Contributor: Aaron Lessen, MD

Educational Pearls:

• Patients with pulmonary embolism (PE) are divided into three risk categories
  • Low risk (non-massive PE): patients are stable
    • Treatment: prescribe anticoagulants and discharge home
  • Intermediate risk (submassive PE): patients are stable but display evidence of clot burden such as elevated troponin, elevated BNP, and/or right heart strain
    • Treatment is controversial
  • High risk (massive PE): patients are unstable with hypotension, hypoxia, and/or respiratory distress
    • Treatment: IV thrombolysis to prevent decompensation
• A recent randomized controlled trial evaluated treatment of intermediate risk PE patients
  • Patients were randomized to receive either thrombectomy with anticoagulation or anticoagulation alone
  • The primary outcome evaluated changes in right ventricular enlargement at 48 hours
    • A controversial primary outcome because it does not speak to mortality or incidence of other necessary aggressive interventions
    • Low clinical significance
  • The study found that thrombectomy significantly reduced right ventricular enlargement faster than anticoagulation alone. However, there was no statistical difference in mortality or need for other treatments
• Treatment for intermediate risk PE patient remains controversial
• The same study will have second follow-up at 90 days to see if there are other benefits

References

1. Lookstein RA, Konstantinides SV, Weinberg I, Dohad SY, Rosol Z, Kopeć G, Moriarty JM, Parikh SA, Holden A, Channick RN, McDonald B, Nagarsheth KH, Yamada K, Rosovsky RP; STORM-PE Trial Investigators. Randomized Controlled Trial of Mechanical Thrombectomy With Anticoagulation Versus Anticoagulation Alone for Acute Intermediate-High Risk Pulmonary Embolism: Primary Outcomes From the STORM-PE Trial. Circulation. 2026 Jan 6;153(1):21-34. doi: 10.1161/CIRCULATIONAHA.125.077232. Epub 2025 Nov 3. PMID: 41183181.

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

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Contributor: Aaron Lessen, MD

Educational Pearls:

• Burns range in complexity from minor first-degree burns to more severe full-thickness burns.
• Initial basic burn management:
  • Run the burn under cool running water for 20 minutes.
  • Do not scrub the skin.
  • Do not use ice water.
  • Ideally initiated as soon as possible, but no later than 3 hours after injury.
  • Applicable to all burns ranging from superficial to full thickness.
• Then apply a non-adherent dressing or sterile gauze.
• Can be done at home or upon presentation to the emergency department.
• These steps decrease pain and minimize tissue damage.
• A study published in Annals of Emergency Medicine found that, out of 371 EMS and emergency medicine providers,
  • 90% had not heard of the recommendation to run burns under cool water for 20 minutes.
  • The majority of providers interviewed expressed motivation to implement this burn cooling practice but cited barriers such as:
    • Difficulty immersing certain body parts (e.g., chest).
    • Critically ill patients requiring other urgent interventions.

References:

1. Holbert MD, Singer Y, Palmieri T, et al. Cool Running Water as a First Aid Treatment for Burn Injuries. Annals of Emergency Medicine. 2025;S0196-0644(25)01138-2. doi:10.1016/j.annemergmed.2025.08.003.
2. Olawoye OA, Isamah CP, Ademola SA, et al. Effect of Prehospital Topical Application of Water and Other Agents on Outcome in Burn Injured Patients: A Prospective Study. Burns. 2025;51(2):107357. doi:10.1016/j.burns.2024.107357.

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

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Contributor: Travis Barlock, MD

Educational Pearls:

What is an internal jugular catheter (IJ) and when do we use it?

• IJs are catheters that can be placed in either the left or the right internal jugular vein to provide central venous catheter (CVC) access. CVCs can be placed in other locations other than the internal jugular vein (i.e. subclavian vein or femoral veins).
• IJs are used when the patient may require long-term venous access or have to receive hyperosmolar solutions (such as solutions with high glucose content for parenteral nutrition); solutions with extreme pHs (<5 or >9); or vesicant drugs (drugs that can cause tissue necrosis with extravasation).
• They are not to be confused with EJs (external jugular vein catheters) which can be placed in difficult to peripherally catheterize patients. EJs function similarly to a peripheral IV.
• The advantage of IJs is their location in larger veins brings them closer to direct access to the heart (i.e. the right internal jugular vein will provide immediate/quicker access to the right atrium to the heart.)

What are concerns of using a right internal jugular catheter versus one in the left?

• The right internal jugular vein provides quick access to the heart via the right atrium, making it ideal in critically ill patients who may require vasopressor support.
• However it is also the site commonly used for additional cannulation procedures such as hemodialysis, pulmonary artery pressure measurements, extracorporeal membrane oxygenation (ECMO) and transvenous pacemaker placement.
• These procedures are not uncommon in critically ill patients who also required a CVC for initial hemodynamic support via vasopressors.
• Gharaibeh et al. found that patients who received a right IJ and hemodialysis had a higher need for re-insertion of the hemodialysis catheter (40% compared to 2.6% in the left IJ group).
• Furthermore, it was found that with a right IJ, hemodialysis catheters had to be exchanged by a guidewire in 23% of those with a right IJ as opposed to 0.9% in the left IJ group (a guidewire exchange is often considered a salvage technique to try and maintain access).

Big Takeaway?

• If you are able to obtain an IJ on the right, you can likely obtain one on the left, and if considering longitudinal care for your patient, consider obtaining an IJ on the left to allow for future critical access in the right IJ.

References

1. Gharaibeh KA, Abdelhafez MO, Guedze KEB, Siddiqi H, Hamadah AM, Verceles AC. Impact of initial jugular vein insertion site selection for central venous catheter placement on hemodialysis catheter complications. Journal of Critical Care. 2025;87:155011. doi:10.1016/j.jcrc.2024.155011
2. Gallieni M, Pittiruti M, Biffi R. Vascular access in oncology patients. CA: A Cancer Journal for Clinicians. 2008;58(6):323-346. doi:10.3322/CA.2008.0015

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

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Contributor: Aaron Lessen, MD

Educational Pearls:

How long do we need to watch patients with a presumed overdose who were treated with naloxone in the field?

• A 2025 study in the Annals of Emergency Medicine took a look at this question
• Methods
  • Prospective, multi-institutional cohort study
  • Included ED patients with suspected acute opioid overdose with biologic testing to confirm substances.
  • This paper performed a secondary analysis evaluating the risk of "delayed intubation," defined as intubation occurring >4 hours after ED arrival.
• Results
  • 1,591 patients with presumed opioid overdose were included.
  • Delayed intubation occurred in only 9 patients (0.6%).
  • 8 of the 9 cases had non-respiratory causes contributing to intubation.
  • Only 1 patient had respiratory-related deterioration, presenting with respiratory acidosis after receiving 6.4 mg naloxone prior to intubation.
• Key Takeaway
  • Delayed respiratory deterioration requiring intubation after 4 hours of ED monitoring is extremely rare, suggesting prolonged monitoring may not be necessary for most stabilized overdose patients.

How else can we mitigate risk?

• Give patients take-home naloxone at discharge and educate them on how to use it (See Episode 673: Leaving the ED with Naloxone).

When are naloxone drips necessary?

• If a patient requires repeated naloxone boluses, consider a drip
• To get the dose, take the total naloxone dose that restored adequate breathing and give two-thirds of that dose per hour
• Typically these patients are admitted to the ICU

References

1. McCabe DJ, Gibbs H, Pratt AA, Culbreth R, Sutphin AM, Abston S, Li S, Wax P, Brent J, Campleman S, Aldy K, Falise A, Manini AF; ToxIC Fentalog Study Group. Risk of Delayed Intubation After Presumed Opioid Overdose in the Emergency Department. Ann Emerg Med. 2025 Jun;85(6):498-504. doi: 10.1016/j.annemergmed.2025.01.022. Epub 2025 Mar 4. PMID: 40047773; PMCID: PMC12955731.

Summarized and edited by Jeffrey Olson MS4

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Contributor: Travis Barlock, MD

Educational Pearls:

• D-dimer: fibrin degradation product used to evaluate for clot formation and breakdown
  • Threshold: <500ng/mL rules out venous thromboembolism in low risk patients
  • Elevated D-dimer indicates recent or ongoing intravascular coagulation and fibrinolysis
• YEARS score: algorithm to assess PE risk using three clinical criteria
  • Criteria: signs of DVT, hemoptysis, and PE as the most likely diagnosis
  • YEARS score of 0 with D-dimer <1000 ng/mL: PE can be ruled out
  • YEARS score of ≥1 with D-dimer <500 ng/mL: PE can be ruled out
  • A study found that YEARS score accurately predicted the presence or absence of PE in 80% of enrolled patients with 90% sensitivity and 65% specificity
• D-dimer may also help exclude aortic dissection: Aortic Dissection Detection Risk Score (ADD-RS)
  • When ADD-RS = 0 or 1 and D-dimer <500ng/mL: aortic dissection may be ruled out in low-risk patients
  • When ADD-RS >1, patients are considered high probability for aortic dissection and CT should be performed

References

1. Fayiad, H., Moussa, H., Nosair, Y. et al. Predictive accuracy of years score in diagnosis of pulmonary embolism. Egypt J Bronchol 18, 18 (2024). https://doi.org/10.1186/s43168-024-00269-y
2. Weitz JI, Fredenburgh JC, Eikelboom JW. A Test in Context: D-Dimer. J Am Coll Cardiol. 2017 Nov 7;70(19):2411-2420. doi: 10.1016/j.jacc.2017.09.024. PMID: 29096812.
3. Yichao Ma,Zhenjiang Ding,Yunong Zhao,Paijiao Zhang,Bo Du,Ye Shen,Junmei Hu,Luqi Zhu,Honghong Zhao,Chunrong Jin,Yuhong Wang,Lizhen Gao,Research progress on multi-marker detection technology for cardiovascular diseases (review), Journal of Electroanalytical Chemistry, 1008, (119969), (2026).

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

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Contributor: Taylor Lynch MD
Educational Pearls:

• Melatonin is an endogenous hormone released primarily by the pineal gland
  • Also released by extrapineal regions in the retina, the GI tract, and some immune cells
• Peak secretion occurs at night and is suppressed during the day
  • Secretion and production decrease with age
  • Older patients experience the greatest improvement in sleep latency and sleep quality
• Mechanism of action in the suprachiasmatic nucleus of the hypothalamus
  • MT1 receptor
    • Reduces normal firing
  • MT2 receptor
    • Shifts the circadian rhythm
• FDA approved for insomnia
  • Decreases sleep latency by 7 minutes
  • Increases total sleep time by 8 minutes
• FDA approved for circadian sleep-wake disorders
  • Jet lag
    • Most effective in west-to-east travel
    • Best if crossing at least 5 time zones
  • Shift work
    • A study examined ED physicians and nurses with rotating shifts
    • Modest increase in deep sleep percentage
    • No difference in cognition or reaction time the day after taking melatonin
    • Nurses on rotating night shifts experienced increased total sleep time by 20 minutes
• Dosing
  • 0.5 - 3 mg is the most evidence-based dosing
  • Higher doses increase the risk of rebound grogginess but do not improve outcomes

References

1. Ahmad SB, Ali A, Bilal M, et al. Melatonin and Health: Insights of Melatonin Action, Biological Functions, and Associated Disorders. Cell Mol Neurobiol. 2023;43(6):2437-2458. doi:10.1007/s10571-023-01324-w
2. Herxheimer A, Petrie KJ. Melatonin for the prevention and treatment of jet lag. Cochrane Database Syst Rev. 2002;(2):CD001520. doi:10.1002/14651858.CD001520
3. Morgenthaler TI, Lee-Chiong T, Alessi C, Friedman L, Aurora RN, Boehlecke B, Brown T, Chesson AL Jr, Kapur V, Maganti R, Owens J, Pancer J, Swick TJ, Zak R; Standards of Practice Committee of the American Academy of Sleep Medicine. Practice parameters for the clinical evaluation and treatment of circadian rhythm sleep disorders. An American Academy of Sleep Medicine report. Sleep. 2007 Nov;30(11):1445-59. doi: 10.1093/sleep/30.11.1445. Erratum in: Sleep. 2008 Jul 1;31(7):table of contents. PMID: 18041479; PMCID: PMC2082098.
4. Thottakam BMVJ, Webster NR, Allen L, Columb MO, Galley HF. Melatonin Is a Feasible, Safe, and Acceptable Intervention in Doctors and Nurses Working Nightshifts: The MIDNIGHT Trial. Front Psychiatry. 2020;11:872. Published 2020 Aug 27. doi:10.3389/fpsyt.2020.00872

Summarized and edited by Jorge Chalit, OMS4

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Contributor: Travis Barlock, MD

Educational Pearls:

• Foul-smelling urine and cloudy urine are commonly misinterpreted as indicators of a UTI. However, these findings alone are not diagnostic.
• Criteria for UTI:
  • Presence of localized urinary symptoms:
  • Suprapubic pain
  • Dysuria
  • Hesitancy
  • Urgency
  • Urinalysis with WBC > 10
  • Urine culture with > 100,000 CFU/mL
• Colonization differs from infection - many patients harbor asymptomatic bacteria but do not have a true infection.
• Consequences of overtreatment
  • One review showed 45% of patients treated with antibiotics for a presumed UTI actually had asymptomatic bacteriuria and were incorrectly treated.
  • Unnecessary antibiotic treatment can have deleterious effects on the gut microbiome, increasing the risk of multidrug-resistant infections.
  • Another problem with overdiagnosing UTI is missing the real diagnosis by explaining symptoms away as "just a UTI."
• Be mindful of the risk of overtesting versus not testing at all.
  • Clinicians must navigate a balance between moving patients efficiently through the ER and testing appropriately when a UTI is truly suspected.

References:

1. Baghdadi JD, Korenstein D, Pineles L, et al. Exploration of primary care clinician attitudes and cognitive characteristics associated with prescribing antibiotics for asymptomatic bacteriuria. JAMA Netw Open. 2022;5(5):e2214268. doi:10.1001/jamanetworkopen.2022.14268
2. Colgan R, Williams M. Acute uncomplicated urinary tract infections in adults. Am Fam Physician. 2024;109(2):167-174. Accessed February 21, 2026. https://www.aafp.org/pubs/afp/issues/2024/0200/acute-uncomplicated-utis-adults.html#afp20240200p167-ta1

Summarized by Ashley Lyons OMS3 | Edited by Ashley Lyons & Jorge Chalit OMS4

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