Zworth Reading
EMMax’s EM Weekly Update
Highlight of the Week
Resuscitation · RCT (LOE 2)
This Australian cluster-RCT randomized 216 ambulance stations to either manual pressure augmentation (MPA) during defibrillation or standard care for adults with shockable OHCA. MPA involves applying manual chest compression during shock delivery to reduce transthoracic impedance. The trial enrolled 560 patients before premature termination due to external safety reviews and operational delays. Survival to hospital discharge was identical: 39.8% vs 39.9% (ARD -0.1%, 95% CI -8.2% to 8.0%). MPA did reduce transthoracic impedance by 8.5 ohms (p<0.001). Critically, compliance with the MPA protocol was only 23.6%. No serious rescuer injuries occurred; perceptible shocks were rare and similar between groups.
This is a well-designed pragmatic cluster-RCT with appropriate randomization and ITT analysis. The major flaw is the 23.6% compliance rate. You cannot conclude a technique doesn't work when it wasn't actually performed in three-quarters of the intervention group. Premature termination further limits conclusions. The safety signal is reassuring (rescuer shocks were rare and comparable) but this trial answers the question 'does telling paramedics to do MPA improve outcomes?' (no), not 'does MPA improve outcomes when actually performed?' (unknown). The identical survival rates are likely a compliance problem, not a biological one.
Bottom line: MPA reduces impedance when performed but compliance was too low to draw conclusions about survival. This trial does not change practice — it tells us the intervention is hard to implement reliably in the field. The technique remains physiologically plausible but unproven.
FOAM Radar
Beyond Weight Loss: ED Implications of the GLP-1 EraClinical review — practice guidance
EMOttawa · Expert review / narrative synthesis
GLP-1 receptor agonists (semaglutide, tirzepatide) have become some of the most commonly prescribed medications in clinical practice. This post reviews what EPs need to know: GI side effects (nausea, vomiting, gastroparesis-like delayed gastric emptying), aspiration risk implications for procedural sedation and airway management, GLP-1-associated pancreatitis, and the cardiovascular benefits that may change how we interpret presentation context.
Bottom line: Practical, timely read. Key ED takeaways: treat GLP-1 patients like potential gastroparetics for airway planning, and recognize GLP-1 as a cause of nausea/vomiting/abdominal pain. Important clinical takeaway for me is that these agents are associated BOTH with relatively benign GI side effects (abdo pain, nausea, vomiting, diarrhea), and more serious ones (cholecystitis, pancreatitis), so we need to be vigilant in our assessment and workup of these patients who present with GI symptoms.
Alternate Defibrillation Strategies for Refractory Ventricular FibrillationKnowledge translation — secondary analysis of RCT
REBEL EM · LOE 2 (secondary analysis of DOSE-VF RCT)
Reviews a secondary analysis of DOSE-VF examining whether reduced time in VF between shocks explains the survival benefit seen with double sequential defibrillation and vector change strategies.
Bottom line: This paper shows that Dual Sequential External Defibrillation (DSED) and Vector Change (VC) Defibrillation both reduces time in VF and improves patient outcomes but does not show causality between time in VF and increased survival. Useful context for understanding why alternative defib strategies might work.
PRoMPT BOLUS: A Landmark PECARN Trial Defining Fluid Choice in Pediatric SepsisKnowledge translation — RCT summary
ALiEM · LOE 2 (large multicenter RCT)
Covers the PRoMPT BOLUS trial comparing balanced crystalloid vs normal saline in pediatric septic shock (reviewed in previous newsletter). This is a major PECARN/PERC/PREDICT network trial that should inform fluid choice in pediatric resuscitation.
Bottom line: Reminder that both 0.9% Saline and balanced fluids (i.e. Ringers Lactate) are safe for treatment of septic shock in children. Based on this trial, fluid type does not influence mortality or risk of kidney injury.
Guidelines Update
European Stroke Organisation
- Do NOT routinely lower BP pre-hospital in suspected stroke (moderate evidence)
- Before IV thrombolysis: maintain BP <185/110 mmHg
- During and 24h after thrombolysis: maintain BP <180/105 mmHg
- After successful thrombectomy: do NOT intensively lower SBP <140 mmHg in first 24h (strong recommendation, high-quality evidence)
- Do NOT routinely use vasopressors to raise BP in AIS without reperfusion therapy
- In acute ICH: expert consensus supports early SBP reduction to <140 mmHg for small-moderate hematomas, but net benefit remains uncertain
Mixed — ranges from high-quality (post-thrombectomy BP target) to low/very low (most other recommendations). GRADE methodology used. Most recommendations are weak and consensus-based.
Conflicts with existing guidance: Largely aligns with AHA/ASA guidance. The strong recommendation against intensive BP lowering post-thrombectomy is now backed by high-quality evidence (likely from ENCHANTED2/MT and similar trials).
Bottom line: The key actionable update: after successful thrombectomy, do NOT chase SBP <140 (less relevant to ED providers). This is now a strong recommendation with good evidence. Everything else is refinement of existing practice with weak evidence.
Major Journals Scan
JAMA
Why it matters to EPs: Directly addresses whether to give TNK before EVT in late-window strokes — a decision EPs at comprehensive centers or those arranging transfers face regularly.
No benefit: functional independence 44.2% TNK+EVT vs 43.2% EVT alone (aRR 1.01, 95% CI 0.83-1.24). sICH numerically higher with TNK (5.1% vs 2.6%) but not statistically significant.
Well-designed PROBE trial with appropriate imaging selection (perfusion mismatch). The confidence interval excludes meaningful benefit. The sICH signal (double the rate) is concerning even if not significant. This aligns with the late-window biology: by 4.5-24h, the clot that's going to lyse has lysed.
Bottom line: In this well-designed trial, thrombolysis with tenecteplase before EVT did not improve outcomes compared to EVT alone.