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.”
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Polyarticular joint pain and swelling. Is it gout?
Polyarticular initial attacks occur in roughly 3-14% of patients.
Bilateral gout is uncommon at presentation.
However, this presentation is more frequent with longstanding , poorly controlled disease.
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This study conclusion states: “Prehospital epinephrine administration in patients with traumatic cardiac arrest was associated with increased survival to hospital discharge and prehospital ROSC.” When you investigate the methods, only 809 of the 22,105 patients in traumatic cardiac arrest actually received epinephrine. In the study country, EMS gets orders from base station physicians for epinephrine. Why did these 809 get the epinephrine and the other 97% did not? It is hard to know what to do with this data. It certainly doesn’t say epinephrine saves patients in traumatic cardiac arrest. More research is needed.
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What is diagnostic excellence in the Emergency Department?
Based on a modified Delphi panel of 11 experts, these authors developed this definition:
“[T]he use of optimal, evidence-based practice to attain an accurate and timely explanation about a patient’s condition based on the information available at the time and communicate that explanation to the patient/family. Diagnostic excellence is patient-centered and equitable. Diagnostic excellence includes avoidance of divergent practices. It leads to better choices in management, prevents missed opportunities, and reduces the risk of preventable patient harm.”
Click below to find the definition of missed diagnostic opportunity. Go to the article https://www.annemergmed.com/article/S0196-0644(26)00247-7/fulltext to read more about the work.
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Severe Community Acquired Pneumonia (SCAP) is broadly defined as CAP that requires ICU admission. Although MRSA pneumonia is overall quite rare (1), it is associated with a high mortality rate. Therefore, empiric MRSA coverage is commonly used for patients with SCAP. Common empiric agents include vancomycin and linezolid. Linezolid has both pharmacologic and clinical data that suggest it may be a preferred option for many patients.
When approaching a patient with SCAP, a key consideration is whether empiric MRSA coverage is needed. Risk factors for MRSA pneumonia include prior MRSA infection or colonization, recurrent skin infections, post-influenza pneumonia, recent hospitalization or antibiotic use (1).
If empiric MRSA coverage is determined to be needed, Linezolid offers several advantages for the treatment of SCAP. Highlights below:
- Linezolid has 100% oral bioavailability which can be especially useful for those patients with difficult IV access
- Linezolid has better lung epithelial lining penetration compared to vancomycin (6)
- In direct comparison between linezolid and vancomycin for confirmed MRSA pneumonia, linezolid was shown to have improved microbiologic cure rates without an improvement in mortality (2, 7)
- Linezolid was shown to have less nephrotoxicity than vancomycin (2, 7)
Side effects to consider with linezolid include:
- Serotonin syndrome, although extremely rare (5). May consider discussion with your pharmacist if taking additional serotonergic agents.
- Myelosuppression (typically thrombocytopenia), although usually with longer treatment courses. This study shows no significant difference in rates of thrombocytopenia compared to vancomycin (4).
If providing linezolid for treatment of SCAP:
- Dose: Linezolid 600mg IV or PO q12 hours
- Ideally should obtain blood cultures, sputum culture, MRSA nares prior to (or closely following) antibiotic administration
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In a randomized pragmatic study of critically ill trauma patients, video laryngoscopy was successful in 88% of first pass attempts versus 68% in direct laryngoscopy.
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This Japanese hospital has a CT scanner hybrid resuscitation room. They did a retrospective study comparing their blunt trauma patients to a Japanese trauma database. Their patients had a shorter time to operative or interventional procedure, slightly less PRBC use over 24 hours and similar 24 hour mortality.
Interesting concept. Not ready for adoption.
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There is sound literature that older patients who board in the ED have higher rates of delirium, longer hospital stays, more complications and possibly higher mortality. Some institutions are starting to prioritize moving older patients upstairs ahead of others who may have been boarding longer in the ED. Hopefully some data will be out soon to see if this intuitive approach actually improves these outcomes.
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This multicenter, retrospective study used the Pediatric Health Information System database to examine TXA (Tranexamic acid) use for post tonsillectomy hemorrhage (PTH) across US children's hospitals, analyzing 19,572 ED encounters for PTH in children <18 years from 2016–2024. The study did not differentiate TXA by route of administration or doses.
TXA use is rapidly increasing but remains highly variable. Median annual TXA use rose dramatically from 0.0% in 2016 to 30.6% in 2024, yet individual hospital-level use ranged from 1.0% to 67.1%, reflecting a lack of standardized protocols and significant practice variation across institutions.
TXA was associated with reduced reoperation but not hospital admission. At the encounter level, TXA administration was associated with 34% lower adjusted odds of reoperation (aOR 0.66, 95% CI 0.56–0.77). However, there was no significant association with hospital admission (aOR 0.93, 95% CI 0.83–1.04).
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This South African study looked at 219 trauma patients who required damage control surgery and, not surprisingly, low GCS, low pH and elevated lactate all were independently associated with mortality.
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The STARS (Special Needs Tracking and Response System) program was started in 2014 to bridge gaps in caring for children with special health care needs in the prehospital setting.
Since its inception, it has evolved into a hospital based, physician lead program with individualized EMS care plans stored on an electronic server and accessible to units responding to these patients.
In addition to the development of patient specific plans that are not within the local EMS protocol, this program has led to targeted EMS training and improved interdisciplinary care coordination. This program has also shown a decrease in EMS transports to the hospital.
The program started with 14 patients in one EMS jurisdiction and has now expanded to 2424 patients across 3 states. As the program expands, there is an aim to expand these care plans to include disaster preparedness, such as back up plans for patients dependent on electricity and plans to access critical medications during emergencies.
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Acute Hypoxemic Respiratory Failure (AHRF) is very common in the ED/ICU. In this multicenter cohort of 21,714 patients in a Canadian ICU registry (iCORE) receiving oxygen or respiratory support, 50% met criteria for acute hypoxemic respiratory failure within 24 hours of ICU admission, and 76% of those patients required invasive mechanical ventilation.
- AHRF severity was categorized using the same Pao2/Fio2 thresholds as the Berlin definition for ARDS: mild (201–300), moderate (101–200), and severe (<100).
- When Pao2/Fio2 ratios were unavailable, severity was assigned using Spo2/Fio2 thresholds: mild (236–315), moderate (149–235), and severe (< 148). One-third of patients were actually classified this way.
PaO2/FiO2 remains the conventional standard and is important for ARDS severity/prognosis, but SpO2/FiO2 is noninvasive, continuous, inexpensive, and showed good agreement with PaO2/FiO2-based severity classification. According to these authors, SpO2/FiO2 can be a practical substitute for PaO2/FiO2 when an ABG is unavailable.
- Important limitations are the reduced accuracy of SpO2 at high saturations and potential pulse-oximetry bias, including overestimation of oxygenation in patients with darker skin tones.
Worsened hypoxemia strongly tracked with worse outcomes. ICU mortality increased from 17% in mild AHRF to 26% in moderate and 44% in severe AHRF; severe disease was also associated with fewer ventilator-free days and a lower probability of ICU discharge.
- AHRF patients were often treated using ARDS-style lung-protective ventilation. Median tidal volume was about 6.5 mL/kg predicted body weight, and most measured plateau/driving pressures were within protective ranges. However, plateau pressure was infrequently documented.
- Among patients with severe AHRF, 26% received neuromuscular blockade, 13% received prone positioning, 12% received iNO, and 12% received ECLS within the first 30 days of ICU admission..
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Question
The construction worker presents to the ED with this rash. What is it and what is the treatment?
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A new study evaluated the number of medication administrations (surrogate for nursing time) for patients with severe alcohol withdrawal and found that patients who were treated with phenobarbital required fewer repeat medication administrations within the first 3 and 6h of ED arrival. Patients were included if they received at least 100mg diazepam or 260mg phenobarbital and approximately 30% had documented alcohol withdrawal delirium in the ED. There were no differences in safety outcomes or intubations. Patients who received phenobarbital were also less likely to require ICU admission.
Phenobarbital's impact on nursing time is an important consideration as we continue to experience delays, overcrowding and boarding in the emergency department.
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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.