Emergency medicine updates: Lower gastrointestinal bleeding.

INTRODUCTION: Lower gastrointestinal bleeding (LGIB) is a condition commonly seen in the emergency department. Therefore, it is important for emergency medicine clinicians to be aware of the current evidence regarding the diagnosis and management of this disease. OBJECTIVE: This paper evaluates key evidence-based updates concerning LGIB for the emergency clinician. DISCUSSION: LGIB is most commonly due to diverticulosis or anorectal disease, though there are a variety of etiologies. The majority of cases resolve spontaneously, but patients can have severe bleeding resulting in hemodynamic instability. Initial evaluation should focus on patient hemodynamics, the severity of bleeding, and differentiating upper gastrointestinal bleeding from LGIB. Factors associated with LGIB include prior history of LGIB, age over 50 years, and presence of blood clots per rectum. Computed tomography angiography is the imaging modality of choice in those with severe bleeding to diagnose the source of bleeding and guide management when embolization is indicated. Among stable patients without severe bleeding, colonoscopy is the recommended modality for diagnosis and management. A transfusion threshold of 7 g/dL hemoglobin is recommended based on recent data and guidelines (8 g/dL in those with myocardial ischemia), though patients with severe bleeding and hemodynamic instability should undergo emergent transfusion. Anticoagulation reversal may be necessary. If bleeding does not resolve, embolization or endoscopic therapies are necessary. There are several risk scores that can predict the risk of adverse outcomes; however, these scores should not replace clinical judgment in determining patient disposition. CONCLUSIONS: An understanding of literature updates can improve the care of patients with LGIB.

Emergency medicine updates: Upper gastrointestinal bleeding.

INTRODUCTION: Upper gastrointestinal bleeding (UGIB) is a condition commonly seen in the emergency department (ED). Therefore, it is important for emergency clinicians to be aware of the current evidence regarding the diagnosis and management of this disease. OBJECTIVE: This paper evaluates key evidence-based updates concerning UGIB for the emergency clinician. DISCUSSION: UGIB most frequently presents with hematemesis. There are numerous causes, with the most common peptic ulcer disease, though variceal bleeding in particular can be severe. Nasogastric tube lavage for diagnosis is not recommended based on the current evidence. A hemoglobin transfusion threshold of 7 g/dL is recommended (8 g/dL in those with myocardial ischemia), but patients with severe bleeding and hemodynamic instability require emergent transfusion regardless of their level. Medications that may be used in UGIB include proton pump inhibitors, prokinetic agents, and vasoactive medications. Antibiotics are recommended for those with cirrhosis and suspected variceal bleeding. Endoscopy is the diagnostic and therapeutic modality of choice and should be performed within 24 h of presentation in non-variceal bleeding after resuscitation, though patients with variceal bleeding may require endoscopy within 12 h. Transcatheter arterial embolization or surgical intervention may be necessary. Intubation should be avoided if possible. If intubation is necessary, several considerations are required, including resuscitation prior to induction, utilizing preoxygenation and appropriate suction, and administering a prokinetic agent. There are a variety of tools available for risk stratification, including the Glasgow Blatchford Score. CONCLUSIONS: An understanding of literature updates can improve the ED care of patients with UGIB.

Epidemiology of back pain visits and medication usage among United States emergency departments from 2016 to 2023.

INTRODUCTION: Low back pain is a common reason for presentation to the Emergency Department (ED). However, there are limited large-scale, recent data on the epidemiology, disposition, and medication administration for this condition. The objective of this was to assess the incidence, admission rates, medication administrations, and discharge prescriptions among ED visits for low back pain in the United States. METHODS: This was a cross-sectional study of ED presentations for low back pain from 1/1/2016 to 12/31/2023 using the Epic Cosmos database. All ED visits for adults with low back pain identified by ICD-10 codes were included. Outcomes included admission rates, distribution of opioid, benzodiazepine, (non-benzodiazepine) muscle relaxant, acetaminophen, NSAID, and corticosteroid medications administered in the ED, and distribution of opioid, benzodiazepine, muscle relaxant, and corticosteroid medications given upon discharge. Subgroup analyses were performed by specific medication. RESULTS: Of 207,154,419 ED encounters, 12,241,240 (5.9%) were due to back pain with 1,957,299 of these (16.0%) admitted. The admission rate increased over time from 12.8% to 17.1%. The most common medication given in the ED was opioids (40.7%), followed by acetaminophen (37.8%), NSAIDs (22.6%), muscle relaxants (18.4%) benzodiazepines (12.8%), and corticosteroids (5.5%). The most common medications prescribed upon discharge were muscle relaxants (32.1%), followed by opioids (23.2%), corticosteroids (12.2%), and benzodiazepines (3.0%). CONCLUSION: Low back pain represents a common reason for presentation to the ED, and admissions have been increasing over time. Opioids remain the most common ED medication, whereas muscle relaxants have arisen as the most common discharge prescription. These findings can help inform health policy decisions, resource allocation, and evidence-based interventions for medication administration.

Emergency medicine updates: Acute diverticulitis.

INTRODUCTION: Acute diverticulitis is a condition commonly seen in the emergency department (ED). Therefore, it is important for emergency medicine clinicians to be aware of the current evidence regarding the diagnosis and management of this disease. OBJECTIVE: This paper evaluates key evidence-based updates concerning acute diverticulitis for the emergency clinician. DISCUSSION: Diverticulitis is a complication of diverticulosis and most commonly affects the sigmoid and descending colon in Western countries. History and examination can suggest the diagnosis, with abdominal pain and tenderness in the left lower quadrant being the most common symptom and sign, respectively. Change in bowel habits and fever may also occur. Laboratory testing may demonstrate leukocytosis or an elevated C-reactive protein. Imaging options can include computed tomography (CT) of the abdomen and pelvis with intravenous contrast, magnetic resonance imaging (MRI), or ultrasound (US), though most classification systems for diverticulitis incorporate CT findings. While the majority of diverticulitis cases are uncomplicated, complications may affect up to 25% of patients. Treatment of complicated diverticulitis requires antibiotics and surgical consultation. Antibiotics are not required in select patients with uncomplicated diverticulitis. Appropriate patients for supportive care without antibiotics should be well-appearing, have pain adequately controlled, be able to tolerate oral intake, be able to follow up, have no complications, and have no immunocompromise or severe comorbidities. CONCLUSIONS: An understanding of literature updates can improve the ED care of patients with acute diverticulitis.

Emergency medicine updates: Transient ischemic attack.

INTRODUCTION: Transient ischemic attack (TIA) is a condition commonly evaluated for in the emergency department (ED). Therefore, it is important for emergency clinicians to be aware of the current evidence regarding the diagnosis and management of this disease. OBJECTIVE: This paper evaluates key evidence-based updates concerning TIA for the emergency clinician. DISCUSSION: TIA is a harbinger of ischemic stroke and can result from a variety of pathologic causes. While prior definitions incorporated symptoms resolving within 24 h, modern definitions recommend a tissue-based definition utilizing advanced imaging to evaluate for neurologic injury and the etiology. In the ED, emergent evaluation includes assessing for current signs and symptoms of neurologic dysfunction, appropriate imaging to investigate for minor stroke or stroke risk, and arranging appropriate disposition and follow up to mitigate risk of subsequent ischemic stroke. Imaging should include evaluation of great vessels and intracranial arteries, as well as advanced cerebral imaging to evaluate for minor or subclinical stroke. Non-contrast computed tomography (CT) has limited utility for this situation; it can rule out hemorrhage or a large mass causing symptoms but should not be relied on for any definitive diagnosis. Noninvasive imaging of the cervical vessels can also be used (CT angiography or Doppler ultrasound). Treatment includes antithrombotic medications if there are no contraindications. Dual antiplatelet therapy may reduce the risk of recurrent ischemic events in higher risk patients, while anticoagulation is recommended in patients with a cardioembolic source. A variety of scoring systems or tools are available that seek to predict stroke risk after a TIA. The Canadian TIA risk score appears to have the best diagnostic accuracy. However, these scores should not be used in isolation. Disposition may include admission, management in an ED-based observation unit with rapid diagnostic protocol, or expedited follow-up in a specialty clinic. CONCLUSIONS: An understanding of literature updates concerning TIA can improve the ED care of patients with TIA.

Ultrasound-guided paramedian approach: A novel technique for lumbar puncture in the Emergency Department.

Lumbar puncture is performed to evaluate for multiple neurologic conditions, including meningitis and subarachnoid hemorrhage. However, success rates with the landmark-based technique are limited. Ultrasound is most commonly used for pre-marking without dynamic guidance, which presents several limitations, including absence of real-time guidance and lack of reliability if any patient movement occurs after skin marking. We describe a novel, ultrasound-guided paramedian approach which was successfully performed in the Emergency Department setting for lumbar puncture. Physicians should consider this technique as an alternate model using real-time guidance to reduce needle passes in those with difficult anatomy.

Artificial intelligence and point-of-care ultrasound: Benefits, limitations, and implications for the future.

The utilization of artificial intelligence (AI) in medical imaging has become a rapidly growing field as a means to address contemporary demands and challenges of healthcare. Among the emerging applications of AI is point-of-care ultrasound (POCUS), in which the combination of these two technologies has garnered recent attention in research and clinical settings. In this Controversies paper, we will discuss the benefits, limitations, and future considerations of AI in POCUS for patients, clinicians, and healthcare systems.

Malaria: A focused review for the emergency medicine clinician.

INTRODUCTION: Malaria is a potentially fatal parasitic disease transmitted by the Anopheles mosquito. A resurgence in locally acquired infections has been reported in the U.S. OBJECTIVE: This narrative review provides a focused overview of malaria for the emergency clinician, including the epidemiology, presentation, diagnosis, and management of the disease. DISCUSSION: Malaria is caused by Plasmodium and is transmitted by the Anopheles mosquito. Disease severity can range from mild to severe. Malaria should be considered in any returning traveler from an endemic region, as well as those with unexplained cyclical, paroxysms of symptoms or unexplained fever. Patients most commonly present with fever and rigors but may also experience cough, myalgias, abdominal pain, fatigue, vomiting, and diarrhea. Hepatomegaly, splenomegaly, pallor, and jaundice are findings associated with malaria. Although less common, severe malaria is precipitated by microvascular obstruction with complications of anemia, acidosis, hypoglycemia, multiorgan failure, and cerebral malaria. Peripheral blood smears remain the gold standard for diagnosis, but rapid diagnostic tests are available. Treatment includes specialist consultation and antimalarial drugs tailored depending on chloroquine resistance, geographic region of travel, and patient comorbidities. Supportive care may be required, and patients with severe malaria will require resuscitation. Most patients will require admission for treatment and further monitoring. CONCLUSION: Emergency medicine clinicians should be aware of the presentation, diagnosis, evaluation, and management of malaria to ensure optimal outcomes.

Transvenous Pacemaker Placement: A Review for Emergency Clinicians.

BACKGROUND: Transvenous pacemaker placement is an integral component of therapy for severe dysrhythmias and a core skill in emergency medicine. OBJECTIVE: This narrative review provides a focused evaluation of transvenous pacemaker placement in the emergency department setting. DISCUSSION: Temporary cardiac pacing can be a life-saving procedure. Indications for pacemaker placement include hemodynamic instability with symptomatic bradycardia secondary to atrioventricular block and sinus node dysfunction; overdrive pacing in unstable tachydysrhythmias, such as torsades de pointes; and failure of transcutaneous pacing. Optimal placement sites include the right internal jugular vein and left subclavian vein. Insertion first includes placement of a central venous catheter. The pacing wire with balloon is then advanced until electromechanical capture is obtained with the pacer in the right ventricle. Ultrasound can be used to guide and confirm lead placement using the subxiphoid or modified subxiphoid approach. The QRS segment will demonstrate ST segment elevation once the pacing wire tip contacts the endocardial wall. If mechanical capture is not achieved with initial placement of the transvenous pacer, the clinician must consider several potential issues and use an approach to evaluating the equipment and correcting any malfunction. Although life-saving in the appropriate patient, complications may occur from central venous access, right heart catheterization, and the pacing wire. CONCLUSIONS: An understanding of transvenous pacemaker placement is essential for emergency clinicians.

Analgesic Techniques for Managing Orthopedic Injuries: A Review for the Emergency Clinician.

BACKGROUND: Orthopedic injuries are commonly managed in the emergency department (ED) setting. Fractures and dislocations may require reduction for proper management. There are a variety of analgesic and sedative strategies to provide patient comfort during reduction. OBJECTIVE: This narrative review evaluates hematoma block, intra-articular injection, intravenous regional analgesia (IVRA) (also known as the Bier block), and periosteal block for orthopedic analgesia in the ED setting. DISCUSSION: Analgesia is an essential component of management of orthopedic injuries, particularly when reduction is necessary. Options in the ED setting include hematoma blocks, intra-articular injections, IVRA, and periosteal blocks, which provide adequate analgesia without procedural sedation or opioid administration. When used in isolation, these analgesic techniques decrease complications from sedation and the need for other medications, such as opioids, while decreasing ED length of stay. Emergency clinicians can also use these techniques as analgesic adjuncts. However, training in these techniques is recommended prior to routine use, particularly with IVRA. CONCLUSIONS: Knowledge of analgesic techniques for orthopedic procedures can assist clinicians in optimizing patient care.

Three-Month Symptom Profiles Among Symptomatic Adults With Positive and Negative Severe Acute Respiratory Syndrome Coronavirus 2 Tests: A Prospective Cohort Study From the INSPIRE Group.

BACKGROUND: Long-term symptoms following severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection are a major concern, yet their prevalence is poorly understood. METHODS: We conducted a prospective cohort study comparing adults with SARS-CoV-2 infection (coronavirus disease-positive [COVID+]) with adults who tested negative (COVID-), enrolled within 28 days of a Food and Drug Administration (FDA)-approved SARS-CoV-2 test result for active symptoms. Sociodemographic characteristics, symptoms of SARS-CoV-2 infection (assessed with the Centers for Disease Control and Prevention [CDC] Person Under Investigation Symptom List), and symptoms of post-infectious syndromes (ie, fatigue, sleep quality, muscle/joint pains, unrefreshing sleep, and dizziness/fainting, assessed with CDC Short Symptom Screener for myalgic encephalomyelitis/chronic fatigue syndrome) were assessed at baseline and 3 months via electronic surveys sent via text or email. RESULTS: Among the first 1000 participants, 722 were COVID+ and 278 were COVID-. Mean age was 41.5 (SD 15.2); 66.3% were female, 13.4% were Black, and 15.3% were Hispanic. At baseline, SARS-CoV-2 symptoms were more common in the COVID+ group than the COVID- group. At 3 months, SARS-CoV-2 symptoms declined in both groups, although were more prevalent in the COVID+ group: upper respiratory symptoms/head/eyes/ears/nose/throat (HEENT; 37.3% vs 20.9%), constitutional (28.8% vs 19.4%), musculoskeletal (19.5% vs 14.7%), pulmonary (17.6% vs 12.2%), cardiovascular (10.0% vs 7.2%), and gastrointestinal (8.7% vs 8.3%); only 50.2% and 73.3% reported no symptoms at all. Symptoms of post-infectious syndromes were similarly prevalent among the COVID+ and COVID- groups at 3 months. CONCLUSIONS: Approximately half of COVID+ participants, as compared with one-quarter of COVID- participants, had at least 1 SARS-CoV-2 symptom at 3 months, highlighting the need for future work to distinguish long COVID. CLINICAL TRIALS REGISTRATION: NCT04610515.

Severe Fatigue and Persistent Symptoms at 3 Months Following Severe Acute Respiratory Syndrome Coronavirus 2 Infections During the Pre-Delta, Delta, and Omicron Time Periods: A Multicenter Prospective Cohort Study.

BACKGROUND: Most research on severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variants focuses on initial symptomatology with limited longer-term data. We characterized prevalences of prolonged symptoms 3 months post-SARS-CoV-2 infection across 3 variant time-periods (pre-Delta, Delta, and Omicron). METHODS: This multicenter prospective cohort study of adults with acute illness tested for SARS-CoV-2 compared fatigue severity, fatigue symptoms, organ system-based symptoms, and ≥3 symptoms across variants among participants with a positive ("COVID-positive") or negative SARS-CoV-2 test ("COVID-negative") at 3 months after SARS-CoV-2 testing. Variant periods were defined by dates with ≥50% dominant strain. We performed multivariable logistic regression modeling to estimate independent effects of variants adjusting for sociodemographics, baseline health, and vaccine status. RESULTS: The study included 2402 COVID-positive and 821 COVID-negative participants. Among COVID-positives, 463 (19.3%) were pre-Delta, 1198 (49.9%) Delta, and 741 (30.8%) Omicron. The pre-Delta COVID-positive cohort exhibited more prolonged severe fatigue (16.7% vs 11.5% vs 12.3%; P = .017) and presence of ≥3 prolonged symptoms (28.4% vs 21.7% vs 16.0%; P < .001) compared with the Delta and Omicron cohorts. No differences were seen in the COVID-negatives across time-periods. In multivariable models adjusted for vaccination, severe fatigue and odds of having ≥3 symptoms were no longer significant across variants. CONCLUSIONS: Prolonged symptoms following SARS-CoV-2 infection were more common among participants infected during pre-Delta than with Delta and Omicron; however, these differences were no longer significant after adjusting for vaccination status, suggesting a beneficial effect of vaccination on risk of long-term symptoms. Clinical Trials Registration. NCT04610515.

Prevalence of Symptoms ≤12 Months After Acute Illness, by COVID-19 Testing Status Among Adults - United States, December 2020-March 2023.

To further the understanding of post-COVID conditions, and provide a more nuanced description of symptom progression, resolution, emergence, and reemergence after SARS-CoV-2 infection or COVID-like illness, analysts examined data from the Innovative Support for Patients with SARS-CoV-2 Infections Registry (INSPIRE), a prospective multicenter cohort study. This report includes analysis of data on self-reported symptoms collected from 1,296 adults with COVID-like illness who were tested for SARS-CoV-2 using a Food and Drug Administration-approved polymerase chain reaction or antigen test at the time of enrollment and reported symptoms at 3-month intervals for 12 months. Prevalence of any symptom decreased substantially between baseline and the 3-month follow-up, from 98.4% to 48.2% for persons who received a positive SARS-CoV-2 test results (COVID test-positive participants) and from 88.2% to 36.6% for persons who received negative SARS-CoV-2 test results (COVID test-negative participants). Persistent symptoms decreased through 12 months; no difference between the groups was observed at 12 months (prevalence among COVID test-positive and COVID test-negative participants = 18.3% and 16.1%, respectively; p>0.05). Both groups reported symptoms that emerged or reemerged at 6, 9, and 12 months. Thus, these symptoms are not unique to COVID-19 or to post-COVID conditions. Awareness that symptoms might persist for up to 12 months, and that many symptoms might emerge or reemerge in the year after COVID-like illness, can assist health care providers in understanding the clinical signs and symptoms associated with post-COVID-like conditions.

Diagnosis and Management of Monkeypox: A Review for the Emergency Clinician.

The outbreak of monkeypox in May and June 2022 is the largest outside of central and western Africa since the 2003 outbreak in the United States. Monkeypox, like smallpox, is caused by an orthopoxvirus, though its clinical manifestations tend to be less severe. It is characterized by a prodromal flu-like illness with lymphadenopathy followed by a centrifugally spreading rash, sometimes involving the face, palms, soles, and oral mucosa. Although the vast majority of cases resolve with symptomatic management, a small number of patients can suffer severe outcomes including, but not limited to, secondary bacterial skin infections, pneumonitis, ocular sequelae, encephalitis, hypovolemia, and death. Local, state, and federal health authorities should be involved in the care of people under investigation for this illness. With confirmed cases worldwide and the possibility of community spread, emergency clinicians need to be aware of the manifestations and management of this disease, both to treat those with the disease as well as to provide education to those exposed and at risk of infection.

Characteristics of Emergency Medicine Residency Programs With Unfilled Positions in the 2023 Match.

STUDY OBJECTIVE: The unprecedented number of unfilled emergency medicine post-graduate year 1 (PGY-1) residency positions in the 2023 National Resident Matching Program shocked the emergency medicine community. This study investigates the association between emergency medicine program characteristics and the likelihood of unfilled positions in the 2023 Match. METHODS: This cross-sectional, observational study examined 2023 National Resident Matching Program data, focusing on program type, length, location, size, proximity to other programs, previous American Osteopathic Association (AOA) accreditation, first accreditation year, and emergency department ownership structure. We constructed a generalized linear mixed model with a logistic linking function to determine predictors of unfilled positions. RESULTS: A total of 554 of 3,010 (18.4%) PGY-1 positions at 131 of 276 (47%) emergency medicine programs went unfilled in the 2023 Match. In our model, predictors included having unfilled positions in the 2022 Match (odds ratio [OR] 48.14, 95% confidence interval [CI] 21.04 to 110.15), smaller program size (less than 8 residents, OR 18.39, 95% CI 3.90 to 86.66; 8 to 10 residents, OR 6.29, 95% CI 1.50 to 26.28; 11 to 13 residents, OR 5.88, 95% CI 1.55 to 22.32), located in the Mid Atlantic (OR 14.03, 95% CI 2.56 to 77.04) area, prior AOA accreditation (OR 10.13, 95% CI 2.82 to 36.36), located in the East North Central (OR 6.94, 95% CI 1.25 to 38.47) area, and corporate ownership structure (OR 3.21, 95% CI 1.06 to 9.72). CONCLUSION: Our study identified 6 characteristics associated with unfilled emergency medicine residency positions in the 2023 Match. These findings may be used to guide student advising and inform decisions by residency programs, hospitals, and national organizations to address the complexities of residency recruitment and implications for the emergency medicine workforce.

Head impulse, nystagmus, and test of skew examination for diagnosing central causes of acute vestibular syndrome.

BACKGROUND: Dizziness is a common reason for people to seek medical care. Acute vestibular syndrome (AVS) is a specific type of dizziness, which can include severe vertigo, nausea and vomiting, nystagmus, or unsteadiness. Acute vestibular syndrome can be due to peripheral or central causes. It is important to determine the cause, as the intervention and outcomes differ if it is from a peripheral or central cause. Clinicians can assess for the cause using risk factors, patient history, examination findings, or advanced imaging, such as a magnetic resonance imaging (MRI). The head impulse, nystagmus, test of skew (HINTS) examination is a three-part examination performed by clinicians to determine if AVS is due to a peripheral or central cause. This includes assessing how the eyes move in response to rapidly turning a person's head (head impulse), assessing the direction of involuntary eye movements (nystagmus), and assessing whether the eyes are aligned or misaligned (test of skew). The HINTS Plus examination includes an additional assessment of auditory function. OBJECTIVES: To assess the diagnostic accuracy of the HINTS and HINTS Plus examinations, with or without video assistance, for identifying a central etiology for AVS. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, Google Scholar, the International HTA database, and two trials registers to September 2022. SELECTION CRITERIA: We included all retrospective and prospective diagnostic test accuracy studies that evaluated the HINTS or HINTS Plus test used in a primary care clinic, an urgent care clinic, the emergency department, or during inpatient hospitalization against a final diagnosis of a central etiology of AVS, as defined by the reference standard of advanced imaging or final diagnosis by a neurologist. DATA COLLECTION AND ANALYSIS: Two review authors independently determined eligibility of each study according to eligibility criteria, extracted data, assessed the risk of bias, and determined the certainty of evidence. Disagreements were adjudicated by consensus or a third review author if needed. The primary outcome was the diagnostic accuracy of the HINTS and HINTS Plus examinations for identifying a central etiology for AVS, conducted clinically (clinician visual assessment) or with video assistance (e.g. video recording with goggles); we independently assessed the clinical and video-assisted examinations. Subgroup analyses were performed by provider type (e.g. physicians, non-physicians), time from symptom onset to presentation (e.g. less than 24 hours, longer than 24 hours), reference standard (e.g. advanced imaging, discharge diagnosis), underlying etiology (e.g. ischemic stroke, alternative etiologies [hemorrhagic stroke, intracranial mass]), study setting (e.g. outpatient [outpatient clinic, urgent care clinic, emergency department], inpatient), physician level of training (e.g. resident, fellow/attending), physician specialty (e.g. otolaryngology, emergency medicine, neurology, and neurologic subspecialist [e.g. neuro-ophthalmology, neuro-otology]), and individual diagnostic accuracy of each component of the examination (e.g. head impulse, direction-changing nystagmus, test of skew). We created 2 x 2 tables of the true positives, true negatives, false positives, and false negatives and used these data to calculate the sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio with 95% confidence intervals (95% CI) for each outcome. MAIN RESULTS: We included 16 studies with a total of 2024 participants (981 women and 1043 men) with a mean age of 60 years. Twelve studies assessed the HINTS examination; five assessed the HINTS Plus examination. Thirteen studies were performed in the emergency department; half were performed by neurologists. The clinical HINTS examination (12 studies, 1890 participants) was 94.0% (95% confidence interval [CI] 82.0% to 98.2%) sensitive, and 86.9% (95% CI 75.3% to 93.6%) specific (low-certainty evidence). The video-assisted HINTS examination (3 studies, 199 participants) was 85.0% to 100% sensitive (low-certainty evidence), and 38.9% to 100% specific (very low-certainty evidence). The clinical HINTS Plus examination (5 studies, 451 participants) was 95.3% (95% CI 78.4% to 99.1%) sensitive, and 72.9% (95% CI 44.4% to 90.1%) specific (low-certainty evidence). The video-assisted HINTS Plus examination (2 studies, 163 participants) was 85.0% to 93.8% sensitive, and 28.6% to 38.9% specific (moderate-certainty evidence). Subgroup analyses were limited, as most studies were conducted in the emergency department, by physicians, and with MRI as a reference standard. Time from symptom onset to presentation varied across studies. Three studies were at high risk of bias and three studies were at unclear risk of bias for participant selection. Three studies were at unclear risk of bias for the index test. Four studies were at unclear risk of bias for the reference standard. Two studies were at unclear risk of bias for flow and timing. One study had unclear applicability concerns for participant selection. Two studies had high applicability concerns for the index test and two studies had unclear applicability concerns for the index test. No studies had applicability concerns for the reference standard. AUTHORS' CONCLUSIONS: The HINTS and HINTS Plus examinations had good sensitivity and reasonable specificity for diagnosing a central cause for AVS in the emergency department when performed by trained clinicians. Overall, the evidence was of low certainty. There were limited data for the role of video-assistance or specific subgroups. Future research should include more high-quality studies of the HINTS and HINTS Plus examination; assessment of inter-rater reliability across users; accuracy across different providers, specialties, and experience; and direct comparison with no HINTS or MRI to assess the effect on clinical care.

Emergency medicine updates: Spontaneous bacterial peritonitis.

INTRODUCTION: Spontaneous bacterial peritonitis (SBP) is a common infection in patients with cirrhosis and ascites and is associated with significant risk of mortality. Therefore, it is important for emergency medicine clinicians to be aware of the current evidence regarding the diagnosis and management of this condition. OBJECTIVE: This paper evaluates key evidence-based updates concerning SBP for the emergency clinician. DISCUSSION: SBP is commonly due to Gram-negative bacteria, but infections due to Gram-positive bacteria and multidrug resistant bacteria are increasing. The typical presentation of SBP includes abdominal pain, worsening ascites, fever, or altered mental status in a patient with known liver disease; however, some patients may be asymptomatic or present with only mild symptoms. Paracentesis is the diagnostic modality of choice and should be performed in any patient with ascites and concern for SBP or upper gastrointestinal bleeding, or in those being admitted for a complication of cirrhosis. Ultrasound should be used to optimize the procedure. An ascites absolute neutrophil count (ANC) ≥ 250 cells/mm3 is diagnostic of SBP. Ascitic fluid should be placed in blood culture bottles to improve the culture yield. Leukocyte esterase reagent strips can be used for rapid diagnosis if available. While many patients will demonstrate coagulation panel abnormalities, routine transfusion is not recommended. Management traditionally includes a third-generation cephalosporin, but specific patient populations may require more broad-spectrum coverage with a carbapenem or piperacillin-tazobactam. Albumin infusion is associated with reduced risk of renal impairment and mortality. CONCLUSIONS: An understanding of literature updates can improve the care of patients with suspected SBP.

Distribution of emergency medicine programs by location and reproductive rights: A cross-sectional study of the 2023 Match.

INTRODUCTION: The 2023 Match saw over 500 unfilled positions in emergency medicine (EM). Geographic location is the third most important factor for all United States (US) EM-bound senior medical students when selecting programs to rank and can be affected by political climate. Given the perceived importance of geography on program selection and recent changes to reproductive rights in the US, we sought to evaluate the impact of geography and reproductive rights on unmatched positions among EM programs. METHODS: This was a cross-sectional study assessing Match rates in EM by program US state, region, and degree of reproductive rights. We included all EM programs participating in the 2023 Match year. Our primary outcome was to determine the unfilled programs and positions rate per US state. Secondary outcomes included Match rates by region and by degree of reproductive rights. RESULTS: We found notable differences in unfilled programs by US state, with the highest percentage of unfilled programs and positions in Arkansas (100%, 56.3%), Nevada (100%, 35.5%), Kansas (100%, 40.0%), Ohio (81.3%, 33.3%), and Michigan (80.0%, (36.8%). Among regions, the highest percentage of unfilled programs (62.5%) and residency positions (26.0%) was East North Central (IL, IN, MI, OH, WI). US states with limited reproductive rights had the highest percent (52.9%) of programs with unmatched positions and the highest percent (20.5%) of unfilled positions. CONCLUSION: We identified notable differences in unmatched positions by US state and region, as well as the highest rate of unmatched positions in US states with more limited reproductive rights.

Crush injury and syndrome: A review for emergency clinicians.

INTRODUCTION: Primary disasters may result in mass casualty events with serious injuries, including crush injury and crush syndrome. OBJECTIVE: This narrative review provides a focused overview of crush injury and crush syndrome for emergency clinicians. DISCUSSION: Millions of people worldwide annually face natural or human-made disasters, which may lead to mass casualty events and severe medical issues including crush injury and syndrome. Crush injury is due to direct physical trauma and compression of the human body, most commonly involving the lower extremities. It may result in asphyxia, severe orthopedic injury, compartment syndrome, hypotension, and organ injury (including acute kidney injury). Crush syndrome is the systemic manifestation of severe, traumatic muscle injury. Emergency clinicians are at the forefront of the evaluation and treatment of these patients. Care at the incident scene is essential and focuses on treating life-threatening injuries, extrication, triage, fluid resuscitation, and transport. Care at the healthcare facility includes initial stabilization and trauma evaluation as well as treatment of any complication (e.g., compartment syndrome, hyperkalemia, rhabdomyolysis, acute kidney injury). CONCLUSIONS: Crush injury and crush syndrome are common in natural and human-made disasters. Emergency clinicians must understand the pathophysiology, evaluation, and management of these conditions to optimize patient care.

Emergency medicine updates: Atrial fibrillation with rapid ventricular response.

INTRODUCTION: Atrial fibrillation (AF) may lead to stroke, heart failure, and death. When AF occurs in the context of a rapid ventricular rate/response (RVR), this can lead to complications, including hypoperfusion and cardiac ischemia. Emergency physicians play a key role in the diagnosis and management of this dysrhythmia. OBJECTIVE: This paper evaluates key evidence-based updates concerning AF with RVR for the emergency clinician. DISCUSSION: Differentiating primary and secondary AF with RVR and evaluating hemodynamic stability are vital components of ED assessment and management. Troponin can assist in determining the risk of adverse outcomes, but universal troponin testing is not required in patients at low risk of acute coronary syndrome or coronary artery disease - especially patients with recurrent episodes of paroxysmal AF that are similar to their prior events. Emergent cardioversion is indicated in hemodynamically unstable patients. Rate or rhythm control should be pursued in hemodynamically stable patients. Elective cardioversion is a safe option for select patients and may reduce AF symptoms and risk of AF recurrence. Rate control using beta blockers or calcium channel blockers should be pursued in those with AF with RVR who do not undergo cardioversion. Anticoagulation is an important component of management, and several tools (e.g., CHA2DS2-VASc) are available to assist with this decision. Direct oral anticoagulants are the first-line medication class for anticoagulation. Disposition can be challenging, and several risk assessment tools (e.g., RED-AF, AFFORD, and the AFTER (complex, modified, and pragmatic) scores) are available to assist with disposition decisions. CONCLUSION: An understanding of the recent updates in the literature concerning AF with RVR can assist emergency clinicians in the care of these patients.