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.
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There is sound literature that older patients who board in the ED have higher rates of delirium, longer hospital stays, more complications and possibly higher mortality. Some institutions are starting to prioritize moving older patients upstairs ahead of others who may have been boarding longer in the ED. Hopefully some data will be out soon to see if this intuitive approach actually improves these outcomes.
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This multicenter, retrospective study used the Pediatric Health Information System database to examine TXA (Tranexamic acid) use for post tonsillectomy hemorrhage (PTH) across US children's hospitals, analyzing 19,572 ED encounters for PTH in children <18 years from 2016–2024. The study did not differentiate TXA by route of administration or doses.
TXA use is rapidly increasing but remains highly variable. Median annual TXA use rose dramatically from 0.0% in 2016 to 30.6% in 2024, yet individual hospital-level use ranged from 1.0% to 67.1%, reflecting a lack of standardized protocols and significant practice variation across institutions.
TXA was associated with reduced reoperation but not hospital admission. At the encounter level, TXA administration was associated with 34% lower adjusted odds of reoperation (aOR 0.66, 95% CI 0.56–0.77). However, there was no significant association with hospital admission (aOR 0.93, 95% CI 0.83–1.04).
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This South African study looked at 219 trauma patients who required damage control surgery and, not surprisingly, low GCS, low pH and elevated lactate all were independently associated with mortality.
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The STARS (Special Needs Tracking and Response System) program was started in 2014 to bridge gaps in caring for children with special health care needs in the prehospital setting.
Since its inception, it has evolved into a hospital based, physician lead program with individualized EMS care plans stored on an electronic server and accessible to units responding to these patients.
In addition to the development of patient specific plans that are not within the local EMS protocol, this program has led to targeted EMS training and improved interdisciplinary care coordination. This program has also shown a decrease in EMS transports to the hospital.
The program started with 14 patients in one EMS jurisdiction and has now expanded to 2424 patients across 3 states. As the program expands, there is an aim to expand these care plans to include disaster preparedness, such as back up plans for patients dependent on electricity and plans to access critical medications during emergencies.
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Acute Hypoxemic Respiratory Failure (AHRF) is very common in the ED/ICU. In this multicenter cohort of 21,714 patients in a Canadian ICU registry (iCORE) receiving oxygen or respiratory support, 50% met criteria for acute hypoxemic respiratory failure within 24 hours of ICU admission, and 76% of those patients required invasive mechanical ventilation.
- AHRF severity was categorized using the same Pao2/Fio2 thresholds as the Berlin definition for ARDS: mild (201–300), moderate (101–200), and severe (<100).
- When Pao2/Fio2 ratios were unavailable, severity was assigned using Spo2/Fio2 thresholds: mild (236–315), moderate (149–235), and severe (< 148). One-third of patients were actually classified this way.
PaO2/FiO2 remains the conventional standard and is important for ARDS severity/prognosis, but SpO2/FiO2 is noninvasive, continuous, inexpensive, and showed good agreement with PaO2/FiO2-based severity classification. According to these authors, SpO2/FiO2 can be a practical substitute for PaO2/FiO2 when an ABG is unavailable.
- Important limitations are the reduced accuracy of SpO2 at high saturations and potential pulse-oximetry bias, including overestimation of oxygenation in patients with darker skin tones.
Worsened hypoxemia strongly tracked with worse outcomes. ICU mortality increased from 17% in mild AHRF to 26% in moderate and 44% in severe AHRF; severe disease was also associated with fewer ventilator-free days and a lower probability of ICU discharge.
- AHRF patients were often treated using ARDS-style lung-protective ventilation. Median tidal volume was about 6.5 mL/kg predicted body weight, and most measured plateau/driving pressures were within protective ranges. However, plateau pressure was infrequently documented.
- Among patients with severe AHRF, 26% received neuromuscular blockade, 13% received prone positioning, 12% received iNO, and 12% received ECLS within the first 30 days of ICU admission..
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Question
The construction worker presents to the ED with this rash. What is it and what is the treatment?
