26 October–1 November 2026 · EM Mastery Academy
1. Lithium toxicity: assess the patient and the trajectory
EMCrit 437 · 29 October · Educational refresher · Written notes reviewed; audio not reviewed
Study: An expert discussion with toxicologist–nephrologist Josh King revisits severe lithium poisoning and extracorporeal treatment.
Key finding: Neurological status, renal function and serial concentrations guide assessment. Existing EXTRIP recommendations support extracorporeal treatment for decreased consciousness, seizures or life-threatening dysrhythmias irrespective of lithium concentration.
Main caution: Treatment evidence is limited. Off-label gastrointestinal binders discussed in the episode have uncertain clinical benefit and should not become routine treatment solely on expert opinion.
Bedside takeaway: Involve toxicology and nephrology early in significant poisoning. Interpret concentration trends alongside the examination and kidney function, and plan monitoring for rebound after dialysis.
Read the review · EXTRIP recommendations. emcrit.org
2. TEE-guided CPR: better physiology is not proven clinical benefit
EMNerd/EMCrit · 30 October · Critical appraisal reviewed; original trial: Abstract-based brief
Study: A new appraisal revisits EXECT-CPR, a cluster-randomized trial of 132 adults reaching a Taiwanese ED with ongoing CPR after nontraumatic cardiac arrest.
Key finding: Sustained ROSC occurred in 44% with TEE-guided compression adjustment versus 39% with conventional CPR: adjusted odds ratio 1.21 (95% CI 0.64–2.29). Clinical outcomes did not differ significantly.
Main caution: The small trial was underpowered. It was published on 23 March 2026; only the appraisal is new this week.
Bedside takeaway: Avoid presenting TEE-guided compression adjustment as an established survival intervention. These findings do not resolve other diagnostic or procedural roles of resuscitative TEE.
Read the appraisal · Original trial. emcrit.org
3. More TIA workup is moving into the ED
JAMA Neurology · 26 October · Observational research · Abstract-based brief
Study: A repeated cross-sectional analysis examined a nationally representative US sample representing approximately 2.15 million adult TIA ED encounters during 2013–2021.
Key finding: The model-estimated probability of discharge increased from 45% to 66%. Among discharged encounters, estimated CT angiography use rose from 4% to 45%, and MRI use from 17% to 53%.
Main caution: These are weighted encounters and adjusted probabilities—not a prospective discharge trial. The study does not establish the safety of increased discharge.
Bedside takeaway: Audit whether your ED can deliver the necessary evaluation and dependable follow-up. Discharge trends elsewhere do not validate a local TIA pathway.
Mamer et al. · Read the paper. jamanetwork.com
4. Adding chlorhexidine did not improve the oral-care bundle
Critical Care · 29 October · Randomized research · Full paper reviewed
Study: A cluster-randomized crossover trial compared an oral-care bundle with or without 0.12% chlorhexidine in 1,035 ventilated adults across six medical ICUs at one Indian hospital.
Key finding: VAP incidence was 18.8 versus 16.9 per 1,000 ventilator-days with versus without chlorhexidine; adjusted incidence-rate ratio 1.08 (95% CI 0.84–1.38). No mortality benefit was demonstrated.
Main caution: Only six clusters contributed, VAP used a clinical-score definition, and quantitative bundle adherence was not recorded. This was an ICU study.
Bedside takeaway: Review routine chlorhexidine use with critical-care and infection-prevention teams. The finding concerns the added antiseptic, not abandonment of structured oral care.
Anushapreethi et al. · Read the paper. link.springer.com
5. A sepsis order set is only useful if it is used
JAMA Network Open · 29 October · Implementation research · Full paper reviewed
Study: A survey conducted in October–November 2025 examined sepsis-specific nurse-initiated standing orders across 68 Michigan hospitals.
Key finding: Thirty-nine hospitals had ED sepsis standing orders, but only eight of those 39 reported use in more than half of sepsis cases. Orders mainly enabled diagnostic testing; none included antibiotics.
Main caution: These were representatives’ reports, not observed patient-level adherence. The survey cannot demonstrate improved treatment times or outcomes.
Bedside takeaway: Audit activation, usability and the handoff from recognition to treatment. Identify whether delays arise from recognition, ordering, delivery or reassessment before adding another order set.
Deshpande et al. · Read the paper. jamanetwork.com
