Emergency Medicine Journals

Clinical introduction A 72-year-old female presented to the emergency department with sudden-onset severe back pain after straining while defecating. It was associated with new urinary incontinence and bilateral lower limb numbness and pain. Examination revealed loss of power and reduced sensation of the lower limbs. She had a medical history of hypertension, osteoarthritis and previous stroke for which she took clopidogrel daily. Urgent MRI scanning of the lumbosacral spine was performed, see figure 1 and figure 2. QuestionWhat is the diagnosis? Lumbar disc herniation Spontaneous spinal epidural haematoma Metastatic spinal cord compression Spinal meningioma Answer: B Figure 1 shows large mixed signal posterior epidural soft tissue resulting in critical canal stenosis and cauda equina compression. Figure 2 shows marked internal increased susceptibility consistent with blood product. Spontaneous spinal epidural haematoma... [...]

A short systematic review assessed the diagnostic accuracy of malaria rapid diagnostic tests in febrile adults from malaria-endemic regions. A database search of MEDLINE, EMBASE, Cochrane and Google Scholar returned 138 papers. Six papers met the inclusion criteria and were included in our analysis. [...]

Advances in trauma care have improved survival after firearm injury; however, survivors often experience substantial financial hardship, which has been linked to worse physical and mental health outcomes.1 2 US insurance claims data demonstrate that firearm injury survivors incur more than US$25 000 in healthcare spending in the first month after injury, with patient cost-sharing increasing nearly 19-fold.3 Government-based victim compensation programmes provide financial support to violent crime victims and have existed in the USA since the 1980s, with comparable programmes internationally in the UK, European Union, Canada and Australia.4 These programmes typically cover medical bills, mental health services, lost wages, funeral and burial costs and emergency relocation. Emergency clinicians are often the first point of healthcare contact after violent injury and play a critical role in connecting patients to social work services and hospital violence intervention programmes (HVIPs), which support... [...]

I graduated from medical school in Addis Ababa in 2024 into an emergency medicine system that barely existed a decade ago. Working in Ethiopia’s emergency departments has underscored that building emergency care infrastructure in a resource-limited country requires creativity, governmental commitment and acceptance that progress will be uneven and incomplete for years. One illustration of this reality occurred during periods when commercial inhaler spacers were unavailable, when clinicians locally fabricated simple spacer devices using clean plastic bottles to facilitate bronchodilator administration for patients in acute respiratory distress. Used as a temporary mitigation rather than a substitute for standard equipment, this approach illustrates how frontline teams adapt care processes when essential resources are lacking. Ethiopia’s emergency medicine expansion was driven by necessity. Ethiopia faces one of the world’s highest injury mortality rates at 94 per 100 000 population, substantially higher than the sub-Saharan African average of 30–40 per 100 000 and more than... [...]

Health inequalities are often discussed as a challenge for primary care, public health and social policy. Yet few specialties encounter their consequences as directly as emergency medicine. Every day, emergency departments provide care to patients whose health outcomes have been shaped by poverty, deprivation, discrimination, violence, language barriers and unequal access to healthcare long before they arrive at our doors. In this issue of the Emergency Medicine Journal, several papers highlight how inequalities influence who becomes ill, who accesses emergency care, what care they receive and, ultimately, whether they survive. Emergency care services are uniquely positioned at the intersection of health inequalities and therefore have an important role to play in addressing them.1 It is becoming clearer that health inequalities are not the result of a single factor. Rather, they arise through the interaction of bias, structural inequity and the cumulative effects of social disadvantage. Bias remains... [...]

Social prescribing (SP) connects patients to community organisations, activities and resources with the aim of improving their health and well-being. Social Prescribing Link Workers (SPLWs) use ‘what matters to you?’ conversations to co-produce personalised care plans with patients.1 While this model has been embedded in primary care settings in the UK, the role of SPLWs in emergency departments (EDs) is early in development. A pilot study2 and conceptual research3 has identified that SP in ED has potential to reach patients requiring support with a range of health, social and well-being needs, particularly those impacted by health inequalities. Yet, the current availability of SP in UK EDs is unknown. The aim of this work is to explore the current SP capacity in UK EDs. Freedom of Information requests were sent in early 2025 to National Health Service Trusts and Health Boards covering the 235... [...]

Emergency departments (EDs) and NHS ambulance services often serve as the first and only point of contact with healthcare for individuals from deprived communities, marginalised populations and other groups that face inequalities in both access to, and quality of healthcare. These include ethnic minorities, people experiencing homelessness, asylum seekers, sex workers, individuals transitioning from criminal justice settings as well as older adults, children and pregnant women. These populations face disproportionate burdens of disease and systemic barriers to care. Integration of Public Health into Urgent and Emergency Care (UEC) services presents an opportunity to address these challenges. These issues cannot be solved by UEC services alone. EDs and ambulance services, however, are uniquely positioned to identify and address health inequalities by building close relationships with local authorities, primary care, social care and voluntary, community and social enterprises to support preventive efforts, help people before they need to come to ED, reduce repeat attendances and improve patients’ experiences and outcomes. Health inequalities cost the NHS billions of pounds each year. Embedding public health in EDs is not just a clinical improvement—it is an economically sound, ethically responsible, equity intervention that addresses the social determinants of health and ensures the most vulnerable receive timely, tailored support. EDs and NHS ambulance services are more than services for time of crisis—they are places of opportunity. By embedding public health principles into emergency care, we can transform emergency care into engines of equity, resilience and prevention. Investing in public health within these settings is not only the right thing to do for patient outcomes and health equity—it is ultimately cost-effective, reducing demand on UEC and improving population health in the long term. [...]

Background Female patients who experience out-of-hospital cardiac arrest (OHCA) are less likely to receive bystander cardiopulmonary resuscitation (CPR) than male patients. However, the interaction between the patient and the sex of the bystander in CPR provision remains underexplored. Therefore, this study aimed to investigate the interaction between patient and sex of bystander in CPR provision during OHCA and to assess CPR rates based on dispatcher-assisted CPR (DA-CPR) administration status. Methods This cohort study used prospectively collected nationwide registry data between January 2019 and June 2023. Adult patients with medical aetiology of OHCA who were transported by emergency medical services were included. The primary outcome was bystander CPR provision according to sex. The secondary outcome was the provision of bystander CPR based on DA-CPR administration status. Results A total of 6487 patients with OHCA were included (median (IQR) age: 55 (52–64) years; male bystanders treated 3977 patients (61.3%)). The bystander CPR rate was lower when the patient and sex of bystander differed (male patient–male bystander, 85.0% vs male patient–female bystander, 79.2%; female patient–male bystander, 79.5% vs female patient–female bystander, 82.1%). Female bystanders were less likely to provide bystander CPR than male bystanders (adjusted OR (aOR): 0.83, 95% CI 0.73 to 0.95). The odds of a female bystander providing CPR to a male patient were significantly lower than those of a male bystander (aOR: 0.684, 95% CI 0.578 to 0.810). This difference was reduced when DA-CPR was administered (without DA-CPR, aOR: 0.673, 95% CI 0.475 to 0.952 vs with DA-CPR, aOR: 0.822, 95% CI 0.706 to 0.957). Conclusion An interaction between the patient and the sex of bystander was observed, particularly when the patient was a male and the bystander was a female. DA-CPR may serve as a potential intervention to help mitigate this disparity. [...]

Clinical introduction A girl aged 5 months was brought to the emergency department with irritable crying and tonic posturing with upward gaze. The mother reported a 30 cm fall from a bed earlier that morning, with symptoms appearing 1 hour later. There was no preceding fever or vomiting. On arrival, she was afebrile and haemodynamically stable. Physical examination revealed ecchymoses over the forehead, right arm and calf with a tense anterior fontanelle. Bedside cranial ultrasonography was performed (figure 1). Question What is the most likely diagnosis? Subarachnoid haemorrhages (SAH) Subdural haematomas (SDH) Subdural hygromas Benign enlargement of subarachnoid spaces (BESS) Answer B. Subdural haematomas (SDH). Discussion Cranial ultrasonography through the anterior fontanelle demonstrated bilateral heterogeneous, multilayered collections (figure 2A and ). Colour Doppler showed displacement of subarachnoid vessels towards the cortical surface, with absence of traversing... [...]

This month’s update is by the new clinical academic group at the University of Oxford. We used a multimodal search strategy, drawing on free, open-access medical education resources and literature searches. We identified the five most interesting and relevant papers from outside our specialty (decided by consensus) and highlighted the main findings, key limitations and clinical bottom line. The papers are ranked as follows: Worth a peek—interesting, but not yet ready for prime time. Head turner—new concepts. Game changer—this paper could/should change practice. Non-surgical casting vs surgical reduction for children with severely displaced distal radial fractures (the CRAFFT Study): a multicentre, randomised, controlled non-inferiority trial and economic evaluation by Perry et al Topic: Paediatric trauma Rating: Game changer Severely displaced distal radius fractures in children are often reduced under anaesthesia or sedation, yet no previous trial has tested whether this benefits young children, who... [...]

Background Knife-related deaths in children present a serious public health challenge. This study reports the demographics and preinjury, injury and postinjury factors associated with death in children and young people (CYP), under the age of 18 years, who died of knife wounds in England between 2019 and 2024. Methods A retrospective cohort review of the English National Child Mortality Database between April 2019 and March 2024. Rates of death were corrected for population size using the 2021 census. Preinjury, injury and postinjury factors associated with death are reported descriptively. Results 145 CYP died of knife wounds. The mean age was 14.4 years (SD 4.2) and 90.3% (n=131) were male. The rates of death per 100 000 CYP, per year were highest in children of ‘Black/Black British’ ethnicity (1.40 (95% CI 1.03 to 1.86)), with an incidence rate ratio (IRR) of 13.29 (95% CI 8.23 to 20.00), compared with CYP of ‘White’ ethnicity. Children living in the most deprived areas, had a greater than seven times higher risk of death (IRR 7.48 (95% CI 3.22 to 17.29), compared to CYP living in the least deprived areas. Of the 57 cases available for detailed analysis, injuries to the chest and neck were responsible for the fatal injuries in 75.9% of cases (n=44) and 60.3% (n=35) died before reaching hospital. A thoracotomy was performed in 56.9% (n=33) of cases. Prior to death, 75.4% (n=43) had been known to social services and 57.9% (n=33) had experienced domestic violence and abuse. Neurodiversity or mental health concerns were reported in 50.9% (n=29) of CYP. Conclusions Death of CYP secondary to knife wounds occurred in all regions of England. Many children are exposed to adverse childhood experiences before death and known to statutory services. The identification of interventions to decrease the risk to children from knife violence remains a priority. [...]

Background In rural settings, women with ST-elevation myocardial infarction (STEMI) are less likely to receive timely reperfusion than men. We explore factors that may impact time to reperfusion by sex for patients with STEMI. Methods We conducted a cohort study of adults with STEMI activations from 2016 to 2020 using regional North Carolina STEMI registry data, which included eight rural emergency medical services (EMS) agencies and three percutaneous coronary intervention (PCI) centres. The primary outcome was EMS first medical contact to PCI in ≤90 min. By sex, we evaluated prehospital time intervals (dispatch, response, time-to-ECG, catheterisation laboratory activation, on-scene, transport and total EMS) and door-to-balloon time with clustered Wilcoxon rank-sum tests. We also evaluated agency and patient factors associated with timely reperfusion using generalised estimating equations. Results Of the 365 patients included, 30.1% (110/365) were female with a mean age of 62.5±12.7. Fewer women received PCI within 90 min compared with men (43.6% vs 67.8%, p [...]

Academic Emergency Medicine, Volume 33, Issue 7, July 2026. [...]

ABSTRACT Patient-centered communication (PCC) underpins high-quality medical care, yet its traditional dyadic, longitudinal models are ill-suited to the emergency department (ED). In the ED, visits are brief, unpredictable, and often involve clinicians and patients with no prior relationship. This mismatch creates a paradox: the fast-paced, high-uncertainty environment heightens the need for PCC while simultaneously impeding its enactment. Drawing on the science of teamwork, we propose conceptualizing PCC as a team process. Our approach reconceptualizes communication as a coordinated, interdisciplinary process. In this model, an ED PCC team—comprising physicians, nurses, ancillary staff, and the patient (and caregivers when appropriate)—functions as a “swift-starting action team,” required to achieve high-stakes goals shortly after formation. By integrating teamwork constructs, including the input-process-outcome-input model and the consideration of team cognition, our proposed conceptualization expands the scope of PCC research and creates a pathway to design interventions that facilitate PCC in the fast-paced ED setting. This opens new avenues for research, education, and quality improvement across emergency settings. [...]

ABSTRACT Objectives Patients presenting to emergency departments (EDs) have been described as expecting a diagnosis or explanation for symptoms, yet diagnostic uncertainty is especially prevalent for those with nonspecific symptoms like headache, dizziness, abdominal pain, and chest pain. Given limited research examining patient and caregiver expectations about diagnosis when uncertainty exists, we aimed to investigate these expectations to inform safe, high quality, patient-centered diagnostic communication in emergency settings. Methods We conducted a qualitative study in two Australian metropolitan EDs using semi-structured interviews with patients presenting with nonspecific symptoms (n = 24) and their caregivers (n = 11) about their expectations regarding the visit and diagnosis. We analyzed interview transcripts in NVivo using content and thematic analysis. Results Participant expectations about their ED visit and diagnosis were shaped by previous healthcare experiences, understanding of symptom characteristics, familiarity with medical knowledge and uncertainty tolerance. Three themes captured expectations by content: outcomes (understanding, treatment and guidance), processes (diagnostic investigations and being taken seriously), and the health service (timely, integrated care). While most participants reported wanting a diagnosis or explanation, many demonstrated awareness of diagnostic uncertainty and its implications, revealing diverse expectations across a certainty spectrum. Many expected diagnostic investigations, regarding them as integral to determining outcomes but recognized they may not resolve uncertainty. Some regarded EDs as a ‘one-stop shop’ providing timely diagnostic outcomes. Patients who had previously experienced symptom invalidation expressed strong expectations about being taken seriously. Conclusions Patient and caregiver expectations about their ED visit and diagnosis are more nuanced than previously recognized. Findings highlight the importance of clinicians soliciting and responding to hopes and expectations in ways that address the uncertainty inherent in diagnosis. Understanding patient and caregiver hopes and expectations better equips clinicians to communicate in a patient-centered way about diagnosis and the diagnostic process in EDs, to enhance care even when uncertainty persists. [...]

ABSTRACT Objectives Confidential status is a hospital trauma center practice of restricting communication with all visitors of violently injured patients, including family and friends. The practice is intended to protect patients and staff from harm in situations involving violence or safety concerns, though it may have unintended negative impacts. Methods A mixed-methods study using retrospective cohort and qualitative study designs was conducted at a single urban academic Level 1 trauma center with a confidential status practice. Using retrospective chart review of traumatically injured patients from 2015 to 2020, we performed multivariable logistic regression examining associations between placement on confidential status and patient characteristics including age, race/ethnicity, and intent of injury. Surveys and semi-structured interviews were conducted to examine knowledge of the confidential status policy and perceived effects on patient care and clinical workflow. Results Of the 42,540 traumatically injured patients were included, 319 were placed on confidential status. Those with confidential status were most commonly injured by assault (62%). Multivariable regression showed Black (OR 2.69, 95% CI 1.97–3.68) and Latine (OR 1.46, 95% CI 1.03–2.07) patients were more likely to be placed on confidential status compared to White patients. All survey respondents reported providing direct care for patients in which the confidential status was enforced; however, only 38% reported having read the policy. Most respondents reported neutral perceptions regarding the policy's impact on patient care and patient experience, while only 12% reported positive perceptions. Four qualitative themes were identified: family trauma, discrimination, stressed workplace environment, and policy ineffectiveness. Conclusions Racial/ethnic differences were observed in the use of confidential status. Staff perceptions raised concerns regarding unintended negative effects of the policy on patients and families. [...]

Academic Emergency Medicine, Volume 33, Issue 7, July 2026. [...]

Academic Emergency Medicine, Volume 33, Issue 7, July 2026. [...]

ABSTRACT Objectives A 0/2-h algorithm for the i-STAT point-of-care (POC) high sensitivity troponin I (hs-cTnI) assay was recently derived in Australia. The objective of this study was to validate and optimize the performance of the 0/2-h algorithm in a multisite U.S. Emergency Department (ED) cohort. Methods A prospective cohort study was conducted at three U.S. EDs (February–September 2025). Adults without STEMI and at least one hs-cTnI ordered were accrued. Blood samples were collected simultaneously for POC hs-cTnI measurement on an i-STAT 1 analyzer (Abbott Laboratories) and central laboratory hs-cTnI measurement (Beckman Coulter). The primary outcome was index myocardial infarction (MI), adjudicated by experts using clinical hs-cTnI measures. Diagnostic performance of the Australian 0/2-h algorithm was assessed by calculating negative and positive predictive values (NPV, PPV) with associated 95% confidence intervals. Efficacy, defined as the proportion of patients classified into the rule-out zone, was calculated. Algorithm optimization tested modified cut points to increase efficacy while maintaining NPV ≥ 99% and achieving PPV ≥ 65%. Results During the study period, 578 patients with complete 0/2-h algorithm assessments were accrued. These patients were 48% (279/578) female, 40% (233/578) non-White, with a median age of 60 years (IQR: 50–70). Index MI occurred in 7.4% (43/578). Algorithm efficacy was 54.8% (317/578) and 8.8% (51/578) were classified to the rule-in zone. Among patients ruled-out, the NPV was 99.4% (95% CI: 97.7%–99.9%). The rule-in zone was associated with a PPV of 62.7% (95% CI: 48.1%–75.9%). Among 36.3% (210/578) patients classified to the observation zone, 4.3% (9/210) had an adjudicated index MI. An optimized 0/2-h algorithm increased efficacy to 60.0% (347/578) while achieving an NPV of 99.4% (95% CI: 97.9%–99.9%) and PPV of 74.4% (95% CI: 58.8, 86.5%) for index MI. Conclusions The original Australian and optimized 0/2-h algorithms for i-STAT POC hs-cTnI measurement had high NPV and efficacy in a multisite U.S. cohort. Trial Registration Trial Registration: NCT06899776 [...]

ABSTRACT Background Early Warning Scores (EWS) are widely used to standardize the identification of clinical deterioration, yet their comparative performance against clinical judgment in Emergency Department (ED) triage remains uncertain. We aimed to evaluate whether commonly used EWS match or outperform clinical judgment in predicting early adverse outcomes. Methods We conducted a retrospective observational study including 361,927 adult ED presentations at a tertiary-care academic center from 2015 to 2024. Clinical judgment was operationalized as the triage category assigned at the initial evaluation. Five EWS (NEWS, NEWS2, MEWS, REMS, and ViEWS) were computed using vital signs recorded at ED presentation. The primary outcome was a composite of 24-h mortality or intensive care unit (ICU) admission. Discrimination, calibration, decision curve analysis, and reclassification metrics were used to compare models. Results The primary outcome occurred in 1.17% of patients. Discriminatory performance was highest for ViEWS (AUC 0.875) and clinical judgment (AUC 0.872), with no significant difference between them. Other EWS demonstrated significantly lower AUCs. In precision–recall and threshold-based analyses, clinical judgment maintained higher specificity at higher-risk thresholds while preserving adequate sensitivity. Decision curve analysis showed comparable or greater net benefit for clinical judgment than for all tested EWS across clinically relevant thresholds. Reclassification metrics showed no improvement with EWS over clinical judgment. Conclusion Commonly used EWS did not clearly outperform triage clinical judgment in predicting early ICU admission or death. These findings support further investigation of how structured scores and clinical judgment may provide complementary information, particularly in identifying patients whose risk may be modified by timely escalation of care. [...]

Academic Emergency Medicine, Volume 33, Issue 7, July 2026. [...]

Academic Emergency Medicine, Volume 33, Issue 7, July 2026. [...]

ABSTRACT Background Elder mistreatment is common, underreported, and associated with significant morbidity and mortality. Emergency department (ED) visits provide an important opportunity to identify elder mistreatment and initiate intervention, but the evidence for the impact of screening or intervention strategies in this clinical setting is not well characterized. Our goal was to conduct systematic literature reviews to describe the impact of ED-based screening tools and ED-initiated interventions for elder mistreatment. Methods We conducted two systematic reviews following PRISMA 2020 guidelines using predefined Patient Intervention Comparator Outcome (PICO) frameworks. PICO 1 evaluated ED based screening tools for patients aged 60 years and older. PICO 2 evaluated ED initiated interventions for patients with known or suspected elder mistreatment. Searches were performed in MEDLINE, Embase, Web of Science, and Cochrane CENTRAL from December 2018 through December 2024 and supplemented by prior scoping reviews. Results For PICO 1 (ED screening) the prior scoping review identified 5 studies and the updated search identified 208 additional articles, of which 5 studies underwent full-text review. For PICO 2 (ED intervention), the prior scoping review identified 5 studies and the updated search identified 191 additional articles, of which 2 studies underwent full-text review. No studies were identified that met full inclusion criteria for either PICO. Existing studies described multiple screening tools and multidisciplinary intervention models, but lacked comparator groups, standardized reference standards, or clinically meaningful outcome measures required for inclusion. Conclusions These empty systematic reviews emphasize the large existing knowledge gaps about ED elder mistreatment screening and intervention. These gaps affect the ability to make practice recommendations and highlight opportunities for future rigorous research to inform guideline development. [...]

Academic Emergency Medicine, Volume 33, Issue 7, July 2026. [...]

Palmiero and Figueiredo present a valuable synthesis of cervical spine clearance evidence across adult and pediatric trauma populations (1). Their tiered framework, which combines clinical clearance for cooperative adults satisfying Canadian C-Spine Rule criteria, computed tomography (CT)–based clearance for unreliable examinations, and targeted magnetic resonance imaging (MRI) for neurologic discordance or indeterminate findings, is pragmatic and consistent with contemporary trauma practice. Several methodological issues, however, influence how these recommendations should be interpreted and applied at the bedside. [...]

We read with interest the article by Heaney et al. about a 66-year-old man with pituitary apoplexy due to a pituitary macroadenoma, which was not detected in the initial cranial computed tomography (CCT) scan of the brain, but only 2 days later after performing a computed tomography angiography (CTA) (1). The symptoms subsided after conservative treatment (1). It was concluded that a normal CCT does not rule out the diagnosis of pituitary apoplexy (1). The study is interesting, but some points should be discussed. [...]

We thank Dr. Finsterer for the thoughtful engagement with our case report describing pituitary apoplexy presenting as intractable headache with an initially unrevealing noncontrast computed tomography (CT) scan. We welcome the opportunity to clarify several points and to further contextualize the diagnostic considerations relevant to emergency medicine practice. [...]

Capillary blood glucose measurement is frequently performed in emergency departments but may cause pain and discomfort. Vapocoolant spray is a rapid, non-invasive, and low-cost analgesic option, although its effectiveness during glucose testing remains insufficiently studied. [...]

: Opioid use disorder (OUD) is associated with high emergency department (ED) utilization, overdose, and unmet social needs. ED-based peer navigator (EDPN) programs may improve engagement in care and address social determinants of health, but data on their clinical and behavioral impact are limited. [...]

To the Editor, [...]

Health administrators, policymakers, and emergency physicians need accurate and clinically relevant data on current trends in emergency department (ED) visits. However, national databases do not apply operationally and clinically relevant categories to ED visit volumes. [...]

Knowledge about a third-trimester pregnancy is essential for guiding management of a pregnant patient presenting to the emergency department (ED) in labor or with an acute obstetrical complaint. Unfortunately, patients in their third trimester may present without prenatal obstetric care or with a condition (e.g. ill, altered, or trauma) in which information about the pregnancy is not immediately available. Moreover, many rural and community hospitals do not have an obstetrician available during all hours of the day. [...]

Intravenous tissue plasminogen activator (tPA) improves outcomes in acute ischemic stroke but carries a risk of intracranial hemorrhage, particularly parenchymal hematoma (PH), which is associated with poor prognosis. Early risk stratification remains clinically important. [...]

Acute venous air embolism is an uncommon but feared complication of central venous catheter procedures. Large volumes of intravascular air (generally estimated at approximately 50–100 mL) may obstruct right ventricular outflow and provoke circulatory collapse, whereas smaller volumes may still cause clinically significant arterial embolization in the presence of a right-to-left shunt such as a patent foramen ovale (1,2). Mortality in procedural air embolism is driven less by the absolute amount of air introduced and more by the velocity of entrainment, the patient’s intrathoracic pressure status, and whether a right to left shunt is present (e.g., a patent foramen ovale) (2). [...]

Internal jugular vein(IJV) cannulation is a critical component of trauma resuscitation but is often associated with significant pain during vessel dilation and suturing when performed under local anesthetic(LA) infiltration. We hypothesized that an ultrasound(USG)-guided superficial cervical plexus block(SCPB) would provide superior analgesia and improve procedural efficiency in awake trauma patients compared to standard LA infiltration. [...]

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. [...]

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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. [...]

For several years, there has been a focus on optimising resuscitation and increase survival rates in out-of-hospital cardiac arrest (OHCA),1,2 coinciding with an increased public discussion and focus from healthcare professionals on when to refrain from resuscitation attempts. In 2025, a Danish law was implemented in clinical practise stating that all capable citizens over the age of 60 can opt out of resuscitation attempts without prior consultation with a physician. This citizen-issued do-not-attempt-resuscitation (DNAR) order is self-registered in an online database and is accessible in all electronic record systems used in the Danish healthcare system, including the dispatching system used in the emergency medical dispatch centre (EMDC). [...]

The initial rhythm in out-of-hospital cardiac arrest (OHCA) strongly predicts survival. However, the association between electrocardiographic (ECG) abnormalities preceding OHCA and the initial rhythm remains unclear. [...]

In-hospital cardiac arrest is a rare but life-threatening event associated with poor outcomes in pediatric patients. Cardiac arrest is generally defined as the cessation of cardiac activity with unresponsiveness, absence of normal breathing, and no signs of circulation.1 In Utstein-style registries, in-hospital cardiac arrest is typically defined as an in-hospital event in which chest compressions and/or defibrillation are delivered to a hospitalized patient.2,3 Previous regional and international studies have reported widely varying incidences of pediatric in-hospital cardiac arrest, ranging from approximately 0.3 to 0.8 per 1,000 hospital admissions or discharges,4–7 with survival to hospital discharge rates varying from 32% to 57%. [...]

During neonatal resuscitation, emergency medication or volume administration is uncommon and difficult to predict but it may be critical for achieving return of spontaneous circulation (ROSC).1,2 Studies suggest that timely medication delivery may improve outcome. Halling showed that in neonates who received chest compressions and epinephrine in the delivery room (DR), early administration of medication significantly increased the chance of establishing ROSC.3 The need to achieve rapid vascular access during neonatal resuscitation extends beyond the DR to other resuscitation settings, including emergency departments, critical care units, and out-of-hospital environments. [...]

We read with some concern the recent paper “Comparison of intraosseous line placement location and rates of return of spontaneous circulation and survival to discharge among patients with out-of-hospital cardiac arrest” by Witherell et al. 1 In this observational study, the authors compare outcomes for patients with tibial or humeral placement of an intraosseous line during out-of-hospital cardiac arrest. They find that outcomes are substantially better in patients with humeral placement. The adjusted odds ratio for return of spontaneous circulation was 2.55 (95%CI: 1.54; 4.22) and it was 2.04 (95%CI: 1.03; 4.17) for survival to hospital discharge. [...]

Efforts to protect the brain date to the earliest era of resuscitation science. For more than half a century, sedative and anesthetic agents have been shown to reduce injury in preclinical models of global and focal brain ischemia. In 1978, Bleyaert and colleagues showed thiopental loading after global ischemia in monkeys reduced both neurologic deficits and histologic damage.[1] Similar neuroprotective signals have been identified for propofol,[2] dexmedetomidine,[3] ketamine,[4] and volatile anesthetics,[5] with inconsistent evidence for benzodiazepines and opioids. [...]

Socioeconomic and ethnic disparities in out-of-hospital cardiac arrest have been established across the chain of survival.[1–3] Patients from less affluent backgrounds and from ethnic minorities are more likely to suffer a cardiac arrest[4,5], receive bystander interventions[6–9], advanced hospital treatment[10] and less likely to survive.[4] The challenge is no longer to establish whether disparities in cardiac arrest exist, but to develop and implement effective strategies to reduce them and improve outcomes in underserved communities. [...]

Graphical abstract. Advanced hemodynamic monitoring modalities in post-cardiac arrest care. Hemodynamic variables assessed during post-resuscitation care after out-of-hospital cardiac arrest, including invasive and derived measures of systemic pressure, cardiac output, filling pressures, pulmonary hemodynamics, and oxygen transport, alongside current guideline-based conventional targets for MAP, lactate, and urine output. Abbreviations: CVP, central venous pressure; ERC, European Resuscitation Council; MAP, mean arterial pressure; mPAP, mean pulmonary artery pressure; PAPi, pulmonary artery pulsatility index; PCWP, pulmonary capillary wedge pressure; PVR, pulmonary vascular resistance; RAP, right atrial pressure; ScvO2, central venous oxygen saturation; SvO2, mixed venous oxygen saturation. [...]

Approximately 31% of patients achieve a return to spontaneous circulation (ROSC) and 7.5% are discharged home alive, with even fewer recovering completely, after out-of-hospital cardiac arrest (OHCA).[1] [...]

Ventilation and chest compressions are the two fundamental components of cardiopulmonary resuscitation (CPR). While real-time measurement and feedback on chest compression quality are well established, comparable approaches for ventilation are lacking. Current guideline recommendations for intra-arrest ventilation are based on low-quality evidence. Recommendations for ventilation monitoring are particularly sparse.[1] At the same time, a growing body of evidence indicates that ventilation during CPR is frequently delivered outside recommended targets, underscoring the need for reliable ventilation feedback. [...]

In the context of a global shortage of organs for transplantation, patients in brain death represent a source of organs.1 Cardiac arrest is the most common extracranial cause of brain death, and despite ischemia-reperfusion injury, the quality of organs retrieved in this setting remains acceptable.2,3 [...]

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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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