Emergency Medicine

Noninvasive ventilation best limits desaturation during emergency intubation

This network meta-analysis pooled 15 RCTs (2939 critically ill adults) comparing noninvasive respiratory support vs conventional oxygen for emergency intubation preoxygenation. Both high-flow oxygen therapy and noninvasive ventilation increased the lowest achieved SpO2 vs conventional oxygen, with larger improvement for noninvasive ventilation. Noninvasive ventilation also reduced severe desaturation events (SpO2 <80%) without increasing aspiration, hypotension, barotrauma, arrhythmia, or arrest. There were no differences in postintubation gas exchange, mechanical ventilation duration, or mortality across preoxygenation strategies, and overall certainty was low. 1

Etomidate linked to higher mortality than ketamine for ED RSI

This multicenter Brazilian cohort emulated a target trial comparing etomidate vs ketamine for RSI in 1810 critically ill ED adults. Patients receiving ketamine had higher baseline shock indices and more vasopressor use, indicating greater pre-intubation hemodynamic instability. After weighting, etomidate was associated with higher 28-day and 7-day in-hospital mortality compared with ketamine. Ketamine caused more new hemodynamic instability within 30 minutes, but first-pass success and other major adverse events were similar. Findings suggest potential longer-term harm with etomidate despite less immediate hypotension, though residual confounding cannot be excluded. 2

ED ultrasound-guided fascia iliaca blocks cut delirium after hip fracture

In this stepped-wedge cluster RCT across 7 EDs, 694 non-delirious adults ≥65 years with hip fracture were enrolled. A brief, structured training program increased fascia iliaca block use from about 2% to 53% among eligible patients. Implementation reduced delirium incidence within 7 days (adjusted OR 0.72) without changing delirium duration. Blocks were usually effective for pain relief, had median procedure time around 15 minutes, and produced only one minor hematoma. Results support ED-led ultrasound-guided regional anesthesia as a feasible delirium-prevention and analgesia strategy. 3

Switching from hs-cTnI to hs-cTnT increases admissions without outcome benefit

This interrupted time-series study evaluated 25,849 suspected ACS patients before and after a system-wide switch from hs-cTnI to hs-cTnT. After the switch, myocardial injury diagnoses rose from 21% to 38%, and hospital admissions increased markedly (OR 2.24). Serial troponin testing increased about six-fold with hs-cTnT, substantially escalating diagnostic intensity. Despite more testing and admissions, 1-year rates of MI, heart failure, or cardiovascular death were unchanged. Findings suggest assay transitions can drive downstream utilization without clear cardiovascular benefit. 4