Am J Emerg Med
· 2026 Jun · PMID 42263335
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Pneumocephalus is the presence of air in the brain parenchyma, ventricular cavities, or epidural, subdural, or subarachnoid spaces. Simple pneumocephalus is often asymptomatic; however tension pneumocephalus can present...Pneumocephalus is the presence of air in the brain parenchyma, ventricular cavities, or epidural, subdural, or subarachnoid spaces. Simple pneumocephalus is often asymptomatic; however tension pneumocephalus can present with the altered sensorium, cardiorespiratory arrest, and the Cushing's triad. The Cushing's triad (widened pulse pressure, bradycardia, and irregular respirations) is known to emergency medicine practitioners to be an ominous sign of increased intracranial pressure and indicates imminent brainstem herniation. Here we present a case of acute pneumocephalus from the patient blowing their nose. The patient was bradycardic, hypertensive, and tachypneic in triage. Her CT was notable for extensive pneumocephalus around the brainstem with a visible tract connecting the external auditory canal, through the internal auditory canal, to the infratentorial space with pressure on the brainstem. Upon further imaging, the patient had a defect in her left round window allowing for this air entry. The etiology of pneumocephalus is discussed as well as management strategies.
Am J Emerg Med
· 2026 Jun · PMID 42263334
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INTRODUCTION: The need for alternative analgesia to opioids in the emergency department (ED) has become increasingly urgent due to the opioid epidemic. Ketamine, traditionally used for sedation, has emerged as a promisin...INTRODUCTION: The need for alternative analgesia to opioids in the emergency department (ED) has become increasingly urgent due to the opioid epidemic. Ketamine, traditionally used for sedation, has emerged as a promising alternative for pain control in the acute care setting. This scoping review evaluates the use of intranasal (IN) ketamine compared with intravenous (IV) opioids for analgesic efficacy in treating acute pain in the ED. METHODS: A search of PubMed, CINAHL and PRIMO databases was conducted for randomized controlled trials (RCTs) published between 2015 and 2025. A total of 561 records were identified, and 8 RCTs evaluating analgesic efficacy as the primary outcome were included in this review. This review was conducted in accordance with the PRISMA-ScR reporting guidelines. RESULTS: Eight RCTs including 846 patients were included (2016-2025), all conducted in Iran, Israel, or Thailand. IN ketamine (0.3-1.5 mg/kg) was most commonly compared with IV morphine (0.1 mg/kg). Across studies, IN ketamine demonstrated comparable reductions in pain scores to IV morphine, with several trials reporting no statistically significant differences at measured time points, although IV morphine was generally associated with faster onset of analgesia. In one study, IV fentanyl produced greater pain reduction than IN ketamine. Adverse effects were generally mild and transient with IN ketamine associated with fewer adverse events compared to IV morphine. CONCLUSION: IN ketamine may be useful for acute pain management in the ED. However, further research is needed to determine optimal dosing, compare its efficacy with more potent opioids, and evaluate long-term outcomes associated with its use.
Am J Emerg Med
· 2026 Jun · PMID 42258903
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Lacosamide is a third-generation antiseizure medication that enhances slow inactivation of voltage-gated sodium channels. Although generally well tolerated, it has been associated with cardiac conduction abnormalities, m...Lacosamide is a third-generation antiseizure medication that enhances slow inactivation of voltage-gated sodium channels. Although generally well tolerated, it has been associated with cardiac conduction abnormalities, most commonly in the setting of intravenous administration, overdose, or dose escalation. We report a case of a 79-year-old woman with a history of hypertension (treated with losartan and metoprolol), restless legs syndrome (treated with ropinirole), peripheral neuropathy, and seizure disorder who presented to the emergency department with several days of intermittent confusion and generalized weakness following a recent admission for seizure-like activity, during which lacosamide had been initiated. On arrival, she was afebrile with a heart rate of 74 beats per minute, blood pressure 165/88 mmHg, and oxygen saturation 98% on room air; she was oriented to person and year but not to place, which represented a change from her baseline. Initial laboratory evaluation, including complete blood count, comprehensive metabolic panel with normal renal and hepatic function, B12, and thyroid stimulating hormone, was unremarkable, and her admission electrocardiogram showed normal sinus rhythm with a PR interval of 208 ms. While boarding in the emergency department, she received her scheduled oral lacosamide 150 mg, and approximately two hours later was found unresponsive with a heart rate in the 30s and systolic blood pressure of 50 mmHg. She responded to atropine 1 mg IV and 50μg of epinephrine IV, with improvement of her vital signs and mental status. Six hours later, she received a second scheduled dose of lacosamide 150 mg along with her home medications, including metoprolol tartrate 50 mg, and again two hours later became minimally responsive with a heart rate of 49 beats per minute, blood pressure 64/32 mmHg, and a new first-degree atrioventricular block; she again responded to atropine. The second episode was more pronounced and associated with conduction delay not previously present. No seizure activity was observed during either episode. Lacosamide was discontinued, and the patient had no further bradycardic or hypotensive events. The reproducible temporal relationship between dosing and symptoms, along with resolution after medication cessation, supports a causal association. This case highlights that clinically significant cardiac adverse effects can occur with standard oral dosing of lacosamide, particularly in older adults and in the presence of other medications that affect cardiac conduction. Emergency physicians should maintain a high index of suspicion for medication-induced bradycardia and hypotension in patients receiving lacosamide. This case also underscores how hospital boarding can increase the risk of iatrogenic harm, as patients may receive routine medications in a high-acuity environment where evolving adverse effects can be more difficult to anticipate and detect.
Bar-Or D, Jarvis S, Acuna D
… +4 more, Berg G, Palacio C, McGuire E, Zaw-Mon C
Am J Emerg Med
· 2026 Jun · PMID 42247809
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BACKGROUND: Incarcerated individuals experience elevated injury rates, yet data on their injuries-particularly by race-are limited. This study aimed to describe racial differences in the occurrence, characteristics, and...BACKGROUND: Incarcerated individuals experience elevated injury rates, yet data on their injuries-particularly by race-are limited. This study aimed to describe racial differences in the occurrence, characteristics, and outcomes of traumatic prison injuries. METHODS: This retrospective cohort study included adult trauma patients admitted to five Level I trauma centers (01/2016-07/2022). Patients were categorized as non-Hispanic (NH-) White, Black, or Hispanic. The primary outcome was the proportion of prison injuries among all traumatic injuries. Secondary outcomes included length of stay (LOS), intensive care unit (ICU) admission, and discharge disposition. RESULTS: Among 53,872 trauma admissions, 187 (0.35%) occurred in prison. Black (0.8%) and Hispanic (0.4%) patients had a higher proportion of prison injuries than NH-White patients (0.3%) (p < 0.0001). After adjustment, Black [OR:2.34 (1.50-3.67)] and Hispanic patients [OR:1.44 (1.02-2.03)] had higher odds of sustaining prison injuries than NH-White patients. There was a trend towards Black patients suffering assaults more than Hispanic or NH-White patients (p = 0.06). NH-White patients (19.3%) sustained self-harm injuries significantly more than Black patients (0%), with no difference compared to Hispanic patients (10%). ICU admission was similar by race. Differences were observed in LOS and discharge disposition, Hispanic patients had the longest stays. CONCLUSIONS: Black and Hispanic patients had higher odds of having a prison injury than NH-White patients. NH-White patients suffered self-harm more than Black patients, whose most common cause of injury was assault. Differences in injury and discharge patterns suggest potential structural inequities in prisons and discharge practices.
Am J Emerg Med
· 2026 Jun · PMID 42247808
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Organophosphate (OP) poisoning frequently results in respiratory failure and requires rapid atropine titration to clinical endpoints that are often subjective and difficult to assess in high-acuity emergency settings. We...Organophosphate (OP) poisoning frequently results in respiratory failure and requires rapid atropine titration to clinical endpoints that are often subjective and difficult to assess in high-acuity emergency settings. We report the use of serial point-of-care lung ultrasound (LUS) as a complementary diagnostic adjunct during atropine escalation in severe OP poisoning. A young patient presented with severe cholinergic toxidrome and hypoxic respiratory distress. Baseline 4-zone anterior LUS demonstrated diffuse confluent B-lines consistent with marked interstitial-alveolar involvement. Atropine was administered using a sequential doubling strategy, and repeat LUS examinations during resuscitation demonstrated a progressive reduction in B-line burden corresponding with cumulative atropine dosing and clinical improvement. The patient recovered without requiring mechanical ventilation. This case illustrates a novel application of lung ultrasound as a complementary diagnostic adjunct during assessment of pulmonary involvement in acute OP poisoning and suggests a potential role for ultrasound in toxicologic resuscitation.
Llorens P, Cano S, Espinosa B
… +6 more, Villar M, Pastor Bellod E, Miró Ò, González Del Castillo J, Ramos-Rincón JM, SIESTA Investigators - Spanish Investigators in Emergency Situations TEam
Am J Emerg Med
· 2026 Jun · PMID 42236377
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Jain VS, Vong T, Thompson VL
… +10 more, Lopez-Silva C, Sequeira L, Rizer N, Hinson JS, Klein E, Copenhaver MS, Brookmeyer C, Purnell T, Woreta T, Strauss AT
Am J Emerg Med
· 2026 May · PMID 42229200
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BACKGROUND: Incidental findings in the Emergency Department (ED) are often not acted upon due to acuity of care and lack of referral pathways. Artificial intelligence (AI) can be used to combine heterogeneous data collec...BACKGROUND: Incidental findings in the Emergency Department (ED) are often not acted upon due to acuity of care and lack of referral pathways. Artificial intelligence (AI) can be used to combine heterogeneous data collected during ED encounters to computationally identify patients with specific disease phenotypes allowing for directed care-paths. We identified ED patients with undiagnosed Metabolic Dysfunction-Associated Liver Disease (MASLD) to demonstrate the feasibility of automated algorithms for clinical phenotypes. METHODS: We identified adults in 5 EDs with abdominal imaging between 1/1/2018-12/31/2023. Using a large language model, we included patients with hepatic steatosis on imaging and liver enzyme measurements. We excluded patients with prior liver disease. The K-means algorithm, an unsupervised machine learning method, was used to cluster patients into clinical phenotypes. RESULTS: We identified 80,211 individuals with abdominal imaging, and 9103 (11.34%) met inclusion criteria. Clustering revealed three distinct phenotypes: Cluster 1 (Low Metabolic Burden Hepatic Steatosis), Cluster 2 (MASLD Dominant Hepatic Steatosis), and Cluster 3 (Non-MASLD Dominant Liver Disease). Cluster 2 (n = 1762, 19.4%) showed increased incidence of hypertension (76.6%), type 2 diabetes mellitus (53.7%), and dyslipidemia (48.6%). Cluster 3 (n = 520, 5.7%) had significantly elevated FIB-4 values (4.50 vs. 0.98 p < 0.001) but low incidence of MASLD risk factors. Finally, Cluster 1, the largest group (n = 6821, 74.9%) showed low FIB-4 values and low incidence of MASLD risk factors. CONCLUSION: An automatic AI-based algorithm identified a subset of patients with high risk factors for MASLD with low liver disease screening scores (FIB-4) allowing for future integration into health surveillance algorithms.
Fritz CL, Tibbles J, De La Bastide C
… +8 more, Liu AJ, Sargent J, Gupta A, Parsons C, Moore E, Schoenfeld DW, Rosen CL, Thomas SH
Am J Emerg Med
· 2026 Sep · PMID 42217297
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BACKGROUND: Snowmobile accidents occur in areas that may be difficult to reach by ground Emergency Medical Services (GEMS) vehicles. Helicopter EMS (HEMS) can potentially be useful in these situations, but there are few...BACKGROUND: Snowmobile accidents occur in areas that may be difficult to reach by ground Emergency Medical Services (GEMS) vehicles. Helicopter EMS (HEMS) can potentially be useful in these situations, but there are few available data assessing HEMS-associated survival improvement in patients injured in snowmobile accidents. This study evaluates the national trauma database (NTDB) to identify snowmobile-related injury cases to determine if HEMS transport was associated with improved outcome, and whether any improvement in outcome is associated with worse functional status as indicated by disposition destination. METHODS: Using the American College of Surgeons National Trauma Data Bank (NTDB) for the years 2017-2022, snowmobile-related injury cases that were transported from the scene and in which transport mode (HEMS or GEMS) and survival status was known were assessed. Multivariable logistic regression (including use of Mahalanobis metrics within propensity-score calipers) was used to evaluate the primary endpoint of survival, with effect estimates reported as adjusted odds ratio (OR) with 95% confidence interval (CI). A secondary endpoint "unfavorable disposition destination" was assessed in survivors, to determine whether any HEMS-associated survival improvement came at the cost of a worse functional outcome. RESULTS: The study assessed 10,541 cases in which there were 521 (4.9%) deaths. Classical logistic regression incorporating demographics, vital signs, and receiving hospital characteristics indicated HEMS-associated improvement in survival (OR 1.9, 95% CI 1.4-2.7), which was confirmed in propensity-scored modeling indicating absolute risk difference of 2.7% (number needed to transport by HEMS to save one additional life: 37 with 95% CI 24-83). Secondary endpoint analysis did not suggest that improved HEMS survival came at cost of functional outcome; HEMS cases were slightly less likely to have unfavorable disposition destinations but the difference was not significant (OR 0.9, 95% CI 0.7-1.2, p = .461). CONCLUSION: In a group of cases injured using snowmobiles, HEMS transport is associated with significantly improved mortality without any indication that improved survival comes at a cost of worse functional outcome.
London KS, Cherney A, Neupane S
… +9 more, Tomlinson HA, Cervone J, Qian E, Fishman C, Davis J, McGann S, Goswami V, Koenig G, Randolph F
Am J Emerg Med
· 2026 Sep · PMID 42214304
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BACKGROUND: Non-trauma center (NTC) emergency departments (EDs) play regular but underappreciated roles in the management of severely injured patients, yet many lack formal protocols to guide care. We describe the implem...BACKGROUND: Non-trauma center (NTC) emergency departments (EDs) play regular but underappreciated roles in the management of severely injured patients, yet many lack formal protocols to guide care. We describe the implementation and outcomes of a structured trauma evaluation and transfer protocol at an urban NTC emergency department. METHODS: A multidisciplinary trauma protocol was implemented on April 1, 2023, at an urban NTC, supported by a Level I trauma center, 2.5 miles apart. The study period ran from January 1, 2019, to June 30, 2025. Using pre-post study design, 62 patients treated prior to implementation were compared with 49 post-intervention patients. The primary outcome was time to transfer to the trauma center. Secondary outcomes included time to trauma alert activation, time to CT imaging, documentation completeness across six process metrics, clinical intervention rates, and mortality. RESULTS: The two cohorts were well-matched in demographics and injury characteristics by regression analysis. Median time to transfer decreased significantly from 78 min (IQR 47-212) to 50 min (IQR 39-97) post-intervention (p = 0.011). Time to CT imaging decreased from a median of 90 to 34 min (p = 0.003). Documentation metrics improved (p ≤ 0.001). Mortality decreased from 9.7% to 6.1%, although this difference did not reach statistical significance. CONCLUSIONS: Implementation of a structured trauma protocol reduced time to transfer and time to imaging in an urban community ED. These findings demonstrate that NTC hospitals can achieve meaningful improvements in trauma processes and support their integration as active contributors within inclusive regional trauma systems.
Khalid A, Riaño AS, Mohnkern JD
… +5 more, Ibrahim M, Dave V, Hess J, Finch PT, Martins Shehan TS
Am J Emerg Med
· 2026 Sep · PMID 42190636
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IMPORTANCE: Sickle cell disease is frequently complicated by vaso-occlusive events, which represent one of the leading causes of acute pain and emergency care utilization in pediatric patients. However, there is limited...IMPORTANCE: Sickle cell disease is frequently complicated by vaso-occlusive events, which represent one of the leading causes of acute pain and emergency care utilization in pediatric patients. However, there is limited and inconsistent data about the time to administer opioids in pediatric patients with sickle cell vaso-occlusive episodes (VOE). OBJECTIVE: We aim to conduct a systematic review and meta-analysis to compare early and delayed opioid administration in pediatric patients with VOE. DATA SOURCES: We systematically searched PubMed, Embase, and Cochrane Library from inception to November 2025. STUDIES SELECTION: Randomized controlled trials or observational studies comparing early and delayed opioid administration in pediatric patients with sickle cell VOE. Five reviewers independently screened titles and abstracts, followed by full-text evaluation of potentially eligible articles. Disagreements were resolved through discussion and adjudication by a third reviewer. DATA EXTRACTION AND SYNTHESIS: We followed PRISMA guidelines. Data were independently extracted by multiple reviewers. MAIN OUTCOMES AND MEASURES: Our main endpoint was hospital admission from the index emergency department (ED) visit. Additional endpoints included ED discharge, ED length of stay, and pain reassessment. Risk ratios (RRs) were calculated for binary outcomes and mean differences (MDs) or standardized mean differences (SMD) for continuous outcomes with 95% confidence intervals (CIs). We performed a random-effect meta-analysis for all outcomes using R software (version 4.3.2). RESULTS: Six studies comprising 3367 patients were included, of whom 67% received early and 32% delayed opioid. The mean age was 9-16 years, and males accounted for 50% of participants. There was no significant difference when comparing early vs delayed opioid administration for hospital admission (RR 0.96; 95% CI 0.85 to 1.10), ED discharge (RR 1.04, 95% CI 0.89 to 1.22), ED length of stay (MD -6.02 min; 95% CI -1.22,45 to 110.42) and pain reassessment (SMD 0.85; 95% CI -1.92 to 3.63). A subgroup analysis comparing ≤60 min with ≥60 min of opioids administration also showed no difference between intervention arms. Individual studies showed potential benefits with timely repeat opioid dosing and the use of intranasal fentanyl (INF). CONCLUSIONS AND RELEVANCE: Our analysis showed no difference comparing early and delayed opioid administration in pediatric patients with sickle cell related VOE across hospital admission, ED discharge, ED length of stay, and pain reassessment.
Glawe DA, Marincovich A, Kang T
… +3 more, Kontowicz E, Howard M, Lee S
Am J Emerg Med
· 2026 Sep · PMID 42190635
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BACKGROUND: Delirium affects up to one-third of older adults in the emergency department (ED) and is frequently underrecognized. Head CT obtained during ED evaluation may reveal structural brain abnormalities in this pop...BACKGROUND: Delirium affects up to one-third of older adults in the emergency department (ED) and is frequently underrecognized. Head CT obtained during ED evaluation may reveal structural brain abnormalities in this population. This study evaluated whether structural lesions identified on head CT are associated with delirium in older ED patients. METHODS: We conducted a retrospective matched case-control study of adults aged ≥65 years who underwent delirium screening and head CT within 24 h of ED arrival. Delirium was defined by a positive Delirium Triage Screen followed by a positive Brief Confusion Assessment Method. Cases were matched 1:1 to non-delirious controls by age, sex, Emergency Severity Index, and chief complaint. Structural lesions were identified through radiology report review. Conditional logistic regression estimated associations between lesion presence and delirium, adjusting for pre-existing dementia and comorbidity. RESULTS: A total of 244 patients were included (122 delirium cases and 122 matched controls). Structural brain lesions were present in 55.7% of delirium cases compared with 37.7% of controls. The presence of any structural brain lesion was associated with higher odds of delirium (unadjusted OR = 2.2, 95% CI: 1.3-3.7; adjusted OR = 2.1, 95% CI: 1.1-3.8). Ischemic lesions were the most frequently identified abnormality. CONCLUSIONS: Structural brain lesions on head CT were associated with higher odds of delirium among older ED patients. When clinically indicated, imaging findings may complement bedside screening and known risk factors but do not establish additional diagnostic value beyond standard delirium assessment.
Sun M, Bergamo D, Loiselle CE
… +2 more, Hossain J, Thompson AD
Am J Emerg Med
· 2026 Sep · PMID 42190634
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OBJECTIVE: To examine the differences in the use of anxiolysis and sedation for facial laceration repair in the pediatric emergency department by patient race, ethnicity, and preferred language. METHODS: This was a retro...OBJECTIVE: To examine the differences in the use of anxiolysis and sedation for facial laceration repair in the pediatric emergency department by patient race, ethnicity, and preferred language. METHODS: This was a retrospective cross-sectional analysis of pediatric patients who underwent facial laceration repair in two pediatric emergency departments between January 2015 and December 2024. The primary outcome was receipt of any anxiolysis or sedation prior to laceration repair. We performed bivariate and multivariable mixed-effects logistic regression to evaluate associations between race, ethnicity, language, and the use of sedation. RESULTS: Of the 12,650 patients with facial lacerations who met inclusion criteria, 762 received sedation and 2,769 received anxiolysis only for the repair. Our study population was 51.8% non-Hispanic White, 13.4% non-Hispanic Black, 25.9% Hispanic, 8.5% Other race and ethnicity (including American Indian or Alaska native, Asian, Native Hawaiian or Other Pacific Islander, other (not specified), or patients listing two or more races), and 7.3% spoke a language other than English. Non-Hispanic White children had higher odds of receiving anxiolysis or sedation prior to repair compared with the grand mean (aOR 1.17; 95% CI 1.02, 1.35). There was no significant difference between patient language and administration of anxiolysis or sedation. CONCLUSION: Among children undergoing facial laceration repair in the pediatric emergency department, differences in the use of anxiolysis and sedation were observed by race and ethnicity, but not by preferred language. Targeted provider education and decision-support tools should be considered to promote equitable use of anxiolysis and procedural sedation in the emergency department.
Lee YR, Ruffolo I, Mashouri P
… +2 more, Brudno M, Ben-Yakov M
Am J Emerg Med
· 2026 Sep · PMID 42184774
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Early recognition of patients at risk for deterioration in the emergency department (ED) is critical for patient safety. Traditional early warning scores rely on structured triage data and often perform poorly in the dyn...Early recognition of patients at risk for deterioration in the emergency department (ED) is critical for patient safety. Traditional early warning scores rely on structured triage data and often perform poorly in the dynamic ED environment. We developed and evaluated two machine learning models integrating structured triage data with transformer-based embeddings of free-text nursing triage notes to predict early clinical deterioration prior to initial physician assessment, designed as a risk-based prioritization tool to rank patients by predicted probability of adverse outcome. We analyzed 17,481 consecutive adult ED visits over six months. Structured variables (demographics, vital signs, eCTAS scores) were combined with BioClinicalBERT-derived embeddings from free-text nursing triage notes to form a multimodal feature representation. Two XGBoost models (A, B) were trained on the same binary classification task, predicting "early deterioration" (ICU admission or death within 7 days, prevalence 4.5%) versus all other outcomes, differing only in class weighting. Model A used standard class weighting; Model B applied increased weighting to the early deterioration class to prioritize identification of high-risk patients. Model A achieved a recall of 0.66 (95% CI: 0.59-0.73), precision of 0.17 (95% CI: 0.15-0.20), and ROC-AUC of 0.75 (95% CI: 0.72-0.79). Model B improved recall to 0.77 (95% CI: 0.72-0.84), precision to 0.22 (95% CI: 0.19-0.25), and ROC-AUC to 0.90 (95% CI: 0.88-0.92). While XGBoost's internal feature importance attributed the majority of predictive weight to free-text embeddings, SHAP analysis identified age, respiratory rate, and systolic blood pressure as the dominant individual contributors, with triage note embeddings providing meaningful incremental value confirmed by structured-variable ablation. These findings suggest that AI-driven risk prioritization may function as an adjunct layer of situational awareness in the ED, complementing clinical judgement rather than replacing it. Safe clinical adoption will require prospective shadow testing in real-time workflows to quantify ranking accuracy, assess operational feasibility, and evaluate impact on decision-making before any clinician-facing implementation.
Gartenberg A, Dalla EE, Scoccimarro A
… +1 more, Halperin M
Am J Emerg Med
· 2026 Sep · PMID 42167134
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INTRODUCTION: Carbon monoxide (CO) poisoning remains a leading cause of toxic exposure worldwide. Beyond hypoxic injury, CO exerts direct cardiotoxic effects that contribute to both short- and long-term morbidity and mor...INTRODUCTION: Carbon monoxide (CO) poisoning remains a leading cause of toxic exposure worldwide. Beyond hypoxic injury, CO exerts direct cardiotoxic effects that contribute to both short- and long-term morbidity and mortality. Myocardial injury occurs frequently after CO exposure, including in patients without known coronary artery disease, and is associated with an increased risk of death, heart failure, and arrhythmias months to years after exposure. Nonetheless, cardiac injury often goes clinically unrecognized and is inconsistently evaluated in acute care settings. METHODS: A comprehensive scoping review was performed to summarize evidence published from between January 1990 and to December 2025 on the epidemiology, pathophysiology, clinical manifestations, and diagnostic evaluation of CO-related myocardial injury, with an emphasis on early detection and risk stratification in the ED. Findings were summarized qualitatively with emphasis on clinical relevance to acute care. RESULTS: Across studies, 20-40% of patients with moderate to severe CO poisoning demonstrated evidence of myocardial injury, as identified by elevated cardiac biomarkers or abnormal electrocardiography. Such injury is linked to a twofold increase in long-term mortality and adverse cardiovascular events. Mechanisms extend beyond hypoxia and include mitochondrial dysfunction, oxidative stress, endothelial injury, and catecholamine-mediated toxicity. Advanced imaging studies reveal persistent myocardial fibrosis and subclinical dysfunction even after apparent clinical recovery. CONCLUSIONS: As cardiac involvement is often clinically occult, reliance on symptoms alone may miss clinically significant myocardial injury, particularly in younger patients and those without known cardiac disease. Routine use of electrocardiography, cardiac biomarkers, and bedside echocardiography may improve early detection and risk stratification.
Kendrick E, Morales ED, Nathan P
… +6 more, Stilley J, Eubanks J, Helming D, Pollock K, Ge B, Robinson MT
Am J Emerg Med
· 2026 Sep · PMID 42167133
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BACKGROUND: Shift work is essential to hospital operations but disrupts circadian rhythms and is associated with increased metabolic, cardiovascular, and sleep health risks. Medications, naps, etc. may reduce symptoms bu...BACKGROUND: Shift work is essential to hospital operations but disrupts circadian rhythms and is associated with increased metabolic, cardiovascular, and sleep health risks. Medications, naps, etc. may reduce symptoms but do not solve the underlying problem of an unstable sleep schedule. Anchor sleep, where an individual maintains a core daily sleep period, is recommended to reduce circadian misalignment but is difficult to maintain. Casino schedules, which use a 4:00 a.m. turnover, provide a practical way to preserve anchor sleep, particularly during dark hours. Reports suggest casino schedules benefit wellness and cognition in healthcare workers, but other potential benefits have not yet been evaluated. METHODS: We completed a pilot study to assess inflammatory biomarkers and sleep in 12 emergency medicine physicians over a 6-month period. Each participant was studied under three conditions: baseline (96 h without overnight shifts), traditional overnight shifts, and casino shifts. We measured white blood cell and platelet counts, erythrocyte sedimentation rates, hemoglobin, and hematocrit. We also measured minutes of deep sleep using Fitbits and post-shift sleepiness using surveys. RESULTS: Traditional overnight shifts were associated with higher inflammatory markers and worse sleep outcomes, while casino shifts showed improvement. White blood cell and platelet counts increased during traditional overnight shifts and returned to baseline during casino shifts. Hemoglobin and hematocrit were unchanged. Deep sleep was better-preserved and participants reported less sleepiness during casino shifts. CONCLUSION: Casino shifts may improve sleep and inflammatory markers. These preliminary findings support larger, long-term studies on implementing casino shifts in healthcare.
Nicolaidis R, Bordini Ferro E, Martinho MAD
… +4 more, M de Andrade MV, Cordeiro Júnior W, Feuchard Linhares Ceraso AF, Oliveira J E Silva L
Am J Emerg Med
· 2026 Sep · PMID 42167132
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BACKGROUND: Emergency department crowding is a global challenge associated with adverse outcomes. It comprises distinct dimensions, including congestion and inpatient boarding, which may have different clinical implicati...BACKGROUND: Emergency department crowding is a global challenge associated with adverse outcomes. It comprises distinct dimensions, including congestion and inpatient boarding, which may have different clinical implications but are often assessed using composite indices. We aimed to characterize patterns of crowding and evaluate the association between its key components and early in-hospital mortality in Brazil. METHODS: We conducted a multicenter observational study using operational data from hospitals participating in a national quality improvement program (2019-2025). Two indicators were analyzed: occupancy ratio (census divided by designated beds) and boarding proportion (admitted patients remaining in the ED divided by total census). Associations with early in-hospital mortality (<24 h from presentation) were assessed at the hospital-month level using adjusted negative binomial regression with admissions as an offset, adjusting for hospital characteristics and temporal factors. RESULTS: A total of 160 hospitals were included. Crowding was persistent, with a median occupancy ratio of 1.03 and boarding proportion of 0.45. Boarding was associated with increased early mortality: each 0.10 increase in boarding proportion was associated with an IRR of 1.14 (95% CI 1.06-1.22). Occupancy was not associated with early mortality. CONCLUSIONS: Boarding, but not occupancy, was associated with early mortality, suggesting that interventions targeting exit block may be more impactful than those focused solely on ED input or capacity. This study also provides a novel large-scale longitudinal description of ED crowding in Brazil.