Hippo ERcast July 2022

Cybersecurity

Cyberattacks in healthcare are operational disasters, not just IT problems. Ransomware can lock down the EMR, orders, and communications for 3 to 4 weeks, while distributed denial of service attacks can halt networked systems across the hospital and delay care. Cyberattacks in Emergency Care Hospital-wide attack surface: Anything connected to a network is vulnerable during a cyberattack, including the EMR, radiology, lab analyzers, elevators, and HVAC systems. Ransomware clinical fallout: Ransomware is financially motivated and increasingly aggressive; once systems are encrypted, the average recovery time is 3 to 4 weeks, with immediate consequences for patient care. DDoS disruption pattern: Distributed denial of service attacks are built for disruption, flooding systems with traffic from compromised machines until core hospital functions slow or stop. Patient harm stakes: Cyberattacks in healthcare can cause delays to care and even patient deaths, and ransomware events may be less visible than expected because reporting requirements are limited. Threat actor landscape: The major players range from nation-state groups and organized criminal networks to hacktivists and inexperienced script kiddies, each with different motives and risk patterns. The distinctions are worth hearing in the episode. ED Preparedness and Prevention Downtime as disaster drill: Treat scheduled downtime like a mass-casualty exercise: if the network fails, clinicians need a practiced plan for paper charting, orders, and communication. Analog backup workflows: When the EMR and ordering systems go dark, departments need paper processes, offline phone numbers, call schedules, and runners to move orders and results. Staffing after an attack: Post-attack care is slower and more labor-intensive, so surge staffing matters even after systems come back online, a practical point we get into in the chapter. Password hygiene basics: Strong unique passwords matter more than any single style, whether built with a password manager or memorable long phrases; the key rule is never reuse them. Phishing and identity protection: One person can open the door to an attack, so never send Social Security numbers or other sensitive personal data in unencrypted email and avoid suspicious links or attachments. Two-factor and local engagement: Two-factor authentication adds an important barrier, and frontline clinicians can reduce institutional risk by taking mandatory cybersecurity training seriously and joining prevention efforts.

Oncologic Emergencies: Metabolic + Treatment Effects

Cancer-related metabolic emergencies often present with vague symptoms but carry immediate renal, neurologic, and hemodynamic risk. Hypercalcemia in malignancy is usually a euvolemic process rather than simple dehydration, and treatment complications like febrile neutropenia and tumor lysis syndrome demand early recognition in the ED. Metabolic complications of malignancy Cancer hypercalcemia physiology: Malignancy-associated hypercalcemia is usually driven by PTHrP, osteoclast activation, or vitamin D analog production, and these patients are often euvolemic rather than volume depleted. Vague symptom pattern: Lethargy, confusion, anorexia, headache, and fatigue are recurring clues across oncologic metabolic emergencies, with severity often tracking the speed of the underlying derangement. Hydration as first move: Isotonic IV fluids are the ED mainstay for hypercalcemia, hyperviscosity syndrome, and tumor lysis syndrome because dilution and renal perfusion buy time before disease-specific therapy. Hyperviscosity red flags: Hyperviscosity should be suspected with altered mental status, headache, thrombosis, or abdominal pain in leukemia or polycythemia, especially when rouleaux or extreme counts appear. Serum viscosity clue: A serum viscosity above 4 strongly supports hyperviscosity syndrome, although routine lab testing may be technically difficult. We get into the practical bedside clues in the episode. Cancer-associated thrombosis: Venous thromboembolism affects roughly 15% of patients with cancer and remains a leading cause of death; low-molecular-weight heparin is the preferred initial anticoagulant. Complications from cancer treatment Febrile neutropenia definition: Febrile neutropenia pairs fever with an ANC below 1000 cells/mm3, with severe neutropenia below 500, and localizing symptoms may be absent because inflammation is blunted. Empiric sepsis approach: Management starts with pan-cultures, including indwelling lines, a careful source search, and prompt broad-spectrum antibiotics because delay is dangerous even when the exam looks quiet. Tumor lysis signature: Tumor lysis syndrome classically causes hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia after rapid cytolysis, with renal failure, seizures, or dysrhythmias as the major threats. TLS emergency treatment: Aggressive IV hydration anchors ED care for tumor lysis syndrome, alongside standard hyperkalemia treatment and dialysis when needed. We walk through the escalation points in the chapter. Biologic therapy reactions: Monoclonal antibodies and immune checkpoint therapies can trigger cytokine release syndrome, a presentation that may mimic anaphylaxis with fever, hypotension, tachycardia, and myalgias. Supportive care priorities: Initial treatment of biologic-therapy complications is severity-based supportive care with IV fluids, circulatory support, and antibiotics when infection remains on the table.

Lit Matters #1: US vs. Palpation of Pulse During Cardiac Arrest

Manual pulse checks during cardiac arrest are unreliable, and femoral artery Doppler ultrasound appears substantially more accurate for detecting return of spontaneous circulation. A femoral peak systolic velocity signal may also help distinguish any flow from a more meaningfully perfusing blood pressure during pulse checks. Femoral Doppler for ROSC Detection Manual palpation limits: Finger pulse checks miss too much and vary widely in accuracy, making manual palpation a weak standalone test for ROSC during cardiac arrest. Doppler accuracy signal: Femoral artery Doppler outperformed palpation for detecting any pulse, with about 95% accuracy versus roughly 54% for manual exam. Peak systolic velocity threshold: A femoral Doppler PSV above 20 cm/s tracked with a systolic pressure of at least 60 mmHg, giving clinicians a more objective pulse-check target. Sensitivity specificity tradeoff: Ultrasound is excellent at finding any blood flow, but that sensitivity can overcall true perfusion when the pressure is still too low to matter clinically. Bedside workflow reality: Measuring femoral PSV in an active code is feasible but not frictionless, especially when the same machine may also be needed for cardiac views. We get into the practical tradeoffs in the episode.

STI Updates

Gonorrhea and chlamydia management changed with the 2020 CDC STI guidelines: gonorrhea now centers on higher-dose ceftriaxone, while doxycycline has overtaken azithromycin for many chlamydial infections. Pelvic inflammatory disease is broader than GC/CT alone, and a normal self-swab does not rule it out. Gonorrhea and Chlamydia Updates Ceftriaxone first-line shift: Uncomplicated urogenital, rectal, and pharyngeal gonorrhea is now treated with ceftriaxone 500 mg IM, reflecting pharmacokinetic targets and rising resistance rather than a simple preference change. Dual therapy abandoned: Azithromycin is no longer routine second-agent therapy for gonorrhea; the move away from dual treatment reflects stewardship concerns and poorer performance at some extragenital sites. Doxycycline preferred for chlamydia: Doxycycline 100 mg twice daily for 7 days now leads for suspected chlamydial coinfection, with rectal-chlamydia data showing 100% microbiologic cure versus 74% with azithromycin in one trial. Fallback regimens matter: Oral cefixime 800 mg is the main backup when IM ceftriaxone is not feasible, but pharyngeal gonorrhea remains the weak spot and severe allergy cases need a different plan we get into in the episode. No more ED one-and-done: A practical change is that STI care no longer ends with a single ED dose; every treated patient needs a prescription because companion therapy now extends beyond the visit. PID Diagnosis and Testing Limits PID is polymicrobial: Pelvic inflammatory disease is not just gonorrhea and chlamydia; anaerobes, bacterial vaginosis flora, and Mycoplasma genitalium all contribute, which is why metronidazole now matters. Pelvic exam still essential: If PID is on the table, a pelvic exam is required because CDC minimum criteria hinge on cervical motion, uterine, or adnexal tenderness rather than lab confirmation alone. Self-swab has boundaries: Vaginal self-swabs perform well for cervicitis testing, with one ED study showing about 95% sensitivity, but they cannot assess for TOA, cervical friability, or pelvic tenderness. Urine testing sex difference: Urine NAAT performs much better in men than women for gonorrhea, with male sensitivity around 90% to 100% versus roughly 75% in women, making specimen choice clinically important. Upper versus lower infection: Lower-tract STI treatment and PID are no longer interchangeable: suspected upper-tract disease adds metronidazole and extends doxycycline duration. We walk through that distinction in the chapter. Partner Therapy and Public Health Expedited partner therapy: Expedited partner therapy is now allowed or potentially allowed across all US states and territories, letting you treat exposed partners even when they are not in front of you. Partner prescription practicalities: For EPT, the prescription can simply say expedited partner therapy without the partner's name, a small workflow detail that removes a common barrier to actually breaking the reinfection cycle. Screening beyond symptoms: Asymptomatic infection is common enough that ED prevalence in general patients has approached 10%, which is why symptom-based testing misses a meaningful number of cases we discuss in the episode. Pregnancy exception remains: Azithromycin still keeps an important role in pregnancy for chlamydia, even as doxycycline becomes the default in many nonpregnant patients.

Lit Matters 2: Apixaban > Rivaroxaban for VTEs

Untreated deep vein thrombosis and pulmonary embolism carry a substantial recurrence risk, and direct oral anticoagulants are now standard therapy for many patients with acute VTE. In a large real-world comparison, apixaban was associated with fewer recurrent VTEs and fewer major bleeding admissions than rivaroxaban. Apixaban vs Rivaroxaban for VTE Large real-world comparison: A propensity-matched insurance database study compared roughly 18,000 patients per arm, giving this apixaban-versus-rivaroxaban question more power than earlier small observational studies. Recurrent VTE signal: Apixaban showed lower recurrent venous thromboembolism rates than rivaroxaban, with event rates of 8.9 versus 11.4 per 100 person-years. Bleeding outcome advantage: Major bleeding severe enough for admission, specifically GI bleed or intracranial hemorrhage, was also lower with apixaban at 7.2 versus 11.0 events per 100 person-years. Prior trial context: Head-to-head randomized data are still pending, but prior pivotal trials already suggested apixaban has a bleeding edge over warfarin while rivaroxaban was more bleeding-neutral by comparison. Practice-changing takeaway: For a new VTE when both DOACs are reasonable options, apixaban currently looks like the stronger default on effectiveness and safety. We get into how much this should change prescribing in the episode. Cost and access reality: Drug cost still matters: DOAC therapy may run about $550 per month versus roughly $11 for warfarin, so affordability can outweigh marginal outcome differences in real practice.

High Risk/Low Prevalence: Hemophilia

Hemophilia is a clotting-factor deficiency in which history drives emergency care more than the initial exam, labs, or imaging. Intracranial, retroperitoneal, and joint bleeding can be occult, and early factor replacement should not wait for test results. ED Approach to Hemophilia Bleeding History over initial testing: Acute management hinges on the bleeding history and mechanism, because exam findings can be normal early and labs should never delay indicated factor replacement. Early factor replacement: The mainstay is immediate clotting factor replacement based on suspected bleeding, with a target of 100% factor activity for major bleeds and 50% for minor bleeds. Major bleed locations: Treat bleeding in the CNS, retroperitoneum, throat, neck, eye, chest, or GI tract as major, and count rapidly expanding hemarthrosis with neurovascular compromise the same way. Head injury exception: A concerning head mechanism warrants factor concentrate first and imaging second, because spontaneous or traumatic intracranial hemorrhage may present with a normal early exam. We get into that sequencing in the episode. Low threshold for imaging: PECARN, the Canadian CT Head Rule, and Ottawa extremity rules do not apply in hemophilia; imaging decisions should follow the story and exam, not standard trauma tools. Diagnosis, Dosing, and Inhibitors Hemophilia types and inheritance: Hemophilia A is factor VIII deficiency and Hemophilia B is factor IX deficiency; females can be symptomatic, and about one-third of cases arise from spontaneous mutation. Classic lab pattern limits: Suspected hemophilia may show an isolated prolonged aPTT with normal PT and platelets, but a normal aPTT does not exclude the disease. Mixing study clue: Correction after mixing points toward factor deficiency, while failure to correct suggests an inhibitor such as acquired hemophilia or treatment-related anti-factor antibodies. Headline replacement doses: To reach full correction, factor VIII concentrate is dosed at 50 U/kg and factor IX at 100 U/kg; if the baseline level is unknown, assume it is zero. Inhibitor rescue therapy: Breakthrough or recurrent bleeding despite factor raises concern for inhibitors, and recombinant factor VIIa becomes the safest first-line option for life- or limb-threatening hemorrhage. Medication pitfalls: Avoid drugs that impair platelet function or coagulation, especially aspirin, NSAIDs, anticoagulants, and antiplatelet agents; the practical exceptions come up in the chapter.

Lit Matters 3: Choosing Opiates Wisely

Initial opioid choice may shift risk in different directions: hydrocodone tracks more with subsequent chronic use, while oxycodone tracks more with later overdose. For acute pain prescribing, the bigger durable signal is still dose and quantity, especially at higher total morphine milligram equivalents. Hydrocodone Versus Oxycodone Risks Divergent risk pattern: Among opioid-naive adults, hydrocodone was more associated with first-year chronic use after adjustment, while oxycodone carried a higher subsequent overdose risk. Overdose signal with oxycodone: The overdose difference favored hydrocodone, with oxycodone linked to about a 65% higher adjusted hazard of fatal or nonfatal overdose after the index prescription. Chronic use definition: The study used a strict utilization marker for chronic use: more than 6 opioid prescriptions in the first year with minimal uncovered days between fills. Absolute risk perspective: Most patients did not develop chronic use or overdose after a first short course, and that low baseline risk matters when discussing opioid harms at the bedside. Dose and quantity matter most: Total prescribed MME remains the more actionable lever; index prescriptions above 300 MME have been linked to roughly 4-fold higher odds of chronic use. We get into the prescribing implications in the episode. Practical Opioid Prescribing Takeaways Small initial prescriptions: Prior evidence consistently supports shorter courses and fewer tablets for acute pain, rather than assuming one specific opioid is categorically safer. Likeability score skepticism: Choosing an opioid because patients like it less is not clearly patient-centered, and preference alone is a weak surrogate for addiction or overdose risk. Chronic use is imperfect: Long-term opioid use is not synonymous with opioid use disorder; some patients on chronic opioids never develop misuse, addiction, or overt abuse. Shared decision framing: When opioids are appropriate, frame risk around dose, quantity, and follow-up rather than implying that any single short prescription will start an inevitable path to OUD.

EEM Rewind: Syncope ADP

Syncope is a common ED complaint with wide practice variation, low diagnostic yield from routine testing, and high disposition uncertainty. The Canadian Syncope Risk Score helps risk-stratify 30-day serious outcomes after a normal initial evaluation, while ECG red flags like abnormal axis, conduction delay, and prolonged QT can identify patients who should not be treated as benign. Canadian Syncope Risk Pathway Risk score scope: The Canadian Syncope Risk Score applies to patients age 16 and older presenting within 24 hours of syncope after a thorough history, exam, and normal initial evaluation that has already ruled out obvious dangerous mimics. Thirty-day adverse events: The score predicts both arrhythmic outcomes such as pacemaker placement or death and non-arrhythmic events such as myocardial infarction or pulmonary embolism, which keeps the tool clinically grounded. Low-risk discharge signal: Low-risk patients were discharged home in this pathway, and only 0.2% later needed a significant intervention with no unexplained deaths, a reassuring benchmark for community ED practice. Medium-risk home monitoring: Medium-risk patients were discharged with real-time outpatient monitoring rather than routine admission, and 11% ultimately had a significant diagnosis requiring intervention. We get into how that discharge pathway works in the episode. High-risk admission default: High-risk patients were admitted rather than observed in an accelerated discharge pathway, underscoring that the score is meant to standardize disposition rather than replace judgment. ECG and Initial Syncope Evaluation ECG danger findings: Post-syncope ECG review should actively look for abnormal axis, conduction delay, and prolonged QT because these are the patterns most likely to point toward a serious cardiac cause. Named ECG cutoffs: Useful red flags include axis at or below -30 or above 100 degrees, QRS over 130 ms, and QTc over 480 ms, specific thresholds worth keeping in mind at the bedside. Near-syncope equivalence: For this pathway, near syncope is treated like true syncope, a practical move that avoids under-triaging patients whose physiology may be identical despite less dramatic wording. Testing by suspicion: Additional testing should be driven by clinical suspicion rather than reflex panels, and troponin is not mandatory unless the presentation gives you a reason to look for myocardial injury. ED monitoring nuance: Monitor patients while initial results are pending, but do not prolong the ED stay just to accumulate telemetry time; for more complex cases, a short observation window may still be reasonable. We cover that bedside nuance on the show. Real-Time Outpatient Monitoring Patch monitor model: The pathway uses a simple adhesive chest patch that provides continuous 24/7 telemetry with structured alarms and interventions, extending arrhythmia detection beyond the ED wall clock. Delayed event capture: The average clinically important event occurred around day 8 after placement, which explains why a brief ED monitor period can miss the very diagnoses that matter most. Fourteen-day duration: Monitors were typically applied for 14 days, matching the delayed timing of actionable events without defaulting medium-risk patients to hospital admission. Bradyarrhythmia predominance: In monitored medium-risk patients, bradyarrhythmias were found more often than tachyarrhythmias, and the most common downstream intervention was pacemaker placement. Operational feasibility: At roughly $300 per device placement, this approach pairs positive provider and patient feedback with a concrete operational cost that community hospitals can actually evaluate.