JAMA Internal Medicine recently published a systematic review and Bayesian meta-analysis looking at the utility of prophylactic antibiotics in cirrhotics with acute upper GI bleeding
TLDR: shorter durations of antibiotics (including no antibiotics!) had a 97.3% probability of noninferiority for all-cause mortality
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Bottom Line: We are terrible at estimating how much blood people are losing just by looking at it. Use calibrated drapes (drapes with markings that tell you how much blood is being lost), or just a large bag and then weigh it afterwards (1g ~ 1ml of blood loss).
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This case report reminds us that vasculitis is an inflammatory process that attacks blood vessels leading to organ dysfunction. The etiology can be a hypersensitivity reaction (think drugs) or an IgA mediated process secondary to infection (Strep or Mycoplasma). In this case, concomitate use of NSAIDS (very common etiology of hypersensitivity) and Mycoplasma lead to vasculitis. Treatment ranges from supportive care, to steroids to immunosuppressive agents such as azathioprine.
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Of 925 ED headache patients in this meta analysis comparing extrapyramidal side effects of bolus vs. continuous infusion of metoclopremide the majority of the reactions occurred in the bolus group.
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Bottom Line:
Kratom is an herbal extract used as an alternative medicine and recreational substance with marked increase in use over recent years. Kratom contains a complex mixture of psychoactive ingredients with effects at multiple receptors (mu, serotonin, dopamine, and alpha-adrenergic receptors) and causes stimulant effects at lower doses and opioid effects at higher doses. Depending on the predominant clinical effects, treatment with naloxone, benzodiazepine, and labetalol have been reported.
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When compared to saline(!) trauma patients with a high injury severity score who received ketamine via pca for pain control had better quality of life indicators at 1,3, and 6 months post injury.
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Bottom Line: arrival temperature had no prognostic value in non-septic older patients. Hypothermia in sepsis, but not fever, predicted mortality.
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BOTTOM LINE: ED Boarding is now publicly reported in one state (Connecticut). Public reporting of boarding data may encourage new approaches to remedy the problem.
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It is a common scenario in the ICU, and occasionally in the ED, to be asked which pressor you would like to wean first, norepinephrine or vasopressin. This is mostly an “art not science” question, but is there a right answer? Does picking one vs the other to wean first lead to less hypotension?
Bottom Line: This meta-analysis doesn't suggest that either the norepi-first or vasopressin-first strategies for vasopressor wean are associated with an increased incidence of hypotension, although the literature is mixed. Whatever your current practice is, it's probably reasonable to stick with that. See the additional information for my personal approach.
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Key Takeaway: Most emergency department prescription callbacks for clarification are preventable. The most frequently identified causes include unclear directions for use, incorrect medication or dose, allergy or adverse reaction concerns, and duplicate prescriptions. A quick double-check before you hit “send” can save you (and the pharmacist) a callback later.
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Cerebral venous sinus thrombosis (CVST) is an emergent diagnosis frequently missed on standard brain imaging in the ED, with studies reporting miss rates up to 30–73% on noncontrast CT alone. Diagnostic delays average 4–10 days from initial presentation in confirmed cases. CTV and MRV both have very high sensitivity for detection of CVST.
When to Suspect CVST
- Unexplained focal neurologic deficits: Hemiparesis, aphasia, or new seizures without corresponding arterial infarct, mass effect, or hemorrhage on noncontrast CT/CTA.
- Signs of increased ICP without mass lesions or traumatic findings
- Hypercoagulable states: OCP use, malignancy, peripartum status, thrombophilia
- High risk CT findings:
- Skull fracture traversing a dural sinus (SSS, transverse)
- Empty delta sign
- Atypical hemorrhage patterns:
- Multifocal cortical subarachnoid hemorrhage (especially posterior-predominant).
- Nontraumatic-appearing cortical SAH or bilateral thalamic hemorrhages.
- Hemorrhagic venous infarcts (“thumbprint edema”).
Summary: Consider adding CTV in patients with strong thrombotic risk factors, atypical/multifocal hemorrhage patterns, or focal deficits unexplained by CT/CTA.
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Bottom line: Good news! In 2022 and 2023, at ACEP, SAEM and AAEM, invited speakers were evenly split 50/50 women and men (with a small percentage nonbinary) showing no significant gender bias toward speaker invitation.
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Bottom line: Socioeconomic differences in outcomes of cardiac arrest are present in the pediatric population as well and CPR education and resources should be present in ALL communities.
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In a single level 1 trauma center there were 274 patients age over 55 evaluated for falls in a one year retrospective period. Their blood toxicology was reviewed for presence of alcohol, opioids, benzodiazepines and cannabinoids. The authors found:
“detection rates were 21.2% for opioids, 18.6% for ethanol, 13.9% for benzodiazepines, and 9.1% for cannabinoids. Injuries identified included 16.4% spinal fractures, 9.5% extremity fractures, 7.7% hip/thigh/pelvic fractures…In this study, nearly 20% of adults 55+ presenting for fall-related trauma recently used substances that impair psychomotor function.”
An area for injury prevention research and intervention would be to screen patients over age 55 for substance use, consider prescribing patterns in this age group (benzodiazepines) , and discuss with patients fall risk avoidance.
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Bottom line: Education to the public is needed to help to improve the information relayed to telecommunicators in an emergency. Further telecommunicator education can help to overcome the barriers within their control, such as the recognition of agonal breathing.
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Bottom Line: Hypertonic sodium bicarbonate (8.4%) can be used judiciously as an alternative hyperosmolar therapy in the setting of increased intracranial pressure (ICP) or cerebral edema with impending herniation, particularly in setting of concomitant metabolic acidosis. Two 50 mL ampules of hypertonic sodium bicarbonate is the equivalent of approximately 200 mL of 3% sodium chloride (hypertonic saline).
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Bottom Line: Left Optic Disc Elevation was found to be an independent predictor of mortality and need for surgical intervention for patients with head trauma.
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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).