Background Tattooing is increasingly common and generally considered safe but can rarely result in infectious complications ranging from localized skin infection to severe systemic illness. Toxic shock syndrome (TSS) is a rare, yet life-threatening condition caused by toxin-producing Staphylococcus aureus or Streptococcus pyogenes. Tattoo-associated TSS is uncommon, and awareness among emergency physicians may be limited, potentially delaying diagnosis and treatment. Case Report We describe a case of TSS in a previously healthy 21-year-old man following extensive tattooing of the upper arm. Within days of exposure, he developed fever, gastrointestinal symptoms, and rapidly progressed to profound hypotension, multiorgan dysfunction, declining consciousness, and respiratory distress necessitating intubation and intensive care admission. Extensive microbiologic testing and diagnostic imaging was negative. A multidisciplinary team concluded that the clinical course fulfilled diagnostic criteria for staphylococcal TSS. He was treated with hemodialysis, vasopressor therapy, antimicrobial and immunomodulating drugs. He was discharged without sequelae after 10 days of hospitalization. Why should an emergency physician be aware of this? This case highlights that TSS can occur as a rare and likely underrecognized complication of tattooing. Clinicians should consider TSS when gastrointestinal symptoms, fever, acute hypotension and multiorgan dysfunction develop shortly after tattooing, even in the absence of an identifiable pathogen. Early recognition, multidisciplinary evaluation and prompt treatment are crucial for survival and optimal patient outcome.
Background Discharge vital signs are used in emergency department risk assessment, but the association between heart rate trajectory and adverse outcomes after ED discharge remains unclear. Objective To evaluate whether an increase in heart rate from triage to discharge is associated with clinically significant 7-day bounceback among discharged adult ED patients. Methods We conducted a retrospective cohort study of adults discharged from a tertiary academic ED between February 1 and April 30, 2025. The primary predictor was HR increase ≥10 bpm from triage to discharge. The primary outcome was clinically significant 7-day bounceback, defined as a related return visit resulting in admission, observation, transfer, or death. Multivariable logistic regression adjusted for age, sex, comorbidities, and triage acuity. Results The cohort included 6,635 encounters. Any 7-day ED returns occurred at similar rates among patients with and without HR increase ≥10 bpm, 44 of 415 (10.6%) versus 664 of 6,220 (10.7%), respectively. In contrast, clinically significant bouncebacks occurred in 7 of 415 with HR increase ≥10 bpm (1.7%) compared with 30 of 6,220 without it (0.5%). HR increase ≥10 bpm was associated with clinically significant bouncebacks after adjustment, aOR 3.10, 95%CI 1.35-7.13, p=0.008. Discharge tachycardia alone was not associated with clinically significant bouncebacks, aOR 1.08, 95% CI 0.26-4.51, p = 0.921. Conclusions Among discharged adult ED patients, HR increase ≥10 bpm was associated with clinically significant 7-day bounceback but not with any all-cause 7-day ED return. Heart rate trajectory may serve as an additional prompt for reassessment before ED discharge.
Background Sexual assault (SA) remains a major public health issue, yet only a fraction of survivors seek acute medical care in emergency departments (EDs). Although prior studies describe demographic disparities among SA survivors, national patterns of ED arrival timing and operational implications for emergency care systems remain poorly characterized. Objectives To characterize demographic and temporal patterns of ED presentations for SA in the United States Methods We conducted a repeated cross-sectional study using the Epic Cosmos database, including United States ED encounters related to SA from 1/1/2016 through 12/31/2024. Demographic characteristics and arrival patterns were compared with those of all other ED visits using odds ratios (OR) with 95% confidence intervals. Temporal distributions by day of week and 6-hour arrival intervals were analyzed using chi-square testing and standardized Pearson residuals. Results Among 391,352,267 ED visits, 245,475 (0.06%) involved SA evaluation. SA patients were disproportionately adolescents and young adults, female, Medicaid-insured, and from minoritized racial groups. Overnight arrivals (00:00–05:59) had significantly higher odds of SA presentation (OR 1.45, 95% CI 1.43–1.47), with peak presentations occurring on Sundays and Saturdays overnights. Morning presentations were consistently below expected levels. In 2016, 16% of SA patients arrived by ambulance; by 2024, this number increased to 18%. Conclusion SA presentations demonstrate distinct demographic and temporal patterns with important operational implications for EDs. Young and socially vulnerable populations were disproportionately affected. Concentration of presentations during overnight weekend hours highlights the need for expanded access to trauma-informed forensic services, including SANE coverage and prehospital education, especially during high-demand periods.
One common maxim in clinical medicine is that the sickest patient in the emergency department may be in the waiting room (termed: waiting-room maxim). The purpose of this commentary is to discuss five pitfalls related to the waiting-room maxim that can sometimes transform a fundamentally smart idea into a popular misconception. Brevity makes a maxim powerful, yet also creates limitations by leaving out elaboration, logic, and evidence.
Background Early pregnancy complications represent a substantial reason for emergency department (ED) visits, with ectopic pregnancy remaining a significant cause of maternal mortality. Objectives This systematic review and meta-analysis aim to evaluate the effectiveness of ED point-of care ultrasound (POCUS) versus the standard radiology- or obstetric- performed ultrasound (US) for early pregnancy assessment in emergency settings. Methods Four databases were systematically searched for studies including early pregnancy patients (< 20 weeks of gestation) presenting to ED. Differences in the ED length of stay (LOS), time to diagnosis, time to surgery for patients with ectopic pregnancy, and rate of missed ectopic cases were analyzed. Weighted mean differences (WMDs) and risk ratios (RR) with 95% confidence intervals (CI) were calculated. The study was registered on the PROSPERO database (ID CRD420251242734). Results Thirteen studies with 4057 early pregnancy patients (ED POCUS= 1848, Standard US= 2209) were included. Compared to standard imaging, ED POCUS was associated with statistically significant reductions in ED LOS (WMD -59.53 [95%CI] = [- 77.43, -41.62], P <0.00001), and time to definitive diagnosis (WMD -80.93 [95%CI] = [-119.10, -42.77], P<0.0001). Moreover, pooled analysis showed no statistically significant difference in the rate of missed ectopic cases between ED POCUS and standard US (RR 1.22, 95% CI = [0.39, 3.87], P=0.73) Conclusion ED POCUS is associated with measurable improvements in emergency care efficiency, without a statistically significant increase in the missed diagnoses of ectopic pregnancy. Future high-quality, multicenter randomized studies are needed to better define the diagnostic accuracy, safety, and generalizability of ED POCUS in early pregnancy evaluation.
Background Methemoglobinemia is a life-threatening toxidrome characterized by impaired oxygen delivery due to hemoglobin oxidation, often triggering cyanosis, refractory hypoxemia, and a saturation gap between the decreased SpO2 measurements and the “normal” SaO2. Case Report An 82-year-old man with severe coronary artery disease and recent PCI presented with syncope, hypotension, and slate-grey cyanosis. Despite maximal oxygen via high-flow nasal cannula, SpO2 remained refractory at 88%. Evaluation revealed a profound "saturation gap" (PaO2 434 mmHg vs. SpO2 88%) and a methemoglobin level of 20.9%. The cause was the synergistic effect between the patient’s isosorbide mononitrate and a recent dietary change, involving the consumption of up to 6 pounds of boiled beets and their residual juices per week. Following intravenous administration of 1 mg/kg methylene blue, the cyanosis resolved, the methemoglobin levels normalized, and the patient’s SpO2 increased to 99% on room air. The patient was managed without further invasive intervention and discharged following dietary modification. Why should an emergency physician be aware of this? While dietary nitrate-induced methemoglobinemia is documented in infants, we propose that this case is the first involving whole-beet ingestion as a trigger for the condition. The underlying mechanism involves an overwhelmed NADH-methemoglobin reductase pathway, exacerbated by pharmacological nitrates. The resulting myocardial crisis highlights the danger posed to patients with limited cardiac reserve. Methemoglobinemia should be considered when cyanosis and a saturation gap are present. Early recognition and methylene blue administration can prevent inappropriate treatment escalation and improve outcomes.
Background ED-to-ICU delay may reflect access block, but prior studies often combine pre-decision care and post-decision boarding. Objectives To evaluate whether total ED registration-to-ICU-bed delay >4 hours and post-decision boarding were associated with mortality among adults reaching an ICU bed. Methods We conducted a 5-year retrospective cohort of adults transferred from the ED to two level-3 general ICUs at a tertiary training and research hospital. Primary models used early-ED severity-adjusted robust Poisson regression; supportive analyses examined decision-to-ICU boarding, continuous delay, period-specific and COVID-19-negative cohorts, matching, and time-to-event outcomes. Results Among 691 ED-to-study-ICU candidate records, 650 adults were analyzed; 351 (54.0%) had delay >4 hours. Median total transfer time was 4.3 hours: 1.3 hours before ICU decision and 3.0 hours after ICU acceptance. Delay >4 hours was associated with higher in-hospital mortality (adjusted risk ratio [aRR] 2.01; 95% CI 1.46-2.76) and ICU mortality (aRR 1.70; 95% CI 1.20-2.42). Adjusted in-hospital mortality was 27.5% versus 13.8% (adjusted risk difference +13.7 percentage points). Post-decision boarding >4 hours was associated with in-hospital mortality (adjusted odds ratio [aOR] 1.82; 95% CI 1.21-2.73), and each boarding hour was associated with higher death odds (aOR 1.14; 95% CI 1.06-1.24). Conclusion Among adults reaching a study ICU bed, ED-to-ICU delay was common and associated with mortality. Most delay accrued after ICU acceptance, identifying post-decision boarding as a practical target.
Background The combined effect of epinephrine timing and advanced airway management (AAM) timing on outcomes in out-of-hospital cardiac arrest (OHCA) remains poorly characterized. Objectives We investigated the interaction between epinephrine timing and AAM timing and their joint association with neurological and survival outcomes in OHCA. Methods This retrospective study used data from the Korea OHCA Registry (KOHCAR; August 2019–December 2023). Adult patients receiving prehospital epinephrine and AAM were included. Epinephrine timing was categorized as early (≤10 min) or late (>10 min) from EMS arrival; AAM timing as early (≤6 min) or late (>6 min), yielding four groups: EE-EA, EE-LA, LE-EA, and LE-LA. Multivariable logistic regression and interaction analyses were performed for good neurological recovery (Cerebral Performance Category [CPC] 1–2), survival to discharge, and prehospital ROSC. Results Of 20,662 eligible patients, 37.1% were in the EE-EA group. Compared with the LE-LA group, the EE-EA group was associated with significantly higher odds of good neurological recovery (adjusted odds ratio [aOR] 2.44, 95% CI 1.93-3.08) and survival to discharge (aOR 2.18, 95% CI 1.87-2.55). The LE-EA group showed no significant benefit over LE-LA (aOR 0.99, 95% CI 0.71-1.40). A significant interaction between early epinephrine and early AAM was observed for neurological recovery (aOR 1.45, 95% CI 1.08–1.95; P for interaction = 0.045). Conclusions Early epinephrine combined with early AAM was associated with the best neurological recovery. However, this multiplicative interaction was attenuated in sensitivity analyses addressing resuscitation time bias, suggesting a hypothesis-generating rather than confirmatory association.
Background Benign paroxysmal positional vertigo (BPPV) is a common cause of dizziness in the emergency department (ED), yet bedside diagnostic and therapeutic maneuvers remain underused, often leading to unnecessary imaging and resource utilization. Objectives To evaluate the effectiveness of an Epley-first approach and identify predictors of early treatment failure in patients with posterior canal BPPV. Methods In this retrospective observational study, 774 adult ED patients with posterior canal BPPV were managed with the Epley maneuver as the initial treatment strategy. Early treatment success was defined as symptom resolution without the need for additional intervention within 60 minutes. Logistic regression analysis was performed to identify independent predictors of treatment failure. Results Early symptom resolution was achieved in 81.8% of patients, while 18.2% required additional interventions. Patients with treatment failure were significantly older and had longer symptom duration (both p < 0.001). In multivariable analysis, age (OR: 1.06, 95% CI: 1.04–1.08, p < 0.001) and symptom duration (OR: 1.03 per minute, 95% CI: 1.02–1.03, p < 0.001) were identified as independent predictors of failure. The predictive model demonstrated strong discriminative performance (AUC: 0.876). No newly identified focal neurological deficits suggestive of an acute central neurological disorder were documented during ED evaluation. Conclusions The Epley-first approach was associated with rapid early symptom control in appropriately selected patients with posterior canal BPPV presenting to the ED. Age and symptom duration may facilitate early risk stratification and support more individualized diagnostic decision-making in appropriately selected patients.
Background The outcome of a stroke is highly dependent on time to treatment. Reducing prehospital delay is crucial to increase access to effective stroke treatment. Objective We aimed to examine how stroke symptoms are recorded and to assess the association between prehospital registration of stroke symptoms and stroke triage, and prehospital delay. Methods We included patients with a final diagnosis of acute stroke, admitted to X and Y Hospital Trusts from June 2018 to May 2019. Data were extracted from the Emergency Medical Communication Center records, from ambulance reports, and hospital admissions records. Associations between Facial Arm Speech Test (FAST) symptoms and prehospital time were analyzed using linear regression models and the Mann-Whitney U test. Logistic regression was used to assess the association between FAST symptoms and stroke alert. Results Of 295 patients, 273 (92.5%) had ≥1 stroke symptom recorded, and 224 (75.9 %) had one or more FAST symptoms. Documentation of FAST symptoms in ambulance records was associated with a higher likelihood of activating a stroke alert; odds ratio 6.7 (95 % confidence interval: 3.5 - 13.1) and a significantly shorter prehospital time (17.0 minutes vs. 34.5 minutes, p = 0.024). Conclusion Recording of FAST symptoms in the ambulance was associated with the use of stroke alerts and shorter prehospital time delay. However, 24.1 % of the patients with a confirmed stroke did not present with FAST symptoms, highlighting the need to improve prehospital stroke recognition and triage.
Background The emergency department is uniquely positioned within the U.S. healthcare system to provide emergency evaluation and stabilizing treatment regardless of insurance status, ability to pay, or immigration status. Immigration status does not alter the professional obligations of emergency physicians under EMTALA and established ethical standards to provide equitable, evidence-based care, nor does it alter the fundamental human right to quality health care. Emergency physicians must therefore understand the health implications of migration and the distinct needs of these diverse patient populations, including recognizing the unique risks, exposures, and barriers that can shape health outcomes and healthcare interactions among immigrant, refugee, asylum-seeking, and other migration-affected populations. Discussion This article outlines best practices, culminating in the development of four key principles for providing care to these groups, while underscoring the role of emergency medicine in providing equitable care to all migration-affected populations: 1) Evidence-based clinical care to reduce bias, 2) Awareness of local and federal policies and migration factors that may influence patient care trends, 3) Targeted screening for population-specific risks and tailored patient care services, and 4) Community partnership and interdisciplinary care teams. Conclusion Emergency physicians and their departments must recognize the complex health needs of immigrant, refugee, asylum-seeking, and other migration-affected populations, while upholding professional and ethical responsibilities to provide equitable, evidence-based care consistent with EMTALA and established standards of emergency medicine practice.
Background Sternal osteomyelitis is a rare but serious condition that may present with nonspecific symptoms, mimicking benign musculoskeletal chest pain and posing a significant diagnostic challenge in the emergency department. Case Report We report the case of a 44-year-old man with a history of intravenous drug use who presented with one week of anterior chest pain and reproducible chest wall tenderness. Despite an initially reassuring evaluation, persistent symptoms and elevated inflammatory markers prompted computed tomography angiography, which revealed a sternal lytic lesion with associated abscess, osteomyelitis, and mediastinitis. The patient required multiple surgical debridements and a prolonged course of intravenous antibiotics for methicillin-sensitive Staphylococcus aureus infection, resulting in a 49-day hospitalization. Why Should an Emergency Physician Be Aware of This? Reproducible chest wall tenderness is often attributed to a musculoskeletal etiology, but this case illustrates that a serious underlying infection can present similarly, with focal chest wall tenderness and a negative cardiac workup. In patients with risk factors such as intravenous drug use, a low threshold for advanced imaging is essential. Early recognition of sternal osteomyelitis is critical, as delayed diagnosis carries significant morbidity and, in the setting of mediastinal extension, the potential for mortality.
