Arterial lines are essential tools in managing critically ill patients, but it is frustrating when they are not working as expected. It can be hard to tell when an unexpected waveform or pressure reflects the patient's physiology versus a problem with the line. Recognizing common issues and systematic troubleshooting will optimize your hemodynamic monitoring.

Types of arterial line problems

• Overdamping (most common): Flattened waveform
  • Underestimates systolic | overestimates diastolic | typically does not affect MAP
  • Look for: air bubbles, clots, kinked tubing, malposition, or a low pressure bag (<300 mmHg)
• Underdamping: Peaky waveform with "ringing" oscillations and loss of dicrotic notch
  • Overestimates systolic | underestimates diastolic | typically does not affect MAP
  • Look for excessive tubing length
• System issues:
  • Zeroing errors
  • Transducer is not at the level of the right atrium > 4th intercostal space, mid-axillary line (phlebostatic axis)

Troubleshooting Steps

1. Correlate with Non-Invasive BP - MAPs should be within ~10 mmHg. Discrepancies suggest one of the numbers may be inaccurate. Make sure the cuff is the correct size!
2. Verify Transducer Position - Level transducer at the 4th intercostal space, mid-axillary line. For each 10 cm off there is about 8 mmHg of pressure inaccuracy.
3. Inspect Tubing and Pressure Bag
   • Ensure no kinks
   • Make sure the pressure bag is inflated to 300 mmHg
   • Flush vigorously to clear bubbles
4. Check for Clots (radial lines):  Use ultrasound with Doppler to visualize flow and detect perica­theter clots. Reduce insonation angle (<60°) for optimal signal. “Positional” lines may have a clot around it, and the line only works well when it’s “hubbed” or the wrist is flexed.
5. Consider exchanging the line over a micropuncture wire - it's more sterile and safest to place another line, but when access is tough/limited, it's not unreasonable to exchange a 4.45 cm 20g radial catheter for a 12 cm 20g catheter over a micropuncture wire with sterile technique.

By following these steps, you can systematically identify whether waveform or pressure abnormalities are due to technical issues or true patient physiology.

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Looking at 416 patients aged 12-16, 48% at a Peds trauma center vs 20% at adult Level 1 center vs 34% at an adult level 2 center, there was no difference in in hospital mortality between adult and pediatric centers. 
The authors  conclude “These findings suggest that severely injured adolescents aged 12 to 16 years may be safely treated at either adult or pediatric trauma centers.”

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Background:

Approximately 10% of patients presenting to the emergency department (ED) report penicillin allergies, which may lead to use of second- or third-line agents. Alternative therapies (such as aztreonam, clindamycin and fluroquinolones) carry an increased risk of mortality and complications such as Clostridioides difficile infection. Considering that less than 10% of penicillin allergies may be confirmed by formal testing results, the PEN-FAST clinical decision tool was created to identify patients with low risk of true penicillin allergy who do not require formal skin testing for rechallenging with a beta-lactam:

Though PEN-FAST has only been validated in the clinic and inpatient settings, a study from Tran et al. published this January sought to determine the safety and efficacy of utilizing this tool to assess penicillin allergies and re-challenge patients in the ED.

Study design:

This was a single-center, prospective, observational cohort study. Emergency medicine (EM) pharmacists screened patients in the ED with:

• A documented penicillin, amoxicillin or ampicillin allergy who also had an order for IV or oral clindamycin, levofloxacin or aztreonam OR
• A documented penicillin, amoxicillin or ampicillin allergy and an EM physician placed a general consult order to pharmacy requesting evaluation of antibiotic selection.

Screened patients were excluded from the study if orders were placed by a non-EM physician, if they previously tolerated a penicillin/cephalosporin within the healthcare system of the study site, if they were unable to participate in bedside interview, if the antibiotics selected were appropriate despite the penicillin allergy or if there were time constraints that would delay care if the PEN-FAST assessment needed to be completed. 

Study Intervention:

EM pharmacists completed the PEN-FAST assessment for all included patients. They recommended rechallenging with an appropriate beta-lactam for patients with a score of 0-2, recommended to consider rechallenging for patients scoring 3, and did not recommend rechallenging for scores of 4-5 or if it was confirmed patients previously experienced anaphylaxis, angioedema or severe cutaneous reactions with a beta-lactam. Orders for any change in therapy were only placed with discussion and agreement from EM physicians. Rechallenged patients were assessed at bedside for any immune-mediated reactions 45 to 75 minutes after initiation of antibiotics. The primary outcome was the percent of patients with a PEN-FAST score of 0-2 who tolerated a beta-lactam after being rechallenged.

Patient Characteristics:

After screening, one hundred patients were included in this study.

• Median age: 72 [IQR 59-81]
• Penicillin Allergy Label:
  • Penicillin VK, G or unspecified = 88%
  • Amoxicillin or ampicillin = 11%
  • Combined amoxicillin/clavulanate = 1%
• Calculated PEN-FAST scores:
  • 0 = 31%
  • 1 = 26%
  • 2 = 4%
  • 3 = 30%
  • 4 = 3%
  • 5 = 6%

Results:

Primary Outcome: 

• Out of 61 patients with a PEN-FAST score of 0-2, 52 patients were rechallenged. All 52 patients (100%) tolerated rechallenge with a beta-lactam.

Secondary Outcomes:

• Out of 30 patients with a PEN-FAST score of 3, six patients were rechallenged. All six patients (100%) tolerated rechallenge with a beta-lactam.
• The number of immune mediated reactions among all patients rechallenged was 0.
• Median time from initial order entry to entry of new antibiotic order for patients who were re-challenged was 17 minutes (IQR 10-23)
• Median time from initial order to antibiotic administration for patients who were re-challenged was 41 minutes (IQR 29-65)

Key Takeaways:

• The PEN-FAST decision tool was able to safely identify and risk-stratify eligible patients for beta-lactam rechallenge in the ED in this exploratory study.
• Prudent antibiotic selection is of particular significance in the ED, given that antibiotic therapy initiated in the ED influences inpatient ordering.

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Background

Diagnosed by continuous seizure activity that lasts for 5 minutes or more and/or multiple seizures that occur without returning to baseline in-between each.   Further classified as being convulsive or non-convulsive.  Refractory status epilepticus can be defined as status epilepticus that does not respond to an adequately dosed benzodiazepine and another anti-seizure medication.  The primary objective in management is to stop both clinical and electrographic seizures which can become an important point for those patients who require intubation and receive neuromuscular blockade.   Essential to evaluate early for reversible causes (electrolytes, liver function, glucose, ammonia, medications) and for other precipitating causes with toxicology screening and CT head imaging with consideration for angiography and venography. 

Management:

First-Line/Initial Therapy:

Lorazepam IV 0.1 mg/kg up to 4 mg per dose is the preferred agent, can be repeated after 5 minutes if seizures persist

Diazepam 0.15 mg/kg IV/0.2 mg/kg PR up to 10 mg, or midazolam IM 0.2 mg/kg up to 10 mg are also alternatives

Second-line/Urgent control: (Provided to all patients with SE after initial therapy)

- Levetiracetam 60 mg/kg, Valproate 40 mg/kg, and fosphenytoin 20 mgPE/kg were studied by Kapur et al., and they found similar rates of resolution of status epilepticus with similar rates of adverse events. 

- Phenobarbital 15-20 mg/kg is another agent that has good efficacy and is remerging as an effective agent.  Can cause respiratory depression at high doses. 

- Keppra may have the best side-effect profile to consider. 

- Valproate can cause hepatotoxicity, elevated ammonia and thrombocytopenia. 

- Fosphenytoin can cause hypotension and arrhythmias. 

Third-line:

Midazolam 0.2 mg/kg load followed by 0.05 – 2 mg/kg/hr infusion

Propofol 1-2 mg/kg load followed by 20-200 mcg/kg/min infusion

Ketamine 0.5 – 3 mg/kg load followed by 1.5-10 mg/kg/hr infusion 

Pentobarbital 5 mg/kg load followed by 0.5-5 mg/kg/hr infusion

- Propofol carries the risk of propofol infusion syndrome with high doses or prolonged infusions, some favor midazolam because of this. 

No conclusive data to support one over another. 

Important Considerations

- A common mistake is to under-dose benzodiazepines for initial therapy, give the full weight-based dose as described above.

- Following initial management it is important to monitor patients with continuous EEG if they have not returned to their neurologic baseline

- Propofol, midazolam or ketamine are good options for induction for intubation.

- Consider against using etomidate for induction of intubation since it can cause myoclonus which can complicate the picture if you are already worried about seizures, can be hard to differentiate. 

- If intubation is required and EEG is not readily available consider reversal of neuromuscular blockade after intubation to better monitor for continued seizures. 

- If in refractory status epilepticus despite using a second-line agent and a third line agent then consider adding a second agent from the second-line/urgent control that was not previously started (fosphenytoin, valproate, levetiracetam, or phenobarbital).

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In the last few months, there have been multiple articles published regarding the use of prophylactic TXA to prevent postpartum hemorrhage. While almost none of us want to ever be in the situation where we have to deliver a baby in the ED, we need to be prepared for all outcomes.

A meta-analysis by Ker et. al (Oct 2024) and a RCT, blinded study by Zhang et. al (Dec 2024) both demonstrated that giving 1g TXA immediately after delivery of a baby can reduce the rate of severe postpartum hemorrhage in patients with risk factors. These studies had a wide variety in what they considered risk factors, but a few that showed particular significance included: hx of postpartum hemorrhage, history of anemia, gestational diabetes, and placental adhesion.

So next time you've scooped that screaming baby out into your already chaotic emergency department, ask your patient (not the baby) a few questions about their birth history and think about giving 1g of TXA to prevent a horror show for whoever is coming on for you next.

Caveat: These studies were done in delivery rooms and not emergency rooms, but I think we can extrapolate since it would be very hard to find enough patients to conduct a study like this in the emergency department.

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A retrospective look at veterans who received oral and/or IV as needed blood pressure medications while hospitalized in a non-ICU setting found an association with as needed meds and acute kidney injury, greater than 25% blood pressure drop in 3 hours, and death, stroke and MI while hospitalized. IV medications had a higher association. 
While needing prospective validation, this appears to be more evidence to treat the patient not the number.

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For those of us living in a world where ED boarding is a reality and ICU beds are in short supply, a re-up on the basic tenets of post-arrest care to optimize survival and neurologic outcomes in patients with sustained ROSC after OHCA:

1. Actively prevent fever in comatose patients. (“Comatose” = lack of meaningful response to verbal commands.) There may be a subset of patients comatose after ROSC who benefit from actual therapeutic hypothermia, but fever is definitely harmful. Tylenol is not going to cut it; be ready to start active cooling methods to avoid fever, and give yourself a cushion. Starting cooling efforts at 37.9 is probably not going to work to avoid reaching 38.0 deg C.
2. Avoid hypotension and maintain a MAP > 65mmHg; in patients with signs of increased ICP or chronic uncontrolled hypertension, consider a MAP goal > 80mmHg. The literature is still not quite clear that higher MAP targets improve outcomes, but MAPs <65 are associated with poorer neurologic recovery. 
3. Target normoxia with an oxygen saturation between 92-98%. Hypoxia and hyperoxia are associated with poorer neurologic function. An O2 sat of 100% doesn’t tell you whether your PaO2 is 100 or 300, so aim for a lower value. 
4. Target normocarbia to mild hypercarbia (PCO2 35-55).  Arterial PCO2 affects cerebrovascular tone, but the data indicates no difference in outcomes between normocarbia and mild hypercarbia up to 55mmHg.
5. Monitor for seizures with EEG as soon as possible in comatose patients. Treating seizures with Keppra is appropriate and burst suppression with propofol is reasonable. “Prophylactic” antiepileptics are not beneficial and are discouraged.
6. Early coronary angiography is only clearly indicated for ST elevations on EKG post-ROSC. Studies have not found a benefit in short or longer term survival for early catheterization in patients without ST elevations, although it may still be beneficial depending on the patient’s clinical scenario.
7. Utilize bedside (or formal) echocardiography to help guide management in patients with hypotension after cardiac arrest. Whether fluids, vasopressors, or inotropes are needed, bedside echo can inform what you do.
8. Early neuroprognostic determination acutely in the ED is largely impossible. Except in cases with clear goals of care refusing life-support, life sustaining measures should not be removed based on comatose state, prolonged downtime, presence of cerebral edema without herniation, etcetera.

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The suprasternal notch view is a valuable tool for assessing the aorta and identifying signs of thoracic aortic dissection. Proper technique is essential to obtain a clear image and improve diagnostic accuracy. 

Steps to Obtain the Suprasternal Notch View:

Position the Patient: 

Ideally, place the patient in a supine position. 

If the patient cannot tolerate lying flat, the scan can be performed with the patient in an upright position. 

Probe Selection & Orientation: 

Use a phased array probe in cardiac mode. 

Direct the probe marker slightly toward the patient’s left shoulder (or right hip if using abdominal mode). 

Optimize Patient Positioning: 

Ask the patient to extend their neck to improve visualization. 

Having the patient rotate their head to the side may further enhance imaging. 

Placing a rolled towel under the shoulders can help achieve optimal neck extension. 

Probe Manipulation: 

Angle the probe inferiorly toward the chest. 

Adjust the depth to clearly visualize the aortic arch.

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Risk factors for necrotizing soft  tissue infections include:   obesity, diabetes mellitus, peripheral vascular disease, immunosuppression, injection drug use, and deep traumatic wounds.

 “Any anatomical site can be involved, but the most common sites are perineal, anorectal, foot, or lower extremities.”

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Not based on currently available literature. 
This editorial reminds us that the only evidenced based screening criteria we have for C-spine clearance in those over age 65 after trauma is the Canadian C-Spine Rule (2002). This rule recommends imaging for all patients over age 65.   No large, well done study  indicates physical exam or other means can be used to clear C-Spines in those over age 65.

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PECARN, in 2012, published a decision tool aimed at helping avoid unnecessary abdominal CT scans in children with blunt torso trauma. While a prior retrospective validation was done, the tool had not been prospectively validated and generally has not been in widespread use as a standalone, although the original paper may have helped to influence development of local pediatric trauma protocols. Recent prospective validation may make the tool more applicable for broader usage.  

The tool is useful as a rule out given that when all criteria are negative, the risk of intraabdominal injury requiring intervention is less than 0.1%.  The criteria are: 

• Evidence of abdominal wall trauma or seatbelt sign 
• GCS <14 and blunt abdominal trauma 
• Abdominal tenderness 
• Evidence of thoracic wall trauma 
• Abdominal pain 
• Decreased breath sounds 
• Vomiting

If using the rule, it is important to note that the presence of one or more of the criteria does not indicate that the patient needs a CT. Patients who do not rule out should be evaluated based on local pediatric trauma protocols and/or in collaboration with the local pediatric trauma center, which often will involve a stepwise approach based on historical information, laboratory workup, and physical exam findings.

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These infections remain difficult to diagnose early and early diagnosis is key to limiting morbidity and mortality. 
“The classic clinical signs and symptoms are rarely all present especially in early disease. Crepitus or gas in the soft tissues, while specific, is only present in approximately 10% of patients. More often, the presenting symptoms are nonspecific: fever, pain, induration, and edema. Pain out of proportion to examination is a more specific finding that may assist in differentiation of NSTI from cellulitis.”

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Two recent studies (see “Additional Information” for more study details) published in the New England Journal of Medicine evaluated the outcomes of OHCA, comparing drug administration via intraosseous devices versus intravenous access, neither demonstrating benefit to one strategy over the other in terms of sustained ROSC or 30-day survival. [1,2] While there were a few limitations, these results are generally in line with existing literature. Although it is worth noting that some studies signal improved outcomes with IV access, the time to intervention seems to be the more important metric related to outcome. [3-5]

Bottom Line: Intraosseous devices remain rapid and easy to place devices that can provide access for drug administration when IV access is unable to be obtained. In patients with difficult access, use an IO to administer meds, fluids, or blood products as indicated while you and your team work on more definitive IV access and focus on high-quality CPR.

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This small study randomized patients with 2 or greater rib fractures or requiring chest tube insertion into a kerorolac (30 mg) or ketamine (0.25 mg/kg) group and evaluated pain levels pre, 30  and 60 minutes post medication administration. They also looked at need for morphine rescue medication. The ketamine group had superior pain control and required less rescue medication.

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“Hey Doc, do I knee surgery?”

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On March 18, 2022, Congress passed the Dr. Lorna Breen Health Care Provider Protection Act, named after an emergency medicine physician who died by suicide during the pandemic. This landmark legislation allocated $103 million across 45 organizations to introduce evidence-based measures to mitigate and prevent burnout.

As a result, the Impact Wellbeing Guide was developed, outlining the six key evidence-based action steps for organization leaders to address health care workers’ professional well-being listed below:

1. Conduct a review of your hospital’s operations to determine how they support professional wellbeing.
2. Build a dedicated team to support professional wellbeing at your hospital.
3. Break down barriers to seeking help, such as updating and removing intrusive mental health questions on credentialing applications and offering confidential mental health support options.
4. Develop a suite of communication tools that help you share updates with your workforce about your hospital’s journey to improve professional wellbeing.
5. Integrate professional wellbeing into an existing quality improvement project at your hospital.
6. Create a 12-month plan to continue to move your workforce’s professional wellbeing work forward.

The Guide is designed to help hospital leaders and executives accelerate or supplement professional wellbeing work in their hospitals at the operational level.

A PDF of the full guide is available from the CDC: https://www.cdc.gov/niosh/docs/2024-109/

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Delirium in the ICU means badness as delirious ICU patients are associated with longer stay and higher mortality. While medications are not proven to prevent delirium, certain environmental interventions such as window access, light and sound levels have been recognized as legit interventions to prevent ICU delirium.

Settings: This is a retrospective study at Massachusetts General Hospital 
Participants: 3527 patients admitted to a surgical ICU between 2020 and 2023.
Outcome measurement: This study hypothesized that patients in a windowed ICU room will have lower rates of delirium, decreased ICU length of stay, hospital LOS. Multivariable logistic regressions were performed for the association of clinical variables and the presence of delirium.
Study Results: 
Delirium was observed in 460 patients (21%) of the windowed rooms group and 206 patients (16%) of the nonwindowed rooms group. Multivariable logistic regression showed that patients in windowed rooms were associated with higher odds of delirium (aOR, 1.29; 95% CI, 1.07–1.56; p = 0.008), although they were not associated with longer ICU LOS or longer HLOS
Discussion:
The study’s findings added to the literature that natural lighting might not be the effective prevention of delirium. The presence of windows might not be the answer. 
In this study, all the windows were facing another building, and there was no view of other natural scenes, with a limited view of the sky. Therefore, the authors suggested that the overall quality of the windows would be more important.

Conclusion: 
The ICU environment is more important for patients’ delirium than just the presence of windows.

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Stellate Ganglion Blocks (SGB) have been reported in case reports as a last-line treatment for patients with refractory ventricular arrhythmias. 

• A recent multicenter study evaluated the efficacy and safety of SGB in managing refractory ventricular arrhythmias. 

• The study included 117 critically ill patients, with 9 on ECMO, 5 with Impella devices, and 15 with LVADs.

• 70% were given long-acting bupivacaine, 28% were given ropivacaine and 1 patient received lidocaine.

• SGBs were primarily performed by anesthesiologists during short periods of when the patients were not in ventricular arrhythmia

• The median 24-hour episodes of VT/VF decreased from 9.0 (interquartile range [IQR]: 3.0–31.0) pre-SGB to 1.0 (IQR: 0.0–5.0) post-SGB.

• 2 patients had complications; recurrent laryngeal nerve block with resultant hoarseness and brachial plexus block.

Limitations: This study was conducted in a controlled setting (ie not in active arrest, not in the emergency department) and involved a selective cohort. Randomized controlled trials (RCTs) are needed to validate these findings.

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Fractures of the occipital condyles are a relatively rare injury that occur in high energy blunt mechanisms  (IE roll over MVC) most commonly. Physical exam will show signs of basilar skull fracture and significant pain at the base of the skull/upper C-spine. CT scan is the gold standard to make the diagnosis. Look for signs of upper extremity weakness on physical exam or cranial nerve injuries. Those type of findings should also prompt emergent MRI evaluation.  Treatment generally is long term immobilization in  a collar however Type 3 and those with neurologic  findings may require surgical intervention.

Anderson and Montesano Classification

Type I 3% of occipital condyle fracturesImpaction-type fracture with comminution of the occipital condyle

Due to compression between the atlantooccipital joint

Stable injury due to minimal fragment displacement into the foramen magnum 

Type II 22% of occipital condyle fracturesBasilar skull fracture that extends into one or both occipital condyles

Due to a direct blow to skull and a sheer force to the atlantooccipital joint

Stable injury as the alar ligament and tectorial membrane are usually preserved 

Type III 75% of occipital condyle fractures Avulsion fracture of condyle in region of the alar ligament attachment (suspect underlying occipitocervical dissociation)

Due to forced rotation with combined lateral bending 

Has the potential to be unstable due to craniocervical disruption 

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