EM Quick Hits 71 EMC²: Fever Without a Source, Coaching the EM Mind Part 1, Traumatic Pneumothorax Part 2, PECARN C-spine Rule, Medetomidine Withdrawal, EMS Handover
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Mar 10, 2026 
Adriana Rowe, an emergency medicine toxicologist, outlines metatomidine withdrawal signs and treatments. Andrew Petrosoniak, an emergency and trauma physician, breaks down traumatic pneumothorax physiology and chest tube vs pigtail decisions. Dr. Lazier, an emergency clinician-educator, walks a puzzling fever without source case that ends up West Nile. Rapid-fire segments also cover PECARN C-spine critiques and EMS handover tips.
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Recognize Metatomidine As A New Withdrawal Cause
- Metatomidine (veterinary alpha-2 agonist) adulterates street opioids and causes prolonged sedation plus a distinct withdrawal syndrome.
- Withdrawal features include severe tachycardia, hypertension, miosis, hypoactive delirium, and refractory vomiting.
Restore Alpha-2 Agonism For Metatomidine Withdrawal
- Treat metatomidine withdrawal by restoring alpha-2 agonism: clonidine orally if tolerated, or dexmedetomidine infusion (ICU) if severe or refractory.
- Use anti-dopaminergic antiemetics for vomiting; involve addiction and critical care early.
PCARN C-spine Rule Not Ready For Community Use
- The PECARN pediatric C-spine rule was derived in very high-risk pediatric trauma centers and may not generalize to community EDs.
- Applying it broadly risks large increases in imaging and harm without external validation or implementation data.