Hippo ERcast March 2024

Intro: A Round of Beers

The 2023 Beers Criteria flags potentially inappropriate medications in adults 65 and older, but it was built largely for chronic prescribing rather than single-dose emergency care. In the ED, the value is less in blanket drug bans than in spotting drug-disease interactions, renal pitfalls, and safer alternatives for older adults. Beers Criteria in Emergency Care Core purpose and scope: The Beers Criteria is a six-table medication safety framework for adults 65 and older across ambulatory, acute, and institutional settings, excluding hospice and end-of-life care. Chronic care versus ED reality: Most recommendations were written by internists for longer-term therapy, so direct application to one-time ED treatment can misfire when acute indications outweigh baseline medication risk. Highest-yield ED tables: The drug-drug, drug-disease, anticholinergic, and renal adjustment tables are the most practical bedside pieces because they flag interactions and context that often matter immediately. Named medication examples: Amiodarone appears as potentially inappropriate first-line therapy for atrial fibrillation, and TMP-SMX gets a caution flag with ACE inhibitors, ARBs, or reduced creatinine clearance. Safer alternative signal: The 2023 update favors apixaban over rivaroxaban when a DOAC is needed because bleeding risk is lower. We get into how to use that kind of preference in the episode. Limits of Blanket Medication Alerts Nuance over pop-up medicine: A Beers alert is not a stop sign; the real question is whether the risk comes from the drug itself, the renal function, the comorbidity, or the combination. Nitrofurantoin renal exception: Nitrofurantoin can be a reasonable choice for uncomplicated UTI when renal function is adequate, illustrating how a generic potentially inappropriate label can push clinicians toward worse options. Appropriate ED exceptions: Aspirin, nifedipine, diphenhydramine, and benzodiazepines may all trigger concern in older adults, yet each has legitimate emergency indications when the immediate problem changes the risk-benefit balance. Alert fatigue consequences: Excess warnings dilute the important ones, driving alarm fatigue, frustration, burnout, and the risk that clinicians ignore the alerts that truly signal harm. Smarter decision support: A better prescribing tool would integrate diagnosis, medication list, renal function, and comorbidities instead of firing generic warnings. We lay out why STOPP/START and newer AI-style tools may fit that role better in the chapter.

The First 5 Minutes in Managing the Dangerously Agitated Patient

Dangerous agitation is an immediate safety and resuscitation problem, not just a behavioral one. In the emergency department, the first minutes hinge on distinguishing routine agitation from patients who are violent or so altered that a time-critical medical cause must be found fast. First Minutes of Dangerous Agitation Dangerous versus routine agitation: Dangerous agitation means either an immediate threat to self or others or severe agitation with concern for a life-threatening medical cause, so management prioritizes speed over medication safety. Adequate show of force: Safe control starts with at least five people, typically one for each limb and one for the head, while the physician directs rather than physically wrestling the patient. High-risk restraint pitfalls: Compression of the neck, chest, or back can turn restraint into a fatal event, and hog-tie or hobble positioning should never be used. We lay out the practical approach in the episode. Immediate oxygen application: A face-mask oxygen setup goes on right away because it both limits spitting escalation and buys time if hypoxia is contributing to the agitation. Intramuscular ketamine first: For truly dangerous agitation, IM ketamine is the preferred agent because its pharmacokinetics are fast and its effectiveness is near 100%, often producing stillness within about 3 minutes. Monitoring after dissociation: Any non-intubated patient dissociated with ketamine needs continuous resuscitation-level monitoring with special attention to ventilation, then the work shifts to causes like hyperthermia, hypoglycemia, and hypovolemia.

Lit Matters 1: Lytics vs Dual Antiplatelets for Mild Stroke

Mild noncardioembolic ischemic stroke is not automatically low risk just because the NIHSS is low. In patients with NIHSS 3 or less, this study found no functional advantage for IV thrombolysis over early dual antiplatelet therapy, while thrombolysis carried more symptomatic intracranial hemorrhage and early neurologic deterioration. Mild Stroke Reperfusion Decisions Low NIHSS uncertainty: A mild stroke score can hide disabling deficits, but in this registry of noncardioembolic ischemic stroke, IV thrombolysis did not outperform early dual antiplatelet therapy on functional recovery. Head-to-head treatment signal: Early DAPT with aspirin plus clopidogrel looked at least comparable to IV thrombolysis for NIHSS 3 or less, with the treatment-selection caveats and bedside implications we get into in the episode. Hemorrhage risk difference: Symptomatic intracranial hemorrhage was markedly more common after IV thrombolysis, about 1.4% versus 0.1%, a safety signal that persisted after propensity matching. Early deterioration warning: Early neurologic deterioration, defined as a 4-point NIHSS worsening within 24 to 48 hours, was also more frequent with IV thrombolysis than with DAPT. Functional outcome comparison: Modified Rankin outcomes at discharge and at 3 months were not significantly better with IV thrombolysis, despite the common assumption that lytics should help mild stroke patients. Lacunar infarct subgroup: A possible exception appeared in lacunar infarcts, where IV thrombolysis was associated with better outcomes, but the subgroup caveats matter and we walk through them in the chapter.

Upstairs Rumblings: "What I Wish ED Docs Knew About Central Lines”

Central venous access is not a default step for every ICU-bound patient. In emergency and critical care, the real decisions are who truly needs a central line, which site and catheter fit the physiology, and when an arterial line changes management rather than just adds risk. Central line decisions in the ED Who can skip a CVL: A central line is rarely needed just for difficult access now that ultrasound-guided peripheral IVs and PICCs exist, and some patients on low-dose norepinephrine or with a short expected ICU course can often avoid one. Who likely needs a CVL: Crashing patients with poor access, those on high-dose or multiple vasopressors, and patients needing irritant infusions like hypertonic saline are the clearest candidates for central access. Catheter choice matters: Multi-lumen catheters suit patients needing several simultaneous infusions, while introducer sheaths are built for rapid fluids, blood products, or dialysis-level flow. We get into the practical selection logic in the episode. Site-specific tradeoffs: Subclavian has lower CLABSI rates and is often more comfortable, but it is a poor choice when bleeding risk, future dialysis access, or even a small pneumothorax would be a major problem. Dialysis line anatomy: For temporary dialysis access, the right IJ is generally preferred, while the left IJ is less desirable because the sharper turn into the central circulation makes the setup less favorable. Full sterile barrier: Maximal sterile precautions are not optional: skipping full barrier technique can raise CLABSI rates up to sixfold, and any line that was not clearly sterile may need replacement upstairs. Arterial line indications and placement Who needs an A-line: Arterial monitoring is most useful when cuff pressures are unreliable, fluctuating, or falsely reassuring despite shock signs like cold extremities, elevated lactate, altered mentation, or poor urine output. Who does not: Not every patient with a CVL needs an arterial line; stable hemodynamics and a favorable trajectory are strong reasons to skip another invasive device. Radial first default: The radial artery is usually the best first site because it is fast, accessible, and carries lower infection and complication rates than more central options. Femoral rescue site: Femoral arterial access is especially useful during cardiac arrest, but it brings higher risks of bleeding, pseudoaneurysm, retroperitoneal hematoma, and infection. We walk through when that tradeoff is worth it in the chapter. Avoid double sticking: Placing a femoral arterial line and femoral central line on the same side should be avoided when possible because doubling up at one groin can increase CLABSI risk.

A Plastic Surgeon's Approach to Facial Lacerations

Facial laceration repair is mostly about anatomy, tension management, and knowing when specialist consultation actually changes care. Forehead and scalp wounds have different closure priorities, and many facial lacerations do not require immediate plastic surgery repair if fractures, nerve injury, and major tissue loss are absent. Facial Laceration Repair Principles Consult triggers that matter: Hard reasons to involve plastics or ENT are devastating tissue loss, facial fracture, and vascular or nerve injury; many other facial lacerations can be repaired safely in the ED. Wound visualization first: Copious irrigation is the first step because it defines what structures are involved and exposes deeper injuries before you commit to a closure plan. Tension lives in depth: Multilayer closure is the core cosmetic principle: deep dermal sutures should carry the wound tension, while the epidermal layer is mainly for edge approximation and appearance. Running skin closure advantage: Running sutures are often faster than interrupted closure and can improve cosmesis by distributing tension evenly across the full length of the laceration, a distinction we get into in the episode. Skin suture material choices: On the face, fast-absorbing gut suits minor low-tension wounds, while PROLENE remains a low-reactivity nonabsorbable option when follow-up for removal is realistic. Absorbable tradeoffs on skin: Chromic gut holds strength longer but is generally avoided on the face because its slower absorption and greater tissue reactivity can work against cosmetic goals. Forehead and Scalp Closure Linear forehead closure plan: A straightforward forehead laceration usually gets buried 4-0 MONOCRYL for the dermis, with the deep layer doing the real work of keeping the wound closed. Forehead skin options: Common skin-layer choices are a 5-0 PROLENE running stitch, fast-absorbing gut running closure, or a running intracuticular MONOCRYL when skin edges are pristine. Bone exposure changes layers: If a forehead wound exposes bone, inspect for fracture and think in three layers; the deepest muscular layer is commonly reapproximated with 3-0 VICRYL. Scalp hemostasis and galea: Scalp wounds bleed impressively, so hemostasis matters early; if the laceration reaches galea, 2-0 VICRYL is the classic repair suture. Staples for most scalp wounds: Staples are appropriate for most scalp lacerations because they are fast and reliable, while a bald patient may be a better cosmetic fit for chromic gut instead. Hair management pitfalls: Do not trap hair in the closure because buried hair can seed infection or epidermal inclusion cysts. We walk through the practical scalp prep details in the episode.

Lit Matters 2: Lytics Before Transfer for Thrombectomy?

Large vessel occlusion stroke at a primary stroke center creates a different thrombolysis decision than direct presentation to a thrombectomy-capable center. For transfer patients, the key question is whether IV thrombolysis before endovascular therapy improves 90-day outcomes without raising symptomatic intracranial hemorrhage. Lytics Before Transfer for LVO Drip and ship framing: Primary stroke center patients with LVO are not the same as direct-to-CSC thrombectomy patients, so bypass-lysis trials should not be casually extrapolated to transfer decisions. Early reperfusion signal: Systemic thrombolysis can reperfuse a meaningful minority of LVOs before arrival for thrombectomy, roughly 10% to 20%, which is the physiologic argument for treating early. Observed outcome benefit: Across six studies, IV thrombolysis before transfer was associated with better 90-day functional outcomes, including an odds ratio of 1.7 for excellent outcome on mRS 0 to 1. Safety signal on hemorrhage: Symptomatic intracranial hemorrhage did not appear higher with lytics before transfer, an important finding when the major practical objection is bleeding risk. Bias and uncertainty: The evidence base is thin and observational, with moderate overall bias and several severely confounded studies. We get into why the primary outcome signal is shakier than the headline suggests in the episode. Alteplase versus tenecteplase: The included studies used alteplase, so any enthusiasm about tenecteplase's easier administration and possible recanalization advantage remains an open extrapolation rather than proven here.

Hypertensive Disorders of Pregnancy: A Can’t Miss Diagnosis

Preeclampsia is a can’t-miss cause of maternal morbidity that presents during pregnancy and up to 6 to 8 weeks postpartum. In the ED or urgent care, severe-range blood pressure alone can establish severe disease and should trigger immediate evaluation rather than waiting hours for confirmation. Recognizing Peripartum Hypertension Postpartum risk window: Hypertensive disorders of pregnancy do not end at delivery; patients remain at risk for 6 to 8 weeks postpartum, so every triage screen should ask about current or recent pregnancy. Common and dangerous disease: Preeclampsia and related hypertensive disorders affect up to 10% of pregnancies and remain a leading cause of maternal morbidity and mortality, including after discharge. Spectrum of diagnoses: The framework matters: chronic hypertension begins before 20 weeks, gestational hypertension starts after 20 weeks, and preeclampsia adds proteinuria or a severe feature. Severe feature shorthand: It only takes one severe feature to make preeclampsia severe, and sustained severe-range blood pressure is enough on its own. That distinction is worth hearing in the chapter. Diagnosis and Initial Evaluation Accurate blood pressure technique: Before labeling severe hypertension, use the correct cuff and seated or semi-reclined positioning; bad technique can misclassify risk in a time-sensitive obstetric emergency. Do not wait four hours: For severe-range pressures, do not wait for the classic 4-hour spacing used in milder hypertension; a 15-minute sustained recheck is the actionable bedside standard. Protein testing limits: Urine dipstick protein is imperfect, with roughly 60% sensitivity, so it should not be used alone to rule out preeclampsia when symptoms or pressure are concerning. Severe disease markers: Red flags include platelets below 100,000, creatinine above 1.1, liver enzymes more than twice normal, pulmonary edema, refractory headache, visual scotoma, and HELLP syndrome. Essential lab bundle: Patients with severe-range blood pressure need a focused workup with CBC, liver enzymes, creatinine, and urinalysis or a urine protein-creatinine ratio, even without other symptoms. We walk through the early ED priorities in the episode. Emergency Recognition of Eclampsia Seizure equals eclampsia: New-onset generalized tonic-clonic seizure or unexplained coma in a pregnant or recently postpartum patient should be treated as eclampsia until proven otherwise. Superimposed preeclampsia risk: Patients with chronic hypertension can develop superimposed preeclampsia and may deteriorate quickly, making a previously familiar blood pressure history falsely reassuring. Symptom-based suspicion: Headache that does not respond to medication, visual symptoms, and dyspnea from pulmonary edema are major warning signs even before protein results return. Triage system safeguards: A visible EMR pregnancy or postpartum flag helps prevent missed diagnosis when the chief complaint looks non-obstetric, especially in recently delivered patients.

Lit Matters 3: Early versus delayed antihypertensive treatment in ischemic stroke

Acute ischemic stroke management prioritizes reperfusion, not early blood pressure reduction, in patients without extreme hypertension. In CATIS-2, starting antihypertensives within 24-48 hours did not improve 90-day death or functional dependence, reinforcing that sustained control matters more than immediate treatment. Blood Pressure Timing in Ischemic Stroke Reperfusion before pressure lowering: In acute ischemic stroke, the priority is thrombolysis or thrombectomy when indicated; antihypertensive therapy is secondary unless blood pressure reaches clearly dangerous extremes. CATIS-2 main finding: Early antihypertensive treatment begun within 24-48 hours did not improve the 90-day composite of death or functional dependence compared with waiting to restart therapy later. Mild signal toward harm: The early-treatment group had a numerically higher rate of poor 90-day outcome, with a number needed to harm of 65, though the difference was not statistically significant. Low severity study population: The median NIHSS was 3, so these results mainly inform mild acute ischemic stroke rather than large-vessel occlusion, severe deficits, or patients headed to thrombectomy. Sustained control over urgency: The practical takeaway is that smooth long-term blood pressure control matters more than pushing medications immediately in the first week after uncomplicated ischemic stroke. We get into the bedside implications in the episode.