A recent Emergency Medicine digest,
as sent to subscribers

Study Type: Practical/procedural guidance (clinical review), not original research.

Key Question: How should emergency thoracotomy be performed in prehospital and ED settings, updated for contemporary practice?

Key Findings:

• Updates the 2005 Wise et al. guide, incorporating refined indications and clearer survival-window criteria based on two decades of accumulated evidence.
• Emphasises improved understanding of traumatic cardiac arrest pathophysiology, alongside human factors, operational safety, and team-based decision-making.
• Provides stepwise procedural detail and troubleshooting guidance aimed at clinicians who perform this intervention infrequently.

Clinical Relevance: Emergency thoracotomy remains a rare but potentially lifesaving intervention in UK trauma networks and HEMS practice; this guide offers a standardised, up-to-date reference to support rapid, safe decision-making when seconds matter.

Limitations: As a narrative practical guide rather than primary research, recommendations are based on expert consensus and experience rather than new comparative data.

Study Type: Systematic review (narrative synthesis) of 10 studies

Key Question: What factors influence paramedics' decisions to convey or not convey acutely unwell children to the emergency department?

Key Findings:

• Three key themes identified: (1) health system context—geography, resource availability, time of day, and family preference; (2) child presentation—vital signs, respiratory distress, acuity, disease progression, and trauma; (3) safety and risk—clinician experience/education, protocol adherence, access to support, and documentation.
• No quantitative pooled effect sizes reported; findings are qualitative/thematic across the 10 included studies.
• Evidence does not clearly support mandatory conveyance nor confirm non-conveyance is safe, despite both occurring routinely.

Clinical Relevance: With NHS ambulance services and EDs under sustained pressure, understanding what drives paediatric conveyance decisions is essential to inform safe, evidence-based non-conveyance pathways and reduce inappropriate ED attendances.

Limitations: Small number of heterogeneous, mostly qualitative studies limits generalisability and precludes firm conclusions on the safety of non-conveyance decisions.

Study Type: Consensus statement (Faculty of Pre-Hospital Care), based on structured evidence review and expert consensus process.

Key Question: How should UK prehospital providers manage suspected crush injury and crush syndrome to reduce preventable morbidity and mortality?

Key Findings:

• Recommendations diverge from previous guidance, tailored specifically to UK prehospital practice context.
• Aggressive prehospital fluid resuscitation is de-emphasised compared with older protocols.
• Concerns regarding hyperkalaemia as a driver of prehospital management decisions are similarly downplayed.

Clinical Relevance: Provides UK-specific, practicable prehospital guidance for a high-stakes, low-frequency presentation (e.g., major incidents, structural collapse), with potential applicability to EM clinicians receiving these patients and to other developed healthcare systems.

Limitations: As a consensus statement rather than primary research, recommendations rely on expert interpretation of existing evidence rather than new clinical outcome data.

Study Type: Systematic short-cut review (BestBETs format)

Key Question: Is intranasal epinephrine as effective as intramuscular epinephrine for achieving rapid symptom control in anaphylaxis?

Key Findings:

• Of 113 papers identified, only 8 addressed clinical outcomes directly; 7 were case series (6 published only as conference abstracts) and 1 was an open-label phase III study.
• 22 additional studies examined pharmacokinetic/pharmacodynamic properties but were excluded from clinical analysis.
• Evidence quality and quantity were insufficient to establish non-inferiority or equivalence to intramuscular epinephrine.

Clinical Relevance: For UK emergency departments, intramuscular epinephrine should remain first-line treatment for anaphylaxis, as current evidence does not support intranasal epinephrine as an alternative delivery route.

Limitations: The evidence base is weak, dominated by unpublished conference abstracts and small case series rather than randomised controlled trials.

Study Type: Planned secondary analysis of a prospective multicentre cohort study (POCCA)

Key Question: Does adding early brain injury biomarkers and neuroimaging to clinical variables improve prediction of 1-year outcome after paediatric cardiac arrest?

Key Findings:

• In the Outcomes Cohort (n=118), adding day-1 biomarkers (NfL, UCH-L1, GFAP, tau) significantly improved model fit over clinical variables alone (LRT p=0.002), but not in the full imputed cohort (p=0.07).
• Best-performing model (penalised regression) achieved optimism-corrected AUROC 0.868 (95% CI 0.82–0.94), with good calibration.
• Adding MRI Injury Score further improved prediction (adjusted OR 1.13, 95% CI 1.03–1.24, p=0.016).

Clinical Relevance: Multimodal prognostic models combining clinical data, blood biomarkers, and MRI could eventually support earlier, more accurate family counselling and shared decision-making after paediatric cardiac arrest in UK PICUs, though not yet ready for bedside use.

Limitations: Findings derive from a single cohort without external validation, and results were inconsistent between the complete-case and imputed datasets, limiting generalisability.

Study Type: Multicentre prospective registry cohort study (German Cardiac Arrest Registry, G-CAR)

Key Question: What are the long-term cognitive, quality-of-life, and psychological outcomes among OHCA survivors at 6 and 12 months post-arrest?

Key Findings:

• Cognitive impairment (Mini-MoCA) persisted in 30.5% at 6 months and 33.6% at 12 months.
• HRQoL (EQ-5D-5L) and social reintegration (RNLI) were generally comparable to age-matched population norms at both time points.
• Psychological distress was mostly low (PTSS-14 below PTSD threshold), but 13% reported abnormal depressive symptoms on HADS.

Clinical Relevance: Highlights the need for structured post-arrest follow-up pathways in UK resuscitation/critical care services, as many survivors—despite good overall recovery—have unrecognised cognitive and mood impairments requiring proactive screening and rehabilitation referral.

Limitations: Substantial loss to follow-up (416 discharged survivors reduced to 307 at 12 months) may introduce selection bias favouring better-recovered patients.

Study Type: Retrospective nationwide registry-based cohort study

Key Question: What are the frequency, procedural success, and outcomes of prehospital emergency cricothyroidotomy in a physician-staffed EMS system, particularly among OHCA patients?

Key Findings:

• 71 cases identified over 8 years (Denmark); overall procedural success 87.3% (83.3% in OHCA vs 95.7% in non-OHCA patients).
• Cricothyroidotomy performed in only 0.12% (48/39,885) of nationwide OHCA cases; ROSC achieved in 25.0%, but 30-day survival only 4.5% and 1-year survival 2.3%.
• Aspiration (32.4%) and oropharyngeal bleeding (33.8%) were the leading indications.

Clinical Relevance: Reinforces that emergency cricothyroidotomy, though rarely needed, is achievable with high success rates in physician-led prehospital systems—relevant to UK HEMS/critical care paramedic teams reviewing rescue airway pathways and training standards.

Limitations: Small sample size (particularly non-OHCA subgroup) limits precision and generalisability of outcome estimates.

Study Type: Retrospective single-centre cohort study

Key Question: Can early dynamic arterial blood gas (ABG) trajectories within the first 24 hours of ICU admission identify distinct phenotypes of acute hypoxaemic respiratory failure (AHRF) with differing 28-day mortality risk?

Key Findings:

• Unsupervised clustering of 2793 AHRF patients identified three phenotypes: Respiratory (n=882), Metabolic (n=683), and Stable (n=1228).
• The Metabolic phenotype (persistent hyperlactataemia, severe oxygenation failure) had the highest 28-day mortality (24%) and remained independently predictive after adjustment (HR 1.38, 95% CI 1.12–1.70, p=0.003).
• Adding phenotype data to APACHE II improved discrimination modestly (C-index 0.657→0.671, p<0.001).

Clinical Relevance: Early ABG trajectory-based phenotyping could refine risk stratification for AHRF patients beyond static scores, potentially informing earlier escalation decisions in UK EDs/ICUs, though implementation would require serial ABG capture and validated clustering tools.

Limitations: Single-centre, retrospective design limits external validity and causal inference; unsupervised clusters require prospective validation before clinical application.