UMEM Educational Pearls - By Robert Flint

Title: Age friendly hospital quality measure

Category: Geriatrics

Keywords: Age friendly, geriatric, healthcare, quality improvement (PubMed Search)

Posted: 7/6/2025 by Robert Flint, MD (Updated: 7/8/2025)
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In mid-2024 the Center for Medicare and Medicaid Services introduced a new quality measure entitled Age Friendly Hospital Measure. The initial phase went into effect 1/1/25. It is built around programs from the American College of Surgeons, the American College of Emergency Physicians as well as the Institute for Healthcare Improvement (IHI). It is modeled around the IHI’s 4M Framework. 

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Title: Use of shock index in compensated shock state to predict transfusion

Category: Trauma

Keywords: Shock index, transfusion, hypotension (PubMed Search)

Posted: 7/5/2025 by Robert Flint, MD (Updated: 7/8/2025)
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These authors looked at 5958 trauma patients arriving at their trauma center with a systolic blood pressure greater than 90. They calculated shock index (heart rate /sbp) for all of these and then looked at who received a blood transfusion within one hour of arrival.  211 patients received blood in that time frame.  “Patients were stratified by SI using the following thresholds: ? 0.7, > 0.7 to 0.9, > 0.9 to 1.1, > 1.1 to 1.3, and > 1.3.”
“A main effect was observed for shock index with increased risk for required transfusion for patients with admission shock index >0.7 (P < 0.001). In comparison to shock index of ? 0.7, odds ratios were 2.5(1.7 - 3.8), 8.2(5.4 - 12.2), 24.9(15.1 - 41.1), 59.0(32.0 - 108.6) for each categorical increase in SI.”

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Title: Facial Fracture Transfer Guidelines

Category: Trauma

Keywords: facial fracture, transfer, guidelines (PubMed Search)

Posted: 6/29/2025 by Robert Flint, MD (Updated: 7/2/2025)
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Based on a review of  511 patients transferred to a level one trauma center for evaluation of facial fractures, this group developed the Facial Fracture Transfer Guidelines.  they found that over half of the patients transferred to them did not require intervention and were discharged within 6 hours. These guidelines are meant to decrease unneeded transfers yet provide appropriate care to those with traumatic facial injuries. 

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Title: Facial Fracture Review

Category: Trauma

Keywords: facial fracture, Le Fort, orbital fracture (PubMed Search)

Posted: 6/29/2025 by Robert Flint, MD (Updated: 7/8/2025)
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Most common facial fracture is the nasal fracture followed by the zygomatic arch fractures. 

Le Fort Classification of facial fractures/facial stability. The higher the number, the more unstable. 

Orbital blow out fractures may entrap the ocular muscles leading to eye immobility in various directions. 

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Title: BIG for kids

Category: Trauma

Keywords: Head injury, BIG, pediatric (PubMed Search)

Posted: 6/23/2025 by Robert Flint, MD (Updated: 7/8/2025)
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Brain injury guidelines were designed to decrease transfers and neurosurgical consults for adults with head injuries. 

A new retrospective study suggests that modified  guidelines may be feasible in the pediatric population as well. More data is needed but this is an important step in assuring safe resource utilization in pediatric head injury patients.

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Title: Call Neurosurgery for that abscess!

Category: Infectious Disease

Keywords: Abscess, brain, drainage, neurosurgery (PubMed Search)

Posted: 6/22/2025 by Robert Flint, MD (Updated: 7/8/2025)
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In a Danish study of 558  patients with a brain abscess, those that had early surgical drainage did better than those treated conservatively with antibiotics only.  Prompt neurosurgical consultation is warranted for these patients.

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Title: Mortality of ED vs. OR intubation for trauma patients.

Category: Trauma

Keywords: Intubation, trauma, mortality, operating room, Ed (PubMed Search)

Posted: 6/15/2025 by Robert Flint, MD (Updated: 7/8/2025)
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In this Israeli study comparing mortality for trauma patients intubated in the emergency department vs the operating room, in hospital mortality was higher for the ED group before controlling for injury severity score and shock. After controlling for injury severity and shock, there was no difference in In hospital mortality. Coupled with previous research, if intubation can wait until after resuscitation and in the OR, that is ideal. And sometimes it just has to happen in the ED and we should be prepared for rapid resuscitation.

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Title: How to: resuscitative hysterotomy

Category: Trauma

Keywords: Hysterotomy (PubMed Search)

Posted: 6/8/2025 by Robert Flint, MD (Updated: 7/8/2025)
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Another case series of 3 resuscitative hysterotomies, all performed by obstetricians, reported 33% maternal and 67% neonate survival.(1). 
The mechanics of the procedure are:

  • “Duration should not exceed 5 minutes!
  • Incise from pubic symphysis to at least umbilicus with a large scalpel along linea nigra into peritoneal cavity. Layers: skin, subcutaneous tissue, fascia between the rectus muscles, peritoneum.
  • Retract abdominal wall laterally
  • Reflect bladder inferiorly and empty by aspiration
  • Make a small incision (~5cm) vertically into the inferior presenting part of the uterus until amniotic fluid comes or through endometrium
  • Insert 2 fingers and lift up uterus from foetus
  • Extend uterine incision up to fundus with safety scissors curved away from foetus
  • Deliver the foetus. May need to disengage the presenting part from the pelvis.
  • Clamp the cord twice and cut between clamps
  • Give the neonate to the neonatal resuscitation team” (2)

(3)

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A literature search revealed very little evidence, however in 66 women and 68 neonates who underwent resuscitative hysterotomy for out of hospital cardiac arrest 4.5% of women and 45% of neonates survived to discharge. The longest down time was 29 minutes and 47 minutes for women and neonates respectively. While more evidence is needed, it appears this procedure should be performed as early as possible and may lead to some survival benefit.

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Title: Prehospital femur fracture management.

Category: Trauma

Keywords: Femur fracture, splint (PubMed Search)

Posted: 6/6/2025 by Robert Flint, MD (Updated: 7/8/2025)
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The National Association of Emergency Medical Service Physicians reminds us that femur fractures rarely cause enough blood loss to cause hemodynamic instability (look for other sources),  often have concomitant injuries in the pelvis or distal extremity, and can be effectively  splinted either static or with traction (which has contraindications, complications, and technical hurdles).

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Title: Nail gun injuries: surgery and antibiotics?

Category: Trauma

Keywords: Nail gun injury, surgery, antibiotics (PubMed Search)

Posted: 5/31/2025 by Robert Flint, MD (Updated: 6/1/2025)
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An Australian retrospective study of 158 patients treated for nail gun injuries found those treated with operative debridement or with prophylactic antibiotics had no different 30 day infection rates compared to patients receiving no antibiotics.

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Title: Do whole body Ct scans lead to better outcomes in geriatric trauma?

Category: Trauma

Keywords: geriatric, trauma, CT scan (PubMed Search)

Posted: 5/29/2025 by Robert Flint, MD (Updated: 7/8/2025)
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This literature search from 1946-2023 looking at comparing selective use of CT scans vs whole body scans in geriatric trauma found no benefit of whole body CT in mortality, hospital length of stay or ED discharge. This study only included 15,000 pts over that very long time line. More robust, current work needs to be done on this important topic.

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Title: Climate change and Coccidioidomycosis

Category: Infectious Disease

Keywords: Coccidioidomycosis, climate change (PubMed Search)

Posted: 5/26/2025 by Robert Flint, MD (Updated: 7/8/2025)
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Typically Coccidioidomycosis is seen in the Southwestern US. The authors of this study, using climate modeling  predict endemic areas will spread across the US to include Idaho, the Dakotas, Nebraska and Wyoming. 
Clinically, “Patients with pulmonary Coccidioides infection frequently experience fever, cough, and shortness of breath. Chest radiographic imaging may demonstrate lobar, segmental, or multifocal consolidations; cavitary lesions; and lung nodules. Given these nonspecific findings, patients with coccidioidomycosis are often treated for community-acquired pneumonia. Coccidioidomycosis should be considered in patients not improving with antibiotic treatment or in those who have exposure to or reside in endemic areas. Up to 50% of patients with pulmonary coccidioidomycosis have erythema nodosum, approximately 25% to 30% have peripheral eosinophilia, and approximately 25% have arthralgias (particularly symmetric knee and ankle arthralgia). Up to 10% of patients diagnosed with coccidioidomycosis develop disseminated disease, including skin, central nervous system, and bone and joint infection.”

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Title: How likely are TIA pts to develop a stroke?

Category: Neurology

Keywords: CVA, TIA, prediction, one year (PubMed Search)

Posted: 5/21/2025 by Robert Flint, MD (Updated: 7/8/2025)
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How likely is your TIA pt to go on to have a stroke? This study in JAMA gives us some answers. While EM providers aren’t as interested in 5 and 10 year prediction, it provides more evidence TIAs need to be evaluated and are risk factors for future events.

“In this systematic review and meta-analysis of 171?068 patients with TIA or minor stroke from 38 studies, the risk of subsequent stroke was 5.9% within 1 year, 12.8% within 5 years, and 19.8% within 10 years.”

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Title: Antibiotics after nasal packing, yea or neah?

Category: ENT

Keywords: Epistaxis prophylaxis (PubMed Search)

Posted: 5/18/2025 by Robert Flint, MD (Updated: 7/8/2025)
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This large retrospective database study compared those receiving antibiotics after anterior nasal packing to those that did not.  There was no difference in clinically significant infection between the groups leading the authors to conclude prophylactic antibiotics after anterior nasal packing is not required.

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Title: Incarcerated Trauma Patients

Category: Trauma

Keywords: Incarcerated, trauma, mortality, disparity (PubMed Search)

Posted: 5/11/2025 by Robert Flint, MD (Updated: 7/8/2025)
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Looking at a year’s worth of data from the National Trauma Databank, the authors found incarcerated trauma patients were more likely to be stabbed, male, persons of color and have a higher adjusted mortality rate. 

 

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Title: Hip fracture complications

Category: Orthopedics

Keywords: Hip fractures, geriatrics, complications (PubMed Search)

Posted: 5/7/2025 by Robert Flint, MD (Updated: 7/8/2025)
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This article reminds us that hip fractures have a one year mortality rate of 12-25% and 50% of hip fracture patients develop complications while in the hospital. “Almost half of individuals hospitalized with hip fractures experience complications, such as delirium, pneumonia, acute kidney injury, urinary tract infection, and deep vein thrombosis”

Because of these complications, multidisciplinary teams should be caring for these patients and great care should be exercised when evaluating these patients.

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Title: Aortic Dissection Review

Category: Cardiology

Keywords: aorta, dissection (PubMed Search)

Posted: 5/3/2025 by Robert Flint, MD (Updated: 5/4/2025)
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Aortic dissection remains a difficult diagnosis to make. This article is a nice review.  The pathology behind this involves an intimal flap in the aortic wall. Death occurs due to aortic rupture or obstruction of branching artery. 

Risk factors: male 2:1 female, Marfan Syndrome, HTN, aortic aneurysm, cocaine and methamphetamine use, pregnancy

Pain is variable however tearing, ripping migrating, maximum at onset, and sharp are all associated with Aortic Dissection. Think about Dissection with atypical CP with ECG changes as well as in stroke like presentations along with chest pain. 

Gold standard for diagnosis is CT angiogram. Decision rules with the use of D-Dimer have been proposed however there is still not sufficient evidence to use these. ACEP guidelines currently give use of decision rules a long with DDImer a level C recommendation.

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Title: Exposure to gun violence is associated with mental health problems

Category: Trauma

Keywords: Gun violence, mental health, suicide (PubMed Search)

Posted: 4/28/2025 by Robert Flint, MD (Updated: 7/8/2025)
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This study looked at exposure to gun violence and found increased use of mental health resources, depression and suicide risk even with a single exposure. Repetitive exposure increased suicide risk as well as mental health service utilization, depression and overall health service utilization. While further work is needed, screening our patients for gun violence exposure could undercover mental health needs.

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Title: Optimal antibiotics for necrotizing soft tissue infections

Category: Infectious Disease

Keywords: Necrotizing infection, antibiotic selection (PubMed Search)

Posted: 4/27/2025 by Robert Flint, MD
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In the April edition of Annals of EM, there are opposing view points on the optimal antibiotic regiment for necrotizing soft tissue infection. One group proposes linezolid alone will cover all the worrisome pathogens namely group A Strep and Staph. There are less side effects including C. Diff infection with this medication. Another group suggests sticking to vancomycin plus/minus BLactam along with clindamycin. Their arguement centers around clindamycin is useful as an antitoxin more so than its antibacterial property. 

Both offer reasonable evidence and neither is compelling enough to say one is superior to the other.

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