Emergency Medicine Journals

Editor’s note: EMJ has partnered with the journals of multiple international emergency medicine societies to share from each a highlighted research study as selected by their editors. This edition will feature an abstract from each publication. [...]

Background Emergency department (ED) utilisation and delays are a major public health concern internationally, with increased mortality with ED delays and overcrowding. The study aimed to assess how the population characteristics of ED catchment areas are associated with ED use and delays to admission or discharge, and how catchment presentation rates are associated with ED delays. Methods A cross-sectional study of presentations and delays to all 27 Scottish EDs for December 2023–February 2024. Catchment areas were defined for every ED in Scotland and population demographics for each, as Scottish Index of Multiple Deprivation (SIMD) and 8-fold Urban–Rural Classification (UR8). ED performance metrics for the study period were extracted from routinely reported data. Robust regression assessed the associations between catchment area demographics and ED delays, with negative binomial regression analysis of the association between catchment area demographics and presentation rates for the local population, reported as incidence rate ratio (IRR). Results For each decile lower (more deprived) in median SIMD, monthly attendances increased by 10% (IRR 1.10, 95% CI 1.10 to 1.11). For each step more rural in the median UR8 of a catchment, the percentage of patients experiencing a delay to admission or discharge of over 4 hours reduced by 5.3% (95% CI 4.9% to 5.7%), and each step more deprived in median SIMD decile of a catchment area was associated with 4.8% more delays beyond 4 hours (95% CI 3.0 to 6.8%). There was no association between presentation rates and delay to admission or discharge. Conclusion EDs with more deprived catchment areas have higher presentation rates and greater delays in care. More rural EDs have fewer delays, which may mitigate some of the effects of geographical isolation in the provision of more timely care. In isolation, ED presentation rates are not associated with delays to care, adding to evidence that overall attendances are less important than other factors contributing to ED delays. Policymakers should consider the allocation of resources to best promote health equity. [...]

Objectives We evaluated the concordance between the Dutch National Triage Standard (NTS) triage classification and the triage of an artificial intelligence (AI) self-triage programme. Methods This observational comparative study was performed in the emergency departments (EDs) of two OLVG hospital locations in Amsterdam in October and November 2023. Adult patients who entered the ED without ambulance transport and were triaged using NTS (usual care), were asked to complete the digital AI triage programme. Cohen’s kappa (ĸ), per cent agreement and the distribution across urgency categories were used to evaluate the concordance between the triage methods. Results Of the 264 patients approached, 203 consented to participation and were included in analysis and follow-up. Agreement between the triage methods was none to slight, ĸ=0.092 (95% CI –0.196 to 0.380). The AI triage programme overtriaged in 12.8% of cases and undertriaged in 5.4% compared with the NTS. However, the AI triage programme classified more patients with serious clinical sequelae into S1 (ie, emergency care with ambulance) and S2 (ie, emergency care) compared with NTS U1 and U2. The AI triage programme predicted the final diagnosis at ED discharge in 27.1% of the cases. There were significantly more clinical sequelae (eg, death, ward admission or follow-up consultation) for general practitioner referred patients compared with self-referrals. Conclusion The AI triage appeared more distinctive in urgency classification than classic triage when considering clinical sequelae for the patient. However, refinements and better validation of AI triage programmes are needed before these can be implemented in healthcare systems. [...]

Objectives Calcium administration in traumatic haemorrhage is a leading prehospital research priority.1 Previous studies have demonstrated that both trauma-related ionised hypocalcaemia (iHypoCa) and ionised hypercalcaemia (iHyperCa) are present on arrival in the emergency department, and both are associated with increased mortality and adverse outcomes.2–4 No studies have examined how early calcium disturbances occur and whether calcium disturbances are observed prehospital.2 This makes protocolised calcium replacement without ionised calcium (iCa) measurement challenging as it may undertreat some patients and overtreat others.4 5 All UK Helicopter Emergency Medical Services (HEMS) carry blood products and calcium replacement therapy; a small proportion of HEMS use iCa point-of-care testing (POCT).5 This study is hypothesis-generating and aims to identify whether trauma-related calcium disturbances occur before hospital arrival and whether POCT may have a role in detecting these. ... [...]

‘Can’t intubate, can’t oxygenate’ (CICO) is a medical emergency in the paediatric trauma patient requiring emergency front of neck access (eFONA) interventions including needle/cannula cricothyroidotomy, surgical cricothyroidotomy or tracheostomy.1 2 A difficult paediatric airway is a rare event, reported in just 0.28% of cases.1 Of these, 2% require an eFONA procedure.1 However, there are variations between guidelines on how to manage CICO in paediatric trauma patients (table 1). We aimed to establish patterns and outcomes of eFONA procedures performed in paediatric trauma patients by interrogating two established trauma registries: the UK and Ireland Trauma Audit and Research Network (TARN, interrogated January 2000 to December 2022),3 and the Australian Victorian State Trauma Registry (VSTR, inception (2001) to December 2022).4 TARN includes all trauma patients who meet specific length of stay and injury severity criteria. VSTR includes... [...]

Endovascular resuscitation (EVR) describes a collection of novel therapies that aim to bridge patients in shock states or cardiac arrest to definitive treatment, through a combination of haemorrhage control and mechanical circulatory support. The last half-decade has seen landmark trials report on several techniques and adoption is growing despite controversies around risk, efficacy and implementation. As leaders in resuscitation, it is essential that emergency physicians understand the principles and practice of endovascular techniques to advocate for the critically unwell patients that may benefit from EVR and be engaged in future implementation. This practice review aims to provide emergency physicians with an overview of EVR, based around case scenarios of out-of-hospital cardiac arrest and non-compressible haemorrhage. We review the rationale for EVR in these conditions and describe the critical initial step of vascular access. We then describe the physiology, technique, efficacy and safety of three escalating interventions: resuscitative endovascular balloon occlusion of the aorta, selective aortic arch perfusion and extracorporeal cardiopulmonary resuscitation. [...]

This month’s update is by the Johns Hopkins Emergency Department Team and affiliates. We used a multimodal search strategy, drawing on free, open-access medical education resources and literature searches. We identified the five most interesting and relevant papers from outside our specialty (decided by consensus) and highlighted the main findings, key limitations and clinical bottom line. The papers are ranked as: Worth a peek—interesting but not yet ready for prime time. Head turner—new concepts. Game changer—this paper could/should change practice. Vasopressors or fluids in early septic shock by the ARISE FLUIDS investigators, the ANZICS clinical trials group, and the ACEM clinical trials network Topic: Sepsis Outcome Rating: Game Changer The ARISE FLUIDS trial is a multicentre, open-label randomised controlled trial (RCT) from Australia and New Zealand that asked: once fluid resuscitation is underway, is it better to continue with aggressive fluid resuscitation or reach sooner for a vasopressor... [...]

Clinical introduction A man in his 40s with no significant medical history presented to the emergency department with palpitations and malaise, showing no haemodynamic compromise. The 12-lead ECG is shown in figure 1. He received intravenous adenosine (6, 12 and 18 mg) and metoprolol (5 mg) without response. Direct current cardioversion (DCCV) caused only a short-lived restoration of sinus rhythm. Question Which of the following is the most likely diagnosis? Atrial flutter Atrial fibrillation Fascicular ventricular tachycardia (FVT) Supraventricular tachycardia (SVT) with right bundle branch block (RBBB) Answer C. Fascicular ventricular tachycardia (FVT) The ECG shows a regular narrow complex tachycardia with RBBB pattern and left axis deviation, consistent with involvement of the left posterior fascicle. The absence of sawtooth waves and the regular rhythm make atrial flutter and fibrillation unlikely. FVT is often mistaken for SVT with aberrancy because... [...]

I was working as the casualty medical officer in the triage area of the emergency department (ED), where I was doing my emergency medicine residency. The evening had been busy but manageable until a call came from the emergency operating theatre (OT). They had a patient they were unable to intubate or oxygenate. The senior consultant was already occupied with another critical case. There was no difficult airway response team waiting in the background. The responsibility, at that moment, fell to whoever was available. So, on my run from the ED to the OT, I found myself reciting the steps of cricothyroidotomy, which will be the maximum an emergency physician can do to secure an airway. ‘Finger-Scalpel-Finger-Bougie-Tube’. When I reached the OT, I saw another senior resident of anaesthesia was trying to intubate him for the fourth time. The patient had trismus, which was not noted earlier. Oxygen saturation... [...]

Background Hyponatraemia is associated with greater mortality in emergency patients. Therefore, the correction of low serum sodium levels remains an important field in clinical practice. Methods Eligible studies were searched through a literature query in PubMed and Web of Science in August 2024. Sodium correction rates and mortality data were extracted. The articles were grouped based on the threshold used to distinguish between slow and rapid correction. For each group, a random effects model was used for meta-analysis. The sodium correction rate thresholds were 8, 10 and 12 mmol/L/24 hours. Additionally, a random effects model was used to estimate the difference in osmotic demyelination syndrome (ODS) incidence. Results 11 retrospective studies with a total of 27 672 cases were included in the meta-analysis, each scoring at least 8* on the Newcastle-Ottawa quality assessment score. Mortality was significantly lower in the rapid correction group compared with the slow correction group for the 8 mmol/L/day threshold (OR: 0.398, p [...]

Background Measuring and evaluating patient experience in the emergency department (ED) is essential for improving the quality of emergency care. However, specific and validated tools to measure patient experience in the ED are lacking in many countries. The aim of this study was therefore to translate and cross-culturally validate the Australian ED Patient-Reported Experience Measure (ED PREM) for the Dutch setting. Methods A single-centre validation study was conducted in a Dutch academic hospital. Step 1 involved forward and backward translation to produce a Dutch translation of the ED PREM (prototype). Step 2 involved establishing face and content validity of the Dutch prototype through cognitive patient interviews and researcher team consensus meetings. Step 3 involved administering the resultant Dutch pilot ED PREM to an ED population (n=527), to be able to perform psychometric analyses on this sample. Descriptive statistics and item reduction analyses were conducted prior to confirmatory factor analysis (CFA). CFA was used to confirm the structural validity of the Dutch ED PREM, and internal consistency was assessed. Results The face and content validity of the prototype Dutch ED PREM was ‘good’ after 15 cognitive interviews and expert consultation. Over two-thirds of participants (357/527) completed the Dutch pilot ED PREM. Scores were high across all four domains. Several items were removed due to high ceiling effects and a large number of ‘not applicable’ responses. The final 18-item Dutch ED PREM showed acceptable model fit with CFA (2(df) 7519.55 (153), p [...]

Many practising clinicians have voiced concerns about limitations and imperfections associated with evidence-based medicine. Some of those concerns are aimed at the methodology and objectives of present-day medical research; others are a reflection of diverse environments and populations in which medical care is delivered. We argue in this paper that absence of evidence for any particular approach does not equate with evidence of absence of benefit of a considered intervention. Sufficient rather than perfect solutions may reflect patient preference or contextual constraints rather than ignorance on the part of the clinical practitioner. Relying on evidence without applying clinical judgement may sometimes be inappropriate. Medicine that acknowledges gaps in evidence needs to be pragmatic, seeking a solution for the patient in front of us. [...]

Academic Emergency Medicine, Volume 33, Issue 10, October 2026. [...]

Academic Emergency Medicine, Volume 33, Issue 10, October 2026. [...]

Academic Emergency Medicine, Volume 33, Issue 10, October 2026. [...]

ABSTRACT Objectives Triage reflects acute urgency, whereas frailty may also influence disposition in older emergency department (ED) patients. This study aimed to estimate the association between Clinical Frailty Scale (CFS)-defined frailty and hospitalization after ED evaluation within Japan Triage and Acuity Scale (JTAS) categories and assess whether the strength varied across triage categories. Methods We conducted a single-center retrospective cohort study in an urban tertiary hospital in Japan. We identified consecutive triaged ED visits by patients aged ≥ 65 years from November 2025 to March 2026. Visits with CFS scores and covariates constituted the complete-case cohort. CFS ≥ 5 was defined as frailty. The primary outcome was admission to the study hospital or acute-care interhospital transfer. We used a mixed-effects logistic regression model with a CFS-by-JTAS interaction term, adjusting for age, sex, mode of arrival, injury- or poisoning-related visit, living arrangement, and long-term care needs certification, with patient-level random intercept. The global interaction was assessed using a likelihood-ratio test. Results Among 3127 ED visits, 1526 resulted in hospitalization. In JTAS 1, the adjusted odds ratio (OR) for CFS ≥ 5 was not estimated because of quasi-complete separation. In the model excluding JTAS 1, the adjusted OR was 1.00 (95% confidence interval [CI], 0.65–1.55) in JTAS 2, 1.54 (95% CI: 1.19–1.99) in JTAS 3, and 2.01 (95% CI: 1.13–3.58) in JTAS 4/5. The global CFS-by-JTAS interaction was not statistically significant (P for interaction = 0.091). Conclusions Category-specific estimates suggested little association in JTAS 2 but were numerically larger in JTAS 3 and JTAS 4/5. However, the global interaction was nonsignificant, providing insufficient evidence that the association differed across categories. Prospective studies should examine the clinical, geriatric, social, decision-related, and healthcare-system factors that may underlie this association among older patients with comparable triage-assessed urgency. [...]

Academic Emergency Medicine, Volume 33, Issue 10, October 2026. [...]

Academic Emergency Medicine, Volume 33, Issue 10, October 2026. [...]

Academic Emergency Medicine, Volume 33, Issue 10, October 2026. [...]

ABSTRACT Patients frequently present to the emergency department (ED) with pain, swelling, or erythema in the early period following total joint arthroplasty (TJA). Differentiating normal postoperative inflammation from superficial surgical site infection (S-SSI) or early periprosthetic joint infection (PJI) can be difficult due to overlapping clinical and laboratory features, particularly within the first 30 days after surgery. We seek to provide emergency providers with an efficient and evidence-based framework for differentiating normal healing from early infection following TJA. We accomplish this by reviewing postoperative physiology, temporal response of inflammatory markers and synovial fluid analysis, and existing diagnostic criteria for infection. Normal healing after TJA produces predictable inflammatory responses that commonly exceed thresholds established for chronic PJI diagnosis. Therefore, early PJI diagnosis should utilize a time-dependent interpretation of synovial fluid, while S-SSIs remain primarily clinical diagnoses. A structured diagnostic algorithm can safely reduce unnecessary testing and costs, protect against medicolegal pressures, and provide evidence-based practices for effectively detecting early infection following TJA. This is crucial in the setting of the new Transforming Episode Accountability Model (TEAM) that bundles TJA payment. [...]

Academic Emergency Medicine, Volume 33, Issue 9, September 2026. [...]

Academic Emergency Medicine, Volume 33, Issue 9, September 2026. [...]

ABSTRACT Background Falls are a leading cause of emergency department (ED) visits among older adults and represent a critical opportunity to identify cognitive and functional impairments that influence treatment and recovery. While smartphone- and wearable-based assessments are increasingly used to assess cognitive and physical function in older adults, their feasibility in the ED setting, particularly after a fall, remains unclear. Methods From August 2021 to January 2024, community-dwelling older ED patients (≥ 65 years) were screened for cognitive impairment (six-item screener) and functional limitations (modified Barthel Index, mobility equipment). Apple ResearchKit digital assessments measured cognition (Stroop, Trail Making, reaction time) and physical function (gait/balance, timed walk). Wearable devices monitored movement. Feasibility was examined via attempt and completion rates. Reasons for non-attempt/non-completion and associations with patient characteristics were explored. Results Among 196 patients (mean age 78.2 ± 7.6 years, 68% women), 77% attempted at least one digital assessment. Cognitive tests had moderate-to-high completion rates (68%–87%) among those who attempted, and completion was associated with lack of cognitive impairment (p = 0.002, 0.002, 0.01, for Stroop, Trail Making, and reaction time tests, respectively). Non-completion was due most often to lack of glasses, not feeling well, or technology issues. Physical function tests had much lower completion rates (18%–20%), and completion was associated with functional status (Barthel Index; p = 0.02, 0.01 for gait and balance and timed walk tests) and mobility equipment use (p = 0.02, 0.03). Low completion rates were mainly due to safety concerns, pain, and injury. Conclusions Digital assessment of cognitive function is feasible in most older adults presenting to the ED for falls, but physical function tests had low feasibility in this population. Future research will explore whether such data predict clinically relevant outcomes (e.g., time to injury recovery, ED revisits) and can inform personalized intervention (e.g., physical therapy referrals, skilled nursing facility placement). Trial Registration Clinical Trial Number: NCT04304495 [...]

Academic Emergency Medicine, Volume 33, Issue 9, September 2026. [...]

Intranasal (IN) opioids may provide non-invasive analgesia without delays associated with intravenous (IV) access, but their efficacy and safety versus IV morphine remain uncertain. [...]

Ultrasound-guided nerve blocks (UGNBs) are increasingly used in emergency departments (EDs), but factors associated with technical difficulty remain poorly characterized. Objectives: To characterize the frequency of technical difficulty during ED UGNBs and explore patient-, provider-, and block-level factors associated with difficult procedures. [...]

We read with great interest the recent article by DeGraaf et al. titled “Early Extracorporeal Membrane Oxygenation Support in Bupropion-Induced Cardiogenic Shock: A Case Series” (1). [...]

We read with great interest the study by Coşkun et al. evaluating transesophageal echocardiography (TEE) for pulse evaluation during cardiopulmonary resuscitation (CPR) (1). The authors should be commended for addressing a clinically important yet understudied aspect of resuscitation care: reducing pulse-check interruptions during cardiac arrest. Their finding that intra-arrest TEE was associated with markedly shorter pulse evaluation–related decision-making times compared with manual palpation adds meaningful data to the growing literature on ultrasound-assisted resuscitation. [...]

We read with great interest the recent article by Ahmad A. Aalam entitled “Evaluating the Accuracy of Artificial Intelligence Chatbots in Triaging Emergency Cases: A Comparative Study with Expert Clinicians,” published in The Journal of Emergency Medicine (1). The author presents an important and timely evaluation of ChatGPT-4o’s performance in triaging structured emergency scenarios using the Canadian Triage and Acuity Scale. As artificial intelligence (AI) tools are increasingly being explored in emergency medicine, such investigations are both relevant and necessary. [...]

We read the article by Boylan et al., published in the Journal of Emergency Medicine (JEM), with great interest (1). The authors evaluated patterns of fascia iliaca block (FIB) use, analgesic effectiveness, and opioid consumption in patients with acute neck of femur (NOF) fractures presenting through the emergency departments (ED). However, we have some concerns and suggestions regarding the published article, which we would like to highlight in this letter. [...]

We read with interest the prospective cross-sectional study by Saadi Neto et al. evaluating the sonographic feasibility of the great saphenous vein (GSV) at the distal medial thigh as a rescue peripheral intravenous (PIV) access site in emergency department (ED) patients. The authors reported GSV visualization rates of ≥95% across all thigh regions in a mixed pediatric and adult cohort, with consistent results regardless of age, sex, or history of difficult intravenous (IV) access. This work provides a valuable anatomical foundation for a technique with clear clinical appeal in the difficult-access population. [...]

We read with interest the article by Calton et al. about a 4-year-old boy who developed progressive tetraparesis and respiratory failure requiring mechanical ventilation after a minimal spinal injury (1). As investigations revealed a Chiari I malformation, syringomyelia C6 to T1, and spinal cord edema C2 to C6, a central spinal cord syndrome resulting from the trauma was diagnosed. The patient underwent occipital craniotomy, complete C1 laminectomy, and partial C2 laminectomy 9 days after admission (1). [...]

To the Editor: [...]

Hospital staff preparedness for patient evacuation during disasters is a component of healthcare resilience. Current protocols may lack evidence-based foundations and tend to rely on static, checklist-driven approaches. Competency-based models have been proposed as an alternative, but empirical evidence supporting their effectiveness is limited. This study aimed to develop a model for hospital evacuation readiness, grounded in global evidence and local expertise. [...]

The STEMI/NSTEMI paradigm uses ST-elevation as a surrogate for acute coronary occlusion, but ST-elevation criteria miss many occlusions. The occlusion myocardial infarction (OMI) vs. non-occlusion (NOMI) paradigm classifies patients by the presence of an acute occlusion. [...]

The COVID-19 pandemic has turned out to be a huge challenge and a burden for medical services struggling with a huge number of patients and their ailments [1]. Currently in addition to the ever-growing number of COVID-19 cases related to the next wave, our attention should also be paid to patients who will struggle with a number of POST-COVID-19 complications. The implications of COVID-19 infection are continually being studied, both in terms of the frequency with which they occur and the mechanism by which they occur. [...]

This study aimed to examine the usability, feasibility, acceptability, and appropriateness of the information and communication technology for emergency medical services (ICT-EMS) systems to improve the transportation of emergency patients during the COVID-19 pandemic. [...]

The COVID-19 pandemic can exacerbate underlying substance use disorder and has impacted this vulnerable population in a variety of ways. There are limited data regarding how this pandemic has impacted emergency department (ED) patient presentations. [...]

Coronavirus disease 2019 (COVID-19) is primarily a febrile respiratory illness first documented in December 2019 in Wuhan, China that was declared a pandemic by the World Health Organization (WHO) on March 11, 2020 [1]. At the time of this writing COVID 19 infections have impacted 191 counties, and the death toll stands at 1,488,513 [2]. COVID-19 infection is known to cause coagulopathy and an inflammatory state [3], but there are few case reports involving COVID-19 related spontaneous bleeding outside of disseminated intravascular coagulation [3]. [...]

Thank you for sharing your institution's recent data and experience with a case of croup who was seen in your emergency department (ED), admitted on oxygen after dexamethasone treatment, and was found to be co-infected with both SARS-CoV-2 and enterovirus. I am glad your patient had a swift recovery. In our three reported cases of croup associated with SARS-CoV-2 infection over a two-month period, all three patients were positive for a single virus and had a negative viral panel (Biofire® FilmArray Respiratory Panel) (CR) for nineteen other viruses, including the ones most commonly associated with croup [1]. [...]

The efficacy of colchicine administration in patients undergoing percutaneous coronary intervention (PCI) remains controversial. We conduct a systematic review and meta-analysis to explore the influence of colchicine administration versus placebo on treatment efficacy for PCI. [...]

The publisher regrets the below abstract was missed to be included in the article. [...]

Despite the advantages of bone marrow transplantation (BMT), patients receiving this intervention visit the emergency department (ED) frequently and for various reasons. Many of those ED visits result in hospitalization, and the length of stay varies. [...]

A previous population-based study defined a broad set of complications of acute conditions encountered in Pediatric Emergency Departments (PEDs). These conditions represent a spectrum of diagnoses in which optimal PED care seems to reduce the risk of complications [1]. Recent studies on the impact of the severe coronavirus disease 2019 (COVID-19) pandemic found increased rates of appendiceal perforation, and severe diabetic ketoacidosis [2,3]. We investigated the rates of complications of serious acute conditions (CSAC) in PED patients during the COVID-19 pandemic. [...]

To describe the impact of a novel communication and triage pathway called, fast track dialysis (FTD) on the length of stay (LOS), resource utilization, and charges, for unscheduled hemodialysis for end stage renal disease (ESRD) patients presenting, to the emergency department (ED). [...]

We have read the article by Soh et al. reporting two cases of neuroleptic malignant syndrome (NMS) with CoronaVirus 2019 (COVID-19) [1] and we have identified another case by Kajani et al. [2] and the three cases represent NMS with COVID-19, as a part of its neurological complications that was attributed to injury of skeletal muscles and Severe Acute Respiratory Syndrome CoronaVirus 2 (SARS-CoV-2) utilizing central nervous system ACE2 receptors. Also, autopsy studies of COVID-19 patients have shown evidence of neuronal degeneration and hyperemic and edematous brain tissue [3]. [...]

Soon after the first patient in New York City (NYC) was diagnosed with the coronavirus disease of 2019 (COVID-19), the number of confirmed cases in New York State (NYS) skyrocketed with NYC being labeled the national epicenter of the pandemic [1]. State and city attempts to harness resources and stem the tide of infections escalated over the initial weeks, including a “NY on PAUSE” order limiting travel, business, and public gatherings. [...]

Circulation, Ahead of Print. Heart failure (HF) remains a pressing health concern, with rising prevalence globally. Subjectivity and ambiguity in the definition of HF and its antecedent stages have limited research, global surveillance, and prevention programs. To address this, several cardiac societies and foundations convened to standardize the definition of HF in 2021 and designated stage B or pre-HF to identify individuals at risk of developing HF. In subsequent years, substantial progress and changes have been made in aspects of preventing HF, improving HF diagnosis and management, and recognizing the importance of the affected individual’s voice. Global differences and disparities in HF are better understood, as are causes and comorbidities leading to differences in care, which are also influenced by access to care. This consensus document presents the Second Universal Definition of Heart Failure, aiming to standardize terminology and facilitate a uniform approach for clinicians, researchers, health systems, and policymakers. In this definition, the classification of HF phenotypes moves away from rigid left ventricular ejection fraction cutoffs, instead grouping HF into reduced, preserved, and improved ejection fraction categories to better reflect clinical realities. A universal classification of HF causes is also proposed. The document also addresses the dynamic trajectories of HF—improvement, remission, and recovery—and highlights the impact of social determinants and geographic variation on HF risk and outcomes. By providing a comprehensive, standardized framework for HF definition and classification, this document seeks to improve prevention, early detection, and management of HF worldwide, ultimately enhancing patient care and advancing global cardiovascular health. [...]

Circulation, Ahead of Print. BACKGROUND:Undertreatment and delayed treatment of aortic stenosis (AS) are common, both of which are associated with increased mortality. Historically, assessment of quality for AS care has focused on peri- and postprocedural outcomes. The American Heart Association Target: AS registry is the first national registry to provide data and evaluate quality for upstream processes of care for patients with AS.METHODS:Randomly selected patients from 2023 and 2024 with moderate or severe AS from 58 sites in the Target: AS registry were included. The 2 primary quality measures were (1) timely diagnosis (percentage of patients with an echocardiogram consistent with possible severe AS who had all assessments to clarify AS severity and symptoms within 30 days) and (2) timely treatment (percentage of patients with a Class I indication for aortic valve replacement treated within 90 days). Secondary measures included documentation of key echocardiographic parameters in the report, clinical recommendations in the echocardiogram report summary, multidisciplinary heart valve team evaluation, guideline-based performance of multimodality testing, and timely surveillance echocardiograms.RESULTS:Among 8097 patients, 47% were women, 7% Black, 6% Hispanic, and 3% Asian. Timely diagnosis occurred in 54% in 2023, improving to 61% in 2024 (P=0.027) with gaps caused by lack of timely symptom assessment (23% [2023]; 16% [2024]), lack of stroke volume index (35% [2023]; 18% [2024]), or lack of timely multimodality testing (87% [2023]; 75% [2024]). Among those with a Class I indication for aortic valve replacement, timely treatment occurred in 82% (2023) versus 85% (2024) (P=NS). Multidisciplinary heart valve team evaluation occurred in 78% (2023) versus 84% (2024) (P=0.008). Key findings in the echocardiography report were documented in 83% (2023) and 85% (2024) (P=NS), but a clinical recommendation was included in <10% of the time. Timely surveillance echocardiograms for moderate (2 years) and severe AS (1 year) were not performed in ~40% of patients.CONCLUSIONS:The national American Heart Association Target: AS registry demonstrates opportunities for improvement in timely diagnosis, surveillance, and treatment for patients with AS at participating centers. By providing an infrastructure to measure performance and identify best practices, the Target: AS registry has the potential to elevate and optimize care and patient outcomes. [...]

Circulation, Ahead of Print. Heart failure in the perinatal period remains ambiguous in definition and management despite its recognition as a unique disease state. The true incidence and prevalence of heart failure or left ventricular systolic dysfunction during pregnancy and the postpartum period are unknown, although a prevalence as high as 1% to 2% has been reported in the general adult US population. Assessment of heart failure can be challenging in the pregnant or postpartum state, during which symptoms affecting physical function (eg, dyspnea, exercise intolerance, fatigue, and lower-extremity edema) are prevalent because of physiological changes. Delays in the recognition and diagnosis of heart failure during the perinatal period contribute to adverse maternal outcomes, highlighting the need for evidence-based definitions and thresholds, improved diagnostic criteria to aid disease recognition, and effective screening tools. This scientific statement focuses on heart failure with reduced and mildly reduced ejection fraction in the context of pregnancy and the postpartum period, caused by various forms of cardiomyopathy. It addresses challenges related to recognizing heart failure in obstetric patients, outlines established treatment standards, and underscores potential areas for research. To improve the management of preexisting and de novo heart failure in obstetric patients, standardization of disease definitions, specific therapeutic options, implementation of effective screening tools, and interventions to improve maternal health equity are imperative. Future directions include prioritizing the inclusion of pregnant and postpartum individuals in heart failure studies, implementing interventions that facilitate early disease detection, and ensuring the timely initiation of appropriate therapies with the goal of reducing adverse outcomes associated with perinatal heart failure. [...]

Circulation, Ahead of Print. Background: High intakes of fructose-containing sugars among children and adolescents is implicated in obesity and related comorbidities, including hypertension. However, sugar-sweetened beverages (SSBs), fruit juices, and whole fruit have different nutritional profiles and matrices, which may confer different effects on blood pressure.Methods: GUTS (Growing Up Today Study) is a longitudinal cohort of 25 749 individuals (55% female) drawn from 2 enrollment waves, GUTS 1 (n=16 875; baseline 1996) and GUTS II (n=10 918; baseline 2004), followed up prospectively through 2021 (mean age at enrollment, 12 years; mean age at end of follow-up, 36 years). Participants provided updated information on lifestyle, health status, and habitual diet through validated food frequency questionnaires every 1 to 4 years. We conducted multivariable adjusted Cox proportional hazards regression models to estimate the associations of total fructose and SSB, fruit juice, and whole fruit intake (cumulative averages) with incident hypertension (hazard ratios [HRs] and 95% CIs), adjusting for major diet and lifestyle factors. We also modeled substitutions of SSBs or fruit juice with whole fruit, milk, and water.Results: During up to 25 years of follow-up, 1625 participants (6.3%) reported a hypertension diagnosis. Total fructose intake was not associated with incident hypertension (highest versus lowest quintile HR, 1.07 [95% CI, 0.92, 1.25];Ptrend<0.001). However, participants with the highest intake of SSBs (≥2 servings/d versus <3 servings/week) and fruit juice (≥1.5 servings/d versus <1 serving/wk) had a higher risk of hypertension (HR, 1.52 [95% CI, 1.27, 1.83];Ptrend<0.001 and HR, 1.35 [95% CI, 1.06, 1.71];Ptrend=0.018, respectively). In contrast, whole fruit was not associated with hypertension (highest versus lowest category HR, 0.79 [95% CI, 0.59, 1.05];Ptrend=0.08). Replacing 1 serving/d of SSB with milk, water, or whole fruit was associated with a 13% (95% CI, 5%, 20%), 9% (95% CI, 3%, 15%), and 22% (95% CI, 11%, 31%) lower risk of hypertension, respectively. In addition, replacing fruit juice with whole fruit was associated with a 19% (95% CI, 3%, 32%) lower risk of hypertension.Conclusions: SSB and fruit juice intakes were positively associated with a higher risk of hypertension independently of overall diet quality, physical activity, and other factors. Our findings support public health guidelines to limit the overconsumption of SSBs and fruit juice starting in childhood to protect against the development of hypertension. [...]

Circulation, Ahead of Print. Perioperative anemia and red blood cell transfusions are important risk factors for morbidity and mortality in cardiac surgery. Preoperative anemia is common, with up to 50% of patients presenting for cardiac surgery affected. Iron deficiency—the most common and potentially modifiable cause of preoperative anemia—is a major driver of blood transfusions in the cardiac surgical setting, adversely affecting both patient outcomes and resource utilization. Perioperative blood management, a patient-centered approach to blood conservation during cardiac surgery, is a multidisciplinary collaborative effort among anesthesiologists, surgeons, perfusionists, intensivists, and transfusion laboratory teams. Strategies aim to reduce blood loss and transfusions and improve patient outcomes. There has been a recent increase in research related to anemia, iron deficiency, and patient blood management in cardiac surgery. This scientific statement highlights the latest evidence on preoperative anemia assessment and intraoperative blood conservation; discusses considerations for specific patient populations regarding anemia prevalence, treatment, and outcomes; and reviews key challenges and knowledge gaps, with the goal of minimizing the impact of preoperative anemia, intraoperative blood loss, and hemodilution on cardiac surgery outcomes. [...]

Circulation, Volume 153, Issue 25, Page 2102-2105, June 23, 2026. [...]

Circulation, Volume 153, Issue 25, Page 1952-1959, June 23, 2026. [...]

Circulation, Volume 153, Issue 25, Page 2097-2099, June 23, 2026. [...]

Circulation, Volume 153, Issue 25, Page 2091-2096, June 23, 2026. [...]

Circulation, Volume 153, Issue 25, Page 2064-2083, June 23, 2026. Based on the Chapel Hill consensus criteria, the primary forms of vasculitis are classified by the predominant size of the affected blood vessels into large, medium, or small vessels. The two main forms of large vessel vasculitis (LVV) are giant cell arteritis and Takayasu arteritis, both of which are more prevalent in women while showing distinct geographic patterns of prevalence. The pathogenesis of LVV is complex and multifactorial, involving a combination of genetic predisposition, environmental and geographic triggers, immune dysregulation, and aging or (premature) senescence of the immune system and blood vessels. Diagnosis based on clinical presentation alone can be challenging because of the wide variety and often nonspecific symptoms that are associated with LVV. This has prompted the development of novel diagnostic tools to aid patient management, in particular advanced vascular imaging approaches. New therapies targeting specific immune pathways are now becoming available to improve outcomes while limiting the side effects associated with traditional glucocorticoid treatment. Advances in molecular imaging techniques may also enhance our ability to objectively monitor disease and treatment response in patients with LVV. Ongoing research aims to better understand the underlying mechanisms and to develop better targeted therapies for LVV, and to improve patient assessment and life time management. This narrative review will provide an in-depth update on current challenges and future trends in LVV, enhancing our understanding of its pathogenesis, diagnostic features, and management strategies, including disease- and treatment-related cardiovascular complications. [...]

Circulation, Volume 153, Issue 25, Page e1447-e1447, June 23, 2026. [...]

Circulation, Volume 153, Issue 25, Page e1448-e1448, June 23, 2026. [...]

Hypotension after cardiac arrest has been associated with unfavorable outcome in children. The most recent guidelines from the International Liaison Committee on Resuscitation (ILCOR), American Heart Association (AHA), and European Resuscitation Council (ERC) suggested targeting systolic blood pressure (SBP) and mean arterial pressure (MAP) over the 10th percentile for age after cardiac arrest (CA).1–3 This recommendation was based on a systematic review that found SBP > 10th percentile in the first 6 h after CA was associated with survival and favorable neurologic outcome in two studies, and MAP > 10th percentile in the first 6 h after CA was associated with survival and favorable neurologic outcome in one study. [...]

When different out-of-hospital cardiac arrest (OHCA) registries evaluate the same condition in patients with comparable demographics, one might expect them to report similar outcomes. For foreign body airway obstruction (FBAO)-related OHCA, this is not the case. [...]

In the lead-up to European Resuscitation Council (ERC) Congress 2026 in Milan, “Be One” explored the potential of artificial intelligence (AI) to engage the public in resuscitation. Initiated by one of the authors as a social experiment, the campaign invited participants to upload a portrait, generate a personalised image promoting bystander CPR and AED use, share it on social media and invite colleagues to continue the chain. The materials documented visual participation, although reached, engagement and behavioural outcomes were not measured. [...]

To evaluate the clinical-effectiveness of an intraosseous-first strategy compared with an intravenous-first strategy in adult out-of-hospital cardiac arrest in a pre-planned Bayesian secondary analysis of the PARAMEDIC-3 trial. [...]

Biological sex is increasingly recognized as a fundamental variable in cardiovascular and cerebrovascular disease, yet its integration into our understanding of post-cardiac arrest brain injury (PCABI) pathophysiology remains limited. Although mortality following cardiac arrest remains universally high, males have a higher lifetime incidence while females experience disproportionately poor survival and neurological outcomes, particularly after menopause. Rather than a binary difference, evidence indicates three possible functionally distinct risk profiles: males with relatively stable neurological vulnerability across the lifespan, premenopausal females with apparent neuroprotection, and postmenopausal females at increased risk of neurological sequelae. [...]

Acute coronary syndrome (ACS) and occlusive myocardial infarction (OMI) are among the most common causes of sudden cardiac arrest.[1–3] Timely identification and invasive management are critical, as patients undergoing primary percutaneous coronary intervention (PCI) following return of spontaneous circulation (ROSC) show substantially higher survival rates.[4–6] According to current guidelines, ST-elevation myocardial infarction (STEMI) on the electrocardiogram (ECG) following return of spontaneous circulation (ROSC) remains the primary criterion for determining a primary PCI strategy. [...]

In the United States, out-of-hospital cardiac arrest (OHCA) occurs in 83.4 individuals per 100,000 population annually, and only 10% of adults and children survive to hospital discharge, highlighting its substantial public health burden.1–4 Emergency medical services (EMS) serve an essential role in the “chain of survival” for patients with OHCA and provide a number of life-saving interventions.5–9 While the American Heart Association creates treatment guidelines and algorithms for cardiac arrest,6–11 the implementation of these recommendations in clinical practice may vary widely. [...]

Sahai and colleagues demonstrate that an integrated cardiopulmonary resuscitation (CPR) coach curriculum, compressor training, and metronome-guided feedback can improve pediatric chest-compression quality during actual cardiac arrests while maintaining a high chest compression fraction.[1] Their observation that sustained improvement required substantial education and resources raises an important next question: how can gains in CPR performance be maintained without creating an unsustainable training burden? [...]

Out-of-hospital cardiac arrest remains a time-critical emergency in which early cardiopulmonary resuscitation and defibrillation are key to survival. Smartphone Alerting Systems (SAS) mobilize community first responders (CFR) rapidly, but accurate measurement of their arrival times remains challenging for system evaluation and optimization. [...]

Hyperglycemia after cardiac arrest is a common finding and for decades, observational studies have linked abnormal glucose concentrations and glycemic variability with mortality and unfavorable neurological outcomes after cardiac arrest [1,2]. [...]

Bystander presence improves outcomes after out-of-hospital cardiac arrest (OHCA). Although bystander type is reportedly associated with neurological outcomes, the potential modifying effect of age on this association remains uncertain. [...]

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BACKGROUND The modified Brain Injury Guidelines (mBIG) are an established protocol to triage traumatic brain injury with intracranial hemorrhage (ICH) while reducing resource utilization. However, mBIG do not differentiate between isolated and combined intracranial hemorrhage (cICH). This study evaluated whether patients with multiple ICH subtypes require different triage. METHODS We performed a retrospective study of adult patients classified as mBIG 1 or mBIG 2 at two Level I trauma centers January 1, 2017, to June 30, 2023. Patients with cICH (≥2 subtypes) were compared with isolated ICH. Primary outcome was clinical deterioration, defined as new focal neurologic findings, pupillary examination changes or Glasgow Coma Scale score of [...]

Objective: The “REstricted vs. Liberal positive end-expiratory pressure in patients without Acute Respiratory Distress Syndrome (ARDS)” (RELAx) trial compared lower vs. higher positive end-expiratory pressures (PEEP) in invasively ventilated critically ill patients without ARDS, concluding non-inferiority of lower PEEP in frequentist analysis. This study aimed to perform a Bayesian re-analysis of RELAx to assess probabilities of clinically meaningful differences between lower and higher PEEP. Design: A post hoc Bayesian analysis of RELAx data. Setting: RELAx was a non-inferiority multicenter trial conducted between October 2017 and March 2019 in eight ICUs. Patients: The trial included 980 ICU patients expected to require invasive mechanical ventilation greater than or equal to 24 hours for reasons other than ARDS. All patients included in the original analysis entered the Bayesian re-analysis. Interventions: Participants were randomized to the lowest possible PEEP between 0 and 5 cm H2O or to a higher PEEP of 8 cm H2O. Measurements and Main Results: The primary outcome was ventilator-free days at day 28 (VFD-28). Secondary outcomes were 28-day mortality and ventilation duration. The odds ratio for higher VFD-28 with lower PEEP was 1.08 (95% credible intervals, 0.87–1.35), with consistent estimates across priors and with a probability of superiority ranging from 75% to 78%. For 28-day mortality and duration of ventilation, the probability of benefit of the lower-PEEP strategy ranged from 72% to 89%, and from 11% to 28%, respectively. In patients admitted for other reasons than cardiac arrest or intubated for other reasons than respiratory failure, probabilities of benefit with lower PEEP exceeded 90%. Conclusions: Although the probability of benefit in the overall population was modest, the analysis suggested a higher probability of benefit in selected subgroups, particularly patients admitted for other reasons than cardiac arrest or intubated for other reasons than respiratory failure. These findings highlight potential heterogeneity of treatment effect and support further investigations. [...]

Objective: A definition of refractory septic shock is necessary to guide diagnosis, management, prognostication, research, and future guidelines for this most severe form of the disease. We sought to achieve consensus on clinical criteria that would be used to define refractory septic shock. Design: Review of literature, expert panel position statements, and Delphi rounds with an international expert group. Setting: Consensus was defined as having at least 75% of panellists in agreement or disagreement on the three highest or lowest levels of a 7-point Likert scale or based on responses to single- or multiple-choice questions, respectively. Subjects: A panel of multinational, multiprofessional and multidisciplinary critical care experts assembled by the Society of Critical Care Medicine and the European Society of Intensive Care Medicine (57 invitations and 56 participants). Measurements and main results: A five-round Delphi process was conducted for consensus and stability. The steering committee proposed 34 statements, and five of them were rejected by panel experts after round 2. Among 29 statements selected from eight domains, consensus was reached for 13. The panel agreed on the need for a comprehensive consensus set of clinical criteria for refractory septic shock. Markers of organ dysfunction (75%, 2 rounds), tissue perfusion (91.1%, 2 rounds) including lactate (94.6%, 2 rounds) and capillary refill time (76.8%, 2 rounds), assessment of fluid-responsiveness after initial resuscitation (92.9%, 5 rounds), and use of vasoactive drugs at norepinephrine equivalents greater than 0.5 µg/kg/min (75.0%, 3 rounds), were selected as clinical criteria of refractory septic shock. The use of critical care ultrasound (CCUS) (92.9%, 3 rounds) was the single diagnostic modality that reached a consensus-based agreement. Conclusions: A consensus for 13 criteria to frame the definition of refractory septic shock was reached. Refractory septic shock is characterised by persistently elevated lactate concentrations and or prolonged capillary refill time in patients with septic shock who are fluid unresponsive, require a norepinephrine base equivalent dose greater than 0.5 micrograms per kilogram per minute, and undergo CCUS assessment when mixed shock is suspected. [...]

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Objectives: Almost 80% of sepsis cases occur in low-resource settings (LRS), where limited resources impede the effective implementation of international guidelines for sepsis management. In addition, existing sepsis guidelines have not fully addressed specific issues relevant to LRS. Therefore, an international panel of 20 multiprofessional sepsis experts was convened to generate consensus on the gaps in and strategies for sepsis care in LRS. The recently developed “sepsis chain of survival” was used as a framework. Data Sources: MEDLINE, Embase. Study Selection: Studies selected included human studies (clinical trials, cohort, case-control, and case series) reporting clinical outcomes in patients with sepsis from LRS between January 1, 2000, and July 4, 2024. Search terms included “developing countries,” “LMIC,” “resource-poor settings,” and regional terms such as Africa, Southeast Asia, and Latin America. The Delphi process involved iterative, anonymous voting by the expert panel to achieve consensus to draft clinical practice statements. Data Extraction: A detailed literature review was conducted using the “sepsis chain of survival” as a basis, with an emphasis on sepsis prevention, detection, therapy, post-sepsis care, education, and future research priorities. A total of 8865 studies were identified and screened, with 155 included in the review. Data Synthesis: Based on literature review, the Delphi process achieved a stable consensus for 58 of 62 (94%) of the proposed clinical practice statements after eight survey rounds. These statements offer guidance on measures to improve the prevention, early recognition and time-sensitive, comprehensive management of sepsis in LRS through the continuum of care from first response to post-sepsis care and follow-up. Conclusions: There remains a significant lack of high-quality evidence to support improvements in sepsis care for patients in LRS. Pending new data, the clinical practice statements identified here complement the existing international guidelines for sepsis management by serving as a basis for immediate care and future research in LRS. [...]

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Rationale: Older adults (those 65 years old or greater) compose a substantial proportion of the ICU population. As older adults with critical illness possess unique factors and considerations relevant to their care and outcomes, there is a need for evidence-based recommendations to guide critical care clinicians in the care of older ICU patients. Objective: The objective of this guideline is to develop evidence-based recommendations addressing the care of older adults during and after critical illness. Design: The American College of Critical Care Medicine Board convened a 22-member interprofessional panel, comprising physicians, advanced practice providers, nurses, a pharmacist, physical therapist, occupational therapist, and a patient representative. The panel included two expert methodologists specialized in developing evidence-based recommendations in alignment with the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. Conflict-of-interest policies were strictly followed during all phases of guideline development including task force selection and voting. Methods: The panel members prioritized five Population, Intervention, Comparator, and Outcomes questions. A systematic review was conducted for each question to identify the best available evidence, synthesize the evidence and assess the certainty of evidence using GRADE. The evidence-to-decision framework was used to formulate recommendations. Results: The panel generated two conditional recommendations and three “no recommendation” statements. The conditional recommendations are: 1) We suggest a geriatric model of care for all older adults admitted to the ICU and 2) We suggest not using antipsychotic medications for the prevention of delirium in older adults with critical illness. The three “no recommendation” statements are: 1) We make no recommendation regarding specialized post-ICU follow-up for older survivors of critical illness, 2) For older adults (age 65 and over) admitted to the ICU with vasodilatory shock, we make no recommendation with regard to targeting a mean arterial pressure (MAP) of 60–65 mm Hg as compared with usual care (MAP target > 65 mm Hg), and 3) We make no recommendation regarding the use of antipsychotic medication in the treatment of delirium in older adults with critical illness. Conclusions: The guideline panel developed recommendations on caring for older adults during and after critical illness. Areas for future research were also identified during the guideline process. [...]

Objectives: A temperature control strategy is strongly recommended for comatose in-hospital cardiac arrest (IHCA) survivors. We aimed to investigate variation in adherence to this recommendation and associations with outcomes, which have not been comprehensively assessed for IHCA. Design: Prospective observational cohort study with data collected from October 2023 to June 2024. Setting: Multicenter, international (24 hospital systems, 46 enrolling hospitals). Patients: Adults who suffered IHCA, survived initial resuscitation, and remained comatose and eligible for temperature control. Interventions: None. Measurements and Main Results: The main exposure was documentation of a temperature control strategy in the first 24 hours after arrest. Outcomes were survival to hospital discharge (primary), use of temperature control therapy, fever (temperature ≥ 38°C), favorable functional outcome (modified Rankin Scale ≤ 3), and favorable neurologic outcome (Cerebral Performance Category score ≤ 2). Among 1006 enrolled patients, 615 (61.1%) remained comatose and were eligible for temperature control; of those, 273 (44.4%) had a documented temperature control strategy. A documented strategy was associated with higher adjusted odds of receiving a temperature control therapy (adjusted odds ratio [aOR], 21.3; 95% CI, 12.3–36.7; p < 0.01), and lower adjusted odds of fever in the first 24 hours after resuscitation (aOR, 0.63; 95% CI, 0.43–0.92; p = 0.02). Having a strategy, compared with not, had no statistically significant association with survival (32.6% vs. 28.1%; aOR, 1.19; 95% CI, 0.79–1.80; p = 0.42), favorable functional outcome (9.9% vs. 10.5%; aOR, 1.14; 95% CI, 0.53–2.42; p = 0.74), or favorable neurologic outcome (12.8% vs. 12.3%; aOR, 1.15; 95% CI, 0.63–2.12; p = 0.65). Hospital system specific proportions of temperature control strategy ranged from 0% to 100%. Conclusions: Among comatose IHCA survivors, more than half received no documented temperature control strategy. Those with a strategy were less likely to have a fever and more likely to receive temperature control directed therapy, but showed no difference in survival, functional, or neurologic outcomes. [...]

Objectives: To develop a practical consensus-based framework for ten steps to improve sepsis care in low-resource settings (LRSs), aligned with the sepsis chain of survival and informed by global expertise. Data Sources: We reviewed peer-reviewed literature on sepsis epidemiology, prevention, recognition, and management in LRS; international guidelines, including the Surviving Sepsis Campaign; and prior “ten-step” consensus frameworks for resuscitation and emergency care. Study Selection: A Task Force representing adult and pediatric sepsis care, emergency care, critical care, infectious diseases, public health, and implementation science identified key domains from the above data sources. Data Extraction: With guidance from methodologists and implementation science experts, we employed an iterative, consensus-based process—literature review, Delphi survey, Utstein-style conference, stakeholder input, and public comment—to first define and then refine steps and implementation strategies. Data Synthesis: The process resulted in ten nonsequential, actionable steps covering governance and commodities, provider and caregiver education, community and facility prevention, early recognition and rapid response, timely guideline-based interventions, structured post-sepsis care, data systems, quality improvement, a culture of excellence and respect, and holistic well-being of patients, caregivers, and providers. Each step includes a rationale and potential implementation strategies adaptable to local resources and needs. Collectively, the ten steps emphasize integration across the continuum of care, equitable access to essential interventions, and the role of emerging technologies to prevent, recognize, monitor, and follow-up sepsis. Conclusions: The ten steps provide a consensus-driven roadmap for health leaders, clinicians, and policymakers to improve sepsis care, strengthen the sepsis chain of survival, reduce preventable morbidity and mortality, and address global inequities in sepsis outcomes. [...]

Central to managing critically ill patients is the identification of the etiology of cardiorespiratory insufficiency (i.e., shock), early appropriate targeted therapies to support the cardiorespiratory system to sustain adequate blood flow and oxygen to the tissues, plus specific treatments to reverse the cause of shock. Over the past 40 years, numerous advances in our understanding of shock, its severity, and its response to therapies, along with more specific and insightful monitoring approaches, have been developed. This perspective summarizes some aspects of that progress. We have come a long way, but we need to understand three things. First, that once organ injury has occurred all that our treatments can do is mitigate further injury, not reverse it. If initial aggressive resurrection efforts cannot restore organ function, then their actions often cause only iatrogenic injury. Second, existing advanced monitoring devices, no matter how insightful their data, will not improve patient outcomes unless coupled to a treatment that itself improves outcomes. Finally, all our advances over these years have underscored the fundamental need for having a thoughtful and observant bedside clinician cognizant of the pathophysiologic underpinnings of disease and its care who titrates care based on the patient’s individual response. [...]

Objectives: Evidence supporting the benefits of combined nutrition and exercise programs in ICU survivors is limited. We assessed the impact of a combined lifestyle intervention on perceived physical functioning (PF) and health-related quality of life (HRQoL) post-ICU. Design: Single-center randomized control trial. Setting: Teaching hospital in the Netherlands (Frisius Medical Centre Leeuwarden). Patients: Adult long stay ICU survivors (≥ 48 hr) with a PF score of less than 67% on the Dutch translation of the RAND-36 item Health Survey. Interventions: The 12-week intervention included twice-weekly group exercise, dietary advice, and protein supplementation as needed. The control group received standard aftercare according to local protocol. Measurements and Main Results: Primary outcome (PF score at 12 wk) and secondary outcomes were assessed during a clinic visit at baseline and after a 12-week period. 39 patients completed the study (control, n = 20; intervention, n = 19): 26% female, median age 61 years (46–72), median ICU stay 7 days (4–14), and patients were severely ill (Acute Physiology and Chronic Health Evaluation III: 67 [50–89]). Although there were imbalances in ICU characteristics, baseline characteristics and PF scores were similar. At 12 weeks, the intervention group showed a significant improvement (p = 0.024) in PF-domain score. Daily protein intake in the intervention group increased from 82.3 (67.5–97.9) to 116.7 (107.3–138.7) g/kg (p = 0.003), with 68% meeting the minimal intake target of 1.2 g/kg/d. Conclusions: The data of this small-sample size randomized controlled trial suggest that a combined lifestyle intervention program can significantly improve PF and protein intake in ICU survivors with a prolonged PF scores below reference. [...]

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About one-fifth of adults and children over the age of 5 living in the United States report speaking a language other than English (LOE) at home, with a significant portion of this population also self-reporting limited English proficiency. Pediatric emergency medicine providers are seeing increasing numbers of patients and caregivers in this demographic. Care for these patients can be complicated by miscommunication. Research has consistently shown that patients with LOE experience numerous disparities in emergency department (ED) care, including under-triage, longer lengths of stay, increased revisit rates, increased rates of adverse events, and worse analgesia for pain. Overcoming linguistic barriers is important to provide excellent and equitable care for this population, and studies show that the use of professional interpretation can mitigate these disparities. Although general guidelines for the use of medical interpreters exist, there are special challenges involved in caring for patients in the emergency setting while also communicating with adult caregivers. This article aims to familiarize the emergency medicine provider with issues they will likely encounter in their practice setting, suggestions to mitigate these difficulties, and best practices for collaborating with interpreters in a fast-paced medical setting. [...]

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Tranexamic acid (TXA) is an antifibrinolytic medication that helps stabilize clots and reduce bleeding. Although FDA approval is limited, it has become widely used off-label in pediatric and emergency medicine. Evidence shows that TXA decreases blood loss, reduces transfusion requirements, and may improve survival in trauma. It has also been beneficial in pulmonary hemorrhage, post-tonsillectomy bleeding, epistaxis, abnormal uterine bleeding, and secondary postpartum hemorrhage. TXA is generally safe and well tolerated; common side effects include headache and abdominal discomfort, while serious events such as seizures or allergic reactions are rare. Its favorable safety profile and broad applicability make TXA a valuable tool for frontline clinicians managing pediatric bleeding emergencies. More pediatric-specific trials are needed, but current evidence supports TXA as both effective and practical in a variety of emergency settings. [...]

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Background: Sepsis is one of the leading causes of death among children worldwide. The Society of Critical Care Medicine Pediatric Sepsis Definition Task Force developed and validated the Phoenix sepsis criteria, new clinical criteria for pediatric sepsis and septic shock based on organ dysfunction. Although this represents a significant advancement in standardizing sepsis and septic shock definitions, its applicability in emergency department (ED) settings remains unexplored. Importance: Given that EDs are often the first point of contact for critically ill children, we must examine the use of the Phoenix criteria in these settings and across varying resource levels. In this CME review article, we explore the evolution of pediatric sepsis definitions to the Phoenix sepsis criteria, and its utility, strengths, and limitations in emergency care in both high-resource and low-resource ED settings. [...]

Measles is a highly contagious viral infection that resulted in significant morbidity and mortality before widespread vaccination efforts began in the 1960s. In 2000, measles was declared eliminated in the United States; however, continued global circulation combined with rising vaccine hesitancy has resulted in recent outbreaks of increasing severity. This review article highlights relevant epidemiology and prepares clinicians to differentiate measles infection from similar febrile exanthems of childhood. We review available diagnostics and the management of patients with or exposed to measles infection in an era of unfamiliarity with the condition. [...]

Clonidine is being increasingly prescribed in pediatric populations for behavioral conditions such as attention-deficit/hyperactivity disorder (ADHD), contributing to a rise in pediatric exposures and toxic ingestions. This article reviews the toxicokinetics, clinical presentation, and management of pediatric clonidine toxicity. Children under 5 years old account for the highest proportion of clonidine exposures, most of which are unintentional. Clonidine toxicity mimics an opioid toxidrome, often presenting with CNS depression, miosis, bradycardia, and hypotension. Diagnosis is primarily clinical. While supportive care remains the core component of treatment, naloxone may be beneficial in reversing CNS depression, though higher-than-standard doses are often required. Given the potential for delayed and prolonged toxicity, particularly with ingestion of transdermal patches, early recognition and intervention are critical. This review equips clinicians to understand, diagnose, and manage pediatric clonidine toxicity, emphasizing the importance of supportive care and consideration of naloxone for severe cases. [...]

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OBJECTIVE: We assembled a workgroup within the Pediatric Research Collaborative on Critical UltraSound (PeRCCUS), a subgroup of the Pediatric Acute Lung Injury and Sepsis Investigators (PALISI), to define early guidance for point-of-care ultrasound (POCUS) institutional practice and foster future comprehensive guidelines for its broad adoption in pediatric critical care medicine. DESIGN: A modified Delphi method was used for creating the statements. The first meeting was an open proposal session for workgroup members to suggest items for consideration. This was followed by a cycle of voting for levels of agreement along a 7-point Likert-type scale. Items were reviewed, with only items receiving a score of greater than or equal to 6 progressing to the next stage of voting and lower-scoring items reconsidered, with only consensus items proceeding to the next stage for additional rounds of voting until consensus was reached. SETTING: Multi-institutional, multidisciplinary, workgroup of experts on POCUS organized within PeRCCUS as a subgroup of PALISI. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Consensus was obtained for 25 recommendations across five domains: clinical application, quality assurance, equipment, education, and research. CONCLUSIONS: We report consensus recommendations for institutions on clinical use, educational programs, quality assurance, technical requirements, and future research opportunities for the adoption of pediatric critical care medicine POCUS. [...]

OBJECTIVE: Develop a consensus-based framework for point-of care ultrasound in pediatric critical care, or critical care ultrasound (CCUS) education using entrustable professional activities (EPAs). DESIGN: A modified Delphi method utilizing cycles of meetings and surveys for consensus-building. SETTING: The endeavor involved members of the Pediatric Research Collaborative on Critical Ultrasound (PeRCCUS), a subgroup of the Pediatric Acute Lung Injury And Sepsis Investigators. SUBJECTS: An expert panel consisting of 23 members representing 17 institutions, including diverse healthcare professionals involved in pediatric critical care ultrasound. INTERVENTIONS: Three iterative modified Delphi rounds were conducted to propose and refine critical care ultrasound EPAs. MEASUREMENTS AND MAIN RESULTS: The endeavor achieved a 74% response rate. Fourteen EPAs were formulated across five domains: Cardiac, Pulmonary, Abdomen, Procedures, and Vascular, along with two consensus opinions on educational content and methods. EPAs were evaluated using 5-point Likert items, requiring a median score of greater than or equal to 4.5 for progression. CONCLUSIONS: This collaborative effort led to the establishment of fourteen EPAs for pediatric critical care ultrasound, offering a structured approach for education and competency assessment in pediatric critical care. This initiative lays the groundwork for evolving standards in pediatric critical care ultrasound education and practice. [...]

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