Matthew Alfarano, Amy Marks, Daven Patel, Evelyn Schraft, Tina Sundaram, Aylin Ornelas Loredo, Ohm Shukla, Nhat Nguyen, Gary D. Peksa, Michael Gottlieb
In Press, Received September 22, 2025 Accepted December 29, 2025 Available online April 3, 2026
Objective This study aimed to assess the diagnostic value of the sagittal and transverse views of the suprapubic window during a FAST/eFAST examination.
Methods This retrospective chart review analyzed suprapubic windows of FAST/eFAST images performed 08/15/2017-08/01/2024. Each ultrasound video was reviewed for the presence or absence of free fluid, image quality, and diagnostic confidence. Reviewers were blinded to clinical information and did not assess more than one imaging plane in the same patient.
Results Of the 958 FAST/eFAST studies identified, 497 met inclusion criteria. 433 (87.1%) were diagnostic, while 64 (12.9%) were non-diagnostic in at least one imaging plane. Among diagnostic images, 93 (21.5%) sagittal views and 74 (17.1%) transverse views were positive for free fluid. 32 exams (34.3%) showed free fluid in the sagittal views but were negative on the transverse view, whereas 13 cases (17.6%) were positive on the transverse view but negative on the sagittal view. Using both views reduced overall non-diagnostic rate from 12.9% to 1.2%.
Conclusion Using both sagittal and transverse views in the suprapubic window during a FAST/eFAST examination can reduce the non-diagnostic rates and improve identification of free fluid. The observed discrepancies between views and variability in the image quality and confidence support a multi-view approach.
Objective
Hyperkalemia is a potentially life-threatening condition among patients presenting to the Emergency Department (ED). However, most epidemiological studies have focused on those with end-stage renal disease (ESRD) and there is limited recent, large-scale, and robust data available on the incidence and management of hyperkalemia for non-ESRD patients in the ED.
Methods
This was a retrospective cohort study of adults (age ≥ 18 years) without ESRD presenting to the ED with hyperkalemia from 1/1/2016 to 12/31/2024. ICD-10 codes were used to identify patients in the Epic Cosmos database. The primary outcome was the incidence of hyperkalemia from all ED visits. Secondary outcomes included rates of admission, cardiac arrest, hemodialysis, and medications administered to treat hyperkalemia. Data were analyzed using summary statistics and odds ratios (OR) with 95% confidence intervals (CI).
Results
Among 246,235,769 ED visits, 803,186 (0.33%) had an ICD-10 code for hyperkalemia and 539,033 of those (67.11%) were admitted to the hospital. Cardiac arrest occurred in 18,044 (2.25%) patients with hyperkalemia. Sodium bicarbonate was given in 38.75%, calcium gluconate or chloride in 32.64%, sodium zirconium cyclosilicate in 24.68%, sodium polystyrene sulfonate in 23.12%, and patiromer in 3.04%. Only 2.99% received hemodialysis.
Conclusion
Among adult patients without ESRD, hyperkalemia is an uncommon but important condition, with twothirds requiring admission and two percent experiencing cardiac arrest. Sodium bicarbonate and calcium administration is common, while hemodialysis is rare.
Citations
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Treatment of Hyperkalemia-Induced-Cardiac-Arrest by Dynamic Electrocardiogram and Point-of-Care-testing Potassium: A Case Report Jiaozhen Chen, Jizhen Chen, Xinran Dang, Jiali Chen, Yusuo Chen, Yuanli Lei Clinical Medicine Insights: Case Reports.2026;[Epub] CrossRef
Objective Urinary tract infections are a common consideration when assessing pediatric patients with fever. With rising resistance rates and increased focus on antibiotic stewardship, current management needs to be better understood. This study reports the incidence and antibiotic distribution in a nationwide cohort of pediatric emergency department (ED) patients with cystitis and pyelonephritis during an 8-year period. Methods We performed a cohort study from January 1, 2016, to December 31, 2023, using Epic Cosmos data. Pediatric ED patients (<18 years) with an ICD-10 code corresponding to cystitis or pyelonephritis were included. The outcomes were the total number of ED presentations, outpatient antibiotic prescriptions, and antibiotics administered in the ED for patients admitted with cystitis or pyelonephritis. Binary logistic regression models were used to measure the relationship between the year and the dependent variables. Results Among 46,774,814 total pediatric ED visits, 720,863 (1.5%) were for cystitis, and 82,717 (0.2%) were for pyelonephritis. Among those admitted, the most common antibiotics were third-generation cephalosporins (cystitis, 55.6%; pyelonephritis, 62.3%), first-generation cephalosporins (cystitis, 13.8%; pyelonephritis, 13.7%), and ampicillin (cystitis, 10.8%; pyelonephritis, 6.6%). First-generation cephalosporin use rose over time, while ampicillin and ciprofloxacin use declined. Among discharged patients, the most common antibiotics were first-generation cephalosporins (cystitis, 43.1%; pyelonephritis, 33.7%), third-generation cephalosporins (cystitis, 20.8%; pyelonephritis, 25.8%), and trimethoprim-sulfamethoxazole (cystitis, 13.5%; pyelonephritis, 11.7%). First-generation cephalosporin use rose over time, while trimethoprim-sulfamethoxazole and ciprofloxacin use declined. Among those with cystitis specifically, the use of third-generation cephalosporins declined over time. Conclusion Cystitis and pyelonephritis remain common ED presentations, representing nearly 2% of all pediatric ED visits, and antibiotic selection has shifted notably over time. Understanding the current epidemiology can inform public health planning and antibiotic stewardship in the ED.
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Objective Deep vein thrombosis (DVT) is a significant cause of morbidity and mortality worldwide, accounting for substantial healthcare utilization. However, management strategies have evolved, and current data on the incidence, admission rates, and medical management of DVT in the emergency department (ED) setting are needed. Methods This cross-sectional study analyzed ED presentations for DVT from 2016 to 2023 using the Cosmos database. Inclusion criteria were patients aged ≥18 years with an ICD-10 code for acute extremity DVT. The outcomes were incidence rates, admission rates, and anticoagulant prescriptions. Data were analyzed using descriptive statistics, and subgroup analyses were performed for upper and lower extremity DVTs. Results Of 190,144,463 total ED encounters, 368,044 (0.2%) were due to DVT. Among the DVT cases, 119,986 patients (32.6%) were admitted, at a stable rate during the study period. Apixaban was the most prescribed anticoagulant (40.3%), followed by rivaroxaban (28.3%), enoxaparin (7.9%), warfarin (3.6%), and dabigatran (0.3%). Use of apixaban increased from 12.4% in 2016 to 56.2% in 2023. Lower extremity DVTs accounted for 88.5% of cases, with a 32.1% admission rate, whereas upper extremity DVTs accounted for 11.7% of cases, with a 37.0% admission rate. Conclusion This study provides a summary of DVT presentation and management in US EDs during an 8-year period. The findings highlight stable incidence rates, reduced admission rates compared with historical data, and a significant shift toward the use of direct oral anticoagulants, particularly apixaban, for outpatient management. These trends underscore the importance of evidence-based practices and ongoing research to optimize DVT management and improve patient outcomes.
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Objective Emergency medicine (EM) physicians face high burnout rates, even in academic settings. Research on burnout among EM residency program leaders is limited, despite their role in shaping the training environment and influencing resident well-being. This study aims to measure burnout and professional fulfillment among EM residency program leaders and identify contributing factors. Methods A cross-sectional survey using the adapted Stanford Professional Fulfillment Index was conducted in 2023 to assess burnout and professional fulfillment among EM residency program leaders at US programs. The survey, tailored to EM leaders, was distributed to all current EM program directors (PDs) and assistant/associate PDs (APDs) from accredited US programs. Descriptive statistics and odds ratios were used to compare burnout and professional fulfillment across various groups. Results A total of 112 of 281 PDs (response rate, 39.9%) and 130 of 577 APDs (response rate, 22.5%) participated. Professional fulfillment was reported by 59.8% of PDs and 58.5% of APDs. Burnout was experienced by 42.0% of PDs and 26.9% of APDs. Higher professional fulfillment correlated with alignment with expectations, positive work environments, and perceived appreciation, while burnout was strongly associated with negative impacts on personal health and relationships. Approximately 27.7% of PDs and 23.8% of APDs expressed an intention to leave their current position within 18 months. Conclusion A significant proportion of US EM residency program leaders experience burnout and low professional fulfillment. Addressing well-being in this population has important implications for education and mentorship provided to future physicians in the field.
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Airway management is a common procedure within emergency and critical care medicine. Traditional techniques for predicting and managing a difficult airway each have important limitations. As the field has evolved, point-of-care ultrasound has been increasingly utilized for this application. Several measures can be used to sonographically predict a difficult airway, including skin to epiglottis, hyomental distance, and tongue thickness. Ultrasound can also be used to confirm endotracheal tube intubation and assess endotracheal tube depth. Ultrasound is superior to the landmark-based approach for locating the cricothyroid membrane, particularly in patients with difficult anatomy. Finally, we provide an algorithm for using ultrasound to manage the crashing patient on mechanical ventilation. After reading this article, readers will have an enhanced understanding of the role of ultrasound in airway management.
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Objective Feedback is critical to the growth of learners. However, feedback quality can be variable in practice. Most feedback tools are generic, with few targeting emergency medicine. We created a feedback tool designed for emergency medicine residents, and this study aimed to evaluate the effectiveness of this tool.
Methods This was a single-center, prospective cohort study comparing feedback quality before and after introducing a novel feedback tool. Residents and faculty completed a survey after each shift assessing feedback quality, feedback time, and the number of feedback episodes. Feedback quality was assessed using a composite score from seven questions, which were each scored 1 to 5 points (minimum total score, 7 points; maximum, 35 points). Preintervention and postintervention data were analyzed using a mixed-effects model that took into account the correlation of random effects between study participants.
Results Residents completed 182 surveys and faculty members completed 158 surveys. The use of the tool was associated with improved consistency in the summative score of effective feedback attributes as assessed by residents (P=0.040) but not by faculty (P=0.259). However, most of the individual scores for attributes of good feedback did not reach statistical significance. With the tool, residents perceived that faculty spent more time providing feedback (P=0.040) and that the delivery of feedback was more ongoing throughout the shift (P=0.020). Faculty felt that the tool allowed for more ongoing feedback (P=0.002), with no perceived increase in the time spent delivering feedback (P=0.833).
Conclusion The use of a dedicated tool may help educators provide more meaningful and frequent feedback without impacting the perceived required time needed to provide feedback.
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