You've encountered it at ABEM General Hospital, but now a SCUBA diver actually comes into your ED and you're concerned for DCS. What next?
Evaluation:
Symptom nature and timing are key in detailed history. Transient neurocognitive symptoms at depth suggest nitrogen narcosis or oxygen toxicity. Neurological symptoms within 10 minutes of surfacing suggest AGE. Widely variable symptoms within 24 hours of surfacing suggest DCS. Symptom onset greater than 24 hours suggests alternative diagnosis (still discuss with Hyperbaric Medicine or DAN).
Thorough physical exam. DCS may manifest only as localized pain. Look for marine envenomation or trauma to the area.
Neurological exam including detailed sensation and ataxia/balance - get the patient on their feet!
Unbiased differential. E.g. DCS may cause chest pain or SOB, but divers still have heart attacks. SCUBA setting may raise alert for AGE, but divers still have strokes. People go to the tropics to dive, but they also eat local fish (Scombroid and Ciguatera for a future pearl).
Management:
Early consult to Hyperbaric Medicine. In settings with no such team available, a good resource is the Divers Alert Network (DAN) Emergency Hotline at 1-919-684-9111
100% O2 via NRB or highest available delivery. You're not titrating to spO2, you're creating a diffusion gradient for tissue inert gas washout.
IV access and isotonic Fluids. PO if tolerable and unable to obtain IV access.
NSAIDs unless otherwise contraindicated. No special regimen. Standard dosing Ibuprofen or Naproxen are fine. Toradol is ok if limitations to PO.
Horizontal positioning in bed for AGE. Trendelenburg is not recommended.
Manage end organ effects as applicable. E.g. Spinal DCS may yield bladder retention requiring foley
Give consideration to activity specific considerations: hypothermia, restrictive clothing, etc
IV lidocaine has mixed evidence for neuroprotection in AGE. Discuss with Hyperbaricist before starting.
Pre-hospital considerations:
Transport should occur via ground or pressurized air transit capable of 1.0 ATA (sea level) cabin pressure. If non-pressurized aircraft transport is absolutely necessary, maintain continuous oxygen supplementation and altitude less than 2000 feet. This also applies to the inter-hospital setting.
O2 delivery by best means available to include SCUBA regulator mouthpiece or even a rebreather apparatus if present.
PO fluids if tolerable and no IV available.
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While this study is imperfect and may not be measuring patient important outcomes, it does fit with other literature on the topic of intensive blood pressure control in patients with acute ischemic stroke. These patients were randomized to aggressive blood pressure control (SBP 130-140 within 1 hour of TPA administration continued for 72 hours) or the standard SBP <180. Repeat imaging was performed to assess the degree of cerebral swelling that each group developed. There was no difference in swelling between the two groups.
Take away is aggressive blood pressure management in this group of ischemic stroke patients does not seem to be beneficial.
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Have you tried using Large Language Model (LLM) driven searches in clinical practice, for example, OpenEvidence, ChatGPT, or Claude?
A recent paper, far from medicine, argues that LLM searching has changed the way we think about search and what we expect from search.
We have moved from searching for sources to searching for the information contained within sources. With this, our expectations have changed – we expect search to provide answers, not documents.
With this shift, the foundations of trust have shifted. Rather than finding a document that provides the answer, and which is supported by the integrity of the authors and publishers – and which the reader can evaluate – LLMs provide an answer, often with little evidentiary base to support that answer.
Some LLMs do a better job of referencing sources in support of their answers than others. This argument suggests how important such transparency can be.
Find the full conversation here, https://publicera.kb.se/ir/article/view/52258, in Sundin O, Theorising notions of searching, (re)sources and evaluation in the light of generative AI, Information Research 2025, vol 30.
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This editorial reminds us about the use of frailty measures in the geriatric population.
The authors write that frailty “describes a state of vulnerability causing an impaired ability to maintain homeostasis due to reduced physiologic reserve. Frailty is associated with disability, multimorbidity, cognitive impairment, institutionalization, and mortality. **Analogous to troponin testing, frailty assessment has been used to risk stratify older adults.**”
They also remind us that frailty is a syndrome not a disease in and of itself. It impacts how disease affects the patient and should inform our care, but not generate ageism or therapeutic nihilism.
Once frailty is identified, it allows for further assessment looking at the “Geriatric 5M's framework: Mind, Mobility, Medications, Multicomplexity, and Matters Most.”
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Predicting NIV Failure
- Noninvasive ventilation (NIV) is often used in the resuscitation of critically ill patients with acute hypoxemic or hypercapnic respiratory failure.
- Given the frequency of its use in both EDs and ICUs, it is important to recognize NIV failure and when patients should undergo intubation and initiation of mechanical ventilation.
- Patients should be re-evaluated within approximately 60 minutes of initiation of NIV.
- The HACOR score is a risk scoring tool comprised of heart rate, acidosis, consciousness, oxygenation, and respiratory rate and can be used to detect NIV failure in the hypoxemic patient.
- Consider intubation in a patient with a HACOR score > 5 at 1-2 hours after NIV initiation.
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In this retrospective study at 103 hospitals of patients over age 65 who received a head CT:
5948 total patients
3177 (53%) were on at least one anti-thrombotic (warfarin, direct oral anticoag, or anti-platelet agent)
781 (13%) had inter cranial hemorrhage. (ICH)
No form of AC showed an increased risk of ICH.
Risk factors for ICH were: “a high-level fall, a Glasgow coma scale of 14, a cutaneous head impact , vomiting, amnesia, a suspected skull vault fracture or of facial bones fracture”
To me this really begs the question are we ordering head CTs on the right patients? Was there any indication of head injury in these patients or did the mere presence of a patient on AC prompt the imaging order? More work should be done to prevent needless imaging cost, patient time in the emergency department and radiologist work load/turn around time.
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Question
Over 300 ml of blood on a chest CT in a traumatically injured patient requires a tube thoracostomy. How do you calculate 300 ml of blood on a chest CT?
Show Answer
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As emergency clinicians, we frequently encounter patients from diverse cultural and religious backgrounds, including a growing Muslim population. This guide outlines key pharmacological considerations when caring for Muslim patients, focusing on the presence of alcohol and porcine-derived gelatin in commonly prescribed medications, two ingredients that may conflict with Islamic beliefs. Drawing from real cases and institutional data at Jefferson Health, the authors highlight how such conflicts can lead to medication refusal, delays in care, and decreased adherence.
The article presents a practical and EM-friendly framework for identifying potentially problematic ingredients using tools like the FDA’s National Drug Code (NDC) and the DailyMed database. It also offers substitution strategies and highlights that alternatives often exist, such as switching from suspensions to tablets or selecting alcohol-free formulations. Importantly, the authors explore the Islamic principles of necessity (darura) and transformation (istihalah), which allow for flexibility in life-saving situations. By integrating cultural awareness into our prescribing habits and leveraging simple EHR strategies, such as tagging “pork” as an allergy to trigger alerts, we can provide more inclusive, respectful, and effective care in the ED without adding significant burden to clinical workflows.
Attachments
Unplanned extubation (UE) occurs in 0-25 % of patients intubated in the prehospital setting and transfer of patient care is one time where UE can occur. This EMS jurisdiction wanted to improve the rate of communication and confirmation of tube placement at the time of patient transfer. Over 5 months, the jurisdiction introduced 1) memorandums to paramedics, ED chiefs and respiratory therapist leads, 2) individualized paramedic feedback emails and 3) PCR changes that resulted in documentation of tube placement at transfer of care being a mandatory field.
Initially the rate of verbal ETT position at transfer of care was 74%. This increased to > 90% after 8 weeks. The rate of UE was 2/340 patients. The implementation of this project showed improvements in perceived accountability, interprofessional relationships and satisfaction with interventions that were noted in the post project focus group.
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Norepinephrine (NE) is widely accepted as the first-line vasopressor for the management of septic shock, supported by the Surviving Sepsis Guidelines (1). The use of vasopressin as a second-line agent is also supported by the Surviving Sepsis Campaign, although the appropriate “triggers” for its addition remain vague. The SSG recommend adding vasopressin when NE infusion rates reach 0.25-0.6 mcg/kg/min, citing a catecholamine-sparing effect and potentially improved mortality (1, 2, 3).
What’s New?
The OVISS study (“Optimal vasopressin initiation in septic shock. The OVISS reinforcement learning study”) used machine learning to derive and internally validate a set of rules guiding the addition of vasopressin to NE for patients with septic shock using multiple databases of patient encounters across multiple institutions (4).
The machine learning model suggested initiation of vasopressin in more patients (87% vs 31%), earlier, and in less sick patients than was seen to be common practice:
- Timing: 4h after diagnosis of shock (vs. 5h)
- NE dose: 0.2 mcg/kg/min (vs. 0.37mcg/kg/min)
- Serum lactate: 2.5 mmol/L (vs. 3.6 mmol/L)
- SOFA score: 7 (vs. 9)
Practice consistent with the above triggers was associated with decreased odds of in-hospital mortality (AOR 0.81, 95% CI 0.73-0.91).
Limitations
This was not a prospective study or RCT and was only internally validated. Using databases may limit the number of clinical variables available for analysis, and clinical judgment (how the patient looks) is not reflected.
Bottom Line
Consider adding vasopressin for patients with vasodilatory shock with low MAP despite NE >0.2mcg/kg/min and adequate fluid resuscitation, though more evidence is needed for a strong recommendation. As dual-pressor therapy may be riskier via peripheral IV and vasopressin does not have a direct antidote for extravasation, consider central line placement when adding vasopressin (5,6)
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This review article answers the basic question: when does a traumatic pneumothorax require tube thoracostomy?
“A pneumothorax greater than 20% of the thoracic volume on chest x-ray or greater than 35 mm on CT, measured radially from the chest wall to the lung parenchyma, should be treated with tube thoracostomy. Pneumothoraces smaller than this may be observed; approximately 10% of these will fail observation and require tube thoracostomy treatment.”
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The first attempt success rates for neonatal intubation is less than 50%. Video laryngoscopy (VL) has been shown to improve state first pass success compared to direct laryngoscopy (DL) in both children and adults, but few studies have looked at the neonatal population.
This study was a randomized control trial. There was a 74% first pass success rate for VL compared to a 45% first pass success rate for DL. There were no differences in secondary outcomes which include hypoxia, bradycardia, epinephrine administration, oral trauma and correct positioning.
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There are various reasons to give corticosteroids in the emergency department. Many decisions regarding IV vs PO, and the numerous available products can lead to excessive dosing (such as 125mg methylprednisolone). Below is a reference for the most common indications as well as conversion recommendations for each product
Guideline Recommended Dosing for Common ED Indications:
- COPD: 40 mg of prednisone x 5 days
- Asthma: 50 mg prednisone or 200 mg hydrocortisone divided x 5 days
- Anaphylaxis: consider 80 – 125mg methylprednisolone, 60 mg prednisone
- Sepsis: 200mg hydrocortisone divided--50 mg q6h or continuous infusion
Take-away: Methylprednisolone 125mg is frequently requested but provides a dose equivalent to prednisone 150mg. Consider guideline directed dosing and conversion of products to prevent excessive initial steroid dosing.
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Most of us are probably familiar with the PECARN Algorithm for neuroimaging in pediatric head trauma. But fewer people are familiar with the PECARN Pediatric Intra-Abdominal Injury (IAI) Algorithm.
Inclusion criteria can be found in the original study, referenced below
The original study collected data from 20 studies, and found that CT imaging can be avoided (ie patients are at very low risk for IAI) if the following criteria are met:
-No visible abdominal wall trauma or seatbelt sign
-GCS > 13
-No abdominal tenderness
-No thoracic wall trauma
-No abdominal pain
-No decreased breath sounds
-No vomiting
In the original cohort, 42% of study participants met all of these criteria and the risk of IAI requiring intervention was 0.1%
This study has been validated multiple times since its introduction in 2012, with the most recent being a multicenter study published in the Lancet in 2024. This recent study looked at 7542 children with blunt abdominal trauma, and the IAI rule was fond to have a sensitivity of 100% (95% CI 98-100%) and a negative predictive value (NPV) of 100% (95% CI 99.9-100%).
I know, it seems too good to be true…but the takeaway is that these clinical decision making rules can be more reliable than clinical gestalt in the appropriate patient population.
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The concept of positioning the head of bed flat in a patient with a neurologic catastrophe seems like a recipe for badness. For most neurologic emergencies, elevating the head of the bed (HOB) to 30° is standard to help control intracranial pressure and reduce aspiration risk. However, emerging evidence indicates that acute large vessel occlusion (LVO) stroke patients—particularly before thrombectomy—may be an important exception.
The ZODIAC trial, published in June of this year, was a prospective, randomized, multicenter study comparing 0° (flat) versus 30° HOB positioning in patients with confirmed LVO stroke awaiting endovascular thrombectomy. The rationale stems from physiologic studies, including transcranial Doppler ultrasonography, showing that flat positioning can improve cerebral perfusion to ischemic tissue.
The primary outcome was early neurologic deterioration (>2-point worsening in NIHSS prior to thrombectomy). Safety endpoints included hospital-acquired pneumonia and all-cause mortality at 3 months.
In the trial’s 92 enrolled patients, flat positioning markedly reduced early neurologic deterioration, which occurred in 2.2% in the 0° group versus 55.3% in the 30° group. There were no significant differences in pneumonia or 3-month all-cause mortality. The authors also found a statistically insignificant improvement in 90-day functional outcomes in the 0° group. Due to the magnitude of benefit, the study was stopped early at interim analysis.
This technique represents a simple, cost-free, and practical method of preventing neurologic decline ahead of definitive management for LVO. This may be especially beneficial for LVO patients who require interhospital transfer to a thrombectomy-capable center.
Bottom Line: For patients with LVO stroke awaiting thrombectomy, flat (0°) head positioning is safe and significantly reduces early neurologic decline by improving blood flow to ischemic brain tissue.
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Whether you agree or disagree that “roc rocks and succ sucks,” evidence shows that approximately 3-4% of intubated patients experience awareness while paralyzed [1,2], and more of these patients are in the rocuronium subgroup [2,3,4]. Rocuronium acts in a dose-dependent fashion; the relatively standard 1-1.2 mg/kg in emergency department rapid sequence intubation (RSI) can result in a duration of paralysis can of up to 60-90 minutes. Commonly used sedatives in RSI, however, such as etomidate and ketamine, wear off quickly, before before rocuronium's paralytic effects have abated.
A recent single-center study showed that the majority of patients (60%) receiving rocuronium for paralysis during rapid sequence intubation (RSI) received no additional sedation until more than 15 minutes after induction, whether in the ED or ICU [5].
Patients experiencing awareness during paralysis with post-traumatic stress disorder [1,2] including distress from being restrained, feeling procedures, and feeling of impending death.
Bottom line: Start appropriate dose sedation promptly after RSI, especially with rocuronium, to avoid short- and long-term distress to patients.
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Pain, bleeding, fever - what symptoms actually mean something when it comes to ovarian torsion?
Well, in this retrospective case-control study looking at 221 patients from 2011 to 2022, Aiob et. al looked at a ton of history, physical exam, and ultrasound findings to see which ones correlated most strongly with ovarian torsion. They found that vomiting and reports of localized pain (v diffuse pain) were highly associated with surgery-confirmed ovarian torsion. In multivariate analysis, localized pain had an odds ratio of 4.36 and vomiting had an odds ratio of 2.38.
Additionally, on ultrasound findings, ovarian edema was much more likely to be present in torsion cases, with an odds ratio of 5.29.
This is a retrospective single center study that comes with all the limitations that these studies always come with, but let this be a reminder of what should trigger your Spidey-senses!
Additional note: We all know that torsion is a diagnosis that can only be confirmed by surgery, no matter what Doppler flow looks like, and this study just adds onto that pile of evidence: Doppler flow was not significantly different between patients who ended up having torsion and those who didn't. >60% of patients who ended up having torsion had normal flow, so like always, remember that a normal Doppler does not exclude torsion in a patient who you're worried about! Talk to OBGYN!
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This paper outlines the long term effects of surviving a gunshot wound. The authors conclude:
“Firearm injury survivors frequently experience chronic pain, nerve injury, retained bullet fragments that may cause lead toxicity, physical limitations, and PTSD and are at risk for reinjury. In addition to supportive medical and psychiatric care, survivors of firearm injury may benefit from health care–based violence intervention programs.”
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Scaphoid fractures
Make up almost 2/3rds of all carpal fractures
Fractures tend to be localized to 3 anatomic locations
Waist fractures make up 2/3rds. This may be diagnosed with anatomic snuffbox tenderness
Proximal pole fractures make up approximately 25%. This may be diagnosed with bone tenderness about a fingerbreadth distal to Lister’s tubercle
Distal fractures make up the remaining 10%. This may be diagnosed with tenderness at the volar prominence of the distal wrist crease
Imaging:
In addition to standard views of the wrist (PA/lateral/oblique) consider adding a scaphoid view. This imaging view is a PA film taken with the wrist in full pronation and ulnar deviation. This allows full visualization of scaphoid in its longitudinal axis. Also, this allows visualization of the area in question without the annoying overlap of adjacent carpal shadows
Have you ever wondered what happened to your mechanically ventilated patients who developed diarrhea. Apparently, a multicenter study involving 2650 patients from 44 ICUs in the US, Canada and Saudi Arabia investigated the prevalence of diarrhea among these patients.
This study was the Editor’s choice for June 2025.
Results:
The mean age for the population was 59.8 (16.5) years, with APACHE II Score of 22.0 (7.8). Up to 61% of the patients received vasopressors or inotropes on day 1, which mean these patients are relatively ill.
Up to 60% of patients had diarrhea during their ICU stay, with 15% had diarrhea on day 1 or 2.
Initiating laxatives and antibiotics (who in the ICU would not receive vitamin V and Vitamin Z?) were associated with increased risk of diarrhea: HR for laxatives 1.28 (1.13–1.44), p<0.001; HR for antibiotics 1.41 (1.20–1.67), P< 0.001.
Furthermore, enteral feeding with high/moderate protein concentration was also associated with diarrhea (HR 1.13, 1.00-1.28, P=0.045.
Not surprisingly, diarrhea was associated with higher number of C. Diff testing.
Although patients with diarrhea were associated with longer ICU stay (15 [10-23] days) vs. those without diarrhea (8 [6-12] days), it was not associated with higher mortality (HR 0.70, 95% CI 0.57-0.86, P<0.001)
Discussion:
1. The authors did not report the rates of positive C. Diff. infection in these patients during ICU stay, although they did report that for another study in this population, the rate of positive C. Diff. infection during ICU stay was 2.2%. If only 2.2% had C. Diff. infection while up to 60% had diarrhea. Consequently, for every 30 patients with diarrhea, only one patient had C. Diff. infection. Therefore, do we have to check C. Diff. in those ICU patients with diarrhea every time?
2. The authors hypothesized that patients with diarrhea had longer ICU stay and lower mortality because they survived long enough to develop diarrhea. Thus, diarrhea is bad for clinicians, but may not be too bad for patients?
Conclusion:
Diarrhea is common among invasively ventilated patients. Patients who received laxatives, antibiotics, enteral feeding with high protein amount are at higher risk for diarrhea.