblad H, et al. Sakai T, et al. Kudenchuk PJ, et al. Lee YH, et al. Benjamin EJ, et al. Hajjar K, et al. Circulation.

Defibrillator 98

Defibrillator OR ALS Epinephrine 98

EMDocs

JUNE 3, 2023

Figure 1: The Young-Burgess classification of pelvic ring fractures (source: [link] 3 It is paramount to differentiate the definitions of “hemodynamically unstable” and “mechanically unstable” pelvic fractures. The nuances of fracture patterns and delineating mechanically unstable pelvic fractures from stable ones is less important to the ED.

ED 54

ED Operating Room ALS Frozen Plasma 54

ACEP Now

AUGUST 14, 2024

Rate Versus Rhythm in the ED The 2023 AHA/ACC guideline doesn’t give explicit recommendations or preference regarding initial rate or rhythm control strategy for new-onset AF patients who are hemodynamically stable. based care of ED patients with AFRVR. References Joglar JA, Chung MK, Armbruster AL, et al. Circulation.

ALS 105

ALS Emergency Department ED OR 105

Dr. Smith's ECG Blog

JANUARY 27, 2024

Deutch et al. Figure-1: I've labeled the initial ECG in the ED. KEY Point: All patients who present to the ED for new CP should promptly have a triage ECG recorded, that is then immediately interpreted by the ED physician. West J Emerg Med 2024). For clarity — I've labeled this initial ECG in Figure-1.

STEMI 102

STEMI Coronary ACS ED 102

REBEL EM

AUGUST 30, 2023

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. Graphics Image 1: [link] Image 2: [link] References Berbari EF, Kanj SS, et al. PMID: 26316526 Boody B, et al. In: Sherman SC eds.

E-9-1-1 103

E-9-1-1 ALS ED OR 103

EMS 12-Lead

MAY 8, 2022

They are definitely high in amplitude and, intermittently, appear to disproportionately tower over the respective QRS. This is critical for the EMS provider, or ED clinician, as identification of Grade I ischemia (aka, HATW’s) addresses the culprit lesion at the earliest opportunity with excellent downstream prognosis for the patient. [2]

STEMI 130

STEMI ED EMS Firefighter 130

Don't Forget the Bubbles

MAY 31, 2023

The DIMPLES study by PERUKI sought to investigate the incidence of new-onset diabetes in the paediatric population across the UK and Ireland, as well as the characteristics of these ED presentations, and to determine if SARS-CoV2 infection was involved. This meant 2746 ED presentations by 2618 individuals. Which patients were involved?

Emergency Department 135

Emergency Department ED OR ALS 135

EMDocs

SEPTEMBER 25, 2023

Also known as Facilitated intubation (FI), the use of intubating with only a sedative was an accepted alternative intubation technique prior to those definitive studies in the late 1990s but quickly was abandoned for RSI in all emergent endotracheal intubations (ETI) (8,9). To date, ketamine has been the agent of choice (12).

ED 66

ED Emergency Department ALS Paramedic 66

The Skeptics' Guide to EM

FEBRUARY 2, 2018

[display_podcast] Date: January 31st, 2018 Reference: Frohlich LC, et al. display_podcast] Date: January 31st, 2018 Reference: Frohlich LC, et al. Ultrasound imaging of the scrotum is the gold standard for diagnosis of testicular torsion, however can lead to delays in definitive care. Reference: Frohlich LC, et al.

Operating Room 100

Operating Room Emergency Department ALS ED 100

Don't Forget the Bubbles

JULY 22, 2024

Pre-school wheezers remain a poorly understood cohort of children despite seeing them every day in paediatric EDs. However, there was no difference in LOS (83 minutes for placebo vs 79 minutes for prednisolone) in participants who were discharged straight from the ED ( 32% ). Compare this with the Panickar et al.

E-9-1-1 105

E-9-1-1 ALS ACS ED 105

REBEL EM

APRIL 17, 2023

Article: Kim DJ et al. We need high-quality evidence to provide a definite conclusion. The neck and thyroid are particularly vulnerable to radiation (Tipnis et al.). Additionally, potential increases in resource utilization, healthcare expense, and ED length of stay are also essential considerations. Acad Emerg Med.

OR 129

OR ALS ED EMS 129

EMS 12-Lead

APRIL 28, 2022

4-6] In figures 1-4, specifically during the episodes of NSVT, there is a mostly regular cadence with preserved definition of both QRS and T. Josephson’s Clinical Cardiac Electrophysiology: Techniques and Interpretations (6th ed). Chou’s Electrocardiography in Clinical Practice (6th ed). Wolters-Kluwer: Philadelphia, PA. [2]

E-9-1-1 130

E-9-1-1 ALS Coronary EMS 130

Broome Docs

FEBRUARY 22, 2024

PMID: 36946338 Bottom line: This is a well done RCT that demonstrates pretty convincingly that you should not bother trying to but fingernails back on after nail bed repair (and my guess is you definitely shouldn’t be removing them either). Carson JL, Brooks MM, Hébert PC, et al; MINT Investigators. N Engl J Med. 2023 Nov 11.

Emergency Department 103

Emergency Department ALS OR ED 103

The Skeptics' Guide to EM

DECEMBER 21, 2019

Outside of his academic duties, he works clinically in the adult ED at Spectrum Health in Grand Rapids, Michigan, the tertiary care center for Western Michigan. Only then would there be definitive evidence for the efficacy of parachutes. It was published last year in the 2018 BMJ holiday edition ( Yeh et al BMJ Dec 2018 ).

OR 100

OR ALS ED 100

EMS 12-Lead

AUGUST 22, 2022

They are not premature, by definition. Chou’s Electrocardiography in Clinical Practice (6th ed). The blue arrows show RBBB morphology, and it’s tempting to deploy a compulsory diagnosis of PVC’s, but remember: these wide QRS complexes arrive subsequent to a regularly timed P wave. The green arrows, however, do show premature complexes.

E-9-1-1 130

E-9-1-1 Coronary ALS ICU 130

REBEL EM

JUNE 8, 2023

Paper: Singer S, et al. This study chose a relevant topic to analyze that could influence acute management in the ED and has a fairly larger sample size of patients to do so. References: Singer S, et al. PMID: 36108346 Cole JB, et al. PMID: 31270748 Maheshwari K, et al. PMID: 29872882 Jones AE, et al.

Epinephrine 98

Epinephrine Emergency Department ALS Critical Care 98

Dr. Smith's ECG Blog

OCTOBER 30, 2023

Here is the first prehospital ECG (time 0, after one hour of pain): I do not see evidence of OMI, and neither did the Queen of Hearts Here is the 2nd prehospital ECG (time 10 minutes, after 70 minutes of pain): No change On arrival, the first ED ECG was recorded 20 minutes after the last one (90 minutes after pain onset): What do you think?

STEMI 112

STEMI ED ALS OR 112

Dr. Smith's ECG Blog

SEPTEMBER 11, 2024

When the patient arrived in the ED, he was still hypotensive in 70s, slowly improving with EMS fluids. Here is the ED ECG (a photo of the paper printout) What do you think? The initial ECG in today's case was recognized as definitely abnormal — but the question arose as to whether this ECG indicated old infarction vs a new acute event.

EMS 106

EMS CPR ED Coronary 106

Don't Forget the Bubbles

AUGUST 23, 2023

Definitive emotional support is critical to our emotional and psychological well-being. Very rarely are the ED team allowed to stand, in silence, with a purpose. Kapoor et al. This gives rise to feelings of failure alongside the feelings of grief. Psychological harm occurs. Southern Medical Journal. 112 (9),pp. Newell, J. &

Emergency Department 98

Emergency Department ICU ALS Critical Care 98

REBEL EM

JANUARY 23, 2023

Article: Abella BS et al. Key Secondary Endpoints: 5 (3.9%) patients in the IV cetirizine group returned to any ED or clinic within 24 hours compared to 15 (11.1%) in the IV diphenhydramine group; P=0.04 Anecdotally, the persistence of urticaria often has little influence on the decision to discharge a patient from the ED.

Allergic Reaction 52

Allergic Reaction ED E-9-1-1 Emergency Department 52

Dr. Smith's ECG Blog

NOVEMBER 15, 2023

[link] Case continued She arrived in the ED and here is the first ED ECG. Lindahl et al. From Gue at al. Lindahl B, Baron T, Erlinge D, et al. I don't know if her pain was getting better or not. The downsloping ST depression is very suspicious for OMI, but not diagnostic. The Queen no longer thinks it is OMI.

Coronary 100

Coronary E-9-1-1 STEMI ACS 100

EMDocs

NOVEMBER 13, 2024

Definition: SBP is an infection of the peritoneal ascitic fluid without an intra-abdominal focus of infection. Major takeaway: Consider SBP in any patient who comes into the ED with ascites. Biggins SW, Angeli P, Garcia-Tsao G, et al. Mattos AA, Wiltgen D, Jotz RF, et al. Aithal GP, Palaniyappan N, China L, et al.

E-9-1-1 80

E-9-1-1 ALS OR ED 80

REBEL EM

NOVEMBER 20, 2023

Early expeditious definitive hemorrhage control is a major focus in trauma resuscitation. Paper: Jansen JO, Hudson J, Cochran C, et al. Definitive hemorrhage control procedures were performed in 30% of patients in the REBOA and standard care group and 43% in the standard care alone group. 97% of patients sustained blunt trauma.

OR 91

OR Emergency Medical Technician CPR Emergency Medical Services 91

Dr. Smith's ECG Blog

JUNE 5, 2023

Here is his initial ED ECG: What do you think? Then the ED doc would be dependent on that first ECG. It must have re-occluded between the ED and the cath lab) --Lesion was stented. Aside on ECG Research: 20% of Definite diagnostic STEMI (Cox et al.) Or had not had a prehospital ECG on the ambulance.

STEMI 75

STEMI Coronary ED Ambulance 75

Don't Forget the Bubbles

JULY 26, 2023

Prioritise listening to the first 30 minutes which given a good overview of aetiology and treatment (53 mins) Basics of cardiac rhythm problems in the ED Palpitations are a common reason for children to present to the emergency department, the majority of these will be benign from a cardiac perspective and instead related to stress or anxiety.

ALS 98

ALS ED OR CPR 98

FOAMfrat

JULY 3, 2024

If they are not already there, get ALS-level care to the patient as soon as possible. I personally know of 2 ALS providers who were exposed to chlorine gas in a pool incident on the job and both ended up retiring from their service and still have lifelong breathing problems as a result. Thomas, Eds.) Bronstein, A. Fernandez, M.

Life Support 105

Life Support ALS Emergency Response OR 105

Don't Forget the Bubbles

JUNE 30, 2023

All you know, back in ED, is that the ETA is 10 minutes, and there is a single stab wound to the chest. The ODP is caught up leaving theatres and has not yet made it down to ED. Back in ED with Ranulf, and pack two has gone through. The trauma call goes out. Would you like a pigtail catheter or a surgical chest tube?

E-9-1-1 139

E-9-1-1 FFP Plasma Emergency Department 139

EMDocs

NOVEMBER 1, 2023

A 39-year-old male with history of achalasia with recent endoscopic dilation 24 hours prior presents to the ED for progressively worsening chest pain with radiation to his left shoulder. If there will be a delay in definitive management and there is evidence of intra-thoracic gastric contents, consider chest tube placement.

Critical Care 68

Critical Care ED EMS OR 68

EMDocs

AUGUST 12, 2023

Çalışkan Uçkun A, Yurdakul FG, Ergani HM, et al. link] Alkandari A F, Alawadhi A, Alawadhi F A, et al. doi:10.1055/s-0032-1327007 Zhao W, Wang G, Chen B, et al. 0000000000017823 Rosskopf AB, Martinoli C, Sconfienza LM, et al. In: Knoop KJ, Stack LB, Storrow AB, Thurman R. The Atlas of Emergency Medicine, 5e. J Ultrason.

EMS 70

EMS ALS Emergency Department ED 70

Dr. Smith's ECG Blog

SEPTEMBER 23, 2024

Consider the following: We become attuned to looking for acute coronary occlusion in patients who present with acute symptoms to the ED ( E mergency D epartment ). But the History in today's case was acute shortness of breath with dizziness and lightheadedness — and, essentially without chest pain!

E-9-1-1 115

E-9-1-1 Coronary STEMI ALS 115

ACEP Now

NOVEMBER 14, 2023

One of the most hair-raising presentations to the emergency department (ED) can be massive hemoptysis with respiratory failure. The definition of massive hemoptysis is variable across publications with expectorated blood volumes ranging from 100 to 1,000 mL per 24 hours, as these volumes are difficult to estimate for any given patient.

E-9-1-1 52

E-9-1-1 ALS Emergency Department OR 52