Non-Accidental Trauma - A Can’t Miss Diagnosis

NAT image.png

Written by: Dana Loke, MD (NUEM PGY-4) Edited by: Ashley Amick, MD (NUEM ‘18) Expert commentary by: Lauren Riney, DO


Non-accidental trauma (NAT) is a leading cause of pediatric traumatic injury and death. In 2014 alone, there were 1546 reported deaths from NAT and 3.6 million child abuse referrals submitted to Child Protective Services (CPS). [1] NAT is most commonly encountered in young children, but can occur at any age. The classic signs and symptoms of NAT will be reviewed here, but it is important to realize that occult injury is common. Compared with accidental pediatric trauma, patients with NAT have been shown to have higher injury severity scores, rates of intensive care unit admission, and mortality. Furthermore, the diagnosis of NAT is delayed in 20% of cases, increasing the risk of poor outcomes.[2] Therefore, the Emergency Physician (EP) must maintain a high index of suspicion for NAT to prevent the grave consequences of missed diagnosis for the patient and any other children in the home.

Red Flags and Risk Factors

NAT is a frequently missed diagnosis, but there are some red flags and risk factors that should make the EP take pause and consider this diagnosis. Children at greatest risk are generally toddler and younger, and often come from dysfunctional family units. A recent study found that 97% of NAT cases have antecedent familial dysfunction, such as substance abuse (alcohol or drugs), psychiatric disorder, history of violence or incarceration, or child withdrawal. [3] Additionally, over 70% of reported NAT deaths in 2014 were in children under 3 years old. [1]

Red Flags

  • Injuries inconsistent with the caregiver’s history

  • Reported mechanism of injury is unexpected for the child’s developmental status (for instance, a 2 week old infant rolling off of a bed)

  • Delayed presentation

Risk Factors

  • Age under 5 account for 81.5% of cases; children under 1 are most vulnerable [3]

  • Prematurity

  • Multiple medical conditions

  • Young parent

  • Female parent (although males are more likely to inflict fatal NAT)

  • Poor social support

  • Unplanned or unwanted pregnancy

  • Poor prenatal care

  • Shorter birth intervals between children

  • Increased number of separations from the child in the first year

Abuser Characteristics

  • Poor self-esteem

  • Depression and suicide attempts

  • Life stressors

  • Personal history of being abused as a child

  • Exposure to foster care or abandonment as a child

  • Engagement in criminal activity or corporal punishment as a child

Many other suspected risk factors have been studied. There is no consensus regarding whether a particular race is at greatest risk for NAT however black children have a greater risk of mortality from NAT. [4] Similarly, there is no consensus regarding socioeconomic status as it relates to NAT risk, but studies have shown that incidence of non-accidental head trauma and its severity rise during times of economic recession. [4]


Figure 1:  Bruising patterns that suggest child abuse. [6]

Figure 1: Bruising patterns that suggest child abuse. [6]


Bruising is the most common manifestation of NAT but has low specificity. In any child presenting with bruising, it is imperative to note the location, shape and pattern of the lesion and ensure this is clearly documented. Bruising located over soft tissue areas such as the cheeks, neck, genitals, buttocks, torso, and back, are more likely to represent NAT than bruises over bony prominences. [4] The shape of the bruise should be considered as well, since the bruise often reflects the shape of the causative object. Common objects used to inflict injury include belts, cords, shoes, kitchen utensils, hangers, and teeth. [4] Additionally, patterned bruises should raise suspicion for NAT since they generally do not occur with accidental trauma. Lastly, any bruising in non-mobile infants is suspicious for NAT as well. [5]

Figure 2:  Forced immersion burn of buttocks with bilateral, symmetric leg involvement in a “stocking” pattern. [7]

Figure 2: Forced immersion burn of buttocks with bilateral, symmetric leg involvement in a “stocking” pattern. [7]


Burns occur in 8-12% of NAT cases. [2] The most common types of burns from NAT are scald burns and thermal contact burns. Scald burns are the most common and typically occur from forced immersion in hot liquids, usually of the buttock, or in a stocking-and-glove distribution. Scald burns generally have sharp demarcation, uniform depth, and lack splash or drip marks that would be seen in an accidental immersion. Thermal burns occur from contact with hot objects, of which branding with metal implements or cigarettes is a common presentation. Concerning features of burns include:

  • Location on the hands (especially the dorsum), legs, feet, or buttocks

  • Patterned contact burns in the shape of an object (such as a fork, clothing iron, curling iron, or cigarette lighter)

  • Sharp stocking-and-glove pattern with sparing of the flexed protected areas (the classic forced immersion burn pattern)

Figure 3:  Classic metaphyseal lesion. White arrows denote femoral metaphyseal separation and black arrow denotes a proximal tibial lesion or “bucket handle.” [1]

Figure 3: Classic metaphyseal lesion. White arrows denote femoral metaphyseal separation and black arrow denotes a proximal tibial lesion or “bucket handle.” [1]


There are various non-accidental fracture patterns, several with high specificity as described below: 

  • Classic metaphyseal lesion (CML) – Also known as “bucket handle fractures” or “corner fractures,” these fractures are highly specific in children less than one year old. They result from a shearing force applied to a long bone, which causes avulsion of the metaphysis. These fractures are not associated with falls.

  • Multiple posterior and/or lateral rib fractures – These fractures also have a high correlation with NAT in children less than one year old. They arise from a specific mechanism – grasping the child around the torso and exerting a squeezing/compressive force. These fractures are more likely to affect the rib head and neck given the closer proximity to the transverse processes of the spine. NAT should especially be considered when healing fractures are found in a child without recent CPR.

Figure 4:  Posterior and lateral rib fractures of differing ages indicative of NAT [4]

Figure 4: Posterior and lateral rib fractures of differing ages indicative of NAT [4]

  • Clavicular fractures and spiral fractures of long bones in nonambulatory children

  • Multiple fractures, especially if in different stages of healing

  • Scapular fractures

  • Sternal fractures

  • Spinous process fractures

Of note, spiral fractures of long bones generally result from twisting injuries (indicating NAT), but can occur accidentally from falls in ambulatory children. Therefore, these fractures (especially if coupled with clavicular fractures) are more specific for NAT in younger patients, and the specificity decreases with advancing age. Other described non-accidental patterns to consider include epiphyseal separations, vertebral body fractures and separations, digital fractures, linear and complex skull fractures, and subperiosteal bone formation. These patterns have low to moderate specificity for NAT. [1] 

Abusive Head Trauma

Abusive head trauma (AHT) is the most fatal form of non-accidental injury in children. In fact, about 80% of deaths from NAT are caused by AHT and only 15% of patients with AHT survive without any sequelae. [4] AHT is a spectrum of injuries including collisions with stationary objects, direct blows to the head, and a repetitive acceleration- deceleration injury, also known as “Shaken Baby Syndrome.” Infants are particularly vulnerable to traumatic brain injury from shaking due to the relative weight of the head compared to the body, coupled with weak neck musculature. [1] If AHT is suspected, a non-contrast head CT should be obtained even with a nonfocal neurologic examination, because occult intracranial injury is common. Make sure to use age-appropriate dose reduction to minimize radiation exposure and if the CT scan is normal, consider further work-up with an MRI.

Figure 5:  Fundus of child with AHT with too-numerous-to-count retinal hemorrhages indicated by the black arrows. [8] The white arrow indicates small pre-retinal hemorrhages. The white arrowhead denotes hemorrhage extending into the peripheral retina. The black arrowhead denotes a healthy optic disc.

Figure 5: Fundus of child with AHT with too-numerous-to-count retinal hemorrhages indicated by the black arrows. [8] The white arrow indicates small pre-retinal hemorrhages. The white arrowhead denotes hemorrhage extending into the peripheral retina. The black arrowhead denotes a healthy optic disc.

Ocular Manifestations

Although there are many ocular manifestations associated with non-accidental head injuries, retinal hemorrhages occur most often (about 60-85% of non-accidental head injuries). [4] Suspicion for NAT should be especially heightened when retinal hemorrhages are found in combination with signs of head trauma. Other ocular manifestations of NAT include periorbital hematoma, eyelid laceration, subconjunctival hemorrhage, subluxed or dislocated lens, cataracts, glaucoma, anterior chamber angle regression, iridiodialysis, retinal dialysis or detachment, intraocular hemorrhage, optic atrophy, or papilledema. [4] 

Management and Disposition

All patients with suspected NAT should be admitted for protection and coordination of care even if they are clinically stable. Child Protective Services (CPS) must be notified, and engagement with the institutional social worker and child abuse team is recommended. It is important to note patients with NAT often have worse outcomes than other assault patients despite similar mechanisms of injury with intent to harm. [9] These patients often require close monitoring with Intensive Care Unit (ICU) resources. Patients with NAT should undergo a full skeletal survey as indicated in Figure 6 with additional imaging (CT, MRI) tailored to each patient. For instance, CT abdomen and pelvis should be obtained per general trauma guidelines, particularly if there is suspicion for solid organ or visceral injury. 

Figure 6:  Elements of the Skeletal Survey. Although a full skeletal survey is currently the standard of care for patients with NAT, there are ongoing research efforts to tailor X-ray imaging more specifically to each patient. [1]

Figure 6: Elements of the Skeletal Survey. Although a full skeletal survey is currently the standard of care for patients with NAT, there are ongoing research efforts to tailor X-ray imaging more specifically to each patient. [1]

Other diagnoses to consider in these patients include metabolic bone disease (such as rickets, Caffey disease, and osteogenesis imperfecta), blood dyscrasias, benign enlarged subarachnoid spaces (BESS), glutaric aciduria type 1 (which causes brain atrophy and subdural fluid collections). [1] However NAT is far more common than these diagnoses and carries significant morbidity and mortality when overlooked so should be considered and worked-up prior to these diagnoses.

Key Points

  • Pediatric NAT causes significant morbidity and mortality, and therefore EPs must maintain a high degree of suspicion for this diagnosis.

  • Red flags during evaluation include a changing or inconsistent history, injuries inconsistent with the history, an unexpected mechanism of injury based on the child’s developmental status, and delayed presentation despite significant injury.

  • Risk factors for NAT include children younger than school age (with children younger than 1 being most vulnerable), family dysfunction, prematurity, multiple medical conditions, young/female parent, poor social support, unplanned or unwanted pregnancy, poor prenatal care, numerous separations from the child in the first year of life, and history of psychiatric issues, stressors, criminal activity, or childhood abuse or abandonment in the abuser.

  • Although physical exam findings can be non-existent or non-specific, highly specific findings include bruising over soft tissue areas; bruises/burns that are patterned take the form of an object; any bruising in a non-mobile child; scald burns on the hands, legs, feet, or buttocks; and stocking-and-glove patterned burns.

  • Highly concerning fracture patterns include classic metaphyseal lesions (“bucket handle fractures” or “corner fractures”), multiple posterior and/or lateral rib fractures, clavicular or spiral long bone fractures in any nonambulatory child, multiple fractures, fractures in different stages of healing, scapular fractures, sternal fractures, and spinous process fractures.

  • There is a wide range of ocular manifestations in NAT but the most common manifestation is retinal hemorrhage(s).

  • AHT carries the highest mortality rate of all the injuries associated with NAT. Any suspicion for AHT warrants consideration of a non-contrast head CT.

  • Notify Child Protective Services (CPS) and admit these children for further NAT work-up including a full skeletal survey.

Expert Commentary

Excellent overview of NAT in the Emergency Department with emphasis on risk factors and manifestations. I want to add a few pearls about NAT and then will focus my commentary on NAT management in the ED as well as discussion with families, as this was recently a large quality improvement project in our pediatric tertiary care center.

Neglect is the most common form of child abuse accounting for about two-thirds of all forms of abuse and often accompanies other forms of abuse. (1) Neglect is involved in about 50% of all cases of fatal child abuse. (1) Among children less than 1 year of age, 25% of fractures are a result of abuse. (2) Consider two things: does the explanation the provider stated account for the fracture the child has sustained? Is the child developmentally capable of the action being described? After 2 years of age, the history and physical exam should determine the imaging required. Over 5 years of age, the yield of unsuspected fractures from a skeletal survey is only 9%, making this group more amenable to selective radiographic studies. (3) 

Diagnosis of NAT in children remains a challenge due to provider bias, preconceptions, and failure to recognize the presentation as possible abuse. (4,5) As a result, these injuries may go undetected, leading to further injury prior to diagnosis. An estimated 25% of children ultimately diagnosed with NAT have a sentinel injury prior to their abuse diagnosis. (6,7) Of abused children with a previous sentinel injury, the most common were a bruise (80%), a torn frenulum (11%), or a fracture (7%). (8) A large retrospective chart review estimated 80% of deaths from unrecognized abusive head trauma may have been prevented by earlier detection of NAT. (6) The American Academy of Pediatrics (AAP) states that “ANY injury to a young, pre-ambulatory infant” suggests abuse. (9)

Figure 1:  Standardized Physical Abuse Guideline.

Figure 1: Standardized Physical Abuse Guideline.

At our institution, a team of pediatric emergency medicine physicians and child abuse pediatricians convened to develop and implement a standardized NAT guideline for providers in the ED when evaluating children with suspected NAT (Figure 1 Standardized Physical Abuse Guideline). This work stemmed from a chart review showing there was significant variability in the evaluation and management of children with concern for NAT in our Pediatric Emergency Department. The guideline was based on current peer reviewed literature as well as local expert consensus. It is divided into three separate age groups:  < 6 months, 6-12 months, and >12-36 months. Age groups were determined based on risk of injury at different age levels in described literature, acquisition of milestones as age progresses, and increased ability for young children to show specific signs of injury with increasing age.  

Lastly, the evaluation of NAT is stressful for both families and healthcare providers. The second page of our NAT guideline gives a sample script for EPs when discussing the non-accidental trauma evaluation for children. It states, “Any time a child comes to the hospital with this injury/these injuries, we evaluate for other injuries. Sometimes a child can have internal injuries such as fractures, head injury or abdominal injuries that we cannot see on the outside. Just like you, we want to make sure that your child is okay, so it is important to do this testing. We will also have our social worker come talk to you. This is a standard part of our evaluation. We are happy to answer any questions along the way”. It is important to acknowledge that this process is stressful, time consuming, and not comfortable for the child. Explaining each part of the process is important. Ensure that you use language that is non-accusatory. As EPs, we are not the ones to identify who the perpetrator is/was, but rather ensure the full NAT evaluation is completed and allow social work and/or Child Protective Services to determine further action. 

Non-accidental trauma remains too prevalent in our country. Literature continues to show that unrecognized NAT leads to worse injuries and sometimes fatality. Continuing knowledge and education about injuries suspicious for NAT for EPs remains imperative. Standardized evaluations and real time order sets can increase appropriate management of NAT in the Emergency Department.  


  1. Dubowitz H. Epidemiology of Child Neglect. CAN 2011, pp 28-34.

  2. Kaczor K, Clyde Pierce M. Abusive Fractures. CAN 2011, pp 275-295.

  3. Martich KV. Imaging of Skeletal Trauma in Abused Children. CAN 2011, pp 296-308.

  4. Higginbotham N, Lawson KA, Gettig K, et al. Utility of a child abuse screening guideline in an urban pediatric emergency department. J Trauma Acute Care Surg. 2014;76(3):871-877. 

  5. Tiyyagura GK, Gawel M, Koziel JR, et al.  Barriers and facilitators to detecting child abuse and neglect in general emergency departments. Annals of Emergency Medicine. 2015;66(5):447-454. 

  6. Jenny C, Hymel K, Ritzen A, et al. Analysis of missed cases of abusive cases of head trauma. JAMA. 1999;282:621-6.

  7. Rangel EL, Cook BS, Bennett BL, et al. Eliminating disparity in evaluation for abuse in infants with head injury: use of a screening guideline. Journal of Pediatric Surgery. 2009; 44(6):1229-34.

  8. Sheets LK, et al. Injuries in Infants Evaluated for Child Physical Abuse. Pediatrics. 2013, pp 701-707.

  9. Christian CW, Committee on Child Abuse and Neglect. The evaluation of suspected child physical abuse. Pediatrics. 2015;135:e1337–e1354.


Lauren C. Riney, DO

Assistant Professor

Division of Emergency Medicine

UC Department of Pediatrics

How to Cite this Post

[Peer-Reviewed, Web Publication] Loke D, Amick A. (2019, Oct 7). Non-Accidental Trauma. [NUEM Blog. Expert Commentary by Riney C]. Retrieved from

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  1. Pfeifer, C.M., Hammer, M.R., Mangona, K.L., & Booth, T.N. (2017). Non-accidental trauma: the role of radiology. Emerg Radiol, 24, 207-213.

  2. Kim, P.T. & Falcone, R.A. (2017). Non-accidental trauma in pediatric surgery. Surgical Clinics of North America, 97.1, 21-33.

  3. Child maltreatment 2014. Report, Children’s Bureau. Washington, DC: U.S. Department of Health and Human Services; 2014. Available at: http://www.acf.

  4. Paul, A.R. & Adamo, M.A. (2014). Non-accidental trauma in pediatric patients: a review of epidemiology, pathophysiology, diagnosis and treatment. Transl Pediatr, 3, 195-207.

  5. Maguire, S., Mann, M.K., Sibert, J. & Kemp, A. (2005). Are there patterns of bruising in childhood which are diagnostic or suggestive of abuse? A systematic review. Arch Dis Child, 90, 182-186.

  6. Boos, S.C. (2017). Physical child abuse: Recognition. Retrieved April 21, 2017, from

  7. Hobbs, C.J. (1986). When are burns not accidental? Archives of Disease in Childhood, 61, 357-361.

  8. Binenbaum G., Rogers, D.L., Forbes, B.J., Levin, A.V., Clark, S.A., Christian C.W., Liu, G.T., & Avery R. (2013). Patterns of retinal hemorrhage associated with increased intracranial pressure in children. Pediatrics, 132, 430-434.

  9. Litz, C.N., Ciesla, D.J., Danielson, P.D. & Chandler, N.M. (2017). A closer look at non-accidental trauma: Caregiver assault compared to non-caregiver assault. Journal of Pediatric Surgery, 52, 625-627.

Posted on October 7, 2019 and filed under Pediatrics, Trauma.

Assessment of the Suicidal Patient

Assessment of the suicidal patient img.png

Written by:  Kaitlin Ray, MD (NUEM PGY-4) Edited by: Matt Klein, MD (NUEM ‘18) Expert commentary by: Julie Cooper, MD (NUEM ‘11)

Approach to Assessing Suicidal Ideation in the Emergency Department

As the 10th leading cause of death in the United States, suicide has become a pervasive public health issue taking over 44,000 lives annually [1]. Each year, over 12 million emergency department (ED) visits are related to mental health and substance abuse issues, and over 650,000 patients are evaluated for suicide attempts [2]. An estimated 9.3 million American adults reported having suicidal thoughts in 2015, among which 2.7 million thought through a suicide plan. Of those adults who have thought through a plan, half 1.3 million actually attempted suicide [3]. Unfortunately, suicidal ideation is one of the most common psychiatric chief complaints encountered by emergency medicine physicians, and the ED is playing an increasingly critical role in providing acute psychiatric care [3]. 

The unfortunate reality is that many mental health programs and community initiatives have limited resources and are at maximum capacity [2]. As such, the ED is often the only available option for management of acute and subacute psychiatric illness [2]. In fact, the Joint Commission’s National Patient Safety Goal (NPSG) orders that general hospitals “conduct a risk assessment that identifies specific characteristics of the individual served and environmental features that may increase or decrease the risk for suicide”. Further, the National Action Alliance Clinical Care and Intervention Task Force specifies that suicide assessment “should be completed by a professional with appropriate and specific training in assessing for and evaluating suicide risk…and [the professional] must have the skills to engage patients in crisis and to elicit candid disclosures of suicide risk in a non-threatening environment” [4]. 

In an attempt to meet these goals and provide psychiatric care to those in need, EM physicians are faced with the unique expectation to execute an organized, efficient, and effective approach to suicide assessment that ensures patient and public safety. The process of eliciting the aforementioned ‘candid disclosure’ can be a daunting task during an emergent visit without a previously established relationship [2]. This problem is further complicated by the increasing reliance on the ED for acute psychiatric care which can exacerbate overcrowding, leading to decreased quality of care and increased likelihood of medical error. Further, mental health associated visits are 2.5x more likely to result in an admission requiring resource intensive care, which can negatively impact quality of care for other patients [5].

The continued emphasis on screening for suicidal ideation in the ED necessitates EM physicians to understand and perform a suicide risk assessment [6]. Of note, it is critical to differentiate suicide screening and suicide assessment. Screening refers to a standardized instrument or protocol that identifies individuals at risk for suicide; a process often performed in triage independent of chief complaint or presenting symptoms. Assessment refers to a comprehensive evaluation performed by a clinician to not only confirm suspected suicide risk, but also to estimate immediate danger to the patient and implement a treatment plan [4]. The focus of this piece is targeted toward the assessment and evaluation of a patient once already determined to be at risk for suicide per various screening methods (Mental Health Triage Scale, Behavioral Health Screening, Manchester Self-Harm Rule, ReACT Self-Harm Rule, P4 Screener, Beck Depression Scale, Geriatric Depression Scale) [7]. 

Suicide assessment and evaluation in the ED is an imperfect science with a limited evidence base to guide management [4]. Further, neither the American Psychiatric Association nor the American College of Emergency Physicians (ACEP) have issued guidelines addressing acute ED management of suicidal patients, leading to markedly varied practice patterns in hospitals across the United States [2]. While there are efforts to develop a quantitative method through which to identify those at highest risk of suicide, there is no universally accepted scoring system, and currently clinical judgment remains the most essential factor [6].

In the majority of emergency departments across the country, the EM physician is responsible for the assessment and disposition of patients with suicidal ideation. Multiple factors are taken into account when defining the role of an EM physician during this process including the following: 

  • Providing a safe environment: Take care to ensure the safety of both the patient and other health care providers. This process often requires taking patient’s clothing in exchange for a hospital gown, searching and withholding personal belongings, 1:1 observation, and physical or chemical restraints if deemed appropriate. Conduct the evaluation in a non-judgmental fashion, preferably in a private or semi-private setting utilizing open-ended questions [2]. 

  • Ruling out “reversible” causes of depression/suicidal ideation: Consider toxic ingestions, infectious processes, toxic-metabolic etiology, and trauma as possible causative factors when clinically indicated. ACEP issued a Level B recommendation regarding obtaining routine laboratory testing in alert, cooperative patients with normal vital signs and a non-focal history and physical. Routine urine drug screens (UDS) are a Level C recommendation and should not delay patient evaluation or transfer to more advanced psychiatric care [2]. Of note, one should insist on a clinically sober assessment, not based on BAC, given the disinhibiting effect of alcohol. 

  • Assessing the degree of imminent risk to the patient: Arguably the most challenging yet critical component of the process. The Suicide Prevention Resource Center (SPRC) has developed a 5-step process to guide the clinical assessment of patients with suicidal ideation and is one that can be implemented in the ED setting [8]. SAFE-T, the Suicide Assessment Five-Step Evaluation and Triage, is a simple methodical approach that focuses on identifying risk factors for suicide, identifying protective factors, conducting the suicide inquiry, determining the risk level of the patient, and finally documenting the clinical assessment [8]. Each component will be elaborated on separately.

Identifying risk factors for suicide:

  • Prior history of suicide attempts: The single strongest predictor of suicide with these patients being 6x more likely to make another attempt [2].

  • Current lethal plan: Highly predictive of future suicide attempt [6].

  • Older age: While younger patients typically have more attempts at suicide, older patients are more likely to succeed2. The highest rates of suicide are found among middle-aged populations between 45-64 years old [1].

  • Coexisting psychiatric disorder: Major Depressive Disorder, schizophrenia, personality disorder, borderline personality disorder, bipolar disorder, PTSD [2]

  • Recent psychosocial stressor: Ask about marital status, employment, social support, homelessness, financial stressors

  • Caucasian Race: Highest suicide rates among whites, specifically white males who account for 7/10 suicides in the US [1]. The 2nd highest suicide rate is among American Indians/Alaska Natives, where suicide is now the leading cause of death in those aged between 10-34 years of age [3].

  • EtOH/Drug Abuse: Chronic use elevates suicide risk long term, while acute intoxication disinhibits and impairs thought process, increasing suicide risk in a more immediate context [6].

  • Other factors to consider [6]:

    • Gender: Women attempt suicide 4x more frequently than men; however men are 3x as successful as women in completing suicide [2].

    • Access to firearms: Utilization of firearms accounts for 50% of all suicides in the US, with higher rates among men1. Poisoning is the most common method among females [3].

    • Impulsivity: Look for behaviors and statements from the patient that establish a pattern of impulsive behavior [2].

    • Family history of suicide/mental illness

    • History of childhood trauma

    • Chronic physical illness

Identifying protective factors for suicide

  • No past suicidal ideation: Denies feelings of hopelessness and depression [6]

  • Supportive family and social network [9]

  • Willingness to seek and accept help [9]

  • Strong personal relationships [9]

  • Female gender [9]

  • Ethical, moral, or religious suicide taboos [9]

  • Employment and financial stability [9]

  • Having dependents [9]

  • Positive self-esteem [9]

Conducting suicide inquiry [8]

  • Ideation: Frequency? Intensity? Duration? How often in past 48 hours? Past month?

  • Plan: Inquire about timing, location, lethality, availability, and any preparatory acts that may be involved

  • Behaviors: Past attempts? Aborted attempts? Any rehearsals—tying a noose? Loading a gun?

  • Intent: Evaluate the extent to which the patient intends to carry out the plan and believes the act to be lethal versus self-injurious. If possible discuss with patient their reasons to die vs. reasons to live.

Determining risk level and need for interventions

  • A patient’s risk level and subsequent treatment disposition is based on clinical judgment

  • Charted below is a general rule of thumb in guiding a patient’s disposition from the ED [8]:

Screen Shot 2019-09-29 at 10.07.16 AM.png

Documenting the clinical assessment

  • Documentation is the fifth and final component of a suicide assessment in the ED. Be clear to document the patient’s estimated risk level as well as the rationale for doing so. Specify the treatment plan that will address the patient’s current risk [8]. 

Perhaps the most challenging portion of assessing a suicidal psychiatric complaint is determining the patient’s disposition. In many facilities, a formal psychiatric assessment would require an inpatient hospitalization. Additionally, it is state (not federal) laws that govern conditions in which you may involuntarily hold a patient for an emergency psychiatric evaluation, with a hold >72 hours typically requiring a court order. Unfortunately there is no clear evidence to support the use of suicide contracts in the ED—i.e. written or verbal agreements between the physician and the patient in which the patient agrees to abstain from self-harm behaviors while in the ED and for a set amount of time thereafter. While psychotropic medications are rarely initiated in the emergency department, it may be reasonable to prescribe a short course of anxiolytics as a bridge to psychiatric follow up in a patient determined safe for discharge home. Patients determined safe for outpatient follow-up should be given strict return precautions in addition to resources that include emergency and crisis phone numbers. Finally, as with all other life threatening conditions that come through the ED, documentation regarding the risk assessment and disposition of the patient is critical [2].

Ultimately, until our mental health and community resources have the means to meet the growing psychiatric demands of our country, the emergency department will continue to be a resource to provide acute psychiatric care. Limited evidence-based recommendations and no official standardized guidelines exist to assist emergency physicians in assessing risk of suicidality; however, adhering to the basic process of identifying high risk features in addition to protective factors, while simultaneously asking direct questions regarding suicidal ideation, plan, behavior, and intent, can guide EM physicians towards making an appropriately and timely disposition for the suicidal patient.

Expert Commentary

Thanks so much for this excellent review of the approach to the patient with suicidal ideation. What a complex task to perform in our already complex practice, but also what a pleasure to care for someone when the major tool in our toolbox is taking the history!  This review correctly notes that the emergency physician “must have the skills to engage patients in crisis and to elicit candid disclosures of suicide risk in a non-threatening environment”. So, what exactly are those skills? 

First, we know that the typical ED environment is not always conducive to sensitive conversations. I once heard a resident walk up to a patient in the hallway and say “Hi! I heard you were suicidal!”. Whether the patient is mean, intoxicated, or has some kind of perceived secondary gain, observe your cognitive biases and overcome the urge to minimize their perceived risk.  Consider location bias when they are in a hallway, anchoring bias when staff tell you “they were just discharged yesterday”. Those all may be reasons a patient is destabilized and at high risk, so be on alert. Many of these patients wait for hours, have difficult lives and none of us went into medicine to be mean to vulnerable people. Get them the sandwich and a warm blanket, create some privacy and pull up a chair. 

Conversations surrounding mental health and suicidality can trigger intense feelings of shame or embarrassment (in both the patient and clinician), elicit anxiety surrounding the consequences of seeking help or conjure memories of negative experiences with the mental health system. Language really does matter when it comes to building trust and conveying empathy. I always start my history open ended with “how did you end up here today?” and assume no knowledge of the events that brought them in. The details of how a person actually came to be in the ED can shine a light on their risk. Did they come seeking help themselves? Did another person encourage them who may have important collateral information? Was law enforcement involved? If they are not forthcoming I might try “I heard …   is that correct?” 

If a patient doesn’t bring up suicidal thoughts on their own I often start with “It sounds like you have been feeling really badly leading up to today, were you worried about your safety?”. I’ll work up to “were you worried you might harm or kill yourself?” and try to tease out “how close” they might have gotten by asking “did you actually do something to try to harm yourself or was there something you were worried about doing?” For an attempt that doesn’t seem serious to me (a small over the counter ingestion or superficial self-injurious behavior like cutting) I will ask what they thought was going to happen when they did that. Often it might be a serious attempt in their eyes. When considering protective factors I always ask “what kept you from going through with it?”. This might bring up mitigating factors that reduce their suicide risk.  

The assessment of a suicidal patient can be an opportunity to switch gears during a shift and focus on the kind of communication that is fundamental to the practice of medicine.  If you’re looking to build your skills, consider seeking feedback from mental health professionals like psychiatrists, nurses or social workers in your department or observe them on shift to learn language you might integrate. That is how I picked up one of my favorite tools for an emotional patient encounter: expressing gratitude. If a patient acknowledges suicidal feelings, try “thank you so much for sharing that with me, I know it was hard and we are here to help.”


Julie Cooper, MD

How To Cite This Post

[Peer-Reviewed, Web Publication] Ray K,  Klein M. (2019, Sept 30). Assessment of the Suicidal Patient. [NUEM Blog. Expert Commentary by Cooper J]. Retrieved from

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1. American Foundation for Suicide Prevention. (2015). Suicide Statistics — AFSP. Retrieved from

2. Bernard, C., Gitlin, D., & Patel, R. (2011). The Depressed Patient and Suicidal Patient in the Emergency Department: Evidence based management and treatment strategies. Emergency Medicine Practice, 13(9). Retrieved from

3. Suicide Facts at a Glance 2015. Retrieved from

4. Suicide Prevention Resource Center. (2014, September 1). Suicide Screening and Assessment. Retrieved from suicide%20screening_91814%20final.pdf

5. Owens, P., Mutter, R., & Stocks, C. (2010). Mental health and substance abuse-related emergency department visits among adults, 2007 (92). Agency for Healthcare Research and Quality.

6. Ronquillo, L., Minassian, A., Vilke, G. M., & Wilson, M. P. (2012). Literature-based Recommendations for Suicide Assessment in the Emergency Department: A Review. The Journal of Emergency Medicine, 43(5), 836-842. doi:10.1016/j.jemermed.2012.08.015

7. Brim, C., Lindauer, C., Halpern, J., & Storer, A. (2012). Clinical Practice Guideline: Suicide Risk Assessment. Institute for Emergency Nursing Research. Retrieved from

8. Jacobs M.D., Douglas. National Suicide Prevention Lifeline. (2017, January 14). SAFE-T: Suicide Assessment Five-step Evaluation and Triage for Mental Health Professionals. Retrieved from

9. Simon, Robert I. "Assessing protective factors against suicide: questioning assumptions." Psychiatric Times, Aug. 2011, p. 35. Academic OneFile,

northwestern&v=2.1&it=r&id=GALE%7CA264271238&asid=e996d06fc529b9a60a6d5306fb8c8fd4. Accessed 1 Feb. 2017.

Posted on September 30, 2019 and filed under Psychiatry.


preeclampsia image.png

Written by: Priyanka Sista, MD (NUEM PGY-4) Edited by: Matt Klein, MD (NUEM ‘18) Expert commentary by: Shannon Lovett, MD


Expert Commentary

Thank you for this succinct guide to the diagnosis and management of preeclampsia in the ED. 

“The eyes do not see what the mind does not know…..”. The biggest pitfall in the management of preeclampsia in the ED, is failing to consider and recognize the diagnosis. Recognition and prompt treatment of preeclampsia in the ED setting can be challenging due to the variety of presenting complaints. It is important to note that preeclampsia may occur anytime from 20 weeks gestation up to 6 weeks postpartum. 

Postpartum preeclampsia tends to be more diagnostically challenging and depending on your facility, these patients are more likely to present to the ED than pregnant patients who often present to their obstetrician or to labor and delivery. Preeclampsia in the postpartum period most frequently occurs in the first 48 hours after delivery, but should be considered up to 6 weeks postpartum. Patients with postpartum preeclampsia often do not have hypertensive disease or preeclampsia during pregnancy. 

The complaints associated with preeclampsia may be broad and vague- including but not limited to: headache, vision changes, swelling or rapid weight gain, nausea and vomiting, shortness of breath, and abdominal pain. Consider preeclampsia or eclampsia in the critical female patient that arrives in the ED with little known history- for example actively seizing, or in respiratory distress with pulmonary edema. 

The treatment of preeclampsia can be broken down into three parts: treating the hypertension, reducing the risk or recurrence of seizures, and delivery of the fetus and the placenta. In the ED- our focus is on the first two, and involving our obstetric colleagues immediately. Blood pressure is most commonly treated with labetolol or hydralazine IV in the ED, and Mag should be given immediately for seizure prophylaxis (or to reduce recurrence of seizures in eclampsia). 

Lastly, our obstetric and gynecology colleagues at ACOG have recognized the frequency that postpartum patients present to the ED, and have created this ED checklist that can be used as a reference for the management of postpartum preeclampsia- Preeclampsia is a syndrome with potentially devastating consequences to mother and baby, and our early recognition and treatment can improve outcomes.


Shannon Lovett, MD

Associate Professor

Loyola University Medical Center

How To Cite This Post

[Peer-Reviewed, Web Publication] Sista P, Klein M. (2019, Sept 23). Preeclampsia. [NUEM Blog. Expert Commentary by Lovett S]. Retrieved from

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Posted on September 23, 2019 and filed under Obstetrics & Gynecology.

Clearing C-Spine in Intoxicated Blunt Trauma Patients

Written by:  Jason Chodakowski, MD (NUEM PGY-4)  Edited by:  Duncan Wilson, MD (NUEM ‘18)  Expert commentary by : Matt Levine, MD

Written by: Jason Chodakowski, MD (NUEM PGY-4) Edited by: Duncan Wilson, MD (NUEM ‘18) Expert commentary by: Matt Levine, MD

Saturday night in the ED.  A 28 year old man presents after a low speed motor vehicle accident.  Police report that he was seen swerving in the road before rear ending a parked car at approximately 25 mph.  He presents to the ED without visible signs of trauma. His trauma exam reveals no cervical spine tenderness, but he is heavily intoxicated with a GCS of 13.  Head CT and cervical spine CT are negative and he is currently sleeping in the hallway, periodically waking up to remove his cervical collar. You have very low suspicion that he has a significant cervical spine injury, but you ask yourself, can I clear his cervical spine given his level of intoxication?

Evaluating C-Spine Injuries

The Eastern Association for the Surgery of Trauma (EAST) Practice Management Guidelines Committee recommends the following approach to the care of patients with suspected cervical spine injuries: [1]

  • In awake, alert patients with trauma without neurologic deficit or distracting injury who have no neck pain or tenderness with full range of motion of the cervical spine, imaging is not necessary and the cervical collar may be removed.

  • All other patients in whom cervical spine injury is suspected should have radiographic evaluation, preferably with cervical spine CT imaging.

    • In patients with negative CT imaging but persistent neck pain, the patient may have a cervical ligamentous injury.  Three treatment options exist:

      • Continue the cervical collar

      • Cervical collar may be removed after negative MRI

      • Cervical collar may be removed after negative and adequate flexion/extension plain films.

The Canadian C-Spine and National Emergency X-Radiography Utilization Study (NEXUS) criteria are two widely used, prospectively validated decision rules that can be used by clinicians to clinically rule out clinically significant cervical spine injury, thereby obviating the need for imaging.

Canadian C-Spine criteria [10]: If the patient has all of the below, then radiography is not necessary:

  1. No High Risk Factors: Age >/=65; Dangerous Mechanism, paresthesias in extremities

  2. AND has presence of at least one low risk factor: simple rear-end MVC, sitting position in ED, ambulatory at any time, delayed onset of neck pain, and absence of midline c spine tenderness

  3. AND able to range neck actively (i.e. rotate neck 45 degrees left and right)

National Emergency X-Radiography Utilization Study (NEXUS) criteria [9]: If the patient meets all of the below criteria, no radiology is required.

  1. No posterior midline cervical-spine tenderness

  2. No evidence of intoxication

  3. A normal level of alertness

  4. No focal neurologic deficit

  5. No painful distracting injuries

C-Spine Clearance in Intoxicated Patients

Intoxicated patients are an important population to consider in the setting of suspected cervical spine injury: not only do they make up nearly half of all blunt and penetrating trauma patients [2], but intoxication and reduced level of consciousness disqualify the use of the above decision-rules, thereby necessitating CT imaging. CT is insensitive for ligamentous injuries and current practice dictates that after a negative CT c-spine these patients (and obtunded patients generally) are left in a c-collar until they can be reassessed unaltered or have additional imaging performed, usually MRI. 

A wealth of gradually accumulating data challenges the need to keep obtunded patients (and therefore plausibly intoxicated patients) in prolonged immobilization or to obtain MRI after a single negative CT c-spine, notably: 

  • Smith et al [3]: meta-analysis, 16785 obtunded trauma patients 

    • 99.9% Sn and 99.9% Sp for CSI; NPV 100%

  • Panczykowski et al [4]: meta-analysis, 14327 obtunded or intubated patients

    • 99.9% Sn and 99.9% Sp for unstable cervical spine injury

  • Patel et a [5]: systematic review, 1718 obtunded blunt trauma patients

    • NPV 100% for unstable CSI, 91% for any stable CSI

  • Raza et al [6]: meta-analysis, 1850 obtunded blunt trauma patients

    • 93.7% Sn and 99%.7% Sp; NPV 99.7%

  • Hogan et al [7]: retrospective review, 1400 blunt trauma patients

    • NPV 98.9% for ligamentous injury; 100% for unstable CSI

EAST Practice Management Guidelines reflect these findings, conditionally recommending c-collar removal after a negative high-quality CT c-spine alone. [5]

Most recently, a prospective observational study of intoxicated patients with blunt trauma was published by Bush et al [8] in JAMA Surgery in 2016. The authors followed 1696 adult blunt trauma patients who underwent 2mm-thickness, three-view CT c-spine, finding that among intoxicated patients (alcohol or other drugs) a single negative CT c-spine alone had a NPV of 99.2% for all cervical spine injuries and 99.8% for unstable cervical spine injuries. Of the 632 intoxicated patients, only 1 had an unstable ligamentous injury that was missed on CT and later identified on MRI.  This patient had quadriplegia on initial evaluation. The incidence and types of CSI were similar between intoxicated and sober groups. 

Where Do We Go From Here?

Given the high incidence of intoxication in blunt trauma patients who are collared and require c-spine clearance, it is worth considering whether an otherwise neurologically intact intoxicated patient with a negative high-quality CT c-spine requires prolonged immobilization. This is of particular importance in patients that become combative and demand removal of their cervical collar.  In such cases, ED physicians may be forced to sedate the patient in order to keep the cervical collar on or obtain an MRI, which may place the patient at risk. While the data is admittedly limited, it does demonstrate that the incidence of clinically significant c-spine injury in the setting of a negative CT scan is very low, with some authors stating it approaches zero. Given this, it may be justifiable to remove an intoxicated patient’s cervical collar in the setting of a reassuring clinical exam and negative CT scan in settings when the risk of keeping the patient in a cervical collar until sober is deemed to outweigh the risks of missed cervical spine injury.

Expert Commentary

Everything we recommend in medicine is a risk-benefit analysis.  If there is extremely little to benefit, then do not recommend. If the risk exceeds the benefit, then do not recommend.  Keep this in mind when considering various cervical collar scenarios, and the concept of being risk-averse vs being risk-neurotic.

Most of us think we are risk averse, but no one thinks they are risk neurotic.  However, many witnessed practices regarding the use of cervical collars are exactly that.  For instance, a patient that had an MVC yesterday presents with neck pain after waking up this morning.  They have been moving all over, showered, dressed, etc. There is some midline tenderness so now they must lie flat and still and wear a collar. They are not allowed to walk, use the toilet, or move themselves onto a CT table even though they got themselves in and out of the car this morning.  This is risk neurosis. This patient has gained nothing from wearing this collar. Furthermore, we have inconvenienced ourselves by having to now logroll this patient for imaging studies, not to mention the bedpan for the negative pregnancy test. Why are we doing this to ourselves and our patients?  Risk neurosis.

Do not confuse this with the MVC patient who had immediate neck pain, was removed from the car by EMS and immediately placed in a collar.  That patient has not moved around yet and declared themselves low enough risk yet. It is reasonable to handle them with care until the doctor can assess, and possibly image before considering collar removal.  Risk averse.

Back to the intoxicated patient demanding collar removal.  My risk-benefit calculator which is continuously churning in my head considers the two options:  

  1. Sedate and restrain a neurologically intact patient without signs of spine injury, despite not meeting strict clearance criteria due to intoxication.  This puts him at risk for violent behavior, over sedation, aspiration, prolonged ED length of stay, etc. Even if the patient is hiding a fracture, is the struggle to restrain him protecting his spine or putting it at risk?

  2. Do not make him wear the collar but make him stay in the ED until he can be clinically reassessed (when sober).  Even if he has a c spine fracture, how likely is deterioration during this time? 

Which is riskier for the patient’s spine, the restraint to force a collar on or the relatively peaceful collarless period?  My risk-benefit calculator tells me the peaceful collarless period is safest.

So remember to ask yourself when faced with a cervical collar scenario what are the risks and benefits of applying this collar?  Is there any real benefit? And then ask yourself the truly difficult but introspective question: Am I being risk averse or am I being risk-neurotic?


Matt Levine, MD

Assistant Professor of Emergency Medicine

Northwestern Feinberg School of Medicine


  1. Como, John J., et al. "Practice management guidelines for identification of cervical spine injuries following trauma: update from the eastern association for the surgery of trauma practice management guidelines committee." Journal of Trauma and Acute Care Surgery 67.3 (2009): 651-659.

  2. Rivara, Frederick P., et al. "The magnitude of acute and chronic alcohol abuse in trauma patients." Archives of Surgery 128.8 (1993): 907-913.

  3. Smith, Jackie S. "A synthesis of research examining timely removal of cervical collars in the obtunded trauma patient with negative computed tomography: an evidence-based review." Journal of Trauma Nursing 21.2 (2014): 63-67.

  4. Panczykowski, David M., Nestor D. Tomycz, and David O. Okonkwo. "Comparative effectiveness of using computed tomography alone to exclude cervical spine injuries in obtunded or intubated patients: meta-analysis of 14,327 patients with blunt trauma: A review." Journal of neurosurgery 115.3 (2011): 541-549.

  5. Patel, Mayur B., et al. "Cervical spine collar clearance in the obtunded adult blunt trauma patient: a systematic review and practice management guideline from the Eastern Association for the Surgery of Trauma." The journal of trauma and acute care surgery 78.2 (2015): 430.

  6. Raza, Mushahid, et al. "Safe cervical spine clearance in adult obtunded blunt trauma patients on the basis of a normal multidetector CT scan—a meta-analysis and cohort study." Injury 44.11 (2013): 1589-1595.

  7. Hogan, Gerard J., et al. "Exclusion of Unstable Cervical Spine Injury in Obtunded Patients with Blunt Trauma: Is MR Imaging Needed when Multi–Detector Row CT Findings Are Normal? 1." Radiology 237.1 (2005): 106-113.

  8. Bush, Lisa, et al. "Evaluation of cervical spine clearance by computed tomographic scan alone in intoxicated patients with blunt trauma." JAMA surgery 151.9 (2016): 807-813.

  9. Hoffman, J.R., et. al. “Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group.” NEJM. 2000. 343(2):94-99.

  10. Stiell, IG, et. al. “The Canadian C-Spine rule for Radiography in Alert and Stable Patients.” JAMA. 2001. 286(15):1841-8.

How To Cite This Post

[Peer-Reviewed, Web Publication] Chodakowski J, Wilson D. (2019, Sept 16). Clearing C-Spine in Intoxicated Blunt Trauma Patients. [NUEM Blog. Expert Commentary by Levine M]. Retrieved from

Other Posts You May Enjoy

Posted on September 16, 2019 and filed under Trauma.

Rise and Shine: A Review of the WAKE-UP Trial

Written by: Gabrielle Bunney, MD (NUEM PGY-2) Edited by: Alex Ireland, (NUEM PGY-4) Expert commentary by: Chris Richards, MD, MS


Wake up strokes have always been a clinical conundrum. Current practice guidelines from the American Stroke Association on the treatment of acute ischemic strokes specify a maximum of 4.5 hours from time of symptom onset to the delivery of alteplase therapy. [1] However, patients often awaken with these symptoms or are unable to give a clear history of symptom onset and thus are not eligible for alteplase therapy. Initial non-contrast computed tomography can identify whether or not an acute hemorrhage is present, but confirmatory imaging for ischemic stroke involves magnetic resonance imaging (MRI). Studies are now looking at the utility of early MRI in the diagnostic and therapeutic pathways of acute ischemic stroke. These studies are specifically looking at a positive signal on diffusion-weighted imaging (DWI) and a negative signal on FLAIR imaging to identify recent cerebral infarction. Multiple studies have found that there is adequate sensitivity and specificity of DWI-FLAIR mismatch to suggest stroke onset within 4.5 hours. [2-4] Armed with these new data, this paper’s goal was to determine whether patients with an unknown time of symptom onset, but with a mismatch on DWI and FLAIR MRI imaging, would benefit from thrombolysis with intravenous alteplase. 


Thomalla G, Simonsen CZ, et. al “MRI-Guided Thrombolysis for Stroke with Unknown Time of Onset | NEJM.” New England Journal of Medicine, Oxford University Press, [5]

Study Design

This study was a multi-center, randomized, double blind, and placebo controlled clinical trial. It involved 70 experienced stroke research centers in eight European countries. There was a central image-reading committee that reviewed all images for patient enrollment to evaluate inclusion and exclusion, and to arbitrate disagreements. 


Patients between the ages of 18 and 80 were eligible for the study if they clinically had an acute stroke and were able to perform their activities of daily living prior to this event. The patient had to awaken with these symptoms, be unsure about the time of onset secondary to confusion or aphasia, or have a timeline of symptoms greater than 4.5 hours, without an upper limit. 1,362 patients underwent screening. 859 were excluded, leaving 503 that were randomized. 254 of those were given alteplase and 249 received placebo. 


Intervention Protocol

Selected patients underwent DWI and FLAIR MRI imaging. Those who had a mismatch, defined as an abnormal signal on DWI, but no signal on FLAIR, were then randomized. Excluded were those with intracranial hemorrhage, lesions larger than one third of the middle cerebral artery territory, those who were to undergo thrombectomy, those with severe stroke, defined as greater than 25 on the National Institute of Health Stroke Scale (NIHSS), and those that had any other contraindication to alteplase aside from time from last known normal. Those that were randomized into the alteplase group were given 0.9mg/kg of alteplase with 10% administered as a bolus and the rest given as an infusion over 60 minutes. Assessments were then conducted between 22 and 36 hours after randomization, between 5 and 9 days, and finally at 90 days. 

Outcome Measures

This study had two end point measurements: efficacy and safety. The primary efficacy outcome measurement was favorable clinical outcome defined as a score of 0 to 1 on the modified Rankin scale 90 days after randomization. Secondary efficacy outcome measurements ranged from depression scores to activities of daily living measurements. 

The primary safety outcome was death and a composite outcome of death or dependence (4-6 on the modified Rankin scale) at 90 days. Secondary safety endpoints were symptomatic intracranial hemorrhage and the incidence of parenchymal hematoma type 2 on MRI 22 to 36 hours after randomization. 


The demographics between the alteplase and placebo groups were similar for age, sex, and medical history. However, in the alteplase group there was a higher rate of intracranial occlusion of the internal carotid artery. The average time for treatment of the alteplase and placebo groups was 3.1 and 3.2 hours after symptom recognition, respectively. 

Alteplase was found to be associated with favorable outcome at 90 days, with 53.3% in the alteplase group and only 41.8% in the placebo group having a modified Rankin score between 0 and 1 at 90 days, p=0.02. The secondary efficacy endpoints lacked power due to the fact that the study was terminated early because of a loss of funding. Table 2 from the original article describes the efficacy findings.


The safety groups were sized 251 in the alteplase group due to 5 patients not receiving alteplase and 244 in the placebo group due to 4 patients not receiving placebo. Death or dependency was found in 13.5% of the alteplase group and 18.3% of the placebo group, p=0.17. However, death at 90 days was higher in the alteplase group at 4.1%, while in the placebo group it was 1.2%, p=0.07. There were numerically more parenchymal hemorrhages in the alteplase group than in the placebo group, with 10 in the alteplase group and 1 in the placebo group. Table 3 from the original article describes the safety outcomes.



The primary efficacy outcome of this study, favorable functional outcome at 90 days, was higher in the group that received alteplase than in the group that received placebo and was statistically significant. Additionally, the primary safety outcome of death or disability was higher in the placebo group than in the alteplase group, though this was not found to be statistically significant. Death at 90 days was found to be numerically higher in the alteplase group than the placebo group, although not statistically significant. In extrapolating the data from the paper, the number needed to treat is 9.4 and the number needed to harm is 36.3. The ratio of these numbers suggests that treatment provides a greater benefit than risk. 

There are several limitations to this study. The trial was stopped early due to lack of funding, and so we may be overestimating the benefit or underestimating the risk. The authors estimated that they needed approximately 800 patients to have sufficient power, yet enrolled only 503. Bleeding complications and death at 90 days were numerically higher in the alteplase group, though this was not statistically significant. Trials such as ATLANTIS A and B, and ASK, were all stopped early due to harm because of increased bleeding in the alteplase groups. [6-8] It is unknown whether the addition of 297 patients to meet the pre-specified enrollment target of 800 in the WAKE-UP trial would have resulted in statistical significance. 

The population of this study had a median NIHSS of 6 out of 42, a relatively low stroke severity. The DAWN, DEFUSE, NINDS, and SITS-MOST trials, all significant studies in the progression of stroke research, had NIHSS medians of 17, 16, 14, and 12, respectively. [9-12] It is unclear if MRI-guided alteplase therapy would benefit patients with more severe strokes. Additionally, this paper excluded patients who were selected for thrombectomy. Patients selected for thrombectomy have large clot burdens in the internal carotid artery or middle cerebral artery that often have a modified Rankin score greater than 6. [13] By not including these patients, the WAKE-UP trial does not show the benefit of medical treatment in these sicker patients with a larger clot burden. 

Lastly, the study was only performed in experienced research stroke centers with readily available diagnostic pathways and MRI. Of the 1,362 patients imaged and screened, only 37% met intervention criteria. Many did not have DWI-FLAIR mismatch, and some did not have any DWI lesion, suggesting a transient ischemic attack or a stroke mimic. A smaller hospital is unlikely to have the experience or equipment to be able to screen these more difficult patients for the few that can actually proceed to intervention. 

Future Areas of Research

A replication of this study with additional subjects and sufficient power to confirm the beneficial effect of alteplase in MRI-guided thrombolysis would be the next step. Inclusion of alteplase plus thrombectomy in appropriate patients presenting after 4.5 hours with mismatch on DWI-FLAIR is another possible study. For example, TWIST ( Identifier: NCT03181360) and TIMELESS ( Identifier: NCT03785678) are two large clinical trials that will hopefully give more information about expanding the time window for thrombolysis. [14,15]


  • MRI DWI-FLAIR mismatch may be able to allow more patients to receive alteplase therapy after an acute ischemic stroke

  • Alteplase still shows benefit for treating stroke even with an unknown timeline when used in conjunction with MRI DWI-FLAIR mismatch

  • Similar to prior studies, alteplase is associated with numerically higher instances of intracranial hemorrhage 

  • Further research needs to be done to increase the power of this study

Expert Commentary

Really nice summary of the recent WAKE-UP* trial, and you bring up important considerations about both the pros and the cons of this study. WAKE-UP addressed an important clinical question: is it safe and effective for patients who have no other disqualifying reasons aside from their last known normal time to receive thrombolysis, if imaging shows a small area of infarction but a large area of ischemia? As you mention, intervention patients in the study: a) received intravenous tissue plasminogen activator (IV tPA) when otherwise they would not have, b) had increased odds of having a favorable outcome compared to standard of care, c) though with numerically greater instances of hemorrhage. 

WAKE-UP fits into a narrative with two other important recent trials, DAWN* and DEFUSE-3*that studied the outcomes of patients with last known normal (LKN) times greater than conventional LKN time cut-offs (4.5 hours for IV tPA and 6 hours for endovascular therapy) and have found efficacy of reperfusion in these extended windows for select patients. A third trial, EXTEND,* has been presented in abstract form and has demonstrated clinical improvement in select AIS patients receiving IV tPA up to 9 hours from LKN time (!/4715/presentation/13367). Importantly, these trials that expand the time window for reperfusion used imaging-based criteria for inclusion: WAKE-UP used MR, DAWN used a non-contrast CT scan compared to severity of clinical syndrome, DEFUSE-3 used CT perfusion along with a computer software program to identify the infarcted “core” and the ischemic penumbra, and EXTEND required a penumbral mismatch on CT perfusion or MRI.

From a pathophysiological perspective, this makes sense. If imaging can identify a large area of ischemia and small area of infarction, reperfusion should potentially result in the salvage of at least some of those reversibly damaged cells. It should also result in less pronounced hemorrhagic side effects because the area of known infarction is less – remember, not only neurons die in infarcted brain, so do blood vessel endothelium cells, a contributing factor in post-reperfusion hemorrhage. [16]

Looking into the future of acute stroke care, these clinical trials give promise for individualized acute stroke treatment. Rather than being beholden to a rigid time cut-off (that evidence is showing is not one-size-fits-all), we can look to imaging to inform acute treatment decision. We have learned from subgroup analysis from DEFUSE-3 that some patients slowly progress in their stroke pathophysiology, meaning that even beyond 24 hours, some patients have a favorable core to penumbra ratio. [17] Other patients quickly progress in their stroke pathophysiology and may match their ischemic core to their salvageable penumbra well before traditional time-cut offs. [18]

It is possible that image-based selection criteria could be integral to the screening of all candidates for acute reperfusion therapy in the future. As WAKE-UP, EXTEND, DAWN, and DEFUSE-3 have shown us, there are some patients that can be reasonably considered for treatment beyond traditional time cut-offs. The same imaging criteria that extended the window for patients in these studies may be the same criteria that, in the future, could identify patients within the traditional time window who are likely to not benefit from treatment and who may have an increased risk of hemorrhagic conversion. One can image a patient without evidence of a salvageable penumbra presenting at 3 hours, for example, for whom the risks of IV tPA may, in fact, outweigh the potential benefits. 

Lastly, I would hazard readers from interpreting the results of WAKE-UP, EXTEND, DAWN, and DEFUSE-3 as providing comfort in delaying thrombolysis or endovascular therapy for patients in extended time windows who would otherwise have indications for reperfusion. For IV tPA, longer delay is associated with increased risk of symptomatic intracranial hemorrhage and more timely treatment is associated with better outcomes. In the 2015 endovascular therapy trials, [19-23] even for patients within 6 hours of LKN, more timely treatment was associated with better outcomes. Even if the imaging protocols used in WAKE-UP, EXTEND, DAWN, and DEFUSE-3 can identify “slow progressors” that can be treated outside current treatment windows, these patients’ stroke are still progressing as time goes by. [18] Systems that promote timely evaluation of patients with stroke systems should be expected to help patients in extended time window, as they do patients within traditional time windows. {24,25]

Studies like WAKE-UP that test traditional inclusion and exclusion criteria for reperfusion give promise for safer and more effective stroke treatment. We look forward to future clinical trials, like TIMELESS* and TWIST*, that hopefully will give further clarity on this clinical question.

WAKE-UP [5]: Efficacy and Safety of MRI-based Thrombolysis in Wake-up Stroke Trial

DAWN [10]: Diffusion Weighted Imaging (DWI) or Computerized Tomography Perfusion (CTP) Assessment With Clinical Mismatch in the Triage of Wake Up and Late Presenting Strokes Undergoing Neurointervention Trial

DEFUSE-3 [9]: Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke 3 Trial

EXTEND [26]: EXtending the time for Thrombolysis in Emergency Neurological Deficits Trial

TIMELESS: Tenecteplase in Stroke Patients Between 4 and 24 Hours Trial (

TWIST: Tenecteplase in Wake-up Ischaemic Stroke Trial (


Chris Richards, MD, MS

Assistant Professor

Department of Emergency Medicine

Northwestern University

How to Cite this Post

[Peer-Reviewed, Web Publication] Bunney G, Ireland A. (2019, Sept 9). Rise and Shine: A Review of the WAKE-UP Trial. [NUEM Blog. Expert Commentary by Richards C]. Retrieved from

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  1. Powers WJ, Rabinstein AA, Ackerson T, et al. 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2018;49:e46-e110.

  2. Aoki, Junya, et al. “FLAIR Can Estimate the Onset Time in Acute Ischemic Stroke Patients.” Journal of the Neurological Sciences, vol. 293, no. 1-2, 2010, pp. 39–44., doi:10.1016/j.jns.2010.03.011

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  4. Thomalla, Götz, et al. “DWI-FLAIR Mismatch for the Identification of Patients with Acute Ischaemic Stroke within 4·5 h of Symptom Onset (PRE-FLAIR): a Multicentre Observational Study.” The Lancet Neurology, vol. 10, no. 11, 2011, pp. 978–986., doi:10.1016/s1474-4422(11)70192-2.

  5. Thomalla G, Simonsen CZ, et. al “MRI-Guided Thrombolysis for Stroke with Unknown Time of Onset | NEJM.” New England Journal of Medicine, Oxford University Press,

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  7. Clark, Wayne M., et al. “Recombinant Tissue-Type Plasminogen Activator (Alteplase) for Ischemic Stroke 3 to 5 Hours After Symptom Onset.” Jama, vol. 282, no. 21, Jan. 1999, p. 2019., doi:10.1001/jama.282.21.2019.

  8. Donnan, G. A. “Streptokinase for Acute Ischemic Stroke with Relationship to Time of Administration: Australian Streptokinase (ASK) Trial Study Group.” JAMA: The Journal of the American Medical Association, vol. 276, no. 12, 1996, pp. 961–966., doi:10.1001/jama.276.12.961.

  9. Albers, Gregory W, et al. “Thrombectomy for Stroke with Selection by Perfusion Imaging.” New England Journal of Medicine, vol. 378, no. 19, 2018, pp. 1849–1850., doi:10.1056/nejmc1803856.

  10.  Nogueira, Raul G, et al. “Thrombectomy 6 to 24 Hours after Stroke.” New England Journal of Medicine, vol. 378, no. 12, 2018, pp. 1161–1162., doi:10.1056/nejmc1801530.

  11.  “Tissue Plasminogen Activator for Acute Ischemic Stroke.” New England Journal of Medicine, vol. 333, no. 24, 1995, pp. 1581–1588., doi:10.1056/nejm199512143332401.

  12. Wahlgren, Nils, et al. “Thrombolysis with Alteplase for Acute Ischaemic Stroke in the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST): an Observational Study.” The Lancet, vol. 369, no. 9558, 2007, pp. 275–282., doi:10.1016/s0140-6736(07)60149-4.

  13. Campbell, Bruce C V, et al. “Endovascular Thrombectomy for Stroke: Current Best Practice and Future Goals.” Bmj, vol. 1, no. 1, 2016, pp. 16–22., doi:10.1136/svn-2015-000004.

  14. “Tenecteplase in Wake-up Ischaemic Stroke Trial (TWIST).”,

  15. “Tenecteplase in Stroke Patients Between 4 and 24 Hours (TIMELESS).”,

  16. Yaghi S, Eisenberger A, Willey JZ. Symptomatic intracerebral hemorrhage in acute ischemic stroke after thrombolysis with intravenous recombinant tissue plasminogen activator: a review of natural history and treatment. JAMA neurology 2014;71:1181-5. PMCID: 4592535.

  17. Christensen S, Mlynash M, Kemp S, et al. Persistent Target Mismatch Profile >24 Hours After Stroke Onset in DEFUSE 3. Stroke 2019;50:754-7. PMCID.

  18. Rocha M, Jovin TG. Fast Versus Slow Progressors of Infarct Growth in Large Vessel Occlusion Stroke: Clinical and Research Implications. Stroke 2017;48:2621-7. PMCID.

  19. Berkhemer OA, Fransen PS, Beumer D, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med 2015;372:11-20. PMCID.

  20. Campbell BC, Mitchell PJ, Kleinig TJ, et al. Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med 2015;372:1009-18. PMCID.

  21. Fransen PS, Berkhemer OA, Lingsma HF, et al. Time to Reperfusion and Treatment Effect for Acute Ischemic Stroke: A Randomized Clinical Trial. JAMA neurology 2015:1-7. PMCID.

  22. Goyal M, Demchuk AM, Menon BK, et al. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med 2015;372:1019-30. PMCID.

  23. Jovin TG, Chamorro A, Cobo E, et al. Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med 2015;372:2296-306. PMCID.

  24. Prabhakaran S, Ruff I, Bernstein RA. Acute stroke intervention: a systematic review. JAMA 2015;313:1451-62. PMCID.

  25. Higashida R, Alberts MJ, Alexander DN, et al. Interactions within stroke systems of care: a policy statement from the American Heart Association/American Stroke Association. Stroke 2013;44:2961-84. PMCID.

  26. Churilov L, Ma H, Campbell BC, Davis SM, Donnan GA. Statistical Analysis Plan for EXtending the time for Thrombolysis in Emergency Neurological Deficits (EXTEND) trial. International journal of stroke : official journal of the International Stroke Society 2018:1747493018816101. PMCID.

Posted on September 9, 2019 and filed under Neurology.

Chemical Sedation of the Agitated Patient in the ED

Chemical Sedation image.png

Written by: Zach Schmitz, MD (NUEM PGY-3) Edited by: Jason Chodakowski (NUEM PGY-4) Expert commentary by: Spenser Lang, MD (NUEM 2018)

Expert Commentary

Chemical Sedation of the Agitated Patient

This is a wonderful infographic from Dr. Schmitz discussing the various tools at the disposal of the emergency physician regarding agitated patients. Unfortunately, this type of encounter in the Emergency Department occurs rather frequently. Agitated patients can represent danger to themselves, staff, and even other patients, and thus the shrewd emergency physician should be prepared to act quickly and efficaciously. Importantly, organic illness can manifest with agitation as well, and trainees do well to remember that the cause of the agitation is just as important as the management.

I want to highlight the ethical aspect of chemical sedation. Given that this is a relatively frequent encounter in the ED, physicians and nurses risk becoming desensitized to these patients. The decision to chemically sedate a patient is paramount to taking away a patient’s autonomy, so should never be taken lightly. Also, in an academic environment, it is especially important to model professionalism in this vulnerable population. For this reason, I tend to discourage the use of terms such as “chemical takedown” and “B52.”  Still, the safety of the patient and staff remains the most important factor, and if this is in question, it’s time to proceed rapidly and efficaciously.

I always attempt verbal de-escalation – in the “agitated but cooperative” population this will often work (see More often, an experienced nurse or tech can have a tremendous impact on these patients. However, if I am called back to the bedside for a 2nd time to attempt this process, that is usually another trigger for medications. If I have been called twice, that means this patient is taking up an abundance of nursing and support staff, putting other patients at relative risk. At this point I offer oral medications (olanzapine, benzodiazepines) if the patient is receptive, or proceed with IM medications if necessary.

Once you have made the decision to chemically sedate the patient, it is important to do so safely. Gather the necessary staff – this will include security if available, at least one person per limb, plus someone able to control a patient’s head. Before any needles come near the body, it is of utmost important to ensure the limbs are controlled, to avoid accidental needle sticks for the staff. For the best positioning for patients in restraints, see the image below. I always recommend keeping the head of the bed elevated to around 30 degrees. After the patient is appropriately sedated, feel free to remove the restraints if appropriate and safe, and monitor with both pulse oximetry and end-tidal capnography if there is concern for significant respiratory depression.

Image from: Scott Weingart. Podcast 060 – On Human Bondage and the Art of the Chemical Takedown.  EMCrit Blog . Published on November 13, 2011. Accessed on March 8th 2019. Available at [ ].

Image from: Scott Weingart. Podcast 060 – On Human Bondage and the Art of the Chemical Takedown. EMCrit Blog. Published on November 13, 2011. Accessed on March 8th 2019. Available at [ ].

I want to point out one of the tables above comparing the time of onset in the most common medications administered for agitation. As you can see, both antipsychotics and benzodiazepines have significant delays to onset when given intramuscularly. With this significant delay in onset, it can be tempting to redose the medications. I find nursing staff, since they typically remain at the bedside of these patients, can become impatient with a slow time of onset. As the table shows, midazolam works much more quickly than lorazepam and can prevent a second dose of medications which may be unnecessary and potentially harmful to the patient. As part of my process of administering these medications, I try to counsel everyone involved (security, nursing staff) about what to expect and what our next step will be if the first attempt truly fails.


Spenser Lang, MD

Assistant Professor

Department of Emergency Medicine

University of Cincinnati Medical Center

How to Cite This Post

[Peer-Reviewed, Web Publication] Schmitz Z, Chodakowski J. (2019, Sept 2). Chemical Sedation. [NUEM Blog. Expert Commentary by Lang S]. Retrieved from .

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Posted on September 2, 2019 and filed under Psychiatry.

SCUBA Diving Injuries and Treatments


Written by: Aaron Wibberly, MD (NUEM PGY-2) Edited by: Sarah Dhake MD (NUEM Alum ‘19 ) Expert commentary by: Justin Hensley, MD


Expert Commentary

Thanks for writing about one of the topics that isn’t frequently covered in emergency medicine. SCUBA isn’t terribly dangerous, but early recognition of the problems encountered in these patients can save lives.

First, barotrauma exists because of Boyle’s Law (P1V1=P2V2). There is no way to go around this law of nature, only ways to prevent negative outcomes.

Barotrauma mainly affects the ears but can also affect the sinuses or mask.

Mask squeeze is failure to maintain pressure in facemask as pressure increases. Signs include subconjunctival hemorrhages, lid edema, skin ecchymosis, hyphema, and orbital hemorrhage (1)

Both tympanic membrane ruptures and inner ear problems (round and oval window) can be very disorienting underwater, placing the patient in danger of ascending too quickly or not being able to find their way out.

In an unresponsive diver, the arterial gas embolism is assumed until proven otherwise. Alveolar barotrauma is a life threat that needs emergent treatment.

Decompression sickness is known as “the bends” because of caisson workers. It mainly affected the hips and knees, causing them to maintain a bent over stance. For reasons nobody has yet identified, SCUBA divers are affected in the shoulders and elbows.

The “chokes” are bubbles in the pulmonary and cardiac vasculature, and can cause a “mill wheel” murmur (splash, splash, splash).

Skin bends, known as cutis marmorata, may be related to bubbles in the vasculature, but there is some evidence that it may be centrally mediated and symptomatic of more severe DCS. It frequently causes itching. (2,3)

Neurologic DCS most commonly affects the spinal cord and causes 50-60% of sport diver casualties.

Knowing where your closest hyperbaric chamber exists is of utmost importance. Diver’s Alert Network (DAN) does not publish a database but maintains a referral network that you can speak to after emergency evaluation by calling their 24-hour DAN Emergency Hotline at +1-919-684-9111.


1. Barron, E. (2018). The “Squeeze,” an Interesting Case of Mask Barotrauma. Air Medical Journal, 37(1), 74-75. doi: 10.1016/j.amj.2017.10.003

2. Germonpre, P., Balestra, C., Obeid, G. and Caers, D. (2015). Cutis Marmorata skin decompression sickness is a manifestation of brainstem bubble embolization, not of local skin bubbles. Medical Hypotheses, 85(6), pp.863-869.

3. Kemper TC, Rienks R, van Ooij PJ, and van Hulst RA. (2015). Cutis marmorata in decompression illness may be cerebrally mediated: a novel hypothesis on the aetiology of cutis marmorata. Diving Hyperb Med., 45(2), pp. 84-8.


Justin Hensley, MD

Founder and Editor of EBM Gone Wild

Quality Improvement/Assurance Director,

CHRISTUS Health-Texas A&M-Spohn Emergency Medicine Residency

How to Cite this Post

[Peer-Reviewed, Web Publication] Wibberly A, Dhake S. (2019, Aug 27). SCUBA Diving Injuries and Treatments. [NUEM Blog. Expert Commentary by Hensley J]. Retrieved from

Other Posts You Might Enjoy

Posted on August 26, 2019 and filed under Environmental.

Can't Miss Hand and Wrist Fractures in the ED


Written by: Justine Ko, MD (NUEM PGY-3) Edited by: Spenser Lang MD (NUEM Alum ‘18 ) Expert commentary by: Matt Levine, MD

“Can’t Miss” Hand and Wrist Injuries in the ED

In the emergency department, orthopedic complaints make up a large percentage of presentations, up to 50% in the pediatric population and close to 33% in the adolescent and young adult population. Many of these injuries are uncomplicated, but an astute clinician can diagnose subtle and uncommon injury patterns. Three less common injuries are reviewed here. If found, these injuries can alter the management and disposition of the patient. Each of these injuries should be carefully assessed for on physical exam and imaging. 


What exactly is the distal radioulnar joint and why is it important?

The distal radioulnar joint (DRUJ) consists of both the bony radioulnar articulation as well as the soft tissue components, including ligaments. It has significant contributions to the axial load-bearing capabilities of the forearm. The injury can be an isolated injury or associated with forearm fractures and should be tested for with every forearm injury as its presence can alter the disposition and even functionality of the patient. 


When does it occur?

A DRUJ injury may occur, although rarely, in isolation. This is usually related to a fall on outstretched hand (FOOSH). A DRUJ injury is more often associated with a fracture. Common associations include: 

  • Distal radial fracture (DRF)

    • DRF + DRUJ = Galeazzi fracture (pictured to the right)

  • Ulnar styloid fracture 

How should I assess for a possible DRUJ injury?

  • Routine AP and lateral views are poor for determining a DRUJ injury. This is largely a CLINICAL DIAGNOSIS.

  • Piano Key Sign: with the patient’s hand in pronation, push on the dorsal aspect of the ulnar head. Depression and rebound of the ulnar head suggest DRUJ instability

  • Table Top Test: have patient place hands on a table and apply force. A DRUJ injury will show dorsal depression of the ulna

  • Grind Test: hyperextend the wrist and axial load the forearm. A positive sign elicits pain over the joint 

How does this alter management?

When associated with a fracture, operative management is often indicated and consultation with our orthopedist is warranted. When missed, a DRUJ injury will result in instability of the joint and arthrosis. 



It has been reported that these injuries are missed in up to 25% of ED presentations.

How do these injuries occur?

In perilunate and lunate dislocations, the mechanism is usually hyperextension in the setting of trauma. Patients presents with hand and wrist pain/swelling.

How do I distinguish perilunate from lunate dislocations?


Lunate and perilunate dislocations can be easily confused or mistaken for each other. The key to distinguishing these injuries on imaging is the alignment between the metacarpal, carpal, and the radius/ulna bones.

In a normal lateral x-ray, these bones should all align (Figure 1, far left). In a lunate dislocation, the lunate itself is physically removed or out of line with the rest of these bones (Figure 1, far right), resulting in the classic “spilled teacup” appearance on x-ray. In a perilunate dislocation, the lunate sits in line with the radius/ulna, however the capitate/metatarsal bones are dislocated dorsally. 

On an AP film, a break in Gilula’s arc/lines may be used to assess for a perilunate or lunate dislocation (Figure 2).

How Are These Injuries Treated?

In the ED, closed reduction can be attempted. If successful, definitive treatment can occur up to 7 days later. If unsuccessful, operative management is indicated. Definitive treatment involves open reduction and internal fixation. 

How Would I Reduce These Injuries in the ED?

Usually, the assistance of our orthopaedic colleagues is warranted. Finger traps can be used for traction. The wrist should be extended while placing palmar pressure on the lunate. Then, with continued traction, the wrist should be gradually flexed so that the capitate falls back into place within the concavity of the lunate. Once the lunocapitate joint is reduced, the wrist can be extended in traction again for full reduction.


What is a scapholunate dissociation?

Scapholunate dissociation is caused by injury to the scapholunate ligament. Injury to this ligament can occur with acute FOOSH injury or be caused by degenerative rupture of the ligament. 


How do I diagnosis it?

These patients present with radial wrist pain. On imaging, the following signs can aid in diagnosis. 

  • Terry Thomas sign: This is seen on an AP wrist film and is indicated by a gap >3mm between the scaphoid and lunate bones 

  • Cortical Ring sign: occurs when the scaphoid is in a flexed position, making the scaphoid tubercle more prominent. A measure distance less than 7mm between the end of the cortical ring and the proximal end of the scaphoid suggests scapholunate dissociation and instability.  

How do I manage it?

In the ED, patients should be placed in a thumb spica cast for stabilization and referred to orthopaedics for follow up. Operative indication includes injury within 3 weeks and associated imaging and physical exam findings. During this time frame, the SL ligament is still viable for repair. 

Expert Commentary

Great choice by Dr. Ko to highlight these injuries that are often subtle, yet important because of the comorbidities associated with missing the diagnosis. 

The Galeazzi fracture is a classic EM boards question, because it is important!  It was termed by Campbell as the “fracture of necessity” (modern day translation = “this needs surgery!”) in 1942 because nonoperative management was observed to be associated with recurrent ulna styloid dislocations.  Hughston confirmed this is 1957, reporting that 35/38 cases treated nonoperatively had unsatisfactory outcomes.

There’s a saying in orthopedics that “the most commonly missed injury is the second injury”.  The radial shaft fracture is usually obvious and can distract the clinician from the less dramatic DRUJ injury.  DRUJ injury is radiographically diagnosed by:

  • Fracture at the BASE of the ulna styloid process (not the tip)

  • A widened DRUJ (a comparison x ray may be necessary), or

  • >5mm of shortening of the radius relative to the distal ulna.

A subtle clinical finding often associated with the Galeazzi fracture is anterior interosseus nerve injury.  It is a branch of the median nerve and is purely motor, so there will be no sensory deficit or paresthesia!  It manifests as loss of pinch strength between the thumb and index finger.  So have the patient make the OK sign and resist as you try to open it!

Mayfield, Johnson and Kilcoyne described a pattern of carpal injury caused by wrist hyperextension, ulnar deviation and intercarpal supination in 1980. In their original research on cadavers, progressive hyperextension force was applied and resulted in a consistent, sequential, progressively more unstable intercarpal injury pattern known as the four stages of carpal instability:

  1. Scapholunate dissociation

  2. Perilunate dislocation

  3. Perilunate and triquetral dislocation

  4. Lunate dislocation

Acute scapholunate dissociation is the most common pattern of carpal instability. It occurs secondary to a tear of the scapholunate interosseus ligament.  Scapholunate dissociation can also be chronic secondary to arthritic changes when there is no history of recent trauma.

X rays in lunate and perilunate dislocations are often not as clear and obvious as the diagrams used to teach these injuries.  The key to realizing that there is a carpal bone dislocation is recognizing that the carpal arcs are disrupted on the AP view. The distal and proximal carpal rows should never overlap on this view.  If you recognize this, you will heighten your suspicion and won’t miss these injuries, even if you cannot immediately tell the exact diagnosis.  

The name perilunate dislocation has always been a pet peeve of mine. There is no perilunate bone, so this nomenclature just introduces confusion.  It should simply be called a capitate dislocation, because that it what it really is.

All of these injuries, and more, are further detailed in our Ortho Teaching Files!


Matthew R. Levine, MD

Assistant Professor

Department of Emergency Medicine

Northwestern University

How to Cite this Post

[Peer-Reviewed, Web Publication] Ko J, Lang S. (2019, Aug 19). Can't Miss Hand and Wrist Fractures in the ED. [NUEM Blog. Expert Commentary by Levine M]. Retrieved from

Other Posts You Might Enjoy

To learn more about the diagnosis and management of orthopedic injuries from head to toe, check out our Ortho Teaching Files!


  1. Bowen WT, Slaven EM. 2014. “Evidence-based management of acute hand injuries in the emergency department.” Emergency Medicine Practice 16 (12):1-28. 

  2. “Distal Radial Ulnar Joint (DRUJ) Injuries - Trauma - Orthobullets.” n.d. Accessed March 7, 2018.

  3. Kardashian G, CHristoforou DC, Lee SK. 2011. “Perilunate dislocations.” Bulletin of the NYU Hospital for Joint Diseases 69 (1):87-96.

  4. “Lunate Dislocation (Perilunate Dissociation) - Hand - Orthobullets.” n.d. Accessed March 2, 2018.

  5. Pappou, Ioannis P., Jennifer Basel, and D. Nicole Deal. 2013. “Scapholunate Ligament Injuries: A Review of Current Concepts.” Hand (New York, N.Y.) 8 (2): 146–56.

  6. Reisler T, Therattil PJ, Lee ES. 2015 “Perilunate Dislocation.” Eplasty

  7. Rodner CM, Weiss APC. “Acute scapholunate and lunotriquetral dissociation.” American Society for Surgery of the Hand. 155-171.

  8. Scalcione LR, Gimber LH, Ho AM, Johnston SS, Sheppard JE, Taijanovic MS. 2014. “Spectrum of carpal dislocations and fracture-dislocations: imaging and management.” AJR 203: 541-550.

  9. Thomas, Binu P, and Raveendran Sreekanth. 2012. “Distal Radioulnar Joint Injuries.” Indian Journal of Orthopaedics 46 (5): 493–504.

Posted on August 19, 2019 and filed under Orthopedics.

Don't Forget aVL!

Don't forget aVL.png

Written by: Laurie Aluce, MD (NUEM PGY-3) Edited by: Kimberly Iwaki MD (NUEM Alum ‘18 ) Expert commentary by: Daniel Schimmel, MD

The Case: 

Patient: 57 year old male

Chief Complaint: Chest Pain 

PMH: Hypertension

Pain: Mid-sternal, non-radiating, 6/10, constant pressure

Onset:  45 minutes ago while watching TV

Associated symptoms: No diaphoresis, light-headedness, nausea, vomiting, or back pain 

Vitals: T 98.8, HR 70, BP 110/68, RR 14, Sat 100% on room air

Physical Exam:

General: Alert, no apparent distress, sitting comfortably in cart 

Cardiac: Regular rate and rhythm, no murmurs/rubs/gallops

Pulmonary: Clear to auscultation bilaterally, no crackles/wheezes

Extremities: Warm and well perfused, 2+ distal pulses, cap refill < 2s 

Labs: In process 

Triage EKG: 

Image from Stephen Smith, MD.

Image from Stephen Smith, MD.

What abnormalities do you see in this EKG? 

  • Prolonged PR interval

  • Slightly widened QRS

  • Hyperacute T waves in II, III, aVF

  • T wave inversion (TWI) in aVL

  • < 1mm ST depression in I, avL

What are you concerned about? What elements of this EKG raise your concern?   

  • Inferior myocardial infarction (MI) due to hyperacute T waves in II, III, aVF

  • Inferior MI or significant mid left anterior descending (LAD) lesion due to TWI in aVL [3] 

How will you differentiate an inferior MI from a chronic mid LAD lesion? 

Clinical picture and a repeat EKG. If the TWI is due to a chronic mid LAD lesion, it should not change on serial EKGs. If the TWI is due to an inferior MI, you may see it evolve to ST depression in aVL and/or ST elevation in II, III, aVF. [3]

You obtain a repeat EKG with one right-sided lead, V4R:

Image from Edward Burns, MD.

Image from Edward Burns, MD.

What abnormalities do you see in the repeat EKG?

  • Hyperacute T waves and ST elevation in II, III, aVF

  • ST depression and TWI in aVL

  • ST depression in V2

  • <1mm ST depression in I

  • <1mm ST elevation in V4R

What are you concerned about? What elements of this EKG raise your concern?

  • Concern for inferior MI

    • ST elevation in II, III, aVF

    • ST depression and T wave inversion in aVL

      • EKG sensitivity for inferior MI increases from 60% to 77% when criteria includes ≥ 1mm reciprocal ST depression in aVL in addition to ≥ 1mm ST elevation in II, III, aVF [1]

  • Concern for right ventricle (RV) involvement

    • 25% – 53% of inferior MIs have RV involvement [5]

    • ST elevation in III > II

    • Isoelectric ST segment in V1 with ST depression in V2

    • ST depression and T wave inversion in aVL

      • >1mm ST depression in aVL has sensitivity of 87% and positive predictive value of 90% for RV involvement with acute inferior MI [5]

  • Other findings suggestive of RV involvement not pictured in this EKG

    • ST elevation in V2 > 50% the magnitude of ST depression in aVF [4]

    • Right bundle branch block, 2nd and 3rd degree AV block

    • ST elevation in V1

How can your further evaluate for RV involvement?  

You ask for a right-sided EKG to check for ST elevation in V3R-V6R, but your EKG tech doesn’t remember where to place the leads. The tech looks to you for help. Where do you put the leads? 

                 Full Right-Sided EKG                                                         Standard EKG with V4R

Images from Tom Bouthillet.

Images from Tom Bouthillet.

If you don't have the time to perform a full right-sided EKG, you can perform a standard EKG but switch V4 to V4R as shown with the prior EKG. V4R is considered the best single lead for diagnosing a right ventricular MI.[2] ST elevation ≥ 1 mm in V4R has a sensitivity of 88% and a specificity of 78% for RV infarction. [6]

EKG with V4R-V6R:

Image from Ary Goldberger, MD. UpToDate: Electrocardiogram in the diagnosis of myocardial ischemia and infarction

Image from Ary Goldberger, MD. UpToDate: Electrocardiogram in the diagnosis of myocardial ischemia and infarction

What abnormality do you see in the right-sided leads?

  • ST elevation in V4R-V6R  

What is your diagnosis?

  • Inferior MI with RV infarction  

Take Home Points:

  1. Don’t forget aVL. T wave inversion and ST depression in aVL can be a marker of serious cardiac pathology:

    1. Significant mid-LAD lesion

    2. Evolving inferior MI and possible RV involvement

  2. If you are concerned for inferior ischemia, obtain a right-sided EKG to evaluate for right ventricular involvement

Expert Commentary

This is an excellent review of aVL, an important lead for diagnosis and prognosis.  Because it can be a modifier, or is used in conjunction with other criteria for diagnosis, it often gets overlooked.

In the acute setting, aVL can be used to help identify ST elevation myocardial infarction (STEMI) in various locations.  In addition to the aforementioned use in identifying RV involvement in inferior STEMI and mid LAD lesions, aVL is considered a high lateral lead which is fed by diagonal vessels.  As such, acute blockages that affect the proximal LAD with anterior STEMI in V3, V4, anteroseptal involvement in V1, V2 and may also have high lateral involvement in aVL. While I am always watching for shock and unstable arrhythmias taking patients to the cardiac catheterization lab, if I see this distribution with an anterior STEMI, I am even more concerned due to the amount of myocardium subtended by the lesion.  I often preemptively get access for cardiac mechanical support in case cardiogenic shock develops. In this way, the prognostic information from aVL may change practice in the cardiac catheterization lab.

Not to be overlooked, leads I and aVL may be the only leads with ST elevation in an isolated high lateral STEMI in a diagonal vessel.  Diagonal 1 or diagonal 2 may be large vessels and be the only vessel with acute thrombosis. aVL is the reciprocal lead to the inferior leads in inferior STEMI.  Similarly, lead III may move reciprocally, showing ST segment depression in the high lateral STEMI with elevation in aVL.

As nice as it can be to have aVL to prognosticate inferior STEMI, prognosticate anterior STEMI and identify isolated high lateral STEMI, aVL ST segments and T waves can be abnormal for non-acute reasons leading to a lack of specificity.  The most common reason for an abnormal repolarization in aVL is strain in the setting of LVH. So how do we differentiate acute reciprocal changes from strain pattern? 

A frequently overlooked bit of information on the EKG is the QRS-T angle.  Luckily this is reported for us on the EKG at the top. In the setting of T wave inversion, if the angle is greater than 100 degrees, this is more consistent with strain.  Furthermore, if the ST segment leading to the T wave is downwardly concave (think downward parabolic curve) with asymmetry of the T wave, this also is more consistent with strain.  If we look at the presented case’s EKGs, we can dissect them a bit further. In the triage EKG, there isn’t ST segment depression at all. In fact there is elevation with a T wave inversion.  This is concerning. The ST segment may be isoelectric with an inverted T wave, but there should not be ST elevation with a T wave inverted in the opposite direction. This morphology is often used in Sgarbossa criteria to identify STEMI in left bundle branch block.  So in addition to the hyperacute T waves of this triage EKG, aVL is very concerning. In the follow-up EKG, we can see dynamic changes that have occurred in the inferior leads solidifying the diagnosis. But aVL also suggests RV involvement. The ST segment is downsloping, depressed without concavity (more linearly pointing down to the right).  To clinch the diagnosis of RV involvement, we also see the right sided leads with elevation.

It is definitely possible to have a patient with LVH/strain findings and also have an acute inferior STEMI.  As demonstrated successfully in this case, the statement about serial EKGs is a critical one. Even in the setting of a normal EKG, a good story for myocardial infarction should prompt a serial EKG and often a posterior EKG to identify a supposedly electrocardiographically silent STEMI.  Remember STEMI is an EKG diagnosis that is supposed to correlate with the physiologic condition of an acute 100% occlusion of a vessel. In the early period, there can be stuttering pain with opening and closing of the vessel and the EKG may not capture it in that moment or may miss the posterior STEMI if the posterior EKG is not obtained.

To sum up the importance of aVL:

  1. Inferior STEMI: Improved diagnosis when aVL has a depressed ST segment with an inverted T wave

  2. Inferior STEMI: Considered worse prognosis when aVL has a depressed ST segment with an inverted T wave as it suggests a more proximal RCA occlusion with RV involvement.  ST elevation in V1 or right sided V4 may also be helpful in identifying proximal RCA occlusion with RV branch involvement.

  3. Anterior STEMI: aVL STEMI confers a worse prognosis, suggesting more proximal LAD involvement.

  4. Isolated high lateral STEMI: ST elevation in leads I and aVL may identify an acute 100% blockage in a diagonal vessel.  Lead III may have reciprocal ST segment depression.

To differentiate strain from ischemic changes in aVL:

  1. QRS-T angle:  If greater than 100, may be consistent with strain.

  2. ST segment slope:  If concave, consider strain.  If downsloping but the ST segment is more straight as it aims downward, consider an acute event.

  3. T Wave inversion:  If there is asymmetry to the inverted T wave, it may be more consistent with strain.

In summary, the EKG has so much data in it.  Pattern recognition can be a wonderful tool for quick diagnosis of clear problems.   But a methodical evaluation of the EKG can still be done quickly and identify what others may miss.


Dr. Daniel R. Schimmel

Assistant Professor of Medicine

Bluhm Cardiovascular Institute

Northwestern University


1. Birnbaum Y, et al. ST segment depression in aVL: a sensitive marker for acute inferior myocardial infarction. Eur Heart J 1993;14(1):4-7.

2. Carley SD. Beyond the 12 lead: Review of the use of additional leads for the early electrocardiographic diagnosis of acute myocardial infarction. Emergency Medicine 2003;15: 143-54.

3. Hassen GW, et al. Lead aVL on electrocardiogram: emerging as important lead in early diagnosis of myocardial infarction. Am J Emerg Med 2014;32(7)785-88.

4. Somers MP, et al. Additional electrocardiographic leads in the ED chest pain patient: right ventricular and posterior leads. Am J Emerg Med 2003;21(7):563-73.

5. Turhan H, et al. Diagnostic value of aVL derivation for right ventricular involvement in patients with acute inferior myocardial infarction. Ann Noninvasive Electrocardiol 2003;8:185-88.

6. Zehender M, et al. Right ventricular infarction as an independent predictor of prognosis after acute inferior myocardial infarction. N Engl J Med 1993; 328:981-88.

How to Cite this Post

[Peer-Reviewed, Web Publication] Aluce L, Iwaki K. (2019, Aug 12). Don’t Forget aVL. [NUEM Blog. Expert Commentary by Schimmel D]. Retrieved from

Other Posts You Might Enjoy

Posted on August 12, 2019 and filed under Cardiovascular.

Fluid Responsiveness

Fluid responsiveness.png

Written by: Brett Cohen, MD (NUEM PGY-3) Edited by: Duncan Wilson, MD (NUEM Alum ‘18) Expert commentary by: Luisa Morales-Nebreda, MD


Expert Commentary

I’ll start by saying that the assessment of a patient’s intravascular volume status and fluid responsiveness is one of the most difficult tasks in clinical medicine, yet it remains a crucial one to adequately manage acute circulatory failure.

After decades of dedicated research to the critically ill, we’ve learned that rigid protocols lead to large amounts of fluid administration, and that fluid overload is associated with increased morbidity and mortality in septic shock and ARDS patients. As you mentioned, only half of hemodynamically unstable patients are fluid responsive, prompting clinicians to describe novel tools/methods to better evaluate fluid responsiveness.

How do we define fluid responsiveness? What are the determinants of fluid responsiveness?

Fluid responsiveness has been defined as a 10-15% increase in cardiac output after a 500 cc bolus fluid challenge. I find this arbitrary definition unhelpful, but I do think that understanding what determines a fluid bolus leading to a preload-responsive state is important. 

Figure 1: Frank Starling curve

Figure 1: Frank Starling curve

When giving a fluid bolus, the expectation is that it will increase cardiac preload (by increasing both the stressed volume and mean circulatory filling pressure). Once this condition has been met, the next assumption is that the increase in venous return will lead to a change in stroke volume/cardiac output (venous return = cardiac output). This is the ideal situation! Both ventricles working on the ascending limb of the Frank-Starling curve without any major changes in other determinants of cardiac output (contractility, afterload, diastolic function) Figure 1. Unfortunately, our critically ill patients are not that simple and most times display significant changes in cardiac contractility (e.g., due to acidosis) and afterload (e.g., due to vasoactive agents) that could place them on the flat portion of this curve.

Cardiac Output = Heart Rate x Stroke Volume

Stroke Volume is determined by: contractility, preload, afterload

How do we measure fluid responsiveness?

Despite a great amount of evidence showing that “static” measurements, such as central venous pressure (CVP) are poor predictors of fluid responsiveness, they continue to be widely used. I don’t mean to say that measuring CVPs is useless. After all, perfusion is determined by the pressure gradient between MAP (mean arterial pressure) and CVP, and CVP is a good marker of preload (just NOT of preload responsiveness). 

To circumvent this limitation, we can use “dynamic” measurements of heart-lung interactions during mechanical ventilation. Specifically, if changes in intrathoracic pressure under positive pressure ventilation lead to cyclic changes in stroke volume (stroke volume variation or SVV), pulse pressure (pulse pressure variation PVV), or vena cava diameter it indicates that both ventricles are preload-dependent and the patient is fluid responsive. Limitations to these 3 methods include: a) patients need to be mechanically ventilated and without spontaneous breaths (during which changes in intrathoracic pressure become unreliable) b) tidal volume of at least 8 cc/Kg and normal respiratory system compliance (in order to generate significant swings in intrathoracic pressure, tidal volume needs to be on the high end and your lungs/chest wall can’t be stiff). 

So you can think about how limited these maneuvers are in the ICU setting. Most intubated patients take spontaneous breaths (unless paralyzed or deeply sedated). If paralyzed for ARDS, they need to be on low-tidal volume ventilation and their lungs are generally pretty stiff.

As you mentioned a maneuver that is unaffected by these limitations is the passive leg raise test (PLR). Importantly, PLR raises preload by shifting venous blood not only from your lower extremities, but mainly from your splanchnic compartment (where ~70% of unstressed volume reservoir lies). This is why in order to adequately perform the maneuver, patients are placed in a semi-recumbent position (rather than horizontal) and the bed is adjusted to 45֯, followed by assessment of cardiac output changes within 60 seconds (NOT blood pressure changes).

PLR is one of the most validated maneuvers for assessment of fluid responsiveness, and as you described, many downstream methods to measure cardiac output have been used, including: a) velocity time integral of the left ventricular outflow tract b) peak velocity of the carotid artery c) changes in end-tidal CO2. 

Given the widespread use of critical care echocardiography and their inherent practicality, I think echocardiographic indices are the most useful dynamic parameters to predict fluid responsiveness.

What to expect and my two cents on fluid responsiveness

Given the pace of technology, innovation in hemodynamic monitoring methods will likely improve in the not too distant future. Pocket echo probes and non-invasive wearable sensors measuring cardiac output will make assessment of fluid responsiveness much easier and reliable. Check out:

Michard et al. Intensive Care Medicine (2017) 43:440-442

Vincent et al. Intensive Care Medicine (2018) 44:922-924

For now, I go to the bedside and after a physical exam perform a basic point-of-care ultrasound to assess heart function, look for interstitial lung edema (B lines) and IVC collapsibility before and after a PLR maneuver (if tolerated). Combining information from these maneuvers not only allows you to better assess a patient’s current volume status and likelihood to be fluid responsive (hyperdynamic LV, absent B lines, collapsible IVC), but can also help you identify what type of shock your patient has and if giving fluid could make things worse (RV failure). 

When a patient is likely fluid responsive, I give a small/moderate fluid bolus (250-500 cc) then come back to the bedside to repeat my assessment with the tools I feel most comfortable. Then I ask myself: are things getting better? (Improved mental status/blood pressure, increased in urine output and decreased vasoactive agent requirement). And then do it all over again!


Luisa Morales-Nebreda, MD

Fellow, Pulmonary & Critical Care Medicine

Department of Medicine

Northwestern University


How to Cite this Post

[Peer-Reviewed, Web Publication] Cohen B, Wilson D. (2019, Aug 5). Fluid Responsiveness. [NUEM Blog. Expert Commentary by Morales-Nebreda L]. Retrieved from

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Posted on August 5, 2019 and filed under Pulmonary.

Spontaneous Bacterial Peritonitis


Written by: Kevin Dyer, MD (NUEM PGY-4) Edited by: Paul Trinquero, MD (NUEM Alum ‘19) Expert commentary by: Steven K. Herrine, MD


Spontaneous bacterial peritonitis (SBP) is an infection of ascitic fluid without an evident intra-abdominal or surgically-treatable source [1]. The pathophysiology is poorly understood, but likely relates to bacterial translocation across an edematous bowel wall (due to portal hypertension) into the immunologically impaired ascitic fluid. SBP is common in patients with severe hepatic dysfunction (present in 20% of hospitalized patients with ascites) and carries a mortality rate of 10% [2,3]. The high incidence, grave mortality, and potential benefit of early treatment make SBP a can’t-miss diagnosis for the emergency physician.

Clinical Features

The classic triad of SBP is fever, abdominal pain, and increasing ascites [4]. However, like most other “classic triads” in medicine, patients rarely present with all three and instead are much more likely to have only 1 or 2 of these features. The most common signs and symptoms are fever (69%), abdominal pain (59%), altered mental status (54%), and abdominal tenderness (49%). Other less common signs and symptoms include diarrhea (32%), paralytic ileus (30%), hypotension (21%), and hypothermia (17%) [5]. In one study, 13% of patients with SBP were asymptomatic [6].

Importance of Paracentesis

As mentioned above, the clinical signs and symptoms of SBP are variable  and sometimes subtle, making it a difficult clinical diagnosis. Instead, diagnosis hinges on the results of an ascitic fluid sample obtained via a diagnostic paracentesis. Ascitic fluid findings indicative of SBP include an elevated absolute polymorphonuclear leukocyte (PMN) count ≥250 cells/mm3, a positive ascitic fluid bacterial culture, and exclusion of secondary causes of bacterial peritonitis (e.g. perforated viscous, intra-abdominal abscess). For the ED physician, a PMN level ≥250 cells/mm3 necessitates initiation of antibiotics as soon as possible, if they were not already started empirically [7].

Not only do patients at risk for SBP need a diagnostic paracentesis, but because treatment is time sensitive, it should be performed as quickly as is feasible. A study by Kim et al showed a 3.3 percent increase in in-hospital mortality for each hour paracentesis was delayed and revealed that delayed paracentesis for patients ultimately diagnosed with SBP led to a 2.7-fold increased risk of death [8-9].


Empiric therapy should be initiated in patients with ascites who have a temperature >100°F, abdominal pain and/or tenderness, altered mental status, or ascitic PMNs ≥250 cells/mm3. First line treatment is a third-generation cephalosporin such as Ceftriaxone 2g per day or Cefotaxime 2g q8hrs [10]. For those with a severe penicillin allergy, fluoroquinolones are a viable alternative provided the patient has not been on a prophylactic fluoroquinolone. Common choices are levofloxacin 750mg daily or ofloxacin 400mg BID [10-11].

An additional therapeutic consideration is albumin infusion. Current guidelines from the American Association for the Study of Liver Diseases (AASLD) recommend the administration of albumin at a dose of 1.5g/kg for patients with either a BUN >30mg/dL, a serum creatinine >1.30mg/dL, or a total bilirubin >4mg/dL. A meta-analysis of 4 studies demonstrated a significant reduction in renal impairment (8% vs 31%) and a decrease in mortality (16% vs 35%) in patients who received 1.5g/kg of albumin within 6 hours of diagnosis of SBP [12-13].

Take Home Points

  • Spontaneous bacterial peritonitis is an infection of ascitic fluid without an evident intra-abdominal or surgically-treatable source. 

  • Diagnosis is nearly impossible to make clinically due to variable, and sometimes subtle, presenting symptoms and therefore hinges on obtaining a fluid sample via a diagnostic paracentesis.

  • Early diagnostic paracentesis in the ED may improve mortality for hospitalized patients with ascites.

  • Polymorphonuclear leukocyte (PMN) count ≥250 cells/mm3 raises suspicion for SBP and should prompt initiation of empiric antibiotics - first line is 2g of Ceftriaxone and second line is a fluoroquinolone. 

  • In addition, AASLD guidelines recommend 1.5g/kg of albumin for patients with SBP who have BUN >30mg/dL, creatinine >1.3mg/dL, or bilirubin >4mg/dL as this may decrease mortality and reduce the incidence of renal impairment.

Expert Commentary

The blog authors make many excellent points about the recognition and management of SBP in the emergency department. From the standpoint of a hepatologists, several concepts and developments regarding this dangerous diagnosis are worth emphasizing. 

  • Clinical context is vital in making management decisions: a patient with advanced chronic liver disease, manifested by high MELD score, is more likely to have SBP than an individual with acute or less advanced disease. 

  • Prompt paracentesis is the key to proper management. It is considered safe to perform diagnostic paracentesis in all patients but those with evident hyperfibrinolysis or those in DIC. Some have advocated for midline paracentesis to avoid vascular structures, but LLQ has been demonstrated to be safer. (Sakai 2005)

  • Only a small amounts of fluid is required to make the diagnosis of PMN > 250 cells/mL. Even a drop in a hemocytometer can be sufficient

  • Patients on prophylactic antibiotics due to previous SBP or low-protein ascites should raise concern for resistant organisms. It is important to sample the ascites in these individuals before commencing antibiotic therapy. 

  • The use of dipstick (leukocyte esterase) diagnosis is supported by some literature but use has been limited mostly to developing nations (Mendler 2010)

  • There is a growing body of literature that supports initial intravenous therapy followed by transition to oral antibiotics in clinical scenarios meeting certain conditions. (Angeli 2006)


  1. Sakai H, Sheer TA, Mendler MH, Runyon BA. Choosing the location for non-image guided abdominal paracentesis. Liver International 2005;25:984-986. 

  2. Mendler MH, Agarwal A, Trimzi M, Magridal E, Tsushima M, Joo E, Santiago M, et al. A new highly sensitive point of care screen for spontaneous bacterial peritonitis using a leukocyte esterase method. J Hepatol 2010;53:477-483

  3. Angeli P, Guarda S, Fasolato S, Miola E, Craighhero R, Del Piccolo F, Antona C, et al. Switch therapy with ciprofloxacin vs intravenous ceftazidime in the treatment of spontaneous bacterial peritonitis in patients with cirrhosis: similar efficacy at lower cost. Aliment Pharmacol Ther 2006;23:75-84

Steven Herrine.png

Steven K. Herrine, MD

Professor of Medicine, Division of Gastroenterology and Hepatology

Vice Dean for Academic Affairs

Sidney Kimmel Medical College at Thomas Jefferson University

How to Cite this Post

[Peer-Reviewed, Web Publication] Dyer K, Trinquero P. (2019, July 29). Spontaneous Bacterial Peritonitis. [NUEM Blog. Expert Commentary by Herrine S]. Retrieved from

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  1. Such J, Runyon BA. Spontaneous bacterial peritonitis. Clin Infect Dis 1998; 27:669.

  2. Nickson, Chris. “Spontaneous Bacterial Peritonitis.” Life in the Fast Lane Medical Blog, 17 Dec. 2012,

  3. Guiney, Allan. “Should All Admitted Patients with Ascites Get a Paracentesis?” Core EM, 7 Dec. 2017,

  4. “Episode 123.0 – Paracentesis Journal Update.” Core EM, 27 Nov. 2017,

  5. McHutchison JG, Runyon BA. Spontaneous bacterial peritonitis. In Surawicz CM, Owen RL (Eds.), Gastrointestinal and Hepatic Infections, WB Saunders Company, Philadelphia 1995. P.455.

  6. Runyon BA. Monomicrobial nonneutrocytic bacterascites: a variant of spontaneous bacterial peritonitis. Hepatology 1990; 12:710Runyon BA. Monomicrobial nonneutrocytic bacterascites: a variant of spontaneous bacterial peritonitis. Hepatology 1990; 12:710.

  7. Runyon, B. (2018) Spontaneous bacterial peritonitis in adults: Clinical manifestations. In K.D. Lindor (Ed.), UpToDate. Retrieved April 2, 2018, from

  8. Kim JJ, Tsukamoto MM, Mathur AK, et al. Delayed paracentesis is associated with increased in-hospital mortality in patients with spontaneous bacterial peritonitis. Am J Gastroenterol 2014; 109:1436.

  9. Kumar A, Roberts D, Wood KE, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med 2006; 34:1589.

  10. Runyon, B. (2018) Spontaneous bacterial peritonitis in adults: Treatment and prophylaxis. In K.D. Lindor (Ed.), UpToDate. Retrieved April 2, 2018, from

  11. Navasa M, Follo A, Llovet JM, et al. Randomized, comparative study of oral ofloxacin versus intravenous cefotaxime in spontaneous bacterial peritonitis. Gastroenterology 1996; 111:1011.

  12. Salerno F, Navickis RJ, Wilkes MM. Albumin infusion improves outcomes of patients with spontaneous bacterial peritonitis: a meta-analysis of randomized trials. Clin Gastroenterol Hepatol 2013; 11:123.

  13. Pescatore, Rick. “Should You Give Albumin in Spontaneous Bacterial Peritonitis (SBP)?” R.E.B.E.L. EM - Emergency Medicine Blog, 6 July 2017,

Posted on July 29, 2019 .

Pelvic Fractures

Written by: Justine Ko, MD (NUEM PGY-3) Edited by: Terese Whipple, MD (NUEM PGY-4) Expert commentary by: Matt Levine, MD

Pelvic Ring Fractures


Pelvic ring fractures make up about 3% of skeletal fractures [1]. In the emergency department, they are often seen with high-impact blunt trauma, such as MVCs, crush injuries, or falls.

The pelvis consists of the sacrum and the two innominate bones, which are made up of the ilium, ischium, and pubis [2]. The sacrum and the innominate bones together form a posterior arch and an anterior arch that join to make a ring, also known as the pelvic inlet. The stability of the pelvis is enforced by ligaments: the sacroiliac ligaments, the sacrospinous ligaments, and sacrotuberous ligaments [2]. The ligaments and bones together give the pelvis vertical and rotational stability. 

Pelvic ring fractures carry a significant mortality, ranging from 15-25% in closed fractures, and as much as 50% in open fractures [3]. They are often associated with other high-mortality injuries as well, such as chest injuries, spinal injuries.

What are the mechanisms associated with these injuries?

The Young-Burgess classification system categorizes injury patterns based on the mechanism of injury and the forces applied: anteroposterior compression (APC), lateral compression (LC), and vertical shear (VS) [1]. The most common mechanism is lateral compression, which occurs when lateral forces are applied to the pelvis (as the name would suggest). APC injuries result in the classic “open book” pelvic fractures (Figure 1). 

Figure 1

Figure 1

Figure 2

Figure 2

  • Anteroposterior compression: causes disruption of the pubic symphysis. A normal pubic symphysis should not exceed 5mm. Injuries where the symphysis widening is <2.5cm, with no significant posterior column injury or other fractures, are usually considered stable. APC injuries are often associated with significant blood loss, as the pelvic volume increases and can store more blood [4].

  • Lateral Compression: considered rotationally unstable. This mechanism causes the pelvic volume to decrease, and therefore, is associated with less blood loss [4].

  • Vertical shear: the most unstable, often associated with axial loading of the hemipelvis, such as with a fall or a jump from a height. 

table 1.png

What exam findings should I look for?

During a trauma workup, visual inspection for leg-length discrepancy or rotation of the pelvis may provide clues to a hip or pelvic injury. You may assess for stability of the pelvis by applying downward and medial pressure to the bilateral iliac crests. Apply pressure gently and slowly to avoid disruption of any possible clots that may have formed.

A digital rectal exam should also be performed to assess for spinal cord injury and frank blood. In males, the meatus should be assessed for possible bladder or urethral injury.

X-ray reading tips

  • Check the 3 circles! (Figure 3)

    • Pubic inlet

    • Two obturator foramina

    • Check for irregularities along the circles

    • In general, a vertical fracture pattern will be associated with APC or VS mechanisms. Horizontal fracture patterns will be associated with LC. [7]

Figure 3

Figure 3

  • Check the lines! 

    • ilioischial line (orange line in Figure 4)- disruption suggest posterior column fracture [5]. The posterior column involves the posterior half of the acetabulum and extends to the ischial tuberosity [4]. 

    • iliopectineal line (red line in Figure 4)- disruption suggests anterior column fracture [5]. The anterior column involves the anterior half of the acetabulum and extends to the lateral half of the superior pubic ramus [4].

    • It’s a circle! If it breaks in one location, it likely broke in another place. Be wary of isolated rami fractures in the setting of high-impact trauma!

Figure 4

Figure 4


  • As always, still stick to your ABCs!

    • Initiate blood transfusion early for patients in shock 

    • Hemodynamic instability occurs in about 10% of these injuries [1]

  • Try to obtain IV access above the pelvis if a pelvic fracture is suspected.

  • Stabilize the pelvis with a TPOD or a sheet for patients with open book pelvic fractures

    • Apply over the GREATER TROCHANTERS

    • Do not apply a compressive device for isolated lateral compression pelvic fractures as the device can cause further compression and worsen the displacement [4].

  • If the hemorrhage or hypotension is suspected to be from pelvic hemorrhage, activate IR early.

  • If stable, obtain a CTA of the pelvis to assess for vascular injury

What other injuries should I look for?

  • Urologic Injury: incidence in pelvic fractures is ~5%. Patient with blood at the meatus will need a retrograde urethrogram and then a cystogram [4].

  • Neurologic Injury:  pelvic fractures can be associated with plexus injuries and even cauda equina syndrome. Check for rectal tone and saddle anesthesia [4].

  • Gynecologic injury:  blood a the introitus can represent urethral injury or an open pelvic fracture [4].

Expert Commentary

Dr Ko has provided a high yield concise guide of the key cognitive and clinical features of pelvic fractures.  A few points worthy of further emphasis:

When examining for pelvic instability, do not rock on the pelvis to further open it.  Instead, compress medially to feel instability while closing, rather than opening, the pelvis.

For most studies we order, we have the luxury of waiting for a formal report. Pelvis x rays are one of the few radiographic studies that the Emergency Physician must be able to rapidly interpret independently at the bedside for patient management!  Do not just eyeball the film.  It is impossible to find multiple pelvic fractures that way. Go over every arc, curve, and ring visually.  If something appears possibly abnormal, compare to the other side for (a)symmetry.  And if you find one break in the pelvic ring, scrutinize for more, there almost always are.  Many of these are in the posterior ring, the part of the pelvis for which plain films are least sensitive. CT will help evaluate the posterior elements if feasible.

Understanding the classic LC, APC, VS mechanism classifications lend insight into when a binder will help.  Realize, however, that in vehicular trauma, often the forces are multidirectional, so there will be mixed injury patterns.  Ask yourself what you are trying to achieve by placing the binder.  If it is closing the open book to tamponade hemorrhage, then go for it!  If it is to provide some stability to a VS injury so you can move the patient without their pelvis flopping around than OK but it won't be therapeutic.  If it is an LC injury where the femoral head has crushed through the acetabulum, avoid using a binder, you will only further intrude bony fragments into the pelvis!  

Call IR the instant you realize there is a bleeding pelvic fracture.  It takes time to prepare the suite, especially overnight!


Matt Levine, MD

Assistant Professor of Emergency Medicine

Northwestern Feinberg School of Medicine

How To Cite This Post

[Peer-Reviewed, Web Publication] Ko J, Whipple T. (2019, July 22). Pelvic Fractures. [NUEM Blog. Expert Commentary by Levine M]. Retrieved from

Other Posts You May Enjoy


Halawi MJ. Pelvic ring injuries: Emergency assessment and management. Journal of Clinical Orthopaedics and Trauma. 2015;6(4):252-258. 

  1. Khurana B, Sheehan SE, Sodickson AD, Weaver MJ. Pelvic ring fractures: What the orthopedic surgeon wants to know. RadioGraphics. 2014;34:1317-1333

  2. Weatherford B. Pelvic ring fractures. Orthobullets website. Accessed October 14, 2018.

  3. Walls RM, Hockberger RS, Gauche-Hill M. (2018). Rosen's emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders.

  4. Murphy A, Jones J. Pelvic radiograph (an approach). Radiopaedia website. Updated August 2018. Accessed October 14, 2018. 

  5. Tile M. Pelvic ring fractures: should they be fixed? J Bone Joint Surg Br Vol. 1988;70(1):1–12.

  6. Singh, AP. Pelvic fractures: Presentation and treatment.


Case courtesy of Dr Jeremy Jones, From the case" rID: 28928

Posted on July 22, 2019 .

Clostridium Difficile

Written by: Luke Neill, MD (NUEM PGY-4) Edited by: Keith Hemmert, MD (NUEM ‘18) Expert commentary by: Michael Angarone, DO

Expert Commentary

Dr. Neill has provided an excellent overview of the important points from the latest iteration of the IDSA/SHEA guidelines for the diagnosis and management of Clostridioides difficile (formerly Clostridium difficile) infection (CDI). There are a few important changes to this current update to the guidelines. For the diagnosis of C. difficile infection the guidelines recommend hospitals to not test persons on laxatives, that have formed stools or another diagnosis for the patient’s diarrhea. This is an important change in the way that most practitioners think of testing for C difficile and will result in less tests being performed.  Hospitals that do not adopt pretesting criteria for testing stool for C diffiicile should develop a multi-step testing algorithm, such as glutamate dehydrogenase test followed by toxin test, arbitrated by C difficile PCR. The guidelines do not recommend probiotics for primary prevention of CDI stating that there is insufficient data to recommend the use of these agents. This is contrary to a recent Cochrane review from 2017 that analyzed 31 studies and found that in individuals at high risk for CDI may benefit from probiotics, with a number needed to benefit of 12.  The biggest change in this version of the guidelines is that metronidazole is no longer recommended for therapy. Patients should be treated with either oral vancomycin or fidaxomicin. For multiple recurrent CDI (>2 episodes), patients should be considered for fecal microbiota transplantation. This is the first time that FMT has been recommended as a treatment option in the IDSA/SHEA guidelines. The changes in this guideline should not change the way that most practitioners approach CDI, with the exception of the above important changes.


1.       McDonald LC, Gerding DN, Johnson S, et al. Clinical practice guidelines for Clostridium difficile infection in adults and children: 2017 update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) [published online February 15, 2018]. Clin Infect Dis.doi: 10.1093/cid/cix1085

2.       Cochrane Database Syst Rev. 2017 Dec 19;12:CD006095.  Probiotics for the prevention of Clostridium difficile-associated diarrhea in adults and children. PMID 29257353


Michael P. Angarone, DO

Assistant Professor

Department of Medicine (Division of Infectious Diseases) and Medical Education

Northwestern University, Feinberg School of Medicine

How To Cite This Post

[Peer-Reviewed, Web Publication] Neill L,  Hemmert K. (2019, July 15). Clostridium Difficile. [NUEM Blog. Expert Commentary by Angarone M]. Retrieved from

Other Posts You May Enjoy

Posted on July 15, 2019 and filed under Infectious Disease.


Ophthalmology-12 (1).png

Written by: Jonathan Hung, MD, (NUEM PGY-3) Edited by: Matt Klein, MD (NUEM ‘18) Expert commentary by: Dr. Glaucomflecken


Corneal abrasions are a commonly encountered eye-related presentation in the emergency department (ED) [1]. Patients will often have a significant amount of pain from even minor abrasions. Topical anesthetics such as tetracaine have been found to be effective in treating the pain and are now routinely used in the ED [2]. However, the use of topical anesthetics for corneal abrasions in the outpatient setting is controversial due to concerns over safety and delayed healing. These traditional concerns over the prolonged use of topical anesthetics are based on early animal studies and case reports in humans [3]. The current literature suggests that topical anesthetics are, in fact, safe and effective if given as a short course with appropriate follow up, but further studies with larger patient populations are needed to support these findings [4]. A recent study published in Annals of Emergency Medicine is one of the largest studies to date that examines the safety of discharging patients home from the ED with a short supply of tetracaine for corneal abrasions.


Waldman N, Winrow B, Densie I, et al. An Observational Study to Determine Whether Routinely Sending Patients Home With a 24-Hour Supply of Topical Tetracaine From the Emergency Department for Simple Corneal Abrasion Pain Is Potentially Safe. Ann Emerg Med. 2017. 

Study Design

The study design was a single-center, retrospective cohort study with ethics approval given by the Human Ethics Committee at the University of Otago. 


The study was performed at the ED of Southland Hospital, Invercargill, New Zealand. A computer search of the hospital’s ED information system was conducted looking for all eye-related diagnoses and charts were reviewed between February 1, 2014 to October 31, 2015. Patients were initially selected if they were seen in the ED with an injury or illness involving the cornea. 

Intervention protocol

Patients with simple corneal abrasions were discharged home with undiluted 1% tetracaine hydrochloride in addition to the standard treatment of acetaminophen and chloramphenicol eye ointment. Instructions were given to place tetracaine in the eye as often as every 30 minute over the first 24 hours.  

Outcome Measures

  • ED rechecks 

  • Persistent fluorescein uptake

  • Ophthalmology clinic referrals

  • Complications


There was a total of 1,576 ED presentations of corneal abrasions of which 532 were simple corneal abrasions (SCA) and 1,044 were defined as nonsimple corneal abrasions (NSCA). Tetracaine was given to 57% (303) of SCA patients and 14% (141) of NSCA patients. Overall, there were no serious complications or uncommon adverse events in either the SCA or NSCA group (0/459). The relative risk of patients with SCA receiving tetracaine and returning to the ED, having fluorescein uptake, or requiring a referral to ophthalmology was low compared to the standard treatment group. 


This study is one of the largest studies to examine the safety of outpatient tetracaine use in simple corneal abrasions. More importantly, it gives a robust conclusion similar to previous smaller studies in that there was no evidence that using topical tetracaine for a short duration caused harm. The strengths of this study include the large patient population and good patient follow-up. Furthermore, the physicians that administered tetracaine did not know that an observational study was planned, thus increasing the internal validity. However, the researchers were not blinded to the hypothesis which could have led to bias when collecting data. This was also a retrospective study and therefore due to the lack of randomization, those who received tetracaine may have differed from those who did not. Another limitation was that it was not known if all the patients administered the tetracaine as instructed after leaving the ED. Also, the diagnosis of simple corneal abrasion was limited to what the physician documented in the chart. The external validity is limited since this was a single-center study and about 71% of the patients were males. Overall, this study further strengthens the role of tetracaine in treating pain secondary to simple corneal abrasions and may gradually change practice patterns in the emergency department despite traditional teaching. 

Take Home Points

  • Topical tetracaine is effective in treating pain due to corneal abrasions

  • Patients with simple corneal abrasions can benefit from a short course of topical tetracaine to treat pain 

  • Topical tetracaine use over a 24-hour period is generally safe 

  • Emergency medicine physicians should consider incorporating topical tetracaine in their practice for treating SCAs 

Expert Commentary

This is an interesting observational study regarding the safety of prescribing a limited supply of topical tetracaine to patients who present to the emergency department with what the authors describe as “simple corneal abrasions.” It is well documented in the literature that long term use of topical anesthetics can lead to a variety of serious ophthalmic complications, including persistent epithelial defects, neurotrophic ulceration, secondary infectious keratitis, corneal scarring and perforation. However, many of these reports describe long term use of anesthetics ranging from 7 days to 6 months which have helped establish the long-held dogma that topical anesthetics are only appropriate for use during surgery or clinic examination. This study, as well as several smaller previous studies, has attempted to challenge that dogma in an effort to better treat the immense pain often associated with corneal abrasion.

The authors did a great job trying to distinguish between simple and non-simple corneal abrasions. This can be very difficult, even for an ophthalmologist. What may look like a simple corneal abrasion can easily turn out to be a different diagnosis altogether. Herpes simplex keratitis can present as a geographic ulcer, lighting up with fluorescein much like a corneal abrasion without the tell-tale sign of dendritic lesions to accompany it. Dry eye disease can result in confluent, punctate epithelial defects which can look like a corneal abrasion without the magnification afforded by a slit lamp. These conditions should not be treated with topical anesthetics and will only delay the patient in receiving appropriate care. Stating that topical anesthetics are safe for simple corneal abrasions assumes that the examiner is able to accurately diagnose a simple abrasion. In this study, several patients were misdiagnosed as simple abrasions and ultimately required follow up with ophthalmology. Patients who need to see ophthalmology for a non-simple abrasion may be less likely to follow up in a timely manner if they are given topical anesthetic that will effectively mask the pain. This can result in more extensive corneal scarring from a variety of diagnoses such as delayed rust ring removal or treatment of infectious keratitis.

The authors make a compelling point that a limited supply of tetracaine in a subset of corneal abrasions intended to last no more than 24 hours is safe with no significant difference in the number of ED rechecks, ophthalmology clinic referrals, persistent fluorescein uptake, or complications. If this is indeed true, is treating with topical anesthetic worth it? At best, you are providing a minimally-painful healing process which will be complete in 48-72 hours regardless of topical anesthetic use. At worst, you are masking pain of a potentially vision-threatening process that may have been misdiagnosed as a simple abrasion. I contend that setting patient expectations regarding pain (very severe for first 24 hours, then rapid improvement) and discussing more conservative comfort measures like icing and patching are sufficient.

Lastly, I want to discuss the treatment for simple and non-simple corneal abrasions. It is unclear whether or not the patients in this study were treated with topical antibiotics. It is possible that patients with simple corneal abrasions were sent home with a 24 hour supply of tetracaine and no topical antibiotics. Without an epithelial barrier, the underlying corneal stromal is prone to infection. Topical antibiotics act as a preventive measure and are particularly important if a patient is using topical anesthetic, which could mask the pain of infectious keratitis. Although not all sources agree, there is general consensus among ophthalmologists that all corneal abrasions require topical antibiotics at the time of diagnosis.

In conclusion, I agree that a 24 hour prescription of topical anesthetic in a simple corneal abrasion is likely safe. However, given the rapid healing time, consideration should be made to counseling patients on pain expectation and comfort measures in place of topical anesthetic. Lastly, prescribing more than a 1 day supply of topical anesthetic is unnecessary given the rapid improvement in pain after the first 24 hours


Dr. Glaucomflecken, MD

How To Cite This Post

[Peer-Reviewed, Web Publication] Hung J,  Klein M. (2019, July 8). Tetracaine. [NUEM Blog. Expert Commentary by Dr. Glaucomflecken]. Retrieved from

Other Posts You May Enjoy


  1. Verma A, Khan FH. Corneal abrasion. MedscapeAvailable at: Accessed November 1, 2017.

  2. Waldman N, Densie IK, Herbison P. Topical tetracaine used for 24 hours is safe and rated highly effective by patients for the treatment of pain caused by corneal abrasions: a double-blind, randomized clinical trial. Acad Emerg Med 2014;21:374–82.

  3. Chang YS, Tseng SY, Tseng SH, et al. Cytotoxicity of lidocaine or bupivacaine on corneal endothelial cells in a rabbit model. Cornea 2006;25:590–6.

  4. Swaminathan A, Otterness K, Milne K, Rezaie S. The Safety of Topical Anesthetics in the Treatment of Corneal Abrasions: A Review. J Emerg Med. 2015;49(5):810-815. 

Posted on July 8, 2019 and filed under Ophthalmology.

Sink or Swim: The management of submersion injuries

Written by:  Michael Conrardy , MD (NUEM PGY-2)  Edited by:  Gabby Ahlzadeh, MD (NUEM ‘19)  Expert commentary by : Kristina McAteer, MD

Written by: Michael Conrardy , MD (NUEM PGY-2) Edited by: Gabby Ahlzadeh, MD (NUEM ‘19) Expert commentary by: Kristina McAteer, MD


If you are an emergency physician, you likely will see submersion injuries often throughout your career. In the United States, from 2005-2014, there are approximately ten deaths per day from unintentional drowning, and about 3,536 annually. This number increases to eleven per day if you include boating-related deaths. One in five deaths involve children under the age of fourteen, and drowning is the second leading cause of death for children ages 1-14 [1,2]. Approximately 80% of all victims are male [2], and when considering adolescents and adults, alcohol is involved in up to 70% of cases [3]. Statistics for nonfatal drowning events are difficult to obtain, but studies estimate that they may occur several hundred times more frequently than reported deaths [4,5].

Example Case

While working in the emergency department on Friday night, three college students are brought in by EMS after “drinking alcohol and jumping in Lake Michigan.” Patient #1 received CPR for ten minutes en route, has a temperature of 32 degrees Celsius, signs of head trauma, and a cervical collar in place. Patient #2 experienced a short period of submersion and is in mild respiratory distress. Patient #3 was submerged for only a brief period of time and is completely asymptomatic.

Emergency Department Management of Submersion Injuries
Patient #1 - Severely Symptomatic Patients

Initial Management:

In serious cases of drowning, top concerns are hypoxemia, hypothermia, subsequent cardiac arrest, and other signs of trauma.

  1. If in cardiac arrest, start ACLS and consider underlying causes such as hypoxemia or hypothermia

  2. Remove wet clothing and use rewarming techniques

  3. Chest x-ray, blood gas, labs, end tidal CO2. Initial CXR is often normal but can be helpful in tracking the patient’s condition.

  4. Assess for signs of trauma and obtain appropriate imaging. It is important to note that cervical spine injuries are uncommon (<5%) in cases of drowning, and cervical collars should not distract from airway management [6].

Management of airway, ventilation, oxygenation:

Fluid aspiration can lead to loss of surfactant, pulmonary edema, and hypoxemia from V/Q mismatch. Hypoxemia is the primary cause of end-organ damage in submersion injuries (typically cardiac and neurologic) and treating it should be your top priority. Here are some general guidelines:

  • Airway: Intubate patients if unable to protect airway, O2Sat < 90% despite supplemental O2, or PaCO2 >50

  • Ventilation: Positive pressure opens alveoli and improves ventilation in drowning.

    • Unable to protect airway: Start with bag-valve-mask and then intubate. Use ARDS settings of Vt 6-8 mL/kg, Pplateau < 30mmHg, and increased PEEP.

    • Able to protect airway: Use non-invasive positive pressure ventilation in alert, symptomatic patients for goal O2Sat > 94% [6].

  • Oxygenation: Use maximum available supplemental O2 initially and wean as tolerated.


No medications need to be routinely used for submersion injuries. Bronchospasm can occur, and if suspected should be treated with inhaled beta-adrenergic agonists. Glucocorticoids have not been shown to be helpful in preventing subsequent lung injury and may interfere with healing, and not enough data exists to support routine administration of exogenous surfactant. Antibiotics should only be used in cases where signs of infection develop or if the patient was submerged in grossly contaminated water [7].


Data on use of ECMO to treat patients with severe pulmonary edema or signs of ARDS are extremely limited, although initial results are encouraging [9]. This is an area of ongoing research, and perhaps we may eventually see early initiation of ECMO as standard practice for severely symptomatic patients.

Patient #2 - Mildly Symptomatic Patients

The main takeaway from patient #2 is that all patients who are symptomatic on arrival to the ED (requiring ventilatory assistance or supplemental O2) should be admitted to the hospital. Airway, ventilation, and oxygenation should be managed as above, and serial chest x-rays can help monitor for development of pulmonary edema in symptomatic patients [6].

Patient #3 - Asymptomatic Patients

Although most research on safe discharge has been in children, it is generally accepted that asymptomatic patients can be safely discharged after 4-6 hours of monitoring. Patients should have normal pulmonary exam, SaO2>95% on room air, and GCS>13 [6,10]. Some clinicians advocate for observing up to eight hours based on a study that observed one pediatric patient who did not develop symptoms until seven hours post-submersion [11], although six hours in the ED with return precautions is probably adequate in most cases. Many clinicians obtain basic labs on all patients and a chest x-ray prior to discharge to confirm that there are no signs of pulmonary edema, although no strong evidence supports these practices.

Key Takeaways:

  • Hypoxemia is the main cause of harm, prioritize the airway and use positive pressure

  • Initial chest radiographs are often normal, but can be used to track a patient’s clinical status

  • Blood gas is the most useful laboratory test in symptomatic patients, additional testing (e.g. ECG, CBC, chem, troponin) is particularly useful in patients with altered mental status

  • Asymptomatic patients may be safely discharged after six hours of monitoring

Expert Commentary

The terminology can be confusing with such terms as drowning, nonfatal drowning, submersion injury, dry drowning, wet nonfatal drowning, and so on.  Most recently (2010) the AHA recommended a more straightforward approach and supported the Utstein definition which hopefully offers some clarification, relieves some of the angst when approaching this population, and standardizes research and reporting.  The Utstein defines a drowning as “a process resulting in a primary impairment from submersion or immersion in a liquid medium.” [1]

The key is to keep it simple.  Is your patient symptomatic from the exposure?  If so, focus on the ABC’s and get to work! 

You will often see pediatric patients as drowning victims.  Drowning is a leading cause of accidental death in children under 5 years of age, particularly in states where swimming pools or beaches are more accessible. The states of California, Arizona and Florida lead the way [2].  The second peak is in older ages (15-25 yo), primarily males, and involves more rivers, lakes and beaches. [3].  The distinction between fresh and salt water drownings is no longer considered important as the volume of aspirated water is so small that the theorized electrolyte shifts do not have any real physiological impact [4]. Both wash out pulmonary surfactant.  

As appropriately pointed out it is often is not the drowning that causes mortality. It is therefore necessary to consider concomitant trauma, toxic ingestions (at the very least alcohol leading to impaired judgment!), and hypothermia.  Hypoxemia and the resultant hypoxia is ultimately the cause for death, often impacting multiple organ systems, and thus it is your job to reverse the hypoxemia as quickly as possible!  Supplemental oxygen, BIPAP (Bilevel positive airway pressure), endotracheal intubation and if necessary, ECMO (extracorporeal membrane oxygenation) are management options.  There is a neuroprotective effect of hypothermia and in some cases patients make a complete recovery despite a prolonged resuscitation.  Age > 14, duration of submersion > 5 minutes, time to basic life support > 10 minutes, resuscitation duration > 25 minutes, GCS (Glascow coma scale) <5, persistent apnea and requirement of CPR in the emergency department and arterial blood pH <7.1 have all been associated with a poor prognosis.  [5]

  1. Vanden Hoek TJ, Morrison LJ, Shuster M, et al. Part 12: Cardiac Arrest in special situations 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergent Cardiovascular Care. Circulation 2010; 122: S829.

  2. Brenner Ra. Prevention of drowning in infants, children, and adolescents. Pediatrics 2003; 112:440.

  3. DeNivola, LK, Falk, JL, Swanson ME, et al. Submersion injuries in children and adults. Crit Care Clin 1997;12:477.

  4. Orlowski JP, Szpilman D. Drowning, Resucue, resuscitation and reanimation. Pediatr Clin. North Am 2001. 48:627.

  5. Quan L, Mack CD, Schiff MA.  Association of water temperature and submersion duration and drowning outcome. Resuscitation 2014.85:790.


Kristina McAteer, MD

Assistant Professor of Emergency Medicine

Brown University

How To Cite This Post

[Peer-Reviewed, Web Publication] Conrardy M,  Ahlzadeh G. (2019, July 1). Sink or Swim: The management of submersion injuries. [NUEM Blog. Expert Commentary by McAteer Kristina]. Retrieved from

Other Posts You May Enjoy


  1. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS) [online]. Available from: URL:

  2. CDC. Wide-ranging online data for epidemiologic research (WONDER). Atlanta, GA: CDC, National Center for Health Statistics; 2016 [online]. Available at

  3. Driscoll TR, Harrison JA and Steenkamp M. Review of the role of alcohol in drowning associated with recreational aquatic activity. Inj Prev. 2004; 10: 107-13.

  4. Bierens JJ, Knape JT and Gelissen HP. Drowning. Curr Opin Crit Care. 2002; 8: 578-86.

  5. Orlowski JP. Drowning, near-drowning, and ice-water drowning. JAMA : the journal of the American Medical Association. 1988; 260: 390-1.

  6. Schmidt AC, Sempsrott JR, Hawkins SC, Arastu AS, Cushing TA and Auerbach PS. Wilderness Medical Society Practice Guidelines for the Prevention and Treatment of Drowning. Wilderness Environ Med. 2016; 27: 236-51.

  7. Layon AJ and Modell JH. Drowning: Update 2009. Anesthesiology. 2009; 110: 1390-401.

  8. Chandy D, Weinhouse GL. Drowning (submersion injuries). UpToDate. Danzl DF, Grayzel, J (Ed). 2017.

  9. Burke CR, Chan T, Brogan TV, et al. Extracorporeal life support for victims of drowning. Resuscitation. 2016; 104: 19-23.

  10. Causey AL, Tilelli JA and Swanson ME. Predicting discharge in uncomplicated near-drowning. The American journal of emergency medicine. 2000; 18: 9-11.

  11. Noonan L, Howrey R and Ginsburg CM. Freshwater submersion injuries in children: a retrospective review of seventy-five hospitalized patients. Pediatrics. 1996; 98: 368-71.

Posted on July 1, 2019 and filed under Environmental.

Not All Ankle Sprains are Created Equal


Written by:  William Ford, MD, MBA (NUEM PGY-4) Edited by: Simiao Li-Sauerwine, MD (NUEM ‘18) Expert commentary by: Matthew Levine, MD


Ankle injuries are commonly seen in emergency medicine, and serious injuries can be found in the setting of a negative X-ray. The “high ankle sprain” involves the structure of the ankle called the syndesmosis. Isolated ligamentous disruption to the syndesmosis is uncommon, though when it occurs, it is frequently missed. This can lead to serious consequences, including long-term ankle dysfunction and the need for surgery [1]. Identifying these injuries in the ED can improve recovery and facilitate prompt follow-up.

What is the Syndesmosis?

The syndesmosis is the distal articulation of the tibia and the fibula and it keeps the joint stable. For the purposes of this discussion, the focus will be on the ligamentous parts of the syndesmosis not seen on an ankle X-ray.

There are four syndesmotic ligaments: the interosseous ligament (IOL), the anterior inferior tibiofibular ligament (AITFL), the posterior inferior tibiofibular ligament (PITFL), and the inferior transverse tibiofibular ligament (ITTFL) [2].

How Does Syndesmotic Injury Occur?

The motion often involved in syndesmotic injury is external rotation of the foot. Commonly, it is a combination of external rotation of the foot and excessive dorsiflexion of the ankle [3-6]. This is frequently encountered in high-speed collisions, uneven terrain, and cutting and jumping sports [1]. In most cases, syndesmotic injury will occur concurrently with a fracture, but sometimes, ligamentous injury may occur in isolation [7-8].

How Can I Diagnose Syndesmotic Injury?

Since this diagnosis is difficult to make without an MRI, providers must rely on a high index of suspicion. First, ask yourself if the mechanism of injury is consistent with syndesmosis disruption. Localizing the areas of tenderness on physical exam can also be helpful. Anterolateral or posteromedial ankle tenderness, as opposed to direct lateral or medial pain inferior to the malleoli, can suggest syndesmotic involvement. Finally, in accordance with the name “high ankle sprain”, more proximal pain may be indicative of a syndesmotic injury [1].

There are a few provocative tests described for diagnosing syndesmotic injuries. None are slam-dunk maneuvers, but a constellation of positive findings can be helpful in making the diagnosis.

  1. Squeeze test: With the patient sitting at the edge of the bed and knee bent at 90 degrees, a strong compressive force is applied to the tibia and fibula proximal to the mid-calf. Pain indicates a positive finding.

  2. External rotation stress test: If the pain is reproduced with manual external rotation of the foot and ankle relative to the tibia, this test is positive. It is important to make sure the tibia is stabilized while performing this test.

  3. Cotton test: This test is performed by attempting to translate the talus laterally under the tibia. Increased translation compared to the contralateral side or increased pain with this maneuver is a positive finding.

  4. Fibular translation test: Stabilize the tibiotalar joint with one hand, translate the fibula anteriorly and posteriorly with the other hand. Increased pain and translation compared to the contralateral side equals a positive test.

X-ray diagnosis can also be difficult, except in the presence of frank tibiofibular diastasis [1].


Not all ankle sprains are created equal. High ankle sprains involving the syndesmosis can mean triple the recovery time of a regular sprain, chronic instability, or definitive treatment with surgery. Increased awareness and knowledge of how to diagnose these injuries is important to ensure quality care for patients.

Expert Commentary

Ankle injuries are the most common orthopedic complaint we see in the ED.  While most of these presentations are simple sprains, there are other more severe injuries that will resemble uncomplicated sprains.  Given the sheer volume of ankle injuries we see, we undoubtedly have all missed some of these more complicated injuries.  A high ankle sprain is one of these injuries.  Another classic injury that resembles an ankle sprain is the Snowboarder’s fracture. This is a fracture of the lateral process of the talus that occurs from ankle inversion and dorsiflexion.  Snowboarder’s fractures clinically resemble ankle sprains and x rays miss up to 40% of these fractures!  I have seen radiology miss some of these and then found the fracture by going back and magnifying the area of the lateral talus distal to the lateral malleolus on the AP and mortise views. 

Regardless, plain films will not detect all Snowboarder’s fractures or high ankle sprains.  It is tempting to quickly wrap and discharge all ankle “sprains” after a negative x ray.  It is important, however, to discuss with these patients what is a normal healing progression and timeline.  Emphasize that if 10 days go by and there is still significant pain, functional impairment, or reliance on the crutches or air cast, they need to follow up with orthopedics.  Provide them with the means to arrange this follow up. It is not realistic to be able to diagnose every ankle sprain mimic in the ED, but it is our duty to provide every patient (not just ankle sprain patients) with the proper instructions for follow up in case we have missed something.

Matt_Levine-33 (2).png

Matthew Levine, MD

Assistant Professor of Emergency Medicine

Northwestern Medicine

How To Cite This Post

[Peer-Reviewed, Web Publication] Ford W, Li-Sauerwine S. (2019, May 27). Not All Ankle Sprains are Created Equal. [NUEM Blog. Expert Commentary by Levine M]. Retrieved from

Other Posts You May Enjoy


  1. Hunt KJ, Phisitkul P, Pirolo J, et al. High Ankle Sprains and Syndesmotic Injuries in
    Athletes. Journal of the American Academy of Orthopaedic Surgeons. 2015;23(11): 661-73.

  2. Fibular translation test: Stabilize the tibiotalar joint with one hand, translate the fibula anteriorly and posteriorly with the other hand. Increased pain and translation compared to the contralateral side equals a positive test.

  3. Ogilvie-Harris DJ, Reed SC, Hedman TP. Disruption of the Ankle Syndesmosis: Biomechanical Study of the Ligamentous Restraints. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 1994;10(5): 558-60.

  4. Lin C-F, Gross MT, Weinhold P. Ankle Syndesmosis Injuries: Anatomy, Biomechanics, Mechanism of Injury, and Intervention. J. Orthop. Sport. Phys. Ther. 2006;36(6): 372–384. doi:10.2519/jospt.2006.2195.

  5. Dattani R, Patnaik S, Kantak A, et al. Injuries to the tibiofibular syndesmosis. J. Bone Jt. Surg. 2008;90–B(4): 405–410. doi:10.1302/0301-620X.90B4.19750.

  6. Brosky T, Nyland J, Nitz A, et al. The Ankle Ligaments: Consideration of Syndesmotic Injury and Implications for Rehabilitation. J. Orthop. Sport. Phys. Ther. 1995;21(4).

  7. Hopkinson WJ, Pierre P St., Ryan JB, et al. Syndesmosis Sprains of the Ankle. Foot Ankle. 1990;10(6): 325–330.

  8. Miller CD, Shelton WR, Barrett GR, et al. Deltoid and Syndesmosis Ligament of the Ankle without Fracture Injury. Am. J. Sports Med. 1995;23(6): 746–750.

  9. Hunt KJ. Syndesmosis injuries. Curr. Rev. Musculoskelet. Med. 2013;6: 304–312. doi:10.1007/s12178-013-9184-9.

Posted on May 27, 2019 and filed under Orthopedics.

Corneal Abrasions

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Written by: Julian Richardson, MD, MBA (NUEM PGY-2) Edited by: Andrew Moore, MD (NUEM ‘18) Expert commentary by: Brad Sobolewski, MD, MEd

A 40 yo construction worker comes to Emergency Department with a foreign body sensation in his left eye for two days. He states that he forgot to wear his eye protection while sanding a plank of wood the other day and felt like something has been scratching his eye ever since. Upon entering the room, his left eye is hyperemic and the patient appears to be in discomfort.


Approach to the painful red eye with foreign body sensation

The initial differential diagnosis to a painful red eye is broad and includes entities such as keratitis, corneal abrasions, corneal ulceration, acute angle glaucoma, iritis, chemical burn, scleritis, subconjunctival hemorrhage, and conjunctivitis. The patient’s history is particularly concerning for corneal abrasion, corneal ulceration, or globe rupture. A simple test to distinguish these diagnoses is the fluorescein exam.


Fluorescein exam

Fluorescein has been used in ophthalmology since the 1880s. This exam should be included for all patients where there is a suspicion of abrasion, foreign body, or infection. Fluorescein absorbs light in blue-wavelengths and emits energy in green wavelengths. It fluoresces in alkaline environments, for example Bowman’s membrane which is located below the corneal epithelium. It does not fluoresce in acidic environments such as the tear film over intact cornea.  Because of this, defects in the cornea increase fluorescein uptake and assist in locating corneal damage.

The eye should first be numbed usually with the use of a topical anesthetic drop, such as tetracaine. Next, take a fluorescein strip and place one drop of saline or local anesthetic to the strip. Place this strip inside the lower lid, remove, and ask the patient to blink. The key to a good exam is to produce a thin layer covering the surface of the eye. If too much is applied, the excess can easily be removed by asking the patient to blot their eye while closed with a tissue. The eye should then be examined using a Wood’s lamp, blue filter of a slit lamp, or penlight with a blue filter

Warning! this dye will permanently stain soft contact lenses and clothing. Be sure to remove any contacts and have plenty of gauze or other absorbant material available prior to instillation. Irrigating the excess dye out the eye after examination will help minimize staining the patient’s clothing.

Corneal Abrasion



  • Scratch to the epithelium that comprises the cornea and exposes the basement membrane. Patients generally complain of a foreign body sensation, pain, photophobia, and some vision loss. On physical exam, the clinician may find injected conjunctiva, and decreased visual acuity (if the defect is large or lies in the visual axis).

 Fluorescein Exam

  • Typically, abrasions are seen at the central part of the cornea due to limited protection of closure of the patient’s eyelids. The margins are sharp and linear in the first 24hrs. Circular defects suggests an embedded foreign body is present and may persist for greater than 48hrs. Foreign bodies can also produce vertical linear lesions and the upper lid should be lifter up to look for a foreign body under the eyelid


  • Treatment with antibiotics have become the standard of care. Antibiotics are particularly indicated for abrasions caused by contacts (cover for pseudomonas), foreign bodies, or history of trauma with infectious or vegetative matter due to a higher risk of infection. Ophthalmic antibiotic therapy include: erythromycin ointment or sulfacetamide 10%, polymyxin/trimethoprim, ciprofloxacin, or ofloxacin drops (4 times a day for 3-5 days). Pain relief can be provided with oral or topical pain meds. Topical NSAIDs include .1% indomethacin, .03% flubiprofen, .5% ketorolac, 1% indomethacin, and .1% diclofenac.  If symptoms persist greater than 24 hours after treatment the patient should follow-up with a physician. If the abrasion has not healed in 3-4 days the patient should be evaluated by an ophthalmologist.


Corneal Ulceration

after ulceration.png


  • When a defect in the corneal epithelium becomes infected with bacteria or fungi it is defined as a corneal ulceration. This is a common complication of corneal abrasions and if left untreated can result in a corneal perforation.

Fluorescein Exam

  • Corneal staining with infiltrate or opacification around the lesion should raise suspicion for ulceration. Contact lens wearers raise the suspicion of a Pseudomonal infection. Many Pseudomonal organisms fluoresce when exposed to UV light and fluoresce prior to fluorescein application.


  • Concern for ulceration requires an urgent ophthalmology consultation within 24hrs. Discharged patients should be treated with antibiotic drops or ointment.

Globe Rupture


  • Full thickness injury to the cornea, sclera, or both secondary to penetrating of blunt trauma.

Fluorescein Exam

  • Seidel test: instill a large amount of fluorescein onto eye and looking for small stream of fluorescent blue or green fluid leaking from the globe.


  • Once suspected, avoid further examination or manipulation, make the patient NPO, and place an emergent ophthalmology consultation. These patients also require broad spectrum IV antibiotic coverage with a 3rd generation cephalosporin or aminoglycoside and vancomycin to prevent post-traumatic endophthalmitis.

In summary, all patients with eye pain, particularly with a foreign body sensation, warrant a fluorescein exam. A wealth of information can be gained by this simple test and will guide the management of the patient.

Expert Commentary

This is a very comprehensive review of a common complaint in the Emergency Department. You correctly identified that one must be careful to avoid instilling too much fluorescein so as to cause a false positive result. Though a drop of tetracaine or saline dilutes the fluorescein from the strip somewhat the quantity is hard to control at times – especially in noncompliant patients (like the children I usually examine in the Pediatric Emergency Department). Excess fluorescein can collect across the eye making identification of small abrasions challenging. If you put too much in rinse the eye and try again. It is also incredibly important to not sent the patient home with tetracaine drops, as too frequent use may lead to further corneal injury. The evidence is based on animal models and case series and is far from complete. Read more on this great R.E.B.E.L. EM post (link:

One of the main pitfalls to the use of fluorescein strips is the risk of actually causing an abrasion. The method noted in this article – placing the strip inside the lower lid margin and asking the patient to blink – can cause an abrasion if the edge of the strip touches the cornea. This is particularly challenging to do in children, since even with proper restraint the blink reflex and their tendency to recoil is high. Therefore I recommend doing one of the following:

  1. Hold the patient’s eyelids open. Drip the tetracaine or saline down the strip and allow it to drip into the eye, being careful to avoid touching the strip to the eye.

  2. Make a fluorescein dropper. This is well detailed in the Tricks of the Trade: Fluorescein application techniques for the eye form Academic Life in Emergency Medicine (link: The Angiocath dropper allows for better control of droplet size and makes it easier to instill fluorescein into the squinting eye without the risk of touching the cornea.


Brad Sobolewski, MD, MEd

Associate Professor, Assistant Director - Pediatric Residency Training Program

Division of Emergency Medicine

Cincinnati Children's Hospital Medical Center

How To Cite This Post

[Peer-Reviewed, Web Publication] Richardson J, Moore A. (2019, May 20). Corneal Abrasions [NUEM Blog. Expert Commentary by Sobolewski]. Retrieved from

Other Posts You May Enjoy


  1. Images courtesy of

  2. Marx, J. A., & Rosen, P. (2014). Rosen's emergency medicine: Concepts and clinical practice (8th ed.) Ch. 71. Opthamology. Philadelphia, PA: Elsevier/Saunders

  3. Yanoff, M., Duker, J. S., & Augsburger, J. J. (2009). Ophthalmology. Ch 4, Corneal anatomy, physiology, and wound healing. Edinburgh: Mosby Elsevier.

  4. Roberts, J. R., In Custalow, C. B., In Thomsen, T. W., & In Hedges, J. R. (2014). Roberts and Hedges' clinical procedures in emergency medicine. Ch 62. Opthalmologic procedures.

  5. Gardiner, M. F. Overview of eye injuries in the emergency department. Retrieved September 16, 2017, from

  6. Jacobs, D. S. Corneal abrasions and corneal foreign bodies: management. Retrieved September 16, 2017, from

  7. Waldman, N., Winrow, B., Denise, I., Gray, A., McMAster, S., Giddings, G., & Meanley, J. (2017). An observational study to determine whether routinely sending patients home with a 24-hour supply of topical tetracaine from the emergency department for simple corneal abrasion pain is potentially safe. Annals of Emergency Medicine, 02(016).


Posted on May 20, 2019 and filed under Ophthalmology.

C-spine Clearance with Negative CT: Are We There Yet?

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Written by: M. Terese Whipple, MD (NUEM PGY-3) Edited by: Quentin Reuter, MD (NUEM ‘18) Expert commentary by: Matthew Levine, MD

We have excellent decision rules for clinically clearing cervical spine injury in low risk patients without imaging. However, a frustrating situation arises when a CT of their c-spine is obtained and negative, but they are having persistent midline pain. What do we do then? Are we forced to order an MR of the c-spine even when they have no neurological deficits and our gestalt tells us there is no clinically significant injury? MR often means admission, worsening of already overwhelming ED crowding, and unhappy patients when they cannot remove the c-collar for at least several more hours. Recent data and recommendations suggest that this may not be the case; a negative CT may be enough to rule out clinically significant injury. This blog post will explore some of the historical and recent data on the subject of cervical spine clearance after CT scan alone.  

There has been great historical debate over the best management for patients with persistent midline pain after negative CT, however that evidence is beyond the scope of this post. Current common practice and the recommendation of the American College of Radiology leads down the path of cervical spine MR when this situation arises [1]. Due to the cumbersome logistics of MR, much work has been done to determine if MR truly adds value to the patient’s workup. Is MR catching clinically significant injury missed by CT that changes clinical management? The majority of studies have concluded that the answer to that question is no.  

In 2015 the Eastern Association for the Surgery of Trauma (EAST) sought to tackle this question by reviewing all studies to date examining C-spine evaluation in obtunded patients [2]. They evaluated 11 studies with a total of 1718 obtunded patients who underwent C-Spine imaging with CT. None were ultimately found to have unstable fractures or unstable ligamentous injury missed by CT. There was a 9% incidence of stable injuries missed on CT and found on follow up MR, flex-x, upright XR, or clinical follow up. They found a cumulative 100% NPV for unstable C-Spine injury with CT and 91% NPV for stable injury. They did rate the quality of evidence as low for various reasons, including non-comparable imaging protocols, inconsistently reported and variable outcomes, publication bias, and an overall inability to perform a meta-analysis with the data.  However, they rated the data from which they derived the NPV as moderate quality as the NPV was consistently 100% throughout all of the trials. Based on their analysis they provided the following recommendation for obtunded blunt trauma patients:

“We conditionally recommend cervical collar removal after negative high-quality c-spine CT scan results alone.”

 They went on to further clarify,   

“It should be acknowledged that cervical collar removal can result in neurological change and even paralysis, although this may be underreported in the literature. However we cannot continue indiscriminate two-stage sequential screening for C-spine injuries if the injury rate is near 0% for the first test and the second adjunctive test results in false positives and inconsistent treatment plans.”

But the real question that is more pertinent to us as EM physicians (obtunded MR’s are usually dealt with upstairs), is:  if we can remove the c-collars of obtunded patients after negative CT, why couldn’t that be extrapolated to awake patients?  Well, they commented on that too:   

“Therefore, if collars are to be removed in a high risk obtunded population […] cervical collar removal can be logically argued for any population-obtunded or not.” [2]

 They finally call for multicenter prospective research on the subject, again citing the low quality of evidence that they used for their recommendation. That call was answered in 2017 by the Western Trauma Association. The group completed a multi institution trial with 10,000 patients who were getting a CT for evaluation of cervical spine injury prospectively enrolled at 17 centers [3]. They found only 3 CT scans that missed clinically significant injury (.03%). All of those patients had focal neurological abnormalities on exam. There was no clinically significant injury missed by CT and exam combined. CT scan alone had an NPV of 99.97%, and an NPV of 100% when combined with clinical exam. Therefore, they proposed this diagnostic algorithm:


Most trials have found similar results, with a few exceptions. Two trials prior to the publication of the Western Trauma Association (WTA) paper found that CT missed a few clinically significant injuries in patients with no neurological symptoms. Both trials enrolled significantly fewer patients than the WTA paper, and only enrolled patients with negative CT who would be evaluated with MR, meaning they couldn’t comment on the overall sensitivity of CT in unstable c-spine injury. The ReConect trial in 2016 found 5 of 767 patients (.6%) with injuries requiring surgical intervention that were missed on CT [4].  Another study with similar methods published in Annals of Emergency Medicine in 2011 evaluated those who had a negative CT but were MR’ed for persistent midline C-Spine tenderness [5]. They found that out of 178 patients, 5 had injury requiring operative management that was missed on CT but found on subsequent MR (2.8%) [5].  The Annals paper is certainly an outlier, with a considerably higher rate of missed clinically significant injury than the remainder of the literature, with rates usually between 0-1% [6-18]. The authors believe this may be due to more stringent methodology.  For instance, they required MR to be performed within 48 hours when it is the most sensitive for edema, and only enrolled patients with midline tenderness rather than subjective pain [5].  While this may be true, the results have not been replicated in subsequent studies.


With the publication of the WTA paper, evidence certainly seems to be tipping in favor of CT clearance of cervical spine in neurologically intact patients. However, a few questions remain. In every study discussed here, MR resulted in discharge with hard collar in a portion of patients. Indications ranged from stable injury to persistent pain with no evidence of injury on MR. It is unclear whether hard collar placement makes a difference in the clinical course of these patients, if their stable injuries would have become unstable without it, or if it has any long term impact on outcomes such as chronic pain. This is an important question not yet adequately addressed in the literature.  The majority of these trials were also completed at trauma centers with radiologists well trained in reading c-spine imaging and high quality CT scanners. It could be difficult to generalize this data to centers with older scanners or whose radiology departments are not as expert in trauma radiology.

Incredibly high quality and reproducible evidence is required to change practice when high stakes, such as potentially missed cervical spine injury, are involved. So far we have multiple trials showing an NPV of close to 100% when CT and good neurological exam are combined, and the conditional recommendation by the EAST group. Time will tell if recommendations in the future remove the “conditional” portion as CT technology continues to improve, further studies with stringent methodologies are conducted, and the results of the WTA paper are hopefully replicated.

Expert Commentary

Thank you Dr Whipple for that really practical review of a real-life common clinical question we face all the time: Can we remove the collar?  Some important takeaways are:

  1. There is a robust and growing body of evidence that removing the collar after a negative high-quality CT is safe if the patient is neurologically intact.

  2. This practice is endorsed by two major trauma organizations, EAST and WTA. 

The endorsement by respected major trauma societies is important in translating evidence into practice.  It seems like all that is left at this point for widespread implementation is overcoming culture.  This would likely require addressing the outlier studies listed by Dr Whipple to win over those still skeptical.  Part of overcoming culture would involve buy-in from neurosurgical societies.  What do neurosurgical societies say regarding clearing these patients?  There are many instances in which a patient is discharged with recommendations from the neurosurgeon to wear a hard collar despite a negative CT and MRI.  On the surface this seems like defensive medicine and impractical for the patient.  Is the patient really going to comply with this until follow up?  Is this collar really protecting them and preventing further injury which, after negative CT and MRI and with a normal neuro exam, seems exceedingly unlikely?  Does evidence support this practice?

In the end, decision rules should be used when you want evidence to support your clinical decisions, such as removing the C collar after negative imaging in a neurologically intact patient.  Do not use decision rules, however, to overturn or replace sound clinical judgement.  If there is something about a case that makes you still feel like you could be missing an outlier injury by removing the collar, listen to that voice inside of you. It is that sound clinical judgement that will guide you through your career, not decision rules.

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Matthew Levine, MD

Northwestern Medicine, Assistant Professor of Emergency Medicine

How To Cite This Post

[Peer-Reviewed, Web Publication] Whipple T, Reuter Q. (2019, May 13). C-spine clearance with negative CT: Are we there yet? [NUEM Blog. Expert Commentary by Levine M]. Retrieved from

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  1. American College of Radiology. ACR appropriateness criteria on suspected spine trauma. Available at:

  2. Patel MB, et al. Cervical spine collar clearance in the obtunded adult blunt trauma patient: A systematic review and practice management guideline from the Eastern Association for the Surgery of Trauma. J Acute Care Trauma Surgery. 789(2): 432-441.

  3. Inaba, K et al. Cervical Spine Clearance: A Prospective Western Trauma Association Multi-Institutional Trial. J Trauma Acute Care Surg. 2016 Dec: 81(6): 1122-1130.doi: 10.1097/TA.0000000000001194

  4. Maung A, et al. Cervical spine MRI in patients with negative CT: A prospective, multicenter study of the Research Consortium of New England Centers for Trauma (ReCONECT). J Trauma Acute Care Surg. 82 (2): 263-269.

  5. Ackland HM, et al. Cervical Spine Magnetic Resonance Imaging in Alert, Neurologically Intact Trauma Patients With Persistent Midline Tenderness and Negative Computed Tomography Results. Ann of Em Med. 2011 Dec. 58 (6): 521-530.

  6. Chew B, et al. Cervical spine clearance in the traumatically injured patient: is multidector CT scanning sufficient alone? J Neurosurg Spine. 2013. 19: 576-581

  7. Bush L, et al. Evaluation of cervical spine clearance by computed tomographic scan alone in intoxicated patients with blunt trauma. JAMA Surg. 2016; 151 (9): 807-813

  8. D’Alise  et al. Magnetic resonance imaging for the evaluation of the cervical spine in the comatose or obtunded trauma patient. J Neurosurgery  (Spine 1) 1999; 91:54-59.

  9. Resnick S, et al. Clinical relevance of magnetic resonance imaging in cervical spine clearance: a prospective study. JAMA Surg. 2014; 149 (9): 934-9.

  10. Menaker J, Philp A, Boswell S, Scalea TM. Computed tomography alone for cervical spine clearance in the unreliable patient--are we there yet? J Trauma. 2008; 64(4):898–903.

  11. Chew BG, Swartz C, Quigley MR, Altman DT, Daffner RH, Wilberger JE. Cervical spine clearance in the traumatically injured patient: is multidetector CT scanning sufficient alone? Clinical article. J Neurosurg Spine. 2013; 19(5):576–81.

  12. Como JJ, Leukhardt WH, Anderson JS, Wilczewski PA, Samia H, Claridge JA. Computed tomography alone may clear the cervical spine in obtunded blunt trauma patients: a prospective evaluation of a revised protocol. J Trauma. 2011; 70(2):345–9. discussion 9-51.

  13. Khanna P, Chau C, Dublin A, Kim K, Wisner D. The value of cervical magnetic resonance imaging in the evaluation of the obtunded or comatose patient with cervical trauma, no other abnormal neurological findings, and a normal cervical computed tomography. J Trauma Acute Care Surg. 2012; 72(3):699–702.

  14. Schuster R, Waxman K, Sanchez B, Becerra S, Chung R, Conner S, Jones T. Magnetic resonance imaging is not needed to clear cervical spines in blunt trauma patients with normal computed tomographic results and no motor deficits. Arch Surg. 2005; 140(8):762–6.

  15. Anekstein Y, Jeroukhimov I, Bar-Ziv Y, Shalmon E, Cohen N, Mirovsky Y, Masharawi Y. The use of dynamic CT surview for cervical spine clearance in comatose trauma patients: a pilot prospective study. Injury. 2008; 39(3):339–46.

  16. Brohi K, Healy M, Fotheringham T, Chan O, Aylwin C, Whitley S, Walsh M. Helical computed tomographic scanning for the evaluation of the cervical spine in the unconscious, intubated trauma patient. J Trauma. 2005; 58(5):897–901.

  17. Harris TJ, Blackmore CC, Mirza SK, Jurkovich GJ. Clearing the cervical spine in obtunded patients. Spine (Phila Pa 1976). 2008; 33(14):1547–1553.

  18. Steigelman M, Lopez P, Dent D, Myers J, Corneille M, Stewart R, Cohn S. Screening cervical spine MRI after normal cervical spine CT scans in patients in whom cervical spine injury cannot be excluded by physical examination. Am J Surg. 2008; 196(6):857–862.

Posted on May 13, 2019 and filed under Trauma.

Anticoagulation in Distal DVT

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Anticoagulation in Distal DVT

Written by: William LaPlant, MD (NUEM PGY-3) Edited by: William Ford, MD (NUEM PGY-4) Expert commentary by: Kelsea Caruso, PharmD

Currently there is significant heterogeneity in the treatment of distal deep vein thromboses (DDVTs), which are DVTs that occur distal to the popliteal fossa. What is the best course of action when a reasonably healthy patient has a new calf DVT?

The CACTUS trial was a randomized, placebo-controlled, double-blinded trial prospectively assessing anticoagulation for calf DVTs [1]. Notably, the trial was met with slow enrollment resulting in termination of the study prior to enrollment of the prespecified sample size, meaning that it was underpowered to detect a significant difference between the groups. It only enrolled about half of the participants it had intended to, with an initial 90% power to detect a 70% risk reduction in the composite outcome: development of a proximal DVT or symptomatic PE by day 42. This power study assumed a 10% incidence of the primary outcome in the placebo group.


As you can see, in both groups the progression to proximal DVT or PE was quite low. As there were only 12 total composite events (DVT extension, PE), making a comparison between groups with any degree of certainty impossible. This study met neither their enrollment goals (only enrolling half the participants) nor the predicted incidence of the composite outcome (half the projected amount), so it was quite significantly underpowered to detect a difference.

Notably, the study also did not enroll pregnant women, patients with a previous DVT, recent PE, or recent malignancy. These patients were likely not enrolled due to their higher risk of progression, which may have biased the results towards treatment. As such, the results of this trial could never be applied to these groups.

Unfortunately, given the slow recruitment in the CACTUS trial as well as the low event rate of the composite outcome, the likelihood that this will be studied again in a prospective, double-blinded manner is unlikely. As such, we will need to put the CACTUS trial into context of retrospective evidence to try to identify an ideal practice pattern.

With regard to the retrospective data available:

In a 2016 metanalysis, the incidence of PE from DDVT was 0% to 6.2% [median 1.1%] [2], which is in line with the results from the CACTUS trail. As you can see in the chart below, there is some heterogeneity to the results, likely due to the wide variety in study methodology.

Based on the above evidence, what are the best management options? A recent review article (which includes data from CACTUS) offers two suggestions [3]:

  1. The most conservative management will still be anticoagulation of the isolated DDVT. This should be standard for patients with cancer or other pro-thrombotic state that would place the patient at high risk for the development of DVT.

  2. Deferred anticoagulation with follow up ultrasound can be used for patients without significant thrombotic risk factors. You can engage in shared decision making and discuss the risks for bleeding in your patient against the 4-5% risk for clot progression and 1% risk for PE (based on the CACTUS trail as well as retrospective data).

If you decide against anticoagulation in the emergency department, follow up imaging would be recommended in 1-2 weeks to evaluate for progression. This tight follow up window would help to ensure clot progression is identified early and would allow the patient to readdress anticoagulation with his/her primary care physician.

Expert Commentary

Thank you for this really great summary! I think you are bringing up a dilemma that we see quite often in the Emergency Department and one that, unfortunately, still doesn’t have much data to help guide our treatment recommendations. The CHEST guidelines for VTE disease were most recently updated in 2016 and do not include the results of the CACTUS trial or the results of the mentioned meta-analysis. Their recommendation is to treat an unprovoked DVT (distal or proximal) with anticoagulation for at least 3 months.

 The CACTUS trial questioned if this is required for all patients, primarily focusing on those with an isolated calf DVT. The CACTUS trial had some interesting results, but, like you mentioned, a huge patient population was excluded.. We can only extrapolate this data to a very small group of people: young (average age ~50 years old in the trial), healthy and without any risk factors for VTE. Also, the study drug utilized in the trial was nadroparin, a low molecular weight heparin, which is not available in the US. It would have been more applicable to clinical practice if this trial had utilized a direct-oral anticoagulant like rivaroxaban or apixaban. If these were used the safety results could have potentially been reduced.

So the question remains… to anticoagulate or not to anticoagulate? Here are my final thoughts:

  1. The patients you can think about deferring anticoagulation are those without any VTE risk factors (cancer, obesity, immobility, those on estrogen therapy etc.).

    • As mentioned, this should be a discussion with the patient so they understand the risk of deferring anticoagulation. They should have adequate follow-up and understand the signs and symptoms of a pulmonary embolism.

  2. The patients that should be anticoagulated are those that have any risk factor for VTE or patients from the previous point that choose treatment.

    • The anticoagulant should be selected by keeping patient specific factors in mind like past medical history, renal function and current medications

    • Unlike the CACTUS trial, try and prescribe oral therapy. Your patients will thank you if they don’t have to inject themselves daily.

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Kelsea Caruso, PharmD

Emergency Medicine Clinical Pharmacist

Northwestern Memorial Hospital

How To Cite This Post

[Peer-Reviewed, Web Publication] LaPlant W, Ford W. (2019, May 6). Anticoagulation in distal DVT. [NUEM Blog. Expert Commentary by Caruso K]. Retrieved from

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  1. Righini M, Galanaud J, Guenneguez H, et al. Anticoagulant therapy for symptomatic calf deep vein thrombosis ( CACTUS ): a randomised , double-blind , placebo-controlled trial. 2017;3(December 2016). doi:10.1016/S2352-3026(16)30131-4.

  2. Wu AR, Garry J, Labropoulos N, Brook S. Incidence of pulmonary embolism in patients with isolated calf deep vein thrombosis. J Vasc Surg. 2016;5(2):274-279. doi:10.1016/j.jvsv.2016.09.005.

  3. Robert-ebadi H, Righini M. Management of distal deep vein thrombosis ☆. Thromb Res. 2017;149:48-55. doi:10.1016/j.thromres.2016.11.009.

Posted on May 6, 2019 and filed under Hematology.

Ultrasound in Pediatric Distal Forearm Fractures

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Written by: Jason Chodakowski, MD (NUEM PGY-3) Edited by: Logan Weygandt, MD (NUEM ‘17) Expert commentary by: Rachel Haney, MD (NUEM ‘17)

Why use Ultrasound?

Distal forearm fractures are common fractures in the pediatric population. Although plain radiographs of the forearm are still considered the gold standard for definitive diagnosis, there is growing interest in using ultrasound for diagnosis because it provides zero radiation exposure, it can be used to guide local pain control, and it can confirm reduction success at the bedside. Ultrasound is easy to teach and provides value under circumstances when plain radiography might be unavailable (pre-hospital environment, disaster areas, or in developing countries).

A recent meta-analysis of 12 studies, which included 951 children 18 and younger, found that physician performed bedside ultrasound detected distal forearm fractures with a pooled sensitivity of 98% and a specificity of 96% when compared with the gold standard plain radiographs.[1] The pain associated with ultrasound use was also significantly less.[2]


How do I use Ultrasound?

To evaluate musculoskeletal pathology use the high-frequency linear array transducer employing the six-view ultrasound technique as shown below. You may detect a fracture as an apparent discontinuity or irregularity (divots, step-offs, distortion) of the hyperechoic and continuous bony cortex. Disruptions as small as 1mm can be detected.

Six-view technique (Herren et. al. 2015)

Six-view technique (Herren et. al. 2015)

Normal Cortex (Crosby et. al. 2014)

Normal Cortex (Crosby et. al. 2014)

Distal radius fracture (

Distal radius fracture (

Distal radius fracture (

Distal radius fracture (


In children the evaluation of bones is complicated by the open physes, which may be mistaken for fractures. The difference is that physes will appear as smooth, downward-sloping curves unlike fractures, which will have abrupt step-offs.

Normal open tibial physis (Crosby et. al. 2014)

Normal open tibial physis (Crosby et. al. 2014)

What else is Ultrasound Good For?

  • Confirming reductions

    Ultrasound is also utilized by emergency physicians to determine successful realignment of pediatric distal forearm fractures after closed reduction.[4]

Fracture reduction (Socranksy et. al. 2016)

Fracture reduction (Socranksy et. al. 2016)

  •  Achieving adequate pain control

    Ultrasound can also be used to guide hematoma blocks. The hematoma block is a technique wherein the physician injects an anesthetic solution into the hematoma between the fractured bone fragments (see image below). It has been shown to be effective, safe, faster, and uses fewer resources with no significant difference in pain scores when compared to procedural sedation in both adults and children with distal forearm fractures.[6,7]

Clean skin and place a sterile cover over the transducer. Using 5-10cc of 1-2% lidocaine inject into the hematoma between the fractured bone fragments using an 18-22 gauge needle.

Visualization of needle (N) entering between fracture bone fragments (U) (

Visualization of needle (N) entering between fracture bone fragments (U) (

Take Home Points

  • Ultrasound is most useful in evaluating long bone fractures such as the femur, clavicle, ribs, or distal radius and ulna.

  • A reliable alternative to the plain radiograph is the proper six-view method it, with the advantages of being portable and radiation-free.

  • Ultrasound can also be reliably used to confirm fracture reduction, as well as for guiding forearm fracture hematoma blocks. 

Thank you for providing a concise summary of the utility of Point-of-care Ultrasound (POCUS) for pediatric forearm fractures.  

I’d like to mention a few key points regarding the use of POCUS for pediatric fracture assessment.

  • If you do a lot of adult scanning and not much pediatric scanning it is important to keep in mind that children may not be as cooperative (or stationary) as adults.

    • Smaller children may be afraid of the transducer therefore introducing the transducer to the patient as an object that will not hurt them is key. You should hand the probe to the patient, allow them to touch it and even scan themselves initially in order to get them more comfortable with the probe.

  • While the 6-view scan you describe will certainly improve sensitivity, adequate sensitivity can be achieved with a 2-view approach. Additionally, the 6-view technique may be prohibitively time-intensive in a busy Emergency Department.

    • In order to increase sensitivity with the 2-view approach, always start imaging at the point of maximal tenderness, initially in the longitudinal plane with the cortex of the bone parallel to the probe surface. Slide distal and proximal to the point of tenderness. Then rotate the probe 90 degrees to view the cortex in the transverse plane. Fractures are noted as cortical disruptions or step-offs. Fractures are most visible on POCUS when the fracture line is perpendicular to the angle of insonation.

  • Another key pearl is to use copious gel in order to optimize the focal point of the image. The focal zone on the screen is the part of the image with the highest resolution secondary to convergence of the US beams. The focal point can be changed depending upon your machine, but is typically no more shallow than about 1-cm below the probe surface, therefore if you place a good layer of gel about 1cm thick, you will place the cortext of the bone at the optimal focal point. Using copious gel is also important in reducing any potential discomfort caused by pressure from the probe.

    • If gel is a limited resource, you can use a water bath as well.

  • While POCUS is a wonderful tool, especially for fracture detection, I want you to keep in mind that the sensitivity of POCUS for fractures is the highest (low-mid 90s) for the diaphysis of long bones (femur, humerus, radius and ulna). Sensitivity is significantly lower for detecting fractures of other bones and fractures near joint lines secondary to the curvilinear nature of the metaphysis as well as the presence of cartilaginous epiphyseal plates in children.

    • While POCUS can supplant the use of radiography in austere environments, in a well-resourced emergency department, POCUS should be an adjunct to radiography. In this setting, POCUS can have utility in patients in whom you suspect occult fracture despite negative XRs or for real-time fracture reduction assessment before sedation wears off. Unless you are a pediatric POCUS expert, I would order XR’s as usual for a pediatric patient you suspect has a fracture. In the meantime- continue scanning patients with normal anatomy and documented fractures in order to develop your POCUS expertise! Happy Scanning!


Rachel Haney, MD

NUEM ‘17

Ultrasound Fellow at Massachusetts General Hospital

How To Cite This Post

[Peer-Reviewed, Web Publication] Chodakowski J, Weygandt L. (2019, April 28). Ultrasound in pediatric distal forearm fractures. [NUEM Blog. Expert Commentary by Haney R]. Retrieved from

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