Defibrillating the Data

This month's RACC-Lit Review from EMCrit tackles several high-yield resuscitation questions relevant to the acute care setting. Key topics include the efficacy of administering prehospital whole blood, which remains an area needing clear evidence regarding improved outcomes. Another point of interest is assessing whether defibrillators are susceptible to damage from direct current discharge (DSD). Furthermore, the review addresses established guidelines surrounding adenosine use in stable versus unstable supraventricular tachycardia (SVT) management. Given the breadth and critical nature of these topics—ranging from blood product transfusion protocols to device safety and rhythm management—this compilation is highly valuable for keeping up with evolving resuscitation science.

This systematic review synthesized evidence regarding whether maintaining a non-supine position improves the first-pass success rate during emergency department (ED) intubations. The authors searched multiple databases, identifying six prospective studies, including two randomized controlled trials, to address this clinical question. Overall, the meta-analysis found a consistent positive association between patient angulation and achieving successful intubation on the first attempt across three of the included studies. These findings suggest that standardizing an inclined or non-supine approach should be considered part of routine ED intubation protocols.

The TASC trial represents a significant step forward by being the first phase 3 randomized controlled trial to directly compare therapeutic versus prophylactic-dose tinzaparin for managing acute chest syndrome (ACS) in adults with sickle cell disease who do not have pulmonary artery macrothrombosis. The primary finding was that using therapeutic-dose tinzaparin successfully reduced the overall duration of ACS when compared to standard prophylactic dosing. Furthermore, this higher dose regimen was associated with a clinically meaningful reduction in opioid consumption among patients. These results suggest that simply maintaining prophylaxis might be suboptimal for some patients presenting with ACS.

This piece reviews the PRoMPT trial within the context of pediatric emergencies, building upon existing knowledge regarding fluid resuscitation in septic shock. While it references adult data from trials like SMART, which suggested balanced crystalloids might reduce acute kidney injury and mortality compared to normal saline in critically ill adults, the focus remains on translating this evidence for the pediatric setting. The overall message is a reminder that managing critical illness in kids requires constant vigilance and integrating the latest resuscitation science into practice. It serves as an update point within the Critical Kids series, emphasizing evidence-based decision-making when fluids are needed.

This multisite US study focused on validating and optimizing the utility of an existing point-of-care (POC) high sensitivity troponin I (hs-cTnI) algorithm, specifically a 0/2-hour approach. The authors compared performance using both the original Australian protocol and an optimized version of the assay across multiple emergency department settings in the United States. Their primary finding is that both algorithms retained robust diagnostic accuracy, demonstrating high negative predictive values (NPV). Specifically, the optimized algorithm showed promise for rapid risk stratification, achieving a reported efficacy of 60.0% while maintaining a very high NPV of 99.4%. Overall, this supports the continued integration and refinement of these rapid POC troponin assays into routine ED practice.

This retrospective study introduces the GOTHIC score, a novel, easily implementable tool designed to predict bloodstream infection risk in febrile emergency department patients based on variables available immediately upon triage. The authors derived and validated this score using data from two university hospital EDs over 2021, analyzing blood culture collection practices. The resulting seven-variable score incorporates factors such as advanced age (≥75 years), tachycardia exceeding 90 beats per minute, hypotension defined by a systolic blood pressure of 38 degrees Celsius, having isolated fever as the primary complaint, and specific protective complaints like dyspnea or COVID-19 symptoms. While the study reports good diagnostic accuracy in both derivation and validation cohorts, it is important to note that this is an observational analysis derived from retrospective chart review.

This LITFL update revisits the can’t intubate, can’t oxygenate pathway as a practical crisis framework rather than a rare theoretical endpoint. The key clinical point is that CICO is declared only after failure of the three upper-airway rescue options: face-mask ventilation, supraglottic airway ventilation, and tracheal intubation. Once oxygenation remains inadequate despite those attempts, the airway plan has to move quickly from repeated laryngoscopy toward emergency front-of-neck access. For ED teams, the value is less in introducing new evidence and more in reinforcing shared language, early recognition, and deliberate priming for FONA before saturations collapse. This is a useful checklist-style refresher for airway governance, simulation, and pre-briefing during anticipated difficult airways.

This practical guide from St Emlyn's focuses specifically on the role of ketamine within the complex setting of trauma resuscitation, offering actionable tips for the trauma team leader. It emphasizes that ketamine is valuable not just as an analgesic agent but also for procedural sedation in these critically ill patients. A key message revolves around its utility as an opioid-sparing adjunct when standard analgesics begin to plateau in efficacy. The authors stress the importance of maintaining cardiovascular stability while utilizing this agent, and they reiterate that comprehensive monitoring, including routine capnography in the resuscitation bay, is mandatory for all patients receiving ketamine.

This retrospective cohort study examined the utility of routine serum magnesium testing for predicting 28-day mortality among emergency department admissions. The authors found that, after adjusting for numerous confounding patient variables, elevated magnesium levels—hypermagnesemia—were independently associated with increased rates of death within one month. This suggests that Mg status might be more than just a marker of electrolyte disturbance; it appears to carry prognostic weight in the acutely ill ED population. The conclusion emphasizes that incorporating systematic Mg testing could assist clinicians in stratifying risk and identifying patients who are at higher immediate risk upon presentation.

This article evaluates two simple scoring systems, the Roth score and the Dyspnea Severity Score (DSS), to help emergency physicians make discharge decisions for patients presenting with exacerbations of COPD. The authors found that both scores exhibit high sensitivity, suggesting they are reliable tools for quickly assessing which patients can safely go home from the ED. This is particularly useful because it offers a non-invasive and objective method for standardizing disposition in this common clinical scenario. Essentially, these scores provide practical cutoffs to help streamline care pathways without needing more complex workups for every patient.

This multicenter observational cohort study compared various ventilation parameters across different manual ventilation modes and airway devices used during cardiopulmonary resuscitation. The authors found significant variability in these parameters depending on the technique employed, which is a key point for us to consider at the bedside. Specifically, they noted that bag-valve mask (BVM) ventilations appear to have limited overall efficacy compared to other methods. Interestingly, spontaneous assisted ventilation (SAD) provided consistent tidal volumes and pressures across different modes, though leakage was observed to increase over time. Furthermore, asynchronous endotracheal tube (ETT) ventilation was associated with generating high airway pressures. Overall, the study strongly suggests a need for standardized measurement of these ventilation parameters both in research settings and routine clinical practice.

This piece addresses the persistent issue of overutilization of computed tomography (CT) scans for blunt head injury patients presenting to the emergency department. The authors investigated the effectiveness of a comprehensive, multimodal intervention designed to curb unnecessary imaging. Their findings suggest that simply implementing an institutional guideline is insufficient on its own; rather, combining this guideline with structured educational sessions, direct provider feedback mechanisms, and integrating decision support tools directly into the electronic health record (EHR) yields measurable success. Specifically, the combination of these elements was associated with a demonstrable reduction in the rate of CT head studies performed for blunt head trauma. This suggests that process improvement requires more than just policy change.

This piece dives into the application of the YEARS protocol for ruling out pulmonary embolism (PE) using a D-dimer threshold, specifically flagging concerns regarding its utility in patients with active malignancy. While the Hydra trial demonstrated comparable 90-day mortality rates between different diagnostic pathways, the authors raise flags about the YEARS score's ability to accurately stratify risk within this particular cancer cohort compared to what might be expected from other literature. The core argument suggests that because the YEARS approach appears less robust for this group, relying solely on the D-dimer cutoff in cancer patients warrants caution. It’s a good reminder that diagnostic algorithms need careful vetting when applied outside their primary indication.

This piece outlines a structured approach for integrating patient-facing artificial intelligence (PF-AI) into the chaotic environment of the emergency department, acknowledging its dual role as both a safety net and a digital entry point. The authors argue that any implementation must be carefully constrained to ensure that these tools augment, rather than supplant, core clinical judgment. They propose a framework that guides integration across the entire patient journey, from pre-arrival interactions right through to follow-up care. A key focus throughout is mitigating inherent risks associated with AI use, specifically concerning potential undertriage errors and breaches of patient privacy. Ultimately, the goal is to establish clear human oversight and defined accountability checkpoints at every point where PF-AI touches the patient.

This report provides an analysis of airway interventions, specifically focusing on the incidence and outcomes of awake tracheal intubation when performed by emergency physicians in a tertiary care setting. The authors utilized data from both the Airway Interventions Registry and an observational database to characterize these procedures. Understanding the frequency and associated practice patterns is key for optimizing resource utilization and patient safety within the acute care environment. For us, this helps paint a clearer picture of how often we are performing these advanced airway maneuvers in the ED setting. The findings help establish baseline data regarding the utility and safety profile of emergency physician-led awake intubations.

This secondary analysis from the DETECT trial provides an important look at how Hepatitis C Virus (HCV) screening is implemented within the emergency department setting, specifically focusing on individuals experiencing homelessness. The authors examined associations between a patient's homeless status and key outcomes related to HCV testing, including whether the test was offered, if it was accepted, rates of seropositivity, and evidence of viremia. Overall, the findings reinforce the concept that EDs are uniquely positioned to serve as screening hubs for this high-risk population who often face significant barriers to routine care. This underscores the utility of integrating HCV screening into standard emergency department protocols.

This review synthesized data from 150 papers to evaluate whether intranasal (IN) ketamine can adequately provide procedural sedation in the pediatric emergency department, comparing it directly to IV ketamine. The authors analyzed eight relevant studies and concluded that while IN ketamine is a viable needle-free alternative, its success rate appears slightly lower compared to the established efficacy of IV administration. Despite this comparative deficit, the review strongly suggests its utility for specific populations, particularly those children exhibiting severe phobia towards needles. Ultimately, the recommendation hinges on thorough parental counseling and shared decision-making processes.

This paper introduces the KIT-FISTO model, a newly developed risk stratification decision tree designed to help emergency physicians predict obstructive acute kidney injury (AKI) in the ED setting. The study utilized a retrospective derivation and internal validation cohort approach on patients presenting with AKI of any KDIGO stage. The model stratifies risk based on clinical features; notably, the presence of lumbar, flank, or hypogastric pain places a patient in a high-risk category, correlating with an estimated 54-55% chance of obstructive AKI. Conversely, patients without these specific symptoms are categorized as low risk, showing very low predicted rates. While the internal validation appears promising, the authors rightly caution that external and prospective validation is necessary before this tool can be reliably implemented in routine practice.

This systematic review synthesized the current literature regarding the use of high-flow nasal cannula (HFNC) specifically to manage oxygenation during the apneic period encountered during rapid sequence induction (RSI) in the emergency department setting. The authors assessed whether providing continuous, high-flow oxygen could improve oxygenation status or reduce adverse events associated with controlled apnea. While some individual studies suggested that HFNC might correlate with a longer safe duration of apnea without desaturation, the review noted a critical absence of data demonstrating any impact on major clinical endpoints such as mortality rates or overall incidence of significant desaturation events. Overall, the evidence suggests HFNC is an adjunct option for oxygenation during this vulnerable period, but its utility in improving definitive patient outcomes remains unproven based on current data.

This retrospective review details the clinical spectrum and management of pediatric necrotizing pneumonia (PNP), noting it accounts for a relatively small percentage of hospitalized pneumonia cases at tertiary centers. The data strongly suggest that Streptococcus pneumoniae remains the most common causative organism, but importantly, over half of these patients required surgical input due to complications like significant pleural effusion or ongoing infection. A key clinical point emphasized is the need for vigilance; if a child presents with persistent fever or respiratory failure beyond 72 hours despite appropriate antibiotic therapy, thorough chest imaging is warranted to rule out underlying complications. Management involves prolonged IV antibiotics targeting common pathogens like S. pneumoniae and S. aureus, alongside monitoring drug levels for agents like vancomycin.