A case report on use of the abdominal aortic and junctional tourniquet in a 27 year old female with hemorrhagic shock secondary to a pelvic fracture after a 10 meter fall demonstrated improved blood pressure and stabilized vasopressor use prior to operative intervention. This device has been used in battlefield situations, however very few reports of civilian use exist. Much more data is needed, however, it is a device to be aware of for future use.
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BOTTOM LINE: Modify WBC threshold for diagnosing septic arthritis is patients who received recent antibiotics (24h to 2 weeks).
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BOTTOM LINE: It is generally safe and effective to discharge vomiting pediatric patients with a prescription for ondansetron, and a recent study supported this common practice.
While it has become common practice to prescribe ondansetron to children with emesis, a 2025 randomized controlled study showed that a prescription for ondansetron decreased the risk of moderate to severe gastroenteritis in the following 7 days.
This study compared children 6 months to 18 years of age who received either ondansetron or placebo. They found a rates of moderate to severe gastroenteritis to be 5.1% in the ondansetron group versus 12.5% in the placebo group.
*Note that ondansetron is NOT approved for children under 6 months of age or in those with prolonged QT.
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Take Home Point: Andexxa (andexanet alfa) was voluntarily withdrawn from the US market effective December 22, 2025, due to safety concerns. 4-Factor Prothrombin Complex Concentrate (4F-PCC/Kcentra) remains the standard of care for reversing apixaban and rivaroxaban in life-threatening bleeding.
Why was it pulled? AstraZeneca, in consultation with the FDA, discontinued the manufacturing and sale of Andexxa after the ANNEXA-I post-marketing trial showed that the drug's risks outweigh its benefits. The trial compared Andexxa to usual care (primarily 4F-PCC) in intracranial hemorrhage and found a significant safety signal:
- Thrombosis: 14.6% (Andexxa) vs. 6.9% (Usual Care)
- Thrombosis-Related Mortality: 2.5% (Andexxa) vs. 0.9% (Usual Care)
Clinical Action Items:
- Do not order Andexxa: It is no longer commercially available.
- Use 4F-PCC (Kcentra) for Factor Xa Inhibitor Reversal:
- Indication: Life-threatening bleeding or urgent surgery in patients on apixaban (Eliquis) or rivaroxaban (Xarelto).
- Dosing: Use dosing strategies per your institution's protocol.
- Update Order Sets: Ensure your electronic health record order sets for anticoagulation reversal remove Andexxa and default to 4F-PCC for Factor Xa inhibitors.
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Institutional Note: You may recall that our institution (like many others) never added Andexxa to the formulary. We cited the lack of high-quality survival data and cost-benefit concerns as our primary reasoning. Consequently, this market withdrawal requires no change to our local practice. We will continue to use 4F-PCC as our standard for Factor Xa inhibitor reversal, a practice now validated by the FDA's safety findings.
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Diagnostic Errors in the Critically Ill
- Critical illness comprises numerous time-sensitive conditions in which diagnostic errors and delayed diagnoses markedly impact patient outcomes.
- Diagnostic errors in the critically ill can occur in up to 20% of patients and lead to overuse of resources, delayed recovery, and increased mortality.
- The most common cognitive biases leading to diagnostic errors in the critically ill include:
- Anchoring bias: over-reliance on your initial impressions
- Availability bias: favoring diagnoses that easily come to mind
- Premature closure: ending your diagnostic reasoning too early
- Confirmation bias: seeking information that supports your diagnosis and discounting contradictory findings
- Recommended strategies to reduce diagnostic errors in the critically ill include implementation of checklists, standardized handoff protocols, multidisciplinary patient reviews, and explicitly discussing these cognitive biases.
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Well, it depends on who you ask - ACOG defines it as greater or equal to 1000ml of blood loss within that first 24 hours, but most research articles define it as greater or equal to 500ml, while they define severe postpartum hemorrhage as greater or equal to 1000ml. But what is it actually?
The World Health Organization decided to tackle this question to look at what level of blood loss is the most clinically relevant in a meta-analysis from last year. They reviewed 12 different databases and over 300000 patients to look at levels of blood loss and when that was associated with mortality/severe morbidity. They found that the standard 500ml cutoff was actually only around 75% sensitive, but when they dropped those levels to 300/400/450, they lost a lot of specificity. So, what they did is they came up with their own rules and re-evaluated them based on their data to see how sensitive and specific they were.
What they found with a sensitivity of 87% and a specificity of 66-76% was:
Consider someone as having CLINICALLY SIGNIFICANT blood loss if they had EITHER:
- Greater or equal to 300ml of blood loss PLUS abnormal hemodynamics (SBP <100, DBP <60, SI>1, HR>100)
OR
- Greater or equal to 500ml of blood loss
So look at the vitals + the blood loss together, and use those to guide your clinical actions!
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Popliteal artery injuries are very rare (4% of all vascular injuries).
The majority of injuries are secondary to penetrating injury (70+%)
Blunt mechanism of injury has the higher rate of amputation.
Prolonged ischemia time (from injury to repair greater than 6 hours) leads to higher rates of amputation
Hard signs of vascular injury should prompt X-ray imaging of the knee, femur, and lower extremity and transfer to an operating room for repair.
Soft signs ("a history of significant bleeding which has ceased, nonexpanding hematomas, and the presence of an Ankle-Brachial Index of less than 0.9") and shotgun injury should prompt CT angiogram to evaluate arterial injury.
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In a metanalysis of studies looking at intercranial hemorrhage in fall patients older than 65 years, the following were unadjusted odds ratio risk factors for finding an ICH in this patient population:
suspected open or depressed skull fracture , signs of basal skull fracture ), reduced baseline Glasgow Coma Scale score , focal neurologic signs , seizure , vomiting , amnesia , loss of consciousness , headache ), external sign of head trauma , male sex , chronic kidney disease , preinjury single antiplatelet , and dual antiplatelet medication .
Preinjury anticoagulant was not a significant risk factor.
When looking at adjusted odds rations only focal neurologic signs , external sign of head trauma , loss of consciousness , and male sex were found to be associated with intercranial hemorrhage.
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The US drug supply has been found to contain medetomidine as an adulterant to heroine/fentanyl. It is a potent tranquilizer used in animals. It is an alpha 2 blocker (similar pharmacology to clonidine and xylazine). Exposure to this drug can induce withdrawal symptoms to include anxiety, tremor, diaphoresis, nausea, vomiting, agitation, sympathetic hyperactivity, and delirium. Withdrawal can start within 4-6 hours of last use.
Treatment for withdrawal is outlined in this diagram.
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- Transfer and storage of substances to unlabeled or mislabeled food containers is a common occurrence and poses a significant poisoning hazard
- Plastic drink bottles (soda, water, milk, sports) are the most common secondary containers in exposures
- Food imitating products (brightly colored, sweet smelling or tasting, similarity in color or consistency to known food products) are particularly hazardous
- Cleaning products and hydrocarbons are the most cited transferred products
- Serious toxicity is reported from herbicides (paraquat), corrosive chemicals, nicotine products, rodenticides, hydrocarbons, and glycols (antifreeze and brake fluids)
- Identification of substances in unlabeled containers can be difficult. In the case of an ingestion of an unknown substance medical observation is recommended
- Prevention is key… Never reuse food containers for storage of substances. Always keep substances in their original containers with manufacturer labels intact. Never store chemicals in the same cabinet, shelf, or area as food.
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Etomidate is often a go-to agent for RSI because it is considered relatively hemodynamically neutral. However, lab studies have shown an association with transient adrenal suppression, and some observational studies and meta-analyses have suggested that patients intubated with etomidate face higher risk of cardiovascular collapse and in-hospital mortality than those intubated with ketamine.
The RSI trial was a pragmatic open-label multi-center randomized control trial conducted in 6 EDs and 8 ICUs across the US and compared induction with ketamine 1-2mg/kg versus etomidate 0.2-0.3mg/kg for RSI of critically ill adults (excluding trauma patients). They found no significant difference in overall 28 day hospital mortality across the cohort. They found an increased risk of cardiovascular collapse during intubation in the ketamine group. This increased risk was more pronounced in patients with sepsis or septic shock and patients with APACHE II ?20.
Some details:
- Cardiovascular collapse during intubation was defined as systolic BP <65mmHg, new or increased vasopressors, or cardiac arrest within 2 minutes of induction
- The prevalence of 28 day hospital mortality was 28.1% in the ketamine group vs 29.1% in the etomidate group, with an absolute difference -0.8%, 95% CI ?4.5% to 2.9%; P=0.65
- The prevalence of peri-intubation cardiovascular collapse was 22.1% in the ketamine group vs 17.0% in the etomidate group, absolute risk difference 5.1%; 95% CI, 1.9% to 8.3%.
- Among patients with sepsis or septic shock, 30.6% vs 20.9%, absolute risk difference 9.7%; 95% CI, 4.6% to 14.9%.
- Among patients with APACHE II ?20, 31.4% vs 20.7%, absolute risk difference 10.7%, 95% CI 5.5% to 16.0%.
- Both ketamine and etomidate were dosed using actual body weight, whereas data is more supportive of using ideal body weight for ketamine. The dose used for ketamine was also on the higher end of that recommended for critically ill patients. There was no investigation of how the impact of the dose of either drug on the outcomes assessed.
Overall - this was a well conducted randomized control trial that - at the very least - suggests that etomidate is likely as safe (if not safer) than ketamine with respect to 28d mortality and peri-intubation cardiovascular collapse, even among patients with critical illness or septic shock.
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Ultrasound Guided Nerve Blocks (UGNBs) provides targeted analgesia that can effectively alleviate pain from injuries or painful procedures while reducing opioid use.
In 2021, ACEP issued a policy statement affirming that ultrasound-guided regional anesthesia is within the scope of EM physicians and is a core component of multimodal pain management pathways in the ED. However, EM residencies have not uniformly defined nerve block requirements, resulting in a wide range of graduating resident skill levels. Recent ACGME updates may help standardize expectations and address this gap.
A recent review of the National Ultrasound-Guided Nerve Block Registry (NURVE) looked at the impact of operator training level on the analgesic effectiveness of ED-performed UGNBs. The most commonly performed block among attendings was the erector spinae block, while for residents it was the fascia iliaca block. Both resident and attending performed blocks showed a reduction in pain but there was an 80.7% meaningful pain reduction in attendings as compared to 63.4% for residents. Out of the 1595 nerve block cases reviewed there were only 2 complications which included transient episode of LAST and respiratory difficulty from suspected diaphragmatic hemiparesis.
These findings highlight the importance of experience while supporting the safety and effectiveness of UGNBs performed by supervised residents in the training environment.
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An English study describes 30 patients that jumped from a single bridge of 30 meters (98 feet) over the course of 12 years. Twenty six landed in the water. The injury pattern for those landing in water was described as “Hypothermia was the most common presentation (n = 23), followed by pneumothoraces (n = 14), rib fractures (n = 10), thoracic vertebral fractures (n = 9) and lung contusions (n = 8). Lower water temperatures at the time of the incident (p = 0.008) and lower patient body temperatures on arrival to hospital (p = 0.002) were significantly associated with increased 30-day mortality.”
The small group landing on land had more pelvic and extremity fractures than the water group and none had hypothermia.
Remember to start aggressive rewarming in patients who fall into water!
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This small study from South Africa shows stab wounds to the chest with a pneumothorax less than 0.5 cm that were managed conservatively had completely resolved on 12 hour repeat chest X-ray. This could facilitate earlier discharge of these patients. It also supports conservative (non-tube placement) approach to asymptomatic small pneumothoraces from stab wounds.
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Tramadol has been viewed as a safer alternative for pain control than opioids. This study says differently.
“Tramadol use was associated with increased risk of multiple ER utilizations, falls/fractures, CVD hospitalizations, safety event hospitalizations, and mortality (new users only) compared to nonuse.”
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How well does your ED care team communicate? For some high yield strategies and reasons for improvement, read on…
To explore effective and ineffective communication in the ED and its impact of patient care, physician and nurses from several academic EDs completed an online anonymous survey, then attended focus group sessions. Responses highlighted the following themes:
1: Situations, built physical environment, and medium of communications all impact quality of communication.
- Face-to-face communication was most appreciated
- Common work areas facilitate communication
- Electronic communications had highest risk of misinterpretation and being ignored/missed
2: Core elements of desired professional communication include respect, closed-loop communication, and attention, often conveyed through non-verbal behaviors.
- Making eye contact
- Turning toward a speaker
- Nodding at appropriate moments
- Acknowledging active listening
3: Poor communication begets poor communication in later interactions
- ENs may hesitate to share important information if there has been a prior negative interaction with that EP
4: Effective communication is seen as fundamental to patient care but also has impacts beyond patient care
- Creates a shared understanding of the patient’s clinical status and care plan
- Guides clinical actions
- Affects the team’s ability to communicate with patients and families
- Has spillover effects, impacting care beyond any single case, as it affects the “feeling” of the entire department
5: Clinician gender and gender dyads influence communication dynamics, age and experience dyads did not.
- Greatest communication conflict (noted by both disciplines) involved communication in female/female physician/nurse dyads
Do any of these themes resonate with you? What can you do within your department to improve physician-nurse communication and the care you provide?
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A crucial part of cardiac arrest management is identification of the underlying rhythm, with key aspects of management diverging depending whether shockable (pulseless ventricular tachycardia/pVT or ventricular fibrillation/VF) or unshockable (pulseless electrical activity/PEA or asystole).
A recent study prospectively evaluated adult atraumatic out-of-hospital-cardiac-arrests (OHCAs) presenting to the ED, to determine what percentage of cases had “Occult VF” – VF found point-of-care echocardiogram but not by ECG. The researchers only included cases with simultaneous ECG and echo assessments for the initial 3 pulse checks. Echo and ECG determinations for the study were adjudicated by research team members.
They found that:
- 5.3% of patients had occult VF (43/811), with ECG reading PEA in 81.4% (35/43) and asystole in 18.6% (8/43)
- Of the 202/811 patients with VF on ECG, only 23.3% had echo VF
- Interestingly, patients with ECG VF but no VF on echo had a lower rate of ROSC and successful defibrillation than those with Occult VF
- There was no statistically significant difference in survival to hospital discharge between the two
- A higher percentage of patients evaluated by TEE compared to TTE were found to have occult VF (12.5% vs 4.9%)
Major limitations:
- Only have the cases with simultaneous ECG + echo for the first 3 pauses
- Only have the recorded echo clips, which are not the same as in-the-moment viewing during the arrests
- No comparison to how research team interpreted ECGs to how the treating team managed
Bottom Line: Point-of-care echocardiogram continues to have value in the management of cardiac arrest, potentially changing management and affecting post-ROSC decisions. Ensuring high-quality CPR, with appropriate defibrillation and anti-arrhythmic strategies, remains paramount in management of shockable OHCA.
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Consumer use of cannabidiol (CBD) products for medicinal and recreational purposes has increased in recent years. Regulatory barriers have limited randomized controlled trials examining the clinical and physiologic effects of cannabinoids in humans. This study aimed to evaluate the impact of daily cannabidiol oil use on liver enzymes and endocrine hormones in healthy adults.
In this double-blind, randomized, placebo-controlled study conducted at a clinical pharmacology unit in Wisconsin, 201 healthy adults were randomized to receive either oral CBD (2.5 mg/kg twice daily) or placebo. Laboratory testing was performed weekly.
Among participants receiving CBD (n = 151), 8 developed AST and ALT elevations greater than three times the upper limit of normal; 7 of these also had eosinophilia. No participants in the placebo group (n = 50) developed similar transaminase elevations. There were no significant differences between groups in measured endocrine hormones, including total testosterone, inhibin B, thyroid-stimulating hormone, total triiodothyronine, and free thyroxine.
Limitations included a modest sample size, unequal group sizes, and a relatively short duration of exposure and follow-up.
Key Takeaway: CBD use may be associated with elevations in AST and ALT. However, evidence remains limited, and abnormal liver enzymes should still prompt evaluation for alternative etiologies.
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A reminder from a recent position paper on pelvic trauma that we should not be doing stability testing to evaluate pelvic trauma
“EMS clinicians should recognize the challenges in accurately identifying pelvic fractures by physical exam alone. Manual stability testing of the pelvis is neither sensitive nor specific and may cause harm.”
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The recommended approach for patients with suspected septic arthritis is arthrocentesis with fluid analysis sent for: Gram stain, culture, WBC count with differential, and crystal analysis before starting antibiotics.
From a classic meta-analysis of 14 studies involving greater than 6,000 patients the only 3 findings that occur in more than 50% of patients with septic arthritis were
Joint pain (sensitivity, 85%; 95% confidence interval [CI], 78%-90%),
Joint swelling (sensitivity, 78%; 95% CI, 71%-85%),
Fever (sensitivity, 57%; 95% CI, 52%-62%).
Vs.
Sweats (sensitivity, 27%; 95% CI, 20%-34%)
and rigors (sensitivity, 19%; 95% CI, 15%-24%) were less common findings in septic arthritis.
The probability of septic arthritis increases progressively with higher synovial WBC counts:
- <25,000 cells: LR 0.32 (95% CI, 0.23-0.43)
- > 25,000 cells: LR 2.9 (95% CI, 2.5-3.4)
- >50,000 cells: LR 7.7 (95% CI, 5.7-11.0)
- >100,000 cells: LR 28.0 (95% CI, 12.0-66.0)
PMN percentage ?90% suggests septic arthritis with LR 3.4 (95% CI, 2.8-4.2)
VS
PMN <90% lowers the likelihood (LR 0.34, 95% CI 0.25-0.47).