Episode Title: Nausea and Vomiting in the ED: A 2025 Network Meta-Analysis of What Works Best

Episode Summary: In this Lit Hit, we break down the 2025 systematic review and Bayesian network meta-analysis by deSouza et al. regarding pharmacologic therapies for nausea and emesis. We highlight the key evidence emergency clinicians need for rapid, informed decision-making, specifically looking at which agents prevent the need for rescue medications versus those that offer the best safety profiles. This short episode delivers high-yield takeaways you can apply on your next shift to balance efficacy with side effects.

What You’ll Learn

• Top Performers for Efficacy: If the goal is avoiding the need for a rescue drug, IV tropisetron and IV prochlorperazine (Compazine) are "definitely among the most effective" agents. IV tropisetron showed a 93.9% probability of being superior, though it is currently unavailable in the United States and Canada.
• The Problem with Oral Ondansetron: While widely prescribed, oral ondansetron was found to be "definitely among the least effective" single agents for preventing the need for rescue medication.
• The Safety vs. Efficacy Trade-Off: IV ondansetron is the safety winner. It is "most likely superior" for avoiding significant adverse reactions (sedation, akathisia, dystonia). In contrast, the agents with higher efficacy potential—IV metoclopramide (Reglan), IV promethazine (Phenergan), and IV droperidol—are "definitely among the most harmful" regarding these specific adverse effects.
• Droperidol's Role: In this specific analysis of undifferentiated nausea, IV droperidol was effective (reducing the need for rescue drugs) but carried a higher risk of adverse events (OR 3.70 vs placebo). Note that this study did not identify any life-threatening arrhythmias associated with droperidol.
• Metoclopramide's Standing: IV metoclopramide falls into the "possibly among the most effective" category for efficacy but is "definitely among the most harmful" regarding adverse reactions like akathisia.

Key Clinical Tip: Context matters. This study focused on undifferentiated nausea and excluded patients with gastroparesis or Cannabinoid Hyperemesis Syndrome (CHS). The authors note that for CHS and diabetic gastroparesis, droperidol is likely the superior choice over ondansetron or metoclopramide due to different pathophysiologic mechanisms, despite the side effect risks noted in the general population.

Primary Reference: deSouza, I. S., Allen, R., Shrestha, P., Thode, H. Jr., Koos, J., & Singer, A. (2025). Efficacy and Safety of Pharmacologic Therapies for Nausea and Emesis in the Emergency Department: A Systematic Review and Bayesian Network Meta-analysis. Annals of Emergency Medicine, 86, 646-658.

Additional Resources

• Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE-4): Alcohol Use Disorder and Cannabinoid Hyperemesis Syndrome Management.

Episode Title: Major Bleeding in the ED: A 2025 Practical Guide for Optimal Management

Episode Summary: In this Lit Hit, we break down the comprehensive 2025 review "Major Bleeding in the Emergency Department: A Practical Guide for Optimal Management" and highlight the key evidence emergency clinicians need for rapid, informed decision-making. This short episode delivers high-yield takeaways regarding risk stratification, the "lethal diamond," and specific resuscitation goals that you can apply on your next shift.

What You’ll Learn

• The "Lethal Diamond" replaces the "Lethal Triad": The classic triad of coagulopathy, acidosis, and hypothermia has been updated to include hypocalcemia. Calcium is essential for the coagulation cascade; clinicians should treat hypocalcemia aggressively (ionized calcium < 1.2 mmol/L) using calcium chloride (0.5–1.0 g per 500 mL of transfused blood) to prevent dysrhythmias and coagulation defects.
• Restrictive Fluid Resuscitation is Key: For initial stabilization, use balanced crystalloids rather than saline to avoid hyperchloremic acidosis, and limit volume to a maximum of 1–2 liters. Excessive fluid administration is associated with coagulopathy, organ failure, and increased mortality.
• Targeted Blood Pressure Goals:
• • General/Trauma: Aim for "permissive hypotension" with a systolic blood pressure (SBP) target of 80–90 mmHg until bleeding is controlled.
  • Traumatic Brain Injury (TBI): If GCS < 8, maintain Mean Arterial Pressure (MAP) > 80 mmHg to ensure perfusion.
  • Intracranial Hemorrhage (ICH): Target a SBP of 130–140 mmHg to prevent hematoma expansion.
• Massive Transfusion Ratios: While defined strictly for trauma, massive transfusion protocols (MTP) are recommended for all life-threatening bleeding to prevent delays. Evidence supports a ratio of 1:1:1 or 1:1:2 (plasma:platelets:RBCs).
• Tranexamic Acid (TXA) Indications:
• • Indicated: Trauma (within 3 hours), postpartum hemorrhage, and massive hemoptysis.
  • Not Indicated: Gastrointestinal (GI) bleeding. The HALT-IT study showed no mortality benefit and an increased risk of venous thromboembolism in severe GI bleeding.
• Anticoagulation Reversal Strategy:
• • DOACs: Use specific antidotes if available (Idarucizumab for dabigatran; Andexanet alfa for Xa inhibitors). If unavailable, use 4-factor Prothrombin Complex Concentrate (PCC) at 25–50 IU/kg.
  • Warfarin: PCC is preferred over Fresh Frozen Plasma (FFP) because it reverses INR faster, has lower volume, and avoids ABO cross-matching delays. Administer with Vitamin K.
• Risk Stratification with Shock Index (SI): Because hypotension may not appear until 30% of blood volume is lost, use the Shock Index (HR/SBP). An SI > 0.91 predicts the need for massive transfusion and increased mortality in trauma.

Key Clinical Tip: When managing cirrhotic patients with variceal bleeding, avoid FFP for coagulopathy reversal if possible. FFP adds significant volume, which can increase portal pressure and worsen bleeding. Instead, favor viscoelastic test (VET)-guided use of fibrinogen concentrate or PCC.

Primary Reference: Bezati, S.; Ventoulis, I.; Verras, C.; Boultadakis, A.; Bistola, V.; Sbyrakis, N.; Fraidakis, O.; Papadamou, G.; Fyntanidou, B.; Parissis, J.; et al. Major Bleeding in the Emergency Department: A Practical Guide for Optimal Management. J. Clin. Med. 2025, 14, 784.

Additional Resources:

• European Guideline on Management of Major Bleeding and Coagulopathy Following Trauma (2023)
• British Society of Gastroenterology Guidelines for Upper/Lower GI Bleeding
• International Society on Thrombosis and Haemostasis (ISTH) Guidelines

In this Lit Hit, we break down the emerging evidence on blood-based biomarkers for mild traumatic brain injury, focusing on GFAP and UCH-L1 and their role in emergency department decision-making. We highlight what these tests can (and can’t) do, how they perform compared with CT imaging, and where they may fit alongside existing clinical decision rules. This short episode delivers high-yield takeaways you can apply on your next shift when evaluating head-injured patients.

• Which biomarkers matter most right now:GFAP and UCH-L1 are the most clinically validated blood biomarkers for mTBI, with GFAP consistently outperforming others for detecting intracranial injury.

• What they’re good at:These biomarkers have high sensitivity and negative predictive value, making them most useful as rule-out tools for clinically significant intracranial injury.

• What they’re not good at:
  Specificity is modest—positive tests do not reliably confirm intracranial hemorrhage and should not replace CT.

• Timing matters:
  Biomarker levels rise early after injury (often within 1–6 hours) and are most useful within the first 12–24 hours.

• How this fits into ED workflow:Blood biomarkers may help reduce unnecessary CT scans in low-risk mTBI when used in conjunction with clinical decision rules (e.g., Canadian CT Head Rule), not as standalone tests.

• Key controversy / clinical tip:The major debate is whether these tests meaningfully change management beyond good clinical decision rules—use them as an adjunct, not a replacement, and be cautious in elderly patients, polytrauma, or those with extracranial injuries.

Primary reference: Blood-based biomarkers for mild traumatic brain injury (GFAP, UCH-L1 and related markers). Journal: International Journal of Emergency Medicine / related review literature, 2024–2025