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

Introduction: Resuscitationists continue to debate the choice of induction agents in rapid sequence intubation (RSI). Critics of etomidate highlight its link to adrenal suppression in critically ill patients (Albert 2011), while critics of ketamine highlight the higher incidence of post-intubation hypotension (Mohr 2020). Amidst the debate, the Ketased Trial (Jabre 2009), a large multicenter prospective, single-blind randomized clinical trial (RCT), reported no significant difference in SOFA scores or 28-day mortality between the two induction agents. However, the EvK trial (Matchett 2022) id ..read more

Background: Although most intubations are typically successful there is still a portion of patients that may require multiple intubation attempts.  Repeated intubation attempts could lead to respiratory and hemodynamic complications. We recently covered the DEVICE trial on REBEL EM which compared a standard geometry video laryngoscopy approach vs a standard geometry direct laryngoscopy approach in critically ill adults requiring intubation.  Video laryngoscopy outperformed direct laryngoscopy in first pass intubation success (85.1% vs 70.8%). We now have a second trial in an operati ..read more

Background: Hematologic emergencies in the critical care setting are rare but deadly complications that can often be managed appropriately if identified early on and received prompt intervention. In this 2-part review, we will discuss several hematologic emergencies and discuss the literature on current guidelines and principles of management. Shoon Oo MD1 , Vinh Dao MD1, Kenneth Snell MD2, David Goldenberg DO2, Frank Lodeserto MD3 Affiliations 1. Department of Internal Medicine, Cape Fear Valley Medical Center, Fayetteville, North Carolina 2. Department of Anesthesiology, H. Lee Moffitt Canc ..read more

Background: Hematologic emergencies in the critical care setting are rare but deadly complications that can often be managed appropriately if identified early on and received prompt intervention. In this 2 part review, we will discuss several hematologic emergencies and discuss the literature on current guidelines and principles of management. Vinh Dao MD1, Shoon Oo MD1, Kenneth Snell MD2, David Goldenberg DO2, Frank Lodeserto MD3 Affiliations 1. Department of Internal Medicine, Cape Fear Valley Medical Center, Fayetteville, North Carolina 2. Department of Anesthesiology, H. Lee Moffitt Cance ..read more

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 of a reversal agent, unfractionated heparin (UFH) is commonly used when percutaneous or surgical interventions are being considered. The standard weight based dosing of UFH is 80U/kg bolus followed by an infusion started at 18U/kg/hr, titrated to a target activated p ..read more