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POCUS has moderate agreement with cardiology consultative echocardiography for RV strain in the setting of acute pulmonary embolism. Accuracy and agreement increase as the degree of RV dysfunction increases.
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This study looked at rate of administration and time difference between male and female patients presenting with cardiac chest pain receiving morphine.
While initially they found no difference, several confounders painted a different picture:
significant differences in door-to-doc times, higher vs lower triage level and decision to admit all had women at a disadvantage and after adjusting for those, also found a gender based difference , with men receiving morphine more frequently.
Another example of unconscious bias and gender bias we should all be more mindful of
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The PRoMPT BOLUS trial (Pragmatic Pediatric Trial of Balanced versus Normal Saline Fluid in Sepsis) is the largest randomized controlled trial to date comparing balanced crystalloids to 0.9% normal saline in children with septic shock. The primary outcome showed no significant difference in major adverse kidney events at 30 days between the two groups. The secondary outcome showed no significant difference in 30 or 90 day mortality.
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By William Zhu, MD
Centered in the midwestern U.S. and in 30+ states across the country, over 3,000 people have experienced unusually persistent bouts of diarrhea from the parasite cyclospora, according to data collected from the CDC and various state health departments as of July 13th 2026.
Cyclospora cayetanesis is a coccidian protozoa whose hosts are humans. Transmission occurs when contaminated food or water is consumed usually in the form of raw produce. Incubation period is around 1-2 weeks making source identification difficult. When a outbreak is detected, there are more infected than reported.
Symptoms are watery, sometimes explosive diarrhea, fatigue and myalgias. These symptoms may persist for weeks with a waxing-waning course.
Diagnosis requires stool PCR as stool ova parasite tests yield a high false negative rate due intermittent fecal shedding. If in doubt consult infectious disease. Keep other causes of diarrhea like C. Diff, Campylobacter Jejuni and E. Coli on the differential.
Treatment is supportive with correction of fluid loss and electrolyte derangements. Isolation not required as freshly excreted oocytes and not infectious for over a week. In healthy individuals the infection is typically self limiting.
Preferred antimicrobial agent is trimethoprim-sulfamethoxazole at 160mg TMP+800mg SMX BID for 7-10 days with most individuals experiencing symptom improvement and resolution around 2 days on therapy. Consider prolonged therapy for individuals with immunocompromise. For patients with sulfa allergies ciprofloxacin 500mg BID for 7 days then 3 times a week for 2 weeks is acceptable.
Prevention is centered on washing fresh produce, but cooking all fruits and veggies is the only definitive way to avoid infection as the parasite is resistant to municipal chlorination and conventional washing. Washing produce with soap is not recommended.
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This study by Peters et al. (2026), published in Prehospital Emergency Care, is the first nationwide analysis of cardiac arrest occurring during interfacility transport (IFT) by EMS, finding that critical care transport (CCT) was associated with more than double the odds of ROSC compared to ALS (aOR 2.21, 95% CI 1.42–3.48), while BLS care was associated with significantly worse outcomes.
Overall ROSC rate: 50.3% — broken down as 32.9% (BLS), 45.3% (ALS), and 59.5% (CCT)
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A good reminder to consider careful prescribing to older patients at the time of ED discharge.
From this study: “Nearly 1 in 10 older adults filled a high-risk GEMS-Rx medication within 3?days of ED discharge between 2017 and 2022. Despite a decline in GEMS-Rx medication fills over time, younger cohorts of older adults and females were more likely to fill a high-risk medication upon ED discharge.”
Click for Gems-RX list
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At tonight's quarterfinal, a player exhibits signs or symptoms of a possible concussion. How will they be evaluated on the pitch?
The Football-Specific Standardized On-Pitch Concussion Assessment Protocol (FOCUS) was published in July 2026 in JAMA Neurology.
It was developed through a FIFA-led international Delphi consensus process involving experts from all 6 football confederations.
The primary objective of FOCUS is not to diagnose concussion but to determine whether a player exhibits any signs or symptoms that raise suspicion and would require off pitch assessment.
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Low Magnesium in Children has a generally similar approach to adults, however the etiology may be different.
Children can present with low magnesium levels due to many causes including but not limited to renal wasting (which may be drug related), malnutrition, malabsorption, refeeding syndrome, short gut syndrome, or genetic mutations
Hypomagnesemia is often coupled with hypocalcemia or hypokalemia which can be refractory until the magnesium is replaced.
Symptoms may be vague particularly in younger patients, with neuromuscular irritability, though in extreme cases (typically <1.0mg/100ml) seizure activity may occur with severely low levels, and long QTc may cause dysrhythmia
Oral replacement can be used for asymptomatic patients with levels greater than 1.0 mg/100mL
PO replacement:
Goal of 10-20mg/kg/dose (Max 2 g) elemental Magnesium
Magnesium oxide is the most common replacement but does come in pill form and is given up to four times daily
IV replacement with Magnesium Sulfate (given over 2 -4 hours*):
Neonate: 25–50 mg/kg/dose every 8–12 hours
Child: 25–50 mg/kg/dose every 4–6 hours (maximum 2 g/dose)
*In patients with life threatening hypomagnesemia such as those with seizures, a 50mg/kg dose given over 1-5 minutes is warranted.
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Background: The 2020 ACLS algorithm for treatment of SVT recommends an initial adenosine dose of 6 mg, followed by 12 mg via rapid IV push if cardioversion is unsuccessful. Among more recent studies evaluating adenosine dosing, between 45% and 70% of patients required escalation to 12 mg to achieve successful cardioversion, suggesting that the standard 6 mg dose may not be effective for some patients. However, evidence evaluating the use of a 12 mg initial dose is limited.
Study design: Sert et al. conducted a prospective, single-center, observational study of 142 adult patients with SVT in a tertiary care emergency department in Turkey between February 2025 and January 2026. Patients received an initial dose of either 6 mg or 12 mg of adenosine (n=71 per group), selected at the discretion of the treating physician. Adenosine was administered using a proximal IV line using a T-connector or stopcock over 1-2 seconds. Patients with clinical signs of instability were excluded.
Results: More patients in the 12 mg group experienced first-dose conversion compared to the 6 mg group (83.1% vs. 52.1%, p <0.001). Results were consistent among a 1:1 propensity-matched cohort (n=104) adjusted for age, sex, and history of SVT (82.7% vs. 53.8%, p <0.001). Similar rates of adverse events such as chest tightness, flushing, and shortness of breath were observed between the two dosing groups.
Study limitations: Non-randomized design leaves potential for selection bias, results not adjusted for confounding factors such as quantified caffeine intake or absolute body weight, limited generalizability in settings where alternative methods of adenosine administration are used (i.e. single-syringe method), low sample size
Bottom line: This study adds to the growing body of evidence suggesting that an initial 12 mg dose of adenosine may be a safe and more effective alternative to the standard 6 mg dose.
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Intuitively, both younger and older patients would have better outcomes at level 1 vs level 3 centers. This was true in younger patients in this large trauma database study. It was only true for older patients with traumatic brain injury and a high injury severity score. Is this a function of care delivery being better at level 3 or less geriatric focus at level 1 trauma centers?
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University of Maryland Medical Center is a referral center for patients with necrotizing fasciitis in the region, as we have a major hyperbaric chamber, and a specialized Soft Tissue Surgery team. Therefore, patients with soft tissue infection make up a group with frequent transferring to UMMC.
Some of the factors, from recent meta-analysis, suggest higher rate of mortality among this particular group of patients. When they display these factors, which are also consistent with our clinical observations, we should be more aggressive with their treatment:
Acute kidney injury OR 3.23 (2.76–5.04)
Bacteremia OR 3.89 (1.39–10.85)
Hypotension OR 1.97 (1.26–3.10)
Coagulopathy OR 2.81 (1.23–6.40)
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Question
Pt with abdominal pain, nausea and vomiting. You ultrasound the intestines and find this:
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This study looking at older patient contact with the health system within 30 days of ED discharge found an overall lower rate of follow up for those patients with dementia. Perhaps extra care at time of discharge in arranging follow up is warranted for older dementia patients.
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This Canadian study found women, even when controlling for injury severity, socioeconomic conditions etc, were less likely to be admitted to a trauma center than their male counterparts. Further investigation into this bias is warranted.
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Lumbar puncture (LP) carries a relatively small risk of hemorrhagic complications, including traumatic tap (a lab finding) and spinal hematoma (an imaging finding).
In a cohort study of 83,000 LPs, the risk of spinal hematoma was not significantly increased in patients with documented coagulopathy (0.23% versus 0.20%), with coagulopathy defined by Plt < 150,000, INR > 1.4, aPTT > 39s.
Data on platelet transfusion and anticoagulant reversal prior to LP are limited to small retrospective cohort studies and case series. However, the limited data on this subject show no significant difference in major bleeding complications in patients who did or did not receive reversal prior to LP.
Although the risk of iatrogenic spinal hematoma may be low, current guidelines generally support the following practices:
- Plt < 50,000: Platelet transfusion is recommended prior to LP. Some studies suggest 40,000 is also a safe threshold.
- INR > 1.4: Consider correction with Vit K or PCC prior to LP
- aPTT > 40s: Consider correction based on cause (factor deficiency or heparin effect) prior to LP.
- Aspirin: Not considered a contraindication, no reversal needed
- DAPT: No clear guidelines. One small study demonstrated no increased risk of spinal hematoma.
- DOACs: Consider reversal if last dose < 24 hours and LP is emergently indicated.
- Resumption of AC: Generally considered safe after 12-24 hours if no evidence of bleeding or neurological complications.
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Bottom line: Start with X-ray to evaluate for retained stingray barb fragments. Remove foreign bodies with surgical consult as necessary.
Stingrays strikes represent one of the most common human envenomations from marine animals. Venom from these barbs causes immediate local pain and less commonly may cause a variety of systemic symptoms. Rarely are these primary effects life-threatening. A secondary risk, retained barb fragments can lead to complicated infections. Identification of retained fragments for removal is key. This study compared three radiology modalities on cadaveric limbs.
X-ray was associated with the highest sensitivity of 94% for the identification of a retained barb, followed by MRI (83%) and ultrasound (70%). MRI was associated with the highest specificity of 100%, followed by x-ray (98%) and ultrasound (73%).
Consideration must be given to individual sonographer skill level and difficulty variable with regional anatomy. Full article below is worth a look for comparison of images.
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These authors looked at outcomes related to patients who underwent prehospital cold water immersion for acute heat stroke in Phoenix. They found immersion dropped temperature and improved neurologic function. This is a great reminder to cool these patients as soon as possible and a prehospital cooling protocol is feasible and helpful.
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Should patients with mild cognitive impaired take glucosamine for their knee pain?
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This review article in the Journal of Trauma and Acute Care Surgery states:
“In obtunded patients, an adequate and normal high-quality CT supports collar removal without the need for adjunctive imaging.”