Issue #2·Week of April 13, 2026

Zworth Reading

Max’s EM Weekly Update

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Highlight of the Week

Airway management of adults in the acute care setting

BMJ · Narrative Review

Comprehensive evidence-based review of adult airway management covering assessment, preoxygenation, drug selection, device choice, and post-intubation care. Key takeaways: video laryngoscopy should be default over direct laryngoscopy for RSI based on first-pass success data; preoxygenation with NIPPV can help reduce peri-intubation hypoxia; capnography or POCUS for confirmation; and explicit attention to post-intubation sedation to prevent awareness with paralysis.

This is a well-constructed narrative review from authors with strong airway research credentials. It synthesizes current evidence rather than generating new data, so treat it as a high-quality knowledge translation piece. The VL-over-DL recommendation is backed by multiple RCTs and meta-analyses — this is settled science at this point. The preoxygenation and physiological optimization sections reflect the apneic oxygenation and delayed sequence intubation literature that has matured over the past decade. The review appropriately acknowledges that difficult airway prediction tools remain poor. One limitation: the review is necessarily broad, so depth on any single topic is limited. For the ED physician who has kept up with airway literature, little here is new. For someone who hasn't revisited the evidence in a few years, this is a good single-source update.

Bottom line: A solid, evidence-based summary of modern airway management. VL as default, NIPPV for preoxygenation, capnography for confirmation. Nothing revolutionary, but a useful reference document and a good reminder that post-intubation sedation deserves attention.

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FOAM Radar

You Don't Understand Dizziness and Vertigo – But You Need To!!!Knowledge translation / Educational

EMCrit · LOE 3-4 underlying evidence (observational studies on HINTS exam, vestibular testing)

Weingart's latest push on the vertigo knowledge gap. The core message is that we systematically underperform on posterior circulation stroke detection because we don't understand vestibular physiology. The HINTS exam data (sensitivity >95% for central causes when done properly) is solid, but the key word is 'properly.' Big take home for me is that the test is often used in the wrong patients.

Bottom line: Know how to perform HINTS, and know when it should be applied. The test should be performed in patients with spontaneous unidirectional nystagmus.

The OPTION Trial: Late-Window TNK for Non-LVO StrokePrimary literature appraisal

REBEL EM · LOE 2 (RCT)

REBEL's breakdown of OPTION (published Feb 2026) — tenecteplase 0.25 mg/kg in CT perfusion-selected non-LVO strokes 4.5-24 hours out. The trial showed improved outcomes (mRS 0-1) but increased symptomatic ICH. A number of design limitations including open label design, partly subjective endpoint. This is hypothesis-generating for late-window non-LVO treatment, but the sICH signal means this isn't ready for prime time outside of trials.

Bottom line: Interesting signal that perfusion-selected non-LVO strokes might benefit from late TNK, but the bleeding trade-off needs larger replication before this changes practice. File under 'watch this space.'

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Guidelines Update

2026 AHA/ACC/ACCP/ACEP/CHEST/SCAI/SHM/SIR/SVM/SVN Guideline for the Evaluation and Management of Acute Pulmonary Embolism in Adults

AHA/ACC Joint Committee (with ACEP, CHEST, and multiple specialty societies)

Introduction of new 'AHA/ACC Acute PE Clinical Categories' for severity classification — replaces the older massive/submassive/low-risk terminology
Risk stratification should incorporate validated scores (PESI/sPESI) plus imaging and biomarkers for intermediate-risk patients
CTPA remains first-line diagnostic imaging; age-adjusted D-dimer endorsed for low-probability patients
Anticoagulation recommendations: DOACs preferred over warfarin for most patients; specific guidance on when to initiate in the ED
Thrombolysis recommendations refined: systemic thrombolysis for hemodynamically unstable PE; catheter-directed therapy positioned as alternative for intermediate-high risk with bleeding concerns
Guidance on ED disposition: low-risk PE (by validated criteria) can be considered for outpatient management

Conflicts with existing guidance: The new severity categories may cause initial confusion as they replace familiar terminology. Some tension with existing institutional protocols that use submassive/massive language.

Bottom line: A comprehensive update that EPs need to know. The new severity classification will take time to adopt, but the core ED-relevant content — risk stratification, DOAC preference, outpatient management criteria — is what most of us are already doing. Consider printing the risk stratification algorithm for your department.

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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 / Interventional

In LVO stroke patients receiving bridging thrombolysis before thrombectomy, does tenecteplase vs alteplase effect vary by thrombolysis-to-puncture time?

Tenecteplase superiority over alteplase (higher early recanalization, better 90-day functional independence) was only evident when TTP was <60 minutes. With TTP ≥60 minutes, there was no difference between agents. Each 30-minute TTP increase raised hemorrhagic risk for both agents.

Retrospective analysis of 1003 patients from a prospective multicenter cohort. The finding is biologically plausible: TNK's faster fibrin binding and longer half-life matter most when the clot is still accessible. Limitations: observational design means unmeasured confounders (sicker patients may have longer TTP for system reasons); the 60-minute cutoff is somewhat arbitrary; and the functional outcome interaction didn't reach statistical significance (p=0.111 for interaction), only the recanalization endpoint did.

Bottom line: Based on this study TNK's advantages over alteplase seem to be most pronounced when thrombolysis to groin puncture time is under 60 minutes. This supports TNK as preferred agent but emphasizes that workflow optimization is at least as important as drug selection.

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Methodology Flag

Agreement between point-of-care ultrasonography and the Tokyo guidelines 2018 for acute cholecystitis (PACED study)

CJEM

Large multicenter POCUS study with provocative finding that ED ultrasound has only 17% specificity for cholecystitis

Reference standard problem: TG18 is a clinical diagnostic framework incorporating labs, imaging, AND clinical findings
The 'positive POCUS' definition (stones + Murphy's OR wall thickening OR pericholecystic fluid) is extremely sensitive by design — any single secondary sign triggers positivity
Specificity of 17% means 83% false positive rate, but this reflects the test characteristics of the chosen POCUS definition against a composite reference, not necessarily clinical utility
No assessment of how POCUS changed management or whether 'false positives' led to harm
Thai tertiary care population may have different disease spectrum than Canadian EDs

What it does contribute: A good reminder that POCUS for cholecystitis is a rule-out tool, not a rule-in tool. The finding that only gallstones (not secondary signs) independently predicted TG18-confirmed cholecystitis is useful. Reinforces that POCUS should be integrated with clinical assessment, not used as a standalone diagnostic.

Bottom line: The headline '17% specificity' will get attention but misrepresents how POCUS should be used. The real message is appropriate: don't diagnose cholecystitis on POCUS alone. But don't let this paper make you think POCUS is useless. In a patient with right sided abdominal pain, if POCUS shows gallstones, US may be the right diagnostic test even if your cholecystitis findings are equivocal. If you clearly see a gallbladder with no gallstones, consider alternate diagnoses.

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