Author: Anthony Catapano

Gun Laws and Mass Shootings: A Call to Action

Written by Sarah Aly, DO
This post first appeared on REBEL EM

Background: Rob Elementary. Columbine. Sandy Hook. Pulse Night Club. Tops Grocery Store. Irvine Taiwanese Presbyterian Church. Virginia Beach. The Tree of Life Synagogue. Santa Fe High School. The New York City Subway. The Las Vegas Harvest Music Festival. Aurora Movie Theater. The El Paso Walmart. Tulsa. The list goes on.

The United States has a unique epidemic: mass shootings. There is no universal definition of a mass shooting but it is often referred to as an event where greater than four individuals are killed by a single perpetrator (Everytown Research & Policy, 2022). Outside of the US, mass shootings are rare events (Bloomberg 2022, Snopes 2018).

In the United States, we continue to have an average of 19 mass shootings per year (Everytown Research & Policy, 2022). Medical providers, especially Emergency Physicians, bear witness to the toll of mass shootings as we sit on the interface between the community and the hospital. As a result, it is important for us to understand the role of public policy in this epidemic.

Clinical Question: Do states with permissive gun laws have more mass shootings than states with restrictive gun laws?

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REBEL Core Cast – Basics of EM – Introduction

Written by EJ Wright, MD
This post first appeared on REBEL Cast

Welcome to the EMRA Basics of Emergency Medicine Podcast. I am your host EJ Wright, and the following series is an all encompassing approach to the most common chief complaints in the ED based on the well known EMRA Basics of Emergency Medicine, A Chief Complaint-Based Guide. Each cast will highlight myself and a guest attending physician as we take new learners through the differentials, red flags, physical exam findings, and a sample presentation that you need to know to treat patients in the ED.

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Massive Acetaminophen Overdose: Are We Giving Enough N-acetyl-cysteine?

Written by Christopher Hart, DO
This post first appeared on REBEL EM

Introduction: Acetaminophen, N-acetyl-p-aminophenol, or APAP, is one of the most commonly used medications worldwide. While it is generally safely used, overdose can result in the development of liver failure due to APAP’s hepatotoxic metabolites. Hepatic necrosis is preventable in overdose with timely administration of N-acetyl-cysteine (NAC) which restores glutathione reserves, allowing for safe excretion of these hepatotoxic metabolites. NAC use is based on plotting APAP levels, on the Rumack-Matthew nomogram.

Intravenous NAC therapy includes: 
1. An initial dose of 150 mg/kg over 1 hour, 
2. A second dose of 50 mg/kg over 4 hours, 
3. And a final infusion of 100 mg/kg over 16 hours.

However, it is unclear if this dosing regimen is adequate for the treatment of massive overdoses (>32g or concentrations >300 mcg/mL).

Clinical Question: Will increasing the third dose of IV NAC decrease the risk of hepatotoxicity in massive APAP overdose?

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Race Multiplier in the eGFR Equation: What’s the impact for African-Americans?

Written by Amanda Russo, DO
This post first appeared on REBEL EM

Background: Race is a sociological construct that affects how clinicians deliver health care to various racial/ethnic groups.  This in turn affects clinical outcomes.  Thus, African Americans with chronic kidney disease have worse outcomes with respect to hypertension control, timely nephrology referral, dialysis fistula/graft placement, adequate dialysis treatment, and access to transplantation. The precise reason for this difference is unclear but one proposed cause is the race multiplier term in estimated glomerular filtration rate (eGFR) equations.

The MDRD and CKD-EPI studies developed the equations most commonly used for eGFR in hospitals today. This article aims to illuminate how the race multiplier in the eGFR equations impacts care for African Americans with chronic kidney disease. 

Clinical Question: What is the impact of the race multiplier for African-Americans in the CKD-EPI eGFR equation on CKD classification and healthcare delivery?

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The INSPIRATION Trial: Intermediate Dose Anticoagulation in Critically Ill Patients with COVID-19

Written by Jessica DiPeri, MD
This post first appeared on REBEL EM

Background: COVID-19 infection increases the risk of thrombosis due to multiple factors. (Rico-Mesa, 2020). Over the last 2 years, researchers have published 12 RCTs investigating various anticoagulation strategies among patients diagnosed with COVID-19 in multiple clinical settings. To date, only a multiplatform trial in noncritically ill patients, the HEP-COVID trial, and the MICHELLE trial have shown a benefit.

Severely ill patients with COVID-19 in the intensive care setting have an increased risk of thromboembolism, with an incidence reported as high as 31% (Klok, 2020). It remains unclear what the optimal prophylactic anticoagulation strategy is in critically ill patients.

Does intermediate-dose anticoagulation improve clinical outcomes compared to standard prophylactic anticoagulation in patients with COVID-19 treated in the intensive care unit?

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