Quick Hits: Airway update, headache guidelines, status epilepticus, nailbed repair, and shellfish allergies.
Hello Team,
Couple quick items from last shift.
Airway Management Update
This BMJ review provides a practical, evidence-based overview of contemporary airway management, including preoxygenation, apneic oxygenation, RSI medications, and intubation strategies.
Takeaway: Airway management continues to evolve, but success still depends on thoughtful preparation, physiologic optimization, and anticipation of difficult airways.
Status Epilepticus: Stop Seizures Early
One of the recurring themes in status epilepticus management is that delayed treatment leads to worse outcomes. The resources below emphasize a structured approach focused on rapid seizure recognition, prompt benzodiazepine administration, and early escalation to definitive therapy.
SimKit Podcast: https://simkit.co/airway-alchemy-status-epilepticus-intubation-and-management/
EMCrit Status Epilepticus: https://emcrit.org/ibcc/sz/
Takeaway: Time is brain—aggressive early seizure control is often more important than the specific medication chosen. Dose benzos appropriately. Don’t delay the Keppra.
NINJA Trial (Nail Bed Injuries)
The NINJA trial challenged several long-held practices in pediatric nail bed injuries. Routine replacement of the nail after repair did not improve outcomes, and the study supports a less invasive approach to many nail bed injuries.
Takeaway: Routine nail removal and replacement may not provide additional benefit. If the nail remains largely intact, it may already serve as the ideal biologic dressing.
Acute Migraine Management (2025 Headache Guidelines)
Recent headache guidelines highlighted evidence-supported therapies for acute migraine treatment in the ED. Dopamine antagonists, particularly prochlorperazine, are the most effective first-line options. Greater occipital nerve blocks may also have a role in selected patients. Diphenhydramine is no longer routinely recommended as an adjunct, and evidence supporting IV fluids remains limited. As a Reglan guy, this changed my practice.
Takeaway: Consider prochlorperazine as a first-line migraine therapy. Give a greater occipital nerve block a try. Ketorolac is a Level B adjunct. Consider dexamethasone to prevent migraine recurrence as part of your cocktail.
Shellfish Allergy and IV Contrast
The belief that shellfish allergy predicts reactions to iodinated contrast persists despite decades of evidence to the contrary. Shellfish allergy does not confer an increased risk of contrast reactions beyond that associated with other food allergies.
Updated consensus guidelines note that there is NO need to defer contrast or premedicate for those with a shellfish allergy. An article from 1975 propagated this myth…remember correlation does not equal causation.
Takeaway: Shellfish allergy alone is not a contraindication to iodinated contrast and should not alter imaging decisions
