Messous S, Toumia M, Dhaoui R
… +19 more, Ali KBH, Sekma A, Yaakoubi H, Jaballah R, Boukadida L, Zorgati A, Ben Soltane H, Mezgar Z, Khrouf M, Dlala I, Bettout S, Sghaier A, Jerbi N, Chaka A, Grissa MH, Boubaker H, Boukef R, Msolli MA, Nouira S
Ann Emerg Med
· 2026 May · PMID 42138680
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STUDY OBJECTIVE: The aim of this study was to determine whether intravenous MgSO offers additional analgesic benefit when administered simultaneously with paracetamol in emergency department patients presenting with acut...STUDY OBJECTIVE: The aim of this study was to determine whether intravenous MgSO offers additional analgesic benefit when administered simultaneously with paracetamol in emergency department patients presenting with acute nontraumatic headache. METHODS: In this randomized, double-blind, placebo-controlled clinical trial, adults presenting with acute nontraumatic headache received 1 g of oral paracetamol prior to randomization, then were assigned to receive either 2 g intravenous MgSO in 150 mL saline solution or placebo 150 mL saline solution alone, infused more than 30 minutes. The primary outcome was the treatment success, defined as a ≥30% reduction in the numerical rating s̶cale score at 30 minutes. Secondary outcomes were the need for rescue analgesia, patient satisfaction, and adverse events. RESULTS: We included 506 patients in MgSO group and 522 in placebo group. Success was more frequent in the MgSO (78.9 %) versus placebo group (65.1%) (difference 13.8%; 95% confidence interval [CI] 8 to 19); however, all timed numerical rating s̶cale differences were below the 1.3-point accepted threshold for clinical importance. In the MgSO group, rescue analgesia was required less frequently (7.1% versus 15.3%; difference -8.2%; 95% CI -12 to -4.3), patient satisfaction was greater (91.7% versus 85.1%; difference 6.6; 95% CI 2.7 to 10), and adverse events were more frequent (15.4% versus 11.1%; difference 4.3; 95% CI 0.1 to 8.4). CONCLUSION: Adding intravenous MgSO to paracetamol achieved more frequent success in treating acute nontraumatic headache, but at levels below accepted thresholds for clinical importance. MgSO was associated with less frequent rescue analgesia and a modest increase in mild side effects.
Ebert JP, Huo S, Perrone J
… +13 more, Moon J, Mull NK, Flores EJ, Adams L, Berk A, Dart H, O'Donnell N, Xiong RA, Xu L, Snider C, Chen Z, Epps M, Delgado MK
Ann Emerg Med
· 2026 May · PMID 42138679
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STUDY OBJECTIVE: To examine the effectiveness and implementation of a multicomponent strategy to increase emergency department (ED) initiation of evidence-based treatment for patients with alcohol misuse. METHODS: Settin...STUDY OBJECTIVE: To examine the effectiveness and implementation of a multicomponent strategy to increase emergency department (ED) initiation of evidence-based treatment for patients with alcohol misuse. METHODS: Setting was an academic health system with 6 hospitals. Interventions occurred in the ED at 4 of the hospitals, with the other 2 serving as controls. We launched interventions in 2 phases: (1) ED discharge order set with clinical decision support (May 20, 2024); (2) screening for patient concerns about alcohol use and facilitating treatment conversations (August 21, 2024). Multivariate logistic regression assessed changes relative to baseline in the primary outcome, proportion of ED patients with an alcohol-related discharge diagnosis who were discharged with a naltrexone prescription. A difference-in-difference analysis compared intervention hospitals to controls. RESULTS: Across the 43-month study period, there were 8,909 (2.0%) ED patients discharged with an alcohol-related diagnosis code. At intervention hospitals, there were 13 (0.2%) discharged with a naltrexone prescription at baseline, 18 (2.7%) during phase 1, and 81 (3.2%) during phase 2. At control hospitals, the rate of naltrexone prescribing was flat across these periods (0.0%, 0.0%, and 0.3%, respectively). In the multivariate model, patients with alcohol-related diagnoses at intervention hospitals were more likely to be discharged with naltrexone in phase 1 (odds ratio [confidence interval] = 12.3 [6.0 to 25.7]) and phase 2 (14.6 [8.4 to 27.4]) compared to baseline. The difference-in-difference analysis showed a 2.9% [2.4% to 3.5%] greater absolute increase in naltrexone prescribing among intervention hospitals. CONCLUSION: A triage-based ED protocol that integrated universal screening, electronic health record banners, and clinical decision support increased initiation of naltrexone to treat alcohol misuse and alcohol use disorder.
Ann Emerg Med
· 2026 May · PMID 42138678
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STUDY OBJECTIVE: We sought to compile the reported frequencies of adverse events from studies including ≥250 subjects of pediatric emergency department (ED) ketamine sedation by the intravenous route and determine their...STUDY OBJECTIVE: We sought to compile the reported frequencies of adverse events from studies including ≥250 subjects of pediatric emergency department (ED) ketamine sedation by the intravenous route and determine their variances and pooled estimates. We then inventoried the described predictor variables and estimated their clinical importance. METHODS: Systematic review of studies including ≥250 subjects of children receiving intravenous ketamine in the ED for pediatric procedural sedation published after a 2009 systematic review. RESULTS: We identified 20 qualifying studies totaling 67,871 children. There were no reported patient deaths or permanent adverse outcomes/neurologic deficits. The pooled frequency estimate of other sentinel outcomes (ie, tracheal intubation, neuromuscular blockade, chest compressions, aspiration, vasoactive drugs) was 0.0087% (95% confidence interval 0.003% to 0.020%), or 1 per 11,558 sedation encounters. Serious adverse events (defined as sentinel above plus positive pressure ventilation, oral airway, bolus intravenous fluids, sedation insufficient, escalation of care or hospitalization) were noted in 0.34%, with 3 identified predictors: age ≥10 years, upper respiratory infection, and coadministered opioids. Their magnitude of effect was modest; however, we estimate 1 additional serious adverse event for every 103, 110, and 156 ketamine sedations, respectively. Nonpredictors were American Society of Anesthesiologists physical status and coadministered benzodiazepines. CONCLUSION: In this large systematic review, we found that sentinel adverse events were extremely rare, strongly supporting the safety of ED ketamine for procedural sedation of children. The clinical predictor variables studied showed modest or no association with serious adverse events.
Ann Emerg Med
· 2026 May · PMID 42138676
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Diabetic ketoacidosis is a life-threatening endocrine disorder frequently treated by emergency physicians. However, ketoacidosis variations, such as euglycemic diabetic ketoacidosis and nondiabetic ketoacidosis, can prod...Diabetic ketoacidosis is a life-threatening endocrine disorder frequently treated by emergency physicians. However, ketoacidosis variations, such as euglycemic diabetic ketoacidosis and nondiabetic ketoacidosis, can produce diagnostic uncertainty and delay initiation of appropriate treatment. This case report examines a patient with an unusual presentation of severe hypoglycemic, nondiabetic ketoacidosis requiring insulin.
Ann Emerg Med
· 2026 May · PMID 42138675
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STUDY OBJECTIVE: To evaluate the efficacy of a digital patient decision aid, Sexually Transmitted Infection Check in the Emergency Room (STIckER), in increasing sexually transmitted infection testing among adolescents an...STUDY OBJECTIVE: To evaluate the efficacy of a digital patient decision aid, Sexually Transmitted Infection Check in the Emergency Room (STIckER), in increasing sexually transmitted infection testing among adolescents and young adults in the emergency department (ED). METHODS: We conducted a randomized controlled trial in adult and pediatric EDs at a large urban academic medical center. We randomized health care clinicians to deliver either the STIckER digital decision aid or usual care to sexually active adolescents and young adults patients aged 14 to 24 years. The tool, developed through human-centered design, provided personalized sexually transmitted infection testing recommendations and values clarification exercises via smartphone. The primary outcome was documentation of gonorrhea/chlamydia testing. Secondary outcomes included extragenital testing, patient-reported decisionmaking measures, and implementation. We conducted descriptive statistics of patient-level and health care provider-level outcomes by study arms. We estimated the efficacy of STIckER using log-binomial regression. RESULTS: We randomized 44 health care clinicians and enrolled 139 adolescents and young adult participants (median age 19 years). Participants in the STIckER arm were 1.76 times more likely to receive gonorrhea/chlamydia testing (95% confidence interval, 1.10 to 3.00) and 4.56 times more likely to receive pharyngeal testing (95% confidence interval, 1.30 to 28.66). Participants in the STIckER arm reported greater clarity about testing options and higher satisfaction with ED care. Adolescents and young adults and health care clinicians rated the tool as highly acceptable, appropriate, and feasible. CONCLUSION: A digital, patient-centered decision aid increased sexually transmitted infection testing among adolescents and young adults in the ED. STIckER is feasible for integration into ED clinical workflows and may represent a scalable strategy to expand equitable sexual health screening in acute care settings.
Weekes AJ, Raper JD, Esener D
… +5 more, Davison J, Boyd JS, Nomura JT, Anslip A, O'Connell NS
Ann Emerg Med
· 2026 May · PMID 42132714
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STUDY OBJECTIVE: To compare the strength of association and classification characteristics of the Composite Pulmonary Embolism Shock (CPES) score with the simplified Pulmonary Embolism Severity Index (sPESI) and European...STUDY OBJECTIVE: To compare the strength of association and classification characteristics of the Composite Pulmonary Embolism Shock (CPES) score with the simplified Pulmonary Embolism Severity Index (sPESI) and European Society of Cardiology (ESC) classifications for short-term clinical outcomes. METHODS: We performed a retrospective independent assessment using prospectively collected pulmonary embolism (PE) registry data from 6 academic emergency departments (2016 to 2020). CPES score was calculated when 5 or more of the 6 components were available. Our primary outcome was in-hospital death or clinical deterioration. Secondary outcomes were advanced intervention and 30-day mortality. Associations were assessed with logistic regression; classification characteristics included area under the receiver operating characteristic curve (AUC) and likelihood ratios (LRs). RESULTS: Among 1,731 patients, the primary outcome occurred in 193 (11.1%), advanced intervention in 123 (7.1%), and 30-day mortality in 124 (7.2%). For the primary outcome, CPES score 3 or higher yielded sensitivity 72% and specificity 57% (AUC 0.68) and demonstrated LRs similar to sPESI and ESC. For advanced intervention, CPES showed stronger separation (AUC 0.78), with positive and negative LRs of 2.07 (1.90 to 2.25) and 0.20 (0.12 to 0.33), respectively. For 30-day mortality, AUCs and LRs were similar across tools. Central thrombus was independently associated with advanced intervention (odds ratio, 3.46 [1.49 to 8.93]) but not with the primary outcome; concomitant deep venous thrombosis was not associated with outcomes. CONCLUSION: CPES, sPESI, and ESC showed similar associations and LRs for short-term adverse outcomes. CPES demonstrated stronger separation for advanced intervention use.
Pardos Ríos M, López López CA, Greif R
… +10 more, Guillén Martínez D, Cerezo Espinosa C, Alcázar Artero PM, Garcia-Rubio A, García-Viola A, Garrido-Molina JM, Márquez-Hernández VV, Barcala Furelos R, Martinez-Isasi S, Working Group of School Nurses of Murcia, Spain
Ann Emerg Med
· 2026 May · PMID 42104970
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STUDY OBJECTIVE: To assess the feasibility and community reach of a regional, nurse-led school cardiopulmonary resuscitation (CPR) program using hand-made low-cost manikins, and to quantify the multiplying effect of stud...STUDY OBJECTIVE: To assess the feasibility and community reach of a regional, nurse-led school cardiopulmonary resuscitation (CPR) program using hand-made low-cost manikins, and to quantify the multiplying effect of student-led CPR teaching at home. METHODS: Prospective observational study in public and publicly funded private schools in Murcia, Spain (between June and August 2025). Community school nurses (one per health area; n=9) received standardized preparation and delivered a ∼60-minute basic life support session to intact classes of students aged 10 to 12 years old. Students built a low-cost manikin and were invited to teach CPR to a family member/close contact at home and submit a WhatsApp video. Two independent CPR experts, not involved in training delivery, scored eligible videos using an 11-item checklist (total 0 to 11); disagreements were resolved by consensus. Primary outcomes were school reach and multiplying effect (home trainees per participating student); secondary outcomes included video-based CPR performance scores. RESULTS: Nurses trained 1,047 students. The at-home activity was completed by 472/1,047 students (45.1%; 95% confidence interval [CI] 42.1 to 48.1), who trained 1,136 family members/close contacts (multiplying effect 2.41 per student; 95% CI 2.27 to 2.55). Of 1,136 submitted videos, 489 were analyzable (43.0%; 95% CI 40.2 to 45.9). Trainees achieved a mean total performance score of 7.8/11 (95% CI 7.63 to 7.97), with higher scores for recognition/activation and chest compressions than for automated external defibrillator request/simulated use. CONCLUSION: A community-nurse-delivered school CPR program using a low-cost manikin was feasible and produced a substantial home-training multiplier. Video-assessed performance of key basic life support steps was generally adequate, whereas automated external defibrillator-related actions were weaker.
Guo L, Zhang J, Tang G
… +6 more, Wang J, Yang S, Li C, Liu Y, Xiang Y, Guo F
Ann Emerg Med
· 2026 May · PMID 42084585
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STUDY OBJECTIVE: The optimal out-of-hospital referral pathway for patients with acute ischemic stroke due to large vascular occlusion (AIS-LVO)-direct transport to a comprehensive center (mothership) versus initial evalu...STUDY OBJECTIVE: The optimal out-of-hospital referral pathway for patients with acute ischemic stroke due to large vascular occlusion (AIS-LVO)-direct transport to a comprehensive center (mothership) versus initial evaluation at a local hospital followed by transfer (drip-and-ship)-remains controversial. This systematic review and meta-analysis aimed to evaluate the comparative effectiveness of mothership and drip-and-ship strategies on clinical outcomes. METHODS: We searched PubMed, Embase, Web of Science, and the Cochrane Library from inception to March 18, 2025, to identify studies comparing mothership and drip-and-ship paradigms in AIS-LVO patients treated with mechanical thrombectomy. Random-effects meta-analyses were conducted to calculate pooled odds ratios (ORs) for primary outcomes, including 90-day modified Rankin Scale (mRS) 0 to 2, 90-day mRS 0 to 3, successful recanalization, symptomatic intracranial hemorrhage, and 90-day mortality. RESULTS: A total of 42 studies comprising 25,005 patients were included. Clinically, mothership was associated with an increased likelihood of achieving 90-day mRS 0 to 2 (OR 1.15, 95% confidence interval [CI] 1.03 to 1.29, I=53%). However, no differences were observed for 90-day mRS 0 to 3 (OR 1.12, 95% CI 0.97 to 1.29; I=52%), successful recanalization (OR 1.03, 95% CI 0.90 to 1.18; I=60%), symptomatic intracranial hemorrhage (OR 0.84, 95% CI 0.69 to 1.02; I=22%), and 90-day mortality (OR 0.99, 95% CI 0.85 to 1.15; I=60%). CONCLUSION: The mothership strategy may improve 90-day mRS 0 to 2 compared with the drip-and-ship, whereas no significant differences were observed in broader functional outcomes, recanalization rates, hemorrhagic complications, or mortality.
Lee S, Gunaga S, Liu SW
… +4 more, Luo Q, Bayer TA, Rudolph JL, Carnahan RM
Ann Emerg Med
· 2026 May · PMID 42084584
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STUDY OBJECTIVE: Emergency department (ED) boarding, defined as the time an admitted patient remains in the ED awaiting an inpatient bed, has become a growing challenge in the United States, particularly for older adults...STUDY OBJECTIVE: Emergency department (ED) boarding, defined as the time an admitted patient remains in the ED awaiting an inpatient bed, has become a growing challenge in the United States, particularly for older adults with Alzheimer's disease-related dementia. We examined trends in ED boarding from 2015 to 2022, focusing on geographic variation, rurality, and differences by Alzheimer's disease-related dementia status. METHODS: We conducted a cross-sectional analysis using National Hospital Ambulatory Medical Care Survey (NHAMCS) data from 2015 to 2022. Adults aged ≥65 years who were admitted to the hospital were included. Weighted estimates characterized annual boarding rates (≥2, 4, and 8 hours). Linear probability models assessed associations of study year, region, rurality, and Alzheimer's disease-related dementia status with boarding as binary outcomes; linear regression examined boarding duration in minutes. RESULTS: Among an estimated 7.05 million eligible encounters, 4.45 million had complete data; 85.2% experienced boarding ≥2 hours. Rates remained in the mid-80% range from 2015 to 2018, dipped in 2017 and 2020, and rose to 92% in 2021 to 2022. Mean boarding time increased from 138 minutes (95% confidence interval [CI] 112 to 164) in 2018 to 343 minutes (95% CI 238 to 448) in 2022, reaching 501 minutes (95% CI -20 to 1,022) among patients with Alzheimer's disease-related dementia. Each additional calendar year was associated with a 3.2% increase in 4-hour boarding (95% CI 2.4% to 4.0%) and 15.3 more minutes of boarding time (95% CI 10.0 to 20.0). In the Alzheimer's disease-related dementia subgroup, boarding increased most among those aged ≥75 years and in metropolitan areas. CONCLUSION: Emergency department boarding among older adults has worsened over time, especially for those with Alzheimer's disease-related dementia. Regional disparities and disproportionate impacts on vulnerable populations highlight the urgent need for targeted policy and operational interventions.
Amagasa S, Iwamoto S, Okubo M
… +5 more, Utsumi S, Kashiura M, Yasuda H, Kishihara Y, Uematsu S
Ann Emerg Med
· 2026 May · PMID 42084583
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STUDY OBJECTIVE: Adult evidence for extracorporeal cardiopulmonary resuscitation (ECPR) is substantial, but to our knowledge, comparative studies for pediatric out-of-hospital cardiac arrest (OHCA) are lacking. We compar...STUDY OBJECTIVE: Adult evidence for extracorporeal cardiopulmonary resuscitation (ECPR) is substantial, but to our knowledge, comparative studies for pediatric out-of-hospital cardiac arrest (OHCA) are lacking. We compared outcomes of pediatric OHCA with ECPR versus continued cardiopulmonary resuscitation (CPR). METHODS: We conducted a retrospective cohort study of patients <18 years from a multicenter Japanese OHCA registry (2014 to 2022) transported to pediatric ECPR-capable institutions. Exposure was ECPR initiation versus continued CPR among patients at risk for ECPR (no ECPR yet; could receive ECPR later). Outcomes were one-month survival and favorable neurologic outcome (Pediatric Cerebral Performance Category 1 to 3). We applied risk-set matching with time-dependent propensity scores, using full matching with up to 4 controls per case. RESULTS: Of 799 patients, 27 received ECPR; 1:4 matching yielded 108 at-risk controls. ECPR patients were adolescents (median 14 years), witnessed arrest (70.4%), cardiogenic (74.1%); patient characteristics were similar after matching. In patients receiving ECPR versus controls, 1-month survival was 25.9% (7/27) versus 11.1% (12/108) (risk difference 17.3%; 95% confidence interval [CI], -0.9 to 35.6; risk ratio, 3.56; 95% CI, 1.37 to 9.28) and favorable neurologic outcome was 18.5% (5/27) versus 6.5% (7/108) (risk difference 13.9%; 95% CI, -2.9 to 30.8; risk ratio, 3.78; 95% CI; 1.19 to 11.99). CONCLUSIONS: Compared with continued conventional CPR among at-risk patients, ECPR might be associated with improved patient outcomes after pediatric OHCA, but the precision of estimates was limited, with wide confidence intervals. Interpretation is limited by the residual confounding inherent to an observational design; our findings can inform randomized trials of pediatric ECPR.