The national cardiac arrest registry includes information on bystander CPR. An EMS clinician currently enters bystander CPR (B-CPR) information into the prehospital care report. The accuracy of this documentation has not been validated. This study compared EMS documented B-CPR rates to the bystander CPR rates on the 911 audio recordings of the calls in Birmingham Alabama.
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Cardiogenic Shock = a cardiac disorder that results in both clinical and biochemical evidence of sustained tissue hypoperfusion (1).
Cardiogenic shock has high mortality (approx 35-40% in many studies). Mortality worsens at higher stages of cardiogenic shock severity (2,3). Early recognition of cardiogenic shock is critical in order to initiate treatment and transfer patients to an appropriate level of care in a timely manner.
As an ED physician, you need to SUSPECT cardiogenic shock so that you can ensure appropriate definitive management of your patient (4).
SUSPECT = Symptoms/Signs; Urine Output; Sustained Hypotension; Perfusion; EKG/Echo; Congestion; Triage
Take a look at the Additional Materials to break down this mnemonic in more detail and learn what might make you SUSPECT CS!
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Bottom Line: Move over, post-partum hemorrhage, because cardiovascular causes reign supreme! In a new study based on CDC data from 2005-2024, cardiovascular causes were the number one cause of death in pregnancy overall (well, except for COVID…).
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There is increasing evidence that burning lithium-ion batteries produce hydrofluoric acid (HF) and other fluoridated compounds. HF is a weak acid and thus it can penetrate deeper into tissue before causing complications. HF exposure causes irritation to the mucosa/skin and leads to pain out of proportion to the appearance of the burn/exposure. These exposures present a unique risk to first responders and care should be taken to wear appropriate PPE during these events. Regular medical gloves do not protect from exposure. Respiratory protection must be worn to prevent inhalation. Click for treatment options.
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A retrospective analysis of a multicenter prospective cohort study evaluated the association between steroid administration, including hydrocortisone timing and dose, and mortality in patients with septic shock in the ED.
Study findings: Steroid use was associated with lower 28-day mortality (p = 0.001). This association remained in the vasopressin subgroup (p < 0.001) but not in patients who did not receive vasopressin (p = 0.769). A higher norepinephrine-equivalent dose at first steroid administration, a longer interval from first vasopressor initiation to first steroid administration, and hydrocortisone dosing > 300 mg/day were associated with increased mortality.
Bottom line: Steroid administration in the ED was associated with lower 28-day mortality among patients with septic shock, particularly those receiving vasopressin.
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Reducing 28-day all-cause mortality compared to conventional MAP management in sepsis patients requiring vasopressors after initial resuscitation.
- Cardiac output, MAP, and organ-specific vascular resistance determine organ perfusion.
- SEPSISPAM trial showed that a higher MAP reduced need for renal replacement therapy.
- An elevated Renal Resistive-Index (RRI) > 0.7 is associated with impaired perfusion, development of AKI, and increased MR.
- The kidney is a low vascular resistance organ sensitive to hypoperfusion in sepsis.
- 28-day all-cause MR and ventilator free days was decreased.
- RRI-guided MAP titration did not specifically decrease MR, incidence of AKI or need for CRRT.
- Although a pilot trial, this study lends credence to more individualized sepsis hemodynamic management and the need for a larger study.
- Use of RRI-guided MAP titration in sepsis may decrease overall 28-day MR.
- How to Guide. https://ultrasoundpaedia.com/renal-arteries-normal/
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Reminder that the Bova Score (2 points each for heart rate over 110, SBP less than 90, RV strain on CT or echo, and elevated troponin) along with an elevated lactate and BNP can help predict outcomes in hemodynamically stable PE patients.
"Low risk (score <2):
Proceed with standard anticoagulation therapy. Standard outpatient or inpatient monitoring, as appropriate.
Intermediate risk (score 3–4): Consider closer monitoring (e.g., stepdown/ICU). Discuss the possibility of advanced therapies (e.g., thrombolysis) in select cases, especially if clinical status worsens.
High risk (score >4): Maintain continuous ICU monitoring with a clear plan for rapid intervention if clinical status worsens (e.g., hypotension, worsening hypoxia, arrhythmias). Strongly consider multidisciplinary team involvement and potential advanced therapies (e.g., systemic thrombolysis or catheter-directed therapies)."
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A structured interview was conducted with families who had a loved one undergo a field terminated cardiac arrest in Denmark. What they found was pre-arrival instructions were very valued. And “After unsuccessful resuscitation, compassionate and unhurried communication was considered crucial.” I am sure this applies to prehospital and in hospital situations alike. Empathy and time are what these families need.
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BRACHA-S is a 5 item scoring tool that demonstrated moderate discrimination and identified clinically meaningful risk gradients for agitation requiring intervention (ARI) that may support early safety planning.
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Bottom Line:
Lead has no biologic role in the human body. Lead toxicity and accumulation in humans remains a major health concern. Children < 6 years old are especially vulnerable to lead poisoning. Lead is a potent neurotoxin and even low levels can cause irreversible harmful neurologic effects in children. Blood lead level of 3.5 µg/dL requires action in children.
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While many intubations in critically ill patients go smoothly, they are a high risk procedure that EM and ICU physicians seek to continuously improve upon. Blade size is one aspect of the procedure that has received attention over the past several years. We don’t have prospective trials addressing this question, but there are several retrospective analyses that have investigated it.
- For Direct Laryngoscopy:
- The 2022 MacSize-ICU study and a 2023 study by Landefeld and colleagues with the Pragmatic Critical Care Research Group suggested that when using Macintosh geometry blades for direct laryngoscopy there was improved first pass success with size 3 blade. Secondary outcomes for these studies point to a worse glottic view with a size 4 blade.
- For Video Laryngoscopy:
- This finding did not hold up in video laryngoscopy. A 2023 study by Park et al. and now a 2026 retrospective study again by Landefeld et al. that looked at blade size for video laryngoscopy with Macintosh geometry blades found no difference in first pass success with size 3 vs size 4 blades.
Bottom Line: Continue to use your best clinical judgment when selecting a blade size, especially when performing video laryngoscopy. When performing direct laryngoscopy, if you are on the fence, consider using size 3 blade.
*These studies do not address intubation with hyperangulated designs
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Bottom Line: Burn care is directed by the managing surgeons at regional burn centers. Where available, hyperbaric oxygen treatment can be a beneficial adjunct.
Studies and clinical experience of hyperbaric oxygen treatment in burns has shown modulation of burn shock, dampening of the inflammatory response, reduction of edema, reversal of the zone of stasis, reduction of ischemia and ischemic necrosis, prevention of progression of partial- to full-thickness injury, modulation of inflammation, effecting modulation of hyper-metabolic syndrome, lessening of the capillary leak, preservation of dermal elements, a reduced need for grafting, shortened hospital stay, reduced physiological post-discharge problems, and a reduction in cost of care.
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This secondary review of a prospective observational group of 1200 syncope/presyncope patients over age 40 found 5.6% experienced a significant adverse outcome within 30 days. These patients had no diagnosis after their ED evaluation. Their conclusion was admission to the hospital “increased the diagnostic yield for SAOs and accelerated time to diagnosis.”
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Polyarticular joint pain and swelling. Is it gout?
Polyarticular initial attacks occur in roughly 3-14% of patients.
Bilateral gout is uncommon at presentation.
However, this presentation is more frequent with longstanding , poorly controlled disease.
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This study conclusion states: “Prehospital epinephrine administration in patients with traumatic cardiac arrest was associated with increased survival to hospital discharge and prehospital ROSC.” When you investigate the methods, only 809 of the 22,105 patients in traumatic cardiac arrest actually received epinephrine. In the study country, EMS gets orders from base station physicians for epinephrine. Why did these 809 get the epinephrine and the other 97% did not? It is hard to know what to do with this data. It certainly doesn’t say epinephrine saves patients in traumatic cardiac arrest. More research is needed.
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What is diagnostic excellence in the Emergency Department?
Based on a modified Delphi panel of 11 experts, these authors developed this definition:
“[T]he use of optimal, evidence-based practice to attain an accurate and timely explanation about a patient’s condition based on the information available at the time and communicate that explanation to the patient/family. Diagnostic excellence is patient-centered and equitable. Diagnostic excellence includes avoidance of divergent practices. It leads to better choices in management, prevents missed opportunities, and reduces the risk of preventable patient harm.”
Click below to find the definition of missed diagnostic opportunity. Go to the article https://www.annemergmed.com/article/S0196-0644(26)00247-7/fulltext to read more about the work.
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Severe Community Acquired Pneumonia (SCAP) is broadly defined as CAP that requires ICU admission. Although MRSA pneumonia is overall quite rare (1), it is associated with a high mortality rate. Therefore, empiric MRSA coverage is commonly used for patients with SCAP. Common empiric agents include vancomycin and linezolid. Linezolid has both pharmacologic and clinical data that suggest it may be a preferred option for many patients.
When approaching a patient with SCAP, a key consideration is whether empiric MRSA coverage is needed. Risk factors for MRSA pneumonia include prior MRSA infection or colonization, recurrent skin infections, post-influenza pneumonia, recent hospitalization or antibiotic use (1).
If empiric MRSA coverage is determined to be needed, Linezolid offers several advantages for the treatment of SCAP. Highlights below:
- Linezolid has 100% oral bioavailability which can be especially useful for those patients with difficult IV access
- Linezolid has better lung epithelial lining penetration compared to vancomycin (6)
- In direct comparison between linezolid and vancomycin for confirmed MRSA pneumonia, linezolid was shown to have improved microbiologic cure rates without an improvement in mortality (2, 7)
- Linezolid was shown to have less nephrotoxicity than vancomycin (2, 7)
Side effects to consider with linezolid include:
- Serotonin syndrome, although extremely rare (5). May consider discussion with your pharmacist if taking additional serotonergic agents.
- Myelosuppression (typically thrombocytopenia), although usually with longer treatment courses. This study shows no significant difference in rates of thrombocytopenia compared to vancomycin (4).
If providing linezolid for treatment of SCAP:
- Dose: Linezolid 600mg IV or PO q12 hours
- Ideally should obtain blood cultures, sputum culture, MRSA nares prior to (or closely following) antibiotic administration
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In a randomized pragmatic study of critically ill trauma patients, video laryngoscopy was successful in 88% of first pass attempts versus 68% in direct laryngoscopy.
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This Japanese hospital has a CT scanner hybrid resuscitation room. They did a retrospective study comparing their blunt trauma patients to a Japanese trauma database. Their patients had a shorter time to operative or interventional procedure, slightly less PRBC use over 24 hours and similar 24 hour mortality.
Interesting concept. Not ready for adoption.