Ashwin Kumar VA, Barik S, Hansda U
… +2 more, Prusty AV, Sahoo S
Am J Emerg Med
· 2026 Jun · PMID 41812520
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Acute mesenteric ischemia (AMI) is a rare but life-threatening vascular emergency that typically affects elderly individuals with cardiovascular risk factors. We report a unique case of AMI in a previously healthy 15-yea...Acute mesenteric ischemia (AMI) is a rare but life-threatening vascular emergency that typically affects elderly individuals with cardiovascular risk factors. We report a unique case of AMI in a previously healthy 15-year-old boy who presented with acute abdominal pain, hypotension, and metabolic acidosis. Point-of-care ultrasound revealed ascites without clear signs of ischemia, and ascitic fluid analysis was suggestive of secondary peritonitis. Due to clinical deterioration and rising lactate levels, the patient underwent emergency explorative laparotomy, which revealed extensive gangrenous bowel secondary to superior mesenteric vein thrombosis, necessitating resection of approximately 430 cm of small intestine. This case highlights the diagnostic challenges of AMI in adolescents, where classical risk factors and signs may be absent. Early clinical suspicion, bedside diagnostics, and prompt surgical intervention are vital to improving outcomes in such atypical presentations.
Am J Emerg Med
· 2026 Jun · PMID 41812519
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Straddle injury is the most common cause of genital injuries in children and is defined as an injury resulting from a blunt impact to the perineum due to a fall onto a hard object. This type of injury tends to affect the...Straddle injury is the most common cause of genital injuries in children and is defined as an injury resulting from a blunt impact to the perineum due to a fall onto a hard object. This type of injury tends to affect the anterior perineum, and the perianal area is usually spared. Herein, we report a unique case of straddle injury that resulted in concomitant anorectal and posterior urethral injuries due to an atypical impact to the posterior perineum.
Am J Emerg Med
· 2026 Jun · PMID 41807217
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OBJECTIVES: This study evaluated the impact of response time on prehospital return of spontaneous circulation (ROSC) in out-of-hospital cardiac arrest (OHCA) patients in Busan, South Korea. METHODS: We analyzed OHCA case...OBJECTIVES: This study evaluated the impact of response time on prehospital return of spontaneous circulation (ROSC) in out-of-hospital cardiac arrest (OHCA) patients in Busan, South Korea. METHODS: We analyzed OHCA cases from Busan Fire and Disaster Headquarters (January-December 2022). A total of 2388 patients aged ≥18 years with complete EMS records were included. After excluding response time groups with <30 observations, 2268 cases were analyzed using SAS 9.4 for multiple logistic regression. RESULTS: Among 2388 OHCA patients in Busan, 179 (7.5 %) achieved ROSC. Only 2.5 % of cases met the 4-min response time benchmark. Multiple logistic regression identified key factors associated with higher ROSC: younger age (OR = 3.650 for 18-60 years vs. oldest group), witnessed arrest (OR = 2.788), shockable rhythm (OR = 3.105), bystander CPR (OR = 1.881), and EMS defibrillation (OR = 4.554). Response time showed the strongest association at <4 min (OR = 2.812), declining progressively at 5 min (OR = 1.748), 6 min (OR = 1.339), and 7 min (OR = 1.146). CONCLUSIONS: Shorter response times were associated with increased ROSC rates in OHCA patients. This highlights the need for policy measures to reduce response times, including community-based early recognition systems and optimized emergency resource allocation.
Pichardo-Gonzalez R, Le KK, Tran QK
… +4 more, Deogaonkar A, Offer J, Paul C, Pourmand A
Am J Emerg Med
· 2026 Jun · PMID 41806537
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BACKGROUND: Acute decompensated heart failure (ADHF) is commonly managed in emergency departments (ED) and poses significant morbidity and mortality burden. This study quantifies trends in demographics and healthcare cha...BACKGROUND: Acute decompensated heart failure (ADHF) is commonly managed in emergency departments (ED) and poses significant morbidity and mortality burden. This study quantifies trends in demographics and healthcare charges related to ADHF across EDs in the US. METHODS: A descriptive retrospective epidemiological analysis of nationally representative ED visit-level data was conducted using the Nationwide Emergency Department Sample (NEDS) database from 2016 to 2021. NEDS is a publicly available database maintained by the Healthcare Cost and Utilization Project (HCUPS). Adult patients with acute heart failure (HFrEF or HFpEF) were identified through ICD-10 codes. Survey-weighted estimates were used to generate national counts and characterize demographics, comorbidities, hospital characteristics, and disposition outcomes. Temporal trends in ED visits, admission rates, and healthcare charges were analyzed. RESULTS: A total of 10,041,919 ED encounters for ADHF were identified, with 43.6% female and a mean age of 69.8 years. Of these, 33.7% lived in low-income areas, and 83.6% were treated in metropolitan hospitals (primarily in the South, 40.8%). Most patients (82.8%) were admitted from the ED, with a low in-ED mortality rate of 0.1%. Of all patients, 5% were non-compliant with care. Trend analysis shows an increasing number of ADHF patients and rising non-compliance rates, with mean total hospital charges escalating from $71,578 in 2016 to $98,705 in 2021. CONCLUSION: This study underscores the substantial burden of ADHF on the healthcare system, with rising admissions and charges, contrasting with low in-ED mortality. Addressing these trends is essential to mitigate resource strain and enhance patient outcomes.
Tayes C, Schiro S, Smith B
… +3 more, Willner D, Winslow JE, Patel MD
Am J Emerg Med
· 2026 Jun · PMID 41791187
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OBJECTIVE: Rural disparities in in-hospital mortality after traumatic injury are well documented. However, less is known about rural-urban differences in prehospital trauma mortality. We evaluated differences in prehospi...OBJECTIVE: Rural disparities in in-hospital mortality after traumatic injury are well documented. However, less is known about rural-urban differences in prehospital trauma mortality. We evaluated differences in prehospital injury-related deaths between rural, suburban, and urban EMS incidents in North Carolina (NC). METHODS: Data on EMS responses for injury-related 9-1-1 calls from 7/1/2020-6/30/2023 were obtained from a statewide database. Eligible injuries were defined as EMS documentation of possible injury or a primary or secondary impression with an injury-related ICD-10-CM code (S00.x-T34.x, T79.x). The primary outcome was an EMS incident disposition of patient dead at the scene. Incident locations were geocoded and classified by Census tract-level rural, suburban, and urban. Covariates included demographics, dispatch complaint, EMS response mode and time, level of care, and injury cause and mechanism. Multivariable logistic regression was used to estimate adjusted odds ratios (ORs) and 95% confidence intervals (CIs) between prehospital mortality and rurality. RESULTS: Of 569,501 eligible EMS responses for injuries, 24% were rural, 15% were suburban, and 61% were urban. Prehospital mortality was 0.86%. Prehospital mortality was significantly higher with rural injuries (adjusted OR 1.54, 95% CI 1.19-1.98) and suburban injuries (adjusted OR 1.76, 95% CI 1.43-2.18) compared to urban injuries. Self-harm, traffic injuries, and penetrating trauma were strongly associated with prehospital mortality. CONCLUSIONS: This statewide study found significant rural-suburban-urban differences in prehospital mortality from injury, after accounting for demographics and incident and injury characteristics. These findings highlight the need for trauma systems to consider the differential burden of prehospital injury mortality across communities.
Am J Emerg Med
· 2026 Jun · PMID 41791186
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Extended focused assessment with sonography for trauma (E-FAST) is widely used for the rapid evaluation of patients with blunt trauma; however, its diagnostic performance is primarily limited to the detection of intraper...Extended focused assessment with sonography for trauma (E-FAST) is widely used for the rapid evaluation of patients with blunt trauma; however, its diagnostic performance is primarily limited to the detection of intraperitoneal free fluid and may not reliably identify retroperitoneal vascular injuries. A 53-year-old male presented after a high-energy motor vehicle collision with borderline hypotension and persistent tachycardia. Three consecutive E-FAST examinations were negative for pericardial, intraperitoneal, and pleural free fluid. Despite fluid and blood product resuscitation, he developed progressive hemodynamic instability. Contrast-enhanced computed tomography (CT) revealed active contrast extravasation due to isolated left renal vein laceration with a massive retroperitoneal hematoma. Shortly after imaging, the patient deteriorated rapidly and suffered cardiac arrest during preparation for emergency surgery. Resuscitative efforts were unsuccessful. This case demonstrates that negative E-FAST findings do not exclude significant retroperitoneal vascular injury in blunt trauma. In the presence of high-energy mechanisms or unexplained hemodynamic instability, reliance on E-FAST alone may delay definitive diagnosis, and early contrast-enhanced CT should be strongly considered.
Kimoto K, Ogura T, Goto T
… +5 more, Ryo H, An B, Matsuyama T, Koyama Y, Funakoshi H
Am J Emerg Med
· 2026 Jun · PMID 41791185
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BACKGROUND: The Canadian CT Head Rule (CCHR), New Orleans Criteria (NOC), Canadian C-Spine Rule (CCR), and NEXUS criteria are widely used to guide computed tomography (CT) after minor head injury, but many contemporary p...BACKGROUND: The Canadian CT Head Rule (CCHR), New Orleans Criteria (NOC), Canadian C-Spine Rule (CCR), and NEXUS criteria are widely used to guide computed tomography (CT) after minor head injury, but many contemporary patients fall outside their original derivation cohorts. We aimed to externally validate these four rules in an extended, real-world emergency department cohort. METHODS: We conducted a prospective multicenter observational study (HELMET trial) at five emergency and critical care centers. Adults (≥18 years) presenting within 24 h of blunt head trauma with Glasgow Coma Scale (GCS) scores of 13-15 were eligible. We excluded patients with GCS <13, Abbreviated Injury Scale (AIS) >2 in any non-head region, prior intracranial injury or cranial surgery, penetrating trauma, pregnancy, or refusal. Primary outcomes were radiographic intracranial injury on head CT and radiographic cervical injury on cervical CT. Diagnostic accuracy of each rule was estimated in complete-case cohorts and with multiple imputation for missing components. RESULTS: Of 3278 eligible patients, 1706 formed the complete-case cohort (median age 71 years). Traumatic findings were present in 143 head CTs (8.4%) and 14 cervical CTs (0.8%), and 44 patients (2.6%) underwent neurosurgical intervention. For head CT, CCHR sensitivity/specificity were 91.1%/33.8%, and NOC 95.8%/17.9%. For cervical CT, CCR sensitivity/specificity were 93.1%/37.0%, and NEXUS 71.4%/75.5%. CONCLUSIONS: In this extended minor head injury cohort, CCHR, NOC, CCR, and NEXUS did not achieve near-perfect sensitivity and had limited specificity. These rules have limited utility as stand-alone exclusion tools for reducing CT use and may serve as adjuncts to clinical judgment.
Otterness K, Keister M, Zhu J
… +1 more, Singer AJ
Am J Emerg Med
· 2026 Jun · PMID 41791184
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BACKGROUND: Angiotensin-converting enzyme inhibitor (ACEI)-induced angioedema is a potentially life-threatening adverse effect that can lead to airway compromise and hospitalization. Tranexamic acid (TXA) has been propos...BACKGROUND: Angiotensin-converting enzyme inhibitor (ACEI)-induced angioedema is a potentially life-threatening adverse effect that can lead to airway compromise and hospitalization. Tranexamic acid (TXA) has been proposed as a treatment, but comparative outcome data are limited. OBJECTIVE: To evaluate the association of TXA with 30-day mortality and secondary outcomes in patients with ACEI-induced angioedema. METHODS: We performed a retrospective cohort study using the TriNetX global health research network, including 20,787 adults with ACEI-induced angioedema from 144 healthcare organizations. Cohorts included patients receiving TXA (n = 1080) and patients not receiving TXA (n = 19,707) within 7 days on or after diagnosis. Propensity score matching was performed on 20 baseline characteristics, including demographics, comorbidities, concurrent medications, and vital signs. Primary outcome was 30-day mortality; secondary outcomes included venous thromboembolism (VTE), ICU admission, airway intervention, and hospital admission. Risk analyses and Kaplan-Meier survival analyses were conducted. RESULTS: After 1:1 propensity score matching, 30-day mortality was similar between TXA and no-TXA groups (1.0% vs. 0.9%; OR 1.10, 95% CI 0.47-2.56, p = 0.826). Rates of VTE were low and not significantly different (1.0% vs. 1.7%, p = 0.191). TXA-treated patients had higher rates of ICU admission (24.8% vs. 11.9%, OR 2.08, 95% CI 1.72-2.50, p < 0.001), airway interventions (7.8% vs. 5.1%, OR 1.52, 95% CI 1.10-2.13, p = 0.011), and hospital admission (35.8% vs. 27.3%, OR 1.32, 95% CI 1.16-1.49, p < 0.001). CONCLUSIONS: In this observational study, TXA administration was not associated with a reduced 30-day mortality in ACEI-induced angioedema and was associated with higher rates of ICU admission and airway interventions. Routine use of TXA for ACEI-induced angioedema is not supported by current evidence. Prospective studies are warranted to further determine the role of TXA in high-risk patients.
Chhablani C, Shahid U, Parde N
… +6 more, Muslmani S, Hu H, Thorpe D, Afshar M, Karnik N, Chhabra N
Am J Emerg Med
· 2026 Jun · PMID 41785519
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OBJECTIVE: Emergency department (ED) encounters represent valuable opportunities to initiate evidence-based treatments for patients with opioid misuse, but few receive such care. Universal manual screening has been propo...OBJECTIVE: Emergency department (ED) encounters represent valuable opportunities to initiate evidence-based treatments for patients with opioid misuse, but few receive such care. Universal manual screening has been proposed to improve patient identification but is uncommon due to its time and resource-intensive nature. We sought to determine the feasibility of identifying patients with opioid misuse at the time of ED triage using machine learning (ML). METHODS: We conducted a retrospective cohort study of 1123 ED encounters (September 2020 - March 2023) at a tertiary hospital. Encounters were enriched for opioid misuse, manually annotated, and chronologically split for training, validation, and testing. Candidate triage-time features included patient demographics, Emergency Severity Index, arrival time of day, chief complaint, comorbidities, and chronic medications. Model performance was evaluated using F1 score, area under the precision-recall curve (AUPRC), accuracy, recall, and AUROC. Post-hoc explainability analyses included SHapley Additive exPlanations (SHAP) and feature importance. RESULTS: All models performed comparably to opioid-related diagnosis codes placed at any time during the encounter. Random Forest (F1 = 0.75 [95%CI 0.70-0.83], AUPRC = 0.88 [0.81-0.93], accuracy = 0.79 [0.70-0.83]) and Gradient Boosting (F1 = 0.77 [0.71-0.82], AUPRC = 0.89 [0.85-0.93], accuracy = 0.81 [0.720.84]) had among the highest F1 score and AUPRC but confidence intervals overlapped with other methods. Explainability analyses highlighted prior drug-use diagnosis codes, triage acuity, and age as top predictors. CONCLUSION: ML classifiers leveraging routinely collected triage data offer a feasible and scalable alternative to manual screening in flagging opioid misuse before physician evaluation, potentially enabling early harm-reduction interventions. Prospective multi-site validation, calibration, and bias assessments are warranted.
Ijaz MT, Zaheer I, Khurshid MLR
… +6 more, Motasim N, Zahoor A, Ijaz N, Mukhtar H, Farooq RMU, Niazi A
Am J Emerg Med
· 2026 May · PMID 41762755
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BACKGROUND: Patients with psychiatric disorders often have coexisting medical conditions influencing mortality risk. This study analyses mortality trends from various comorbidities across the United States from 1999 to 2...BACKGROUND: Patients with psychiatric disorders often have coexisting medical conditions influencing mortality risk. This study analyses mortality trends from various comorbidities across the United States from 1999 to 2020. METHODS: Mortality data for psychiatric patients with cardiovascular, respiratory, and endocrine/metabolic/nutritional comorbidities were obtained from the CDC WONDER database (1999-2020). Age-adjusted mortality rates (AAMRs) per 100,000 population were calculated. Joinpoint regression was used to evaluate temporal trends and identify periods of change using average annual percentage change (AAPC). RESULTS: The AAMR associated with psychiatric illnesses increased from 72.1 (95% CI: 71.7-72.4) in 1999 to 237.6 (95% CI: 237.1-238.2) in 2020. Cardiovascular, respiratory, and endocrine/metabolic diseases were the major contributors to mortality, all demonstrating sustained increases over time, with Joinpoint analysis identifying distinct periods of accelerated increase. Mortality rates were higher in males than females (overall AAMR: 116.8 [95% CI: 116.7-116.9] vs 77.8 [95% CI: 77.7-77.9]). Substantial geographic variation was observed, with overall AAMRs ranging from 90.7 (95% CI: 90.5-91.0) in California to 294.4 (95% CI: 293.2-295.6) in Oregon; Vermont exhibited the highest cause-specific mortality rates for cardiovascular (167.7), respiratory (124.7), and endocrine/metabolic (71.9) causes. CONCLUSION: Mortality among psychiatric patients has risen markedly over the past two decades, with pronounced sex- and state-level disparities. These findings highlight the increasing burden of medical comorbidities in psychiatric patients presenting to acute care settings, particularly during periods of healthcare strain such as the COVID-19 pandemic, and underscore the importance of early risk recognition and integrated management in emergency care.
Am J Emerg Med
· 2026 Jun · PMID 41762557
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A 31-year-old male with no prior comorbidities presented with rapid-onset quadriparesis following one week of non-bloody diarrhea. Initial evaluation revealed severe hypokalemia (1.41 mmol/L) and an electrocardiogram (EC...A 31-year-old male with no prior comorbidities presented with rapid-onset quadriparesis following one week of non-bloody diarrhea. Initial evaluation revealed severe hypokalemia (1.41 mmol/L) and an electrocardiogram (ECG) demonstrating signs of cardiotoxicity (irregular rhythm, diffuse ST depression, prominent U waves, and prolonged QT interval). The patient subsequently experienced cardiac arrest due to polymorphic ventricular tachycardia (VT). VT was refractory to an initial 200 J DC shock but terminated following the rapid intravenous administration of a 40 mEq potassium chloride (KCl) bolus over 5 min. The patient achieved Return of Spontaneous Circulation (ROSC). Subsequent laboratory workup, including a low urine potassium concentration (10.20 mmol/L), confirmed the etiology was massive extra-renal (gastrointestinal) potassium loss. The patient made a full recovery, highlighting the critical role of prompt, aggressive potassium replacement in severe hypokalemic cardiotoxicity.
Am J Emerg Med
· 2026 Jun · PMID 41762556
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Rib fractures are the most common injury after cardiopulmonary resuscitation (CPR) for non-traumatic cardiac arrest. Pneumothorax can evolve into tension pneumothorax with assisted ventilation leading to hypotension and...Rib fractures are the most common injury after cardiopulmonary resuscitation (CPR) for non-traumatic cardiac arrest. Pneumothorax can evolve into tension pneumothorax with assisted ventilation leading to hypotension and cardiac arrest. Lung hernia post-CPR is rare but a potentially fatal complication. Here we describe a 67-year-old female who presented to the emergency department (ED) with acute infective asthma exacerbation. She received initial treatment of inhaled salbutamol and ipratropium bromide, oral prednisolone, supplemental oxygen, and intravenous ceftriaxone. Shortly after administration of ceftriaxone, she went into unexpected cardiac arrest. She had return of spontaneous circulation with cardiopulmonary resuscitation but remained unconscious. She was intubated but subsequent resuscitation was complicated by tension pneumothorax, bronchospasm resulting in dynamic hyperinflation, rib fractures, and lung hernia. The lung hernia was initially mistaken as subcutaneous emphysema on chest radiography. Despite epinephrine infusion, mechanical ventilation, and decompression tube thoracostomy, the patient suffered a second cardiac arrest and further resuscitation was ceased. The case demonstrates that lung hernia may be misinterpreted as subcutaneous emphysema secondary to tube thoracostomy on chest radiography. Early recognition for consideration of surgical intervention is essential especially in patients with incarcerated lung hernia and respiratory failure.
Am J Emerg Med
· 2026 May · PMID 41740421
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A burr hole is a high-acuity low-occurrence procedure that Emergency Physicians (EPs) must be familiar with in order to treat certain epidural and subdural hematomas in settings where neurosurgery is unavailable. A 32-ye...A burr hole is a high-acuity low-occurrence procedure that Emergency Physicians (EPs) must be familiar with in order to treat certain epidural and subdural hematomas in settings where neurosurgery is unavailable. A 32-year-old male presented to a community Emergency Department in a snowstorm after an All-Terrain Vehicle (ATV) accident with a headache, rib pain, and facial lacerations. He was found to be neurologically intact initially. Computed tomography (CT) imaging revealed a large epidural hematoma (EDH) with midline shift. The patient then had a significant change in mental status. Tertiary care centers and transportation teams were contacted, but due to the weather the patient could not be transferred for an estimated 5 h. An emergent burr hole was completed in the Emergency Department (ED), and he was transferred when it was safe by ground. He underwent surgical evacuation and he does not have any neurologic deficits today. This case portrays the importance of EPs being familiar with performing a burr hole although it is not a required Accreditation Council for Graduate Medical Education (ACGME) skill that Emergency Medicine (EM) residents are specifically trained on. It is vital that EPs know the indications for the procedure in the ED, the resources available at specific hospitals to assist, and the equipment needed to perform a burr hole. Performing an emergent burr hole when neurosurgery is unavailable in rural settings is sometimes necessary. It has been shown to be related to good outcomes for patients and this case serves as an example.
Am J Emerg Med
· 2026 Jun · PMID 41740194
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INTRODUCTION: Emergency department (ED) visits for acute methamphetamine-associated agitation are increasing. Many cases require parenteral medications. Benzodiazepines are often recommended first-line, however randomize...INTRODUCTION: Emergency department (ED) visits for acute methamphetamine-associated agitation are increasing. Many cases require parenteral medications. Benzodiazepines are often recommended first-line, however randomized trials of intravenous medications suggest antipsychotics are also effective. High-quality data on intramuscular medications are lacking. OBJECTIVE: To compare the effectiveness of intramuscular droperidol, olanzapine, midazolam, and lorazepam to treat methamphetamine-associated agitation in the ED. METHODS: This was a secondary analysis of previously published data from 2019 to 2020; medication, dose, route, and agitation etiology were determined by treating physicians. The primary outcome was time to adequate sedation (TAS), assessed via the Altered Mental Status Scale (AMSS), defined as time to AMSS≤0. Secondary outcomes included use of additional (rescue) medications and adverse events. RESULTS: We analyzed 122 patients with similar baseline characteristics; 37 received droperidol (median dose 5 mg, TAS 16 min), 44 received olanzapine (median dose 10 mg, TAS 16 min), 15 received midazolam (median dose 5 mg, TAS 13 min), and 26 received lorazepam (median dose 2 mg, TAS 29 min). Proportional hazards analysis showed lorazepam was associated with longer TAS (p < 0.001). The proportion of patients adequately sedated at 15 min was 43% for droperidol, 45% for olanzapine, 60% for midazolam, and 32% for lorazepam. The proportion of patients receiving rescue medication was 16% for droperidol, 20% for olanzapine, 13% for midazolam, and 46% for lorazepam. We found no difference in adverse events. CONCLUSIONS: Intramuscular droperidol, olanzapine, and midazolam were all similarly effective for treating methamphetamine-associated agitation. All three medications provided more rapid and effective sedation than intramuscular lorazepam.