🩺 THIS WEEK IN EM
🫀 Syncope Risk Stratification: The Canadian Syncope Risk Score Holds Up in the U.S.
Syncope is one of those complaints where everyone has a slightly different threshold to admit. Some lean on age, some on ECG findings, and some on the general sense that the patient looks like they are heading toward a bad outcome. The result is a lot of variability and a lot of admissions that may not change anything.
The Canadian Syncope Risk Score was built to bring some structure to that decision. In a 2026 prospective multicenter U.S. cohort of adults 40 years and older, patients with a score below 0 had strong negative predictive value for 30-day serious outcomes. That does not replace clinical judgment, but it does give you a more reproducible framework than pure gestalt.
For EM practice, that is the real value. This is not a magic discharge calculator. It is a way to make low-risk syncope decisions more consistent and more defensible when the rest of the evaluation fits.
Bottom line: In adults 40 years and older with syncope or presyncope and no serious diagnosis on initial ED evaluation, a low Canadian Syncope Risk Score identified a low-risk group with a 97.5% negative predictive value for 30-day serious adverse outcomes.
Suh EH, et al. Validation of 2 Syncope Risk Scores and Comparison With Physician Risk Estimation. JAMA Netw Open. 2026.
💉 Ketamine Procedural Sedation: Dose Does Not Drive Emergence
There has been a long-running assumption that higher ketamine doses automatically mean rougher emergence. This trial pushes back on that. In adult ED patients undergoing procedural sedation, 0.5 mg/kg IV and 1.0 mg/kg IV performed similarly for recovery agitation, duration, and overall sedation quality.
What seems to matter more is the recovery environment and the patient in front of you. Emergence reactions are still real, but they are not explained by dose alone. If you are worried about a messy recovery, the better move may be a quiet room and selective use of adjuncts rather than reflexively blaming the ketamine dose.
That is where the midazolam question belongs. It can reduce recovery agitation, but it is not a universal fix and it does not make the phenomenon disappear. The practical lesson is to think about the whole sedation, not just the ketamine number.
Bottom line: In one adult ED procedural sedation trial, 0.5 mg/kg IV ketamine and 1.0 mg/kg IV ketamine had similar rates of recovery agitation and similar overall sedation performance.
Türkücü Ç, et al. Comparison of the incidence of recovery agitation with two different doses of ketamine in procedural sedation: a randomized clinical trial. Acad Emerg Med. 2025.
🧪 Procalcitonin in Sepsis: Helpful for Stewardship, Not a Steering Wheel
Procalcitonin has spent years hovering in that uncomfortable space between promising biomarker and overhyped lab. ADAPT-Sepsis gives it a more defensible role. It did help reduce antibiotic duration, but the effect size was modest, and it did not suddenly turn procalcitonin into a substitute for bedside judgment.
That is probably the right way to think about it in EM. It may help in stewardship decisions, especially in selected respiratory cases, but it should not be the thing that talks you out of treating a patient you think is septic. The lab can support the decision. It should not be the decision.
That balance matters because it is easy to overread biomarker studies. ADAPT-Sepsis supports a modest stewardship benefit. It does not support turning procalcitonin into the main steering wheel for critically ill patients.
Bottom line: In ADAPT-Sepsis, procalcitonin-guided discontinuation shortened antibiotic duration by about 0.9 days and met noninferiority for 28-day mortality.
Dark P, et al. Biomarker-guided antibiotic duration for hospitalized patients with suspected sepsis: the ADAPT-Sepsis randomized clinical trial. JAMA. 2025.
🔭 Next Week
Oxygen targets in critical illness: Are we still aiming at the right saturation range?
HFNC vs NIV in acute respiratory failure: Is high-flow good enough, or are we getting too comfortable with it?
HEART score vs EDACS: Which chest pain tool actually helps disposition?
The Hallway Consult is built for EM clinicians who want the useful version of the literature. Forward it to a colleague if it helped.