Contributor: Aaron Lessen MD

Educational Pearls: 

• Recent prospective randomized clinical trial assessed optimal head-of-bed positioning in patients with LVO
  • 0º vs. 30º elevation
  • Objective was to determine superiority of the two angles in stability prior to thrombectomy for LVO patients
• 45 patients randomized to the group with 0° head positioning and 47 patients randomized to the group with 30° head positioning
  • Patients in the 30º group experienced worsening of NIHSS by 2 points or more
  • Patients with head position at 0° showed score stability
  • Hazard ratio 34.40; 95% CI, 4.65-254.37; P < .001
  • All-cause death occurred in 2 patients in the 0° group, compared with 10 patients in the 30° group.
• Results suggest that 0º positioning of the head of the bed may be protective to maintain clinical stability in patients with LVO prior to thrombectomy

References

1. Alexandrov AW, Shearin AJ, Mandava P, et al. Optimal Head-of-Bed Positioning Before Thrombectomy in Large Vessel Occlusion Stroke: A Randomized Clinical Trial. JAMA Neurol. 2025;82(9):905-914. doi:10.1001/jamaneurol.2025.2253

Summarized & Edited by Jorge Chalit, OMS4

Donate: https://emergencymedicalminute.org/donate/

Contributor: Meghan Hurley, MD

Educational Pearls:

1. Initial Assessment

• Start with a physical examination:

• Determine if the bleed is anterior or posterior.

• Perform a primary survey: assess airway, breathing, and circulation (ABCs).

• Airway compromise = intubation immediately.

• If the patient is stable, have them blow out any clots, then re-examine the nares.

2. Topical Medications

• Anesthetics: provide local anesthesia and pain relief.

• Lidocaine

• Tetracaine

• Vasoconstrictors: reduce bleeding.

• LET (Lidocaine, Epinephrine, Tetracaine) is ideal because it provides anesthesia and vasoconstriction.

• Cocaine pledgets (less common).

• Tranexamic acid (TXA).

• Oxymetazoline (Afrin).

• Cautery (Chemical): If an anterior bleed is visualized, silver nitrate can be applied for cauterization

3. Technique Tips

• Use a nasal speculum.

• Spread up and down rather than side to side to avoid injury to the septum.

• Place LET-soaked gauze in the nares.

• Apply a nasal clamp for ~15 minutes to compress the vessels.

• Note that pledgets may cause upper lip numbness

4. Reassessment

• After 15 minutes, remove materials and inspect for a source of bleeding.

• If still bleeding and a source is identified, cauterize the site.

• Observe for 15 minutes to monitor for recurrence of bleeding.

5. Packing

• If the above measures fail to control bleeding:

• Anterior packing:

• Nasal tampon (Merocel)

• Convenient for outpatient removal.

• Balloon device

• Inflate the anterior balloon for compression.

• Posterior packing: 

• More complex, should consult ENT for additional assistance.

6. Disposition & Follow-Up

• Although rare, toxic shock syndrome is a possible complication of nasal packing.

  • Antibiotic prophylaxis is controversial, but may be considered in high-risk patients.

• Outpatient follow-up if stable:

  • Tampon: The patient can remove it at home.

  • Balloon: Return to ED for removal.

7. Risk Factors for Epistaxis & Prevention

• Deviated septum, dry environments, and anticoagulant use

  • Advise on humidifier use, nasal saline, and medication review to minimize future episodes.

References:

1. Tunkel DE, Anne S, Payne SC, et al. Clinical Practice Guideline: Nosebleed (Epistaxis). Otolaryngology–Head and Neck Surgery. 2020;162(1_suppl):S1-S38. doi:10.1177/0194599819890327

Summarized by Ashley Lyons, OMS3 | Edited by Ashley Lyons and Jorge Chalit, OMS4

Donate: https://emergencymedicalminute.org/donate/

Contributor: Ricky Dhaliwal, MD

Educational Pearls:

• Angioedema in anaphylaxis
  • Histamine and mast cell-mediated pathway
  • Treatment:
    • First line: epinephrine for vasoconstriction and bronchodilation
    • Second line: H1 and H2 antihistamines such as Benadryl and famotidine
• ACE inhibitor-induced angioedema
  • Different pathway from anaphylaxis
    • ACE inhibitor-induced angioedema is mediated by bradykinins
    • Therefore, anaphylaxis medications are not beneficial in patients with ACE inhibitor-induced angioedema
  • Leading cause of drug-induced angioedema in the US
  • Patients most commonly present with swelling of the lips, tongue, or face
  • Treatment:
    • Airway management: varies depending on the severity and progression of the presentation
      • If awake nasointubation is required, LMX is a 5% lidocaine water-soluble solution that provides anesthesia to the oropharynx
    • Medications:
      • Icatibant is a synthetic bradykinin B2-receptor antagonist that can be used in acute treatment
      • Tranexamic acid (TXA) inhibits the plasmin-dependent formation of bradykinin, but the data on this treatment are mixed and limited
      • Fresh frozen plasma (FFP) is thought to degrade high levels of bradykinin with subsequent resolution of angioedema
    • Discontinue ACE inhibitor

References

1. Bork K, Wulff K, Hardt J, Witzke G, Staubach P. Hereditary angioedema caused by missense mutations in the factor XII gene: clinical features, trigger factors, and therapy. J Allergy Clin Immunol. 2009 Jul;124(1):129-34. doi: 10.1016/j.jaci.2009.03.038. Epub 2009 May 27. PMID: 19477491.
2. Bova M, Guilarte M, Sala-Cunill A, Borrelli P, Rizzelli GM, Zanichelli A. Treatment of ACEI-related angioedema with icatibant: a case series. Intern Emerg Med. 2015 Apr;10(3):345-50. doi: 10.1007/s11739-015-1205-9. Epub 2015 Feb 10. PMID: 25666515.
3. Karim MY, Masood A. Fresh-frozen plasma as a treatment for life-threatening ACE-inhibitor angioedema. J Allergy Clin Immunol. 2002 Feb;109(2):370-1. doi: 10.1067/mai.2002.121313. PMID: 11842313.
4. Pathak GN, Truong TM, Chakraborty A, Rao B, Monteleone C. Tranexamic acid for angiotensin-converting enzyme inhibitor-induced angioedema. Clin Exp Emerg Med. 2024 Mar;11(1):94-99. doi: 10.15441/ceem.23.051. Epub 2023 Aug 1. PMID: 37525579; PMCID: PMC11009700.
5. Simons FE. First-aid treatment of anaphylaxis to food: focus on epinephrine. J Allergy Clin Immunol. 2004 May;113(5):837-44. doi: 10.1016/j.jaci.2004.01.769. Erratum in: J Allergy Clin Immunol. 2004 Jun;113(6):1039. Dosage error in article text. PMID: 15131564.

Summarized by Meg Joyce, MS2 | Edited by Meg Joyce & Jorge Chalit, OMS4

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Contributor: Aaron Lessen MD

Educational Pearls:

Does the size of a blood pressure (BP) cuff matter?

A recent randomized crossover trial revealed that, indeed, cuff size can affect blood pressure readings

Design

• 195 adults with varying mid-upper arm circumferences were randomized to the order of BP cuff application:

• Appropriate

• Too small

• Too large

• Individuals had their mid-upper arm circumference measured to determine the appropriate cuff size

• Participants underwent 4 sets of triplicate blood pressure measurements, the last of which was always with the appropriately sized cuff

Results

• In individuals requiring a small cuff, the use of a regular cuff resulted in blood pressure readings 3.6 mm Hg lower than with the small cuff

• In individuals requiring large cuffs, the use of a regular cuff resulted in pressures 4.8 mm Hg higher than with the large cuffs

• In individuals requiring extra-large cuffs, the use of a regular cuff resulted in pressures 19.5 mm Hg higher than with extra-large cuffs

Conclusion

• Miscuffing results in significantly inaccurate blood pressure measurements

• It is important to emphasize individualized BP cuff selection

References

1. Ishigami J, Charleston J, Miller ER, Matsushita K, Appel LJ, Brady TM. Effects of Cuff Size on the Accuracy of Blood Pressure Readings: The Cuff(SZ) Randomized Crossover Trial. JAMA Intern Med. 2023;183(10):1061-1068. doi:10.1001/jamainternmed.2023.3264

Summarized by Jorge Chalit, OMSII | Edited by Jorge Chalit

Contributor: Aaron Lessen MD

Educational Pearls:

Is the adage, "GCS of 8, you've got to intubate" accurate? A recent study published in the November 2023 issue of JAMA attempted to answer this question.

Design

• Multicenter, randomized trial, in France from 2021 to 2023.

• 225 patients experiencing comatose in the setting of acute poisoning were randomly assigned to either a conservative airway strategy of withholding intubation or "routine practice" of much more frequent intubation.

• The primary outcome was a composite endpoint including in-hospital death, length of intensive care unit stay, and length of hospital stay.

• Secondary outcomes included adverse events from intubation and pneumonia within 48 hours.

Results

• Results showed that in the intervention group (with intubation withholding), only 16% of patients were intubated, compared to 58% in the control group.

• No in-hospital deaths occurred in either group.

• The intervention group demonstrated a significant clinical benefit for the primary endpoint, with a win ratio of 1.85 (95% CI, 1.33 to 2.58).

• The conservative airway management strategy also saw a statistically significant decrease in adverse events from intubation and pneumonia.

Conclusion

• Among comatose patients with suspected acute poisoning, a conservative strategy of withholding intubation was associated with a greater clinical benefit.

• This suggests that a judicious approach to intubation is appropriate in many other settings and clinicians should rely on more than the GCS to make this decision.

References

1. Freund Y, Viglino D, Cachanado M, Cassard C, Montassier E, Douay B, Guenezan J, Le Borgne P, Yordanov Y, Severin A, Roussel M, Daniel M, Marteau A, Peschanski N, Teissandier D, Macrez R, Morere J, Chouihed T, Roux D, Adnet F, Bloom B, Chauvin A, Simon T. Effect of Noninvasive Airway Management of Comatose Patients With Acute Poisoning: A Randomized Clinical Trial. JAMA. 2023 Dec 19;330(23):2267-2274. doi: 10.1001/jama.2023.24391. PMID: 38019968; PMCID: PMC10687712.

Summarized by Jeffrey Olson MS2 | Edited by Meg Joyce & Jorge Chalit, OMSII

Contributor: Aaron Lessen MD

Educational Pearls:

• A 2013 study randomized families of those in cardiac arrest into two groups:

• Actively offered patients' families the opportunity to observe CPR

• Follow standard practice regarding family presence (control group)

• Of the 266 relatives that received offers to observe CPR, 211 (79%) accepted vs. 43% in the control group observed CPR

• The study assessed a primary end-point of PTSD-related symptoms 90 days after the event

• Secondary end-points included depression, anxiety, medicolegal claims, medical efforts at resuscitation, and the well-being of the healthcare team

• The frequency of PTSD-related symptoms was significantly higher in the control group

• Lower rates of anxiety and depression for the families who witnessed CPR

• There were no effects on resuscitation efforts, patient survival, medicolegal claims, or stress on the healthcare team

• If families choose to witness CPR, it's beneficial to have someone with the family to explain the process

References

1. Jabre P, Belpomme V, Azoulay E, et al. Family Presence during Cardiopulmonary Resuscitation. N Engl J Med. 2013;368(11):1008-1018. doi:10.1056/NEJMoa1203366

Summarized by Jorge Chalit, OMSII | Edited by Jorge Chalit

Contributor: Ricky Dhaliwal, MD

Educational Pearls:

Croup

• Caused by:

• Parainfluenza, Adenovirus, RSV, Enterovirus (big right now)

• Age range:

• 6 months to 3 years

• Symptoms:

• Barky cough

• Inspiratory stridor (Severe = stidor at rest)

• Use the Westley Croup Score to gauge the severity

• Treatment:

• High flow, humidified, cool oxygen

• Dexamethasone 0.6 mg/kg oral, max 16mg

• Severe: Racemic Epinephrine 0.5 mL/kg

• Consider heliox, a mixture of helium and oxygen

• Very severe: be ready to intubate

Bronchiolitis

• Caused by:

• RSV, Rhinovirus

• Symptoms are driven by secretions

• Symptoms:

• Cough

• Wheezing

• Dehydration (often the symptom that makes them look the worst)

• Age range:

• 2 to 6 months

• Treatment:

• Suctioning

• Oxygen

• IV fluids

• Nebulized hypertonic saline

• DuoNebs? No.

Asthma

• Caused by:

• Environmental factors

• Viral illness with a predisposition

• Treatment:

• Beta agonists

• Steroids

• Ipratropium

• Magnesium (relaxes smooth muscle)

References

• Dalziel SR, Haskell L, O'Brien S, Borland ML, Plint AC, Babl FE, Oakley E. Bronchiolitis. Lancet. 2022 Jul 30;400(10349):392-406. doi: 10.1016/S0140-6736(22)01016-9. Epub 2022 Jul 1. PMID: 35785792.

• Hoch HE, Houin PR, Stillwell PC. Asthma in Children: A Brief Review for Primary Care Providers. Pediatr Ann. 2019 Mar 1;48(3):e103-e109. doi: 10.3928/19382359-20190219-01. PMID: 30874817.

• Midulla F, Petrarca L, Frassanito A, Di Mattia G, Zicari AM, Nenna R. Bronchiolitis clinics and medical treatment. Minerva Pediatr. 2018 Dec;70(6):600-611. doi: 10.23736/S0026-4946.18.05334-3. Epub 2018 Oct 18. PMID: 30334624.

• Smith DK, McDermott AJ, Sullivan JF. Croup: Diagnosis and Management. Am Fam Physician. 2018 May 1;97(9):575-580. PMID: 29763253.

• Westley CR, Cotton EK, Brooks JG. Nebulized racemic epinephrine by IPPB for the treatment of croup: a double-blind study. Am J Dis Child. 1978 May;132(5):484-7. doi: 10.1001/archpedi.1978.02120300044008. PMID: 347921.

• https://www.mdcalc.com/calc/677/westley-croup-score

Summarized by Jeffrey Olson | Edited by Meg Joyce & Jorge Chalit, OMSII

Contributor: Ricky Dhaliwal MD

Educational Pearls:

• Three zones of the neck with different structures and risks for injuries:

• Zone 1 is the most caudal region from the clavicle to the cricoid cartilage

• Zone 2 is from the cricoid cartilage to the angle of the mandible

• Zone 3 is superior to the angle of the mandible

• Zone 1 contains the thoracic outlet vasculature (subclavian arteries and veins, internal jugular veins), carotid arteries, vertebral artery, apices of the lungs, trachea, esophagus, spinal cord, thoracic duct, thyroid gland, jugular veins, and the vagus nerve. 

• Zone 2 contains the common carotid arteries, internal and external branches of carotid arteries, vertebral arteries, jugular veins, trachea, esophagus, larynx, pharynx, spinal cord, and vagus and recurrent laryngeal nerves

• Lower risk than Zone 1 or Zone 3

• Zone 3 contains the distal carotid arteries, vertebral arteries, jugular veins, pharynx, spinal cord, cranial nerves IX, X, XI, XII, the sympathetic chain, and the salivary and parotid glands

• Hard signs that indicate direct transfer to OR:

• Airway compromise 

• Active, brisk bleeding

• Pulsatile hematomas

• Hematemesis

• Massive subcutaneous emphysema 

• Soft signs that may obtain imaging to determine further interventions:

• Hemoptysis

• Oropharyngeal bleeding

• Dysphagia

• Dysphonia

• Expanding hematomas

• Soft sign management includes ABCs, type & screen, and airway interventions followed by imaging of the head & neck area

• Patients with dysphonia or dysphagia with subsequent negative CTAs may get further work-up via swallow studies

References

1. Asensio JA, Chahwan S, Forno W, et al. Penetrating esophageal injuries: multicenter study of the American Association for the Surgery of Trauma. J Trauma. 2001;50(2):289-296. doi:10.1097/00005373-200102000-00015

2. Azuaje RE, Jacobson LE, Glover J, et al. Reliability of physical examination as a predictor of vascular injury after penetrating neck trauma. Am Surg. 2003;69(9):804-807.

3. Ibraheem K, Wong S, Smith A, et al. Computed tomography angiography in the "no-zone" approach era for penetrating neck trauma: A systematic review. J Trauma Acute Care Surg. 2020;89(6):1233-1238. doi:10.1097/TA.0000000000002919

4. Nowicki JL, Stew B, Ooi E. Penetrating neck injuries: A guide to evaluation and managementx. Ann R Coll Surg Engl. 2018;100(1):6-11. doi:10.1308/rcsann.2017.0191

Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit, OMSII