Defibrillating the Data

EDCritix scans emergency medicine journals, new papers, selected guideline and consensus updates, and FOAMed resources, then ranks the most clinically useful reads for frontline practice with concise summaries, clinical takeaways, and links to the original source.

Edition
21 June 2026
Scope
Top 20 Articles Ā· Last 14-days
Sources
30 Total Ā· 29 Online Ā· 1 Offline
10 Core-tier Ā· 20 Supporting
Daily Editorial

Resuscitation Protocols: When 'Best Practice' Isn't a Clear Choice

The resuscitation landscape remains complex, and today’s readings underscore that rigid adherence to protocol—whether in septic shock or post-cardiac arrest care—may not translate into superior outcomes. The ARISE-FLUIDS data, for instance, suggest that the debate over early vasopressors versus liberal fluids lacks a clear winner regarding long-term survival endpoints.

This theme of uncertainty echoes across critical care; similarly, systematic reviews caution against routine use of adjuncts like human albumin in suspected sepsis and advise reserving advanced therapies for organophosphate poisoning to core supportive measures. On the stroke front, while late-window EVT shows promise for select patients with functional gains, robust pre-treatment selection criteria are non-negotiable.

Beyond immediate resuscitation, we see valuable insights into system optimization: dedicated critical care zones within the ED appear beneficial for reducing downstream resource utilization, and tracking lactate post-ROSC in pediatrics suggests a useful biomarker for risk stratification. These findings collectively remind us that optimizing emergency medicine is as much about refining our systems and recognizing where evidence falls short as it is about mastering the initial intervention.

Today's top 20 Articles

013 days agoPractice-changingShockConfidence: highSource: St Emlyn's

To squeeze or not to squeeze. The ARISE-FLUIDS trial

This review focuses on the ARISE-FLUIDS trial, which directly compared two distinct resuscitation strategies in septic shock patients presenting to the emergency department. Specifically, it pitted an early vasopressor approach combined with restricted fluid administration against a strategy involving higher initial fluid volumes followed by later vasopressor initiation. The primary finding reported is that neither of these established approaches demonstrated superiority regarding the composite endpoint of days alive at day 90. This lack of difference suggests that current resuscitation guidelines, which often pit early versus delayed vasopressor use and restricted versus liberal fluids, may not have a definitive advantage over one another.

The ARISE-FLUIDS data suggest caution when rigidly adhering to protocols dictating the timing or volume of initial fluid administration versus early vasopressors in septic shock. At the bedside, this implies that while aggressive resuscitation is necessary, the choice between immediate low-volume vasopressor support versus more liberal fluids upfront may not significantly alter long-term outcomes. Always consider the patient's underlying physiology when titrating these interventions.

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022 weeks agoPractice-changingResuscitationConfidence: highSource: EMJ

In adult patients with suspected sepsis, is adjunct resuscitation with human albumin solution associated with improved patient-oriented outcomes?

This systematic review directly addressed whether adding human albumin solution (HAS) as an adjunct resuscitation measure improves patient outcomes specifically in adults presenting with suspected sepsis. The authors synthesized data from three relevant studies found through major databases, providing a focused assessment of the current evidence base. Overall, the analysis suggests that incorporating HAS into routine emergency department management for suspected sepsis is not currently supported by the available literature. Given the high clinical relevance of optimizing resuscitation strategies in septic patients, this negative finding warrants attention. However, the authors rightly point out that the overall body of evidence remains limited, emphasizing the need for larger, definitive trials to guide practice.

For routine management of suspected sepsis in the ED, do not initiate albumin infusion based on current guidelines; the evidence synthesis suggests no benefit. Continue standard resuscitation protocols while recognizing that more robust, large-scale randomized controlled trials are necessary before changing established care pathways. Be mindful that this conclusion is drawn from limited data.

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032 weeks agoPractice-changingToxicologyConfidence: highSource: WestJEM

Therapeutic Interventions in Organophosphate Poisoning: An Umbrella Review of Systematic Reviews

This umbrella review synthesizes evidence from multiple systematic reviews concerning the management of organophosphate (OP) self-poisoning. The authors conclude that atropine remains the cornerstone of therapy for OP envenomation, with oximes being a potential adjunct as per WHO guidelines. More importantly for daily practice, the review casts significant doubt on several commonly considered interventions. Specifically, gastric lavage is noted to have doubtful efficacy and carries potential risks. Furthermore, the authors advise against the routine use of agents such as penehyclidine, rhubarb, or complex therapies like plasma exchange with hemoperfusion.

Atropine remains the primary agent for OP poisoning management; reserve oximes based on WHO recommendations. Avoid routine gastric lavage due to questionable efficacy and potential harm. Do not initiate advanced therapies like plasma exchange or use agents such as penehyclidine unless specifically indicated, keeping your focus on core supportive care.

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041 week agoPractice-changingStrokeConfidence: moderateSource: AJEM

Endovascular intervention for acute stroke in the very late window: A meta-analysis of 90-day mRS and procedural outcomes

This meta-analysis synthesized data regarding the use of Endovascular Therapy (EVT) for acute ischemic stroke presenting in very late windows, specifically beyond the traditional 24-hour mark. The overall conclusion suggests that EVT can indeed confer benefits by improving functional outcomes and reducing all-cause mortality in carefully selected patient cohorts. However, the authors caution that these improvements are not universal across all outcome measures, indicating a complex picture. The emphasis remains heavily placed on rigorous pre-treatment selection criteria to identify those who are most likely to benefit from this advanced intervention.

For patients presenting with ischemic stroke significantly past 24 hours, consider EVT only in the context of robust imaging evidence supporting salvageable penumbra. While the data suggest potential functional gains and mortality reduction in select cases, remember that patient selection is paramount; do not apply this blindly to all late-presenting strokes.

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052 days agoPractice-changingCardiac ArrestConfidence: moderateSource: Resuscitation

Association of Serum Lactate with Outcome After Pediatric Out-of-Hospital Cardiac Arrest: A Secondary Analysis of the Therapeutic Hypothermia After Pediatric Cardiac Arrest (THAPCA) Trial

This secondary analysis re-examined the THAPCA-OH trial data specifically to assess the utility of serum lactate levels in predicting outcomes following pediatric out-of-hospital cardiac arrest. The key finding reported is a correlation between elevated lactate concentrations measured within the first six hours after return of spontaneous circulation (ROSC) and poorer one-year survival rates. This suggests that lactate may serve as an adjunct biomarker for early neuroprognostication and overall mortality risk in this critically ill pediatric population. While promising, it's important to note this is a secondary analysis drawing conclusions from existing trial data.

Consider tracking serial lactate levels within the first six hours post-ROSC in pediatric cardiac arrest survivors; higher values correlate with worse one-year outcomes. This suggests lactate could be useful for risk stratification, but remember that this finding is based on a secondary analysis and should complement, not replace, established resuscitation protocols.

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066 days agoPractice-changingCritical CareConfidence: moderateSource: SJTREM

Critical care delivery models in emergency departments: a systematic review of the literature and meta-analysis of related outcome effects

This systematic review synthesized literature on various organizational models for delivering critical care within the emergency department setting, culminating in a meta-analysis of associated outcomes. The authors categorized several approaches, with dedicated critical care areas, such as an ED-ICU setup, being the most frequently studied model. The quantitative analysis provides evidence suggesting that establishing these specialized, dedicated critical care zones within the ED environment may confer tangible benefits to critically ill patients. Specifically, the meta-analysis points toward a potential reduction in both subsequent ICU admission rates and overall hospital length of stay when compared against other established CC-ED delivery models.

When considering resource allocation for high-acuity resuscitation, establishing a dedicated critical care zone within the ED appears beneficial based on this meta-analysis. This suggests that structured environments can help mitigate downstream utilization, potentially lowering both ICU admissions and overall hospital stay duration. However, remember this is an aggregate finding; implementation should be tailored to local resources, and these models do not replace comprehensive resuscitation protocols.

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072 weeks agoPractice-changingStrokeConfidence: highSource: WestJEM

Early Recognition and Referral of Acute Stroke in Primary and Emergency Care: A Systematic Review

This systematic review synthesizes evidence on improving outcomes for acute stroke patients by focusing on early recognition and robust referral pathways. The authors conclude that the implementation of structured clinical tools and broader system-level interventions are associated with reduced mortality in this population. Furthermore, the review highlights emerging technologies like artificial intelligence and mobile stroke units as potentially beneficial additions to current care models. A key theme emphasized is the necessity of strengthening overall referral systems to ensure equitable access to care, especially when dealing with geographic or resource limitations. Overall, the evidence points toward a multi-faceted approach addressing both clinical process gaps and systemic infrastructure issues.

Focus on implementing structured triage tools at your site as a foundational step for improving recognition rates. Remember that optimizing the entire pathway—from initial suspicion to definitive care—is paramount; don't overlook system barriers when planning local improvements. While AI is promising, current efforts should prioritize strengthening established referral links to ensure timely specialist access.

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082 weeks agoPractice-changingCardiac ArrestConfidence: moderateSource: REBEL EM

Meta-Analysis of Norepinephrine vs Epinephrine After Cardiac Arrest

This meta-analysis directly addresses the comparative safety and efficacy of using norepinephrine versus epinephrine as vasopressors following a return of spontaneous circulation (ROSC) after cardiac arrest. The core question investigated is whether one agent confers a lower risk of subsequent recurrent cardiac arrest compared to the other. By synthesizing data, the authors provide an evidence-based comparison aimed at guiding post-cardiac arrest resuscitation management regarding vasopressor choice. While the meta-analysis provides quantitative comparisons, clinicians should interpret these findings within the broader context of individual patient physiology and institutional protocols.

When managing hypotension after ROSC, current data suggest that neither norepinephrine nor epinephrine is definitively superior in preventing recurrent cardiac arrest based on this pooled analysis. Continue to use your preferred agent while remaining vigilant for signs of inadequate perfusion or evolving shock state; remember that the choice should remain highly individualized.

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091 week agoPractice-changingGeneral Emergency MedicineConfidence: moderateSource: EMJ

Prediction of bloodstream infection using triage variables in the emergency department: retrospective derivation and validation cohort

This retrospective study introduces the GOTHIC score, a novel, easily implementable prediction tool designed to estimate the risk of bloodstream infection in febrile emergency department patients based solely on variables obtainable immediately after triage. The authors derived and validated this score using data from two university hospital EDs over 2021, analyzing factors like age ≄ 75 years, tachycardia >90 beats per minute, systolic blood pressure <38 degrees Celsius, isolated fever complaint, and specific chief complaints. They found that the resulting seven-factor score provides a method to stratify risk in settings where routine blood cultures may have low yield or contamination concerns. The inclusion of protective factors, such as dyspnea or COVID-19 symptoms which actually lowered the odds ratio, adds nuance to its clinical utility.

Consider using this GOTHIC score when managing febrile patients in the ED if you are concerned about blood culture yield. Remember that while tachycardia and age ≄ 75 years increase risk, protective complaints like dyspnea actually decrease it according to this model. However, since this is a retrospective derivation, use it as an adjunct tool rather than replacing clinical judgment.

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102 weeks agoPractice-changingSepsisConfidence: highSource: EMJ

Association between the time to norepinephrine initiation and mortality in patients with sepsis

This prospective, multicenter study examined the relationship between when norepinephrine was started and 28-day all-cause mortality in patients presenting with sepsis. The authors found a clear association between delayed initiation of norepinephrine and worse outcomes; specifically, non-survivors had a significantly longer median time to starting NE compared to those who survived. Furthermore, the analysis highlighted that initiating norepinephrine within the first 60 minutes following hypotension was independently associated with a reduced risk of death. These findings reinforce the critical importance of rapid hemodynamic resuscitation in septic shock management.

Aiming for norepinephrin initiation within one hour of detecting hypotension appears beneficial for reducing 28-day mortality in sepsis. While this suggests an aggressive approach to early vasopressor use, remember that timing must be balanced with the need to achieve adequate mean arterial pressure goals, ideally targeting a MAP greater than 65 mm Hg. Be mindful that this is observational data correlating time to initiation with outcome.

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114 days agoPractice-changingEcgConfidence: highSource: Emergency Medicine Cases

ECG Cases 62 – ACLS Arrhythmia Pitfalls, Part 5: Stable Narrow Complex Tachycardias

This installment of the ECG Cases series tackles the common but tricky pitfalls encountered when interpreting stable narrow complex tachycardias. The resource uses eight real-world case examples to guide readers through differentiating between sinus tachycardia, atrial fibrillation, atrial flutter, and supraventricular tachycardia (SVT). What's most valuable here is the emphasis not just on pattern recognition, but also on considering secondary causes that might be driving the rhythm. Recognizing these subtle distinctions is crucial because misdiagnosis can lead to inappropriate or harmful management decisions in the acute setting.

When faced with a stable narrow complex tachycardia, don't assume the diagnosis based solely on rate and regularity; always systematically rule out atrial flutter versus true SVT, paying close attention to underlying triggers. Remember that secondary causes are often the key differentiator, so a thorough history and physical exam remain paramount before initiating any rhythm conversion or rate control therapy.

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121 day agoHigh-yieldGeneral Emergency MedicineConfidence: highSource: AJEM

Frailty stratification in the emergency department using the triage frailty and comorbidity tool

This article evaluates the utility of integrating the Triage Frailty and Comorbidity (TFC) Tool into standard emergency department triage protocols, specifically targeting low-acuity patients. The core finding suggests that routine use of this tool successfully identifies vulnerable individuals within the low-acuity spectrum. Importantly, implementing the TFC Tool was associated with reducing waiting times to medical assessment for these frail patients without negatively impacting established acuity prioritization pathways. Furthermore, a positive TFC score independently correlated with an increased likelihood of subsequent hospital admission, suggesting it's a useful marker beyond just triage placement.

Consider incorporating the TFC Tool into your low-acuity triage process; it appears to help flag frail patients who might otherwise wait longer without compromising overall acuity flow. Remember that a positive score suggests higher risk for hospitalization, prompting closer monitoring even if their initial presentation is minor. Don't let this replace standard vital sign checks, but use it as an adjunct risk stratification tool.

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132 days agoHigh-yieldGeneral Emergency MedicineConfidence: highSource: Academic Emergency Medicine

Outcomes of Acute PE Treated With DOACs in the Veterans Affairs Health System: A Retrospective Cohort Study

This retrospective cohort study analyzed 30-day mortality in a large U.S. population presenting with acute pulmonary embolism (PE) managed with direct oral anticoagulants (DOACs), stratifying outcomes based on the Wells' criteria equivalent, sPESI score. The key finding is that for patients deemed low risk, specifically those scoring sPESI 0 or 1, hospitalization did not confer a survival benefit compared to appropriate outpatient management. Notably, despite this evidence suggesting reduced inpatient utilization, two-thirds of these low-risk patients were still admitted to the hospital. This strongly suggests an opportunity to refine current guidelines and practice patterns regarding unnecessary short-stay admissions for low-risk PE.

For hemodynamically stable, low-risk acute PE patients (sPESI 0 or 1), routine hospitalization does not appear to improve 30-day mortality compared to discharge. This supports a more aggressive shift toward outpatient management when no other compelling reason for admission exists. Be mindful that this is observational data, so use it to guide resource allocation rather than abandoning inpatient care entirely.

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143 days agoHigh-yieldUltrasoundConfidence: moderateSource: Taming the SRU

No Pause, No Problem? Using Doppler Ultrasound to Detect ROSC Without Pausing Compressions for Pulse Check

This review tackles the persistent issue of interruptions during CPR, specifically focusing on how routine pulse checks disrupt high-quality chest compressions. The core question addressed is whether continuous monitoring via femoral arterial Doppler ultrasound can reliably detect Return of Spontaneous Circulation (ROSC) without necessitating a pause in compressions for manual pulse assessment. The authors evaluate the diagnostic accuracy of detecting pulsatility and anterograde flow signals obtained *during* active CPR, comparing this method against established protocols that require stopping compressions to check for palpable pulses or arterial waveforms. If validated, this technique could significantly streamline resuscitation efforts by maintaining uninterrupted high-quality chest compressions.

If you are concerned about pulse checks interrupting your rhythm during a code, remember that Doppler ultrasound of the femoral artery offers a potential way to detect ROSC without stopping compressions. While promising for workflow improvement, this technique is still under review, so don't abandon standard protocols entirely; use it as an adjunct tool when appropriate.

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151 day agoHigh-yieldToxicologyConfidence: highSource: AJEM

Patterns of emergency department visits for suicidal attempts associated with toxic ingestion: A retrospective cross-sectional study

This retrospective analysis characterizing intentional self-poisoning presentations in Israel highlights a significant trend: most ingestions are medication-related, often involving polypharmacy that includes central nervous system depressants. The authors strongly emphasize the critical role of early toxicology consultation for managing these complex cases. Beyond immediate clinical stabilization, they underscore the broader function of medical toxicologists in surveillance and prevention efforts related to self-harm. Overall, the findings reinforce that these presentations are rarely single-agent exposures.

When managing a patient presenting with intentional overdose, anticipate polypharmacy involving CNS depressants as the most common pattern. Prompt toxicology consultation is non-negotiable for guiding specific antidotal or supportive care pathways. Remember that optimizing outcomes requires integrating both acute stabilization and considering broader prevention strategies.

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162 days agoHigh-yieldGeneral Emergency MedicineConfidence: highSource: EMJ

Risk of obstructive acute kidney injury: derivation and internal validation of a risk stratification tree

This paper introduces the KIT-FISTO model, a newly developed risk stratification decision tree designed to predict obstructive acute kidney injury (AKI) in the emergency department setting. The authors utilized a retrospective derivation and internal validation cohort study involving adult patients presenting with AKI of any KDIGO stage. They found that clinical presentation is highly predictive; specifically, patients reporting lumbar, flank, or hypogastric pain were categorized as 'high risk,' showing an associated obstructive AKI risk around 55%. Furthermore, the model assigned a 'moderate risk' status to those without overt pain but with specific histories such as prior urinary tract surgery or abdominal cancer. The utility of this tool lies in its ability to stratify patients into low, moderate, and high risk groups based on clinical features.

For any patient presenting with AKI where an obstructive etiology is suspected, consider using the KIT-FISTO framework to guide workup intensity. The presence of flank or hypogastric pain strongly suggests a higher pretest probability for obstruction, while patients without pain but with relevant urological history warrant moderate suspicion. Remember that this model requires external validation before it should change routine practice.

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172 days agoHigh-yieldResuscitationConfidence: moderateSource: EMJ

Real-time identification of aetiology in patients able to undergo transoesophageal echocardiography with non-traumatic out-of-hospital cardiac arrest in China: a prospective, single-centre exploratory study

This single-center, prospective study explored the utility of transoesophageal echocardiography (TEE) for identifying reversible causes in patients presenting with non-traumatic out-of-hospital cardiac arrest (NT-OHCA) in China. The authors reported that TEE successfully provided diagnostic images in all 43 patients who underwent the procedure, which is a strong finding regarding feasibility during active resuscitation. They identified reversible etiologies in nearly two-fifths of the cohort, with acute aortic dissection being the most frequently diagnosed cause. While TEE guided interventions were performed in over half of the identified cases, the study noted that there was no significant difference in return of spontaneous circulation or 28-day survival rates between those whose aetiology was found versus those where it was not. Crucially, the authors emphasized that due to the lack of a comparator group, these findings warrant further controlled investigation.

TEE appears to be a feasible tool for rapidly assessing suspected causes during active CPR in NT-OHCA, with acute aortic dissection being a key finding to consider. However, remember this is an exploratory series lacking a control arm; therefore, do not use the reported differences in outcomes as definitive evidence of superior care pathways at the bedside. Proceed cautiously and recognize that its role should be viewed as complementary rather than standalone diagnostic confirmation.

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183 days agoHigh-yieldPolicy StatementsConfidence: highSource: EMJ

Sex-based and gender-based details in accelerated diagnostic protocol implementation among emergency department patients presenting with chest pain: a systematic review

This systematic review critically examines how often sex and gender are factored into the implementation of accelerated diagnostic protocols (ADPs) for chest pain in the emergency department. While most studies reviewing this topic report participant sex, the authors found that less than 20% of included literature actually incorporated sex or gender into their analyses or the ADP application itself. More concerningly, none of the reviewed studies provided disaggregated data for crucial outcomes like length of stay or major adverse cardiac events based on sex or gender. The review concludes by emphasizing a significant gap in current ED cardiac research, stressing that future efforts must improve the consistent integration and reporting of these biological and social factors into established protocols.

When considering chest pain workup, remember that while we know sex can influence presentation, most existing literature fails to provide outcome data stratified by sex or gender. This suggests current ADPs may not be optimally tailored for all patient groups. Always maintain a high index of suspicion for sex-specific risk factors and advocate for more rigorous reporting in local quality improvement initiatives.

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195 days agoHigh-yieldTriageConfidence: moderateSource: JACEP Open

A Prospective, Observational Study Evaluating the Impact and Safety of an Emergency Physician Collaboration With a Nurse Triage Phone Line

This prospective observational study explored the impact and safety profile of integrating emergency physician consultation directly into existing nurse triage phone line (NTPL) calls. The authors found a significant association, noting that involving an EM was linked to changes in triage disposition in over 40% of the cases reviewed. Furthermore, they observed that patients whose initial recommendations were downgraded showed lower subsequent observed emergency department utilization compared to those whose recommendations were upgraded. It is important to note, however, that nearly one-third of these downgraded patients still presented to the ED within a three-day window, suggesting ongoing need for follow-up care.

Incorporating EM input into your triage calls appears useful for modifying initial disposition recommendations, as evidenced by changes in over 40% of cases. Remember that while downgrading a patient's acuity level correlates with lower observed ED visits, this does not eliminate the need for follow-up, given that a substantial minority will still present within 72 hours. Interpret these findings associatively rather than causally.

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201 week agoHigh-yieldTraumaConfidence: highSource: SJTREM

Validation of the 2022 German trauma team activation criteria: a national registry study with focus on geriatric-specific modifiers

This national registry study validates the updated 2022 German trauma team activation (TTA) criteria, paying special attention to how geriatric-specific modifiers impact resource utilization and patient outcomes. The authors found that incorporating these modifications significantly improves the concordance between initial triage assessments and actual observed mortality risk, which is a key metric for system efficiency. This enhancement in predictive accuracy appears particularly pronounced within the elderly population, suggesting the updated guidelines better capture the unique physiological vulnerabilities of older adults presenting with trauma. While the study confirms the improved alignment, it also points toward future work needing to quantify the direct impact on overtriage rates and overall resource allocation decisions.

The integration of geriatric-specific modifiers into TTA criteria appears beneficial for improving risk stratification in older trauma patients compared to standard guidelines. At the bedside, this suggests a more nuanced approach is warranted when assessing elderly patients, potentially leading to better alignment between initial disposition and actual mortality risk. Keep in mind that while the predictive accuracy improves, quantifying overtriage implications remains an area needing further evidence.

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