The American Journal Of Emergency Medicine[JOURNAL]
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200 papers
Providing financial incentives to residents does not improve emergency department length of stay.
Chen EH, Addo N, Peabody C … +3 more , Singh M, Colwell C, Straube S
Am J Emerg Med · 2026 Aug · PMID 42054772 · Publisher ↗
INTRODUCTION: Patient flow through the emergency department (ED) is a health system problem that requires a system-wide approach to interventions. We sought to help address ED flow by reducing consult-to-decision times f...
INTRODUCTION: Patient flow through the emergency department (ED) is a health system problem that requires a system-wide approach to interventions. We sought to help address ED flow by reducing consult-to-decision times for discharged and admitted ED patients requiring a specialist consultation. METHODS: This was a before-and-after study that involved implementing a pay-for-performance patient flow initiative that provided a financial incentive to residents from all specialty services for reducing consult-to-decision times for ED patients requiring consultant input by 20% for at least 6 months of the academic year. Patient flow metrics from the electronic health system were retrospectively collected to calculate the mean and median patient length of stay (LOS) by consulting service. The weighted LOS accounted for the proportion of consults completed by each clinical service. RESULTS: From 7/1/2022-6/31/2024, there were 38,840 ED specialty consultations. Before the intervention, the overall weighted mean LOS for patients requiring a consultant was 733 min (95% CI 726-740 min): 784 min (95% CI 776-792 min) for admitted patients and 531 min (95% CI 524-538 min) for discharged patients. At the end of the 2-year period, the overall weighted mean LOS was 1175 min (95% CI 1160-1190 min): 1348 min (95% CI 1336-1360 min) for admitted patients and 608 min (95% CI 601-614 min) for discharged patients. CONCLUSIONS: Offering financial incentives to trainees to reduce their consultation times did not overcome the systemic barriers to reducing ED LOS. Prioritizing patient flow without compromising resident education may require reimagining traditional team workflows.
The predictive value of skin lesions for intrathoracic and intra-abdominal injuries in patients with blunt thoracic and abdominal trauma.
Fiyakali EA, Şengüldür E, Selki K
Am J Emerg Med · 2026 Aug · PMID 42054771 · Publisher ↗
AIM: To assess whether thoracic and abdominal skin lesions predict CT-detected intrathoracic and intra-abdominal injuries in adults with blunt torso trauma. METHODS: This single-center retrospective study included 1523 a...
AIM: To assess whether thoracic and abdominal skin lesions predict CT-detected intrathoracic and intra-abdominal injuries in adults with blunt torso trauma. METHODS: This single-center retrospective study included 1523 adults (June 2014-June 2024) with blunt thoracic and/or abdominal trauma who underwent both chest CT and contrast-enhanced abdominal CT. Skin lesions and their anatomical locations were extracted from forensic examination forms. Outcomes were any pathological finding on chest CT and abdominal CT. Associations were evaluated using logistic regression, and discrimination was assessed using ROC curves (AUC). RESULTS: Median age was 42 (IQR 27-59) years, and 69.7% were male. Traffic accidents were the most common mechanism (45.9%). Chest CT pathology was present in 24.8% and abdominal CT pathology in 10.6%. Any thoracic skin lesion was associated with higher odds of chest CT pathology (52.6% vs 19.7%; OR 4.52, 95% CI 3.38-6.04; AUC 0.615). Any abdominal skin lesion was associated with higher odds of abdominal CT pathology (33.9% vs 7.6%; OR 6.22, 95% CI 4.28-9.06; AUC 0.639). Region-specific lesion models showed limited discrimination (AUC ∼0.50-0.55). CONCLUSION: Skin lesions are strongly associated with CT-detected intrathoracic and intra-abdominal injuries in blunt torso trauma, but their standalone discriminative performance is limited; they should be interpreted as supportive risk markers rather than definitive screening criteria.
Divergence between guidelines: Management of diabetic ketoacidosis in transition-age patients.
Türe E, Özkaya AK, İldeş EN … +1 more , İldeş S
Am J Emerg Med · 2026 Sep · PMID 42049609 · Publisher ↗
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The authors' responses: "Reader comment regarding prophylactic antibiotics for immunosuppressed individuals with anterior nasal packing: A propensity score matching study".
Tran QK, Camp S, Vanga R … +2 more , Bontempo LJ, Pourmand A
Am J Emerg Med · 2026 Jul · PMID 42036256 · Publisher ↗
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Diagnosis-specific patterns for direct ED discharge after physician-staffed HEMS transport in Japan: A nationwide registry study.
Sato H, Takenaka R, Yoshida S … +6 more , Seki N, Shibata T, Takahashi N, Shimomura T, Sakamoto T, Abe R
Am J Emerg Med · 2026 Aug · PMID 42035506 · Publisher ↗
INTRODUCTION: A proportion of patients transported by helicopter emergency medical services (HEMS) are directly discharged from the emergency department (ED). However, nationwide diagnosis-specific patterns of direct ED...
INTRODUCTION: A proportion of patients transported by helicopter emergency medical services (HEMS) are directly discharged from the emergency department (ED). However, nationwide diagnosis-specific patterns of direct ED discharge after HEMS transport remain unclear. METHODS: This retrospective study analyzed patients transported from the scene by physician-staffed HEMS in Japan (April 2020-March 2023). The primary outcome was direct ED discharge. Mixed-effects logistic regression with a prefecture-level random intercept was performed to explore associations between demographic, clinical, and dispatch factors at first contact and direct ED discharge for trauma and non-trauma patients. RESULTS: Of 28,213 patients, direct discharge occurred in 11.7% (1445/12,321) of trauma and 14.9% (2371/15,892) of non-trauma patients. Among trauma patients, direct discharge was frequent when the main injury involved the upper extremities but uncommon for truncal injuries (abdomen and pelvis). Among non-trauma patients, direct discharge was rare in the cardiac, cerebrovascular, respiratory, and digestive diagnostic categories, but frequent in the mental and behavioral, musculoskeletal, and symptom/sign categories. Younger age, female sex, pre-arrival HEMS activation, and a higher Glasgow coma scale score were associated with a higher likelihood of direct discharge in both trauma and non-trauma patients. Higher systolic blood pressure was associated with direct discharge in trauma patients, while lower values were associated with it in non-trauma patients CONCLUSION: The proportion of direct ED discharge after physician-staffed HEMS transport varied substantially across diagnostic categories in both trauma and non-trauma patients. This pattern may partly reflect diagnostic uncertainty in the initial assessment at first contact by the HEMS physician.
Secondary hypothermia at triage as a predictor of short-term mortality: A retrospective cohort study.
Hsu KC, Wang JC, Chen WK
Am J Emerg Med · 2026 Jul · PMID 42034106 · Publisher ↗
INTRODUCTION: In Taiwan, secondary hypothermia is common in emergency departments (EDs) but is not well incorporated into triage systems. The present study explored patterns of comorbidities and clinical predictors of 30...
INTRODUCTION: In Taiwan, secondary hypothermia is common in emergency departments (EDs) but is not well incorporated into triage systems. The present study explored patterns of comorbidities and clinical predictors of 30-day mortality in ED patients with secondary hypothermia to improve severity assessments and guide early triage. METHODS: This retrospective cohort study included adult patients who presented to a tertiary ED between 2019 and 2021 and had available data on tympanic temperature at triage. Patients were stratified into normothermia, mild hypothermia, and moderate hypothermia groups. Data on demographic characteristics, comorbidities, vital signs, and 30-day mortality were collected. Multivariate logistic regression with backward selection was performed to identify independent predictors of adverse outcomes. RESULTS: The final cohort comprised 4891 patients. Of the patients, 11.4% and 0.4% had mild and moderate hypothermia, respectively, at presentation. Secondary hypothermia was associated with an elevated comorbidity burden, impaired consciousness, and hemodynamic instability. The risk of 30-day mortality increased with hypothermia severity; it was 1.71% in the normothermia group, 8.44% in the mild hypothermia group, and 31.58% in the moderate hypothermia group. After adjustment for age, sex, comorbidities, neurological status, and hemodynamic variables, both mild and moderate hypothermia remained independently associated with an increased risk of 30-day mortality. This association was consistent across major demographic and clinical subgroups. CONCLUSION: In emergency care, secondary hypothermia is a crucial prognostic indicator of systemic vulnerability. Early recognition and severity-based triage may improve treatment decision-making, resource allocation, and clinical outcomes.
Accidental hypothermia in a temperate urban emergency department: Comorbidity, pharmacotherapy, and clinical staging patterns.
Ádám K, Stelkovics A, Farkas BV … +5 more , Hetzman LT, Bognár Z, Fenyves BG, Vörös B, Varga C
Am J Emerg Med · 2026 Jul · PMID 42034105 · Publisher ↗
OBJECTIVE: To characterize AVPU-temperature discordance, comorbidities, pharmacotherapy, and ED mortality in patients with accidental hypothermia at a temperate urban academic emergency department. METHODS: Retrospective...
OBJECTIVE: To characterize AVPU-temperature discordance, comorbidities, pharmacotherapy, and ED mortality in patients with accidental hypothermia at a temperate urban academic emergency department. METHODS: Retrospective single-center cohort study (March 2021-March 2025) at a Hungarian academic emergency department. We included 125 patients with ICD-10-coded accidental hypothermia and tympanic temperature below 35 °C. Severity was classified by original Swiss temperature thresholds. The distribution of AVPU consciousness categories across temperature-defined Swiss stages was analyzed. RESULTS: Twenty-three patients (18.4%) died in the ED. Non-survivors had lower temperatures (median 27.1 vs 29.5 °C, p = 0.029). Patients were found indoors as often as outdoors. Consciousness level frequently diverged from temperature-defined severity: 30.0% of Stage III and 18.2% of Stage IV patients were fully alert on presentation. Alcoholism (54.4%), cardiovascular disease (48.0%), and metabolic disorders (30.4%) dominated the comorbidity profile. No single comorbidity or medication class showed a clear unadjusted association with ED mortality. In Firth penalized logistic regression, each 1 °C higher tympanic temperature was associated with lower ED mortality odds (OR 0.83, 95% CI 0.72-0.95, p = 0.005). CONCLUSIONS: Patients with accidental hypothermia were found indoors as often as outdoors. Lower tympanic temperature characterized non-survivors, and this association persisted in exploratory Firth-corrected models. A substantial proportion of patients with moderate-to-severe hypothermia presented with preserved consciousness, suggesting that AVPU may be an imperfect surrogate for temperature-defined hypothermia depth in this cohort. No individual comorbidity or medication class showed a clear unadjusted association with ED mortality in this sample; these exploratory findings should be interpreted cautiously.
Outcomes of tympanostomy tube insertion in the emergency department versus the operating room for acute mastoiditis in children.
Grayevsky SF, Behar M, Guzner N … +4 more , Gross M, Shwarts NP, Hashavya S, Gross I
Am J Emerg Med · 2026 Jul · PMID 42034104 · Publisher ↗
BACKGROUND: Acute mastoiditis is a complication of acute otitis media in children that often requires surgical intervention. The increasing availability of procedural sedation in pediatric emergency departments (PED) mea...
BACKGROUND: Acute mastoiditis is a complication of acute otitis media in children that often requires surgical intervention. The increasing availability of procedural sedation in pediatric emergency departments (PED) means that some surgical procedures can be performed in the PED rather than in the operating room (OR), but the clinical outcomes of this practice remain unclear. OBJECTIVE: To compare the outcomes of Tympanostomy Tube (TT) insertion for acute mastoiditis performed in the PED vs. in the OR in terms of complications, readmissions, and effectiveness. METHODS: A retrospective observational study of patients aged 0-18 years diagnosed with acute mastoiditis at a tertiary medical center from 2013 to 2023 was conducted. Patients who underwent surgical interventions were categorized by treatment location (PED vs. OR). The data included demographics, laboratory findings, treatment details, and clinical outcomes. RESULTS: Of 197 children with acute mastoiditis, 124 underwent TT insertion: 54 in the PED and 70 in the OR. Baseline demographics and clinical parameters were similar. Time to procedure was shorter in the PED group (2.49 h vs. 3.75 h; p = 0.01). No significant differences were observed in PED length of stay (4.1 h vs. 4.1 h; p = 0.94) or total length of stay (5.2 days vs. 5.3 days; p = 0.80). There were no statistically significant differences in post-operative complications, including PICU admissions (0% vs. 0%, p = 1.00), PED revisit rates (20% vs. 17%, p = 0.77), rehospitalizations (11.1% vs. 8.6%, p = 0.64), or repeat drainage procedures (7% vs. 6%, p = 0.82) No major anesthesia-related or surgical complications were observed. CONCLUSION: Tympanostomy tube insertion for acute mastoiditis in the PED was associated with shorter time to procedure. It was comparable in terms of safety and effectiveness to procedures performed in the OR. No differences were observed in emergency department admissions or hospital length of stay. Thus although PED-based interventions may be feasible in appropriately selected patients, their impact on overall resource utilization is likely to depend on local staffing, workflows, and departmental capacity.
Lung ultrasound in diagnosis of wheezing triggered by infection in children less than 2 years: An observational study.
Bueno-Campaña M, Suarez-Cabezas S, de la Torre-Martin L … +5 more , Del Olmo-Segura P, Barral-Mena E, Canet-Tarres A, Hernández-Villarroel AC, González-Bertolín I
Am J Emerg Med · 2026 Aug · PMID 42034036 · Publisher ↗
OBJECTIVES: Lung ultrasound (LUS) has emerged as a potential tool in diagnosis of lower respiratory tract infections (LRTIs). This study aimed to evaluate its role in the differential diagnosis of LRTIs with respiratory...
OBJECTIVES: Lung ultrasound (LUS) has emerged as a potential tool in diagnosis of lower respiratory tract infections (LRTIs). This study aimed to evaluate its role in the differential diagnosis of LRTIs with respiratory distress and wheezing in children less than 2 years. METHODS: A exploratory, prospective, observational, multicentre study was conducted involving children less than 2 years with LRTIs and respiratory distress. LUS was performed within 24 h of admission. Findings were scored from 0 to 4 based on the type and severity of lesions observed in each of five defined areas and summed to calculate overall lung involvement. Main outcome was final clinical diagnosis (bronchiolitis or recurrent wheezing triggered by LRTI). The effect size, the predictive performance (ROC-AUC), sensitivity (S), and specificity (E) were calculated. RESULTS: 99 patients were included. Pathological LUS findings were present in 84.8%. Its presence in the right posterior lung fields was more frequently observed in clinical bronchiolitis (effect size: 0.674). These findings showed for this diagnosis a ROC-AUC of 0.68 (95% CI: 0.57-0.80) for the entire sample. For patients >6 months ROC-AUC was 0.81 (95% CI: 0.65-0.97), with 50% sensitivity and 96% specificity for the presence of >3 B-lines in this subgroup. CONCLUSIONS: LUS could help differentiate bronchiolitis from wheezing triggered by LRTIs in young children (especially in >6 months). The presence of B-lines in certain lung fields may be of diagnostic value. Variability in image acquisition and interpretation poses challenges. Larger studies are needed to confirm these findings and to establish an objective scale.
Sex differences in acute chest pain care in a multisite U.S. emergency department cohort.
McKnight KH, Snavely AC, Paukner L … +6 more , Ashburn NP, Jean-Louis RP, Supples MW, Hutchison BT, Pearson DA, Mahler SA
Am J Emerg Med · 2026 Jul · PMID 42030690 · Full text
BACKGROUND: Large studies examining sex-based differences in emergency department (ED) cardiovascular care are lacking. This analysis compared cardiovascular healthcare utilization and safety outcomes between women and m...
BACKGROUND: Large studies examining sex-based differences in emergency department (ED) cardiovascular care are lacking. This analysis compared cardiovascular healthcare utilization and safety outcomes between women and men in a large U.S. cohort managed under a standardized high-sensitivity troponin (hs-cTn) pathway. METHODS: We conducted an observational study of ED patients ≥18 years old presenting with chest pain from 1/2021-12/2021 across 25 EDs. Sex was defined by the legal sex EHR variable. The primary safety outcome was 30-day all-cause death or myocardial infarction (MI). The primary healthcare utilization outcome was hospitalizations at 30 days. Secondary healthcare utilization outcomes included 30-day objective cardiac testing (OCT: stress testing, coronary computed tomography angiography, invasive coronary angiography). Outcomes were compared between sexes using chi-squared tests and logistic regression, where models adjusted for cardiovascular disease confounders and initial hs-cTn. RESULTS: Among 40,979 patients, 56.6% (23,188/40,979) were female with mean age 52. Death or MI at 30 days occurred in 2.4% (552/23,188) of women and 5.2% (917/17,791) of men (p < 0.001). After adjustment, women had lower odds of death or MI (aOR 0.65, 95% CI 0.57-0.74). Hospitalizations occurred in 30.2% (6998/23,188) of women compared to 36.0% (6411/17,791) of men (p < 0.001). OCT occurred in 14.9% (3452/23,188) of women and 19.6% (3488/17,791) of men (p < 0.001). With adjustment, women were hospitalized less (aOR 0.93, 95% CI 0.88-0.98) and underwent less OCT (aOR 0.93, 95% CI 0.87-0.98) at 30-days. CONCLUSION: In a large ED cohort of patients with chest pain, rates of death or MI, hospitalizations, and OCT at 30-days were lower in women compared to men.
Permissive hypotension in adult trauma: A systematic review of outcomes across clinical settings, injury type, and resuscitation strategies.
Indorewala Y, Nasef Y, Jayagopi K … +5 more , Hernandez N, Kata A, Rogers LS, Haddadi M, Elkbuli A
Am J Emerg Med · 2026 Jul · PMID 42030689 · Publisher ↗
BACKGROUND: Hemorrhage is a leading cause of preventable trauma death, and aggressive crystalloid resuscitation may worsen coagulopathy. Permissive hypotension has emerged as a key damage-control strategy. This systemati...
BACKGROUND: Hemorrhage is a leading cause of preventable trauma death, and aggressive crystalloid resuscitation may worsen coagulopathy. Permissive hypotension has emerged as a key damage-control strategy. This systematic review aims to evaluate outcomes associated with permissive hypotension in adult trauma patients. METHODS: A systematic review of five databases was conducted from January 1, 2000, to October 18, 2025. Studies assessing hypotensive resuscitation in adult trauma patients based on care setting, injury type, and fluid volume were included. Outcomes of interest included mortality, and complications. RESULTS: 11 studies met the inclusion criteria and analyzed a total of 4529 patients. Permissive hypotension was only associated with decreased mortality within hospital settings (6.3% vs 16.3%, P = .045), while showing no difference in the prehospital settings. In hospital settings, permissive hypotension was also associated with decreased rates of complications such as acute respiratory syndrome (12.2% vs. 30.5%, p = .006), multiple organ failure (12.2% vs. 29.3%, p = .027), and disseminated intravascular coagulation (2.4% vs. 17.1%, p < .039). Compared to standard resuscitation, permissive hypotension was associated with decreased 24-h mortality (3.2% vs. 17.7%; adjusted OR = 0.17; 95% CI 0.03-0.92) in patients with blunt injuries. CONCLUSION: Permissive hypotension is an effective strategy in hemorrhagic shock in blunt trauma, demonstrating reduced complication and mortality rates compared to conventional resuscitation. Resuscitation should be individualized, with fluid volumes guided by patient hemodynamics and injury characteristics.
A case report of malignant catatonia in a patient with apparent intoxication.
Theobald T, Sayed O, Pettis C … +2 more , Klinger JA, Baker SP
Am J Emerg Med · 2026 Jul · PMID 42030688 · Publisher ↗
Catatonia is a neuropsychiatric syndrome characterized by motor and behavioral abnormalities, such as mutism and stupor. Delay in recognition and treatment can lead to progression of a life-threatening condition, maligna...
Catatonia is a neuropsychiatric syndrome characterized by motor and behavioral abnormalities, such as mutism and stupor. Delay in recognition and treatment can lead to progression of a life-threatening condition, malignant catatonia. Benzodiazepines are typically used as first-line treatment, but electroconvulsive therapy (ECT) may be required in cases refractory to benzodiazepines. We present a 24-year-old male presented to the emergency department (ED) with altered mental status and demonstrated several features of catatonia, including immobility, staring, posturing, grimacing, verbigeration, rigidity, negativism, and impulsivity. Despite multiple doses of lorazepam, the patient deteriorated, developing autonomic instability and requiring intubation. He was admitted to the intensive care unit and underwent two sessions of electroconvulsive therapy. Mental status improved on hospital day seven and he was discharged in stable condition on hospital day 8. Catatonia can mimic other conditions such as psychosis, intoxication, or delirium, making diagnosis challenging in the ED. Failure to recognize malignant catatonia can lead to rapid deterioration and even death. Emergency physicians should consider catatonia in patients with altered mental status with motor and behavioral abnormalities. Early recognition and initiation of treatment is crucial to good outcomes.
Routine chest X-ray in atraumatic chest pain with normal vital signs: A propensity-matched TriNetX analysis.
Cheema A, Cheema M, Camp S … +7 more , Mian N, Friedman J, Starks J, Mudd S, Walker JA, Pourmand A, Tran QK
Am J Emerg Med · 2026 Jul · PMID 42019151 · Publisher ↗
BACKGROUND: Patients presenting to the emergency department (ED) with chest pain frequently undergo a range of diagnostic evaluations aimed at rapidly identifying life-threatening conditions while stratifying overall ris...
BACKGROUND: Patients presenting to the emergency department (ED) with chest pain frequently undergo a range of diagnostic evaluations aimed at rapidly identifying life-threatening conditions while stratifying overall risk. However, the utility of chest x-rays (CXR) in patients with chest pain requires further investigation, as the diagnostic yield is uncertain. This study examines the prevalence of clinically relevant diagnoses and procedures identified on CXR in a cohort of patients with chest pain who had CXR, versus those with chest pain without CXR. METHODS: A retrospective analysis was conducted using the real-world database TriNetX Research Network, encompassing 20 years of data and 130 million patients. Adult patients presenting to the ED with an ICD-10 code of chest pain were included and stratified based on whether a CXR was performed on the exact same day as the ED visit. Inclusion criteria strictly required documented normal vital signs at the index visit (oxygen saturation ≥ 94%, respiratory rate 12-20, and temperature ≤ 100.4 °F). Patients with trauma, abnormal electrocardiogram, or acute myocardial infarction were excluded. The TriNetX propensity score matching algorithm was used to balance cohorts based on demographic and clinical covariates, including troponin I. The primary outcome was the presence of pneumonia at the index visit. Secondary outcomes included pulmonary edema, pleural effusion, pneumomediastinum, cardiomegaly, and pneumothorax. RESULTS: The query yielded a total of 461,108 eligible patients. After propensity score matching, the final analysis included 204,966 patients (102,483 per group), with a mean age (±SD) of 43.5 (±17.3) years and 56.3% being female. The primary analysis demonstrated a statistically significant but clinically negligible difference in the diagnosis of pneumonia (1.42% vs 0.70%; Risk Difference [RD] 0.72%, p < 0.001). Secondary outcomes, including cardiomegaly (RD 1.16%) and pleural effusion (RD 0.67%), similarly showed statistically significant but minimal risk differences. CONCLUSION: For patients presenting with chest pain and normal vital signs, routine CXR is associated with a statistically significant but clinically negligible increase in the detection of pneumonia. These findings suggest that CXR offers low diagnostic yield in this specific population and support the reduction of routine imaging for patients without specific risk factors such as abnormal vital signs, trauma, or abnormal electrocardiogram findings.
Reader comment regarding prophylactic antibiotics for immunosuppressed individuals with anterior nasal packing: A propensity score matched analysis.
Lee HC, Wang J
Am J Emerg Med · 2026 Jul · PMID 42014277 · Publisher ↗
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Kratom exposure cases reported to United States Poison Centers: 2016-July 2025.
Leonard JB, Brown K, Colvin JM
Am J Emerg Med · 2026 Jul · PMID 42013627 · Publisher ↗
INTRODUCTION: Kratom has a long history of use internationally. New formulations and extracts have recently come to the market and there has been an increase in interest and news around kratom and its alkaloids. This pap...
INTRODUCTION: Kratom has a long history of use internationally. New formulations and extracts have recently come to the market and there has been an increase in interest and news around kratom and its alkaloids. This paper updates the epidemiology and clinical outcomes from kratom exposures reported to US Poison Centers. METHODS: We analyzed kratom exposures reported to US Poison Centers from January 1, 2016 through July 31, 2025 to describe the epidemiology and compare the more recent exposures in 2025 to those reported before 2025. RESULTS: There were 13,194 exposures over the period. There was a slow increase and steady report of exposures from 2016 through 2024, with an increase in 2025. Males accounted for 68% of the population and the mean age was 32 years. Most patients (11,205, 85.0%) were either in or referred to a healthcare facility. Of these, 16.5% were admitted to the intensive care unit, 15.1% to a non-intensive care unit, 6.2% to a psychiatric facility, and 46.1% were discharged from the emergency department. There were 219 (1.6%) deaths (43 single-substance and 176 polysubstance) and 1324 (10%) major effects (potentially life-threatening signs or symptoms) reported. We identified a difference in the distribution of outcomes comparing pre-2025 and 2025 exposures for single-substance exposures but not polysubstance. Clinical effects were largely similar over time. CONCLUSION: There has been a significant increase in kratom exposures reported to US Poison Centers, but the overall outcomes have remained similar. Further investigation should be performed to identify the causes of the increase.
Association of implementation of an EHR-based sepsis alert system with sepsis-associated acute kidney injury.
Takeuchi T, Renzi S, Glanding KL … +5 more , Hirata K, Rehman AU, Ekrikpo UE, Tolwani AJ, Neyra JA
Am J Emerg Med · 2026 Jul · PMID 42013626 · Publisher ↗
PURPOSE: Given the limited evidence, this study aimed to determine the impact of an electronic health record (EHR)-based sepsis alert on the incidence of sepsis-associated acute kidney injury (SA-AKI), adherence to the 3...
PURPOSE: Given the limited evidence, this study aimed to determine the impact of an electronic health record (EHR)-based sepsis alert on the incidence of sepsis-associated acute kidney injury (SA-AKI), adherence to the 3-h sepsis bundle, and other clinical outcomes. METHODS: This single-center, pre/post-implementation study analyzed adult patients who were admitted from the Emergency Department to the intensive care unit with sepsis at a tertiary hospital in the United States from January 2021 to December 2023. A total of 7137 patients were included in our analysis. We used interrupted time series models, adjusted for seasonality, to assess changes following the implementation of a sepsis screening and alert system at Emergency Department on July 1, 2022. The primary outcome was the incidence of SA-AKI. RESULTS: After implementation, there was no significant immediate change in SA-AKI incidence (0.26%; 95% CI, -4.02 to 4.55), but a significant decreasing monthly trend was observed (-0.47% per month; 95% CI, -0.87 to -0.07). Adherence to the 3-h sepsis bundle showed a significant immediate increase (3.78%; 95% CI, 1.38 to 6.18). However, no significant changes were observed in in-hospital mortality or non-recovery from SA-AKI. CONCLUSIONS: The sepsis alert tool was associated with a progressive reduction in SA-AKI incidence and improved bundle adherence but was not associated with changes in mortality or renal recovery.
Predicting early recurrence after hydrostatic reduction of pediatric intussusception: A nomogram and a simplified clinical score.
Ding Z, Qiang H, Li X … +3 more , Li X, Cao Y, Zhu D
Am J Emerg Med · 2026 Jul · PMID 42013625 · Publisher ↗
OBJECTIVE: Early recurrence after successful hydrostatic reduction of intussusception occurs in 5-15% of children and often requires repeat intervention, yet reliable predictors remain incompletely defined. To identify c...
OBJECTIVE: Early recurrence after successful hydrostatic reduction of intussusception occurs in 5-15% of children and often requires repeat intervention, yet reliable predictors remain incompletely defined. To identify clinical and sonographic predictors of early recurrence (within 48 h) after ultrasound-guided hydrostatic reduction of ileocolic intussusception, and to develop a weighted nomogram and a simplified bedside score for risk stratification. METHODS: This retrospective study included 677 children who underwent successful ultrasound-guided hydrostatic reduction between January 2020 and December 2025. Early recurrence occurred in 66 patients (9.7%). Predictors were identified by LASSO regression and multivariable logistic analysis. A nomogram was constructed, and a simplified scoring system was derived for rapid bedside use. Recurrence timing was analyzed using Kaplan-Meier curves and Spearman's correlation. RESULTS: Five independent predictors were identified: transverse colon location (OR 4.647), previous intussusception history (OR 2.831), target sign diameter > 35 mm (OR 1.075 per mm), peritoneal effusion (OR 2.476), and sonographic features of enteritis (OR 2.347). The nomogram showed good discrimination (AUC 0.805). The simplified score (0-5), assigning 1 point to each predictor, also demonstrated acceptable discrimination (AUC 0.795), with a cutoff of 3 points optimally balancing sensitivity (62.1%) and specificity (84.3%). Median recurrence time was 23 h; recurrences were evenly distributed across the 48-h window, and the five predictors did not influence the exact timing of recurrence. CONCLUSION: A weighted nomogram and a simple bedside score based on five clinical and sonographic features accurately predict early recurrence after hydrostatic reduction of ileocolic intussusception. The tools enable individualized risk assessment and support risk-stratified observation strategies.
Optimization of benzodiazepine use for status epilepticus in the emergency department.
O'Keefe M, Feih J, Feldman R … +2 more , Stanton M, Dang CH
Am J Emerg Med · 2026 Jul · PMID 42013624 · Publisher ↗
BACKGROUND/PURPOSE: Benzodiazepine (BZD) underdosing in status epilepticus (SE) occurs frequently due to perceived risk of respiratory or cardiovascular complications, despite data supporting the guideline-recommended do...
BACKGROUND/PURPOSE: Benzodiazepine (BZD) underdosing in status epilepticus (SE) occurs frequently due to perceived risk of respiratory or cardiovascular complications, despite data supporting the guideline-recommended doses of BZDs and evidence that untreated SE carries higher complication rates. The purpose of this study was to determine the incidence of treatment escalation in patients receiving lower than recommended BZD doses (underdosed group) compared with those who received at or above guideline-recommended doses (guideline-dosed group). METHODS: This is a single-center retrospective analysis of adults presenting to the emergency department with SE who received BZDs as initial therapy. The primary outcome was incidence of treatment escalation, defined as endotracheal intubation (or attempted intubation) or need for a non-BZD second-line anti-seizure medication for ongoing seizure activity, between the underdosed group versus the guideline-dosed group. Secondary outcomes included hospital length of stay (LOS), intensive care unit (ICU) LOS, ventilator dependent days (VDD), and incidence of BZD-related adverse events. Multivariate logistic regression was used to identify predictors for treatment escalation. RESULTS: One hundred forty-four patients met inclusion criteria (mean age 52 years; predominantly male). Based on initial BZD dose, 127 (88.2%) were categorized as underdosed and 17 (11.8%) as guideline-dosed. Patients in the underdosed group were significantly more likely to require treatment escalation (69.3% vs 41.2%; p = 0.029) and had significantly longer hospital LOS (p = 0.043) and ICU LOS (p = 0.009). A separate analysis of cumulative BZD administered within 20 min of the initial dose showed no significant differences between groups in treatment escalation, hospital LOS, ICU LOS, or VDD. Incidence of BDZ-related adverse events did not differ between groups in either analysis. Significant predictors for treatment escalation included an initial BZD dose below guideline recommendations, lower initial Glasgow Coma Scale (GCS), and past history of epilepsy. CONCLUSION: Initial BZD underdosing in SE was associated with a higher rate of treatment escalation, and longer hospital and ICU LOS, without reducing adverse events. In this sample, underdosing appeared to be associated with adverse clinical consequences rather than improved safety. Though future studies are warranted into the reasoning for underdosing and evaluation of confounders which may impact results, our data demonstrate very few patients reach guideline recommended benzodiazepine dosing. Prioritizing guideline-recommended initial dosing may help minimize treatment escalation and reduce prolongation of care.
Prevalence, risk factors, and prognosis of the need for physical and chemical restraint in older patients attending emergency departments. EDEN-50.
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 Jul · PMID 42000676 · Publisher ↗
BACKGROUND: Physical and chemical restraints are used in Emergency Departments (EDs) to manage agitation in older people; however their prevalence and impact on clinical outcomes in this specific setting remain under-res...
BACKGROUND: Physical and chemical restraints are used in Emergency Departments (EDs) to manage agitation in older people; however their prevalence and impact on clinical outcomes in this specific setting remain under-researched. Therefore, the aim of this study was analyze the prevalence, identify independent predictors, and evaluate the impact on clinical prognosis (mortality, admission, and length of stay) of physical and chemical restraint use in a large cohort of older patients. METHODS: An observational, analytical, retrospective, multicenter study (EDEN-50 Study) was conducted across 52 Spanish EDs between 1 and 7 April 2019. We consecutively included 25,321 consecutive patients aged 65 years or older. The primary outcome was the need for restraint, subdivided into chemical and physical modalities. Multivariate logistic regression analysis was performed to determine independent predictors, and models were adjusted to quantify the association with adverse outcomes (all-cause mortality, ED and hospital length of stay). RESULTS: Restraint use was recorded in 109 patients (0.43%), with a predominance of chemical (0.35%; n = 89) over physical restraint (0.14%; n = 36), including 16 patients who received both. Restrained patients exhibited a more vulnerable profile: higher median age (86 vs. 78 years; p < 0.001), previous cognitive impairment (54.1% vs. 13.2%; p < 0.001), and nursing home residence (28.4% vs. 6.0%; p < 0.001). Patients presenting with acute confusion or disorientation had the highest risk of restraint (aOR 6.80; 95% CI 4.30-10.76), followed by arrival by ambulance (aOR 3.43; 95% CI 2.08-5.67) and a history of delirium (aOR 3.25; 95% CI 1.96-5.38)). Institutionalization and high comorbidity were associated with physical rather than chemical restraint. Restraint use was independently associated with higher all-cause mortality (aOR 2.14; 95% CI 1.19-3.85) and prolonged ED and hospital length of stay (aOR 2.52; 95% CI 1.61-3.95 and aOR 2.34; 95% CI 1.41-3.88, respectively). CONCLUSIONS: The use of restraint in the ED identifies a specific patient phenotype-advanced age, with cognitive impairment and altered mental status upon arrival-and serves as a sentinel marker for imminent mortality and prolonged ED and hospital length of stay.
Regional anesthesia in the emergency department: A review of key pharmacotherapeutic considerations.
Ray L, Gottlieb M, Long B … +2 more , Riscinti M, Rech MA
Am J Emerg Med · 2026 Jul · PMID 42000675 · Publisher ↗
INTRODUCTION: Opioid-associated risks and the opioid epidemic have accelerated interest in multimodal analgesia in the emergency department (ED). Regional anesthesia offers a targeted approach with reduced risk of system...
INTRODUCTION: Opioid-associated risks and the opioid epidemic have accelerated interest in multimodal analgesia in the emergency department (ED). Regional anesthesia offers a targeted approach with reduced risk of systemic adverse effects and is increasingly used under ultrasound guidance. OBJECTIVE: This concise, evidence-based review explores pharmacological principles of local anesthetics describing key aspects of structure-activity relationship, providing context for agent selection. Additional considerations include dosing strategy, adjunctive medications, potential risks, toxicity mitigation, and operationalization of regional anesthesia in the ED. DISCUSSION: Regional anesthesia is used with increased frequency in the ED. Pharmacologic properties of commonly used local anesthetics and adjunctive agents determine their advantages and limitations as well as place in therapy. There are a variety of anesthetic agents, including amides (e.g., lidocaine, bupivacaine, ropivacaine, levobupivacaine) and esters (e.g., articaine, chloroprocaine) with differences in onset, duration, and toxicity profiles that influence agent selection in ED patient populations. Adjuncts such as epinephrine, dexamethasone, and alpha-2 agonists may extend nerve block duration or improve analgesia but introduce safety and operational considerations. Recognition of local anesthetic systemic toxicity (LAST) remains central to safe practice, underscoring the importance of weight-based dosing, ultrasound guidance, monitoring, and immediate access to lipid emulsion therapy. Systems-based approaches such as order sets, pharmacist involvement, and structured training support consistent and safe application of regional anesthesia in the ED setting. CONCLUSIONS: Safe integration of regional anesthesia in the ED requires pharmacologic literacy, standardized systems, and multidisciplinary support to optimize analgesia while minimizing risk.
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