Emergency Archives - Broome Docs

Welcome to the June 2026 edition of the podcast. We are tackling all of our favourite subjects – PE, trauma, stroke, COVID, contrast controversies and prehistoric dentistry. What more could you ask for in a podcast? SO have a listen, read the free PDFs below, and you too could save a life or at least relieve your friend’s dental pain with some stone tools.

Butler CC, Pinto AD, Harris V, Holmes J, Rahman NM, Cureton L, Hayward G, Richards DB, Lowe DM, Standing JF, Breuer J, Hood K, Png ME, Petrou S, Dorward J, Patel MG, Thomas NPB, Evans P, Hart ND, Jani BD, Hosseini B, Murthy S, McBrien K, Condon A, McDonald EG, Daley P, Greiver M, da Costa BR, Selby P, Jüni P, Lee TC, Shi H, Detry MA, Saunders CT, Fitzgerald M, Berry NS, Saville BR, Khoo SH, Nguyen-Van-Tam JS, Hobbs FDR, Yu LM, Little P; PANORAMIC Trial and CanTreatCOVID Trial Collaborative Groups. Oral Nirmatrelvir-Ritonavir for Covid-19 in Higher-Risk Outpatients. N Engl J Med. 2026 Apr 23;394(16):1583-1594. doi: 10.1056/NEJMoa2502457. PMID: 42019019

This paper actually describes two separate open-label adaptive platform RCTs: PANORAMIC out of the UK and CanTreatCOVID out of Canada. The trials are pretty similar. If you want the full details you can read Justin’s full rant on here.

Bottom line: Maybe Paxlovid should join Tamiflu on the shelves of the medical misadventure museum?

Lu Y, Guan L, Wu J, Yang Q, Zhang M, Zhou D, Yang H, Pan Y, Wang L, Qiu B, Liu C, Wang Y, Yang Y, Zhou X, Qu H, Liao X, Liu L, Zhao X, Bath PM, Johnston SC, Amarenco P, Turc G, Shi FD, Wang Y, Wang Y; EMPHASIS Investigators. Efficacy and safety of minocycline in patients with acute ischaemic stroke (EMPHASIS): a multicentre, double-blind, randomised controlled trial. Lancet. 2026 Feb 14;407(10529):679-688. doi: 10.1016/S0140-6736(25)01862-8. Epub 2026 Jan 30. PMID: 41628627

So, now acne medication has about the same level of evidence for acute stroke as does tPA?

Bottom line: In this high quality double-blind RCT, minocycline improved functional outcomes from ischemic stroke. 

Broderick JP, Naidech AM, Elm JJ, Toyoda K, Dowlatshahi D, Demchuk AM, Khatri P, Steiner T, Bath PM, Audebert HJ, Vagal A, Yoshimura S, Mayer SA, Wang LL, Sabagha N, Mocco JD, Molina C, Aviv R, Stinson E, Quadri SA, Carrozzella J, Huynh T, Phan A, Beall J, Davis I, Sakai N, Ohta T, Yokosawa M, Hara T, Sangha N, Morita K, Dominc Tse MY, Streib CD, Miyashita F, Silva Y, Nagakane Y, Gheorghiu T, Sun CH, Hirano T, Poli S, Izumo T, Fukuda-Doi M, Ihara M, Koga M, Buck B, Walsh KB, Spokovny I, Grotta JC; FASTEST Investigators. Recombinant factor VIIa versus placebo for spontaneous intracerebral haemorrhage within 2 h of symptom onset (FASTEST): a multicentre, double-blind, randomised, placebo-controlled, phase 3 trial. Lancet. 2026 Feb 21;407(10530):773-783. doi: 10.1016/S0140-6736(26)00097-8. Epub 2026 Feb 4. PMID: 41653933

Recombinant factor VIIa seems like a great idea in principle, yet we know that is rarely one that translates into real world benefits…

Bottom line: An expensive drug that probably does nothing and may cause harm. Sounds like something we should avoid but probably won’t!

Sperry JL, Guyette FX, Cotton BA, Luther JF, Utarnachitt RB, Kutcher ME, Daley BJ, Peetz AB, Patel MB, Goodman MD, Claridge JA, Patel N, Harbrecht BG, Hashmi ZG, Zarychanski R, Neal MD, Yazer MH, Martin-Gill C, Vincent LE, Harner AM, Meyer DE, Latimer AJ, Robinson BR, McKnight CL, Hinckley WR, Miller KR, Jansen JO, Martin D, Fox EE, Rosario-Rivera BL, Wisniewski SR; TOWAR Study Group. Prehospital Resuscitation with Type O Whole Blood for Trauma and Hemorrhage. N Engl J Med. 2026 May 18. doi: 10.1056/NEJMoa2602167. PMID: 42150044

Last episode we looked at the SWIFT trial out the UK which was asking the same question and came up negative. So this new trail from the United States (that’s the country just below Canada on a map) is more data that keeps our Bayesian needle exactly in the same place… meh!

Bottom line: It is not unexpected, but this cluster RCT shows no benefit from whole blood, and the point estimate is a major red flag. 

Rosenfield K, Klok FA, Piazza G, Sharp ASP, Ní Áinle F, Jaff MR, Barco S, Goldhaber SZ, Kucher N, Lang IM, Schmidtmann I, Sterling KM, Araszkiewicz A, Arora V, Cires-Drouet R, Coghlan J, Hobohm L, Ito WD, Jacobson K, Kaiser C, Kopec G, Marx K, McElwee S, Meneveau N, Monteleone P, Montero-Cabezas JM, Olivier CB, Park J, Roik M, Sakhuja R, Tego A, Theurl M, Visveswaran G, Vos JA, Young MN, Asch FM, Konstantinides SV; HI-PEITHO Investigators. Ultrasound-Facilitated, Catheter-Directed Fibrinolysis for Acute Pulmonary Embolism. N Engl J Med. 2026 Mar 28. doi: 10.1056/NEJMoa2516567. PMID: 41910345

We have heard a lot from the interventional folk about invasive devices for the management of biggish PEs in recent times. I wrote an overview earlier this year.

(You can listen to Weingart and Justin argue about HI-PEITHO over on EmCrit.) It is a fun chat between a polite American and a ranty Canadian (i.e. equally polite…)

Bottom line: Despite widely being discussed as a positive trial, there were no real differences – peripheral IV tPA is probably still the more available and reliable treatment option.

Vedantham S, Kahn SR, Marston WA, Weinberg I, Sista AK, Magnuson EA, Cohen DJ, Wasan SM, Razavi MK, Goldhaber SZ, Sanfilippo KM, Comerota AJ, Azene EM, Chaar CIO, Leung DA, Kolli KP, Kalva SP, Rostambeigi N, Desai A, Desai KR, Tafur AJ, Khalsa B, Majerus E, Wang B, Wang Y, Nieters P, Derfler MC, Oliver A, Hardy C, Bashir R, Winokur R, Weger N, Khaja MS, Sharma A, Mani N, Kavali P, Thukral S, Lake LL, Mikkelsen K, Parpia S; C-TRACT Trial Investigators. Endovascular Therapy for Post-Thrombotic Syndrome – A Randomized Trial. N Engl J Med. 2026 Apr 13:10.1056/NEJMoa2519001. doi: 10.1056/NEJMoa2519001. PMID: 41972998

Bottom line: Fractional benefits and possible harms… not really a fair fight as one group got dual anticoags. But good to know what is on offer for our chronic post DVT patients.

Phillips A, Blumenberg A. The dose of iodinated contrast required for a CT scan is below the toxicological threshold of concern for nephrotoxicity: a toxicological perspective. JEM Rep. 2026 Jun;5(2). doi: 10.1016/j.jemrpt.2026.100220

The best evidence that we have tells us that CT contrast simply does not cause kidney injury.

This is an interesting Toxicological perspective on the debate about AKI due to contrast.

Short answer: for diagnostic CT studies we are well below the “Threshold of Toxicologic Concern.” Carry on and contrast.

Greaves RL, Quay A, Bolot R, King J, Gibbs C. Safety of Peripheral Vasoactive Drug Administration in Prehospital and Retrieval Medicine (SPOTLESS-2): A Prospective Observational Cohort Study. Acad Emerg Med. 2026 Apr;33(4):e70271. doi: 10.1111/acem.70271. PMID: 41947342

This is one of my passion projects… the safety and efficacy of peripheral vasopressors can make a big difference to rural Resus patients. This data out of Queensland supports all of my biases and backs up my beliefs!

Bottom line: Peripheral vasopressors are safe to use, and considering the harms of central lines, are honestly the preferred option for early resuscitation in almost all patients. 

Mori H, Yamasaki K, Saishoji Y, Torisu Y, Mori T, Nagai Y, Izumi Y. Diagnostic accuracy of tongue coating in identifying acute appendicitis: a prospective cohort study. Emerg Med J. 2025 Jul 22;42(8):519-525. doi: 10.1136/emermed-2024-214210. PMID: 40169241

The TCI (Tongue Coating Index) is probably about as useful as any other clinical decision score in acute appendicitis. It is very cheap and fast, so why not have a look. Worst case scenario is second-hand halitosis?

I will leave it up to you to decide whether that is because the tongue coating index is valuable, or because most of the clinical decision rules in existence are absolute garbage and are probably making you worse at your job.

Justin says he will buy a pint for anyone who calls a surgeon without imaging and tries to convince them that there is an acute appendicitis based primarily on your tongue exam. Challenge accepted.

Bottom line: Glossal Gestalt for the win?

Zubova AV, Zotkina LV, Olsen JW, Kulkov AM, Moiseyev VG, Malyutina AA, Davydov RV, Markin SV, Maksimovskiy EA, Chistyakov PV, Krivoshapkin AI, Kolobova KA. Earliest evidence for invasive mitigation of dental caries by Neanderthals. PLoS One. 2026 May 13;21(5):e0347662. doi: 10.1371/journal.pone.0347662. Erratum in: PLoS One. 2026 Jun 5;21(6):e0351227. doi: 10.1371/journal.pone.0351227. PMID: 42127021

A fascinating insight into the culture of our Neanderthal cousins – they were likely doing dentistry – planning, making tools and carrying out prolonged procedures in Siberia nearly 60,000 years ago

Given the relative unavailability of acute dental services in most rural places in the world – it is a relief to know that our ancient cousins managed to do this sans anaesthesia with some rock tools. Much cheaper if you have the will power and pain tolerance.

In this video I go over my old SMACC Dublin Diagnsotics talk and revisit the Bayesian reasoning that lays at the heart of what we do in the ED.  If you ned to go back and listen to the original talk, its worth the visit – all you need to know about Bayes’ theorum for ED docs in 22 minutes!

The new Docnomo / Fagan nomogram interactive tool on the website is unveiled and demonstrated with discussions around PE, small bowel obstruction and paediatric appendicitis.

Enjoy the nerdiness!

The May edition of the Journal Club is out now! This is a long podcast, but packed full of fun EBM and some practice changing papers and we even manage to escape our usual evidentiary nihilism.

Links are in the description below to the PDFs and you can listen on your favourite app or just watch the video on Youtube

Smith JE, Cardigan R, Sanderson E, Silsby L, Rourke C, Barnard EBG, Basham P, Antonacci G, Charlewood R, Dallas N, Davies J, Goodwin E, Hawton A, Hudson C, Lucas J, Keen K, Lyon RM, Nolan B, Perkins GD, Rundell V, Smith L, Stanworth SJ, Weaver A, Woolley T, Green L; SWiFT Trial Group. Prehospital Whole Blood in Traumatic Hemorrhage – a Randomized Controlled Trial. N Engl J Med. 2026 Mar 17. doi: 10.1056/NEJMoa2516043. Epub ahead of print. PMID: 41841706

Bottom line: This first RCT of whole blood in trauma showed no benefit over component therapy. We definitely need, and will see, many more trials of whole blood in the future.

You can read more from Justin here. 

Sajdeya R, Yanez ND, Kampp M, Goodman MD, Zonies D, Togioka B, Nunn A, Winfield RD, Martin ND, Kohli A, Huynh TT, Okonkwo DO, Poblete RA, Gilmore EJ, Chesnut RM, Bunnell AE, Ohnuma T, Hashemaghaie M, Treggiari MM. Early Blood Pressure Targets in Acute Spinal Cord Injury: A Randomized Clinical Trial. JAMA Netw Open. 2025 Sep 2;8(9):e2525364. doi: 10.1001/jamanetworkopen.2025.25364. PMID: 40965887

Bottom line: This small, flawed RCT demonstrated no benefit from higher blood pressure targets (MAP 85-90) when compared to conventional targets (MAP 65-70), but does demonstrate harm. There is tremendous uncertainty, but we should clearly favour conventional BP targets until new research is published.

Justin’s full rant can be found here.

Lookstein RA, Konstantinides SV, Weinberg I, Dohad SY, Rosol Z, Kopeć G, Moriarty JM, Parikh SA, Holden A, Channick RN, McDonald B, Nagarsheth KH, Yamada K, Rosovsky RP; STORM-PE Trial Investigators. Randomized Controlled Trial of Mechanical Thrombectomy With Anticoagulation Versus Anticoagulation Alone for Acute Intermediate-High Risk Pulmonary Embolism: Primary Outcomes From the STORM-PE Trial. Circulation. 2026 Jan 6;153(1):21-34. doi: 10.1161/CIRCULATIONAHA.125.077232. Epub 2025 Nov 3. PMID: 41183181.

Bottom line: This is basically a pilot trial, looking at disease oriented rather than patient oriented outcomes. It is an unblinded trial, designed and run by the device manufacturer. Even with those biases, the results are completely underwhelming.

Kjaergaard J, Bang LE, Sonne-Holm E, Wiberg S, Holmvang L, Lassen JF, Sørensen R, Høfsten DE, Ulriksen PS, Jawad S, Palm P, Søe C, Ersbøll MK, Boesgaard S, Møller JE, Thune JJ, Hassager C, Tilsted HH, Lønborg J, Egstrup M, Kristiansen OP, Seven E, Lindholm MG, Eskesen K, Fanø S, Carlsen J. Randomized trial of low-dose -, ultrasound assisted thrombolysis or heparin for pulmonary embolism. Cardiovasc Res. 2026 Jan 29:cvag038. doi: 10.1093/cvr/cvag038. PMID: 41610160

Bottom line: Although thrombolysis might improve the radiological clot burden, there is harm and no evidence of patient-oriented benefits

Morgenstern’s deep thoughts on these two papers can be found in this post. 

You can read my big picture review of modern PE management here.

McKetin R, Shoptaw S, Saunders L, Nguyen L, Clare PJ, Dore GJ, Turner A, Dean OM, Kelly PJ, Arunogiri S, Koeijers J, Degan TJ, Degenhardt L, Farrell M, Goodman-Meza D, Sinclair B, Reid D, Cordaro F, Hill H, Lundin R, Hayllar J, Christmass M, Liaw W, Liu D, Woods A, Brewerton B, Holyoak E, Wu BT, Maher H, O’Dea N, Keygan J, Kontogiannis A, Palmer L, Morrison C, Wrobel A, Hyland B, Kiden G, Romeo V, Kyaw KWY, Byrne M, Colledge-Frisby S, Zahra E, Berk M. Mirtazapine for Methamphetamine Use Disorder: A Randomized Clinical Trial. JAMA Psychiatry. 2026 Apr 1:e260159. doi: 10.1001/jamapsychiatry.2026.0159. PMID: 41920558

Bottom line: In this double-blind placebo-controlled RCT, mirtazapine resulted in less self-reported days using methamphetamine in the next 28 days.

Tan H, Chandru P. Radiologist Approval for CTPA in the ED: A Single-Centre Pilot Study Did Not Demonstrate a Statistically Significant Difference in Diagnostic Yield. Emerg Med Australas. 2026 Feb;38(1):e70237. doi: 10.1111/1742-6723.70237. PMID: 41705429

Bottom line: Not a great trial, probably not gonna change practice… but might help at your next department meeting about CTPA processes.

Luckey A, Balasegaram M, Barbee LA, Batteiger TA, Broadhurst H, Cohen SE, Delany-Moretlwe S, de Vries HJC, Dionne JA, Gill K, Kenyon C, Kittiyaowamarn R, Lewis D, Mueller JP, Naicker V, O’Brien S, O’Donnell JP, Phanuphak N, Spooner E, Srinivasan S, Taylor SN, Unemo M, Zwane Z, Hook EW 3rd; Zoliflodacin Phase 3 Study Group. Zoliflodacin versus ceftriaxone plus azithromycin for treatment of uncomplicated urogenital gonorrhoea: an international, randomised, controlled, open-label, phase 3, non-inferiority clinical trial. Lancet. 2026 Jan 10;407(10524):147-160. doi: 10.1016/S0140-6736(25)01953-1. Epub 2025 Dec 11. PMID: 41391465

Justin has a thing: complaining about non-interiority trials.

Bottom line: Zoliflodacin is clearly inferior to the current standard of care, despite the very misleading conclusions in this paper.

Ali S, Klassen TP, Candelaria P, Bhatt M, Sawyer S, Stang A, Yaskina M, Heath A, Pechlivanoglou P, Offringa M, Drendel AL, Hickes S, Poonai N; KidsCAN PERC Innovative Pediatric Clinical Trials No OUCH Study Team. Acetaminophen (Paracetamol) or Opioid Analgesia Added to Ibuprofen for Children’s Musculoskeletal Injury: Two Randomized Clinical Trials. JAMA. 2026 Mar 10;335(10):863-873. doi: 10.1001/jama.2025.25033. PMID: 41505155

Bottom line: for minor painful MSK injuries adding paracetamol or opiates to ibuprofen was not helpful.

Qandil M, Ransom P, Shammala MA, Srour A, Khafaja M, Alkhateeb N, Jafar AJN, Abughali S. Pericardiocentesis, drainage and instilled tranexamic acid: definitive management in a 25-case series of penetrating cardiac tamponade. Injury. 2026 Feb 16:113106. doi: 10.1016/j.injury.2026.113106. Epub ahead of print. PMID: 41760498

Bottom line: an amazing case series collected in a war zone challenges our thinking about penetrating chest trauma.

You can read my full discussion and thoughts from the authors here: Pericardiocentesis in a War Zone

Eisendle F, Roveri G, Rauch S, Thomassen Ø, Dal Cappello T, Assmus J, Malacrida S, Kammerer T, Schweizer J, Borasio N, Dörck V, Falk M, Falla M, Fruzzetti N, Maxenti M, Mydske S, Sasso GM, Vinetti G, Wallner B, Brattebø G, Brugger H, Strapazzon G. Respiratory Gas Shifts to Delay Asphyxiation in Critical Avalanche Burial: A Randomized Clinical Trial. JAMA. 2025 Oct 8;334(19):1720–7. doi: 10.1001/jama.2025.16837. Epub ahead of print. PMID: 4106066

Bottom line: There is enough air in snow for a basic fan to allow respiration under 50 cm of snow for up to 35 minutes. That is interesting, but perhaps not all that useful information. 

You can read all about the logistics of avalanche rescue here: Avalanche Survival in Broome

Welcome back to another instalment of the Journal Club with my old friend Dr Justin Morgenstern (he is younger than me, but we have been mates for a while…)

This month we tackle bleeding brains, clotting eyes, doing less for pneumothoraces (or is it pneumothoraci? Oh, well its defintitley pl(e)ural!! hehehehe!!). We chat about intra-cardiac arrest echo and Macgyvering urine collection devices for a female patients… quite a mix eh?

As always the PDFs are clickable on the titales below, so read, critique and decide for yourself.

The YouTube version is below or over at Justin’s Youtube channel if you need more middle-aged, hirsute men on your algorithm!

Eyeball Strokes are not that dissimilar to other strokes… a total evidentiary mess!

Préterre C, Gaultier A, Obadia M, Vignal C, Mourand I, Plat J, Sablot D, Gaudron M, Rodier G, Godeneche G, Urbanczyk C, Marc G, Massardier E, Adam S, Boulanger M, Marcel S, Mechtouff L, Ronzière T, Calvière L, Godard-Ducceschi S, Barbin L, Lebranchu P, Guillon B; THEIA collaborators.Intravenous alteplase versus oral aspirin for acute central retinal artery occlusion within 4·5 h of severe vision loss (THEIA): a multicentre, double-dummy, patient-blinded and assessor-blinded, randomised, controlled, phase 3 trial. Lancet Neurol. 2025 Nov;24(11):909-919. doi: 10.1016/S1474-4422(25)00308-4. PMID: 41109232

Traumatic pneumothorax: Less is more; more or less…

Harrison M. Non-Invasive Management of Blunt Traumatic Pneumothorax-a Meta-Analysis. Emerg Med Australas. 2025 Dec;37(6):e70164. doi: 10.1111/1742-6723.70164. PMID: 41163445

Bottom line: Conservative management is a good option even for patients with blunt trauma, as long as you are being selective about the patient you chose, and consider factors like length of transfer to a trauma center, positive pressure use, and ease of chest tube placement in whatever setting the patient might be monitored. 

To Shock, or not to shock, that is the question… but weird data here makes it an odd answer

Gaspari R, Lindsay R, She T, Acuna J, Balk A, Bartnik J, Baxter J, Clare D, Caplan RJ, DeAngelis J, Filler L, Graham P, Hill M, Hipskind J, Joseph R, Kapoor M, Kummer T, Lewis M, Midgley S, Nalbandian A, Narveas-Guerra O, Nomura J, Sanjeevan I, Scheatzle M, Schnittke N, Secko M, Soucy Z, Stowell JR, Theophanous RG, Tozer J, Yates T, Gleeson T. Incidence and Clinical Relevance of Echocardiographic Visualization of Occult Ventricular Fibrillation: A Multicenter Prospective Study of Patients Presenting to the Emergency Department After Out-of-Hospital Cardiac Arrest. Ann Emerg Med. 2025 Oct;86(4):328-336. doi: 10.1016/j.annemergmed.2025.04.014. Epub 2025 Jun 30. PMID: 40590825

Don’t feel pressure to fix the pressure… your patient may benefit?

Shi AC, Taylor T, Huang CC, Singhal AB, Goldstein JN, Bevers MB, Hou PC. Early Intensive Blood Pressure Reduction After Intracerebral Hemorrhage Is Associated With Worse Functional Outcome: The Risk of Overshooting Blood Pressure Goals. Ann Emerg Med. 2025 Dec 9:S0196-0644(25)01303-4. doi: 10.1016/j.annemergmed.2025.10.009. Epub ahead of print. PMID: 41369631

Clinical decision rules vs commonsense…

Kerr G, Chown A, Mercuri M, Clayton N, Mercier É, Morris J, Jeanmonod R, Eagles D, Varner C, Barbic D, Parpia S, Buchanan IM, Ali M, Kagoma YK, Shoamanesh A, Engels P, Sharma S, Worster A, McLeod S, Émond M, Stiell I, Papaioannou A, de Wit K. Applying the Canadian Head CT Criteria to Older Adults Seen in the Emergency Department After a Fall. J Am Geriatr Soc. 2026 Feb;74(2):509-515. doi: 10.1111/jgs.70191. Epub 2025 Oct 31. PMID: 41170758

Adding insult to injury – food in the ED ‘aint great

Barrington V, Carter V, Tagg A, Hitch D. Food as a Component of Patient-Centred Care in Emergency Departments: Preliminary Findings. Emerg Med Australas. 2025 Oct;37(5):e70126. doi: 10.1111/1742-6723.70126. PMID: 40890898

Justin makes some rash decisions about golfers legs…

Cook K. Rash following a round of golf. Emerg Med J. 2026 Feb 24;43(3):150-166. doi: 10.1136/emermed-2025-215366. PMID: 41735021

Madame’s MacGyver Urinal. A problem that needed solving 100 years ago

Booth S, Ellis P, Lyttle MD, Lochab S, Pegrum J, Thomas S. Disposable female urinal bottle (the UniWee) improves patient experience for immobile women with lower limb fractures. Emerg Med J. 2025 Apr 22;42(5):326-333. doi: 10.1136/emermed-2024-214181. PMID: 40081970

Welcome to the first post for 2026. Dr Justin joins me once again for an episode of the Journal Club where we do some deep dives into the recent acute AF literature. We take apart the RSI trial (for those in the Antipodes who don’t have etomidate on the shelf – don’t panic – its a negative trial. And we discuss the relative cuteness of suburban racoons in Canada as captured on mobile phones.

As usual the PDFs are available at the links that you can click below – so read these for yourself and discuss widely.

Casey JD, Seitz KP, Driver BE, et al. Ketamine or Etomidate for Tracheal Intubation of Critically Ill Adults. N Engl J Med. 2025 Dec 9. doi: 10.1056/NEJMoa2511420. Epub ahead of print. PMID: 41369227

Svendsen JH, Diederichsen SZ, Højberg S, Krieger DW, Graff C, Kronborg C, Olesen MS, Nielsen JB, Holst AG, Brandes A, Haugan KJ, Køber L. Implantable loop recorder detection of atrial fibrillation to prevent stroke (The LOOP Study): a randomised controlled trial. Lancet. 2021 Oct 23;398(10310):1507-1516. doi: 10.1016/S0140-6736(21)01698-6. Epub 2021 Aug 29. Erratum in: Lancet. 2021 Oct 23;398(10310):1486. doi: 10.1016/S0140-6736(21)02090-0. PMID: 34469766

Wong CX, Cheung CC, Montenegro G, Oo HH, Peña IJ, Tang JJ, Tu SJ, Wall G, Dewland TA, Moss JD, Gerstenfeld EP, Tseng ZH, Hsia HH, Lee RJ, Olgin JE, Vedantham V, Scheinman MM, Lee C, Sanders P, Marcus GM. Caffeinated Coffee Consumption or Abstinence to Reduce Atrial Fibrillation: The DECAF Randomized Clinical Trial. JAMA. 2025 Nov 9:e2521056. doi: 10.1001/jama.2025.21056. Epub ahead of print. PMID: 41206802

Stiell IG, Taljaard M, Eagles D, Yadav K, Vadeboncoeur A, Hohl CM, Archambault PM, Birnie D, Brown E, Campbell SG, Chen Y, Clement CM, Cournoyer A, de Wit K, Emond M, Macle L, McRae AD, Mercier E, Morris J, Mohamad G, Nemnom MJ, Nicholls SG, Pare D, Parkash R, Sivilotti M, Thavorn K, Perry JJ. Vernakalant versus procainamide for rapid cardioversion of patients with acute atrial fibrillation (RAFF4): randomised clinical trial. BMJ. 2025 Nov 11;391:e085632. doi: 10.1136/bmj-2025-085632. PMID: 41218981

Stewart D. Emotional Analgesia and the Decline of Rational Decision Making in Emergency Medicine. Emerg Med Australas. 2025 Dec;37(6):e70180. doi: 10.1111/1742-6723.70180. PMID: 41305908

Trainee Emergency Research Network (TERN). Understanding corridor and escalation area care in 165 UK emergency departments: a multicentre cross-sectional snapshot study. Emerg Med J. 2025 Dec 27:emermed-2025-215301. doi: 10.1136/emermed-2025-215301. Epub ahead of print. PMID: 41365687

Charlton N, Berry DC, Kannan V, Yee R, Carlson JN, Orkin AM. The use of expired resuscitation medications for life-threatening first aid conditions: a systematic search and narrative review. Resusc Plus. 2025 Sep 23;26:101110. doi: 10.1016/j.resplu.2025.101110. PMID: 41142213

Brindley PG, Morgan M. Diagnosing dying: is it time for doctors to write “dying certificates”? BMJ. 2024 Jun 4;385:q1167. doi: 10.1136/bmj.q1167. PMID: 38834200

Apostolov A, Bradley A, Dreher S, Dwyer C, Edwards J, Evans ME, Gu N, Hansen J, Lewis JD, Mashburn AT, Miller K, Richardson E, Roller W, Stark A, Swift J, Zuniga O, Lesch R. Tracking domestication signals across populations of North American raccoons (Procyon lotor) via citizen science-driven image repositories. Front Zool. 2025 Oct 2;22(1):28. doi: 10.1186/s12983-025-00583-1. PMID: 41039604

Welcome back tot he final edition of the podcast for 2025. Another collection of big paers, long rants and of course – flying rhinoceros physiology. Its all FOAMed goodness.

Byrne A, Macdonald DB, Kirkpatrick IDC, Pham M, Green CR, Copaescu AM, McInnes MDF, Ling L, Ellis A, Costa AF. CAR/CSACI Practice Guidance for Contrast Media Hypersensitivity. Can Assoc Radiol J. 2025 Aug;76(3):400-416. doi: 10.1177/08465371241311253. Epub 2025 Jan 11. PMID: 39797723

Basically: DO NOT use steroids to “pre-treat” patients with IV contrast allergies. Keep calm and carry on to CT… A longer write up can be found here.

Alexandrov AW, Shearin AJ, Mandava P, Torrealba-Acosta G, Elangovan C, Krishnaiah B, Nearing K, Robinson E, Guthrie-Chu C, Holzmann M, Fill B, Trivedi DR, Richardson A, Middleton S, Brewer BB, Liebeskind DS, Goyal N, Grotta JC, Alexandrov AV; ZODIAC Investigators. Optimal Head-of-Bed Positioning Before Thrombectomy in Large Vessel Occlusion Stroke: A Randomized Clinical Trial. JAMA Neurol. 2025 Sep 1;82(9):905-914. doi: 10.1001/jamaneurol.2025.2253. PMID: 40465238

Summary: HEADS DOWN! – if you have a patient in the ED awaiting EV thrombectomy for large vessel CVA the nursing them on a flat (0 degrees) bed may be the best option compared to 30 degrees up which every other patient should probably be at.

Strayer RJ, Oliver M, Chen A, Gerges L, Caputo ND. The Impact of Suctioning on Oxygenation During Rapid Sequence Intubation in the Emergency Department: A Multi-Center Pilot Randomized Controlled Trial. J Emerg Med. 2025 Sep;76:88-94. doi: 10.1016/j.jemermed.2025.04.016. Epub 2025 May 22. PMID: 40533376

Summary: there is no evidence that continuous suction during RSI will do your patient harm or make them hypoxic… so suck away.

ANDROMEDA-SHOCK-2 Investigators for the ANDROMEDA Research Network, Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR), and Latin American Intensive Care Network (LIVEN); Hernandez G, Personalized Hemodynamic Resuscitation Targeting Capillary Refill Time in Early Septic Shock: The ANDROMEDA-SHOCK-2 Randomized Clinical Trial. JAMA. 2025 Oct 29:e2520402. doi: 10.1001/jama.2025.20402. Epub ahead of print. PMID: 41159835

Summary: doing “personalised” resuscitation for septic patients is what we should probably be doing for our sick patients. This trial showed one way to do this using capillary refill as a target.

A longer, more detailed write up of this paper can be found here. 

Muller G, Contou D, Ehrmann S, Martin M, Andreu P, Kamel T, Boissier F, Azais MA, Monnier A, Vimeux S, Chenal A, Nay MA, Salmon Gandonnière C, Lascarrou JB, Roudaut JB, Plantefève G, Giraudeau B, Lakhal K, Tavernier E, Boulain T; CRICS-TRIGGERSEP F-CRIN Network and the EVERDAC Trial Group.. Deferring Arterial Catheterization in Critically Ill Patients with Shock. N Engl J Med. 2025 Oct 29. doi: 10.1056/NEJMoa2502136. Epub ahead of print. PMID: 41159885

Summary: Arterial lines do not save lives. This trial had some super sick, septic patients and there was no overall benefit from art lines over NIBP cuffs…. but there are harms and benefits to both, so think about your practice and what works..

Rippey J, Morris F, Moseley C, Sowerby J, Chiverton L, Mason J. Post-Procedure Perforation Rates in Ultrasound Transducer Covers Used for Ultrasound-Guided Percutaneous Procedures in Emergency Medicine: A Comparison Between Polyurethane Covers and Polyethylene Covers. Australas J Ultrasound Med. 2025 Sep 25;28(4):e70025. doi: 10.1002/ajum.70025. PMID: 41017784

Summary: Ultrasound probe covers leak. You should not trust the last person who used the probe and assume it is dirty before you do a sterile procedure. Clean the probe properly yourself!

Dubucs X, Gingras V, Boucher V, Carmichael PH, Ruel M, De Wit K, Grewal K, Mercier É, Blanchard PG, Benhamed A, Charpentier S, Émond M. Risk Factors for Traumatic Intracranial Hemorrhage in Older Adults Sustaining a Head Injury in Ground-Level Falls: A Systematic Review and Meta-analysis. Ann Emerg Med. 2025 Jul 22:S0196-0644(25)00313-0. doi: 10.1016/j.annemergmed.2025.05.021. Epub ahead of print. PMID: 40699169

Summary:  Biased data sets can result in weird conclusions that need further thought. Don’t believe the hype, DOACS do not protect your brain if you fall over!

Ilgen JS, Dhaliwal G. Educational Strategies to Prepare Trainees for Clinical Uncertainty. N Engl J Med. 2025 Oct 23;393(16):1624-1632. doi: 10.1056/NEJMra2408797. PMID: 41124633

“Uncertainty is ubiquitous in medical practice. If there was no uncertainty, society would not need physicians to render judgments.”

Summary: We should routinely train doctors to deal with uncertain situations – the rest is pretty simple.

Atkinson P, Lang E. Can emergency medicine be saved? CJEM. 2025 Oct;27(10):760-763. doi: 10.1007/s43678-025-01034-w. Epub 2025 Oct 18. PMID: 41108498

Summary: An editorial that is worth a read. Big picture thinking about what Emergency Medicine is and should be.

Radcliffe RW, Jago M, Morkel PV, Morkel E, du Preez P, Beytell P, Kotting B, Manuel B, du Preez JH, Miller MA, Felippe J, Parry SA, Gleed RD. THE PULMONARY AND METABOLIC EFFECTS OF SUSPENSION BY THE FEET COMPARED WITH LATERAL RECUMBENCY IN IMMOBILIZED BLACK RHINOCEROSES (DICEROS BICORNIS) CAPTURED BY AERIAL DARTING. J Wildl Dis. 2021 Apr 1;57(2):357-367. doi: 10.7589/2019-08-202. PMID: 33822147

Summary: You just need to look at this picture to appreciate how easy your job is!

The latest podcast with Dr. Justin Morgenstern. We look at all the latest evidence and a few older pieces from the world of Emergency care. This month we tackle: AI bots for OMIs, paracentesis plumbing, antiplatelet pharma, facial fractures and a sublingual anaphylaxis agent!  Its a lot!  #FOAMed

Shroyer S, Mehta S, Thukral N, Smiley K, Mercaldo N, Meyers HP, Smith SW. Accuracy of cath lab activation decisions for STEMI-equivalent and mimic ECGs: Physicians vs. AI (Queen of Hearts by PMcardio). Am J Emerg Med. 2025 Jul 30;97:193-199. doi: 10.1016/j.ajem.2025.07.061. Epub ahead of print. PMID: 40763602

Daniel NJ, Storn JM, Weinberg NE, Galvin WA, Irons HR, Barksdale AN, Rischall ML, Bilodeau SM, Gale JY, Willet KG, Wilson A, Keiper K, Chevalier J. Assessment of sous vide water baths in the acute rewarming of frostbitten extremities: A multicenter study. Acad Emerg Med. 2025 May;32(5):574-577. doi: 10.1111/acem.15061.PMID: 39654121

Konerman MA, Price J, Torres D, Li Z. Randomized, controlled pilot study comparing large-volume paracentesis using wall suction and traditional glass vacuum bottle methods. Therap Adv Gastroenterol. 2014 Sep;7(5):184-92. doi: 10.1177/1756283X14532704. PMID: 25177365

 This post from Maimonides goes into a little more detail. 

Kutcher SA, Dendu

kuri N, Dandona S, Nadeau L, Brophy JM. Ticagrelor Compared to Clopidogrel in Acute Coronary Syndromes trial (TC4): a Bayesian pragmatic cluster randomized controlled trial. CMAJ. 2025 Mar 30;197(12):E309-E318. doi: 10.1503/cmaj.241862. PMID: 40164463

Lajeunesse MD, Olivera TR, April MD, Benesch HA, Castaneda P, Couperus KS, Dang VN, Park MS, Deboer RS, Dougherty CA, Downing NC, Gray MW, Hull AM, Jimenez BL, Klausner MJ, Sakai JHM, McLean TJ, Nepal N, Patten HW, Schwartz BT, Walther ND, Wolterstorff CS, Oliver JJ. Trigger Point Injection for Myofascial Pain Syndrome of the Low Back: A Partially Blinded Three-Arm Randomized Controlled Trial. Ann Emerg Med. 2025 Jun 17:S0196-0644(25)00298-7. doi: 10.1016/j.annemergmed.2025.05.008. PMID: 40531073

Rech MA, Carpenter CR, Aggarwal NT, Hwang U. Anti-Amyloid Therapies for Alzheimer’s Disease and Amyloid-Related Imaging Abnormalities: Implications for the Emergency Medicine Clinician. Ann Emerg Med. 2025 Jun;85(6):526-536. doi: 10.1016/j.annemergmed.2024.12.002. Epub 2025 Jan 17. PMID: 39818674

More details here.

Castillo Diaz F, Anand T, Khurshid MH, Kunac A, Al Ma’ani M, Colosimo C, Hejazi O, Ditillo M, Magnotti LJ, Joseph B. Look me in the face and tell me that I needed to be transferred: Defining the criteria for transferring patients with isolated facial injuries. J Trauma Acute Care Surg. 2025 May 9. doi: 10.1097/TA.0000000000004651. Epub ahead of print. PMID: 40341445

Kraus CN, Wargacki S, Golden D, Lieberman J, Greenhawt M, Camargo CA Jr. Integrated phase I pharmacokinetics and pharmacodynamics of epinephrine administered through sublingual film, autoinjector, or manual injection. Ann Allergy Asthma Immunol. 2025 May;134(5):580-586. doi: 10.1016/j.anai.2025.01.006. Epub 2025 Jan 16. PMID: 39826899

Welcome back to a somewhat delayed, yet typically on target episode of the Journal Club with Dr Morgenstern.

This month is a really eclectic bunch of papers from all walks of science – bench science to the purely clinical and a bit about fruit in the mix there.

Papers are listed below for reference. Enjoy over a long drive or a slow shift !

Gualtieri R, Verolet C, Mardegan C, Papis S, Loevy N, Asner S, Rohr M, Llor J, Heininger U, Lacroix L, Pittet LF, Posfay-Barbe KM. Amoxicillin vs. placebo to reduce symptoms in children with group A streptococcal pharyngitis: a randomized, multicenter, double-blind, non-inferiority trial. Eur J Pediatr. 2024 Nov;183(11):4773-4782. doi: 10.1007/s00431-024-05705-1. Epub 2024 Aug 31. PMID: 39215861

Related: You don’t understand non-inferiority trials (and neither do I)

Leech C, Nutbeam T, Chu J, Knight M, Hinshaw K, Appleyard TL, Cowan S, Couper K, Yeung J. Maternal and neonatal outcomes following resuscitative hysterotomy for out of hospital cardiac arrest: A systematic review. Resuscitation. 2025 Feb;207:110479. doi: 10.1016/j.resuscitation.2024.110479. Epub 2024 Dec 29. PMID: 39736393

This paper is not going to change your day to day clinical practice, but might help set our expectations if you are faced with performing a perimortem hysterotomy.

Li B, Elsten-Brown J, Li M, Zhu E, Li Z, Chen Y, Kang E, Ma F, Chiang J, Li YR, Zhu Y, Huang J, Fung A, Scarborough Q, Cadd R, Zhou JJ, Chin AI, Pellegrini M, Yang L. Serotonin transporter inhibits antitumor immunity through regulating the intratumoral serotonin axis. Cell. 2025 Jul 10;188(14):3823-3842.e21. doi: 10.1016/j.cell.2025.04.032. Epub 2025 May 21. PMID: 40403728

Keijzers G. Deliberate clinical inertia: A paradoxical strategy to improve patient flow? Emerg Med Australas. 2025 Apr;37(2):e70016. doi: 10.1111/1742-6723.70016. PMID: 40045755

Deliberate clinical inertia: the conscious process of ‘doing nothing’ as a positive response to clinician and system intervention bias.

Zaman F, Bach C, Junaid I, Papatsoris AG, Pati J, Masood J, Buchholz N. The floppy iris syndrome – what urologists and ophthalmologists need to know. Curr Urol. 2012 May;6(1):1-7. doi: 10.1159/000338861. Epub 2012 Apr 30. PMID: 24917702

Endo A, Yamakawa K, Tagami T, et al. Efficacy of targeting high mean arterial pressure for older patients with septic shock (OPTPRESS): a multicentre, pragmatic, open-label, randomised controlled trial. Intensive Care Med. 2025 May;51(5):883-892. doi: 10.1007/s00134-025-07910-4. Epub 2025 May 13. PMID: 40358717

Bottom line: Although I don’t think the massive mortality difference is believable, everything in this trial points at harm from targeting higher MAPs. 65 is the target.

Dönmez S, Şener A, Işık Nİ, Koca S, Akbaş İ. Analgesic and Anxiolytic Effects of Virtual Reality and Classical Music Therapy on Tension-Type Headache: A Randomized Controlled Trial. Ann Emerg Med. 2025 Jun 4:S0196-0644(25)00278-1. doi: 10.1016/j.annemergmed.2025.04.032. Epub ahead of print. PMID: 40464717

Chen YH, Zink T, Chen YW, Nin DZ, Talmo CT, Hollenbeck BL, Grant AR, Niu R, Chang DC, Smith EL. Postoperative Aspiration Pneumonia Among Adults Using GLP-1 Receptor Agonists. JAMA Netw Open. 2025 Mar 3;8(3):e250081. doi: 10.1001/jamanetworkopen.2025.0081. PMID: 40036031

Bottom line: Although there are anecdotal reports coming from anesthesia about an increased risk of aspiration with GLP1 agonists, that concern does not appear to be supported by this large observational data set. 

Barone JE. Comparing apples and oranges: a randomised prospective study. BMJ. 2000 Dec 23-30;321(7276):1569-70. doi: 10.1136/bmj.321.7276.1569. PMID: 11124178

G’day and welcome to another instalment of the Journal Club with Dr Justin Morgenstern.

This month we cover some diltiazem papers, a few on airway hacks, some population studies and discuss some nerwer management options for big PEs, and kids seizures.

Unfortunately, we had soe technical glitches which means that the usual video / Youtube version will not be available – so you will have to stare at a picture of Justin as you listen to the chat!

Az A, Sogut O, Dogan Y, Akdemir T, Ergenc H, Umit TB, Celik AF, Armagan BN, Bilici E, Cakmak S. Reducing diltiazem-related hypotension in atrial fibrillation: Role of pretreatment intravenous calcium. Am J Emerg Med. 2025 Feb;88:23-28. doi: 10.1016/j.ajem.2024.11.033. Epub 2024 Nov 17. PMID: 39577214

An additional note raised by Scott Weingart is related to the significant whole body burning that is often caused by calcium chloride. Justin’s full blog write up is here. 

Bottom line: Calcium probably has some minor hemodynamic effects, but when diltiazem is used correctly, adverse events are incredibly rare, and therefore there is really no reason for prophylaxis.

Ray WA, Chung CP, Stein CM, Smalley W, Zimmerman E, Dupont WD, Hung AM, Daugherty JR, Dickson A, Murray KT. Serious Bleeding in Patients With Atrial Fibrillation Using Diltiazem With Apixaban or Rivaroxaban. JAMA. 2024 May 14;331(18):1565-1575. doi: 10.1001/jama.2024.3867. PMID: 38619832

Bottom line: There is an association between diltiazem and increased bleeding in patients on DOACs (as compared to metoprolol), but this is almost certainly the result of obvious confounders, so I can’t see any reason to change current practice. 

Morgenstern J, Radecki R, Westafer L, Niforatos JD, Atkinson P. CJEM debate: clinical decision rules-thinking beyond the algorithm.CJEM. 2025 Feb 3. doi: 10.1007/s43678-025-00870-0. PMID: 39900742

You can read Justin’s full write up on why  decision rules are ruining medicine. 

Jaber WA, Gonsalves CF, Stortecky S, Horr S, Pappas O, Gandhi RT, Pereira K, Giri J, Khandhar SJ, Ammar KA, Lasorda DM, Stegman B, Busch L, Dexter DJ 2nd, Azene EM, Daga N, Elmasri F, Kunavarapu CR, Rea ME, Rossi JS, Campbell J, Lindquist J, Raskin A, Smith JC, Tamlyn TM, Hernandez GA, Rali P, Schmidt TR, Bruckel JT, Camacho JC, Li J, Selim S, Toma C, Basra SS, Bergmark BA, Khalsa B, Zlotnick DM, Castle J, O’Connor DJ, Gibson CM; PEERLESS Committees and Investigators*. Large-Bore Mechanical Thrombectomy Versus Catheter-Directed Thrombolysis in the Management of Intermediate-Risk Pulmonary Embolism: Primary Results of the PEERLESS Randomized Controlled Trial. Circulation. 2025 Feb 4;151(5):260-273. doi: 10.1161/CIRCULATIONAHA.124.072364. Epub 2024 Oct 29. PMID: 39470698

Bottom line: At this point there is absolutely no evidence that mechanical thrombectomy or catheter directed thrombolysis help patients. There might be times where they are reasonable, even without evidence, such as in a very sick patient with contraindications to systemic thrombolysis. However, neither of these procedures should be used routinely until we see real evidence.

Justin’s full write up of this paper is here. 

Lauren Westafer, Justin & Dr. Bourke Tillman do a great discussion of the modern management of intermediate and high risk PE at length on this recent Emergency Medicine Cases podcast, and Justin has a write up of more evidence here. 

Hansel J, Law JA, Chrimes N, Higgs A, Cook TM. Clinical tests for confirming tracheal intubation or excluding oesophageal intubation: a diagnostic test accuracy systematic review and meta-analysis. Anaesthesia. 2023 Aug;78(8):1020-1030. doi: 10.1111/anae.16059. Epub 2023 Jun 16. PMID: 37325847

This is Casey’s pet topic of the month and a personal peeve in airway management.

Bottom line: The only test you should use to confirm endotracheal tube position is waveform capnography. – save yourself 30 seconds of somebody else’s life!!

Markham T, AlFarra AS, Tejani M, Tate DJ, Barrera JE, Paladugu S, Saroukhani S, Jiang Y. Effectiveness of Ventilation via an Endotracheal Tube in Pharynx Versus a Facemask in Patients With Potentially Difficult Airway: A Randomized, Crossover, and Blind Trial. Anesth Analg. 2025 Feb 1;140(2):280-289. doi: 10.1213/ANE.0000000000007273. Epub 2024 Dec 20. PMID: 39705182

This is a weird McGyverism – using an ETT in the place of a device that is universally availabel and works extremely well – the humble LMA!

Bottom line: We generally suck at BVM, so looking for alternatives, especially in difficult patients (obese with a beard), makes sense. However, I am not sure BVM is the correct comparison to this technique, as it appears to me more of a replacement for an LMA.

Lutsey PL, Misialek JR, Young MT, Berman J, Leiser CL, Pope ZC, Cushman M, Folsom AR, Kaufman JD. Air pollution is associated with increased risk of venous thromboembolism: the Multi-Ethnic Study of Atherosclerosis. Blood. 2025 Mar 6;145(10):1089-1096. doi: 10.1182/blood.2024026399. PMID: 39652776

Bottom line: There are limitations that significantly limit certainty, but there seems to be an association between air pollution and VTE (among numerous other health implications). 

Amr A. Othman, Abdelrahim A. Sadek, Esraa A. Ahmed, Elsayed Abdelkreem, MD, PhD. Combined Ketamine and Midazolam Versus Midazolam Alone for Initial Treatment of Pediatric Generalized Convulsive Status Epilepticus (Ket-Mid Study): A Randomized Controlled Trial Pediatric Neurology 167 (2025) 24e32

Bottom line: When used very late in status epilepticus, ketamine plus midazolam is better than midazolam alone, but we should be cautious of the limitations of this small single center study looking at a very different population than we are used to treating.

Spellberg B. The Policy to Override Policies-One Policy to Rule Them All. JAMA Intern Med. 2024 Dec 1;184(12):1408-1409. doi: 10.1001/jamainternmed.2024.4625. PMID: 39401007

This is the “deep thinker” of the month – a paper to make us reconsider about how we run our hospitals and who can make the pragmatic and potentially game-changing decisions whilst in the middle of busy practice. This describes a fascinating policy created in a single hospital that handed executive privileges to the coal-face clinical staff adn it seems to be a win-win for their hospital and patients.

If you listen into the podcast regularly then you will know that we sometimes disappear down nerdy rabbit holes ( I blame Justin!) – this month was no exception – we somehow got talking about the New World Screw-worm … so here is a picture or two to help you visualise the horror!

Welcome to the first episode of the Broomedocs podcast for 2025. Justin and I are back for more nerdy goodness to make you smarter in the Resus room, or at a pub trivia night more likley… wether it is about salt correction, dissection or infection we can help you out! Listen in and learn!

Or if you don’t have enough Youtube content featuring aging bearded men – you can watch over on Justin’s channel here:

Garcia SI, Jacobson A, Moore GP, Frank J, Gifford W, Johnson S, Lazaro-Paulina D, Mullan A, Finch AS. Airway, breathing, cellphone: a new vital sign? Int J Emerg Med. 2024 Nov 22;17(1):177. doi: 10.1186/s12245-024-00769-0. PMID: 39578750

Bottom line: This is a well done observational study that demonstrates an association between cell phone use and disposition to home, but I think the complexity really highlights the difficulty of making strong conclusions from observational data, and I can’t imagine that this data is at all helpful clinically. (I would be worried if people were using this as a data point to make medical decisions.)

Ayus JC, Moritz ML, Fuentes NA, Mejia JR, Alfonso JM, Shin S, Fralick M, Ciapponi A. Correction Rates and Clinical Outcomes in Hospitalized Adults With Severe Hyponatremia: A Systematic Review and Meta-Analysis. JAMA Intern Med. 2024 Nov 18:e245981. doi: 10.1001/jamainternmed.2024.5981. PMID: 39556338

Bottom line: This meta-analysis of observational data shows an association between slower sodium correction in severe hyponatremia and increased mortality. These results are not definitive, but considering the rarity of demyelination, and the magnitude of the mortality results, this should probably influence clinical practice until we get the proper RCTs.

WOMAN-2 Trial Collaborators. The effect of tranexamic acid on postpartum bleeding in women with moderate and severe anaemia (WOMAN-2): an international, randomised, double-blind, placebo-controlled trial. Lancet. 2024 Oct 26;404(10463):1645-1656. doi: 10.1016/S0140-6736(24)01749-5. PMID: 39461792

Bottom line: The WOMAN 2 trial is a large double-blind RCT that shows no benefit of TXA in the prevention of postpartum hemorrhage, which fits with all of the existing literature demonstrating no role for TXA in the management of postpartum hemorrhage. 

Full blog post here.

Yassi N, Zhao H, Churilov L, Wu TY, Ma H, Nguyen HT, Cheung A, Meretoja A, Mai DT, Kleinig T, Jeng JS, Choi PMC, Duc PD, Brown H, Ranta A, Spratt N, Cloud GC, Wang HK, Grimley R, Mahawish K, Cho DY, Shah D, Nguyen TMP, Sharma G, Yogendrakumar V, Yan B, Harrison EL, Devlin M, Cordato D, Martinez-Majander N, Strbian D, Thijs V, Sanders LM, Anderson D, Parsons MW, Campbell BCV, Donnan GA, Davis SM; STOP-MSU Trial Investigators. Tranexamic acid versus placebo in individuals with intracerebral haemorrhage treated within 2 h of symptom onset (STOP-MSU): an international, double-blind, randomised, phase 2 trial. Lancet Neurol. 2024 Jun;23(6):577-587. doi: 10.1016/S1474-4422(24)00128-5. Epub 2024 Apr 20. PMID: 38648814

We have covered TXA relatively extensively (probably too extensively for the value of the product) in the past, including previous negative trials in intracerebral hemorrhage.

Sim M, Sharma V, Li K, Gowland MH, Garcez T, Shilladay C, Pumphrey R, Patel N, Turner PJ, Boyle RJ. Adrenaline Auto-Injectors for Preventing Fatal Anaphylaxis. Clin Exp Allergy. 2024 Oct 9. doi: 10.1111/cea.14565. Epub ahead of print. PMID: 39383344

Morello et al., Diagnosis of acute aortic syndromes with ultrasound and D-dimer: the PROFUNDUS study.    European Journal of Internal Medicine, https://doi.org/10.1016/j.ejim.2024.05.029

You can listen to my 27-minute rant on Youtube here: https://youtu.be/j_ejoaVynXI

This multinational trial looked at a three-pronged diagnostic protocol in the ED for adults with suspected acute aortic syndromes.  The protocol used the ADD score, a POCUS echo protocol and D-dimer to try and exclude AAS in the ED.   They recruited 1979 patients with 9% ultimately diagnosed with AAS.  The bottom line was that they had ZERO misses at 30-day follow up.  They estimated that they would have prevented 40% of patients from requiring Advanced imaging.

ADD score is really a very blunt tool and does not add much to standard ED doc thinking.  Every patient got a “not simple” bedside echo and based on the ADD score and the echo findings was stratified as low or high pre-test probability.

The low risk group [1581 pt] got a Dimer (age adjusted was as good as < 500ng with more specificity ~6%) and either ruled out (none had a AAS if low PTP and negative dimer) or if positive went onto CT or MRI.  The dimer “caught another 36 patients with AAS”

The high risk group [398pts] – 40% ultimately ruled in for AAS – so they were very high risk!

If you could achieve this process in your ED – then great.  However, the elephant in the room is that the need to do a relatively comprehensive “expert level” POCUS exam on every patient makes this unfeasible in most places.  Some views eg. suprasternal views are tricky and niche.

I think that the protocol could be simplified and reversed in order such that clinical risk is high vs low.  Dimer is useful in the low risk group.  The high risk group, or those with a positive Dimer get a echo – primarily to either – speed up imaging if echo can see a flap (37 x RR of AAS)… or look for alternate diagnosis.  In this trial patients with echo findings got their scan at 1 hour vs 2 hours for the echo negative folk.

Problems with this trial 

– AAS patients do not present with a flashing light- we see them in the context of “chest pain” and it is difficult  to know from this inclusion criteria how these patients were selected as “having AAS as a meaningful diagnostic concern”.  Given the high burden of echo for all, it would be nice to have a more objective inclusion criteria?

– Does the ADD score really add much to simple gestalt/ commonsense? Justin will have clear thoughts on this!

– no echo images were formally recorded for QI or to assess interobserver reliability – this is a big miss as we know that echo is far from perfect – and this would have added some useful safety data (e.g. 1.4% of patients with a “flap” on echo had a normal CT or MRI…  I want to know how many had “inadequate views” as this is a real barrier to applying echo in ED practice.

– we do not know what the other 91% of cases were diagnosed with – that would be useful to know.  Did they pick a heap of PEs? Was echo useful in the 91% not having AAS?

Bottom Line: if you have access to expert echo skills this trial suggests that you could use it to achieve a very highly sensitive exam for AAS, it will probably also expedite thise with dissection into the OR.  However, you need to think about the opportunity:cost of echoing every patient with chest pain… there is probably a better way.

Weber EJ, Carlton EW. Side effects of decision rules, or the law of unintended consequences. Emerg Med J. 2019 Jan;36(1):2-3. doi: 10.1136/emermed-2018-208151. Epub 2018 Oct 25. PMID: 30361207

Dark P, Hossain A, McAuley DF, Brealey D, Carlson G, Clayton JC, Felton TW, Ghuman BK, Gordon AC, Hellyer TP, Lone NI, Manazar U, Richards G, McCullagh IJ, McMullan R, McNamee JJ, McNeil HC, Mouncey PR, Naisbitt MJ, Parker RJ, Poole RL, Rostron AJ, Singer M, Stevenson MD, Walsh TS, Welters ID, Whitehouse T, Whiteley S, Wilson P, Young KK, Perkins GD, Lall R; ADAPT-Sepsis Collaborators. Biomarker-Guided Antibiotic Duration for Hospitalized Patients With Suspected Sepsis: The ADAPT-Sepsis Randomized Clinical Trial. JAMA. 2024 Dec 9. doi: 10.1001/jama.2024.26458. PMID: 39652885

Bottom line: If you are willing to risk a substantial increase in mortality, you can cut back on antibiotic use by following a patient’s procalcitonin. 

B.BENNETT.  Doctrine of Signatures: An Explanation of Medicinal Plant :Discovery or Dissemination of Knowledge?’   Economic Botany, 61(3), 2007, pp. 246-255.

The Doctrine of Signatures asserts that the form of a plant reveals their therapeutic values.  Classic examples include the use of liverwort to treat hepatic ailments, bloodroot for blood disorders and walnuts for brain ailments.   My personal favourite is the use of saxifrage – its root are able to split rock as they grow in rocky outcrops – therefore it is used to treat renal stones!

The DOS has a long history dating back to many prehistoric peoples and modern day traditional herbalism in many remote parts of the world.

In the post-Renaissance era the DOS was largely ridiculed by the emerging European scientific community.  In 1825 Dr Hahnemann described it as “the folly of the ancients” – he then went on to found the concept of homeopathy….  

On its surface the Doctrine of Signatures does seem ludicrous – the resemblance of the roots of the common purslane to faecal worms lead it to be used by traditional American healers for intestinal worms?

The reality is much more fascinating.  Ethnobotanists have studied the relationships between form and function – the Europeans made a reverse attribution error.  Many of these plants do actually contain bioactive chemicals which have been used successfully for millennia – the shape of the leaf or root is simply an aide-memoire to recall the use in people with non-written languages.  No ancient people really thought that a heart-shaped leaf would cure heart disease due to its form.   – they simply used the form as a way of cataloging the natural pharmacopeia around them.  Turns out that purslane root is actually an effective anti-helmintic!

So before we ridicule our ancient forebears we should take a moment to consider what passes for medicine in 2025 with very little scientific study or benefit.  Just pop onto Youtube and you can find many influencers pushing various plants and herbal fixes based upon the literal and ridiculous assertion that form determines function in “alternate medicine” – clearly these folk have not learned from the wisdom of the ages.