Hani Kuttab · University of Wisconsin-Madison · PhdFit
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Hani Kuttab
· MDVerified
University of Wisconsin-Madison · Emergency Medicine
Hani Kuttab, MD, is an Assistant Professor in the Division of Emergency Ultrasound at the University of Wisconsin–Madison Department of Emergency Medicine. He completed his undergraduate studies with degrees in communication and molecular and cellular biology at the University of Illinois at Urbana-Champaign, followed by his medical degree at Loyola University Stritch School of Medicine. He then completed his residency at the University of Chicago Medical Center, serving as chief resident in his third year. Dr. Kuttab further specialized with a fellowship at the University of Wisconsin Hospitals and Clinics, focusing on ultrasound, resuscitation in sepsis, advanced echo applications, and ultrasound in medical education. He joined the ultrasound faculty at UW after his fellowship, during which he also served as a flight physician with UW Health Med Flight. Currently, he is the medical director for the emergency department and Med Flight at East Madison Hospital and serves as assistant director for clinical ultrasound at the same hospital. His research and clinical work emphasize ultrasound applications in emergency medicine, trauma care, and resuscitation, with a particular focus on portable ultrasound technology to improve patient outcomes. Dr. Kuttab is also involved in community health outreach and education, advocating for underserved populations. His contributions have been recognized with multiple awards, including the Rising Star in Clinical Practice Physician Excellence Award and the Ripple Faculty Award for Leadership & Service.
Facial fractures are common injuries in emergency departments across the United States. These can present various challenges for emergency medicine (EM) physicians and other healthcare providers. Managing these injuries can be complex which may be exacerbated by varying availability of specialist support, particularly in rural or community settings. This review aims to provide a comprehensive, evidence-based approach to the management of facial fractures for emergency medicine (EM) clinicians. This review highlights key principles in trauma evaluation, imaging, and indications for surgical consultation to improve decision-making and patient care. Facial fracture management begins with systematic trauma evaluation, prioritizing stability, hemorrhage control, and airway patency. Maxillofacial CT without contrast is the preferred imaging modality for most facial fractures with some requiring further imaging. Emergency physicians should recognize high risk features requiring surgical consultation, including displacement, malocclusion, and neurovascular compromise. Orbital and midface fractures may require ophthalmologic consultation if the patient presents with entrapment, globe rupture, or orbital compartment syndrome. In many cases, stable, non-displaced fractures may be managed outpatient with clear return precautions and outpatient surgical follow-up. This review is designed to be accessible and instructive for EM trainees and clinicians. These multidisciplinary guidelines provided can equip EM providers with the knowledge to safely and effectively triage facial fractures.
Western Journal of Emergency Medicine · 2025-05-19
articleOpen accessSenior author
INTRODUCTION: Point-of-care ultrasound (POCUS) is integral to emergency medicine (EM) training. It is unclear how EM residents use POCUS and how these skills are maintained as they progress in residency training. The purpose of this study was to evaluate resident use of POCUS at various timepoints in EM training. METHODS: This was a retrospective cohort study of EM residents at a single, three-year training program between July 1, 2014-June 30, 2022. Residents were included if they had completed three consecutive years of training and an ultrasound rotation in their postgraduate year (PGY)-1. The following time points were assessed: PGY-1 rotation and 3-, 6-, 12-, 18-, and 24-months post-rotation. Number of scans, accuracy of interpretation, acceptability for credit, and percentage of technically limited studies (TLS) were collected at each point. We analyzed performance characteristics using mixed-effects binomial logistic regression with time as a fixed effect and resident as a random effect. Models were fit separately for each performance characteristic and likelihood ratio tests were performed to determine whether performance varied over time. RESULTS: A total of 65 residents were included with a total of 13,229 exams performed during the study period. Cardiac and focused assessment with sonography in trauma examinations were performed most commonly. Overall accuracy of all exams during the examination period was 97.1% (95% confidence interval [CI] 96.2-98.0%), TLS was 14.5% (95% CI 9.7-20.6%), and acceptability was 82.9% (95% CI 76.3-88.2%). Trend over time (3, 6, 12, 18, and 24 months) found no differences in accuracy (P = 0.84), TLS (P = 0.20), or acceptability (P = 0.28). Further analyses by individual exam types also showed no significant differences in accuracy, acceptability, nor TLS. CONCLUSION: Accuracy, acceptability, and percentage of technically limited scans did not significantly vary over time, suggesting that POCUS skills are maintained from PGY-1 rotation to each time point evaluated in this study.
OBJECTIVES: While general agreement exists on many sepsis management principles, the details of early fluid resuscitation in sepsis remain contentious. The aim of the current review is to examine the impact of early (≤ 8 hr) fluid dosing, timing, and guideline-based resuscitation on mortality in sepsis. DATA SOURCES: PubMed, Scopus, Cochrane, and Google Scholar from January 1, 2000, to November 8, 2024. STUDY SELECTION: Randomized controlled trials and observational data, adjusting for confounding, for adults (≥ 18 yr) with sepsis. DATA EXTRACTION: From 2,169 citations, 30 studies with 119,583 patients were included. DATA SYNTHESIS: Dosing: three randomized trials suggest no mortality difference between more liberal (~43-72 mL/kg) vs. more restrictive (as low as 30 mL/kg) fluid resuscitative strategies (relative risk, 1.00 [0.81-1.24]). Eleven of 13 studies observed mortality risk when low-fluid volumes were administered (< 20 mL/kg; effect direction/sign test: p < 0.001). Six of 11 studies observed mortality risk when fluid volume dosing exceeded higher limits (> 45 mL/kg; p = 0.55). Timing: four of four studies observed a survival benefit with earlier completion of 30 mL/kg (within 3 hr; p = 0.12). Thirty mL/kg by discrete time: less than or equal to 1 and less than or equal to 2 hours-two studies observed survival benefit; less than or equal to 3 hours-one study observed survival benefit and three studies observed no mortality impact; and less than or equal to 6 hours-two studies observed a survival benefit, four studies observed no impact, and two studies observed increased mortality risk (both > 30 groups received > 50 and > 70 mL/kg). CONCLUSIONS: For fluid resuscitation within 8 hours of sepsis diagnosis: 1) randomized trials suggest no mortality difference between more restrictive and more liberal fluid resuscitative strategies (certainty of evidence: low); 2) dosing less than 20 mL/kg has an effect on increased mortality (low certainty); 3) observational studies trend toward increased mortality with higher volume resuscitation (> 45 mL/kg) but are not supported by randomized trials (very low certainty); and 4) survival benefit is observed when 30 mL/kg is completed within 3 hours (low certainty).
Peritonsillar abscess (PTA) is the most common deep neck space infection with ~45,000 annual cases in the United States and treatment costs exceeding $150 million USD [1]. Standard management typically involves surgical drainage by needle aspiration or incision and drainage [2]. However, emerging evidence suggests that many uncomplicated PTAs can be managed successfully with medical therapy alone [1, 3-9]. Several centers have adopted primary medical treatment algorithms, demonstrating reduced costs and minimizing overtreatment [1, 3]. This report presents preliminary findings from a quality improvement project evaluating whether a medical therapy algorithm, combined with close telehealth follow-up, can safely reduce unnecessary procedures and inter-hospital transfers for patients with small, uncomplicated PTAs. This study was designated a quality improvement project by the Institutional Review Board (ID: 2023-0874). A PTA medical therapy algorithm was developed by a multidisciplinary workgroup of emergency medicine physicians, otolaryngologists, and pharmacists based on evidence from prior publications [1, 4, 10] and implemented at a tertiary academic referral center beginning February 2024. Eligible patients presenting to an affiliated emergency department (ED) or requesting transfer from non-affiliated hospitals were managed according to this algorithm. At affiliated hospitals, the algorithm was embedded in the electronic record, allowing ED providers to initiate medical management without otolaryngology consultation. All transfer requests from non-affiliated hospitals or from affiliated hospitals without otolaryngology services were reviewed by the on-call attending otolaryngologists at the tertiary center for potential enrollment. The algorithm (Figure 1) applied to otherwise healthy adults with new-onset (i.e., not previously treated) PTA presenting with mild to moderate symptoms and abscess size ≤ 2.0 cm on computed tomography (CT) imaging. A 2 cm cutoff was selected based on prior literature [5, 7] and was agreed upon by the multidisciplinary workgroup as a pragmatic balance between patient safety—by restricting eligibility to lower risk, smaller abscesses—and provider acceptance, by choosing a threshold comfortable for clinicians accustomed to managing nearly all PTAs surgically. Discharged patients were scheduled for a phone or video telehealth follow-up appointment with an otolaryngology Advanced Practice Provider at the tertiary referral center, ideally within 48 h. Patients also received standardized discharge instructions outlining return precautions and clinic contact information. Outcomes were assessed through follow-up documentation or, if unavailable, by chart review. Treatment failure was defined as undergoing a salvage procedure (e.g., needle aspiration, incision and drainage) or developing a major PTA-related complication (e.g., airway obstruction, mediastinitis) within 30 days of initial presentation. Forty-eight patients were managed according to the algorithm (median age: 35 years; interquartile range: 26–49.5; 50% female). Thirty-seven patients (77.1%) presented to affiliated hospitals and 11 (22.9%) to non-affiliated hospitals. Notably, 27 patients (56.3%) presented to hospitals without otolaryngology services, which—prior to the algorithm's implementation—would have traditionally necessitated transfer for surgical drainage. The average distance from non-affiliated hospitals to the tertiary center was 48.4 miles (range: 22.3–85.2 miles). Medical therapy alone was successful for 43 (89.6%) patients. No major PTA-related complications occurred. Five patients (10.4%) experienced treatment failures: four underwent salvage incision and drainage within 48 h of initial presentation, and two required transfers from hospitals without otolaryngology services. Therefore, 25 of 27 patients (92.6%) presenting to hospitals without otolaryngology services were successfully medically managed locally without requiring transfer. Telehealth follow-up was completed for 28 patients (58.3%), with 16 (33.3%) patients completing follow-up within 48 h. Consistent with prior studies, this report suggests that surgical drainage can often be safely avoided for small (≤ 2 cm), uncomplicated PTAs, potentially reducing morbidity and healthcare costs of inter-hospital transfers [1, 3-7]. Southern California Kaiser Permanente Medical Group reported thousands of medically managed PTA cases, citing an 8.1% treatment failure rate [1]. In the present study, the medical treatment failure rate was 10.4%, and inter-hospital transfers were avoided for 92.6% of patients presenting to hospitals without otolaryngology services. Prior to implementation, our institution typically accepted most transfer requests from hospitals without otolaryngology coverage for surgical drainage of PTAs, including those with small (< 2 cm) abscesses. Although historical transfer rates for small PTAs were not captured and cannot be quantified retrospectively, our findings suggest that the algorithm enabled many of these patients to be safely managed locally without transfer. To the authors' knowledge, this is the first PTA medical therapy algorithm to incorporate telehealth follow-up. Telehealth appointments were used to evaluate treatment response, provide further education, and counsel patients on return precautions and signs of treatment failure (e.g., worsening throat or neck pain, worsening trismus, respiratory distress). Additional advantages of telehealth included improved clinic resource utilization and increased convenience for patients, particularly those referred from non-local hospitals. Although standardized discharge instructions were provided to all patients, scheduled telehealth follow-up served as an added safeguard by enabling timely reassessment and early recognition of treatment failure. This report describes preliminary findings from an ongoing prospective quality improvement study, with several limitations. Although standardized inclusion criteria were established, there was variability in decision-making across providers, and patients from outside non-affiliated centers were eligible only if the on-call otolaryngology attending was contacted. Data on transfer calls, excluded patients, and reasons for non-enrollment were not systematically available. A medical therapy algorithm with close telehealth follow-up may safely reduce unnecessary procedures and inter-hospital transfers for small, uncomplicated PTAs. Further patient enrollment will be important to confirm the safety and efficacy of the PTA medical therapy algorithm. The authors have nothing to report. The authors declare no conflicts of interest. The data that support the findings of this study are available from the corresponding author upon reasonable request.
