The Journal Of Emergency Medicine[JOURNAL]
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200 papers
Changes in Cormack-Lehane View Between First and Second Emergency Department Intubation Attempts.
Nikolla DA, Rajput M, Osorio B … +3 more , April MD, Carlson JN, Brown CA
J Emerg Med · 2026 May · PMID 41962231 · Publisher ↗
BACKGROUND: The laryngeal view from an unsuccessful first intubation attempt is critical for planning the next attempt. OBJECTIVE: To estimate the agreement of glottic views, as measured by the Cormack-Lehane classificat...
BACKGROUND: The laryngeal view from an unsuccessful first intubation attempt is critical for planning the next attempt. OBJECTIVE: To estimate the agreement of glottic views, as measured by the Cormack-Lehane classification, between the first and second intubation attempts in the emergency department (ED). METHODS: We performed a retrospective cohort study of ED intubations in the National Emergency Airway Registry from 2016 to 2018 in adults who received both a sedative and paralytic, were intubated with either direct or video laryngoscopy, and received multiple (more than one) intubation attempts. We excluded cases where laryngoscopes, supine vs. nonsupine positioning, or external laryngeal manipulation were altered between attempts. We divided cases into two cohorts: the different intubator cohort (first and second attempts by different intubators) and the same intubator cohort (both attempts by the same intubator). We measured the percent agreement and calculated a weighted kappa (κ) as a secondary measure of agreement. RESULTS: We included 640 ED intubation cases: 200 in the different intubator cohort and 440 in the same intubator cohort. Between the first and second attempts, the Cormack-Lehane grade was the same in 100 (50.0%, 95% confidence interval [CI] 43.1-56.9) cases for the different intubator cohort (κ = 0.40, 95% CI 0.29-0.51) and 317 (72.0%, 95% CI 67.6-76.1) cases in the same intubator cohort (κ = 0.53, 95% CI 0.46-0.61). CONCLUSION: Among ED intubations with multiple attempts under similar conditions, the glottic view changed in half of all cases when the intubator changed, and in over a quarter of cases when the same intubator tried again.
Cervical Spine Clearance in Adult and Pediatric Trauma: A Systematic Review.
de Oliveira Manduca Palmiero H, Gadelha Figueiredo E
J Emerg Med · 2026 Jun · PMID 41955954 · Publisher ↗
BACKGROUND: Cervical spine clearance after trauma is essential for preventing secondary neurologic injury while avoiding unnecessary immobilization and imaging. Advances in computed tomography (CT) and standardized clini...
BACKGROUND: Cervical spine clearance after trauma is essential for preventing secondary neurologic injury while avoiding unnecessary immobilization and imaging. Advances in computed tomography (CT) and standardized clinical decision rules such as National Emergency X-Radiography Utilization Study and the Canadian C-Spine Rule have changed protocols for adult and pediatric patients. OBJECTIVES: This systematic review aims to compile current evidence to identify safe, effective, and evidence-based methods for cervical spine clearance. METHODS: A PubMed/MEDLINE systematic search was conducted through October 2025 for studies evaluating cervical spine clearance in adult and pediatric trauma patients. Eligible studies analyzed clinical decision tools or imaging modalities (such as physical examination, radiography, CT, magnetic resonance imaging [MRI], ultrasound) and reported on diagnostic accuracy, safety, or workflow outcomes. Data was extracted and narratively synthesized due to methodological heterogeneity. RESULTS: Thirty-three adult and eleven pediatric studies met the inclusion criteria. In adults, multidetector CT with multiplanar reconstructions achieved 98-100% sensitivity and >99% negative predictive value for clinically significant or unstable injury, supporting collar removal after a normal CT even in obtunded or intoxicated patients. MRI detected additional findings in 0.4-3% of cases, rarely changing management. In children, structured clinical protocols combining physical examination and plain radiography safely reduced CT use by up to 70%, with MRI reserved for persistent symptoms or ligamentous concerns. CONCLUSION: Modern multidetector CT is the gold standard for adult cervical spine clearance, while pediatric management favors radiation-sparing, protocol-based approaches. Evidence supports tiered, algorithmic strategies emphasizing clinical assessment, selective imaging, and early collar removal to optimize safety and efficiency in trauma care.
Evaluation of an Emergency Department Over-the-Counter Analgesic Medication Starter Pack Initiative on 30-day Revisits.
Sheikh S, Alacevich C, Montague M … +4 more , Layton C, Henson M, Salloum R, Hendry P
J Emerg Med · 2026 Jun · PMID 41955953 · Full text
BACKGROUND: An Over-The-Counter (OTC) Starter Pack Initiative was implemented in the emergency department (ED) of a safety-net institution. Select OTC analgesic medications were dispensed free to patients experiencing fi...
BACKGROUND: An Over-The-Counter (OTC) Starter Pack Initiative was implemented in the emergency department (ED) of a safety-net institution. Select OTC analgesic medications were dispensed free to patients experiencing financial/healthcare access barriers. STUDY OBJECTIVE: We compared 30-day all-cause ED revisit rates in program participants before and after program participation. METHODS: An institutional review board (IRB) approved retrospective observational study of ED visits made by program participants from 01/01 to 10/21/2021 was conducted. Demographics, number of ED visits, ICD-10 codes, and pain scores were collected. A modified patient fixed-effects Poisson regression estimated the relative risk of 30-day all-cause ED revisit after receiving assistance ("OTC-assisted") compared with the preprogram "usual care" risk. RESULTS: There were 149 unique participants with both "usual care" and"OTC-program assisted" visits. Among these participants, the 30-day revisit rate was lower after program assistance (34%) compared to their revisit rate following a usual care visit (52%). OTC-Starter Pack program assistance was associated with a 20% reduction in the relative risk of revisiting the ED within 30 days (RR: 0.80, 95% CI: 0.71, 0.910) (p = 0.000). A cost saving analysis suggests that the program was associated with a per-patient saving of $53.21, on average, in avoided ED costs, net of the cost of the starter pack. CONCLUSIONS: The OTC-Starter Pack Program was associated with reduced 30-day revisit rates among patients with financial or healthcare access barriers and suggested cost savings within our study population.
Implementing Patient-Reported Measures into Emergency Care Workflows: A Scoping Review.
Kuhn D, Lemen L, Ramirez M … +3 more , Gleason KT, Mazurenko O, Ramly E
J Emerg Med · 2026 Jun · PMID 41955952 · Publisher ↗
BACKGROUND: Researchers have increasingly used patient-centered quality measures, such as patient experience and functional assessments, in the emergency department (ED) setting. However, understanding of how these measu...
BACKGROUND: Researchers have increasingly used patient-centered quality measures, such as patient experience and functional assessments, in the emergency department (ED) setting. However, understanding of how these measures are implemented (timing, mode, terminology and reporting) remains limited. OBJECTIVES: This paper aims to summarize the current knowledge and articulate future research directions for implementing patient-reported measures in ED settings. METHODS: We performed a scoping review of the peer-reviewed literature on the implementation of patient-reported outcome and experience measures in the ED from January 1, 2010, to June 1, 2024 following PRISMA guidelines. We used a combination of controlled vocabulary (such as MeSH terms in PubMed) and keywords, including related terms and synonyms. Title and abstract screening followed by full text screening was performed independently by two reviewers, with adjudication through regular meetings. RESULTS: The initial search yielded 6103 articles, with 74 articles included in the final study. Thirty-five of 74 (47.3%) articles were related to instrument development, and articles related to patient experience were more common than articles related to patient outcomes (48.6% vs 27.0%). Key overall findings include: (1) inconsistent terminology leading to ambiguity regarding the measure being implemented; (2) a need for standardized ways of reporting on research related to patient-reported measures in the ED, and (3) a greater emphasis on the patient-centered measures themselves than the implementation process in existing literature. CONCLUSIONS: Clarification of concepts and focus on the implementation process, including key clinical stakeholders, will facilitate the use of patient-reported quality measures in the ED.
Evaluating the Performance of Large Language Models for Generating Emergency Department Discharge Instructions.
Hernández P, Rodriguez G, Fischetti C … +5 more , Baugh CW, Baymon D, Ellis J, Sarma D, Marshall ADA
J Emerg Med · 2026 Jun · PMID 41955951 · Publisher ↗
BACKGROUND: Clear discharge instructions are essential for safe emergency department (ED) care, yet creating patient-centered, health literate materials remain challenging. Large language models (LLMs) may improve patien...
BACKGROUND: Clear discharge instructions are essential for safe emergency department (ED) care, yet creating patient-centered, health literate materials remain challenging. Large language models (LLMs) may improve patient communication, but their role in the ED remains underexplored. OBJECTIVE: The objective of this study was to evaluate the feasibility of using LLMs to generate ED discharge instructions and to compare readability across models. METHODS: We generated discharge instructions for 20 ED diagnoses across Emergency Severity Index (ESI) levels using GPT-4, GPT-4o, GPT-5.2, Gemini 2.5 Pro, Gemini 3 Pro, Gemini 3 Flash, and compared them with available electronic medical record (EMR) stock discharge templates. Readability was assessed with eight indices, and differences across ESI levels were tested via Kruskal-Wallis analysis. Diagnosis-level paired comparisons versus stock discharges were performed with effect sizes and multiplicity adjustment. Four blinded emergency medicine attendings evaluated GPT-4 generated instructions for medical accuracy, clarity, completeness, and understandability using a validated survey. Inter-rater reliability (IRR) was calculated using the kappa statistic. RESULTS: Across models, readability frequently exceeded recommended 6-8 grade health-literacy targets despite prompting. Compared with stock templates, readability differences varied by model and index, with Gemini 2.5 Pro and Gemini 3 Pro generally producing the lowest grade-level outputs, whereas GPT-5.2 produced the highest. We observed a general trend that instructions for lower ESI levels had poorer readability. Physician ratings generally exceeded 4/5 in most domains, with > 50% rated 5/5 for clarity, understandability, completeness, and accuracy. However, approximately 25% of instructions scored ≤ 3/5 for completeness or understandability. IRR was fair (κ = 0.40), with lower agreement for lower ESI levels. CONCLUSIONS: LLMs can generate ED discharge instructions with strong clinician-rated quality in many domains, but readability performance varies substantially by model and metric and often fails to meet health-literacy standards. Careful model selection, prompt refinement, and human oversight remain necessary to ensure accessible and complete discharge communication. With further refinements, LLMs could improve patient comprehension and support safe discharge practices in the ED.
Emergency Medicine Clerkship Experiences: A Comparison of Freestanding and Hospital-Based Emergency Departments.
Simon EL, Mahmood F, Drogell K … +2 more , Pratt I, Krizo J
J Emerg Med · 2026 May · PMID 41955889 · Publisher ↗
BACKGROUND: Emergency medicine (EM) clerkships are essential in undergraduate medical education, yet the impact of clinical setting-freestanding emergency departments (FSEDs) vs. hospital-based emergency departments (HBE...
BACKGROUND: Emergency medicine (EM) clerkships are essential in undergraduate medical education, yet the impact of clinical setting-freestanding emergency departments (FSEDs) vs. hospital-based emergency departments (HBEDs)-on students' educational experiences remains understudied. OBJECTIVE: This study evaluates how these environments influence autonomy, procedural opportunities, and learning preferences. METHODS: The authors conducted a survey-based study of medical students who completed EM clerkships between May and December 2023. Students anonymously reported their experiences across FSED and HBED settings. The survey captured demographic characteristics, educational preferences, procedural exposure, and perceived autonomy. RESULTS: Of 51 eligible students, 39 (76%) responded. Students expressed similar overall preferences for both FSEDs and HBEDs. At FSEDs, students reported greater autonomy (n = 30 [77%]) and more time with attending physicians (n = 22 [56.4%]). HBEDs, in contrast, offered more procedural opportunities (n = 29 [74%]), including trauma care. The most frequently performed procedures were laceration repair (92%), ultrasound (67%), ultrasound-guided intravenous placement, and splinting (31%). Students preferred learning from both attendings and residents. However, resident interaction varied by site, with fewer residents present in FSEDs. Students indicated that each setting contributed uniquely to their learning, with FSEDs allowing greater independence and HBEDs offering higher patient volume and acuity. CONCLUSIONS: Students reported distinct benefits from both settings. FSEDs provided more autonomy and attending interaction and HBEDs enhanced procedural experience and trauma exposure. Incorporating both ED environments into EM clerkships may maximize educational value. Further research should evaluate how setting exposure influences student performance and preparedness for residency.
From Dysphonia to Danger: Traumatic Laryngeal Complications; A Case Report.
Verhage B, Dollée N
J Emerg Med · 2026 May · PMID 41955888 · Publisher ↗
BACKGROUND: Acute dysphonia following blunt head trauma is uncommon but may indicate significant laryngeal injury with potential for progressive airway compromise, particularly in patients receiving anticoagulant therapy...
BACKGROUND: Acute dysphonia following blunt head trauma is uncommon but may indicate significant laryngeal injury with potential for progressive airway compromise, particularly in patients receiving anticoagulant therapy. CASE REPORT: A 79-year-old patient on direct oral anticoagulant therapy presented to the emergency department with suddenonset dysphonia after a mechanical fall, resulting in a low-occipital head impact without direct neck trauma. Collateral history revealed immediate and pronounced voice change, distinct from baseline. On initial assessment, the patient was hemodynamically stable and exhibited no respiratory distress. Flexible fiberoptic laryngoscopy revealed a large hematoma of the right arytenoid, consistent with blunt cranial trauma in the context of anticoagulation, conferring a substantial risk of progressive upper airway obstruction. The patient was transferred to the intensive care unit for close airway monitoring and anticipatory management. DISCUSSION: This case illustrates that isolated arytenoid haematoma may constitute the sole clinical manifestation of significant laryngeal injury in anticoagulated patients and underscores the importance of early laryngoscopic assessment and proactive airway surveillance to avert life-threatening deterioration.
Under-Investigation and Delays Experienced by Females Presenting with Chest Pain to Emergency Departments: A Study of Five Linked Canadian Hospitals.
Hill J, Yang E, Doran S … +5 more , Graham MM, van Diepen S, Raizman JE, Tsui AK, Rowe BH
J Emerg Med · 2026 May · PMID 41955887 · Publisher ↗
BACKGROUND: Previous research has shown that among patients presenting with classic cardiac pain, women receive fewer investigations than men do. OBJECTIVE: To assess whether a protocolized assessment strategy for chest...
BACKGROUND: Previous research has shown that among patients presenting with classic cardiac pain, women receive fewer investigations than men do. OBJECTIVE: To assess whether a protocolized assessment strategy for chest pain presentations would mitigate sex-based differences in clinical testing or investigations. METHODS: We conducted a retrospective cohort study of all adult patients presenting with chest pain, including what was felt to be ischemic/cardiac (Canadian Triage Acuity Score (CTAS) II) and non-cardiac (CTAS III) chest pain from November 9, 2020, to June 20, 2022. An advanced diagnostic pathway including high-sensitivity troponin (hs-TnI) was in use. The primary outcome was a composite of repeat hs-TnI testing, imaging, and consultations. Secondary outcomes included 30-day major adverse cardiac events (MACE). RESULTS: Overall, 19,324 patients (49.7% females) were included. Women had a higher proportion of single hs-TnI testing (75.1% vs 64.7%; p < 0.0001) than men; this finding persisted when adjusting for age, comorbidities, acuity, and troponin results. Women waited 19% longer to be assessed by a physician (median difference 16 (95% CI: 12.4-19.6) minutes). Finally, men experienced a higher risk of MACE (aHR: 1.45, 95% CI: 1.29-1.63). CONCLUSION: Women were significantly less likely to receive serial troponin testing, while experiencing delays in care and longer length of stay; however, MACE outcomes were worse in men. Evidence-based protocols with specific risk stratification based on initial hs-TnI results do not prevent sex-based differences from occurring.
Oxygenation Through the Working Channel of Fiberscope During Awake Tracheal Intubation in Severe Glottic Edema Following Caustic Agents Injury.
Rinaldi P, Canciello S, Sinagoga A … +6 more , Schettino F, Lauro G, Porcelli ME, Tomasello A, Villani R, Cotena S
J Emerg Med · 2026 Jun · PMID 41950691 · Publisher ↗
BACKGROUND: Airway management in the context of caustic ingestion and subsequent laryngeal edema is fraught with complexity and urgency. Awake tracheal intubation (ATI), particularly with continuous oxygen insufflation v...
BACKGROUND: Airway management in the context of caustic ingestion and subsequent laryngeal edema is fraught with complexity and urgency. Awake tracheal intubation (ATI), particularly with continuous oxygen insufflation via the fiberscope's working channel, represents a refined approach that preserves oxygenation and enhances procedural success in anticipated difficult airways. CASE REPORT: We present the case of a 48-year-old male presenting with acute respiratory distress following accidental caustic ingestion. Despite initial stabilization, progressive desaturation and imaging-confirmed laryngeal edema necessitated urgent airway control. ATI was performed using combined video laryngoscopy and flexible bronchoscopy, with continuous oxygen delivered through the fiberscope. This maintained optimal oxygenation, improved visualization, and facilitated successful intubation after downsizing the endotracheal tube due to severe glottic narrowing. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case underscores the critical value of continuous oxygen insufflation during ATI in edematous airway emergencies. By prolonging safe oxygenation time and improving visual clarity, this technique emerges as a compelling adjunct in securing compromised airways, particularly when anatomical distortion precludes conventional intubation.
Capillary Refill Time and Resuscitation of Septic Shock: Lessons From ANDROMEDA.
Ford JS, Wardi G
J Emerg Med · 2026 Jun · PMID 41950690 · Publisher ↗
Abstract loading — click title to view on PubMed.
Analgesic and Physiologic Effects of Ketamine Compared with Opioids in Prehospital Trauma Care: A Systematic Review and Meta-Analysis.
Meyer AC, Kuo M, Duriancik DM
J Emerg Med · 2026 Jun · PMID 41950689 · Publisher ↗
BACKGROUND: Effective prehospital analgesia is vital in trauma care. Although opioids are first line, they carry risks of adverse events. Ketamine has emerged as a promising alternative, offering potent analgesia, dissoc...
BACKGROUND: Effective prehospital analgesia is vital in trauma care. Although opioids are first line, they carry risks of adverse events. Ketamine has emerged as a promising alternative, offering potent analgesia, dissociation, and a favorable hemodynamic profile suited to resource-limited, time-sensitive prehospital care. OBJECTIVE: The objective of this systematic review and meta-analysis was to evaluate the analgesic effectiveness and physiologic effects of ketamine compared with opioid-based analgesia in adult patients with traumatic injuries treated in the prehospital setting. METHODS: CINHAL Plus (EBSCO), OVID, and Cochrane Central were searched (2013-2024) using MESH terms such as ``ketamine,'' ``prehospital,'' and ``trauma.'' Included studies involved adults with traumatic injuries treated by prehospital clinicians with ketamine. Comparators included opioid monotherapy and ketamine-opioid combinations. Primary outcomes were pain scores, hemodynamic parameters, and adverse events. Risk of bias was assessed using established tools for randomized and nonrandomized studies, and certainty of evidence was evaluated using GRADE (Grading of Recommendations, Assessment, Development, and Evaluations). Meta-analyses were conducted using a quality-effects model incorporating study-level risk of bias. RESULTS: Eighteen studies met inclusion criteria; three were suitable for meta-analysis comparison of ketamine and opioid monotherapy. Ketamine was not associated with a significant difference in pain reduction compared with opioids (weighted mean difference [WMD] 0.00; 95% confidence interval [CI] -0.77-0.78). Heart rate increased modestly with ketamine (WMD 3.19 beats/min, 95% CI 1.48-4.90), whereas systolic blood pressure showed no difference as compared with opioids (WMD 1.53 mm Hg, 95% CI -2.68-5.75). No difference in respiratory rate was observed (WMD -0.07 breaths/min, 95% CI -0.84-0.70). Adverse events were infrequent and were primarily mild, with emergence reactions most common. CONCLUSIONS: Ketamine provides analgesia consistent with similar effectiveness to opioids in prehospital trauma care, with comparable physiological effects and low reported rates of serious adverse events.
The Nuance of Clinical Decision Support in Intravenous Fluid Shortages.
Sun WW, Rothenberg C, Venkatesh AK … +19 more , Alfano A, Aydin A, Balcezak T, Brining D, Cahill JC, Chmura C, Davison CM, Dubin S, Liebhardt B, McGovern M, Mittleman C, Parwani V, Powers E, Rose MJ, Ulrich A, Van Tonder R, Tuffuor K, Zahn E, Sangal RB
J Emerg Med · 2026 Jun · PMID 41950688 · Publisher ↗
BACKGROUND: After Hurricane Helene made landfall in September 2024, the U.S. faced a nationwide intravenous (IV) fluid shortage due to damage at a key manufacturing facility. To prioritize supplies for the most critical...
BACKGROUND: After Hurricane Helene made landfall in September 2024, the U.S. faced a nationwide intravenous (IV) fluid shortage due to damage at a key manufacturing facility. To prioritize supplies for the most critical patients, Yale - New Haven Health System (YNHHS) introduced an interruptive pop-up within electronic health workflows, reminding clinicians of the IV fluid shortage and to consider oral hydration. OBJECTIVE: To evaluate the effectiveness of interruptive pop-up alerts during an acute medication shortage. METHODS: YNHHS deployed the pop-up across nine Emergency Departments, prompting clinicians to consider oral hydration when attempting to order IV fluids. We evaluated clinician responses to the decision support alert from inception on October 8, 2024, to January 16, 2025. RESULTS: A total of 5500 patients received IV fluids during the 15-week study period, of which 5410 (98.4%) were visits that had the pop-up. In week one, 74.7% of clinicians canceled their IV fluid orders after encountering the pop-up. However, effectiveness of the alert declined rapidly. By week 6, only 18.4% of orders were canceled, and week 15, 8.3%. The percent of visits where patients received IV fluids decreased from a baseline of 20.9% to a nadir of 3.4% during the acute phase of the crisis, but had increased to 10.1% by week 15. CONCLUSION: Interruptive alerts can be effective for immediate behavior change during acute crises. However, the effect of interruptive alerts diminishes over time due to clinician adaptation. For sustained practice change, pop-ups can be integrated into a broader strategy that includes education, workflow redesign, clinician team engagement, and timely pop-up deactivation.
Analysis of Initial Emergency Department Ventilator Settings in Accordance with Ability to Oxygenate.
Verwiel C, Cogan AS, Drescher G … +4 more , Caputo J, Lawrynowicz MM, Gaieski DF, Goyal M
J Emerg Med · 2026 Jun · PMID 41950687 · Publisher ↗
BACKGROUND: In most emergency department (ED) patients, mechanical ventilation is initiated with limited data. Ability to oxygenate is usually available and could indicate acute respiratory distress syndrome (ARDS). OBJE...
BACKGROUND: In most emergency department (ED) patients, mechanical ventilation is initiated with limited data. Ability to oxygenate is usually available and could indicate acute respiratory distress syndrome (ARDS). OBJECTIVE: To determine if patients' ability to oxygenate is associated with initial ventilator settings. We hypothesize that severely hypoxemic patients were exposed to similar initial settings compared to those oxygenating normally. METHODS: Retrospective chart review of adults intubated in nine EDs in 2019. Partial pressure of arterial oxygen (PaO:fraction of inspired oxygen (FiO (P:F) was calculated based on postintubation arterial blood gas (ABG) and concurrent ventilator settings. Patients were grouped into severe hypoxemia = P:F ≤ 100 and normal oxygenation = P:F > 300. The primary outcome was the association of oxygenation group with initial Tidal Volume (V), FiO and positive end-expiratory pressure (PEEP). Group differences were analyzed using chi-square for categorical variables and Wilcoxon rank sum for continuous data, following normality testing with Shapiro Wilk. RESULTS: Of 1995 adults intubated, 175 were severely hypoxemic and 578 had normal oxygenation yielding a cohort of 753. Severely hypoxemic patients were more likely white, female, and had a higher body mass index (BMI). They were initiated on similar V (7.0 [6.3-7.9] vs. 7.0 [6.4-7.8] mL/kg/ideal body weight [IBW]; p = 0.94), higher PEEP (5 [5-8] vs. 5 [5-5] cm HO; p < 0.0001), and more likely to be placed on 100% FiO (81% vs. 53%; p < 0.0001). CONCLUSION: Initial PEEP and FiO, but not V differ based on a patient's ability to oxygenate. Most severely hypoxemic patients were started on a PEEP of 5 and most normally oxygenating patients were started on 100% FiO.
The Great Abdominal Escape: A Delayed Complication after Endoscopy in Pediatric Aerophagia.
Shieh A, Chogle AS, Yu PT
J Emerg Med · 2026 Jun · PMID 41950686 · Publisher ↗
Abstract loading — click title to view on PubMed.
Emergency Department Interfacility Transfers Requiring Critical Procedures are Increasing: A United States Nationwide Analysis.
Nikolla DA, Ahuja A, Frack E … +6 more , Battista A, Colleran CA, Poremba M, Nawrocki PS, Nesbit CE, Carlson JN
J Emerg Med · 2026 May · PMID 41950593 · Publisher ↗
BACKGROUND: Given the changing landscape of healthcare since the COVID-19 pandemic, many hospitals have reduced or limited services, leading to increased interfacility transfers. Appropriate management by emergency medic...
BACKGROUND: Given the changing landscape of healthcare since the COVID-19 pandemic, many hospitals have reduced or limited services, leading to increased interfacility transfers. Appropriate management by emergency medical services (EMS) requires specialized training and resources, particularly for critically ill patients status post critical procedures. OBJECTIVES: This study aimed to quantify and trend the number of interfacility transfers involving critical procedures from United States (US) emergency departments (EDs) from 2018 to 2022. METHODS: The study is a retrospective cross-sectional study using the 2018-2022 Nationwide Emergency Department Sample (NEDS) datasets. Adult patient encounters (≥18 years old) transferred from EDs to other short-term hospitals were included. Critical procedures performed in the ED were identified using procedure codes for tracheal intubation, noninvasive ventilation, blood transfusion, central line insertion, chest tube insertion, arterial line insertion, transcutaneous pacing, and transvenous pacing. Counts and estimates with 95% confidence intervals (CIs) were weighted to account for the complex survey design. RESULTS: During the study period, an estimated 9867701 (95% CI 9475559-10259843) adult patients were transferred from US EDs. Among those transferred, 655442 (6.6%, 95% CI 6.4-6.9) had at least 1 critical procedure. Time in years was associated with any critical procedure, with an odds ratio of 1.09 (95% CI 1.07-1.11). After adjusting for patient and hospital characteristics, the estimate remained unchanged, with an adjusted odds ratio of 1.09 (1.07-1.11). The association was significantly positive for all critical procedures, except for transcutaneous and transvenous pacing. CONCLUSIONS: The rising number of interfacility transfers involving critical procedures underscores the need for enhanced EMS resources and training. This trend highlights the growing demands on EMS systems to manage complex patient needs during transfers.
Evaluating the Diagnostic Accuracy of Point-of-Care Ultrasound for Long Bone Fractures in the Emergency Department.
Tom E, Suseel A, Abraham SV … +4 more , K KC, Palatty BU, Saji JG, Varghese J
J Emerg Med · 2026 May · PMID 41945995 · Publisher ↗
BACKGROUND: Long bone fractures are a common emergency department presentation. Conventional radiography, though standard, is limited by accessibility, radiation exposure, and delays. Point-of-care ultrasound (POCUS) pro...
BACKGROUND: Long bone fractures are a common emergency department presentation. Conventional radiography, though standard, is limited by accessibility, radiation exposure, and delays. Point-of-care ultrasound (POCUS) provides a rapid, bedside, radiation-free alternative that may enhance diagnostic efficiency. OBJECTIVES: To evaluate the diagnostic accuracy of POCUS performed by emergency physicians in detecting long bone fractures compared with conventional radiography. METHODS: This prospective observational study included a convenience sample of patients of all ages presenting with potential long bone fractures to a tertiary emergency department. Each patient underwent POCUS for fracture with a high-frequency linear probe, followed by plain radiographs as the reference standard. The diagnostic accuracy of POCUS for fracture detection was assessed through calculation of diagnostic parameters. Secondary outcomes included time to diagnosis and physician preference of imaging modality RESULTS: A total of 174 patients included in the analysis. Overall, POCUS detected radiographically-confirmed long bone fractures with a sensitivity of 87.8% (95% CI 81.0-94.6), specificity of 91.7% (95% CI 85.7-97.7), +LR of 10.5 (95% CI 5.2-197 21.7), -LR of 0.13 (95% CI 0.08-0.23), PPV 91.9% (95% CI 86.1-97.7) and NPV of 87.5% (95% CI 80.6-94.4). POCUS provided a significantly faster time to diagnosis than radiography with a mean time of 7.92 ± 2.22 minutes compared to 62.84 ± 23.79 minutes for X-ray (t = 31.194, p < 0.001). Physicians preferred POCUS as the initial imaging modality of choice in a majority of cases (96%). CONCLUSION: Compared to plain radiography, POCUS provides a rapid, reasonably accurate, and noninvasive modality for the evaluation of potential long bone fractures. Its efficiency and clinician acceptance support its role as an adjunct in fracture diagnosis, particularly in time-sensitive and resource-limited settings.
Emergency Physicians' Ethical Duty to Patients with Undiagnosed Idiopathic Normal Pressure Hydrocephalus.
Iserson KV
J Emerg Med · 2026 May · PMID 41945994 · Publisher ↗
BACKGROUND: Idiopathic normal pressure hydrocephalus (iNPH) is a progressive yet potentially reversible neurological disorder affecting older adults, characterized by gait disturbance, urinary incontinence, and cognitive...
BACKGROUND: Idiopathic normal pressure hydrocephalus (iNPH) is a progressive yet potentially reversible neurological disorder affecting older adults, characterized by gait disturbance, urinary incontinence, and cognitive impairment. Unlike most dementias, iNPH responds to cerebrospinal fluid shunting, with early intervention yielding optimal outcomes. OBJECTIVES: To examine the ethical obligations of emergency physicians (EPs) in recognizing iNPH and to review practical screening methods applicable to emergency department (ED) settings. DISCUSSION: Despite affecting approximately 2% to 5% of older adults presenting to U.S. EDs, iNPH remains profoundly underdiagnosed. Symptoms are frequently dismissed as normal aging or untreatable dementia. Recent randomized controlled trials demonstrate significant improvements in gait velocity and survival following shunt surgery, with the greatest benefits accruing from early intervention. EPs can identify possible iNPH through brief gait assessment, focused history, and standard neuroimaging. Recent advances in smartphone-based gait analysis and wearable sensor technology enable objective evaluation without specialized equipment. The principles of justice and beneficence mandate that older adults receive equitable access to treatments that can preserve cognition, mobility, and independence. CONCLUSION: EDs should implement structured screening protocols, staff education, and referral pathways to ensure ethically sound practice. Recognizing possible iNPH represents both a clinical imperative and an ethical obligation.
ST-Segment Elevation in Lead aVR and Acute Intracranial Pathologies: Reconsidering the Association.
Eken C, Serinken M, Mutlu H
J Emerg Med · 2026 May · PMID 41945083 · Publisher ↗
Abstract loading — click title to view on PubMed.
Ultrasound-Guided Truncal Blocks for Tube Thoracostomy Analgesia in the Emergency Department.
Reeves MT, Lee Y, Shalaby M
J Emerg Med · 2026 May · PMID 41936304 · Publisher ↗
BACKGROUND: Tube thoracostomy is a common yet exceedingly painful emergency department (ED) procedure requiring potent analgesia for safe performance. Traditionally, emergency physicians provide premedication or procedur...
BACKGROUND: Tube thoracostomy is a common yet exceedingly painful emergency department (ED) procedure requiring potent analgesia for safe performance. Traditionally, emergency physicians provide premedication or procedural sedation in combination with local anesthetic infiltration of the insertion tract prior to tube thoracostomy. However, more advanced pain management strategies, such as ultrasound-guided truncal blocks, may offer a targeted and effective analgesic alternative. OBJECTIVE: Herein, the authors discuss the thoracic paravertebral, erector spinae, and serratus plane blocks, and their potential application in the ED to provide more comprehensive pain control of tube thoracostomy. DISCUSSION: Truncal blocks are local anesthetic injections that target hemithoracic nerves within a compartment or fascial plane, producing ipsilateral chest wall analgesia or anesthesia across multiple contiguous thoracic dermatomes. These ultrasound-guided regional anesthesia techniques may obviate the need for sedation or high-dose opioid therapy, reshaping traditional pain management paradigms for ED tube thoracostomy. CONCLUSION: Ultrasound-guided regional anesthesia is increasingly employed in the emergency care setting as part of an opioid-sparing, multimodal pain management strategy. For chest tube insertion, truncal blocks can provide safe yet potent anesthetic coverage spanning up to the full thickness of the thoracic wall, limiting the need for other adjunctive therapies to facilitate procedural performance.
Early Extracorporeal Membrane Oxygenation Support in Bupropion-Induced Cardiogenic Shock: A Case Series.
DeGraaf L, Bhatnagar G, Ovakim DH
J Emerg Med · 2026 May · PMID 41934731 · Publisher ↗
BACKGROUND: Bupropion overdose is increasingly a cause of severe neurologic and cardiac toxicity, often leading to refractory seizures, cardiac conduction abnormalities, and hemodynamic collapse. While extracorporeal mem...
BACKGROUND: Bupropion overdose is increasingly a cause of severe neurologic and cardiac toxicity, often leading to refractory seizures, cardiac conduction abnormalities, and hemodynamic collapse. While extracorporeal membrane oxygenation (ECMO) has been used in such cases, it is often initiated after cardiac arrest. CASE REPORT: This case series describes four cases of massive bupropion ingestions in three patients that developed progressive cardiotoxicity. In three cases, early recognition of clinical deterioration, guided by serial electrocardiograms and the development of hemodynamic instability, led to early ECMO cannulation and survival to discharge. In the fourth case, however, ECMO was initiated during intraoperative cardiac arrest. Although successfully decannulated, the patient suffered a fatal neurologic injury. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: These findings support the consideration of early ECMO in bupropion overdose when worsening cardiotoxicity is evident and highlight the need for multidisciplinary protocols and clearer clinical criteria to guide timely intervention in toxicologic emergencies.
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