Since the publication of the sepsis trilogy, PROMISE, ARISE, and PROCESS 1,2,3, abruptly displaced early goal directed therapy (EGDT) as the cornerstone of sepsis management, we have been searching to fill the therapeutic vacuum its sudden departure left behind. The Center for Medicare and Medicaid Services (CMS) and the Surviving Sepsis Campaign (SSC) have both rushed […]

February 7th 2019 marked a auspicious day in the history of the NEJM and its relationship with the pharmaceutical industry. In 2015, the NEJM shifted their significant weight in support of a strong union between industry and medicine1,2,3. With the simultaneous publication of four pharmaceutical sponsored trials, each brimming with its own unique form of […]

In October 2016 the Emergency Medicine community was faced with the publication of the now infamous PESIT trial, and the symbolic wrench its authors carelessly tossed into the already indecisive diagnostic work up of patients presenting to the Emergency Department following a syncopal event1. Published in the NEJM, Prandoni et al enrolled patients who were admitted […]

Often in the interpretation of medical literature we are forced into false dichotomies. Compelled to choose between two hypotheses, neither of which are representative of the data presented. Such is the case with a recent trial published in Intensive Care Medicine in which Guitton et al1 examine the efficacy of apneic oxygenation during RSI in critically […]

Lung-protective ventilation is often considered a simple truth when managing critical care patients on mechanical ventilation. Despite this sense of certainty, the knowledge of exactly how and when to perform such ventilatory strategies is incomplete. The recently published PReVENT adds yet more uncertainty to the true efficacy of low tidal volume ventilation in patients without […]

A recent post examining the utility of cricoid pressure and how to interpret non-inferiority trials stimulated discussion on Bayesian analysis and the question of whether a formal quantitative analysis is necessary or if an informal qualitative assessment is adequate. A recent reanalysis of the EOLIA trial published in JAMA by Goligher et al1 allows us to […]

A perfect trial would require minimal statistical tools to assist in its analysis. Such a trial would be so large that the sample approached the true likeness of the broader population it intended to emulate, thus the risk of sampling error would be minimal. The confidence intervals surrounding the point estimates would be so minute, […]

Until recently the management of acute appendicitis has lay squarely in the hands of the surgeon. But there is a growing body of evidence examining the use of antibiotics alone in uncomplicated appendicitis. Most of the data exploring this question has found that the majority of patients treated with antibiotics alone will avoid surgery in […]

If Maslow were to generate a hierarchy of needs to assess the utility of the coronary CT angiogram (CCTA) in the Emergency Department for the evaluation of chest pain it would look something like this: We have fairly robust data demonstrating the use of CCTA does not improve mortality, nor does it decrease the rate […]

Since the NEJM publication by Pope et al in 2000 found 2% of patients with myocardial infarctions were discharged home from the Emergency Department, we have been in search of a tool capable of identifying a cohort of patients who are truly safe for discharge1. Many have anointed the high-sensitivity troponin assay (hs-cTnI) to this […]

Airway has been paramount to the management of cardiac arrest since the earliest endeavors in resuscitation. The use of tobacco smoke enemas to resuscitate drowning victims on the banks of the Thames was documented as far back as 17461. Such efforts while anatomically misplaced, were in principle well intended. Although, we have since discovered alternative […]

Epinephrine has been a fundamental therapeutic agent in the management of cardiac arrest since the inception of advanced life support. Despite its ubiquitous use, this practice has never been supported by high quality evidence. With the publication of the PARAMEDIC-2 trial by Perkins et al1, we are now far closer to understanding the true value […]

Since the publication of NINDS, a large number of registry based observational studies have been used for the weaponization of tPA in the clinical setting. Initially utilized to justify the use of tPA outside the controlled setting of a clinical trial, and later used to support the profitable indication creep we have observed in the […]

A brief editorial aside: Both Josh and Scott have commented on the BICAR-ICU Trial in previous posts, each presenting well thought out erudite analyses. I recommend reading/listening to them. EMCrit: Acid Base Episode 7 PulmCrit: pH-guided fluid resuscitation & BICAR-ICU The overwhelming need for euboxia has inspired a multitude of therapeutic endeavors, including the use of […]

Let’s face it, we have an unhealthy relationship with antibiotics. We are all aware that we are currently in an antibiotic resistance crisis that is driven by overuse. And despite our enlightenment we cannot seem to stop prescribing antibiotics for complaints that have been clearly shown not to require antibiotics. And so, given our appalling […]