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ACS/ACRM 2024 TBI best-practice update

The revised ACS/ACRM TBI best-practices guidance spans acute and longitudinal care. The official ACS release highlights advanced neuromonitoring for intracranial pressure and cerebral oxygenation, blood-based biomarkers to help characterize injury severity and guide imaging decisions, tiered intracranial-pressure management, early multidisciplinary rehabilitation, and prophylactic antiseizure medication for patients at high risk of early post-traumatic seizures.

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2025 ACS guidance: reperfusion, antithrombotics and anemia

The updated ACS guideline integrates STEMI and NSTE-ACS care. It recommends emergency culprit-vessel revascularization in cardiogenic shock, with no routine concurrent PCI of other arteries. For ACS with anemia without active bleeding, transfusion to maintain hemoglobin around 10 g/dL may be reasonable; this is a weak recommendation, not a universal transfusion mandate.

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2026 PE guideline: severity categories connect risk to disposition

The first AHA/ACC multisociety acute PE guideline introduces categories A–E to connect severity with outpatient care, admission and advanced therapy. It emphasizes prompt anticoagulation and prefers DOACs over vitamin K antagonists when appropriate.

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2025 AHA adult ALS: IV first; avoid unproven arrest adjuncts

The 2025 adult ALS guideline recommends attempting IV access first during adult cardiac arrest; IO is reasonable when IV access fails or is infeasible. Head-up CPR is not recommended outside clinical trials. POCUS for reversible causes or prognostication remains insufficiently established.

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ANDROMEDA-SHOCK-2: personalized resuscitation improved a hierarchical composite

In 1,467 analyzed patients with early septic shock, a personalized protocol targeting capillary refill normalization improved a hierarchical composite of death, duration of vital support, and hospital stay versus usual care. The difference was driven mainly by shorter vital support, rather than demonstrated mortality reduction.

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ARISE FLUIDS: early vasopressors did not improve hospital-free survival

This trial randomized 1,000 adults presenting to EDs with septic shock to restricted fluids with earlier vasopressors or more fluids with later vasopressors. Among 963 patients in the intention-to-treat population, median days alive and out of hospital at day 90 were 76 in both groups.

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BIHCA: routine bicarbonate did not improve sustained ROSC

In this double-blind trial at 21 Danish hospitals, routine IV sodium bicarbonate did not improve sustained ROSC after in-hospital cardiac arrest. Of 913 randomized patients, 779 were eligible for the primary analysis.

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ESO/EANS 2025: ICH care without premature prognostic limits

This GRADE guideline updates spontaneous ICH management across 37 clinical questions. It favors stroke-unit care and advises against using the ICH score alone to determine prognosis. For minor-to-moderate ICH, it suggests early controlled systolic BP lowering below 140 mmHg while avoiding excessive reductions.

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IDSA 2025: shorter cUTI treatment and earlier oral switch

IDSA suggests shorter treatment for improving cUTI: 5–7 days of an effective fluoroquinolone or 7 days of another effective antibiotic. It also supports IV-to-oral transition when patients improve, tolerate oral medication and have an active oral option. Duration starts on the first effective treatment day.

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LOGICAL: conservative oxygen did not improve functional survival

This trial enrolled 1,840 ventilated adults who remained unresponsive after cardiac arrest. Conservative oxygen did not improve favorable functional survival at 180 days compared with a liberal strategy.

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PRoMPT BOLUS: balanced fluid did not reduce major kidney events

In this pragmatic trial at 47 EDs, balanced fluid and saline produced similar major adverse kidney event rates in children treated for suspected septic shock. Of 9,041 enrolled, 8,482 remained for analysis after withdrawal without permission to use data.

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RSI: ketamine did not improve survival and increased cardiovascular collapse

This multicenter trial assigned 2,365 critically ill adults undergoing intubation to ketamine or etomidate. In-hospital mortality by day 28 was similar, while cardiovascular collapse during intubation occurred more often with ketamine.

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SSC 2026 adults: immediate treatment, repeated reassessment and conditional fluid targets

The adult update provides 129 statements, including 46 new statements. For ED care, it retains rapid antibiotics for shock or probable/definite sepsis, permits rapid investigation for possible sepsis without shock, and frames initial fluids as a conditional recommendation requiring repeated reassessment.

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SSC 2026 children: reassess each bolus and recognize limited evidence

The pediatric update provides 61 statements, but only three recommendations have high- or moderate-certainty evidence. In settings with intensive care availability, it conditionally suggests up to 40–60 mL/kg during the first hour, using repeated small boluses and reassessment.

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SWiFT: two units of whole blood were not superior to blood components

Across ten English air ambulance services, prehospital whole blood did not reduce death or massive transfusion within 24 hours compared with red cells and plasma. Of 942 randomized patients, 616 were analyzed after exclusions including nontraumatic hemorrhage and traumatic cardiac arrest.

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BALANCE: seven days for selected bloodstream infections

BALANCE randomized 3,608 hospitalized patients with bloodstream infection to 7 or 14 days of antibiotics. Ninety-day mortality was 14.5% versus 16.1% (difference −1.6 percentage points; 95.7% CI −4.0 to 0.8), meeting the prespecified 4-point noninferiority margin. More than half were in an ICU at enrollment.

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DISTAL: no disability benefit from routine distal-vessel thrombectomy

DISTAL randomized 543 patients with selected medium/distal intracranial occlusions to EVT plus medical care or medical care alone within 24 hours. Ninety-day disability did not improve (common OR 0.90; 95% CI 0.67–1.22; P=.50). Symptomatic intracranial hemorrhage occurred in 5.9% versus 2.6%.

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ESCAPE-MeVO: no functional benefit and concerning safety signals

ESCAPE-MeVO randomized 530 patients with medium-vessel ischemic stroke and favorable imaging within 12 hours to EVT plus usual care or usual care alone. Excellent 90-day outcome occurred in 41.6% versus 43.1% (adjusted rate ratio 0.95; 95% CI 0.79–1.15). Mortality and symptomatic intracranial hemorrhage were numerically higher with EVT.

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IVIO: easier access did not translate into more sustained ROSC

IVIO randomized 1,506 adults with nontraumatic OHCA; 1,479 entered the primary analysis. Sustained ROSC occurred in 30% with IO-first versus 29% with IV-first access (RR 1.06; 95% CI 0.90–1.24; P=.49), despite greater two-attempt access success with IO.

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PARAMEDIC-3: IO-first access did not improve survival

PARAMEDIC-3 randomized 6,082 adults with OHCA requiring drug access to an IO-first or IV-first strategy. Thirty-day survival was 4.5% versus 5.1% (adjusted OR 0.94; 95% CI 0.68–1.32; P=.74). Favorable neurologic outcome at discharge was 2.7% versus 2.8%.

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REMAP-CAP: fixed-course hydrocortisone did not show a large mortality benefit

This adaptive platform comparison assigned 658 ICU patients with severe CAP to hydrocortisone 50 mg IV every 6 hours for 7 days or no corticosteroid. Enrollment stopped for futility. Ninety-day mortality was 15.0% versus 9.8%; stratum-specific adjusted ORs were 1.52–1.63, with all 95% credible intervals crossing 1.

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SAHARA: liberal transfusion did not establish neurologic benefit

SAHARA randomized 742 critically ill adults with aneurysmal SAH and anemia to liberal or restrictive transfusion. Unfavorable 12-month neurologic outcomes occurred in 33.5% versus 37.7% (RR 0.88; 95% CI 0.72–1.09; P=.22). Adverse-event incidence was similar.

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ACMT fentanyl incidental-exposure statement

ACMT states that incidental proximity or dermal contact with street fentanyl does not cause opioid intoxication and that routine handling requires standard precautions rather than extraordinary decontamination. It recommends nitrile gloves for routine handling, prompt soap-and-water washing after incidental dermal exposure, eye and face protection when splash is possible, and naloxone for objective hypoventilation rather than failure to awaken.

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O’CAFÉ: optional AF decision support did not significantly increase anticoagulation

O’CAFÉ was a pragmatic stepped-wedge cluster randomized trial across 13 community EDs in 9 clusters testing physician education, facility-level audit and feedback, and optional atrial-fibrillation decision support among 1,203 anticoagulation-initiation-eligible adults discharged home with primary AF or flutter. Anticoagulation was initiated by ED discharge or within 30 days in 63.0% of control encounters versus 68.4% during intervention; the adjusted OR was 1.33 (95% CI 0.75-2.35; P=.13), so the intervention did not significantly improve the primary outcome.

PREOXI: a better start before intubation

PREOXI randomized 1,301 critically ill adults to NIV or an oxygen mask before intubation. Hypoxemia (SpO2 <85%) occurred in 9.1% versus 18.5% (absolute difference -9.4 percentage points; 95% CI -13.2 to -5.6).

AAP 2026: pediatric UTI diagnosis and treatment

The 2026 AAP guideline expands UTI guidance to medically noncomplex children from 8 days through 5 years and uses GRADE methodology. It suggests antibiotic courses of 7 days or less for most children, with age- and syndrome-specific durations, and recommends oral rather than hospitalization-requiring parenteral or sequential therapy for children older than 28 days and younger than 5 years who tolerate oral treatment and do not otherwise require admission. It also updates post-UTI imaging, including renal/bladder ultrasonography after a first febrile UTI and a suggestion against routine VCUG when ultrasonography is normal.

VASSPR: earlier vasopressin did not reduce mortality

VASSPR was a pragmatic, open-label, cluster-randomized cluster-crossover strategy trial across 13 US hospitals involving 3,959 adults receiving vasopressors for septic shock. Hospitals alternated between recommending fixed-dose vasopressin 0.03 U/min when other vasopressors reached 0.1 versus 0.4 micrograms/kg/min norepinephrine-equivalent. Twenty-eight-day mortality was 31.8% versus 33.0% (adjusted marginal OR 0.98, 95% CI 0.87-1.06; adjusted risk difference -0.4 percentage points, 95% CI -2.7 to 1.3), with no difference in kidney replacement therapy-free days.

CLOVERS: fluids first, or earlier vasopressors?

CLOVERS randomized 1,563 adults after initial fluid resuscitation to a restrictive strategy prioritizing vasopressors or a liberal fluid strategy. Death before discharge home by day 90 occurred in 14.0% versus 14.9% (difference -0.9 percentage points; 95% CI -4.4 to 2.6; P=0.61).

DEVICE: first-pass success with video laryngoscopy

In 1,417 critically ill adults, video laryngoscopy achieved first-pass success in 85.1% versus 70.8% with direct laryngoscopy (difference 14.3 percentage points; 95% CI 9.9 to 18.7). Severe complications occurred in 21.4% versus 20.9% (difference 0.5 points; 95% CI -3.9 to 4.9).