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What do you see?
There is no clear fracture line
Much like ice floats on water, fat also floats on water/blood because it is less dense.
An intra-articular fracture may allow for blood and fat to exit the bone marrow and settle in the joint space.
This is called a lipohemarthrosis.
Best seen with a cross-table horizontal lateral view x-ray.
Go back to the image and examine the supra patellar pouch.
Most commonly seen in the knee in presence of a tibial plateau fracture.
Seen in approximately 1/3rd of tibial plateau fractures
If you see this without a clear fracture, consider CT of knee which can help detect the hidden fracture.
Remember the DDx of knee hemarthrosis with negative plain films:
Meniscal tear, ligament tear (usually ACL), patellar dislocation and osteochondral fracture.
Except for meniscal tearing (>6h) these other pathologies cause rapid onset swelling (<2h).
The presence of an endotracheal tube by itself does not mandate sedation and many patients require no sedatives while intubated in the ICU. However, patients intubated in the emergency department usually require initial sedation while still paralyzed from RSI. Sedation can also help facilitate procedures and imaging in critically ill patients during initial management.
Current literature has found increased mortality and length of ventilator requirement in oversedated ED patients. The target sedation level for the general population remains a goal RASS (Richmond Agitation-Sedation Scale) of 0 to -1. Society of Critical Care Medicine guidelines from early 2025 recommend dexmedetomidine over propofol as the preferred sedative for light sedation and reducing delirium risk in intubated critically ill patients. A recent trial re-examined other clinical outcomes between these two common sedative agents.
A2B Randomized Clinical Trial - JAMA 2025
Clinical Question: Does alpha 2 adrenergic receptor agonist sedation (dexmedetomidine or clonidine) reduce duration of mechanical ventilation in mechanically ventilated patients compared to a propofol based regimen (usual care)?
Where: 41 UK ICU’s from December 2018 to October 2023
Who: 1438 adults receiving mechanical ventilation for less than 48 hours, receiving propofol and opioid for sedation/analgesia, expected to require mechanical ventilation for greater than 48 hours
Intervention: protocol driven sedation to reach a RASS score of -2 to +1 (either dexmedetomidine, clonidine, or propofol). Of note, propofol could be added to achieve deeper sedation goal if deemed necessary by care team.
Outcomes:
Bottom Line:
While either dexmedetomidine or propofol, with appropriate use of opiates for pain management, are appropriate agents in non-paralyzed mechanically-ventilated patients, propofol may be a more appropriate choice in patients with greater agitation while boarding in the emergency department. However, close attention is needed to avoid the overly deep analgosedation associated with increased mortality. Maintain a goal RASS of 0 to -1 with frequent re-evaluation of your ICU boarders.
Digital nerve blocks are commonly used to provide anesthesia for finger injuries such as lacerations and dislocations. However, the procedure can be painful, as it often requires multiple injections into sensitive areas.
A recent single-center, unblinded randomized study compared the subjective discomfort and analgesic efficacy of traditional digital nerve blocks with ultrasound-guided peripheral nerve blocks. The study included 106 patients, with 53 in each group.
Results showed that patients in the peripheral nerve block group reported higher satisfaction rates. They also experienced less pain during the initial injection and longer-lasting analgesia compared to those who received digital nerve blocks. While digital blocks had a faster onset of anesthesia, they were associated with a higher rate of block failure.
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.
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.”
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.
When To Initiate RRT in the Critically Ill Patient
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.
Haglund’s deformity
Calcaneal bony growth at the Achilles insertion
Also known as a “pump bump”
Risks: Tight & rigid shoes. Shoes with a hard heel counter. High arches. Tight Achilles tendon. Repetitive heel stress (jumping). Genetically prone bone structures.
Most common in woman between the ages of 15 and 35. Wearing heels. Runners.
Hx: Heel pain and tenderness with a noticeable bump at back of heel. Worse with walking and with certain footwear.
PE: Swelling and redness around bony prominence.
Pain and tenderness in the posterior heel, especially when pressure is applied.
Imaging: Excessive traction and abnormal biomechanics lead to insertional calcifications and bone spurs.
Over time, an exostosis may develop at posterior superior calcaneus as shown in the attached film.
Tx: Physical therapy and orthotics that alter heel height in shoe.
Surgery for chronic cases.
Malpractice Insurance comes in two varieties: Occurrence and Claims-made.
Occurrence covers lawsuits for which the event occurs while the insurance is active.
Claims-made only covers lawsuits for which the insurance is active both during the event and when the lawsuit is announced. It’s less expensive because the coverage period is both shorter and more definitive.
This is an important distinction when an event and a lawsuit may be separated by years, as happens with medical malpractice.
Occurrence is the “good” kind.
Claims-made requires a tail to cover any claims brought after the insured period ends.
Read how this can go awry in Emergency Medicine at Leon Adelman’s April post here, https://substack.com/home/post/p-161044772.
Patient-ventilator dyssynchrony is a sign of a disagreement between the patient's breathing and the ventilator's settings. Recognizing and fixing it is a critical skill to prevent lung injury and improve comfort. Ineffective triggering and double-trigger are two common types of dyssynchrony.
The patient tries to take a breath, but they are too weak to trigger the ventilator. This is the most common type of dyssynchrony. It causes increased work of breathing and discomfort.
Look for a small dip in the pressure waveform and a simultaneous scoop out of the expiratory flow waveform that is not followed by a delivered breath.
Troubleshooting options:
The patient's own breath outlasts the ventilator's set inspiratory time (Ti), causing one patient effort to trigger two stacked breaths. This results in delivery of large tidal volumes, risking lung injury (volutrauma).
Look for two consecutive breaths on the ventilator screen without a full exhalation in between.
Troubleshooting options:
Dyssynchrony means the ventilator settings do not match the patient's needs. Watch the waveforms to diagnose the mismatch, then either adjust the ventilator or treat the underlying problem.
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.
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.
Despite ongoing attacks against the principles of DEI, most medical organizations know and have acknowledged the necessary role of creating a more diverse, equitable and inclusive environment. Doing so requires both a bottom up and a top down approach, with engaged leadership supporting active efforts to increase diversity
This author, published just this month in Annals, details a unique and exciting way to engage resident leadership in the DEI efforts of an emergency department, with the creation of a Chief Resident for DEI role. They detail the creation of the role, and describe some of the roles and responsibilities and thoughfully discuss some of the limitations. It's an exciting and thought provoking read.
Intranasal (IN) midazolam is often used for anxiolysis in pediatrics prior to procedures. In this study, 0.2 mg/kg of IN midazolam (up to 6 mg total dose) was given prior to laceration repair in children 2-10 years.
90% of children were at least minimally sedated at the start of the procedure and these children also displayed less anxiety when measured on a standardized anxiety scale.
Children's whose procedure started 10-20 minutes after IN medication compared to 25-35 minutes had significantly lower anxiety.
IN midazolam can be successful as an anxiolytic, but careful attention should be directed at the timing of the procedure.
GCS was first introduced in 1974 and now includes a preverbal version for patients < 2 years.
This study looked for non inferiority between motor Glascow Coma Scale (mGCS) and the total GCS in pediatric patients. The study also examined if a mGCS<6 was non inferior to a GCS < 14 in children. 582 patients < 18 years were reviewed in this retrospective review.
The mGCS was noninferior to total GCS as a triage tool in pediatric trauma. It also validated the use of mGCS <6 in place of GCS <14 in the field with identification of children at risk of death or requiring ICU care.
Acute respiratory distress syndrome (ARDS) is an acute, inflammatory lung injury that effects the lung diffusely and can be triggered by various insults. Aside from the Kigali modification, the most recent updated definition of ARDS was the Berlin definition in 2012. There have been many advances and changes in the understanding and clinical practice for managing patients with ARDS since then. In 2024, Matthay, et al. proposed the new global definition to build upon the Berlin criteria [1]. They addressed several important issues with the Berlin definition to improve the diagnostic criteria and improve ability for diagnosis in resource-limited settings.
ARDS Berlin Definition
Important updates for the Global definition of ARDS
Diagnostic Criteria for the New Global Definition of ARDS from Matthay et al.
The Global Definition of ARDS expands upon the Berlin definition. It was shown that this new definition improves diagnosis in resource-limited settings, allows for earlier detection, and better classification [2]. A retrospective study evaluating this new global definition found that there was a significant number of patients identified using this new definition who would have been missed using the Berlin definition [3]. These patients may benefit from ARDS directed therapies and further prospective studies will be needed to assess how this new definition effects clinical management of these patients using the new definition.
A hip effusion can cause pain with leg movement in both pediatric and adult patients.
A recent multicenter, prospective study assessed the diagnostic accuracy of POCUS performed by pediatric emergency physicians in detecting hip effusion.
They found that POCUS had a sensitivity of 89.3% (95% CI 80.6 to 95.0%) and specificity of 99.2% (95% CI 97.0 to 99.9%).
To scan the hip:
-Position the patient supine with the patient’s hip externally rotated.
-Place the probe transversely across the patient’s leg with the marker towards the patient’s right and scan proximally.
-Upon reaching the proximal femur, rotate the probe marker so it points towards the patient’s umbilicus.
-Look for an anechoic stripe at the femoral neck, preceding the femoral head.
An anechoic stripe measuring at least 5 mm in the anterior synovial space or an asymmetry exceeding 2 mm compared to the opposite, asymptomatic hip is diagnostic for hip effusion in BOTH pediatric and adult populations.
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.
NSAIDs are first line analgesic medications for many pain related ED presentations
All NSAIDs are not created equal in their side effect profile
Ibuprofen and ketorolac are both commonly used NSAIDs in the ED
A 2010 review looked at relative risk estimates of individual NSAIDs and associated upper GI bleeding/perforation.
Definitions: Most of included studies included patients with NSAID use within prior week and daignosed upper GI bleed admitted to the hospital.
Daily use predicted increased risk.
In comparison between these two common medications Ibuprofen and Ketorolac: RR as follows
Ibuprofen (2.69 [95% CI 2.17-3.33]) vs ketorolac (14.54 [95% CI 5.87-36.04])
Ketorolac has approximately double the half life of ibuprofen
Other commonly used ED medications were also included:
RRs:
Naproxen 5.63 (95% CI 3.83-8.28)
Indomethacin 5.40 (95% CI 4.16-7.00)
Meloxicam 4.15 (95% CI 2.59-6.64)
Diclofenac 3.98 (95% CI 3.36-4.72)
Conclusion: The risk of upper GI bleeding varies between individual NSAIDs at the doses commonly used in the general population. When possible, consider the relative risk of a particular NSAID when making a selection.
