Podcast
REBEL EM – Emergency Medicine Blog
Hosted by Salim R. Rezaie, MD · EN
Rational Evidence-Based Evaluation of Literature
23episodes
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REBEL MIND: Performance Under Pressure – What Medicine Can Learn from Elite Teams
Jan 2100:39:11Tap to summarize🧭 REBEL Rundown 📌 Key Points 🎯Partnership Focus: New collaboration with Arena Labs aimed at enhancing healthcare worker wellness.🏃🏽‍️‍➡️Personalized Coaching: Tools and coaching programs designed for stress management and performance improvement.📊Data-Driven Insights: Utilizing wearable sensor data to tackle burnout effectively.🌄Broad Impact: Offers a unique opportunity to contribute to large-scale healthcare improvements. Click here for Direct Download of the Podcast. 📝 Introduction Welcome back to REBEL MIND, where MIND stands for Mastering Internal Negativity during Difficulty. Here we sharpen the person behind the practitioner by focusing on things that improve our performance, optimizing team dynamics and the human behavior that embodies the hidden curriculum of medicine. In this episode, hosted by Drs. Mark Ramzy and Marco Propersi, we’re excited to introduce a collaboration with Arena Labs. Arena Labs is helping us measure healthcare performance through innovative programs designed to combat burnout and enhance personal wellness using data-driven strategies.  Cognitive Question What would it look like in emergency medicine and critical care to be set up with the same tools as elite teams and professional athletes when it comes to...
Transcribe →REBEL Core Cast 148.0–Demystifying Non-Invasive Ventilation & HiFlow
Jan 1200:23:21Tap to summarize🧭 REBEL Rundown 🗝️ Key Points 💨 NIV = Support without a tube: CPAP, BiPAP, and HFNC improve oxygenation and reduce the work of breathing.🫁 CPAP = Continuous pressure: Best for hypoxemic patients (e.g., pulmonary edema, OSA).️ BiPAP = Two pressures (IPAP/EPAP): Great for hypercapnic failure (e.g., COPD, obesity hypoventilation).🌬️ HFNC = Heated, humidified high flow: Reduces effort, improves comfort, and enhances oxygen delivery.🩺 Supportive, not definitive: NIV stabilizes patients while the underlying cause is treated. Click here for Direct Download of the Podcast. 📝 Introduction Non-invasive ventilation (NIV) refers to respiratory support provided without endotracheal intubation. The most common modalities include continuous positive airway pressure (CPAP), bilevel positive airway pressure (BiPAP), and high-flow nasal cannula (HFNC). These therapies aim to improve oxygenation, reduce the work of breathing, and potentially prevent invasive mechanical ventilation. 💨 CPAP and BiPAP CPAP delivers a single, continuous pressure during inspiration and expiration. This pressure (commonly 5–10 cm H₂O) helps recruit atelectatic alveoli, reduce shunt, and improve oxygenation. It is commonly used for conditions like pulmonary edema, obstructive sleep apnea, or mild hypoxemia without significant ventilatory failure.BiPAP alternates between two pressures:Inspiratory positive airway pressure (IPAP), augments tidal volume and unloads inspiratory muscles.Expiratory positive airway pressure (EPAP), maintains alveolar recruitment and improves oxygenation.The differential between IPAP and EPAP is critical for reducing hypercapnia in patients with COPD exacerbations or acute hypercapnic respiratory failure.IndicationsCPAP: hypoxemia without major ventilatory failure (e.g., cardiogenic pulmonary edema, atelectasis, OSA).BiPAP: hypercapnia with increased work of breathing (e.g., COPD exacerbation, neuromuscular weakness, obesity hypoventilation).A helpful way to conceptualize CPAP and BiPAP is through the hairdryer analogy. Imagine placing a hairdryer in your mouth:<div id="ezoic-pub-...
Transcribe →Threading the Needle: Bougie-First Intubation
Nov 25, 2024Tap to summarizeBackground: In 2018, the BEAM Trial, a small single-center randomized clinical trial, conducted in the emergency department at Hennepin County Medical Center, demonstrated that bougie use significantly increased the first-attempt intubation success rate compared to the endotracheal tube with stylet (98% vs 87% (absolute difference, 11% [95% CI, 7% to 14%]).1 Conversely, the 2021 BOUGIE trial—a larger, multicenter randomized clinical trial conducted by the same investigators—found no significant difference in first-attempt intubation success between the bougie and an endotracheal tube with stylet among critically ill adults.2 Moreover, the American Society of Anesthesiologists’ 2022 Practice Guidelines for Management of the Difficult Airway recommend the use of adjuncts like bougies in anticipated difficult airways but stop short of endorsing their routine universal use.3 The question of whether bougies should be used as the primary approach for all intubations remains unresolved. The systematic review and meta-analysis covered here aims to provide clarity by pooling clinical trial data to obtain a single point estimate. Paper: von Hellmann R, Fuhr N, Maia IWA, et al. Effect of Bougie Use on First-Attempt Success in Tracheal Intubations: A Systemic Review and Meta-Analysis. Ann Emerg Med. 2024 Feb 83(2):132-144. PMID: 37725023 Clinical Question: In adult patients requiring tracheal intubation, does the use of a bougie compared to a stylet improve the first-attempt success rate? What they did: The authors performed a systematic review and meta-analysis utilizing the PRISMA guidelines. A medical librarian with expertise in systematic reviews, searched Cochrane, Embase, Medline, Scopus, and Web of Science for relevant randomized controlled trials and comparative observational studies from inception to June 2023. Included patients from out-of-hospital, emergency department, intensive care unit, and operating-room intubations. Researchers used the Cochrane Risk of Bias Tool to assess bias in randomized controlled trials, and observational studies were assessed with the modified Newcastle-Ottawa scale. The Grade methodology was utilized to asses the level of certainty. Registered at PROSPERO (CRD42023403212) Population: Inclusion criteria: Adult intubation using a bougie as an intervention compared to usual care (intubation with or without a stylet). Intubation performed in all settings (out-of-hospital, emergency department, ICU, and operating room). Studies that report the outcome of first-attempt intubation success for both bougie and non-bougie groups. Randomized controlled trials or comparative non-randomized observational studies. Exclusion criteria: Manikin and cadaver studies. Studies using only hyper-angulated video laryngoscopy or channeled laryngoscopic devices (e.g., airway scope). Studies comparing different types of bougies. Studies published in languages other than English, Portuguese, or Spanish. Conference abstracts. Studies lacking a control group or that do not report first-attempt success for both bougie and non-bougie groups. Intervention: Intubation performed using a bougie.. Comparator: Intubation performed using a standard stylet or no introducer at all. Outcomes: Primary Outcome: First-attempt intubation success The successful placement of the endotracheal tube on the first laryngoscope insertion. Secondary Outcomes: First-attempt success without clinically important complications (e.g., hypotension, hypoxemia). Incidence of hypoxemia, defined as oxygen saturation <90%. Postintubation arrest. Duration of intubation. Incidence of intubation-related injuries, such as airway trauma. Occurrence of esophageal intubations. Occurrence of postprocedural sore throat. Results: Article selection: 3915 studies identified. 1217 duplicated removed. 2699 studies screened for review. 2565 studies excluded after reviewing titles and abstracts. 134 full-text articles were assessed for eligibility. 116 studies excluded based on eligibility criteria. 18 studies were included: 12 randomized controlled trials 6 observational studies The papers included a total of 9151 intubated patients. Primary outcome: First-attempt intubation su...
Transcribe →Levitan/Rezaie Practical Airway Course
Nov 19, 2024Tap to summarizeView Course Dates This 2-day course provides an in-depth look at effective surgical airway management techniques that you will actually use in your next emergency airway. There is a unique focus on airway anatomy and imaging combined with one-of-a-kind opportunity to practice the techniques on a large variety of non-embalmed, specially prepared cadavers. This is the only cadaver airway course available. This course teaches practical, effective skills and strategies for adult and pediatric intubation that promote patient safety and increase provider confidence. Day 1 • Didactic presentations by Dr. Levitan and Dr. Rezaie on crisis performance, oxygenation, airway anatomy, laryngoscopy, endoscopy, pediatrics, rescue oxygenation techniques and critical care. • Hands-on practice with OR SIM bronchoscopic simulators, long endoscopes on custom designed intubation manikins, and self-nasoendoscopy using sterile sheaths. • End of day will involve discussion of challenging airway management cases from participants and faculty. • Enrollment limited to 32 maximum • Breakfast. lunch and refreshments provided on site Start time: 0745 End time: 1700 Day 2 • Hands-on practice with 12 specially prepared cadavers*, plus unique custom built intubation models (with anatomic variation) and unique custom built male and female surgical models. Intense procedural instruction focused on an incrementalized approach to performing critical airway procedures. The morning is dedicated to laryngoscopy (direct & video), tube delivery, stylets and bougies, endoscopy, and supraglottic airways. The afternoon includes more time with endoscopy, video laryngoscopes, and ends with surgical airways (cricothyrotomy). • Breakfast, lunch and refreshments provided on site Start time: 0745 End time: ~1600 *Please note: In the event the course does not have full enrollment the number of cadavers may be reduced, between 8 and 12 specimens. Course Hotel: Hampton Inn Bulverde Texas Hill Country (Email Alison.McCully@hiscentre.com for Corporate Booking Link). The hotel is a 25 minute ride from San Antonio Airport. If you do not have a vehicle, van transport will available from the hotel to the course location (approximately a 5 minute drive). Available Credit: 15.00 CME Category 1 15.00 CEU Pre-Hospital *Military Discounts Available* View Course Dates The post Levitan/Rezaie Practical Airway Course appeared first on REBEL EM - Emergency Medicine Blog.
Transcribe →REBEL Core Cast 131.0 – Traumatic Arthrotomy
Nov 13, 202400:06:54Tap to summarizeTake Home points: Always suspect an open joint if there is a laceration, regardless of size, the lies over joint CT scan of the affected joint is widely considered to be the standard approach to evaluation but the saline load test may be useful in certain circumstances. Obtain emergency orthopedics consultation for all open joints and administer antibiotics and update tetanus in all patients REBEL Core Cast 131.0 – Traumatic Arthrotomy Click here for Direct Download of the Podcast. Definition: a deep laceration that extends into the joint capsule, exposing the intra-articular surface to the environment A laceration into the joint exposes the normally sterile intra-articular contents to external contamination Inoculation of the joint often results in septic arthritis Physical Exam: Laceration over joint (can be variable in size) Local wound exploration may be sufficient in identifying the open joint Exam findings suspicious for joint capsule involvement: Air bubbles Extravasation of joint fluid – straw colored, viscous, sometimes oily in appearance Diagnostic testing: Imaging: X-ray Limited ability to see air in joints but a reasonable first test CT scan Intra-articular air visualized on CT (Konda 2013) May be up to 100% sensitive for joint violation Study limited by small numbers, inclusion bias + inadequate gold standard May be considered the standard evaluation modality in many settings. Saline load test Has mainly been supplanted by CT scan due to ease in obtaining, reported performance characteristics, consultant recommendation and difficulty in interpreting test. Useful if physical examination equivocal or plain radiographs non-diagnostic Technique (Video) Perform arthrocentesis of the joint with a large bore needle (18-20 gauge) Sterile saline is injected into the joint while passive movement is applied to the joint The laceration site is watched for saline extravasation indicating communication between the joint and external environment Sensitivity ranges from 34%-99% depending on the study, joint, and the amount of saline used to load the joint (Browning 2016) Methylene blue Aids in distinguishing a true positive from additional bleeding from the wound Recent studies suggest that the addition of methylene blue does not increase sensitivity if a sufficient amount of saline is used (Metzger 2012) Volume of fluid injected Varies depending on the joint in which you are injecting Higher volumes increase sensitivity but also increase pain for the patient Knee Joint (Keese 2007) 50 ml: Sensitivity of about 46% 194 ml: sensitivity of 95% Elbow Joint (Feathers 2011) 20 ml: Sensitivity of 86% 40 ml: Sensitivity of 95% Ankle Joint (Bariteau 2013) 7 ml: Sensitivity of 50% 30 ml: Sensitivity of 95% ED Management: Reduce open fractures if present Irrigate grossly contaminated wounds in the ED Immobilize the joint to prevent further injury Obtain early orthopedic evaluation for joint exploration, and washout to be performed within 6-24 hours Tetanus prophylaxis Prophylactic antibiotics (best if given within 6 hours) Staph/strep coverage: 1st generation cephalosporin (i.e. cefazolin or cefuroxime) If risk factors for MRSA present, use agent with activity against MRSA (i.e. vancomycin) If significant soft tissue injury, add gram negative coverage like late generation cephalosporin, extended-spectrum penicillin, or aminoglycoside (i.e. gentamycin) If concern for fecal or clostridial infection, add high dose penicillin (i.e. zosyn) If seawater contamination and concern for vibrio vulnificus, add doxycycline Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter/X: @srrezaie) The post REBEL Core Cast 131.0 – Traumatic Arthrotomy appeared first on REBEL EM - Emergency Medicine Blog.
Transcribe →Is Pip-Tazo Harming Sepsis Patients?
Nov 11, 2024Tap to summarizeBackground: Patients with sepsis are routinely treated with empiric broad-spectrum antibiotics while awaiting source identification, as recommended by the surviving sepsis campaign.2 Vancomycin, in combination with either piperacillin-tazobactam or cefepime, is commonly used for empiric treatment in these cases. Literature comparing the two regimens has largely focused on the adverse effects of each medication, rather than on overall efficacy. In 2021, Buckley et. al. found no difference in mortality in critical care patients treated with vancomycin and piperacillin- tazobactam compared to vancomycin and cefepime or meropenem.3 The same year, Ross et. al. compared cefepime to piperacillin-tazobactam in a cohort of 250 patients with septic shock and found a signal toward higher mortality in those receiving cefepime.4 The 2023 ACORN Trial (covered here on REBEL EM) randomized 2,511 patients requiring antipseudomonal coverage to receive either cefepime or piperacillin-tazobactam. Investigators found no statistically significant difference in the incidence of acute kidney injury (AKI) or death at 14 days, however, those who received cefepime had higher rates of neurologic dysfunction.5 Interestingly, while the effects of piperacillin-tazobactam and cefepime on rates of organ dysfunction have been explored, there are far fewer studies evaluating all-cause mortality as a primary endpoint, which Chanderraj et. al. address in the article discussed below. Article: Chanderraj R, Admon AJ, He Y, et al. Mortality of Patients With Sepsis Administered Piperacillin-Tazobactam vs Cefepime. JAMA Intern Med. 2024;184(7):769-777. PMID: 38739397 Clinical Question: In adult patients with suspected sepsis treated empirically, does the administration of piperacillin-tazobactam compared to cefepime affect 90-day mortality? What They Did: Investigators performed a retrospective cohort study in the Emergency Department at the University of Michigan between July 1, 2014 through December 31, 2018. They analyzed the electronic health records of patients presenting to the ED who met modified Center for Disease Control and Prevention (CDC) sepsis surveillance criteria and received empiric treatment with either vancomycin/piperacillin-tazobactam or vancomycin/cefepime. When determining inclusion and exclusion criteria, only the first 24 hours were considered to better emulate a randomized controlled trial. Evaluated data 90-day mortality and organ-failure free days, comparing unadjusted data to that adjusted for patient demographics and comorbidities. Ran an instrumental variable analysis, using the piperacillin-tazobactam shortage to simulate a randomized control trial in a retrospective manner Performed a subgroup analysis, comparing patients that received anaerobic coverage (i.e. Piperacillin-tazobactam or Cefepime and Metronidazole) and those that did not (i.e. Cefepime only) In response to the publication of the ACORN trial, they repeated their analysis, only looking at the first 14 days Population: Inclusion Criteria: Age ≥18, presenting to the ED Met the modified Centers for Disease Control and Prevention sepsis surveillance criteria Blood samples drawn for culture on arrival Evidence of acute organ dysfunction within the first 24 hours Antibiotics given for at least 1 day Exclusion Criteria: Patients with an indication for anti-anaerobic therapy Necrotizing infections, intra-abdominal infections, head and neck infections CNS infections Transfers from outside hospitals Missing data around the source of infection or antibiotic administration Intervention: Administration of cefepime in combination with vancomycin in the setting of a piperacillin-tazobactam shortage. Comparator: Empiric therapy with piperacillin-tazobactam and vancomycin for treatment of suspected sepsis. Outcomes: Primary outcome: All-cause mortality within 90 days of ED presentation Secondary outcomes: Organ-failure-free days at 28 days, that is how many days in the first 28 after arriving in the ED not requiring mechanical ventilation, vasopressors, or dialysis. Results: Patient Selection: 28,627 Screening admissions (July 2014 – December 2018) 9,794 Excluded 1,297 Outside hospital transfers 8,497 Repeat admissions 18,833 First admission via emergency department 8,958 Excluded 6,491 Vancomycin not administered 2,467 Neither piperacillin-tazobactam nor cefepime administered 9,875 Administration of vancomycin and either piperacillin-tazobactam or cefepime 2,306 Excluded 1,583 Intra-abdominal infection 438 Necrotizing infection 24 Head and neck infection 22 Central nervous system infection 239 Multiple excluded d...
Transcribe →Elbow Dislocations
Nov 6, 2024Tap to summarizeElbow Dislocation Definition: Disarticulation of the proximal radius & ulna bones from the humerus Epidemiology: Incidence Second most common joint dislocation (after shoulder) in adults Most commonly dislocated joint in children Accounts for 10-25% of all injuries to the elbow (Cohen 1998) Posterolateral is the most common type of dislocation (80%) Demographics Most commonly affects patients between ages 10-20 years old As age increases, elbow dislocation rates tend to decrease More common in men than women (53% vs. 47%) (Layson 2023) Most common sports: football, roller-blading or skateboarding, & wrestling Elbow Dislocations (D1) Classification: Differentiate by the direction of the olecranon relative to the humerus (Layson 2023) (e.g. posterolateral, posteromedial, posterior, anterior, medial or lateral) (D1) Complete: The coronoid is completely dissociated from the trochlea Subluxated (Perched): The coronoid rests on the trochlea Simple: Dislocation with injury to only capsular or ligamentous structures Complex: Dislocation with injury involving fracture Radial head (36%) (F3), coronoid process (13%), olecranon (4%) (F2), distal humerus, medial (F4) or lateral epicondyles (Josefsson 1986) Radial head most common associated fracture in adults Medial epicondyle fracture most common associated fracture in children Up to 60% of medial epicondyle fractures are associated with elbow dislocations in children (Gottschalk 2012) Terrible Triad (F5) Elbow dislocation associated with a LCL tear, radial head & coronoid process fracture Associated with poor outcomes (Mathew 2009) Varus Posteromedial Rotatory Instability Elbow injury associated with LCL tear & coronoid fracture Trans-Olecranon Fracture Dislocation Posterior Dislocation (F1) Olecranon Fracture (F2) ...
Transcribe →REBEL Core Cast 130.0 – Omphalitis
Oct 30, 202400:05:45Tap to summarizeTake Home Points Early diagnosis: erythema and warmth of the skin surrounding the umbilicus isn’t normal. Get labs, start abx and get the patient admitted Consult peds surgery on all of these patients as progression to nec fast, while uncommon, is devastating If the patient appears toxic or has systemic symptoms, the simply omphalitis has progressed and aggressive treatment including surgery is likely indicated REBEL Core Cast 130.0 – Omphalitis Click here for Direct Download of the Podcast. Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter/X: @srrezaie) The post REBEL Core Cast 130.0 – Omphalitis appeared first on REBEL EM - Emergency Medicine Blog.
Transcribe →REBEL Core Cast 129.0 – Gastric Lavage
Oct 16, 202400:06:13Tap to summarizeTake Home Points Orogastric lavage may still play an important role in treatment of the overdose patient. Do not perform lavage if the ingestion has limited toxicity at any dose or the ingested dose is unlikely to cause significant toxicity. Strongly consider orogastric lavage in a patient who has taken an overdose of drugs that are particularly toxic, suspected extreme doses associated with high morbidity/mortality and do not have easily available and effective antidotes. Secure the airway prior to placing the lavage tube to minimize aspiration risk. REBEL Core Cast 129.0 – Gastric Lavage Click here for Direct Download of the Podcast. Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter/X: @srrezaie) The post REBEL Core Cast 129.0 – Gastric Lavage appeared first on REBEL EM - Emergency Medicine Blog.
Transcribe →REBEL Core Cast 128.0 – Toxic Alcohols
Oct 2, 202400:16:50Tap to summarizeTake Home Points Toxic alcohols generally refer to methanol and ethylene glycol as these substances pose significant metabolic derangement and end-organ damage. Patient who present shortly after ingestion will simply look inebriated – no different than ethanol intoxication. At this point, patients will have an elevated osmolar gap and little to no anion gap. Patient who presents in a delayed fashion after ingestion may have a normal osmolar gap however will manifest the signs of end-organ damage: anion gap metabolic acidosis, visual impairment, or renal dysfunction. The osmolar gap is poorly sensitive, specific surrogate measure that is used to detect the presence of toxic alcohols. A normal osm gap does not rule out a toxic alcohol ingestion. Management includes fomepizole, hemodialysis, and vitamin supplementation. REBEL Core Cast 128.0 – Toxic Alcohols Click here for Direct Download of the Podcast. Reference: Wiener SW. Chapter 106. Toxic Alcohols. In: Nelson LS, Howland MA, Lewin NA, Smith SW, Goldfrank LR, Hoffman RS, , Flomenbaum NE. eds. Goldfrank’s Toxicologic Emergencies, 11e New York, NY: McGraw-Hill; 2019. Accessed October 2, 2024. Guest Expert: Dr. Sanjay Mohan, MD (Link) Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter/X: @srrezaie) The post REBEL Core Cast 128.0 – Toxic Alcohols appeared first on REBEL EM - Emergency Medicine Blog.
Transcribe →