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.
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Cardiogenic Shock = a cardiac disorder that results in both clinical and biochemical evidence of sustained tissue hypoperfusion (1).
Cardiogenic shock has high mortality (approx 35-40% in many studies). Mortality worsens at higher stages of cardiogenic shock severity (2,3). Early recognition of cardiogenic shock is critical in order to initiate treatment and transfer patients to an appropriate level of care in a timely manner.
As an ED physician, you need to SUSPECT cardiogenic shock so that you can ensure appropriate definitive management of your patient (4).
SUSPECT = Symptoms/Signs; Urine Output; Sustained Hypotension; Perfusion; EKG/Echo; Congestion; Triage
Take a look at the Additional Materials to break down this mnemonic in more detail and learn what might make you SUSPECT CS!
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Bottom Line: Move over, post-partum hemorrhage, because cardiovascular causes reign supreme! In a new study based on CDC data from 2005-2024, cardiovascular causes were the number one cause of death in pregnancy overall (well, except for COVID…).
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There is increasing evidence that burning lithium-ion batteries produce hydrofluoric acid (HF) and other fluoridated compounds. HF is a weak acid and thus it can penetrate deeper into tissue before causing complications. HF exposure causes irritation to the mucosa/skin and leads to pain out of proportion to the appearance of the burn/exposure. These exposures present a unique risk to first responders and care should be taken to wear appropriate PPE during these events. Regular medical gloves do not protect from exposure. Respiratory protection must be worn to prevent inhalation. Click for treatment options.
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A retrospective analysis of a multicenter prospective cohort study evaluated the association between steroid administration, including hydrocortisone timing and dose, and mortality in patients with septic shock in the ED.
Study findings: Steroid use was associated with lower 28-day mortality (p = 0.001). This association remained in the vasopressin subgroup (p < 0.001) but not in patients who did not receive vasopressin (p = 0.769). A higher norepinephrine-equivalent dose at first steroid administration, a longer interval from first vasopressor initiation to first steroid administration, and hydrocortisone dosing > 300 mg/day were associated with increased mortality.
Bottom line: Steroid administration in the ED was associated with lower 28-day mortality among patients with septic shock, particularly those receiving vasopressin.
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Reducing 28-day all-cause mortality compared to conventional MAP management in sepsis patients requiring vasopressors after initial resuscitation.
- Cardiac output, MAP, and organ-specific vascular resistance determine organ perfusion.
- SEPSISPAM trial showed that a higher MAP reduced need for renal replacement therapy.
- An elevated Renal Resistive-Index (RRI) > 0.7 is associated with impaired perfusion, development of AKI, and increased MR.
- The kidney is a low vascular resistance organ sensitive to hypoperfusion in sepsis.
- 28-day all-cause MR and ventilator free days was decreased.
- RRI-guided MAP titration did not specifically decrease MR, incidence of AKI or need for CRRT.
- Although a pilot trial, this study lends credence to more individualized sepsis hemodynamic management and the need for a larger study.
- Use of RRI-guided MAP titration in sepsis may decrease overall 28-day MR.
- How to Guide. https://ultrasoundpaedia.com/renal-arteries-normal/
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Reminder that the Bova Score (2 points each for heart rate over 110, SBP less than 90, RV strain on CT or echo, and elevated troponin) along with an elevated lactate and BNP can help predict outcomes in hemodynamically stable PE patients.
"Low risk (score <2):
Proceed with standard anticoagulation therapy. Standard outpatient or inpatient monitoring, as appropriate.
Intermediate risk (score 3–4): Consider closer monitoring (e.g., stepdown/ICU). Discuss the possibility of advanced therapies (e.g., thrombolysis) in select cases, especially if clinical status worsens.
High risk (score >4): Maintain continuous ICU monitoring with a clear plan for rapid intervention if clinical status worsens (e.g., hypotension, worsening hypoxia, arrhythmias). Strongly consider multidisciplinary team involvement and potential advanced therapies (e.g., systemic thrombolysis or catheter-directed therapies)."
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A structured interview was conducted with families who had a loved one undergo a field terminated cardiac arrest in Denmark. What they found was pre-arrival instructions were very valued. And “After unsuccessful resuscitation, compassionate and unhurried communication was considered crucial.” I am sure this applies to prehospital and in hospital situations alike. Empathy and time are what these families need.
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BRACHA-S is a 5 item scoring tool that demonstrated moderate discrimination and identified clinically meaningful risk gradients for agitation requiring intervention (ARI) that may support early safety planning.
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Bottom Line:
Lead has no biologic role in the human body. Lead toxicity and accumulation in humans remains a major health concern. Children < 6 years old are especially vulnerable to lead poisoning. Lead is a potent neurotoxin and even low levels can cause irreversible harmful neurologic effects in children. Blood lead level of 3.5 µg/dL requires action in children.
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While many intubations in critically ill patients go smoothly, they are a high risk procedure that EM and ICU physicians seek to continuously improve upon. Blade size is one aspect of the procedure that has received attention over the past several years. We don’t have prospective trials addressing this question, but there are several retrospective analyses that have investigated it.
- For Direct Laryngoscopy:
- The 2022 MacSize-ICU study and a 2023 study by Landefeld and colleagues with the Pragmatic Critical Care Research Group suggested that when using Macintosh geometry blades for direct laryngoscopy there was improved first pass success with size 3 blade. Secondary outcomes for these studies point to a worse glottic view with a size 4 blade.
- For Video Laryngoscopy:
- This finding did not hold up in video laryngoscopy. A 2023 study by Park et al. and now a 2026 retrospective study again by Landefeld et al. that looked at blade size for video laryngoscopy with Macintosh geometry blades found no difference in first pass success with size 3 vs size 4 blades.
Bottom Line: Continue to use your best clinical judgment when selecting a blade size, especially when performing video laryngoscopy. When performing direct laryngoscopy, if you are on the fence, consider using size 3 blade.
*These studies do not address intubation with hyperangulated designs
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Bottom Line: Burn care is directed by the managing surgeons at regional burn centers. Where available, hyperbaric oxygen treatment can be a beneficial adjunct.
Studies and clinical experience of hyperbaric oxygen treatment in burns has shown modulation of burn shock, dampening of the inflammatory response, reduction of edema, reversal of the zone of stasis, reduction of ischemia and ischemic necrosis, prevention of progression of partial- to full-thickness injury, modulation of inflammation, effecting modulation of hyper-metabolic syndrome, lessening of the capillary leak, preservation of dermal elements, a reduced need for grafting, shortened hospital stay, reduced physiological post-discharge problems, and a reduction in cost of care.
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This secondary review of a prospective observational group of 1200 syncope/presyncope patients over age 40 found 5.6% experienced a significant adverse outcome within 30 days. These patients had no diagnosis after their ED evaluation. Their conclusion was admission to the hospital “increased the diagnostic yield for SAOs and accelerated time to diagnosis.”