🩺 THIS WEEK IN EM
PERC-Peds (BEEPER): Ruling Out PE in Children Without Imaging
Adult EM has had PERC for years. Pediatrics has had little evidence-based guidance, so a lot of kids with chest pain or dyspnea get a D-dimer and, often, a CT angiogram. PERC-Peds is a pediatric version of the rule, and BEEPER is a large prospective test of whether it works.
This was a prospective, observational diagnostic accuracy study at 21 US pediatric EDs. It enrolled a consecutive series of children aged 4 to 17 whose emergency physician ordered, or strongly considered ordering, a test for PE. Clinicians recorded the PERC-Peds components at the bedside, and all other testing, including D-dimer, was left to clinician discretion. The criterion standard was any image-proven PE or proximal DVT within 45 days, adjudicated by an independent committee of three pediatric emergency physicians.
Of 4,039 children enrolled, 4,011 were adjudicated and 3,988 had complete data. The median age was 15, and 64% were female. PE or proximal DVT was found in 6.3%. PERC-Peds had a sensitivity of 99.6% (95% CI 97.8 to 100.0) and a false-negative rate of 0.1% (95% CI 0.0 to 0.8), well within the prespecified safety threshold (an upper confidence limit below 1.5%). But specificity was only 19.6%. PERC-Peds is safe when it's negative, but it was negative in only about one in five children who turned out not to have VTE. Used in sequence with D-dimer, PERC-Peds followed by a D-dimer ruled out PE or proximal DVT in 54.3% of patients, with a false-negative rate of 0.9% (95% CI 0.6 to 1.4).
Two cautions. This was an observational accuracy study, not a trial of using the rule to change management. And the median age was 15 (IQR 13 to 16), so the data are likely thinner for younger children.
Bottom line: In about 4,000 children aged 4 to 17 with suspected PE across 21 US pediatric EDs, a negative PERC-Peds had a 0.1% false-negative rate for PE or proximal DVT at 45 days. It rules out a minority of patients on its own (specificity 19.6%), but the authors conclude a negative PERC-Peds can safely rule out PE without a D-dimer or imaging. PERC-Peds followed by a D-dimer ruled out more than half (54.3%).
Ellison AM, Kuppermann N, Shihabuddin BS, et al. PERC-Peds rule for bedside exclusion of pulmonary embolism without radiation in children in the USA (BEEPER): a multicentre, prospective, observational, diagnostic accuracy study. Lancet Respir Med. 2026;14(8):694-703.
Modified vs. Standard Valsalva for SVT: A Meta-Analysis
Vagal maneuvers are first-line for stable SVT, and the standard Valsalva usually doesn't work. The modified Valsalva adds a step after the strain: the patient is laid flat and their legs are raised. It's free, it takes a minute, and this meta-analysis asks how much it actually adds.
The authors pooled randomized controlled trials comparing the modified with the standard maneuver for converting SVT to sinus rhythm in hemodynamically stable ED patients. They searched through March 2026 and assessed risk of bias with the Cochrane RoB 2 tool. Nine trials with 1,415 patients were included.
The modified Valsalva converted 50.1% of patients versus 18.8% with the standard maneuver (pooled RR 2.63, 95% CI 2.22 to 3.11). The trials were very consistent (I² = 0%). No major adverse events were reported in either group. The authors call for more trials in children and head-to-head comparisons with drugs.
Bottom line: Across nine RCTs and 1,415 stable ED patients with SVT, the modified Valsalva (strain, then lie flat with the legs raised) converted about half of patients, versus about one in five with the standard Valsalva (RR 2.63), with no major adverse events. That supports the modified maneuver as the safe, cheap first-line vagal attempt, though head-to-head comparisons with drugs are still needed.
Tesch J, Ruziska C, Urie C, et al. Effectiveness of the modified Valsalva maneuver vs the standard Valsalva maneuver for the conversion of supraventricular tachycardia to normal sinus rhythm in the emergency department: a systematic review and meta analysis. Intern Emerg Med. 2026;21(7):2723-2731.
PRESC1SE-MI: Does a 1-Hour Troponin Pathway Get Patients Out Faster?
The 0/1-hour high-sensitivity troponin pathway is guideline-recommended in Europe, and the pitch is simple: if you can rule out MI two hours sooner, patients should leave sooner. PRESC1SE-MI tested that pitch directly.
This was an international, pragmatic, stepped-wedge, cluster-randomized trial at 19 hospitals in 10 countries. Hospitals that were using a 0/3-hour pathway were randomized to switch to 0/1 hours after either 6 or 12 months. The trial included 67,624 consecutive ED presentations with suspected MI; 8.7% had an adjudicated MI. The coprimary outcomes were safety (death or new type 1 MI at 30 days) and efficacy (ED length of stay).
The 1-hour pathway met its prespecified noninferiority criterion for safety. Death or new type 1 MI occurred in 1.1% with 0/1 hours versus 1.2% with 0/3 hours (adjusted OR 0.93, 95% CI 0.77 to 1.13). But it didn't make the ED faster. The median ED length of stay was 309 minutes in both groups (ratio 1.00, 95% CI 0.97 to 1.02, P=0.65). The authors conclude that implementing the 0/1-hour pathway alone shouldn't be expected to improve throughput.
The US experience is mixed. RACE-IT, a stepped-wedge randomized trial across 9 Michigan EDs with 32,609 patients, found that a 0/1-hour hs-cTnI protocol didn't increase safe ED discharges compared with 0/3 hours plus a modified HEART score (57.8% vs. 59.5%, aOR 1.05), with 30-day death or MI at 0.4% in both groups (aOR 0.84, 95% CI 0.43 to 1.68). A prespecified secondary analysis did find fewer downstream tests: fewer stress tests (3.3% vs. 3.9%), fewer cardiology consults (8.6% vs. 12.2%), fewer left heart catheterizations, and a median ED stay about 20 minutes shorter. That's a secondary analysis, but it's the one place a 1-hour pathway moved throughput.
Bottom line: In 67,624 ED presentations across 10 countries, switching from a 0/3-hour to a 0/1-hour hs-troponin pathway was safe (30-day death or type 1 MI 1.1% vs. 1.2%) but didn't shorten ED length of stay (309 vs. 309 minutes). The US RACE-IT trial also found no increase in safe discharges, though it showed fewer stress tests and consults. A 1-hour pathway is safe to adopt, but don't expect it alone to fix ED throughput.
Boeddinghaus J, Bima P, Crisanti L, et al. Safety and efficacy of the 0/1 h pathway for myocardial infarction in the emergency department: an international, pragmatic, stepped-wedge, cluster-randomised, controlled trial. Lancet. 2026;408(10567):1941-1952.
Miller J, Cook B, Gandolfo C, et al. Rapid Acute Coronary Syndrome Evaluation Over One Hour With High-Sensitivity Cardiac Troponin I: A United States-Based Stepped-Wedge, Randomized Trial. Ann Emerg Med. 2024;84(4):399-408.
Miller J, Cook B, Gunaga S, et al. Health Care Resource Utilization for Patients With Suspected Myocardial Infarction: A Secondary Analysis of the RACE-IT Randomized Clinical Trial. JAMA Netw Open. 2025;8(4):e256930.
🔭 Next Week
Intermediate-risk PE, from both ends: Does admitting sPESI 2–3 patients with negative biomarkers actually change mortality in a 6,400-patient VA cohort? And for the ones who need a procedure, how does large-bore thrombectomy stack up against catheter-directed lysis in a 550-patient RCT?
Bicarb in cardiac arrest: A double-blind, placebo-controlled trial across 21 Danish hospitals finally tests the amp of bicarb we push mid-code.
Antibiotics for cirrhotic GI bleeds: Guidelines say 5–7 days of prophylactic antibiotics. A Bayesian meta-analysis of 14 RCTs asks how much evidence actually stands behind that number.
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— The Hallway Consult team