Emergency Medicine Journals

A short cut review of the literature was carried out to examine the evidence supporting the use of absorbable suture for definitive closure of facial lacerations. Two papers were identified as suitable for inclusion using the reported search strategy. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of the best papers are tabulated. The current evidence suggests that use of absorbable sutures for definitive wound closure in facial lacerations delivers comparable cosmetic outcomes, with no difference in reported complications. Use of absorbable sutures may be more cost effective, through avoidance of further downstream healthcare resource use. [...]

Editor’s note: EMJ has partnered with the journals of multiple international emergency medicine societies to share from each a highlighted research study as selected by their editors. This edition will feature an abstract from each publication. Annals of Emergency Medicine Official Journal of the American College of Emergency Physicians Intranasal versus subcutaneous ketamine for the treatment of acute traumatic pain in the ED: a randomised clinical trial Randa Dhaoui, Cyrine Kouraichi, Marwa Toumia, Khaoula Bel Haj Ali, Adel Sekma, Rahma Jaballah, Hajer Yaakoubi, Lotfi Boukadida, Kaouthar Beltaief, Zied Mezgar, Mariem Khrouf, Amira Sghaier, Nahla Jerbi, Imen Zemni, Wahid Bouida, Mohamed Habib Grissa, Jamel Saad, Hamdi Boubaker, Riadh Boukef, Mohamed Amine Msolli, Semir Nouira Study objective: To compare the efficacy and safety of subcutaneous versus intranasal ketamine in controlling pain following acute musculoskeletal trauma. Methods: We conducted a randomised, double-blinded, double-dummy prospective study, including adult... [...]

Background The optimal timing for initiating norepinephrine in sepsis remains unclear. This study aimed to assess the link between the timing of norepinephrine initiation (NE time) and the 28-day all-cause mortality in sepsis. Methods We conducted a prospective multicentre study. We recorded NE time, the 28-day all-cause mortality rate, the time to achieve a mean arterial pressure (MAP) >65 mm Hg, net fluid balance and lactate clearance. These parameters were compared between survivors and non-survivors. Cox regression analysis was used to determine their association with mortality. Results A total of 138 patients were included in the study. Non-survivors had a longer median NE time (98.5 min (IQR 60.0–131) vs 49.5 min (IQR 25.5–75.0), p [...]

Introduction The Global Burden of Disease Study has showcased the global impact of trauma, but underrepresented low- and middle-income countries lacking a trauma registry (TR), where 90% of injury-related deaths occur with the highest rate of disabilities and trauma care limitations.1 2 Traumatic injury is the seventh cause of death in Palestine, yet remains unexplored.2 The trauma care pathway in Palestine, particularly Gaza, has been severely compromised by the ongoing conflict, movement restrictions and limited resources. Relevant studies report inadequate documentation as another obstacle in Palestinian trauma care.3 4 We have formed a directory of trauma in the West Bank as the basis of the first Palestinian TR, labelled PTR1. Our group will disseminate our findings to describe this unique landscape of injury while informing local and global health decisions. Methodology This study is a retrospective... [...]

Advanced vascular access skills are an essential component of all critical care specialty curricula. However, common femoral artery (CFA) cannulation and sheath insertion has thus far not been emphasised within emergency medicine training. The advent of life-saving endovascular resuscitation techniques in both medical and traumatic disease, along with the inherent advantages of central arterial pressure monitoring in the severely haemodynamically compromised patient, mandates the prioritisation and deliberate practice of this procedure. CFA access facilitates central invasive arterial pressure monitoring as well as Seldinger-guided sheath insertion through which a number of resuscitation devices may be inserted further into the arterial system and left heart—termed ‘endovascular resuscitation’. Arterial line placement is considered core to emergency medicine training by Australasian College for Emergency Medicine (ACEM) and Royal College of Emergency Medicine (RCEM), but this is not specific to the skill of CFA access. Extracorporeal Membrane Oxygenation (ECMO) CPR is likely to become increasingly common in refractory cardiac arrest. ECMO is listed as a scope of practice skill for emergency medicine by ACEM. ECPR is now an American Heart Association (AHA) Class 2 recommendation for cardiac arrest. The ELSO registry reports indicate a steady increase in ECPR globally in the last 5 years. ECMO technology development and increasingly procedural and indication refinements will also likely mean this intervention will become simpler to perform and manage. There is an increasing focus on perfecting this skill prior to embarking on training programmes for endovascular resuscitation or ECPR in both the prehospital and in-hospital emergency medicine environment. We describe the key technical steps in performance of this procedure, discuss acquisition and maintenance of competency, and describe pitfalls. CFA access in emergency medicine has an increasing relevance to practice. It is imperative that this procedural skill is given diligence in training, process, governance and relevance to emergency medicine practice. [...]

Objective This study seeks to explore the experiences of emergency nurses in providing care to patients nearing the end of life and to identify the needs of emergency nurses in the palliative care (PC) process. Methods A qualitative meta-synthesis approach (following Enhancing Transparency in Reporting the Synthesis of Qualitative Research guidelines) was implemented to systematically review relevant qualitative studies. A comprehensive search was conducted across multiple databases, encompassing PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature; (CINAHL), PsycINFO, Web of Science, CNKI (China National Knowledge Infrastructure), Wanfang database and Scopus. The search duration was from database inception to March 2025. Results In total, 22 studies complied with the inclusion criteria and were included in the meta-synthesis. Three main themes were identified: (i) needs for emergency palliative care (EPC) and current practice in emergency departments (EDs); (ii) emotional, ethical and communication experiences of nurses in providing PC in EDs; (iii) nurses’ perceived needs for training, support and system coordination. Across studies, EPC in the ED was described as occurring alongside acute life-saving care. Nurses’ experiences and attitudes towards EPC varied significantly, ranging from positive engagement to perceived incompatibility with their roles in emergency care. Conclusion This meta-synthesis highlights the complexity of providing PC in EDs and the urgency of implementing systematic interventions. To enhance the effectiveness and quality of EPC, it is necessary to provide systematic support and targeted strategies, thereby helping emergency nurses better meet the needs of patients at the end of life. PROSPERO registration number CRD420251008755. [...]

We suggest that low-cost innovations, termed as frugal, when diffused from low-income and middle-income countries to high-income countries, offer an opportunity to diversify sources of ideas and solutions in emergency medicine. We outline examples from a preliminary search of the literature, consider the barriers faced by such innovations and suggest what needs to be done to improve their chances of being considered for use in emergency medicine. [...]

Endovascular treatment of medium-vessel-occlusion strokes (ORIENTAL-MeVO) by Hu et alTopic: strokeOutcome rating: head turner Evidence for endovascular thrombectomy in medium-vessel occlusion stroke has been inconsistent, despite these occlusions accounting for 25%–40% of ischaemic strokes. Recent randomised trials have largely been neutral or negative, leaving uncertainty about which patients may benefit most. Endovascular treatment in acute intracranial distal medium vessel occlusion stroke (ORIENTAL-MeVO) was an open-label, blinded-outcome RCT conducted at 48 centres in China. Adults treated within 24 hours of symptom onset with moderate-to-severe stroke (NIH Stroke Scale (NIHSS)≥6) due to medium-vessel occlusion were randomised 1:1 to thrombectomy plus medical management or medical management alone.1 The primary outcome was functional independence (Modified Rankin Score (mRS) 0–2) at 90 days. Among 563 patients (median NIHSS 10; 36.6% receiving intravenous thrombolysis), functional independence was achieved in 58.6% of the thrombectomy group versus 46.6% of controls (adjusted rate... [...]

"She said lorazepam twice a day and something about diplo- or diclofenac," said a flight attendant quietly a few rows behind me. I was half asleep in seat 35F of the commercial twinjet, on the way home to Georgia on a chilly December evening. Minutes later, the overhead rang. "If there are any doctors or nurses on board, please press the call button." On a flight out of Boston, the odds were in the patient’s favour, I thought. Surely, a healthcare provider from one of the 25 metro-area hospitals would respond. I didn’t press the button. I felt suspended between roles: trained enough to recognise an emergency, but uncertain whether I possessed the earned authority to act. As the flight attendant walked past again, a pace brisker than usual, I stopped her. "Excuse me," I said. "I’m a medical student, not licensed or anything, but uh, if you need... [...]

Tracheal intubation in critically ill patients carries a high risk of peri-intubation hypoxaemia.1 Effective preoxygenation is essential to extend safe apnoea time and reduce the risk of desaturation during airway management. Recent studies in emergency departments and intensive care units have shown that non-invasive ventilation (NIV) with positive end-expiratory pressure (PEEP) significantly reduces hypoxaemia compared with conventional approaches like non-rebreathable face masks (NRM).1 2 Although NIV is increasingly used in hospitals, it may be unavailable or impractical in prehospital settings, where airway interventions are still common. A retrospective analysis of over 227 000 Emergency Medical System (EMS) missions in Germany found that 8% of patients required advanced airway management.3 Prehospital intubation is often more complex than in-hospital procedures and associated with a higher risk of hypoxaemia.4 5 Despite this, little is known about preoxygenation strategies used in prehospital... [...]

In this month’s EMJ, we are reminded that emergency care is not only about providing the best medical care to our patients, but also addressing the needs of nursing staff, trainees and the public. We guarantee that several articles will be relevant and topical for your next shift. Intravenous opiates are often used for treating severe pain; however, most of us would undoubtedly have seen the associated risks firsthand—particularly in older, frail adults. In patients with hip fractures, use of regional anaesthesia is recognised as a safe, effective and opiate-sparing analgesic strategy, but is it more effective? In our Editor’s choice, Sri-on and colleagues present their randomised trial examining pericapsular nerve group (PENG) blocks versus intravenous morphine for hip fractures. Their findings suggest that the PENG block is safer and more effective at providing earlier and longer-lasting analgesia. Given that there is also evidence that PENG blocks are more... [...]

Aim Resident doctors in their 3rd year of emergency medicine training in the UK face multiple challenges, leading to very high levels of burnout and exodus from the training programme. The North West School of Emergency Medicine trialled reflective practice (Balint) groups to try and help this. This involves regular small group meetings focusing on case-based reflections on the emotional aspects of practice. We aimed to explore the impact of Balint groups on emergency medicine resident doctors. Methods Qualitative study involving semistructured interviews with resident doctors in their 3rd year of training (ST3) in the UK. Participants included those who had undertaken Balint group sessions, ST3s who did not participate, and Balint group facilitators. Interviews were recorded, transcribed and analysed using reflexive thematic analysis. Findings 12 participants were included between September 2023 and May 2024. They reported Balint groups to be a hugely positive part of their training. Participants developed a psychological toolkit and a supportive community to help manage the emotional and stress-related aspects of emergency medicine. This led to improved job satisfaction, which participants believed would enhance retention. Participants felt their ability to manage the emotional needs and challenges of their patients had improved. The groups were feasible to run but required planning and communication to facilitate release from clinical work. Conclusion Balint groups for ST3 emergency medicine resident doctors are feasible. Clinicians report benefits for themselves and perceived benefits for their patients. This supports continuing and developing the programme locally and piloting similar programmes in other professional groups and localities. [...]

Academic Emergency Medicine, Volume 33, Issue 9, September 2026. [...]

Academic Emergency Medicine, Volume 33, Issue 9, September 2026. [...]

Academic Emergency Medicine, Volume 33, Issue 9, September 2026. [...]

ABSTRACT Objective The Tetanus, Diphtheria, Pertussis (Tdap, “tetanus”) vaccine is recommended for adults every 10 years. In a national sample of adult emergency department (ED) patients, we sought to determine (1) knowledge and up-to-date status of the tetanus vaccine; (2) reasons for nonreceipt of the vaccine; (3) vaccine acceptability if offered in the ED; and (4) reasons for nonacceptance in the ED if offered. Methods This was a cross-sectional survey study among non-critically ill adults at 10 US EDs, asking questions about knowledge, receipt, and acceptability of the tetanus vaccine. Vaccine receipt was determined by self-report. Aggregate responses are reported as descriptive statistics. Logistic regression modeling was performed, and data are presented as adjusted odds ratios (aOR) with 95% confidence intervals (CIs). Results Of 4326 patients approached, 3285 (75.9%) agreed to participate, and 5 were excluded because of incomplete responses. Among 3280 participants, 13.4% had not heard of the vaccine; and 58.0% were not up-to-date. Factors associated with not being up-to-date included age 34–48 (aOR 0.65; 95% CI 0.53–0.81), African American race (aOR 1.46; 95% CI 1.19–1.79), no primary care doctor (aOR 1.29; 95% CI 1.04–1.61) and no insurance (aOR 1.86; 95% CI 1.36–2.56). Among participants not up-to-date, 21.6% would accept it during their ED visit. Primary reasons for nonacceptance were needing more information, concerns about side effects, and preference to get it from their doctor. Conclusions Over half of adult ED patients are not up-to-date on the tetanus vaccine but only one-fifth would accept it if offered during an ED visit. ED-centered efforts to increase uptake should provide messaging to address vaccine hesitancy. [...]

Academic Emergency Medicine, Volume 33, Issue 9, September 2026. [...]

Academic Emergency Medicine, Volume 33, Issue 9, September 2026. [...]

Academic Emergency Medicine, Volume 33, Issue 8, August 2026. [...]

ABSTRACT Emergency departments (EDs) are increasingly sites of interaction between clinicians and federal immigration authorities. Recent shifts in federal enforcement policy have intensified these encounters. Patients now more frequently arrive in custody, accompanied by immigration enforcement officers who may assert control over communication, decision-making, or access to patients. These circumstances introduce challenges for maintaining standard clinical practice. Clinicians may encounter situations in which patient confidentiality, informed consent, and independent medical judgment are difficult to operationalize in the presence of immigration enforcement officers. In addition to impacts on patient care, these encounters may contribute to clinician moral injury and distress, particularly when emergency medicine (EM) clinicians feel pressured to compromise patient privacy, deviate from standard practices, or navigate conflicts between enforcement priorities and patient care priorities. Uncertainty regarding institutional policy and the appropriate limits of immigration enforcement authority may exacerbate tensions related to liability and compliance. For patients, disruptions in care and delays in treatment may increase the risk of adverse outcomes. In response to these urgent concerns, the National Immigration Law Center (NILC), a leading advocacy organization in U.S. immigration, has developed Advocating On Behalf of Patients in ICE Custody: A Resource for Health Care Providers and Medical Staff, a national resource guide outlining practical considerations for clinicians and healthcare institutions caring for patients in immigration custody. In this commentary, we build on this resource to provide practical, bedside-oriented guidance for EM clinicians when interacting with immigration enforcement officers or caring for patients in immigration custody. We examine the implications of immigration enforcement within healthcare settings while articulating a path forward that protects patient rights, clinical integrity, and the ethical foundations of medical practice. The following highlights clinical questions that EM clinicians may have when caring for patients in immigration custody or interacting with immigration enforcement officials in hospital settings. [...]

Academic Emergency Medicine, Volume 33, Issue 8, August 2026. [...]

Academic Emergency Medicine, Volume 33, Issue 8, August 2026. [...]

Academic Emergency Medicine, Volume 33, Issue 8, August 2026. [...]

ABSTRACT Background Low back pain (LBP) is a common reason for presentation to an emergency department (ED) but LBP-care in this setting is frequently low-value, costly and often fails to meet system and patient needs. Other service options are urgently required. This study evaluated a novel care pathway that diverted people with suspected non-serious LBP seeking ED-care to a community-based, hospital avoidance service in a large South Australian health network. Methods A retrospective quantitative analysis was conducted on data extracted from electronic medical records (demographics, service activity, subsequent presentations/admissions) for patients seen March–December 2024, and analyzed using descriptive statistics. Repeated measures analysis of selected EQ-5D-5L items (pain/discomfort, usual activities, anxiety/depression) was conducted using the Wilcoxon signed-rank test. Semi-structured interviews undertaken May-Nov 2024 with consecutive eligible patients explored experiences of care via qualitative thematic analysis. Results There were 143 patients (mean age = 52.1 years, SD = 19.0) managed via this pathway. All received multidisciplinary care and 101 (78%) registered for digitally supported follow-up. Patients reported significant improvements in pain/discomfort and usual activities (p  [...]

Ventriculoperitoneal (VP) shunts are the most commonly used surgical treatment for hydrocephalus. Although generally safe and effective, they may be associated with a variety of abdominal complications, including infection, pseudocyst formation, bowel obstruction, and, rarely, gastrointestinal perforation. Bowel perforation occurs in approximately 0.1–1% of patients with VP shunts but carries significant morbidity due to the risk of ascending central nervous system infection. Transanal extrusion of shunt tubing is an uncommon but pathognomonic manifestation of bowel perforation and requires prompt recognition and surgical management. [...]

Opioids still have a role in treating severe ischemic pain during acute myocardial infarction. Their gastrointestinal effects, however, may slow absorption of oral P2Y12 inhibitors and postpone platelet inhibition at a time when antiplatelet loading and percutaneous coronary intervention often occur close together. [...]

One common maxim in clinical medicine is that the sickest patient in the emergency department may be in the waiting room (termed: waiting-room maxim). The purpose of this commentary is to discuss five pitfalls related to the waiting-room maxim that can sometimes transform a fundamentally smart idea into a popular misconception. Brevity makes a maxim powerful, yet also creates limitations by leaving out elaboration, logic, and evidence. [...]

Pediatric patellar injuries are common causes of anterior knee pain in children and adolescents and are frequently encountered in emergency and acute care settings. These conditions range from load-related overuse syndromes to acute traumatic injuries requiring timely recognition and referral. Unique features of the skeletally immature knee, including evolving ossification centers, open physes, and cartilaginous structures, may complicate diagnosis and contribute to missed or delayed recognition. [...]

We thank Mahida and Jagtap for their thoughtful letter and careful review of our study (1). We welcome the opportunity to clarify several methodological points. Our responses to each issue raised are provided below. [...]

Sexual assault (SA) remains a major public health issue, yet only a fraction of survivors seek acute medical care in emergency departments (EDs). Although prior studies describe demographic disparities among SA survivors, national patterns of ED arrival timing and operational implications for emergency care systems remain poorly characterized. [...]

Shoulder dislocation is among the most common major joint injuries encountered in emergency medicine and remains a core procedural competency for emergency physicians. Despite its frequency, successful reduction is often influenced by far more than the position of the humeral head alone. Pain, involuntary muscle guarding, patient anxiety, associated injuries, clinician experience, available resources, and emergency department workflow collectively determine whether reduction is straightforward or unexpectedly challenging. [...]

Routine diagnostic testing for asymptomatic adults with markedly elevated blood pressure (BP) in the emergency department (ED) imposes a substantial operational burden despite uncertain clinical benefit. [...]

: Several scoring systems have been developed and are used to aid in the differentiation of necrotizing soft tissue infection (NSTI) from non-necrotizing soft tissue infections; however, their diagnostic performance in patients with clinical suspicion of NSTI requiring surgical evaluation remains uncertain. [...]

Delays in analgesia remain common after traumatic injury, but whether greater injury severity is associated with faster analgesia is not well defined. [...]

Pyelonephritis with concurrent ureterolithiasis is associated with substantial morbidity and mortality, yet data on using point-of-care ultrasound (POCUS) to evaluate these patients are limited. [...]

The COVID-19 pandemic has turned out to be a huge challenge and a burden for medical services struggling with a huge number of patients and their ailments [1]. Currently in addition to the ever-growing number of COVID-19 cases related to the next wave, our attention should also be paid to patients who will struggle with a number of POST-COVID-19 complications. The implications of COVID-19 infection are continually being studied, both in terms of the frequency with which they occur and the mechanism by which they occur. [...]

This study aimed to examine the usability, feasibility, acceptability, and appropriateness of the information and communication technology for emergency medical services (ICT-EMS) systems to improve the transportation of emergency patients during the COVID-19 pandemic. [...]

The COVID-19 pandemic can exacerbate underlying substance use disorder and has impacted this vulnerable population in a variety of ways. There are limited data regarding how this pandemic has impacted emergency department (ED) patient presentations. [...]

Coronavirus disease 2019 (COVID-19) is primarily a febrile respiratory illness first documented in December 2019 in Wuhan, China that was declared a pandemic by the World Health Organization (WHO) on March 11, 2020 [1]. At the time of this writing COVID 19 infections have impacted 191 counties, and the death toll stands at 1,488,513 [2]. COVID-19 infection is known to cause coagulopathy and an inflammatory state [3], but there are few case reports involving COVID-19 related spontaneous bleeding outside of disseminated intravascular coagulation [3]. [...]

Thank you for sharing your institution's recent data and experience with a case of croup who was seen in your emergency department (ED), admitted on oxygen after dexamethasone treatment, and was found to be co-infected with both SARS-CoV-2 and enterovirus. I am glad your patient had a swift recovery. In our three reported cases of croup associated with SARS-CoV-2 infection over a two-month period, all three patients were positive for a single virus and had a negative viral panel (Biofire® FilmArray Respiratory Panel) (CR) for nineteen other viruses, including the ones most commonly associated with croup [1]. [...]

The efficacy of colchicine administration in patients undergoing percutaneous coronary intervention (PCI) remains controversial. We conduct a systematic review and meta-analysis to explore the influence of colchicine administration versus placebo on treatment efficacy for PCI. [...]

The publisher regrets the below abstract was missed to be included in the article. [...]

Despite the advantages of bone marrow transplantation (BMT), patients receiving this intervention visit the emergency department (ED) frequently and for various reasons. Many of those ED visits result in hospitalization, and the length of stay varies. [...]

A previous population-based study defined a broad set of complications of acute conditions encountered in Pediatric Emergency Departments (PEDs). These conditions represent a spectrum of diagnoses in which optimal PED care seems to reduce the risk of complications [1]. Recent studies on the impact of the severe coronavirus disease 2019 (COVID-19) pandemic found increased rates of appendiceal perforation, and severe diabetic ketoacidosis [2,3]. We investigated the rates of complications of serious acute conditions (CSAC) in PED patients during the COVID-19 pandemic. [...]

To describe the impact of a novel communication and triage pathway called, fast track dialysis (FTD) on the length of stay (LOS), resource utilization, and charges, for unscheduled hemodialysis for end stage renal disease (ESRD) patients presenting, to the emergency department (ED). [...]

We have read the article by Soh et al. reporting two cases of neuroleptic malignant syndrome (NMS) with CoronaVirus 2019 (COVID-19) [1] and we have identified another case by Kajani et al. [2] and the three cases represent NMS with COVID-19, as a part of its neurological complications that was attributed to injury of skeletal muscles and Severe Acute Respiratory Syndrome CoronaVirus 2 (SARS-CoV-2) utilizing central nervous system ACE2 receptors. Also, autopsy studies of COVID-19 patients have shown evidence of neuronal degeneration and hyperemic and edematous brain tissue [3]. [...]

Soon after the first patient in New York City (NYC) was diagnosed with the coronavirus disease of 2019 (COVID-19), the number of confirmed cases in New York State (NYS) skyrocketed with NYC being labeled the national epicenter of the pandemic [1]. State and city attempts to harness resources and stem the tide of infections escalated over the initial weeks, including a “NY on PAUSE” order limiting travel, business, and public gatherings. [...]

Circulation, Ahead of Print. Heart failure (HF) remains a pressing health concern, with rising prevalence globally. Subjectivity and ambiguity in the definition of HF and its antecedent stages have limited research, global surveillance, and prevention programs. To address this, several cardiac societies and foundations convened to standardize the definition of HF in 2021 and designated stage B or pre-HF to identify individuals at risk of developing HF. In subsequent years, substantial progress and changes have been made in aspects of preventing HF, improving HF diagnosis and management, and recognizing the importance of the affected individual’s voice. Global differences and disparities in HF are better understood, as are causes and comorbidities leading to differences in care, which are also influenced by access to care. This consensus document presents the Second Universal Definition of Heart Failure, aiming to standardize terminology and facilitate a uniform approach for clinicians, researchers, health systems, and policymakers. In this definition, the classification of HF phenotypes moves away from rigid left ventricular ejection fraction cutoffs, instead grouping HF into reduced, preserved, and improved ejection fraction categories to better reflect clinical realities. A universal classification of HF causes is also proposed. The document also addresses the dynamic trajectories of HF—improvement, remission, and recovery—and highlights the impact of social determinants and geographic variation on HF risk and outcomes. By providing a comprehensive, standardized framework for HF definition and classification, this document seeks to improve prevention, early detection, and management of HF worldwide, ultimately enhancing patient care and advancing global cardiovascular health. [...]

Circulation, Ahead of Print. BACKGROUND:Undertreatment and delayed treatment of aortic stenosis (AS) are common, both of which are associated with increased mortality. Historically, assessment of quality for AS care has focused on peri- and postprocedural outcomes. The American Heart Association Target: AS registry is the first national registry to provide data and evaluate quality for upstream processes of care for patients with AS.METHODS:Randomly selected patients from 2023 and 2024 with moderate or severe AS from 58 sites in the Target: AS registry were included. The 2 primary quality measures were (1) timely diagnosis (percentage of patients with an echocardiogram consistent with possible severe AS who had all assessments to clarify AS severity and symptoms within 30 days) and (2) timely treatment (percentage of patients with a Class I indication for aortic valve replacement treated within 90 days). Secondary measures included documentation of key echocardiographic parameters in the report, clinical recommendations in the echocardiogram report summary, multidisciplinary heart valve team evaluation, guideline-based performance of multimodality testing, and timely surveillance echocardiograms.RESULTS:Among 8097 patients, 47% were women, 7% Black, 6% Hispanic, and 3% Asian. Timely diagnosis occurred in 54% in 2023, improving to 61% in 2024 (P=0.027) with gaps caused by lack of timely symptom assessment (23% [2023]; 16% [2024]), lack of stroke volume index (35% [2023]; 18% [2024]), or lack of timely multimodality testing (87% [2023]; 75% [2024]). Among those with a Class I indication for aortic valve replacement, timely treatment occurred in 82% (2023) versus 85% (2024) (P=NS). Multidisciplinary heart valve team evaluation occurred in 78% (2023) versus 84% (2024) (P=0.008). Key findings in the echocardiography report were documented in 83% (2023) and 85% (2024) (P=NS), but a clinical recommendation was included in <10% of the time. Timely surveillance echocardiograms for moderate (2 years) and severe AS (1 year) were not performed in ~40% of patients.CONCLUSIONS:The national American Heart Association Target: AS registry demonstrates opportunities for improvement in timely diagnosis, surveillance, and treatment for patients with AS at participating centers. By providing an infrastructure to measure performance and identify best practices, the Target: AS registry has the potential to elevate and optimize care and patient outcomes. [...]

Circulation, Ahead of Print. Heart failure in the perinatal period remains ambiguous in definition and management despite its recognition as a unique disease state. The true incidence and prevalence of heart failure or left ventricular systolic dysfunction during pregnancy and the postpartum period are unknown, although a prevalence as high as 1% to 2% has been reported in the general adult US population. Assessment of heart failure can be challenging in the pregnant or postpartum state, during which symptoms affecting physical function (eg, dyspnea, exercise intolerance, fatigue, and lower-extremity edema) are prevalent because of physiological changes. Delays in the recognition and diagnosis of heart failure during the perinatal period contribute to adverse maternal outcomes, highlighting the need for evidence-based definitions and thresholds, improved diagnostic criteria to aid disease recognition, and effective screening tools. This scientific statement focuses on heart failure with reduced and mildly reduced ejection fraction in the context of pregnancy and the postpartum period, caused by various forms of cardiomyopathy. It addresses challenges related to recognizing heart failure in obstetric patients, outlines established treatment standards, and underscores potential areas for research. To improve the management of preexisting and de novo heart failure in obstetric patients, standardization of disease definitions, specific therapeutic options, implementation of effective screening tools, and interventions to improve maternal health equity are imperative. Future directions include prioritizing the inclusion of pregnant and postpartum individuals in heart failure studies, implementing interventions that facilitate early disease detection, and ensuring the timely initiation of appropriate therapies with the goal of reducing adverse outcomes associated with perinatal heart failure. [...]

Circulation, Ahead of Print. Background: High intakes of fructose-containing sugars among children and adolescents is implicated in obesity and related comorbidities, including hypertension. However, sugar-sweetened beverages (SSBs), fruit juices, and whole fruit have different nutritional profiles and matrices, which may confer different effects on blood pressure.Methods: GUTS (Growing Up Today Study) is a longitudinal cohort of 25 749 individuals (55% female) drawn from 2 enrollment waves, GUTS 1 (n=16 875; baseline 1996) and GUTS II (n=10 918; baseline 2004), followed up prospectively through 2021 (mean age at enrollment, 12 years; mean age at end of follow-up, 36 years). Participants provided updated information on lifestyle, health status, and habitual diet through validated food frequency questionnaires every 1 to 4 years. We conducted multivariable adjusted Cox proportional hazards regression models to estimate the associations of total fructose and SSB, fruit juice, and whole fruit intake (cumulative averages) with incident hypertension (hazard ratios [HRs] and 95% CIs), adjusting for major diet and lifestyle factors. We also modeled substitutions of SSBs or fruit juice with whole fruit, milk, and water.Results: During up to 25 years of follow-up, 1625 participants (6.3%) reported a hypertension diagnosis. Total fructose intake was not associated with incident hypertension (highest versus lowest quintile HR, 1.07 [95% CI, 0.92, 1.25];Ptrend<0.001). However, participants with the highest intake of SSBs (≥2 servings/d versus <3 servings/week) and fruit juice (≥1.5 servings/d versus <1 serving/wk) had a higher risk of hypertension (HR, 1.52 [95% CI, 1.27, 1.83];Ptrend<0.001 and HR, 1.35 [95% CI, 1.06, 1.71];Ptrend=0.018, respectively). In contrast, whole fruit was not associated with hypertension (highest versus lowest category HR, 0.79 [95% CI, 0.59, 1.05];Ptrend=0.08). Replacing 1 serving/d of SSB with milk, water, or whole fruit was associated with a 13% (95% CI, 5%, 20%), 9% (95% CI, 3%, 15%), and 22% (95% CI, 11%, 31%) lower risk of hypertension, respectively. In addition, replacing fruit juice with whole fruit was associated with a 19% (95% CI, 3%, 32%) lower risk of hypertension.Conclusions: SSB and fruit juice intakes were positively associated with a higher risk of hypertension independently of overall diet quality, physical activity, and other factors. Our findings support public health guidelines to limit the overconsumption of SSBs and fruit juice starting in childhood to protect against the development of hypertension. [...]

Circulation, Ahead of Print. Perioperative anemia and red blood cell transfusions are important risk factors for morbidity and mortality in cardiac surgery. Preoperative anemia is common, with up to 50% of patients presenting for cardiac surgery affected. Iron deficiency—the most common and potentially modifiable cause of preoperative anemia—is a major driver of blood transfusions in the cardiac surgical setting, adversely affecting both patient outcomes and resource utilization. Perioperative blood management, a patient-centered approach to blood conservation during cardiac surgery, is a multidisciplinary collaborative effort among anesthesiologists, surgeons, perfusionists, intensivists, and transfusion laboratory teams. Strategies aim to reduce blood loss and transfusions and improve patient outcomes. There has been a recent increase in research related to anemia, iron deficiency, and patient blood management in cardiac surgery. This scientific statement highlights the latest evidence on preoperative anemia assessment and intraoperative blood conservation; discusses considerations for specific patient populations regarding anemia prevalence, treatment, and outcomes; and reviews key challenges and knowledge gaps, with the goal of minimizing the impact of preoperative anemia, intraoperative blood loss, and hemodilution on cardiac surgery outcomes. [...]

Circulation, Volume 153, Issue 25, Page 2102-2105, June 23, 2026. [...]

Circulation, Volume 153, Issue 25, Page 1952-1959, June 23, 2026. [...]

Circulation, Volume 153, Issue 25, Page 2097-2099, June 23, 2026. [...]

Circulation, Volume 153, Issue 25, Page 2091-2096, June 23, 2026. [...]

Circulation, Volume 153, Issue 25, Page 2064-2083, June 23, 2026. Based on the Chapel Hill consensus criteria, the primary forms of vasculitis are classified by the predominant size of the affected blood vessels into large, medium, or small vessels. The two main forms of large vessel vasculitis (LVV) are giant cell arteritis and Takayasu arteritis, both of which are more prevalent in women while showing distinct geographic patterns of prevalence. The pathogenesis of LVV is complex and multifactorial, involving a combination of genetic predisposition, environmental and geographic triggers, immune dysregulation, and aging or (premature) senescence of the immune system and blood vessels. Diagnosis based on clinical presentation alone can be challenging because of the wide variety and often nonspecific symptoms that are associated with LVV. This has prompted the development of novel diagnostic tools to aid patient management, in particular advanced vascular imaging approaches. New therapies targeting specific immune pathways are now becoming available to improve outcomes while limiting the side effects associated with traditional glucocorticoid treatment. Advances in molecular imaging techniques may also enhance our ability to objectively monitor disease and treatment response in patients with LVV. Ongoing research aims to better understand the underlying mechanisms and to develop better targeted therapies for LVV, and to improve patient assessment and life time management. This narrative review will provide an in-depth update on current challenges and future trends in LVV, enhancing our understanding of its pathogenesis, diagnostic features, and management strategies, including disease- and treatment-related cardiovascular complications. [...]

Circulation, Volume 153, Issue 25, Page e1447-e1447, June 23, 2026. [...]

Circulation, Volume 153, Issue 25, Page e1448-e1448, June 23, 2026. [...]

It is with great interest and admiration that we read the article recently published in Resuscitation entitled “The dynamics of cerebral blood flow and cerebral oedema evaluated by MRI following resuscitation from cardiac arrest; a porcine study.”1 [...]

Accurate neuroprognostication after out-of-hospital cardiac arrest (OHCA) depends on a multimodal approach in which brain imaging is interpreted within clinical context rather than as a stand-alone test 1,2. However, less attention has been paid to how reliably routine CT and MRI reports identify hypoxic-ischaemic brain injury (HIBI) in clinical practice. We highlight findings from a single-centre quality improvement project (QIP) of imaging reports used in post-cardiac arrest neuroprognostication. [...]

More than 30,000 resuscitation attempts are undertaken by emergency medical services (EMS) in the UK each year, yet survival following out-of-hospital cardiac arrest (OHCA) remains poor. Conventionally, ‘high-quality CPR’ is defined by rescuer performance: chest compressions at 100-120/min, a depth of 5-6 cm, complete chest recoil, and minimal interruptions.1 These metrics are measurable, reproducible, and readily teachable, but they describe what the rescuer does, rather than what the intervention achieves. [...]

Out-of-hospital cardiac arrest (OHCA) is a leading cause of brain injury and death.1 Although survival outcomes are globally poor,2 improved survival is associated with activation of the chain of survival, including early high-quality Cardiopulmonary Resuscitation (CPR).3,4 High-quality CPR generates approximately 20–30% of normal cardiac output,5 which is usually sufficient to produce coronary and cerebral blood flow, but not sufficient to result in consciousness. For over 60 years, signs of consciousness and awareness during cardiac arrest resuscitation have been documented. [...]

Pulseless electrical activity (PEA) and asystole are the predominant initial rhythms in pediatric in-hospital cardiac arrest (IHCA) and are often grouped as “non-shockable.” Whether they represent distinct entities in children remains unclear. [...]

Evaluating if employee instigated deletion of newborn resuscitation videos resulted in selection bias compromising the validity of the NeoBeat trial. [...]

Rapid defibrillation is the standard treatment for ventricular fibrillation (VF) and pulseless ventricular tachycardia (pVT) after OHCA [1–5]. However, during extended resuscitation, circulation might not be restored despite delivering repeated defibrillations at guideline-recommended energies. Factors such as coronary perfusion pressure and myocardial metabolic state can influence how well defibrillation works [6–9]. End-tidal carbon dioxide levels and VF waveform features have also been linked to defibrillation success or return of spontaneous circulation (ROSC) [10–19]. [...]

The study by Kennedy and colleagues in this issue of Resuscitation provides an important opportunity to reconsider how witness status is interpreted in paediatric out-of-hospital cardiac arrest (OHCA). 1 OHCA in children is an uncommon but devastating event, with mortality approaching 90% in population-based cohorts.2,3 Witness status is routinely recorded in OHCA registries as unwitnessed, bystander-witnessed, or emergency medical services (EMS)-witnessed. Yet these categories may be interpreted too readily as simple proxies for whether collapse was observed. [...]

To the Editor, [...]

To the Editor, [...]

Post-cardiac arrest supportive care of children remains an area with little evidence guiding management. Current practice consists largely of supportive care and prevention of secondary insults. This involves a period of neuroprotection followed by subsequent imaging and neurological assessment of the child. Despite ongoing interest in the potential benefits of cooling post-cardiac arrest (such as the current international multi-centre trial, Pediatric Influence of Cooling duration on Efficacy in Cardiac Arrest Patients, p-ICECAP) 1, care currently focusses on maintenance of tight ‘normal’ parameters with other aspects guided by the individual, specific circumstances. [...]

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BACKGROUND The modified Brain Injury Guidelines (mBIG) are an established protocol to triage traumatic brain injury with intracranial hemorrhage (ICH) while reducing resource utilization. However, mBIG do not differentiate between isolated and combined intracranial hemorrhage (cICH). This study evaluated whether patients with multiple ICH subtypes require different triage. METHODS We performed a retrospective study of adult patients classified as mBIG 1 or mBIG 2 at two Level I trauma centers January 1, 2017, to June 30, 2023. Patients with cICH (≥2 subtypes) were compared with isolated ICH. Primary outcome was clinical deterioration, defined as new focal neurologic findings, pupillary examination changes or Glasgow Coma Scale score of [...]

Objective: The “REstricted vs. Liberal positive end-expiratory pressure in patients without Acute Respiratory Distress Syndrome (ARDS)” (RELAx) trial compared lower vs. higher positive end-expiratory pressures (PEEP) in invasively ventilated critically ill patients without ARDS, concluding non-inferiority of lower PEEP in frequentist analysis. This study aimed to perform a Bayesian re-analysis of RELAx to assess probabilities of clinically meaningful differences between lower and higher PEEP. Design: A post hoc Bayesian analysis of RELAx data. Setting: RELAx was a non-inferiority multicenter trial conducted between October 2017 and March 2019 in eight ICUs. Patients: The trial included 980 ICU patients expected to require invasive mechanical ventilation greater than or equal to 24 hours for reasons other than ARDS. All patients included in the original analysis entered the Bayesian re-analysis. Interventions: Participants were randomized to the lowest possible PEEP between 0 and 5 cm H2O or to a higher PEEP of 8 cm H2O. Measurements and Main Results: The primary outcome was ventilator-free days at day 28 (VFD-28). Secondary outcomes were 28-day mortality and ventilation duration. The odds ratio for higher VFD-28 with lower PEEP was 1.08 (95% credible intervals, 0.87–1.35), with consistent estimates across priors and with a probability of superiority ranging from 75% to 78%. For 28-day mortality and duration of ventilation, the probability of benefit of the lower-PEEP strategy ranged from 72% to 89%, and from 11% to 28%, respectively. In patients admitted for other reasons than cardiac arrest or intubated for other reasons than respiratory failure, probabilities of benefit with lower PEEP exceeded 90%. Conclusions: Although the probability of benefit in the overall population was modest, the analysis suggested a higher probability of benefit in selected subgroups, particularly patients admitted for other reasons than cardiac arrest or intubated for other reasons than respiratory failure. These findings highlight potential heterogeneity of treatment effect and support further investigations. [...]

Objective: A definition of refractory septic shock is necessary to guide diagnosis, management, prognostication, research, and future guidelines for this most severe form of the disease. We sought to achieve consensus on clinical criteria that would be used to define refractory septic shock. Design: Review of literature, expert panel position statements, and Delphi rounds with an international expert group. Setting: Consensus was defined as having at least 75% of panellists in agreement or disagreement on the three highest or lowest levels of a 7-point Likert scale or based on responses to single- or multiple-choice questions, respectively. Subjects: A panel of multinational, multiprofessional and multidisciplinary critical care experts assembled by the Society of Critical Care Medicine and the European Society of Intensive Care Medicine (57 invitations and 56 participants). Measurements and main results: A five-round Delphi process was conducted for consensus and stability. The steering committee proposed 34 statements, and five of them were rejected by panel experts after round 2. Among 29 statements selected from eight domains, consensus was reached for 13. The panel agreed on the need for a comprehensive consensus set of clinical criteria for refractory septic shock. Markers of organ dysfunction (75%, 2 rounds), tissue perfusion (91.1%, 2 rounds) including lactate (94.6%, 2 rounds) and capillary refill time (76.8%, 2 rounds), assessment of fluid-responsiveness after initial resuscitation (92.9%, 5 rounds), and use of vasoactive drugs at norepinephrine equivalents greater than 0.5 µg/kg/min (75.0%, 3 rounds), were selected as clinical criteria of refractory septic shock. The use of critical care ultrasound (CCUS) (92.9%, 3 rounds) was the single diagnostic modality that reached a consensus-based agreement. Conclusions: A consensus for 13 criteria to frame the definition of refractory septic shock was reached. Refractory septic shock is characterised by persistently elevated lactate concentrations and or prolonged capillary refill time in patients with septic shock who are fluid unresponsive, require a norepinephrine base equivalent dose greater than 0.5 micrograms per kilogram per minute, and undergo CCUS assessment when mixed shock is suspected. [...]

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Objectives: Almost 80% of sepsis cases occur in low-resource settings (LRS), where limited resources impede the effective implementation of international guidelines for sepsis management. In addition, existing sepsis guidelines have not fully addressed specific issues relevant to LRS. Therefore, an international panel of 20 multiprofessional sepsis experts was convened to generate consensus on the gaps in and strategies for sepsis care in LRS. The recently developed “sepsis chain of survival” was used as a framework. Data Sources: MEDLINE, Embase. Study Selection: Studies selected included human studies (clinical trials, cohort, case-control, and case series) reporting clinical outcomes in patients with sepsis from LRS between January 1, 2000, and July 4, 2024. Search terms included “developing countries,” “LMIC,” “resource-poor settings,” and regional terms such as Africa, Southeast Asia, and Latin America. The Delphi process involved iterative, anonymous voting by the expert panel to achieve consensus to draft clinical practice statements. Data Extraction: A detailed literature review was conducted using the “sepsis chain of survival” as a basis, with an emphasis on sepsis prevention, detection, therapy, post-sepsis care, education, and future research priorities. A total of 8865 studies were identified and screened, with 155 included in the review. Data Synthesis: Based on literature review, the Delphi process achieved a stable consensus for 58 of 62 (94%) of the proposed clinical practice statements after eight survey rounds. These statements offer guidance on measures to improve the prevention, early recognition and time-sensitive, comprehensive management of sepsis in LRS through the continuum of care from first response to post-sepsis care and follow-up. Conclusions: There remains a significant lack of high-quality evidence to support improvements in sepsis care for patients in LRS. Pending new data, the clinical practice statements identified here complement the existing international guidelines for sepsis management by serving as a basis for immediate care and future research in LRS. [...]

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Rationale: Older adults (those 65 years old or greater) compose a substantial proportion of the ICU population. As older adults with critical illness possess unique factors and considerations relevant to their care and outcomes, there is a need for evidence-based recommendations to guide critical care clinicians in the care of older ICU patients. Objective: The objective of this guideline is to develop evidence-based recommendations addressing the care of older adults during and after critical illness. Design: The American College of Critical Care Medicine Board convened a 22-member interprofessional panel, comprising physicians, advanced practice providers, nurses, a pharmacist, physical therapist, occupational therapist, and a patient representative. The panel included two expert methodologists specialized in developing evidence-based recommendations in alignment with the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. Conflict-of-interest policies were strictly followed during all phases of guideline development including task force selection and voting. Methods: The panel members prioritized five Population, Intervention, Comparator, and Outcomes questions. A systematic review was conducted for each question to identify the best available evidence, synthesize the evidence and assess the certainty of evidence using GRADE. The evidence-to-decision framework was used to formulate recommendations. Results: The panel generated two conditional recommendations and three “no recommendation” statements. The conditional recommendations are: 1) We suggest a geriatric model of care for all older adults admitted to the ICU and 2) We suggest not using antipsychotic medications for the prevention of delirium in older adults with critical illness. The three “no recommendation” statements are: 1) We make no recommendation regarding specialized post-ICU follow-up for older survivors of critical illness, 2) For older adults (age 65 and over) admitted to the ICU with vasodilatory shock, we make no recommendation with regard to targeting a mean arterial pressure (MAP) of 60–65 mm Hg as compared with usual care (MAP target > 65 mm Hg), and 3) We make no recommendation regarding the use of antipsychotic medication in the treatment of delirium in older adults with critical illness. Conclusions: The guideline panel developed recommendations on caring for older adults during and after critical illness. Areas for future research were also identified during the guideline process. [...]

Objectives: A temperature control strategy is strongly recommended for comatose in-hospital cardiac arrest (IHCA) survivors. We aimed to investigate variation in adherence to this recommendation and associations with outcomes, which have not been comprehensively assessed for IHCA. Design: Prospective observational cohort study with data collected from October 2023 to June 2024. Setting: Multicenter, international (24 hospital systems, 46 enrolling hospitals). Patients: Adults who suffered IHCA, survived initial resuscitation, and remained comatose and eligible for temperature control. Interventions: None. Measurements and Main Results: The main exposure was documentation of a temperature control strategy in the first 24 hours after arrest. Outcomes were survival to hospital discharge (primary), use of temperature control therapy, fever (temperature ≥ 38°C), favorable functional outcome (modified Rankin Scale ≤ 3), and favorable neurologic outcome (Cerebral Performance Category score ≤ 2). Among 1006 enrolled patients, 615 (61.1%) remained comatose and were eligible for temperature control; of those, 273 (44.4%) had a documented temperature control strategy. A documented strategy was associated with higher adjusted odds of receiving a temperature control therapy (adjusted odds ratio [aOR], 21.3; 95% CI, 12.3–36.7; p < 0.01), and lower adjusted odds of fever in the first 24 hours after resuscitation (aOR, 0.63; 95% CI, 0.43–0.92; p = 0.02). Having a strategy, compared with not, had no statistically significant association with survival (32.6% vs. 28.1%; aOR, 1.19; 95% CI, 0.79–1.80; p = 0.42), favorable functional outcome (9.9% vs. 10.5%; aOR, 1.14; 95% CI, 0.53–2.42; p = 0.74), or favorable neurologic outcome (12.8% vs. 12.3%; aOR, 1.15; 95% CI, 0.63–2.12; p = 0.65). Hospital system specific proportions of temperature control strategy ranged from 0% to 100%. Conclusions: Among comatose IHCA survivors, more than half received no documented temperature control strategy. Those with a strategy were less likely to have a fever and more likely to receive temperature control directed therapy, but showed no difference in survival, functional, or neurologic outcomes. [...]

Objectives: To develop a practical consensus-based framework for ten steps to improve sepsis care in low-resource settings (LRSs), aligned with the sepsis chain of survival and informed by global expertise. Data Sources: We reviewed peer-reviewed literature on sepsis epidemiology, prevention, recognition, and management in LRS; international guidelines, including the Surviving Sepsis Campaign; and prior “ten-step” consensus frameworks for resuscitation and emergency care. Study Selection: A Task Force representing adult and pediatric sepsis care, emergency care, critical care, infectious diseases, public health, and implementation science identified key domains from the above data sources. Data Extraction: With guidance from methodologists and implementation science experts, we employed an iterative, consensus-based process—literature review, Delphi survey, Utstein-style conference, stakeholder input, and public comment—to first define and then refine steps and implementation strategies. Data Synthesis: The process resulted in ten nonsequential, actionable steps covering governance and commodities, provider and caregiver education, community and facility prevention, early recognition and rapid response, timely guideline-based interventions, structured post-sepsis care, data systems, quality improvement, a culture of excellence and respect, and holistic well-being of patients, caregivers, and providers. Each step includes a rationale and potential implementation strategies adaptable to local resources and needs. Collectively, the ten steps emphasize integration across the continuum of care, equitable access to essential interventions, and the role of emerging technologies to prevent, recognize, monitor, and follow-up sepsis. Conclusions: The ten steps provide a consensus-driven roadmap for health leaders, clinicians, and policymakers to improve sepsis care, strengthen the sepsis chain of survival, reduce preventable morbidity and mortality, and address global inequities in sepsis outcomes. [...]

Central to managing critically ill patients is the identification of the etiology of cardiorespiratory insufficiency (i.e., shock), early appropriate targeted therapies to support the cardiorespiratory system to sustain adequate blood flow and oxygen to the tissues, plus specific treatments to reverse the cause of shock. Over the past 40 years, numerous advances in our understanding of shock, its severity, and its response to therapies, along with more specific and insightful monitoring approaches, have been developed. This perspective summarizes some aspects of that progress. We have come a long way, but we need to understand three things. First, that once organ injury has occurred all that our treatments can do is mitigate further injury, not reverse it. If initial aggressive resurrection efforts cannot restore organ function, then their actions often cause only iatrogenic injury. Second, existing advanced monitoring devices, no matter how insightful their data, will not improve patient outcomes unless coupled to a treatment that itself improves outcomes. Finally, all our advances over these years have underscored the fundamental need for having a thoughtful and observant bedside clinician cognizant of the pathophysiologic underpinnings of disease and its care who titrates care based on the patient’s individual response. [...]

Objectives: Evidence supporting the benefits of combined nutrition and exercise programs in ICU survivors is limited. We assessed the impact of a combined lifestyle intervention on perceived physical functioning (PF) and health-related quality of life (HRQoL) post-ICU. Design: Single-center randomized control trial. Setting: Teaching hospital in the Netherlands (Frisius Medical Centre Leeuwarden). Patients: Adult long stay ICU survivors (≥ 48 hr) with a PF score of less than 67% on the Dutch translation of the RAND-36 item Health Survey. Interventions: The 12-week intervention included twice-weekly group exercise, dietary advice, and protein supplementation as needed. The control group received standard aftercare according to local protocol. Measurements and Main Results: Primary outcome (PF score at 12 wk) and secondary outcomes were assessed during a clinic visit at baseline and after a 12-week period. 39 patients completed the study (control, n = 20; intervention, n = 19): 26% female, median age 61 years (46–72), median ICU stay 7 days (4–14), and patients were severely ill (Acute Physiology and Chronic Health Evaluation III: 67 [50–89]). Although there were imbalances in ICU characteristics, baseline characteristics and PF scores were similar. At 12 weeks, the intervention group showed a significant improvement (p = 0.024) in PF-domain score. Daily protein intake in the intervention group increased from 82.3 (67.5–97.9) to 116.7 (107.3–138.7) g/kg (p = 0.003), with 68% meeting the minimal intake target of 1.2 g/kg/d. Conclusions: The data of this small-sample size randomized controlled trial suggest that a combined lifestyle intervention program can significantly improve PF and protein intake in ICU survivors with a prolonged PF scores below reference. [...]

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About one-fifth of adults and children over the age of 5 living in the United States report speaking a language other than English (LOE) at home, with a significant portion of this population also self-reporting limited English proficiency. Pediatric emergency medicine providers are seeing increasing numbers of patients and caregivers in this demographic. Care for these patients can be complicated by miscommunication. Research has consistently shown that patients with LOE experience numerous disparities in emergency department (ED) care, including under-triage, longer lengths of stay, increased revisit rates, increased rates of adverse events, and worse analgesia for pain. Overcoming linguistic barriers is important to provide excellent and equitable care for this population, and studies show that the use of professional interpretation can mitigate these disparities. Although general guidelines for the use of medical interpreters exist, there are special challenges involved in caring for patients in the emergency setting while also communicating with adult caregivers. This article aims to familiarize the emergency medicine provider with issues they will likely encounter in their practice setting, suggestions to mitigate these difficulties, and best practices for collaborating with interpreters in a fast-paced medical setting. [...]

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Tranexamic acid (TXA) is an antifibrinolytic medication that helps stabilize clots and reduce bleeding. Although FDA approval is limited, it has become widely used off-label in pediatric and emergency medicine. Evidence shows that TXA decreases blood loss, reduces transfusion requirements, and may improve survival in trauma. It has also been beneficial in pulmonary hemorrhage, post-tonsillectomy bleeding, epistaxis, abnormal uterine bleeding, and secondary postpartum hemorrhage. TXA is generally safe and well tolerated; common side effects include headache and abdominal discomfort, while serious events such as seizures or allergic reactions are rare. Its favorable safety profile and broad applicability make TXA a valuable tool for frontline clinicians managing pediatric bleeding emergencies. More pediatric-specific trials are needed, but current evidence supports TXA as both effective and practical in a variety of emergency settings. [...]

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Background: Sepsis is one of the leading causes of death among children worldwide. The Society of Critical Care Medicine Pediatric Sepsis Definition Task Force developed and validated the Phoenix sepsis criteria, new clinical criteria for pediatric sepsis and septic shock based on organ dysfunction. Although this represents a significant advancement in standardizing sepsis and septic shock definitions, its applicability in emergency department (ED) settings remains unexplored. Importance: Given that EDs are often the first point of contact for critically ill children, we must examine the use of the Phoenix criteria in these settings and across varying resource levels. In this CME review article, we explore the evolution of pediatric sepsis definitions to the Phoenix sepsis criteria, and its utility, strengths, and limitations in emergency care in both high-resource and low-resource ED settings. [...]

Measles is a highly contagious viral infection that resulted in significant morbidity and mortality before widespread vaccination efforts began in the 1960s. In 2000, measles was declared eliminated in the United States; however, continued global circulation combined with rising vaccine hesitancy has resulted in recent outbreaks of increasing severity. This review article highlights relevant epidemiology and prepares clinicians to differentiate measles infection from similar febrile exanthems of childhood. We review available diagnostics and the management of patients with or exposed to measles infection in an era of unfamiliarity with the condition. [...]

Clonidine is being increasingly prescribed in pediatric populations for behavioral conditions such as attention-deficit/hyperactivity disorder (ADHD), contributing to a rise in pediatric exposures and toxic ingestions. This article reviews the toxicokinetics, clinical presentation, and management of pediatric clonidine toxicity. Children under 5 years old account for the highest proportion of clonidine exposures, most of which are unintentional. Clonidine toxicity mimics an opioid toxidrome, often presenting with CNS depression, miosis, bradycardia, and hypotension. Diagnosis is primarily clinical. While supportive care remains the core component of treatment, naloxone may be beneficial in reversing CNS depression, though higher-than-standard doses are often required. Given the potential for delayed and prolonged toxicity, particularly with ingestion of transdermal patches, early recognition and intervention are critical. This review equips clinicians to understand, diagnose, and manage pediatric clonidine toxicity, emphasizing the importance of supportive care and consideration of naloxone for severe cases. [...]

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OBJECTIVE: We assembled a workgroup within the Pediatric Research Collaborative on Critical UltraSound (PeRCCUS), a subgroup of the Pediatric Acute Lung Injury and Sepsis Investigators (PALISI), to define early guidance for point-of-care ultrasound (POCUS) institutional practice and foster future comprehensive guidelines for its broad adoption in pediatric critical care medicine. DESIGN: A modified Delphi method was used for creating the statements. The first meeting was an open proposal session for workgroup members to suggest items for consideration. This was followed by a cycle of voting for levels of agreement along a 7-point Likert-type scale. Items were reviewed, with only items receiving a score of greater than or equal to 6 progressing to the next stage of voting and lower-scoring items reconsidered, with only consensus items proceeding to the next stage for additional rounds of voting until consensus was reached. SETTING: Multi-institutional, multidisciplinary, workgroup of experts on POCUS organized within PeRCCUS as a subgroup of PALISI. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Consensus was obtained for 25 recommendations across five domains: clinical application, quality assurance, equipment, education, and research. CONCLUSIONS: We report consensus recommendations for institutions on clinical use, educational programs, quality assurance, technical requirements, and future research opportunities for the adoption of pediatric critical care medicine POCUS. [...]

OBJECTIVE: Develop a consensus-based framework for point-of care ultrasound in pediatric critical care, or critical care ultrasound (CCUS) education using entrustable professional activities (EPAs). DESIGN: A modified Delphi method utilizing cycles of meetings and surveys for consensus-building. SETTING: The endeavor involved members of the Pediatric Research Collaborative on Critical Ultrasound (PeRCCUS), a subgroup of the Pediatric Acute Lung Injury And Sepsis Investigators. SUBJECTS: An expert panel consisting of 23 members representing 17 institutions, including diverse healthcare professionals involved in pediatric critical care ultrasound. INTERVENTIONS: Three iterative modified Delphi rounds were conducted to propose and refine critical care ultrasound EPAs. MEASUREMENTS AND MAIN RESULTS: The endeavor achieved a 74% response rate. Fourteen EPAs were formulated across five domains: Cardiac, Pulmonary, Abdomen, Procedures, and Vascular, along with two consensus opinions on educational content and methods. EPAs were evaluated using 5-point Likert items, requiring a median score of greater than or equal to 4.5 for progression. CONCLUSIONS: This collaborative effort led to the establishment of fourteen EPAs for pediatric critical care ultrasound, offering a structured approach for education and competency assessment in pediatric critical care. This initiative lays the groundwork for evolving standards in pediatric critical care ultrasound education and practice. [...]

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