Contributor: Aaron Lessen, MD

Educational Pearls:

A 2025 multistate outbreak of infant botulism has been linked to ByHeart infant formula

• As of December 10-17th, there have been at least 51 infants with suspected or confirmed botulism who were exposed to this formula across 19 states

• All reported cases resulted in hospitalization but no deaths reported to date

Infant botulism

• Occurs when C. botulinum spores germinate in the infant's intestine, producing toxin

• Spores are classically found in honey but can also be in dirt or contaminated in infant formula

• Infants are particularly susceptible because their body can't neutralize the spores

• Symptoms may include initial constipation, poor feeding, weak cry, floppy movements, loss of head control, difficulty swallowing, generalized weakness, and respiratory compromise if progressive

• Can be treated with antitoxin

• Maintain a high index of suspicion for infant botulism in infants fed the recalled formula presenting with neuromuscular symptoms.

References

1. Human Foods Program. Outbreak Investigation of Infant Botulism: Infant Formula. U.S. Food and Drug Administration. Published 2025. https://www.fda.gov/food/outbreaks-foodborne-illness/outbreak-investigation-infant-botulism-infant-formula-november-2025

Summarized by Meg Joyce, MS2 | Edited by Meg Joyce & Jeffrey Olson, MS4

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Carepoint Journal Club is a quarterly series with discussions about a medical topic, brought to you by Carepoint's Emergency Physicians.

Contributor: Meghan Hurley, MD

Educational Pearls:

OTC Medications

• Dextromethorphan (DM)
  • Most common OTC cough suppressant
  • Minimal efficacy: Little evidence that it shortens the duration or severity of cough.
  • Potential side effects:
    • At recommended doses: Mild dizziness, drowsiness, GI symptoms
    • Higher doses: Decreased consciousness, dissociative effects
• Guaifenesin
  • Found in Mucinex and other severe cough/cold products
  • Thins secretions and loosens mucus in airways
  • No more effective than increasing oral fluid intake

Prescription Medications

• Codeine-containing products
  • Suppresses cough center in the medulla
  • Metabolized via CYP2D6 with significant differences in metabolism between individuals:
    • Low metabolizers experience little effect, high metabolizers have risk of increased toxicity
• Benzonatate (Tessalon Perles)
  • Topical anesthetic; inhibits pulmonary stretch receptors and reduces cough reflex.
  • Efficacy is mixed; no clear benefit over placebo.
  • Precautions: do not bite or chew; dangerous in children
• Inhaled/Nebulized Lidocaine
  • Used for chronic or refractory cough (patients with lung cancer, COPD)
  • Side effects: bitter taste, perioral numbness
  • Precautions: Keep patient NPO with continuous monitoring due to aspiration risk
  • Improvement usually within a few hours; duration of effect unclear

Children Over 1 Year

• Many children's OTC cough products are naturopathic and not FDA-approved.
• Other remedies:
  • Honey (only age >1 year; risk of botulism in infants), Vicks VapoRub on chest, thyme/honey/lemon tea mixture

Prolonged Cough

• Cough >2 weeks or post-tussive emesis → consider pertussis.
• Tdap immunity wanes over time; risk increases if Tdap is not received routinely.
• If pertussis is suspected, consider trial of a macrolide antibiotic.

References

1. Chong CF, Chen CC, Ma HP, Wu YC, Chen YC, Wang TL. Comparison of lidocaine and bronchodilator inhalation treatments for cough suppression in patients with chronic obstructive pulmonary disease. Emerg Med J. 2005 Jun;22(6):429-32. doi: 10.1136/emj.2004.015719. PMID: 15911951; PMCID: PMC1726806.
2. Havers FP, Moro PL, Hunter P, Hariri S, Bernstein H. Use of Tetanus Toxoid, Reduced Diphtheria Toxoid, and Acellular Pertussis Vaccines: Updated Recommendations of the
3. Lam SHF, Homme J, Avarello J, Heins A, Pauze D, Mace S, Dietrich A, Stoner M, Chumpitazi CE, Saidinejad M. Use of antitussive medications in acute cough in young children. J Am Coll Emerg Physicians Open. 2021 Jun 18;2(3):e12467. doi: 10.1002/emp2.12467. PMID: 34179887; PMCID: PMC8212563.
4. Malesker MA, Callahan-Lyon P, Ireland B, Irwin RS; CHEST Expert Cough Panel. Pharmacologic and Nonpharmacologic Treatment for Acute Cough Associated With the Common Cold: CHEST Expert Panel Report. Chest. 2017 Nov;152(5):1021-1037. doi: 10.1016/j.chest.2017.08.009. Epub 2017 Aug 22. PMID: 28837801; PMCID: PMC6026258.
5. Singu B, Verbeeck RK. Should Codeine Still be Considered a WHO Essential Medicine? J Pharm Pharm Sci. 2021;24:329-335. doi: 10.18433/jpps31639. PMID: 34192509. U.S. National Library of Medicine. Benzonatate capsule. DailyMed. Updated July 31, 2023. Accessed December 13, 2025. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=c21afd18-3b04-4f15-874b-25e0c768f801

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

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Contributor: Taylor Lynch, MD

Educational Pearls:

What is orbital compartment syndrome, and how is it assessed in the emergency room?

• Orbital compartment syndrome (OCS) is an emergent ophthalmic condition in which intraorbital pressure in the orbital compartment rises dramatically, compromising perfusion of the optic nerve and retina, leading to risk of irreversible vision loss.
• OCS occurs in the context of traumatic lesions with retrobulbar hemorrhage.
• Intraocular pressures (IOP) are measured via tonometry as a surrogate for intraorbital pressures, with emergent pathology being present when IOP exceeds 30-40 mmHg (normal being around 20 mmHg).

What might be some physical exam findings beyond increased IOP for orbital compartment syndrome?

• Proptosis (physical outward protrusion of eye) with resistance to being pushed posterior.
• Afferent pupillary defect (when the non-impacted eye has light shown into it, the impacted eye will have pupillary constriction, and when light is removed it will begin to dilate, but when light is shown into the impacted eye, it will not constrict and continue to dilate).
• Generalized complaints of vision loss or an inability to move the eye.

What is the treatment for orbital compartment syndrome?

• Lateral canthotomy must be performed immediately upon clinical suspicion as permanent vision loss can occur within minutes to hours.
• Lateral canthotomy Step-by Step:
  • Ideally have the patient sedated or highly cooperative.
  • Numb and vasoconstrict the surrounding eye/orbital skin tissue with lidocaine and epinephrine.
  • Take hemostats and clamp the interior and exterior eyelid at the lateral canthus at a 90º angle towards the orbital rim for 30-60 seconds to further devascularize the region.
  • Take iris scissors and cut laterally to the orbital bone/rim to reveal the lateral lanthal tendon.
  • Cut the inferior crus of the lateral lanthal tendon as this will provide the most significant reduction in IOP.
  • Reassess IOP during each step of the procedure to measure procedure efficacy. If no pressure reduction is noted with inferior cantholysis, cutting the superior crus of the lateral canthal tendon may be required to further allow the eye to bulge out and reduce intraorbital pressure.

Big takeaways?

• Ocular compartment syndrome is a rare but emergent vision threatening condition that requires immediate lateral canthotomy to reduce intraocular and intraorbital pressures.
• Lateral canthotomy done within 30-60 minutes of symptom development can save the patient from permanent vision loss.

References:

1. Mohammadi F, Rashan A, Psaltis A, et al. Intraocular Pressure Changes in Emergent Surgical Decompression of Orbital Compartment Syndrome. JAMA Otolaryngol Head Neck Surg. 2015;141(6):562-565. doi:10.1001/jamaoto.2015.0524
2. Haubner F, Jägle H, Nunes DP, et al. Orbital compartment: effects of emergent canthotomy and cantholysis. Eur Arch Otorhinolaryngol. 2015;272(2):479-483. doi:10.1007/s00405-014-3238-5
3. Bailey LA, van Brummen AJ, Ghergherehchi LM, Chuang AZ, Richani K, Phillips ME. Visual Outcomes of Patients With Retrobulbar Hemorrhage Undergoing Lateral Canthotomy and Cantholysis. Ophthalmic Plast Reconstr Surg. 2019;35(6):586-589. doi:10.1097/IOP.0000000000001401

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

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Contributor: Aaron Lessen, MD

Educational Pearls:

How do amiodarone and lidocaine work on the heart?

• Amiodarone
  • Blocks potassium channels (Class III effect).
  • Also blocks sodium and calcium channels.
  • Additional noncompetitive beta-blocker effects.
  • Stabilizes cardiac tissue, slows heart rate, and suppresses both atrial and ventricular arrhythmias.
• Lidocaine
  • Blocks fast sodium channels in ventricular tissue (Class Ib).
  • Shortens the action potential in ventricular myocardium, especially in ischemic tissue.
  • Suppresses abnormal automaticity in damaged/irritable myocardium.

Which one should you pick for a patient in vtach/vfib cardiac arrest?

• The current guidelines recommend amiodarone for shock-refractory cases but this is based on randomized trials showing better arrhythmia termination and short-term outcomes, but not long-term survival benefits.
• Two recent studies suggest that lidocaine might actually be preferable.
• A 2023 paper published in Chest
  • Performed a large retrospective cohort study for treating in-hospital VT/VF cardiac arrest.
  • Among more than 14,000 patients, lidocaine was associated with higher rates of ROSC, 24-hour survival, survival to discharge, and favorable neurologic outcomes.
  • These results held after adjusting for covariates and using propensity score methods. Overall, lidocaine outperformed amiodarone across all major clinical outcomes in this population.
• A 2025 paper published in Resuscitation
  • Performed a target trial emulation in adults with out-of-hospital shockable cardiac arrest.
  • After propensity score matching in more than 23,000 eligible cases, lidocaine was associated with higher odds of prehospital ROSC, fewer post-drug defibrillations, and greater survival to hospital discharge.
  • These advantages were consistent across matched patient pairs.
• Dose for lidocaine is an initial 1-1.5 mg/kg IV bolus, followed by additional boluses of 0.5-0.75 mg/kg every 5-10 minutes up to a total of 3 mg/kg if needed.
• Dose for amiodarone is a 300 mg bolus followed by an additional 150 mg bolus if needed.

References

1. Al-Khatib SM, Stevenson WG, Ackerman MJ, Bryant WJ, Callans DJ, Curtis AB, Deal BJ, Dickfeld T, Field ME, Fonarow GC, Gillis AM, Granger CB, Hammill SC, Hlatky MA, Joglar JA, Kay GN, Matlock DD, Myerburg RJ, Page RL. 2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: Executive summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Heart Rhythm. 2018 Oct;15(10):e190-e252. doi: 10.1016/j.hrthm.2017.10.035. Epub 2017 Oct 30. Erratum in: Heart Rhythm. 2018 Nov;15(11):e278-e281. doi: 10.1016/j.hrthm.2018.09.026. PMID: 29097320.
2. Smida T, Crowe R, Price BS, Scheidler J, Martin PS, Shukis M, Bardes J. A retrospective 'target trial emulation' comparing amiodarone and lidocaine for adult out-of-hospital cardiac arrest resuscitation. Resuscitation. 2025 Mar;208:110515. doi: 10.1016/j.resuscitation.2025.110515. Epub 2025 Jan 23. PMID: 39863130; PMCID: PMC11908894.
3. Wagner D, Kronick SL, Nawer H, Cranford JA, Bradley SM, Neumar RW. Comparative Effectiveness of Amiodarone and Lidocaine for the Treatment of In-Hospital Cardiac Arrest. Chest. 2023 May;163(5):1109-1119. doi: 10.1016/j.chest.2022.10.024. Epub 2022 Nov 2. PMID: 36332663.

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

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Contributor: Megan Hurley, MD

Educational Pearls:

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

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

Removal Techniques

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

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

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

References

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

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

Contributor: Aaron Lessen MD

Educational Pearls:

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

References

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

Summarized & Edited by Jorge Chalit, OMS4

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Contributor: Meghan Hurley, MD

Educational Pearls:

1. Initial Assessment

• Start with a physical examination:

• Determine if the bleed is anterior or posterior.

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

• Airway compromise = intubation immediately.

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

2. Topical Medications

• Anesthetics: provide local anesthesia and pain relief.

• Lidocaine

• Tetracaine

• Vasoconstrictors: reduce bleeding.

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

• Cocaine pledgets (less common).

• Tranexamic acid (TXA).

• Oxymetazoline (Afrin).

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

3. Technique Tips

• Use a nasal speculum.

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

• Place LET-soaked gauze in the nares.

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

• Note that pledgets may cause upper lip numbness

4. Reassessment

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

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

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

5. Packing

• If the above measures fail to control bleeding:

• Anterior packing:

• Nasal tampon (Merocel)

• Convenient for outpatient removal.

• Balloon device

• Inflate the anterior balloon for compression.

• Posterior packing:

• More complex, should consult ENT for additional assistance.

6. Disposition & Follow-Up

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

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

• Outpatient follow-up if stable:

  • Tampon: The patient can remove it at home.

  • Balloon: Return to ED for removal.

7. Risk Factors for Epistaxis & Prevention

• Deviated septum, dry environments, and anticoagulant use

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

References:

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

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

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Contributor: Travis Barlock, MD

Educational Pearls:

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

What are some of the key considerations in electrical burns?

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

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

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

Clinical Pearl on Voltage and Current:

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

References

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

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

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

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

Talk 1- Digoxin Overdose

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

• How does digoxin work?

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

• What are the EKG findings of digoxin toxicity?

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

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

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

Talk 2- Propranolol Overdose

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

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

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

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

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

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

References

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

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

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

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

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

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

Produced by Jeffrey Olson, MS4

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