Zworth Reading
EMMax’s EM Weekly Update
Highlight of the Week
Resuscitation · Systematic Review (LOE 1)
ILCOR-commissioned systematic review comparing supraglottic airways (SGAs) to bag-valve-mask (BVM) ventilation by BLS providers during cardiac arrest. Included 3 RCTs and 13 observational studies. The pooled RCT data showed no difference in survival to discharge (RR 1.28, 95% CI 0.46-3.55) with low certainty of evidence. Observational studies were inconsistent with very low certainty evidence for neurological outcomes and ROSC. One RCT suggested higher chest compression fraction with SGAs. Notably, no studies included true first rescuers (lifeguards, police, firefighters).
This is a well-conducted systematic review using GRADE methodology and registered with PROSPERO. The conclusion of no evidence of benefit is appropriately cautious given the evidence quality. The RCT confidence interval is wide enough to include both meaningful benefit and harm. The heterogeneity that precluded meta-analysis of observational studies is a limitation of the underlying literature, not the review itself. The finding of similar emesis rates challenges one theoretical advantage of SGAs. This review does what good systematic reviews should do: it clarifies that our enthusiasm for SGAs in BLS has outpaced our evidence.
Bottom line: No evidence supports SGAs over BVM for BLS providers in cardiac arrest. Doesn't really change our ED management of cardiac arrest but good to be aware of this evidence (or lack thereof). BLS crew should probably continue doing whatever they are trained and comfortable with.
FOAM Radar
Acute Liver FailureKnowledge translation / clinical review
EMOttawa · Educational synthesis of existing literature — no new primary data
Dr. Northrop gives a comprehensive overview of ALF epidemiology, etiology (acetaminophen dominant in North America), ED recognition, and initial management. Covers the key decision points: when to involve hepatology, when to transfer for transplant evaluation, and supportive care priorities. Big takeaway for me was recognition and diagnostic criteria - think ALF in a patient with newly elevated liver enzymes, coagulopathy (INR > 1.5), altered mental status, lactic acidosis, hypoglycemia. Also important to distinguish these patients from cirrhotic patients because the pathophysiology and workup is different. Unlike in cirrhosis, ammonia levels are useful as they with cerebral complications. Lastly, remember to think about NAC in this population.
Bottom line: Solid refresher on a rare but high-stakes condition. Good for trainees or as a quick reference while managing a case. No new evidence, but well-organized clinical guidance.
Adjacent Specialties
Intensive Versus Conventional Blood Pressure Lowering After Successful Endovascular Thrombectomy: OPTIMAL-BP 1-Year OutcomesLOE 2 (RCT follow-up)
Stroke · Neurology / Stroke
In patients with successful EVT and elevated BP (n=306), does intensive BP control (<140 systolic) vs conventional (140-180) for 24 hours affect 1-year functional independence?
Functional independence at 1 year was lower in the intensive group (40.5% vs 52.7%, aOR 0.59, 95% CI 0.34-1.00, p=0.051 ITT; significant in per-protocol analysis). No mortality difference.
This is the 1-year extension of OPTIMAL-BP, which showed harm from intensive BP lowering at 3 months. The 1-year data confirms the signal persists — early aggressive BP management after successful thrombectomy seems to cause harm. The p=0.051 in ITT is borderline, but the per-protocol analysis is significant and the direction is consistent with the original findings.
Bottom line: Evidence does not support aggressively lowering BP after successful thrombectomy. Target seems to be 140-180 systolic for the first 24 hours. These patients are generally being managed in stroke units, but I find it interesting and useful to stay on top of debates about BP targets in stroke..