Hippo ERcast August 2022

Changing of the Guard

Clinical handoffs shape patient safety, diagnostic continuity, and team performance in the emergency department. Shift change is a high-risk moment where omissions, unclear ownership, and workflow friction can compound quickly. Emergency Department Handoffs Shift change risk: Care transitions are a predictable vulnerability in emergency medicine, with missed tasks and diagnostic drift clustering when ownership changes at the bedside. Structured sign-out elements: High-reliability handoffs hinge on illness severity, active problems, pending data, and contingency planning rather than a loose recap of the ED course. Closed-loop ownership: The safest transfers make explicit who owns the next action, especially for time-sensitive follow-up like repeat exams, callbacks, and disposition pivots. Interruption control: Sign-out quality degrades when pages, new arrivals, and side conversations fragment attention; protecting a brief sterile handoff interval matters. We get into practical workflow fixes in the episode. Culture and accountability: Strong handoffs are less about memorized mnemonics than shared team expectations, direct questions, and a low-friction way to surface uncertainty before it becomes error.

Essentials Masterclass: BRUE

A BRUE is a sudden, brief, resolved event in an infant under 1 year with cyanosis or pallor, abnormal breathing, tone change, or altered responsiveness—and if history or exam reveals a cause, it is not a BRUE. Most low-risk infants need little testing, while non-low-risk cases hinge on targeted evaluation and disposition. BRUE Definition and Risk Stratification Core BRUE definition: BRUE applies only to infants under 1 year after a sudden, brief, fully resolved episode with cyanosis or pallor, abnormal breathing, marked tone change, or altered responsiveness. Not a BRUE clues: A diagnosis from the history or exam takes the child out of the BRUE bucket; choking or gagging is one of the most common mimics, and a symptomatic infant at presentation is not a BRUE. Low-risk criteria framework: Only about 15% of infants meet low-risk BRUE criteria, which require an older infant, a single short event, no concerning history, and a reassuring physical exam. We walk through the practical risk split in the episode. Abuse red flags: Non-accidental trauma remains a key alternative diagnosis, with concerning bruising, injury patterns, or social risk factors carrying special weight in a preverbal infant. High-risk clinical context: Age under 2 months, prematurity, recurrent episodes, provider-delivered CPR, or preceding fever, poor feeding, lethargy, or URI symptoms should push evaluation beyond the low-risk pathway. Evaluation, Etiologies, and Disposition Low-yield routine testing: For low-risk BRUE, routine diagnostic testing has low utility; the two studies with the best yield are an ECG and pertussis testing. Common final diagnoses: When a final diagnosis is eventually found, about two-thirds are gastroesophageal reflux and roughly 10% are seizures, with feeding problems and laryngomalacia also showing up. Serious alternate diagnoses: Seizures, airway anomalies, serious bacterial infection, inborn errors of metabolism, toxin exposure, and non-accidental trauma make up the dangerous minority, especially in non-low-risk infants. Observation and discharge: Low-risk infants can usually go home with follow-up within 24 hours, while non-low-risk infants may need a short ED observation period or discharge after a targeted workup and shared decision-making. Counseling and follow-up: Discharge counseling should cover safe sleep, recurrence precautions, and the fact that home cardiorespiratory monitors are not routinely recommended. The return-precaution language is worth hearing in the chapter.

Anaphylaxis

Anaphylaxis is a clinical diagnosis, and delayed epinephrine is the major preventable cause of death. The defining pattern is an allergic exposure plus multisystem involvement such as hypotension, skin or mucosal findings, respiratory compromise, or GI symptoms; everything besides IM epinephrine is adjunctive. Recognizing and Treating Anaphylaxis Clinical diagnosis pattern: Anaphylaxis is an allergic reaction with involvement of at least two organ systems, classically hypotension, skin or mucosal findings, respiratory compromise, or GI symptoms. Epinephrine comes first: IM epinephrine is the first-line treatment in adults at 0.3 to 0.5 mg of 1:1000 solution, and the memorable hierarchy is first-, second-, and third-line therapy are all epinephrine. IM over subcutaneous: Intramuscular delivery matters because epinephrine reaches peak levels far faster than subcutaneous dosing, a practical point that explains why route errors can cost time. Adjuncts stay adjuncts: Antihistamines, steroids, albuterol, fluids, and antiemetics may help specific symptoms, but none reverse the core hemodynamic and airway physiology like epinephrine does. We get into the bedside prioritization in the episode. Children present differently: Pediatric anaphylaxis may show less early airway involvement and more lethargy, fatigue, and hypotension, an easy way to miss a sick child if you anchor on wheeze or stridor alone. Monitor early deterioration: True anaphylaxis can progress to cardiac arrest within minutes, with especially short timelines after medication triggers, so severe reactions belong in a monitored bed immediately. Shock, Refractory Cases, and Disposition When IM epi fails: More than two IM epinephrine doses without resolution should prompt escalation to an IV epinephrine drip rather than repeated delays with adjunctive medications. Beta blocker exception: Glucagon is the named rescue agent for patients on beta blockers who remain hypotensive or bradycardic despite epinephrine, because beta blockade can blunt the expected response. Anaphylactic shock physiology: Anaphylactic shock is distributive shock with capillary leak, reduced SVR, and direct myocardial effects, so the main treatment is still more epinephrine, not just fluids. Airway danger signs: Significant stridor, rising work of breathing, or poor oxygenation should trigger early airway planning, with awake techniques and video laryngoscopy sometimes offering the best chance of success. Biphasic reaction reality: Biphasic reactions can recur hours later and are unpredictable enough that observation decisions hinge on severity and response, a nuance we walk through in the chapter. Discharge essentials: Patients leaving after improvement should go home with an epinephrine auto-injector and allergy follow-up, especially when the trigger is uncertain or the reaction was severe.

Lit Matters #1: SMRs No Better Than Placebo for LBP

Acute nonradicular low back pain usually improves within a week with conservative therapy. In ED patients treated with an NSAID, seven commonly used skeletal muscle relaxants performed no better than placebo on functional recovery, while cyclobenzaprine produced more adverse effects. Acute Low Back Pain Treatment Placebo-level SMR benefit: Across 887 ED patients with acute nonradicular low back pain, baclofen, methocarbamol, tizanidine, diazepam, metaxalone, orphenadrine, and cyclobenzaprine were no better than placebo for 1-week functional improvement. Meaningful early recovery: Average Roland-Morris Disability Questionnaire scores improved by about 10 points in all groups, comfortably exceeding the 5-point threshold for clinical significance and reinforcing the usual favorable short-term course. Mild pain by one week: Roughly 60% to 68% of patients had no pain or only mild pain at follow-up regardless of which adjunct they received, a practical expectation-setting point worth hearing in the episode. No clear responder subgroup: Age, sex, baseline disability, and prior low back pain episodes did not meaningfully change outcomes, arguing against a reliable demographic profile that benefits more from adding a muscle relaxant. Cyclobenzaprine adverse effects: Cyclobenzaprine stood out for harm, with adverse events in 35% versus 16% on placebo, mostly drowsiness, dry mouth, dizziness, and nausea. NSAID-first framing: All patients received naproxen or ibuprofen, so the strongest takeaway is NSAID-based conservative care first; the unanswered NSAID-only question is one we get into in the podcast.

Updated AHA/ACC Chest Pain Guidelines

Low-risk chest pain rarely benefits from urgent stress testing or cardiac imaging. The 2021 AHA/ACC chest pain guideline leans on high-sensitivity troponin and structured pathways to define low risk, while shared decision-making, ECG nuance, and selective testing remain where bedside judgment matters most. Low-Risk Chest Pain Strategy Low-risk outcome threshold: The guideline defines low risk as under 1% 30-day risk of death or major adverse cardiac events, making routine urgent testing unnecessary in that group. No routine stress testing: For low-risk acute or stable chest pain, stress testing and coronary imaging within 30 days have not shown outcome benefit; the real priority is risk-factor modification. High-sensitivity troponin preference: High-sensitivity troponin is the preferred biomarker because it accelerates rule-out and improves ED throughput with 1- to 2-hour repeat strategies, though downstream testing remains a concern. Clinical pathway definitions: The guideline endorses pathways like HEART and EDACS to identify low-risk patients, but the external validity and true outcome benefit are less certain than the recommendation sounds. We get into that tension in the episode. Shared decision-making role: For intermediate-risk patients, shared decision-making is a formal recommendation because it improves understanding and reduces low-value testing while better matching care to patient risk tolerance. Nuance the Guideline Misses Subtle occlusion MI patterns: STEMI criteria miss important occlusion MI equivalents, and the update gives little practical guidance beyond new ST elevation, ST depression, or new left bundle branch block. Focused echo limitations: Bedside TTE is useful in intermediate-risk chest pain for wall-motion abnormalities, ventricular function, valve complications, and pericardial effusion, but its discharge-risk role is much less clear. Atypical chest pain language: The guideline discourages the term atypical chest pain, favoring cardiac, possibly cardiac, and noncardiac labels, but symptom descriptors like exertional pressure versus pleuritic fleeting pain are often more useful. Selective chest radiography: Chest x-ray should be guided by clinical suspicion rather than reflex ordering, because it often does not reveal an intervention-requiring diagnosis despite broad guideline wording. Testing warranty skepticism: The proposed warranty periods for prior normal stress tests and coronary imaging are controversial, especially given the limited sensitivity of exercise stress testing and plaque biology. We walk through why that matters in the chapter.

Lit Matters #2: Suicide Risk Assessment in the ED

Suicide risk assessment in the emergency department is more accurate when clinician judgment is supplemented by structured patient self-report and electronic health record data. In psychiatric ED patients, combined models outperformed bedside assessment alone for predicting suicide attempts at both 1 and 6 months. Suicide Risk Assessment in the ED Clinician gestalt limits: Treating clinician assessment had the weakest discrimination for both 1-month and 6-month suicide attempts, a useful reminder that bedside impression alone misses meaningful risk. Brief patient self-report: A short tablet-based self-report performed better than clinician assessment for near-term and 6-month prediction, supporting structured questioning over unstructured interview alone. EHR risk signal: Machine-learning predictions drawn from data already in the electronic health record also outperformed clinician judgment, showing that chart-level history carries actionable prognostic value. Best combined approach: The strongest performance came from pairing patient self-report with an EHR-based risk score rather than choosing one tool over the other. We get into what that means for ED workflow in the episode. Meaningful event rate: Suicide attempts after the index ED visit were common in this cohort, with roughly 13% by 1 month and about 22% by 6 months, underscoring why missed risk matters. High-risk psychiatric cohort: These findings came from adults presenting with psychiatric complaints and seen by psychiatric services, so the signal is most applicable to behavioral health ED populations rather than undifferentiated screening.

Brace For Impact: Incoming Documentation Changes

ED documentation changed in 2023 by shifting chart leveling away from history and physical exam toward medical decision-making. The practical implication is less note bloat and more emphasis on documenting your differential, actions, discussions, and social determinants of health. 2023 ED Documentation Changes MDM becomes the center: History and exam still matter clinically, but they no longer drive ED chart leveling; the billable work is increasingly the medical decision-making you capture in the note. Four D charting frame: A durable bedside structure is Differential, Doing, Discuss, and social Determinants of health, which turns vague note-writing into defensible documentation. We walk through that frame in the episode. Targeted differential language: Avoid sprawling complaint-based dot phrases; a focused differential tied to the actual workup, with named rationale such as Wells or PERC, is both cleaner and more credible. Rationale for tests ordered: Modern E/M logic gives credit not just for tests and treatments you do, but also for studies you deliberately defer when the chart clearly states why. Recognizing chronic instability: Asymptomatic hypertension or hyperglycemia can still count as unstable chronic illness when not at goal, provided you recognize it and document a plan such as PCP follow-up. Social determinants as risk: Homelessness, injection drug use, and threat of job loss now belong in the MDM risk picture, reflecting a major shift from older coding priorities toward health equity.

Lit Matters #3: Anticoagulating SSPEs and Recurrent VTE Risk

Subsegmental pulmonary embolism is often overcalled on CTPA, and isolated SSPE without proximal DVT carries a low but real short-term risk of recurrent VTE. The key clinical question is not whether every SSPE gets anticoagulated, but which low-risk patients may be observed with structured follow-up and shared decision-making. Subsegmental PE Without Anticoagulation False positive signal: Isolated subsegmental PE on CTPA is less reliable than larger clot burden, with retrospective radiology review calling many solitary SSPEs false positives or even negative on reread. Guideline supported surveillance: CHEST guidelines allow clinical surveillance over anticoagulation in selected SSPE patients when there is no lower-extremity DVT and recurrence risk appears low. Ninety day recurrence risk: In this prospective cohort, untreated isolated SSPE had a 3.1% cumulative recurrent VTE risk at 90 days, reinforcing that the hazard is low but not zero. Single versus multiple defects: Clot burden mattered: single SSPE had about 2.1% recurrence, while multiple isolated SSPEs were closer to 5.7%, a distinction worth hearing in the episode. Screening for occult DVT: Patients underwent bilateral leg ultrasound before withholding anticoagulation, underscoring that observation is tied to actively excluding proximal DVT rather than simply discharging. Shared decision framing: There were no PE deaths in follow-up, but recurrence still occurred, so the practical takeaway is shared decision-making that balances recurrent clot risk against anticoagulant bleeding harm.