UMEM Educational Pearls

Category: Trauma

Title: Hypertonic Saline or Mannitol for Head Injury?

Keywords: Head injury mannitol saline ICP (PubMed Search)

Posted: 10/1/2023 by Robert Flint, MD (Updated: 10/2/2023)
Click here to contact Robert Flint, MD

"The main findings were the following: (1) there was no evidence of an effect of HTS compared with other agents (mainly mannitol) on long-term neurological outcome in patients with raised ICP; (2) similarly, there was no evidence of a beneficial effect of HTS on all-cause mortality, uncontrolled ICP, length of hospital or ICU stay, and ICP reduction; and (3) HTS may be associated with increased risk of adverse hypernatremia.”


Show References

Kids eat everything (except perhaps carefully prepared and balanced meals). While button battery ingestions are feared, there is more to worry about. Magnet ingestions – especially rare earth metal magnet ingestions – can lead to high morbidity and mortality.

When more than one magnet (or a magnet and another metallic object) are ingested, they can become stuck together through walls in the GI tract, creating risk for obstruction, erosion, fistula formation, and perforation. Sharp metallic foreign objects can be particularly dangerous as they can do much damage while being moved around by the magnet.  

If there is concern for magnet ingestion, care should be taken to try to determine the number ingested (if parents have the magnets, you can compare the size of an object on xray to the size of the magnets as it can otherwise sometimes be difficult to differentiate if it is one magnet or more than one stuck together).  

Higher risk features of ingestion include: 

  • Ingestion of a magnet and a sharp metallic object
  • Higher number of magnets ingested
  • A longer interval over which the magnets were ingested
  • Multiple magnets in the esophagus (raises concern for concomitant aspiration)


Ingestions should prompt consultation with pediatric GI and surgery when isolated as many will require either endoscopic or surgical removal. This may include need for referral and transfer.  


Show References

Category: Administration

Title: Physician Workforce Diversity in EM

Keywords: Workforce, Diversity, Under-represented minorities (PubMed Search)

Posted: 9/27/2023 by Mercedes Torres, MD (Updated: 10/2/2023)
Click here to contact Mercedes Torres, MD

Physician Workforce Diversity in EM

Health inequities along racial, ethnic, and socioeconomic lines are a brutal reality of the current state of health care in the US.  One way to attempt to address these inequities is to make a concerted effort to diversify our physician workforce.  As authors have noted, “Having physicians from diverse backgrounds as colleagues and role models can promote understanding and tolerance in nonminority physicians, ultimately improving medical care for patients who are part of these racial and ethnic groups. Increasing the population of underrepresented minority (URM) physicians in the workforce also directly improves health care for medically underserved populations from all racial and ethnic backgrounds, as studies have shown that physicians from URM backgrounds are more likely to work with these patients.”

Administrators are often tasked with the difficult job of creating a cohesive group of emergency physicians to meet the needs of the community they serve.  Strategies to diversify that workforce would benefit from a multi-level approach, including the following:

  • Focus on the high school and college pipeline to increase the number of URM entering the field of medicine and emergency medicine more specifically.
  • Make a conscious effort to recruit and interview URM candidates for open positions.
  • In meetings, ask specific questions from individuals whose voices are often marginalized.
  • In group settings, pay attention to your physical position; if you are a White male, let your URM colleagues position themselves at the head of the table.

 Small steps can create big changes.


Show References

Category: Hematology/Oncology

Title: Approaches to neutropenic fever- what's out there?

Keywords: Neutropenic Fever, Phamacology, Infectious Disease, Oncology (PubMed Search)

Posted: 9/25/2023 by Sarah Dubbs, MD
Click here to contact Sarah Dubbs, MD


Treatment of neutropenic fever is evolving, especially in the context of multidrug-resistant (MDR) organisms. This article reviews an update on best practices and describes two approaches to antimicrobial therapy- "escalation" and "de-escalation". Escalation begins with a narrow spectrum of antimicrobials and increases based on patient response, suitable for uncomplicated cases. De-escalation starts with broad-spectrum antibiotics and narrows down, recommended for complicated cases. The choice depends on the institution's MDR prevalence. Initial antimicrobials like cefepime or carbapenems are selected based on resistance rates. De-escalation timing varies per guidelines, but clinical trials support its safety and efficacy. Benefits include reducing C. difficile risk, antimicrobial resistance, and complications. Despite these advantages, some centers lack explicit de-escalation guidance, emphasizing the need for clear protocols to optimize patient outcomes by minimizing antibiotic therapy duration.

Show More In-Depth Information

Show References

Category: Orthopedics

Title: Exercise and asthma, still water and oil?

Keywords: asthma, reactive airway disease, lung function (PubMed Search)

Posted: 9/24/2023 by Brian Corwell, MD (Updated: 10/2/2023)
Click here to contact Brian Corwell, MD

The role of exercise in patients with asthma is complicated.

Asthma symptoms can worsen or be triggered by physical activity. This can lead to avoidance response. Patients with asthma are less physically active than their matched controls.

Recently, however, the role of exercise and physical activity as an adjunct therapy for asthma management has received considerable attention. There is an emerging and promising role of physical activity as a non-pharmacologic treatment for asthma. Exercise reduces inflammatory cytokines and increases anti-inflammatory cytokines thereby reducing chronic airway inflammation.

Physical activity can help improve lung function and boost quality of life. As fitness improves, asthma patients report better sleep, reduced stress, improved weight control, and more days without symptoms.

The Global Initiative for Asthma recommends twice-weekly cardio and strength training. Strength training requires short periods of exertion allowing for periods of rest and recovery. High-intensity interval training (HIIT) is a promising option for people with asthma. These types of workouts allow ventilation to recover intermittently vs conventional cardio exercises.

A 2021 study in adults with mild-to-moderate asthma found that low volume HIIT classes (three 20-minute bouts/week) significantly improved asthma control.  Patients also had improved exertional dyspnea and enjoyment of exercise which will, in turn, increase the odds of further exercise.

A 2022 study compared constant-load exercise versus HIIT in adults with moderate-to-severe asthma. Exercise training lasted 12 weeks (twice/week, 40 minutes/session).  Both groups showed similar improvements in aerobic fitness however the HIIT group reported lower dyspnea and fatigue perception scores and higher physical activity levels.

Conclusion: Patients with asthma should be encouraged to safely incorporate exercise in their daily lives bother for overall health benefits but also as an effective non-pharmacologic asthma treatment.




Show References

Since the switch from fee for service to value based care in the US, there has been a marked push to improve our documentation to expand our MDM and differential considerations.  We are all here becoming adept at the medical documentation (thanks Dr. Adler!), but may not be adequately documenting our patients' social determinants of health using the social Z codes, a subset of ICD-10 coding language

This study wanted to look at the overall prevelance of social Z code utilization.  They used the Nationwide Emergency Department Sample (NEDS), a nationwide database of ED visits, to look at this particular documentation.  They examined 35 million (!) ED visits and found that only 1.2% had any social Z code included in the documentation.  Given how many resources are linked to a verified (eg documented) need, this raises the idea that if Z codes are better documented, this may lead to increased funding for things like food, housing and transportation insecurities.

Limitations- the authors only examined the ED visits for ICD-10 codes, they didn't specifically look at the notes themselves which may have contained SDOH information.  They also found that the social Z codes were more often documented in visits coded for mental health diagnoses, potentially indicating bias.  There is also the concern that patients may not want the social z codes included, given the stigma around things like homelessness.

Overall, social Z code documentation could potentially unlock better resources for our patients by documenting a specific need in a population.  More will come as documentation continues to evolve.

Show References

Category: EMS

Title: What are the barriers for laypeople to be trained in CPR?

Keywords: cardiac arrest, CPR, bystander (PubMed Search)

Posted: 9/20/2023 by Jenny Guyther, MD (Updated: 10/2/2023)
Click here to contact Jenny Guyther, MD

Prior studies have shown that CPR education is associated with a greater willingness to perform CPR.  This was a review of 23 studies to determine factors that enable and hinder a layperson from learning CPR.
Enabling factors included having witnessed someone collapse in the past, awareness of public AEDs, certain occupations and legal requirements for training (i.e. mandatory high school CPR training).
Married people were more likely to be trained than those that were not married and people with children younger than 3 years were less likely to take a BLS course.  
Barriers that were found to impact people taking CPR classes included lower socioeconomic status and education level, and advanced age and language barriers.  
Bottom line: CPR education sessions should target groups with these identified barriers.

Show References

The BRASH syndrome (Bradycardia, Renal failure, AV nodal blockade, Shock, Hyperkalemia) has been increasingly described in the literature in the past 3-5 years.  

The inciting factor is generally considered to be something that prompts acute kidney injury, often hypovolemia of some sort.  Rather than AV nodal blocker overdose or severe hyperkalemia causing conduction problems, the combination of AV nodal blocker use (most often beta-blockers, but can be any type) and hyperkalemia (often only moderate) has a synergistic effect on cardiac conduction with ensuing bradycardia that can devolve into a cycle of worsening renal perfusion and shock.

Treatment is supportive, but most effective when the syndrome is recognized and all parts simultaneously managed.  ED physicians should be familiar with its existence for targeted whole-syndrome stabilization and to avoid diagnostic delay.

  • Shock – If hypovolemic, IV fluid resuscitation. Concomitantly or if still hypotensive, epinephrine infusion is recommended as it provides both chronotropy and inotropy, and also assists with hyperkalemia.
  • Hyperkalemia – usually mild/moderate; IV calcium for any ECG abnormalities, intracellular shifting medications, and kaliuresis (may require high-dose loop diuretics, with IV fluids if needed to maintain volume)
  • Bradycardia – will usually respond to IV calcium and chronotropy (epinephrine, isoproterenol); pacing rarely but sometimes needed
  • Renal failure – IVF and perfusion support as noted above, but patients may require dialysis if renal failure is severe and hyperkalemia is unable to be medically managed

Show References


Point of Care Ultrasound has been shown to change medical management and decrease time to diagnosis. 

However, sometimes on a busy shift we may get an xray or radiological study prior to performing a POCUS exam due to time constraints.

A recent study looked at the time it takes to perform a bedside ultrasound.

The authors measured the duration of time from starting the exam through the ultrasound worklist to the timestamp on the last recorded image. 

They reviewed 2144 studies and found a median time of 6 minutes to perform a study. 

Of course the study is limited by the time it takes to find a machine, make sure it is functioning and other supplies such as gel. 


Conclusion: You can take 6 minutes to assist in your patient's clinical care.

Show References

Category: Gastrointestional

Title: Can appendectomy wait until the morning?

Keywords: appendicitis, delayed operating room, appendectomy (PubMed Search)

Posted: 9/17/2023 by Robert Flint, MD (Updated: 10/2/2023)
Click here to contact Robert Flint, MD

This Scandinavian study from the Lancet says yes. They randomized 1800 patients over age 18 to appendectomy either within 8 hours or 24 hours and found no difference in perforation rate or other complications. 


Show References

Category: Pediatrics

Title: Spontaneous Pneumomediastinum in Children: What should I do?

Keywords: Spontaneous Pneumomediastinum, asthma, crepitus, esophagram (PubMed Search)

Posted: 9/15/2023 by Jenny Guyther, MD
Click here to contact Jenny Guyther, MD

Spontaneous pneumomediastinum (SPM) is air within the mediastinum in the absence of trauma.  This occurs more often in males and has 2 age peaks: children younger than 6 years as a result of lower respiratory tract infections and adolescents due to asthma exacerbations.  Typical symptoms include chest pain, subcutaneous emphysema and shortness of breath, but can also include neck pain, dysphagia, pneumopericardium, and pneumorrhachis (air in the spinal cord).   SPM has been seen in patients with a history of asthma, current influenza infection and hyperventilation with anxiety, but many have no known precipitating factor. 
The diagnosis of SPM is typically made on CXR.  The literature is mixed on the utility of CT scans, esophagrams, esophagoscopy and bronchoscopy.  This study looked at 179 pediatric patients who were diagnosed with SPM.  No patients were found to have an esophageal injury.  Also, CT scans did not provide additional information or change management based on what was seen on the chest xray.
The author's concluded that CT scans and esophagrams can be avoided unless there is a specific esophageal concern.  Management should be guided based on the patient's symptoms.

Show References

Category: Pharmacology & Therapeutics

Title: DOAC "Loading Dose" = Misnomer

Keywords: DOAC, apixaban, rivaroxaban, loading dose (PubMed Search)

Posted: 9/14/2023 by Wesley Oliver (Updated: 10/2/2023)
Click here to contact Wesley Oliver

DOACs (dabigatran*, apixaban, rivaroxaban) each have different dosing strategies based on indication and patient characteristics. While there is no official term for the doses, the higher initial doses for apixaban (10 mg BID for 7 days) and rivaroxaban (15 mg BID for 21 days) for the treatment of venous thromboembolism (VTE) are commonly referred to as “loading doses.” However, the term “loading dose” is actually a misnomer.

Loading doses are used to reach therapeutic drug levels quicker with medications such as vancomycin and phenytoin/fosphenytoin. However, this is not the purpose of the higher initial doses of apixaban and rivaroxaban. The purpose of the higher doses is to provide increased levels of anticoagulation during the acute phase of VTE when patients are hypercoagulable. For this reason, VTE and heparin-induced thrombocytopenia are the only indications where a higher dose is used initially, all other indications start with the standard dose. The difference in duration of these higher doses between apixaban (7 days) and rivaroxaban (21 days) are due to the durations used in trials by the drug company, versus any pharmacokinetic reasons.

To apply this concept:

Apixaban/Rivaroxaban: For the treatment of VTE, a higher dose is only required for the initial 7- (apixaban) or 21-day period (rivaroxaban). After this period, if there is any interruption in therapy, the standard dose can be restarted because therapeutic levels are rapidly achieved and higher doses are not needed outside of the acute phase.

One caveat to this would be if the patient developed a new VTE while therapy is interrupted, in which case another period of the higher dosing could be considered.


*Remember: Dabigatran cannot be used for initial treatment of VTE and must be started only after at least 5 days of a parenteral anticoagulant. (Dabigatran and the parenteral anticoagulant should not be overlapped).

Show References

Category: Critical Care

Title: CPAP vs HFNC for undifferentiated acute respiratory failure

Keywords: NIPPV, CPAP, HFNC, High Flow, Respiratory Failure (PubMed Search)

Posted: 9/12/2023 by Mark Sutherland, MD
Click here to contact Mark Sutherland, MD

When patients fail simple respiratory support therapies like nasal cannula or non-rebreather, it is often a point of debate whether to move next to High Flow Nasal Cannula (HFNC) or Noninvasive Positive Pressure Ventilation (NIPPV).  This study randomized patients in acute respiratory failure (ARF) to CPAP, a form of NIPPV, vs HFNC.  They looked at all comers in ARF, and primary outcome was need for intubation.  Importantly, they excluded asthma/COPD exacerbation, for which BiPAP is typically considered the first line therapy due to improved CO2 clearance.

They found a significantly lower number of patients required intubation in the CPAP (28.9%) group than the HFNC (42.6%) group (p=0.006).  They hypothesized that the enhanced PEEP improved oxygenation (hypoxia being a common trigger for moving to intubation), but as opposed to BiPAP,  the lack of additional driving pressure limited tidal volumes and Patient Self-Inflicted Lung Injury (P-SILI), which is a known mechanism of ARDS and mortality.  They use this argument to explain why trials like FLORALI, pitting HFNC vs BiPAP, tend to not find an advantage for the NIPPV arm.  While this rationale makes sense, it should be noted that the study does not directly investigate if this was the reason for the difference, and for what its worth the inverse argument that using driving pressure to reduce respiratory rate, hypercarbia, and work of breathing (other very common indications for intubation) would also theoretically reduce intubations.  Furthermore, it's not clear why reducing P-SILI, which tends to cause mortality on a much longer duration, would improve the short-term outcome of need for intubation.


Bottom Line: This study demonstrated a benefit to CPAP over HFNC in terms of decreasing need for intubation amongst non-asthma/non-COPD patients with acute respiratory failure, and offered a physiologic rationale but one that requires further verification and discussion.  While it may be reasonable to choose CPAP instead of HFNC in marginal patients at risk of intubation (but stable enough to trial noninvasive support first), in my opinion more studies are likely needed before a wholesale change in practice.  The study also does not take into consideration the enhanced comfort and compliance we tend to see with HFNC over NIPPV, which should be considered as well.  

Show References

Category: Trauma

Title: Rural damage control laparotomy can be life saving

Keywords: rural, trauma, laparotomy, damage control (PubMed Search)

Posted: 8/19/2023 by Robert Flint, MD (Emailed: 9/10/2023) (Updated: 10/2/2023)
Click here to contact Robert Flint, MD

For rural emergency departments, the decision to transfer a trauma patient to a level one center involves multiple factors including the patient’s hemodynamic stability. Harwell et al. looked at 47 trauma patients transferred from a rural hospital to a level one center. They found: “Overall mortality was significantly different between patients who had damage control laparotomy at a rural hospital (14.3%), were unstable transfer patients (75.0%), and stable transfer patients (3.3%; P < 0.001).”  They concluded: “Rural damage control laparotomy may be used as a means of stabilization prior to transfer to a Level 1 center, and in appropriate patients may be life-saving.”

Preplanning with emergency medicine, surgery, radiology, anesthesia, nursing, and the receiving trauma center on how to manage these patients is critical.  

Show References

Sport related concussion has been estimated to affect almost 2 million children and adolescents in the United states annually

Patients who take longer than four weeks to recover are considered to have persistent post concussive symptoms

This diagnosis is associated with poor educational, social and developmental outcomes in pediatric patients

Following sport related concussion, patients are recommended to have an individualized aerobic exercise program

Prior studies have found that sub symptom threshold aerobic exercise safely and significantly speeds recovery from sport related concussion.

Purpose: This study attempted to answer whether there is a direct relationship between adherence to a personalized exercise prescription and recovery or if initial symptom burden effects adherence to the prescription.

Design: Male and female adolescents aged 13 to 18 years old presenting within 10 days of injury and diagnosed with sport related concussion.

Almost all participants (94%) sustained concussion during interscholastic games or practices.

As it is known that physician encouragement can influence patient adherence to medical interventions, treating physicians in the study were blinded to study arm assignment.

Patients were given aerobic exercise prescriptions based on their heart rate threshold at the point of exercise intolerance on a graded treadmill test

Adherence to prescription was determined objectively with heart rate monitors. No participants exercised above their prescribed heart rate intensity.

Patients who completed at least 2/3 of their aerobic exercise prescription were considered to be adherent

Results: 61% of adolescents met the adherence criterion

Adherent patients were more symptomatic and were more exercise intolerant (worse initial exercise tolerance) at their initial visit.

These patients were also more adherent than those with fewer symptoms and with better exercise tolerance. This likely indicates a stronger motivation for those more symptomatic patients to engage in a potentially effective intervention.

Adherent patients recovered faster than those who were not adherent (median recovery time 12 days versus 21.5 days (P = 0.016)

Adherence during week one was inversely related to recovery time and to initial exercise tolerance but not to initial symptom severity

Conclusion: Adherence to individualized sub symptom threshold aerobic exercise within the first week of sport related concussion is associated with faster recovery. The initial degree of exercise intolerance (but not initial symptom severity) affects adherence to aerobic exercise prescription in an adolescent population with sport related concussion




Show References

The literature is not completely new regarding the use of intranasal dexmedetomidine for pediatric sedation, with several articles confirming noninferiority to benzodiazepines. It is a potent a2- adrenergic receptor agonist, which allows for sedation without analgesic properties. It can be considered for patients who are undergoing PAINLESS procedures. A recent article gave further clarification for dosing considerations when selecting this option. This study assessed varying weight-based doses and found the best effect with doses of 3 to 4 mcg/kg  


Importantly, there is limited data that suggests this may result in longer discharge, duration of procedure and total time in the department compared to other sedation methods. Additionally, this option is not always readily available and approved for pediatric patients in every hospital.  


Overall, Dexmedetomidine may be an excellent option for painless procedures, such as CT imaging or even MRI based on the literature, when available. 


Show References

It's back to school season which means back to school injuries! 

Scalp lacerations often require suturing or staple closure, but what if you can close the wound without any sharps that scare the kiddos? Consider using the Hair Apposition Technique (HAT)!

What is HAT?

- A very quick and easy technique for superficial scalp laceration closure made by twisting hair on each side of the laceration and sealing the twist with a small dot of glue for primary closure. 

When do I consider HAT?

- For linear, superficial lacerations that are <10cm in length 

- Laceration has achieved adequate hemostasis

- Patient has hair on both sides of the laceration

What are contraindications to HAT? 

- Hair strands are less than 3cm in length

- Laceration is longer than 10cm in length

- Active bleeding from laceration despite hair apposition

- Significant wound tension

- Laceration is highly contaminated

How do I perform HAT?

- Debride wound as you normally wound for any laceration  

- Take approximately 5 strands of hair on one side of the laceration and twist them together to make one twisted bundle

- Take approximately 5 strands of hair directly on the other side of the laceration and twist them together to make another twisted bundle

- Then take each bundle and intertwine the two bundles until the wound edges appose. 

- Place a drop of glue on the twist

- Repeat along the length of the laceration until laceration is closed

Benefits of HAT:

- Based on a RCT from Singapore that compared suturing to HAT for superficial scalp lacerations that were <10cm, patient's were more satisfied, had less scaring, lower pain scores, shorter procedure tiems, adn less wound breakdown in the HAT group compared to the sutured group. 

- A follow up study by the same group also assessed cost-effectievness of HAT compared to suturing (by taking into account staff time, need for staple/suture removal, treatment of complications, materials, etc) and found that HAT saved $28.50 USD when compared to suturing. 


Modified hair apposition of scalp wounds- UpToDate

Bottom Line:

- Consider Hair Apposition Technique (HAT) for linear, superficial scalp lacerations, especially in pediatric patients as it is much more well tolerated (can also do this in adults!)

Show References

Pearls for the Patient in Cardiogenic Shock

  • Cardiogenic shock is generally defined as tissue hypoperfusion due to ineffective cardiac output.
  • Despite therapeutic advances, 30-day mortality for cardiogenic shock can reach 50%.
  • Though there are several different phenotypes and severity of staging, consider the following pearls in the initial resuscitation of patients with cardiogenic shock:
    • Early arterial line placement for accurate blood pressure monitoring.
    • Supplemental oxygen to maintain O2 > 90%.
    • NIPPV to reduce the work of breathing for patients with pulmonary edema.
    • Use of lung-protective ventilation for patients who require intubation and mechanical ventilation.
    • Vasopressor and inotrope therapy for hemodynamic support.
      • Norepinephrine is the preferred first-line vasopressor. 
      • Dobutamine or milrinone for inotrope support.
    • Early revascularization for patients with cardiogenic shock due to acute MI.

Show References

Category: Trauma

Title: Post mortem Ct scan study identifies blunt traumatic arrest injuries

Keywords: arrest, trauma, pneumothorax, CT scan (PubMed Search)

Posted: 8/19/2023 by Robert Flint, MD (Emailed: 9/3/2023) (Updated: 10/2/2023)
Click here to contact Robert Flint, MD

In a study looking at 80 blunt trauma patients that died within 1 hour of arrival to a trauma center who underwent a noncontrast post mortem CT scan the following injuries were identified:

            -40% traumatic brain injury

            -25% long bone fracture

            -22.5% hemoperitoneum

            -25% cervical spine injury

            - 18.8% moderate/large pneumothorax

            -5% esophageal intubation


Blunt trauma arrest patients deserve decompression of the chest (preferred method is open with finger sweep). Intubation should be verified with end tidal CO2. Verification on arrival at the trauma center is also prudent.

Show References

Category: Trauma

Title: Liver Laceration Grading

Keywords: liver laceration, trauma (PubMed Search)

Posted: 8/31/2023 by Robert Flint, MD
Click here to contact Robert Flint, MD

Show References