BACKGROUND:Acute ankle trauma is a frequent emergency department (ED) presentation, yet bedside assessment remains largely focused on fracture detection despite variation in injury burden and functional recovery. We developed the Emergency Department Ankle Burden Score (ED-ABS), a simple bedside score integrating routine clinical findings to quantify injury burden during initial ED assessment. This study evaluated its association with functional recovery, fracture, and healthcare resource utilisation. METHODS:In this prospective observational study, consecutive adults with acute ankle trauma meeting Ottawa Ankle Rules criteria for radiography were enrolled. ED-ABS was calculated before radiographic interpretation. Functional recovery was assessed with the Foot and Ankle Ability Measure-Activities of Daily Living (FAAM-ADL) questionnaire 42 ± 3 days post-discharge. Multivariable regression and ROC analyses were performed. RESULTS:Among 200 patients, 23 (11.5%) had radiographically confirmed fractures. The median ED-ABS score was 4.5 (IQR 2.0-7.0). Higher ED-ABS scores were associated with poorer functional recovery (adjusted β = -1.30, 95% CI -1.70 to -0.90; p < 0.001) and fracture (adjusted OR = 1.83, 95% CI 1.43-2.33; p < 0.001). ED-ABS showed good fracture discrimination (AUC 0.855, 95% CI 0.783-0.928) and higher scores were associated with greater computed tomography utilisation and orthopaedic consultation. CONCLUSIONS:ED-ABS is a bedside injury-burden score integrating routinely available clinical findings during initial ED assessment. By quantifying overall injury burden rather than focusing solely on fracture detection, ED-ABS demonstrated consistent associations with functional recovery, fracture, and healthcare resource utilisation. Multicentre external validation is required before routine clinical implementation.
INTRODUCTION:Critical acyanotic congenital heart lesions are uncommon but potentially life-threatening causes of neonatal shock and cardiovascular collapse. OBJECTIVE:This review highlights key aspects of acyanotic CHD, including presentation, diagnosis, and management in the emergency department (ED), based on current evidence. DISCUSSION:Acyanotic CHD encompasses a number of conditions, including critical coarctation of the aorta (CoA), interrupted aortic arch (IAA), critical aortic stenosis (AS), and anomalous left coronary artery from the pulmonary artery (ALCAPA). These conditions should be considered in critically ill neonates presenting with shock and cardiovascular collapse, often without prominent cyanosis. Evaluation involves a thorough assessment of the patient's cardiovascular and respiratory status. Diagnostic tools include pulse oximetry, laboratory testing, electrocardiogram, chest radiograph, and ultrasonography. Management requires prompt recognition and hemodynamic stabilization, which may involve the administration of prostaglandin, vasoactive/inotropic agents, and airway management. Expert consultation and coordination of transfer to a tertiary or quaternary care center are crucial. Surgical repair serves as the definitive treatment. CONCLUSION:A thorough understanding of acyanotic congenital heart disease is essential for emergency clinicians to effectively diagnose and manage these potentially life-threatening conditions.
BACKGROUND:Lingual hematoma is a rare but potentially life-threatening condition because of the risk of rapid airway obstruction. Patients receiving antithrombotic therapy or undergoing hemodialysis may be at particularly high risk of progressive hemorrhage. We report a case of airway-threatening lingual hematoma caused by tongue biting that was successfully managed with fiberoptic intubation and transcatheter arterial embolization (TAE). CASE PRESENTATION:A hemodialysis patient with a history of stroke-related hemiplegia and aphasia was receiving aspirin for secondary prevention of cerebrovascular disease. She had a history of recurrent involuntary tongue biting during both sleep and meals. Following presumed tongue biting during sleep while hospitalized, progressive tongue swelling developed with impending airway obstruction. Contrast-enhanced computed tomography demonstrated active contrast extravasation within the right side of the tongue. Because rapid enlargement of the lingual hematoma made airway compromise imminent, awake fiberoptic intubation was successfully performed after failed attempts using video laryngoscopy. Subsequent angiography demonstrated focal vascular irregularity of the distal right lingual artery corresponding to the suspected bleeding site, and selective TAE achieved successful hemostasis. Marked systemic fluid overload, caused by delayed hemodialysis and recent blood transfusion with intravenous fluid administration, may also have contributed to the rapid progression of tongue swelling. Early tracheostomy was performed because prolonged airway compromise was anticipated, and the lingual hematoma gradually resolved without ischemic complications. DISCUSSION:Although tongue biting is generally considered a minor injury, it may result in life-threatening lingual hematoma in patients with bleeding risk factors such as hemodialysis and antiplatelet therapy. Early recognition, prompt airway protection, contrast-enhanced computed tomography to identify active bleeding, and selective TAE may provide an effective multidisciplinary treatment strategy while avoiding surgical exploration. CONCLUSION:Clinicians should recognize that seemingly minor tongue trauma can rapidly progress to critical airway obstruction in high-risk patients. Early airway control combined with selective TAE should be considered when active hemorrhage is identified.
OBJECTIVES:We aimed to determine the frequency of stress hyperglycemia (SH) among ill-appearing children, identify clinical correlates of hyperglycemia at presentation, and evaluate the association between glucose levels and life-saving interventions (LSIs), severe outcomes and length of stay (LOS). METHODS:This retrospective study included ill-appearing children identified by the Pediatric Assessment Triangle who presented to a tertiary PED between January 1 and December 31, 2025. Initial capillary glucose was analyzed as a continuous variable. Multivariable models were adjusted for age, sex, comorbidities, high-risk vital signs, and GCS score. Outcomes included LSIs (airway, hemodynamic, medication, electrical and procedural), severe outcomes (PICU admission or death), and LOS. RESULTS:Among 1116 children, 10.6% had hyperglycemia (≥150 mg/dL). Patients with diabetic ketoacidosis (n = 15) were excluded. Overall, 10.8% were admitted to the PICU and 0.4% died. Glucose showed modest discrimination for severe outcomes (AUC 0.654; optimal cutoff 125 mg/dL; sensitivity 43.3%, specificity 80.4%). After adjustment, higher glucose levels were independently associated with severe outcomes (aOR 1.13 per 10 mg/dL increase; p < 0.001) and airway intervention (aOR 1.10; p = 0.001), but not with receipt of any LSI overall (p = 0.42). Although glucose was not associated with mean LOS, its effect increased across longer stays, corresponding to increases of 0.9, 2.5, and 5.3 h per 10 mg/dL increase at the 25th, 50th, and 75th percentiles, respectively (all p < 0.001). CONCLUSIONS:Initial glucose may serve as a useful marker of clinical risk in ill-appearing children. Higher glucose levels were independently associated with airway intervention, severe clinical outcomes and longer hospitalization. These findings suggest that glucose measurement may contribute to early risk assessment in the PED and warrant further prospective validation.
BACKGROUND:Multiple, simultaneous resuscitations in pediatric emergency departments (PEDs) strain resources and exacerbate crowding. In 2015, our pediatric institution implemented a Multiple Resuscitation Activation (MRA) to coordinate team response. The impact of MRAs on PED crowding remains unclear. OBJECTIVES:Evaluate whether MRAs are associated with changes in PED crowding and patient census. METHODS:A retrospective cohort study was conducted at a tertiary pediatric level one trauma center from January 2023 to December 2024. MRA events were matched 1:2 with non-activation control periods by time of day and calendar proximity. Crowding was measured using the Pediatric Emergency Department Overcrowding Scale (PEDOCS) at baseline and at 1 and 2 h after activation (or matched control time). Difference-in-differences analyses were used to compare changes in PEDOCS and patient census between activation and control periods. RESULTS:Thirteen MRAs involving 59 patients were identified, with a median activation duration of 73 min. Although PEDOCS scores and patient census increased following MRAs, these changes were not significantly different from those in matched control periods. The difference-in-differences estimate for PEDOCS was 6.0 points (95% CI, -15.4 to 27.4) at 1 h and 7.8 points (95% CI, -13.6 to 29.2) at 2 h. Corresponding estimates for patient census were 2 patients (95% CI, -17 to 21) and 6 patients (95% CI, -16 to 28). CONCLUSIONS:MRAs were not associated with significant increases in PED crowding or patient census compared with matched non-activation control periods. These findings suggest that coordinated response systems may help mitigate the operational impact of multiple simultaneous resuscitations.
Orbital compartment syndrome (OCS) is a vision-threatening emergency. In adult cases, most are caused by trauma. Pediatric OCS is rare and associated with non-traumatic etiologies. Pediatric OCS poses unique diagnostic and procedural challenges related to anatomy, intraocular pressure measurement, and sedation.A 15-year-old male presented to the pediatric emergency department (PED) with three days of progressive right eye pain, swelling, and blurry vision with similar milder episodes one year prior. Eye exam revealed decreased right vision (20/70), proptosis, and ophthalmoplegia. CT imaging demonstrated multiple right intra-orbital masses. The patient suddenly developed severe eye pain prompting OCS concerns with emergent lateral canthotomy. MRI demonstrated lymphatic malformation with complete optic nerve encasement, severe proptosis, and posterior scleral tenting. With definitive management (percutaneous drainage, steroids, and sirolimus), visual acuity improved with no optic nerve damage.This pediatric OCS case highlights the non-traumatic etiologies, particularly lymphatic malformations prone to spontaneous intralesional hemorrhage. For pediatric eye pain complaints, emergency physicians must maintain vigilance for OCS by recognizing worsening orbital signs and facilitating decisive intervention lateral canthotomy.
Amlodipine is a commonly prescribed antihypertensive, and among the calcium channel blockers is associated with the most fatalities in the United States. Vasoplegic shock secondary to dihydropyridine overdose is typically managed with intravenous fluids, calcium replacement and vasopressors. While high dose insulin (HDI) has established efficacy in non-dihydropyridine calcium channel blocker induced cardiogenic shock, utility in amlodipine toxicity remains controversial.
There are a marked number of Emergency Department (ED) patients with shoulder pain and pathologies including shoulder dislocation and proximal humeral fractures that benefit from nerve blocks. Further, there is a significant interest in nerve blocks that are low-risk and pose no risk of phrenic nerve paralysis. There was a recent nerve block developed in anesthesia and cadaveric studies, called the SHoulder Anterior Capsule Block (SHAC Block). The thought, compared to an interfascial plane block alone (injecting in between deltoid and subscapularis), by also injecting anesthetic deep to subscapularis, there would be more reliable coverage beyond the axillary nerve distribution. This technique was employed in the ED; to our knowledge, this is the first case series exploring the applications of its use in the ED. There were three patients that received a SHAC block (two proximal humerus and one shoulder dislocation); these all had successful pain management without any complications. The patient with an anterior shoulder dislocation underwent reduction without sedation and in minimal pain. This highlights the potential of this block in the ED, and also poses the potential of future research of this block, including studies comparing the efficacy of the SHAC to alternative blocks.
BACKGROUND:In quaternary academic centers with sustained high demand, level-loading strategies that transfer selected emergency department (ED) admissions to community affiliates can preserve capacity and reduce boarding. In one such system in Portland, Oregon, a mature ED-to-affiliate transfer infrastructure existed; however, consent rates remained low when discussions were largely mediated by ED physicians, limiting transfer execution reliability. OBJECTIVES:To evaluate whether a team-based Transfer Consent Partner model could achieve a consent-to-transfer success rate of at least 75% for ED-to-affiliate hospital transfers. STUDY DESIGN:Single-center quality improvement initiative. METHODS:A Transfer Consent Partner was implemented during a learning launch (November 2025-January 2026) in a quaternary academic ED. The Transfer Consent Partner delivered standardized, emotionally informed consent discussions, addressed patient and family questions, prepared documentation, engaged social work for barriers, and coordinated transfer logistics. The primary outcome was the proportion of Transfer Consent Partner-involved encounters resulting in consent to transfer, with a prespecified target of at least 75%. A secondary analysis compared Transfer Consent Partner-involved encounters with non-Transfer Consent Partner encounters during the concurrent learning-launch period and calculated the absolute difference and its 95% confidence interval. Secondary outcomes included operational demand, temporal distribution, and clinician and patient experience. RESULTS:Over a 12-month evaluation period (February 2025-January 2026), 1909 eligible encounters occurred (overall consent to transfer 40.2%). During the learning launch, 27 of 35 Transfer Consent Partner-involved encounters resulted in consent to transfer (77.1%), meeting the prespecified target. Consent-to-transfer success was 48.3% among concurrent non-Transfer Consent Partner encounters, corresponding to an absolute difference of 28.8 percentage points (95% CI, 12.2 to 40.4). The Transfer Consent Partner supported 1-6 conversations per shift (median 3), lasting 5-40 min (median 10). Physician survey respondents (n = 8) rated teamwork very or extremely strong in 80% of responses. CONCLUSION:In this early learning launch involving 35 Transfer Consent Partner-supported encounters, consent-to-transfer success was higher than among concurrent encounters without Transfer Consent Partner involvement. Broader implementation and evaluation are needed to determine whether these preliminary findings are reproducible and sustainable.
