REBEL Cast

Joanna Piero, a pediatric hematologist oncologist at Staten Island University Hospital, shares her expertise in managing critical pediatric hematology and oncology emergencies. She emphasizes the life-saving importance of administering antibiotics within an hour for patients with fever and neutropenia. Joanna stresses that fever in sickle cell patients is always an emergency, requiring immediate cultures and treatment. She also discusses crucial red flags in pediatric headaches that may suggest a brain tumor, highlighting the need for swift specialist consultations.

Explore the critical steps for managing hyperkalemia in emergency care. Learn why an EKG is essential upon patient presentation, especially for those with renal issues. Discover the common causes, including medications and massive cell death, that lead to elevated potassium levels. Hear about the alarming cardiac effects and neuromuscular symptoms that can arise. The discussion emphasizes timely interventions like administering calcium salts for unstable patients, showcasing the urgency in tackling this common electrolyte disorder.

Take Home Points Management of severe beta-blocker and calcium-channel blocker toxicity should occur in a stepwise fashion: potential gastric decontamination, multiple lines of access, judicious fluids, calcium, glucagon, and vasopressors as needed. Initiation of high dose insulin therapy requires a tremendous amount of logistical and cognitive resources as it requires cross-disciplinary collaboration and is prone to mismanagement. If the patient doesn’t respond to maximum pharmacologic therapy, venous-arterial ECMO should be considered. REBEL Core Cast 124.0 – Hyperinsulinemia Euglycemia Therapy Click here for Direct Download of the Podcast. Background and Physiology Shock secondary to beta-blocker (BB) or calcium-channel blocker (CCB) toxicity bears a tremendous degree of morbidity and mortality. According to the 2022 Annual Report of the National Poison Data System from America’s Poison Center, CCBs and BBs account for the sixth and seventh largest number of fatalities from overdose.1 Recall that cardiac output is a function of both stroke volume and heart rate. The natural response to diminishing stroke volume is a compensatory rise in heart rate (tachycardia). Keep a low threshold to search a patient’s medication list for BB/CCBs, when a hypotension is seen with a “normal heart rate.” Clinical Manifestations Both BBs and CCBs ultimately cause reduced levels of intracellular calcium within myocytes. Depending on the degree of toxicity, subsequent effects include: decreased systemic vascular resistance, vasodilation, bradycardia, various conduction delays, and ultimately hypotension and cardiogenic shock. In addition to abnormal vital signs, look for surrogates of poor clinical perfusion: acidemia, lactate, decreasing urinary output Traditional Management Consider GI decontamination to reduce systemic absorption: 1g/kg up to 50g of activated charcoal. Patient must be alert or the airway must be secured as to avoid aspiration. Obtain multiple lines of intravenous access (3 PIVs or triple lumen CVC) and provide a judicious amount of fluids. (more on this below) Pharmacotherapy Calcium Gluconate: 1-3g intravenous Glucagon: 3mg-5mg slow intravenous push. Rapid administration may induce nausea and emesis. Vasopressors as a bridge to… HIET Mechanism of action is still not fully elucidated however several factors are implicated: Insulin augments cardiac contractility by activating “reverse-mode” Na-Ca exchange and subsequently increasing calcium concentration in the sarcoplasmic reticulum. 2 At a resting physiologic state, the heart utilize free fatty acids as its primary energy course. Under stressed conditions, glucose is used instead. Insulin helps to facilitate glucose metabolism. HIET Dosing: 1 unit/kg IV bolus. Then infusion starting at 1 unit/kg/hr infusion and titrate q30-60 minutes, keeping in mind that effects are not instant. Relative maximum is ~10 unit/kg/hr. If glucose <250 mg/dL, administer a bolus of dextrose 25-50 g (or 0.5-1 g/kg) IV. Ask pharmacy to concentrate insulin from 1 unit/mL to 10 units/ml. Patients often succumb to volume overload given pre-existing cardiac disease and the volume of medical resuscitation through their hospital stay. Once HIET is initiated, dextrose and potassium infusions should simultaneously be started to obviate hypoglycemia and hypokalemia Dextrose: 0.5-1 g/kg/hr via D50/D20 Replete potassium to a minimum of 3.5mEq/L A central venous catheter (often a triple lumen) is often needed to emergently replete potassium and provide D50/D20 safely (given its high osmolarity) Serial monitoring of dextrose (q15-30 minutes) and potassium (q1 hour) is critical HIET has been demonstrated to improve perfusion without necessarily increasing SVR/MAP – while MAPs may not markedly increase dramatically in the short term, obtain serial blood gases, lactate, and track urinary output to track perfusion. 3 Hyperinsulinemia Euglycemia Therapy (HIET) for BB/CCB Toxicity Management of severe beta-blocker and calcium-channel blocker toxicity should occur in a stepwise fashion: potential gastric decontamination, multiple lines of access, judicious fluids, calcium, glucagon, and vasopressors as needed. Initiation of high dose insulin therapy requires a tremendous amount of logistical and cognitive resources as it requires cross-disciplinary collaboration and is prone to mismanagement. HIET Dosing: 1 unit/kg IV bolus. Then infusion starting at 1 unit/kg/hr infusion and titrate q30-60 minutes, keeping in mind that effects are not instant. Relative maximum is ~10 unit/kg/hr. HIET therapy requires simultaneous dextrose and potassium infusions as insulin will induce hypoglycemia and shift potassium intracellularly. If the patient doesn’t respond to maximum pharmacologic therapy, venous-arterial ECMO should be considered. References Gummin DD, Mowry JB, Beuhler MC, et al. 2022 Annual Report of the National Poison Data System® (NPDS) from America’s Poison Centers®: 40th Annual Report. Clin Toxicol (Phila). 2023;61(10):717-939. doi:10.1080/15563650.2023.226898 von Lewinski D, Bruns S, Walther S, Kögler H, Pieske B. Insulin causes [Ca2+]i-dependent and [Ca2+]i-independent positive inotropic effects in failing human myocardium. Circulation. 2005;111(20):2588-2595. doi:10.1161/CIRCULATIONAHA.104.497461 Holger JS, Engebretsen KM, Fritzlar SJ, Patten LC, Harris CR, Flottemesch TJ. Insulin versus vasopressin and epinephrine to treat beta-blocker toxicity. Clin Toxicol (Phila). 2007;45(4):396-401. doi:10.1080/15563650701285412 Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter/X: @srrezaie) The post REBEL Core Cast 124.0 – Hyperinsulinemia Euglycemia Therapy appeared first on REBEL EM - Emergency Medicine Blog.

Discover the rare yet life-threatening condition of posterior epistaxis. The discussion focuses on its unique symptoms and the crucial differences from anterior epistaxis. Learn about effective diagnosis and management protocols, as well as treatment options. The speakers emphasize rapid control techniques and the necessity of surgical intervention. They also highlight the importance of involving ENT specialists and ensuring proper monitoring for affected patients.

The discussion kicks off with an exploration of the implications of andexanet alfa in treating factor 10A inhibitor-related brain hemorrhages, stressing the need for more research. It critically assesses the drug’s hemostatic efficacy and raises concerns about biases in clinical trials funded by its manufacturer. Key criticisms focus on patient outcomes, with a striking emphasis on the risk of thrombotic events. Finally, the conversation highlights the importance of transparency and ethical standards in medical research.

Neutropenic fever poses serious risks, especially for chemotherapy patients. The podcast discusses its causes, emphasizing that the body's own flora can be the biggest threat. Quick administration of broad-spectrum antibiotics is crucial in reducing mortality. Additionally, management strategies such as initial resuscitation and collaboration with infection specialists are highlighted. The shift in infection prevalence from gram-negative to gram-positive is another important point, making vigilant monitoring essential.

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.       Most organizations recommend adults to be ventilated with tidal volumes of 500 to 600mL/breath during ongoing CPR.  Large adult BVMs can have maximum tidal volumes of ≈1500mL and deliver about 750mL per one handed ventilation.  Simulation studies have shown that health care professionals often provide minute ventilation well above these recommended ranges.       One of the recommendations from many experts to mitigate the perceived risk of large adult BVMs is using smaller adult BVMs.  This change would result in decreasing the maximum volume from 1500 to 1000mL and an expected delivered tidal volume from 750 to 450mL/breath  (much more inline with recommended ranges). However, evidence that this approach makes is difference is lacking. REBEL Cast 126: Should We Not Be Recommending Small Adult BVMs in OHCA? Click here for Direct Download of the Podcast Paper: Snyder BD et al. Association of Small Adult Ventilation Bags with Return of Spontaneous Circulation in Out of Hospital Cardiac Arrest. Resuscitation 2023. PMID: 37805062 Clinical Question: Is large adult BVM or small adult BVM associated with more ROSC in adult patients treated with advanced airway placement for nontraumatic OHCA? What They Did: Retrospective, observational cohort analysis of prospectively obtained data from a single urban EMS system Evaluating adults treated with advanced airway placement for nontraumatic OHCA Jan 2015 to Dec 2021 Changed from large adult BVMs to small adult BVMs in summer of 2017 (3 month crossover period was allowed and excluded from analysis) Used a Mercury medical CPR-2 small ventilation bag Compared rates of ROSC, ventilation rate, and mean end tidal carbon dioxide (ETCO2) by minute before and after small adult BVM implementation Outcomes: Primary: ROSC at the end of EMS care (i.e. Arrival to ED or terminated efforts in the field) Secondary: Ventilation rate Mean end-tidal CO2 (ETCO2) during CPR Inclusion: Adult patients with nontraumatic OHCA Treated with an advanced airway (i.e. Endotracheal intubation or iGel) Exclusion: Age <18 years Received basic life support only Termination of resuscitation due to advanced directives ALS interventions prior to EMS arrival Insufficient capnography data Cricothyrotomy Advanced airway placed while patient had spontaneous circulation Airway was managed with BVM only Did not receive CPR while under EMS ALS care Results: 1994 Patients included in analysis 1331 (67%) treated with small adult BVM 663 (33%) treated with large adult BVM 21% had an initial shockable rhythm ROSC Small Adult BVM: 33% Large Adult BVM: 40% uOR 0.74; 95% CI 0.61 to 0.90; P = 0.003 After adjustment for age, sex, witnessed arrest, bystander CPR, and initial rhythm this finding remained statistically significant (aOR 0.74; 95% CI 0.61 to 0.91) Ventilation rates did not differ between cohorts (≈12BPM) ETCO2 Small Adult BVM: 36.9 +/- 19.2mmHg Large Adult BVM: 33.2 +/- 17.2mmHg P <0.01 Strengths: Written records are compared to cardiac monitor files and audio recordings to adjudicate differences before integrating information into the registry Intubations confirmed with ETCO2 Took into account the COVID-19 pandemic time period Also took into account the potential for trends over time by visualizing the incidence of ROSC by month over a seven year period and found no significant change in the slope before and after the implementation of the small adult BVM Limitations: Only included patients that were intubated with an endotracheal tube or iGel (these results may not apply in patients without these devices) There were some confounding baseline differences (explained more in discussion) Unclear what other interventions were performed in terms of ACLS medications or what the specific causes of the cardiac arrest were from This was a before and after study not allowing for a control group. Before and after studies can introduce numerous biases particularly if other pieces of care changed between the two time periods. (Can also go in the discussion) The actual tidal volume delivered was not measured in this trial and therefore the delivered minute ventilation is unknown As this is a retrospective study, we can only show association, BUT NOT causation of the size of the adult BVM affecting ROSC outcomes Discussion: There are some key BASELINE DIFFERENCES that could account for the results of this trial (i.e. confounders): More patients in the small adult BVM cohort received bystander CPR (64% vs 59%). This would favor more ROSC in the small adult BVM cohort Unwitnessed arrest was slightly greater in the large adult BVM cohort (58% vs 53%)…This would favor more ROSC in the small adult BVM cohort Fewer patients in the small adult BVM cohort arrested in public (22% vs 27%…Unclear how this would impact ROSC The interval from 911 call to start of CPR (10 vs 9min) and advanced airway placement (20 vs 18min) were longer in the small adult BVM cohort…Not sure 1 to 2min of difference would result in more ROSC in the large adult BVM cohort Adherence to guideline recommended ventilation rates of 10 BPM was more common in the small adult BVM cohort (28.4% vs 31.2%)…This would favor more ROSC in the small adult BVM cohort It would appear most things at baseline favored the small adult BVM cohort (Although the authors did account for most of these in adjusted analyses) The end of this trial took place during the COVID-19 PANDEMIC: Anyone who took care of cardiac arrest patients during the COVID-19 pandemic knows that there were significant delays in care According to the authors any cases of OHCA that occurred after the start of the pandemic (Feb 2020) were censored from the analysis and the results were evaluated again When looking at cases of OHCA that occurred prior to Feb 2020 the small adult BVM cohort had a similarly lower odds of ROSC (OR 0.75; 95% CI 0.60 to 0.93; p = 0.008) as the entire time period this intervention was implemented This remained the case even after adjusting for initial rhythm, age, sex, witnessed arrest and bystander CPR (aOR 0.76; 95% CI 0.61 to 0.95; p = 0.018) While I would imagine during a code most people are bagging faster than 10BPM, in this study 6 to 18 BPM were delivered in 82.5% of the measured ventilations. Is this a result of Hawthorne effect or the implementation of a metronome to guide chest compression and ventilation rates (implemented June of 2015) or simply a well trained EMS system? This addition would seem to favor the small adult BVM group This EMS organization appears to be very high functioning with lots of training and education which may not be the standard at other agencies. The fact that the medics are providing a good RR and good TV throughout a 7-year period would suggest this and in doing so a simple change from a large adult BVM to a small adult BVM may have resulted in the association of lower ROSC whereas an agency that does not get as much training or high functioning may actually still be causing harm with the large adult BVM Finally, there was a higher ETCO2 in the small adult BVM cohort compared to the large adult BVM cohort. As ventilatory rate was essentially similar between groups, this most likely means a smaller tidal volume was delivered with each breath.  This smaller tidal volume could have lead to physiologic changes that are potentially harmful: Hypoventilation Increased dead space fraction Alveolar decruitment Atelectasis causing shunt physiology Author Conclusion: “Use of small adult bag during OHCA was associated with lower odds of ROSC at the end of EMS care.  The effects on acid base status, hemodynamics, and delivered minute ventilation remain unclear and warrant additional study.” Clinical Take Home Point: This is a really messy trial, with lots of methodological and confounding issues that make it difficult to interpret.  It does show that when experts recommend an intervention it is important to study it.  Until better evidence shows us differently it is probably best to stick with a large adult BVM but use one hand for bagging and maintain a rate of 10BPM. References: Snyder BD et al. Association of Small Adult Ventilation Bags with Return of Spontaneous Circulation in Out of Hospital Cardiac Arrest. Resuscitation 2023. PMID: 37805062 Post Peer Reviewed By: Anand Swaminathan, MD (Twitter/X: @EMSwami) The post REBEL Cast Ep126: Should We Not Be Recommending Small Adult BVMs in OHCA? appeared first on REBEL EM - Emergency Medicine Blog.

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 – Four or more episodes of ARS per year, with interim symptom resolution Epidemiology: (Anon 2004) 20 million cases of sinusitis annually in the US, costing $3.5 billion/year Source of 1 in 5 antibiotic prescriptions for adults Presentation: Sinusitis is most commonly diagnosed by clinical symptoms Common symptoms Purulent nasal discharge Nasal congestion Facial pain or pressure, especially over a sinus or unilaterally Anosmia Hyposmia Fever Cough Fatigue Maxillary pain Ear pressure or fullness. Classification of Sinusitis: ●Acute viral rhinosinusitis (AVRS) ARS with viral etiology (i.e. rhinovirus, influenza, and parainfluenza) Most common form of ARS ●Uncomplicated acute bacterial rhinosinusitis (ABRS) ARS with a bacterial etiology without clinical evidence of extension outside the paranasal sinuses and nasal cavity Bacterial superinfection: 0.5-2% of all ARS ●Complicated acute bacterial rhinosinusitis ARS with bacterial etiology with clinical evidence of extension outside the paranasal sinuses and nasal cavity Sinusitis: Viral vs. Bacterial: Color change in sputum does not determine whether infection is viral or bacterial Viral infections Tend to begin resolution by 7-10 days Rarely have associated fevers If fever present, usually only in the first 48 hours. Guidelines for diagnosing ABRS are Presence of URI/cold symptoms that Don’t improve after 10 days Worsen after 5-7 days of improvement Severe symptoms including high fever, purulent discharge or facial pain for 3-4 days The Data Behind Antibiotic Use Clinically diagnosed acute sinusitis Multiple studies show the same cure rate at 7 days, but improved cure rate at 7-14 days for those who use antibiotics (Lemiengre 2012, Berg 1986, Gwaltney 1996) Overall Treatment Effect NNT = 18 Overall Harm NNH = 8 (mostly GI side effects) Radiographically-diagnosed acute sinusitis (Ahovuo-Saloranta 2008) Endpoint: clinical cure at 7-15 days NNT = 15 NNH = 8 IDSA Recommendations for Antibiotic Treatment (Chow 2012) Patients that should be treated Persistent symptoms w/o improvement (> 10 days) Severe symptoms (> 3-4 days) Worsening (“double-sickening”) (> 3-4 days) Antimicrobials 1st Line Amoxicillin 875 mg PO BID X 5-7 days Doxycycline 100 mg PO BID X 5-7 days 2nd Line Amoxicillin/Calvulanate 875/125 mg PO BID X 5-7 days Levofloxacin 500 mg PO Q24 X 5 days Bottom Line: Given the risk for adverse events associated with antibiotic use, the growing specter of resistance and the lack of significant differences in outcomes with antibiotic use, it is better to avoid antibiotics in most patients with ARS. Antibiotics should be considered in those with severe disease and in immunocompromised patients 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. References Anon JB et al. Antimicrobial treatment guidelines for acute bacterial rhinosinusitis. Otolaryngol Head Neck Surg 2004; 130(Suppl 1): 1-45. PMID: 14726904 Lemiengre MB et al. Antibiotics for Clinically Diagnosed Acute Rhinosinusitis in Adults. Cochrane Database Syst Rev 2012. PMID: 23076918 Berg O et al. Occurence of asymptomatic sinusitis in common cold and other acute ENT-infections. Rhinology 1986; 24(3): 223-5. PMID: 3775189 Gwaltney JM. Acute community-aquired sinusitis. Clin Infect Dis 1996; 23(6): 1209-23. PMID: 8953061 Ahovuo-Saloranta A et al. Antibiotics for acute maxillary sinusitis. Cochrane Database Syst Rev 2008. PMID: 18425861 Chow AW et al. IDSA Clinical practice guideline for acute bacterial rhino sinusitis in children and adults. Clin Infect Dis 2012; 54(8): e72-e112. PMID: 22438350 Read More The NNT.com: Antibiotics for Clinically Diagnosed Acute Sinusitis in Adults The NNT.com: Antibiotics for Radiologically-Diagnosed Acute Maxillary Sinusitis Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter/X: @srrezaie) The post REBEL Core Cast 121.0 – Acute Sinusitis appeared first on REBEL EM - Emergency Medicine Blog.

Podcast Direct Download: Link Release Date: April 16th, 2024 Show Notes The Visible Voices Podcast Dr. Glaucomflecken: Power of Ultrasound with Emergency Medicine Dr. Resa Lewiss Adaira I Landry MD Resa E Lewiss MD is a Professor of Emergency Medicine at the University of Alabama at Birmingham. A TEDMED speaker and TimesUp Healthcare founder, she’s an internationally renowned point-of-care ultrasound educator and champion for diverse, equitable, and inclusive workplaces. She attended college at Brown, medical school at Penn, Emergency Medicine residency at Harvard, and fellowship at Mount Sinai St. Luke’s Roosevelt.  She led point-of-care ultrasound sections at St. Luke’s Roosevelt, the University of Colorado, and Thomas Jefferson. A physician healthcare design consultant for Perkins&Will, her design focus has been ultrasound hardware and workflows. She’s helped to redesign the built environment of a Harvard ICU and an infectious diseases unit in Malawi. As host and founder of the Visible Voices Podcast, she’s interviewed dozens of subject matter experts in healthcare, equity, and current trends. Her writings are published in the popular press and scientific journals, such as Harvard Business Review, Slate, Nature, and Fast Company. Her new book, MicroSkills : Small Actions, Big Impact is forthcoming from HarperCollins in 2024. Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter/X: @srrezaie) The post REBEL EM Book Club – MicroSkills appeared first on REBEL EM - Emergency Medicine Blog.

Dr. Dara Kass, an emergency medicine physician and former Regional Director for the U.S. Department of Health and Human Services, is joined by Dr. Monica Saxena, an assistant professor at Stanford and advocate for reproductive justice. They delve into how the Emergency Medical Treatment and Labor Act (EMTALA) shapes access to reproductive health services. The discussion highlights the legal challenges post-Dobbs v. Jackson, the tension between state laws and federal protections, and the critical need for greater awareness of patient rights and physician advocacy.