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Rose and colleagues used a framework (Autor’s Framework) developed in labor economics to evaluate the work of the emergency physician and the potential for replacement by AI. Mapping emergency physician tasks to a four-quadrant grid, they found that most time on shift is spent in non-routine abstract or manual tasks, areas more protected from AI penetration.
Rose C, Molins E, Schoeffler A, Kabeer R, Frank MR, Preiksaitis C. Will Artificial Intelligence Replace Me? Automation Susceptibility of Emergency Physician Tasks; Annals of Emergency Medicine, 2026; 88, 551-561.
This study found no reason to decrease pregnant women’s dosing of medication for opiate use disorder. There was no increase in neonatal withdrawal with standard dosing vs decrease dosing.
As with most things, what is good for mom is good for baby. Keeping mom from relapsing to opiate use is the number one goal of MOUD.
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45 year old male presents with nausea, vomiting, profuse diarrhea, and abdominal cramping occurring 6-7 hours after eating a meal he cooked containing wild mushrooms he picked the day before. What is you diagnosis?
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Norepinephrine is widely viewed as the first line vasopressor for many types of shock, including undifferentiated shock and septic shock. But as the norepinephrine dose escalates, a perennial question is when to add a second agent, most commonly vasopressin. Based in part on trials like VASST and VANISH, a norepinephrine dose of roughly 0.1-0.2 mcg/kg/min is commonly cited as the time to add on vasopressin.
The VASSPR study was a cluster crossover randomized trial comparing lower (0.1 mcg/kg/min of norepinephrine) vs higher (0.4 mcg/kg/min of norepinephrine) threshold for initiation vasopressin in septic shock patients and was published in JAMA just a few weeks ago.
Bottom Line: This relatively large, high-quality study found no mortality benefit for initiating vasopressin when at a norepinephrine dose of 0.1 mcg/kg/min (or equivalent), which is a common practice, vs initiating vasopressin when at a norepinephrine dose of 0.4 mcg/kg/min. So whether you choose to stick with the current threshold of roughly 0.1-0.2 of norepi that many of us use as your queue to start a second agent, or wait a little later up to 0.4, that's a reasonable approach. Equipoise remains as to the benefit of adding a second agent and when it should be initiated. Of note, the surviving sepsis guidelines say 0.25-0.5 mcg/kg/min, so you also have support from those guidelines if you choose to wait.
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Question
A male in his 70s presents to the emergency department after a syncopal episode with hypotension and abdominal pain.
What's the diagnosis? What's the correct measurement?
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This review article reminds us that pigtail catheters can be effectively used to drain pneumothoraces, pleural effusions, hemothoraces, emphysemas, and other fluid collections within the thorax. It also offers three patient positions to use for pigtail placement.
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Bottom Line:
This multicenter trial demonstrated improved physiological outcomes such as lactate clearance and renin clearance in septic shock by using early multimodal vasopressor strategy but was not powered to detect mortality benefit. Further studies looking at more patient specific outcomes with this strategy are needed.
When caring for a critically ill ICU boarder in the ED, remember to add vasopressin early for escalating norepinephrine requirements (0.2-0.3 mcg/kg/min NEE).
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A patient presents with hypoxia, anemia, and the following CT findings:
What is the diagnosis? What will you do next?
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As a reminder, age friendly health care says we should address the 4Ms with older patients; what matters, medication, mentation, and mobility.
This article says we aren’t good about discussing firearm access with older depressed patients and patients with dementia. We can do better having these conversations with our vulnerable older patients and their families.
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Noninvasive Respiratory Support for Acute Respiratory Failure
- Acute respiratory failure (ARF) is a leading cause of ICU admission, intubation, and initiation of mechanical ventilation.
- The American Thoracic Society (ATS) recently published its evidence-based clinical practice guideline on the use of noninvasive ventilation (NIV) in adults with ARF.
- The guideline focused on four categories: acute hypoxemic respiratory failure, acute hypercapnic respiratory failure, preoxygenation during endotracheal intubation, and post-extubation support.
- With respect to adult patients undergoing endotracheal intubation, ATS recommends the use of high-flow nasal cannula or noninvasive ventilation compared to standard oxygen therapy for preoxygenation.
- This strong recommendation is based on their pooled analysis of 15 randomized controlled trials, including over 3,000 patients, that demonstrated HFNC and NIV decreased the risk of peri-intubation hypoxemia compared to standard oxygen.
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This meta analysis looking at the literature regarding fall prevention measures in patients over 60 years old found a significant amount of heterogeneity in the literature and no proof that fall prevention measures had any impact on 3,6,12 month mortality or re-hospitalization. More work is needed in this area to know better what, if anything, can impact this important patient safety measure.
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Parental presence during pediatric resuscitation is supported by family-centered care principles and AHA guidelines, yet implementation remains inconsistent due to divided provider attitudes and a lack of institutional policies.
Methods: Qualitative exploratory descriptive study across three Iranian pediatric hospitals. Semi-structured interviews were conducted with 33 resuscitation team members (nurses and physicians) and 20 parents who experienced their child's resuscitation. Thematic analysis identified key patterns. Of 16 resuscitated children, 87.5% died.
Conclusions: Parental presence is not a binary choice but requires preparation, support, and shared decision-making. The authors recommend formal institutional policies, staff simulation training, designated family support persons, and structured pre-briefing and debriefing protocols.
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The BRIDGE-TNK trial in 2025 showed that Tenecteplase AND thrombectomy offered better functional outcome for patients with ischemic stroke from large vessel occlusion.
However, the ATTENTION LATE trial (published in September 2026) showed that for patients with basilar artery occlusion, routine administration of Tenecteplase before Thrombectomy did not improve functional outcome, when compared with thrombectomy alone, between 4.5-24 hour window, while rates of symptomatic intracranial hemorrhage were the same in both groups.
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Evaluation of non-fatal strangulation patients with these signs is a CT angiogram of the neck.
Also note that this is a common finding in domestic violence and is a predictor of future injury and death from this partner.
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This South African study looked at 194 hanging or strangulation injury patients and found that no clinical feature excluded blunt cerebral vascular injury (BCVI) in these patients. Nearly 5% of these patients had BCVI. The authors concluded the only safe way to exclude BCVI in post hanging/strangulation injury was CT angiography of the neck.
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Bottom line: Consider low dose CT in children with concern for aspiration events
Pediatric foreign body aspiration can be a challenge. The patient obvious airway obstruction is clear, but what to do in patients who choked and are stable? Old convention used bilateral decubitus chest X-rays for evaluation for air trapping, and if positive consider scoping. More recent literature suggests that low dose CT may be more optimal for assessment of foreign body. It has similar (and in some cases less) total radiation exposure for children, shortens length of stay, and can prevent the unnecessary bronchoscopy of patients- removing the risks of the procedure and the sedation. For patients in community EDs, this may also prevent unnecessary and costly transfers.
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In this retrospective study of 4635 patients, continuing oral beta blocker within 48 hours of presentation for patients with sepsis was associated with a reduced risk of all-cause mortality within 90 days of hospital admission (hazard ratio 0.77; 95% CI, 0.61–0.98; p = 0.03), and a shorter hospital stay (incidence rate ratio 0.39; 95% CI, 0.38–0.41; p < 0.001).
Therefore, it is reasonable to consider Beta-blocker if patients are adequately resuscitated.
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Emergency Physicians have a high specificity and moderate sensitivity for detecting cholecystitis with point-of-care ultrasound.
Signs of Cholecystitis on Ultrasound include:
- Sonographic Murphy's sign = The patient has pain when the ultrasound probe is directed over the gallbladder and compressed
- Pericholecystic Fluid = Fluid around the gallbladder
- Increased Gallbladder Wall Thickness = A wall thickness > 3 mm measured on the anterior gallbladder wall
- Most patients will have gallstones. Acalculus cholecystitis can occur with patients who are chronically ill, critically ill, on TPN or immunocompromised.
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How well do the Denver and Memphis screening criteria identify blunt cerebral vascular injury?
From 2021:
Not very well! Blunt injury to the head and neck may be enough to prompt you to order a CTA of the neck.
Click to see Memphis criteria which overlap Denver
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One-liner
A large prospective PECARN study developed and validated a highly sensitive clinical prediction rule to safely reduce unnecessary cervical spine imaging in children with blunt trauma.
Background: Pediatric cervical spine injury (CSI) is rare (<1% of blunt trauma), but missing an injury has devastating consequences. Existing adult rules (NEXUS, Canadian C-Spine Rule) are not well validated in children.
Methods: This multicenter prospective observational study enrolled over 22,000 children with blunt trauma across PECARN hospitals. Investigators identified clinical variables associated with CSI and derived a risk-stratification rule.
Results: The rule demonstrated very high sensitivity (~94%) and an extremely high negative predictive value (>99.9%) for clinically significant CSI. High-risk factors (e.g., GCS 3–8, focal neurologic deficits) warrant CT, whereas intermediate-risk factors may be evaluated with plain radiographs. Children without identified risk factors generally do not require imaging.
Limitations: Observational derivation/validation study rather than an interventional trial. Clinical judgment remains important in atypical presentations.
Clinical Relevance: This is likely to become the pediatric equivalent of the PECARN head trauma rule and should reduce unnecessary CT imaging while maintaining patient safety.
Take-home Points
- First large, validated pediatric-specific CSI rule.
- Helps identify children who require CT versus radiographs versus no imaging.
- Expected to reduce radiation exposure.
- May become the new standard for pediatric cervical spine evaluation.