BACKGROUND:Acetaminophen overdose remains one of the leading causes of both intentional and unintentional medication-related liver injury and acute liver failure in both adults and children. Although N-acetylcysteine remains the standard of care and is highly effective when administered early, massive ingestions and delayed presentation cases may exceed its ability to prevent hepatocellular injury. Fomepizole, a CYP2E1 inhibitor traditionally used for toxic alcohol poisoning, has emerged as a potential adjunctive therapy for high-risk acetaminophen overdoses. OBJECTIVE:This article reviews the mechanism of action of acetaminophen, the pathophysiology of acetaminophen-induced hepatotoxicity, outlines current management strategies, and examines the emerging role of fomepizole as an adjunctive therapy. Added focus is given to implications for nursing practice, including safe preparation, administration, and monitoring. SUMMARY:Acetaminophen toxicity develops when glutathione stores become depleted, leading to accumulation of the toxic metabolite N-acetyl-p-benzoquinone imine. N-acetylcysteine replenishes glutathione and mitigates early injury; however, extremely high acetaminophen concentrations can overwhelm detoxification pathways. Fomepizole inhibits CYP2E1 and reduces conversion of acetaminophen to N-acetyl-p-benzoquinone imine, potentially limiting hepatic damage. Evidence from animal studies and small human case series suggests benefit in massive ingestions, although large, randomized-controlled trials are lacking. IMPLICATIONS:Further research is needed to establish and standardize protocols and further clarify the role of fomepizole in the management of acetaminophen overdose cases.
ABSTRACT:Patients presenting to the emergency department (ED) with suspected acute coronary syndrome (ACS) require immediate acquisition of a 12-lead electrocardiogram (ECG) to support early diagnosis and clinical decision making. Acute coronary syndrome includes ST-elevation myocardial infarction, non-ST-elevation myocardial infarction, and unstable angina. However, symptoms consistent with ACS may also include arrhythmias, such as premature ventricular contractions, atrial fibrillation, or supraventricular tachycardia. Accurate and timely ECG interpretation is essential for prompt risk stratification and initiation of appropriate management of the detected arrhythmia. The diagnostic accuracy of the ECG is highly dependent on signal quality, particularly the signal-to-noise ratio and the presence of artifacts from patient movement and monitoring equipment. Poor signal fidelity may contribute to misinterpretation and false-positive coronary activation. This literature review examines studies published over the past 5 years that evaluate advancements in ECG electrode technology and artifact-reduction strategies, including algorithm-based approaches, relative to conventional ECG systems. A review of current best practices for skin electrode optimization is also summarized.
ABSTRACT:Outpatient settings, including emergency departments, urgent care centers, and primary care clinics in underserved communities, face persistent workforce instability because of high patient volumes, limited resources, and burnout. This qualitative single-site case study explored retention strategies as perceived by Hispanic Generation Z employees working in a rural primary care clinic near the US-Mexico border. Semi-structured interviews were conducted with 12 medical assistants and analyzed using thematic analysis. Four themes influencing retention emerged: feeling appreciated and recognized, psychologically safe workplace relationships, flexibility with opportunities for professional growth, and cultural affirmation and belonging. Although conducted in an outpatient setting, the findings have conceptual relevance to the broader direct patient-care workforce. Results underscore the importance of relational, cultural, and developmental factors often overlooked in retention strategies that emphasize structural or operational solutions. Culturally responsive approaches may enhance workforce well-being, improve team stability, and support sustainable care delivery in underserved communities.
OBJECTIVE:The purpose of this narrative review was to review existing literature to determine a consensus of established best practices to mitigate the risks of boarding geriatric and high acuity patients. METHODS:The PubMed database was searched using the following key terms: quality care, inpatient boarding, emergency department, nursing care, and access block. RESULTS:Fourteen articles were reviewed, identifying quality and safety concerns, organizational imperatives, and potential solutions. CONCLUSION:The care of boarding patients poses unique challenges for hospitals, physicians, and nurses. Organizational priorities should include strategies to minimize boarding in the ED and interventions to improve the quality and consistency of care when boarding cannot be avoided. Discharge lounges, a popular alternative, fail to demonstrate a return on investment or improved throughput.
ABSTRACT:Anisocoria, characterized by unequal pupil diameters typically ranging from 0.3 mm to over 2.0 mm, represents a clinically significant finding that requires thorough evaluation in the emergency department. This asymmetry may indicate dysfunction of the cranial nerves or iris musculature, thereby providing valuable insight into the integrity of the autonomic nervous system. Although anisocoria may be physiologic or benign, it can also serve as a warning sign of severe neurologic or ophthalmologic pathology, including intracranial hemorrhage, oculomotor nerve palsy, or Horner syndrome. In the absence of overt trauma, the diagnostic process may be complicated by a lack of clear clinical indicators, potentially delaying appropriate intervention. Timely recognition and accurate differentiation between benign and pathologic causes are critical, given the association of anisocoria with high-risk neurologic emergencies, pharmacologic influences, and considerable patient distress. This case report details the presentation of a previously healthy 40-year-old man who arrived at the emergency department with acute-onset anisocoria. It includes a comprehensive review of the underlying pathophysiology, clinical manifestations, diagnostic algorithms, and therapeutic considerations. Particular emphasis is placed on the role of a meticulous history and focused physical examination in guiding prompt and effective clinical decision making.
ABSTRACT:The Research to Practice column is intended to improve the research critique skills of the advanced practice registered nurse (APRN) and the emergency nurse (RN) and to assist with the translation of research into practice. A topic and a research study are selected for each column. A patient scenario is presented as a vehicle, in which to review and critique, the findings of the selected research study. In this column, we review the conclusions of Gabet, M., et al. in the article on the Effectiveness of emergency department-based interventions for frequent users with mental health issues: A systematic review.
ABSTRACT:Falls are a leading cause of emergency department (ED) visits among older adults, often resulting in fractures. Point-of-care ultrasound (POCUS) has emerged as a valuable diagnostic tool for emergency nurse practitioners (ENPs), offering rapid, radiation-free evaluation of musculoskeletal injuries. This article examines the effectiveness of POCUS in detecting fractures, with evidence demonstrating high sensitivity and specificity, particularly for long-bone injuries. A case study of a patient with a humeral fracture highlights the utility of POCUS in diagnosis and expedited orthopedic referral. The article also discusses ultrasound physics, bone imaging techniques, and transducer selection for musculoskeletal assessments. Beyond clinical accuracy, POCUS use is associated with reduced ED length of stay and healthcare costs. While operator-dependent, structured training models are expanding ENP proficiency in POCUS. Integrating this modality into ED practice enhances timely triage and improves patient outcomes, particularly in resource-limited or high volume settings.
Abstract Skin and soft tissue infections, known as cutaneous abscesses, are a frequent problem seen in primary and acute care settings. The gold standard of treatment for cutaneous abscesses is conventional incision and drainage (CID). The loop drainage technique (LDT) is a safe and effective alternative to CID to avoid premature closure, pain from packing and repacking, and reducing the need for follow-up medical care. Utilization of LDT also requires smaller incisions, resulting in smaller scars, which is particularly important for cosmetic outcomes. LDT offers a patient-centered, cosmetically favorable, and efficient alternative to CID, with improvements in comfort, adherence, and outcomes across care settings, while representing a practical option for emergency clinicians managing cutaneous abscesses.
ABSTRACT:Advanced practice providers (APPs), including nurse practitioners (NPs) and physician assistants (PAs), play a vital role in emergency medicine (EM), addressing workforce shortages and enhancing patient care. Despite their growing presence, position statements from the American College of Emergency Physicians (ACEP) and the American Academy of Emergency Medicine (AAEM) challenge APP autonomy and scope of practice. This article critically examines the educational pathways, clinical competencies, and certification standards of APPs, highlighting disparities in recognition and misrepresentation of training. It explores the historical context of EM specialization, the evolution of APP roles, and the impact of restrictive policies-particularly in underserved areas. The authors propose actionable solutions, including standardized credentialing, formal recognition of postgraduate training, and policy reform to support full practice authority. Emphasizing collaboration over division, the article advocates for a team-based approach to emergency care that values the contributions of all provider types and promotes equitable integration.
ABSTRACT:The recreational use of cannabis is a significant (and growing) contemporary public health issue, confounded by the rapidly changing state and federal marijuana regulation and legislation. As of 2025, 24 states and the District of Columbia have legalized cannabis for medicinal and recreational use, and 39 of the 50 states have legalized it for medicinal use. With the increased use of recreational and medicinal marijuana, there has been an uptick in emergency department (ED) visits for cannabis-related illnesses, including gastrointestinal, cardiac, and mental health disorders. Nausea and vomiting, which are the hallmarks of cannabinoid hyperemesis syndrome (CHS), have been reported as the most common reasons for cannabis-related ED visits in nationwide ED data set analysis. Emergency department staff need to be familiar with CHS, its presentation, pathophysiology, and treatments to quickly recognize, diagnose, and triage/treat patients suffering from this acute cannabis-related GI illness.
Abstract Vibrio vulnificus is a highly virulent gram-negative aquatic bacterium found in warm brackish waters and in molluscum shellfish worldwide that can cause sepsis after ingestion of raw oysters or undercooked molluscum shellfish as well as deadly skin and soft-tissue infections from immersion in contaminated seawater. Populations at a higher risk of infections are men older than 60 years with diabetes mellitus, liver cirrhosis, renal disease, or elevated iron levels and those who are immunocompromised. Three severe syndromes caused by V. vulnificus are gastroenteritis, primary septicemia, and wound infections. Gastroenteritis caused by ingestion is self-limited; however, sepsis can develop rapidly with a mean survival rate of 50%, and wound infections can progress to necrotizing skin and soft-tissue infections with 24 hours. Early identification, prevention of hypotension, initiation of antibiotics, and surgical debridement of necrotic wound tissue is paramount to survival. Public education and awareness of this deadly pathogen is necessary to prevent exposure and improve clinical outcomes, especially for high-risk populations.
ABSTRACT:Cervical artery dissection represents a relevant cause of stroke, predominantly in young adults. The diagnosis can be challenging both clinically and radiographically frequently resulting in underdiagnosis, and management can be controversial. This case study explores a young adult diagnosed with a nontraumatic associated cervical artery dissection and provides an evidence-based overview on diagnostic evaluation, treatment approaches, and outcomes.
ABSTRACT:Characteristic ST- and T-wave changes in the precordial electrocardiogram leads may indicate acute coronary syndrome, cardiomyopathies, channelopathies, catecholamine surge states, or perimyocarditis. This case presented involves a man who presented after sudden loss of consciousness. The patient's electrocardiogram was concerning for Type B Wellens sign, and cardiac biomarkers were low. Coronary artery occlusion was considered despite an absence of chest pain and the presence of left ventricular hypertrophy. Cardiac testing revealed pathognomonic obstruction of the left anterior descending artery associated with Wellens syndrome.
ABSTRACT:Snakebite envenoming affects an estimated 10,000 people annually in the United States. Two FDA-approved antivenoms, ANAVIP® (equine F(ab') 2 ) and CroFab® (ovine Fab), are standard treatments. However, higher-than-expected adverse reactions to ANAVIP have been reported in the southeastern United States, paralleling the regional prevalence of alpha-gal syndrome (AGS), an IgE-mediated allergy induced by lone star tick ( Amblyomma americanum ) bites. Although AGS typically manifests after ingestion of mammalian meat, parenteral exposure to alpha-gal-containing biologics may trigger immediate hypersensitivity. We describe a patient in central North Carolina who developed severe hypotensive anaphylaxis shortly after ANAVIP initiation for copperhead ( Agkistrodon contortrix ) envenomation. Despite elevated alpha-gal-specific IgE, he reported tolerating mammalian meat and subsequently received ovine Fab antivenom without complication. This case underscores the need for clinicians in alpha-gal-endemic regions to anticipate antivenom-associated hypersensitivity and be prepared for rapid recognition and management.
AIM:The authors sought to clarify the difference between evidence-based versus evidence-informed practice by providing historical descriptions and practical applications for Advanced Practice Nurses from the literature. METHOD:For this review, the database PubMed was searched using the following terms: evidence-based practice, evidence-informed practice, and nursing. Evidence within five years was preferred; however, owing to limitations in the available literature, articles were considered if they had been published post-2000. FINDINGS:Twenty-one articles were retrieved using these search terms. The authors present the articles beginning with a historical perspective and a contrast with current practice. CONCLUSION:This article describes the difference between evidence-based practice, a scientific methodology of applying evidence to practice, and evidence-informed practice, using evidence and clinical judgment in making care decisions, with historical context and relevant examples. This important distinction must be understood by Advanced Practice Registered Nurses to not only advance patient outcomes but to distinguish Advanced Practice Registered Nurses as having expertise in these elements, as implementation science (practice, education, and dissemination) is a core feature of advanced nursing preparation.
