Research and Reviews in the Fastlane 093

Research and Reviews in the Fastlane

Welcome to the 93rd edition of Research and Reviews in the Fastlane. R&R in the Fastlane is a free resource that harnesses the power of social media to allow some of the best and brightest emergency medicine and critical care clinicians from all over the world tell us what they think is worth reading from the published literature.

This edition contains 6 recommended reads. The R&R Editorial Team includes Jeremy Fried, Nudrat Rashid, Soren Rudolph, Anand Swaminathan and, of course, Chris Nickson. Find more R&R in the Fastlane reviews in the R&R Archive, read more about the R&R project or check out the full list of R&R contributors

This Edition’s R&R Hall of Famer

AirwayR&R Hall of Famer - You simply MUST READ this!

Bair AE, Chima R. The Inaccuracy of Using Landmark Techniques for Cricothyroid Membrane Identification: A Comparison of Three Techniques. Acad Emerg Med 2015. PMID 26198864

  • This randomized trial of Emergency Physicians use if various techniques to identify landmarks for cricothyrotomy showed that these techniques have limited sensitivity (46-62%), when ultrasound was used as the gold standard. The paper doesn’t speak to procedural success or patient outcomes but given the potential inadequacy of landmark identification, it seems prudent to use ultrasound to mark anatomy in an anticipated difficult airway, should time allow.
  • This study of 50 volunteers suggests that three commonly taught methods for finding the cricothyroid membrane (general palpation, four-finger, skin crease) are relatively inaccurate, using ultrasonography as the gold standard. I conclude:1. The landmark techniques are inaccurate for finding the CTM *and that’s okay.* Make your best guess using general palpation and if you feel nothing, use four-finger or skin crease **and then make a long vertical incision.** Once you get through the skin you are very likely to be able to feel the CTM, and even if you still can’t at that point, that’s fine too, cut to air.2. If you have time to prepare (e.g. prior to RSI in a patient predicted to be very difficult laryngoscopy) put the ultrasound probe on the neck and mark the CTM.
  • Recommended by Lauren Westafer, Reuben Strayer

The Best of the Rest

Emergency MedicineSchechter MT, Sheps SB. Diagnostic testing revisited: pathways through uncertainty. Can Med Assoc J 1985;132(7):755-60. PMID: 3884119

  • The authors in this review, describe 4 principles clinicians can use and teach to stop the epidemic of over testing which beleaguers healthcare. Did I mention this was published in 1985? The principles are
  1. In the diagnostic context, patients do not have a disease, only a probability of disease.
  2. Diagnostic tests are merely revisions of probability.
  3. Test interpretation should precede test ordering.
  4. In general, if the revisions in probabilities caused by a diagnostic test do not entail a change in subsequent management, use of the test should be reconsidered.
  • Full of pearls and examples of how to apply these principles at the bedside, this article is a great read. Also, not to be missed, is the appendix with a MS-BASIC program to calculate post-test probabilities given a positive or negative test result.
  • Recommended by Jeremy Fried
  • Further information Diagnostic Decision Making in Emergency Medicine (Emergency Medicine Cases)

Emergency MedicineCapp R et al. Emergency Department With Sepsis and Progress to Septic Shock Between 4 and 48 Hours of Emergency Department Arrival. Crit Care Med. 2015; 43(5): 983-8. PMID: 25668750

  • It would be great if we could predict which patients with sepsis will develop septic shock within a short period of time after admission to the hospital. This retrospective chart review attempts to identify factors from the patient’s Emergency Department course which may predict short term decompensation. Although the article has inherent flaws based on its design, it has important findings that can be used to improve patient care. In particular, it points out that non-persistent hypotension is strongly associated with short term decompensation (OR = 6.24)
  • Recommended by Anand Swaminathan

Emergency MedicineCostantino G et al. Syncope risk stratification tools vs clinical judgment: an individual patient data meta-analysis. Am J Med 2014; 127(11): 1126. PMID: 24862309

  • Although limited by it’s retrospective nature, this meta-analysis is an interesting contribution to the current state of knowledge on syncope patients presenting to the emergency department, and importantly, demonstrates that clinical judgement outperforms decision tools.The authors identified all prospective studies in which one of the many syncope tools could be derived. They then contacted the primary author of the initial studies to obtain the individual patient data. Six of the thirteen identified authors did so. The decision to admit or discharge the patient was used as a proxy for clinical judgement of high v low risk, and compared to the different decision tools. While there was no difference in specificity between any rule and clinical judgement (all low), the sensitivity of clinical judgement was significantly better than that of the decision tools. A well done article that reminds us there is an important role for clinical judgement in risk stratification of syncope patients.
  • Recommended by Jeremy Fried

TraumaPerez MR et al. Sternal fracture in the age of pan-scan. Injury 2015; 46(7):1324-7. PMID: 25817167

  • Not surprisingly, sternal fractures found only on CT aren’t associated with serious underlying injuries. This makes a lot of sense: first, the classic teaching that sternal fractures indicate badness refers to sternal fractures found based on exam or CXR, which are plausibly the worst of the worst. This paper is perhaps most interesting not for this specific finding but for what it represents: classic signs of badness likely don’t portend bad outcomes when found incidentally on advanced imaging.
  • Recommended by Seth Trueger

Intensive CareMalbrain ML et al. Fluid overload, de-resuscitation, and outcomes in critically ill or injured patients: a systematic review with suggestions for clinical practice. Anaesthesiol Intensive Ther 2014; 46(5):361-80. PMID: 25432556

  • If the intensive care literature is consistent about one thing, it is that there is nothing positive about positive fluid balance. This paper reviews the literature, offers up a host of relevant definitions – including one for ‘de-resuscitation’ – and suggests how ‘Late Goal Directed Fluid Removal’ might be done. Paul Marik is one of the authors so ‘iatrogenic salt water drowning’ gets a mention. Enjoy!
  • Recommended by Chris Nickson

The R&R iconoclastic sneak peek icon key

Research and Reviews The list of contributors R&R in the FASTLANE 009 RR Vault 64 The R&R ARCHIVE
R&R in the FASTLANE Hall of Famer R&R Hall of famer You simply MUST READ this! R&R Hot Stuff 64 R&R Hot stuff! Everyone’s going to be talking about this
R&R in the FASTLANELandmark Paper R&R Landmark paper A paper that made a difference R&R Game Changer 64 R&R Game Changer? Might change your clinical practice
R&R Eureka 64 R&R Eureka! Revolutionary idea or concept R&R in the FASTLANE RR Mona Lisa R&R Mona Lisa Brilliant writing or explanation
R&R in the FASTLANE RR Boffin 64 R&R Boffintastic High quality research R&R in the FASTLANE RR Trash 64 R&R Trash Must read, because it is so wrong!
R&R in the FASTLANE 009 RR WTF 64 R&R WTF! Weird, transcendent or funtabulous!

That’s it for this week…

That should keep you busy for a week at least! Thanks to our wonderful group of editors and contributors Leave a comment below if you have any queries, suggestions, or comments about this week’s R&R in the FASTLANE or if you want to tell us what you think is worth reading.

The post Research and Reviews in the Fastlane 093 appeared first on LITFL: Life in the Fast Lane Medical Blog.

Free #FOAMed based courses at St.Emlyn’s. The next step in shared learning

St.Emlyn's - Meducation in Virchester #FOAMed

Before #FOAMed was invented the St.Emlyn’s team were already deeply immersed in online learning. Back in 2005 we began using a moodle platform to teach our junior doctors online such that we did not have to rely on everyone being in the same place at the same time. This was invention born of necessity as […]

The post Free #FOAMed based courses at St.Emlyn’s. The next step in shared learning appeared first on St.Emlyn's.

When Anaphylaxis Makes a Comeback

The frequency of biphasic anaphylaxis is a subject of some controversy, with most estimates derived from retrospective chart review.  The frequency may be as high as 20%, as low as 3%, or those may yet be gross overestimations based on partial symptom recurrence.

For these folks, the answer was: 14.7%.

This is yet another evaluation of Emergency Department visits for anaphylaxis, as collected by retrospective chart review.  Looking at one year’s worth of data collected at two pediatric hospitals in Canada, these authors identified 484 visits for anaphylaxis with adequate data for analysis.  Of these visits, 71 met their criteria for a biphasic reaction: a period of full symptom resolution lasting at least an hour, followed by recurrence of symptoms requiring additional pharmacologic intervention.  They subsequently reviewed features of the initial reaction to determine any potential predictors of biphasic manifestations.

Some of their features make sense, and some – none.  Independent predictors included delayed ED presentation, wide pulse pressure, multiple doses of epinephrine to treat the initial episode, and administration of beta-agonists in the initial episode.  Essentially, those patients with the most severe, multi-system involvement.  However, their strongest odds ratio for predicting return of symptoms was for patients simply aged 6-9 years of age – and the authors do not address the aberration in their discussion.

So, ultimately, this study doesn’t reliably alter our management.  Chances are, you’ve already been observing the mildest anaphylaxis for the shortest time, and the most severely ill for longer.  Thus, as seen in this cohort, most of these severely ill patients were still undergoing observation in the ED when the biphasic reaction occurred – 3 to 6.5 hours later.  All told, 18 patients were discharged from the ED and returned with biphasic symptoms – with a median time of 18.5 hours to return.  So, unfortunately, there’s no reasonably useful clinical endpoint to observation that would catch all revisits – and the best course of action is simply to ensure patients have epinephrine for home use at discharge, and inform them of the small likelihood of recurrence.

“Epidemiology and clinical predictors of biphasic reactions in children with anaphylaxis”

PHARM Podcast 121 : African prehospital care with Craig Wylie

Craig Wylie at a road scene
Craig Wylie at a road scene
Craig getting pepper sprayed for training! only in South Africa!
Craig getting pepper sprayed for training! only in South Africa!
Craig simulating the effects of pepper spray on a human
Craig simulating the effects of pepper spray on a human

Hi Folks

On today’s show, I talk with Craig Wylie an Emergency care Practitioner in Cape Town, South Africa.

Show notes:

  2. African Emergency Medicine FOAMEd – Online training for HEMS
  4. Tell Me and I will Forget ( South African prehospital documentary)
  5. Tales from My Stethscope
  6. Paramedic Rapid Sequence Intubation (RSI) in a South African Emergency Medical Service (EMS) is effective, but is it safe?
  7. These are some preliminary communication notes between Craig and Yugan Pillay , another ECP doing prehospital research on RSI : 1. Reality check…RSI is an elective procedure i.e. the clinician makes a conscious decision to take away the patient’s ability to breathe 2. Training and availability of skilled RSI assistants (eg. ILS provider) is seriously lacking in SA 3. There is generally under-reporting of the presence of perceived difficult airways, especially in Trauma. This correlates to a risk of underestimating intubation difficulty. 4. More than 60% of ECPs believe that ALL ALS practitioners should be allowed to practice RSI, as long as adequate bridging training and mentorship is provided to CCAs and NDip practitioners5. Failed intubation is rare (less than 5%). There is concern however that reporting of failed intubations are inconsistent/inaccurate 6. Scene times must be viewed in terms of time-critical vs therapy-critical types of patients. 7. The use of mechanical ventilation has steadily improved since 2008 until now. 8. There is generally poor documentation of ventilation (Mode, rate, I:E ratio, waveform) 9. All PCR forms need to be standardized to include EtCO2 in the VITAL SIGNS block 10. A big concern is exposure of ECPs to the RSI procedure especially because there are so many more ECPs available now as compared to 5 years ago. Average RSI rate is less than 12 per year per ECP 11. Private does most of the RSIs. Government sector…there is more RSI activity in Gauteng and Western Cape. Minimal activity in KZN and other provinces 12. Private sector (big players) tends to be more proactive in managing risk surrounding RSI 13. prepackaged RSI kits are recommended 14. Infection control during RSI must be kept in mind!

Now, onto the PODCAST!


Click and Choose Save-as to Download the


Filed under: airway, Emergency anaesthesia, Emergency medicine and critical care, FOAMEd, prehospital and retrieval medicine podcast, Prehospital medicine, SMACCUS Tagged: africa, airway, craig-wylie, emergency, itunes, prehospital

ECG of the Week – 27th July 2015 – Interpretation

This ECG is from a 28 year old female who presented complaining of intermittent pre-syncope and palpitations. She is normally fit & well and is 34 weeks pregnant.
Check out the comments from our original post here.

Click to enlarge
  • 78
  • Regular
  • Normal
  • PR - Short (~200ms)
  • QRS - Normal (80ms)
  • QT - 320ms (QTc Bazette 365ms)
  • Subtle ST depression leads I, V4-6
  • Voltage criteria LVH
    • S wave V1 + R wave V6 =~38mm

  • Short pr
    • Could this be Lown-Ganong-Levine ?
  • Voltage criteria for LVH

What happened ?

The patient was admitted for investigation under joint care of cardiologists and obstetricians.
Investigation for PE was normal. Echo showed:
  • Normal left ventricular size with normal wall thickness and normal systolic function.
  • Possible mild dilatation of the right ventricle
    • May be physiological due to stage of pregnancy.
  • Normal right ventricular systolic function.
  • Normal atrial size
  • No significant valvular abnormality
In-patient telemetry revealed no arrhythmia despite the patient complaining of palpitations.
The patient was discharge with on-going obstetric follow-up.

Lown-Ganong-Levine (LGL)

LGL is often grouped with WPW as part of the pre-excitation syndromes the major ECG difference is that LGL has only pr shortening without the QRS changes associated with WPW. The advent of EP studies has resulted in a greater understanding of cardiac conduction and it's role in arrhythmogenesis with the existence of LGL as a clinical entity disputed. It is likely the short pr reflects an extreme of the normal variation and may not play any role in arrhythmogenesis.
This eMedicine article has a great review of LGL an the current evidence around it's existence as a clinical entity:
References / Further Reading

Life in the Fast Lane
  • Chan TC, Brady WJ, Harrigan RA, Ornato JP, Rosen P. ECG in Emergency Medicine and Acute Care. Elsevier Mosby 2005.