Dogmalysis

Swapping the lab hs-troponin I for a bedside version, with the same pathway, cut ED stays across six NZ departments: 30 minutes excluding the non-randomised site, 47 minutes overall (−13%, calendar-time adjusted). 30-day MI or cardiac death after discharge was 0.39% in both arms, but with no noninferiority margin. We cover the appeal to ignorance, the base-rate case for speed, industry ties, and guidance catching up rather than dogma falling.

Stewart's model treats CO2 and the strong ion difference as independent. A BJA study of 263 apnoea tests shows acute hypercapnia raises SID by about 1.2–1.5 mmol/L per 0.1 fall in pH, mostly through sodium. Standard base excess largely stays put, though that rests on experimental and in vitro data. We cover reification, the false dilemma of acid–base "tribes", a bedside correction tested only on its authors' own data, and a first look at Dr Haydon's "Beyond pH" method ahead of an interview episode.

PRAGUE-26 tests catheter-directed alteplase on top of anticoagulation, and most of its benefit is in soft, unblinded decompensation outcomes. But does the anticoagulation itself work? We go back to Barritt 1960, look at the closest proximal DVT trial, and find that the placebo-controlled evidence prevents recurrence (not death). For calf clots and a lone subsegmental PE, watching is a real option.

For years, null trials of intermittent haemodialysis versus CRRT were read as proof the two are interchangeable. ICRAKI, a French trial in ventilated or shocked patients with AKI, failed to show intermittent dialysis noninferior. Day-90 mortality was higher, but the trial stopped early with no prespecified decision rule. We unpack the appeal to ignorance, truncation bias and HARKing, why the direction is more credible than the size, and why it supports the CRRT-first default in ANZ ICUs.

'Paediatric PE is too rare to need a rule' uses the wrong base rate: about 6% of children who are worked up for it have it. BEEPER, a prospective study of nearly 4,000 children, found that a negative PERC-Peds (with gestalt under 15%) missed 1 in 734, and PERC-Peds then D-dimer ruled out 54.3% of children, just inside a 1.5% test threshold. Why adult rules don't transfer, why D-dimer alone isn't enough, and why this is evidence about adolescents.

Many of us were taught to add vasopressin early, at a low noradrenaline dose, to spare catecholamines and save kidneys. VASSPR, a trial of nearly 4,000 patients in JAMA this month, compared starting it at 0.1 vs 0.4 µg/kg/min and found no difference in mortality or kidney outcomes. We trace the belief back to a VASST subgroup that didn't survive testing and to confounded observational signals, and land on vasopressin as a reasonable second pressor where timing isn't the lever.

Why an accurate AI tool isn't automatically a useful one in the emergency department. Teaching content only, not clinical advice.

Oxygen and temperature targets after ROSC: what the trials actually show. Teaching content only, not clinical advice.

Does bicarbonate help in cardiac arrest and shock, or are we treating a number? Teaching content only, not clinical advice.

Fluids first or early vasopressors in septic shock? We test the dogma against the evidence. Teaching content only, not clinical advice.