The 2025 American Headache Society guidelines give the greater occipital nerve (GON) block a level A recommendation for ED migraine treatment, boldly calling it a “must offer” therapy for migraine patients requiring parenteral treatment.
- Mechanism:
- The GON, a branch of the C2 spinal nerve, innervates the posterior scalp and converges with trigeminal afferents at the C2 dorsal horn. Blocking the GON dampens trigeminal signaling at this convergence point, reducing acute migraine pain. Since central sensitization drives migraine chronicity, benefits often outlast the local anesthetic, persisting for weeks to months.
- Efficacy:
- A meta-analysis of over 400 patients showed a mean reduction of 3.6 headache days/month and lower pain severity scores versus controls, with greater benefit from scheduled, recurring blocks. For acute migraine, one large study found 82% of patients reported moderate-to-significant relief.
- How to:
- Positioning:
- Seat the patient with the head flexed slightly forward. Avoid any lateral or rotational movement, which may distort landmarks.
- Landmark-based:
- Palpate the external occipital protuberance and mastoid process. The GON runs about one-third of the distance (2-4 cm) between them, just medial to the occipital artery (which is often palpable). Prep the skin, advance the needle while aspirating until you hit bone, withdraw slightly, then inject 1-3 mL of 1% lidocaine or 0.5% bupivacaine with a fanning technique.
- Ultrasound-guided (more precise):
- Place a linear probe with sterile cover transversely over the occipital protuberance, then slide down to the C2 spinous process, which has a characteristic bifid appearance. Moving laterally from here, identify the GON between the semispinalis capitis and obliquus capitis inferior fascial plane, medial to the occipital artery (consider color Doppler to confirm). Inject 1-3 mL of anesthetic into this fascial plane, avoiding injection into the nerve fascicles themselves.
- Adjuncts?
- Dexamethasone mixed with local anesthetic has evidence of benefit with cervicogenic headache and occipital neuralgia, but has no proven added benefit for migraine specifically.
- Positioning:
Bottom Line: Consider adding the GON block to your toolkit for migraine treatment in the ED.
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Rarely do more than a few months go by without us posting yet another pearl about the dangers of hypoxemia or hyperoxemia. The data in general is strong that patients with significant exposure to either very high or very low oxygen levels do worse than patients with normoxia. But if the first step intervention is simple – if the SpO2/PaO2 is high, turn the oxygen support down, and if the SpO2/PaO2 is low, turn the oxygen support up - then in this day and age can we improve this with a closed-loop system? Click the Additional Information to find out!
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…Which we knew already, but in case you need help convincing your patients, this meta-analysis came out just a few months ago and looked at 43 different studies in a systematic review (17 in a meta-analysis) totaling >300000 patients evaluated and showed that there is NO association between acetaminophen/paracetamol in pregnancy and autism/ADHD/intellectual disabilities.
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These authors used a database of 323 hospitals to find over 20,000 firearm injured patients. They looked at positive cultures to assess for post injury infection. Infection rate was 5%. Most infections were in the immediate post injury period. Those with surgical procedures on head, neck, lower abdomen, and spine were most likely to develop infection. Infection did not appear to be associated with increased mortality. Current guidelines recommend antibiotics for the first 24 hours post injury only.
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Bottom Line
This trial showed that the percentage of mechanically ventilated patient post arrest who received conservative oxygen therapy (SaO2 90-95%) with favorable neurological outcomes was not significantly different compared to the percentage of patients who received liberal oxygen therapy (minimum FiO2 of 0.3, SaO2 > 90%). While avoiding hypoxemia along with hypercapnia remains a hallmark of post arrest care, exact oxygenation goals above SaO2 of 90% remain unclear.
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One-liner:
Point-of-care ultrasound was noninferior to radiographs for diagnosing distal forearm buckle fractures while improving patient experience.
Summary:
Background: Distal forearm buckle fractures are among the most common pediatric fractures and are often straightforward to diagnose.
Methods: Multicenter randomized trial comparing ultrasound-first evaluation with conventional radiography (n=270).
Results: Ultrasound accurately diagnosed buckle fractures with similar clinical outcomes. Families reported greater satisfaction, ED length of stay decreased, and radiation exposure was avoided.
Limitations: Requires physician ultrasound training. Results apply primarily to uncomplicated distal forearm injuries.
Clinical Relevance: Supports expanding POCUS use for selected pediatric orthopedic injuries and reducing unnecessary radiographs.
Take-home Points:
POCUS is an effective first-line imaging modality, ideal for experienced ultrasound users.
Shorter ED stays.
Eliminates radiation.
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Looking at a national EMS database, these authors found advanced airway management (intubation, cricothyrotomy, rescue devices) occurred in 4/1000 trauma patients. Firearm related injury and motorcycle crashes had the highest use rate. Firearm related injury had the highest use rate of cricothyrotomy. This data should help drive prehospital education.
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Bottom Line:
The most effective treatment for snake bite envenomation is prompt administration of antivenom which neutralizes venom toxins. Early administration has been shown to improve clinical outcomes by stopping progression of venom effects however it cannot reverse tissue injury that has already occurred making early treatment critical. The potential risk of causing an adverse reactions in non-envenomated patients must be weighed against the benefit of giving antivenom early in patients with significant envenomation.
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This single center study at an academic center compared pre and post provider in triage implementation radiology ordering rate. They found higher CT utilization and lower positive CT findings in the post implementation period. Further work is needed, however is provider in triage good medicine or good for metric numbers?
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In 2023 there was a similar Canadian wildfire smoke pollution issue in the United States as there was in July 2026. The CDC found:
“Emergency department visits for asthma were 17% higher than expected during 19 days of wildfire smoke that occurred during April–August 2023.”
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The US FDA has approved the first freeze dried plasma. It is stored at room temperature in plastic bags which makes it ideal for austere environments. It is easily reconstituted and is given to patients who require plasma, bypassing the need to thaw FFP.
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Bottom Line: In patients with acute ischemic stroke due to medium or distal vessel occlusion, mechanical thrombectomy did not improve functional outcomes at 3 months and was associated with an increased risk of symptomatic intracranial hemorrhage.
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This single center study asked patients about barriers to health carrier after ED discharge (example transportation, lack of PCP, inability afford medications, trouble with ADLs) and then surveyed EM residents about those same patients' barriers. Resident physicians way under perceived barriers to care in their patients. ("20.4% of patients reported they had no primary care physician (PCP) and 9.8% of residents reported their patient had no PCP . Limited health literacy was identified in 59.0% of patients and reported by 37.6% of residents . Abnormal cognition was present in 53.6% of adults age ??65 and reported by 16.7% of residents .")
Another example of if you do not ask, you will not know. Be careful of assumptions.
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This Canadian study looking at older patients presenting to EDs with suicidal ideation or attempt found most were female, arrived by ambulance from home, had poor social determinates of health, had a mental health history and attempts were by poisoning. Similar risk factors to other age groups. Mental health conditions donot tend to improve with age.
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The common teaching that “the key to diagnosis is in the HPI” holds true for many of the patients we care for in the ED.
But, what if ChatGPT was tasked with obtaining the initial HPI rather than the provider? How accurate/reliable can a ChatGPT-driven history prove to the physician, or seem to the patient?
Researchers in the field of AI applications are beginning to tackle these questions as emergency departments pilot AI-driven history platforms to leverage time spent in the waiting room with a goal of improving efficiency and provider workload. What do you think?
Click the link to see a summary of some interesting findings in this pilot study conducted in a large urban pediatric ED waiting room.
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A multicenter double-blind RCT published in 2025 found that adult patients hospitalized with acute chest syndrome (ACS) who received 7 days of prophylactic therapeutic anticoagulation had a shorter time to ACS resolution (by approx 1 day) and reduced opioid consumption when compared to those receiving standard VTE prophylaxis.
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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.