Zworth Reading

Ventilation parameters during Advanced Life Support in cardiac arrest (CAvent): A multicentre observational cohort studyLOE 3 (Prospective observational)

Resuscitation

In adult out-of-hospital cardiac arrest (OHCA) patients receiving manual ventilation during CPR, what are the actual delivered tidal volumes and airway pressures across different airway devices (bag-valve-mask [BVM], supraglottic airway device [SAD], endotracheal tube [ETT]) and ventilation modes (synchronous vs asynchronous)?

241 OHCA patients across 5 Advanced Life Support (ALS) systems in Sweden and the Netherlands, 28,120 ventilations captured via portable pneumotachograph. Median expiratory tidal volumes: synchronous BVM 186 mL (95% CI 104-260), asynchronous BVM 93.7 mL (95% CI 31.2-155), synchronous SAD 395 mL (316-475), asynchronous SAD 333 mL (227-437), asynchronous ETT 404 mL (371-435). Asynchronous ETT ventilation produced the highest peak airway pressures (51.0 cmH2O, 95% CI 48.7-53.1) and the most time above 30 cmH2O (5.8 sec/min, 95% CI 5.1-6.4).

Large-scale objective measurement of what actually gets delivered during real-world resuscitations. Important caveat: this is a physiologic/parameter study, not a patient-centered outcomes study. It does not tell us whether these ventilation differences translate into ROSC, survival, or neurologic outcome. Figure 2 is where the most important data lives, and honestly the confidence intervals are wide enough that firm conclusions are hard to draw from any single number. The synchronous BVM tidal volume of 186 mL is striking on its face but the CI (104-260) is huge. Where I do think this is signal, not noise, is (a) BVM ventilation during CPR often delivers substantially less than intended, and (b) asynchronous bagging through an ETT can generate quite high peak pressures, which has implications for gastric insufflation and preload.

Bottom line: Not practice-changing but worth knowing. Two clinical takeaways: (1) BVM ventilation during CPR is probably less effective than we assume, which reinforces the value of getting to a definitive airway when circumstances allow; (2) once you have an ETT in and are ventilating asynchronously, you're generating higher pressures than intuition suggests, and a lighter hand on the bag is probably a good idea. My personal practice is to stick with 30:2 until the patient has a supraglottic or is intubated, though newer protocols support asynchronous compressions/ventilation earlier in the interest of simplicity and continuous compressions.

HFNC vs. NIV in Acute Cardiogenic Pulmonary Edema: Go with the Flow?Knowledge translation / critical appraisal

REBEL EM  ·  LOE 2 (RCT) being appraised

REBEL EM appraises an RCT comparing high-flow nasal cannula (HFNC) with non-invasive positive-pressure ventilation (NIPPV) as first-line respiratory support in acute cardiogenic pulmonary oedema (ACPE), looking at reduction in respiratory rate and distress in the first 2 hours.

Bottom line: Useful critical appraisal, appropriately cautious in its conclusions. The underlying trial has limitations, but HFNC appears to be a safe alternative to NIPPV in ACPE as long as you have the ability to escalate if the patient doesn't respond. Not a call to abandon NIPPV, but a reasonable option for the patient who can't tolerate the mask.

The Case of the Malignant CohortCommentary / critical appraisal

EMCrit (EM Nerd)  ·  Appraisal of a Level 2 RCT (Hydra Trial, JAMA 2026)

Spiegel takes on the Hydra Trial (YEARS algorithm in cancer patients — the highlight of last week's newsletter) and makes some sharp Bayesian points. Two things worth carrying: (1) 275 of 352 patients (78.1%) in the YEARS arm still ended up getting a CTPA, so the large majority of patients in both arms received chest imaging regardless of assigned strategy. (2) The baseline VTE rate in the Hydra cohort was surprisingly high even in patients scoring 0 on YEARS (~10%), which suggests YEARS did not risk-stratify this population as effectively as it does in general-population cohorts. Spiegel's overall conclusion: it is probably safe to use YEARS in cancer patients, but you should accept a slightly higher posterior risk than you would tolerate in a general-population patient.

Bottom line: Great piece and a great reminder of Bayesian thinking (pretest probability really does matter, and a decision rule performs differently when it's applied to a higher-prevalence population). Definitely worth reading in conjunction with the Hydra Trial itself.Iit doesn't undo the conclusion that YEARS is safe in cancer patients, but it appropriately calibrates our expectations of how much CT-avoidance you can actually achieve in this group.

Hip Fractures: A ReviewLOE 5 (Narrative review)

JAMA

Why it matters to EPs: Hip fractures are a bread-and-butter ED presentation. This review covers classification, prognosis, and post-acute management. Useful background for counselling patients and families, and for the context behind why ortho pushes for early time-to-OR.

Key numbers: 22% median 1-year mortality, 42-71% regain baseline ADLs at 6 months. Men have higher 1-year mortality (26.9%) than women (18.5%). Risk factors include age (HR 1.35 per 5-year increase), low bone mineral density, prior fracture, and fall risk factors. Post-surgical care should include physiotherapy, fall reduction strategies, and antiresorptive therapy.

Solid JAMA clinical review. Nothing here is new or surprising, but it's a useful refresher on the epidemiology and downstream care. The mortality statistics are worth knowing. The emphasis on post-fracture osteoporosis treatment is important for the whole care pathway but largely outside our lane in the ED.

Bottom line: Good background reading. The 22% one-year mortality figure is worth remembering when discussing prognosis with families of the frail elderly patient with a hip fracture. Otherwise, this confirms what you already know.