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Rezaie’s Evidence-Based Evidence of the Literature

7 01, 2014

The HEART Score: A New ED Chest Pain Risk Stratification Score


chest_pain_1600_clr_2153Chest pain is a common presentation complaint to the emergency department (ED) and has a wide range of etiologies including urgent diagnoses (i.e. acute coronary syndrome (ACS), pulmonary embolism, aortic dissection) and non-urgent diagnoses (i.e. musculoskeletal pain, gastroesophageal reflux disease (GERD), pericarditis). The challenge in the ED is to not only to identify high risk patients but also to identify patients who can be safely discharged home. Specifically, when dealing with ACS, dynamic ECG changes or positive cardiac biomarkers is pretty much a slam dunk admission in most cases, but a lack of these does not completely rule out ACS. Currently, most guidelines and risk stratification scores focus on the identification of high risk ACS patients that would benefit from early aggressive therapies, but what about all the other chest pain patients that don’t have ACS… are they accounted for?


27 11, 2013

Subsegmental Pulmonary Embolisms (SSPE) are Important


0125Multi-detector computed tomographic pulmonary angiography (CTPA) allows for better visualization of peripheral pulmonary arteries allowing for diagnosis of small peripheral emboli limited to the subsegmental pulmonary arteries. Interestingly as these SSPE’s get diagnosed more and more, two questions come to mind:

  1. What is the prognostic utility of diagnosing SSPEs?
  2. What is the morbidity and mortality of SSPEs compared to more proximal PEs?

A recent study in 2013 Blood looked at these questions. 1


25 11, 2013

Shock Index: A Predictor of Morbidity and Mortality?


a_11Emergent airway management and severe sepsis are both high-risk situations that are commonly encountered by emergency physicians. It is well known that complications can be high in both situations, which in turn can lead to increased morbidity and mortality. For instance, about 1/4 of patients who are hemodynamically stable prior to intubation get post-intubation hypotension (PIH) after rapid sequence intubation. Also septic patients may not be reliably identified by systemic inflammatory response syndrome (SIRS) markers early in their disease course. The Shock Index (SI) may be an adjunct that is easy to calculate and could predict both PIH and severe sepsis.


30 10, 2013

Introducing REBEL in EM and IM


As a physician and newcomer to FOAM, I am finding that I have learned a lot of myths and pearls that are not true as I matriculated through school. This has taught me that learning from textbooks may be great for board exams, but  more importantly it is not optimal for patient care and has made me question a lot of different practices. We all want to know clinically relevant information that is evidence based and up to date that will make a difference in our care of patients. The purpose and goal of REBEL is to create a sustained change in beliefs, attitudes, and behavior through review of the best evidence available.


28 10, 2013

CPR: Hands-on or Hands-off Defibrillation?

website cpr image 2Pauses in chest compressions are known to be detrimental to survival in cardiac arrest, so much so that the 2010 American Heart Association (AHA) emphasize high-quality compressions while minimizing interruptions. There have been some studies that now advocate for continuous chest compressions during a defibrillation shock. There have been substantial changes to external defibrillation technology  including:

  • Biphasic shocks with real-time impedance monitoring to reduce peak voltages
  • Paddles being replaced by adhesive pre-gelled electrodes
  • Enhancement in ECG filtering permitting rhythm monitoring during chest compressions.

So the mantra of “hard and fast” may be true when it comes to CPR, but the real question now becomes, should we be continuing CPR during defibrillation?


23 10, 2013

Mechanical vs Manual CPR Chest Compressions


lucasWhen talking about Out of Hospital Cardiac Arrest (OHCA) there are really only three things that make a true difference on outcomes (i.e. survival and neurologic function):

  • High quality, non-interrupted CPR
  • Early defibrillation
  • Therapeutic hypothermia

The quality of CPR is often under appreciated and performed incorrectly (too slow and/or not hard enough).  With mechanical CPR, chest compressions are delivered uninterrupted and at a predefined depth and rate. In my own practice I have seen these devices being used more and more, but my questions is do these devices impact outcomes?


8 10, 2013

Acute Pulmonary Embolism: Size does matter and ECG can give us clues



Acute pulmonary embolism (PE)  is a common condition that can be both severe and difficult to diagnose. Half of all acute PE cases are diagnosed in the emergency department, and acute PE follows acute coronary syndrome as the second most common cause of sudden unexpected death in outpatients. Also, right ventricular dysfunction is a consequence of massive/submassive acute pulmonary embolism and correlates with a poor prognosis and high mortality rate. Although an ECG lacks both sensitivity and specificity for acute PE, there are some clues that can help in determining the size of an acute PE.