J Emerg Med
· 2026 May · PMID 42269257
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BACKGROUND: Arterial gas embolism is a rare complication of several percutaneous procedures, including lung biopsy, and can lead to debilitating and deadly consequences for patients when not treated promptly. CASE REPORT...BACKGROUND: Arterial gas embolism is a rare complication of several percutaneous procedures, including lung biopsy, and can lead to debilitating and deadly consequences for patients when not treated promptly. CASE REPORT: A 67-year-old woman who had a history of a lung nodule underwent percutaneous lung biopsy with interventional radiology. She tolerated the procedure well, but shortly afterwards developed profound left neglect and hemiparesis. Computed tomography imaging was negative, and the patient was suspected to have developed an arterial gas embolism secondary to her procedure. She was intubated for airway protection after multiple seizures (prior to intubation, patient was not placed on supplemental oxygen in the emergency department) and was transferred to a facility capable of performing hyperbaric treatment, which she underwent. However, her brain damage was significant, with subsequent imaging showing significant cerebral edema, and she was eventually made palliative and passed. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Cerebral arterial gas embolism (CAGE) is a high acuity, low-occurrence event, where outcomes are predicated on early treatment that includes 100% supplemental oxygen delivered via non-rebreather and hyperbaric treatment. To facilitate early treatment, emergency physicians must recognize CAGE as an entity and the circumstances under which it might occur.
Siddiqua N, Panda BPD, Joshi S
… +1 more, Jamshed N
J Emerg Med
· 2026 Jun · PMID 42269256
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BACKGROUND: Idiopathic angioedema is a potentially life-threatening cause of acute airway compromise, with reported mortality rates up to 30% when airway intervention is delayed. Methemoglobinemia, a dyshemoglobinemia th...BACKGROUND: Idiopathic angioedema is a potentially life-threatening cause of acute airway compromise, with reported mortality rates up to 30% when airway intervention is delayed. Methemoglobinemia, a dyshemoglobinemia that reduces hemoglobin's oxygen-carrying capacity, can be acquired from drugs such as dapsone and occurs in approximately 0.4-1% of exposed patients. The coexistence of these two entities is exceptionally rare, posing diagnostic and management challenges in the emergency setting. CASE REPORT: A 16-year-old male presented to the emergency department with an acute onset swelling of the tongue and lips, accompanied by hypoxia. Endotracheal intubation was performed for airway protection. Adrenaline and fresh-frozen plasma were administered, resulting in the rapid resolution of angioedema. However, refractory hypoxia persisted despite adequate ventilation, normal point-of-care lung ultrasound, and unremarkable chest radiography. Arterial blood gas analysis revealed elevated methemoglobin levels (28%), confirming methemoglobinemia, attributed to recent dapsone use. Intravenous methylene blue was administered, leading to prompt normalization of oxygen saturation. The patient was extubated and discharged the following day without complications. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case underscores the importance of recognizing that more than one life-threatening condition can coexist in the same patient. Anchoring on a single diagnosis may delay identification of an equally dangerous concurrent pathology. Emergency physicians should maintain diagnostic vigilance, especially when expected improvement after treatment is incomplete or followed by unexplained deterioration. Timely recognition and targeted management of each condition can be lifesaving.
BACKGROUND: Vertigo is a common emergency department (ED) presentation. Assessment can be challenging due to various etiology and subtle clinical signs. Nystagmus is an important clinical feature, yet documentation of it...BACKGROUND: Vertigo is a common emergency department (ED) presentation. Assessment can be challenging due to various etiology and subtle clinical signs. Nystagmus is an important clinical feature, yet documentation of its key descriptors is often incomplete. OBJECTIVES: This study aimed to evaluate the documentation of nystagmus characteristics in patients presenting with acute vertigo to two regional EDs. Secondary objectives included examining neuroimaging utilization and the relationship between nystagmus and HINTS (+) testing (Head Impulse, Nystagmus, and Test of Skew plus the addition of sensorineural hearing loss and truncal ataxia). METHOD: Retrospective observational audit of electronic medical records from two EDs within the Central Coast Local Health District, New South Wales, Australia. Patients presenting with acute dizziness (n = 1942) from January-December 2023 who reported vertigo (n = 325) were included. Documentation of nystagmus and its characteristics, HINTS (+) competition, and neuroimaging utilization were analyzed and compared between sites. RESULTS: Nystagmus was documented in 89 cases, with direction reported in 97% (n = 86), duration 22% (n = 20), and magnitude in 13% (n = 12). Assessment with fixation removed was not performed. Neuroimaging was conducted in 47% (n = 152) of all vertigo presentations; with computed tomography angiogram used in 32% (n = 105), showing a diagnostic yield of 2%. HINTS (+) was documented in 25% (n = 80) of vertigo presentations, of which 60% (n = 48) were performed despite absent or undocumented spontaneous nystagmus. CONCLUSION: Nystagmus assessments are frequently performed in the ED, but detailed descriptors are inconsistently recorded. Neuroimaging utilization remained high despite low diagnostic yield. HINTS (+) examinations were frequently performed in patients that had no documented spontaneous nystagmus. These findings identified clear practice gaps, highlighting the need for targeted training in nystagmus assessment.
Çinar R, Özturan İU, Daylan P
… +5 more, Yıldırım SA, Doğan NÖ, Yaka E, Yılmaz S, Pekdemir M
J Emerg Med
· 2026 May · PMID 42263379
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BACKGROUND: Managing difficult airways in prehospital settings is particularly challenging, especially in rural or resource-limited environments and during patient transport. Inexperienced providers performing endotrache...BACKGROUND: Managing difficult airways in prehospital settings is particularly challenging, especially in rural or resource-limited environments and during patient transport. Inexperienced providers performing endotracheal intubation (ETI) during ambulance transport may have lower success rates, highlighting the potential value of real-time expert support. OBJECTIVES: This study aimed to evaluate the effectiveness of real-time teleguidance from a remote airway expert in improving ETI success among inexperienced operators using videolaryngoscopy (VL) in a moving ambulance environment. METHODS: This randomized controlled study included paramedic students with no prior clinical experience using VL, all of whom received standardized VL training immediately before participation. Participants were randomized to either a standard group (no external support) or a teleguidance group (remote expert assistance via the VL device's teleconsultation feature). All ETIs were performed on a high-fidelity manikin in a moving ambulance. The primary outcome was first-attempt ETI success. Secondary outcomes included intubation duration, number of attempts, successful glottic visualization, self-perceived confidence, and procedural feasibility. RESULTS: Ninety-eight participants were enrolled. First-attempt ETI success was significantly higher in the teleguidance group compared with the standard group (79% vs. 49%, p = 0.002). Median intubation time was shorter with teleguidance (30 vs. 61 seconds, p = 0.003), and fewer attempts were required (median 2 vs. 3, p = 0.001). No significant differences were observed in glottic visualization, confidence, or feasibility scores. CONCLUSIONS: In a simulated prehospital setting involving a moving ambulance, real-time teleguidance was associated with higher first-pass ETI success and shorter intubation times among inexperienced providers.
Coşkun SM, Efgan MG, Bora ES
… +3 more, Bilgin S, Yamanoğlu A, Karakaya Z
J Emerg Med
· 2026 May · PMID 42250406
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BACKGROUND: Accurate and rapid pulse assessment during cardiopulmonary resuscitation (CPR) is essential to minimize interruptions in chest compressions. Manual arterial palpation (MP) is subjective and often unreliable....BACKGROUND: Accurate and rapid pulse assessment during cardiopulmonary resuscitation (CPR) is essential to minimize interruptions in chest compressions. Manual arterial palpation (MP) is subjective and often unreliable. This is especially true in low-flow states. Transesophageal echocardiography (TEE) enables continuous intra-arrest cardiac visualization. It may facilitate faster decision-making during pulseless arrest. OBJECTIVES: To compare pulse evaluation-related decision-making time during CPR using TEE versus MP and to explore associated resuscitation outcomes. METHODS: This prospective observational study enrolled adult patients (≥18 years) with non-traumatic in-hospital cardiac arrest in a tertiary emergency department. Pulse assessment during CPR was performed either by MP or intra-arrest TEE. The method depended on the treating physician's clinical judgment. The primary outcome was the time spent on pulse evaluation-related decision-making. This was defined as the time from initiation of pulse assessment to the decision to continue or stop chest compressions. Secondary outcomes included total CPR duration and the rate of return of spontaneous circulation (ROSC). These were considered exploratory. Nonparametric statistical tests were used as appropriate. RESULTS: A total of 112 patients were included (median age 75 years; 39.3% female). Pulse evaluation-related decision-making time was significantly shorter in the TEE group compared with the MP group (median 2 [2-3] vs. 7 [5-8] s; p = 0.001). Total CPR duration was also shorter in the TEE group (median 15 [6-65] vs. 30 [2-72] min; p = 0.005). A higher proportion of ROSC was observed in the TEE group; however, this finding should be interpreted strictly as exploratory and hypothesis-generating. Moreover, the study was not powered to establish causality. CONCLUSIONS: Intra-arrest TEE was associated with significantly shorter pulse evaluation-related decision-making times compared with MP during CPR. By enabling rapid, continuous cardiac assessment, TEE reduced time to pulse evaluation-related decision-making. These findings are exploratory; their impact on clinically meaningful outcomes remains uncertain. Observed differences in ROSC should be interpreted cautiously. Confirmation in randomized, multicenter trials is needed.
Ekrem Çebi G, Ertan A, Ege Zilan D
… +4 more, Koçak H, Kınık K, Bek Yağmur Ö, Çalışkan C
J Emerg Med
· 2026 May · PMID 42242034
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BACKGROUND: Mass gatherings (MGs) are associated with increased healthcare demand and may pose a risk for mass casualty incidents if medical services are not adequately planned. Trauma presentations constitute an importa...BACKGROUND: Mass gatherings (MGs) are associated with increased healthcare demand and may pose a risk for mass casualty incidents if medical services are not adequately planned. Trauma presentations constitute an important component of medical encounters during MGs; however, evidence regarding trauma patterns and preparedness requirements remains fragmented. OBJECTIVE: The primary aim of this study was to examine rates of trauma-related presentations to in-event health care areas during MGs. Secondary aims were to identify trauma patterns across different event types, support planning of in-event health services and develop a practical checklist to assist trauma preparedness and response planning. METHOD: Following PRISMA guidelines, a systematic search was conducted across PubMed, Web of Science, and Scopus databases for studies published between 2015 and 2025. Articles were screened based on the PICOS framework, focusing on observational studies of MG participants exposed to trauma. Inclusion required the reporting of in-event healthcare data, while studies solely using hospital-based records or lacking trauma-specific metrics were excluded. Data were extracted using a standardized form to identify event characteristics, patient presentation rate (PPR), and transport to hospital rates (TTHR). The primary outcome was the incidence of trauma, while secondary outcomes included the identification of trauma subtypes (e.g., musculoskeletal, soft tissue). RESULTS: The initial search yielded 382 articles. After removal of duplicates and exclusions, 18 relevant studies were included in the final synthesis. The proportion of trauma-related visits relative to all patients treated at in-event medical stations ranged from 11.7 to 81.7%. The highest trauma rate was reported at the European Youth Olympic Winter Festival (81.7%), whereas the Guadalajara International Book Fair reported the lowest (11.7%). Soft tissue injuries (13-42.3%) were the most prevalent across music and sporting events, followed by musculoskeletal injuries (3-35.7%). Events involving mosh pit behavior showed a distinct clustering of head and facial injuries (65%). CONCLUSIONS: This review demonstrates that trauma-related presentations in MGs are highly heterogeneous and influenced by event type and participant behavior. Soft-tissue injuries constitute the majority of reported trauma cases, while endurance/open-course sports and high-energy music events show higher trauma burdens. These findings support event-specific medical planning and trauma preparedness for in-event healthcare services.
Shah FI, Lee R, Reich K
… +17 more, Crowder K, VandenBerg S, Schonnop R, Ismail Z, Lang E, Holroyd-Leduc J, Lee JS, McGillivray M, McLane P, Silvius JL, Ewa V, Bakal J, Seitz DP, Watt JA, Hoben M, Blanchard IE, Goodarzi Z
BACKGROUND: Undifferentiated agitation in older adults is common in the prehospital setting, and in transitions from emergency medical services (EMS) to emergency department care. Restraints are commonly used in the mana...BACKGROUND: Undifferentiated agitation in older adults is common in the prehospital setting, and in transitions from emergency medical services (EMS) to emergency department care. Restraints are commonly used in the management of agitation, although there is little evidence to inform the development of best practices. OBJECTIVES: To explore paramedic experiences and determine perceptions on issues when managing older adults with agitation and using restraints in EMS. METHODS: We conducted a descriptive cross-sectional survey of paramedics in Alberta, Canada, with a mix of multiple choice and open-ended questions that were interpreted using descriptive statistics and a qualitative thematic analysis, respectively. RESULTS: Paramedics (n = 162) reported that older adults were commonly restrained due to risk of harm to self (81.5%) or others (76.5%), combative behavior (73.5%), or resistance to care (58.0%). Most paramedics believed that restraints were effective in facilitating care (76.9%) and had not resulted in adverse events (72.8%). Only 44.5% believed they had the necessary training to provide restraint alternatives, however, 93.6% agreed they have de-escalated situations without restraints, and 80.0% felt capable of using non-restraint-based agitation management strategies. Nearly half endorsed having suffered physical injury from patient agitation (48.1%). The mean total moral injury score was 20.9 ± 6.8 (range 9-35), indicating a relatively high level of moral injury. CONCLUSION: Restraints are frequently used by EMS for the management of agitation among older adults, especially when there was a perceived risk of harm. Physical and moral injury is high among paramedics, as well as insufficient training regarding restraint alternatives.
BACKGROUND: Emergency department (ED) return visits within 72 h, commonly referred to as ``bouncebacks," are used as a quality metric and may reflect issues related to care delivery, follow-up, or patient understanding....BACKGROUND: Emergency department (ED) return visits within 72 h, commonly referred to as ``bouncebacks," are used as a quality metric and may reflect issues related to care delivery, follow-up, or patient understanding. Previous studies suggest that race and insurance status may influence ED utilization, yet data on their association with bounceback visits remain limited. OBJECTIVE: To determine if patient race was associated with increased ED bounceback rates. METHODS: We conducted a retrospective cohort study of 562,131 ED encounters across 17 EDs in a large integrated health system from January 1, 2021 to December 31, 2022. Patient demographics, insurance type, comorbidities, triage acuity, and visit characteristics were extracted from the electronic medical record. Poisson and logistic regression analyses assessed the association between race, sex, insurance, and 72-h return visits, adjusting for confounders. RESULTS: Of all encounters, 32,075 (8%) resulted in a 72-h return visit. Non-White patients have 21% higher odds than White patients to return within 72 h (adjusted odds ratio 1.21; 95% confidence interval 1.17-1.24). Medicaid recipients were 49% more likely and Medicare recipients 25% more likely to have bouncebacks than those with private insurance. Non-White patients had higher overall ED utilization, were younger, and were more likely to be insured by Medicaid. CONCLUSION: Race and socioeconomic status are independently associated with increased ED bounceback visits. These disparities may reflect systemic barriers to outpatient care access and warrant targeted quality improvement initiatives, including improved discharge processes and enhanced follow-up support for high-risk populations.
BACKGROUND: Combined calcium channel blocker (CCB) and β-blocker poisoning is highly lethal due to synergistic negative inotropy, conduction blockade, and vasodilation, often leading to refractory cardiogenic shock or ca...BACKGROUND: Combined calcium channel blocker (CCB) and β-blocker poisoning is highly lethal due to synergistic negative inotropy, conduction blockade, and vasodilation, often leading to refractory cardiogenic shock or cardiac arrest. CASE REPORT: An 18-year-old male presented after ingesting massive doses of nifedipine (5 mg × 200 tablets) and propranolol (10 mg × 300 tablets). Despite approximately 18 h of persistent cardiac arrest, early initiation of veno-arterial extracorporeal membrane oxygenation (VA-ECMO), followed sequentially by hemoperfusion and plasma exchange, restored cardiac rhythm. ECMO was successfully weaned, and the patient recovered with intact neurological function. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case demonstrates that even in prolonged cardiac arrest from ultra-high-dose CCB/β-blocker poisoning, aggressive support with VA-ECMO combined with toxin-removal techniques can achieve survival with good neurological outcome. It highlights a potentially lifesaving approach for similar severe poisoning scenarios.
BACKGROUND: Acute otolaryngologic emergencies such as sudden sensorineural hearing loss (SSNHL), epistaxis, and acute facial paralysis frequently present to emergency departments (EDs), where early guideline-concordant d...BACKGROUND: Acute otolaryngologic emergencies such as sudden sensorineural hearing loss (SSNHL), epistaxis, and acute facial paralysis frequently present to emergency departments (EDs), where early guideline-concordant decisions are critical to prevent irreversible morbidity. Large language models (LLMs) are increasingly explored for clinical decision support, yet their ability to consistently apply specialty guidelines in time-sensitive settings remains uncertain. Retrieval-augmented generation (RAG), which supplies LLMs with authoritative guideline content during response generation, may improve accuracy and safety. OBJECTIVES: To determine whether integrating American Academy of Otolaryngology-Head and Neck Surgery (AAOHNS) Clinical Practice Guidelines via RAG improves the accuracy, guideline adherence, and safety of LLM-generated decision support for acute ear, nose and throat (ENT) emergencies in the ED. METHODS: Twelve standardized clinical vignettes representing ED presentations of SSNHL, epistaxis, and Bell's palsy were developed. Two LLMs (ChatGPT and Gemini) generated responses under baseline conditions and with guideline-integrated RAG. Five blinded otolaryngologists independently evaluated outputs using a nine-domain rubric assessing diagnostic accuracy, diagnostic workup, management quality, referral appropriateness, guideline adherence, and risk of misleading information. Non-parametric tests compared performance, and inter-rater reliability was assessed using intraclass correlation coefficients. RESULTS: Inter-rater reliability was excellent. Compared with baseline models, RAG-enabled models demonstrated significantly improved diagnostic accuracy, diagnostic workup quality, management planning, referral appropriateness, and guideline adherence. RAG reduced misleading recommendations and modestly decreased overtreatment, while overtesting rates were unchanged. CONCLUSIONS: Guideline integration through RAG improves the reliability, safety, and guideline alignment of LLM outputs for acute otolaryngologic emergencies and may support evidence-based decision-making in emergency care.
BACKGROUND: In the management of severe hyponatremia, guidelines recommend rapidly increasing serum sodium levels by 4-6 mEq/L via administration of 100-150 mL 3% sodium chloride (HTS). However, this approach may cause m...BACKGROUND: In the management of severe hyponatremia, guidelines recommend rapidly increasing serum sodium levels by 4-6 mEq/L via administration of 100-150 mL 3% sodium chloride (HTS). However, this approach may cause medication administration delays and errors because guideline recommended HTS doses are not commercially available. In comparison, 8.4% sodium bicarbonate (HTB) is commercially available as a 50 mL prefilled syringe and provides a comparable sodium content as a 100 mL 3% HTS solution. OBJECTIVES: Determine if a single 50 mL dose of HTB meets guideline recommendations for acutely increasing serum sodium levels and assess the impact of renal function on clinical outcomes. METHODS: This retrospective cohort study's primary endpoint was the number of patients whose serum sodium levels increased by ≥ 4 mEq/L following administration of a single 50 mL HTB dose. A subgroup analysis was performed to compare outcomes in patients with an estimated glomerular filtration rate ≥ 60 and < 60 mL/min/1.73m to determine if renal function influenced outcomes. Patients were included if they were ≥ 18 years of age, received a single dose of 50 mL HTB within 12 hours of presenting to the emergency department, and presented with severe hyponatremia (initial serum sodium level ≤ 120 mEq/L). RESULTS: Thirteen of the 28 (46%) included patients' serum sodium level increased by ≥ 4 mEq/L following administration of HTB. The median change in serum sodium levels following HTB administration was 3 mEq/L. No significant differences in outcomes were observed in the subgroup analysis comparing patients with reduced and preserved renal function. No osmotic demyelination syndrome events were observed. CONCLUSION: This study provides preliminary evidence suggesting that HTB may be a practical option for acute serum sodium correction in patients with varying degrees of renal function.
BACKGROUND: Retinal detachment is an important condition for emergency physicians to be aware of, as it can be challenging to diagnose on physical examination alone and, if it is missed, can lead to vision loss. Ultrasou...BACKGROUND: Retinal detachment is an important condition for emergency physicians to be aware of, as it can be challenging to diagnose on physical examination alone and, if it is missed, can lead to vision loss. Ultrasound has demonstrated utility in diagnosis. CLINICAL QUESTION: What is the utility of point-of-care ultrasound (POCUS) for diagnosing retinal detachment? EVIDENCE REVIEW: Studies retrieved included three systematic reviews and meta-analyses evaluating the use of POCUS for diagnosing retinal detachment. These studies provide estimates of the potential utility of POCUS, with a sensitivity of 94-100% and specificity of 83-100%, positive likelihood ratios ranging from approximately 12-25, and negative likelihood ratios ranging from 0.06-0.25. CONCLUSION: Based upon the available literature, POCUS by emergency clinicians can reliably diagnose retinal detachment.