Does REBOA in the emergency department save lives?
REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta) is explored as a potential emergency department tool to control life‑threatening torso bleeding and buy time for surgery. However, a major UK Bayesian trial evaluating its effectiveness was stopped early after 90 patients due to evidence of harm. The study found higher mortality in the REBOA group, early signs of increased risk within hours of use, and delays to definitive haemorrhage control. Although the methodology was robust, challenges such as small sample size, severe patient illness, and limited device deployment influenced outcomes. Overall, the findings suggest routine ED use of REBOA should be reconsidered in favour of rapid surgical intervention, while future research may explore different patient groups or alternative REBOA techniques.
Are the serratus anterior blocks the solution to rib # management?
The SABER trial evaluated whether adding a serratus anterior plane block to standard care improves pain control for patients with rib fractures in the emergency department. This multicentre pragmatic study of 210 patients found a significant improvement in early pain relief and indications of reduced complications, including lower 30‑day mortality and fewer respiratory issues. However, concerns around internal validity—such as missing data, lack of blinding, small sample size, and inconsistent documentation—raise questions about the reliability of the findings. With multiple secondary outcomes and potential for therapeutic drift, the study highlights both the promise and the uncertainty surrounding serratus anterior blocks. Future research will require larger, blinded, multicentre trials, though these are challenging to fund and deliver within emergency medicine.
Do crystalloids trump human albumin solution in sepsis resuscitation?
This discussion reviews a feasibility study comparing balanced crystalloids with 5% human albumin solution for early sepsis resuscitation in UK emergency departments. While albumin was associated with a higher 30‑day mortality rate, the study found no clinically meaningful difference between the two fluids. Given the results and clinicians’ strong preference for crystalloids, the evidence supports continuing crystalloids as the first‑line resuscitation fluid for sepsis in the ED.
Acute aortic dissection – Who should get a CT aortogram?
Acute aortic syndrome (AAS) is a rare but life‑threatening condition that is frequently difficult to diagnose, with many cases initially missed or delayed. It can present with chest, back, or abdominal pain, or signs of poor perfusion, making early suspicion crucial. Recent studies—including ASUS and DASH—are reshaping imaging guidance, as current recommendations advise CT aortography only in patients with high‑risk features. Tools such as the Aortic Dissection Detection Risk Score (ADDRS) and D‑dimer testing can support decision‑making, though both have limitations in specificity. International guidelines vary in their approach, and modelling suggests that some strategies could lead to unmanageable increases in CT scanning. Ultimately, clinical judgment remains central: patients with obvious red‑flag symptoms require immediate CTA, while those with mild or ambiguous findings should be assessed using risk scores alongside thoughtful documentation. Alternative methods such as bedside ultrasound may help in selected cases, but diagnosis often remains challenging, reinforcing the need for vigilance and careful clinical reasoning.
Do clinical decision rules help in the diagnosis of aortic dissection?
This discussion explores the role of clinical decision rules—such as ADDRS, AORTS, and the Canadian score—in diagnosing acute aortic syndromes, using real patient examples and findings from the multicentre DASH cohort study. While decision tools show high test positivity and often uncover alternative diagnoses on CT, the evidence suggests that clinician judgment consistently outperforms these rules, demonstrating excellent diagnostic accuracy. The session also reviews what makes a robust diagnostic accuracy study, the limitations of current tools—including bias, poor generalisability, and “mission creep”—and the risk of over‑relying on structured scores. Despite these challenges, decision rules can still support clinicians when used alongside experience and careful documentation. Future research may compare clinical judgment directly with rule‑based strategies, but for now, the emphasis remains on thoughtful, clinician‑led assessment.
Is double sequential defibrillation the answer to refractory VF?
This session reviews a major 2022 NEJM study comparing defibrillation strategies for refractory ventricular fibrillation, including standard defibrillation, vector change, and double sequential external defibrillation (DSED). Conducted as a cluster‑randomized crossover trial across six Canadian EMS systems, the study enrolled adults with refractory out‑of‑hospital cardiac arrest and found markedly higher survival to hospital discharge with DSED compared to the other techniques. However, the trial was stopped early and under‑powered, raising concerns about bias, generalisability, and the risk of both false‑positive and false‑negative findings. While DSED showed no evidence of harm, its use requires additional equipment, coordination, and training that may limit feasibility in some settings. Vector change remains a practical alternative where dual defibrillation is not possible. Ultimately, implementation is challenging, and further robust research is needed before DSED can be considered standard practice, though some centres are already exploring alternative pad positions or dual‑shock strategies.
How accurate is CT in the diagnosis of subarachnoid haemorrhage?
This discussion examines the diagnostic pathway for suspected subarachnoid haemorrhage (SAH), using the case of a patient presenting with sudden severe headache and a CT scan performed more than six hours after onset. A major validation study of over 3,600 patients showed that CT within six hours has very high sensitivity for SAH, but accuracy declines significantly beyond that window, creating uncertainty in cases scanned later. The study also evaluated the SAH clinical decision rule, which showed high sensitivity but poor specificity and limited external validity. Challenges include defining what constitutes a clinically important haemorrhage and recognising that aneurysmal bleeds carry the greatest risk. External validity, prevalence differences, and limitations in the evidence all affect how widely the findings can be applied. While MRI offers no advantage over CT, the results support shared decision‑making and selective omission of lumbar puncture in appropriate patients. Ultimately, the study informs safer diagnostic decisions, highlights legal defensibility based on best evidence, and guides emergency clinicians in balancing risk, resource use, and the potential harms of unnecessary admission or invasive testing.
What is the best oxygenation strategy in trauma patients?
This discussion reviews the Tromox‑2 multicentre randomized trial, which investigated whether a restrictive oxygen strategy—targeting saturations around 94%—improves outcomes for trauma patients compared with the liberal oxygen doses historically recommended by guidelines. Conducted across 1,900 patients in several European countries, the study found no significant difference between the two groups in the composite outcome of death or major respiratory complications, and subgroup analyses showed similar results across patient types, including those with severe head injury. Strengths included its pragmatic, real‑world design, while limitations involved its open‑label nature and reliance on a composite outcome. The broader evidence base increasingly supports cautious, individualized oxygen use rather than routine high‑flow oxygen, highlighting the potential harms of hyperoxia and the lack of proven benefit from liberal oxygenation. The conversation encourages a more nuanced, patient‑centred approach to oxygen therapy, tailoring treatment to avoid both hypoxia and unnecessary oxygen exposure.