Contributor: Megan Hurley, MD

Educational Pearls:

Assess first: confirm the hook isn't near vital structures.

• Automatic subspecialty consult for eye involvement or proximity to carotid artery, radial artery, peritoneum, testicle, or urethra
• Barbed hook: cannot be pulled back through the entry without disengaging the barb

Removal Techniques

1. String-Pull: best for superficial, single-barbed hooks
   • Depress shank and eye of hook to disengage barb and then pull string taut and jerk suddenly along the long axis
   • Can only be used when the hook is in a body part that can be firmly secured so it won't move during the procedure
   • Little or no anesthesia needed
2. Push-Through & Snip: best choice when barb is near the skin surface
   • Anesthetize first and advance the hook forward until the barb emerges. Cut off the barb and then back hook out
   • Small exit wound, no sutures needed
3. Needle Cover: for larger hooks that are superficial
   • Anesthetize first and then slide an 18 or 20-gauge needle along the hook until the bevel covers the barb. Then back out the needle and hook together
4. Cut-it-out: last resort
   • Make an incision along the body of hook to barb and then remove hook

Adjuncts: Hydrodissection with lidocaine along the tract can ease removal
Post-Procedure

• Irrigate thoroughly and apply antibiotic ointment
• Routine prophylaxis not needed because complications are rare
  • Consider prophylactic antibiotics if hook is deeply embedded in high-risk area or contaminated by fresh water or salt water

References

1. Aiello LP, Iwamoto M, Guyer DR. Penetrating ocular fish-hook injuries. Surgical management and long-term visual outcome. Ophthalmology. 1992 Jun;99(6):862-6. doi: 10.1016/s0161-6420(92)31881-0. PMID: 1630774.
2. Malitz DI. Fish-hook injuries. Ophthalmology. 1993 Jan;100(1):3-4. doi: 10.1016/s0161-6420(93)31700-8. PMID: 8433823.

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

Contributor: Aaron Lessen MD

Educational Pearls:

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

References

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

Summarized & Edited by Jorge Chalit, OMS4

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Contributor: Meghan Hurley, MD

Educational Pearls:

1. Initial Assessment

• Start with a physical examination:

• • Determine if the bleed is anterior or posterior.

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

• • Airway compromise = intubation immediately.

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

2. Topical Medications

• Anesthetics: provide local anesthesia and pain relief.

• • Lidocaine

  • Tetracaine

• Vasoconstrictors: reduce bleeding.

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

  • Cocaine pledgets (less common).

  • Tranexamic acid (TXA).

  • Oxymetazoline (Afrin).

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

3. Technique Tips

• Use a nasal speculum.

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

• Place LET-soaked gauze in the nares.

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

• Note that pledgets may cause upper lip numbness

4. Reassessment

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

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

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

5. Packing

• If the above measures fail to control bleeding:

• • Anterior packing:

  • • Nasal tampon (Merocel)

    • • Convenient for outpatient removal.

    • Balloon device

    • • Inflate the anterior balloon for compression.

  • Posterior packing:

  • • More complex, should consult ENT for additional assistance.

6. Disposition & Follow-Up

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

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

• Outpatient follow-up if stable:

  • Tampon: The patient can remove it at home.

  • Balloon: Return to ED for removal.

7. Risk Factors for Epistaxis & Prevention

• Deviated septum, dry environments, and anticoagulant use

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

References:

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

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

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Contributor: Travis Barlock, MD

Educational Pearls:

• Quick Statistics on Electrical Burns:
  Electrical burns compose roughly 2 to 9% of all burns that come into emergency departments.
• The majority of patients who receive electrical burns are male, typically aged 20's to 30's, accounting for 80 to 90% of all electrical burn victims.
• The majority of burns are linked to occupational exposure.
• The upper extremities are more commonly impacted by electrical burns, accounting for 70 to 90% of entry points into the body during an exposure.

What are some of the key considerations in electrical burns?

• Unlike chemical or fire/heat related burns, electrical burns have the potential to cause significant internal damage that may not be physically appreciated externally.
• This damage can include, but is not limited to:
  • Cardiac dysthymias (PVCs, SVT, AV block, to more serious ventricular dysrhythmias such as ventricular fibrillation or ventricular tachycardia).
  • Deep tissue injury resulting in rhabdomyolysis from the initial surge of electricity
  • Rare cases of compartment syndrome

What are the treatment considerations for patients who suffer electrical burns?

• Remembering that cutaneous findings associated with burns may underestimate the severity of the injury, with deeper structures being more likely to be involved as the voltage of the burn injury is directly correlated to severity.
• Manage the patient's airway, breathing, and circulation as always, and conduct further workup into potential cardiac involvement with EKGs, as well as analysis of the extremities where entry occurred for muscle breakdown and compartment syndrome.

Clinical Pearl on Voltage and Current:

• Voltage can be thought of being equivalent to pressure in a fluid/liquid system. Higher voltages are equivalent to higher pressures, but the ultimate damage delivered to the system is from the rate of delivery/speed of the electrical energy surging (current) through the body.
• Current is dependent on the tissue it is travelling through, with different tissues having differing electrical resistances. Tissues like the stratum corneum of the skin and the human bone confer the most resistance (thus lower current) whereas skeletal muscle confers lower electrical resistance (thus higher current) due to water and electrolyte content, which is why injuries like rhabdomyolysis are possible and increase with increasing voltage.

References

1. Khor D, AlQasas T, Galet C, et al. Electrical injuries and outcomes: A retrospective review. Burns. 2023;49(7):1739-1744. doi:10.1016/j.burns.2023.03.015
2. Durdu T, Ozensoy HS, Erturk N, Yılmaz YB. Impact of Voltage Level on Hospitalization and Mortality in Electrical Injury Cases: A Retrospective Analysis from a Turkish Emergency Department. Med Sci Monit. 2025;31:e947675. doi:10.12659/MSM.947675
3. Karray R, Chakroun-Walha O, Mechri F, et al. Outcomes of electrical injuries in the emergency department: epidemiology, severity predictors, and chronic sequelae. Eur J Trauma Emerg Surg. 2025;51(1):85. doi:10.1007/s00068-025-02766-1
4. Faes TJ, van der Meij HA, de Munck JC, Heethaar RM. The electric resistivity of human tissues (100 Hz-10 MHz): a meta-analysis of review studies. Physiol Meas. 1999;20(4):R1-10. doi:10.1088/0967-3334/20/4/201

Summarized by Dan Orbidan, OMS2 | Edited by Dan Orbidan and Jorge Chalit, OMS4

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Contributors: Preeya Prakash MD, Adam Greenhaw PharmD, Travis Barlock MD, and Jeffrey Olson MS4

In this episode, cardiologist Preeya Prakash and medical student Jeffrey Olson listen in as two cases are presented from EMM's recent event, Tox Talk 2025.

Talk 1- Digoxin Overdose

Dr. Adam Greenhaw presents a case of a Digoxin overdose along with many pearls. During the studio listen in, Dr. Prakash helps to answer the questions of:

• How does digoxin work?

• Why might a patient still be on digoxin in 2025?

• What are the EKG findings of digoxin toxicity?

• Is there any utility in atropine for bradycardia caused by digoxin?

• Should you use calcium to treat hyperkalemia in the setting of a digoxin overdose?

• If/when might a cardiologist get involved in a patient with a digoxin overdose?

Talk 2- Propranolol Overdose

Dr. Travis Barlock presents a case of a beta blocker overdose as well as many associated pearls. During our studio listen in, Dr. Prakash helps to answer the questions of:

• What are the different beta blockers and how do they work?

• If you are worried about a propranolol overdose, what medications do you want on hand?

• What POCUS cardiac view can give you the most information for different scenarios?

• Why or why not might transcutaneous or intravenous pacing be a good idea for a beta blocker overdose?

• If/when might you want a cardiologist to get involved in a patient with a beta blocker overdose?

References

• Alahmed AA, Lauffenburger JC, Vaduganathan M, Aldemerdash A, Ting C, Fatani N, Fanikos J, Buckley LF. Contemporary Trends in the Use of and Expenditures on Digoxin in the United States. Am J Cardiovasc Drugs. 2022 Sep;22(5):567-575. doi: 10.1007/s40256-022-00540-x. Epub 2022 Jun 24. PMID: 35739347; PMCID: PMC10263277.

• Chan BS, Buckley NA. Digoxin-specific antibody fragments in the treatment of digoxin toxicity. Clin Toxicol (Phila). 2014 Sep-Oct;52(8):824-36. doi: 10.3109/15563650.2014.943907. Epub 2014 Aug 4. PMID: 25089630.

• Hack JB, Wingate S, Zolty R, Rich MW, Hauptman PJ. Expert Consensus on the Diagnosis and Management of Digoxin Toxicity. Am J Med. 2025 Jan;138(1):25-33.e14. doi: 10.1016/j.amjmed.2024.08.018. Epub 2024 Sep 11. PMID: 39265879.

• Krenz JR, Kaakeh Y. An Overview of Hyperinsulinemic-Euglycemic Therapy in Calcium Channel Blocker and β-blocker Overdose. Pharmacotherapy. 2018 Nov;38(11):1130-1142. doi: 10.1002/phar.2177. Epub 2018 Oct 4. PMID: 30141827.

• Patocka J, Nepovimova E, Wu W, Kuca K. Digoxin: Pharmacology and toxicology-A review. Environ Toxicol Pharmacol. 2020 Oct;79:103400. doi: 10.1016/j.etap.2020.103400. Epub 2020 May 7. PMID: 32464466.

• Rotella JA, Greene SL, Koutsogiannis Z, Graudins A, Hung Leang Y, Kuan K, Baxter H, Bourke E, Wong A. Treatment for beta-blocker poisoning: a systematic review. Clin Toxicol (Phila). 2020 Oct;58(10):943-983. doi: 10.1080/15563650.2020.1752918. Epub 2020 Apr 20. PMID: 32310006.

Produced by Jeffrey Olson, MS4

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Contributor: Aaron Lessen, MD

Educational Pearls:

Traumatic Brain Injuries are a frequent complaint in the Emergency Department and have increased in recent years. The American Association for Surgery of Trauma (AAST) has created Brain Injury Guidelines (BIG), in an attempt to categorize brain injuries and the level of treatment they require. They are…

BIG 1

• Normal neuro exam
• Not intoxicated
• Not on anticoagulation or antiplatelet medications
• Minimal findings on head CT
  • No fracture
  • <4 mm bleed (subdural, epidural, intraparenchymal (max one location))
  • Maximum of "trace" subarachnoid hemorrhage
  • No intraventricular hemorrhage
• Monitor for 6 hours
• No need to repeat the head CT
• No need to consult neurosurgery

BIG 2

• Normal neuro exam
• Not on anticoagulation or antiplatelet medications
• Any of the following
  • Intoxicated
  • Slightly more findings on head CT
    • Non-displaced skull fracture
    • 4-8 mm bleed (subdural, epidural, intraparenchymal (max two locations))
    • Maximum of "localized" subarachnoid hemorrhage
    • No intraventricular hemorrhage
• Hospitalize
• No need to transfer
• No need to repeat the head CT
• No need to consult neurosurgery

BIG 3

• Abnormal neuro exam
• On anticoagulation or antiplatelet medications
• Intoxicated
• Significant findings on head CT
  • Displaced skull fracture
  • >8 mm bleed (subdural, epidural, intraparenchymal (or more than 2 locations))
  • "Scattered" subarachnoid hemorrhage
  • Intraventricular hemorrhage
• Full treatment, admission to trauma center, neurosurgery evaluation

References

1. Joseph B, Friese RS, Sadoun M, Aziz H, Kulvatunyou N, Pandit V, Wynne J, Tang A, O'Keeffe T, Rhee P. The BIG (brain injury guidelines) project: defining the management of traumatic brain injury by acute care surgeons. J Trauma Acute Care Surg. 2014 Apr;76(4):965-9. doi: 10.1097/TA.0000000000000161. PMID: 24662858.
2. Joseph B, Obaid O, Dultz L, Black G, Campbell M, Berndtson AE, Costantini T, Kerwin A, Skarupa D, Burruss S, Delgado L, Gomez M, Mederos DR, Winfield R, Cullinane D; AAST BIG Multi-institutional Study Group. Validating the Brain Injury Guidelines: Results of an American Association for the Surgery of Trauma prospective multi-institutional trial. J Trauma Acute Care Surg. 2022 Aug 1;93(2):157-165. doi: 10.1097/TA.0000000000003554. Epub 2022 Mar 28. PMID: 35343931.

Summarized by Jeffrey Olson, MS4 | Edited by Jeffrey Olson and Jorge Chalit, OMS4

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Contributor: Taylor Lynch, MD

Educational Pearls:

• A recent study published in a pediatric journal in April 2025 compared temporal and oral thermometers
• Paired temperature measurements (temporal and oral temperature within 30 minutes) were obtained from 1,412 pediatric patients
  • 26% of patients had statistically different temporal and oral temperatures
    • The temporal reading was always lower than the oral reading
    • Children less than 12 years old were 2-3x more likely to actually have that statistical difference in temperatures
• The study also evaluated 1,000 adult patients
  • 36% had a temporal temperature that was 0.5 degrees Celsius lower than the oral temperature
• Reasons for the statistical difference between the two types of thermometers:
  • Environment: temporal thermometers are affected by ambient room temperature, diaphoresis, and inaccuracy in measuring temperature at the site of the temporal artery
  • Physiologic: a patient with inadequate perfusion will not have an accurate temporal reading
• Impact:
  • Obtaining an accurate temperature is crucial in patient care
  • For example, in the setting of sepsis, temperature is a necessary component to identifying when a patient meets SIRS criteria

References

1. Salhi RA, Meeker MA, Williams C, Iwashyna TJ, Samuels-Kalow ME. Inaccuracy of Temporal Thermometer Measurement by Age and Race. Acad Pediatr. 2025 Apr;25(3):102620. doi: 10.1016/j.acap.2024.102620. Epub 2024 Dec 15. PMID: 39681266.

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

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Contributor: Taylor Lynch, MD

Educational Pearls:

• Delusional parasitosis is a subtype of the psychiatric condition delusional disorder
  • Defined as a fixed, false belief of infestation by parasites or other organisms
  • A somatic type of delusional disorder
• Primary delusional parasitosis
  • Occurs in the absence of other psychiatric or medical conditions
• Secondary delusional parasitosis
  • Causes include methamphetamine use disorder, schizophrenia, neurologic diseases, or medical conditions such as thyroid disease
• Pathophysiology
  • Poorly understood
  • Upregulation of striatal dopamine system is implicated
• Management
  • Form a strong therapeutic alliance and do not discredit the patient immediately
  • Perform a full physical exam
    • This helps reassure the patient and strengthen the therapeutic alliance
    • Some day there may be a patient in whom this is not a delusion
• Treatment & Management
  • Discontinuation of substances if substance-induced
  • Antipsychotic medications like risperidone or olanzapine

References

1. Lepping P, Russell I, Freudenmann RW. Antipsychotic treatment of primary delusional parasitosis: systematic review. Br J Psychiatry. 2007;191:198-205. doi:10.1192/bjp.bp.106.029660
2. Moriarty N, Alam M, Kalus A, O'Connor K. Current Understanding and Approach to Delusional Infestation. Am J Med. 2019;132(12):1401-1409. doi:10.1016/j.amjmed.2019.06.017
3. Skelton M, Khokhar WA, Thacker SP. Treatments for delusional disorder. Cochrane Database Syst Rev. 2015;2015(5):CD009785. Published 2015 May 22. doi:10.1002/14651858.CD009785.pub2

Summarized and Edited by Jorge Chalit, OMS4

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