J Emerg Med
· 2026 Mar · PMID 41610792
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BACKGROUND: Focused transthoracic echocardiography (TTE) during cardiopulmonary resuscitation (CPR) is a useful tool for the identification of reversible causes of cardiac arrest. Recent evidences also indicated a predic...BACKGROUND: Focused transthoracic echocardiography (TTE) during cardiopulmonary resuscitation (CPR) is a useful tool for the identification of reversible causes of cardiac arrest. Recent evidences also indicated a predictive function of focused TTE in distinguishing patients for whom resuscitation efforts may be futile. OBJECTIVES: The aim of this systematic review and meta-analysis is to evaluate the diagnostic accuracy of cardiac standstill, irrespective of the etiology and of presentation rhythm cardiac arrest, in identifying patients who are unlikely to achieve return of spontaneous circulation (ROSC). METHODS: Population: we included adult patients (age ≥16 years) affected by either nontraumatic or traumatic cardiac arrest, with no restrictions regarding the setting. INDEX TEST: performance of focused TTE during CPR, assessing the presence or absence of any wall or valve movement (cardiac standstill). Target condition: ROSC after cardiac arrest. We defined "Disease Positive" as death (ROSC-) and "Disease Negative" as ROSC achievement (ROSC+). RESULTS: A total of 24 studies comprising 3684 patients were included. The pooled sensitivity and specificity of the cardiac standstill in predicting the absence of ROSC were 0.856 (95% CI 0.789-0.904) and 0.790 (95% CI 0.671-0.874), respectively. The calculated diagnostic odds ratio was calculated as 22.595 (95% CI 12.452-40.999). The summary receiver operating characteristic curve showed an area under the curve of 0.871 (95% CI 0.836-0.909), indicating a good diagnostic accuracy. CONCLUSION: Cardiac standstill has demonstrated considerable sensitivity, specificity, and odds ratio in predicting unsuccessful CPR.
Ting MJ, Hsieh CC, Yang HY
… +2 more, Jaw FS, Chen PC
J Emerg Med
· 2026 Feb · PMID 41581298
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BACKGROUND: Early risk stratification in ST-segment elevation myocardial infarction (STEMI) remains challenging. The Hypoxia-Age-Shock Index (HASI), incorporating SpO₂, age, heart rate, and systolic blood pressure, offer...BACKGROUND: Early risk stratification in ST-segment elevation myocardial infarction (STEMI) remains challenging. The Hypoxia-Age-Shock Index (HASI), incorporating SpO₂, age, heart rate, and systolic blood pressure, offers improved prediction over traditional indices but may benefit from machine learning (ML) and environmental data. OBJECTIVES: To compare HASI with established shock indices for mortality prediction in STEMI triage and assess whether adding machine learning and ambient NOx data improves early risk assessment. METHODS: We retrospectively analyzed 711 STEMI patients. HASI was compared with the Shock Index (SI) and Age-Adjusted Shock Index (ASI) for predicting in-hospital mortality. ML models (logistic regression, random forest, support vector machine, XGBoost) were developed using HASI variables. Ambient nitrogen oxides (NOx) data were matched to emergency department arrival times. Model performance was evaluated using area under the receiver operating characteristic curve (AUC), sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and area under the precision-recall curve (AUPRC). SHapley Additive exPlanations (SHAP) analysis assessed variable importance. RESULTS: Among 711 STEMI patients, 41 (5.8%) died during hospitalization and 77 (10.8%) underwent endotracheal intubation. HASI outperformed both SI and ASI (AUC: 0.747 vs. 0.628 and 0.700; p < 0.05). The application of machine learning further improved predictive performance, with the random forest model achieving an AUC of 0.961 and sensitivity of 0.750. Incorporating ambient NOx further enhanced prediction, increasing the AUPRC to 0.907 and the XGBoost sensitivity to 0.833. NOx ranked third in feature importance. CONCLUSIONS: HASI, combined with ML and ambient NOx exposure, provides a rapid and interpretable tool based on SHAP analysis for transparent feature contribution and early mortality risk assessment in STEMI triage.
J Emerg Med
· 2026 Feb · PMID 41581297
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BACKGROUND: Scalp necrotizing fasciitis (NF) is an exceptionally rare and potentially fatal soft-tissue infection. Early recognition of the condition is challenging in cases where classical skin changes are absent. CASE...BACKGROUND: Scalp necrotizing fasciitis (NF) is an exceptionally rare and potentially fatal soft-tissue infection. Early recognition of the condition is challenging in cases where classical skin changes are absent. CASE REPORT: A 59-year-old male patient suffering from diabetes mellitus presented with a foul-smelling purulent discharge from a scalp wound that had been sutured ten days prior following a fall from a height of three meters. Notwithstanding the absence of necrosis, bullae, or crepitus, laboratory tests demonstrated leukocytosis (white blood cells [WBC] 16,120/µL) and elevated C-reactive protein (337 mg/L). Cranial Computed Tomography (CT) revealed diffuse subcutaneous emphysema and fascial thickening extending from the frontal to occipital region. The surgical exploration was performed in an urgent manner, which resulted in the exposure of necrotic fascia with purulent exudate. Subsequent histopathological analysis provided definitive confirmation of NF. The presence of polymicrobial infection involving Acinetobacter spp. and Staphylococcus aureus was identified. Following comprehensive debridement and the administration of broad-spectrum antibiotics, the patient exhibited a complete recovery. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: NF of the scalp can present deceptively, with normal-appearing skin despite deep fascial necrosis. The presence of subcutaneous gas on imaging in patients with diabetes who have sustained trauma should prompt immediate surgical consultation. It is imperative to recognize that early suspicion and multidisciplinary action can be life-saving.
Altun M, Kudu E, Yakin F
… +5 more, Korgan MB, Unal E, Demir O, Karavin EO, Akoglu H
J Emerg Med
· 2026 Feb · PMID 41581296
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BACKGROUND: Emergency department (ED) crowding is a major operational problem driven by access block. Transition units (TUs) have been proposed to mitigate boarding delays, but their quantitative impact remains insuffici...BACKGROUND: Emergency department (ED) crowding is a major operational problem driven by access block. Transition units (TUs) have been proposed to mitigate boarding delays, but their quantitative impact remains insufficiently characterized. OBJECTIVES: To evaluate the effect of implementing medical and surgical TUs on ED crowding, measured by the National Emergency Department Overcrowding Scale (NEDOCS). METHODS: This single-center prospective study evaluated crowding in a tertiary academic ED before and after TU implementation. NEDOCS scores were prospectively measured 6 times daily between April 23 and May 31, 2025, when both medical and surgical TUs were fully operational. Data from identical calendar periods in 2021 (pre-TU) and 2023 (medical TU only) served as comparators. The primary outcome was the NEDOCS score; secondary outcomes were NEDOCS parameters and categorical level distributions. RESULTS: The median NEDOCS score in 2025 was 85.6 (IQR 66.2-117.0), significantly lower than 2021 (137 [IQR 114.0-173.0]) and 2023 (132 [IQR 108.0-181.0]) (both p < 0.001). Overcrowded or worse conditions (Levels IV-VI) decreased from 81.5% (2021) and 80.6% (2023) to 38.4% (2025) (p < 0.001). Boarding numbers and longest boarding times also fell significantly, whereas overall patient inflow to the ED remained comparable across years. CONCLUSIONS: Implementation of dual TUs was associated with substantial reductions in ED crowding severity, as reflected by lower NEDOCS scores and improved operational metrics. Expanding TU capacity across specialties is an effective structural strategy to relieve access block in high-volume EDs.
J Emerg Med
· 2026 Feb · PMID 41579845
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BACKGROUND: In emergency medicine, the belief that some physicians are "Black Clouds" consistently facing heavier workloads, while others are "White Clouds" experiencing lighter shifts, persists despite limited scientifi...BACKGROUND: In emergency medicine, the belief that some physicians are "Black Clouds" consistently facing heavier workloads, while others are "White Clouds" experiencing lighter shifts, persists despite limited scientific validation. OBJECTIVE: This study aimed to evaluate whether these reputational labels correspond to measurable differences in clinical workload. METHODS: A retrospective observational study was conducted in a tertiary emergency department with an average of 830 daily visits. Physicians with at least 6 months of service were surveyed to identify peers as "luckiest" (White Clouds) and "unluckiest" (Black Clouds), resulting in four physicians per group. Duty rosters over 6 months were classified as black, white, or gray days depending on on-duty combinations. Objective parameters-including patient volume, red triage cases, admissions, cardiopulmonary resuscitations, trauma cases, and deaths-were extracted from electronic records and statistically compared. RESULTS: A total of 156 shifts were analyzed: 57 white, 51 gray, and 48 black days. Mean daily patient volume was slightly lower on black days (814.31 ± 8.90) compared to white (825.91 ± 9.10) and gray (829.09 ± 10.24), though not statistically significant (p = 0.429). No significant differences were found in red triage patients, admissions, intensive care unit (ICU) admissions, resuscitations, trauma cases, or deaths across groups. CONCLUSION: The study found no statistically significant differences between Black Cloud and White Cloud shifts. These labels appear to reflect subjective perception rather than objective workload, underscoring the need to address cultural superstitions in emergency medicine to reduce stigma and support physician well-being.
Chandelia S, Sahu P, Kaushik S
… +3 more, Kumar N, Makol J, Tandon D
J Emerg Med
· 2026 Feb · PMID 41579844
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BACKGROUND: A successful cardiopulmonary resuscitation (CPR) requires quality chest compressions (CCs). Use of a step stool during CPR might improve CC quality, though there is no consensus. OBJECTIVES: To analyze the ef...BACKGROUND: A successful cardiopulmonary resuscitation (CPR) requires quality chest compressions (CCs). Use of a step stool during CPR might improve CC quality, though there is no consensus. OBJECTIVES: To analyze the effects of a rescuer using a step stool on CC during CPR. METHODS: We conducted a systematic review and searched five databases (PubMed, Embase, Cochrane, Web of Science, and Scopus). Two independent authors did screening, data extraction, risk of bias, and GRADE (Grading of Recommendations, Assessments, Development, and Evaluation) assessment. Random effects model was used for data analysis. Risk of bias was assessed using theCochrane tools (RoB 2 for randomized and ROBINS-1 V2 for nonrandomized studies. RESULTS: Six studies (four adult and two pediatric) were included in the meta-analysis. Most domains in studies were at serious risk of bias. Overall, using a step stool during CPR may slightly increase depth of CC (mm) (mean difference [MD], 95% confidence interval [CI]; 2.74, 1.26-4.21; p < 0.0003; I = 35%; low certainty); pediatric (MD 1.63, 95% CI 0.33-2.93; p = 0.01; I = 24%; low certainty); adult (MD 4.24, 95% CI 2.18-6.31; p = 0.0001; I = 0%; low certainty). Overall, using a step stool may slightly increase CC rates toward 120/min (MD 2.97, 95% CI 0.74-5.20; p = 0.009; I = 49%; low certainty); adult (MD 5.61, 95% CI 3.0-8.22; p = 0.0001; I = 0%; low certainty); but in children effects are uncertain (MD 1.30, 95% CI (-1.52-4.12; p = 0.37; I = 69%; very low certainty). Effects on chest recoil (MD 0.18, 95% CI 0.04-0.32; p = 0.01; I = 0%; two studies; very low certainty) and angle between rescuer and manikin (MD 10.43, 95% CI 8.14-12.72; p = 0.0001; I = 0%; one study; very low certainty) are very uncertain. Minimized interruption and excessive ventilation were not reported in any studies. CONCLUSION: Low certainty evidence suggests rescuer use of a step stool may slightly increase depth and rate of CCs in simulation set-up, with unclear clinical implications. Effects of using a step stool on chest recoil, angle between the rescuer and manikin, duty cycle, minimized interruption, and excessive ventilation are very uncertain in view of very low certainty/no evidence.
Altundağ I, Doğruyol S, Yavuz BG
… +2 more, Afacan MA, Çolak Ş
J Emerg Med
· 2026 Feb · PMID 41576782
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BACKGROUND: Radial arterial blood gas (ABG) sampling is a common but painful procedure essential for assessing critically ill patients. Effective pain control is vital for patient comfort and procedural success. OBJECTIV...BACKGROUND: Radial arterial blood gas (ABG) sampling is a common but painful procedure essential for assessing critically ill patients. Effective pain control is vital for patient comfort and procedural success. OBJECTIVE: This study aimed to compare the analgesic efficacy of topical 10% lidocaine and 1% diclofenac sprays versus placebo in alleviating pain during radial ABG sampling. We also explored perfusion index (PI) as an objective pain assessment tool. METHODS: This randomized, double-blind, placebo-controlled study was conducted in the emergency department. A total of 150 patients undergoing radial ABG sampling were randomly assigned to three groups: placebo (n = 50), 10% lidocaine (n = 50), and 1% diclofenac (n = 50). Baseline perfusion index (PI) was recorded, sprays applied, and a 10-min waiting period followed. After ABG sampling, post-procedure measurements were obtained, including PI and pain intensity assessed using the Visual Analog Scale (VAS). Analgesic effects were compared based on VAS scores and changes in PI (ΔPI and %ΔPI). RESULTS: The mean post-procedure VAS scores were 4.18 ± 2.09 (lidocaine), 4.80 ± 2.70 (diclofenac), and 4.90 ± 2.59 (placebo), with no significant differences between groups (p = 0.292). As a secondary finding, a moderate positive correlation was observed between VAS scores and %ΔPI (r = 0.379, p < 0.001). PI significantly decreased in all groups after ABG sampling, but no significant differences were observed among groups. CONCLUSION: Topical 10% lidocaine and 1% diclofenac sprays did not provide significant pain relief compared to placebo. Although a moderate correlation between VAS and PI was observed, further research is needed to establish PI's clinical utility. TRIAL REGISTRATION: ClinicalTrials.gov (NCT06918340).
J Emerg Med
· 2026 Feb · PMID 41576781
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BACKGROUND: Long emergency department (ED) waiting room times are associated with increased morbidity and mortality. STUDY OBJECTIVE: This study sought to determine if sociodemographic disparities exist in ED waiting roo...BACKGROUND: Long emergency department (ED) waiting room times are associated with increased morbidity and mortality. STUDY OBJECTIVE: This study sought to determine if sociodemographic disparities exist in ED waiting room times at a single institution. METHODS: This retrospective observational study was conducted at a single center ED between July 1 and December 31, 2023. The main outcome was door-to-provider (DTP) time. Variables included basic demographic information, ED visit characteristics, social risks, and prior healthcare utilization. Trauma activations and patients who "left without being seen" were excluded. Two separate analyses were conducted: 1) for patients with DTP times of less than or equal to 6 h (n = 34,385), and 2) a comparison of these patients to those with DTP times greater than 6 h (n = 4363). RESULTS: For patients with DTP times less than or equal to 6 h, incidence rates of having a 1 h longer DTP time was greater for females compared to males (incidence rate ratios [IRR] 1.02, 95% confidence interval [CI] 1.01-1.04), Hispanic compared to non-Hispanic patients (IRR 1.02, 95% CI 1.01-1.04), and Black compared to White patients (IRR 1.03, 95% CI 1.01-1.05). Odds of having a DTP time greater than 6 h was higher for females compared to males (odds ratio [OR] 1.14, 95% CI 1.06-1.22), Hispanic compared to non-Hispanic patients (OR 1.26, 95% CI [1.15-1.38), Black compared to White patients (OR 1.35, 95% CI [1.24-1.48), and homeless compared to housed patients (OR 1.46, 95% CI 1.23-1.72). CONCLUSION: This single-center study found that female sex, Hispanic ethnicity, Black race, and homelessness were associated with longer ED wait times.
Thom C, Vo V, Ottenhoff J
… +7 more, Mullins C, Simpson A, Homan S, Kerich L, Ortiz LV, Hamza D, Jarrett P
J Emerg Med
· 2026 Feb · PMID 41564563
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BACKGROUND: Plain radiography traditionally serves as the first-line imaging modality for extremity injuries. However, x-rays have limitations in subtle fracture detection and soft tissue visualization. Ultrasound repres...BACKGROUND: Plain radiography traditionally serves as the first-line imaging modality for extremity injuries. However, x-rays have limitations in subtle fracture detection and soft tissue visualization. Ultrasound represents an alternative modality with potential diagnostic benefit but requires substantial operator expertise. OBJECTIVE: We sought to evaluate the image quality and patient comfort associated with a novel volumetric ultrasound system (Accuro XV) that intends to automate imaging acquisition. Scans obtained by clinical research assistants (CRAs) were compared to those obtained by board-certified emergency physicians. METHODS: This was a prospective, multi-site study of patients aged 5 and older presenting with acute ankle or wrist trauma. 205 subjects were enrolled, each undergoing x-ray and Accuro XV imaging. Pain levels were assessed using a Numerical Rating Scale. Fifty CRA and 50 physician-acquired studies were randomly selected for blinded image quality analysis. RESULTS: There was no significant difference in image quality between CRA and physician groups (mean scores 3.6 vs. 3.7; p = 0.24), with over 90% of studies rated as diagnostically adequate. Interrater reliability amongst reviewers was moderate (intraclass correlation coefficient 0.53-0.56). Pain scores were similar with both showing minimal discomfort (median pain increase during imaging of 0; interquartile range 0-1). CONCLUSION: This study demonstrates the feasibility of high-quality extremity ultrasound imaging using the Accuro XV device, including by nonphysician operators with minimal training. The technology shows potential for broader adoption in acute care with nonphysician operators. Further studies are warranted to evaluate diagnostic accuracy and clinical impact.
Schwei RJ, Shank C, Tsuchida RE
… +5 more, Arias F, Lor M, Shah MN, Wiegmann D, Pulia MS
J Emerg Med
· 2026 Feb · PMID 41564562
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BACKGROUND: Prior studies have found increases in sepsis-related mortality among patients with non-English language preference (NELP) vs. English language preference (ELP) in the inpatient setting, even after controlling...BACKGROUND: Prior studies have found increases in sepsis-related mortality among patients with non-English language preference (NELP) vs. English language preference (ELP) in the inpatient setting, even after controlling for demographic, illness severity, and clinical encounter variables. It is unclear if disparities in sepsis care extend to the emergency department. OBJECTIVE: We compared time to sepsis alert and antibiotics between patients with NELP vs. ELP overall and by emergency severity index (ESI) subgroup. METHODS: In this retrospective observational cohort study, the independent variable was preferred language, and the dependent variables were time to sepsis alert (clinician-initiated vs. automatic) and antibiotics. We developed multivariable adjusted plus inverse probability of treatment weight (IPTW) Cox proportional hazard models. RESULTS: There were no overall differences in the time to sepsis alerts or time to antibiotic administration. In the ESI 2 subgroup, NELP patients had faster time to sepsis alert than ELP patients in clinician-initiated alerts (clinician-initiated: absolute difference: 17 min; covariate +IPTW: HR: 1.76, 99.44% CI 1.22, 2.54, p < 0.001). Within the ESI 3 to 5 subgroup, among patients with a clinician-initiated alert, NELP patients had slower time to sepsis alert than ELP patients (absolute difference: 17 min; covariate +IPTW: HR: 0.64, 99.44% CI 0.44, 0.94, p = 0.012). CONCLUSION: While we found no overall differences in time to sepsis alert, there were significant differences in subgroups, suggesting that language preference may be associated with triage score assignment and sepsis recognition. The lack of differences observed in time to antibiotics underscores the potential for thoughtfully designed best practice alerts to support equitable clinical practice.