These authors reiterate principles that have been discussed previously regarding intubation in head/brain injured patients.
-Avoid hypoxia with preoxygenation
-Avoid hypotension by fluid resuscitation/vasopressors/blood in the correct clinical setting
-Use hemodynamically neutral induction agents such as Etomidate or Ketamine (it is ok use this in head injured patients!)
-Video laryngoscope gives best first pass success which minimizes hypoxia/raised ICP
-Post-Intubation aim for eucapnia (avoid hyperventilation)
-Use adequate post-intubation sedation to avoid raised ICP
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From this position statement on management of HTN key points are beta blockers are a second line medication choice, dual therapy in a combination pill is often warranted and primary medications should be thiazides, long acting calcium channel blockers, ACE or Arbs.
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Evidence shows the effectiveness of inhaled corticosteroids during pediatric asthma attacks.
A metanalysis from 2020 reviewed 7 different studies between 2009 to 2018 that included patients < 18 years. The studies compared the use of inhaled corticosteroids to placebo, inhaled corticosteroids compared to systemic corticosteroids, and inhaled corticosteroids in addition to systemic corticosteroids. Please note that in the studies children were still being treated with albuterol.
The results showed:
-Inhaled corticosteroids would significantly reduce the hospital admission rate when compared to placebo (by about 83%).
-Inhaled corticosteroids reduced hospital admission rates when compared to systemic steroids only (by 27%) for mild to moderate asthma.
-When combining systemic steroids with inhaled corticosteroids, the hospital admission rate would be reduced by 25% compared to using only systemic steroids for moderate to severe asthma attacks.
Bottom line: Consider administering inhaled corticosteroids in pediatric asthma patients.
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If a patient is experiencing issues with their Foley catheter, consider using POCUS.
Using a curvilinear probe over the suprapubic region, you can obtain a transverse view of the bladder by orienting the marker towards the patient’s right side, or a sagittal view by orienting the marker towards the patient’s head.
In a properly functioning Foley, the bladder will appear decompressed, and you may only see the Foley balloon.
In cases of obstruction or malposition, you may notice a distended bladder. The next step is to attempt to visualize the Foley balloon. If you do not see a Foley balloon within the bladder, try deflating the balloon and advancing the catheter.
If you notice debris blocking the foley or heterogenous material in a patient with hematuria, you can attempt to flush the catheter, but if the patient has a large amount of hematuria, you may need to replace the current Foley with a three-way catheter for continuous bladder irrigation.
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What is the ideal oxygen saturation goal for a mechanically ventilated patient? Literature over the past decade has led away from the perfect 100% oxygen saturation due to its association with worse patient outcomes across many disease states. It is theorized that excess oxygen leads to free radical production causing a lung injury pattern. However, there is no clear guidance for the ideal range of oxygen saturation goals, particularly in the mechanically ventilated patient, despite a meta-analysis and several recent trials.
UK-ROX Trial - JAMA - June 2025
Question: Does an oxygen saturation goal of 88-92% lead to a lower 90-day mortality compared to usual care?
Population: 16,500 mechanically ventilated adult patients in 97 ICU’s across the UK, excluded patients on ECMO
Intervention: Goal oxygen saturation of 88-92%, using the lowest possible FiO2
Control: Usual care, defined as oxygen supplementation at the discretion of the treating physician (no limits set to FiO2 or SaO2)
Outcomes:
- Conservative and usual therapy groups were randomized 1:1 and had similar characteristics
- 90 day all-cause mortality - 35.4% in conservative group vs. 34.9% in usual care group (p=0.28)
- Time at 88-92% SaO2 - 62.6 hrs in conservative group vs. 27.2 hrs in usual care group (did not look at oxygen exposure peri-intubation)
- No difference in secondary outcomes - duration of ICU stay, days alive and free of organ support, duration of acute hospital stay, and others
Bottom Line:
Ideal oxygenation targets remain elusive. UK-ROX adds to the growing literature of oxygenation targets in mechanically ventilated patients but does not clearly show that lower oxygen saturation targets lead to improved ICU outcomes. In your emergency department ICU boarder, avoid a 100% oxygen saturation to prevent oxygen toxicity associated lung injury and consider an oxygen saturation goal of 90-96% (88-92% if history of COPD).
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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?
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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.