You are stabilising a 34‑year‑old STEMI at 3 a.m. or admitting a 45‑year‑old with necrotising pancreatitis and triglycerides of 1400 mg/dL.

In those moments, dyslipidemia can feel like someone else’s follow‑up problem. The 2026 ACC/AHA Dyslipidemia Guideline is a polite but firm reminder that it is your problem too.

This guideline replaces the 2018 “blood cholesterol” document and expands the focus to LDL‑C, triglycerides, and lipoprotein(a), with an explicit goal: reduce lifelong exposure to atherogenic lipoproteins and prevent recurrent events. For acute care physicians, this means aligning in‑hospital decisions with long‑term targets rather than leaving lipids to vague outpatient plans.

Big picture: what actually changed?

Three shifts matter in acute care:

• From “current LDL” to “lifetime exposure”
  The guideline emphasizes early lifestyle and pharmacologic treatment in youth and young adults, especially those with familial hypercholesterolemia (FH) or LDL‑C ≥160 mg/dL with strong family history of premature ASCVD. The rationale is simple: event risk in the ED often reflects decades of cumulative LDL burden.​

• From Pooled Cohort Equations to PREVENT
  For adults 30–79 years with LDL‑C 70–189 mg/dL and no clinical or subclinical ASCVD, the PREVENT‑ASCVD equations replace the Pooled Cohort Equations for 10‑ and 30‑year risk estimation. Categories are:​

  • Low: <3%

  • Borderline: 3–<5%

  • Intermediate: 5–<10%

  • High: ≥10% 10‑year risk.​
    As an acute physician, you may not open a calculator mid‑resus, but you should know that risk tools have changed and now explicitly incorporate 30‑year risk for 30–59‑year‑olds.​

• From “start a statin” to “hit a target”
  LDL‑C and non‑HDL‑C goals are back. Secondary prevention and high‑risk groups now have targets like LDL‑C <70 mg/dL for all ASCVD and <55 mg/dL for very‑high‑risk or heavy CAC. Your discharge prescriptions should be written with these numbers in mind.

In the ED and ICU: what should you actually do?

1. Treat every ACS as a lipid intervention opportunity

For any patient with clinical ASCVD (ACS, prior MI, stroke, PAD):

• Start or escalate to high‑intensity statin (e.g., atorvastatin 40–80 mg, rosuvastatin 20–40 mg) during the index admission unless contraindicated.​

• The goal in “standard‑risk” ASCVD is:

  • ≥50% reduction in LDL‑C, and

  • LDL‑C <70 mg/dL with non‑HDL‑C <100 mg/dL (Class I).​

For very high‑risk ASCVD (e.g., multiple events, multivessel coronary disease, diabetes plus ASCVD):

• The recommended goal is:

  • LDL‑C <55 mg/dL and non‑HDL‑C <85 mg/dL.​

• If your patient is already on a high‑intensity statin and clearly above these targets, document the need to add ezetimibe and/or a PCSK9 monoclonal antibody as soon as feasible (Class IIa).​

Your role: make sure high‑intensity statin is started, contraindications are documented, and the discharge summary explicitly states the LDL‑C target and the need to escalate if it is not met.

2. Recognise severe hypercholesterolemia and FH in young MI

In a 30‑ or 40‑year‑old with MI:

• If LDL‑C is ≥190 mg/dL, this is severe hypercholesterolemia and often FH.​

• The guideline recommends:

  • High‑intensity statin as a baseline.

  • For those without ASCVD, additional non‑statins (ezetimibe, PCSK9 mAb, bempedoic acid) to reach LDL‑C <100 mg/dL and non‑HDL‑C <130 mg/dL are Class I.​

  • If there is clinical ASCVD or confirmed HeFH/high CAC, targets tighten to LDL‑C <70 or <55 mg/dL depending on risk, with combination therapy recommended.​

Your role: identify these patients early, flag possible FH, and ensure the team plans family screening and multi‑drug therapy rather than “MI at 35, statin alone”.

3. Manage hypertriglyceridemia to prevent pancreatitis and later events

For patients presenting with severe hypertriglyceridemia, especially with pancreatitis:

• TG ≥1000 mg/dL:

  • Very low‑fat diet, restricted refined carbohydrates, complete elimination of alcohol and added sugars, plus referral to a registered dietitian nutritionist are Class I recommendations to lower TG and prevent pancreatitis.​

  • In familial chylomicronemia syndrome with TG ≥1000 mg/dL, olezarsen (apoC3 inhibitor) is recommended as adjunct to diet to reduce pancreatitis risk (Class I).​

• TG 500–999 mg/dL:

  • Similar aggressive lifestyle measures plus pharmacologic TG‑lowering (fibrates or omega‑3 ethyl esters), tailored to clinical context.​

Once the acute phase is controlled, statins remain the backbone of long‑term ASCVD risk reduction in these patients.​

Your role: in pancreatitis and severe hyperTG, act decisively in the first 24–48 hours on diet, secondary causes, and TG‑lowering therapy, and then ensure a plan to start/intensify statins is documented for follow‑up.

4. Use admissions to trigger Lp(a) and future risk workup

The guideline recommends measuring lipoprotein(a) once in all adults for ASCVD risk assessment (Class I).​

For emergency/hospital physicians, practical opportunities include:

• Young or “unexpected” MI or stroke.

• Patients with premature ASCVD in multiple family members.

• Recurrent events despite “acceptable” LDL‑C.

Elevated Lp(a) (≥125 nmol/L or ≥50 mg/dL) is a risk‑enhancing factor associated with ~1.4‑fold higher ASCVD risk; ≥250 nmol/L or ≥100 mg/dL roughly doubles risk. In those with ASCVD and elevated Lp(a), adding a PCSK9 mAb with proven CV benefit when LDL‑C goals are not met is recommended (Class I).​

Your role: in high‑yield cases (young MI, stroke, heavy family history), order Lp(a) during admission and hand off its interpretation to cardiology or lipid clinic with a note that elevated levels warrant more intensive LDL‑C lowering.

Risk tools and imaging: what do you need to know?

PREVENT equations (C‑P‑R model)

You may not be the one running risk calculators in the ED, but you will see PREVENT‑derived risk printed in discharge summaries. For adults 30–79 with LDL‑C 70–189 mg/dL and no ASCVD or subclinical disease, PREVENT‑ASCVD equations are now the preferred tool (Class I).​

The guideline recommends a C‑P‑R framework:​

• Calculate PREVENT 10‑year (and 30‑year if 30–59 years).

• Personalise with risk enhancers (e.g., Lp(a), ApoB, adverse pregnancy history, CKM syndrome, inflammatory disease).

• Reclassify with Coronary Artery Calcification (CAC) if decisions remain uncertain in intermediate or select borderline risk patients.

For acute care physicians, the key is recognising that borderline risk is no longer “ignore” territory; it’s a zone where risk enhancers and CAC can tip you toward statins.

CAC and incidental findings

Coronary artery calcium is now a major decision tool:

• In intermediate‑risk and selected borderline‑risk adults with no ASCVD, if you’re unsure about LLT, CAC should be used (Class I).​

• CAC thresholds tie directly to LDL‑C goals:

  • CAC 100–299 or ≥75th percentile: recommend LLT to LDL‑C <70 and non‑HDL‑C <100.​

  • CAC 300–999: treat to at least LDL‑C <70, and it is reasonable to intensify toward <55 and non‑HDL‑C <85 (I/IIa).​

  • CAC ≥1000: treat like very‑high‑risk ASCVD with LDL‑C <55 and non‑HDL‑C <85 (Class I).​

Importantly, incidental CAC on non-cardiac CT (e.g., HRCT chest, CT aorta, CTKUB) “should be considered” in LLT decisions (Class I).​

Your role: when you see “moderate‑severe coronary calcification” in a CT report on an ED or ward patient, don’t ignore it. Document that this is subclinical ASCVD and that aggressive LLT and risk factor modification are indicated.

Triglycerides, diet, and the RDN: practical bedside moves

The lifestyle section may seem “clinic‑heavy”, but there are ED/ward implications:

• For TG ≥1000 mg/dL, involving an RDN is Class I; for TG 150–999 mg/dL with CKM features it is reasonable (IIa).​

• Core diet messages for acute care:

  • Eliminate alcohol in severe hyperTG and pancreatitis.

  • Restrict total fat in TG ≥1000 mg/dL, and reduce added sugars and refined carbs across hyperTG strata.​

  • Encourage modest weight loss (5–10%) and progressive physical activity once stable.​

You may not design the whole diet plan, but putting “RDN referral” and “alcohol elimination” into your initial orders is now guideline‑aligned.

New drugs: what you need to recognise by name

You will increasingly see these agents in medication histories and discharge plans:

• PCSK9 mAbs (evolocumab, alirocumab)

  • Indicated for severe hypercholesterolemia and very‑high‑risk ASCVD not at LDL‑C goals despite maximally tolerated statin ± ezetimibe (Class I/IIa).​

• Bempedoic acid

  • Oral agent recommended or reasonable in severe hypercholesterolemia and ASCVD when LDL‑C remains above goal on statin ± ezetimibe or in statin‑intolerant cases (Class I/IIa).​

• Inclisiran

  • Twice‑yearly siRNA, reasonable in severe hypercholesterolemia or very‑high‑risk ASCVD when PCSK9 mAbs are not tolerated or available, or when less frequent dosing is preferred (IIa; outcomes pending).​

• Olezarsen

  • ApoC3 inhibitor recommended in familial chylomicronemia with TG ≥1000 mg/dL to reduce TG and pancreatitis (Class I).​

Your role is not to initiate these from the ED in most settings, but to recognise their indications, avoid harmful drug interactions, and avoid inadvertently stopping them on admission unless absolutely necessary.

Where this guideline is strong, and where you should be cautious

Strengths for acute care:

• Clear Class I mandates for high‑intensity statin use in all appropriate ASCVD admissions.​

• Explicit LDL‑C and non‑HDL‑C targets that make discharge planning goal‑oriented.​

• Structured handling of severe hyperTG and pancreatitis risk, including diet and new therapies.​

• Integration of Lp(a), ApoB, and CAC to explain “why did this young patient infarct?”​

Cautions from the ED/ICU perspective:

• Complexity: PREVENT, risk enhancers, ApoB, Lp(a), CAC, and multiple LDL targets are too much to carry in memory; local protocols and order sets will be crucial.​

• US‑centric risk: PREVENT is not calibrated for South Asians and may underestimate risk; for Indian patients, have a lower threshold to treat.​

• Resource constraints: routine Lp(a), ApoB, CAC and advanced drugs may not be widely available; you may need to adapt the principles (aggressive statin, early identification of FH) to what is feasible in your context.​

At first glance, the 2026 Surviving Sepsis Campaign guidelines look familiar.
Same bundles. Same urgency. Same resuscitation priorities.

But look closer.

This is not a routine revision.
It’s a philosophical shift — from protocol-driven sepsis care to context-aware, system-level, precision acute care.

And if you work in the emergency department or ICU, this changes how you think — not just what you do.

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What Changed (and Why It Matters)

1. Sepsis is now a system problem, not just a bedside problem

2026:

• Performance improvement programs + quality improvement (QI)
  → Strong recommendation, moderate certainty of evidence

• Introduction of:

  • “Code sepsis” / sepsis huddle
    → Conditional recommendation, low certainty

2021:

• Performance programs recommended
  → Strong, moderate-quality evidence (screening)

What changed?

QI is no longer administrative — it’s therapeutic.

Acute care takeaway:

You’re not just treating septic shock anymore.
You’re part of a hospital-wide intervention system.

2. Antibiotics: The death of the “1-hour rule for everyone”

2021:

• Antibiotics within 1 hour for all sepsis
  → Strong recommendation (low/very low evidence)

2026:

• Septic shock / high suspicion → immediate antibiotics

• Possible sepsis (no shock) → investigate, give within 3 hours

• Low likelihood → defer antibiotics

👉 Evidence:

• Strong (shock)

• Weak / very low (non-shock)

Why this matters:

A major pivot toward antimicrobial stewardship

Acute care reality:

You now need to balance:

• Delay = harm

• Overuse = harm

That’s a harder — and more honest — guideline.

👉 Dosing strategy finally gets attention

Prolonged infusion of beta-lactams over bolus dosing
→ Weak recommendation, moderate-quality evidence

Why this matters

• Aligns with PK/PD principles

• Improves time above MIC, especially in:

  • Septic shock

  • Altered pharmacokinetics

Practical takeaway

• Start thinking beyond “which antibiotic”

• Move toward:
  👉 How you give it matters as much as what you give

Antibiotics don’t just start early — they must stop early

👉 Daily assessment for de-escalation based on culture and susceptibility
→ Weak recommendation, very low-quality evidence

👉 Avoid prolonged broad-spectrum therapy once pathogen is identified

Why this matters

This is a major philosophical shift:

• Earlier guidelines focused on early administration

• 2026 emphasizes early de-escalation

Acute care takeaway

• Antibiotics are not a one-time decision

• They are a dynamic therapy

👉 Start broad (when needed)
👉 Narrow early (when possible)

3. Screening: Less faith in qSOFA, more in broader tools

2021:

• Against using qSOFA alone
  → Strong recommendation, moderate-quality evidence

2026 reinforces and clarifies:

👉 Use NEWS, NEWS2, MEWS, or SIRS over qSOFA as a single screening tool
→ Strong recommendation, moderate certainty of evidence

Also adds:

• Prehospital screening
  → Conditional, very low evidence

Why this matters

qSOFA was attractive because it was simple.
But simplicity came at the cost of sensitivity.

👉 The 2026 guideline firmly moves away from qSOFA as a standalone tool.

Acute care takeaway

• Stop relying on qSOFA alone

• Use early warning scores + clinical judgment

• Screening is not a number — it’s a system + process

4. Fluids: The quiet downgrade

2021:

• 30 ml/kg fluids
  → Weak recommendation, low-quality evidence (downgraded)

2026 direction:

• Reinforces individualized resuscitation

• Moves away from rigid fluid mandates

Takeaway:

The guideline no longer believes in “one-size-fits-all fluids”

5. Lactate, CRT, and monitoring: still here, still weak

• Lactate-guided resuscitation
  → Weak, low-quality evidence

• Capillary refill time
  → Weak evidence

Translation:

We use them.
We trust them.
But the evidence is still not strong.

6. Adjuncts: Less enthusiasm, more skepticism

Strong:

• No starch → Strong, high-quality evidence

• Norepinephrine first-line → strong

Weak / against:

• Vitamin C → Weak against

• Hemoperfusion → Weak against

Pattern:

Most adjuncts either:

• Don’t work

• Or don’t have good evidence

7. Ventilation: One of the few stable areas

• Low tidal volume → Strong, high-quality evidence

• Proning → Strong, moderate-quality evidence

• HFNC over NIV → Weak, low-quality evidence

Insight:

Respiratory care remains one of the most evidence-consistent domains

8. New emphasis: survivorship and transitions of care

2026 expands into:

• Goals of care discussions

• Post-sepsis syndrome

• Transitions of care

Mostly:
👉 Best practice / weak evidence

Shift:

Sepsis is no longer an ICU event.
It is a longitudinal disease process

If you remember only few things from 2026:

• Think before antibiotics (unless shock)

• How you give antibiotics (infusion strategy) matters

• De-escalate early — stewardship is core care

• Fluids are individualized, and type matters

What This Means: A Critical Appraisal

a). The uncomfortable truth: Evidence is still weak

Across domains:

• Antibiotics (non-shock) → very low certainty

• Fluids → low certainty

• CRT/lactate → low certainty

• Code sepsis → low certainty

👉 Despite decades of research, high-certainty evidence is limited

b). The “GRADE paradox”

The guideline uses structured GRADE methodology:

• “We recommend” → strong

• “We suggest” → conditional

But:

👉 Strong recommendations sometimes sit on low-quality evidence (especially earlier guidelines)
👉 Many new recommendations remain conditional

💡 Implication:

This is transparent science — but still uncertain medicine

c). From protocols → clinical judgment

Old era:

• Bundles

• Timelines

• Protocol compliance

2026:

• Diagnostic probability

• Stewardship

• Context-aware decisions

This is the real shift:

The guideline now expects thinking, not just following

d). The antibiotic pivot is the most practice-changing update

Before:

• Everyone gets antibiotics early

Now:

• Timing depends on:

  • Severity

  • Probability of infection

Clinical reality:

You are now balancing:

• Sepsis mortality vs antimicrobial harm

This is harder — but more accurate.

e). Real-world applicability (especially LMIC settings)

The guideline acknowledges:

• Resource variability

• Need for adaptable systems

💡 Interpretation:

• “Code sepsis” may help more in chaotic, resource-limited systems

• Protocols alone don’t fix outcomes without infrastructure

f). The deeper truth: Sepsis remains poorly understood

Even in 2026:

• Few high-certainty interventions

• Many weak recommendations

• Heavy reliance on physiology and pragmatism

👉 Sepsis is still a syndrome, not a single disease

The 2026 Surviving Sepsis Guidelines don’t give you more answers.
They give you better questions.

And in the resuscitation bay at 3 AM —
that might be exactly what we needed.

Source -

SSC 2026 guidelines update

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The 2026 ACG Clinical Guideline reframes HE as a systems disease, not just a biochemical one. When combined with ACC 2022 ICU care principles, it demands a shift in how we triage, investigate, and treat these patients.

1. HE Is Not “Just Ammonia”

The Three Villages + Five Axes Framework

The guideline introduces a conceptual model that should anchor bedside thinking:

“Three Villages of HE”

• Village 1 – Pathogenesis (gut–brain axis, inflammation, ammonia, sarcopenia)

• Village 2 – Impact (patients, caregivers, healthcare systems)

• Village 3 – Multidisciplinary care (ED, hepatology, ICU, rehab, social systems)

HE is now classified across five axes:

1. Type (A/B/C)

2. Severity (West Haven)

3. Time course

4. Precipitated vs non-precipitated

5. Social infrastructure (NEW)

👉 Game changer:
You must now ask:

“Can this patient actually survive outside the hospital?”

• Covert HE → Overt HE → Recurrent admissions → Cognitive decline

• ED clinicians often see patients too late in this curve

2. Covert/Minimal HE (CHE/MHE): The Missed Diagnosis in ED

Who should trigger suspicion?

• Hypoalbuminemia

• Decompensated cirrhosis

• Portal hypertension/shunts

• Falls, traffic violations, navigation issues

• Subtle cognitive complaints

👉 Key ED pearl:
Isolated asterixis ≠ OHE

How to test (NOT ammonia)

• Single-test strategy (ACG recommendation)

• Practical tools:

  • Stroop / EncephalApp

  • Animal Naming Test

  • Critical Flicker Frequency

❌ Do NOT use ammonia to diagnose CHE

Treatment: “Theragnostic trial”

• Lactulose (4–8 week trial)

• Reassess cognition + function

Useful in ED follow-up planning and liaison clinics

3. “Is This Really HE?” — The Cognitive Differential

“Cirrhosis + Cognitive Complaint Pathway”

More than 50% of suspected HE ≠ HE

Common mimics:

• Dementia / MCI

• Depression / PTSD

• Obstructive sleep apnea

• Substance use

• Metabolic/endocrine disorders

👉 ED shift:
Stop reflex lactulose escalation → start structured differential evaluation

4. Overt HE in ED & ICU

Triage: Who Needs Admission?

“Admission Decision Flowchart”

Admit if:

• Grade 3–4 HE

• First episode

• Infection, bleed, AKI

• Poor social support

Strong Recommendations That Change Practice

• Lactulose for OHE (strong)

• Secondary prophylaxis after first episode (strong)

• Add rifaximin for recurrence (strong)

• Protein 1.2–1.5 g/kg/day (strong)

• Branched Chain Amino Acid (BCAA) —> if needed (strong)

• Rifaximin pre-TIPS (strong)

🚨 What to STOP Doing

• Routine ammonia testing

• Routine CT brain without focal deficit

👉 A normal ammonia ≠ no HE
👉 HE = clinical diagnosis of exclusion

5. Acute Management: ED + ICU Integration (ACG 2026 + ACC 2022)

Acute HE Treatment Algorithm

First-line (ED + ICU)

Lactulose

• Oral/NG: every 1–2 hrs → 2–3 soft stools

• Enema if needed

⚠️ Avoid overuse → dehydration, hypernatremia

See more about Lactulose in HE, here

PEG (Alternative)

• Faster resolution in trials

• Useful if ileus/bloating

Rifaximin

• Add in recurrent HE

• Consider early in severe ICU cases

ACC 2022 ICU Principles (Add These to Your Workflow)

Airway & Neuroprotection

• Intubate if:

  • GCS ≤ 8

  • Aspiration risk

• Avoid oversedation (benzodiazepines worsen HE)

Hemodynamic & Metabolic Targets

• Maintain MAP ≥ 65 mmHg

• Correct:

  • Hypokalemia

  • Hyponatremia

  • Hypoglycemia

Infection Control

• Low threshold for antibiotics

• Sepsis = major precipitant

ICP & Cerebral Edema (Severe HE / ACLF)

• Head elevation

• Avoid hypercapnia

• Consider hypertonic saline if needed

Nutrition (Critical Update)

• DO NOT restrict protein

• ICU patients may need up to 2 g/kg/day

6. Nonresponse at 48–72 Hours

📌 Insert Figure 9 here – “Nonresponse Algorithm”

If not improving:

1. Reconsider diagnosis

2. Re-look for precipitants

3. Evaluate for:

   • TIPS

   • Large shunts

👉 Do NOT just increase lactulose blindly

7. Preventing Recurrence

“Recurrence Prevention Pathway”

Core Strategy

• Lactulose (target 2–3 stools/day)

• Rifaximin (↓ recurrence 58%)

System-Level Changes

• Use Bristol stool scale

• EMR alerts/order sets

• Patient education tools

Deprescribing (Critical ED Role)

Stop/minimize:

• Benzodiazepines

• Opiates

• Gabapentinoids

• Z-drugs

• PPIs (when inappropriate)

Nutrition & Sarcopenia

• Protein: 1.2–1.5 g/kg/day

• Late-night snack

• Exercise programs

👉 Muscle = ammonia buffer

8. TIPS, Refractory HE & Transplant

TIPS-related HE

• Start rifaximin 14 days before TIPS

• Continue ≥ 6 months

Refractory HE

• Consider:

  • Shunt embolization

  • TIPS revision

Transplant Implications

• HE underestimates MELD risk

• Consider transplant even at low MELD

👉 Early referral if:

• Recurrent HE

• Grade III–IV

• Persistent cognitive decline

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References

1. Bajaj JS, Jakab SS, Jesudian AB, et al. ACG Clinical Guideline: Hepatic Encephalopathy. Am J Gastroenterol. 2026;121:588-618. doi:10.14309/ajg.0000000000003899

2. Vilstrup H, Amodio P, Bajaj J, et al. Hepatic Encephalopathy in Chronic Liver Disease: 2022 Practice Guidance. Hepatology. 2022;76(3):1027-1040. doi:10.1002/hep.32477
   
   

Sepsis management in emergency and acute care does not fail because we lack guidelines.
It fails when we mistake protocol compliance for physiologic care.

Across emergency departments, wards, and ICUs, the modern understanding of sepsis is evolving. The shift is subtle but profound:

From rigid bundles → to individualized, physiology-guided resuscitation.

For acute care clinicians, this is not an academic nuance. It is the difference between fluid overload and organ recovery. Between delayed vasopressors and preserved perfusion. Between antibiotics alone and definitive source control.

Let’s break this down pragmatically.

1️⃣ Sepsis Is a Time-Critical Emergency — Like STEMI or Stroke

We would never wait for ST elevation to “fully declare itself” before activating a cath lab.
We should not wait for hypotension before activating a sepsis response.

Early recognition hinges on identifying:

• Suspected infection plus

• Evidence of organ dysfunction

Not just shock.

Red flags at the front door:

• Altered mentation

• Tachypnea

• Rising oxygen requirement

• Oliguria

• Cool or mottled extremities

• Elevated lactate despite preserved BP

The dangerous patient is often the one with “normal blood pressure.”

This is cryptic shock — where hypoperfusion precedes hypotension.

Acute care clinicians must integrate early warning scores with clinical gestalt. No scoring system replaces bedside judgment.

2️⃣ The First Hours Matter — But Not All Fluids Are Beneficial

The traditional 30 mL/kg reflex has simplified thinking — but oversimplification carries harm.

Excess fluid leads to:

• Pulmonary edema

• Delayed extubation

• Worsened renal outcomes

• Increased mortality in some subgroups

The emerging model is dynamic:

Small bolus (250–500 mL) → reassess → repeat if responsive

Use physiology to guide you:

• Passive leg raise

• Stroke volume change

• Bedside echo (LV function)

• Capillary refill

• Urine output

• Lactate trend (not single value)

Sepsis resuscitation should be a loop:

Resuscitate → Reassess → Redirect.

Not a one-time fluid event.

Particularly in elderly patients or those with heart failure, CKD, or cirrhosis, restraint is not undertreatment — it is precision.

3️⃣ Earlier Vasopressors Prevent Fluid Creep

Waiting to “finish fluids” before starting vasopressors is increasingly indefensible.

When hypotension persists after limited fluid resuscitation:

• Start norepinephrine early.

• Peripheral initiation via a well-functioning IV is acceptable.

• Target MAP ≈ 65 mmHg, individualized to perfusion markers.

Earlier vasopressors:

• Restore perfusion sooner

• Limit excess fluid accumulation

• Shorten time to hemodynamic stability

Septic shock is distributive at its core. Fluids alone cannot correct vasoplegia.

4️⃣ Antibiotics Are Urgent — But Source Control Is Definitive

Timely antibiotics save lives — especially in septic shock.
Early intravenous antibiotics remain the only intervention consistently associated with reduced mortality in sepsis — particularly in septic shock.

In patients with septic shock or life-threatening instability, antibiotics should be administered within 1 hour of recognition, after obtaining appropriate cultures if this does not cause delay.

In patients without shock, where diagnostic uncertainty exists, a short period of focused evaluation is reasonable. Current guidance supports administration within 3 hours if concern for infection persists, with closer monitoring throughout. The mortality signal for delay is strongest in shock; in stable patients, modest delays to improve diagnostic precision are unlikely to worsen outcomes.

Empirical therapy should reflect local resistance patterns and individual risk factors for drug-resistant organisms. Once microbiology data become available, prompt de-escalation to narrow-spectrum therapy is essential to limit antimicrobial resistance and toxicity.

Shorter courses (generally 5–7 days) are adequate for most infections unless there is deep-seated or complicated disease. Importantly, antibiotics are not definitive therapy when source control is required.

Modern sepsis care demands both urgency and stewardship —
1 hour for the unstable, 3 hours with thoughtful precision for the uncertain.

But antibiotics are not the endpoint. They are the bridge.

Definitive therapy often requires :- Source Control

• Drainage

• Debridement

• Decompression

• Device removal

Obstructed urosepsis.
Perforated viscus.
Necrotizing soft tissue infection.
Infected lines.

The emergency department must initiate source control conversations immediately — not defer them.

Time-to-source-control may matter as much as time-to-antibiotics.

5️⃣ Point-of-Care Ultrasound Is Now Foundational

Sepsis is hemodynamically heterogeneous.

Some patients are:

• Pure vasoplegia

• Septic cardiomyopathy

• Mixed shock

• Fluid responsive

• Fluid intolerant

Without ultrasound, we are often guessing.

POCUS allows rapid differentiation:

• LV systolic function

• RV strain

• IVC variability

• B-lines (early pulmonary edema)

• Pericardial effusion

• Intra-abdominal source clues

Modern sepsis care in acute settings is incomplete without bedside echocardiographic assessment.

6️⃣ Organ Support Begins in the ED — Not in the ICU

Many decisive interventions occur before ICU transfer:

• High-flow nasal oxygen

• Noninvasive ventilation

• Early intubation with hemodynamic preparation

• Lung-protective ventilation

• Vasopressor titration

• Renal function surveillance

Disposition is not administrative. It is physiological triage.

Patients on vasopressors, escalating oxygen support, rising lactate, or evolving multi-organ dysfunction require ICU-level care — early.

Clear handovers must include:

• Fluids administered

• Current vasopressor dose

• Lactate trajectory

• POCUS findings

• Source control plan

7️⃣ Stewardship and Individualization Matter

Sepsis pathways must balance urgency with precision.

Over-resuscitation harms.
Indiscriminate broad-spectrum antibiotics drive resistance.
Delayed de-escalation perpetuates ICU burden.

Clinical decisions must incorporate:

• Age

• Co-morbidities

• Functional baseline

• Patient preferences

• Resource realities

Early goals-of-care discussions are not therapeutic defeat — they are ethical medicine.

The Shift We Must Embrace

The evolution in sepsis management is not about abandoning bundles.
It is about maturing beyond them.

Sepsis is not a protocol problem.

It is a physiology problem.

And physiology demands continuous reassessment.

Reference -

Singer M, Angus DC, Annane D, et al. Sepsis. Lancet. Published online February 26, 2026. doi:10.1016/S0140-6736(25)02422-5

1. SGLT-2 Inhibitors as Foundational Therapy

What has changed

SGLT-2 inhibitors are now recommended first-line (with metformin) across:

• No comorbidity

• Heart failure

• ASCVD

• CKD (down to eGFR 20)

• Early-onset T2DM

• Obesity

Acute Care Relevance

1.1 Expect near-universal exposure

A large proportion of T2DM patients presenting to ED will be on:

• Empagliflozin

• Dapagliflozin

This includes patients with:

• Advanced CKD (eGFR 20–30, combined with DPP-4 inhibitor)

  type-2-diabetes-in-adults-manag…

• Heart failure with preserved or reduced EF

• ASCVD on triple therapy

1.2 Increased Risk of Eu-glycaemic DKA

The guideline explicitly:

• Requires DKA risk assessment before starting SGLT-2

• Advises suspension during ketogenic diets and intercurrent illness

EM/ICU Translation

Lower threshold to:

• Check blood ketones in:

  • Sepsis

  • Major surgery

  • AKI

  • Reduced oral intake

  • Steroid therapy

• Diagnose DKA despite glucose <250 mg/dL

• Stop SGLT-2 immediately on admission if:

  • Shock

  • Hypoxia

  • AKI

  • Severe infection

  • Peri-operative state

Clinical shift: Hyperglycaemia is no longer required to suspect DKA.

2. Sick-Day Rules Become Mandatory Documentation

The updated guideline mandates explicit sick-day plans including temporary cessation of:

• Metformin

• SGLT-2 inhibitors

Acute Care Implication

In ED/ICU you are now:

• Justified in holding these agents in:

  • Dehydration

  • Hypotension

  • Sepsis

  • Contrast exposure

• Expected to document:

  • When to restart

  • Under what renal/hemodynamic parameters

Metformin: Stop in hypoxia, shock, significant AKI (lactic acidosis risk).
SGLT-2: Stop early in any catabolic or volume-depleted state.

3. Advanced CKD Patients Will Still Be on SGLT-2

The update allows:

• Dapagliflozin or empagliflozin down to eGFR 20

• Combination with DPP-4 inhibitor between eGFR 20–30

EM/ICU Implications

You will encounter:

• Dialysis-adjacent patients still taking SGLT-2

• Lower baseline glucose but ongoing osmotic diuresis risk

Monitor for:

• Volume depletion

• Hypotension

• AKI worsening

• Electrolyte shifts

4. Early Triple Therapy is Now Common

For ASCVD, obesity, and early-onset T2DM:

• Metformin

• SGLT-2 inhibitor

• GLP-1 RA or tirzepatide

ICU Implications

Expect:

• Lower HbA1c but polypharmacy

• Reduced insulin requirements at baseline

• Higher GI side-effect burden

5. GLP-1 Receptor Agonists & Tirzepatide in Acute Care

Recommended strongly for ASCVD and obesity

Acute Care Consequences

5.1 Delayed Gastric Emptying

Implications:

• Increased aspiration risk

• Nausea/vomiting complicating NIV tolerance

• Enteral feeding delays

5.2 Peri-intubation considerations

Consider:

• Full stomach assumption

• RSI preference in unstable patients

6. Glucose Monitoring: Acute Illness and Steroids

The guideline emphasizes:

• Acute intercurrent illness increases hyperglycaemia risk

• Short-term capillary monitoring is appropriate during steroid initiation

EM/ICU Translation

Expect:

• Marked steroid-induced hyperglycaemia

• Rapid escalation of insulin requirements

• Need for structured monitoring post-discharge

Steroid-treated pneumonia/COPD patients will frequently require:

• Basal-bolus insulin

• Escalated capillary monitoring

7. Continuous Glucose Monitors (CGM) Use Will Increase in Hospital

Clear endorsement of:

• isCGM

• rtCGM in insulin-treated T2DM with recurrent/severe hypoglycaemia

Acute Care Implications

You will see:

• CGM sensors in admitted patients

Important:

• Do NOT rely solely on CGM in:

  • Shock

  • Rapid glucose change

  • Vasopressor states

• Capillary testing remains required for accuracy confirmation.

Ensure:

• Backup strips are available

• Device knowledge confirmed at discharge

8. Organ-Protection Bias Over Glycaemia

The guideline states that SGLT-2 and GLP-1 RAs are recommended as much for CV/renal benefit as glycaemia

Critical Care Reframing

When rationalising medications in ICU:

Do not interpret normal HbA1c as overtreatment.

Instead:

• Distinguish glycaemic drugs from organ-protective drugs

• Restart SGLT-2 and GLP-1 early once:

  • Hemodynamically stable

  • Renal function recovered

  • Oral intake adequate

These are now secondary prevention agents.

9. Frailty and Hypotension Risk

For frail adults:

• SGLT-2 only if low risk of volume depletion/hypotension

ED/ICU Implication

In elderly septic patients:

• SGLT-2 may contribute to:

  • Pre-existing volume contraction

  • Orthostatic collapse

  • AKI

High vigilance for polypharmacy-related hypotension.

10. Peri-Operative and Critical Care Protocol Adjustments

Because SGLT-2 use is now foundational:

Every diabetic ICU admission should trigger:

• Medication reconciliation focused on SGLT-2

• Ketone surveillance if acidosis

• Clear peri-operative cessation plan

The era of “metformin only” diabetics is over.

Start/stop decision plan in EM/Acute care

Bedside decision algorithm - for stop/restart of DM drugs in acute care.

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References-
NICE 2026 update on T2DM

It kills by right ventricular failure.

The role of the emergency physician is not simply to diagnose PE—but to identify which patient will deteriorate, which patient needs reperfusion, and which patient can safely go home.

The 2026 AHA/ACC/ACEP classification (A–E) provides a physiology-based roadmap for treatment escalation, monitoring, and disposition.

This is where classification becomes action.

Step 1: Immediate ED Stabilization

COR 1, LOE B-NR

Initial management priorities in suspected or confirmed PE:

• Oxygenation
• Circulatory support
• RV perfusion preservation
• Prevention of hemodynamic collapse

Key immediate assessments:

• Blood pressure
• Oxygen requirement
• Lactate
• Mental status
• RV function

Patients in Category D or E require immediate resuscitation.

Oxygen and Respiratory Support

COR 1, LOE C-LD

Indicated in hypoxemic patients.

Target:

SpO₂ ≥ 90%-94%

Preferred escalation:

1. Nasal cannula

2. High-flow nasal oxygen

3. Non-invasive ventilation

Avoid unnecessary intubation.

Positive pressure ventilation reduces venous return and worsens RV failure.¹

If intubation unavoidable:

• Use hemodynamically stable induction agents
• Initiate vasopressors first

—> Physiologically difficult airway modification, give RV supporting ionotropes.

Circulatory Support

COR 1, LOE B-NR

Hypotension reflects RV failure and impaired cardiac output.

First-line vasopressor:

Norepinephrine

Benefits:

• Improves coronary perfusion
• Improves RV contractility
• Improves systemic vascular resistance¹

Avoid aggressive fluid boluses.

Excess fluid worsens RV dilation and reduces LV filling.

Step 2: Anticoagulation — The Foundation of Treatment

Anticoagulation prevents clot propagation and allows endogenous fibrinolysis.

COR 1, LOE A

Anticoagulation is recommended in all patients with confirmed PE unless contraindicated.¹

Choice of Anticoagulant

DOACs preferred in stable patients

COR 1, LOE A

Preferred agents:

• Apixaban
• Rivaroxaban

Advantages:

• Lower bleeding risk
• Rapid onset
• No monitoring required
• Suitable for outpatient treatment¹

LMWH preferred when inpatient management required

COR 1, LOE B-R

Preferred in:

• Hospitalized patients
• Cancer-associated thrombosis
• Moderate-risk PE¹

Advantages:

• Predictable anticoagulation
• Lower HIT risk

UFH preferred in unstable patients

COR 1, LOE B-NR

Indications:

• Category C3
• Category D
• Category E
• Planned thrombolysis or thrombectomy¹

Reason:

Rapid reversibility.

Step 3: Reperfusion Therapy

Indicated in RV failure and shock

Reperfusion reduces RV afterload and restores circulation.

Systemic Thrombolysis

COR 1, LOE B-R

Indicated in:

Category E1 — cardiogenic shock
Category E2 — cardiac arrest¹

Reduces mortality and improves hemodynamics.

Consider thrombolysis in Category D

COR 2a, LOE B-NR

Indicated if evidence of:

• Normotensive shock
• Elevated lactate
• Progressive hypoxia
• RV dysfunction¹

These patients are at high risk of deterioration.

Not recommended routinely in Category C

COR 3, LOE B-R

Routine thrombolysis in stable patients increases bleeding risk without mortality benefit.

Alteplase (tPA) Dose for Acute Pulmonary Embolism

Standard dose for high-risk PE (massive PE with shock)

Dose: 100 mg IV over 2 hours

Regimen:

• 100 mg alteplase IV infusion over 120 minutes

• No bolus required (standard regimen)

This is the FDA-approved and guideline-recommended dose.

Alternative accelerated regimen (commonly used in ED / ICU)

Dose: 0.6 mg/kg IV over 15 minutes (max 50 mg)

Used when:

• Rapid hemodynamic collapse

• Need for faster reperfusion

• Peri-arrest or severe shock

Evidence shows similar efficacy with potentially lower bleeding risk.

Alteplase Dose During Cardiac Arrest due to PE

When PE is suspected or confirmed cause of arrest:

Recommended regimen (AHA cardiac arrest guidance)

50 mg IV bolus over 2–5 minutes

Then:

• Continue CPR for at least 15–30 minutes

• If no ROSC, may repeat another 50 mg bolus after 15–30 minutes

Maximum total dose: 100 mg

Most commonly used cardiac arrest protocol in emergency medicine

Option 1 (most widely used):

• Alteplase 50 mg IV push

• Continue CPR 15–30 min

• Repeat 50 mg if needed

Option 2 (alternative):

• Alteplase 100 mg IV bolus over 10 minutes

Used less commonly due to bleeding risk.

Catheter-Directed Therapy

COR 2a, LOE B-NR

Indicated when:

• Thrombolysis contraindicated
• Failed thrombolysis
• Progressive deterioration¹

Advantages:

• Lower bleeding risk
• Targeted therapy

Mechanical Thrombectomy

COR 2a, LOE B-NR

Indications:

• Category D or E
• Contraindication to thrombolysis
• Failed thrombolysis¹

Improves hemodynamics rapidly.

Increasingly used in modern PE management.

ECMO

COR 2a, LOE C-LD

Indicated in refractory shock or cardiac arrest.

Provides circulatory support until reperfusion effective.

Step 4: Treatment and Disposition by A–E Group

This is the most important ED decision.

Category A — Incidental PE

Mortality risk: <1%

Treatment:

Anticoagulation or observation depending on risk factors¹

Disposition:

Discharge with outpatient follow-up

Category B — Symptomatic, Low Risk

Mortality risk: ~1%

Treatment:

DOAC preferred¹

Disposition:

Outpatient management recommended

Criteria:

• Stable vitals
• No hypoxia
• Reliable follow-up¹

Category C1 — Intermediate Risk, No RV Injury

Mortality risk: 3–5%

Treatment:

Anticoagulation¹

Disposition:

Hospital admission, telemetry

Category C2 — RV Injury or Biomarker Elevation

Mortality risk: 5–15%

Treatment:

Anticoagulation

Disposition:

Hospital admission with monitoring¹

Category C3 — RV Injury + Biomarker Elevation

Mortality risk: 15–30%

Treatment:

UFH preferred
Consider reperfusion if deterioration¹

Disposition:

Step-down or ICU

PERT consultation recommended.

Category D — Normotensive Shock

Mortality risk: 20–40%

Treatment:

UFH
Consider thrombolysis or thrombectomy¹

Disposition:

ICU

Immediate specialist consultation required.

Category E — Cardiogenic Shock or Arrest

Mortality risk: >40%

Treatment:

Immediate reperfusion therapy¹

Options:

• Thrombolysis
• Thrombectomy
• ECMO

Disposition:

ICU

Medical emergency.

Step 5: Monitoring

COR 1, LOE B-NR

Monitor for deterioration:

• Blood pressure
• Oxygen requirement
• Heart rate
• Lactate
• Mental status¹

Serial reassessment essential.

Patients may deteriorate rapidly.

Step 6: Complications and Sequelae

Acute complications

Right ventricular failure
Cardiogenic shock
Cardiac arrest

Primary causes of death.

Chronic thromboembolic pulmonary hypertension (CTEPH)

Occurs in 2–4% of patients.¹

Caused by persistent pulmonary vascular obstruction.

Symptoms:

• Progressive dyspnea
• Exercise intolerance

Post-PE syndrome

Occurs in up to 50% of patients.¹

Symptoms:

• Dyspnea
• Reduced exercise tolerance
• Functional impairment

Step 7: Duration of Anticoagulation

COR 1, LOE A

Minimum duration:

3 months¹

Extended anticoagulation recommended if:

• Unprovoked PE
• Persistent risk factors¹

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Reference

1. American College of Cardiology/American Heart Association Joint Committee. 2026 AHA/ACC guideline for the diagnosis and management of acute pulmonary embolism. J Am Coll Cardiol. 2026.

Not because it is rare—but because it is unpredictable.

Some patients with PE are discharged safely from the emergency department within hours. Others arrest suddenly despite appearing stable minutes earlier.

The difference is not clot size.

It is physiology of clot against RV.

The 2026 AHA/ACC Pulmonary Embolism guideline replaces the outdated “massive vs submassive vs low-risk” terminology with a dynamic, physiology-based classification system (Groups A–E) that integrates clinical severity scores, biomarkers, RV imaging, hemodynamics, and respiratory status.

This framework begins in the emergency department—at the moment of diagnosis—and directly determines prognosis, monitoring, disposition, and treatment.

This article focuses on definition, classification, evaluation, and diagnosis—from the emergency department.

Definition of Acute Pulmonary Embolism

Acute pulmonary embolism is defined as:

Obstruction of pulmonary arterial circulation by thrombus, resulting in impaired pulmonary perfusion, increased pulmonary vascular resistance, and potential right ventricular (RV) failure.

The clinical consequences depend on the interaction between:

• Clot burden
• Speed of vascular obstruction
• RV reserve
• Cardiopulmonary reserve
• Systemic compensation

The right ventricle—not the clot—is the primary determinant of outcome.

Epidemiology: The ED Reality

Pulmonary embolism presents a paradox in emergency medicine.

It is common—but rarely confirmed.

Key ED statistics:

• Only 4–10% of patients undergoing CTPA for suspected PE actually have PE

• Acceptable diagnostic miss rate: <2% at 3 months

• Age-adjusted D-dimer diagnostic strategy failure rate: 0.3% (95% CI 0.1–1.7%)

• DVT is present in 44–71% of confirmed PE patients

This defines the core emergency medicine challenge:

Identify dangerous PE while safely excluding PE in the majority.

The New AHA/ACC/ACEP Classification (A–E)

The 2026 guideline introduces a five-group classification system reflecting progressive physiological severity.

Each group directly correlates with mortality risk, disposition, and treatment escalation.

GROUP A: Subclinical (Incidental) PE

Definition:
Pulmonary embolism detected incidentally on imaging, without attributable symptoms.

These patients have no physiological compromise.

Mortality risk: <1%

Subgroups

A1: Subsegmental incidental PE

Features:

• Isolated subsegmental embolus
• No symptoms
• No RV dysfunction
• No hypoxia
• Normal biomarkers

Physiology intact.

Lowest-risk group.

A2: Segmental or proximal incidental PE

Features:

• Larger clot burden
• Still asymptomatic
• Normal hemodynamics
• No RV dysfunction

Anatomical clot present—but physiological compensation intact.

GROUP B: Symptomatic PE, Low Clinical Severity

Definition:
Symptomatic PE with low severity scores:

• PESI Class I–II
• sPESI = 0
• Hestia negative

RV function preserved.

Mortality risk: ~1%

Subgroups

B1: Symptomatic sub-segmental PE

Features:

• Symptoms present
• Minimal clot burden
• Normal RV function
• Normal biomarkers

B2: Symptomatic segmental or proximal PE

Features:

• Larger clot burden
• Symptoms present
• RV function preserved
• Hemodynamically stable

These represent compensated pulmonary embolism physiology.

Many can be safely treated as outpatients.

GROUP C: Symptomatic PE with Elevated Clinical Severity

RV injury present, but no shock

Definition:

Symptomatic PE with elevated clinical severity scores:

• PESI Class III–V
• sPESI ≥1
• Hestia positive
• Bova score ≥4

Represents early RV dysfunction.

Mortality risk increases progressively across subgroups.

Subgroups

C1: Elevated clinical severity score only

Features:

• Elevated PESI/sPESI
• Normal RV function
• Normal troponin
• Normal BNP

Risk driven by co-morbid vulnerability.

Mortality risk: ~3–5%

C2: RV dysfunction OR biomarker elevation

Features:

Either:

• RV dilation on imaging
OR
• Elevated troponin or BNP

Indicates early RV myocardial stress.

Mortality risk: ~5–15%

C3: RV dysfunction AND biomarker elevation

Features:

• RV dilation present
• Elevated troponin
• Elevated BNP

Represents established RV injury.

Blood pressure still preserved due to compensation.

Mortality risk: 15–30%

This is the highest-risk normotensive subgroup.

Equivalent to old ‘Intermediate - High Risk Group’

Respiratory Modifier: “R”

Any subgroup may receive a respiratory modifier (R) if respiratory failure present.

Examples:

C3R
D2R
E1R

Defined by:

• Oxygen requirement ≥6 L/min
• Non-invasive ventilation
• Mechanical ventilation

Pulm Embolism new guidelines

This identifies patients at risk of respiratory collapse independent of hypotension.

GROUP D: Incipient Cardiopulmonary Failure

Shock physiology emerging

Most important group to identify

These patients demonstrate circulatory compromise without persistent hypotension.

Mortality risk: 20–40%

Subgroups

D1: Transient hypotension

Features:

• Temporary hypotension
• Responds to fluids
• No persistent organ hypoperfusion

Represents unstable compensation.

D2: Normotensive shock

Features:

• SBP ≥90 mmHg
• Lactate ≥2 mmol/L
• Evidence of organ hypoperfusion

Shock present despite preserved blood pressure.

Extremely high risk.

GROUP E: Cardiopulmonary Failure

Established shock or cardiac arrest

Highest-risk group.

Mortality risk: >40%

Pulm Embolism new guidelines

Subgroups

E1: Cardiogenic shock

Features:

• Persistent hypotension
• Vasopressor requirement
• RV failure present

E2: Refractory shock or cardiac arrest

Features:

• Persistent shock despite therapy
• Cardiac arrest

Highest mortality subgroup.

Emergency Department Diagnostic Approach (COR and LOE)

The guideline recommends a structured, stepwise approach.

Step 1: Clinical Assessment

COR 1, LOE A

Pulm Embolism new guidelines

Includes:

Symptoms:

• Dyspnea
• Chest pain
• Syncope
• Hemoptysis

Signs:

• Tachycardia
• Hypoxia
• Hypotension
• Signs of DVT

Risk factors:

• Prior VTE
• Surgery
• Immobilization
• Cancer
• Pregnancy

Step 2: Clinical Probability Assessment

COR 1, LOE A

Pulm Embolism new guidelines

Validated tools:

• Wells Score
• Revised Geneva Score
• PERC Rule

These determine need for testing.

Step 3: D-Dimer Testing

COR 2a, LOE B-R

Pulm Embolism new guidelines

Indicated in low or intermediate probability patients.

Age-adjusted D-dimer improves diagnostic efficiency.

Failure rate: 0.3%

Step 4: Imaging with CTPA

COR 1, LOE A

Pulm Embolism new guidelines

CTPA is diagnostic standard.

Advantages:

• High sensitivity and specificity
• Rapid diagnosis
• RV assessment
• Alternative diagnoses identified

Step 5: RV Assessment and Biomarkers

COR 1, LOE B-R

Pulm Embolism new guidelines

Critical prognostic parameters include:

• RV/LV ratio ≥1.0
• Troponin elevation
• BNP elevation
• TAPSE <1.6 cm

These identify RV dysfunction.

Echocardiographic Findings in Acute PE: Sensitivity, Specificity, and Likelihood Ratios

Important guideline principle:
The AHA/ACC guideline emphasizes that echo should NOT be used to rule out PE (COR 3 – No Benefit), but is strongly recommended for risk stratification and identification of RV dysfunction (COR 1, LOE B-NR).

Pulm Embolism new guidelines

Single findings have limited sensitivity.
Multiple findings greatly increase diagnostic probability.

Highest-Value Echo Findings Ranked by Likelihood Ratio

From strongest to weakest diagnostic strength:

1. McConnell sign → LR+ up to 12

2. Septal flattening → LR+ up to 10

3. Multiple RV dysfunction markers → LR+ up to 20

4. TAPSE <1.6 cm → LR+ up to 6

5. RV dilation → LR+ up to 4

Guideline-Specific Key Recommendations on POCUS/Echo (COR and LOE)

POCUS for diagnosis

COR 3 (No Benefit), LOE B-NR

Echo should not be used alone to diagnose or exclude PE.

Reason: poor sensitivity.

Cardiac POCUS for risk stratification

COR 1, LOE B-NR
Echo is recommended to assess RV dysfunction and risk.

Pulm Embolism new guidelines

Multiple parameters improve accuracy

Guideline explicitly states:

Sensitivity and specificity improve significantly when multiple RV dysfunction parameters are present.

Pulm Embolism new guidelines

Emergency Medicine Interpretation Algorithm Using Likelihood Ratios

Pretest probability determines how POCUS (Cardiac) findings affect diagnosis.

Example: Moderate probability patient

Pretest probability: 30%

McConnell sign present
LR+ = 10

Post-test probability → ~80–90%

Strongly supports PE diagnosis and high-risk physiology.

Example: Echo normal

LR− ~0.6

Post-test probability drops modestly.

Cannot exclude PE.

CTPA still required.

Most Important ED Clinical Insight

POCUS is not sensitive enough to exclude PE.

highly valuable for identifying dangerous PE.

identifies physiology—not clot.

answers the question:

Is the right ventricle failing?

Not:

Is there a clot?

Highest-Yield Bedside Rule for Emergency Physicians

Presence of ≥2 of the following strongly supports acute PE with RV strain:

• RV dilation
• McConnell sign
• Septal flattening
• TAPSE <1.6 cm
• Elevated RVSP

Post-test probability becomes very high.

Why Classification Matters in the Emergency Department

This classification determines:

• Who can be discharged
• Who requires admission
• Who requires ICU care
• Who requires reperfusion therapy

This decision begins in the emergency department.

Not after admission.

Critical Emergency Medicine Insight

The most dangerous PE is not the hypotensive patient.

It is the normotensive patient with failing RV physiology.

The new A–E classification allows emergency physicians to identify these patients before collapse occurs.

This is the true purpose of classification.

New Insights: Update on diagnosis of hemo-dynamically unstable patient - unstable to shift to CTPA

In hemodynamically unstable patients where computed tomography pulmonary angiography (CTPA) is unsafe or impossible, multi-organ point-of-care ultrasound (POCUS)—combining focused cardiac, lung, and lower limb venous assessment—can support a working diagnosis of pulmonary embolism and guide urgent reperfusion decisions, although it cannot definitively exclude PE.

Focused cardiac ultrasound primarily evaluates for acute right ventricular (RV) pressure overload, with key findings including RV dilation (RV/LV ratio >1), septal flattening (“D-sign”), reduced TAPSE, tricuspid regurgitation, and McConnell’s sign, which demonstrates high specificity (~98.6%) but low sensitivity (~29%) for acute PE (Fields et al., 2017; Falster et al., 2021; Oh & Park, 2023).

Lung ultrasound may identify peripheral pleural-based wedge-shaped infarcts with sensitivity of approximately 80–81% and specificity of 87%, supporting the diagnosis in the appropriate clinical context (Falster et al., 2021; Du et al., 2024; Mohamed et al., 2023). Compression ultrasound demonstrating proximal deep venous thrombosis is highly specific (96–97%) and, when combined with shock and RV strain, strongly supports PE as the cause of hemodynamic instability (Dwyer et al., 2017; Falster et al., 2021).

Importantly, multiorgan POCUS protocols significantly improve diagnostic performance compared with single-organ assessment, achieving sensitivity up to 90% and specificity ranging from 69–86% in critically ill populations (Girardi et al., 2022; Lieveld et al., 2022; Melo et al., 2025).

In unstable patients with high clinical probability and concordant POCUS findings—particularly RV strain with or without confirmed DVT—current evidence supports initiating anticoagulation or thrombolysis when alternative causes of shock have been reasonably excluded (Falster et al., 2021; Oh & Park, 2023).

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Coming Next: Part 2

Part 2 will cover:

• Anticoagulation selection
• Thrombolysis and thrombectomy indications
• ICU vs ward vs discharge decisions
• Monitoring and escalation
• Complications including CTEPH
• Follow-up strategies

All mapped directly to A–E classification.

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References

1. American College of Cardiology/American Heart Association Joint Committee. 2026 AHA/ACC guideline for the diagnosis and management of acute pulmonary embolism. J Am Coll Cardiol. 2026.

2. Fields JM, Davis J, Girson L, et al. Transthoracic echocardiography for diagnosing pulmonary embolism: a systematic review and meta-analysis. J Am Soc Echocardiogr. 2017;30(7):714-723.e4. doi:10.1016/j.echo.2017.03.004

3. Falster C, Jacobsen N, Coman KE, et al. Diagnostic accuracy of focused deep venous, lung, cardiac and multiorgan ultrasound in suspected pulmonary embolism: a systematic review and meta-analysis. Thorax. 2021;77(7):679-689. doi:10.1136/thoraxjnl-2021-216838

4. Girardi AM, Turra E, Loreto M, et al. Diagnostic accuracy of multiorgan point-of-care ultrasound compared with pulmonary CT angiography in critically ill patients with suspected pulmonary embolism. PLoS One. 2022;17(10):e0276202. doi:10.1371/journal.pone.0276202

5. Mohamed H, Farouk N, Elnaeem E, et al. Sensitivity and specificity of chest ultrasound in the diagnosis of pulmonary embolism in the emergency department. Can J Respir Ther. 2023;59:123-129. doi:10.29390/cjrt-2022-065

6. Dwyer KH, Rempell JS, Stone MB. Diagnosing centrally located pulmonary embolisms in the emergency department using point-of-care ultrasound. Am J Emerg Med. 2017;36(7):1145-1150. doi:10.1016/j.ajem.2017.11.033

7. Melo RB, Gioli-Pereira L, Lourenço I, et al. Diagnostic accuracy of multi-organ point-of-care ultrasound for pulmonary embolism in critically ill patients: a systematic review and meta-analysis. Crit Care. 2025;29:59. doi:10.1186/s13054-025-05359-x

8. Lieveld AWE, Heldeweg MLA, Smit JM, et al. Multi-organ point-of-care ultrasound for detection of pulmonary embolism in critically ill patients. J Crit Care. 2022;69:153992. doi:10.1016/j.jcrc.2022.153992