Zworth Reading
EMMax’s EM Weekly Update
Highlight of the Week
Airway management of adults in the acute care setting
BMJ · Narrative review
Gottlieb and colleagues deliver a comprehensive state-of-the-art review on acute airway management. Key takeaways: video laryngoscopy should be default for RSI (improves first-pass success), preoxygenation with NIPPV is superior to passive oxygen, and physiological optimization before induction is non-negotiable. The review emphasizes that existing difficult airway prediction tools perform poorly — preparation matters more than prediction. Post-intubation care gets appropriate attention: capnography for confirmation, adequate sedation to prevent awareness, and vigilance against the hemodynamic consequences of positive pressure ventilation.
This is a well-constructed narrative review from authors with strong airway research track records. It synthesizes RCT data (FELLOW, PREOXI, PREPARE II) alongside observational evidence appropriately. The recommendations align with current best evidence and reflect actual practice evolution over the past decade. Limitations: narrative reviews inherently involve author judgment in evidence selection, and some recommendations (e.g., specific induction agent choice) remain preference-driven rather than evidence-mandated. The review doesn't break new ground but consolidates scattered evidence into a coherent framework.
Bottom line: Not practice-changing for experienced airway operators, but an excellent reference document and teaching resource. If your department still defaults to direct laryngoscopy or uses high-flow nasal cannula alone for preoxygenation in high-risk patients, this review provides the evidence to update those practices.
FOAM Radar
The OPTION Trial: Late-Window TNK for Non-LVO StrokeKnowledge translation — RCT appraisal
REBEL EM · LOE 2 (underlying trial is an RCT)
REBEL covers the OPTION trial: tenecteplase 0.25 mg/kg in CT perfusion-selected non-LVO strokes 4.5-24 hours from last-known-well. The trial showed improved excellent outcomes (mRS 0-1) but increased symptomatic ICH. The post appropriately flags that the benefit-harm balance is sensitive to how you define both outcomes and sICH — a critical point that often gets lost in headline summaries.
Bottom line: Interesting signal but not ready for prime time. The sICH increase is real, the benefit modest, and the perfusion imaging requirement limits generalizability. Wait for larger replication before expanding your thrombolysis window for non-LVO strokes.
Adjacent Specialties
Thrombolysis-to-Puncture Time Determines the Differential Effect of Tenecteplase Versus Alteplase in Large Vessel OcclusionLOE 3 — Retrospective analysis of prospective cohort
Stroke · Neurology/Stroke
In LVO patients receiving bridging thrombolysis before thrombectomy, does tenecteplase vs alteplase improve outcomes, and does this vary by thrombolysis-to-puncture time?
Tenecteplase showed superior early recanalization (19% vs 9%) and functional independence (61% vs 49%) compared to alteplase, but only when thrombectomy occurred within 60 minutes of thrombolysis. Beyond 60 minutes, no difference between agents.
Retrospective design with inherent selection bias — patients getting to thrombectomy faster may differ systematically from those with delays. The interaction analysis is hypothesis-generating, not confirmatory. Adjusted for key confounders but unmeasured confounding remains possible. The 60-minute cutoff is data-derived, not pre-specified. That said, the biological plausibility is strong: tenecteplase's faster fibrin binding and longer half-life should matter more when the clot is still accessible.
Bottom line: Supports tenecteplase as the preferred bridging agent, but the time-dependency finding is preliminary. The practical message: if you're giving TNK before transfer for thrombectomy, the benefit may be greatest when your systems are fast enough to get the patient on the table quickly. Don't use this to justify delays.
Mechanical ventilation for ICU patient with obesity: current best practices and future directionsLOE 5 — Expert review/consensus
Intensive Care Medicine · Critical Care
How should mechanical ventilation be managed in critically ill patients with obesity?
Key points: use predicted body weight for tidal volume (lung size doesn't scale with BMI), higher PEEP often needed to counteract elevated pleural pressure, elevated plateau pressures may not indicate excessive lung stress due to chest wall contribution, and esophageal manometry can help distinguish lung from chest wall mechanics. Preoxygenation with positive pressure and video laryngoscopy recommended for intubation.
This is expert synthesis, not new evidence. The recommendations are physiologically sound but largely extrapolated from general ICU populations — the authors explicitly acknowledge the lack of obesity-specific RCTs. The practical guidance on interpreting airway pressures in obesity is genuinely useful and often overlooked.
Bottom line: Useful framework for the increasingly common scenario of ventilating patients with severe obesity. The key ED-relevant points: don't panic at high plateau pressures if the patient is 150kg, use positive pressure preoxygenation before RSI, and have video laryngoscopy ready. Nothing here changes practice, but it reinforces physiological principles that should guide it.
Methodology Flag
CJEM
Large multicenter POCUS study with provocative headline finding that ED ultrasound has 'poor agreement' with definitive cholecystitis diagnosis
- Reference standard mismatch: TG18 is a composite clinical-laboratory-imaging criterion, not a pure imaging standard. Comparing POCUS (imaging alone) to TG18 (imaging + clinical + labs) is comparing apples to oranges.
- The 17% specificity is misleading — POCUS was never intended to rule out cholecystitis in isolation, only to identify sonographic findings that contribute to the clinical picture.
- Selection bias: patients with 'suspected cholecystitis' who got POCUS likely had higher pretest probability than the general RUQ pain population.
- The study essentially confirms that ultrasound findings alone don't diagnose cholecystitis — which is exactly what TG18 says, making the 'poor agreement' framing somewhat circular.
What it does contribute: Confirms that individual POCUS signs (wall thickening, pericholecystic fluid, sonographic Murphy's) have limited standalone diagnostic value. Reinforces that POCUS should inform, not replace, clinical decision-making. The large sample size (n=783) provides robust estimates of test characteristics in a real-world ED population.
Bottom line: Don't let the headline change your practice. POCUS for cholecystitis was never meant to be a standalone diagnostic test — it's one input into a clinical synthesis. This study confirms that reality but frames it as a limitation rather than appropriate use. Keep using POCUS for RUQ pain; just don't expect it to give you a diagnosis in isolation.