Background Information: Out of hospital cardiac arrest (OHCA) is a medical emergency that requires immediate intervention to increase the chance of survival. The global survival rate of OHCA patients who received CPR has increased in the past 40 years [1]. However, CPR related rib and sternal injuries are observed more frequently in OHCA and are an independent factor in mortality [2]. We’ve reviewed prior literature on this before on REBEL EM that can be found here. Since then more evidence has emerged that suggests no significant difference in clinical outcome when mechanical chest compressio ..read more

A 67-year-old woman with a history of atrial fibrillation on apixaban presents to the ED for epistaxis that began 30 minutes ago. Her bleeding is difficult to control with direct nasal pressure and topical agents but resolves with silver nitrate cauterization. Her vital signs are within normal limits. How should this patient’s apixaban be managed? Administer a one-time dose of intravenous vitamin K Administer andexanet alfa Bolus 1 unit of prothrombin complex concentrate Give intravenous tranexamic acid Hold her next dose of apixaban References Garcia DA, Crowther M. Management of bleedin ..read more

Background: IV subdissociative ketamine at a dose of 0.1 to 0.3mg/kg is increasingly being used as an opioid sparing option for short-term acute pain relief. Alternatively, nebulized ketamine can be used for this indication and may have a benefit as it does not require IV access. In the KetaBAN trial, authors randomized 120 patients to 0.75mg/kg vs 1mg/kg vs 1.5mg/kg of nebulized ketamine [REBEL EM Link].  The results showed all three doses were equally effective in relieving pain for up to 120 minutes in the ED.  However, there was no comparison of nebulizerdketamine to IV ketamine ..read more

Take Home Points: There are many causes of neutropenia, chemotherapy being by far the most dangerous. Febrile neutropenia is a condition conveying high mortality. Early administration of antibiotics is the only factor known to reduce this mortality. For a patient with neutropenic fever, remember that the body’s own flora is the greatest danger. Isolate, but do not wait to initiate treatment. Check old blood cultures and obtain new cultures prior to starting treatment. Identify low risk patients and send them home with PO antibiotics and close oncology follow-up in conjunction with your oncol ..read more

Background: The holy grail of outcomes in OHCA is survival with good neurologic outcome.  The only interventions proven to increase this outcome are high quality CPR and defibrillation in shockable rhythms.  Ventilation is also an important component of resuscitation in OHCA.  Excess minute ventilation can adversely affect hemodynamics due to increased intrathoracic pressure (i.e. decreased venous return). Additionally, low CO2 levels from hyperventilation can lead to cerebral vasoconstriction which could lead to worsened secondary brain injury.       ..read more

Background: STEMI can be complicated by cardiogenic shock and this complication is associated with a high morbidity and mortality rate. Decreased cardiac output  results in inadequate perfusion and subsequent end-organ damage. Mechanical circulatory support can improve perfusion and, in theory, result in better outcomes. The ECLS-Shock trial did not demonstrate improved mortality with ECMO compared to medical therapy alone in patients with acute myocardial infarction complicated by cardiogenic shock. However, the lack of benefit in that trial may have been due to poor patient selection a ..read more

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 initial improvement. REBEL Core Cast 121.0 – Acute Sinusitis Click here for Direct Download of the Podcast. Definition: Acute rhinosinusitis (ARS) – Symptoms for less than four weeks Subacute rhinosinusitis – Symptoms for 4 to 12 weeks Chronic rhinosinusitis – Symptoms persisting greater than 12 weeks Recurrent acute rhinosinusitis ..read more

Critically ill patients requiring resuscitation often present with many challenges including the ability to secure safe, sterile, fast, and reliable intravenous (IV) access. Over the years emergency and critical care physicians have tried many ways to establish IV access in emergencies including the “crash” or “dirty” central line. If you are not familiar with this term, it’s the act of rapidly trying to place a central line (usually femoral), placing the needle for access over strict sterile precautions. The “crash” or “dirty” line usually involves femoral vein cannulation; however, some cli ..read more

Bottom Line Up Top: Steroids provide modest improvement in time to resolution and degree of resolution of symptoms in pharyngitis. They should be considered in patients presenting to the ED after weighing potential benefits and risks. Clinical Scenario: A 22-year-old man with a history of poorly controlled diabetes presents with 3 days of sore throat. Vitals are HR 82, BP 120/73, RR 16, Temp 98.8, O2 sat 99% on RA. He endorses cough and nasal congestion but no fevers. His primary symptoms are sore throat and odynophagia  He has tried over-the-counter NSAIDs with only minor improvement in ..read more

Background: Hypoxemic respiratory failure is a frequent complicating feature of severe COVID-19 infection. Early in the pandemic, extensive efforts were made to identify the best approach to oxygenation in this group of patients. Best practices settled on aggressive use of non-invasive ventilation (NIV) and delaying invasive mechanical ventilation (IMV) where feasible. Advanced interventions include proning (both on NIV and IMV) and extracorporeal mechanical oxygenation (ECMO). As therapies are escalated, it’s critical for clinicians to have high-quality data on target oxygen levels. Paper: N ..read more