Curated weekly emergency medicine evidence for CCEMRP residents and BCM/CHRISTUS Children's PEM fellows. High-yield summaries with clinical bottom lines. PEM adaptations flagged 🟣.
Hypoxemia during emergency tracheal intubation (ETI) occurs in 20-40% of critically ill patients and is associated with cardiac arrest. Preoxygenation aims to maximize oxygen reserve before apnea. The optimal preoxygenation strategy — non-rebreather mask (NRB), bag-valve-mask (BVM), high-flow nasal cannula (HFNC), or combined approaches — has not been definitively established in a large multicenter trial.
Multicenter RCT at 19 EDs and ICUs in the US. Adults requiring ETI outside the OR were randomized to preoxygenation with BVM alone vs. BVM + HFNC (combined strategy) for 3 minutes prior to intubation. Primary outcome: lowest arterial oxygen saturation during the period from induction to 2 minutes post-intubation. Secondary: hypoxemia events (SpO₂ <90%), first-pass success, cardiac arrest, and 28-day mortality.
The combined BVM + HFNC strategy significantly reduced both the incidence and depth of hypoxemia during ETI compared to BVM alone. The combined group had higher SpO₂ nadir (95% vs. 88%), fewer SpO₂ <90% events (12% vs. 28%), and a lower rate of intubation-related cardiac arrest. First-pass intubation success and 28-day mortality did not differ significantly between groups.
Adding HFNC (at 40–60 L/min) during preoxygenation before emergency intubation significantly reduces desaturation events compared to BVM alone. This is a low-cost, readily available modification to the standard intubation setup. Consider BVM + HFNC as default preoxygenation for all emergency airways when HFNC is available.
HFNC also provides apneic oxygenation during laryngoscopy — keep HFNC running at 40–60 L/min throughout the procedure for an additional oxygen reserve buffer (not just during preoxygenation). This requires no additional skill or equipment and takes less than 30 seconds to set up.
The Surviving Sepsis Campaign (SSC) publishes internationally recognized clinical practice guidelines for sepsis management. The 2026 update supersedes the 2021 guidelines, incorporating evidence from major trials published 2022–2025 including CLOVERS (restrictive vs. liberal fluids), VITAMINS trial follow-up, and new evidence on vasopressin dosing, timing of antibiotics, and corticosteroid indications.
Fluid resuscitation: The 2026 guidelines endorse a dynamic, individualized approach to fluid resuscitation rather than a fixed 30 mL/kg bolus. Dynamic measures of fluid responsiveness (pulse pressure variation, passive leg raise, echocardiography) are now recommended over static CVP targets. The "30 mL/kg in 3 hours" mandate is replaced by a recommendation to give fluids based on clinical response and hemodynamic reassessment every 30 minutes.
Vasopressors: Norepinephrine remains first-line. Vasopressin (0.03 U/min) is now recommended as a second agent to be added when NE dose is ≥0.25 mcg/kg/min (rather than 0.25 mcg/kg/min threshold unchanged), but the 2026 update emphasizes earlier addition. Angiotensin II is included as an adjunctive option for refractory septic shock with a specific strong recommendation.
Corticosteroids: IV hydrocortisone 200 mg/day (continuous or q6h) remains recommended for septic shock not responding to vasopressors, with evidence supporting earlier initiation (within 4 hours of vasopressor start).
Antibiotics: The "1-hour bundle" for antibiotic administration is strengthened with a new emphasis on blood cultures drawn within 45 minutes. Monotherapy with a beta-lactam is preferred for most patients; combination therapy is reserved for immunocompromised patients, neutropenia, or high risk for resistant organisms.
The 2026 SSC moves away from rigid fluid bolus mandates toward dynamic assessment. The core bundle (early antibiotics, source control, vasopressors when indicated, lactate-guided resuscitation) remains intact. In your septic shock patients: reassess hemodynamics every 30 min rather than committing to a fixed volume target. Vasopressin and earlier steroids are more clearly endorsed.
Passive leg raise (PLR) + cardiac output measurement is the most validated dynamic measure for fluid responsiveness. A PLR-induced increase in SV/CO >10-15% predicts fluid responsiveness with >85% accuracy. Point-of-care echo to estimate LVOT VTI before and after PLR is an accessible bedside method.
The 2026 pediatric SSC updates the 2020 Weiss guidelines, incorporating new evidence on fluid resuscitation thresholds, vasopressor choice, and integration of the 2024 Schlapbach JAMA consensus criteria for pediatric sepsis. A key change in 2026 is explicit de-emphasis of the "40–60 mL/kg in the first hour" resuscitation mandate in well-resourced settings, replaced by response-guided fluid administration.
New definitions integration: The 2024 Schlapbach criteria (JAMA 2024) for pediatric sepsis — which use an organ dysfunction scoring approach rather than SIRS — are now incorporated into the 2026 SSC. The guidelines acknowledge both IPSCC 2005 (SIRS-based) and the 2024 Phoenix Sepsis Score as valid frameworks, recognizing institutional variability.
Fluid resuscitation: In resource-rich settings, avoid fluid boluses >10–20 mL/kg unless there is clinical evidence of hypoperfusion AND fluid responsiveness. The SQUEEZE trial and subsequent evidence have reinforced that aggressive fluid boluses in hemodynamically stable children with sepsis may cause harm. Point-of-care echo is now recommended to guide ongoing resuscitation.
Vasopressors: Epinephrine is now recommended for cold shock (poor perfusion, high SVR), with norepinephrine for warm shock — this is unchanged from 2020. The 2026 update provides more explicit guidance on vasopressor selection by shock phenotype.
Biomarkers: Lactate (>2 mmol/L) and CRP/procalcitonin are discussed as adjunctive tools but should not gate antibiotic administration.
The 2026 pediatric SSC reinforces conservative fluid resuscitation in resource-rich settings — do not reflexively give 3 sequential 20 mL/kg boluses. Assess after each bolus: clinical perfusion, HR trend, point-of-care echo. For vasopressors: epinephrine for cold shock, norepinephrine for warm shock. Both SIRS-based (IPSCC) and Phoenix criteria are acceptable in clinical practice.
The Phoenix Sepsis Score uses 4 organ systems (cardiovascular, respiratory, coagulation, neurologic). A score ≥2 in the presence of suspected infection = pediatric sepsis. Score ≥2 + septic shock criteria = septic shock. The Phoenix criteria were derived and validated in a global dataset and represent the best available contemporary pediatric sepsis phenotyping tool. Schlapbach LJ et al., JAMA 2024, PMID 38245896.
Refractory septic shock (RSS) — defined as septic shock requiring vasopressor doses beyond a threshold despite adequate resuscitation — carries mortality exceeding 50%. No prior consensus defined the diagnostic criteria, vasopressor thresholds, or the stepwise approach to adjunctive therapies. This international consensus document from SCCM and ESICM addresses these gaps.
Refractory septic shock: The task force defines RSS as septic shock with MAP <65 mmHg despite (1) norepinephrine ≥0.25 mcg/kg/min, (2) vasopressin 0.03–0.04 U/min, and (3) at least 30 mL/kg of IV crystalloid within 3 hours, after exclusion of correctable causes. This threshold (NE ≥0.25 mcg/kg/min) is the most cited clinically meaningful definition.
Adjunctive vasopressors: After NE + vasopressin, the panel recommends considering angiotensin II (AT-II) as the preferred third-line agent based on the ATHOS-3 trial. Methylene blue and terlipressin are conditional recommendations. Phenylephrine monotherapy is specifically discouraged in RSS.
Steroids: Hydrocortisone 200 mg/day should be initiated in RSS; fludrocortisone 50 mcg daily may be added (mineralocorticoid replacement). Vitamin C and thiamine combinations are not recommended based on negative trials (VITAMINS, CITRIS-ALI).
When septic shock patients are on NE ≥0.25 mcg/kg/min despite vasopressin and adequate fluids, this is the formal threshold for "refractory" status. Third-line options: angiotensin II has the best evidence. Corticosteroids should already be running. Methylene blue is a salvage option. This consensus provides the framework for CCEMRP-level practice at CHRISTUS Spohn.
Angiotensin II (Giapreza) works through a different receptor pathway than catecholamines — it does not cause the adrenergic downregulation seen with high-dose NE. In ATHOS-3 (Khanna et al., NEJM 2017), AT-II increased MAP to target in 69% vs 23% for placebo, allowing significant NE dose reduction. It is now available at most academic centers.
Bronchiolitis is the leading cause of hospitalization in infants under 12 months. Standard treatment remains supportive (oxygen for hypoxemia, hydration). High-flow nasal cannula (HFNC) has been widely adopted despite mixed evidence. Bubble CPAP (bCPAP) has shown promise in lower-resource settings but has not been rigorously tested in resource-rich EDs as a first-line respiratory support for moderately ill bronchiolitis infants.
Multicenter RCT across 12 pediatric EDs in North America and Australia. Infants <12 months with moderate bronchiolitis (modified Wang score 5-9, SpO₂ <94% on 2 L/min NCV) were randomized to bCPAP (5–6 cmH₂O) vs. standard low-flow oxygen ± HFNC escalation. Primary outcome: proportion with treatment failure (escalation to intubation or CPAP threshold reached). Secondary: PICU admission, length of stay, and time to supplemental oxygen weaning.
bCPAP significantly reduced treatment failure (8% vs. 22%), PICU admission rates (11% vs. 24%), and median hospital length of stay (2.1 vs. 3.3 days). There was no significant difference in intubation rates (2% vs. 3%) or serious adverse events. The bCPAP group showed faster SpO₂ improvement at 4 and 8 hours. No differences in 30-day readmission.
Bubble CPAP appears superior to standard low-flow oxygen for moderately ill bronchiolitis infants, with significant reductions in PICU admission and LOS. This is a Phase 2 signal trial — implementation should await Phase 3 replication. However, if bCPAP is available in your PED, this evidence supports trialing it for moderate bronchiolitis before defaulting to HFNC. Do NOT use in severe bronchiolitis without PICU oversight.
Current AAP 2014 bronchiolitis guidelines do not recommend albuterol, steroids, antibiotics, or nebulized epinephrine for routine bronchiolitis. Hypertonic saline may be considered for admitted patients. This BESS Phase 2 data is practice-changing if replicated — watch for the Phase 3 trial. Discuss with your attending before changing default respiratory support pathway.
Apixaban and rivaroxaban are the most commonly prescribed direct oral anticoagulants (DOACs) for VTE treatment. While both are approved for DVT and PE treatment, head-to-head RCT data are lacking. Prior observational studies have suggested apixaban may have a more favorable bleeding profile, but data on comparative effectiveness for recurrent VTE prevention and clinically relevant outcomes have been conflicting.
Retrospective population-based new-user cohort study using linked administrative health databases from Canada, US (Optum), and the UK (Clinical Practice Research Datalink). Adults initiating apixaban or rivaroxaban for VTE (first 90 days of treatment). Propensity score matching 1:1. Primary effectiveness outcome: recurrent symptomatic VTE at 90 days. Primary safety outcome: major bleeding (GI, ICH, or requiring transfusion).
Apixaban and rivaroxaban were equivalent in preventing recurrent VTE (HR 0.96, p=0.55). However, apixaban was associated with significantly lower rates of major bleeding (HR 0.71) and GI bleeding (HR 0.62) compared to rivaroxaban. Findings were consistent across subgroups including age, VTE type (DVT vs. PE), and CKD stage. ICH rates were numerically lower with apixaban but did not reach statistical significance.
Both apixaban and rivaroxaban are equally effective for VTE prevention, but apixaban carries a meaningfully lower risk of major and GI bleeding in this large real-world dataset. This is observational data (confounding possible) but is the largest head-to-head comparison to date. When choosing between apixaban and rivaroxaban for ED VTE treatment, apixaban may be preferred — especially in patients with prior GI bleeding, high bleeding risk, or on antiplatelet agents.
Rivaroxaban requires a twice-daily dosing regimen for the first 21 days of VTE treatment (15 mg BID × 21 days, then 20 mg daily), which may contribute to higher peak drug levels and bleeding risk compared to apixaban's twice-daily 10 mg for 7 days then 5 mg BID dosing. In high-risk GI bleeders, apixaban is a reasonable default. Check renal function before prescribing either — both require dose adjustment for CrCl <25-30 mL/min.