Emergency Medicine

Faster sodium correction in severe hyponatremia linked to better 90-day outcomes

Among 13 988 adults admitted with serum sodium ≤120 mEq/L, 21% had 90-day death or delayed neurologic events. Compared with slow correction (<8 mEq/L/24 h), medium (8–12 mEq/L) and fast (>12 mEq/L) correction showed lower adjusted risk of the composite outcome. Absolute risk reductions with faster correction were greatest in patients with highest predicted baseline risk, though risk ratios were similar across strata. Outcomes and osmotic demyelination were identified from diagnostic codes, and residual confounding from illness severity or treatment selection is likely. These data argue against uniformly slow early correction in severe hyponatremia and support reconsidering guideline limits while still avoiding overshoot. 1

Low-dose thrombolysis improves intermediate high-risk PE clot burden but raises bleeding concerns

In this multicenter trial, 210 patients with intermediate high-risk PE were randomized to ultrasound-assisted low-dose alteplase, low-dose IV alteplase, or heparin alone. Low-dose thrombolysis, regardless of route, achieved greater reduction in CT-based thrombus score versus heparin alone. Ultrasound-assisted catheter delivery offered no additional thrombus reduction over IV alteplase; the mean difference in score change was negligible. Bleeding complications and death were numerically higher with low-dose thrombolysis, and other clinical outcomes were similar across groups. For ED patients escalated beyond anticoagulation, systemic low-dose alteplase appears sufficient, but net clinical benefit remains uncertain. 2

Mobile stroke units sharply reduce missed IV thrombolysis in eligible ischemic stroke

This BEST-MSU analysis included 927 ischemic stroke patients without guideline IV thrombolysis contraindications. Potential missed IVT occurred in 5.5% overall, but only 0.7% with mobile stroke units versus 12.6% with standard ED care. Lower NIHSS and longer last-known-well–to–door time independently predicted missed IVT when study group was omitted from models. Common documented reasons for withholding IVT were resolving symptoms, time-window concerns, and minor deficits. Among patients with missed IVT and 3-month outcomes, 39% were dead or functionally dependent, challenging therapeutic nihilism in “mild” strokes. 3

BRUE outcomes are excellent; serious diagnoses and deaths are rare and testing is low yield

This systematic review included 24 studies and 6603 infants meeting 2016 AAP criteria for brief resolved unexplained event. Serious underlying diagnoses were found in about 6% of infants, while 3‑month mortality was extremely low. Multiple BRUE episodes and prematurity increased risk of serious diagnosis, whereas age ≤60 days alone did not. Metabolic panels, ECGs, and chest radiographs had extremely low diagnostic yields with very high numbers needed to test. ED management should emphasize history for recurrent events and prematurity, selective testing, and strong reassurance about excellent prognosis. 4