This Week in Emergency Medicine — Sep 15, 2026

Welcome to This Week in Emergency Medicine. This week we're covering 10 notable papers spanning resuscitation science and the cardiac arrest chain of survival, prehospital systems of care including paediatric transfusion and quality metrics, and the bread-and-butter diagnostics of infection and poisoning. Let's dive in.

We'll start with cardiac arrest, where three papers this week look at different links in the chain. The headline comes from Resuscitation, where Holmberg and colleagues pooled individual participant data from two randomised trials comparing an intraosseous-first with an intravenous-first vascular access strategy in out-of-hospital cardiac arrest, covering just over 7,500 patients [1]. There was no statistically significant difference in thirty-day survival, and none in favourable neurological outcome. For sustained return of spontaneous circulation the point estimate drifted slightly in favour of intravenous access, but that too was not statistically significant, and the Bayesian analysis suggested a high probability that whatever difference exists between the two routes is small. Certainty of evidence was moderate for survival and low for the other outcomes. The practical reading is permissive rather than prescriptive: use the route your team can establish fastest and most reliably, because the data do not support insisting on one over the other.

Upstream of the drug route, a second Resuscitation paper reminds us that the bigger wins are still on the telephone. Boberg and colleagues transcribed emergency calls from five Swedish cardiac arrest studies and linked them to the national resuscitation registry, looking specifically at what goes wrong after the dispatcher has already recognised arrest [2]. Across more than three thousand confirmed arrests, close to half OF CALLS contained at least one barrier — most commonly the caller being physically unable to move the patient, which accounted for well over half OF BARRIER-PRESENT CALLS, along with callers not being with the patient, hanging up, language barriers, distress, or outright refusal. Barrier-free calls reached bystander CPR initiation of about 85 percent; calls with three or more barriers stayed below half. And these weren't just process measures — barriers were associated with lower rates of return of spontaneous circulation and with thirty-day survival cut by roughly 40 percent. That's a much larger signal than anything in the access-route debate, and it points at dispatcher training, scripting for moving patients off beds and sofas, and interpreter access as high-yield targets.

The third arrest paper, in Prehospital Emergency Care, looked at the handover itself. Myers and colleagues reviewed defibrillator recordings from thirty-five adult non-traumatic arrests transported to a single tertiary emergency department, comparing paramedic baseline, pre-transition, post-transition and emergency department baseline intervals [3]. Reassuringly, chest compression fraction stayed guideline-compliant throughout, in the high eighties to low nineties percent, with no deterioration across the handover, and compression rate stayed within range as well. The one signal was depth: compressions were on target during the paramedic phases at around 5.8 to 5.9 centimetres, but significantly deeper in the emergency department, reaching 6.8 centimetres — beyond guideline targets. It's a small single-centre study, but it inverts the usual worry. The handover isn't where quality falls apart; the issue may be enthusiastic over-compression once the hospital team takes over, which is an easy thing to feed back with real-time depth monitoring.

Our second theme is prehospital systems, and Prehospital Emergency Care dominates here. Magill and colleagues ran a modified Delphi process with a twenty-member multidisciplinary panel of paediatric surgeons, paediatric emergency physicians and emergency medical services physicians, working through 208 candidate items over six rounds to define who should get prehospital blood in children [4]. They landed on thirty-five recommendations built around a three-part gate: known or suspected severe haemorrhage, at least one indicator of shock persisting after first-line haemorrhage control, and clinician judgement that transfusion is needed. Shock indicators include haemodynamic instability, poor perfusion, low cardiac output, or an abnormal validated paediatric shock index. Contraindications were limited to do-not-resuscitate orders prohibiting transfusion and non-haemorrhagic shock. Notably, the panel could not reach consensus on end-tidal carbon dioxide as a transfusion trigger. This is expert opinion, not trial evidence, but it fills a real protocol vacuum.

A companion question is what blood to give, and Yazer and colleagues addressed the Rhesus D anxiety head-on, also in Prehospital Emergency Care [5]. Using an in silico simulation anchored to 957 females of childbearing potential transfused with RhD-positive products in the prehospital setting across the United States, they modelled downstream haemolytic disease of the fetus and newborn. The peak risk for a woman of unknown RhD type was about 0.8 percent, occurring between ages eighteen and twenty. Across the whole transfused cohort, the modelled yield was roughly one case every two to eighty years depending on geographic region, driven by the relatively advanced maternal age of those transfused and the low probability of being RhD-negative. In other words, withholding urgent RhD-positive blood from a haemorrhaging woman to protect a future pregnancy is trading a near-certain immediate risk for a very small future one.

Two further prehospital papers address quality infrastructure. Martin-Gill and colleagues performed their biennial systematic review of evidence-based guidelines for prehospital care, identifying seventy-one new guidelines published between 2023 and 2025 [6]. Most addressed clinical rather than operational topics, with a heavy concentration on time-critical conditions. About half OF THESE GUIDELINES met all adapted National Academy of Medicine criteria for high quality, and the great majority of those were compilations relating to resuscitation, emergency cardiovascular care and trauma — meaning quality remains patchy outside the resuscitation space. And Burnett and colleagues examined a concrete safety measure: weight documentation before weight-based drug administration in children [7]. Across more than fifty-seven thousand paediatric nine-one-one responses in a national dataset, just under three quarters had a documented weight or length-based estimate. Documentation was less likely in adolescents, in lower-acuity cases, and in patients described as Black, and more likely with advanced life support units — roughly double the odds. That racial disparity in a basic paediatric safety process deserves attention.

Our final theme is diagnosis at the bedside. The BMJ published a clinical review by Long and colleagues on skin and soft tissue infections, reinforcing that laboratory testing adds little in most patients and that point-of-care ultrasound is the tool of choice when you can't tell cellulitis from abscess [8]. Abscess management remains incision and drainage, with antibiotics reserved for selected patients; non-purulent cellulitis is still streptococcal until proven otherwise, treated with penicillin, dicloxacillin or a cephalosporin, plus limb elevation and anti-inflammatories. Decolonisation for recurrent disease remains contested. Pairing with that, a prospective observational study in the American Journal of Emergency Medicine by Zotti and colleagues enrolled 244 emergency department patients with sepsis, half OF THEM carrying indwelling medical devices [9]. Multidrug-resistant organisms turned up in about a third OF CASES overall, and device presence roughly doubled the odds of isolating one, independent of other factors. Importantly, devices were not independently associated with in-hospital mortality — age and septic shock drove death — but resistant organisms did mean longer stays and longer antibiotic courses. The message is empiric-therapy calibration, not prognostic alarm. Finally, Nature Reviews Disease Primers published a comprehensive primer on toxidromes by Roberts and colleagues, a useful refresher on recognising opioid, sympathomimetic, serotonergic, antimuscarinic, muscarinic and nicotinic patterns, plus less classical syndromes including bradycardia with hypotension, knockdown, neuroleptic malignant syndrome and uncoupling of oxidative phosphorylation — and on the complexity of overlapping toxidromes after polysubstance exposure [10].

If you only have time for one paper this week, make it the individual participant data meta-analysis on intraosseous versus intravenous access in cardiac arrest [1]. It settles a question that has consumed a lot of resuscitation bandwidth and frees you to choose whichever route gets drugs in fastest in front of you.

Here are the key takeaways from this week in Emergency Medicine. First, intraosseous and intravenous first-line access in out-of-hospital cardiac arrest perform comparably — pick speed and reliability over dogma. Second, the far larger survival lever sits in the dispatch centre, where barriers after arrest recognition are common and associated with markedly worse survival. Third, compression quality survives the paramedic-to-emergency-department handover, but hospital teams may push too deep. Fourth, in haemorrhaging girls and women of childbearing potential, the modelled future risk from RhD-positive prehospital blood is very low and should not delay transfusion. Fifth, an indwelling device in a septic emergency department patient roughly doubles the odds of a resistant organism, which should shape your empiric antibiotic choice even though it doesn't predict death. And sixth, weight documentation before paediatric drug dosing is missing in about a quarter of prehospital cases, with troubling disparities by age and race.

That's your roundup for This Week in Emergency Medicine. The full transcript and references are available on the episode page in your AudioScholar library. This is an AI-curated summary — for clinical decisions, always consult primary sources and current guidelines. See you next week.

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This is an automated summary generated by artificial intelligence, which can make mistakes. Always review the original source materials.