Emergency Medicine

2015 CoSTR-era management modestly improves outcomes in nonshockable OHCA

Using Japan’s nationwide Utstein registry, investigators compared adults with witnessed nonshockable OHCA managed in the 2010 versus 2015 guideline eras. Among 73,874 eligible patients, 30-day neurologically intact survival was higher in the 2015 era after adjustment. For bystander-witnessed arrests, adjusted odds of neurologically intact survival were 1.175 (95% CI 1.014–1.362) versus the 2010 era. Similar benefit was seen in EMS-witnessed arrests, with no new safety concerns reported. Findings support system-level implementation of 2015 high-quality CPR recommendations even for nonshockable rhythms. 1

Video-assisted dispatcher assessment improves recognition of OHCA

A metropolitan dispatch center piloted a video-assisted protocol for calls where audio-only assessment left cardiac arrest status uncertain. Over six months, the protocol was used in 115 calls and led dispatchers to newly classify 15 additional cases as cardiac arrest. Fourteen of these 15 cases (93.3%) were confirmed as arrest on EMS arrival. Overall protocol sensitivity was 66.7%, with very high specificity at 98.9%. Results suggest that real-time video can enhance dispatcher recognition of OHCA and trigger earlier telephone CPR in borderline cases. 2

Day-4 de-escalation of broad-spectrum antibiotics in sepsis appears safe

This target trial emulation across 67 hospitals examined adults hospitalized with community-onset sepsis started on broad-spectrum antibiotics. Patients eligible for de-escalation of anti-MRSA or anti-Pseudomonas coverage on day 4 were compared with those who continued broad therapy. Weighted analyses showed similar 90-day mortality for de-escalation versus continuation for both anti-MRSA and anti-Pseudomonas regimens. De-escalation was associated with fewer antibiotic days to day 14 and shorter length of hospitalization. These data support planning for early narrowing of broad-spectrum therapy once cultures and clinical trajectory allow. 3

Emergent carotid stenting during EVT improves outcomes in tandem lesion stroke

The CERES-TANDEM multicenter cohort studied 4,053 adults with anterior circulation tandem lesions treated with EVT at 49 stroke centers. Most patients (2,522) underwent emergent carotid stenting during EVT, while 1,531 had EVT without stenting. After inverse probability weighting, stenting was associated with better 90-day modified Rankin outcomes (common OR 1.31; 95% CI 1.17–1.47). Odds of achieving mRS 0–1 and 0–2 were higher with stenting, without a statistically significant increase in symptomatic intracranial hemorrhage. Benefits were consistent across prespecified subgroups, supporting eCAS as a reasonable default when anatomically and procedurally feasible. 4