What's new in emergency medicine

The following represent additions to UpToDate from the past six months that were considered by the editors and authors to be of particular interest. The most recent What's New entries are at the top of each subsection.

ADULT RESUSCITATION

Vascular access for cardiac life support (April 2025)

Few studies have directly compared intraosseous (IO) and intravenous (IV) vascular access in adults with cardiac arrest. A systematic review and meta-analysis identified three randomized trials that enrolled over 9300 patients with out-of-hospital cardiac arrest treated by emergency medical services and compared a strategy of IO-first with IV-first vascular access [1]. While successful placement was more common for IO-first participants (92 to 94 percent, proximal tibia or humerus placement) than for IV-first participants (58 to 80 percent), the time to first drug administration did not vary, and there was no significant difference in 30-day survival. However, in two studies (7545 participants), the rate of sustained return of spontaneous circulation was higher in the IV-first group (25 versus 23 percent). While IV access is preferred, when it cannot be readily established, IO lines are safe and effective. (See "Advanced cardiac life support (ACLS) in adults", section on 'Vascular access for medication administration'.)

Advanced respiratory support in COVID-19 (January 2025)

In patients with COVID-19 who need advanced respiratory support, choosing between high-flow oxygen delivered via nasal cannulae (HFNC) and noninvasive ventilatory (NIV) support is challenging. In a recent trial of 1800 patients with acute respiratory failure from COVID-19 randomized to HFNC versus NIV, similar rates of endotracheal intubation (approximately 30 percent) and death (12 percent) were reported at the end of one week [2]. Subgroup analyses were not helpful in modality selection. In patients with COVID-19 who need advanced respiratory support, we use the patient's comorbidities and the tolerability of the device to help choose between NIV and HFNC. (See "COVID-19: Respiratory care of the nonintubated hypoxemic adult (supplemental oxygen, noninvasive ventilation, and intubation)", section on 'Choosing oxygen via high-flow nasal cannulae versus noninvasive ventilation'.)

Electronic alert systems for sepsis (January 2025)

Increasingly, hospitals are automatically screening patients for evidence of sepsis, but the effectiveness of this approach is unclear. In a recent cluster randomized trial of an electronic medical record (EMR) sepsis screening alert system in 5 hospitals and over 60,000 patients, adjusted 90-day mortality was lower in patients who were electronically screened (adjusted relative risk 0.85; 95% CI, 0.77-0.93) [3]. Screening reduced vasopressor therapy administration and new multidrug-resistant organisms but increased kidney replacement therapy and new C difficile (colonization or infection unknown). Automated EMR alerts for sepsis may impact provider behavior and patient outcomes; however, which factors should be used for screening, and the best way to alert providers to this information, require further study. (See "Sepsis syndromes in adults: Epidemiology, definitions, clinical presentation, diagnosis, and prognosis", section on 'Identification of early sepsis (qSOFA, NEWS)'.)

Point-of-care-ultrasound in patients with shock (January 2025)

Point-of-care-ultrasound (POCUS) is increasingly being used in patients with shock to assess etiology and monitor treatment response. A recent meta-analysis of 18 randomized trials in patients with shock found that POCUS-guided resuscitation reduced the duration of vasoactive medication (mean difference -0.73 days), and may reduce 28-day mortality and the need for kidney replacement therapy (relative risk 0.88 and 0.80, respectively; borderline statistical significance) [4]. The use of POCUS did not impact the administration of fluids or inotropes, length of stay, or need for mechanical ventilation. We continue to encourage the use of POCUS when managing patients with shock of unclear etiology. (See "Evaluation of and initial approach to the adult patient with undifferentiated hypotension and shock", section on 'Point-of-care ultrasonography'.)

Extracorporeal life support for hypothermic cardiac arrest (January 2025)

Extracorporeal life support (ECLS) may improve overall survival and neurologically intact survival in select adults with hypothermic cardiac arrest. A multicenter registry study of 127 patients in hypothermic cardiac arrest treated with ECLS reported a survival rate of 49 percent, with 89 percent of survivors having good neurologic outcomes [5]. Lower age and lower serum potassium and lactate concentrations were associated with a higher likelihood of survival. This survival rate, compared with a historical survival rate of 10 to 37 percent without ECLS, supports our recommendation for treatment with ECLS in a salvageable patient with severe hypothermia and a non-perfusing cardiac rhythm. A Hypothermia Outcome Prediction after ECLS probability ≥10 percent is one reasonable criterion to determine salvageability. (See "Accidental hypothermia in adults: Management", section on 'Benefit of extracorporeal life support'.)

Video laryngoscopy during intubation in critically ill patients (October 2024)

In a new meta-analysis with 20 trials and over 4000 emergency department and intensive care unit patients, video laryngoscopy (VL) increased first-pass success during endotracheal intubation compared with direct laryngoscopy (DL; 82 versus 72 percent) [6]. These findings are consistent with a previous meta-analysis and support our recommendation to use VL, if available, instead of DL during emergency intubation. (See "Overview of advanced airway management in adults for emergency medicine and critical care", section on 'Choice of laryngoscopy technique'.)

ENVIRONMENTAL EMERGENCIES

Predictors of lung injury after pediatric drowning (April 2025)

Children with nonfatal drowning often develop lung injury and require respiratory support; however, it is often difficult to determine the appropriate disposition for children with less severe presentations at initial evaluation in the emergency department (ED). In a multicenter, retrospective study of over 4200 children seen in a pediatric ED after drowning, risk factors associated with clinically significant lung injury included age >5 years, submersion duration >5 minutes, any resuscitation at the scene or during the ED evaluation, altered mental status or abnormal heart rate, respiratory rate, or lung auscultation. [7]. These findings provide guidance on which children who are not obviously critically ill following drowning may need admission for respiratory monitoring. (See "Drowning (submersion injuries)", section on 'Hypoxic and other severely ill patients'.)

Extracorporeal life support for hypothermic cardiac arrest (January 2025)

Extracorporeal life support (ECLS) may improve overall survival and neurologically intact survival in select adults with hypothermic cardiac arrest. A multicenter registry study of 127 patients in hypothermic cardiac arrest treated with ECLS reported a survival rate of 49 percent, with 89 percent of survivors having good neurologic outcomes [5]. Lower age and lower serum potassium and lactate concentrations were associated with a higher likelihood of survival. This survival rate, compared with a historical survival rate of 10 to 37 percent without ECLS, supports our recommendation for treatment with ECLS in a salvageable patient with severe hypothermia and a non-perfusing cardiac rhythm. A Hypothermia Outcome Prediction after ECLS probability ≥10 percent is one reasonable criterion to determine salvageability. (See "Accidental hypothermia in adults: Management", section on 'Benefit of extracorporeal life support'.)

GENERAL ADULT EMERGENCY MEDICINE

Outcomes associated with sepsis bundles (April 2025)

A "sepsis bundle" refers to a set of early interventions (eg, intravenous fluids, antibiotics, and laboratory tests) that improve the diagnosis, management, and survival of patients with sepsis; the time required to complete the "sepsis bundle" is widely used in hospitals as a pay-for-performance measure. A recent review analyzed 17 observational trials examining outcomes associated with compliance or implementation of a sepsis bundle [8]. Five studies demonstrated a mortality benefit from bundle compliance while seven did not. Only one study showed a mortality benefit from bundle implementation. High-quality data are needed to demonstrate a clear mortality benefit from sepsis bundles. (See "Evaluation and management of suspected sepsis and septic shock in adults", section on 'Early goal-directed therapy'.)

Procalcitonin and antibiotic duration in sepsis (April 2025)

While procalcitonin (PCT) has a clear role in determining antibiotic duration for patients with community-acquired pneumonia, its role in managing sepsis is less clear. A recent multicenter randomized trial of 2760 adults with sepsis, reported a reduction in antibiotic duration for patients in whom a daily PCT-guided protocol was implemented compared with standard care (9.8 versus 10.7 days) [9]. However, over half of study participants had lower respiratory tract infections which may have impacted the outcome. Based upon these and other cumulating data in patients with sepsis, we support measuring PCT to guide antibiotic duration. (See "Evaluation and management of suspected sepsis and septic shock in adults", section on 'Initial investigations'.)

Red blood cell transfusion in patients with acute coronary syndromes (April 2025)

Previous evidence suggests a possible benefit with use of a liberal red blood cell transfusion threshold (hemoglobin <10g/dL) in patients with acute myocardial infarction (MI). In a recently published meta-analysis of over 4300 patients from four trials, patients randomly assigned to a liberal or restrictive (hemoglobin <7 to 8 g/dL) transfusion threshold had similar rates of mortality and recurrent MI after 30 days [10]. In patients with acute MI and anemia who do not have signs of shock, ongoing ischemia, blood loss, or symptoms of anemia, the approach to transfusion is individualized. (See "Overview of the acute management of non-ST-elevation acute coronary syndromes", section on 'Anemia'.)

Male partner treatment to prevent recurrence of bacterial vaginosis (March 2025)

Treatment of male sex partners to reduce bacterial vaginosis (BV) recurrence in females is an area of ongoing study. In a trial of 150 male-female monogamous couples with confirmed BV in the female, treatment of the male partner for one week with an oral and topical antibiotic (metronidazole tablet and clindamycin cream) in addition to standard antimicrobial treatment of the female patient reduced recurrences at 12 weeks compared with treating the female patient only (35 versus 63 percent; risk difference -2.6 recurrences per person-year) [11]. Based on these results, we now suggest dual topical and oral antimicrobial male partner therapy as an effective strategy to reduce BV recurrence in female patients. (See "Bacterial vaginosis: Initial treatment", section on 'Males'.)

Society of Critical Care Medicine guidelines on critical care ultrasonography use (March 2025)

The Society of Critical Care Medicine (SCCM) recently updated its guidelines on the use of bedside critical care ultrasonography (CCUS) [12]. The SCCM conditionally recommended CCUS use in patients with septic shock, acute respiratory failure, and acute cardiogenic shock as well as in patients with unclear volume status. It was unable to make a clear recommendation for CCUS use in patients undergoing cardiopulmonary resuscitation. We agree with these recommendations. (See "Indications for bedside ultrasonography in the critically ill adult patient", section on 'Introduction'.)

Suzetrigine, a first-in-class nonopioid analgesic, now available for acute pain (March 2025)

Suzetrigine, a first-in-class nonopioid oral analgesic, has been approved by the US Food and Drug Administration for management of acute pain in adults and is now available. Suzetrigine is a selective inhibitor of the Na_v 1.8 voltage-gated sodium channel, which is expressed in the dorsal root ganglia and is involved in transmission of nociceptive signals to the spinal cord. In randomized trials of 303 patients who had acute pain after abdominoplasty and 274 patients after bunionectomy, suzetrigine (100 mg orally followed by 50 mg orally every 12 hours) reduced pain scores compared with hydrocodone/acetaminophen (5 mg/325 mg orally every six hours) or placebo [13]. Further study is required to determine the role of suzetrigine in acute pain management. (See "Nonopioid pharmacotherapy for acute pain in adults", section on 'Suzetrigine, a novel Nav1.8 inhibitor'.)

Tenecteplase versus alteplase for intravenous thrombolysis of acute ischemic stroke (November 2024, Modified March 2025)

The benefit of intravenous thrombolysis (IVT) for acute ischemic stroke was initially established by randomized trials using alteplase. However, tenecteplase is easier to administer than alteplase, and there is mounting evidence that tenecteplase has efficacy and safety outcomes similar to alteplase. This evidence is bolstered by a recent meta-analysis of 11 randomized trials of IVT within 4.5 hours of acute ischemic stroke comparing tenecteplase (n = 3788) with alteplase (n = 3757) [14]. Tenecteplase and alteplase had similar rates of both excellent and good functional outcomes and similarly low rates of symptomatic intracerebral hemorrhage and mortality. For eligible patients with acute ischemic stroke, we recommend IVT using either alteplase or tenecteplase for treatment within 3 hours of the time last known well, and we suggest IVT with alteplase or tenecteplase for treatment within 3 to 4.5 hours of the time last known well. Tenecteplase was approved by the US Food and Drug Administration for this purpose in February 2025 [15]. (See "Approach to reperfusion therapy for acute ischemic stroke", section on 'Tenecteplase'.)

Buprenorphine initiation by emergency clinicians (February 2025)

Initiating buprenorphine in emergency department (ED) patients with opioid use disorder (OUD) is feasible and increases treatment engagement, but barriers to routine use remain. In a retrospective study of a California program involving more than 80 percent of the state’s acute care hospital EDs, buprenorphine initiations in the ED increased from 0.1 percent of total buprenorphine initiations to 5 percent over five years [16]. Buprenorphine use continued in approximately one in three patients at 40 days and one in nine patients at one year. Strategies that directly engage emergency clinicians can help increase buprenorphine prescribing and lead to continued OUD treatment for many individuals. (See "Acute opioid intoxication in adults", section on 'Prevention of recurrent opioid overdose'.)

Trial of emergency clinician palliative care educational program (January 2025)

Emergency department (ED) patients with chronic, severe, or life-threatening conditions may benefit from palliative interventions, but the benefit of such care provided by ED clinicians is unclear. In a cluster randomized trial conducted in almost 30 EDs and including 99,000 visits, a palliative care educational intervention for emergency physicians, nurses, and advanced practice providers resulted in fewer hospital admissions in the post-intervention period (61 versus 64 percent), but the findings did not achieve statistical significance [17]. While ED-based palliative care interventions may have the potential to accomplish important goals, the optimal approach is still unknown. (See "Palliative care for adults in the ED: Concepts, presenting complaints, and symptom management", section on 'Why the integration of palliative care in the ED is important'.)

Endovascular thrombectomy for stroke due to basilar artery occlusion (December 2024)

While previous trials of endovascular thrombectomy (EVT) for posterior circulation stroke have shown inconsistent results, findings from the recent VERITAS individual patient data meta-analysis support the benefit of EVT for stroke due to basilar artery occlusion (BAO) [18]. VERITAS included four trials and 988 patients with acute ischemic stroke caused by BAO who were randomly assigned to treatment with EVT or standard medical care. Most patients had an National Institutes of Health Stroke Scale score ≥10 (consistent with moderate to severe stroke) and a posterior circulation ASPECTS score ≥6, consistent with a limited extent of ischemia. At 90 days, rates of good functional status and functional independence were higher and mortality was lower in the EVT group despite an increased rate of symptomatic intracranial hemorrhage. We suggest EVT for patients with acute stroke due to BAO who can be treated within 24 hours and are similar to those in the VERITAS meta-analysis. (See "Mechanical thrombectomy for acute ischemic stroke", section on 'Basilar artery occlusion'.)

Association of hyponatremia correction rates with in-hospital mortality (December 2024)

In patients with severe, chronic hyponatremia (ie, serum sodium <120 mEq/L), the goal of initial therapy is to raise the serum sodium level slowly to avoid overcorrection. This recommendation was challenged by a meta-analysis of retrospective cohort studies that found that rapid correction of severe hyponatremia in hospitalized patients was associated with lower in-hospital mortality compared with slow correction [19]. However, the major limitation of this study is its analysis of all-cause in-hospital mortality rather than death from cerebral edema (the cause of death potentially caused by slower correction). Thus, the findings were likely confounded by the fact that severely ill patients, who are at high risk for in-hospital mortality, have hyponatremia that is more recalcitrant and less likely to correct without hypertonic saline; conversely, patients with acute hyponatremia or less severe underlying disease (and a lower risk of in-hospital mortality) are more likely to correct quickly when the cause of hyponatremia is eliminated. We continue to suggest slow correction in patients with severe, chronic hyponatremia. (See "Overview of the treatment of hyponatremia in adults", section on 'Goal rate of correction'.)

Choice of management strategy in older patients with non-ST-segment elevation myocardial infarction (December 2024)

In patients with non-ST-segment elevation myocardial infarction (NSTEMI), the approach to management typically includes early coronary angiography and appropriate percutaneous coronary intervention (PCI), but the efficacy and safety of this approach in older patients are unclear. In a recent trial in over 1500 patients ≥75 years old with NSTEMI, patients randomly assigned to an invasive management strategy (ie, coronary angiography and PCI) had a lower rate of recurrent myocardial infarction but a similar rate of all-cause death when compared with those assigned to a conservative management strategy [20]. The rate of non-fatal bleeding was not significantly higher in the invasive management group. In patients with NSTEMI, we suggest invasive coronary angiography rather than other management strategies. (See "Non-ST-elevation acute coronary syndromes: Selecting a management strategy", section on 'Evidence of infarction (NSTEMI)'.)

Concurrent administration of parenteral olanzapine and a benzodiazepine not associated with increased risk of tracheal intubation (November 2024)

Concurrent use of intravenous or intramuscular olanzapine with a parenteral benzodiazepine has been discouraged based on a post-marketing report of excess sedation and respiratory depression, including 29 fatalities. In a retrospective study of nearly 700 patients treated for agitation in the emergency department, the 144 patients receiving parenteral olanzapine and a benzodiazepine within 60 minutes of each other had similar rates of tracheal intubation compared with those receiving two doses of parenteral olanzapine only (549 patients, 3.8 versus 3.5 percent, respectively) [21]. Other studies (most retrospective) have also found similar rates of complications. Combining parenteral olanzapine with a benzodiazepine is likely not associated with an increased risk of complications compared with olanzapine alone or other sedative agents; potential complications can be mitigated with proper monitoring and avoidance of this coadministration in patients with alcohol intoxication or compromised respiratory function. (See "The acutely agitated or violent adult: Pharmacologic management", section on 'Second-generation (atypical) antipsychotics'.)

GENERAL PEDIATRIC EMERGENCY MEDICINE

Expanded approval for intranasal glucagon for hypoglycemia in young children with diabetes (April 2025)

The US Food and Drug Administration (FDA) has expanded regulatory approval for intranasal glucagon for the treatment of severe hypoglycemia in patients with type 1 and type 2 diabetes; while previously it was approved for those aged ≥4 years old, approval now includes those aged ≥1 year old. This expanded approval was based on a phase 1 single-arm study of seven patients age 1.8 to 4 years with type 1 diabetes [22]. All patients experienced an increase in blood glucose ≥20 mg/dL from baseline within 30 minutes of administration of 3 mg of intranasal glucagon. No serious adverse events were reported, although several minor events occurred (eg, vomiting, epistaxis, nasal discomfort and eye irritation). Based on these data, we consider intranasal glucagon to be a safe and effective alternative to intramuscular glucagon for the treatment of severe hypoglycemia in patients with diabetes aged 1 year and older. (See "Type 1 diabetes in children and adolescents: Prevention and management of hypoglycemia", section on 'Glucagon'.)

Nonoperative management of appendicitis in children (January 2025)

For children with early appendicitis, the role of nonoperative management with antibiotics (NOM) has been debated. In a multicenter trial of 846 children with appendicitis, 34 percent of children assigned to NOM required an appendectomy within one year. Approximately one-half of these patients required appendectomy at the index admission, of whom 35 percent had perforated appendicitis [23]. For children assigned to prompt appendectomy, 7 percent had normal pathology and 6 percent had perforation. Based on this first randomized trial of NOM in children with early appendicitis, we continue to perform appendectomy for most of these patients. However, NOM may be an option for selected children after shared decision-making (algorithm 1). (See "Acute appendicitis in children: Management", section on 'Nonoperative management'.)

Pediatric opioid use-associated neurotoxicity with cerebellar edema (POUNCE) syndrome (January 2025)

The pediatric opioid use-associated neurotoxicity with cerebellar edema (POUNCE) syndrome occurs rarely following an opioid overdose in young children (typically ≤3 years old). In a recent case report, a 31-month-old girl presented with coma, miosis, bradypnea, right gaze deviation, and shaking of the extremities following an accidental methadone overdose; naloxone improved alertness and miosis [24]. Brain imaging showed bilateral cerebellar edema typical of POUNCE syndrome. Clinicians should consider this rare syndrome in a young child with persistent neurologic findings after treatment of opioid overdose; some children may require neurosurgical intervention for tonsillar herniation or obstructive hydrocephalus. (See "Opioid intoxication in children and adolescents", section on 'Physical examination'.)

Laparoscopic repair of intestinal malrotation without volvulus in children (January 2025)

Laparoscopic repair is an option for children who have malrotation without volvulus, but, compared with laparotomy, it has been associated with a higher risk of postoperative volvulus. However, in a retrospective study of 226 such children with malrotation, laparoscopic repair and laparotomy were both associated with a low rate of postoperative volvulus (≤1 percent) [25]. These data suggest that laparoscopic repair in these patients may have fewer postoperative complications than previously believed, particularly when performed by an experienced surgeon in an older child without comorbidities. (See "Intestinal malrotation in children", section on 'Laparoscopic repair'.)

PEDIATRIC RESUSCITATION

New pediatric resuscitation consensus recommendations (December 2024)

An international task force has updated consensus recommendations on pediatric resuscitation [26]. The task force recommends that, during pediatric post-cardiac arrest care, infants and children receive fluids and/or vasoactive medications to maintain a systolic blood pressure of at least >5^th percentile for age and suggests a target of >10^th percentile for age. It also suggests against prophylactic antiseizure medication administration in these patients. During treatment of out-of-hospital cardiac arrest in children, the task force suggests bag-mask ventilation rather than ventilation through an advanced airway (endotracheal tube or supraglottic airway). These recommendations are largely consistent with guidance in UpToDate. (See "Initial post-cardiac arrest care in children", section on 'Maintain blood pressure and treat shock' and "Initial post-cardiac arrest care in children", section on 'Seizures' and "Pediatric considerations in prehospital care", section on 'Pediatric procedures'.)

PRIMARY CARE ORTHOPEDICS AND SPORTS MEDICINE

High rate of iron deficiency in athletes (January 2025)

High-intensity athletics can cause iron deficiency by several mechanisms including reduced iron intake, gastrointestinal blood loss, iron loss in sweat, and traumatic hemolysis. A new meta-analysis including over 17,000 college athletes and military recruits reported iron deficiency in 31 percent, using a ferritin cutoff of 30 ng/mL [27]. Female athletes are more likely than male athletes to have iron deficiency; younger and older athletes are equally affected. These observations confirm that high-intensity athletics is a significant risk factor for iron deficiency and support a role for screening in this population. (See "Diagnosis of iron deficiency and iron deficiency anemia in adults", section on 'Epidemiology'.)

PROCEDURES

Reduction of radial head subluxation ("pulled elbow") in children (March 2025)

Radial head subluxation (RHS) commonly occurs in young children (<5 years old) when a parent or caregiver grabs the arm to prevent falling or pulling away (figure 1); the best method for reduction of an RHS is debated. In a meta-analysis of 11 randomized trials (almost 1200 children with RHS undergoing reduction), the pooled first-attempt success rate was higher following the use of the hyperpronation method (figure 2) compared with the supination/flexion method (figure 3) (91 versus 75 percent, respectively) [28]. Limitations of this analysis include the high risk of bias in most of the included studies and interstudy differences in the definition of a successful reduction. These findings support our suggestion for the hyperpronation method rather than the supination/flexion method to reduce an RHS; however, the supination/flexion method is a reasonable alternative if the clinician is more familiar and skilled with this technique. (See "Radial head subluxation (pulled elbow): Evaluation and management", section on 'Radial head subluxation reduction'.)

Crystallization of mixtures of drugs used for regional anesthesia (February 2025)

Regional anesthesia often involves the use of two different local anesthetics (with or without adjuvant drugs) to speed onset, improve block quality, and/or prolong the block effect. A new laboratory study found that even commonly used combinations may precipitate in the syringe; many of the tested combinations precipitated immediately, and most precipitated after one hour [29]. The safety of perineural injection of crystallized solutions and the potential for in situ crystallization after injection have not been determined. Whenever possible, compatibility of drug combinations should be confirmed prior to the use of admixtures. (See "Clinical use of local anesthetics in anesthesia", section on 'Combinations of local anesthetics'.)

TOXICOLOGY

Two-bag acetylcysteine dosing protocol for acetaminophen poisoning (April 2025)

There are many acetylcysteine (N-acetylcysteine) dosing protocols for acetaminophen poisoning, including the 21-hour three-bag intravenous (IV) protocol and a simplified 20-hour two-bag IV protocol. A meta-analysis with more than 7600 patients found that a two-bag protocol, as compared with the three-bag protocol, was associated with fewer nonallergic anaphylactic reactions and other adverse events (3 versus 11 percent) without an increased risk of hepatoxicity [30]. Given these findings, we suggest use of the two-bag protocol instead of other protocols. For a patient with an acute acetaminophen ingestion, regardless of which protocol is chosen, it should deliver at least 300 mg/kg acetylcysteine orally or IV during the first 20 to 24 hours of treatment. The acetylcysteine IV solution product label has been updated to include the two-bag protocol. (See "Acetaminophen (paracetamol) poisoning: Management in adults and children", section on 'Simplified 20-hour (two-bag) intravenous protocol'.)

Ibogaine toxicity reported to United Kingdom poison centers (March 2025)

Ibogaine is a psychoactive alkaloid extracted from the root of Tabernanthe iboga, a perennial shrub found in Africa. Although not approved by the FDA and illegal in many countries, it is used to mitigate opioid withdrawal symptoms and has been previously reported to prolong the QT interval and cause ventricular dysrhythmias. In a case series of seven patients from United Kingdom poison centers, three patients developed either cardiac arrest or torsade de pointes while the others had intoxication, somnolence, bradycardia, or vomiting [31]. Ibogaine toxicity should be considered in a patient with an opioid use disorder who presents with a ventricular dysrhythmia or cardiac arrest. (See "Intoxication from LSD and other common hallucinogens", section on 'Ibogaine'.)

Sibutramine and sildenafil found in weight loss supplements in France (March 2025)

Weight loss supplements are commonly used worldwide and may contain active ingredients that can cause adverse effects. In 2023, 29 people from France reported using weight loss supplements that were analyzed and found to contain sibutramine and sildenafil [32]. Sibutramine is no longer available by prescription because it increases the risk of stroke and myocardial infarction. Many of the patients in this study reported anorexia, tachycardia, chest pain, increased blood pressure, headaches, and insomnia. These findings support our recommendation to counsel patients not to use weight loss dietary supplements since none are proven safe or effective, and they often contain potentially harmful adulterants. (See "High-risk dietary supplements: Patient evaluation and counseling", section on 'Weight loss supplements'.)

Adult cannabis poisoning in states with medical and recreational cannabis laws (March 2025)

States with medical and recreational cannabis laws have seen an increase in pediatric cannabis poisoning, but the impact of these laws on poisoning in adults is less clear. A study of an employer-sponsored United States health insurance claims database (over 110 million enrollees) from 2011 to 2021 found that adult patients in states with medical and recreational cannabis laws were associated with an increase of 89 and 32 percent, respectively, in cannabis poisoning diagnoses compared with states without these laws [33]. These results suggest that cannabis legalization is also associated with an increase in adults poisoning, although likely to a lesser extent than pediatric poisoning. (See "Cannabis (marijuana): Acute intoxication", section on 'Epidemiology'.)

Endoscopic removal of retained packets in asymptomatic body packers (March 2025)

In asymptomatic body packers, whole bowel irrigation (WBI) is the first-line treatment as it is safe and hastens packet removal; endoscopic packet removal is controversial because packet perforation can release dangerous amounts of drug. However, a study with 82 patients who underwent endoscopic removal of retained cocaine packets (all covered with a wax coating) found no evidence of packet rupture [34]. Sophisticated modern packaging techniques (ie, outside wax coating) and improved endoscopic techniques (ie, basketing instead of snaring) likely mitigate the risk of packet perforation. Given these findings, we suggest endoscopic removal in asymptomatic patients who have a few retained packets following WBI or when WBI is otherwise contraindicated. (See "Internal concealment of drugs of abuse (body packing)", section on 'Role of endoscopic removal of packets'.)

TRAUMA

Fractures and child abuse in young children (March 2025)

The American Academy of Pediatrics has published a clinical report that provides guidance for the evaluation of fractures in young children [35]. This report reaffirms the importance of a careful history and physical examination with special attention to the reported mechanism of injury, the developmental capability of the child, associated injuries on examination, and the specific type of fracture. A skeletal survey (table 1), under the guidance of a pediatric radiologist or a multidisciplinary child abuse team led by a child abuse specialist, is indicated for children <24 months old who have a fracture that is concerning for abuse (table 2). (See "Orthopedic aspects of child abuse", section on 'Overview' and "Physical child abuse: Recognition", section on 'Fractures'.)

Risk of delayed bleeding in older adults following head trauma (January 2025)

Older adults, particularly those taking anticoagulant medication, are at high risk for intracranial hemorrhage (ICH) following blunt head trauma. However, the risk of delayed ICH is less well studied. In a prospective observational study of 3425 older adult patients with acute head injury (median age 82, 33 percent of whom were prescribed anticoagulants), acute ICH was identified in 6.7 percent of patients but only 0.4 percent had delayed ICH [36]. The rates of delayed bleeding were similar for patients prescribed anticoagulants versus those who were not. All delayed bleeding occurred between several hours and five days following injury. These findings are consistent with prior studies and support the safety of discharge in older adults with isolated closed head injury who have a normal initial neurologic examination, no bleeding on CT scan (if obtained), and remain stable with no change in neurologic status after 12 hours of observation. (See "Geriatric trauma: Initial evaluation and management", section on 'Risk of bleeding'.)

Ice for treating musculoskeletal injury (November 2024)

For many years, ice has been a standard treatment for acute muscle and tendon injuries. However, evidence supporting the effectiveness of cryotherapy is largely unstudied. The authors of a systematic review identified only 27 controlled studies of cryotherapy for acute soft tissue injury, of which 26 were animal studies, most involving muscle injury [37]. No randomized trials in humans were identified. While ice can provide analgesia and may offer benefits for acute treatment of minor injuries, its longer-term effects on more severe muscle or tendon injury are largely unknown. Pending further research, we believe it is reasonable to apply ice as part of the acute treatment of soft tissue musculoskeletal injury. (See "Initial management of soft tissue musculoskeletal injuries", section on 'Evidence'.)