From Other Journals

1. Out of Time, Not Out of Tissue

The OPTION trial tackles a research gap in acute stroke care: how to treat patients with non‐large vessel occlusion (non‐LVO) ischaemic stroke who present beyond the conventional 4.5‐h thrombolysis window. This group is more common than LVO stroke but has been poorly served by the evidence base. The major late‐window thrombolysis trials studied different populations, focussing large on or medium vessel occlusions. Compounding this, the recent evidence has showed that thrombectomy does not benefit medium and distal vessel occlusions, leaving these patients with no effective late‐window reperfusion option. OPTION is the first randomised trial to isolate this non‐LVO population.

In this multicentre, open‐label, blinded‐endpoint trial across 48 Chinese centres, 566 patients were given either intravenous tenecteplase (0.25 mg/kg) or standard medical care. Eligibility hinged on automated CT perfusion demonstrating salvageable tissue, a small ischaemic core (< 50 mL) with a substantial perfusion mismatch, while large vessel occlusion was excluded. The penumbra, not the clot, defined who was treated. Patients were required to have good baseline function, with a pre‐stroke mRS of 0–1, and clinically meaningful deficits, defined as NIHSS 6–25 or NIHSS 4–5 with a disabling feature such as aphasia, hemianopia or loss of hand function. The practical message for emergency clinicians is that a patient many hours from onset, including on awakening, may still harbour viable tissue identifiable on automated perfusion software, and elapsed time alone should not exclude them.

The demonstrated benefit was meaningful: an excellent functional outcome (mRS 0–1) at 90 days occurred in 43.6% of treated patients versus 34.2% with standard care, a number needed to treat of 11, supported by higher early reperfusion and neurological improvement.

The principal adverse effect was symptomatic intracranial haemorrhage (2.8% vs. 0.0%). The authors highlight that this risk appears concentrated where the ischaemic core is underestimated: About 2 of the 8 haemorrhages occurred among 21 patients whose non‐contrast CT hypodensity exceeded the perfusion‐defined core (a ‘mismatch inconsistency’). Perhaps suggesting that careful scrutiny of established hypodensity on plain CT is advisable before late‐window thrombolysis as perfusion software may occasionally under‐call the true infarct size and falsely flag patients deemed suitable for late window lysis. Tenecteplease showed benefit in both the 4.5–9 h and > 9–24 h subgroups, but reached significance only the later stratum. This almost certainly reflects the limited power of an exploratory subgroup rather than a genuine absence of early benefit. There was no interaction between the time of lysis and the trend to benefit.

OPTION supports extending tenecteplase thrombolysis to 24 h in carefully selected non‐LVO stroke in adults with good premorbid function and, accepting a modest haemorrhage risk that is plausibly minimised by rigorous radiological assessment. Further studies are needed to confirm these findings in broader populations and, ideally, to determine whether benefit can be stratified across the 4.5‐to‐24‐h window (Ma G, Mo R, Zuo Y, Ma Q, Zhao G, Yao X, Liang J, Zhou L, He Y, Long F, Yuan Z. Tenecteplase for Acute Non–Large Vessel Occlusion 4.5 to 24 h After Ischemic Stroke: The OPTION Randomised Clinical Trial. Jama. 2026;335(13):1137–47).

2. When, Not Whether—Pre‐Hospital Heparin in STEMI

Primary percutaneous coronary intervention is the preferred reperfusion strategy for STEMI and patency of the infarct‐related artery at first angiography is associated with better outcomes. Unfractionated heparin is a standard anticoagulant during the procedure, but the point in the pathway at which it is administered varies. The HEPARIN‐STEMI trial examined whether moving heparin to first prehospital medical contact improves pre‐procedural patency. In this single‐centre, open‐label trial within the Ljubljana network in Slovenia, 593 patients with symptom duration of 6 h or less were randomised to receive pre‐hospital or intra‐procedure intravenous heparin bolus.

The intervention group of 298 patients received a weight‐based bolus of 70–100 IU/kg at first contact, with an activated‐clotting‐time‐adjusted supplement before intervention. The control group of 295 patients received heparin after the initial diagnostic angiogram and before primary PCI. Patency, defined as TIMI Grade 2–3 perfusion of the infarct‐related artery at first angiography, was 43% with prehospital heparin and 27% with the control, an absolute difference of 16 percentage points, with no significant difference in major bleeding. Early ST‐segment resolution and 24‐h troponin favoured the prehospital group, while post‐PCI flow, shock and cardiac arrest did not differ.

The results of the Chinese HELP‐PCI trial, published in 2025, similarly demonstrated a 6% increase in pre‐procedural flow with heparin at first medical contact compared to administration in the catheter laboratory. In both trials, the benefit was confined to findings on first angiography and was not associated with differences in later flow or short‐term mortality.

In Australia, the timing of anticoagulation relative to coronary angiography is not standardised by national guidance. The 2025 ACS guidelines from the National Heart Foundation of Australia & Cardiac Society of Australia and New Zealand recommends unfractionated heparin for STEMI patients undergoing PCI without specifying timing. The ANZCOR Guideline 14.2 lists unfractionated heparin or enoxaparin as appropriate agents to be administered either in the prehospital or in‐hospital setting.

Practice across Australia is therefore heterogeneous. At the prehospital level, some ambulance services administer heparin while others do not. The timing is not specified and the dose may vary; Queensland Ambulance Service, for example, gives a fixed 5000‐unit intravenous bolus to PCI‐accepted STEMI patients while Ambulance Victoria gives 4000 units, followed by 1000 units every hour if delayed. The fixed‐dose prehospital regimens used in Australia also differ from the weight‐based, clotting‐time‐adjusted protocol evaluated in HEPARIN‐STEMI and would be at the lower end of the range used in the study.

HEPARIN‐STEMI adds evidence that anticoagulation at first medical contact increases pre‐procedural infarct‐related artery patency without a measurable increase in bleeding. It does not establish an effect on infarct size or clinical outcomes, nor was it powered to address clinical endpoints such as 30‐day mortality or degree of heart failure. For Australian practice, where the timing of heparin is neither standardised nor addressed by current guidance, these findings offer a reasonable rationale for earlier administration, while falling short of the evidence required to mandate it. (Fister, M., et al. Prehospital Heparin Administration in Patients With STEMI Undergoing Primary PCI: HEPARIN‐STEMI Randomised Controlled Trial. Circulation. 2026;153(20):1526–1534).

3. Paediatric Head Injury—The Greater the Height, the Greater the Impact

Paediatric head trauma is a common and important emergency department presentation. Assessment focuses on risk stratification to identify the small subset of patients who have sustained clinically important traumatic brain injuries (ciTBI). This retrospective cohort study conducted at the National Center for Child Health and Development in Tokyo found a linear relationship between fall height and risk of ciTBI without a statistically significant association between ciTBI and impact surface.

The study included 1893 children under 2 years of age presenting with head trauma between 1 January 2017 and the 31 December 2021 and excluded injury mechanisms that did not involve ground impact, suspected non‐accidental injury, unreliable clinical histories and those with co‐morbidities that would affect ciTBI risk, such as previous neurosurgical intervention, genetic skeletal disorders associated with bone fragility, bleeding disorders, or current use of antithrombotic agents. ciTBI was defined as TBI resulting in death, neurosurgical intervention, intubation for more than 24 h due to TBI, or hospitalisation for at least two nights due to TBI.

Data was analysed using a multivariable logistic regression with ciTBI as the outcome and impact surface type and fall height as the main exposures. Both exposure variables were included simultaneously and mutually adjusted for to manage confounding. After adjusting to age and fall height, impact surface type was not significantly associated with ciTBI. On the other hand, fall height was significantly associated with the risk of ciTBI. For every 10 cm increase in fall height the adjusted odds ratio for ciTBI was 1.31 (95% CI 1.19–1.45). More importantly, the adjusted log odds increased in a linear fashion with increasing fall height without a clear inflection point.

Fall height features in decision rules such as PECARN, CATCH and CHALICE, each treating a fall above an arbitrarily defined height as a severe mechanism. This study found that ciTBI risk rises approximately linearly with fall height, with no inflection point, suggesting that falls below a given cut‐off should not be regarded as inherently reassuring.

As a retrospective study, it carries several limitations. Fall height and impact surface were drawn from caregiver reports and subjective classification, raising the possibility of measurement error. Furthermore, because the decision to image was guided by rules that themselves incorporate fall height, children who fell from greater heights were more likely to undergo CT, and therefore more likely to have ciTBI detected, which could bias the observed association. Additionally, the reliance on electronic medical records may have resulted in documentation and data variability, missing data and limited follow‐up.

Overall, this is a well‐conducted study addressing an interesting clinical question. Despite its limitations, the study demonstrates a linear relationship between fall height and risk of ciTBI. With current guidelines using different binary thresholds for risk stratification of paediatric head injury, this study suggests there may be more to consider when assessing risk related to fall height. (Oishi T, et al. Fall Height and Impact Surface in Relation to Clinically Important Traumatic Brain Injury Among Children Under Two Years. American Journal of Emergency Medicine. 2026;104:79–84).

4. Distal Radius Fractures. Is Plastering Alone Just CRAFFTwork?

Distal radius fractures are a common presentation in children. The treatment of severely displaced (including off ended) distal radius fractures remains controversial. This study builds on published data from case series and one small RCT to understand best practice in fracture management and additionally looks at the health economic implications.

The Non‐surgical casting versus surgical reduction for children with severely displaced distal radial fractures (CRAFFT) study is a randomised multicentre non‐inferiority trial across 49 secondary and tertiary paediatric trauma centres in the UK. It compared surgical reduction to non‐surgical casting (i.e., without any manipulation) of severely displaced distal radius fractures in children aged 4–10. The primary outcome was non inferiority of upper limb function at 3 months in the casting group with a non‐inferiority margin defined as −2.5 points (and −5 points for completely off ended fractures) on a validated scale of patient reported outcomes. The study also measured complications and serious adverse events between the two groups. An economic evaluation was done at several time points over a 12‐month period.

The trial did not demonstrate non‐inferiority at the primary outcome of 3 months. It did, though, demonstrate non‐inferiority in a pre‐specified subgroup of ‘off ended’ fractures where a larger non‐inferiority margin was defined in the protocol. Non‐inferiority was also shown at both 6 and 12 month follow‐up. Follow‐up to 3 years is ongoing. Complications rates were low and generally occurred within the first 8 weeks. These included pressure damage, infection, scarring and nerve irritation and were marginally higher in the surgical group. Refracture rates were low and unplanned return to surgery was rare in both groups.

The health economic evaluation examined health care costs, quality of life measures including pain, cosmesis and parental satisfaction along with school absence. Unsurprisingly, non‐surgical casting was found to be more cost effective without a significant long‐term difference in function or morbidity.

The authors concluded that non‐surgical casting offers substantial cost savings with only a small transient loss of health utility and that their findings support conservative management for severely displaced fractures.

This study highlights how the short‐term benefits of surgery to cosmetic appearance must be weighed up against the risk of complication and the overall healthcare and societal costs. It provides evidence to support a more conservative patient‐centred approach to the management of distal radius fractures in the 4–10 age group. (Perry DC, Zimmermann A, Achten J, Nicolaou N, Metcalfe D, Kounali D, Lyttle MD, Frempong S, Appelbe D, Mason J, Kandiyali R. Non‐Surgical Casting Versus Surgical Reduction for Children With Severely Displaced Distal Radial Fractures (the CRAFFT Study): A Multicentre, Randomised, Controlled Non‐Inferiority Trial and Economic Evaluation. The Lancet. 2026;407(10538):1538–48).

5. Best Shoulder Forward: Can Improved Classification Finesse Glenohumeral Reduction Technique?

Anterior shoulder dislocations are rarely subtyped beyond ‘anterior’ in emergency practice. This retrospective review of 101 cases examined whether clinicians distinguished between Type 1 (subcoracoid) and Type 2 (subglenoid) in anterior dislocations and proposed a novel measurement for subtype differentiation.

Of the 101 cases studied from October 2021 to 2023 with xrays performed, there were 86 Type 1 subcoracoid and 15 Type 2 subglenoid dislocations. About 72 cases were excluded as they were reduced without prior xray. Both emergency physicians and radiologists predominantly described both forms as anterior or anterior inferior dislocations in documentation and reports, without further specifying a formal subtype of dislocation. Type 1 subcoracoid dislocations have been the most common in prior literature.

Adduction‐based reduction methods, such as Kocher's and Cunningham's, are designed around the anatomical relationship found in subcoracoid glenohumeral dislocations and require full humeral adduction as a starting position, difficult in subglenoid injuries. Subglenoid dislocations are more suited to scapular manipulation and Milch's method of reduction. The authors observe that an operator who labels every case ‘anterior’ and reaches for a single favourite adduction technique is likely misapplying it in the cases that are subglenoid. There are potential risks associated with using an inappropriate reduction technique, such as failed reduction, prolonged pain or iatrogenic injury.

The authors went on to further analysis to aid differentiation between Types 1 and 2 dislocations on xray, with the vertical distance from inferior glenoid to inferior anatomical neck measurement in mm (IGIANV) having the most potential as a discriminator but requiring further study for validation.

Theoretically, subtype classification of anterior shoulder dislocations may provide benefit for patient care and warrants further prospective evaluation looking into success and complication rate following classification and reduction technique. (Adams D, et al. Review of Radiological and Clinical Interpretation of Anterior Group Shoulder Dislocations and Testing of a Novel Radiological Measurement to Distinguish Between Subcoracoid and Subglenoid Subtypes. BMC Emergency Medicine. 2026;26:137).

Beck, S. , Doolabh A., Dunlop T., et al. 2026. “From Other Journals.” Emergency Medicine Australasia 38, no. 5: e70329. 10.1111/1742-6723.70329.

Data Availability Statement

Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.