This week in Emergency Medicine

This AudioScholar briefing is generated by artificial intelligence for healthcare professionals and trainees. It is not medical advice.

Welcome to This Week in Emergency Medicine. This week we're covering 10 notable papers spanning cardiac arrest and resuscitation systems, chest pain and the ED's role in cardiovascular care, and toxicology and symptom control. Let's dive in.

We start with out-of-hospital cardiac arrest, where this week brings both one of the more striking positive signals in recent memory and a sobering null result, both in the New England Journal of Medicine. Reis Miranda and colleagues report a nationwide, nonrandomized study from the Netherlands comparing young adults, aged 50 or under, with refractory arrest who were attended by helicopter emergency medical teams equipped to start extracorporeal CPR on scene, against those attended by helicopter teams without that capability [1]. Survival to hospital discharge was 40 percent with prehospital ECPR versus 20 percent with conventional care, and favorable neurologic outcome at six months was about 36 percent versus 13 percent. Adverse events were more frequent in the ECPR group, 32 against 11. Because allocation depended on which team responded rather than randomization, residual confounding remains possible, and the finding applies to a narrow, younger population served by a highly organized national system. Still, a doubling of survival is a large association, and it reopens the question of whether bringing the circuit to the patient beats bringing the patient to the circuit. In contrast, Malta Hansen and colleagues ran a registry-based cluster-randomized trial across North Carolina counties testing a four-part community and EMS package: telecommunicator training for faster arrest recognition and better CPR coaching, community CPR training, and expanded early defibrillator use [2]. Across more than 22,000 patients, survival with good neurologic outcome was about 9 percent in both arms, with no meaningful difference. This is a rigorous negative result for implementation bundles of this kind, and it suggests that the bystander links of the chain may be harder to move at population scale than observational data implied.

Two further resuscitation papers round out this theme. In the American Journal of Emergency Medicine, Duchatelet and colleagues studied 362 intubated arrest patients managed by a physician-staffed prehospital team in Belgium, using intratracheal pressure recordings to verify whether positive end-expiratory pressure was actually delivered [3]. Mechanical ventilation with PEEP was associated with roughly one and a half times the odds of return of spontaneous circulation, and an unadjusted association with survival to discharge. This is single-centre and observational, with a result near the edge of significance, so it is hypothesis-generating rather than practice-changing, but the objective pressure measurement makes it a useful foundation for a trial. And in Resuscitation, Bray and colleagues publish the annual International Liaison Committee on Resuscitation consensus summary, spanning basic, advanced, pediatric and neonatal life support, education and teams, and first aid [4]. The document grades evidence with GRADE criteria, explains the reasoning behind each treatment recommendation, and lists priority research gaps; it is the reference point against which this week's ECPR and PEEP data will eventually be weighed.

Our second theme is chest pain and acute coronary syndromes, and how emergency care for these patients has shifted. In Annals of Emergency Medicine, Chou, Wharam and Hsia analyzed more than 770,000 commercially insured ED visits for chest pain without myocardial infarction between 2007 and 2021 [5]. Hospitalization fell by more than half, to under a fifth of visits, and seven-day noninvasive testing dropped to about 9 percent. Despite that, the rate of myocardial infarction admission within six months stayed flat at around one percent. The exception was patients aged 70 and older, who saw a modest rise. The authors read this as reassurance that de-escalation has been broadly safe, while flagging older and higher-risk adults as the group where the value of admission and testing still needs quantifying. Claims data cannot capture clinical risk scores or troponin strategies, so the mechanism of the decline is inferred rather than shown. Complementing this, Long, Tannenbaum and Sandefur offer a narrative review of spontaneous coronary artery dissection in the Journal of Emergency Medicine [6]. They emphasize that SCAD presents like typical acute coronary syndrome, often with ST elevation, and disproportionately affects young-to-middle-aged women, including in the peripartum period. Angiography is needed for diagnosis, most lesions heal with conservative management, and revascularization is reserved for ongoing ischemia, instability, ventricular dysrhythmias, or left main involvement. As a review, it summarizes rather than adds evidence, but it is a timely reminder given how many low-risk-appearing patients are now discharged.

Staying with the question of who benefits from what kind of ED care, Lo and colleagues in Academic Emergency Medicine examined Geriatric Emergency Management programs in Ontario among nearly 146,000 older adults living with dementia [7]. After propensity weighting, patients seen at EDs with these programs spent about seven and a half more days alive and at home over the following year, with roughly half of that gain coming from fewer days in long-term care. They also had fewer return ED visits, although their index length of stay and admission rates were higher. This is observational, and sites with these programs may differ in ways weighting cannot capture, but the authors argue it supports continued investment in geriatric ED models aimed at delaying institutionalization.

Our final theme covers symptom control and toxicology. O'Brien and colleagues, also in Academic Emergency Medicine, used the TriNetX network to compare treatments for suspected cannabinoid hyperemesis syndrome [8]. After matching, both haloperidol and droperidol roughly halved the odds of a return ED visit within 72 hours compared with ondansetron, with return rates of about 8 percent versus 15 percent for haloperidol, while the two butyrophenones did not differ from each other. Coded adverse events were rare. This is retrospective and diagnosis-code based, so the authors frame it as support for prospective trials rather than a settled answer, though it aligns with growing clinical experience. On analgesia, Fida and colleagues in the Journal of Emergency Medicine pooled ten randomized trials of about 1,160 adults and children comparing intranasal opioids with intravenous morphine for moderate-to-severe acute pain [9]. Pain reduction at 20 and 30 minutes was essentially identical, rescue analgesia needs were the same, and there was no clear difference in adverse events, apart from a borderline increase in altered taste. The evidence supports intranasal opioids as a comparable option when intravenous access is delayed, though the trials were small and rare serious harms remain uncertain. Finally, Blumenberg and colleagues in Annals of Emergency Medicine address an emerging toxicologic scenario: unintended exposure to medical aid in dying drug mixtures, as these medications become more available in homes across the United States [10]. The mixtures typically combine sedatives, opioids, and cardiotoxins such as digoxin, beta-blockers, or tricyclic antidepressants, and a partial dose may be survivable. The authors propose preliminary management principles including early poison center involvement, serum digoxin and serial electrocardiograms, digoxin immune Fab when indicated, high-dose insulin for propranolol, bicarbonate for tricyclic QRS widening, and avoidance of flumazenil and naloxone in mixed ingestions. These are expert recommendations, not tested protocols.

If you only have time for one paper this week, make it the Dutch prehospital ECPR study in the New England Journal of Medicine [1]. Alongside a large negative trial of community interventions, it reopens the question of where the next real gains in refractory cardiac arrest survival are likely to come from, even though the nonrandomized design means a randomized answer is still needed.

That's your roundup for This Week in Emergency Medicine. The full transcript and references are available on the episode page. See you next week.

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