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Evaluation of non-fatal strangulation patients with these signs is a CT angiogram of the neck.
Also note that this is a common finding in domestic violence and is a predictor of future injury and death from this partner.
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This South African study looked at 194 hanging or strangulation injury patients and found that no clinical feature excluded blunt cerebral vascular injury (BCVI) in these patients. Nearly 5% of these patients had BCVI. The authors concluded the only safe way to exclude BCVI in post hanging/strangulation injury was CT angiography of the neck.
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Bottom line: Consider low dose CT in children with concern for aspiration events
Pediatric foreign body aspiration can be a challenge. The patient obvious airway obstruction is clear, but what to do in patients who choked and are stable? Old convention used bilateral decubitus chest X-rays for evaluation for air trapping, and if positive consider scoping. More recent literature suggests that low dose CT may be more optimal for assessment of foreign body. It has similar (and in some cases less) total radiation exposure for children, shortens length of stay, and can prevent the unnecessary bronchoscopy of patients- removing the risks of the procedure and the sedation. For patients in community EDs, this may also prevent unnecessary and costly transfers.
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In this retrospective study of 4635 patients, continuing oral beta blocker within 48 hours of presentation for patients with sepsis was associated with a reduced risk of all-cause mortality within 90 days of hospital admission (hazard ratio 0.77; 95% CI, 0.61–0.98; p = 0.03), and a shorter hospital stay (incidence rate ratio 0.39; 95% CI, 0.38–0.41; p < 0.001).
Therefore, it is reasonable to consider Beta-blocker if patients are adequately resuscitated.
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Attachments
Emergency Physicians have a high specificity and moderate sensitivity for detecting cholecystitis with point-of-care ultrasound.
Signs of Cholecystitis on Ultrasound include:
- Sonographic Murphy's sign = The patient has pain when the ultrasound probe is directed over the gallbladder and compressed
- Pericholecystic Fluid = Fluid around the gallbladder
- Increased Gallbladder Wall Thickness = A wall thickness > 3 mm measured on the anterior gallbladder wall
- Most patients will have gallstones. Acalculus cholecystitis can occur with patients who are chronically ill, critically ill, on TPN or immunocompromised.
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How well do the Denver and Memphis screening criteria identify blunt cerebral vascular injury?
From 2021:
Not very well! Blunt injury to the head and neck may be enough to prompt you to order a CTA of the neck.
Click to see Memphis criteria which overlap Denver
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One-liner
A large prospective PECARN study developed and validated a highly sensitive clinical prediction rule to safely reduce unnecessary cervical spine imaging in children with blunt trauma.
Background: Pediatric cervical spine injury (CSI) is rare (<1% of blunt trauma), but missing an injury has devastating consequences. Existing adult rules (NEXUS, Canadian C-Spine Rule) are not well validated in children.
Methods: This multicenter prospective observational study enrolled over 22,000 children with blunt trauma across PECARN hospitals. Investigators identified clinical variables associated with CSI and derived a risk-stratification rule.
Results: The rule demonstrated very high sensitivity (~94%) and an extremely high negative predictive value (>99.9%) for clinically significant CSI. High-risk factors (e.g., GCS 3–8, focal neurologic deficits) warrant CT, whereas intermediate-risk factors may be evaluated with plain radiographs. Children without identified risk factors generally do not require imaging.
Limitations: Observational derivation/validation study rather than an interventional trial. Clinical judgment remains important in atypical presentations.
Clinical Relevance: This is likely to become the pediatric equivalent of the PECARN head trauma rule and should reduce unnecessary CT imaging while maintaining patient safety.
Take-home Points
- First large, validated pediatric-specific CSI rule.
- Helps identify children who require CT versus radiographs versus no imaging.
- Expected to reduce radiation exposure.
- May become the new standard for pediatric cervical spine evaluation.
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Metformin, a biguanide, is the most widely used and recommended first line treatment for type 2 diabetes due to its efficacy and low hypoglycemic risk. It's mechanisms of action include inhibition of mitochondrial complex I electron transport and oxidative phosphorylation (causing inhibition of hepatic gluconeogenesis and increases insulin sensitivity) and decreased intestinal absorption of glucose. It does not stimulate pancreatic insulin secretion so does not cause hypoglycemia even in overdose (except in massive dosages > 60 grams and rare cases).
Metformin’s most serious toxicity is due to lactic acidosis. Metformin associated lactic acidosis (MALA) is a rare but life-threatening condition with incidence of 1 in 30,0000 and high mortality rate of 30-50%. Lactic acidosis can occur in both acute overdose and chronic therapeutic use in predisposed individuals. MALA is a serious condition with that requires early recognition and aggressive treatment to increase survival and should be considered in all patients on metformin who present with lactic acidosis.
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Background: The 2025 AHA guidelines changed their recommended initial IV atropine dose for unstable bradycardia from 0.5 mg to 1.0 mg, while the 2025 ERC guidelines continue to recommend an initial dose of 0.5 mg. A 2025 review found limited comparative studies and noted that using 0.5 mg as an initial dose seems “clinically reasonable" [1].
Now: One tertiary care center performed a retrospective propensity-score matched study [2] comparing the 2 groups of patients with unstable bradycardia who had received an initial dose of 0.5 mg versus 1 mg in their ED between 2020 and 2025.
- Primary outcome = First-Dose Success (reaching a heart rate >50 bpm within 3 minutes without additional therapy).
- Notably excluded were patients with noncardiac secondary bradycardia (hyperkalemia, drowning, trauma, etc.) and those with pacemaker failure, amongst others.
Results in the propensity score-matched cohort:
- First-dose success was significantly higher in the 1.0 mg vs the 0.5 mg group (45 vs 25%; p=0.007)
- NNT of 6 (95% CI, 3-18)
- The 1.0 mg group had lower rates of:
- Additional atropine requirement (26 vs 48%, p=0.003)
- Other rescue therapy requirement (51% vs 74%, p=0.002)
- ICU admission (53% vs 74%, p=0.005).
- No difference between groups in 30-day mortality or subsequent permanent pacemaker placement
Bottom Line: Acknowledging the small size & retrospective nature of the study, it appears that an initial dose of 1mg IV atropine helps us work smarter--not harder--in the stabilization of patients with unstable bradycardia.
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Naltrexone, an opioid antagonist, is an FDA-approved first-line medication for alcohol use disorder. It is available as a daily oral formulation or a monthly extended-release intramuscular injection. Naltrexone does not treat acute alcohol withdrawal; instead, it is used to reduce cravings, heavy drinking, and support abstinence. Patients can continue to drink while taking it without a disulfiram-like reaction. Common adverse effects include self-limited nausea, headache, and insomnia. It is contraindicated in patients with current opioid use, acute hepatitis, or liver failure.
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This institution implemented universal CTA of the neck to evaluate cerebral vascular injury in blunt trauma patients. In the 531 patients, 6% had cerebral vascular injury and 23% had incidental findings of which 22% required follow up. Another example of a test ordered has potential unanticipated downstream effect.
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Anterior shoulder dislocations are commonly seen during an ED shift.
During a busy shift, the choice of analgesia may be a strong consideration.
Analgesia for reduction can be provided by intra-articular lidocaine injection or intravenous sedation among other options.
How do these 2 analgesic options compare?
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The emergency department may be the only point of access to the health care system for migrants. As emergency physicians, we face the challenge of balancing our ethical obligations to our patients with our responsibilities to employers, the government, and/or law enforcement. In consideration of the mandate of EMTALA and this complex role within an evolving political landscape, this publication offers four principles to guide best practices when caring for migration-affected patients in the ED.
Click the link to review these four principles which focus on ensuring equitable care for all migration-affected patients.
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Question
The following is an actual case.
An ED patient without any history of asthma or COPD is intubated to facilitate an emergent MRI. After the MRI is completed (and without abnormalities). The patient is breathing synchronously and comfortably on minimal PS settings. Further sedation is weaned to facilitate extubation in the ED as the patient has no need for continued mechanical ventilation and no ICU requirements. All of a sudden, you are emergently called overhead to the patient's room because the patient is “blue” and hypoxic.
These are the ventilator waveforms.
The patient did not receive any contrast or bronchospastic medications. The ETT is clear and without obstruction.
What is going on?
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This commentary points out the missed opportunity to improve chronic hypertension care in the ED. A substantial number of patients seeking care for asymptomatic hypertension and an even larger cohort seen for other complaints who are also chronically untreated hypertensives leave the ED without a prescription for antihypertensives. ACEP and AHA say we should be treating these people and arranging follow up.
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This small qualitative study demonstrated that representation and hearing from other URiM residents is an important factor in recruitment during EM residency application.
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This was a retrospective review of children < 18 years who presented to the pediatric emergency department with torticollis in a single center over a 6 year period.
Clinically significant underlying etiologies included infection, tumor, or atlantoaxial rotary fixation requiring surgery (AARF).
352 children with a median age of 4.8 years presented with torticollis and 59 were found to have a significant underlying etiology.
Children with infectious causes were younger and more likely to be febrile and have an elevated CRP. Infections included retropharyngeal abscess, lymphadenitis and cervical spine osteomyelitis. AARF was associated with prolonged symptoms, older age, midline tenderness and restricted motion. Tumor related cases often featured additional red flag symptoms such as headache and vomiting and symptom duration ranging from 5 days to 3 months.
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This case report describes a 2 week delayed hemorrhage from a lacerated profunda femoris artery after an intertrochanteric fracture that requires ORIF. The patient represented with anemia, pain and swelling in the surgically repaired hip. Pulses were still present. The authors conclude:
“The profunda femoris artery is the vessel most commonly involved in vascular complications associated with proximal femoral fractures because of its close anatomical relationship with the lesser trochanter. Delayed presentations may occur weeks after injury as repeated mechanical irritation from a displaced bone fragment leads to pseudoaneurysm formation and subsequent rupture.”
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The national cardiac arrest registry includes information on bystander CPR. An EMS clinician currently enters bystander CPR (B-CPR) information into the prehospital care report. The accuracy of this documentation has not been validated. This study compared EMS documented B-CPR rates to the bystander CPR rates on the 911 audio recordings of the calls in Birmingham Alabama.