Hippo ERcast May 2022

Andy Little on the “No Ego IO”

In cardiac arrest, delayed vascular access delays reversible-cause treatment. For the difficult IV access patient, intraosseous access is the fastest reliable rescue line, while endotracheal drug delivery is too limited for problems like suspected hyperkalemia. No Ego IO in Cardiac Arrest One attempt one minute: For arrest resuscitation, the rule is one nursing attempt and one minute for an 18-gauge AC-or-higher line; if that fails, move straight to IO rather than losing more time. Tibial plateau first choice: The proximal tibia is a practical first IO site in the crashing patient, giving immediate resuscitative access for meds and fluids while more definitive access waits. We walk through that bedside decision in the episode. Hyperkalemia access urgency: Suspected renal failure with possible hyperkalemia raises the stakes because calcium, bicarbonate, and other key therapies need vascular access now, not after repeated IV attempts. ET tube drug limits: Endotracheal drug delivery is a poor fallback here; the classic NAVEL options do not include the medications you actually need for suspected hyperkalemic arrest. IO reliability and capacity: IOs are reliable enough for most resuscitation drugs and can handle roughly 5 to 7 liters of fluid over 24 hours, making them a true bridge rather than a token line. Access Strategy for Awake DIVA Patients Different algorithm when awake: Awake difficult-access patients need a different plan, with ultrasound-guided peripheral access, an Easy IJ, or a wire-friendly basilic approach often beating a reflex IO. Easy IJ bailout: A single-lumen 18-gauge right internal jugular line can function as a fast large-bore rescue option and may be exchanged over a guidewire if you later need central access. IO pain and cooperation: Avoid IO in a fully awake, aware patient when possible because periosteal infusion hurts and the visible drill-in-leg setup often creates immediate compliance problems. Analgesia through the IO: If an awake but altered patient truly needs an IO, local anesthetic to the periosteum plus lidocaine through the line can substantially reduce infusion pain. Who is a DIVA: ESRD, IV drug use, cancer, immunologic disease, sepsis, hypotension, cardiac arrest, and children in extremis are all high-risk patterns that should lower your threshold for early backup access.

Lit Matters 1: Phenobarb vs. Benzos for ETOH Withdrawal

Alcohol withdrawal has a high short-term ED bounceback rate, and the choice of phenobarbital versus benzodiazepines may change who returns within a week. This review centers on discharged ED patients with ethanol withdrawal, where underdosed benzodiazepines may be part of the story. Alcohol Withdrawal Return Visits Short-term recidivism signal: Among discharged ED patients with alcohol withdrawal, phenobarbital-treated patients had fewer 3-day and 7-day return visits than those treated with benzodiazepines alone. Headline return rates: The gap was clinically large: 3-day returns were 25% with benzodiazepines versus 13% with phenobarbital, and 7-day returns were 38% versus 18%. Combination therapy pattern: Phenobarbital plus other agents also outperformed benzodiazepines alone, with no clear advantage over phenobarbital by itself, a nuance we get into in the episode. Dose equivalence concern: Average benzodiazepine dosing looked light compared with the phenobarbital exposure delivered, supporting the concern that underdosed lorazepam may partly explain the bounceback difference. Withdrawal-driven revisits: Most return encounters were still alcohol-related, with 92 of 120 revisits tied to withdrawal or intoxication rather than an unrelated complaint. Discharge safety caveat: Phenobarbital's long half-life raises a real outpatient safety question after ED discharge, especially if patients resume alcohol or benzodiazepines; we cover the patient-selection tension on the show.

OB Nightmares: Third Trimester Vaginal Bleeding

Third-trimester vaginal bleeding is an obstetric emergency until maternal and fetal stability are proven. Painful bleeding points toward abruption or labor, while painless bleeding raises concern for placenta previa, accreta spectrum, or vasa previa; the first fork in the ED is resuscitation and OR readiness versus ultrasound-first evaluation. Third-Trimester Bleeding Evaluation Maternal and fetal stability: The first priority is vital signs for both mother and baby; if either is unstable, involve OB immediately, prepare for the OR, and start hemorrhage resuscitation. Blood loss appearance trap: Visible bleeding does not predict severity in late-pregnancy hemorrhage, so even spotting can accompany a dangerous maternal or fetal condition. Painful versus painless pattern: Painful bleeding favors placental abruption or labor, while painless bleeding should push placenta previa, accreta, and vasa previa high on the differential. Ultrasound before pelvic exam: Placenta previa should be excluded with ultrasound before a pelvic exam in painless bleeding, because the wrong exam can worsen hemorrhage. We get into the bedside exceptions in the episode. Abruption imaging limitation: Ultrasound may show placental abruption, but a normal study does not rule it out, making clinical assessment more important than imaging reassurance. Initial ED Management Priorities OR versus ED pathway: Unstable patients need parallel resuscitation and cesarean readiness, with OB activation, large-bore IV access, labs, and massive transfusion protocol early. Stable patient tempo: If mother and baby are stable, management shifts from immediate delivery to defining the cause, checking for labor, and coordinating next steps with OB. Fetal benefit medications: When delivery may be imminent but not emergent, antenatal betamethasone, magnesium for neuroprotection, and antibiotics for selected patients become the key early therapies. Speculum and labor clues: A gentle speculum exam can help identify bulging membranes or fetal parts when labor is suspected, but exam sequencing depends on whether previa is still on the table. Tocolytic nuance: Tocolytics may help in placenta previa but can be contraindicated in abruption or impending delivery; that decision is usually safest in direct consultation with OB, and we walk through the practical distinctions in the chapter.

High Risk/Low Prevalence: Traumatic Arthrotomy with Brit Long

Traumatic arthrotomy is an easily missed open-joint injury where delayed recognition can end in septic arthritis, washout, and permanent loss of function. Knee wounds are the classic presentation, but normal x-rays do not exclude the diagnosis and imaging performance varies sharply by joint. Recognizing Traumatic Arthrotomy Open joint definition: Traumatic arthrotomy is capsule violation with contamination of the intra-articular space, a small wound with outsized consequences once bacteria reach the joint. High-stakes complications: Missed cases can progress to septic arthritis, with roughly 15% mortality and irreversible functional loss in many survivors when debridement and washout are delayed. Typical risk patterns: The knee accounts for most cases, often after gunshot wounds or other penetrating trauma in younger adults, but any periarticular laceration deserves suspicion. Suggestive wound findings: Synovial fluid, visible capsule disruption, or bubbles and fat droplets from the wound all raise concern, while bedside gestalt alone performs poorly for ruling it out. Ortho-first mindset: High-risk periarticular wounds warrant early orthopedic discussion even before the diagnosis is nailed down, and we get into the practical threshold for that call in the episode. Imaging And Saline Load Testing Plain film limitation: Free intra-articular air on x-ray is highly suggestive, but plain radiographs miss many cases; a normal film should not reassure you away from traumatic arthrotomy. CT joint dependence: CT looks strongest for the knee, where tiny volumes of intra-articular air can be detected and management changes are common, but performance falls off in smaller joints. Ultrasound caution: Ultrasound has been studied but remains too unreliable for routine diagnosis, with cadaver data showing only modest sensitivity and specificity. Saline load role: The saline load test remains the reference bedside test because it checks capsule integrity directly by looking for saline extravasation from the wound. Volume matters most: Saline load sensitivity depends heavily on injecting enough volume, and the needed amount varies by joint. We lay out the joint-specific numbers in the chapter. Common test failures: False negatives often come from missing the joint space, underfilling the capsule, or stopping early when the patient cannot tolerate the procedure; dynamic range of motion can help. Emergency Department Management Early antibiotics for all: Any suspected traumatic arthrotomy should receive antibiotics promptly, with a first-generation cephalosporin as the default starting point for smaller uncomplicated wounds. Coverage for contamination: Extensive soft-tissue injury, MRSA risk, or seawater exposure should broaden therapy, including Vibrio coverage when marine contamination is in play. Initial ED priorities: Analgesia, fracture reduction, irrigation of gross contamination, splinting, and tetanus prophylaxis are core early steps while definitive operative planning is underway. Procedural tolerance planning: If the saline load test is needed and the patient cannot tolerate it, procedural sedation may be the difference between a diagnostic exam and an aborted one.

Lit Matters 2: Ketamine Non-inferior to Morphine for Sickle Cell Pain

Vaso-occlusive crisis in sickle cell disease often means severe pain in patients who may already be opioid tolerant. Pain-dose ketamine appears non-inferior to morphine for 2-hour analgesia in acute sickle cell pain, while reducing total rescue opioid exposure. Ketamine for Sickle Cell VOC Pain Noninferior 2-hour analgesia: A randomized double-blind trial found pain-dose ketamine matched morphine for pain relief at 2 hours in vaso-occlusive crisis, with end pain scores that were essentially identical. Lower cumulative opioid use: Ketamine reduced cumulative morphine milligram exposure despite similar pain control, a practical signal for opioid-tolerant sickle cell patients. We get into where that matters most in the episode. Adverse effect tradeoff: Dizziness, nausea, and vomiting were more common with ketamine, so the opioid-sparing benefit comes with a tolerability tradeoff rather than cleaner symptom control. Post nonopioid failure population: The trial enrolled sickle cell patients whose crisis pain persisted after IV or IM non-narcotic analgesics, making the comparison relevant to the ED escalation step rather than first touch. Operational reality in community EDs: Ketamine's main limitation may be logistics, since a 30-minute infusion and monitoring workflow can be harder to execute than morphine in smaller departments.

EEM Rewind: Optimizing Team Performance in Cardiac Arrest

High-quality CPR is the strongest modifiable factor during cardiac arrest, and team performance often determines whether guideline-based care actually happens. Better codes come from deliberate CPR coaching, shorter peri-shock pauses, and shared leadership that reduces cognitive overload in the resuscitation room. Cardiac Arrest Team Performance CPR-first team framing: Stating the goal out loud—"we are going to deliver excellent CPR"—focuses the room on compression quality first, a simple leadership move that can immediately sharpen performance. Live CPR feedback: Real-time rate and depth feedback works best when the compressor can see it directly, whether from the defibrillator screen, an accelerometer, or a dedicated app. Dedicated CPR coach: A trained CPR coach improves compression rate, depth, and pause awareness while offloading the team leader; the practical wording for that role is worth hearing in the episode. Pre-charged defibrillation: Charging the defibrillator before the rhythm check is a high-yield way to cut peri-shock pauses, one of the most correctable delays in shockable arrest care. Dual-lead code leadership: A nurse co-lead can handle timekeeping, pulse-check prompts, and epinephrine tracking while the physician remains most responsible, reducing cognitive load during a chaotic code. Rescuing the stalled resuscitation: When a code goes sideways, positivity and humble team language matter; standing beside the leader and using "we" suggestions can reopen problem-solving without escalating tension.

Trauma-Informed Care: The GU Exam

Trauma-informed genitourinary exams start from a simple clinical assumption: many patients have prior trauma, whether disclosed or not. In pelvic, rectal, and other sensitive exams, patient control, explicit consent, careful draping, and neutral language can reduce distress while preserving diagnostic quality. Trauma-Informed GU Exam Principles Universal trauma-informed mindset: The safest default is to assume prior trauma may be present, because shame and stigma often prevent disclosure during pelvic, rectal, and other sensitive exams. Intentional control language: Loss of control is a core trauma theme, so explicitly hand control back: patients should know they can pause, reposition, or stop the exam at any point. Affirmative consent check: Clear consent should be obtained before proceeding with the exam, and consent is revocable throughout rather than a one-time permission at the doorway. Neutral clinical wording: Language shapes the encounter as much as technique; terms like exam table and drape help desexualize the interaction. We lay out practical talk tracks in the episode. Minimal exposure technique: Liberal draping with exposure of only the necessary body part is a basic comfort intervention that lowers vulnerability during sensitive examinations. Post-exam redressing pause: After the exam, step out and let the patient get dressed before discussing the plan, a small workflow change that can meaningfully restore dignity. Practical Exam Modifications Chaperone as standard practice: Sensitive body-part exams should be performed with a chaperone present, supporting patient safety, comfort, and clear professional boundaries. Narrate before each step: Describe what you are about to do before you do it, which reduces surprise and gives the patient another opportunity to consent, pause, or decline. Side-position bimanual approach: For bimanual exams, stepping to the side rather than standing between the patient's legs can make the interaction feel less sexualized and less triggering. Self-swab sampling option: Self-collected swabs for STI testing and wet mount evaluation are accurate and should be offered when appropriate, especially for patients seeking more control. Self-insertion and self-exposure: Speculum self-insertion and patient-assisted exposure for rectal or perianal exams can improve comfort and often give a better view. We get into where this fits in the chapter. Immediate stop for distress: If a patient becomes visibly uncomfortable, stop immediately, acknowledge the distress, and offer a break or termination of the exam rather than pushing through.

Lit Matters 3: Combining PE Decision Rules is Safe

Pulmonary embolism workup is safer and leaner when pretest probability and D-dimer thresholds are matched correctly. In suspected PE, combining YEARS with age-adjusted D-dimer can reduce CTPA use without increasing missed venous thromboembolism in low- to moderate-risk emergency department patients. Combining PE Decision Rules Low-risk YEARS pathway: Zero YEARS criteria supports a higher D-dimer threshold of 1000 ng/mL FEU in low-pretest-probability suspected PE, a practical way to avoid unnecessary chest imaging. Age-adjusted D-dimer use: For low- to moderate-risk patients, age-adjusted D-dimer remains the rule when one or more YEARS criteria are present, preserving sensitivity while limiting overtesting. Safety signal at follow-up: Three-month VTE after an initially negative workup was 0.15% with the combined strategy versus 0.80% in control, supporting non-inferior safety. Imaging reduction effect: CT imaging fell from 40% to 30.4% with the intervention strategy, a meaningful drop in radiation, contrast exposure, and downstream false positives. Why overdiagnosis matters: CTPA has driven a major rise in PE diagnoses, yet one study found a 26% false-positive rate, making diagnostic restraint a real patient-safety issue. We get into the practical implications in the episode.

Oncologic Emergencies: Local Tumor Effects

Local tumor effects from cancer can threaten airway, spinal cord, venous return, bone integrity, and cardiac filling long before a diagnosis is confirmed. In emergency medicine, the key is recognizing the pattern early and choosing the imaging study that actually answers the question. Local Tumor Effect Emergencies Bone metastasis clues: Metastatic bone disease usually hits the axial skeleton and proximal limbs, with localized pain and mixed osteolytic or osteoblastic change as the bedside clue in patients with breast, lung, or prostate cancer. Imaging beyond plain films: Plain x-ray misses roughly half of metastatic bone lesions, so CT with IV contrast is the ED workhorse when suspicion for pathologic fracture stays high after a negative film. We get into the imaging logic in the episode. Superior vena cava syndrome: SVC syndrome is an upper-body venous obstruction problem, most often from lung tumors in about 70% of cases and lymphoma in about 20%, producing facial swelling, dyspnea, and arm edema. Airway obstruction pitfall: Malignant airway obstruction can present with stridor and tachypnea from an oropharyngeal, neck, or mediastinal mass, and direct laryngoscopy is a classic mistake because it can convert partial obstruction into complete obstruction. Malignant pericardial effusion: Up to 35% of cancer patients have pericardial involvement, but most malignant effusions are small and silent; electrical alternans or an enlarged cardiac silhouette can be the clue before echo confirms it. Spinal cord compression warning: Malignant spinal cord compression is a thoracic-spine disease until proven otherwise, with back pain, radicular symptoms, or bowel and bladder dysfunction demanding MRI with IV contrast of the entire spine.