UMEM Educational Pearls

Category: Critical Care

Title: CT FIRST: Should we pan-CT everyone post-ROSC?

Keywords: OHCA, ROSC, cardiac arrest, resuscitation, CT, pan-scan, computed tomography (PubMed Search)

Posted: 7/25/2023 by Kami Windsor, MD
Click here to contact Kami Windsor, MD


Background: Prior evidence1,2 has suggested that early “pan-scan” after ROSC provides clinically-relevant information that assists in the care of the patient in question, when the cause of OHCA is unclear.

The recent CT FIRST trial looked at patients pre- and post- implementation of a protocol for head-to-pelvis CT within 6 hours of ROSC for adult patients without known cause or evidence of possible cardiac etiology, stable enough for scan. *Patients with GFR <30 were excluded from assignment to CT, although were included in the post/CT cohort if their treating doctors ordered CT scans based on perceived clinical need. To balance this, a similar number of patients with GFR <30 were included in the pre/“standard of care” cohort.

  • Pre/SOC cohort (143 pts) vs. Post/SOC+CT cohort (104 pts)
  • CT protocol: Dry head CT, CTA chest, venous phase CT abd/pelvis
  • In pre/SOC group, CTs ordered by treating docs in 52% (one or mix of the above CTs)

Outcomes After Protocol (Pre- vs. Post-):

  • Increased identification of OHCA diagnosis (75% vs. 92%, p = 0.001)
    • In SOC + CT group, diagnosis only found by CT in 13%
    • In SOC group, diagnosis only found by CT in 17%
  • Faster OHCA diagnosis (14.1h vs. 3.1h, p= 0.0001)
  • Fewer delays in time-critical diagnoses* (62% vs. 12%, p= 0.001)  *both OHCA dx and resuscitation-related injury
  • No difference in ultimate diagnosis of time-critical diagnoses, rates of AKI, or survival to hospital discharge, allergic contrast reactions (0), scan complications (0), inappropriate treatments based on CT findings (0)


Bottom Line: Early pan-CT allows for earlier definitive diagnosis and stabilization without increase in adverse events. While this earlier diagnosis does not seem to yield better survival, earlier stabilization may provide some benefits in terms of resource allocation and disposition, a notable benefit during our current crisis of staffing shortages and ED boarding. 



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Category: Trauma

Title: How much is too much? Imaging before transfer.

Keywords: radiology, transfer, trauma, imaging, rural (PubMed Search)

Posted: 7/23/2023 by Robert Flint, MD (Updated: 10/2/2023)
Click here to contact Robert Flint, MD

Evaluating trauma patients at Level 3 or 4 centers, rural hospitals, and non-trauma centers is difficult. Understanding the amount of work-up to perform prior to transfer is important. Summers, et al suggest less is more when it comes to imaging. The receiving facility often repeats imaging leading to time delays, additional radiation exposure, and increased costs. Chest X-ray and FAST exam may be all that is indicated in centers that do not have the resources to care for injures identified on CT imaging prior to transfer.

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Category: Orthopedics

Title: Evaluation of SLAP tears

Keywords: shoulder pain, labrum tear (PubMed Search)

Posted: 7/22/2023 by Brian Corwell, MD (Updated: 10/2/2023)
Click here to contact Brian Corwell, MD

SLAP tear/lesion – Superior labral tear oriented anterior to posterior

Glenoid labrum – A rim of fibrocartilaginous tissue surrounding the glenoid rim, deepening the “socket” joint.

Integral to shoulder stability.


O’Brien’s test aka active compression test for superior labral pathology.


2 parts – generally performed with the patient standing.


The patient’s shoulder is raised to 90 degrees with full elbow extension and approximately 30 degrees of adduction across the midline.

Resistance is applied, using an isometric hold.

Test in both full internal and external rotation

         -This alters the position and rotation of the humerus against the glenoid

A positive test is when pain is elicited when the shoulder is in internal rotation with forearm pronation (thumb to floor) and much less or no pain when in external rotation (supination).

Note: AC joint pain may test similarly but will localize to different area of shoulder

The presence of similar, reproducible deep and diffuse glenohumeral joint pain is most indicative of a true positive test.




Substance use disorder is now known to be a function of brain disease and not a moral failure.  Patients with substance use disorder are highly complex and often use the ED at a higher frequency than those without the disorder.  However, these patients are also frequently the target of implicit bias and stigmatizing behavior from the healthcare team that can lead to worsened outcomes.  Add on top of that a racial disparity, and we can see how this group of patients can have really bad health outcomes.

This study looked at the length of time to treatment of patients with SUD, to see if there was a difference within this group based on racial or ethnic differences. It did find that black patients with SUD did wait on average 35% longer in the ED before being seen or treated.  This difference was statistically significant.

While this study wasn't designed to identify the causes of such a disparity, it does raise concern for implicit bias being in effect among not only the healthcare workers, but ingrained into the healthcare systems themselves.

Patient's with SUD are a vulnerable group of patients, and black patients with SUD are experiencing a disparity in time to treatment.  This should remind us all to seek out ways to remove these biases and disparities from the systems where we work.

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Category: Pediatrics

Title: Should blood cultures be drawn in a child with fever and lower extremity pain?

Keywords: fever, limp, bacteremia, osteomyelitis, septic joint (PubMed Search)

Posted: 7/21/2023 by Jenny Guyther, MD (Updated: 10/2/2023)
Click here to contact Jenny Guyther, MD

This was a cross sectional review of 698 patients ages 1 year to 18 years who presented to a tertiary care center with fever of at least 38 degrees centigrade and non traumatic acute lower extremity pain. This hospital was located in the North East of the United States. Lower extremity pain was defined as an antalgic gait by report or on exam, inability or refusal to bear weight or reported bone or joint pain in the verbal patient within the past 14 days.
Blood cultures were available for review in 510 patients.  Blood cultures were positive in 70 of them (13.7%).  Pathogens included MSSA, MRSA, Strep pyogenes and Salmonella.  Significant predictors of bacteremia included an elevated CRP and localizing exam findings.  
8 blood culture contaminants were identified.  6/8 of these patients had other testing and treatment consistent with osteomyelitis.  
The final diagnosis of the patients with bacteremia included osteomyelitis, septic arthritis, pyomyositis and toxic shock syndrome.
Bottom line: The prevalence of bacteremia, even in Lyme endemic areas, in healthy children presenting to the ED with fever AND lower extremity pain is high enough to strongly consider obtaining a blood culture with other lab work during the initial evaluation. 

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Category: Toxicology

Title: Fomepizole for acetaminophen overdose?

Keywords: acetaminophen overdose, fomepizole, NAC (PubMed Search)

Posted: 7/19/2023 by Natasha Tobarran, DO (Emailed: 7/20/2023) (Updated: 10/2/2023)
Click here to contact Natasha Tobarran, DO

Acetaminophen (APAP) is the leading cause of acute liver failure worldwide. Standard treatment for APAP overdose is with N-acetylcysteine (NAC), which is highly effective if given within 8 hours of ingestion.  However, in delayed presenters or massive ingestions patients can still develop hepatotoxicity. Adjunctive therapies can be considered in these cases including augmented NAC dosing, renal replacement, and fomepizole.

A small amount of APAP is metabolized to N-acetyl-p-benzoquinone imine (NAPQI) by cytochrome 2E1. In therapeutic doses, the body is able to detoxify the NAPQI using glutathione. In overdose, glutathione stores get depleted and NAPQI can cause hepatotoxicity. Mitochondrial damage in APAP overdose is mediated by the c-Jun-N-terminal Kinase (JNK) pathway. 

NAC works to replenish glutathione stores and detoxify NAPQI. In large overdoses, increased dosing of NAC may be necessary. Fomepizole is typically used for its alcohol dehydrogenase inhibitor property to treat methanol and ethylene glycol poisoning. Fomepizole is also a cytochrome 2E1 and JNK inhibitor and can be used in APAP overdose to block the formation of NAPQI and mitigate mitochondrial damage.  Dialysis can be used to eliminate APAP from the body completely in massive overdoses or if significant acidosis or renal failure. 

This study is a case series of 14 patients treated for APAP overdose between 2017 – 2021 at a tertiary hospital

  • Patients treated with standard NAC therapy
  • They also received IV fompeizole loading dose of 15 mg/kg followed by 10mg/kg every 12 hours at the discretion of the treating team
  • Most cases received only the loading dose
  • Some cases also received renal replacement therapies
  • Patients had “better than expected outcomes” based on initial presentation, APAP levels, liver function tests, and expected clinical course
  • No unfavorable outcomes
  • No side effects

Limitations of the study:

  • Patients were treated with NAC which is the standard of care
  • No formal protocol for the administration or identification of patients treated with fompeizole

In summary:

  • NAC is the standard of care in acetaminophen poisonings
  • Consider fomepizole as an adjunctive therapy in patients that are critically ill
  • Consult your poison center 1-800-222-1222 or friendly toxicologist for help in identifying these patients

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Category: EMS

Title: ED handoff of pediatric patients by EMS

Keywords: handoff, communication, adverse outcomes (PubMed Search)

Posted: 7/19/2023 by Jenny Guyther, MD
Click here to contact Jenny Guyther, MD

Ineffective handoff communications have been shown to occur in up to 80% of medical errors.  Previous studies have shown that up to 1/3 of pertinent information is lost during the handoff of trauma patients.  Interruptions, lack of listening and ED team preoccupation with their own patient assessment have been associated with adverse outcomes.
This study reviewed videotaped footage of pediatric critical care resuscitations and the handoff between the ED and EMS.  Inefficient communication occurred in 87% of handoffs, including 51% of cases with interruptions by staff, 40% with questions from the ED leader about information that had already been given and 65% requesting information that had not yet been communicated.
Bottom line: Allow for an uninterrupted hand off from EMS followed by closed loop communication and asking any additional questions.

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Category: Critical Care

Title: Platelet Transfusion before CVC Placement

Keywords: Central Lines, Platelets, Bleeding (PubMed Search)

Posted: 7/18/2023 by Mark Sutherland, MD (Updated: 10/2/2023)
Click here to contact Mark Sutherland, MD

Central Venous Catheter (CVC; aka central line) placement is a common procedure in both the ED and ICU, and while overall quite safe, does carry some risk.  In particular, many of us regularly are confronted with the challenge of placing a line in a patient with profound thrombocytopenia, which can result in significant bleeding.  In these cases, should we give platelets before we place the line?

Van Baarle et al published a randomized study in NEJM comparing an empiric 1u platelet transfusion vs no transfusion in patients with a platelet count of 10,000-50,000, prior to line placement.  The study included both HD and non-HD (e.g. TLC) lines, from all three major access sites, in patients in their ICU or hematology ward.  They found statistically fewer serious bleeding events in the transfusion group (4.8%) vs no transfusion group (11.9%).  The study wasn't powered to look at more patient oriented outcomes like mortality, but I'm sure we can all agree less bleeding is probably a good thing.  Also importantly, this study did not evaluate the risks/benefits of delaying line placement to obtain platelets when the line is urgently needed, so I would not recommend extending this to conclude platelets must be given before line placement if the line is needed for something highly time-sensitive (e.g. only available access to infuse pressors in a hypotensive patient).  


Bottom Line: It is probably beneficial and appropriate to provide prophylactic platelet transfusion prior to CVC placement in patients with a platelet count less than 50,000, assuming circumstances allow.  

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Category: Trauma

Title: Tme to Access: IO vs IV

Keywords: access, IO, IV, resucitation (PubMed Search)

Posted: 7/9/2023 by Robert Flint, MD (Emailed: 7/16/2023)
Click here to contact Robert Flint, MD

This study found that time to intraosseous was faster than time to peripheral IV. This lead to quicker resuscitation time. This was particularly true in pateints that arrived without a pre-hospital IV. 


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Category: Pediatrics

Title: Pediatric fever: Is response to antipyretics enough to discharge?

Keywords: Pediatrics, infectious disease, fever, bacteremia (PubMed Search)

Posted: 7/14/2023 by Kathleen Stephanos, MD (Updated: 10/2/2023)
Click here to contact Kathleen Stephanos, MD

This study attempts to answer the age old question: What is the importance of fever in pediatric illnesses?

The authors' goal was to assess if response to antipyretics was associated with bacteremia. This article retrospectively reviewed 6,319 febrile children in whom blood cultures were sent and found that 3.8% had bacteremia.  They then looked at the fever curve in response to antipyretics for these two groups in the emergency department over 4 hours. The study concluded that patients with bacteremia have a higher rate of persistent fever despite antipyretics. It is important to note the limitations of this study. As this was retrospective, it is unclear what clinical findings resulted in blood cultures being sent - most febrile children did not have any drawn (23,999 were excluded for this reason). They did not assess other vital signs, and did not address other bacterial infections (UTI, cellulitis, meningitis, otitis media, etc).  Additionally, while patients with bacteremia did have a higher likelihood of fever, the majority of patients in both groups had fever resolution within 4 hours, and both groups had some children with persistent fevers. 

Overall, this does seem to support the decision to consider obtaining further testing in those children with a persistent fever, but also emphasizes the importance of not using fever resolution alone as support for discharge to home or exclusion of bacteremia from the differential. 

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Category: Pharmacology & Therapeutics

Title: Optimal calcium repletion for massive transfusion protocol

Keywords: Calcium, Massive transfusion protocol, Citrate, Blood products (PubMed Search)

Posted: 7/13/2023 by Wesley Oliver (Updated: 10/2/2023)
Click here to contact Wesley Oliver

Citrate is an anticoagulant added to blood products to maintain stability for storage. With the administration of large volumes of blood products, citrate binds to ionized calcium, which can cause hypocalcemia. Evidence for specific calcium administration during massive transfusion protocols is limited; however, a proposed strategy has been to administer calcium gluconate 2 grams for every 2-4 units of red blood cells.

Robinson, et al. performed a retrospective analysis attempting to determine the optimal Citrate:Ca ratio (a novel ratio created for this study) to reduce 30-day mortality. They did not find any differences in mortality; however, they found a Citrate:Ca ratio of 2-3 produced a normalized ionized calcium level with 24 hours of a massive transfusion protocol.

Based on their calculations, this would equate to supplementing 1 g of calcium gluconate for every 3 units of red blood cells given.

***Reminder: Based on the amount of elemental calcium in each gram of calcium gluconate (4.7 mEq) and calcium chloride (13.6 mEq); 3 g calcium gluconate=1 g calcium chloride.***

Bottom Line: Supplementing with calcium gluconate 1 g for every 3 units of red blood cells should be sufficient to maintain normal ionized calcium levels after a massive transfusion protocol.

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Age >36


Prolonged exposure (>24hrs)

COHgb level >25%

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Category: Trauma

Title: Pelvic Fractures

Keywords: pelvic fracture, binder, hemorrhage (PubMed Search)

Posted: 7/9/2023 by Robert Flint, MD
Click here to contact Robert Flint, MD

Pelvic fractures can be a major source of life threatening hemorrhage. Suspect fracture with significant force/mechanism. Signs are pelvic tenderness (no need to “rock” the pelvis), bruising at perineum, and hypotension in the setting of major trauma. Major classifications of pelvic fractures are lateral compression, anterior posterior (wide public ramus, open book), and vertical sheer (fall from height). An appropriately applied pelvic binding device can be lifesaving. The biggest mistake in applying these devices is to apply them too high. Maximum pressure is achieved with application directly across the greater trochanters.

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Multiple vision disorders may occur after concussion including injury to the systems that control binocular vision including: Convergence insufficiency and Accommodation insufficiency

In order to obtain a single binocular vision, simultaneous movement of both eyes in opposite directions is required.

To look at an object close by such as when reading, the eyes must rotate towards each other (convergence).

Convergence insufficiency is the reduced ability to converge enough for near vision and is a common visual dysfunction seen after concussion.

One of both eyes may also turn outward.

May lead to complaints with reading such as diplopia, blurry vision, eyestrain, and skipping words or losing one's place.

Patient or parent may also report other difficulties such as becoming more easily fatigued when reading, needing to squint and/or having disinterest in reading.

Take home: consider testing convergence in patients with some of these complaints in setting of acute or subacute head trauma.



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Burns are common pediatric injuries and usually represent preventable unintentional trauma.
Approximately 10% of children hospitalized with burns are victims of abuse. Thermal burns are the most common type of burn and can result from scalding injuries or contact with objects (irons, radiators, or cigarettes). Features of scald burns that are concerning for inflicted trauma include clear lines of demarcation, uniformity of burn depth and characteristic pattern. Abusive contact burns tend to have distinct margins (branding of the hot object), while accidental contact burns tend to have less distinctive edges
How Kids are Different than Adults: 
- Kids have thinner skin, so time to burn/energy required to cause a burn is less. 
- Kids have increased blood volume relative to their mass, so may need more volume resuscitation compared to adults. 
- Kids are more likely to become hypoglycemic so give glucose in mIVF in kids <20 kgs.
- Risk of airway compromise in kids following inhalation injury is higher due to their smaller airway openings 
- Initial treatment should follow ABCs of resuscitation
- Airway: Airway management should include assessment for presence of airway or inhalation injury, with early intubation if such an injury is suspected. Smoke inhalation may be associated with carbon monoxide toxicity; 100% humidified oxygen should be given if hypoxia or inhalation is suspected.
- Circulation: Parkland's formula
     - Fluid requirements = TBSA burned (%) x weight (kg) x4mL
     - Give ½ of total requirements in 1st 8 hours, then give 2nd half over the next 16 hours. 
          - Rule of 9's for adults: 9% for each arm, 18% for each leg, 9% for head, 18% for front torso, 18% for back torso
          - Rule of 9's for children" 9% for each arm, 14% for each leg, 18% for head, 18% for front torso, 18% for back torso. 
Options for pain management
- fentanyl IN
- morphine IV
- ketamine IV
 Burns you should consider admission
- >6% TBSA
- full thickness burns
- specialty areas: face, eyes, airway, genitalia, palmar crease, sole of foot
- concern for non-accidental injury
- caused by treadmill


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Category: Toxicology

Title: Pediatric edible cannabis toxicity

Keywords: cannabis exposure, pediatric, toxicity, NPDS (PubMed Search)

Posted: 7/6/2023 by Hong Kim, MD, MPH (Updated: 10/2/2023)
Click here to contact Hong Kim, MD, MPH

Medical Cannabis is permitted in 39 states and Washington DC while 18 sates and Washington DC has legalized recreational cannabis use. As cannabis products become more available, pediatric exposure has also increased.

A retrospective study of National Poison Data System involving children < 6 years from 2017 and 2021 showed: Pre-COVID (2017-2019) & COVID (2020-2021)

  • 7043 exposures: (increase of 1375%)
  • 2017: 207  
  • 2021: 3054 
  • Residential exposure: 97% (n=6842)

Common Clinical effects

  • CNS depression: 70% (n=3381)
    • Pre-COVID: 61.6% --> COVID: 72.9% (p<0.05)
  • Tachycardia: 11.4% (N=548)
    • Pre-COVID: 10.3% -->COVID: 11.6% (p,0.05)
  • Vomiting: 9.5% (n=4827)
    • Pre-COVID: 7.5% -->COVID: 10.0% (p<0.05)
  • Ataxia: 7.4% (n=352)
  • Confusion: 6.1% (n=294)
  • Mydriasis: 5.9% (n=284)
  • Respiratory depression: 3.1%


  • Admission: 22.7%
  • Critical care: 8.1% (n=533)
    • Pre-COVID: 6.6% -->COVID: 8.6% (increase of 30%) (p<0.05)
  • Non-critical care: 14.6% (n=1027)
    • Pre-COVID: 9.7% -->COVID: 16.3% (increase of 68%)(p<0.05)


  • Pediatric cannabis exposure has increased between 2017 and 2021. consequently, more pediatrics patients developing toxicity and being hospitalized.

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Category: Gastrointestional

Title: POCUS for Appendicitis

Keywords: POCUS, Appendicitis, Pregnancy (PubMed Search)

Posted: 7/3/2023 by Alexis Salerno, MD
Click here to contact Alexis Salerno, MD

POCUS can be used to screen for appendicitis.

A recent study showed a sensitivity of 66.7% (CI 95% 47.1–82.7), and a specificity of 96.8% (CI 95% 83.3–99.9) during pregnancy, with the highest sensitivity in the first trimester. 

2 methods to locate the appendix are:

1) have your patient point to the area where it hurts the most

2) perform a lawnmower technique over the right lower quadrant looking for the right psoas mucle and the iliac vessels. The appendix will usually be near these structures. 

Sometimes it is easiest to use your curvilinear probe to identify an area of inflammation and then change to the linear probe for better visualization. 

On ultrasound, appendicitis is defined as a non-compressible blind pouch with an outer diameter greater than 6 mm. On short axis the inflammed appendix will look like a target sign:


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Category: Trauma

Title: Abnormal pre-hospital SI is a poor predictor even with a normal arrival SI

Keywords: shock index, trauma, pre-hospital (PubMed Search)

Posted: 7/2/2023 by Robert Flint, MD (Updated: 10/2/2023)
Click here to contact Robert Flint, MD

Shock index (heart rate/systolic blood pressure) has been used to predict trauma outcomes. This study from American Journal of Emergency Medicine looked at 89,000 pre-hospital patients who had a normal shock index on arrival at an emergency department. They then looked for those with abnormal pre-hospital shock index vs. those without an abnormal shock index and compared outcomes. Those with an abnormal pre-hospital shock index had worse outcomes than those with normal pre-hospital shock index.

Bottom line: A good handoff from pre-hospital to emergency department staff is critical because any abnormal shock index predicts a worse outcome than those with a normal shock index.

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Category: Ophthamology

Title: Identify this eye exam finding.

Keywords: Optho. (PubMed Search)

Posted: 6/16/2023 by Robert Flint, MD (Emailed: 6/29/2023) (Updated: 6/29/2023)
Click here to contact Robert Flint, MD



What is this called? What does it indicate? Treatment?

Show Answer

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Category: Administration

Title: Predictive Rule for Likelihood to Occupy Inpatient Bed

Keywords: predictive rule, EHR, utilization, AI (PubMed Search)

Posted: 6/16/2023 by Robert Flint, MD (Emailed: 6/28/2023) (Updated: 10/2/2023)
Click here to contact Robert Flint, MD

Author- Steve Schenkel, MD MPP Professor of Emergency Mediciner at UMEM:

A recent Annals of Emergency Medicine Publication (here tested a predictive rule for Likelihood to Occupy an Inpatient Bed associated with a common Electronic Health Record.


At the individual patient level, the score performed ok. Depending on the chosen threshold, it traded off sensitivity and specificity and generally became more accurate the longer the patient was in the ED.


The authors and the associated editorial (here suggest a different, potentially more beneficial use: to allow aggregate prediction of admissions across an entire department and therefore prompt earlier planning to prevent crowding on account of boarding.


The takeaway: Administrative prediction rules oriented toward individual patients may be more meaningfully used to predict resource needs, including in-patient beds, across the ED population.

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