Association of D-Dimer Screening With Emergency Department Length of Stay

Author: Brandon Maughan, Lauren Westager, Portia England, Angela Jarman

Background: Although guidelines recommend a D-dimer first approach to the diagnostic evaluation for pulmonary embolism (PE) in most patients, literature suggests physicians may avoid D-dimer due to concerns about potential delays in care. We are aware of no studies on the association of D-dimer screening with ED patient throughput. 

Objective: We hypothesized that a D-dimer-first strategy was associated with a faster time to ED disposition than a CT-only strategy.

Methods: We performed a retrospective cohort study of adult patients (18-79 years) who had D-dimer testing or CT pulmonary angiography at 3 EDs between 2017-23. Our primary outcome was the time between a patient’s first PE test order and the time of their ED disposition order, in minutes. We excluded patients with hypotension, a chief complaint of PE, and those who died in the ED, eloped, left against medical advice, were transferred, or had D-dimer ordered after CT. Covariates included demographics, vital signs, ED volumes, time of day, and comorbidities. We estimated inverse-probability-weighted (IPW) marginal treatment effects on time to ED disposition using the Stata stteffect ipw command with a Weibull survival distribution. Estimates included the average treatment effect (ATE) and the average treatment effect on the treated (ATT), with robust standard errors to account for uncertainty in treatment and outcomes models. There was no censoring.

Results: The sample included 7,983 patients with D-dimer and 5,718 patients with CT only. The D-dimer group was younger (50.4 vs. 58.5 years), had lower rates of chronic heart disease (17.8% vs. 25.7%) and cancer (13.3% vs. 31.5%); and had a lower hospitalization rate (28.4% vs. 57.4%). The D-dimer first strategy was associated with a shorter time to ED disposition, with an ATE of -10.4 minutes (95% confidence interval [CI] [-14.7, -6.1], p < 0.001) and an ATT of -14.3 minutes (95% CI [-19.1, -9.4], p < 0.001).

Conclusion: A D-dimer-first approach to evaluation of PE was not associated with a delay in disposition from the emergency department.

Trends in nitrous oxide abuse and misuse: a 22-year analysis of United States poison center data

Author: Courtney Temple, Amber Lin, and Adrienne Hughes

Introduction: Nitrous oxide is widely available for medical, industrial, and culinary use. However, its euphoric effects and accessibility have contributed to increasing recreational abuse/misuse. Chronic exposure disrupts vitamin B12 function, resulting in potentially severe neurologic and psychiatric complications. Although case reports suggest a rise in abuse/misuse, trends in the United States remain poorly characterized.

Methods: We conducted a retrospective analysis of intentional nitrous oxide abuse/misuse reported to the National Poison Data System® from 2003 through 2024. Included cases involved individuals aged 13 years and older, in whom nitrous oxide was identified as the primary substance. Data were analyzed for demographic characteristics, clinical effects, treatments, and outcomes using standardized coding definitions.

Results: Of 3,632 cases initially identified, 1,751 met the inclusion criteria. Most were male (63%), and most exposures occurred in private residences (85%). Individuals aged 20–29 years accounted for the largest proportion (37%) of cases. Annual cases rose from 28 in 2003 to 401 in 2024, a 1,332% increase. Over half (55%) of the exposures resulted in the moderate or major clinical effects, including ataxia (11%), numbness (12%), and confusion (14%). Hospital admission occurred in 29% of cases, with 10% admitted to the intensive care unit. Vitamin B12 and folate supplementation were documented in only 6.3% of cases.

Discussion: These findings demonstrate a sustained and substantial increase in reported intentional nitrous oxide abuse/misuse over two decades in the United States, with a notable rise in cases involving neurologic injury and functional impairment. The high proportion of single-substance exposures and limited use of targeted treatment suggest under recognition of both the diagnosis and its potential severity. Emerging formulations, including flavored high-volume tanks, may be contributing to this trend.

Conclusions: Intentional nitrous oxide abuse/misuse reported to United States poison centers has risen sharply in both frequency and severity in the United States. Improved clinical awareness, regulatory oversight, and public health interventions are needed to address this growing toxicologic concern.

Parental Beliefs and Communication Needs during a Pediatric Disaster

Author: Megan Walusiak, Sunhee Chung

Background: Emergency department (ED) boarding affects over 90% of U.S. hospitals and is associated with delays, errors, and worse outcomes. While many interventions have been studied, less is known about how high-performing EDs sustain efficiency under boarding pressure.

Objective: To characterize operational strategies and organizational enablers used by high-performing EDs despite high boarding burden.

Methods: In this national mixed-methods study, ED Benchmarking Alliance data (2021–2023) identified high-performing EDs based on throughput metrics within volume cohorts. Operational leaders from selected sites completed surveys assessing utilization and effectiveness of crowding interventions, supplemented by qualitative responses.

Results: Eleven EDs were analyzed. Sites implemented a median of 15 strategies, with highest use and effectiveness in throughput interventions. Common strategies included nurse-initiated orders, active bed management, and vertical care models. Interventions most often rated “extremely effective” included fast track, surge staffing, and point-of-care testing. No consistent adoption patterns emerged. Qualitative analysis identified key enablers: cross-department collaboration, data-driven staffing, centralized coordination, leadership alignment, and supportive institutional culture.

Conclusions: High-performing EDs use diverse, context-specific strategies rather than standardized models. Operational success appears driven by strong organizational enablers supporting flexible implementation.

Observed Toxicokinetics of Amlodipine in Overdoses

Author: Christopher Kennedy, Daniel Tirado, Colleen Cowdery, Keahi M Horowitz, Robert G Hendrickson

BACKGROUND: Amlodipine is a dihydropyridine calcium channel antagonist that may result in vasoplegic shock in overdose. Amlodipine has an elimination half-life of 30-50 hours in therapeutic doses, however the pharmacokinetics of amlodipine in large overdoses have not been well-described. We present amlodipine concentrations and apparent half-life using serial amlodipine concentrations from four patients who were treated with V-A ECMO following overdose.

METHODS: Serial plasma samples were collected from four patients who required V-A ECMO following severe amlodipine overdose. Plasma samples were sent for quantitative analysis via high performance liquid chromatography/tandem mass spectrometry. 

Apparent half-life was calculated using the formula t_(1⁄2)=0.693/k_e , where ke was derived from the formula k_e=((ln⁡〖(c_1)〗-ln⁡(c_2 )))/((t_2-t_1)). 

RESULTS:Toxicokinetics were highly variable among all 4 patients. Patient A (6 samples) had a peak amlodipine concentration of 260 ng/mL (unknown time of ingestion) that decreased to 180 ng/mL over 42 hours with an apparent half-life of 243 hours. Patient B (8 samples) had a peak concentration of 590 ng/mL (10 hours after ingestion) that decreased to 180 ng/mL over 54 hours with an apparent half-life of 75 hours. Patient C (4 samples) with a peak concentration of 180 ng/mL (10 hours after ingestion) that decreased to 140 ng/mL over 11 hours with an apparent half-life of 29 hours. Patient D (5 samples) had a peak concentration of 310 ng/mL (unknown time of ingestion) that decreased to 180 ng/mL over 26 hours with an apparent half-life of 24 hours. 

In the 2 patients with accurate ingestion time, the peak concentration was about 10 hours after ingestion. The apparent half-life varied widely and was 24-243 hours. All patients had significant improvement in clinical status at the end of data collection including patient B who was decannulated from V-A ECMO despite an amlodipine concentration of 180 ng/mL. Plasma concentration did not correlate well with clinical symptoms. At one plasma concentration (180 ng/mL), one patient was hemodynamically stable without vasopressors or ECMO support, one patient was at peak plasma concentration, and one patient was on multiple vasopressors and V-A ECMO 26 hours after ingestion. 

Limitations of this study include small sample size, relatively few samples collected for each patient, and unknown time of ingestion for two patients. It is not known whether V-A ECMO alters toxicokinetics or apparent half-life. 

CONCLUSION: The toxicokinetics of amlodipine in overdose can be highly variable with prolonged apparent half-life and concentrations may not correlate to clinical symptoms. 

Relationship between reported ingestion dose and outcome in amlodipine poisoning

Author: Courtney Temple, Colleen Cowdery

Background: Amlodipine, a dihydropyridine calcium channel antagonist, is increasingly prescribed and is a growing cause of poisoning fatalities in the United States. Amlodipine reaches peak plasma concentration at 6–12 h following therapeutic ingestion. As such, the severity of an overdose may not be immediately apparent to acute care clinicians and early risk stratification tools are needed. 

Methods: We reviewed 25 years of poison center records to identify cases of amlodipine overdose which included reported ingestion doses, were treated with vasoactive/inotropic agents, and did not involve co-ingestion of other cardioactive substances (such as bupropion, tricyclic antidepressants, alpha-2 agonists, and Vaughan Williams Class 1, 2, 3, 4, or 5 anti-dysrhythmics excluding amlodipine). We examined the relationship between reported amlodipine dose, the maximum number of simultaneous vasoactive/inotropic infusions used during treatment, the utilization of veno-arterial extracorporeal oxygenation (V-A ECMO), and clinical outcome. 

Results: Forty-one cases met inclusion criteria. Cases with ingestions ≤ 250 mg (n = 20) rarely required advanced interventions, with only one case involving V-A ECMO and no deaths. By contrast, in cases reporting ingestions ≥ 400 mg (n=14), 86% (n = 12) were treated with ≥ 4 simultaneous vasoactive/inotropic infusions and 64% (n = 9) either received V-A ECMO or died. Seven cases reported ingestions ≥ 800 mg; all received ≥ 4 vasoactive/inotropic infusions. Two died (29%), four received V-A ECMO and survived (57%), one survived without V-A ECMO but required ongoing dialysis at discharge. Conclusion: Amlodipine overdose can result in profound vasoplegic shock refractory to standard therapy. Reported ingestion dose appears to be associated with severity of clinical course, vasopressor requirements, utilization of V-A ECMO, and mortality. Although limited by sample size, these findings suggest amlodipine ingestions ≥ 400 mg are at high risk for refractory shock and may benefit from early transfer to a medical center capable of advanced interventions such as V-A ECMO. Reported ingestion dose may serve as a useful early risk stratification tool for clinicians.

Evaluation of Vasopressor Volume Administration in Amlodipine Poisoned Patients

Author: Daniel Tirado, Keahi Horowitz, Colleen Cowdery, Christopher Kennedy, Rudi Zurbuchen, Alyssa Rabon, Robert Hendrickson

Background: Amlodipine is a dihydropyridine calcium channel antagonist targeting L-type calcium channels that can result in vasoplegic shock in the overdose setting. Treatment of refractory vasoplegic shock can include high-dose vasopressors in addition to other infusions. Diluents in continuous infusions may be an unrecognized source of significant amounts of volume in patients already at risk for difficult-to-manage volume status. Large volumes of fluid administration, as a result, may cause iatrogenic injury. We sought to evaluate the volume of vasopressors administered to critically ill amlodipine-poisoned patients and calculate the difference in volume when applying our institution’s most concentrated vasopressor guidelines. 

Hypothesis: Amlodipine-poisoned patients receive a significant volume of fluid from vasopressors during their initial resuscitation period. 

Methods: We reviewed 25 years of our poison center records and searched for amlodipine poisoning cases with reported ingestions ≥ 400 mg who did not report co-ingestion of cardioactive substances (such as bupropion, tricyclic antidepressants, alpha-2 agonists, and Vaughan Williams Class 1, 2, 3, 4, or 5 anti-dysrhythmics). The rate and concentrations of all vasopressors administered were recorded and used to calculate the total volume administered. Patients were excluded if they did not have 24 hours of vasopressor data. The vasopressor volume administered to each patient was summed from the start of the first vasopressor to 24 hours. We then applied our institution’s most concentrated vasopressor guidelines to calculate the difference in fluid volume had these protocols been initiated during their initial resuscitation period. 

Results: Eleven patients met initial inclusion criteria, of which four were excluded due to death or early initiation of V-A ECMO. The mean(±SD) volume of fluids related to vasopressors was 3433 (±2774) mL. Using concentrated vasopressors would have theoretically resulted in a mean 1.0 liter less fluid volume, a mean reduction of 32% (SD±0.15). Three of the seven patients developed radiologic evidence of pulmonary edema, all of whom had an ejection fraction (EF) > 55%, suggesting fluid overload. The largest volume difference in administered fluid volume compared to our most concentrated guidelines in a single patient was 2.6 liters (L); this patient later developed oliguria and pulmonary edema. 

Conclusion: Patients with amlodipine-induced vasoplegic shock receive large amounts of fluid in the form of vasopressors. Adopting a concentrated vasopressor policy for amlodipine-poisoned patients may limit the amount of fluid administered during their initial resuscitation period. Limitations include the theoretical outcome of these calculations. 

Fentanyl-Overdose Patients Reporting Self-Harm or Suicide Intent Versus Those Seeking Euphoria: A Comparison

Author: Daniel Tirado, Rachel Culbreth, Alyssa Falise, Kim Aldy, Paul Wax, Jeffrey Brent, Alex Krotulski, Robert Hendrickson

Background: The intent of opioid use is complex and multifactorial, and there is little data describing overdose intent, or the rodse or route that is used related to that intent. We sought to evaluate the characteristics of patients who overdosed on fentanyl with the intent for self-harm/suicide and compare them to those who were pursuing euphoric effects. 

Hypothesis: Among those with fentanyl in their blood, subjects who use fentanyl for the purpose of self-harm/suicide use by a familiar route and have higher average fentanyl concentrations compared to those seeking euphoric effects. 

Methods: The Toxicology Investigators Consortium (ToxIC) Drug Overdose Toxico-Surveillance (DOTS) Reporting Program included ED patients ages 13 and older who presented to 17 U.S. medical centers with suspected opioid or stimulant overdoses. Data collection included comprehensive chart reviews, detailed patient interviews, and qualitative and quantitative toxicology analyses conducted by the Center for Forensic Science Research and Education for the detection of over 1,200 drugs and metabolites. 

This analysis compared subjects who reported that the intent of substance use was self-harm/suicide to those who reported utilizing the substance for euphoria. Variables included use-history, fentanyl concentrations, and naloxone doses. 

Results: There were 609 subjects who completed interview questions and presented as a clinical opioid overdose. Thirty subjects (4.8%) reported intent of self-harm, 326 (52.5%) were seeking euphoria, and 265 (42.7%) used for other reasons. The self-harm group had a median (ng/mL, IQR) fentanyl concentration of 2.6 (1.6, 5.5), whereas the euphoria-seeking group had a median concentration of 4.7 (2.3, 9.4). 

The self-harm/suicide group self-reported (# of subjects, %) having used the following drugs: opioids only (16, 53.3%), stimulants only (4, 13.3%), opioids and stimulants (3, 10.0%), pharmaceuticals only (1, 3.3%), and other combinations (6, 20%). Five (17.2%) subjects reported their first time using this drug. Subjects with the intent of self-harm/suicide were more likely to report ingestion/swallowing the overdose drug compared to those with euphoric intent (42.3% vs. 12.6%; respectively, p=0.004) and first time using the drug (17.2% vs. 11.3%; respectively, p=0.01).

Conclusion: Approximately five percent of all opioid overdoses reported their fentanyl use as a self-harm/suicide attempt. Our results are limited by reliance on subject self-report and recall bias, and self-harm/suicide may be underreported. These subjects had lower blood fentanyl concentrations, used a familiar drug but not by the usual route, and had a high rate of ingestion of the drug rather than injection or smoking. 

Cognitive load demands from emotionally challenging tasks in emergency care

Author: Brandon Maughan, Avery Whipple, George Deardorff, Steven Durning

Background: The mental effort required to process information is known as cognitive load (CL). Sustained high CL impairs working memory and is associated with poor recall, medical errors, and physician burnout. Traditional sources of CL in the ED include complex tasks; interruptions or distractions; and learning demands. Recent experimental evidence shows that emotional regulation tasks impose substantial CL. Emotionally demanding tasks are endemic in ED care, yet no studies have measured the impact of these tasks on ED clinicians. We hypothesized that emotional demanding activities impose high CL similar to other common ED tasks. 

Methods: We designed an electronic survey to assess clinicians’ beliefs regarding the CL demands of different clinical tasks. Participants rated the mental effort required for 15 common ED tasks (e.g., patient interviews; electronic health record tasks; procedures; interruptions; teaching), including two emotionally difficult tasks: delivering bad news and responding to angry or dissatisfied patients. Participants used a visual analog scale (VAS) to rate each task from 0 (very low mental effort) to 100 (very high mental effort). Surveys were sent to ED physicians and advanced practice providers who participated in a prior study and expressed interest in future surveys. 

Results: We sent 232 email invitations, received 99 responses (43% response rate), and had surveys finished by 92 individuals in 12 states (93% completion rate). The sample was 50% female and 76% physicians (61 attending/staff; 9 residents) with a mean age of 42 years (range 27-68). Of the 15 tasks, the highest VAS scores were reported for “responding to angry or dissatisfied patients” (mean 78.8, 95% confidence interval [CI] [75.1-82.6]) and “delivering bad news” (mean 77.2, 95% CI [72.9, 81.6]). These scores were statistically similar to the third-highest task (“critical patient resuscitation”, mean 77.1, 95% CI [72.3, 81.5]) and were significantly higher than all 12 remaining tasks including intubation (mean 61.4, 95% CI [56.4, 66.4]), prolonged interruptions (mean 55.7, 95% CI [516, 59.8), and clinical documentation (mean 49.6, 95% CI [44.9, 54.2]).

Conclusions: Emotionally demanding tasks produce higher CL burdens than many other complex ED tasks. Future research should examine educational and system-level interventions to mitigate these effects.

The Impact of HAS-BLED Scores on OAC Prescription Rates in the ED

Author: Ashley Mora-Garcia, Maja Strusinska-Thayer, Seiji Koike, Bradley Hopkins, Bilal Sultan, Ky Bissell, Thuan Nguyen, Nikolai Schnittke, Matthew Neth, Bory Kea

Background: Atrial Fibrillation/Flutter (AFF) is the most common arrhythmia diagnosed in the emergency department (ED) and is associated with an increased stroke risk. Oral anticoagulants (OAC) can reduce stroke risk by 64%. The CHA2DS2-VASc and HAS-BLED scores are used to assess a patient’s stroke and bleeding risk, respectively. We sought to assess whether a moderate-to-high HAS-BLED score (≥2) influences OAC prescription rates. 

Methods: This was a retrospective chart review of patients diagnosed with AFF at three Portland-area EDs from January 2020 to April 2023. Data was extracted from Phase 0 of a larger step-wedged trial, in which we examined clinician adherence to OAC prescription guidelines without intervention. The study included patients ≥ 18 years with a documented HAS-BLED score. Patients were excluded based on OAC use within one year of index ED visit, specified comorbidities, and lack of documented HAS-BLED score. We employed a matching approach, where patients with high bleeding risk were matched to patients with low bleeding risk on a set of predefined covariates (CHADS-VASc). The average causal effect (ACE) of bleeding risk on the likelihood of OAC prescription was estimated using a generalized linear mixed effect model, binomial family with logit link. Risk ratios were derived using cluster bootstrap standard errors. 

Results: Of 403 eligible patients, 243 were included (51% female, 95% White). 38% of patients with a recorded HAS-BLED score were prescribed an OAC; among those, 38.7% had a low-risk score and 36.6% had a medium/high risk score. There was no significant difference in OAC prescribing between the groups (OR 0.95, 95% CI: 0.78, 1.29). 

Conclusion: The HAS-BLED score did not have a significant relation to OAC prescriptions. Patients with moderate-high risk bleeding risk are 95% as likely to receive an OAC than those with a low bleeding risk. 

The Effect of Language Barriers on Shared Decision Making in the Emergency Department

Author: Bilal Sultan, Maja Strusinska-Thayer, Seiji Koike MAS, Bradley Hopkins, Ashley Mora-Garcia, Ky Bissell, Thuan Nguyen, Nikolai Schnittke, Matthew Neth, Bory Kea 

Background: Atrial fibrillation/flutter (AFF) are common arrhythmias often first diagnosed in the emergency department (ED) and known to increase stroke risk. Prescription of oral anticoagulants (OAC) can reduce the risk of stroke by 64%. Language barriers during ED visits can obstruct shared decision-making conversations, and, thereby, hinder a patient's understanding of their condition and possible treatments. We sought to evaluate the association between OAC prescription and language barriers for patients diagnosed with AFF in the ED. 

Methods: Charts were reviewed of patients diagnosed with AFF between January 2020 and February 2026 at 3 Portland-area EDs. We included patients ≥18 years with clear documentation of the need for an interpreter and available OAC prescription data. Patients were excluded based on prespecified comorbidities, OAC use within 1 year of index visit, and if the need for interpreter was not specified. The effect of need for interpreter on the likelihood of receiving an OAC prescription was estimated across phases by fitting a binomial generalized linear mixed model with logit link. The model was tested for the potential of a phase effect. Finally, an odds ratio was estimated to determine prescription likelihood across groups. 

Results: Out of the 6,619 study-eligible patients, 953 met inclusion criteria. Of those included, 6.3% required an interpreter, while 93.7% of patients did not. OACs were prescribed to 45.0% of patients who needed an interpreter and 48.8% of patients that did not need an interpreter. Patients who needed an interpreter had 0.92 times the odds of receiving an oral anticoagulant prescription compared with patients who did not need an interpreter (95% CI: 0.57,- 1.48). 

Conclusion: Patients who need an interpreter are prescribed OACs 8% lower than those who do not. Although this difference was not statistically significant and may reflect random chance, grouping results by individual hospitals could reveal measurable statistical significance. 

Predictors of POLST completion in high-acuity patients discharged alive from an Oregon academic hospital

Author: Daniel Gaynor, David McCoy, Abby Dotson 

Ensuring patient autonomy and goal-concordant care at the end of life is a critical aspect of healthcare. However, gaps remain in identifying patients who may benefit from POLST discussions, particularly during hospitalizations. This study aims to identify high-risk patient groups and evaluate the appropriateness of POLST discussions prior to hospital discharge. The primary objective was to determine which clinical criteria could serve as indicators for initiating POLST conversations.

A retrospective, cross-sectional study was conducted using data from Oregon Health & Science University’s (OHSU) electronic medical records (EMR), the Oregon POLST Registry (OPR), and Oregon Health Authority (OHA) mortality records. The study included patients discharged alive from OHSU Hospital between January 2019 and December 2022. Data analysis focused on 1-year mortality rates and POLST completion rates among high-risk groups. 

Our initial findings highlight the importance of integrating POLST discussions into discharge planning for patients at high-risk for death, ensuring their end-of-life preferences are documented, potentially reducing unwanted treatments.

Characteristics of Overdoses in Patients Who Obtain Opioids From an Unfamiliar /Atypical Source Versus a Usual/Typical Source

Author: Tricia Dowis; Daniel Tirado, Rachel Culbreth, Paul Wax, Jeffrey Brent, Kim Aldy,  Alyssa Falise, Robert G Hendrickson

Background: People who use fentanyl often use multiple times a day and rely on a consistent source for this supply. Obtaining drugs from a new dealer or an unfamiliar source may increase the risk of overdose. There is little data describing the clinical characteristics and blood concentrations of fentanyl in patients that use fentanyl from an unfamiliar source. 

Research Question: Is using fentanyl from an unfamiliar source associated with higher blood fentanyl concentrations among subjects who overdose?

Methods: The Toxicology Investigators Consortium (ToxIC) Drug Overdose Toxico-Surveillance (DOTS) Reporting Program (2022 – 2024) consisted of ED patients ages 13 and older who presented to 17 U.S. medical centers with suspected opioid or stimulant overdose. DOTS data collection included chart reviews (e.g., prehospital naloxone), subject interviews, and qualitative/quantitative toxicology analyses conducted by the Center for Forensic Science Research and Education. Summary data includes medians and interquartile ranges [IQR] for skewed data, and Wilcoxon Rank Sum Tests with Continuity Corrections and Chi-Square or Fisher’s Exact Tests were used for testing statistical differences. 

Results: Among 587 subjects with an opioid overdose presentation, 361 used drugs from their usual source, and 226 used from an unfamiliar source. Subjects who used fentanyl from an unfamiliar source generally used a single drug (61%) and by a usual route (66%) and had similar markers of risk-taking behavior than those with a usual source (e.g. previous overdose, previously incarcerated, using more than one drug, p=NS). Of those with unfamiliar sources, there was no difference in fentanyl concentration amongst subjects who used someone else’s medication (3.1 ng/mL; IQR 1.6, 9.8), usual dealer but not usual brand (4.8 ng/mL; IQR 3.0, 11.0), not usual dealer but usual brand (4.0 ng/mL; IQR 2.1, 8.7), not usual dealer and not usual brand (4.9 ng/mL; IQR 2.8, 7.0). However, a higher percentage of subjects that used fentanyl from an unfamiliar source received 2 or more naloxone doses (50.4% vs. 43.2%, p=0.03) and had a higher average IN dose (unfamiliar source: mean: 6.5 mg; median: 4.0 mg; IQR: 4.0, 8.0 vs. usual source: mean 5.1 mg; median: 4.0 mg; IQR: 2.0, 8.0; p=0.02). 

Conclusion: Subjects who used fentanyl from an unfamiliar source had similar characteristics to those who used from a usual source but were treated with more doses of naloxone and had higher average IN naloxone doses. Our results are limited by subject self-report and the potential for recall bias. 

Physician Estimation of Risk Factors and Clinical Heuristics in Diagnostic Evaluation of Pulmonary Embolism (the PERCEIVE-PE study)

Author: Brandon Maughan, Lauren Westafer, David Vinson, Scott Casey, Michael Pulia, Elizabeth Goldberg, Chris Baugh, Chris Kabrhel, Tracy Madsen, Susan Peterson, Lauren Stewart, Joseph Bledsoe, Austin Smith, Kerstin de Wit, Jeff Kline, Angela Jarman

Background: Although evidence-based algorithms guide testing once pulmonary embolism (PE) is suspected, less is known about how clinicians “decide” to suspect PE. This gap is critical since PE remains frequently misdiagnosed. We hypothesized that PE testing is influenced by implicit biases regarding sex and race.

Methods: We designed an electronic survey that described 7 fictional adult emergency department (ED) patients with chest symptoms. Using a 2x2x2 factorial design, participants randomly received 1 of 8 versions of each case that differed by sex (female/male), race (Black/White), and a case-specific clinical factor. Each case had 2 outcomes. Question 1 (Q1) asked participants to rate concern for 5 conditions (including PE) on a 0-to-100 visual analog scale (VAS). In Question 2 (Q2), participants chose diagnostic tests for each case; we used a binary outcome of whether PE tests (e.g., D-dimer, computed tomography) were ordered or not. Pilot testing by 16 ED physicians showed good test-retest validity (Pearson’s r = 0.84) and criterion validity (higher VAS score in cases with higher Wells scores). We used linear mixed-effects regression (Q1) and logistic mixed-effects regression (Q2) to examine each factor, with fixed effects for case (sex; race; order) and participant traits (sex; race; age). Crossed random intercepts for participants and cases accounted for repeated measures.

Results: We invited 2011 ED clinicians via in-person appeals at a conference and email invitations to staff at 37 EDs in the United States and Canada. The study had a 43% response rate (n=863) and 78% completion rate (n=673). Cases with female patients had higher reported PE risk (β = 5, 95% confidence interval [CI] [3.2, 6.8], p < 0.001) and odds of testing (odds ratio [OR] = 1.6, 95% CI [1.4, 2], p < 0.001) compared with males. Patient race was not significantly associated with perceived PE risk (β = -0.7, 95% CI [-2.5, 1.1], p=0.43) or PE testing (OR = 0.9, 95% CI [0.8, 1.1], p = 0.48).

Conclusion: Implicit sex bias, but not racial bias, appears to influence PE diagnostic evaluation. Since females have lower PE incidence than males, this heuristic could contribute to low-value testing (via over-testing) in females and diagnostic failures (via under-testing) in males.

Emergency clinicians’ perceived consequences of high cognitive load on patient care

Author: Brandon Maughan, George Deardorff, Avery Whipple, Steven Durning

Background: ED clinicians experience cognitive load (CL) from job-related tasks and interruptions. When CL exceeds the limited capacity of working memory, individuals display poor recall and impaired reasoning (“cognitive overload”); this phenomenon is implicated in medical errors. We are aware of no studies examining the ED clinicians’ perceptions of cognitive overload or how it impacts their performance. Since experience attenuated CL through established mental schemas, we hypothesized that clinicians with more experience report fewer CL-related performance impairments than newer clinicians.

Methods: We designed an electronic survey to assess clinicians’ beliefs on CL and job performance. Participants rated the impact of high CL on different tasks (e.g., overall performance; diagnosis; treatment; patient communication) using a visual analog scale (VAS) from -100 (much worse) to 100 (much better). Participants estimated the percentage of ED shifts in which CL was high enough to cause these effects. Surveys were sent to ED physicians and advanced practice providers who participated in a prior study and expressed interest in future surveys.

Results: Out of 232 invitations, respondents started 99 surveys (43%) and completed 92 (93%). The sample had respondents from 12 states and included 50% females and 76% physicians. The mean length of experience (e.g., after training) was 11.2 years and was dichotomized (<11 years vs. 11+ years) for analysis. Respondents perceived that high CL reduced quality of all aspects of care, including but not limited to initial assessment (mean -46.5, 95% confidence interval [CI] [-42.3, -25.8]), diagnosis (mean -29.5, 95% CI [-35, -23.9]), and treatment (mean -26.1, 95% CI [-31.7, -20.5]). These results did not differ by experience or role. However, experienced clinicians perceived that these harms occurred in a higher percentage of shifts, including adverse effects on diagnosis (mean difference 10.2% of shifts, 95% CI [1.9, 18.5%], p = 0.016), treatment (mean difference 12.9%, 95% CI [3.2, 22.6%], p = 0.01), and patient communication (mean difference 21.8%, 95% CI [10.9, 32.6], p = 0.0001).

Conclusion: ED clinicians perceive that high CL adversely impacts many aspects of patient care. Experienced clinicians perceive that these harms occur more often than newer clinicians do. Future research should quantify these exposures and outcomes using prospective methods.

CRISP: A Structured Student Research Workforce to Support Clinical Research in the Emergency Department

Author: Annick Yagapen, David Sheridan

Background: Conducting clinical research in the emergency department (ED) presents unique operational challenges, including time-sensitive enrollment, high patient turnover, and limited research staffing outside standard business hours. Simultaneously, undergraduate and pre-health students often seek meaningful exposure to clinical research and academic medicine but lack structured pathways for engagement. The Clinical Research Investigative Studies Program (CRISP) was developed to address both needs by creating a trained student workforce integrated into ED research operations.

Objectives: To describe the implementation of CRISP as an operational and educational model supporting clinical research workflows while providing structured training and mentorship for students pursuing careers in healthcare and research.

Methods: CRISP recruits and trains undergraduate and post-baccalaureate students through a standardized onboarding emphasizing research ethics, human subjects protections, study protocols, and clinical workflow integration. CRISP interns support multiple prospective studies through supervised activities including patient screening, enrollment coordination, data collection, documentation, and quality assurance tasks. Program infrastructure includes standardized operating procedures (SOPs), mentorship by project leaders and investigators, and centralized oversight to ensure regulatory compliance and data quality consistency across studies.

Results: Since implementation, CRISP interns have supported 80+ ED-based clinical research studies, expanding screening coverage across extended hours (7 days/week, 16h/day). The program has enabled scalable study support while supporting student development in clinical research operations, academic communication, and interprofessional collaboration. Pre-health Students gain longitudinal exposure to research methodology and clinical exposure in a busy ED setting, with many remaining engaged for multiple years.

Conclusions: CRISP demonstrates a sustainable model for integrating a structured student workforce into clinical research operations in a high-acuity clinical environment. The program simultaneously enhances research capacity and provides experiential learning opportunities aligned with workforce development in academic medicine. This model may be adaptable to other institutions seeking scalable approaches to support clinical research while provider clinical exposure to future healthcare professionals.

Area Level Deprivation and Stroke Prophylaxis for New Atrial Fibrillation in the Emergency Department

Author: Ky Bissell, Seiji Koike, Thuan Nguyen, Miriam R. Elman, Bradley Hopkins, Ashley Mora-Garcia, Bilal Sultan, Maja Strusinska-Thayer, Bory Kea

Background:Atrial fibrillation (AF) is an arrhythmia that increases stroke risk, which can be reduced by 64% with appropriate oral anticoagulation (OAC). Many patients are first diagnosed in the emergency department (ED), where treatment decisions rely on risk scores that exclude socioeconomic factors such as the Area Deprivation Index (ADI). ADI may influence providers’ decision-making and contribute to inequities in stroke prevention. We examined the relationship between ADI and OAC prescription among patients with newly diagnosed AF in the ED.

Methods:This retrospective chart review included patients >17 years with a primary ED diagnosis of AF or paroxysmal AF at an urban tertiary academic center and two community hospitals from 2020-2025. Patients with valvular disease or high bleeding risk were excluded. Demographics, comorbidities, and encounter-related outcomes were abstracted from electronic health records. ADI was linked to zip codes and grouped into tertiles. Multivariable logistic regression was used to analyze the association between ADI and OAC initiation, adjusting for CHA₂DS₂-VASc score, comorbidities, social history, and cardiologist recommendation.

Results: Among 683 eligible patients, the model showed a significant association between ADI and OAC prescribing. Compared with the highest ADI tertile, patients in the lowest tertile had greater odds of receiving an OAC (OR 2.0, 95% CI 1.0-2.7). The adjusted probability of OAC prescribing for the lowest tertile was 54.7% (95% CI 47.1–62.2%), the middle 46.2% (95% CI 41.1–51.3%), and the highest 42.8% (95% CI 35.4–50.2%). Higher stroke risk was also associated with OAC initiation; the odds of OAC prescription for patients with CHA₂DS₂-VASc >2 were greater than those with low risk (OR 2.5 95% CI 1.4–4.5). Cardiology consultation showed the strongest association with OAC prescription (OR 40.5, 95% CI 14.9–110.0).

Conclusion:Our findings suggest that there is an association between area-level deprivation and OAC prescription for patients with newly diagnosed AF, which warrants further study. 

Lead Screening in Patients with Gunshot Wounds

Author: Kristin C. Potter, Colleen Cowdery, Myra Khushbakht

Introduction: Over 120,000 people per year in the United States experience traumatic injury as a result of gunshot wounds (GSWs), and over 25% of this population will be hospitalized for their injuries. Amongst those with retained ballistic fragments, as many as 38% may experience elevated blood lead levels (BLLs) >10 μg/dL in the months following their injury. These patients experience symptoms of lead toxicity similar to other routes of exposure, and they make up nearly 5% of all exposures with BLL >80 μg/dL. Furthermore, patients with retained fragments are at risk of increasing BLL for several months post-injury due to oxidation, increasing risk of toxicity. In addition, although persons with retained bullet fragments are at higher risk of elevated BLLs compared to persons afflicted by GSWs without retained fragments, there have been multiple cases of elevated BLLs in these persons without retained fragments. To date, no unifying recommendations exist for screening patients with retained ballistic fragments, leading to a population in which lead toxicity may go undetected. In addition, underserved communities are disproportionately affected by gun violence, raising concern for increased susceptibility to lead poisoning in this at-risk population.

Methods/Proposal: We recommend patients with GSWs undergo screening with a BLL prior to hospital discharge. Those with high-risk retained fragments (intra-articular, intra-osseous, or vascular or CSF spaces) should undergo screening every 3 months for the first year. Lower-risk patients (with low-risk or no retained fragments) should be screened at 1-3 months and 6-12 months. Thereafter, patients and providers can share decision-making regarding future monitoring. Those with high-risk retained fragments, rising BLLs, or symptoms of lead toxicity should seek screening at least annually. Phase 1: Create and implement BLL screening within the trauma lab order set. Phase 2: Engage the Oregon Poison Center to validate screening guidelines. Phase 3: Coordinate with social work to design educational resources and discharge instructions. Phase 4: Collaborate with the Gun Violence Prevention Team of Multnomah County to expand into the community and additional care centers. Results: At this juncture, an initial lead level has been incorporated into the penetrating trauma order set. Oregon and Washington Poison Center faculty have validated the clinician guidelines for ongoing outpatient lead screening. Patient education resources have been distributed for social work to provide on discharge. 

Future Considerations: Following a period of successful implementation, we aim to expand our impact into other hospitals, including the other level I trauma center in the state. We also intend to engage local clinics for low-cost interval screenings with the help of the county’s gun violence support group. This study may also generate a population that the Oregon Poison Center wishes to track for outcomes and treatment purposes.

Ketamine Add-on Therapy for Established Status Epilepticus Treatment Trial (KESETT)

Author: Tiffany Nguyen, Dasha Kolpakov, Annick Yagapen, Mac Day, Bory Kea

Background: Status Epilepticus (SE) is a life-threatening emergent medical event that requires rapid intervention to prevent neuronal injury, circuit reorganization, or mortality. First-line treatment with benzodiazepine is typically effective, but a significant percentage of patients develop benzodiazepine-refractory SE and require a second-line intervention. A prior study, the Established Status Epilepticus Treatment Trial (ESETT), reported 45-47% efficacy for commonly used second-line treatments, including levetiracetam. Though these treatments are effective, their seizure termination rates are not ideal. This leads us to the addition of ketamine, a noncompetitive NMDA receptor antagonist, where clinical evidence suggests that it may provide antiseizure effects when combined with a benzodiazepine by targeting excitatory pathways that contribute to sustained seizures.

Objective: To evaluate whether adding ketamine (KET) to levetiracetam (LEV) is more effective than LEV alone in treating patients one year and older with benzodiazepine-refractory status epilepticus (SE). A secondary objective is to assess the effectiveness and safety of these treatments in pediatric patients. 

Methods: This is a multicenter, randomized, double-blinded, response-adaptive clinical trial run by two national emergency research networks, Strategies to Innovate EmeRgENcy Clinical Trials Network (SIREN) and Pediatric Emergency Care Applied Research Network (PECARN). The target population is adults and children age ≥1 year weighing ≥10 kg presenting to the Emergency Department with ongoing generalized convulsive seizures despite receiving an adequate dose of benzodiazepines within the preceding 5-30 minutes. Participants will be randomly assigned to one of the three treatment arms: (1) levetiracetam 60 mg/kg alone, (2) levetiracetam 60 mg/kg + ketamine 1 mg/kg, or (3) levetiracetam 60 mg/kg + ketamine 3 mg/kg. Study drug vials are identical in appearance and will be administered intravenously for over five minutes in tandem with the application of a Ceribell rapid EEG device. Following the treatment administration, participants are monitored for seizure activity and level of consciousness for 60 minutes. The primary outcome is termination of seizure activity beginning 15 minutes after study drug infusion and sustained for 60 minutes without additional treatment. 

Impact: This trial is expected to determine whether targeting NMDA excitatory pathways with ketamine improves seizure outcomes in benzodiazepine-refractory status epilepticus. If effective, the addition of ketamine to a second-line treatment may enhance its effectiveness for high-risk and time-sensitive SE cases in both adult and pediatric populations. KESETT represents a collaborative effort that hopes to inform future emergency medicine management of status epilepticus and future clinical treatment guidelines.

Before the Fall: Community-Based STEADI Screening to Identify Hidden Fall Risk Before ED Presentation

Author: Nathaniel Stanley, Ren Rosz, Hiroko Kiyoshi-Teo, Sarah Gold, Bory Kea

Background: Falls are the leading cause of emergency department (ED) visits for trauma among U.S. adults aged ≥65, and approximately one in four older adults fall each year.1 Multifactorial and multiple-component interventions can reduce fall rates among community-dwelling older adults.2 The CDC’s Stopping Elderly Accidents, Deaths, and Injuries (STEADI) initiative was developed as an evidence-based framework to screen, assess, and intervene for fall risk in clinical practice.3 However, fall-prevention screening remains inconsistently integrated into primary care.4 Community-based STEADI screening may extend fall-risk identification, education, and referral beyond primary care, creating an opportunity to reach high-risk older adults before injury or ED presentation.(5) 

Objective: To: (1) determine whether community-based STEADI screening identifies older adults with underrecognized fall risk; (2) characterize gaps among objectively measured fall risk, self-perceived risk, and primary care fall-prevention engagement; and (3) deliver and assess uptake of individualized, risk-based fall-prevention education in this setting. 

Methods: We conducted a pilot implementation study at five walk-in urban community events since November 2023. Adults aged ≥65 completed the 12-item STEADI fall-risk questionnaire, self-reported fall-risk perception items, and the Falls Efficacy Scale–International (FES-I). Participants then completed orthostatic blood pressure measurements and physical function testing, including the Timed Up and Go, 30-second sit-to-stand, and 4-stage balance test. Screening was followed by motivational interviewing and individualized, risk-based fall-prevention education. Scores ≥4 on the 12-item STEADI questionnaire were classified as high fall risk and scores ≤19 on the FES-I indicated a low concern about falling. Results: Of 187 attendees, 135 were eligible and 53 consented to participate. Mean age was 74.6 years, and 73% were female. The mean STEADI score was 5.6 (SD 3.9). Of all participants, 66% screened as high fall risk and only 45% reported discussing fall prevention in the prior year Half of high-risk participants (33% of all participants) did not perceive themselves to be at elevated risk. Despite objective high-risk status, 83% of high-risk participants had FES-I scores indicating low concern about falling. At least one follow-up survey was completed by 43.4% of participants. 

Limitations: As community health fair attendees, our sample likely represents a more ambulatory and independent subset of older adults, potentially underrepresenting those at highest risk and intersecting vulnerabilities. Limited resources for follow-up survey completion yielded lower response rates than anticipated, constraining longitudinal conclusions. 

Conclusions: Community-based STEADI screening identified substantial, often underrecognized fall risk among older adults, including individuals with limited recent primary care fall-prevention engagement. These findings suggest that community screening may serve as an upstream intercept point to identify hidden fall risk and provide evidence-based intervention before injury or ED presentation. Future work will expand screening to rural and high-burden communities and evaluate whether community-based STEADI improves fall-prevention engagement, evidence-based intervention uptake, and reduces fall-related ED utilization.

Opioid-Related ED Visits in Washington and Oregon Before and After Policy Changes: Comparison With Opioid-Related ED Visits Idaho Trends

Author: Myra Khushbakht

Introduction: In November of 2020, Oregon voters passed Measure 110, to decriminalize possession of drugs and went into effect in February of 2021. By August of 2024, HB 002 was passed, reclassifying drug possession as a misdemeanor, with many in the public citing concern for a surge in overdose rates. During about the same time period, Washington in 2021 had a Supreme Court decision that temporarily decriminalized drug possession with full recriminalization policies that took effect again with SB 5536 in 2023. Idaho has had no similar decriminalization policies. 

Question: Did recriminalization efforts in Washington and Oregon correlate with a change in opioid-related ED visits and was this meaningfully different in comparison to opioid-related ED visits trends in Idaho during this similar time period. 

Methods: Washington, Oregon, and Idaho geospatial data regarding opioid-related ED visits from 2019 to 2025 was used for this analysis. An annual year over year percent change was calculated for each state. Idaho was the comparison state since no decriminalization laws or policies were passed and a descriptive comparative exploratory trend analysis. In addition, a Pearson correlation coefficient was used to analyze year-over-year percent-change trends between the states. 

Results and Discussion: Between 2021-2023, Idaho had the largest divergence from Washington and Oregon. Between 2021 to 2022, around the time period after decriminalization took effect in Washington and Oregon, where rates increased by 22.6% and 12.8%, respectively, while Idaho decreased by 29.8%. There was no meaningful percent change after recriminalization around 2023 and 2024 between Washington and Oregon and Idaho, and opioid-related ED visits declined across all three states. Using the Pearson correlation coefficient, Washington and Oregon had strong positive correlation in year over year percent changes whereas no meaningful correlation was shown with either state to Idaho, which suggests that Idaho had a yearly pattern different from both states.

Comparing the effectiveness of a biomarker-plus-clinical guidelines algorithm versus clinical guidelines only for safely decreasing brain CT utilization during TBI evaluations: The PIONEER Comparative Effectiveness Study

Author: Fred Korley, Loren Myers, Maja Strusinska-Thayer, Bory Kea

Background: Traumatic brain injury (TBI) accounts for approximately 4.8 million emergency department (ED) visits annually in the United States, with 82% of patients undergoing head computed tomography (CT), despite 91% of scans demonstrating no acute intracranial pathology. The Canadian CT Head Rule (CHCTR) is an internationally recognized tool developed for the ED context to help clinicians in making head CT imaging decisions during the evaluation of adult minor head injury. Glial fibrillary acidic protein (GFAP) and ubiquitin carboxy-terminal hydrolase L1 (UCH-L1) are blood-based biomarkers that have been cleared by the FDA to aid in brain CT imaging decisions following trauma. They have demonstrated high sensitivity and negative predictive value exceeding 99% for clinically significant intracranial injury, offering a potential strategy to safely reduce unnecessary imaging . 

Objectives: To compare the clinical effectiveness, safety, and implementation feasibility of a biomarker-guided algorithm integrated with clinical decision rules versus clinical decision rules only in reducing low-value head CT imaging in ED patients with suspected mild TBI. 

Methods: The PIONEER study is a open-label, multi-center, matched-pair, cluster-randomized Type II hybrid implementation-effectiveness study, evaluating both the implementation process and clinical effectiveness of a biomarker-guided algorithm to reduce brain CT utilization in TBI evaluations. This will be conducted across six U.S. Emergency Departments and include at least 3000 patients. All six participating EDs will contribute baseline data for the first 6 months under usual care (clinical guidelines only). Beginning in month 7, two sites will transition to implementing the biomarker-guided algorithm. At month 13, two additional sites will implement the biomarker-guided approach, and the final two sites will transition at month 19. By the end of the 24-month rollout period, all sites will have implemented the biomarker-guided pathway. Adult patients (≥18 years) presenting with trauma and Glasgow Coma Scale scores of 13–15 are included. Exclusion includes planned CT maxillofacial, chest, or abdomen, or anticoagulant therapy, or trauma >24 hours. This pragmatic, open-label design allows real-world assessment of both patient-level outcomes (e.g., CT utilization, safety events) and implementation outcomes (e.g., adoption, fidelity, and provider-reported acceptability). The stepped-wedge design ensures that each site serves as its own control, enhances statistical power by leveraging within-site comparisons over time, and allows for staggered implementation that supports operational readiness and continuous learning. The primary endpoint is the proportion of eligible ED patients with suspected TBI who receive brain CT imaging. Secondary endpoints include proportion of eligible ED patients with suspected TBI who receive brain CT imaging and have a clinically significant traumatic lesion, ED length of stay, initial and sustained provider adherence at 6 and 24 months post-implementation, provider and nurse acceptability and feedback, and provider trust in biomarker-guided CT decision making. The study comparative arms include two clinical pathways. The first pathway will have a biomarker-plus-clinical guidelines algorithm that integrates point-of-care whole blood GFAP and UCH-L1 testing with established clinical decision rules to guide CT use in ED patients with suspected mild TBI (GCS 13–15). The second pathway will be a clinical-guideline only care pathway based on the Canadian Head CT decision rule. The study duration is four years, and the participant duration is six months.

Results (Anticipated): We hypothesize that implementation of the biomarker-guided algorithm will result in a ≥15% reduction in CT utilization without compromising patient safety . Additional anticipated benefits include improved ED throughput without increasing 30-day ED re-visits and hospitalizations, reduced radiation exposure, and high provider acceptability with integration into clinical workflows. 

Conclusion: The PIONEER study evaluates a novel, scalable approach to improving imaging stewardship in mild TBI by combining validated clinical decision rules with rapid biomarker testing. If effective, this strategy has the potential to reduce low-value imaging, improve operational efficiency, and inform national guidelines for ED management of head injury. Reference: All information is sourced from the study

Level-Loading Across a Health System: A Collaborative Model for Interhospital Transfers

Author: Obert Xu, Peter Graven, Beech Burns, Angela Alday, Alvaro Lewis, Matthias Merkel, James Clements

Background: The boarding of admitted patients in the emergency department (ED) is a serious patient safety issue in the United States, resulting in increasing wait times and morbidity and mortality rates and diminishing overall efficiency. Level-loading, the balanced allocation of patients across its hospitals within a healthcare system, represents one effective solution for alleviating the capacity imbalance but is filled with complicated managerial issues.

Objectives: To assess how new, system-wide level-loading programming affected patients at the quaternary academic health center in terms of transfer volumes, ED boarding times, hospital capacity and patient outcomes. 

Methods: A retrospective analysis took place over 28 months (September 2023 to December 2025), including a pre-intervention period followed by four consecutive Plan-Do-Study-Act (PDSA) cycles. The intervention included redesigning transfer workflows, integrating EMR functionality throughout the system, enhancing hospitalist oversight, establishing common communication protocols, and streamlining patient transport infrastructure. The primary outcomes to be assessed were transfer rates and ED boarding duration for transferred patients. Secondary and balancing measures were inpatient length of stay (LOS), early clinical deterioration (defined as rapid response activation or ICU transfer within 48 hours), mortality, readmissions, and adverse events related to transfer. 

Results: Number of transfers increased over tenfold from 1.5 to 14.9 a week (+1026%). ED boarding time for transferred patients decreased by 56%, from 6.5 to 2.9 hours, thus reducing the total boarding time by 7,523 boarding hours. The intervention allowed for approximately 2,292 inpatient bed-days to be preserved and an 8–16% increase in inbound transfers for complicated care cases. Transferred patients had shorter LOS (102.0 vs 162.5 hours) and less early clinical deterioration (1.2% vs 18.6%), and 30-day readmissions were less (14.7% vs 17.6%), when compared to pre-intervention patients. Notably, there were no increases in mortality and adverse event rates. Results of adjusted analyses indicated substantial decreases in ED boarding times (by 14.8 hours) and early deterioration among transferred patients. Conclusions: Introduction of a systematic approach among multidisciplinary level-loaders is useful in improving patient accessibility, expediting ED boarding and optimizing hospital capacity with no detrimental impact on patient safety. By transferring patients to different parts of a health system, both the level of patient care and the working efficiency are better. The model implies potential scalability and refining of its structure to further enhance healthcare delivery systems.

Emergency Department Care Differences for Abdominal Pain: A Multicenter Analysis of Language Based Disparities

Author: John Marshall, Olivia R. Willis, Victoria Caldera, Todd Ellingson, Jamie Kennel

Prior studies suggest that patients with a primary language other than English (PLOE) are less likely to receive the standard of care in the Emergency Department (ED) when presenting with abdominal pain. Existing studies have largely focused on single ED settings and opioid administration, prompting the need to examine additional care processes, including pain screening, imaging modality, length of stay, and analgesic administration. We conducted a retrospective cohort study of ED patients presenting with a chief complaint of abdominal pain from 2018 to 2024. We excluded interfacility transfers, patients who died in the ED, individuals with missing sex data, and those with documented analgesic allergies. Among 54,814 abdominal pain presentations, 42,038 met inclusion criteria across one urban and two suburban EDs. Outcomes included pain screening, diagnostic imaging, analgesics, opioid administration, and ED length of stay. Covariates included PLOE status, race, ethnicity, sex, and initial pain score. Descriptive analysis, logistic, and linear regression models were used to characterize the sample and assess associations while adjusting for clinical and demographic covariates. Descriptive analyses indicated that PLOE patients comprised 6,994 (17%) of the sample. Compared with non-PLOE patients, a greater proportion of PLOE patients were female (61% vs. 57%) and had documented severe pain (50% vs 46%), while a smaller proportion received pain screening (80% vs 86%). Regression analyses indicated several significant associations, including lower odds of pain screening (aOR 0.67; CI 0.62, 0.73; p < .001), opioid administration (aOR 0.83; CI 0.77, 0.89; p < .001), diagnostic imaging (aOR 0.88; CI 0.83, 0.94; p < .001), and a slightly longer average ED LOS (B -12.2; CI -18.55, -5.84; p<.001) among PLOE patients when compared with non-PLOE patients. The findings both reinforce previous evidence surrounding opioid administration in PLOE patients and signal a possible deficit in care in the management of ED abdominal pain, as evidenced by language-based differences in diagnostic and treatment approaches, particularly in pain screening. However, this potential deficit cannot be conclusively determined without comprehensive illness severity and outcomes data. Further research should be done to elicit those findings.

Impact of Sequential Workflow Interventions on Emergency Department CT Turnaround Times

Author: Alexandra, Morgan Black, Obert Xu, Beech Burns

Background: Computed tomography (CT) is essential for diagnostic decision-making in the emergency department (ED), yet delays between order placement, patient readiness, and scan initiation contribute to inefficiencies, prolonged length of stay, and ED crowding. Key sources of delay include unnecessary pre-scan laboratory requirements and limited real-time coordination between ED and radiology teams.

Objective: To reduce CT turnaround times by targeting three workflow intervals: order-to-ready, ready-to-CT start, and order-to-CT start.

Methods: We conducted a prospective, before-and-after quality improvement study in an academic adult ED with approximately 40,000 annual visits. Two sequential Plan–Do–Study–Act (PDSA) interventions were implemented: (1) removal of routine pre-scan laboratory requirements (January 2025), and (2) introduction of a real-time CT tracking column in the ED trackboard to improve coordination (February 2025). Data were extracted from electronic medical record timestamps for CT order, readiness, and initiation. Monthly median times were analyzed from baseline (January–December 2024) through post-intervention (February 2025–January 2026). Exclusion criteria included pediatric, trauma, stroke activation, and incomplete encounters.

Results: Median order-to-CT start time decreased from 58.5 to 46.5 minutes (20.5% reduction), with a further improvement to 37.5 minutes by January 2026 (35.9% overall reduction). Order-to-ready time improved from 19.5 to 13.5 minutes (30.8% reduction). Ready-to-CT start time decreased from 44.5 to 31.5 minutes (29.2% reduction), reaching 26 minutes in the final month (41.6% reduction). Order-to-ready time improved from 19.5 to 13.5 minutes (30.8% reduction).

Conclusions: Sequential workflow interventions targeting both pre-scan preparation and post-readiness coordination significantly reduced CT turnaround times in the ED. These improvements were durable and achieved without additional resources, demonstrating that targeted process optimization can meaningfully enhance imaging efficiency and ED throughput.

A Hybrid Physician‑in‑Triage and Rapid Medical Evaluation Model Reduces LBTC in a Crowded Community Emergency Department

Author: Kyle Taylor, Obert Xu, Joshua Johnson, Todd Ellingson

Hillsboro Medical Center Emergency Department (≈40,000 annual visits) faced persistent crowding, inpatient boarding, and limited front‑end capacity (16 treatment rooms, 4 hallway spaces, 2 triage rooms, a 4‑bed fast‑track, and a 9‑bed observation unit), contributing to delays in initial provider contact and elevated Left Before Treatment Complete (LBTC) rates. To address these bottlenecks, the ED repurposed a large treatment room into two chair‑based rapid evaluation bays and implemented a hybrid Physician‑in‑Triage (PIT) + Rapid Medical Evaluation (RME) model in which a PIT physician partnered with a dedicated RN to rapidly evaluate ESI 2–3 patients, initiate diagnostics and treatment, and disposition straightforward ESI 4–5 patients. Two PDSA cycles were executed: Cycle 1 (Nov 2024–Jul 2025) introduced 8 hours/day of PIT coverage; Cycle 2 (Jul 2025–Feb 2026) expanded to a waterfall schedule (9 hours Mon–Wed; 6 hours Thu–Sun) aligned to arrival surges, with the PIT space functioning as a rapid‑cycle flow cell parallel to fast track. The primary outcome, monthly LBTC, declined from 4.84% pre‑intervention to 4.70% during PDSA Cycle 1 and 3.34% during PDSA Cycle 2, representing a 31% relative reduction from baseline; this improvement was sustained for seven months. Notably, gains occurred despite increased monthly arrivals (pre: 3,293; PDSA 1: 3,479; PDSA 2: 3,447), suggesting that the PIT/RME model effectively mitigated front‑end congestion and improved early access to evaluation. Key lessons included that limited PIT space created bottlenecks during high‑acuity or high‑volume periods and that nursing workload was underestimated—PIT RNs required additional support for IV placement, medication administration, order execution, flow management, and chair turnover. For scalable, sustainable throughput, a larger dedicated front‑end evaluation area and a second support person (an ED tech or an additional RN) are essential. This hybrid PIT/RME approach offers a practical strategy to reduce LBTC and improve early ED access in space‑constrained community settings.

Re-designing Emergency Medicine Physician Schedules to Augment Emergency Department Capacity: A Pre/Post Evaluation of a Waterfall Schedule with Modified Physician-in-Triage (2022–2025)

Author: Emily Sykes, Obert Xu, Laura Chess, Tonya Brockman, Melinda Hartenstein, Beech Burns

Emergency department crowding compromises safety, patient experience, and operational efficiency. Boarding of admitted inpatients reduces available capacity, increasing waiting room congestion and delaying initial evaluation. In this condition, Left Without Being Seen (LWBS) becomes a sentinel failure of timely access. Although inpatient boarding is largely beyond direct ED control, front-end operational redesign can mitigate risks.

Two strategies with supportive but mixed evidence include: 1. Physician in Triage (PIT) to expedite medical screening and begin diagnostics earlier. 2. Physician Waterfall Scheduling (PWS) to stagger shift starts, smooth transitions, and align staffing with peak patient arrivals. We implemented a combined Physician Waterfall Schedule and modified Physician-in-Triage workflow to improve access, early engagement, and throughput during sustained crowding. Despite increased post-intervention demand, access and flow improved: LWBS decreased from 7.58 percent to 4.71 percent, a 37.8 percent relative reduction, meeting the predefined improvement target. LBTC decreased from 10.54 percent to 7.93 percent (24.7 percent relative reduction). Elopement decreased from 1.92 percent to 1.63 percent (14.9 percent relative reduction). AMA remained stable, approximately 0.96 percent to 0.99 percent. Discharge length of stay improved from 5.02 hours to 4.80 hours, a reduction of approximately 13 minutes. Door to disposition time remained stable, from 4.20 hours to 4.18 hours, reflecting persistent inpatient boarding constraints. Door to doctor time remained stable, increasing only slightly from 52 minutes to 53 minutes.

Breaking the bottleneck: a quality improvement initiative to reduce overnight CT turnaround times in the emergency department

Author: Grace Furnari, Obert Xu, Keith Cross, Louis P. Riccelli, Steven McGaughey, Jack Marshall, Kenneth DeVane, Skyler Kieran, Beech Burns

Background: Emergency departments nationwide face increasing patient volumes and imaging utilization, driving the need for improved operational efficiency. At our institution, delays between radiology resident preliminary reads and initiation of attending-level teleradiology (vRad) reviews contributed significantly to prolonged overnight CT turnaround times (TATs).

Objective: Reduce preliminary read to teleradiology request time by 25%.

Methods: Multiyear QI project using four sequential PDSA cycles. Interventions included: (1) ED order phrase signaling discharge intent; (2) automatic worklist-based referrals for prelim negative CTs; (3) an EMR-integrated track-board column providing real-time request status visibility; and (4) a radiology initiated “Request Nighthawk Read” button embedded in the radiology workflow.

Results: Among 12,126 encounters (baseline n=3,058; post n=3,698), median preliminary to request time improved from 30.5 → 21.6 minutes (−29.2%, p<0.001). CT order to result improved 157.3 → 130.0 min (−17.4%), and CT complete to result improved 84.2 → 72.6 min (−13.8%; both p<0.001). ED arrival to discharge decreased modestly (413 → 396 min). Teleradiology referrals increased 57% (255→396/month).

Conclusion: A low cost, EMR integrated, radiology initiated workflow significantly reduced delays in teleradiology requests, improving key CT turnaround metrics and supporting more efficient ED disposition.

Recurrent Seizures After Party Drug Ingestion

Author: Christopher Kennedy, Daniel Tirado, Rachel Castelli

BACKGROUND: Novel Psychoactive Substances (NPS) are designer drugs in the illicit drug market that mimic the effects of traditional illicit drugs such as cocaine, ecstasy, or cannabis, and can be associated with severe clinical effects. The legality of these NPS vary from state to state but are often sought as a “legal high.” These designer drugs are classified based on their chemical structure such as phenethylamines, amphetamines, synthetic cathinones, synthetic cannabinoids, piperazines, pipradrols/piperidines, aminoindanes, and tryptamines.

CASE REPORT: We present a case of a 20-year-old male with a past medical history of cocaine use who presented via EMS for witnessed seizures. Per EMS reports, the patient was at a “rave” the night prior and used “5-APB” and “DMNPC” with no other reported substances. Enroute, the patient had a seizure that was aborted after 7.5mg midazolam. A CT head did not show any acute intracranial pathology, and his mental status improved over the course of hours before he eloped from the emergency department (ED).

He was brought back to the ED a few hours later, close to 24 hours after his initial ingestion, via EMS for recurrent seizures witnessed by family. Shortly after arrival, another seizure was observed and was aborted after 6 mg IV lorazepam. His blood work showed a WBC 32.11cells x103/µL, sodium 135mmol/L, BUN 22mg/dL, creatinine 1.35mg/dL, bicarbonate 11mmol/L, pH 7.12, lactate 5.2mmol/L, creatinine kinase (CK) 1,004U/L and temperature of 101.7 ºF. He was evaluated by neurology who recommended a dose of lacosamide with no recommendations for ongoing antiepileptics following discharge. The poison center was consulted and recommended liberal benzodiazepine use and continued supportive care. 

Repeat labs 12-hours after admission showed worsening kidney function with a BUN and creatinine of 48mg/dL and 4.52mg/dL respectively, with a CK of 41,920U/L. He was transferred to the medical intensive care unit (MICU) due to his worsening kidney function where he became oliguric. His CK was greater than 60,000 U/L over three days, and his kidney function worsened with a peak BUN of 77 mg/dL and creatinine of 9.96 mg/dL. Despite his oliguria and worsening kidney function, he did not require CRRT or iHD, and his kidney function slowly improved with supportive therapy. 

Testing was performed and confirmed the presence of DMNPC parent compound, N,O-Dimethyl-4β-(2-naphthyl)piperidine-3β-carboxylate and its metabolite N-Methyl-4β-(2-napthyl)piperidine-3β-carboxylic acid. The metabolites of 5-APB including hydroxy-5-APB, hydroxy-dihydro-5-APB, and 2-(5-9aminopropyl)-2hydroxyphenyl)acetic acid were confirmed as well. 

DISCUSSION: This patient experienced recurrent seizures, severe rhabdomyolysis, acute tubular necrosis, and acute kidney failure after ingestion of novel psychoactive substances. The patient did not require invasive procedures for CRRT or iHD and made full recovery with supportive care.

CONCLUSIONS: Novel psychoactive substances are sought for a “legal high,” however they are associated with severe clinical outcomes and should be considered in cases of recurrent seizures and acute kidney failure.

Wernicke's Encephalopathy in a patient with cannabinoid hyperemesis

Author: Emily Mollenkopf, Kelsey Hilley

A 32-year-old female with a history of cannabinoid hyperemesis syndrome (CHS) and frequent ED visits for nausea and vomiting develops Wernicke’s Encephalopathy (WE) during hospital admission. The case underscores the importance of early recognition of thiamine deficiency syndrome in cannabinoid hyperemesis patients and a reminder of the potential dangers of administering dextrose-containing fluids without concurrent thiamine repletion.

Acute on Chronic Cyanide Toxicity Following Amygdalin and Coffee 'Parasite Cleanse’

Author: Myra Khushbakht, Colleen Cowdery, Courtney Temple

Background: Cyanide toxicity results in severe lactic acidosis and hypotension secondary to cytochrome c oxidase inhibition and impaired cellular respiration. Chronic cyanide toxicity has been demonstrated to cause encephalopathic features and in some cases pronounced metabolic derangement. We present a case of acute on chronic cyanide toxicity in the setting of chronic amygdalin ingestion, with documented cyanide and thiocyanate concentrations.

Case Report:  A 64 year old female presented with somnolence, confusion, and nausea, with last known well seven hours prior to hospital arrival. Initial vital signs were notable only for tachycardia at 120 bpm. Blood work revealed a lactate >15 mmol/L, pH of 7.23, bicarbonate of 10 mmol/L, and an anion gap of 29. A comprehensive urine drug screen, salicylate and acetaminophen concentrations, and lumbar puncture were unremarkable. After administration of intravenous fluids and antibiotics, repeat lactate improved to 11 mmol/L, but the pH remained unchanged. Her blood pressure subsequently decreased to 95/60, and her mental status worsened. Collateral information indicated that for three months, the patient had been performing an ongoing “parasite cleanse” involving coffee enemas and use of an unknown but escalating regimen of amygdalin. Her most recent increase in amygdalin dosing occurred six days prior to presentation.

Following admission to the intensive care unit, hydroxocobalamin was administered. Within 30 minutes, the patient was awake and speaking, with a blood pressure of 171/90 mmHg and heart rate of 102 bpm. Repeat lactate was 2 mmol/L, with a pH of 7.39 and an anion gap of 2. Serum cyanide concentration measured two hours prior to hydroxocobalamin administration was 1.2 mcg/mL, and decreased to 0.227 mcg/mL three hours after treatment. Twenty two hours post treatment, serum thiocyanate concentration was 20 mcg/mL.

The patient reported that her coffee and amygdalin cleanse was performed under the advice of an unlicensed individual in another state. She remained alert and hemodynamically stable, and subsequently self discharged the following morning. 

Discussion: This case illustrates an unusual but clinically significant presentation of acute on chronic cyanide toxicity resulting from continuous use of amygdalin, marketed in alternative medicine despite its known cyanogenic effects. The patient’s elevated lactate, wide anion gap metabolic acidosis, hypotension, and neurologic symptoms are consistent with chronic cyanide toxicity. Rapid clinical improvement following hydroxocobalamin administration further supports the diagnosis. Importantly, while cyanide is rapidly cleared from the bloodstream, thiocyanate, its primary metabolite, has a longer half-life and may serve as a more reliable biomarker in suspected chronic toxicity. Though cyanide concentrations were confirmatory, pending amygdalin concentrations may offer further insight into exposure timing and metabolism. 

Conclusion:  This case represents an uncommon case of acute on chronic cyanide toxicity with confirmed cyanide and thiocyanate concentrations. It underscores the ongoing risks posed by alternative therapies and reinforces the importance of considering cyanide toxicity in patients with unexplained metabolic acidosis and supplement use history.

T1 Weighted Basal Ganglia Hyperintensities Secondary to Chronic Dietary Supplement

Author: Christopher Kennedy, Matthew S. Correia

Background: Basal ganglia damage is often associated with a constellation of parkinsonian-like symptoms. Etiologies vary and include primary neurodegenerative, hepatic dysfunction, ischemia, and toxin mediated. The latter include carbon monoxide, copper, methanol, kratom and manganese. Manganism can present with cognitive abnormalities such as deficits in attention and memory; classically, it is associated with extrapyramidal movement abnormalities including bradykinesia, rigidity, postural instability and gait disturbance. 

Hypothesis: Chronic use of over-the-counter dietary supplements can result in hyperdensities on MRI due to manganese deposition. 

Methods: This is a case report of a 77-year-old female with a history of ethanol-induced cirrhosis who was referred to our outpatient medical toxicology clinic for an elevated blood manganese concentration. Neurology had previously evaluated her for mild cognitive impairment and workup was notable for an MRI demonstrating T1-hyperintensity in the basal ganglia along with an elevated whole blood manganese concentration. Other labs including heavy metal screen for mercury, arsenic, lead and copper were below detection limits, and her autoimmune workup was negative. 

Further history revealed she was taking an over-the-counter dietary supplement: Ligaplex II, which contained 35 mg of manganese (1,522% of the recommended daily value) for approximately 20 years. Her physical exam displayed mild stooped posturing with decreased arm swing. No other significant parkinsonian features were noted. 

She was given dietary guidance on high manganese containing foods. Manganese supplements are high risk in cirrhosis patients as manganese is excreted primarily via the bile and can gradually accumulate. Risk of chelation therapy with Na2Ca-EDTA outweighed potential benefits and para-aminosalicylic acid was contraindicated due to her liver disease. 

Results: Manganese concentrations were obtained via quantitative inductively coupled plasma-mass spectrometry (ICP-MS) with an initial whole blood concentration of 27.2 µg/L (Reference range 4.2 - 16.5 µg/L). Her neurologist instructed her to discontinue her supplement and her manganese concentration down-trended to 18.4 µg/L prior to outpatient toxicology evaluation. MRI-dementia protocol showed T1 hyperintensity of the bilateral basal ganglia most prominently involving the globus pallidus.

Conclusion: Chronic dietary supplements with elevated manganese content can result in mild cognitive symptoms and bilateral basal ganglia lesions without significant parkinsonism symptoms. 

Takotsubo Cardiomyopathy Following Intentional Clonidine Overdose: A Rare Manifestation of a Common Toxic Exposure

Author: Lily Sloan, Christopher Kennedy, Courtney Temple

Background: Clonidine toxicity typically presents with central nervous system depression, bradycardia, and hypotension. At higher doses, clonidine loses alpha-2 receptor selectivity, resulting in paradoxical alpha-1 activation and catecholamine surge. This pathophysiology may predispose patients to type II myocardial injury and stress-induced cardiomyopathy. Takotsubo cardiomyopathy is an uncommon sequela of toxic exposures and has been rarely associated with clonidine ingestion. 

Hypothesis: Clonidine overdose can cause Takotsubo cardiomyopathy in adults through catecholamine-mediated myocardial stunning. 

Methods: This is a single-patient case report from the Oregon Poison Center and an affiliated tertiary care medical center. Clinical data were obtained through chart review, as well as documentation from the poison center. Laboratory, electrocardiographic, and echocardiographic findings were reviewed to characterize the cardiac effects of clonidine ingestion. 

Results: A 20-year-old female with no cardiac history presented approximately four hours after intentionally ingesting 71 tablets of 0.1 mg clonidine. On arrival in the emergency department, she was lethargic with a heart rate of 30 bpm and systolic blood pressure of 100 mmHg. After administration of 1 mg atropine, her heart rate increased to 108 bpm with a systolic blood pressure of 150 mmHg. Laboratory evaluation in the ED demonstrated an elevated troponin at 222 ng/L that peaked at 624 ng/L. Her electrocardiograms revealed sinus bradycardia and QTc prolongation of 521 ms. 

During her admission a transthoracic echocardiogram identified hypokinesis of the basal segments of the left ventricle along with left ventricular systolic thickening, consistent with Takotsubo cardiomyopathy. The patient was treated with supportive care, including intravenous fluids and atropine. Vasopressors were not required. Over the next 48 hours, her heart rate and blood pressure normalized, and the patient was ultimately discharged in stable condition. 

Conclusion: This case represents a rare instance of Takotsubo cardiomyopathy following clonidine overdose in an adult patient. While pediatric cases have been described, adult presentations are exceedingly uncommon. The proposed mechanism involves catecholamine-mediated myocardial stunning secondary to alpha-adrenergic activation. Clinicians should maintain a high index of suspicion for cardiac complications, which could present from clonidine toxicity, particularly when troponin elevation or ECG abnormalities are present. Recognition of this potential complication may influence both diagnostic workup and monitoring in clonidine overdose patients.

Tizanidine Withdrawal in an Expectant Mother

Author: Daniel Tirado, Christopher Kennedy, Colleen Cowdery, Keahi Horowitz, Matthew S. Correia

Background: α2-agonist withdrawal may be seen in patients incorrectly self-administering prescription medications, prolonged infusions in the intensive care unit (ICU), or consistent use of adultered substances (e.g. street fentanyl). The withdrawal symptoms include hypertension, tachycardia, and anxiety. We present a unique case of chronic tizanidine misuse in an expectant mother and the complexities associated with managing her symptoms. 

Case Report:  

A 34-year-old female at 28 weeks of gestation presented to clinic with anxiety in the setting of longstanding tizanidine use disorder where she reported regularly insufflating 80mg per day. Our poison center was consulted for guidance to help taper her off tizanidine due to concern for fetal withdrawal. 

Eleven days thereafter, she presented to our hospital for detox at the recommendation of her addiction medicine specialist with involvement of our inpatient consult service. She began to withdraw within 3 hours of arrival. She was given 10mg IV diazepam and 12mg PO tizanidine with some improvement in her agitation and discomfort. Nevertheless, she ultimately left AMA that same day. Three days later, she again presented to our hospital and was admitted to the ICU for detox. She was started on a dexmedetomidine infusion with a rate up to 1.2mcg/kg/hr, and additionally received 32 mg tizanidine PO and 7 mg lorazepam over 24 hours. Her symptoms remained poorly controlled, and she subsequently signed out AMA after a 2-day admission. 

At 32 weeks of gestation, she was admitted a second time to an outside-hospital's ICU for planned detox. She was started on 1.4mcg/kg/hr dexmedetomidine, received a 260 mg phenobarbital bolus, clonidine patch, with additional PRN lorazepam and tizanidine. Her symptoms worsened following admission, and she was electively intubated for more aggressive treatment. She was maintained on 1.4mcg/kg/hr dexmedetomidine and 100 mcg/kg/hr propofol following intubation. Sedation was challenging to achieve despite the addition of multiple boluses of IV propofol, midazolam, and phenobarbital. The ICU team had difficulty weaning dexmedetomidine as decreased infusion dose rates resulted in her RAAS scores increasing to +1 or +2. Forty-eight hours following intubation, the patient requested via text that she be extubated and within hours, left AMA once again.

At 35 weeks of gestation, she underwent a scheduled cesarean section and was electively intubated for management of tizanidine withdrawal and detoxification while on midazolam and tizanidine infusions. The patient was extubated after 4 days and transferred to the medicine service with oral tizanidine but required re-escalation of care to the ICU for dexmedetomidine infusion, clonidine patches, and clonidine 0.6mg every 6 hours PRN. Eight days following her admission and delivery, she requested and was ultimately discharged from the hospital. 

Discussion: This patient exhibited severe α2-agonist withdrawal despite the aggressive use of α2-agonists and various GABA-A agonists in her care. 

Conclusion: Management of expectant mothers suffering from α2-agonist withdrawal poses a unique and challenging set of circumstances for management, as there is very little information available regarding best practices and outcomes. 

Naltrexone Precipitated Withdrawal Six Months After Long-acting Buprenorphine Injection Confirmed by Serum Quantification

Author: Christopher Kennedy,  Courtney Temple

Introduction: Long-acting injectable buprenorphine (Sublocade®) is used for both opioid use disorder and chronic pain. Product information describes prolonged opioid receptor activity for at least two months. Pharmacokinetic data indicates that clinically significant serum concentrations persist well beyond this period. We present a case of naltrexone precipitated opioid withdrawal after six months of buprenorphine abstinence. 

Hypothesis: Naltrexone initiation can precipitate opioid withdrawal six months after discontinuation of long-acting injectable buprenorphine.

Case: A 72-year-old male with pertinent past medical history of chronic back pain following prior laminectomy and alcohol use disorder presented to the emergency department with complaints of myalgias, anxiety and altered mental status. He previously received five monthly subcutaneous injections of buprenorphine 300 mg for chronic back pain. The final injection was given approximately six months prior to presentation. At a routine clinic visit, he was noted not to be taking opioid therapy and was started on oral naltrexone 50 mg daily for alcohol use disorder. About 45 minutes after the first dose, he developed significant symptoms and presented for evaluation. Initially alcohol withdrawal was suspected. Intravenous benzodiazepines (2 mg midazolam and 30 mg diazepam) and 260 mg phenobarbital were administered without improvement. Review of his medication history revealed prior Sublocade® exposure. A trial of sublingual 16 mg buprenorphine-naloxone (Suboxone) resulted in rapid improvement of all symptoms.

Results: Serum blood samples were analyzed via liquid chromatography/tandem mass spectrometry (LC-MS/MS) for buprenorphine, norbuprenorphine, naltrexone and 6-beta-naltrexol. Buprenorphine concentration was 2.7 ng/mL and norbuprenorphine was 0.65 ng/mL. The parent compound naltrexone was not detected. The active metabolite 6-beta-naltrexol was present at 66 ng/mL, confirming recent naltrexone exposure. Pharmacokinetics of long-acting buprenorphine at 300 mg predict serum concentrations of approximately 5 to 10 ng/mL during active monthly dosing. Modeled concentrations remain above 2 ng/mL for up to nine months after discontinuation. Serum concentrations of 2 to 3 ng/mL are considered sufficient to produce therapeutic opioid receptor occupancy. The measured concentration of 2.7 ng/mL was consistent with ongoing opioid activity during naltrexone administration. 

Conclusion: This case describes naltrexone-precipitated opioid withdrawal six months after the last Sublocade® injection. Rapid improvement with suboxone supported an opioid mediated mechanism. Clinicians should recognize that long-acting buprenorphine can persist at clinically active levels for many months and antagonists such as naltrexone may precipitate withdrawal. 

Exploratory Ingestion of 7-hydroxymitragynine Leading To Profound Respiratory Depression In Two Pediatric Cases

Author: Emilie Lothet, Courtney Temple

Background: 7-hydroxymitragynine (7-OH), a mu receptor agonist, is a naturally occurring alkaloid from the Mitragyna speciosa plant, commonly found in kratom products. 7-OH has a greater binding affinity for the mu opioid receptor and is now being produced and sold as an unregulated, high potency standalone product. In July of 2025 the U.S. Food and Drug Administration (FDA) issued a warning of the toxicological concerns around 7-OH as an emerging opioid threat. 

Hypothesis: Ingestion of 7-OH-containing products can lead to severe sedative hypnotic syndrome requiring naloxone infusion and intensive care monitoring in pediatric patients. 

Methods: This is a case series of two siblings, aged 20 months and two years, who received care from the Washington and Oregon Poison Centers following an exploratory ingestion of an unknown quantity of 7-OH–containing tablets. Case details were abstracted from Poison Center records. In both instances, the parents reported missing “7-hydroxymitragynine tablets,” although the exact number ingested by each child was unknown. Expanded drug screening was obtained for both patients. 

Results: Both children developed symptoms within approximately 10 minutes of ingestion, with notable somnolence, prompting EMS evaluation and transport to a healthcare facility. The 20-month-old was altered and hypotensive upon EMS arrival and responded initially to naloxone boluses but experienced recurrent desaturation events. He required three naloxone boluses before initiation of a continuous naloxone infusion, which was maintained for more than 12 hours until respiratory function stabilized. The two-year-old sibling required two naloxone boluses but did not require an infusion. Both children were discharged within 24 hours of the presumed ingestion time. Urine immunoassay testing was found to be positive for kratom and 7-hydroxymitragynine, conformation via liquid chromatography/mass spectrometry (LC/MS-MS) with a limit of detection of 1.0 ng/mL confirmed the presence of both mitragynine and 7-hydroxymitragynine. 

Conclusion: 7-OH-containing products can cause severe respiratory depression in young children, requiring intensive supportive care and, in some cases, prolonged naloxone infusion akin to opioid toxicity management. Clinicians should be aware of the potential severity of pediatric exposures, particularly given the increasing availability of concentrated 7-OH products. 

Exercise-Induced Neurocobaltism Associated With A Low Cobalt Concentration

Author: Emilie Lothet, Keahi Horowitz, Matthew Correia

Background: Cobaltism is a well-described syndrome with symptoms including cardiomyopathy, thyroid dysfunction, and neurotoxicity classically associated with serum cobalt concentrations greater than 10 mcg/L. Patients with cobalt-alloy orthopedic implants are at increased risk of developing systemic cobaltism, particularly in the setting of prosthetic wear and failure. However, it is believed that symptoms do not typically occur with serum cobalt concentrations less than 10 mcg/L. 

Hypothesis: Cobalt neurotoxicity can be observed even at mildly elevated serum cobalt concentrations. 

Methods: This is a single case report of a 49-year-old previously very physically active physician, with a remote history of a cobalt-chromium metal-on-metal hip implantation, who presented due to increased hip pain, fatigue, and cognitive functional decline. Her decrease in functionality corresponded to a strenuous mountaineering expedition. As part of her workup, a serum cobalt concentration and an MRI of the hip were obtained. Alternative diagnoses and sequalae of cobaltism were investigated by obtaining a brain MRI, thyroid function tests, and cardiac studies. The patient was managed in consultation with the Oregon Poison Center in the outpatient setting, throughout multiple admissions, and after explantation was performed. 

Results: Serum cobalt was mildly elevated at 7.1 mcg/L. A hip MRI performed after a period of intense exertion demonstrated early signs of synovitis near the prosthetic hip. Thyroid function studies and echocardiography were unrevealing. A brain MRI did not reveal an intracranial pathology. The patient was initiated on oral N-acetylcysteine (NAC) with minimal improvement. However, she became progressively more impaired in performing her professional and personal daily tasks prompting multiple hospital encounters where she received IV NAC with marginal improvement in functionality. Despite progressively increasing doses of oral NAC culminating at 1200 mg daily to mitigate her symptoms but her neurocognitive symptoms persisted to the point of being unable to perform her duties as a physician. She underwent a revision arthroplasty, where her prosthetic hip was replaced with a cobalt-free metal-on-plastic material. The operative site demonstrated early prosthetic failure and metal staining of the synovium. The patient’s neurocognitive symptoms progressively improved in the ensuing weeks. 

Conclusion: Despite not having a serum concentration greater than 10 mcg/L, patients with cobalt-based implants may still be at risk of developing cobalt neurotoxicity. 

Zonisamide-Induced Toxic Epidermal Necrolysis

Author: Emilie Lothet, Keahi Horowitz

Background: Zonisamide is a newer generation broad spectrum antiepileptic approved as an adjunctive therapy for seizures in 2000. Although newer generation antiepileptics have a greater safety profile, serious cutaneous adverse events have been linked to their use. The mechanism by which hypersensitivity reactions occur is ill-defined but is thought to be associated with accumulation of arene oxide derivatives. Zonisamide itself is also a sulfonamide derivative, potentially adding to the risk for hypersensitivity reactions. 

Hypothesis: Zonisamide can produce rapidly progressive toxic epidermal necrolysis. 

Methods: This is a single case report of an 80-year-old gentleman with a history of traumatic brain injury on alprazolam who presented with 3 to 4 days of fevers at home, sore throat, odynophagia, injected conjunctiva, and an erythematous, non-desquamating rash not involving the palms, soles or mucosa. The patient reported that his neurologist started him on zonisamide 24 days prior due to a breakthrough seizure. 

Results: On initial presentation, the patient was hemodynamically stable and afebrile but became progressively more tachypneic during his emergency department stay. His workup was notable for a creatinine of 1.4 mg/dL, elevated transaminases (AST: 924 U/L; ALT: 1538 U/L) and a total bilirubin of 4.7 mg/dL, but otherwise a normal white blood cell count without eosinophilia. His workup revealed an undetectable acetaminophen concentration, normal creatine kinase and hepatitis panel, proteinuria and hematuria on urinalysis, and a markedly elevated ferritin at 2617 ng/mL. Aside from zonisamide initiation, the patient did not have any other medication change, making an adverse drug reaction the most likely. The patient was started on steroids, prophylactic antibiotics, and N-acetylcysteine. Zonisamide was discontinued and he was initiated on lacosamide. Toxicology cautioned the use of lacosamide since it has also been associated with toxic epidermal necrolysis. The patient had a history of having tolerated lacosamide, so the primary team opted to continue lacosamide for seizure precautions. Despite maximal supportive care at a burn center, the patient continued to deteriorate, rapidly progressed to nearly 100% total body surface area involvement of desquamation by hospital day 4. He died 8 days after initially presenting. 

Conclusion: Although newer antiepileptics are considered to have a better safety profile, zonisamide is capable of producing profound and rapidly progressing toxic epidermal necrolysis. The initial presentation may be subtle or present as a mild allergic reaction. It is important for clinicians to be aware of this rare and potentially lethal hypersensitivity profile. 

Cardiac Arrest Secondary to Oral Lidocaine Ingestion

Author: Caroline Wight, Christopher Kennedy , Courtney Temple

BACKGROUND: Local anesthetic systemic toxicity (LAST) is a complication that must be mitigated when performing local or regional anesthesia. LAST can affect the central nervous system and cardiovascular systems through a classic continuum of symptoms that progress from peri-oral numbness and paresthesia, altered mental status, to seizures and cardiac toxicity with risk of cardiac arrest. Rarely, these life-threatening systemic symptoms can be observed after oral ingestion of local anesthetics.

CASE REPORT: We present a case of a 31-year-old female with a past medical history of autism spectrum disorder, bipolar disorder, and polycystic ovarian syndrome who suffered a cardiac arrest as the result of intentional ingestion of oral lidocaine as a suicide attempt. The patient called emergency medical services (EMS) after her suicide attempt. On EMS arrival, the patient was confused, agitated, and tachycardic. Shortly after the initial evaluation, the patient suffered witnessed seizures and became unresponsive. No pulse was appreciated. The patient received cardiopulmonary resuscitation (CPR) through Advanced Cardiac Life Support (ACLS) protocol with return of spontaneous circulation (ROSC) after one round of compressions. She was intubated in the field and transported to the emergency department (ED) for further medical care. An unmarked generic bottle was transported with the patient, which was reported to have contained the ingested lidocaine. The poison control center was consulted after arrival in the ED, who recommended treatment with one dose intralipid (1.5 mg/kg over 30 mins). The patient was admitted to the medical intensive care unit (MICU) for further medical care. No further seizures were observed during her hospitalization. While her clinical presentation was consistent with oral-ingestion associated LAST, a confirmation test was obtained through samples from the unmarked bottle and the patient. NMS 1876 expanded drug screen resulted presumptive positive for the following medications: caffeine, hydroxyzine, levetiracetam, lidocaine, and midazolam. Reflex testing for confirmation resulted with a concentration of 23 ng/mL of midazolam and 33 ng/mL of hydroxyzine; lidocaine was not seen in the reflex confirmation. Fluid from the unmarked bottle was sent to NMS lab for CRIM_26000 lab testing. This test confirmed the identity of the unmarked liquid as lidocaine by GC/MS and weight/volume determination.

DISCUSSION: While no blood concentration level of lidocaine was obtained, our patient’s history and clinical presentation was consistent with a severe presentation of LAST. By pursuing advanced testing for diagnostics, her blood screened positive for lidocaine, and confirmation testing on the liquid from the unmarked bottle was confirmed as lidocaine. After CPR with ROSC, treatment with Intralipid and supportive care in the MICU helped this patient to achieve a medical recovery after a life-threatening ingestion of oral lidocaine.

CONCLUSIONS: Although a rare mechanism to cause LAST syndrome, oral ingestion should be considered in the correct clinical setting. As in this case, oral lidocaine can have severe systemic consequences including death, so prompt diagnosis and treatment is critical to help patients survive toxic ingestion.

Education:

A Model Curriculum For An Emergency Medicine Resident Track In Global Health and Limited Resource Medicine

Author: Kali Schultz, Nikolai Schnittke

Audience and type of curriculum: This curriculum is designed for emergency medicine residents to pursue structured learning about topics in Global Health and Limited Resource Medicine.

Length of curriculum: The curriculum runs on a rolling 18-month cycle. This allows residents who join the track as late as halfway through second year of a three-year residency, to still have time to finish the curriculum. For residents who join the track soon after starting residency, this curriculum length offers spaced repetition with key topics covered twice during their residency.

Introduction: The field of Global Health (GH) focuses on “improving health and achieving equity in health for all people worldwide.”1 As a specialty, Emergency Medicine (EM) serves as a safety net for diverse and often underserved patient populations, and is therefore intimately linked with the challenges and lessons that can be learned from the study of GH. Despite the value and relevance of GH to an EM education, standardized residency curricula are rare and poorly described (2). In this manuscript, we describe a framework for a reproducible curriculum of a Global Health and Limited Resource Medicine (GH/LRM) Track. 

Research Methods: A pilot didactic portion of this curriculum was available to residents as optional instruction in the 2020-2021 academic year. This was then expanded into the GH/LRM track, which was formally implemented in the 2021-2022 academic year. Attendance logs and qualitative feedback were collected from attendees.

Results: Between July 2021- June, 2025, 19 residents attended one or more didactic sessions, and nine residents completed the didactic portion of the track by attending at least six sessions. 13/19 (68%) residents completed a summative survey. All respondents agreed or strongly agreed that the sessions were a valuable use of their time. 85% (11/13) agreed or strongly agreed that the sessions were applicable to their clinical practice. All of the respondents reported that they would have liked to attend more of the sessions, however time and scheduling was rated a significant barrier by 84.6% (11/13) of respondents. Seven residents have taught at least one GH/LRM topic. Five residents have completed an elective rotation relevant to GH/LRM. One resident completed the track.

Discussion: A GH/LRM didactic curriculum is a valuable tool for emergency medicine residents to explore the role of GH in their careers. The curriculum integrated asynchronous online resources with in-person didactic sessions, including discussions covering a variety of topics in GH/LRM that can inform residents’ future practice. Exploring global health concepts longitudinally allows integration of these concepts into clinical practice and exploration of future professional development and interests. Interested residents were able to apply the lessons learned from the curriculum by teaching GH/LRM relevant topics to others, and by completing a GH/LRM experience themselves. Time and scheduling were perceived as a common barrier to completing the didactic curriculum. Scheduling, cost, and institutional restrictions during the COVID pandemic posed a significant barrier to completing electives.

Wilderness Medicine Education for Laypersons: An Open-Access Community Event

Author: Gergana Alteva, Patrick Hamann, K.C. Hummer, Brian Drury

Wilderness and outdoor recreation are highly common among Oregon residents. These activities have predictable and recurrent patterns of injury, with Mount Hood notably being one of the most hazardous peaks in the United States. There is limited data on wilderness recreation-related injuries in the Pacific Northwest (PNW) region; however, national park data indicate that inadequate preparation, particularly during day hiking, is a leading reason for Search and Rescue (SAR) deployment. To address this gap, we developed an open-access layperson education event in wilderness medicine hosted at a PNW taphouse to be held in March 2026 called Bandages&Brews. This event features four hands-on stations: first aid kits and trail logistics, splinting, bleeding control, and head trauma. Stations will be staffed by medical students and medical professionals. Curriculum for each station has been developed with evidence-based guidelines, such as the Wilderness Medical Society Clinical Practice Guidelines. Participant learning will be assessed with a retrospective pre-post survey and a 60-day follow-up survey evaluating self-reported knowledge, confidence, and intended behavior related to wilderness and safety and medicine. At the event, an objective skills performance assessment will be available to supplement survey findings. Bandages&Brews is currently being advertised to running groups, climbing gyms, outdoor gear stores, and local community centers in the surrounding area. This novel initiative aims to improve layperson preparedness for wilderness recreation through hands-on skill teaching while also cultivating a culture of safety.

Preservation of Toxic Plants and Fungi for Medical Toxicology Training

Author: Courtney Temple

Background: Toxic plants and fungi are important causes of poisoning worldwide, yet medical trainees rarely encounter preserved specimens suitable for teaching. Fresh specimens rapidly degrade after collection, losing key morphological features necessary for identification. Traditional herbarium techniques flatten or distort specimens and eliminate three-dimensional structure, limiting their educational value. Emerging preservation techniques such as freeze-drying may allow long-term preservation of toxicologically relevant specimens while maintaining structural features. In parallel, digital imaging and three-dimensional scanning technologies offer the opportunity to create a permanent digital library of toxic species accessible for education and reference. This project aimed to develop a combined physical and digital preservation approach for toxic plants and fungi native to the Pacific Northwest.

Methods: Toxic plants and fungi of clinical relevance were collected from the Pacific Northwest based on known toxicologic significance. Specimens were preserved using a multi-step process designed to maintain morphology and durability. Fresh specimens were initially frozen after collection to stabilize structural features prior to processing. Frozen specimens were then processed using a laboratory freeze dryer to remove moisture while preserving shape and three-dimensional morphology. During drying, specimens were supported to minimize deformation. Following freeze-drying, surface stabilization techniques were applied using preservation sprays or sealants to improve durability and reduce fragmentation during handling and display. In parallel, specimens were digitally preserved using high-resolution photography and three-dimensional photogrammetry to generate detailed visual records and rotatable models. Physical and digital specimens were cataloged with species identification and toxicologic relevance.

Results: Freeze-drying preserved many key morphological features of toxic plants and fungi, including caps, stems, leaves, and overall structural form. Some specimens demonstrated partial shrinkage or discoloration depending on species and tissue composition. Surface stabilization improved structural durability of freeze-dried specimens during handling. Digital imaging and photogrammetry produced high-resolution visual records that allowed detailed examination of specimen morphology independent of physical degradation. Three-dimensional models enabled visualization of structural features from multiple viewing angles. Together, these methods produced a growing collection of preserved physical specimens and digital models suitable for toxicology education.

Conclusion: A combined strategy using freezing, freeze-drying, surface stabilization, and digital imaging allows preservation of toxic plants and fungi for educational use. This approach supports development of a physical teaching collection alongside a digital toxin library that may enhance training in medical toxicology and improve access to high-quality reference materials.

Qualitative Review and Joint Needs Assessment of Poison Centers in Thailand and Japan

Author: Myra Khushbakht, Courtney Temple, Rob Hendrickson

Introduction: Poisonings are a major global health emergency, responsible for more than 100,000 deaths each year, particularly in low-resource settings where access to toxicology expertise and poison center services is limited. The World Health Organization has emphasized that improving the management of poisonings is a priority area that requires additional training capacity and international collaboration. Despite this need, there are very few structured programs that connect U.S. medical toxicology training with global regions that carry the highest burden of toxic exposures. This project addresses the need for sustainable global partnerships in medical toxicology by approaching international collaboration through an equitable lens. 

Purpose: An in-person qualitative review was done to conduct a joint needs assessment and compare outcomes with Siriraj Thailand Poison Center and Japanese Poison Center in collaboration with the Oregon Poison Center. 

Methods: A systematic review of structural barriers and systems delivery was performed with both poison centers. In March and April of 2026, an in-person joint needs and capacity assessment was performed while visiting Thailand’s Siriraj Poison Center and the Japanese Poison Center. 

Results: Siriraj Poison Center is run by medical toxicologists and has a specialized laboratory integrated within the poison center. It is one of two poison controls in Thailand, and they have a formalized medical toxicology fellowship that includes simulation based education. Their specialists in poison information (SPI) are pharmacists and see about 25,000 cases a year. They also have an antidote system. They are self-supported in terms of funding, and also perform a regional case conference in English with Singapore. Identified areas of international collaboration includes ongoing case discussions, protocol sharing, data-sharing strategies, research topics in tylenol and scombroid poisoning, emergency preparedness, occupational and environmental health clinic training, and Specialist in Poison Information training. The Osaka branch of the Japanese Poison Center is run by pharmacists and has a mixed source of funding from both private and public funders. The subscription process to their poison center creates a unique quick feedback service directly to companies for any poison related concerns with products. They see about 20,000 cases annually, and they predominantly see unintentional pediatric ingestions. The most significant ingestions are related to agrochemicals. Identified areas of international collaboration include formal training, case conferences, funding models, electronic medical record development, staff capacity, and sustainable poison information resources. 

Conclusion and Next Steps: Both poison centers were run differently and had some overlap in terms of systems development needs. Thailand infrastructure integrated medical toxicologists and Japan was primarily pharmacist driven. Creating shared educational opportunities between programs can strengthen local capacity in the context of language and cultural sensitivity, broaden clinical understanding, and support long-term public health and research improvements.

 

Best Student Research Project: Maja Strusinska-Thayer “Clinical Decision Support Tool Impact on Emergency Department Returns in Low-Income Atrial Fibrillation Patients”

Best Resident Educational Project: Maddie Ryan “ OHSU Student Rotation Re-Imagining”

Best Resident Case Report: Tie between Alvaro Lewis “Fournier's Gangrene: Can't Miss Diagnosis, Can't Miss Sonographic Findings” and Jeffrey Phillips “Amoxicillin-Clavulanate-Induced Liver Injury with Cholestatic Pattern”

Best Resident Research Project: Berhane Hagos “University of California Summer Mentorship Program”

Best Fellow Quality Improvement Project: Tie between Michaela Go “Exploring Impact of Secure Chat Implementation on Emergency Department Communication” and Jack Marshall “The Impact of an Assigned Primary Care Physician on Return Visits to the Emergency Department”

Best Fellow Educational Project: Abiezer Disla “PEM PULSE: A Fellow-Led Innovation in Disseminating Pediatric Emergency Medicine Education”

Best Fellow Research Project: Keahi Horowitz “Clinical features of Paralytic Shellfish Poisoning cases from the 2024 Oregon outbreak”

Best Fellow Case Report: Colleen Cowdery “Caffeine clearance data utilizing in-line AAVV hemodialysis attached to VA ECMO outflow cannula”

Best Faculty Educational Project: Briana Miller “Cyberattack Preparedness: A Tabletop Simulation of Unexpected Electronic Health Record Downtime”

Best Faculty Research Project: Courtney Temple “Fentanyl Toxicity in Children Under Six: A Retrospective Analysis of Clinical Presentation and Outcomes”