The edition · Emergency & Critical Care
Nothing supports holding the home beta-blocker in suspected infection
A target trial emulation in 4,635 admissions found continuation associated with lower 90-day mortality; a pupillometer adds little to a torch after arrest; AI raises fracture sensitivity most for the juniors reading the film; and more bupivacaine does not make a better nerve block.
The edition in brief
Five findings for the emergency and critical care desk. A target trial emulation at one US academic emergency department took 4,635 adults on chronic beta-blockers admitted with suspected infection — blood cultures plus broad-spectrum antibiotics — excluding those in shock or with extreme heart rates; only 25.3% had their beta-blocker continued within 48 hours. Continuation was associated with lower 90-day all-cause mortality (hazard ratio 0.77, 95% CI 0.61–0.98) and shorter stay, though in-hospital mortality did not differ significantly. In 442 comatose patients after cardiac arrest at two European centres, quantitative pupillometry correlated closely with electroencephalogram, evoked potentials and neuron-specific enolase, and a Neurological Pupil index of 2 or less was 99% specific for poor outcome at 34% sensitivity — but the ordinary bedside pupillary light reflex was more sensitive at comparable specificity, and no pupillometry threshold predicted good outcome well. A meta-analysis of 17 studies found AI assistance raised pooled fracture detection sensitivity from 73% to 87% with specificity unchanged at about 95%, with junior clinicians gaining 21 absolute percentage points. A four-arm randomised dose-finding study in 220 emergency department patients with headache found no advantage to larger doses of bupivacaine in sphenopalatine ganglion block, with sustained relief between 19% and 35% across all arms. And a 20-patient retrospective series described dexmedetomidine infusion as bridge sedation for severely agitated adolescents, with 45% still needing additional sedation.
The pupillometer does not beat the torch after cardiac arrest
Use pupillometry for reproducible documentation within multimodal prognostication, and do not treat it as more informative than a carefully performed bedside pupillary examination.
AI raises fracture detection sensitivity by 14 points, and most for juniors
Where AI fracture assistance is available, use it as a second read alongside your own — and keep the same low threshold for cross-sectional imaging when the plain film is negative but the patient is not.
More bupivacaine does not make a better sphenopalatine block
If you perform a sphenopalatine ganglion block, use 1 mL of 0.5% bupivacaine per side — the larger doses bought nothing.
Dexmedetomidine as a bridge for the agitated adolescent waiting for a psychiatric bed
Consider a dexmedetomidine infusion only where continuous monitoring and a defined escalation plan exist — and expect about half of patients to need additional sedation anyway.
A normal lactate does not unwrite the shock
Treat lactate as a trend and one input among several — a normal value does not exclude shock and a raised one does not establish it.
Continuing the home beta-blocker in suspected infection was associated with lower mortality
In a patient with suspected infection who is not in shock and whose heart rate is between 40 and 120, continue the home beta-blocker rather than holding it by default.
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