BOTTOM LINE: Modify WBC threshold for diagnosing septic arthritis is patients who received recent antibiotics (24h to 2 weeks).
BOTTOM LINE: It is generally safe and effective to discharge vomiting pediatric patients with a prescription for ondansetron, and a recent study supported this common practice.
While it has become common practice to prescribe ondansetron to children with emesis, a 2025 randomized controlled study showed that a prescription for ondansetron decreased the risk of moderate to severe gastroenteritis in the following 7 days.
This study compared children 6 months to 18 years of age who received either ondansetron or placebo. They found a rates of moderate to severe gastroenteritis to be 5.1% in the ondansetron group versus 12.5% in the placebo group.
*Note that ondansetron is NOT approved for children under 6 months of age or in those with prolonged QT.
Take Home Point: Andexxa (andexanet alfa) was voluntarily withdrawn from the US market effective December 22, 2025, due to safety concerns. 4-Factor Prothrombin Complex Concentrate (4F-PCC/Kcentra) remains the standard of care for reversing apixaban and rivaroxaban in life-threatening bleeding.
Why was it pulled? AstraZeneca, in consultation with the FDA, discontinued the manufacturing and sale of Andexxa after the ANNEXA-I post-marketing trial showed that the drug's risks outweigh its benefits. The trial compared Andexxa to usual care (primarily 4F-PCC) in intracranial hemorrhage and found a significant safety signal:
Clinical Action Items:
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Institutional Note: You may recall that our institution (like many others) never added Andexxa to the formulary. We cited the lack of high-quality survival data and cost-benefit concerns as our primary reasoning. Consequently, this market withdrawal requires no change to our local practice. We will continue to use 4F-PCC as our standard for Factor Xa inhibitor reversal, a practice now validated by the FDA's safety findings.
Diagnostic Errors in the Critically Ill
Well, it depends on who you ask - ACOG defines it as greater or equal to 1000ml of blood loss within that first 24 hours, but most research articles define it as greater or equal to 500ml, while they define severe postpartum hemorrhage as greater or equal to 1000ml. But what is it actually?
The World Health Organization decided to tackle this question to look at what level of blood loss is the most clinically relevant in a meta-analysis from last year. They reviewed 12 different databases and over 300000 patients to look at levels of blood loss and when that was associated with mortality/severe morbidity. They found that the standard 500ml cutoff was actually only around 75% sensitive, but when they dropped those levels to 300/400/450, they lost a lot of specificity. So, what they did is they came up with their own rules and re-evaluated them based on their data to see how sensitive and specific they were.
What they found with a sensitivity of 87% and a specificity of 66-76% was:
Consider someone as having CLINICALLY SIGNIFICANT blood loss if they had EITHER:
OR
So look at the vitals + the blood loss together, and use those to guide your clinical actions!
Popliteal artery injuries are very rare (4% of all vascular injuries).
The majority of injuries are secondary to penetrating injury (70+%)
Blunt mechanism of injury has the higher rate of amputation.
Prolonged ischemia time (from injury to repair greater than 6 hours) leads to higher rates of amputation
Hard signs of vascular injury should prompt X-ray imaging of the knee, femur, and lower extremity and transfer to an operating room for repair.
Soft signs ("a history of significant bleeding which has ceased, nonexpanding hematomas, and the presence of an Ankle-Brachial Index of less than 0.9") and shotgun injury should prompt CT angiogram to evaluate arterial injury.
In a metanalysis of studies looking at intercranial hemorrhage in fall patients older than 65 years, the following were unadjusted odds ratio risk factors for finding an ICH in this patient population:
suspected open or depressed skull fracture , signs of basal skull fracture ), reduced baseline Glasgow Coma Scale score , focal neurologic signs , seizure , vomiting , amnesia , loss of consciousness , headache ), external sign of head trauma , male sex , chronic kidney disease , preinjury single antiplatelet , and dual antiplatelet medication .
Preinjury anticoagulant was not a significant risk factor.
When looking at adjusted odds rations only focal neurologic signs , external sign of head trauma , loss of consciousness , and male sex were found to be associated with intercranial hemorrhage.
The US drug supply has been found to contain medetomidine as an adulterant to heroine/fentanyl. It is a potent tranquilizer used in animals. It is an alpha 2 blocker (similar pharmacology to clonidine and xylazine). Exposure to this drug can induce withdrawal symptoms to include anxiety, tremor, diaphoresis, nausea, vomiting, agitation, sympathetic hyperactivity, and delirium. Withdrawal can start within 4-6 hours of last use.
Treatment for withdrawal is outlined in this diagram.
Etomidate is often a go-to agent for RSI because it is considered relatively hemodynamically neutral. However, lab studies have shown an association with transient adrenal suppression, and some observational studies and meta-analyses have suggested that patients intubated with etomidate face higher risk of cardiovascular collapse and in-hospital mortality than those intubated with ketamine.
The RSI trial was a pragmatic open-label multi-center randomized control trial conducted in 6 EDs and 8 ICUs across the US and compared induction with ketamine 1-2mg/kg versus etomidate 0.2-0.3mg/kg for RSI of critically ill adults (excluding trauma patients). They found no significant difference in overall 28 day hospital mortality across the cohort. They found an increased risk of cardiovascular collapse during intubation in the ketamine group. This increased risk was more pronounced in patients with sepsis or septic shock and patients with APACHE II ?20.
Some details:
Overall - this was a well conducted randomized control trial that - at the very least - suggests that etomidate is likely as safe (if not safer) than ketamine with respect to 28d mortality and peri-intubation cardiovascular collapse, even among patients with critical illness or septic shock.
Ultrasound Guided Nerve Blocks (UGNBs) provides targeted analgesia that can effectively alleviate pain from injuries or painful procedures while reducing opioid use.
In 2021, ACEP issued a policy statement affirming that ultrasound-guided regional anesthesia is within the scope of EM physicians and is a core component of multimodal pain management pathways in the ED. However, EM residencies have not uniformly defined nerve block requirements, resulting in a wide range of graduating resident skill levels. Recent ACGME updates may help standardize expectations and address this gap.
A recent review of the National Ultrasound-Guided Nerve Block Registry (NURVE) looked at the impact of operator training level on the analgesic effectiveness of ED-performed UGNBs. The most commonly performed block among attendings was the erector spinae block, while for residents it was the fascia iliaca block. Both resident and attending performed blocks showed a reduction in pain but there was an 80.7% meaningful pain reduction in attendings as compared to 63.4% for residents. Out of the 1595 nerve block cases reviewed there were only 2 complications which included transient episode of LAST and respiratory difficulty from suspected diaphragmatic hemiparesis.
These findings highlight the importance of experience while supporting the safety and effectiveness of UGNBs performed by supervised residents in the training environment.
An English study describes 30 patients that jumped from a single bridge of 30 meters (98 feet) over the course of 12 years. Twenty six landed in the water. The injury pattern for those landing in water was described as “Hypothermia was the most common presentation (n = 23), followed by pneumothoraces (n = 14), rib fractures (n = 10), thoracic vertebral fractures (n = 9) and lung contusions (n = 8). Lower water temperatures at the time of the incident (p = 0.008) and lower patient body temperatures on arrival to hospital (p = 0.002) were significantly associated with increased 30-day mortality.”
The small group landing on land had more pelvic and extremity fractures than the water group and none had hypothermia.
Remember to start aggressive rewarming in patients who fall into water!
This small study from South Africa shows stab wounds to the chest with a pneumothorax less than 0.5 cm that were managed conservatively had completely resolved on 12 hour repeat chest X-ray. This could facilitate earlier discharge of these patients. It also supports conservative (non-tube placement) approach to asymptomatic small pneumothoraces from stab wounds.
Tramadol has been viewed as a safer alternative for pain control than opioids. This study says differently.
“Tramadol use was associated with increased risk of multiple ER utilizations, falls/fractures, CVD hospitalizations, safety event hospitalizations, and mortality (new users only) compared to nonuse.”
How well does your ED care team communicate? For some high yield strategies and reasons for improvement, read on…
To explore effective and ineffective communication in the ED and its impact of patient care, physician and nurses from several academic EDs completed an online anonymous survey, then attended focus group sessions. Responses highlighted the following themes:
1: Situations, built physical environment, and medium of communications all impact quality of communication.
2: Core elements of desired professional communication include respect, closed-loop communication, and attention, often conveyed through non-verbal behaviors.
3: Poor communication begets poor communication in later interactions
4: Effective communication is seen as fundamental to patient care but also has impacts beyond patient care
5: Clinician gender and gender dyads influence communication dynamics, age and experience dyads did not.
Do any of these themes resonate with you? What can you do within your department to improve physician-nurse communication and the care you provide?
A crucial part of cardiac arrest management is identification of the underlying rhythm, with key aspects of management diverging depending whether shockable (pulseless ventricular tachycardia/pVT or ventricular fibrillation/VF) or unshockable (pulseless electrical activity/PEA or asystole).
A recent study prospectively evaluated adult atraumatic out-of-hospital-cardiac-arrests (OHCAs) presenting to the ED, to determine what percentage of cases had “Occult VF” – VF found point-of-care echocardiogram but not by ECG. The researchers only included cases with simultaneous ECG and echo assessments for the initial 3 pulse checks. Echo and ECG determinations for the study were adjudicated by research team members.
They found that:
Major limitations:
Bottom Line: Point-of-care echocardiogram continues to have value in the management of cardiac arrest, potentially changing management and affecting post-ROSC decisions. Ensuring high-quality CPR, with appropriate defibrillation and anti-arrhythmic strategies, remains paramount in management of shockable OHCA.
Consumer use of cannabidiol (CBD) products for medicinal and recreational purposes has increased in recent years. Regulatory barriers have limited randomized controlled trials examining the clinical and physiologic effects of cannabinoids in humans. This study aimed to evaluate the impact of daily cannabidiol oil use on liver enzymes and endocrine hormones in healthy adults.
In this double-blind, randomized, placebo-controlled study conducted at a clinical pharmacology unit in Wisconsin, 201 healthy adults were randomized to receive either oral CBD (2.5 mg/kg twice daily) or placebo. Laboratory testing was performed weekly.
Among participants receiving CBD (n = 151), 8 developed AST and ALT elevations greater than three times the upper limit of normal; 7 of these also had eosinophilia. No participants in the placebo group (n = 50) developed similar transaminase elevations. There were no significant differences between groups in measured endocrine hormones, including total testosterone, inhibin B, thyroid-stimulating hormone, total triiodothyronine, and free thyroxine.
Limitations included a modest sample size, unequal group sizes, and a relatively short duration of exposure and follow-up.
Key Takeaway: CBD use may be associated with elevations in AST and ALT. However, evidence remains limited, and abnormal liver enzymes should still prompt evaluation for alternative etiologies.
A reminder from a recent position paper on pelvic trauma that we should not be doing stability testing to evaluate pelvic trauma
“EMS clinicians should recognize the challenges in accurately identifying pelvic fractures by physical exam alone. Manual stability testing of the pelvis is neither sensitive nor specific and may cause harm.”
The recommended approach for patients with suspected septic arthritis is arthrocentesis with fluid analysis sent for: Gram stain, culture, WBC count with differential, and crystal analysis before starting antibiotics.
From a classic meta-analysis of 14 studies involving greater than 6,000 patients the only 3 findings that occur in more than 50% of patients with septic arthritis were
Joint pain (sensitivity, 85%; 95% confidence interval [CI], 78%-90%),
Joint swelling (sensitivity, 78%; 95% CI, 71%-85%),
Fever (sensitivity, 57%; 95% CI, 52%-62%).
Vs.
Sweats (sensitivity, 27%; 95% CI, 20%-34%)
and rigors (sensitivity, 19%; 95% CI, 15%-24%) were less common findings in septic arthritis.
The probability of septic arthritis increases progressively with higher synovial WBC counts:
PMN percentage ?90% suggests septic arthritis with LR 3.4 (95% CI, 2.8-4.2)
VS
PMN <90% lowers the likelihood (LR 0.34, 95% CI 0.25-0.47).
Study Overview
Title: Identification of Knee Effusions With Ultrasound: A Comparison of Three Methods
Design: Prospective cohort study
Setting: Outpatient orthopaedic clinic
Participants: 52 adults (104 knees), including 57 painful knees
Objective
Determine whether two simple dynamic techniques improve ultrasound detection of suprapatellar knee effusions compared with static scanning.
Ultrasound Methods Compared
Static scanning: Patient relaxed; standard long- and short-axis views.
Parapatellar pressure (Method 1): Examiner compresses medial and lateral parapatellar recesses during scanning.
Quadriceps contraction (Method 2): Patient actively contracts quadriceps during scanning.
Outcome Measure
Presence of fluid in the suprapatellar recess (graded using a standardized ultrasound effusion scale).
Key Results
Effusions detected:
Static scanning: 45
Parapatellar pressure: 58
Quadriceps contraction: 77
Comparative performance:
Quadriceps contraction was superior to parapatellar pressure for detecting:
All effusions (PR 1.33; P < 0.001)
Painful knees (PR 1.24; P = 0.036)
Painless knees (PR 1.50; P = 0.006)
Both dynamic methods outperformed static scanning.
Additional detection beyond static scanning:
Parapatellar pressure: +16.9% of knees
Quadriceps contraction: +54.2% of knees
Reliability (Inter-rater Agreement)
Static scanning: ? = 0.771
Parapatellar pressure: ? = 0.686
Quadriceps contraction: ? = 0.846
All methods showed high reliability, with quadriceps contraction highest.
Conclusions
Both parapatellar pressure and patient-initiated quadriceps contraction significantly improve ultrasound detection of suprapatellar knee effusions.
Quadriceps contraction is the most effective method, especially for small or occult (grade 1) effusions.
