Hippo ERcast February 2022

Spontaneous Carotid Dissection

Spontaneous carotid and vertebral artery dissection can present as isolated facial pain, headache, or neck pain with a completely normal neurologic exam. In younger patients, cervical artery dissection accounts for up to 25% of strokes, and the miss often starts with false reassurance from reproducible tenderness or a familiar migraine story. Spontaneous Cervical Artery Dissection Normal exam false reassurance: Cervical artery dissection may look benign at first: normal vitals, normal neuro exam, and even focal TMJ or trapezius tenderness do not exclude a dangerous carotid or vertebral lesion. Pain-only presentation pattern: Unilateral headache, facial pain, or neck pain are common presenting symptoms, and embolic complications may be delayed rather than obvious on the first ED visit. High-yield associated clues: Partial Horner syndrome, pulsatile tinnitus, cranial or cervical neuropathy, and posterior-circulation findings like Wallenberg syndrome should sharply raise suspicion. Younger stroke epidemiology: Up to 25% of strokes in younger patients are linked to cervical artery dissection, with higher prevalence in connective-tissue disease, pregnancy or postpartum state, smoking, and even minor neck torque. We get into the easy-to-overlook triggers in the episode. Imaging test selection: CTA and MRA are both used for diagnosis; some radiologists favor CTA for vertebral artery evaluation, while carotid imaging is often reasonable with either modality. Initial antithrombotic approach: Aspirin is standard treatment for most uncomplicated cases, while dual antiplatelet therapy adds bleeding risk without clear routine benefit in the usual presentation.

Blunt Cardiac Injury

Blunt cardiac injury is an underrecognized cause of chest pain, tachycardia, dysrhythmia, and shock after thoracic trauma. In suspected BCI, a normal ECG plus a normal troponin essentially rules it out, while hypotension or a new arrhythmia should push you toward echocardiography. Blunt Cardiac Injury Evaluation High-risk clinical clues: Chest pain after blunt thoracic trauma and tachycardia out of proportion to pain control or bleeding are the two bedside findings most likely to raise suspicion for BCI. Mechanism and injury spectrum: BCI spans direct impact, deceleration, blast, and indirect injury, ranging from myocardial contusion to coronary dissection, valve injury, papillary muscle tear, and rupture. Rule-out test pair: A normal ECG together with a normal troponin essentially excludes BCI, making this the key screening combination when the diagnosis is on your differential. ECG findings that matter: New dysrhythmia, ST-segment change, or heart block should be treated as abnormal screening findings, while isolated sinus tachycardia does not by itself make the diagnosis. When to admit or echo: Any abnormal ECG or troponin warrants admission, and hypotension or a new arrhythmia is the trigger for echocardiography. We walk through the protocol logic in the episode. CT and advanced imaging: Chest CT is the workhorse study for blunt thoracic trauma, and cardiac CT or MRI can help separate traumatic cardiac injury from true STEMI when catheterization decisions get messy. Commotio Cordis Recognition Classic arrest mechanism: Commotio cordis is ventricular fibrillation triggered by a blunt precordial blow, classically from a ball or fist, causing sudden collapse without structural penetration. Who gets affected: The syndrome is overwhelmingly seen in males and usually in patients younger than 20, especially during baseball, softball, hockey, football, soccer, and lacrosse. Immediate lifesaving response: Prompt bystander CPR and rapid AED use are the interventions that change survival, with mortality falling dramatically as public access defibrillation has spread. Prevention strategies: Risk reduction includes softer baseballs for younger players and sport-specific chest protection, although prevention has practical limits that are worth hearing in the chapter. Survivor emergency workup: Patients who survive the initial event still need ECG, continuous cardiac monitoring, basic labs, and cardiology admission because malignant rhythm complications can recur.

Lit Matters #1: Dalbavancin Reduces SSTI Admits

Moderately severe skin and soft tissue infection often triggers admission mainly to deliver IV antibiotics. A single-dose ED pathway using dalbavancin cut hospitalization substantially in stable SSTI patients with presumed gram-positive infection, while raising mostly mild adverse events. Dalbavancin for SSTI Disposition Disposition-changing antibiotic option: Single-dose IV dalbavancin offers an outpatient path for selected moderately severe SSTIs when the main reason for admission is parenteral gram-positive coverage. Headline hospitalization reduction: Hospitalization fell from 38.5% with usual care to 17.6% after pathway implementation, a memorable effect size for patients who otherwise look admit-for-IV-only. Patient selection boundaries: The pathway targeted clinically stable SSTI patients felt to need IV therapy but still appropriate for discharge, while excluding sepsis, immunosuppression, IV drug use, and high-risk wound types. Single-dose renal adjustment: Dalbavancin was given as a one-time IV dose with creatinine-clearance adjustment, keeping treatment simple at the bedside. We get into the practical selection details in the episode. Follow-up as safety net: Early reassessment mattered: patients received a 24-hour phone call and a 48- to 72-hour follow-up visit, underscoring that outpatient management still needs a deliberate backstop. Adverse event tradeoff: Adverse events were more common in the pathway group, but most were mild and no infection-related or antibiotic-related deaths occurred in either arm.

EEM Rewind: Blood in the Diaper

Blood in an infant’s diaper is usually not one diagnosis: the source may be urinary, vaginal, or gastrointestinal, and the first job is localization. In a hemodynamically stable newborn or infant, common benign mimics and a short list of high-yield pathology usually separate home discharge from further workup. Localizing Blood in the Diaper Urinary crystal mimic: Brick-red diaper staining is often uric acid crystalluria rather than true blood, especially in dehydrated breastfed newborns reacting with disposable diapers. Hematuria first pass: Suspected urinary bleeding starts with infection, bleeding diathesis, medication exposure, and structural causes; unless infection is the concern, a bag urinalysis avoids cath-induced hematuria. Physiologic withdrawal bleeding: Neonatal vaginal bleeding from maternal progesterone withdrawal typically appears on days 2-10 of life, lasts 3-4 days, and needs no treatment. Food and drug impostors: Red stool is often not blood at all; cefdinir, beets, fruit punch, frosting, gelatin, and spicy snacks can all convincingly mimic hematochezia. Stable infant triage frame: Most hemodynamically stable infants with a small amount of diaper blood go home after source localization and a focused exam, and we walk through that bedside sequence in the episode. High-Yield GI Causes in Infants Swallowed maternal blood: Maternal blood can explain neonatal bloody stool after delivery, from cracked nipples, or with rusty pipe syndrome, and the Apt test helps distinguish maternal from fetal hemoglobin. Anal fissure pattern: Anal fissure is common from 6-24 months, with painful defecation, blood streaks on wiping or coating firm stool, and often a visible fissure or sentinel skin tag. Mineral oil pearl: For constipation-related fissures in children older than 1 year, oral mineral oil is a practical first-line option alongside comfort measures and stool softening. Allergic proctocolitis clue: Food-protein induced allergic proctocolitis usually begins at 1-4 weeks with frothy mucoid bloody stools, often in breastfed infants exposed to cow’s milk protein. Vitamin K deficiency warning: Late vitamin K deficiency can present up to 12 weeks with GI bleeding or bleeding elsewhere, especially after prophylaxis refusal, with INR elevation and prolonged PTT. Meckel bleeding signature: Meckel’s diverticulum is a must-not-miss cause of painless rectal bleeding in children under 2, with bright or dark red blood mixed into stool. We get into the disposition split in the chapter.

Lit Matters #2: Dalbavancin Lacks Economic or Efficacy Advantage for SSTIs

Dalbavancin does not appear to outperform standard antibiotics for acute bacterial skin and skin structure infections, and its upfront price is substantial. In this multisite SSTI study, single-dose dalbavancin was associated with higher net cost and more 30-day SSTI readmissions than standard care. Dalbavancin for SSTI Value High acquisition cost: Dalbavancin carries a wholesale price around $4,600, so the real question is whether a one-dose strategy can replace hospitalization without sacrificing outcomes. No economic advantage: The study found a markedly higher net cost to the health system with dalbavancin than standard care, despite similar reimbursement per patient. Lower treatment success: Treatment success, defined as no SSTI-related readmission within 30 days, was lower with dalbavancin at 74% versus 85% with standard care. Readmission signal: Thirty-day SSTI-related readmissions were higher in the dalbavancin group, a practical outcome that undercuts the appeal of single-dose convenience. Possible niche subgroup: A treatment-naive subgroup showed an odds ratio favoring dalbavancin, but the broader results still leaned toward standard care. We get into where that exception may matter in the episode.

Epiglottitis and Bacterial Tracheitis

Epiglottitis and bacterial tracheitis are pediatric airway infections that can deteriorate quickly and are easy to confuse with croup. In the post-Hib vaccine era, Staphylococcus aureus now leads epiglottitis, and the bedside distinction often hinges on toxicity, cough, stridor, and a few classic radiographic signs. Epiglottitis and Bacterial Tracheitis Post-Hib microbiology shift: Staphylococcus aureus is now the most common cause of epiglottitis, while Hib is uncommon except in unvaccinated or immunocompromised patients. Croup versus tracheitis clues: Children with bacterial tracheitis usually look toxic and often lack a cough, a useful contrast with croup when upper-airway symptoms seem out of proportion. Stridor and drooling patterns: Tracheitis more often presents with stridor, while epiglottitis may not; in older children with epiglottitis, drooling and tripoding can be absent. Classic neck film findings: A lateral neck radiograph may show the thumbprint sign in epiglottitis, while an AP film can show a steeple sign with tracheitis. We get into when imaging helps versus harms in the episode. Airway-first management stance: Keep the patient upright in a position of comfort and involve ENT or anesthesia early, because airway obstruction can progress rapidly and a surgical airway backup may be needed. Empiric antimicrobial coverage: Initial therapy should cover typical upper-airway bacteria with a third-generation cephalosporin or ampicillin-sulbactam, adding antistaphylococcal coverage when MRSA risk is present. Tracheitis With Tracheostomy Secretion change warning signs: In children with a tracheostomy, changes in secretion color, odor, or volume can be an early clue to developing bacterial tracheitis. Prior culture guided antibiotics: With an artificial airway, empiric treatment should include antipseudomonal activity and be tailored to pathogens recovered on prior tracheal cultures. Plugging and bleeding risk: Tracheostomy-associated tracheitis raises the risk of mucus plugging and bleeding, making airway toileting as important as antimicrobial choice. We walk through the practical bedside priorities in the chapter. Supportive airway clearance: Humidified air, saline, and deep suctioning can materially improve secretion management while definitive treatment is started.

Lit Matters #3: Bougie or Stylet? Master Both

First-pass intubation success in critically ill adults was similar with a bougie or a standard stylet in a large multicenter randomized trial. The practical airway lesson is not device loyalty but competence with both techniques when urgent ED and ICU intubation gets difficult. Bougie Versus Stylet Intubation Equivalent first-pass success: A 1,106-patient multicenter RCT found no meaningful difference in first-attempt intubation success between bougie and stylet, reinforcing that either approach can work in critically ill adults. Real-world airway mix: About 40% of patients had at least one difficult-airway predictor, making this a pragmatic test of common high-stakes intubations rather than an idealized elective airway study. Video laryngoscopy context: Video laryngoscopy with a standard-geometry blade was used in roughly three quarters of cases, so the findings mainly reflect modern VL practice rather than universal direct laryngoscopy. Procedure time signal: Median time to intubation was slightly longer with bougie than stylet, a useful reminder that familiarity and setup matter when seconds count. We get into the bedside implications in the episode. Important trial limits: Open-label design and exclusion of cases where operators felt one device was required make the results less applicable to the obviously difficult airways where technique preference matters most. Practical airway takeaway: The headline conclusion is to master both bougie and stylet, because first-pass success depends less on device tribalism than on operator skill, patient selection, and rescue readiness.

The Curious Case of the Negative Pregnancy Test

A negative urine pregnancy test does not rule out ectopic pregnancy. In reproductive-age patients with pelvic pain, abdominal pain, cramping, or bleeding, ruptured ectopic remains on the table even when the point-of-care UPT is negative. Negative UPT and Ectopic Pregnancy Ruptured ectopic after negative UPT: A hemodynamically unstable ruptured ectopic can present after one or even two negative urine pregnancy tests, as this salpingectomy case makes painfully clear. High-risk symptom pattern: Pelvic pain, abdominal pain, cramping, and vaginal bleeding are the complaints where a negative UPT is least reassuring; that clinical distinction is worth hearing in the episode. Real-world false negatives: ED data suggest urine pregnancy tests are good but not perfect, with overall false-negative rates around 0.3% to 1.6% and higher miss rates in high-risk presentations. Missed ectopic signal: In one urban ED cohort, 12 ectopic pregnancies occurred despite a negative UPT, and most were in the high-risk symptom group rather than low-risk incidental testing. Serum testing backstop: If the story is concerning or the patient reports a prior positive home test, send a serum hCG instead of relying on a single negative bedside urine assay. Why Urine Pregnancy Tests Fail Early pregnancy limitation: Very early pregnancy can produce too little hCG to trigger the assay, with reported detection thresholds in the roughly 50 to 100 mIU/mL range. Hook effect mechanism: The hook effect is a sandwich-assay failure where excess hCG saturates binding sites and prevents the positive signal from forming, yielding a false negative. Late pregnancy paradox: A false negative UPT is not just an early-pregnancy problem; markedly elevated hCG later in pregnancy can also defeat the assay through the same mechanism. Technique and timing matter: Point-of-care urine testing can be falsely reassuring if read too quickly; waiting the full manufacturer interval before calling it negative is a basic safety step.