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EM@3AM: Pediatric Non-Accidental Trauma - emDocs
A 3-month-old previously healthy male is brought to the ED by his parents. His father says he rolled off the couch onto a hardwood floor, started crying immediately, and then seemed sleepy and more fussy than usual. On exam, the patient is minimally consolable with a small bruise on his left forehead. Vitals are stable. There are no palpable skull fractures. Due to the age and mechanism, you obtain a head CT which shows a subdural hematoma without midline shift. You obtain a skeletal survey which shows a healing posterior rib fracture. What is the diagnosis?
US Probe: Upper Extremity DVT - emDocs
Upper extremity DVT (UEDVT) is a rare but clinically significant condition often linked to catheters or thoracic outlet syndrome. This guide reviews POCUS scanning techniques, relevant anatomy, diagnostic accuracy, and case-based pearls for identifying and managing UEDVT at the bedside.
US Probe: POCUS for the Diagnosis of Acute Pediatric Distal Radius Fractures - emDocs
POCUS is emerging as a safe, accurate, and radiation-free tool for diagnosing pediatric distal forearm fractures, offering faster results and improved patient comfort compared to x-ray. This case highlights its role in emergency medicine.
US Probe: POCUS for the Diagnosis of Acute Pediatric Distal Radius Fractures - emDocs
POCUS is emerging as a safe, accurate, and radiation-free tool for diagnosing pediatric distal forearm fractures, offering faster results and improved patient comfort compared to x-ray. This case highlights its role in emergency medicine.
emDOCs Videocast: EBM Update – Acute Brain Injury - emDocs
https://youtu.be/s8NAlZO5MOA?si=Wp8hfOsy6mGPeAEg Welcome to the emDOCs Videocast – please subscribe to our YouTube channel. These videos will cover post summaries, takehomes on clinical condition, and EBM/guideline literature updates. Today we focus on acute brain injury, including the effects of hypotension, antibiotics in mechanically ventilated patients, transfusion thresholds, and ventilation strategies. Article #1: Lee JW, Wang W, Rezk A, et al. Hypotension and Adverse Outcomes in Moderate to Severe Traumatic Brain Injury: A Systematic Review and Meta-Analysis. JAMA Netw Open. 2024 Nov 4;7(11):e2444465. Clinical Question: In patients with moderate to severe TBI, is hypotension associated with adverse outcomes? Design: Systematic review and meta-analysis. Included RCTs and cohort studies evaluating patients > 10 years with moderate to severe TBI and hypotension. Excluded studies with mild TBI. Outcomes: Hypotension with death and/or vegetative state within 6 months and incidence of hypotension Results: 51 studies with 384,329 patients. Overall hypotension incidence 18% (95% CI, 12%-26%) (P < .001;I2 = 99.84%). Significant increase in mortality in patients with hypotension and moderate to severe TBI (crude OR, 3.82; 95% CI, 3.04-4.81;P < .001; I2 = 96.98%; adjusted OR, 2.22; 95% CI, 1.96-2.51; P < .001; I2 = 92.21%). Considerations: No reported data on vegetative state, and lack of uniformity of reported data. Limited data on duration of hypotension and management of hypotension. High heterogeneity in mortality outcome data, reducing generalizability and applicability. The Bottom Line: Hypotension in patients with moderate to severe TBI is associated with higher mortality. Article #2: Dahyot-Fizelier C, Lasocki S, Kerforne T, et al; PROPHY-VAP Study Group and the ATLANREA Study Group. Ceftriaxone to prevent early ventilator-associated pneumonia in patients with acute brain injury: a multicentre, randomised, double-blind, placebo-controlled, assessor-masked superiority trial. Lancet Respir Med. 2024 May;12(5):375-385. Background: Ventilator-associated pneumonia (VAP), or infection-related ventilator-associated complication (IVAC), is a nosocomial pneumonia occurring on day 3 of mechanical ventilation that was preceded by 2 days of stable or decreasing ventilator requirements. Overall incidence is 5-40%, but in patients with TBI, the risk may reach 60%. Clinical Question: In adults with severe brain injury who require invasive mechanical ventilation (IMV), does an early, single dose of ceftriaxone compared with placebo reduce early VAP? Design: Multicenter, double-blind, placebo-controlled RCT; conducted at nine ICUs at 8 French hospitals. Included adults with GCS < 12, within 12 hr of intubation and within 48 hr of hospitalization, expected IMV duration > 48 hr. Brain injury: defined as head trauma, stroke, subarachnoid hemorrhage Patients randomized to single dose of ceftriaxone 2 g IV versus placebo. All patients underwent standard VAP-preventative measures: Hand washing before any care, Head of bed elevation at 30 degrees mounted every 4 hours, Preferential use of heat and humidity exchange filters, changed only when soiled, Monitoring of cuff pressure of tracheal tube every 8 hours to maintain pressure between 25-30 cm H20, Tracheal aspiration using sterile equipment, and only when required, Mouth care every 8 hours at minimum, No systemic changes of the respirator circuits, Preferential oral insertion of feeding tubes, Starting enteral feeding as soon as possible, Blood glucose monitoring every 4 hours, Ulcer prophylaxis, Extubation as soon as possible. Outcomes: Primary: Development of early VAP (2ndto 7th day of mechanical ventilation) VAP confirmed by 2-3 intensivist committee based on clinical, radiological, microbiological criteria outlined by American Thoracic Society (ATS) Clinical criteria: temperature ≥38°C or <36°C, white blood cell count >12,000/mm3 or <4000/mm3, purulent tracheal aspirates Radiological criteria: new or changed chest X-ray infiltrate Micro criteria: positive respiratory cultures Secondary: At ICU discharge or day 28 (whichever came first) Development of late VAP (>7 days after intubation) Organism identified with development of VAP Number ventilator-free days Number antibiotic-free days Development of ventilator-associated events (VAE) Comparison to global number of VAE Time from inclusion to first spontaneous breathing trial Number patients with ESBL-producing Enterobacteriaceae Neuro outcomes: mRS and GCS Mortality Safety At day 60: Number ICU-free days Number hospital-free days Neuro outcomes: mRS and GCS Mortality Results: Included 319 patients; 162 ceftriaxone vs. 157 placebo Primary outcome: early VAP 14% vs. 32% (HR 0.60; 95% CI 0.38-0.95) Secondary outcomes at day 28: Lower VAP risk, fewer median vent days, improved mRS, lower mortality Secondary outcomes at day 60: More median ICU/hospital free days, no difference in neuro/mortality Considerations: Study was multicenter, randomized, blinded. Used intention to treat analysis. Groups were well balanced. Authors used standardized VAP definition and prevention measures. Primary outcome controversial, as the detection/diagnosis of VAP is inaccurate. Limited generalizability. Definition of VAP is controversial, as diagnosis is inaccurate. VAP prevention measures not monitored. Limited generalizability. Secondary outcomes hypothesis generating. The Bottom Line: A single dose of ceftriaxone likely reduces VAP in intubated patients with severe brain injury. Article #3: Taccone FS, Rynkowski CB, Møller K, et al; TRAIN Study Group. Restrictive vs Liberal Transfusion Strategy in Patients With Acute Brain Injury: The TRAIN Randomized Clinical Trial. JAMA. 2024 Nov 19;332(19):1623-1633. Clinical Question: In patients with acute brain injury who are intubated and mechanically ventilated, does ventilation with lower VT and higher PEEP versus conventional ventilation improve clinical outcomes? Design: Multicenter, open-label RCT. Included adults with TBI who were mechanically ventilated. Outcomes: Primary: Unfavorable neurologic outcome 180 days based on Glasgow Outcome Scale extended. Secondary: 28-day mortality, organ failure, ICU LOS, adverse events, cerebral ischemia Results: 806 patients; 393 liberal, 413 restrictive Primary outcome unfavorable neurologic outcome: liberal 62.6% vs. restrictive 72.6% (aRR 0.86; 95% CI 0.78-0.95). Secondary outcome: No difference in 28-day mortality, organ failure, ICU LOS, but fewer cerebral ischemic events in liberal 8.8% vs. 13.5% (RR 0.65; 95% CI 0.44-0.97). Considerations: Study was multicenter, randomized. Blinded outcome assessors, but ICU staff not blinded. Groups were well balanced. Slow enrollment, requiring two sample size adjustments. Most patients enrolled at hospital/ICU day 3; unknown if patients received transfusion prior to enrollment. Broad range of neurocritical illnesses included, and serum hemoglobin is a nonspecific surrogate for cerebral oxygenation. Limited generalizability. Definition of VAP is controversial, as diagnosis is inaccurate. The Bottom Line: In patients with acute brain injury and anemia, hemoglobin transfusion threshold of 9 g/dL may reduce unfavorable neurologic outcomes at 180 days. Further randomized data needed. Article #4: Mascia L, Fanelli V, Mistretta
EM@3AM: Genitourinary Trauma - emDocs
A previously healthy 32-year-old male presents to the ED via EMS following a high-speed motor vehicle collision on the interstate. The lower part of his abdomen hit the steering wheel. He reports significant pain in the perineum and groin. He has the urge to urinate but is unsure if he is able to. Vital Signs on arrival to the ED: HR 110, RR 18, blood pressure of 120/80, temperature (oral) of 99.1F, with an oxygen saturation of 99% on room air. On secondary survey, the patient has mild diffuse lower abdominal tenderness. His pelvis is stable. There is no testicular swelling or pain; however, you observe blood at the urethral meatus.
EM@3AM: Panhypopituitarism - emDocs
A 70-year-old male with presents with 5 days of fever and 3 days of anuria and malaise. He also notes worsening abdominal distention and shortness of breath. He found and removed a tick 3 weeks ago and another one 1 week ago. Labs reveal WBC 2,200 cells/microL, HGB 11.2 g/dL, Plt 21 × 109/L, BUN 86 mg/dL, Creatinine 6.8 mg/dL, AST 350 U/L, ALT 119 U/L.
EM@3AM: Tachycardia - emDocs
A 70-year-old male with presents with 5 days of fever and 3 days of anuria and malaise. He also notes worsening abdominal distention and shortness of breath. He found and removed a tick 3 weeks ago and another one 1 week ago. Labs reveal WBC 2,200 cells/microL, HGB 11.2 g/dL, Plt 21 × 109/L, BUN 86 mg/dL, Creatinine 6.8 mg/dL, AST 350 U/L, ALT 119 U/L.
Alcohol Use Disorder in the ED: Screening and MAUD - emDocs
A 70-year-old male with presents with 5 days of fever and 3 days of anuria and malaise. He also notes worsening abdominal distention and shortness of breath. He found and removed a tick 3 weeks ago and another one 1 week ago. Labs reveal WBC 2,200 cells/microL, HGB 11.2 g/dL, Plt 21 × 109/L, BUN 86 mg/dL, Creatinine 6.8 mg/dL, AST 350 U/L, ALT 119 U/L.
PECARN STELAR Podcast - Episode 5: Addressing Substance Use Disorder in children and adolescents – The impactful role of the ED - emDocs
Adolescent substance use is significantly more prevalent than is recognized. The emergency department (ED) can be a great resource to acutely manage complications and help set up long term management goals and provide resources.
Medical Malpractice Insights: SCFE - Who called whom and when? - emDocs
Author: Chuck Pilcher, MD FACEP (Editor, Med Mal Insights) // Reviewers: Alex Koyfman, MD (@EMHighAK) and Brit Long, MD (@long_brit) Here’s another case from Medical Malpractice Insights – Learning from Lawsuits, a monthly email newsletter for ED physicians. The goal of MMI-LFLis to improve patient safety, educate physicians, and reduce the cost and stress of medical malpractice lawsuits. To opt in to the free subscriber list, click here. Chuck Pilcher, MD, FACEP Editor, Med Mal Insights SCFE: Who called whom and when? “Who?” “What?” and “I don’t know.” Another version of Abbott & Costello’s classic skit “Who’s on first” Facts: An 11-year-old female feels a sudden pain in her L hip while doing a flip turn during swimming practice. She sees her PCP a week later and is diagnosed with a “groin strain.” The pain persists and she is re-examined by different PCP a few days later. The dx is changed to “adductor strain.” A month later she falls and feels a “pop” in her hip and is taken to the ED. An x-ray of her hip reveals a slipped capital femoral epiphysis (SCFE). The EP claims that Orthopedist A is contacted and advised that the patient can be seen in the office. The name of Orthopedist A is not recorded. The patient is seen by Orthopedist B and undergoes fixation stabilization 4 days later. Avascular necrosis (AVN) develops and the pt requires a total hip replacement. An attorney is contacted and a lawsuit is filed claiming delay in dx caused the avascular necrosis. The lawsuit named the first 2 PCP’s for delay in diagnosis. The EP and orthopedist A and/or B were all named for an inappropriate delay in surgery. Plaintiff: The first two PCP’s missed my diagnosis. They didn’t even do an x-ray. The EP made the correct diagnosis, claimed he spoke with Orthopedist A but didn’t document it and allowed Orthopedist A to convince him that immediate surgery was unnecessary. Phone records show that it was actually Orthopedist B with whom the EP spoke, so we’re suing both of them. Defense: Orthopedist A testifies that he was “on vacation” on the day of the ED phone call. Orthopedist B testifies that he wasn’t called because “If I was called, I would have operated immediately.” The surgery was successful. Avascular necrosis is a potential complication no matter when the fixation stabilization is done. Result: Because of all the unknowns in this case, the various parties agreed to settle for undisclosed amounts pre-trial. Takeaways: If you speak with a consultant, identify him/her/them, what advice you were given and why you did or did not follow it. Share the agreed upon plan with the patient, e.g., “Dr. X recommends Y. He and I have discussed this and you should follow up according to our plan.” One cannot prove when the slipped epiphysis would have manifested itself on an x-ray. It could have been at the time of the swimming incident or only after the fall a month. Once SCFE is identified, surgical stabilization should be done ASAP. That said, the role of timing as a cause of complications like AVN remains a debatable issue. SCFE classically presents in an overweight adolescent with non-radiating, dull, aching pain in the hip, groin, thigh, or knee, and no history of trauma. Reference: Slipped Capital Femoral Epiphysis Treatment & Management. Walter KD. Medscape eMedicine. Updated Sep 29, 2023.
EM@3AM: Ehrlichiosis - emDocs
A 70-year-old male with presents with 5 days of fever and 3 days of anuria and malaise. He also notes worsening abdominal distention and shortness of breath. He found and removed a tick 3 weeks ago and another one 1 week ago. Labs reveal WBC 2,200 cells/microL, HGB 11.2 g/dL, Plt 21 × 109/L, BUN 86 mg/dL, Creatinine 6.8 mg/dL, AST 350 U/L, ALT 119 U/L.
EM@3AM: Corneal Transplant Complications - emDocs
A 61-year-old male with a history of bilateral corneal transplants due to Fuchs' endothelial dystrophy presents with progressive visual decline in his right eye over the past three days. He describes associated redness, photophobia, and mild foreign body sensation. He denies trauma but acknowledges inconsistent use of his prescribed steroid eye drops. He has decreased visual acuity in the right eye, mild conjunctival redness, and absence of purulent discharge. Slit-Lamp reveals corneal swelling with scattered keratic precipitates and mild anterior chamber inflammation.
EM@3AM: Thyrotoxic Periodic Paralysis - emDocs
A 28-year-old otherwise healthy male presents for an acute episode of bilateral lower extremity weakness causing him to fall in the bathroom. The episode started approximately 30 minutes prior to arrival. He had a similar episode three months prior which resolved quickly during his ED visit. Neuro exam includes intact sensation in all distributions to light touch. Hip flexion ⅖ bilaterally, knee extension ⅗ bilaterally, plantar and dorsiflexion ⅘. Bilateral upper extremities shoulder flexion, elbow flexion, and extension 5/5. Labs reveal low potassium, phosphate, magnesium, TSH.