Hippo ERcast January 2025

New Years' Resolutions

Early bedside contact, standardized consultant handoffs, and repeat ECGs with delta troponins are small emergency medicine habits that materially affect disposition, communication, and chest pain safety. Clinical excellence in the ED often comes from doing the reliable basics every shift, especially when the department is busy. Emergency Medicine Practice Habits Early bedside introduction: Seeing each handoff patient early to introduce yourself, make a quick assessment, and update the family can accelerate disposition by establishing the connection before tasks stack up. Visible attending reassessment: A brief first-pass attending evaluation catches immediate issues sooner and reinforces to residents that early physician contact is part of disciplined ED workflow. Structured consultant calls: Keeping consultant conversations formal and uniform, even with familiar colleagues, reduces omissions and models a reproducible standard learners can copy. Communication beyond the note: Consult calls still add value when the chart seems sufficient because closed-loop verbal communication clarifies the ask, the urgency, and the shared plan. We get into the practical phrasing on the show. Delta ECG with troponin: A repeat ECG should accompany a delta troponin in chest pain workups, because safe discharge depends on following the evidence-supported protocol rather than just trending biomarkers. Protocol fidelity under pressure: Busy shifts are exactly when key steps get skipped, but those omissions erode the reliability of modern chest pain pathways and other high-volume ED decisions.

Tiny Airways, Mighty Challenges: Peds Airways

Pediatric airways are anatomically more anterior and physiologically unforgiving, with markedly shorter safe apnea time than adults. Difficult pediatric intubation hinges on positioning, blade choice, and an early rescue plan for oxygenation when first-pass success fails. Pediatric difficult airway approach Anterior airway anatomy: The pediatric larynx sits more proximal and anterior, so tube delivery often needs a sharper hockey-stick bend plus external laryngeal manipulation rather than routine adult mechanics. Short safe apnea window: Children desaturate fast because oxygen consumption is high and functional residual capacity is low, making any starting saturation below 100% a real warning sign. Positioning fundamentals: A large occiput changes alignment, and younger children often need a shoulder roll to line up the external auditory meatus with the sternal notch. We get into the bedside setup in the episode. LEMONS airway screen: LEMONS helps flag trouble before paralysis, especially small mouth, large tongue, recessed chin, stridor, drooling, retractions, and limits from spinal immobilization. Standardized RSI checklist: Treat every pediatric airway as potentially difficult and run a laminated RSI checklist with a second clinician, using a 45-second cap on laryngoscopy attempts. Equipment and rescue options Miller blade preference: Miller is often the better pediatric blade because its geometry lifts the epiglottis directly, matching the anatomy better than a Macintosh in small children. Video versus direct laryngoscopy: Video laryngoscopy can improve the view and teaching, but in an anterior pediatric airway a beautiful screen image does not guarantee the tube will pass. Endotracheal tube sizing: Pediatric tube size still follows age-based formulas, and depth can be estimated at roughly three times the tube size. We walk through the practical shortcuts in the chapter. LMA as rescue oxygenation: An LMA is a safe rescue device even in neonates and is often the fastest way to restore oxygenation, but it is a bridge rather than a definitive airway. Needle cric temporizing role: Needle cricothyrotomy is the usual pediatric front-of-neck rescue, providing oxygenation but not adequate ventilation; open or percutaneous cric is generally reserved for older children with palpable landmarks.

Lit Matters 1: Safety of procedural sedation in the ED

Emergency department procedural sedation has no single safest agent; adverse events cluster by drug rather than yielding one clear winner. In adult ED PSA, hypoxia is the most frequent complication, and capnography detects more respiratory events than pulse oximetry alone. Procedural Sedation Safety Signals No universal safest agent: RCT-only adult ED data showed no medication dominated overall safety; each sedative carried a distinct complication pattern, so agent choice should match the procedure and patient rather than chase a single 'best' drug. Hypoxia as leading event: Hypoxia was the most common adverse event at about 105 per 1000 sedations, while severe events needing immediate intervention remained uncommon across the pooled ED literature. Propofol hemodynamic tradeoff: Propofol stood out for hypotension at roughly 55 per 1000 sedations, reinforcing its familiar blood-pressure liability even when its procedural conditions are otherwise attractive. Ketamine mixed profile: Ketamine had the lowest hypoxia signal at about 21 per 1000 sedations but a much higher agitation and vomiting burden, a tradeoff worth hearing in the episode. Midazolam respiratory concern: Midazolam alone carried the highest hypoxia and apnea estimates, including hypoxia above 200 per 1000 sedations, which supports moving away from benzodiazepine-only sedation when better options are available. Capnography reveals more events: Studies using end-tidal CO2 reported more hypoxia and apnea, suggesting capnography finds subclinical respiratory compromise earlier rather than making sedation less safe. We get into that monitoring nuance in the episode.

Upstairs Rumblings: What I Wish ER Docs Knew About Septic Shock

Septic shock is common, but the dangerous miss is treating the bundle while missing the source or the mimic. Early appropriate antibiotics matter in unstable patients, source control matters more than any single drug choice, and hypotension is not automatically sepsis. Septic Shock Pearls and Pitfalls Early appropriate antibiotics: In septic shock, each hour of delay after hypotension begins is linked to about an 8% rise in mortality, so unstable patients need broad appropriate coverage up front. Therapeutic momentum risk: What gets started in the ED often persists in the ICU, so the first antimicrobial choice has outsized consequences for coverage, culture interpretation, and downstream source control. Premature closure bias: A plausible shock diagnosis like CHF, STEMI, GI bleed, or PE does not exclude bacteremia; if sepsis is in play, get cultures and start antibiotics early because they can be narrowed or stopped later. Source control priority: Bacteremia starts somewhere, and the highest-yield sepsis question is where the infection began; when the source is not obvious, the stepwise search strategy is worth hearing in the episode. Risk-tailored empiric therapy: Prior culture data should change front-end treatment: a history of ESBL pushes toward a carbapenem, and prior fungemia should raise early antifungal coverage. Shock mimic red flags: Hypotension with bradycardia is not typical septic physiology, and every hypotensive patient deserves a broader screen for STEMI, myocarditis, hemorrhage, PE, pancreatitis, and toxicologic mimics. Finding the Source of Bacteremia Common source checkpoints: Start with the basics: urine, chest, and indwelling hardware, because pneumonia, urinary infection, and line-related infection still account for many septic presentations. Occult abdominal sources: Worsening shock despite fluids and antibiotics should raise concern for biliary sepsis, acalculous cholecystitis, intra-abdominal infection, or obstructing pyelonephritis. Skin and soft tissue exam: Necrotizing soft tissue infection and Fournier gangrene are easy to miss if you do not look, making a full skin exam part of source control rather than an optional extra. Meningitis treatment timing: If meningitis or encephalitis is a real concern, start antibiotics first; CSF cultures may sterilize, but cell counts typically still show the inflammatory pattern. Indwelling line approach: A suspected infected central line should not be used, but routine line cultures create false positives from colonization; the bedside line strategy has useful nuance in the chapter. Host risk factor clues: Frequent hospitalizations, immunosuppression, biliary stents, prior obstructing stones, and recent resistant organisms all sharpen both source suspicion and empiric coverage.

A World Without Propofol

Emergency department procedural sedation does not begin and end with propofol. Ketamine, etomidate, dexmedetomidine, midazolam, and methohexital each fit different procedures, sedation depths, and hemodynamic profiles, while safe practice still hinges on consent, staffing, and capnography. Non-Propofol Procedural Sedation Sedation privilege barriers: Deep sedation is often constrained by CMS-style hospital privileging, with anesthesia controlling access and a two-provider requirement that can block single-physician ED settings. Sedation planning essentials: Drug choice should match procedure length and onset time, and patients should be consented for deep sedation up front because moderate sedation can easily progress further. Monitoring that matters: Pulse oximetry lags behind apnea, especially on oxygen, so end-tidal CO2 with supplemental oxygen and 3-lead ECG is the real safety floor for moderate, deep, and dissociative sedation. Ketamine tradeoffs: Ketamine is hemodynamically stable and preserves airway reflexes, but it provides no muscle relaxation and often needs redosing with recovery monitoring that extends beyond 30 minutes. Etomidate sweet spot: Etomidate is a strong choice for brief deep procedures like cardioversion or joint reduction, with myoclonus or fasciculations seen in about 30% of cases. Dexmedetomidine niche: Dexmedetomidine offers moderate sedation with an unusually low apnea risk, making it useful for less painful procedures, though the setup and timing details are worth hearing in the episode. Procedure-Specific Sedation Choices Recent meal hip reduction: For prosthetic hip dislocation soon after eating, ketamine is attractive because airway reflexes are maintained, but aspiration-risk documentation still matters if deep sedation is chosen. Pediatric facial laceration repair: Ketamine is particularly well suited for children needing painful facial repair, with a track record of good pediatric tolerability and titratable dissociation for longer work. Atrial fibrillation cardioversion: Etomidate is the default non-propofol option when cardioversion needs to happen fast, especially if the patient is hemodynamically unstable. Anxious lumbar puncture: Midazolam fits anxiolysis for a terrified lumbar puncture patient, but its slow onset makes it a poor standalone choice for moderate or deep procedural sedation. We get into the escalation options in the chapter. Fentanyl limitations: Fentanyl has a role as pre-procedure analgesia, but using it alone for sedation or stacking it with other sedatives raises the hypoxemia risk.

Lit Matters 2: Dexmedetomidine versus propofol

Ketamine-based procedural sedation is effective in the ED, but the choice of co-agent changes recovery time and physiologic tradeoffs. In adults undergoing painful procedures, ketofol and ketodex both outperformed ketamine alone, while propofol delivered the fastest return to baseline. Ketamine Combinations for Procedural Sedation Head-to-head trial design: A double-blind randomized ED trial compared ketamine alone with ketofol and ketodex in 135 adults needing procedural sedation, giving the results more bedside credibility than usual PSA anecdote. Recovery time advantage: Ketofol produced the shortest recovery, about 8 to 10 minutes faster than ketodex or ketamine alone, which matters when throughput and discharge readiness are part of the sedation plan. Induction time tradeoff: Ketodex had a longer induction than ketamine alone, while looking similar to ketofol on time to procedural readiness, a nuance we get into in the episode. Rescue dosing burden: Ketamine alone needed more rescue ketamine and more midazolam for recovery agitation, reinforcing that combination regimens were smoother and more effective than monotherapy. Respiratory event signal: Ketodex showed a smaller early SpO2 drop, but apnea, laryngospasm, and bag-valve-mask use still appeared in that arm, so no regimen looked complication-proof. Hemodynamic profile: Combination sedation blunted ketamine’s usual tachycardic and hypertensive push, while dexmedetomidine carried some transient hypotension that responded to fluids without major downstream instability.

Micro-Dose Pressors

Microdose vasopressors are a bridge for peri-intubation or shock-related hypotension when a vasopressor infusion is not ready yet. In emergency airway management and crashing patients, safer terminology, standardized concentrations, and team preparation matter as much as the drug choice. Microdose Pressors in the ED Bridge before infusion: Microdose epinephrine or phenylephrine buys time when hypotension cannot wait for a vasopressor drip, especially around intubation or after adequate fluid resuscitation in a patient with a high shock index. Safer bedside terminology: Calling these medications microdose pressors instead of push-dose pressors reduces ambiguity, because code epinephrine is also technically a push dose and that wording has contributed to dangerous dosing errors. Standard epinephrine language: Referring to epinephrine in mcg rather than mg cuts conversion mistakes at the bedside; a common microdose syringe is labeled 100 mcg in 10 mL, and we get into the practical wording in the episode. Headline dosing ranges: Typical adult dosing uses epinephrine 10 to 50 mcg or phenylephrine 40 to 200 mcg every 2 to 5 minutes as needed, with the setup nuances for real resuscitations covered in the chapter. Preparation and team safety: Pharmacist involvement lowers cognitive load for the team leader and helps prevent medication delays and compounding errors during critical events, especially when local prep methods and stock differ. Simulation for competence: Microdose pressors are high-risk and low-frequency, making simulation the right tool for initial training, syringe preparation practice, and debriefing near misses. We walk through a workable training model in the podcast.

Lit Matters 3: Nitrous oxide for pediatric procedural sedation

Nitrous oxide provides rapid-on, rapid-off pediatric procedural sedation with a strong safety record in the ED. In children needing laceration repair or other brief procedures, adding intranasal fentanyl may deepen sedation but does not appear to improve overall success and does increase vomiting. Nitrous Oxide Pediatric Sedation High procedural success: Nitrous oxide achieved successful pediatric procedural sedation in 97.4% of 831 ED cases, reinforcing it as a reliable option for short, painful procedures. Light to moderate sedation: The typical sedation depth was mild on the UMSS, and moderate sedation was reachable without IV access, a practical point we get into in the episode. Serious safety signal: No significant adverse events were reported across a decade of use, supporting nitrous oxide as a low-risk ED sedation strategy when patients are appropriately selected. Vomiting as main tradeoff: Vomiting was the dominant minor adverse event, and the odds rose with higher nitrous oxide concentrations, longer exposure, deeper sedation, and added intranasal fentanyl. Fentanyl add-on effect: Combining intranasal fentanyl with nitrous oxide was associated with deeper sedation but not better overall procedural success, making the analgesia-versus-emesis tradeoff the key decision. Mask tolerance limitation: Most failed sedations were not pharmacologic failures at all but inability to tolerate the facemask, a practical barrier that matters at the bedside and comes up in the chapter.