Research and Reviews in the Fastlane 049

Research and Reviews in the Fastlane

Welcome to the 49th 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 10 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

Emergency Medicine, Cardiology

R&R Hall of Famer - You simply MUST READ this!R&R Eureka - Revolutionary idea or concept

Stolker JM et al. Re-Thinking Composite Endpoints in Clinical Trials: Insights from Patients and Trialists. Circulation. 2014. PMID: 25200210

  • Composite endpoints are commonplace, especially in cardiology literature. It takes massive power to find mortality/major mobidity benefits for many interventions; thus, many studies are powered for a primary composite outcome, often: death, myocardial infarction (MI), and revascularization. This cardiology survey data highlights that both patients and trial researchers appreciate the inequity between death and revascularization. The shocker? Patients rated MI and stroke worse than death, whereas researchers rated MI and stroke as 1/3 to 1/2 as important as death. Both clinical trialists and patients rated revascularization as a minor event, in contradistinction to the equal weight placed in the composite primary outcome in many trials.
  • Recommended by: Lauren Westafer, Anand Swaminathan
  • Read More: Would You Rather . . . (Lauren Westafer)

The Best of the Rest

Resuscitation, Emergency Medicine

R&R Game Changer? Might change your clinical practice

Hernandez, C et al. C.A.U.S.E.: Cardiac arrest ultra-sound exam–a better approach to managing patients in primary non-arrhythmogenic cardiac arrest.Resuscitation. 2008 Feb;76(2):198-206. PMID: 17822831

  • Having a practical approach to managing a PEA is crucial. This paper has used the C.A.U.S.E. mnemonic (appropriately termed) to find reversible causes. In addition this protocol has the potential to reduce the time required to determine the etiology of a cardiac arrest and thus decrease the time between arrest and appropriate therapy.
  • Recommended by: Sa’ad Lahri

Emergency Medicine

R&R Landmark paper that will make a difference
Calder KK et al. The mortality of untreated pulmonary embolism in emergency department patients. Ann Emerg Med. 2005 Mar;45(3):302-10. PMID: 15726055

  • This 2005 paper questions the mortality rate of untreated PE — they find only 5%. Scary numbers from PE probably represent old data when the only PEs we found were big, bad… and obvious.
  • Recommended by: Seth Trueger

Emergency Medicine, Cardiology

R&R Hot Stuff - Everyone’s going to be talking about this
Thiruganasambandamoorthy V et al. Outcomes in Presyncope Patients: A Prospective Cohort Study. Ann Emerg Med 2014. PMID: 25182542

  • Pre-syncope is often thought of as a benign occurrence but in this prospective study, the authors found that 5.1% of patients with presyncope had serious outcomes at 30 days. This rate was only 1.9% in the group sent home from the Emergency Department. Emergency Physicians had a tough time determining which patients with presyncope were at risk for serious outcomes after discharge. This area needs more research but it is clear that we should take presyncope seriously.
  • Recommended by: Anand Swaminathan

Pre-hospital/Retrieval, Resuscitation
R&R Game Changer? Might change your clinical practice

Jabre P et al. Family presence during cardiopulmonary resuscitation. NEJM 2013; 368(11):1008-18. PMID: 23484827 (OPEN ACCESS ARTICLE)

  • Should the family watch? In this study, home CPR was performed by responding EMS units, half offered the family the opportunity to be present for resuscitation, half did not. Post-surveys were conducted 90 days later on family and health care workers.
    PTSD and anxiety symptoms were less in the family members who witnessed the resuscitation. Health care workers did not report increased stress levels or that family interfered with resuscitation.
  • Application to emergency department and critical care setting is questionable given this was a French pre-hospital study, but it suggests that family presence in resuscitation may be good for family members and does not hinder the care provided.
  • Recommended by: Zack Repanshek

Pediatrics, Emergency Medicine
R&R Game Changer? Might change your clinical practice

Cohen HA et al. Effect of honey on nocturnal cough and sleep quality: a double-blind, randomized, placebo-controlled study. Pediatrics. 2012 Sep;130(3):465-71. PMID: 22869830 (OPEN ACCESS ARTICLE)

  • If you aren’t using honey for cough in kids (>!yr old only!), then you should be. Not many drugs are effective, and this RCT shows that it wasn’t simply sticky sweet syrup, but something specific about honey as yet unidentified.
  • Recommended by: Justin Hensley

Emergency Medicine

R&R Eureka - Revolutionary idea or concept

Rising KL et al. Return Visits to the Emergency Department: The Patient Perspective. Ann Emerg Med 2014. PMID: 25193597

  • New article in Annals looking at 60 bouncebacks — great qualitative research with patient perspectives on why they had to come back. A lot of uncertainty, worry, poor explanation. And, not surprisingly, patients thought blood work or imaging would have been necessary (would be nice to see the physicians’ perspectives!)
  • Recommended by: Seth Trueger

Emergency Medicine

R&R Eureka - Revolutionary idea or concept
Sheehy AM et al. The Role of Copy-and-Paste in the Hospital Electronic Health Record. JAMA Intern Med. 2014 Aug 1;174(8):1217-8. PMID: 24887572

  • We are seeing more attention paid to how we use electronic health records (EHRs), and this paper addresses one the most contentious issues in the EHR era, the use of “macros” or templates to document care. The authors outline the problem (documenting what you did not do, i.e. fraud) and propose user-based and systems-based solutions. Ultimately they conclude the force that drives inappropriate documentation is the perverse ways in which hospitals and physicians are reimbursed (e.g. by documenting a “complete” review of systems) and that without changing these incentives, progress on the copy & paste front will be difficult.
  • Recommended by: Reuben Strayer

Pediatrics, Resuscitation

R&R Game Changer? Might change your clinical practice
Tibballs J, Russell P. Reliability of pulse palpation by healthcare personnel to diagnose paediatric cardiac arrest. Resuscitation. 2009 Jan;80(1):61-4. PMID: 18992985

  • In the healthy child, finding a pulse is not a problem. Unfortunately, our management is not usually contingent upon finding a pulse in the healthy kid, whereas it is vital in the sick one… especially if they are unresponsive. “Do you feel a pulse?” “Hmmm… I think so… well, maybe not…” “Does anyone feel a pulse?” This paper essentially points out that we are not perfect at determining whether there is a pulse present or not. When time is of the essence, wasting time trying to be perfect is unwise. This helps advocate for two things in my mind: 1) More liberal use of chest compressions in the patient who is unresponsive , lacks movement, or has poor respirations and (2) more liberal use of bedside ultrasound (although not right away… as you only have 10 seconds to make a decision).
  • Recommended by: Sean Fox
  • Read More: Palpation of Pulse for Cardiac Arrest (Sean Fox)

Obstetrics/Gynecology, Emergency Medicine

R&R Game Changer? Might change your clinical practice

Glasier A et al. Can we identify women at risk of pregnancy despite using emergency contraception? Data from randomized trials of ulipristal acetate and levonorgestrel. Contraception 2011; 84: 363-7. PMID: 21920190

  • Not all women respond to emergency contraception medications the same. This study found that women with higher BMI (> 25) were at an increased risk for medication failure (OR 3.60). The authors recommend that women with higher BMIs should be offered copper IUDs (not realistic in most EDs). Alternatively, some agents are more effective and may be viable options.
  • Recommended by: Anand Swaminathan

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!

 

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FACEMs at Night: A Mattress Stuffed with Flaw

This is the second of two perspectives on whether FACEMs should work night night shifts, for the first, see Anand Swaminathan’s ‘FACEMs at Night: An American Perspective‘.

Let us take ourselves one fact. One, simple, undeniable fact. One cannot, after all, dispute a fact. A fact, according to most reputable definers of words (and a few, which are my more preferred sources, disreputable ones) is a truth. A thing that is universally known to be true. Merriam-Webster (American, I know, but in light of it’s lexicographically poetic etymology, we must forgive its murderous spelling) defines it as ‘a true piece of information.’

So I offer you a fact.

Patients presenting to the Emergency Department at night are safer if there is a FACEM present.

A simple statement, you will agree, and entirely plausible to you, dear reader, if this is the first time you have given the matter consideration. But, as luck would have it, you have evidence with which to securely back it up. There is not quite a wealth, rather a comfortable income of data to support it. The supply of this evidence, has, most fortunately, been done by somebody else who finds pleasure in the collation of such material, and I refer you to the references outlined in the article below.(1) Although there are no numbers upon which to convert this ‘fact’ into a NNT at this point, the balance of current evidence, opinion, and basic plausibility can safely move this idea well into fact territory. It has the added advantage of making good sense. You know that if a loved, or even moderately liked one presented to ED in the dark strange hours of night, would you not want them to be treated by the most experienced, knowledgeable and capable doctor possible? Thus once we’ve established that this statement is a fact, then we have no option but to act. Swiftly, decisively and with somebody else doing the rosters (yes, the person who left the room just before the moment of portfolio distribution). As for the pot of money required to make this happen, what matters this if it improves patient safety?

As an aside (and aren’t asides wonderful, as this is where all the good learning happens, out of eyeshot of the main tedious topic) we should take just a moment, leaning on our fence (not the one upon which Schrödinger’s cat sits) to narrow our eyes at what a fact really is. In truth (and there I go again) there are very few facts in the world. The Earth is (mostly) spherical – we know this as we have rather dreamy photos from space – however this was the opposite of a fact up until the 1700’s. It was a lie and a heresy. And aside for a few other scientific tenets, our fact cupboard is surprisingly bare. Take these others: The Eiffel Tower is in Paris, Miss Havisham’s adopted daughter is named Estella, and three plus two equals five. These things are all subject, with enough philosophical, scientific, and socio-linguistic wrestling, to a little crumbling, and possibly even frank disintegration. It is possible that there are NO facts out there.

So, to return to our now rather flimsy looking fact, it shouldn’t take much effort to dismantle it.

There are a number of cogent arguments put forward in our second exhibit (2), which argue against the presence of ED Consultants at night on the floor, however I am most interested in deconstructing that single fact mentioned earlier.

How could having FACEM’s present on the floor at night decrease the safety of patients.

  • Senior trainees need protected time when the ‘buck stops with them.’ If they are sheltered, and prevented from having these periods, they may possibly miss some crucial and unmeasurable experiences which will impact their management of future patients. Trust me, having grown up in the ‘I’ll give it a crack’ era of registrar training, the skill of self-reliance and independence is invaluable. It is arguable that even with the wisest, Yoda-like consultant, standing in the shadows at 0345, the impetus for self-knowing is reduced. Could the future patients of these doctors missing out on vital educational lessons be less safe?
  • This pot of money is finite. If resources are taken from other areas to service our fact, could we be putting other patients, elsewhere, in unknown corners at risk? Making them less safe?
  • If resourcing is an issue, and rosters not ideal (thank you very much, fictional roster person), could tired, grumpy, burnt out ED consultants make the occasional suboptimal decision? Leading to the odd less safe patient interaction.

I have no doubt, considered reader, now that you are on this savage and destructive path, peeling off layers of supposed truth from statements like a busy ED nurse trying to get an ECG on one of those delightful elderly ladies, who think nothing of wearing their entire wardrobe in on a summer’s night when coming in for a checkup, as you discard undergarments and petticoats and spencers and cardigans, you can see the pale wrinkly soul beneath. And she is just a slip of a thing, hardly there at all. All facts are like that, I’m afraid.

So, what do I think? What is my opinion in the yes/no debate? Well here it gets harder. My interpretation of this fact is entirely and utterly, slopping at the sides like a bucket full of mud, full of conflict. I am a FACEM and have worked in an inner city ED as a consultant for 14 years. Night shifts may well come. I would rather like to do night shifts. But not necessarily for the above fact, although that would be a rather nice collateral, if it were, indeed, true. No, it is because during the ashen hours, in the middle of a strange city, is when one of the strangest places on earth become even stranger. I love this part of my job (as long as it is in the once in a while category).

So the debate will go on for some time longer, and then Consultants will be rostered on for night shift, or they will not. As long as they are not done so under the guise of the fact that patients are definitely safer when there is a FACEM present on the floor. For a much more sensible discussion, I beseech you to read the two articles presented, and make up your own mind.

References and Links

  • Runciman B. Is it time for consultants to join trainees in working night shifts? Yes. Emerg Med Australas. 2014 Sep 7. doi: 10.1111/1742-6723.12292. [Epub ahead of print] PubMed PMID: 25196595.
  • Markwell A. Is it time for consultants to join trainees in working night shifts? No. Emerg Med Australas. 2014 Sep 3. doi: 10.1111/1742-6723.12293. [Epub ahead of print] PubMed PMID: 25186978.

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FACEMs at Night: An American Perspective

This is the first of two perspectives on whether FACEMs should work night night shifts, for the second, see Michelle Johnston’s ‘FACEMs at Night: A Mattress Stuffed with Flaw‘.

My father, an active general surgeon who has been in practice for almost five decades often recounts stories of “the good ‘ole days” when it was interns and junior residents who cared for patients most of the day. Supervising physicians were uncommonly found in patient care areas (except the operating room). Residents made critical decisions, often without the necessary training, and they and their patients lived (or died) with them. This system makes for amazing stories and experiences and surely has shaped him into the physician he now is.

It’s with this background that I read the pro (Runciman 2014) and con (Markwell 2014) editorials in Emergency Medicine Australasia discussing whether FACEM certified consultants should expand their coverage of Emergency Departments from 60% to 100% coverage. Essentially, this begs the question of whether board certified physicians should work overnight with their trainees. It would be impossible for me, an American, to give a reasonable opinion on the matter since I neither live nor work in Australia. However, I thought it would be helpful to give a perspective from EM in the states as it was less than 20 years ago that we went through the same discussion and debate.

The story in the US starts with the Libby Zion case in 1984. Although many physicians know this story, it’s worth a review. After her death, New York State worked to enact a law (widely known as the Libby Zion law) to limit resident work hours to 80/week. Along with this, forward thinking EM physicians also recommended that physicians supervising trainees in the Emergency Department should have a minimum of three years of training in Emergency Medicine with the intention to become board certified. In April 1994, The Josiah Macy Jr. Foundation created a panel to give recommendations on what level of training should be required to provide emergency care. A New York Times article published comments from leading EM physicians at the time including Dr. Lewis Goldfrank.

The argument at that time against 24/7 board certified (or board eligible) EM physicians was similar to those detailed in the current editorials: working night shifts would be disruptive to academics, trainees wouldn’t learn as well because of the security blanket etc. Interestingly, there was less of a debate centered on burnout and physician satisfaction.

Ultimately, the decision to staff EDs with board certified/eligible Emergency Physicians round the clock came down to what was believed to be best for the patient. Who would I want to take care of my mother should she fall ill in the middle of the night? Of course, this is a zero-sum game. If we add 24/7 coverage, something else must be sacrificed. I think it’s easy to argue that coverage at night from trained Emergency Physicians is far more valuable than having the same consultant during the day. Why? Because while we in the ED work 24 hours a day, many of our subspeciality colleagues do not. Getting a consultant in ENT or orthopedics is considerably easier during banking hours than at 3:00 am. So what we actually need in the middle of the night, is the ED physician who has experience to handle anything that comes in without back up.

In the US, the motto of EM is anyone, anywhere, anytime. Training and patient care has benefited from the presence of board certified physicians around the clock. Do trainees still learn by doing? The answer is definitively yes. Is it the same as it was 50 years ago? No. But patient safety is improved. There is ample room for middle ground. Consultants can be present without holding the residents hand but rather allowing them to run the show with expert supervision close at hand. None of us are asking to return to the days of the “Wild, Wild West” when interns ran the roost. The question really is what sacrifices need to be made to move towards 100% coverage and are they worth it.

I’m interested to hear your thoughts.

References and Links

  • Runciman B. Is it time for consultants to join trainees in working night shifts? Yes. Emerg Med Australas. 2014 Sep 7. doi: 10.1111/1742-6723.12292. [Epub ahead of print] PubMed PMID: 25196595.
  • Markwell A. Is it time for consultants to join trainees in working night shifts? No. Emerg Med Australas. 2014 Sep 3. doi: 10.1111/1742-6723.12293. [Epub ahead of print] PubMed PMID: 25186978.

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Pacemaker Panic #2

ECG Exigency 016

A 68-year old woman presents by ambulance to the Emergency Department. Per the ambulance crew, she was brought from home after experiencing 7 out of 10 chest discomfort and weakness. She has a history of hypertension that is well controlled with furosemide, and has a pacemaker because her “heart used to go funny.” The ambulance crew are basic life support only, so the patient has received 324mg of aspirin, and oxygen by nasal cannula. Upon arrival she is seated upright on the stretcher breathing rapidly, with the following vitals: heart rate 107, blood pressure 180/110, respirations 20 and slightly laboured, oxygen saturation 100% on 2 L/min by nasal cannula, and blood glucose 110 mg/dL (6.1 mmol/L). The medical student said the patient appeared to be in ventricular tachycardia on the monitor, and so has brought the crash cart to the bedside.

 

Her ECG is shown below:

pacemaker panic 2a 2

 

Q1: Can you describe the ECG?

  • Broad complex tachycardia at 107 bpm.
  • Extremely wide QRS complexes.
  • Indeterminate QRS axis.
  • Pacemaker spikes dissociated from QRS complexes.

 Q2: What is the significance of these ECG findings?

There are a number of causes for a wide QRS complex, including:

  • Bundle branch block
  • Pacemaker
  • Wolff-Parkinson-White syndrome
  • Ventricular Rhythm
  • Metabolic
  • Sodium Channel Blockade
  • Nonspecific Intraventricular Conduction Delay

 However, when the QRS duration is greater than 200 ms, hyperkalemia should immediately move to the top of the differential. Hyperkalemia would also explain the pacemaker failure to capture. When the QRS becomes too wide, the pacemaker attempts to trigger during the refractory period and fails to capture.

Q3: What other diagnostics are warranted at this point?

The ECG alone is neither particularly sensitive nor specific for diagnosing hyperkalemia. Serial blood draws should be used to track the patient’s potassium. A VBG using an ED-based gas analyser is often the most rapid way to get an initial potassium reading, and may give useful information about acid-base status. Urea and electrolytes should be checked to detect renal dysfunction.

Her initial potassium returns at 8 mmol/L.

Q4: How would you manage this patient?

There are 3 goals in treating hyperkalemia: membrane stabilisation, shift potassium into cells, and increased potassium elimination from the body.

  1. Membrane stabilisation:
    • Calcium chloride and gluconate are both effective. Remember that calcium gluconate does not have to be metabolised by the liver to work.
  2. Shift potassium:
    • Sodium bicarbonate: alone does not lower potassium, and there is debate whether it will potentiate the effects of salbutamol / albuterol and insulin + dextrose.
    • Insulin + Dextrose
    • Salbutamol / Albuterol
  3. Increase potassium elimination:
    • Diuretics such as furosemide
    • Dialysis
    • Kayexalate: while a mainstay of treatment, there is no evidence that kayexelate reduces potassium levels. The original research that promoted its has serious methodological flaws.


After your initial round of treatment, you acquire another ECG, shown below:

Pacemaker panic 2b 2

Q5: Can you describe this ECG?

  • Underlying rhythm is a dual chamber AV sequential pacemaker.
  • Pacemaker rate: 100 bpm, Ventricular rate captured: 50 bpm.
  • Pacemaker failure to capture
  • Wide QRS complex
  • ST-T wave abnormalities

 

Q6: What is the significance of these ECG findings?

 

While the patient’s pacemaker has taken over, it is still unable to capture 100% of the time. The wide QRS from the underlying hyperkalemia is causing half the pacemaking impulses to fall during the refractory period of the QRS and fail to conduct.

Q7: Based on the ECG findings, do you believe the patient’s condition has improved?

 

Yes. A blood draw confirms that the patient’s potassium level has dropped to 6.6 mmol/L.

Q8: Can you guess how the patient wound up in this state?

 

Furosemide is a loop diuretic that when administered alone may cause low potassium levels. As such, many patients on furosemide will be taking a potassium supplement. After additional interviewing, you find that the patient misunderstood the dosing instructions for the potassium and unintentionally overdosed.

 

References

  • Circulation. 2005; 112: IV-121-IV-125. Published online before print November 2005, doi: 10.1161/​CIRCULATIONAHA.105.166563 [free full text]
  • Martin TJ, et al. Ionization and hemodynamic effects of calcium chloride and calcium gluconate in the absence of hepatic function. Anesthesiology. 1990 Jul;73(1):62-5.  [PubMed] [free full text]
  •  Ann Emerg Med. 1991 Nov;20(11):1229-32. The ability of physicians to predict hyperkalemia from the ECG. Wrenn KD, Slovis CM, Slovis BS. [PubMed]
  •  Brian T. Montague, Jason R. Ouellette, and Gregory K. Buller. Retrospective Review of the Frequency of ECG Changes in Hyperkalemia. CJASN March 2008 3): (2) 324-330 [PubMed]

Learn from the experts

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Research and Reviews in the Fastlane 048

Research and Reviews in the Fastlane

Welcome to the 48th 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 10 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

Prehospital/Retrieval, Resuscitation

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

R&R Game Changer? Might change your clinical practice

Mal S et al. Effect of Out-of-Hospital Noninvasive Positive-Pressure Support Ventilation in Adult Patients With Severe Respiratory Distress: A Systematic Review and Meta-analysis. Ann of EM 2014; 63(5):600-607. PMID: 24342819

  • Over the last decade, health care providers have been increasingly aggressive in starting NIPPV early in management. Numerous studies demonstrate decreased ICU admissions and decreased intubation rates when NIPPV is used in the ED in patients with COPD exacerbations and acute decompensated heart failure. This systematic review and meta-analysis demonstrates significant reductions in in-hospital mortality (NNT = 18) and invasive ventilation (NNT = 8) when NIPPV is applied in the prehospital setting.
  • Recommended by: Salim Rezaie, Anand Swaminathan
  • Read More: September REBEL Cast (Salim Rezaie)

The Best of the Rest

Emergency Medicine, Pediatrics

R&R Hot Stuff - Everyone’s going to be talking about this

Del Pizzo J1, Callahan JM. Intranasal medications in pediatric emergency medicine. Pediatr Emerg Care. 2014;30(7):496-501. PMID: 24987995

  • This is a really helpful review of intranasal administration of medications in the Peds ED. This route is often underutilized and may be a means by which you can optimize your door to analgesic administration time. Despite our best intentions, kids with significantly painful processes (like a long bone fracture) often go for prolonged periods without appropriate (or any) analgesics. (See article PMID: 22270501). Using the intranasal route can help hasten the delivery of pain medications! Consider this the next time you see the kid with the obviously deformed extremity… yes, you will likely still need an IV, but that intranasal fentanyl can make getting the IV and those important xrays much more humane.
  • Recommended by: Sean Fox
  • Read More: Intranasal Analgesia (Sean Fox)

Emergency Medicine, Resuscitation

R&R Hot Stuff - Everyone’s going to be talking about this
McPhee LC et al. Single-dose etomidate is not associated with increased mortality in ICU patients with sepsis: analysis of a large electronic ICU database. Crit Care Med. 2013;41(3):774-83. PMID: 23318491

  • The use of etomidate for RSI has been much maligned in recent years for it’s side effect of transient adrenal suppression. However, there has been little, if any, if any evidence of its effect on patient centered outcomes. In this retrospective analysis, etomidate was not associated with increased mortality or other adverse outcomes in patients with shock or the subgroup with septic shock. Until a large, well-done RDCT is performed, the issue will not be put to rest but for now, etomidate is a viable option for RSI.
  • Recommended by: Anand Swaminathan

Emergency Medicine

R&R Game Changer? Might change your clinical practice
Campagna JD et al. The Use of Cephalosporins in Penicillin-allergic Patients: A Literature Review. J Emerg Med. 2012;42(5):612-20. PMID: 21742459

  • Although a myth persists that approximately 10% of patients with a history of penicillin allergy will have an allergic reaction if given a cephalosporin, the overall cross-reactivity rate is approximately 1% when using first-generation cephalosporins or cephalosporins with similar R1 side chains. For penicillin-allergic patients, the use of third- or fourth-generation cephalosporins or cephalosporins with dissimilar side chains than the offending penicillin carries a negligible risk of cross allergy.
  • Recommended by: Salim Rezaie

Public Health, Emergency Medicine
R&R Game Changer? Might change your clinical practice

Smith-Bindman R et al. Radiation dose associated with common computed tomography examinations and the associated lifetime attributable risk of cancer.  Arch Intern Med. 2009;169(22): 2078-86. PMID: 20008690

  • Quantifying risks of ionizing radiation is tough. This article shows that many patients get more radiation than studies using phantoms would imply. There was also a wide variation in the dose each patient received.
    You might be able to use this to dial back the number of not-absolutely-necessary CTs performed in the ED.
  • Recommended by: Justin Hensley

Public Health, Emergency Medicine
R&R Trash - Must read, because it is so wrong!

 

Doss M. Radiation dose justification and optimization should not be applied to medical imaging in emergency medicine. Ann Emerg Med 2014; 64(3):332-3. PMID: 25149970

  • Editorial that discusses the idea that what we know about radiation and risks of malignancy is wrong. The author reviews recent literature and argues that the estimates of medical imaging induced malignancy are off base as they are based on an incorrect risk projection model. Furthermore, he goes on to state there is reason to suspect that low dose radiation may, in fact, be beneficial and reduce cancer risk. While it’s clear that we don’t fully comprehend the impact of medical radiation, this editorial adds little to the discussion. The author only cites his own research on the topic. The claims of reducing cancer are particularly short on data to support them.
  • Recommended by: Jeremy Fried, Reuben Strayer

Cardiology

R&R Boffintastic - High quality research

Blood pressure-lowering treatment based on cardiovascular risk: a meta-analysis of individual patient data. The Blood Pressure Lowering Treatment Trialists’ Collaboration. Lancet 2014; 384 (9943): 591-598. PMID: 25131978

  • OK its preventative care – not sexy. But a great look at risk and the way we get carried away with numbers.
    Does lowering a pts BP help reduce their CVD risk?
    Well… yes
    Relative risk benefits for all CVD risk groups fell with BP reduction – but, it is really only in the higher risk groups where you get a useful ABSOLUTE risk reduction.
    So most importnat to target therapy at pts who will derive the benefits
  • Recommended by: Casey Parker

Toxicology, Emergency Medicine

R&R Game Changer? Might change your clinical practice
Williams BT et al. Emergency department identification and critical care management of a Utah prison botulism outbreak. Ann Emerg Med 2014; 64(1):26-31. PMID: 24331717

  • This article reviews an outbreak of botulism in a US prison system resulting from consumption of pruno (jailhouse wine). Food borne botulism is infrequent (20 cases/year in US) and outbreaks like this (8 cases) are critical in learning more about the disease. The authors provides information about time from consumption to onset of symptoms and severity of symptoms that are critical in understanding and recognizing this rare and potentially devastating disease. 
  • Recommended by: Anand Swaminathan

Emergency Medicine

R&R Eureka - Revolutionary idea or concept
Petinaux B et al. Accuracy of radiographic readings in the emergency department. Am J Emerg Med 2011; 29(1):18-25. PMID: 20825769

  • Many emergency physicians read their own plain films in real time and make clinical decisions based on their own reads.
    This study looked at one institution’s discrepancy rate between EP and radiologist plain film reads over 10 years. They found overall an ~3% discrepancy rate on all plain films. This of course does not mean the radiologist was correct in every discrepancy. But it does show we agree most of the time.
    Most interestingly, the rate of discrepancies requiring emergent change in management was a mere 0.056%!
  • Recommended by: Zack Repanshek

Prehospital/Retrieval

R&R Hot Stuff - Everyone’s going to be talking about thisR&R Game Changer? Might change your clinical practice

Braude D et al. Air Transport of Patients with Pneumothorax: Is Tube Thoracostomy Required Before Flight? Air Med J. 2014 Jul-Aug;33(4):152-6. PMID: 25049185

  • Conventional teaching dictates that all patients with any pneumothorax (PTX) should have a tube thoracostomy placed prior to air medical transport. However, this “rule” may delay transfer for definitive management of injuries and has not been shown to decrease the risk of adverse outcomes. This article is a retrospective review of trauma patients transported to a single trauma center with confirmed PTX who did not have a tube thoracostomy placed prior to transport. They found a low complication rate (6%) and all patients were successfully treated with needle decompression. Although prospective validation is required, this article challenges the conventional dogma.
  • Recommended by: Anand Swaminathan

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 048 appeared first on LITFL.

The LITFL Review 151

LITFL review

The LITFL Review is your regular and reliable source for the highest highlights, sneakiest sneak peeks and loudest shout-outs from the webbed world of emergency medicine and critical care. Each week the LITFL team casts the spotlight on the blogosphere’s best and brightest and deliver a bite-sized chuck of FOAM.

Welcome to the 151st edition, brought to you by:

The Most Fair Dinkum Ripper Beaut of the Week

resizer

Its shared by these four beauties this week…..

Simon Finfer (@icuresearch) should need no introduction… His talk on ICN is essential listening if you want to understand the importance of critical care research and how it works. Listen to Finfer: The Dark Side of Research NOW. [CN]

Last week marked the 5 year anniversary of LITFL and Mike Cadogan shares with the FOAM world 5 lessons he’s learned over the last 5 years. Mike’s contributions to FOAM have been limitless and impossible to quantify. The tips here are critical to all the educators out there looking to make an impact. [AS]

What exactly is “pseudo PEA”? The ED ECMO podcast tackles this question, and suggests a new way to think about PEA arrest. [MG]

Unthinkably awesome- the “establishment” are embracing FOAMed! The UK College of Emergency Medicine has launched its rather excellent FOAMed website, with weekly updates of FOAMy goodness- and mapped out to the UK EM curriculum. This really sets the bar high. Other colleges please take note… [SO]

The Best of #FOAMed Emergency Medicine

The Best of #FOAMcc Critical Care

#FOAMTox Toxicology

#FOAMPed Paediatrics

  • KIDS (Kids Intensive care and Decision Support) is a 24 hour referral, coordination, advice and transport service working out of the West Midlands in Birmingham, UK. All of their guidelines and SOPS are available via an awesome free app here. [SO]
  • More fantastic resources from the Severn Emergency Medicine team on paediatric acute presentations. [SL]
  • Don’t Forget the Bubbles looks at thrombocytosis in children – is it just benign? [TRD]

#FOAMus Ultrasound

#MedEd Education and Social Media

News from the Fast Lane

Reference Sources and Reading List

The post The LITFL Review 151 appeared first on LITFL.