Bottom Line: Lactate is a useful but imperfect marker of critical illness. Below are some key points to consider when interpreting lactate.
Bottom Line: In pediatric patients, identifying the underlying etiology of hypercalcemia is essential to guide appropriate long-term management.
Etiology: The causes of hypercalcemia in children are diverse and are broadly classified into parathyroid hormone (PTH)-mediated and non–PTH-mediated categories. Non–PTH-mediated causes include endocrine disorders, inborn errors of metabolism, medication-induced hypercalcemia, granulomatous diseases, immobilization, and malignancy.
Clinical Presentation: Symptoms vary depending on the severity of hypercalcemia. Mild hypercalcemia may be asymptomatic or present with findings such as shortened QT interval, polyuria, and constipation. Severe hypercalcemia can lead to significant complications, including seizures, altered mental status (e.g., hallucinations), dehydration, cardiac dysrhythmias, abdominal pain, and pancreatitis.
Management: In the emergency setting, the primary treatment is intravenous hydration, typically with 0.9% saline, to cause calcium dilution and increased urinary excretion of calcium. Loop diuretics should be used with caution in pediatric patients due to the risk of exacerbating dehydration. Additional pharmacologic therapies, including calcitonin, bisphosphonates, and glucocorticoids, may be indicated depending on the etiology and severity, and should be administered in consultation with a nephrologist and/or endocrinologist. In patients with contraindications to aggressive fluid management (e.g., renal or cardiac dysfunction), or in cases of severe, life-threatening hypercalcemia, dialysis may be required.
When managing suspected or proven Group A Streptococcus (GAS) Necrotizing Soft Tissue Infections (NSTIs), standard beta-lactams can lose efficacy due to the Eagle effect—where stationary-growth phase bacteria become less susceptible to cell-wall acting agents.
To counteract this and aggressively suppress life-threatening bacterial toxin production, always add a protein-synthesis inhibiting antibiotic to your empirical broad-spectrum base.
Expert consensus recommends not prescribing these eight classes of medications to older adults mostly due to sedative affect and fall risk. 1. Benzodiazepines 2. Barbiturates 3. Muscle relaxants 4. 1st generation antihistamines 5. Sulfanylureas 6. 1st generation antipsychotics 7. Zolpidem 8. Metocloprimide
A recent study shows marginal improvement in not prescribing these medications to older ED patients.
This single center study looked at diabetic patients who had a POC glucose over 300 and POC ketone over 1.1 and reviewed their diagnosis vs the laboratory accepted diagnosis of DKA.
“The most recent international consensus laboratory definition of (non-euglycemic) DKA includes a glucose of >?250; a pH <?7.3 or a bicarbonate ??18?mmol/L; and a beta-hydroxybutyrate (BOHB) ??3.0?mmol/L or urine ketone strip ??2+”
This nice review article reminds us “The AO-Spine classification is the most frequently utilized system for thoracic and lumbar fractures, and it categorizes fractures into three types. Type A fractures are compression injuries. In these fractures, the assessment of the involvement of the posterior elements of the vertebral body is essential. Type B fractures are distraction injuries implying tension band involvement, whereas type C fractures are translational or dislocated injuries. The AO-Spine Upper Cervical Injury Classification System… In this classification system, type A injuries have no ligamentous involvement and are considered stable. Type B injuries have tension band or ligamentous injury and may be unstable. Type C injuries are characterized by significant translation and loss of anatomic integrity and are considered unstable."
A 22 year old normally healthy male presents with tachycardia (HR 140), dilated pupils (7 mm), dry flushed hot skin, and confusion/agitation. His mother states he has a 1 day history of “talking out of his head not making sense”, “seeing things that aren’t there”, and “speaking to video game characters”. He has suprapubic tenderness with markedly distended bladder on exam revealing over 1 liter of urine on bladder scan. She found a small bottle containing a large amount of small 2-3 mm black seeds in his room and suspects he ingested them. What treatment options would you consider?
Do you have a patient with shortness of breath and pulmonary edema?
Don’t forget to place the color doppler over the mitral valve to look for acute mitral regurgitation.
These authors argue that bystander interventions in the early minutes (they call them the diamond minutes) can have an impact on trauma survival. Particular attention to External hemorrhage control; Airway opening and maintenance; Safe positioning of unconscious patients; Mitigation of early hypoxia and hypothermia could improve survival. We need to publicize this information and undo the years of teaching not to move these patients due to concern of secondary spinal cord injury. Many studies have dispelled that concern.
This article suggest that freeze-dried plasma (FDP) is an acceptable adjunct to whole blood for prehospital resuscitation of trauma patients. “FDP is pathogen-reduced, shelf-stable for up to two years at room temperature, lightweight, and rapidly reconstituted at the point of care.” This method offers an advantage when caring for patients in remote areas with long transport times and has been used by NATO and Canadian armed forces.
Of the 215 Norwegian patients on oral anticoagulation seen for a head injury and having a normal initial head CT, none developed delayed hemorrhage. Median age was 83 years.
A recently published commentary highlights the importance of looking beyond the numbers and remembering the core mission of emergency practice. It warns against “gaming” the system to create processes that give better metrics using the example of rates of patients who leave without being seen (LWBS). In the author’s words, efforts aimed at improving this metric create strategies that “raise concerns about distributive justice, beneficence, and professional integrity.” See link for key take home points.
Sodium bicarbonate significantly reduced the need of renal replacement therapy (risk ratio [RR] 0.69; 95% CI, 0.61–0.78) but not mortality (RR, 0.84; 95% CI, 0.55–1.30). However, there was not enough sample size to support the outcome of mortality.
There was still significant heterogeneity between studies as the sources of metabolic acidosis were different between different studies in this meta-analysis study of randomized control trial. One study recruited patients with septic shock only, while other studies enrolled patients with different disease states.
There was also heterogeneity in the threshold for pH to enter the study.
Bottom Line: In adults presenting to the ED with bacteremia, bandemia may be associated with increased short-term mortality, with higher band percentages correlating with greater risk. Although bacteremia is rarely diagnosed during the ED visit because blood cultures require time to result, the presence of bandemia should raise concern for possible occult critical illness.
20yo college swimmer presents to the ED with a constellation of non-specific symptoms such as poor sleep, fatigue, depression/anxiety, weight loss.
Despite regular 2/day practices, his coach tells him his performance is worse than ever.
Previous pediatric studies have shown that 1) air transport has shown improved outcomes compared to matched ground transports but 2) air transport may be overutilized.
This was a multicenter retrospective study using the Pediatric Emergency Care Applied Research Network Registry from 2012-2021 looking at pediatric patients transported to the ED by helicopter. This registry does not differentiate between field transports and interfacility transfers. The study looked to identify patients who were discharged from the ED or had a hospital stay < 48 hours. 7722 patients were included with a median age of 5.9 years. 20% of these patients were discharged from the ED. Among those admitted, over half were discharged within 48 hours. Patients who were discharged from the ED were found to have triage < ESI 1, missing a systolic blood pressure or temperature. Tachycardia, tachypnea, hypertension and abnormal temperature were associated with a lower rate of ED discharge.
Bottom line: Additional research is needed to identify patients who may be more appropriate for ground transport or when transport is not needed (or could be replaced with telemedicine).
Not all patients with an acute PE will be crashing and critically ill, but it seemed worthwhile to remind everyone that there are new guidelines and recommendations from AHA/ACC/ACCP/ACEP/CHEST/SCAI/SHM/SIR/SVM/SVN/XYZLMNOP about the management of patients with acute pulmonary embolism in the 2026 AHA/ACC Joint Committee statement. A few key takeaways, with highlights for the sicker PE patients:
Highlights for the sicker PE patients, i.e. Categories C+:
For a great breakdown and further discussion of the new guidelines, I recommend checking out the Life in the Fast Lane blogpost here.
This is a small qualitative study that focused on barriers to care and how to overcome them when dealing with patients with dementia, who are primarily Spanish speaking. The authors found to big themes that patients and caretakers thought would improve their care:
1- use of a certified translator, either telephonically or in person, eased social dynamics in communication
2- those same translators tended to only be used in an episodic manner- during HPI, exlaining results or discharge planning. But the patients and caretakers would prefer to have access to them in the “in between” periods so that it would be a more patient centered experience
Here are two techniques to remove a helmet from an injured motorcyclist. The first uses a cast saw to bivalve the helmet. A link for a video is also provided.
