It is almost impossible to summarize a year’s worth of medical research in a 15 minute talk, but given that limitation, here are the articles that I selected as the most interesting or important for this year’s North York General Emergency Medicine Update:
The RSI trial: Ketamine vs Etomidate
Casey JD, Seitz KP, Driver BE, et al. Ketamine or Etomidate for Tracheal Intubation of Critically Ill Adults. N Engl J Med. 2025 Dec 9. doi: 10.1056/NEJMoa2511420. Epub ahead of print. PMID: 41369227
In critically ill patients, ketamine and etomidate are probably mostly equivalent as sedatives. (However, if you were concerned that etomidate increased mortality before this trial, the 1% increase in mortality here in an under-powered trial probably won’t reassure you.)
Whole blood in trauma
Smith JE, Cardigan R, Sanderson E, Silsby L, Rourke C, Barnard EBG, Basham P, Antonacci G, Charlewood R, Dallas N, Davies J, Goodwin E, Hawton A, Hudson C, Lucas J, Keen K, Lyon RM, Nolan B, Perkins GD, Rundell V, Smith L, Stanworth SJ, Weaver A, Woolley T, Green L; SWiFT Trial Group. Prehospital Whole Blood in Traumatic Hemorrhage – a Randomized Controlled Trial. N Engl J Med. 2026 Mar 17. doi: 10.1056/NEJMoa2516043. Epub ahead of print. PMID: 41841706
This is the first RCT of whole blood in trauma patients, and it shows no benefit. I believe that outcome, but generalizability of this trial is extremely limited, given that they only randomized the first 2 units of blood, and everything after that was identical between the 2 groups.
ANDROMEDA SHOCK
ANDROMEDA-SHOCK-2 Investigators. Personalized Hemodynamic Resuscitation Targeting Capillary Refill Time in Early Septic Shock: The ANDROMEDA-SHOCK-2 Randomized Clinical Trial. JAMA. 2025 Oct 29:e2520402. doi: 10.1001/jama.2025.20402. PMID: 41159835
Given that this is an open label trial, mortality is completely unchanged, and the only difference seems to be 24 hours of renal replacement therapy – which is a subjective decision made by the unblinded clinicians – this is not a practice changer. That being said, sick septic patients clearly need resuscitation, you are going to need a target for resuscitation, capillary refill has good evidence as that target, and the components of their bundle are basically the things you are going to consider for resuscitation anyway – so the paper is worth reading carefully.
BONUS: OPTRESS
Endo A, Yamakawa K, Tagami T, et al. Efficacy of targeting high mean arterial pressure for older patients with septic shock (OPTPRESS): a multicentre, pragmatic, open-label, randomised controlled trial. Intensive Care Med. 2025 May;51(5):883-892. doi: 10.1007/s00134-025-07910-4. Epub 2025 May 13. PMID: 40358717
In this open-label RCT, targeting a higher MAP (80–85 mmHg) in older patients with septic shock appeared to cause harm, including an increased mortality. At this time, there is no role for routine high MAP targets, even in patients with chronic hypertension. Stick to a target of 65–70 mmHg and focus on clinical signs of good perfusion rather than chasing numbers.
Blood pressure management in ICH: treating numbers hurts patients
Shi AC, Taylor T, Huang CC, Singhal AB, Goldstein JN, Bevers MB, Hou PC. Early Intensive Blood Pressure Reduction After Intracerebral Hemorrhage Is Associated With Worse Functional Outcome: The Risk of Overshooting Blood Pressure Goals. Ann Emerg Med. 2025 Dec 9:S0196-0644(25)01303-4. doi: 10.1016/j.anneergmed.2025.10.009. Epub ahead of print. PMID: 41369631
Really, this retrospective dataset is not all that important by itself. However, when you remember that the two large RCTs on this topic have previously shown no benefit from managing blood pressure, it becomes very clear that this is a bad idea.
BONUS: Blood pressure management in spinal cord injury: treating numbers doesn’t help
Sajdeya R, Yanez ND, Kampp M, Goodman MD, Zonies D, Togioka B, Nunn A, Winfield RD, Martin ND, Kohli A, Huynh TT, Okonkwo DO, Poblete RA, Gilmore EJ, Chesnut RM, Bunnell AE, Ohnuma T, Hashemaghaie M, Treggiari MM. Early Blood Pressure Targets in Acute Spinal Cord Injury: A Randomized Clinical Trial. JAMA Netw Open. 2025 Sep 2;8(9):e2525364. doi: 10.1001/jamanetworkopen.2025.25364. PMID: 40965887
This is the first ever RCT asking this question. A target MAP of 65 resulted in the same neurologic outcomes as a target MAP of 85. There were more adverse events with higher blood pressure.
The Canadian Association of Radiology Contrast Allergy Guidline: Stop with the steroids
Byrne A, Macdonald DB, Kirkpatrick IDC, Pham M, Green CR, Copaescu AM, McInnes MDF, Ling L, Ellis A, Costa AF. CAR/CSACI Practice Guidance for Contrast Media Hypersensitivity. Can Assoc Radiol J. 2025 Aug;76(3):400-416. doi: 10.1177/08465371241311253. Epub 2025 Jan 11. PMID: 39797723
Depending on your hospital, this might be the most important paper of the year. They say very clearly: stop with the silly, prolonged steroid pretreatment bundles for contrast allergy. In addition to that game changing statement, there is plenty of excellent information in this paper.
Bed positioning in stroke
Alexandrov AW, Shearin AJ, Mandava P, Torrealba-Acosta G, Elangovan C, Krishnaiah B, Nearing K, Robinson E, Guthrie-Chu C, Holzmann M, Fill B, Trivedi DR, Richardson A, Middleton S, Brewer BB, Liebeskind DS, Goyal N, Grotta JC, Alexandrov AV; ZODIAC Investigators. Optimal Head-of-Bed Positioning Before Thrombectomy in Large Vessel Occlusion Stroke: A Randomized Clinical Trial. JAMA Neurol. 2025 Sep 1;82(9):905-914. doi: 10.1001/jamaneurol.2025.2253. PMID: 40465238
In patients waiting for endovascular therapy for large vessel occlusion strokes, having the head of the bed flat rather than at 30 degrees resulted in dramatically better short term neurologic findings and improved mortality. This is not definitive by any means, but you will hear about it.
DECAF trial – coffee and atrial fibrillation
Wong CX, Cheung CC, Montenegro G, Oo HH, Peña IJ, Tang JJ, Tu SJ, Wall G, Dewland TA, Moss JD, Gerstenfeld EP, Tseng ZH, Hsia HH, Lee RJ, Olgin JE, Vedantham V, Scheinman MM, Lee C, Sanders P, Marcus GM. Caffeinated Coffee Consumption or Abstinence to Reduce Atrial Fibrillation: The DECAF Randomized Clinical Trial. JAMA. 2025 Nov 9:e2521056. doi: 10.1001/jama.2025.21056. Epub ahead of print. PMID: 41206802
Atrial fibrillation patients were randomized to either consumption or or abstinence from coffee after they were cardioverted. The coffee consumption group actually had lower recurrence rates of atrial fibrillation.
Ozempic not related to post op aspiration
Chen YH, Zink T, Chen YW, Nin DZ, Talmo CT, Hollenbeck BL, Grant AR, Niu R, Chang DC, Smith EL. Postoperative Aspiration Pneumonia Among Adults Using GLP-1 Receptor Agonists. JAMA Netw Open. 2025 Mar 3;8(3):e250081. doi: 10.1001/jamanetworkopen.2025.0081. PMID: 40036031
Despite concerned about delayed gastric emptying, in a very large dataset, GLP1 agonists are not associated with an increased risk of aspiration pneumonia in patients undergoing surgery. (In fact, its the opposite.)
Really, this paper was just included to remind everyone of last year’s talk: Let them eat. NPO rules don’t make any sense.
Honourable Mentions
There was a ton of interesting research that couldn’t find a spot in a short conference summary, but here are a few papers that were on the list until the final draft of the talk:
Morgenstern J, Radecki R, Westafer L, Niforatos JD, Atkinson P. CJEM debate: clinical decision rules-thinking beyond the algorithm. CJEM. 2025 Feb 3. doi: 10.1007/s43678-025-00870-0. PMID: 39900742
OK, I probably wasn’t going to include this as a shameless plug, but I am always tempted to rant about decision rules and the demise of modern medicine. If you have never thought critically about whether your practice is better with or without decision rules, I recommend starting here.
Stiell IG, Taljaard M, Eagles D, Yadav K, Vadeboncoeur A, Hohl CM, Archambault PM, Birnie D, Brown E, Campbell SG, Chen Y, Clement CM, Cournoyer A, de Wit K, Emond M, Macle L, McRae AD, Mercier E, Morris J, Mohamad G, Nemnom MJ, Nicholls SG, Pare D, Parkash R, Sivilotti M, Thavorn K, Perry JJ. Vernakalant versus procainamide for rapid cardioversion of patients with acute atrial fibrillation (RAFF4): randomised clinical trial. BMJ. 2025 Nov 11;391:e085632. doi: 10.1136/bmj-2025-085632. PMID: 41218981
The value of this paper will depend on whether vernakalant is available to you, and whether you ever use chemical cardioversion for atrial fibrillation, but vernakalant looks like a better option than procainamide.
Muller G, Contou D, Ehrmann S, Martin M, Andreu P, Kamel T, Boissier F, Azais MA, Monnier A, Vimeux S, Chenal A, Nay MA, Salmon Gandonnière C, Lascarrou JB, Roudaut JB, Plantefève G, Giraudeau B, Lakhal K, Tavernier E, Boulain T; CRICS-TRIGGERSEP F-CRIN Network and the EVERDAC Trial Group.. Deferring Arterial Catheterization in Critically Ill Patients with Shock. N Engl J Med. 2025 Oct 29. doi: 10.1056/NEJMoa2502136. Epub ahead of print. PMID: 41159885
The value of arterial lines in emergency medicine probably deserves a full talk at the conference. Personally, I think we under use them in emergency medicine, but they are overused in ICU. This is an ICU RCT that showed no benefit of arterial lines over noninvasive BP monitoring.
Strayer RJ, Oliver M, Chen A, Gerges L, Caputo ND. The Impact of Suctioning on Oxygenation During Rapid Sequence Intubation in the Emergency Department: A Multi-Center Pilot Randomized Controlled Trial. J Emerg Med. 2025 Sep;76:88-94. doi: 10.1016/j.jemermed.2025.04.016. Epub 2025 May 22. PMID: 40533376
If Reuben Strayer had been speaking at EMU this year, like he often does, I would have probably tried to sneak this neat little RCT in. Basically, some people worry that if you leave suction in the pharynx throughout intubation, that could rob the patient of oxygen, and he designed an RCT to show that isn’t the case (with some important limitations).
Az A, Sogut O, Dogan Y, Akdemir T, Ergenc H, Umit TB, Celik AF, Armagan BN, Bilici E, Cakmak S. Reducing diltiazem-related hypotension in atrial fibrillation: Role of pretreatment intravenous calcium. Am J Emerg Med. 2025 Feb;88:23-28. doi: 10.1016/j.ajem.2024.11.033. Epub 2024 Nov 17. PMID: 39577214
When using diltiazem to treat atrial fibrillation, some people think that pretreating with calcium might be a good idea, to prevent hypotension. That is what this study purports to show, but I think there were some problems. Calcium probably has some minor hemodynamic effects, but when diltiazem is used correctly, adverse events are incredibly rare, and therefore there is really no reason for prophylaxis.
Othman AA, Sadek AA, Ahmed EA, Abdelkreem E. Combined Ketamine and Midazolam Versus Midazolam Alone for Initial Treatment of Pediatric Generalized Convulsive Status Epilepticus (Ket-Mid Study): A Randomized Controlled Trial. Pediatr Neurol. 2025 Mar 22;167:24-32. doi: 10.1016/j.pediatrneurol.2025.03.011. Epub ahead of print. PMID: 40186980
Ketamine definitely fits somewhere into the status epilepticus algorithm, but the children in this trial were simply seizing way too long for this to extrapolate directly to your practice.