REBEL Cast

Eric Acker, DO, a resident physician specializing in emergency medicine, joins the discussion on non-invasive ventilation techniques. They break down the differences between CPAP and BiPAP, highlighting their uses for conditions like pulmonary edema and COPD. The conversation dives into practical aspects, such as mask discomfort and sedation risks, while demystifying high-flow nasal cannula (HFNC) mechanics. Acker emphasizes how these supportive modalities stabilize patients and improve oxygenation, all without needing invasive measures.

🧭 REBEL Rundown 📌 Key Points 💀 Mortality: No statistically significant difference in 28-day mortality between ketamine vs etomidate for intubation in critically ill patients, though there was a ~1% absolute difference favoring ketamine. 📉🫀⚠️ Hemodynamics: Ketamine induction was associated with more cardiovascular collapse, mainly driven by new/increased vasopressor use (dose escalation or addition of a vasoactive agent). 💉⬆️ Click here for Direct Download of the Podcast. 📝 Introduction Etomidate or ketamine? The debate over the ideal agent for emergency rapid sequence intubation (RSI) has raged for years with no clear winner. Etomidate has been touted in the past for its rapid onset and minimal intrinsic effects on hemodynamics. However, the drug is well known as a transient adrenal suppressant though the impact of this suppression isn’t clear. Ketamine has risen in recent years as an alternative, due to its perceived hemodynamic stability, analgesic properties and absence of adrenal suppression. Additionally, recent data points towards improved mortality when ketamine was selected over etomidate (Kotani 2023). High quality randomized controlled trials are needed to further elucidate which agent should be selected in critically ill patients. 🧾 Paper Casey JD et al. Ketamine or etomidate for tracheal intubation of critically ill adults. NEJM 2025. PMID: 41369227 🔙Previously Covered On REBEL REBEL EM: The EvK Trial: Ketamine vs Etomidate for Rapid Sequence IntubationREBEL EM: From Debate to Data: Emerging Insights into RSI Induction with Ketamine vs Etomidate ️ What They Did CLINICAL QUESTION In critically ill adults undergoing tracheal intubation, does the use of ketamine instead of etomidate result in improved 28 day mortality? STUDY DESIGN Multicenter, randomized, open-label trial in both emergency departments and ICUs. POPULATION Inclusion Criteria:Critically ill patients > 18 years of age undergoing tracheal intubation with the use of an induction agentExclusion Criteria:Known pregnancyPrisonersPrimary diagnosis of traumaNeed for immediate intubation precluding randomizationClinicians determined that the use of ketamine or etomidate was either necessary or contraindicated INTERVENTION & COMPARATOR Intervention (HFNC Group):Ketamine administered based on a provided nomogram: full dose (2.0 mg/kg), intermediate dose (1.5 mg/kg) or reduced dose (1.0 mg/kg)Comparator (BPAP Group):Etomidate administered based on a provided nomogram: full dose (0.3 mg/kg), intermediate dose (0.25 mg/kg) or reduced dose (0.2 mg/kg) OUTCOMES Primary: In-hospital death from any cause by day 28.Secondary:Cardiovascular collapse during intubation defined as SBP < 65 mm Hg, receipt of new or increased dose of vasopressors or cardiac arrest.Exploratory Procedural:Lowest systolic blood pressureLowest systolic blood pressure below 80 mmHgHighest systolic blood pressure above 180 mmHgLowest oxygen saturationLowest oxygen saturation below 80%Successful first attempt intubationTime from induction to intubationExploratory Clinical:Number of ventilator free daysVasopressor-free daysICU free days Safety: Systolic blood pressure at 24 hours after enrollmentOngoing receipt of vasopressors at 24 hours 📈 Results: 2365 patients were randomizedKetamine: 1176Etomidate: 1189> 99% of patients received the drug they were randomized to receiveNMBA: 69% of patients in both groups received rocuronium~ 95% of patients had video laryngoscopy for the primary intubation attempt 💥 Critical Results 💪 Strengths Multicenter ED + ICU cohort of critically ill patients → improves external validityStrong randomization → balanced baseline characteristicsRight population for the question → appropriately focused on a sick cohort where induction choice matters mostHigh protocol adherence → most patients received the agent they were randomized toExcellent follow-up → minimal loss to follow-up / outcome capture ⚠️ Limitations No blinding → potential performance/resuscitation biasTrauma excluded → limits applicability to peri-intubation trauma careCase-mix skewed toward septic shock → may reduce generalizability to other shock etiologiesPower assumptions → designed to detect a 5% mortality difference (possibly overly ambitious)Equipoise-only enrollment → excluded patients with clear indication/contraindication → selection bias + reduced real-world applicabilityComposite secondary outcome with non-equivalent endpoints (e.g., cardiac arrest vs vasopressor titration)Ketamine dosing by actual body weight (vs ideal) → may have increased dose/exposure in some patients 🗣️ Discussion The increase in cardiovascular collapse seen with ketamine was driven by the “new or increased vasopressor use” piece of the composite outcome not by the more clinically relevant severe hypotension (SBP < 65 mm Hg) or cardiac arrest.The increase in CV collapse is a secondary outcome and hypothesis generating onlyCare beyond induction agent isn’t clearly delineated and may have varied between groupsReasons why there was more CV collapse in the ketamine group:Patients in the etomidate group were more likely to be on pressors or have pressor increases prior to induction agent administrationKetamine has analgesic properties which may affect hemodynamics (etomidate does not have analgesic effects)The standard ketamine dose of 2 mg/kg is higher than the induction dose used by most (1-1.5 mg/kg)Ketamine dosing was based on actual body weight though ideal body weight dosing is more accepted. This may have resulted in unnecessarily large ketamine doses that may have had a greater effect on hemodynamics.This is a study of patients with clinical equipoisePatients who the clinician determined would clearly benefit from one agent or the other or in whom one agent or the other was contraindicated were excluded from the study.This may add a selection bias to the results.Clinicians were not blinded to the induction agent administeredThe absence of blinding can introduce bias.For instance, knowledge of the agent the patient was randomized to may result in different resuscitative treatment prior to intubation.An induction agent nomorgram was provided to allow clinicians to choose their induction dose depending on patient stability.A 5% difference in mortality may be overly ambitious. As Josh Farkas points out in his post on this article, PCI for STEMI only has a 3% absolute difference in mortality versus standard care.The 1% absolute difference in mortality while not statistically significant would be clinically significant if it was real. The study would have to be much larger to show a statistically significant 1% difference.About 2% of patients in each group received additional medications during induction (propofol, benzodiazepines, opiates). It is unclear why these agents were selected in specific cases and how they may have affected the outcomes in question. 📘 Author's Conclusion “Among critically ill adults undergoing tracheal intubation, the use of ketamine to induce anesthesia did not result in a significantly lower incidence of in-hospital death by day 28 than etomidate.“ 💬 Our Conclusion In this well done RCT, induction with ketamine did not result in a lower 28-day mortality when compared to induction with etomidate in critically ill adults. The secondary outcome of an increase in cardiovascular collapse is interesting and should be studied more in the future. 🚨 Clinical Bottom Line This data should not drive clinicians to abandon the use of ketamine in RSI. To the contrary, the study leaves open the possibility of a clinically meaningful difference in mortality favoring ketamine that may be borne out in a larger study. However, etomidate can be considered as a first-line option for RSI and may be the superior drug in patients at high-risk for cardiovascular decompensation. Post Peer Reviewed By: Post Peer Reviewed By: Mark Ramzy, DO (X: @MRamzyDO) and Marco Propersi, DO 📚 References Kotani Y et al. Etomidate as an induction agent for endotracheal intubation in critically ill patients: a meta-analysis of randomized trials J Crit Care 2023;77:154317. PMID: 37127020 👤Associate Author Anand Swaminathan MD, MPH All Things REBEL EM Meet The Team 🔎 Your Deep-Dive Starts Here The RSI Trial: Ketamine vs Etomidate in Rapid Sequence Intubation Etomidate or ketamine? The debate over the ideal agent for emergency rapid sequence ... Resuscitation Read More REBEL Cast Ep120: Etomidate vs Ketamine for RSI in the ED? Background: Standard rapid sequence intubation (RSI) in the emergency department involves administration of ... Procedures and Skills Read More The post The RSI Trial: Ketamine vs Etomidate in Rapid Sequence Intubation appeared first on REBEL EM - Emergency Medicine Blog.

🧭 REBEL Rundown 📌 Key Points 🧠 We don’t know what we don’t know: Low experience can inflate confidence; true expertise usually brings humble certainty.🏥 ED relevance is universal: From central lines to transvenous pacing, over- or under-confidence shows up at every level—intern to seasoned attending.🧩 Metacognition matters: Accurate self-assessment is a clinical skill; reflection + feedback loops keep us calibrated.🛠️ Practice beats bravado: Skill decay is real; deliberate practice and HALO (high-acuity, low-occurrence) refreshers protect patients.🤝 Psychological safety ≠ niceties: “Confident humility” enables questions, feedback, and better resuscitation decisions—especially under uncertainty. Click here for Direct Download of the Podcast. 📝 Introduction Welcome to REBEL MIND—Mastering Internal Negativity during Difficulty. In this series, we turn the same critical lens REBEL EM uses for literature inward—into mindset, leadership, and psychological safety—so we can deliver better care outward to patients and teams.In this episode and blog post, hosts Mark Ramzy and Kim Bambach (Assistant Professor of Emergency Medicine, The Ohio State University) explore a deceptively simple question: How accurately can we assess our own performance? The answer hinges on a classic cognitive bias that touches all of us in emergency medicine. 🧾 Paper Kruger J, Dunning D. Unskilled and unaware of it: how difficulties in recognizing one’s own incompetence lead to inflated self-assessments. J Pers Soc Psychol. 1999 Dec;7 PMID: 10626367 Cognitive Question How accurately can we assess our own performance? 💭 What is the Dunning-Kruger Effect? The Dunning–Kruger Effect is a cognitive bias where:Lower-skill individuals tend to overestimate their competence, andHigher-skill individuals often underestimate theirs.Translation for the busy clinician: early on the learning curve, confidence spikes (“Mount Stupid”) because we don’t yet see the complexity. As experience accrues, confidence dips (“Valley of Despair”) with growing awareness, then rises again—grounded in nuance and humility.Key insight: True expertise ≠ louder certainty; it’s often quieter, more curious, and more collaborative. How It Applies to the Emergency Department Procedures (e.g., central lines, TVP): Watching a 5-minute video creates “I got this” energy—until the wire won’t pass, the patient thrashes, or you hit carotid. Competence includes troubleshooting in context.Skill Decay is Inevitable: If you haven’t done a chest tube or a TVP in months, you’re not as sharp as last time. Without deliberate refreshers, you drift below the safe-performance line.Everyone’s a Novice Somewhere: New disease entities, evolving algorithms, new tools (POCUS, decision support) mean even attendings routinely re-enter novice zones.Feedback Blind Spots: Lower performers can both overestimate their skills and resist feedback—while many high performers (particularly women, per discussed literature) undervalue their abilities.Culture is Clinical: The ED demands decisive action amid uncertainty. Psychological safety + confident humility lets teams surface alternative diagnoses, challenge momentum, and correct course fast. ⏩Immediate Action Steps for Your Next Shift Run a 60-second debrief on two casesWhat went well? What would I do differently next time? Write one improvement you’ll test today.Play “What if the opposite were true?”Anchored on “lumbosacral strain”, Ask, What if fever/incontinence appears? How does that change my path?Solicit 360° micro-feedbackAsk a nurse, resident, and peer: “One thing I did well; one thing to improve.” Say “thank you,” not “but.”Schedule a HALO refresher this weekPick one high-acuity, low-occurrence procedure (TVP, cric, thoracotomy). Do a 10-minute mental model + equipment walk-through; book sim time if available.Adopt a pre-procedure pauseIf X goes wrong, I’ll do Y. Name two likely failure modes (e.g., “wire won’t advance,” “delirium/agitation”) and your first corrective step.Language shift on shiftSwap “I’m sure” → “I’m reasonably confident, here’s my plan B.” Invite input: “What am I missing?” Conclusion The Dunning–Kruger Effect isn’t a moral failing; it’s a predictable human pattern that every clinician rides—often multiple times per day in the ED. The antidote is metacognition: routine reflection, explicit debiasing, deliberate practice, and feedback within a psychologically safe culture. 🚨 Clinical Bottom Line Competence is quiet and curious. The more we know, the more we recognize what we don’t—and the better we become at caring for patients and each other. Further Reading Dunning D, Kruger J. Unskilled and Unaware of It (1999). Classic paper introducing the effect.Croskerry P. Cognitive forcing strategies in clinical decision-making.Kahneman D. Thinking, Fast and Slow. Heuristics & biases in high-stakes decisions.Ericsson KA. Peak: Secrets from the New Science of Expertise. Deliberate practice & skill acquisition.Edmondson AC. The Fearless Organization. Psychological safety and learning culture in teams. Meet the Authors Mark Ramzy, DO Co-Editor-in-Chief Cardiothoracic Intensivist and EM Attending RWJBH / Rutgers Health, Newark, NJ Kim Bambach, MD Podcasting Manager Assistant Professor of Emergency Medicine Ohio State University The post REBEL MIND – The Dunning Kruger Effect: Why Looking Inward Improves Patient Care appeared first on REBEL EM - Emergency Medicine Blog.

Delve into the dynamics of mechanical ventilation with a focus on vital pressures. Discover the distinctions between Peak Inspiratory Pressure and Plateau Pressure, and what they reveal about lung compliance. Learn how PEEP is crucial in preventing alveolar collapse, especially in severe ARDS cases. Explore the significance of driving pressure in minimizing lung injury. The experts also uncover how to safeguard against barotrauma and the benefits of low tidal volumes in ventilation strategies. It's a must-listen for anyone in critical care!

🧭 REBEL Rundown 🗝️ Key Points ❌ Don’t chase perfect numbers: Adequate and safe is often better than “perfect but harmful.”💨 Oxygenation levers: Start with FiO₂ and PEEP, but remember MAP is the true driver.🫁 Ventilation levers: Adjust RR and TV, tailored to underlying physiology.🚫 Watch your obstructive patients: Sometimes less RR is more. Click here for Direct Download of the Podcast. 📝 Introduction Ventilator management can feel overwhelming—there are so many knobs to turn, numbers to watch, and changes to make. But before adjusting any settings, it’s crucial to understand why the patient is in distress in the first place, because the right strategy depends on the underlying cause. In this episode, we’ll walk through three different cases to see how the approach changes depending on the problem at hand. ️ The 4 Main Ventilator Settings  Tidal Volume (Vt) 🌬️ Amount of air delivered with each breath Typically set based on ideal body weight (6–8 mL/kg for lung protection) Respiratory Rate (RR) ⏱️ Number of breaths delivered per minute Adjusted to control minute ventilation and manage CO₂  FiO₂ (Fraction of Inspired Oxygen) ⛽ Percentage of oxygen delivered Adjusted to maintain adequate oxygenation (goal SpO₂ 92–96%, PaO₂ 55–80 mmHg). PEEP (Positive End-Expiratory Pressure) 🎈 Pressure maintained in the lungs at the end of exhalation to prevent alveolar collapse and improve oxygenation 🧮 Modes of Ventilation AC/VC (Assist Control – Volume Control)How it Works: Delivers a set tidal volume with each breath (whether patient- or machine-triggered).When It’s Used / Pros: Most common initial mode; guarantees minute ventilation; good for patients with variable effort.Limitations / Cons: May cause patient–ventilator dyssynchrony if set volumes don’t match patient’s demand.AC/PC (Assist Control – Pressure Control)How it Works: Delivers a set inspiratory pressure for each breath; tidal volume varies depending on lung compliance/resistance.When It’s Used / Pros: Useful in ARDS (lung-protective strategy), limits peak airway pressures.Limitations / Cons: Tidal volume not guaranteed; must closely monitor volumes and minute ventilation.PRVC (Pressure-Regulated Volume Control)How it Works: Hybrid: set target tidal volume, ventilator adjusts inspiratory pressure breath-to-breath to achieve it (within limits).When It’s Used / Pros: Common default mode on newer vents; combines benefits of VC (guaranteed volume) + PC (pressure limitation).Limitations / Cons: Can increase pressures if compliance worsens.SIMV (Synchronized Intermittent Mandatory Ventilation)How it Works: Delivers set breaths, but allows spontaneous patient breaths in between (without guaranteed volume).When It’s Used / Pros: Used for weaning; allows patient effort.Limitations / Cons: Risk of increased work of breathing if spontaneous breaths are inadequate.PSV (Pressure Support Ventilation)How it Works: Every breath is patient-initiated; ventilator provides preset pressure support to overcome airway resistance.When It’s Used / Pros: Weaning trials; patients with intact drive who just need assistance.Limitations / Cons: Not a full-support mode; not for unstable patients without spontaneous drive. ♟️ Ventilation Strategies Airway ProtectionLow GCS, seizure, strokeLoss of gag/cough reflexHigh aspiration risk (vomiting, GI bleed, poor mental status)Hypoxemic Respiratory FailureSevere pneumoniaARDSPulmonary edemaInhalation injuryVentilatory (Hypercapnic) Failure / Increased Ventilation DemandSevere metabolic acidosis (DKA, sepsis, renal failure) → need high minute ventilationCOPD, asthma (if decompensating)Neuromuscular weakness (myasthenia, Guillain–Barré, spinal cord injury)Airway Obstruction / Anticipated Loss of AirwayTumor, anaphylaxis, angioedemaFacial or airway traumaPre-op / anticipated deterioration Post Peer Reviewed By: Marco Propersi, DO (Twitter/X: @Marco_propersi), and Mark Ramzy, DO (X: @MRamzyDO) 👤 Show Notes Priyanka Ramesh, MD PGY 1 Internal Medicine Resident Cape Fear Valley Internal Medicine Residency Program Fayetteville NC Aspiring Pulmonary Critical Care Fellow 🔎 Your Deep-Dive Starts Here It seems we can't find what you're looking for. The post REBEL Core Cast 146.0–Ventilators Part 4: Setting up the Ventilator appeared first on REBEL EM - Emergency Medicine Blog.

🧭 REBEL Rundown 📝 Introduction Welcome to the Rebel Core Content Blog, where we delve into crucial knowledge for emergency medicine. Today, we share insightful tips from PEM specialist Dr. Elise Perelman, shedding light on respiratory challenges in infants, toddlers, and young children during the viral season. Understanding that most cases involve typical viruses, we aim to equip you with diagnostic pearls to identify more serious pathologies. Click here for Direct Download of the Podcast. 🔍 Recognizing Respiratory Patterns Pearl #1: Look at Your PatientBegin exams from the doorway. Observing patterns such as accessory muscle usage can reveal a patient’s respiratory effort. Specify whether the work of breathing occurs during inspiration, expiration, or both. Inspiratory work indicates difficulty getting air in, while expiratory work suggests trouble pushing air out. Silent tachypnea may point to other issues, like acidemia or pneumothorax. 🩺 Localizing Sounds for Accurate Diagnosis Pearl #2: Localize the SoundBreathing noises signal varied respiratory issues. Stridor, often heard on inspiration, results from obstructions above the thoracic inlet. Conversely, wheezing, generally linked to exhalation, indicates obstructions in the lower airways. Watch for signs like ‘silent chest’—a dangerous, severe obstruction, and distinguish grunting as a bodily mechanism to prevent alveolar collapse. Correctly identifying the sound assists in determining the appropriate intervention. 💉 Tailoring Treatment for Effective Results Once a sound is localized, treatments vary. We explore Soder from nasal congestion, typically needing supportive care and suctioning. Stridor from conditions like croup is eased with interventions to reduce airway swelling, such as steroids or inhaled epinephrine. Conversely, wheezing in infants is often due to bronchiolitis—not bronchospasms—and over-treatment is to be avoided. Supportive measures including suction, hydration, and oxygen are preferred unless improvement warrants bronchodilators. 🌬️ Intervening with Severe Asthma In severe cases of asthma or bronchiolitis, where standard at-home treatments fail, immediate adjunct therapies like intramuscular epinephrine become essential. Administering this quickly can alleviate obstruction when inhalants aren’t effective due to low air movement. 🦓 Navigating the Zebras of Respiratory Cases When recognizing Zebras—uncommon cases overshadowed by routine diagnoses—remain vigilant for histories or presentations that don’t conform. Conditions like pneumonia, bacterial tracheitis, and even myocarditis may mimic more common issues. 📌 Conclusion As attending physicians, our role extends beyond conventional treatment—it’s about discerning the atypical from the typical. Dr. Perelman urges continual reassessment, emphasizing reliance on observational skills as much as technological aid. Keeping keen on respiratory nuances ensures we catch those outlier cases, paving the way for adept medical care despite the overwhelming prevalence of viral infections.Stay tuned for more pearls and insights in our future posts, as Dr. Perelman shares further strategies for effective pediatric emergency care. For more resources, continue exploring our faculty’s valuable contributions on our site. Until then, stay safe and perceptive in your practice. Post Peer Reviewed By: Mark Ramzy, DO (X: @MRamzyDO), and Marco Propersi, DO (X: @Marco_Propersi) 👤 Guest Elise Perlman MD Pediatric Emergency Medicine​ Assistant Professor, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Meet The Team 🔎 Your Deep-Dive Starts Here REBEL CAST – RENOVATE Trial: HFNC vs BPAP in Acute Respiratory Failure The RENOVATE trial set out to answer a high-impact question ... Resuscitation Read More REBEL MIND: Performance Under Pressure – What Medicine Can Learn from Elite Teams Welcome back to Rebel MIND, the podcast where we sharpen ... Human Behavior Read More REBEL Core Cast 148.0–Demystifying Non-Invasive Ventilation & HiFlow Non-invasive ventilation (NIV) refers to respiratory support provided without endotracheal ... Thoracic and Respiratory Read More REBEL MIND – The Dunning Kruger Effect: Why Looking Inward Improves Patient Care In this episode and blog post, hosts Mark Ramzy and ... Human Behavior Read More REBEL Core Cast 147.0–Ventilators Part 5: Key Mechanical Ventilator Pressures & Definitions Made Simple This episode reviews essential ventilator pressures and how to interpret ... Thoracic and Respiratory Read More REBEL Core Cast 146.0–Ventilators Part 4: Setting up the Ventilator Ventilator management can feel overwhelming—there are so many knobs to ... Thoracic and Respiratory Read More The post REBEL Core Cast – Pediatric Respiratory Emergencies: Beyond Viral Season appeared first on REBEL EM - Emergency Medicine Blog.

Tarlan Hedayati, an EM educator focused on ECGs and arrhythmia care. Simon Carley, a resuscitation and pre-hospital care leader from Manchester. Jess Mason, a procedural and simulation-focused educator skilled in HALO procedures. They discuss rethinking atrial fibrillation, preparing mentally and practically for resuscitative hysterotomy, innovative live simulations, and incremental neurocritical care improvements.

Dr. Sanjay Mohan, an in-house toxicologist and emergency physician, delves into the critical topic of QTc prolongation and its implications. He explains the importance of recognizing prolonged QT intervals, detailing risks associated with torsades de pointes. Listeners learn about common medications that contribute to QTc issues and the necessity of monitoring electrolytes. Sanjay shares effective management strategies for torsades, highlighting emergency protocols and preventive measures to ensure patient safety.

Tourniquets are essential for saving lives and limbs, especially during arterial bleeding. Proper placement is crucial—aim for 5-6 cm above the bleed and avoid the joints. The windlass technique offers minimal extra pressure; tighten the Velcro first, then twist the windlass carefully. Timing is critical—note when you apply a tourniquet to help with future treatment decisions. Immediate application can make a significant difference, alleviating past concerns about limb loss with timely, correct use.

In this conversation, Dr. Mark Ramzy interviews Dr. George Willis, an accomplished emergency medicine educator who has spoken globally about complex medical issues. They discuss the importance of the Incrementum conference in fostering international collaboration in emergency medicine. George highlights selective sodium bicarbonate use, preferred interventions for diabetic ketoacidosis, and innovative responses to aortic dissection. He also mentions considerations for hyperkalemia management and gives teasers on diagnosing thyroid storms and treating hypoglycemia.