Hippo ERcast November 2022

Favorite Procedures

Emergency department procedures are often more painful than clinicians expect, especially in awake patients. Nasogastric tube placement, abscess drainage, fracture reduction, and urethral catheterization rank high for procedural pain, while routine immobilization measures like cervical collars and backboards can also cause substantial discomfort in older adults. Procedural Pain in the ED Patient pain ranking: Nasogastric intubation, abscess drainage, fracture reduction, and urethral catheterization were the most painful common ED procedures by patient report, a useful reset when planning analgesia before touching the patient. Clinician pain underestimation: Practitioner and patient pain scores correlated only poorly to fairly, underscoring that bedside intuition is an unreliable gauge of procedural suffering and worth hearing about in the episode. Local anesthesia gap: Local anesthetics were used in just 12.8% of procedures, yet more patients said they would want analgesia for a similar future procedure, pointing to a clear treatment gap. Pain versus distress distinction: Not every difficult procedure is driven by nociception alone; separating pain from distress helps decide when anxiolysis, not just local anesthesia, may be the missing intervention. Low-cost comfort measures: Simple options like LET and vapocoolant spray can meaningfully reduce procedural discomfort without slowing flow, and we get into where they fit best in the chapter. Hidden Pain From Routine Care Elderly patient pain triggers: In older ED patients, urinary catheterization, cervical collars, and immobilization mattresses frequently caused moderate or severe pain despite being framed as routine supportive care. Collars and backboards: Cervical collars and backboards are easy to overlook as pain sources, but they can be more distressing than many diagnostic studies and should prompt earlier reassessment and relief. Imaging contrast point: X-rays, CT, and bedside ultrasound were associated with a median pain score of zero in one cohort, sharpening the contrast with the discomfort from restraint and immobilization. Ask before proceeding: A simple offer of analgesia before routine procedures can uncover unmet needs, especially in older adults who may otherwise endure significant discomfort without volunteering it.

Essentials Masterclass: Antibiotics – Why Shorter is Better, part 1

Antibiotic duration is often longer than the evidence supports, and excess exposure mainly selects resistance in colonizing flora rather than the target pathogen. Across common outpatient infections, the best strategy is the narrowest effective agent for the shortest effective course. Shorter Narrower Antibiotic Strategy Resistance ecology principle: Antibiotic resistance is driven largely by selection pressure on colonizing bacteria like gut flora, so unnecessarily broad or prolonged courses can do harm even when the infection improves. Arbitrary duration problem: Seven-, ten-, and fourteen-day prescriptions are often habit rather than science; across many common infections, shorter courses are usually just as effective. Targeted spectrum choice: The core stewardship move is matching therapy to the likely pathogen set and avoiding collateral damage, with nitrofurantoin a useful example of minimal gut-flora disruption. Symptom-guided stopping point: Once symptoms are clearly improving, ongoing benefit from continuing the same antibiotic often falls off quickly. We get into the practical stopping nuance in the episode. Respiratory Infections and Sinusitis Outpatient CAP first line: IDSA outpatient pneumonia guidance favors narrow oral therapy with amoxicillin 1 g three times daily or doxycycline 100 mg twice daily, each for at least 5 days. Borderline pneumonia caution: Subtle chest radiograph changes do not always mandate antibiotics; in low-certainty cases, watchful waiting with solid return precautions can be appropriate, especially outside higher-risk groups. Acute bronchitis distinction: Uncomplicated acute bronchitis does not improve with antibiotics, and patients should be told the cough can last about 3 weeks without implying treatment failure. Chronic bronchitis exacerbation: Antibiotics can help acute exacerbations of chronic bronchitis or COPD marked by increased dyspnea, sputum volume, and sputum purulence, with amoxicillin-clavulanate a practical choice. Bacterial sinusitis timing: Worsening sinus symptoms beyond day 10 points toward bacterial sinusitis, and short-course therapy performs well. We walk through the agent choice nuance in the chapter. Urinary and Skin Infection Pearls Pyelonephritis drug logic: Fluoroquinolones are strong oral options for younger women with pyelonephritis because they achieve high renal tissue and urinary levels, allowing short effective courses. Nitrofurantoin sweet spot: Nitrofurantoin 100 mg twice daily for 5 days is a high-value option for uncomplicated cystitis in women when renal function is adequate, with limited impact on gut flora. Male UTI caveat: Afebrile UTI in men can often be treated with 7 days of ciprofloxacin or TMP-SMX, but missing prostatitis will lead you into the wrong duration strategy. Cellulitis coverage myth: For uncomplicated cellulitis, cephalexin alone performs as well as cephalexin plus TMP-SMX, arguing against reflex MRSA double coverage in routine cases. Drained abscess benefit: After incision and drainage of an uncomplicated abscess, TMP-SMX for 7 days improves cure compared with placebo, though shorter courses may still be enough in selected patients.

Lit Matters 1: Can the ECG help us reliably pick up RV dysfunction in PE patients?

Pulmonary embolism can produce ECG signs of right-heart strain, but most findings are better at flagging RV dysfunction than predicting who will crash. In acute PE, supraventricular tachycardia stands out as the ECG finding most associated with early clinical deterioration, while a normal ECG lowers that risk. ECG Risk Stratification in PE SVT as danger signal: Supraventricular tachycardia was the standout red flag for 5-day clinical deterioration in acute PE, with an odds ratio near 2.9 and clear bedside implications when the patient otherwise looks borderline. Normal ECG reassurance: Absence of ECG abnormalities was associated with lower short-term deterioration risk, making a completely unremarkable tracing modestly reassuring rather than simply nondiagnostic. RV strain patterns: Precordial T-wave inversion, incomplete RBBB, S1Q3T3, sinus tachycardia, and ST elevation in aVR all tracked with abnormal right ventricular findings on echo. Echo still matters: Goal-directed echocardiography remained the stronger marker of impending trouble, with abnormal RV findings carrying an odds ratio above 4 for early deterioration. We get into the bedside role of ECG versus echo in the episode. Pattern burden signal: About 65% of patients had at least one abnormal ECG finding, and the total number of strain patterns helped identify patients less likely to be low risk by standard PE tools. Bedside takeaway: Use an abnormal ECG in confirmed PE as a risk-stratification prompt, especially when you see SVT or clustered RV-strain findings, while remembering chronic baseline abnormalities can muddy the picture.

Asthma Isn't What it Used to Be

Asthma care now leans harder on inhaled corticosteroids, antimuscarinics, and trigger control rather than rescue inhalers alone. In the ED, the crashing asthmatic is still an airflow and work-of-breathing problem where bronchodilators, steroids, magnesium, and selective noninvasive support all matter. Updated Asthma Control Principles Inhaled steroid early role: Inhaled corticosteroids do more than reduce inflammation over hours; they also have an immediate synergistic effect with albuterol by upregulating beta-2 receptors. Frequent exacerbation signal: Two to three or more asthma flares a year leading to ED visits is a practical marker that controller therapy should be escalated, especially with inhaled corticosteroids. LAMA add-on option: Long-acting antimuscarinic antagonists are a useful alternative when LABAs are not tolerated and can be used alone or paired with inhaled corticosteroids. Allergic trigger mitigation: Environmental control still matters in allergic asthma: carpet removal, mattress covers, pet exclusion from the bedroom, and mold remediation can reduce ongoing airway irritation. We get into the counseling details in the episode. Antihistamine trial signal: A two-week trial of a non-sedating antihistamine can help selected patients with allergic asthma by reducing bronchial inflammation without adding sedation burden. Emergency Management of Acute Asthma Bronchodilator delivery options: Albuterol remains the mainstay, and MDI plus spacer can substitute for nebulization; a rapid bronchodilator effect starts within minutes and lasts several hours. Ipratropium early pairing: Ipratropium bromide improves FEV1 by reducing bronchoconstriction and secretions, making it most useful early as part of initial combination bronchodilator therapy. Steroid route principle: Prednisone, methylprednisolone, and dexamethasone all fit acute care because oral and parenteral steroids have similar bioavailability; route should follow severity and practicality. Magnesium rescue bronchodilator: IV magnesium sulfate is a key adjunct for more severe exacerbations because it relaxes bronchial smooth muscle; the escalation approach is worth hearing in the chapter. Epinephrine severe asthma role: IM epinephrine 0.3-0.5 mg is a frontline move in life-threatening asthma when airflow is collapsing, with IV options reserved for selected monitored patients. BiPAP and ketamine bridge: Noninvasive ventilation can unload work of breathing and drive aerosol deeper, while subdissociative ketamine may improve tolerance and adds bronchodilatory benefit. Crashing Asthmatic and Intubation Intubation as last resort: Endotracheal intubation in status asthmaticus is a salvage step because positive-pressure ventilation can worsen dynamic hyperinflation and hemodynamic collapse. Delayed sequence approach: A delayed sequence strategy using ketamine while maintaining noninvasive support can preserve oxygenation and buy time before committing to the tube. Large tube low rate: Post-intubation ventilation favors a large endotracheal tube, low respiratory rate, and prolonged expiratory time to limit air trapping. We walk through the setup on the show. Beta agonist receptor washout: Heavy beta-agonist exposure can functionally blunt response, which is one reason steroids remain essential early: they help restore receptor responsiveness.

Lit Matters 2: Conjunctivitis: Can we figure out who is bacterial and who is viral?

Acute infectious conjunctivitis is common, and history matters more than discharge color alone. In adults, red eye is usually viral; in children, bacterial causes are more common. The dangerous misses are the painful, photophobic, vision-changing eyes that may be something other than routine conjunctivitis. Viral Versus Bacterial Conjunctivitis Age-based prevalence shift: Adults with acute infectious conjunctivitis are far more likely to have viral disease, while children skew bacterial, a useful pretest frame before you overcall mucopurulent discharge. Viral leaning findings: Pharyngitis is the strongest bedside clue toward viral conjunctivitis, with preauricular lymphadenopathy and recent contact with someone with red eye adding diagnostic weight. Bacterial leaning findings: Eyelids stuck together on awakening and mucopurulent discharge increase the likelihood of bacterial conjunctivitis, and otitis media is a particularly helpful clue in children. Discharge is imperfect: Watery does not rule out bacterial and purulent does not rule out viral; roughly 1 in 5 viral cases had purulence, a nuance we get into in the episode. Watchful waiting option: Most uncomplicated bacterial conjunctivitis improves within 1 to 2 days even without antibiotics, making delayed prescribing or outpatient follow-up a reasonable strategy. Serious red eye warnings: Decreased visual acuity, significant pain, or severe photophobia should push you away from routine conjunctivitis and toward a more dangerous ocular diagnosis.

Essentials Masterclass: Antibiotics – Shorter is Better, Part 2

Short-course antibiotics are usually enough for common outpatient infections, and longer default durations often add collateral damage without better outcomes. In bronchitis, UTI, sinusitis, skin infections, and community-acquired pneumonia, the winning strategy is narrow-spectrum therapy for the shortest effective course. Why shorter antibiotic courses work Resistance ecology principle: Antibiotic resistance is driven largely by selection in colonizing flora like gut E. coli, not just the target pathogen, so excess duration creates harm even when the infection itself is improving. Narrowest spectrum strategy: The core stewardship move is matching the narrowest active agent to the syndrome and stopping once symptoms are clearly turning the corner rather than reflexively finishing 7 or 10 days. TMP-SMX collateral effect: Two weeks of trimethoprim-sulfamethoxazole can leave patients carrying nearly all-resistant fecal E. coli, a vivid reminder that duration decisions matter beyond the presenting infection. We get into the stewardship implications in the episode. Nitrofurantoin exception: Nitrofurantoin is a standout bladder agent because it has minimal impact on gut flora, making it an unusually clean choice when the infection is limited to uncomplicated cystitis. Pneumonia and bronchitis decisions Borderline CAP restraint: For subtle chest x-ray changes and equivocal outpatient community-acquired pneumonia, it is reasonable to hold antibiotics with solid return precautions, especially if the patient is otherwise low risk. Guideline first-line CAP: IDSA outpatient CAP guidance favors amoxicillin 1 g three times daily or doxycycline 100 mg twice daily, each for at least 5 days, with broader coverage reserved for higher-risk comorbid patients. Acute bronchitis reality: Antibiotics do not help routine acute bronchitis, even when bacteria are present, and setting expectations matters because the cough commonly lasts about 3 weeks while gradually improving. COPD flare subset: Acute exacerbation of chronic bronchitis is the exception: increased dyspnea, sputum volume, and sputum purulence identify the group most likely to benefit, and 5 days performs like 10 days in trials. Sinusitis and urinary infections Bacterial sinusitis timing: Think acute bacterial sinusitis when congestion and sinus symptoms worsen after day 10 rather than steadily improve, a timing clue that helps avoid unnecessary early antibiotics. Short sinusitis course: Short-course therapy holds up in sinusitis, and amoxicillin-clavulanate for 5 days is a practical choice when treatment is warranted. We cover the syndrome clues that separate watchful waiting from treatment in the podcast. Pyelonephritis drug choice: In younger women with pyelonephritis, fluoroquinolones remain strong options because they achieve systemic kidney levels and concentrate heavily in urine, sometimes outperforming a discouraging lab susceptibility read. Nitrofurantoin for cystitis: For uncomplicated cystitis in women, nitrofurantoin 100 mg twice daily for 5 days is a high-yield option when renal function is adequate, with far less ecological disruption than broader agents. Male UTI caution: Afebrile UTI in men can often be treated with 7 days of ciprofloxacin or trimethoprim-sulfamethoxazole, but missing prostatitis will make a simple duration plan fail.

Does that PTX Need a Chest Tube?

Pneumothorax and hemothorax drainage has shifted toward smaller tubes and pigtail catheters without sacrificing effectiveness. In emergency medicine, the key decisions are who needs pleural decompression now, where to enter the chest, and when speed still favors a standard tube. Chest Tube Choice and Placement Pigtail first approach: Pigtail catheters in the 10-16 Fr range now cover most standard thoracostomy indications, with less chest wall trauma and complication burden than traditional large-bore tubes. Same indications different device: Pneumothorax, hemothorax, hemopneumothorax, empyema, chylothorax, and clinically significant pleural effusions can all be managed with a pigtail when the patient and setup allow. Complication tradeoff pattern: For spontaneous pneumothorax, small-bore drainage achieved similar success rates to larger tubes while large-bore devices carried more infections; dislodgement is the main pigtail downside. Preferred decompression site: The 4th or 5th intercostal space at the mid-axillary line is favored over anterior 2nd-space needle decompression because procedural success is better across body habitus. We get into the landmarking nuance in the episode. Trauma and unstable exceptions: Blunt or penetrating trauma resuscitation still leaves room for a standard chest tube, because speed and simplicity can matter more than the lower-trauma pigtail setup. Direction and fixation pearls: During pigtail placement, aim toward the contralateral sternoclavicular joint to keep the catheter tip superior, then secure it well because dislodgement remains a recurring failure mode.

How You Speak to Paramedics is Mission Critical

EMS handoff is mission-critical communication, especially for unstable patients where omitted prehospital details can change immediate care. Communication failures drive many sentinel events, and the prehospital report often supplies the first shared mental model for diagnosis, priorities, and next steps. Receiving the EMS Handoff Well Mission-critical communication: Prehospital report is a high-stakes exchange where disruption can produce catastrophic failure, and Joint Commission data tied communication to 70% of hospital sentinel events. Shared mental model: EMS clinicians gather history and exam data in the same clinical frame we do, often with scene context the ED never sees, a distinction we get into in the episode. Whole-team presence: ACEP-backed handoff practice is to have the care team present for report so everyone starts from the same facts and priorities rather than reconstructing the story later. Quiet room for report: Silence, no interruptions, and no multitasking protect the handoff from dropped details; a simple “quiet room for report” cue can reset the room immediately. Four handoff anchors: The most useful EMS report gives four essentials: the focused priority, prior care, current state, and immediate needs, which keeps questions organized under pressure. Three post-handoff questions: After report, the ED team should be able to state what EMS saw on arrival, what they found on exam, and what they did with the patient’s response. We lay out how to use that check in the chapter. Professional Communication With Paramedics Team-sport mindset: Emergency care starts before the bay; treating paramedics as integral teammates improves efficiency and preserves the chain of survival from prenotification onward. Interruptions derail recall: Cutting off a medic can break their sequence and bury critical data, especially when they are trying to deliver a concise trauma or resuscitation report. Clarifying questions after report: Active listening matters, but the best time for clarification is after the core story lands so the medic can finish the high-yield narrative without fragmentation. Pause for critical interventions: If the patient needs an immediate intervention, ask EMS to hold briefly, complete the task, then return and give the report your full attention rather than half-listening. Private debrief after stabilization: A brief post-stabilization debrief can close loops, surface scene details, and reinforce professionalism when questions remain after the initial transfer of care. Respect for austere care: Paramedics work with limited personnel, equipment, and scene constraints; acknowledging that reality builds trust and makes future handoffs cleaner and faster.

Lit Matters 3: IV Sodium valproate for migraines?

Acute migraine in the emergency department is still a first-line NSAID problem, but IV sodium valproate may be a reasonable option for migraine without aura when usual therapies are limited. The key caution is external validity: this trial excluded secondary headache and patients with aura. IV Migraine Therapy Evidence First-line NSAID framing: NSAIDs remain preferred first-line acute migraine therapy per headache guidelines, with ibuprofen a familiar benchmark because it reduces prostaglandin-mediated perivascular nociceptor activation. Valproate clinical niche: IV sodium valproate appears safe and likely effective for migraine without aura, making it a practical alternative when standard migraine regimens are unsuitable or have already failed. Head-to-head trial signal: In this randomized double-blind ED study, 800 mg IV sodium valproate beat 800 mg IV ibuprofen on the primary endpoint of at least 50% pain reduction from baseline. Recurrence and rescue use: Rescue analgesia and 48-hour headache recurrence were not statistically different between groups, but the recurrence pattern raises a few practice-level questions we get into in the episode. Applicability limits: The findings apply to adults with migraine without aura, not suspected secondary headache, pregnancy, recent analgesic use, or patients already taking valproate for seizures. Placebo effect concern: No placebo arm leaves an important uncertainty in a symptom-driven condition like migraine, where receiving any active IV treatment can meaningfully shift reported pain scores.