The global suffering wrought by SARS-CoV-2 pandemic is undeniable. But so is the ferocity with which the world has pursued a cure. And while some potential remedies have held more promise than others, the enthusiasm supporting these novel treatments often outpaced their evidentiary support. In fact, none have demonstrated efficacy backed by high quality randomized […]

The use of IV vitamin C as a therapeutic agent in sepsis has caught the hearts and minds of emergency medicine and critical care clinicians. Since the publication of a small single center before and after study by Marik et al in 2017 (1), we have spent countless hours screaming into the void that is […]

There has been a long-standing debate in the fields of emergency medicine and critical care regarding the ideal paralytic agent to use during RSI, rocuronium or succinylcholine. This dispute, has even developed slogans such as Roc Rocks, Sux Sucks as one side attempts to definitively proclaim its superiority through witty aspersions. But up until now […]

Disclosures: None Recently a letter to the editor was sent to us at the EMCRIT Consortium regarding a recent post I had written about the use of high sensitivity (HS) troponin assays for the work up of ACS in the emergency department. Typically, such remarks are posted in the comments section of the individual blog […]

Studies examining the use of tranexamic acid (TXA) inescapably seem to pit our methodological rigorous demons against our practical clinical angels.  The CRASH-2 trial published in the Lancet in 2010 by Shakur et al, randomized 20,211 adult trauma patients presenting to 274 hospitals in 40 different countries to receive 1g of TXA over 10 min […]

In 2015, Centers for Medicare & Medicaid (CMS) published their sepsis core measure (SEP-1). This represented a nationally mandated sepsis management strategy presented in the form of a 3 and 6-hour bundle. Since its publication, the Surviving Sepsis Campaign (SSC) released their own 1-hour bundle (1), adding even more urgency to an already frenetic effort […]

In 2017 Marik et al (1) published an observational before and after study examining the initiation of the sepsis cocktail for ICU patients admitted with sepsis. The authors noted, following the introduction of this cocktail, which included IV vitamin C, thiamine and hydrocortisone, ICU mortality dropped by an extraordinary 31.9% (40.4% to 8.5%). Since this […]

In the management of sepsis, the acquisition of blood cultures prior to the administration of antibiotics has been a long-held dictum, even before it gained the regulatory support due to its place in the SEP-1 3-hour bundle. But how much is lost if we defer the acquisition of blood cultures until after the administration of […]

Whether we like it or not, high-sensitivity troponin assays, recently approved by the FDA, will soon replace the 4th generation assays currently in operation. And while many claims have been made regarding their clinical utility, the implications for our standard chest pain workflow are unclear.  A recent publication by Chew et al, provides us a […]

With each publication from Maitland et al we are granted a brief glimpse of a greater medical truth. Only our view is obstructed, as we peer through the constricted aperture created by the questions regarding its external validity.  In 2011, Maitland et al published the FEAST trial in the NEJM (1). This landmark trial called […]

In the FOAM community a great deal of time is spent discussing the appropriate manner of transitioning critically ill patients onto mechanical ventilation. A far larger portion of the practice of critical care is spent determining how best to liberate our patients from the ventilatory shackles with which we have bound them. The specifics of […]

  A recent post on the EXTEND Trial stimulated a passionate debate regarding the use of adjusted analysis in RCTs. A number of of those partaking in this discussion argued feverishly for the use of adjusted analysis in RCTs, and made very strong arguments in favor of such methods. I argued that while adjusted analyses […]

Since the earliest trials examining the efficacy of tPA for acute ischemic stroke there has been a tendency to play it fast and loose with the scientific method. The results of the landmark NINDS-2 trial (1), a moderate sized RCT, with a tenuously positive primary outcome (Fragility Index of 3), were never validated. The results […]

Very little about the management of atrial fibrillation is an emergency. And yet we in the Emergency Medicine community have embraced it as such. We gleefully bring to bear the full technological powers available to an Emergency Physician in our attempts to tame its irregular irregularity. Using this aggressive approach, we have proven ourselves quite […]

The process of rapid sequence induction (RSI) often forces the clinician to choose between two conflicting priorities. Torn between maintaining a safe level of oxygen, rendering the patient apneic, and limiting the amount of positive pressure ventilatory support given prior to obtaining a secure airway in the hopes of minimizing the risk of aspiration. Traditionally […]