Contributor: Alec Coston, MD

Educational Pearls:

Benign Paroxysmal Positional Vertigo (BPPV)

• Common inner ear condition that can cause dizziness

• Diagnosis of BPPV can help to avoid admissions and extra imaging

• Three categories: positional, horizontal, and anterior

• • Positional is the most common

  • • Dizziness is not a positive indicator, a torsional nystagmus must be induced

    • Dix's hallpike maneuver is done to diagnose and an epley maneuver is then used for treatment

  • Horizontal

  • • Usually determined to be the case if the vertigo seems positional and the dix hallpike does not work. A supine roll test would then be done to help diagnose.

    • Instead of a rotational nystagmus, a unilateral horizontal nystagmus is expected. The two patterns are termed geotropic and apogeotropic.

    • Geotropic means the fast phase beats toward the ground, and is treated by a barbeque roll maneuver. Apogeotropic means the fast phase beats toward the ceiling, and is treated by Gufoni maneuver.

  • Anterior is more rare

  • • Most cases require neuro consults

    • Determined by attempting to induce a down-beating nystagmus, which is a higher risk nystagmus.

    • Treatment is tilting their head back up in a similar way

    • Inducing the nystagmus is not sided and is more central

References

1. You, P., Instrum, R. and Parnes, L. (2019), Benign paroxysmal positional vertigo. Laryngoscope Investigative Otolaryngology, 4: 116-123. https://doi.org/10.1002/lio2.230

2. Ling X, Zhao D-H, Shen B, Si L-H, Li K-Z, Hong Y, Li Z-Y and Yang X (2020) Clinical Characteristics of Patients With Benign Paroxysmal Positional Vertigo Diagnosed Based on the Diagnostic Criteria of the Bárány Society. Front. Neurol. 11:602. doi: 10.3389/fneur.2020.00602

3. Rah YC. Advances in Benign Paroxysmal Positional Vertigo: Updated Insights on Diagnostic Pitfalls and Management. J Audiol Otol. 2026 Jan;30(1):1-12. doi: 10.7874/jao.2025.00717.

Summarized by Aaryn David | Edited by Aaryn David & Ahmed Abdel-Hafiz, NREMT-P

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Contributor: Aaron Lessen, MD

Educational Pearls:

Blunt cerebrovascular injury (BCVI)

• BCVI is a traumatic injury to the carotid or vertebral arteries

• • Patients may initially have no neurologic symptoms

  • In some cases, a thrombus can form at the site of the injury and later cause ischemic stroke, sometimes hours after the original trauma

• CT angiography (CTA) of the neck is a useful screening tool for BCVI

• • HIstorically, CTA was reserved for patients with high-risk mechanisms or neurologic symptoms

  • CTA screening has expanded as understanding of BCVIs and their prevention progresses

• The Denver criteria were developed to identify patients with increased risk for BCVI

• • High-risk findings include cervical spine injuries and severe facial or skull-base fractures

  • Screening practices still vary between trauma centers, though expansion of proactive CTA is an increasingly common practice

References

1. Kim DY, et al. Evaluation and management of blunt cerebrovascular injury: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2020.

2. Biffl WL, et al. Screening for and treatment of blunt cerebrovascular injuries: Western Trauma Association critical decisions algorithm. J Trauma. 2009.

3. Brommeland T, et al. Best practice guidelines for blunt cerebrovascular injury. Scand J Trauma Resusc Emerg Med. 2018.

4. Harper PR, et al. Routine CTA screening identifies blunt cerebrovascular injuries missed by clinical risk factors. Trauma Surg Acute Care Open. 2022.

Summarized by Sam Pahl | Edited by Sam Pahl & Ahmed Abdel-Hafiz, NREMT-P

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Contributor: Aaron Lessen, MD

Educational Pearls:

• Big question in cardiac arrest: is the rhythm shockable?

• • Shockable: ventricular fibrillation (VF) and pulseless ventricular tachycardia

  • Non-shockable: asystole and pulseless electrical activity (PEA)

• Rhythm classification is typically based on ECG, but echocardiography can directly visualize myocardial fibrillation

• • Occult VF: a rhythm that appears non-shockable on ECG but demonstrates VF on echocardiography

• A 2025 multicenter prospective study looked at 811 patients with out-of-hospital cardiac arrest

• • 5.3% had occult VF detected by echocardiography

  • Of the patients with occult VF:

  • • 81.4% had PEA on ECG

    • 18.6% had asystole on ECG

  • Patients with occult VF were less likely to receive defibrillation because their ECG suggested a nonshockable rhythm

• Clinical takeaway: echocardiography during cardiac arrest may reveal a potentially shockable rhythm hiding behind an apparently nonshockable ECG

• • This identifies a subset of cardiac arrest patients who would otherwise be managed as PEA or asystole based on ECG

References

1. Gaspari R, Adhikari S, Gleeson T, Kapoor M, Lindsay R, Noble V, Nomura JT, Weekes A, Theodoro D. Occult Ventricular Fibrillation Visualized by Echocardiogram During Cardiac Arrest: A Retrospective Observational Study From the Real-Time Evaluation and Assessment for Sonography-Outcomes Network (REASON). J Am Coll Emerg Physicians Open. 2025 Jan 13;6(1):100028. doi: 10.1016/j.acepjo.2024.100028. PMID: 40012664; PMCID: PMC11853361.

Summarized by Meg Joyce, MS3 | Edited by Meg Joyce & Ahmed Abdel-Hafiz, NREMT-P

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Contributor: Taylor Lynch, MD

Educational Pearls:

• CPR is an important life-saving measure designed for anyone to perform.

• • Chest compressions works by two mechanisms:

  • • Cardiac pump: Direct squeezing of the heart

    • Thoracic pump: Increasing intrathoracic pressure, causing increased blood flow

  • Proper hand placement per current AHA guidelines:

  • • Hands are placed in the center of the chest, on the lower half of the sternum

  • A recent study challenged this approach, using TEE during chest compressions to visualize the cardiac structures being compressed.

  • • They found that when hands were placed ~1cm to the left of the sternum, this compressed the left ventricular outflow tract, potentially restricting forward blood flow.

    • Hand placement ~4cm to the left of the sternum resulted in more effective compression of the left ventricle.

    • • While this is not yet reflected in AHA guidelines, the study presents an interesting finding that may influence how CPR is performed in the future.

      • Key takeaway: Always prioritize administering high quality compressions.

References:

1. American Heart Association. 2025 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2025;152(23_suppl_1). doi:10.1161/CIR.0000000000001378.

2. Chu S, Cheng C, Chang C, et al. Transesophageal echocardiography during CPR in patients with out-of-hospital cardiac arrest: the EXECT-CPR randomized clinical trial. JAMA Intern Med. 2026;186(5):557-566. doi:10.1001/jamainternmed.2026.0102.

Summarized by Ashley Lyons, OMS4 | Edited by Ashley Lyons & Ahmed Abdel-Hafiz, NREMT-P

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Contributor: Meghan Hurley, MD

Educational Pearls:

What is hyperkalemia?

• Hyperkalemia is when the measured blood level of potassium reaches above 5.2 - 5.5 mEq/L (normal 3.5 - 5.2 mEq/L).

What are common causes of hyperkalemia?

• Chronic or acute kidney disease.

• Medications that impact the Renin-Angiotensin-Aldosterone-System (RAAS).

• Hypoaldosteronism and primary adrenal insufficiency (Addison's Disease).

What are concerns of hyperkalemia?

• The biggest concern with hyperkalemia is the impact on the cardiac conduction system.

• • At differing levels of hyperkalemia, the patient may initially have peaked T waves, that then progress into a widening of the QRS complex which may eventually lead to a sine wave pattern.

  • This increases risk for cardiac arrest with ventricular fibrillation, PEA, and asystole.

What is the treatment algorithm for hyperkalemia?

• Works through a three-tier approach.

• First tier treatment is with a calcium agent (calcium gluconate or chloride).

• • Thought for the longest time to "stabilize the cardiac membrane/action potential". Recent research shows the true mechanism of action is likely through acting on calcium dependent channels.

  • Does not fix underlying hyperkalemia, but buys time for the heart.

• Second tier treatment is inducing intracellular potassium shift.

• • Can be achieved through agents such as insulin (which may need to be bolused with glucose to prevent hypoglycemia), albuterol, or sodium bicarbonate.

• Third tier is potassium elimination

• • If the patient is producing urine, loop or thiazide diuretics can be considered.

  • Hemodialysis may also be considered based on patient condition.

  • Long term (and slowest method of elimination) through fecal excretion. Unlikely to see benefits in emergency management.

Key Takeaways?

• Hyperkalemia is a condition that can be brought on by primarily renal conditions and medication side effects. Careful attention must be paid to the patient's cardiac status, and urgent cardiac stabilization (though now we may know that calcium doesn't truly "stabilize" the cardiac membrane) must be performed to prevent deadly arrhythmias. Definitive management involves addressing the offending agent, offloading potassium, and stabilizing the patient long term.

References:

1. Geldermann N, Dzimiera J, Fischer H, Christ M. Acute hyperkalaemia in emergency care: evidence-based approaches. Emerg Med J. 2026;43(5):305-311. doi:10.1136/emermed-2025-215469

2. Piktel JS, Wan X, Kouk S, Laurita KR, Wilson LD. Beneficial Effect of Calcium Treatment for Hyperkalemia is Not Due to "Membrane Stabilization." Crit Care Med. 2024;52(10):1499-1508. doi:10.1097/CCM.0000000000006376

3. Hunter RW, Bailey MA. Hyperkalemia: pathophysiology, risk factors and consequences. Nephrol Dial Transplant. 2019;34(Suppl 3):iii2-iii11. doi:10.1093/ndt/gfz206

Summarized by Dan Orbidan, OMS3 | Edited by Dan Orbidan & Ahmed Abdel-Hafiz, NREMT-P

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Contributor; Aaron Lessen, MD

Educational Pearls:

• A 2026 survey asked Canadian emergency medicine (EM) physicians about their eating and drinking habits while on shift.

• • Among 527 respondents, 35% reported that they never or hardly ever ate during shifts, and 37% said the same about drinking water.

  • Lack of time was the most commonly cited barrier, reported by 91% of respondents.

  • Lack of available food, personal health goals, perceived mental clarity, and emergency department culture were also commonly identified factors.

  • Physicians who did not eat or drink on shift often reported that this negatively affected their work.

  • Years in practice were associated with eating more often while on shift, suggesting that newer physicians may be less likely to eat during shifts.

• A 2023 study by Kontrick et al. found that 89% of US-based EM residency programs did not have a dedicated meal break, which may help explain why early-career physicians are less accustomed to eating during clinical shifts.

• Studies outside of emergency medicine have also suggested that inadequate food and fluid intake can affect fatigue, mood, attention, and cognitive performance, though direct evidence in emergency department physicians and patient care remains limited.

• Future studies could examine whether physician eating and drinking habits during shifts are associated with patient outcomes and broaden the scope of this study to other emergency department providers, nurses, and technicians.

References:

1. Farquhar, Madeleine et al. "A lot on their plates? Examining the on-shift eating and drinking habits of Canadian emergency medicine physicians." CJEM vol. 28,1 (2026): 64-73. doi:10.1007/s43678-025-01044-8

2. Kontrick, Amy V et al. "Do emergency medicine residents have access to healthy food options during work hours?." AEM education and training vol. 7,4 e10890. 17 Jul. 2023, doi:10.1002/aet2.10890

3. Lemaire, Jane B et al. "Physician nutrition and cognition during work hours: effect of a nutrition based intervention." BMC health services research vol. 10 241. 17 Aug. 2010, doi:10.1186/1472-6963-10-241

4. Wittbrodt, Matthew T, and Melinda Millard-Stafford. "Dehydration Impairs Cognitive Performance: A Meta-analysis." Medicine and science in sports and exercise vol. 50,11 (2018): 2360-2368. doi:10.1249/MSS.0000000000001682

Summarized by Sam Pahl | Edited by Sam Pahl & Ahmed Abdel-Hafiz, NREMT-P

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Contributor; Taylor Lynch, MD

Educational Pearls:

• Thoracotomy

• • Thoracotomy is used in traumatic cardiac arrest to replace conventional CPR with direct access to the chest.

  • Goals include identifying and controlling reversible causes of bleeding, prioritizing blood flow to the heart and brain, and performing open cardiac massage.

• Trauma categories

• • Penetrating trauma: Gunshot wounds and stab wounds.

  • • Has a higher chance of survival because the injury may be localized and directly repairable.

    • Cardiac stab wounds may have the highest survivability because the defect can be visualized, repaired, and treated with blood administration.

  • Blunt trauma: Motor vehicle collisions and falls from height.

  • • Has a much lower chance of survival.

• Western guidelines

• • EMS must witness the patient lose pulses.

  • Penetrating trauma: CPR for less than 15 minutes.

  • Blunt trauma: CPR for less than 10 minutes.

  • Survival decreases to essentially zero beyond these time limits.

• Eastern guidelines

• • Focus on the presence of signs of life in blunt or penetrating trauma.

  • Signs of life may include:

  • • Pupillary response.

    • Measurable blood pressure.

    • Purposeful movement.

• Patient selection

• • Thoracotomy should only be performed when the patient has a reasonable chance of survival.

  • It is a highly morbid procedure with significant occupational risks, including needlestick injury.

  • Appropriate patient selection and timing are essential.

• Procedure

• • Begin on the left side of the chest.

  • Cross-clamp the aorta to restrict blood flow below the heart and prioritize circulation to the heart and brain.

  • Identify and repair visible sources of bleeding involving structures such as the heart or lungs.

  • Perform open cardiac massage as the equivalent of CPR.

  • ACLS medications may still be administered.

References:

1. Cothren CC, Moore EE. Emergency department thoracotomy for the critically injured patient: Objectives, indications, and outcomes. World J Emerg Surg. 2006;1:4. Published 2006 Mar 24. doi:10.1186/1749-7922-1-4

2. Rhee, Peter M. ; Acosta, Jose ; Bridgeman, Amy et al. / Survival after emergency department thoracotomy : Review of published data from the past 25 years. In: Journal of the American College of Surgeons. 2000 ; Vol. 190, No. 3. pp. 288-298.

3. Nunn, Andrew ; Prakash, Priya ; Inaba, Kenji et al. / Occupational exposure during emergency department thoracotomy : A prospective, multi-institution study. In: Journal of Trauma and Acute Care Surgery. 2018 ; Vol. 85, No. 1. pp. 78-84.

4. Burlew CC, Moore EE, Moore FA, et al. Western Trauma Association critical decisions in trauma: resuscitative thoracotomy. J Trauma Acute Care Surg. 2012;73(6):1359-1363. doi:10.1097/TA.0b013e318270d2df

5. Seamon MJ, Haut ER, Van Arendonk K, et al. An evidence-based approach to patient selection for emergency department thoracotomy: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2015;79(1):159-173. doi:10.1097/TA.0000000000000648

Summarized by Steven Fujaros NREMT | Edited by Steven Fujaros & Ahmed Abdel-Hafiz, NREMT-P

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