Emergency Medicine Journals

Background Attempting to improve emergency care (EC) advanced clinical practitioner (ACP) training, Health Education England (HEE) South West (SW) implemented a pilot, whereby emergency departments (ED) were provided with enhanced funding and support to help ED consultants deliver teaching and supervision to EC ACPs to ensure more timely completion of EC ACP training compared with previous cohorts training in the region. We explored the experiences of trainee EC ACPs and consultant EC ACP leads working in EDs, which had implemented the new regional pilot. Methods We used a qualitative design to conduct semi-structured interviews with trainee EC ACPs and consultant EC ACP leads across five EDs that had implemented the HEE SW pilot. Interview data were analysed thematically. Results Twenty-five people were interviewed. We identified four themes: (1) the master’s in advanced practice could be better aligned with the Royal College of Emergency Medicine credentialling e-portfolio; (2) EC ACP training needs some flexibility to reflect the individual—‘one size does not fit all’; (3) supervision and teaching were recognised as important but requires significant staff capacity that is impacted by external pressures and (4) unclear role expectations and responsibilities hinder role transition and impact role identity. It was notable that EC ACPs primarily spoke about the development of their clinical skills both academically and within the workplace, despite there being other skills mentioned in the multiprofessional framework for advanced practice (leadership and management, education and research). Conclusion A clear supervision structure with protected time allocated for teaching and assessment of clinical skills within the ED is essential to facilitate trainee EC ACP progression. However, increasing demands on EDs make this a challenging goal to achieve. Role identity issues continue to persist despite the introduction of new guidance designed to provide more clarity around the ACP role. [...]

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. [...]

Background Emergency department (ED) crowding causes increased mortality. Professionals working in crowded departments feel unable to provide high-quality care and are predisposed to burnout. Awareness of the impact on patients, however, is limited to metrics and surveys rather than understanding perspectives. This project investigated patients’ experiences and identified mitigating interventions. Methods A qualitative service evaluation was undertaken in a large UK ED. Adults were recruited during periods of high occupancy or delayed transfers. Semi-structured interviews explored experience during these attendances. Participants shared potential mitigating interventions. Analysis was based on the interpretative phenomenological approach. Verbatim transcripts were read, checked for accuracy, re-read and discussed during interviewer debriefing. Reflections about positionality informed the interpretative process. Results Seven patients and three accompanying partners participated. They were aged 24–87 with characteristics representing the catchment population. Participants’ experiences were characterised by ‘loss of autonomy’, ‘unmet expectations’ and ‘vulnerability’. Potential mitigating interventions centred around information provision and better identification of existing ED facilities for personal needs. Conclusion Participants attending a crowded ED experienced uncertainty, helplessness and discomfort. Recommendations included process and environmental orientation. [...]

Objective Care partners play a vital role in supporting persons living with dementia (PLWD) in using medical services. We conducted a meta-synthesis to explore care partner perspectives of ED care for PLWD, as well as healthcare provider (HCP) perceptions of care partner roles within the ED, to identify care gaps and facilitators across the ED continuum. Methods MEDLINE, PsycINFO and Embase databases were searched from inception to 8 May 2023. Grey literature was also searched. Articles were included if they reported on care partner roles or experiences regarding care delivery for PLWD in the ED, either from the perspective of care partners or HCPs. A charting exercise was used to categorise the primary focus and outcomes of the articles selected for inclusion. A second charting exercise was used to derive overarching themes based on care partner roles in ED care for PLWD, and care partner perspectives surrounding barriers and facilitators to care. Results 16 articles were included. Important barriers and facilitators to care for PLWD were identified and organised according to the timepoint of the visit (pre-ED, during a visit and post-ED). Key care gaps and barriers to care included: gaps in primary care access and care planning, ED environment and organisational processes, deficits in communication regarding patient care, lack of care partner involvement in clinical decisions, and difficulties with discharge transitions and follow-up care. Key facilitators to care included: clinical information provided by care partners, care coordination, and care partner support and engagement. Conclusion These findings can aid in developing dementia-friendly EDs by informing policy and practices, as well as environmental modifications. Future studies should focus on the feasibility and effectiveness of interventions targeted towards EDs and primary care settings. Engagement of care partners in these intervention studies will be critical to their success. [...]

Dementia, the great thief of our times, robs peoples’ memories of who they are and who they were and can break the heart and spirit of those caring for them. Unpaid carers supporting someone with dementia undoubtedly saves health economies billions each year, this does not include the unquantifiable value of carers in the ED setting where they can be enormously helpful, advocating for and providing accurate clinical details of their loved one. The ED can be a very stressful place for patients with dementia as well as their carers and often it is not the right place for them. Research by Alzheimer’s Society UK (2019) found that nearly two-thirds of all emergency admissions of people with dementia were for avoidable illnesses and injuries caused by failures in care.1 To date, there has been little focus on the experiences of family members of being with an older... [...]

Introduction Civilian healthcare workers (HCW) and medical facilities are directly and indirectly impacted by armed conflict. In the Russia-Ukraine war, acute trauma care needs grew, the workforce was destabilised by HCW migrating or shifting roles to meet conflict needs, and facilities faced surge events. Chemical, biological, radiological, nuclear and explosive (CBRNE) exposure risks created unique preparedness needs. In response, an academic and international non-governmental organisation partnership was formed to design, implement and evaluate a locally prioritised training programme in Ukraine. Methods Seven in-person training courses (Advanced Trauma Life Support, Trauma Nursing Fundamentals, Pediatric Trauma Fundamentals, Prehospital Trauma Fundamentals, Stop the Bleed, Mass Casualty Management and CBRNE Preparedness) were adapted, translated, taught and evaluated in seven Ukrainian oblasts (regions; Kyiv, Dnipropetrovsk, Zaporizhzhia, Odesa, Lviv, Chernihiv and Mykolaiv) during the war. Topics were determined by available needs assessments and further adapted based on course participant feedback and evolving logistic and security challenges. Change in participant knowledge and confidence levels was assessed through precourse and postcourse knowledge and self-confidence evaluations and follow-up surveys. Initial courses were taught by international instructors and transitioned to Ukrainian instructors as they were trained. Web-based asynchronous videos in Ukrainian were developed to complement and reinforce in-person training. Results 4368 participants were trained in 164 courses from August 2022 to April 2023. 223 instructors were trained. Aggregate participant knowledge and self-confidence significantly improved in all courses. Interval follow-up responses indicated that the training was useful and 83.3% had used the skills within 8 weeks of training. Twenty-seven training videos were created which, as of April 2023, have been viewed over 1 700 000 times in 500 cities throughout Ukraine. Conclusions Locally prioritised training can be rapidly developed and delivered in an armed conflict setting providing civilians and frontline HCW with the skills and knowledge required to care for patients. Logistics, communication, equipment and security challenges can be overcome through strategic in-country partnerships. Short asynchronous video learning can complement and scale in-person training. [...]

A shortcut review of the literature was conducted to examine the sensitivity and specificity of point-of-care ultrasound (POCUS) in detecting paediatric skull fractures. A total of 162 publications were screened by title and abstract, 13 studies underwent full text review, and after review of bibliographies of meta-analyses and systematic reviews, a total of 6 articles were included. Details about the author, date of publication, country of publication, patient group studied, study type, relevant outcomes (skull fracture), results and study limitations were tabulated. The clinical bottom line is that, in paediatric patients with a minor head injury, POCUS performed by emergency medicine physicians has a sensitivity ranging between 77% and 100% and a specificity between 85% and 100% for skull fracture detection, and its use in clinical decision-making has yet to be validated. [...]

Hidradenitis suppurativa (HS) is a complex, chronic skin disease characterised by painful inflammatory nodules, abscesses, dermal tunnels, sinus tracts and fistulae with a predilection for intertriginous skin. HS carries a substantial disease burden due to its prevalence, associated comorbidities and quality of life impacts and is associated with high healthcare resource utilisation. Clarity regarding the prevalence and pathogenesis of HS has led to improved therapies and more patients seeking care in both outpatient and acute care settings, including the emergency department. Emergency medicine providers play a critical role in HS diagnosis, management of acute flares and connection of HS patients with long-term dermatologic care, which can in turn help manage utilisation of acute care resources. [...]

Emergency medicine (EM) advanced clinical practitioners (ACPs) are an innovative autonomous multiprofessional non-medical practitioner (NMP) workforce in EDs. Historically from nursing and paramedicine backgrounds, regulated by their primary professional regulatory bodies, they already possess considerable clinical experience pre-ACP training. ACP qualification is underpinned by Masters-level education in conjunction with extensive work-based assessments and independent non-medical prescribing which fully maximises role utilisation.1 2 Recognised prospective EM benefits,3 novel governmental enablers, and the 2017 Health Education England multiprofessional framework and definition for ACP in England4 potentiated this new NMP role for current and future UK healthcare delivery.5 Furthermore, the Royal College of Emergency Medicine (RCEM) supports the EM ACP role, including a ‘gold-standard’ credentialing process underpinned through submission of a rigorous portfolio of assessment evidence.2 2018 voluntary RCEM membership data estimated 400 EM ACPs, and a 2022 EM ACP... [...]

Thoracostomies, and subsequent placements of chest tubes (CTs), are a standard procedure in several domains of medicine. In emergency medicine, thoracostomies are indicated to release a relevant hemothorax or pneumothorax, particularly a life-threatening tension pneumothorax. In many cases, an initial finger-assisted thoracostomy is followed by placement of a CT to ensure continuous decompression of blood and air. CTs prevent the reoccurrence of a hemothorax or pneumothorax, which may otherwise develop by closure of the initial thoracostomy incision. CTs are commercial, purpose-made products; however, in certain settings, those may not be readily available. Triggered by own experience, we review the use of endotracheal tubes as back-up alternatives to commercial CTs. On a structural base, commercial CTs may not be available in economically challenged regions. Furthermore, in settings with restricted capacity for equipment weight and volume, for example, in mountain rescue backpacks, it might not be feasible to carry CTs, even if the care provider is adequately trained. Finally, care providers may run out of stock of commercial CTs, for example, in civil mass casualty (‘MASCAL’) scenarios, natural disasters or on the battlefield with difficult resupply. Literature on this topic is very limited. In this manuscript, we discuss the advantages and disadvantages of standard endotracheal tubes as alternatives in settings, where commercial CTs are not readily available. Although certainly not advocated as standard, the use of endotracheal tubes as CTs may be a suitable alternative or back-up solution in settings where commercial CTs are not readily available. We assume that this technique will be particularly of interest in settings with a high risk for thoracic injuries and limited availability of commercial CTs, for example, in military conflicts. Given the virtual absence of scientific data, more research on risks, benefits and patient outcome is required. [...]

Background Advanced cardiovascular life support (ACLS) for cardiac arrest is a cornerstone of emergency care and yet remains poorly studied in low- and middle-income countries. We characterised the clinical epidemiology and outcomes of cardiac arrest and ACLS in an ED in central Haiti, a lower middle-income country with a nascent emergency care system. Methods We conducted a prospective observational study of adult and paediatric patients who suffered cardiac arrest in an academic hospital ED in central Haiti from January 2019 to August 2020. Patients were identified prospectively at the time of clinical care. Data on demographics, comorbidities, clinical presentation, management with or without ACLS and outcomes were extracted from patient charts using a standardised form and analysed in SAS V.9.4. The primary outcome was survival to 24 hours after arrest. Results We identified 161 patients who suffered cardiac arrest in the ED. The mean age was 45 years; 55.9% were female, and 82.6% were aged >18. Common presenting diagnoses were pneumonia (16.1%), sepsis (14.9%), congestive heart failure/cardiogenic shock (11.2%) and cerebrovascular accident (10.6%). Few patients were on cardiac or oxygen saturation monitors (23.1%; 63.5%) prior to arrest. 43 (27%) patients received ACLS (two patients missing data). Among these, 58.1% had initial rhythm assessed, and 2/25 (8%) patients had shockable rhythms. The median time to arrest was 23.6 hours. Sustained return of spontaneous circulation was achieved in two patients (4.7%). Among patients for whom ACLS was not initiated, the majority were due to poor prognosis (66.4%) or irreversible cause (22.4%) in the setting of available resources. One patient survived to 24 hours; none survived to hospital discharge. Conclusion In this lower middle-income setting, cardiac arrest in the ED was associated with poor survival despite ACLS. Survival may be impacted by limited resources for prearrest monitoring as well as for ongoing critical care. [...]

Objectives Underutilisation of thrombolysis is a major problem in patients with stroke in Bangladesh as patients do not arrive within the therapeutic window due to delays in their way to emergency department. This study aims to assess the time delay from patients’ symptom onset to arrival in the hospital and the factors that are associated with it. Methods This cross-sectional survey of a prospective cohort of stroke patients was conducted between January and March 2023. 448 stroke patients meeting the inclusion criteria were enrolled in the study from five tertiary-level hospitals in Bangladesh. After obtaining informed consent, trained data collectors conducted face-to-face interviews of the patient/patients’ guardians via a pretested structured questionnaire. Stata (V.16) was used to analyse data. Median and IQRs were used to summarise quantitative variables, and qualitative variables were summarised using frequency and relative frequency. Pearson’s 2 test and Mann-Whitney U test were used to explore the bivariate relationship between predictor and outcome variables. Finally, a binary logistic regression model was fit to explore the factors associated with delayed arrival (>4.5 hours) at the hospital. Results The median age of the patients was 61 years (54–70) and 63% were men. The majority hailed from rural (59.6%) areas and had primary (25.89%) education. The patients had an overall median prehospital delay of 14 (8–28) hours, 3 (1–6) hours of decision delay, 1 (0–2) hours of medical contact delay, and 14 (6.5–25.75) hours of referral delay. Patients with master’s education (adjusted OR (AOR): 0.04, p=0.023) and private transport (AOR: 0.26, p=0.029) had a lower chance of late arrival. However, patients having unknown onset, self-medicating, having a previous history of stroke, and being admitted to a private hospital had a significantly higher chance of late arrival. Conclusion Nearly 90% of the patients were late to arrive (>4.5 hours) at hospital and referral delay comprises the majority of the prehospital delay. Therefore, fast symptom recognition and the urgency of seeking healthcare as soon as symptoms appear should be the focus of public awareness efforts. [...]

Academic Emergency Medicine, EarlyView. [...]

Abstract Objective The emergency department (ED) is an essential setting for diagnosis of pregnancy, confirmation of pregnancy location, and management of pregnancy loss and other complications. This health care service delivery is especially important for patients with limited or complicated access into reproductive health care elsewhere. We seek to assess emergency physicians’ knowledge, training, attitudes, and practices related to pregnancy options counseling, reproductive health referrals, and provision of medical- and procedural-induced abortion. Methods We surveyed a sample of emergency physicians in person at a U.S. national medical meeting regarding knowledge, attitudes, and practices related to reproductive health care delivery. Wilcoxon rank sum tests were used to evaluate differences between abortion-restrictive and -permissive states and chi-square tests were used to compare proportions between the two groups and Wilcoxon signed rank was used to compare median scores between questions. Thematic analysis was used to review qualitative responses. Results Of the 295 emergency physicians approached, 252 (85.4%) completed study procedures. The majority (n = 218, 86.5%) practiced in abortion-permissive states. Most (n = 178, 70.6%) supported abortion provision in the ED if legally allowed, though only about half (n = 131, 52.0%) reported ever prescribing medication abortion pills. Despite higher proportions reporting training in services, a small minority responded they could still independently provide pregnancy options counseling (25.1%), direct referrals for abortion (34.9%), medical management for early pregnancy loss (15.1%) or induced abortion (10.7%), or uterine aspiration for any pregnancy indication (1.6%). Training and knowledge were similar, though practice patterns and attitudes differed when comparing abortion-restrictive to -permissive states. Conclusions This national survey demonstrates that, while most emergency physicians support the provision of abortion care in this setting, they do not routinely provide this care due to a variety of factors including lack of knowledge, lack of training, and legal and institutional restrictions. [...]

Academic Emergency Medicine, EarlyView. [...]

Abstract Background Acute intoxication is common in patients evaluated for traumatic brain injury (TBI). However, the effect of elevated blood alcohol levels (BALs) on the diagnostic accuracy of FDA-cleared biomarkers for evaluating traumatic intracranial injury on computed tomography (CT) scan, namely, glial fibrillary acidic protein (GFAP) and ubiquitin carboxy-terminal hydrolase L1 (UCH-L1), has not been well studied. Methods We investigated the effect of significantly elevated (>300 mg/dL) and modestly elevated BAL (81–300 mg/dL) at emergency department presentation on the diagnostic accuracy of GFAP and UCH-L1 for predicting a positive CT in patients presenting to 18 U.S. Level I trauma centers within 24 h of TBI as part of the prospective, Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) study. Plasma GFAP and UCH-L1 were measured using Abbott i-STAT Alinity and ARCHITECT assays. Discrimination was evaluated using the area under the receiver operating characteristic curve (AUC). Results Of 2320 TRACK-TBI participants studied, 54 (2.3%), 332 (14.3%), 1209 (52.1%), and 725 (31.3%) had significantly elevated BAL, modestly elevated BAL, nonelevated BAL (0-80 mg/dL), and no BAL available, respectively; 48.3% of the cohort had a positive brain CT. Those with significantly elevated and modestly elevated BAL were more likely to have positive CT (61.1% and 60.5% vs. 46.9% and 44.0%) and had higher plasma GFAP and UCH-L1 levels than those with nonelevated BAL and no BAL available. The AUC of GFAP and UCH-L1 combined for predicting CT positivity was higher in those with significantly elevated BAL (0.949) than those with modestly elevated BAL (0.858), nonelevated BAL (0.849), and no BAL available (0.883). Conclusions Modestly and significantly elevated BAL does not lower the diagnostic accuracy of GFAP and UCH-L1 for predicting traumatic intracranial injury on CT. These biomarkers may be useful in decreasing avoidable brain CT imaging in persons with acute alcohol intoxication. [...]

Academic Emergency Medicine, EarlyView. [...]

Academic Emergency Medicine, EarlyView. [...]

Academic Emergency Medicine, EarlyView. [...]

Academic Emergency Medicine, EarlyView. [...]

Abstract Background Despite the importance of effective communication during verbal de-escalation, research regarding patient primary language during management of agitation symptoms is limited. We evaluated associations between patient primary language and use of physical restraints and intramuscular (IM) sedation in the emergency department (ED). Methods This was a retrospective cohort analysis evaluating physical restraint and IM sedation characteristics using electronic medical records from 13 EDs affiliated with a large regional health care network located in the northeast United States. Data were collected for ED visits from 2013 to 2023 for all adult patients ages 18 and older. We performed logistic regression models using the presence of physical restraint and IM sedation orders as primary outcomes, adjusting for patient primary language, sex assigned at birth, age, race and ethnicity, and chief complaints. Results In our analysis of 3,406,474 visits, 3,086,512 included English speakers, 250,912 included Spanish speakers, 9,057 included Portuguese speakers, 6,616 included Arabic speakers, 6,425 included Italian speakers, 39,303 included other language speakers, and 7,649 included unknown language speakers; 18,546 visits included use of physical restraints and 48,277 visits included use of IM sedation. After demographic and clinical characteristics were adjusted for, visits with Spanish- and Portuguese-speaking patients had a reduced likelihood of physical restraints and IM sedation compared to English speakers, with adjusted odds ratios (95% confidence intervals) of 0.70 (0.65–0.76) and 0.82 (0.79–0.87) for Spanish speakers and 0.39 (0.20–0.68) and 0.84 (0.66–1.05) for Portuguese speakers, respectively. Conclusions ED visits with Spanish- and Portuguese-speaking patients were found to have lower odds of physical restraints and IM sedation, while Arabic, Italian, other, and unknown language–speaking patients were found to have higher odds. Factors contributing to linguistic differences in physical restraint and IM sedation use, such as cultural interpretations of behavior, quality of clinical interactions, and patient–clinician communication strategies, merit further investigation. [...]

Academic Emergency Medicine, EarlyView. [...]

Academic Emergency Medicine, EarlyView. [...]

Academic Emergency Medicine, Volume 32, Issue 2, Page 176-178, February 2025. [...]

I read with great interest the recent article by Zhou et al., “Improving Initial Management of Septic Patients: Comparing Intravenous Push vs. Intravenous Piggyback Antibiotics,” published in The Journal of Emergency Medicine (1). The authors are to be commended for addressing an important and practical question in emergency care, and for demonstrating that intravenous push (IVP) administration was associated with a shorter time to antibiotic delivery and sepsis bundle completion compared with intravenous piggyback (IVPB). [...]

We thank Higgins et al. (1) for their thoughtful letter and for their careful review of our study. We appreciate the opportunity to clarify several methodological points. Our responses to each of the issues raised are provided below. [...]

To The Editor, [...]

To The Editor, [...]

Undifferentiated, agitation in older adults is common in the prehospital setting, and in transitions from emergency medical services (EMS) to emergency department (ED) care. Restraints are commonly used in the management of agitation, although there is little evidence to inform the development of best practices. [...]

Intravenous thrombolysis is traditionally avoided in patients with early recurrent acute ischemic stroke due to concerns for increased hemorrhagic risk. Although emerging evidence suggests repeat intravenous thrombolysis may be safe in selected patients, nearly all published cases involve alteplase, with limited data on repeated use of tenecteplase. [...]

Intravenous thrombolysis is traditionally avoided in patients with early recurrent acute ischemic stroke due to concerns for increased hemorrhagic risk. Although emerging evidence suggests repeat intravenous thrombolysis may be safe in selected patients, nearly all published cases involve alteplase, with limited data on repeated use of tenecteplase. [...]

Vertigo is a common Emergency Department (ED) presentation, assessment can be challenging due to various aetiology and subtle clinical signs. Nystagmus is an important clinical feature, yet documentation of its key descriptors if often incomplete. [...]

Vertigo is a common Emergency Department (ED) presentation, assessment can be challenging due to various aetiology and subtle clinical signs. Nystagmus is an important clinical feature, yet documentation of its key descriptors if often incomplete. [...]

We have read with great interest the review article entitled “Oxygenation through the working channel of fiberscope during awake tracheal intubation (ATI) in severe glottic edema following caustic agents injury” by Rinaldi P et al. published in “The Journal of Emergency Medicine”1. [...]

Hit my trembling handsTrying to wrestle lifeInto her limp body, losingA fight she surrenderedWhen her feet slippedOff the ledge. [...]

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, Volume 153, Issue 17, Page 1337-1339, April 28, 2026. [...]

Circulation, Volume 153, Issue 17, Page 1340-1342, April 28, 2026. [...]

Circulation, Volume 153, Issue 17, Page 1343-1346, April 28, 2026. [...]

Circulation, Volume 153, Issue 17, Page e1151-e1152, April 28, 2026. [...]

Circulation, Volume 153, Issue 17, Page e1153-e1153, April 28, 2026. [...]

Circulation, Ahead of Print. Background: To improve survival in patients at risk of sudden cardiac death, subcutaneous ICDs (S-ICDs) require optimal implant positioning for effective shocks. Defibrillation (DF) testing is recommended but carries serious risks. The PRAETORIAN score predicts defibrillation outcomes based on chest X-rays. The PRAETORIAN-DFT trial evaluated whether omission of DF testing guided by the PRAETORIAN score is non-inferior for first-shock efficacy.Methods: In this multinational trial, S-ICD patients from 37 centers were randomized to DF testing or no DF testing. In the No-DF testing group, the PRAETORIAN score was evaluated before discharge. The primary endpoint was failed first shock for spontaneous ventricular arrhythmias, as a surrogate for defibrillation success, tested for non-inferiority with a 3% absolute risk margin. Secondary endpoints included mortality, potential DF testing-related complications, and S-ICD revisions.Results: The included 965 patients (No-DF testing, n=483;DF testing, n=482) were followed for a median of 41 months. Failed first shock for spontaneous ventricular arrhythmia occurred in 1.7% of the No-DF testing group versus 2.3% of the DF testing group (–0.6%, 95% CI [ –2.6 to 1.4]; p<0.001). There were no significant differences in all-cause mortality (HR 0.9 [95% CI 0.6–1.4]) or arrhythmic death (HR 0.4 [95% CI 0.04–3.4]). Potential DF testing-related complications occurred in 1.7% in the DF testing group. Postoperative S-ICD revisions due to inadequate positioning were identical between groups (n=2 each).Conclusions: PRAETORIAN score–guided omission of DF testing- after S-ICD implantation did not increase the risk of failed first shocks for spontaneous ventricular arrhythmias and reduced procedural risk without increasing S-ICD revisions. (Funded by Boston Scientific; PRAETORIAN-DFT). [...]

Circulation, Ahead of Print. Physical activity (PA) is essential for the cardiovascular, emotional, and social health of all children and adolescents. However, for pediatric patients with cardiomyopathy, decades of risk-averse clinical guidance have resulted in widespread PA restriction due to fears of sudden cardiac death and disease progression. This has contributed to sedentary behavior, poor cardiorespiratory fitness, and increased risk of secondary cardiometabolic conditions in this population. However, emerging data challenge this restrictive paradigm, showing that the risk of sudden cardiac death may not be higher in some patients with cardiomyopathy who exercise than in those who are less active, and that participation in PA may also have a positive effect on reverse remodeling. This American Heart Association scientific statement provides an evidence-based framework for the promotion of PA in pediatric patients with hypertrophic cardiomyopathy, dilated cardiomyopathy, restrictive cardiomyopathy, or arrhythmogenic cardiomyopathy, as well as those with implantable cardioverter defibrillators; outlines the physical, social, and emotional benefits of PA for these children and adolescents; and provides updated risk stratification strategies, including the use of advanced imaging, exercise testing, and genotype-specific data. This scientific statement underscores the importance of shared decision-making tailored to developmental maturity and family goals and emphasizes the need for longitudinal surveillance as clinical phenotypes evolve. With individualized assessment and informed shared decision-making, most children and adolescents with cardiomyopathy can safely engage in PA, with important implications for long-term cardiometabolic and psychologic health. [...]

Circulation, Ahead of Print. BACKGROUND:SIRT5 (sirtuin 5) is a member of the sirtuin family known to regulate cardiac metabolism, aging, and function. However, its role in cardiac fibroblast (CFB) metabolism, activation, and fibrosis remains elusive.METHODS:Expression changes of SIRT5 in CFBs from cardiac tissue of human and mouse with heart failure were determined. The functional role of SIRT5 in cardiac fibrosis was evaluated through CFB-specific knockout and overexpression ofSirt5in mice. The involvement of succinylation of lysine 489 (Lys489) on PCK2 (phosphoenolpyruvate carboxykinase 2) in SIRT5-mediated regulation of cardiac fibrosis was assessed by introducing the Lys489-to-arginine mutation of PCK2 inSirt5-deficient CFBs and in CFB-specificSirt5knockout mice.RESULTS:SIRT5 expression was markedly reduced in CFBs from humans and mice with heart failure and showed a negative correlation with cardiac fibrosis severity. Loss ofSirt5in CFBs exacerbated left ventricular dysfunction, cardiac hypertrophy, and cardiac fibrosis in mice subjected to transverse aortic constriction, whereas overexpression ofSirt5in CFBs significantly attenuated these pathological changes.Sirt5deficiency promoted CFB activation by driving a metabolic shift from oxidative phosphorylation to glycolysis. Mechanistically,Sirt5deficiency increased the succinylation of PCK2 at Lys489, a key enzyme linking glycolysis and the tricarboxylic acid cycle, which consequently inhibited this enzyme activity in CFBs. Importantly, this specific modification at the Lys489 mutation that prevents succinylation effectively reversed both the metabolic reprogramming and the hyperactivation of CFBs induced bySirt5knockout.In vivo, introducing thePck2 K489Rmutation fully rescued the exacerbated cardiac fibrosis and dysfunction observed inSirt5-deficient mice after transverse aortic constriction.CONCLUSIONS:By desuccinylating PCK2 at Lys489, SIRT5 prevents the metabolic reprogramming and subsequent activation of CFBs, protecting against cardiac fibrosis. [...]

Circulation, Ahead of Print. BACKGROUND:Atrial fibrillation (AF) is the most common arrhythmia and is associated with high morbidity and mortality, particularly in the aging population. Current treatment and prevention strategies remain suboptimal, highlighting the urgent need to better understand the mechanisms underlying aging-associated AF. We recently reported a causal role of the stress-activated kinase JNK2 (c-Jun N-terminal kinase 2) in aging-associated AF pathogenesis, mediated by JNK2-driven sarcoplasmic reticulum Ca2+dysfunction. However, the mechanisms by which cardiac JNK2 is activated during aging to promote AF remain unclear. Emerging evidence suggests that interorgan crosstalk contributes critically to the development of cardiovascular diseases. A hyperpermeable gastrointestinal epithelial barrier (“leaky gut”), commonly observed in aged individuals, is associated with elevated levels of proinflammatory cytokines and an increased risk of AF. Although proinflammatory cytokines have been proposed as predisposing factors for AF, clinical and experimental studies have yielded inconsistent results, underscoring the complexity of inflammation-associated AF pathogenesis. Here, we investigated whether cardiac JNK2 integrates diverse stress stimuli, including proinflammatory cytokines and lipopolysaccharide, to drive AF pathogenesis.METHODS:We used aged mice, intestinal epithelium–specific tight junction OD (occludin) knockdown (OD+/−) mice, and a well-established dextran sulfate sodium–induced leaky gut mouse model characterized by reduced gastrointestinal epithelial occludin expression. A series of physiological and molecular approaches was applied to assess cardiac and gastrointestinal responses.RESULTS:We found that leaky gut significantly activates atrial JNK2, which, in turn, drives Ca2+-triggered arrhythmic activity and increases AF inducibility in aged, dextran sulfate sodium–treated, and OD+/−mouse models. Restoration of gut barrier function in dextran sulfate sodium mice, a clinically relevant model, reduced AF susceptibility. Similarly, either JNK2 inhibition or TNF-α (tumor necrosis factor α) blockade abolished the increased AF risk associated with leaky gut. Furthermore, we demonstrate, for the first time, that leaky gut–associated proinflammatory cytokines, including TNF-α and IL-17A (interleukin-17A), together with lipopolysaccharide, activate cardiac JNK2. This activation promotes AF pathogenesis through JNK2-mediated arrhythmogenic mechanisms, including diastolic sarcoplasmic reticulum Ca2+leak, Ca2+waves, and delayed afterdepolarizations.CONCLUSION:Activated JNK2 functions as a pathological nodal integrator of leaky gut–associated stress signals, mediating gut-to-heart crosstalk and driving inflammation-induced AF pathogenesis. Targeting JNK2 may represent a novel therapeutic strategy for AF. [...]

Circulation, Volume 153, Issue 16, Page 1230-1232, April 21, 2026. [...]

Circulation, Volume 153, Issue 16, Page e1124-e1125, April 21, 2026. [...]

Circulation, Volume 153, Issue 16, Page e1128-e1129, April 21, 2026. [...]

Out-of-hospital cardiac arrest (OHCA) treated by emergency medical services (EMS) in the United States (U.S.) has a neurologically intact survival to hospital discharge rate of 7.2 % with substantial regional variation.1,2 Bystander cardiopulmonary resuscitation (CPR) and high-quality CPR by EMS crews improves neurologically intact survival following OHCA.3–5 However, conventional CPR has limitations which has led investigators to seek novel strategies to optimize CPR and improve patient outcomes [...]

Following cardio-pulmonary resuscitation (CPR) and return of spontaneous circulation (ROSC) after out-of-hospital cardiac arrest (OHCA), post-resuscitation management aims to minimise anoxic brain damage1 and high-quality resuscitation care intends to reduce the complexity for care providers.2 To improve patient ventilation without requiring specific skills for endotracheal intubation (ETI), the concept of supraglottic airway management evolved and is guideline-recommended as a first-line, in particular for less skilled rescuers. [...]

Electroencephalography (EEG) is routinely used for prognostication after cardiac arrest (CA).1 Integrated with clinical examination, somatosensory evoked potentials (SSEP), serum neuron specific enolase (NSE), and brain imaging, highly malignant EEG (suppressed or burst-suppressed background with or without periodic discharges2 reliably estimates the likelihood of a poor outcome.1,3 Over the years, increasing attention has been directed towards favorable outcome prediction, forecasted by early continuous, reactive EEG background, along with motor response to stimuli, and low NSE. [...]

The initial rhythm is a known predictor of survival in extracorporeal cardiopulmonary resuscitation (ECPR) patients. However, the effect of the rhythm at hospital admission on outcomes in these patients is less clear. [...]

The incorporation of artificial intelligence (AI) into medical education and evaluation is transforming how clinical skills are assessed, offering new opportunities for efficiency, scalability, and uniformity in testing1–2. A recent study led by Wang et al.3, “Suitability of GPT-4o as an Evaluator of Cardiopulmonary Resuscitation Skills Examinations”, explores the use of GPT-4o4, a large language model, as a tool for evaluating CPR skills among medical students. With AI gradually becoming a fixture in medical examinations5,6, this research highlights its potential to improve both the efficiency and accuracy of practical skills assessments. [...]

The combination of controlled automated head/thorax elevation, active compression-decompression (ACD) cardiopulmonary resuscitation (CPR), and an impedance threshold device (ITD-16), termed AHUP-CPR, lowers intracranial pressure and increases circulation and neurologically-sound survival in pigs versus conventional (C) CPR. This study examined whether AHUP-CPR increased end tidal (ET) CO2, a non-invasive marker of cardiac output and organ perfusion, compared with C-CPR in witnessed out-of-hospital cardiac arrest patients. [...]

To the editor, [...]

The Utstein Out-of-Hospital Cardiac Arrest Resuscitation Registry Template, introduced in 1991 and updated in 2004 and 2015, standardizes data collection to enable research, evaluation, and comparisons of systems of care. The impetus for the current update stemmed from significant advances in the field and insights from registry development and regional comparisons. This 2024 update involved representatives of the International Liaison Committee on Resuscitation and used a modified Delphi process. [...]

The terms ‘heart attack’ and ‘cardiac arrest’ are distinct entities that are regrettably frequently confused, particularly within the media. Complicating the issue further is the fact that the two conditions frequently overlap, with coronary artery disease being the main aetiology of sudden cardiac arrest (SCA) In patients over 25 years of age1. Determining the precise degree of overlap (Figure 1) is of high importance given the heavy medical, societal and economic burden imposed by both conditions2–3. [...]

Despite significant research efforts, the “holy grail” of post-cardiac arrest prognosis remains elusive. Factors related to the arrest, resuscitation care, post-arrest care, and underlying comorbidities all play a role in determining who will survive the arrest beyond admission and who will have a neurological outcome that is meaningful. Much effort has been directed toward understanding hypoxic and ischemic brain injury (HIBI) during the post-arrest phase, especially the dysregulation phase, in which cellular injury to brain tissue progresses1. [...]

In our recent study of emergency ambulance phone calls for out-of-hospital cardiac arrest (OHCA), we identified that callers frequently encounter barriers to performing cardiopulmonary resuscitation (CPR).1 Emergency call-takers have the task of persuading callers to perform CPR as quickly as possible. However, very little has been published about what strategies call-takers use.2,3 We examined whether the “Behavioural Change Technique (BCT) Taxonomy”4 could be useful to classify call-taker strategies. [...]

This study aimed to predict blood pressure during CPR using chest compression waveform information obtained from a CPR feedback device. [...]

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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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