This abstract from ACEP's most recent research forum looked at the effect a patient's preferred language had on ED LOS, rate of admission, hospital length of stay and resource utilization both in the ED and the hospital.
Overall, those patients who spoke English as their primary language had lower ED LOS, less testing done in the ED, but if they got admitted they had the longest hospital LOS. Patients who preferred Spanish language had the shortest hospital LOS and were most likely to be discharged home with no services. Non-English/non-Spanish languages had the longest ED LOS and highest admission rates and had similar resource use as patients who preferred Spanish
This abstract opens the door for further research into what the underlying cause of these disparities are.
This pearl was adapted from a literature update presented by Castin Schulz, PharmD on November 13, 2025.
A 2025 study in the American Journal of Emergency Medicine provides new real-world data on the two most common reversal agents for factor Xa (fXa) inhibitor-related intracranial hemorrhage (ICH).
This national retrospective cohort study evaluated 350 Veterans who received either andexanet alfa (AA) or 4-factor prothrombin complex concentrate (4F-PCC) for fXa inhibitor-related ICH.
Key Findings (Propensity-Matched Analysis)
Clinical Takeaway
In this study of Veterans with fXa inhibitor-related ICH, andexanet alfa did not improve 90-day mortality compared to 4F-PCC. However, its use was associated with a significantly increased risk of 30-day thrombotic events, particularly ischemic stroke.
This study adds to a growing body of literature questioning the safety profile of AA. The authors conclude that the selection of AA should be carefully weighed against the patient's underlying risk of thrombotic events.
Anecdotally, we as emergency physicians are fairly comfortable prescribing odansetron to adults with nausea and vomiting. However, emergency physicians often treat pediatric gastroenteritis with a single dose of odansetron in the department. A recent study in NEJM examined effects of discharging with odansetron. Full details can be found in the study, but the take-home:
Sending children home with ondansetron after an emergency visit for gastroenteritis cut the rate of moderate-to-severe illness from 12.5% to 5.1% compared to placebo, with no uptick in adverse events. Those taking ondansetron experienced fewer vomiting episodes in the first 48 hours. Targeted, as-needed dosing helps the sickest children recover faster, while avoiding unnecessary medication for most kids.
This study surveyed 111 emergency medicine (EM) trainees to identify factors influencing their choice of critical care (CC) fellowship pathways, particularly surgical critical care (SCC). Respondents included 42 fellows and 69 residents, with most pursuing anesthesiology or medicine CC; only 15 intended SCC.
Key determinants of pathway selection were:
Limited exposure to EM-SCC during residency was noted—only 28% had access to such fellowships, and 42% interacted with surgical intensivists, despite 41% envisioning SCC practice.
Intellectual appeal ranked highest for entering CC, above job prospects or lifestyle.
Fellowship components most valued were:
While descriptive, the authors noted many respondents cited the "preliminary surgical year" as a reason that the Surgical Critical Care pathway is less attractive.
The authors conclude that respondents pursued a career in CC for "intellectual appeal and desire for additional expertise" and that improving EM-SCC matriculation requires targeted interventions.
TLDR: Being on antidepressants (specifically SSRIs and SNRIs) does not increase the risk of miscarriage in the first trimester if started before pregnancy, while starting them during pregnancy might present a small increase in risk of miscarriage in that first trimester.
Researchers in the UK looked at patient data from 1996-2018, with almost a million pregnancies evaluated, to look for an association between antidepressant use and first trimester miscarriage, because studies in the past have been iffy about this whole thing. They looked at exposed patients, who were split into two categories: prevalent (started antidepressants at least 3 months prior to pregnancy) and incident (started antidepressants during pregnancy), and nonexposed patients.
The data was analyzed raw and then also after taking out what they felt like would be important confounders (including hx of miscarriage, smoking hx, antipsychotic/seizure medication use, age). Data analyzed after the confounders were taken out of the equation showed that there was no statistical difference in first trimester seizures among patients who were not exposed to SNRIs/SSRIs and prevalent users (or patients who started before pregnancy).
Among incident users, there was a small increase in risk, though the researchers noted that they were concerned about “reserve causation” or patients being started on antidepressants after they had had a miscarriage, which could have screwed with these numbers. The absolute increase in risk was 0.5% (13.1% in non-exposed, and 13.6% in exposed).
Takeaways: Given that we cannot ethically do RCTs on our pregnant patients, this is probably one of the largest population studies to date looking at this issue, and it provides reassuring data. For our patients who are on SSRIs/SNRIs before they get pregnant, you can reassure them that there is good data saying that they are not putting the fetus at increased risk of miscarriage in that first trimester. For patients who need to start on SSRIs/SNRIs during pregnancy, counsel closely, but let them know that our data shows a relatively small absolute risk increase for first trimester miscarriage.
These authors followed 250 consecutive trauma activation patients over a one year period. In hospital elevated blood pressure and glucose level correlated with a new diagnosis of hypertension and diabetes respectively over that 1 year time line. Some of these patients also had a new diagnosis of HIV, substance use disorder and hepatitis C. Using their contact with the health system due to trauma can be a way to screen for undiagnosed medical problems such as diabetes and hypertension. Assuring outpatient follow up for these patients will have an effect on their long term morbidity and mortality.
Chondrocalcinosis is a condition where calcium pyrophosphate crystals form in the joints (particularly the knee and wrist), leading to inflammation and pain.
Appears as a cloudlike radiopacity in the knee’s articular cartilage and meniscus on XR, reflecting abnormal calcium-based crystal deposition.
This can be distinguished from the radiolucent appearance of monosodium urate crystals of gout.
https://www.wikidoc.org/index.php/File:MSUandCPPD.png
These calcium crystals are common in end-stage knee osteoarthritis and have been associated with disease severity.
Due to this well-observed coexistence (chondrocalcinosis and knee osteoarthritis), chondrocalcinosis is commonly considered a manifestation of osteoarthritis pathology.
However, this does not explain the commonly encountered instances where chondrocalcinosis appears in radiographically normal knees. This raises questions of whether chondrocalcinosis is a cause or merely a consequence of end-stage osteoarthritis.
Population studies have identified that about 6.% of individuals have chondrocalcinosis in joints unaffected by osteoarthritis
In a recent analysis including more than 6400 middle-aged to older adults, individuals with knee chondrocalcinosis were 75% more likely to develop knee OA than those without the condition at baseline.
Chondrocalcinosis may contribute to the risk of osteoarthritis through inflammation. These deposited crystals could induce the production of inflammation markers, matrix-degrading enzymes and induce chondrocyte hypertrophy or chondrocyte death. These effects not only damage the joint but also form a positive feedback loop to produce more calcium crystals.
Individuals with chondrocalcinosis may represent a specific subgroup of patients, for which a treatment targeting chondrocalcinosis induced inflammation may present a viable strategy to prevent osteoarthritis in this patient subgroup.
This idea has some support from the 2023, LoDoCo2 trial, (approx. 5500 patients) which showed an association between the use of colchicine, 0.5 mg daily, with a lower incidence of total knee and total hip replacements.
A recent randomized control trial published in JAMA Pediatrics in January 2025 showed improvement in first attempt for IV access when using ultrasound in the pediatrics ED.
This trial was performed at a quaternary pediatric hospital in Australia with a total of 164 patients (ages 18 and younger). Median age of the patients was 24 months. There was computerized system that randomized patients into either getting an IV by standard procedure vs ultrasound-guided. Those placing the ultrasound-guided IV had extensive training. Overall, the first time success rate was higher in the ultrasound group with about 85.7% compared to 32.5% in the standard group.
Main point: US IV decreases the number of sticks a child has to experience for IV access with a higher first stick success rate. Consider US IV training in your Pediatric Emergency Department in the future. Also use ultrasound guidance with first attempt IV access for your chronically ill children or for very anxious parents.
Summary:
This study evaluated whether the line-of-sight approach improves the speed and accuracy of ultrasound-guided needle placement into the subdeltoid bursa among novice operators, compared to the side approach. A secondary aim was to assess the usefulness of the APPLES mnemonic (Angle, Position, Perpendicular, Line up, Entry, Sweep) as a teaching aid.
Methods:
Medical students and residents were randomized to perform the procedure using both approaches in a crossover design. Two blinded reviewers measured procedure time, and participants completed a survey on their preferences and perceptions of APPLES. Statistical tests (paired t test, McNemar test) compared performance time and accuracy.
Results:
The line-of-sight approach significantly reduced procedure time (mean 14.4 s vs. 18.6 s; P = .00029).
Participants were more likely to hit the target within 30 s using the line-of-sight approach (P = .035).
72.7% preferred the line-of-sight approach.
88.2% found the APPLES mnemonic helpful.
Conclusions:
The operator’s positioning plays a key role in ultrasound-guided procedures. The line-of-sight approach improves both speed and accuracy for novice users, and the APPLES mnemonic is a valuable educational tool for teaching these techniques.
Kerith Joseph MD, RMSK
Clinical Associate Professor
University of Maryland School of Medicine
Baltimore Veterans Affairs Medical Center, Emergency Department
Cyanide is one of the deadliest known poisons causing immediate toxic effects and lethality within seconds to minutes. Exposures are rare, most commonly by inhalational route (HCN gas) from structural fires due to combustion of synthetic materials or from ingestion of cyanide salts. Cyanide toxicity can also occur from dermal or parental (sodium nitroprusside) exposure.
The preferred first line antidote is hydroxycobalamin (vitamin B12) available as Cyanokit, which has higher affinity for cyanide than cytochrome oxidase and binds to form harmless cyanocobalamin and is renally excreted. Limited studies reveal good survival rates in noncardiac arrest patients. Hydroxycobalamin has minimal side effects (red skin and urine, increased BP) and is well-tolerated with safer and simpler mechanism of action than Nithiodote (original antidote), containing sodium nitrite (CN preferentially binds methemoglobin to form cyanomethemoglobin) and thiosulfate (provides sulfur to convert cyanide to thiocynate for excretion). Sodium nitrite has numerous adverse effects causing hypotension and methemoglobin (contraindicated in smoke inhalation victims due to concern for carbon monoxide poisoning, G6PD deficiency, preexisting amenia), and hypersensitivity reactions. Sodium thiosulfate has less side effects and augments cyanide excretion but is considered less effective due to its slow onset, short half-life, low volume of distribution, and poor intracellular penetration.
As of August 2025, the American Society of Health -System Pharmacists (ASHP) Drug Shortage lists Cyanokit as “limited availability” in the U.S. as manufacturing was suspended due to investigation of ongoing quality defect with concern for sterility and endotoxin content. Impacted batches were released and their numbers are listed in an FDA bulletin (see references). Healthcare providers should weigh the potential benefit of using Cyanokit against the risk of infection. Infusion set with 0.2 micron in line filter can be temporarily used for administration of Cyanokit 5 mg hydroxycobalmin to prevent potential infection.
Another month, another study of hemodynamic targets in sepsis… The age-old questions: is a MAP > 65 a good target for everybody, or should we individualize? Should we just give a bolus of fluids to everyone and then move to pressors, or should this strategy change patient to patient?
Huet et al have a preprint that'll appear in Intensive Care Medicine looking at this question in 517 patients. I can't reprint it here due to copyright (follow link below, go to full PDF and scroll to figures at bottom if curious), but basically their algorithm was 1) check if patient is fluid responsive via either echo or swan, 2) give fluid if yes, 3) do something else (pressors) if no.
Importantly the differences were not statistically significant, but they found a strong, nearly significant, trend towards benefit on SOFA score, ICU and hospital LOS in the “personalized therapy” group (also of note, these are dubious as patient oriented outcomes). The sickest patients (by SOFA) showed the most benefit.
Bottom Line: The “personalized hemodynamic therapy” literature continues to show a modest benefit of using tools like echo (e.g. LVOT VTI) to determine if the patient is fluid responsive (or fluid tolerant) and NOT give fluid (instead using pressors) if that is not the case, but for now there's relatively limited support for hyper-personalized approaches like varying MAP goals or otherwise mixing up your strategy. Some day we'll likely find a more nuanced approach, but for now I think a reasonable strategy in critically ill septic patients is to use ultrasound to determine if the patient needs fluid, if yes give fluid and reassess, and if not move to pressors, to maintain a MAP > 65.
E-point septal separation (EPSS)—the distance between the anterior mitral valve leaflet and the interventricular septum during early diastole—is a well-established marker of left ventricular (LV) systolic function in adults. A threshold of 7.0 mm is commonly used to screen for severely depressed LV function. But how well does this cutoff translate to pediatric populations?
A recent retrospective study set out to explore this very question. Researchers reviewed 770 pediatric echocardiograms, including 148 with abnormal LV function and a 4:1 random sample of normal studies. Using post-exam ultrasound software, blinded operators measured EPSS across three age groups: 0-3 years, 4-12 years and 13-18 years.
Results:
Among children with LV systolic dysfunction, EPSS values increased progressively with severity:
When applying the adult 7.0 mm threshold: Sensitivity: 76.4% (95% CI: 68.5–82.8%) Specificity: 95.8% (95% CI: 93.8–97.2%)
However, the study-derived optimal threshold of 6.0 mm improved sensitivity to 81.8% (95% CI: 74.4–87.4%) while maintaining high specificity at 91.4% (95% CI: 88.9–93.5%).
Special Consideration for the Youngest Patients
In children aged 0–3 years, a lower threshold of 4.9 mm outperformed the adult cutoff: Sensitivity at 4.9 mm: 77.8% (95% CI: 51.9–92.6%) vs sensitivity at 7.0 mm: 55.6% (95% CI: 31.3–77.6%)
While these findings are promising, further research is needed to validate EPSS thresholds in emergency department (ED) settings using point-of-care ultrasound (POCUS), and to assess their feasibility in real-time clinical workflows.
Bottom Line: For older children an EPSS threshold of 7.0 mm appears to be accurate in identifying children with LV systolic dysfunction, but a lower threshold may be needed for children ages 0-3. Further studies are needed.
In a German study comparing one EMS jurisdiction which used IV paracetamol (acetaminophen) in combination with nalbuphine (Nubian, opiate agonist/antagonist) to another jurisdiction which used piritramide (synthetic opioid similar to fentanyl) for prehospital traumatic pain, the combination worked better to decrease pain on a numerical scale. There were no differences in typical safety measures.
The use of an antagonist/agonist theoretically could precipitate withdrawal in non-opiate naive patients and could influence in hospital analgesic choices. The literature on this is mixed.
This study offers further evidence of the efficacy of multi-modal pain control, the feasibility of paramedics using IV paracetamol and the possibility of using rapid onset opioid agonist/antagonist in the prehospital setting.
A scoping review of literature involving norepinephrine use during cardiac arrest associated with a shockable rhythm found:
-evidence in animal and signal in human trials of improved myocardial and cerebral blood flow
-a suggestion of less re-arrest
There is not enough evidence comparing epinephrine to norepinephrine however this would be an excellent area of research with a theoretical advantage to norepinephrine.
In the newly released American Heart Association guidelines on CPR and cardiovascular care, they state there is no evidence that mechanical compression devices show improvement in survival when compared to manual CPR. They do not recommend routine use of mechanical devices except when high quality CPR can not be maintained or when healthcare personnel safety is impacted such as during transport to the hospital.
Surely there will be more to follow on this topic.
These authors looked at survival to discharge pre and post-implementation of a single dose epinephrine protocol for out of hospital cardiac arrest as it relates to age ranges. They found that older patients had a survival rate of 12% in the single dose protocol compared to 6% in the multidose protocol. Younger and middle aged patients had no difference in survival pre and post-implementation. At least in older adults, epinephrine does not seem to offer much benefit when given more than one time during cardiac arrest.
Bottom line:
If a ventilated patient exhibits at least one of: persistent end expiratory flow, unequal inspiratory and expiratory flow-time areas, or ineffective breath triggers; autoPEEP must be evaluated by performing an end-expiratory hold.
If present, ventilator settings should be changed to maximize exhalation time.
In critically ill patients with obstructive lung disease, intubation and mechanical ventilation is often a last resort as it does not fix the underlying pathology of small airway disease. While many complications can arise, the most feared complication is autoPEEP.
What is autoPEEP?
AutoPEEP is excess air trapping in the lungs because the patient has insufficient time to fully exhale. Patients at highest risk include those with obstructive lung pathology due to their increased resistance (from bronchospasm) and sometimes increased compliance (such as in emphysema).
However, it is possible for any patient to develop autoPEEP depending on the amount of time they have to exhale. As respiratory rate increases, the expiratory time decreases proportionally if inspiratory time is kept constant. Ultimately, autoPEEP can lead to rapidly increasing intrathoracic pressures causing decreased preload leading to hemodynamic instability and potentially cardiac arrest. These elevated pressures also place the patient at significant risk of barotrauma/volutrauma.
How do I find it?
There are several signs on the ventilator waveforms for autoPEEP. Some patients may only exhibit one of the following signs of autoPEEP. They are demonstrated in the attached pictures in various ventilator modes.
Image A. Persistent end expiratory flow on the flow-time curve (middle curve) - demonstrated by the expiratory limb of the flow curve not returning to zero (remains negative)
Image B. Unequal inspiratory and expiratory volumes on the flow-time curve (area of flow curve inspiratory limb does not equal area of flow curve expiratory limb)
Image C. Ineffective triggering (seen on flow-time curve; patient has to perform more work to reach trigger threshold when autoPEEP is present; they are sometimes unable to trigger a breath)
If any of these are present, an end-expiratory hold maneuver should be performed.
Image D - End-expiratory hold maneuver (done if patient is passive on the ventilator) - the pressure-time curve will begin at ventilator set PEEP and reach total PEEP at the end of the maneuver. The difference between total PEEP and set PEEP is autoPEEP.
If autoPEEP is present, ventilator changes to allow for more exhalation time should be made. The most effective change is by decreasing the respiratory rate though small improvements can be made by changing the inspiratory time and tidal volume. Appropriate bronchodilator therapy, sedation, and treatment of underlying pathology is also critical in these patients.
For more information on autoPEEP, check out this post by Dr. John Greenwood discussing autoPEEP on MarylandCCProject with video demonstrations!
The authors conducted a pre- and post-implementation study after five North Carolina county EMS agencies switched to single dose epinephrine during out of hospital cardiac arrest treatment from the traditional multidose (every 3-5 minutes) protocol. They looked at 1 year before and 1 year after implementation. They found no difference in survival to discharge from the hospital in the two groups but there was less return to spontaneous circulation in the single dose group.
Another paper emphasizing care for brain injured patients should include:
-pre-intubation preoxygenation to avoid hypoxia
-pre-intubation avoid extremes in blood pressure (hypotension kills)
-use hemodynamically neutral induction agents such as ketamine or etomidate
-post intubation target eucapnia on the ventilator. (do not aim for low CO2)
-post intubation maintain adequate sedation to avoid increased intercranial pressure
Low-Dose Radiation Therapy for Osteoarthritis
Current options for osteoarthritis include NSAIDs, physical therapy, intraarticular steroid injections, and lifestyle modifications, such as weight loss and exercise. After these options have been exhausted, there is joint replacement.
Problems with these options in older patients are that about 25% of all patients will not respond to these therapies or lose their responsiveness over time. NSAIDs also may not be great options in those with renal impairment and increased risk of GI bleeding.
Conventional radiation therapy (RT) in the treatment of malignant disorders relies on its antiproliferative effects. Alternatively, at doses of less than 1 Gray, RT has been shown to have strong anti-inflammatory effects.
RT may be an appropriate option for those with OA who have failed other conservative measures but are not ready for joint replacement…ideally before the onset of bone-on-bone changes at which point RT is less likely to be effective.
Appropriate candidates are older than 50 years. Patients do not typically experience acute side effects. There may be slight redness, milder than a sunburn, on the skin of the area radiated. Malignancy induced by RT treatment remains a small theoretical risk and is mitigated by selection of non central joints (i.e. not for spine OA).
The most commonly treated joints include hands, feet, knees, and elbows.
Pain relief can last from several months to years, with studies reporting that 30%-60% of patients maintain significant pain reduction 1-2 years after treatment. In one study, patients reported 85% decreased use of analgesic medications.
Typical treatment regimens involve 6 sessions of 0.5 Gy each conducted 2-3 times per week.
RT may be an effective modality for patients who have failed conventional treatment and are either not ready for surgery or are poor surgical candidates.
