A good reminder to consider careful prescribing to older patients at the time of ED discharge.
From this study: “Nearly 1 in 10 older adults filled a high-risk GEMS-Rx medication within 3?days of ED discharge between 2017 and 2022. Despite a decline in GEMS-Rx medication fills over time, younger cohorts of older adults and females were more likely to fill a high-risk medication upon ED discharge.”
Click for Gems-RX list
At tonight's quarterfinal, a player exhibits signs or symptoms of a possible concussion. How will they be evaluated on the pitch?
The Football-Specific Standardized On-Pitch Concussion Assessment Protocol (FOCUS) was published in July 2026 in JAMA Neurology.
It was developed through a FIFA-led international Delphi consensus process involving experts from all 6 football confederations.
The primary objective of FOCUS is not to diagnose concussion but to determine whether a player exhibits any signs or symptoms that raise suspicion and would require off pitch assessment.
Low Magnesium in Children has a generally similar approach to adults, however the etiology may be different.
Children can present with low magnesium levels due to many causes including but not limited to renal wasting (which may be drug related), malnutrition, malabsorption, refeeding syndrome, short gut syndrome, or genetic mutations
Hypomagnesemia is often coupled with hypocalcemia or hypokalemia which can be refractory until the magnesium is replaced.
Symptoms may be vague particularly in younger patients, with neuromuscular irritability, though in extreme cases (typically <1.0mg/100ml) seizure activity may occur with severely low levels, and long QTc may cause dysrhythmia
Oral replacement can be used for asymptomatic patients with levels greater than 1.0 mg/100mL
PO replacement:
Goal of 10-20mg/kg/dose (Max 2 g) elemental Magnesium
Magnesium oxide is the most common replacement but does come in pill form and is given up to four times daily
IV replacement with Magnesium Sulfate (given over 2 -4 hours*):
Neonate: 25–50 mg/kg/dose every 8–12 hours
Child: 25–50 mg/kg/dose every 4–6 hours (maximum 2 g/dose)
*In patients with life threatening hypomagnesemia such as those with seizures, a 50mg/kg dose given over 1-5 minutes is warranted.
Background: The 2020 ACLS algorithm for treatment of SVT recommends an initial adenosine dose of 6 mg, followed by 12 mg via rapid IV push if cardioversion is unsuccessful. Among more recent studies evaluating adenosine dosing, between 45% and 70% of patients required escalation to 12 mg to achieve successful cardioversion, suggesting that the standard 6 mg dose may not be effective for some patients. However, evidence evaluating the use of a 12 mg initial dose is limited.
Study design: Sert et al. conducted a prospective, single-center, observational study of 142 adult patients with SVT in a tertiary care emergency department in Turkey between February 2025 and January 2026. Patients received an initial dose of either 6 mg or 12 mg of adenosine (n=71 per group), selected at the discretion of the treating physician. Adenosine was administered using a proximal IV line using a T-connector or stopcock over 1-2 seconds. Patients with clinical signs of instability were excluded.
Results: More patients in the 12 mg group experienced first-dose conversion compared to the 6 mg group (83.1% vs. 52.1%, p <0.001). Results were consistent among a 1:1 propensity-matched cohort (n=104) adjusted for age, sex, and history of SVT (82.7% vs. 53.8%, p <0.001). Similar rates of adverse events such as chest tightness, flushing, and shortness of breath were observed between the two dosing groups.
Study limitations: Non-randomized design leaves potential for selection bias, results not adjusted for confounding factors such as quantified caffeine intake or absolute body weight, limited generalizability in settings where alternative methods of adenosine administration are used (i.e. single-syringe method), low sample size
Bottom line: This study adds to the growing body of evidence suggesting that an initial 12 mg dose of adenosine may be a safe and more effective alternative to the standard 6 mg dose.
Intuitively, both younger and older patients would have better outcomes at level 1 vs level 3 centers. This was true in younger patients in this large trauma database study. It was only true for older patients with traumatic brain injury and a high injury severity score. Is this a function of care delivery being better at level 3 or less geriatric focus at level 1 trauma centers?
University of Maryland Medical Center is a referral center for patients with necrotizing fasciitis in the region, as we have a major hyperbaric chamber, and a specialized Soft Tissue Surgery team. Therefore, patients with soft tissue infection make up a group with frequent transferring to UMMC.
Some of the factors, from recent meta-analysis, suggest higher rate of mortality among this particular group of patients. When they display these factors, which are also consistent with our clinical observations, we should be more aggressive with their treatment:
Acute kidney injury OR 3.23 (2.76–5.04)
Bacteremia OR 3.89 (1.39–10.85)
Hypotension OR 1.97 (1.26–3.10)
Coagulopathy OR 2.81 (1.23–6.40)
Pt with abdominal pain, nausea and vomiting. You ultrasound the intestines and find this:
This study looking at older patient contact with the health system within 30 days of ED discharge found an overall lower rate of follow up for those patients with dementia. Perhaps extra care at time of discharge in arranging follow up is warranted for older dementia patients.
This Canadian study found women, even when controlling for injury severity, socioeconomic conditions etc, were less likely to be admitted to a trauma center than their male counterparts. Further investigation into this bias is warranted.
Lumbar puncture (LP) carries a relatively small risk of hemorrhagic complications, including traumatic tap (a lab finding) and spinal hematoma (an imaging finding).
In a cohort study of 83,000 LPs, the risk of spinal hematoma was not significantly increased in patients with documented coagulopathy (0.23% versus 0.20%), with coagulopathy defined by Plt < 150,000, INR > 1.4, aPTT > 39s.
Data on platelet transfusion and anticoagulant reversal prior to LP are limited to small retrospective cohort studies and case series. However, the limited data on this subject show no significant difference in major bleeding complications in patients who did or did not receive reversal prior to LP.
Although the risk of iatrogenic spinal hematoma may be low, current guidelines generally support the following practices:
Bottom line: Start with X-ray to evaluate for retained stingray barb fragments. Remove foreign bodies with surgical consult as necessary.
Stingrays strikes represent one of the most common human envenomations from marine animals. Venom from these barbs causes immediate local pain and less commonly may cause a variety of systemic symptoms. Rarely are these primary effects life-threatening. A secondary risk, retained barb fragments can lead to complicated infections. Identification of retained fragments for removal is key. This study compared three radiology modalities on cadaveric limbs.
X-ray was associated with the highest sensitivity of 94% for the identification of a retained barb, followed by MRI (83%) and ultrasound (70%). MRI was associated with the highest specificity of 100%, followed by x-ray (98%) and ultrasound (73%).
Consideration must be given to individual sonographer skill level and difficulty variable with regional anatomy. Full article below is worth a look for comparison of images.
These authors looked at outcomes related to patients who underwent prehospital cold water immersion for acute heat stroke in Phoenix. They found immersion dropped temperature and improved neurologic function. This is a great reminder to cool these patients as soon as possible and a prehospital cooling protocol is feasible and helpful.
Should patients with mild cognitive impaired take glucosamine for their knee pain?
This review article in the Journal of Trauma and Acute Care Surgery states:
“In obtunded patients, an adequate and normal high-quality CT supports collar removal without the need for adjunctive imaging.”
The first step toward developing a healthy ED is to develop a vision of the way emergency medicine should be practiced. The second is to analyze the way it is practiced within a physician group or department. The third is to generate a plan for transitioning from the way it is to the way it ought to be.
A robust department begins with principled physician and nursing leadership.
- Laura Pimentel, The Healthy Emergency Department, in Croskerry P, Cosby KS, Schenkel SM, Wears RL (editors), Patient Safety in Emergency Medicine, Wolters Kluwer, Philadelphia, PA, 2009; 41-44.
A mentor, a colleague, a leader, and a friend, Dr. Laura Pimentel died on June 23, 2026. She led the Emergency Departments at Bon Secours (1993-94), Mercy Medical Center (1995-2007), and Upper Chesapeake Medical Center (2007-08). She was Vice President and then CEO of the Maryland Emergency Medicine Network and, from 2011-2013, President of Maryland ACEP. She will be greatly missed. Her legacy of caring and clarity live on.
Taking a slight detour into the trauma critical care realm today…
BLUF: Favor aggressive calcium supplementation following trauma, especially when patient requires transfusion. Recent evidence is pointing towards a signal for improved outcomes.
Hypocalcemia in trauma is common. Roughly half to two-thirds of trauma patients are hypocalcemic on arrival, driven by both shock physiology and citrate chelation from blood products. Some authors advocate for hypocalcemia to be added as the fourth element of a "lethal diamond" alongside coagulopathy, acidosis, and hypothermia. See reference 1&2 for good discussions of this physiology.
Time for a grain of salt: A recent article in JTACS advocates for favoring calcium chloride during whole-blood or massive transfusion and was associated with improved early survival. Calcium chloride at a threshold of at least 1 g per 2 units of low-titer O whole blood was independently associated with an 84% (!) reduction in 24-hour mortality, with the benefit strongest at this 1:2 ratio and weaker at less aggressive thresholds. (LOTS of caveats with this finding, but interesting nonetheless).
Current major civilian guidelines say only that hypocalcemia should be prevented, with limited specificity on timing or dose, and the Joint Trauma System recommends 1 g calcium after the first unit and after every fourth unit thereafter. The current CAVALIER trial is evaluating prehospital calcium specifically. Those results and other recent literature could push major trauma organizations to update their recommendations in the near future.
Bottom Line: Among hospitalized patients boarding in the emergency department, care at an academic safety-net hospital, overnight admission, and elevated lactate levels may be independent predictors of early clinical deterioration.
In a randomized multicenter trial comparing direct vs video laryngoscopy in trauma patient intubation, video had a higher first pass success rate and equal complication to direct laryngoscopy.
This study found that of all 283 EM residencies in the US, only 4% listed pronouns on resident webpages, 3% had LGBT+ dedicated sections of their website, and only 31% had DEI sections of the website at all.
In the post COVID era of residency interviews, the programs' websites become a vital source of information for the applicants. There is still a large gap in the visibility of the LGBTQIA+ population in the majority of program websites.
