Research and Reviews in the Fastlane 054

Research and Reviews in the Fastlane

Welcome to the 54th 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

Critical Care, NutritionR&R Hall of Famer - You simply MUST READ this!R&R Hot Stuff - Everyone’s going to be talking about thisR&R Game Changer? Might change your clinical practiceVan Zanten AH, et al. High-Protein Enteral Nutrition Enriched With Immune-Modulating Nutrients vs Standard High-Protein Enteral Nutrition and Nosocomial Infections in the ICU: A Randomized Clinical Trial. JAMA 2014; 312(5): 514-524. PMID:25096691

  • The MetaPlus study compared high-protein enteral nutrition enriched with immune-modulating nutrients vs standard high-protein enteral nutrition in the critically ill. Results showed that the addition of immune modulating nutrients was not associated with a reduction in infectious complications or other assessed clinical end points. In addition to this there is a suggestion of harm from the increased adjusted mortality at 6 months.
  • Recommended by: Nudrat Rashid

The Best of the Rest

Research and Critical AppraisalR&R Hot Stuff - Everyone’s going to be talking about thisEbrahim S, et al. Reanalyses of randomized clinical trial data. JAMA. 2014; 312(10): 1024-32. PMID: 25203082

  • These authors looked at RCTs that were followed by a published re-analysis of the data. A whopping 35% of the studies had different findings about the type of patient who should be treated. Of note, compared with the number of RCTs in the literature, only a few re-analyses (n=36) were published; however most (n=31) were published by the same research group…meaning maybe these authors don’t agree with themselves? Either that or we should be wary of the way statistics are used to paint a selective picture…
  • Recommended by: Lauren Westafer
  • Read More: Are a Third of Research Conclusions Wrong? (emlitofnote)

Critical Care, CardiologyR&R Mona Lisa -Brilliant writing or explanation” width=R&R Eureka - Revolutionary idea or conceptGuyton AC. Regulation of cardiac output. Anesthesiology. 1968; 29(2): 314-26. PMID: 5635884

  • The modern emphasis on echo might make you think that the heart determines cardiac output. This classic paper by Guyton shows that unless the heart is failing, it has a permissive role in determining cardiac output. The real determinants are (1) the degree of vasodilation of the peripheral vasculature, especially veins, and (2) the filling of the circulatory system, indicated by the mean systemic filling pressure. Gotta love those Guyton curves!
  • Recommended by: Chris Nickson

Emergency Medicine, Obstetrics/GynecologyR&R Game Changer? Might change your clinical practiceSlaughter SR et al. FDA approval of doxylamine-pyridoxine therapy for use in pregnancy. NEJM 2014; 370(12): 1081-3. PMID: 24645939

  • Great editorial on the history and politics of the re-introduction of doxylamine-pyridoxine for N/V of pregnancy in the U.S
  • Recommended by: Jeremy Fried

Trauma, Orthopedics
R&R Game Changer? Might change your clinical practiceRodriguez L et al. Evidence-based protocol for prophylactic antibiotics in open fractures: Improved antibiotic stewardship with no increase in infection rates. J Trauma Acute Care Surg 2014; 77(3): 400-8. PMID: 25159242

  • Standard treatment for open fractures with significant tissue damage is variable but typically involves a 1st generation cephalosporin and an aminoglycoside. This study looks at infection rates before and after implementation of an evidence based protocol for prophylactic antibiotics in open fractures. The authors show a decrease in aminoglycoside use without an increase in infection rate. Ceftriaxone was substituted so the impact to antibiotic resistance is questionable.
  • Recommended by: Anand Swaminathan

ResuscitationR&R Game Changer? Might change your clinical practiceMeaney PA et al. Cardiopulmonary resuscitation quality: improving cardiac resuscitation outcomes both inside and outside the hospital: a consensus statement from the American Heart Association. 2013; 128(4): 417-35. PMID:23801105

  • Great overview on how to improve CPR performance both inside and outside the hospital.  This group has made excellent recommendations which are nicely summarised in a table as well as giving directions for the future to close existing gaps in knowledge.
  • Recommended by: Søren Rudolph

Emergency Medicine, CardiologyR&R Hot Stuff - Everyone’s going to be talking about thisR&R Game Changer? Might change your clinical practiceCavender M, Sabatine MS. Bivalirudin versus heparin in patients planned for percutaneous coronary intervention: a meta-analysis of randomised controlled trials. Lancet 2014; 384(9943): 599-606. PMID: 25131979

  • Bivalirudin is a direct thrombin inhibitor that has been used as an alternate therapy to heparin in patients undergoing PCI. In this meta-analysis of randomized controlled trials, the authors found that a bivalirudin-based regimen increases the risk of myocardial infarction and stent thrombosis in comparison to heparin. Bleeding was lower but the included studies had variable use of clopidogrel (mainly given with heparin). More evidence that expensive therapies are not necessarily better ones.
  • Recommended by: Anand Swaminathan

Critical Care, ResuscitationR&R Game Changer? Might change your clinical practiceWang CH et al. The effect of hyperoxia on survival following adult cardiac arrest: A systematic review and meta-analysis of observational studies. Resuscitation. 2014. PMID: 24892265

  • A review and meta analysis looking at the impact of hyperoxia in arrest patients after ROSC is achieved. Limited by the heterogeneity of the studies, an association was found between hyperoxia and increased in hospital mortality. While we will likely never have the RCT examining this issue, this hints at what we know from many other disease states…there can definitely be too much of a good thing.
  • Recommended by: Jeremy Fried

Critical CareR&R Game Changer? Might change your clinical practiceHocker, SE et al. Indicators of Central Fever in the Neurologic Intensive Care Unit. JAMA Neurol. 2013;70(12):1499-1504. PMID: 24100963

  • Fever is common in this subgroup of patients. The authors provide a reliable model to differentiate central from infectious fever thus helping clinicians in selecting those patients that would not be harmed from stopping antibiotics. Blood transfusion, absence of infiltrate on chest x-ray, diagnosis of subarachnoid haemorrhage, intraventricular haemorrhage or tumour; and onset of fever within 72 hours of hospital admission were independent predictors of central fever.
  • Recommended by: Nudrat Rashid

Critical careR&R Hot Stuff - Everyone’s going to be talking about thisOostdijk EN, et al. Effects of Decontamination of the Oropharynx and Intestinal Tract on Antibiotic Resistance in ICUs: A Randomized Clinical Trial. JAMA. 2014; 312(14): 1429-1437. PMID: 25271544

  • The Dutch are at it again showing that application of Selective decontamination of the digestive tract (SDD) and selective oropharyngeal decontamination (SOD) throughout the intensive care unit was associated with low levels of antibiotic resistance but no differences in day-28 mortality.
  • Recommended by: Nudrat Rashid

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

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The LITFL Review 153

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 153rd edition, brought to you by:

The Most Fair Dinkum Ripper Beaut of the Week

resizerWhat do we do when our diagnostic capabilities outstrip our abilities to understand the disease and it’s necessary treatment? Rory Spiegel gives turns a critical eye onto the practice of cardiac catheterization for all cardiac diseases that aren’t STEMI. [AS]

The University of Maryland Emergency Medicine (UMEM) Department has been churning out high-yield pearls for years. Now, you can get the free UMEM app for free and bring those pearls directly to your handheld device. [AS]

The Best of #FOAMed Emergency Medicine

  • Looking for a way to reduce a mandibular dislocation without procedural sedation? Ryan Radecki reviews the syringe technique this week. [AS]
  •  More pearls from Amal Mattu’s EKG series. This week he covers the prolonged QT interval, the general causes and a great trick to narrow the differential without further testing. [AS]
  •  FOAMCast covers a rarely mentioned topic in FOAM; the spleen. Great pearls about asplenic patients, traumatic splenic injuries and more. [AS]
  • Although the recommendations seem to be rapidly changing, EM Basic gives a sensical, non-alarmist update on Ebola screening and treatment as of October 16th 2014. [AS]
  • emDocs.net offers a concise review of the literature surrounding outpatient treatment of low risk patients with pulmonary embolism. [AS]

The Best of #FOAMcc Critical Care

  • When should trauma patients get TXA? What is the ideal initial access in trauma patients? IO or CVL? FFP or PCC for coagulopathy of trauma and more questions via EM Lyceum. [AS]
  •  Trying to reduce advanced chest imaging in trauma? Check out a review from ALiEM on the NEXUS Chest rule. High sensitivity but low specificity. Many questions left unanswered but it’s a start. [AS]
  •  The Maryland CC Project features a great video cast reviewing Thromboelastometry (TEM) Guided Transfusion for Perioperative Coagulopathy with Klaus Gorlinger. [AS]
  •  The NICE guidelines for managing acute heart failure are out and it appears that no Emergency Physician is happy with its recommendations. St. Emlyn’s gives a nice critique of the key pieces. [AS]
  •  The VITdAL-ICU study looking at the effects of vitamin D supplementation in ICU was another fab study from ESICM in Barcelona. Oli Flower interviews the lead author here. [SO]
  •  THe Maryland CC Project (again!) has a wonderful lecture by Sanjay Desai on Ventilator Waveform analysis. [SO]
  •  Looking to make yourself more ECMO than EC-NO? The Alfred Hospital recently completed an ECMO course. Lots of handy tips were tweeted out, and have been wonderfully compiled by the INTENSIVE blog here. [SO]
  •  The Australia and New Zealand Intensive Care Society have a youtube page where lots of talks from their Annual Meetings have been recorded. Lots of wonderful #Foamcc to be imbibed- including a great talk by Chris Nickson on rapid response teams. [SO]
  •  More “great physiology in 1000 words” by Jon-Emile Kenny for Pulmccm: This time he tackles Stroke Volume Variation. [SO]
  •  CTA has replaced angiography as the standard diagnostic modality for a large number of indications but The Skeptics Guide to Emergency Medicine points out that CTA sensitivity for blunt cerebrovascular injury detection is suboptimal. A negative CTA for this indication should not end the diagnostic workup. [AS]

#FOAMTox Toxicology

#FOAMus Ultrasound

  • Handsonecho is an amazing FOAMus resource featuring links to courses and lots of video tips- including a large selection of tips on US from Daniel Lichtenstein himself! [SO]

#FOAMpeds Pediatrics

  • The PEMED podcast discusses a physically and mentally challenging clinical entity that is all too common – child abuse. Andy sits down with Marci Donaruma-Kowh to discuss cornerstone exam findings and red flags that will help you identify these patients and get them the protection and care they need. [AS]

News from the Fast Lane

Reference Sources and Reading List

The post The LITFL Review 153 appeared first on LITFL.

Axis: Bold As Love

Axis determination is one of the most common ECG topics that I see junior doctors (and some senior doctors!) struggling with. Hopefully this tutorial will clear things up…  

ECG Axis Determination

The diagram below illustrates the relationship between QRS axis and the frontal leads of the ECG.

Hexaxial Reference system

Image reproduced from Chung

 

  • Normal Axis = QRS axis between -30 and +90 degrees.
  • Left Axis Deviation = QRS axis less than -30 degrees.
  • Right Axis Deviation = QRS axis greater than +90 degrees.
  • Extreme Axis Deviation = QRS axis between -90 and 180 degrees (AKA “Northwest Axis”).

There are several complementary approaches to estimating QRS axis, which are summarised below.

Method 1 – The Quadrant Method

The most efficient way to estimate axis is to look at leads I + aVF.

Lead I
Lead aVF
Quadrant
Axis
PositivePositiveLeft lower quadrantNormal (0 to +90 degrees)
PositiveNegativeLeft upper quadrantPossible LAD (0 to -90 degrees)
NegativePositiveRight lower quadrantRAD (+90 to 180 degrees)
NegativeNegativeRight upper quadrantExtreme Axis Deviation (-90 to 180 degrees)

 

Method 2 – Leads I + II

Another rapid method is to look at leads I + II.

A positive QRS in lead I puts the axis in roughly the same direction as lead I.

lead I

Image reproduced from Chung

 

A positive QRS in lead II similarly aligns the axis with lead II.

lead II

Image reproduced from Chung

 

Therefore, if leads I and II are both positive, the axis is between -30 and +90 degrees (i.e. normal axis).

normal axis I and II

Image reproduced from Chung

 

Combining Methods 1 and 2

By combining these two methods, you can rapidly and accurately assess axis.

Lead I
Lead aVF
Axis
PositivePositiveNormal (0 to +90 degrees)
PositiveNegativePossible LAD
Is lead II positive?
Yes -> Normal (0 to -30 degrees)
No -> LAD (-30 to -90 degrees)
NegativePositiveRAD (+90 to 180 degrees)
NegativeNegativeExtreme Axis Deviation (-90 to 180 degrees)

 

Method 3 – The Isoelectric Lead

This method allows a more precise estimation of QRS axis, using the axis diagram below.

Hexaxial Reference system

Reproduced from Chung

 

Key Principles

  • If the QRS is positive in any given lead, the axis points in roughly the same direction as this lead.
  • If the QRS is negative in any given lead, the axis points in roughly the opposite direction to this lead.
  • If the QRS is isoelectric in any given lead (positive deflection = negative deflection), the axis is at 90 degrees to this lead.

Step 1. Find the isoelectric lead.

The isoelectric (equiphasic) lead is the frontal lead with zero net amplitude. This can be either:

  • A biphasic QRS where R wave height = Q or S wave depth.
  • A flat-line QRS with no discernible features.

Step 2. Find the positive leads. 

Look for the leads with the tallest R waves (or largest R/S ratios).

Step 3. Calculate the QRS axis. 

The QRS axis is at 90 degrees to the isoelectric lead, pointing in the direction of the positive leads.

This concept can be difficult to understand at first, and is best illustrated by some examples.

 

Example 1

Axis eg1

  • Leads I + aVF are both positive.
  • This puts the axis in the left lower quadrant, between 0 and +90 degrees, i.e. normal axis.
  • Lead II is also positive, which confirms the normal axis.

  • Lead aVL is isoelectric, being biphasic with similarly sized positive and negative deflections (no need to precisely measure this).
  • From the diagram above, we can see that aVL is located at -30 degrees.
  • The QRS axis must be ± 90 degrees from lead aVL, either at +60 or -120 degrees.
  • With leads I (0), II (+60) and aVF (+90) all being positive, we know that the axis must lie somewhere between 0 and +90 degrees.
  • This puts the QRS axis at +60 degrees.

 

Example 2

Ex2

  • Lead I = negative.
  • Lead aVF = positive.
  • This puts the axis in the right lower quadrant, between +90 and +180 degrees, i.e. RAD.

  • Lead II (+60 degrees) is the isoelectric lead.
  • The QRS axis must be ± 90 degrees from lead II, at either +150 or -30 degrees.
  • The more rightward-facing leads III (+120) and aVF (+90) are positive, while aVL (-30) is negative.
  • This puts the QRS axis at +150 degrees.

This is an example of right axis deviation secondary to right ventricular hypertrophy.

 

Example 3

Ex3

  • Lead I = positive.
  • Lead aVF = negative.
  • This puts the axis in the left upper quadrant, between 0 and -90 degrees, i.e. normal or LAD.
  • Lead II is neither positive nor negative (isoelectric), indicating borderline LAD.

  • Lead II (+60 degrees) is isoelectric.
  • The QRS axis must be ± 90 degrees from lead II, at either +150 or -30 degrees.
  • The more leftward-facing leads I (0) and aVL (-30) are positive, while lead III (+120) is negative.
  • This confirms that the axis is at -30 degrees.

This is an example of borderline left axis deviation due to inferior MI.

 

Example 4

Ex4

  • Lead I = negative.
  • Lead aVF = negative.
  • This puts the axis in the upper right quadrant, between -90 and 180 degrees, i.e. extreme axis deviation.

NB. The presence of a positive QRS in aVR with negative QRSs in multiple other leads signifies extreme axis deviation. 

  • The most isoelectric lead is aVL (-30 degrees).
  • The QRS axis must be at ± 90 degrees from aVL at either +60 or -120 degrees.
  • Lead aVR (-150) is positive, with lead II (+60) negative.
  • This puts the axis at -120 degrees.

This is an example of extreme axis deviation due to ventricular tachycardia.

 

Example 5

Ex5

  • Lead I = isoelectric.
  • Lead aVF = positive.
  • This is the easiest axis you will ever have to calculate. It has to be at right angles to lead I and in the direction of aVF, which makes it exactly +90 degrees!

This is referred to as a “vertical axis”  and is seen in patients with emphysema who typically have a vertically orientated heart.

EmphysemaCXR

Vertical Heart in Emphysema

 

Causes of Axis Deviation

Right Axis Deviation

 

Left Axis Deviation

 

Extreme Axis Deviation

 

References

  • Chung DC, Nelson HM. ECG – A Pictorial Primer [internet]. Accessed 20/10/2014.
  • Surawicz B, Knilans TK. Chou’s Electrocardiography in Clinical Practice. 6th Edition. Saunders Elsevier 2008.
  • Wagner, GS. Marriott’s Practical Electrocardiography (11th edition), Lippincott Williams & Wilkins 2007.

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Research and Reviews in the Fastlane 053

Research and Reviews in the Fastlane
Welcome to the 53rd 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, Critical Care, CardiologyR&R Hall of Famer - You simply MUST READ this!R&R Hot Stuff - Everyone’s going to be talking about thisR&R Game Changer? Might change your clinical practice

Arsen D. Ristić et al. Triage strategy for urgent management of cardiac tamponade: a position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases. European Heart Journal 2014; 35(34): 2279-2284. PMID: 25002749

  • Diagnosis of cardiac tamponade is based on the integration of clinical symptoms, signs, and echo findings. This excellent article describes a 3 step scoring system for the triage of patients requiring urgent percutaneous or surgical drainage of pericardial effusion. In addition to this there are recommendations towards making a diagnosis, transferring the patient to a specialized or tertiary institution, guidance on how to perform pericardiocentesis, prevent complications and how long to leave the drain in for.
  • Recommended by: Nudrat Rashid

The Best of the Rest

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

R&R Game Changer? Might change your clinical practice

Shahrami A et al. Comparison of Therapeutic Effects of Magnesium Sulfate vs. Dexamethasone/Metoclopramide on Alleviating Acute Migraine Headache. J Emerg Med 2014. PMID: 25278139

  • Migraine headaches can be debilitating for patients and Emergency Departments as treatment failure, length of stay and revisits are all common. Successful treatment itself can often lead to prolonged ED times as the most commonly used medications are extremely sedating. In this small (n = 70) RDCT, MgSO4 was found to be superior to a combination of metoclopramide + dexamethasone for early pain relief. At 20 minutes, MgSO4 had a marked effect on pain relief. Unfortunately, the study doesn’t follow patients out past the 2-hour mark so we are unable to tell if MgSO4 had effects on rebound headaches.
  • Recommended by: Anand Swaminathan

Toxicology

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

Volkow ND et al. Adverse health effects of marijuana use. N Engl J Med 2014. 370(23): 2219-27. PMID: 24897085

  • With the changing legal landscape in the U.S., this review article provides a nice general overview of the state of knowledge on marijuana use and it’s known benefits and risks.
  • Recommended by: Jeremy Fried

Critical CareR&R Eureka - Revolutionary idea or concept

Thille AW et al. Comparison of the Berlin Definition for Acute Respiratory Distress Syndrome with Autopsy, Am J Resp Crit Care Med 2013. 187(7): 761-767. PMID: 23370917

  • ARDS isn’t always ARDS. An ICU looked at the autopsy results for 356 patients who met clinical criteria for ARDS at time of death. The pathologic “hallmark” of ARDS, diffuse alveolar damage (DAD) was found in less than half (45%) of the patients that met the revised Berlin clinical criteria for ARDS. This non-specific clinical criteria (Sp 37% for all ARDS, 58% for moderate/severe) suggests that we are likely lumping a heterogenous array of pathophysiologic processes under the heading of this “syndrome.” This may explain some of the frustration with a lack of consistently effective therapies for ARDS, except general lung protection.
  • Recommended by: Lauren Westafer
  • Read More: ARDS: An Evidence Based Update (Rob MacSweeney)

PediatricsR&R Game Changer? Might change your clinical practice

Little, P et al. Clinical score and rapid antigen detection test to guide antibiotic use for sore throats: randomised controlled trial of PRISM (primary care streptococcal management)

  • Big trial out of the UK looking at the utility of a clinical decision score (FeverPAIN) vs rapid antigen detection test (RADT) for strept throat. The idea was to target antibiotics to these predictors.
    The FeverPAIN score performed as well as a RADT – and adding a RADT did not improve the symptomatic scores.
    The score use resulted in a significant reduction in antibiotic prescribing.
    So – NO more swabs? Just treat on symptoms?
  • Recommended by: Casey Parker

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

Poon SJ, Greenwood-Ericksen MB. The Opioid Prescription Epidemic and the Role of Emergency Medicine. Ann Emerg Med. 2014. PMID: 25017821

  • As part of ALiEM’s mission to help the Annals of Emergency Medicine discuss some of their articles, we read and reviewed a GREAT eye-opening paper about the Opioid Prescription Epidemic… and yes, it IS an epidemic.
  • Recommended by: Poon, Greenwood-Ericksen
  • Read More: The Opioid Prescription Epidemic (ALiEM)

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

Simes J et al. Aspirin for the Prevention of Recurrent Venous Thromboembolism: The INSPIRE Collaboration. Circulation 2014. PMID: 25156992

  • Prophylactic treatment for VTE after a full anticoagulation course for unprovoked VTE continues to be debated. This study combines the results from the WARFASA and ASPIRE trials looking at aspirin prophylaxis. The results are promising. Aspirin 100 mg reduced the rate of recurrent VTE from 7.5%/year to 5.1%/year (HR = 0.68) without a significant change in bleeding rate (0.5%/year vs 0.4%/year). We often see patients in the ED with a history of unprovoked VTE who are on no long-term prophylaxis. This article argues that we consider aspirin for all these patients.
  • Recommended by: Anand Swaminathan

Trauma

R&R Eureka - Revolutionary idea or concept

Stevens AC, Trammell TR, Billows GL, Ladd LM, Olinger ML. Radiation Exposure as a Consequence of Spinal Immobilization and Extrication. J Emerg Med. 2014 Sep 23. PMID: 25256410

  • Retrospective study comparing extrication by EMS vs. self-extrication in awake, alert, cooperative, neurologically intact drivers involved in IndyCar crashes. Patients who arrive in the ED with backboard and C spine collar receive dramatically more CT scans than otherwise. No firm conclusions can be drawn from this methodology, but it is likely that emergency clinicians are much more likely to use CT on patients arriving with backboard and collar, irrespective of other clinical features of the case. Most healthy blunt trauma patients with normal vitals and mentation should be taken off the backboard and their cervical spine cleared clinically at the outset of care.
  • Recommended by: Reuben Strayer

PediatricsR&R Game Changer? Might change your clinical practice

Pflaumer A1, Davis AM. Guidelines for the diagnosis and management of Catecholaminergic Polymorphic Ventricular Tachycardia. Heart Lung Circ 2012; 21(2): 96-100. PMID: 22119737

  • Ok, so the school-aged kid presents with a syncopal episode. You aren’t worried because the kid looks well and the ECG is normal; however, did you consider Cataecholaminergic Polymorphic Vtach? This is life threatening and presents with a normal ECG and no structural abnormalities. Seriously, how am I supposed to diagnose this one? By thinking of it and asking the right questions!
  • Recommended by: Sean Fox
  • Read More: Catecholaminergic Polymorphic VTach (Pediatric EM Morsels)

International and Tropical MedicineR&R WTF Weird, transcendent or funtabulous!” width=R&R Trash - Must read, because it is so wrong!

Feng L et al. Clinical observation on 30 cases of transient cerebral ischemia attack treated with acupuncture and medication. J Tradit Chin Med 2007; 27(2): 100-2. PMID: 17710801

  • Where to begin on this article. First, TIAs are supposed to completely resolve, otherwise they’re called CVAs. Second, to get significant differences in efficacy they had to go down to 20% effectiveness for the treatment. Third, are they attributing the treatment effect to the accupuncture, the leech capsules, the centipede capsules, or is it only if you combine all of them?
  • Recommended by: Justin Hensley

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 Trash

The post Research and Reviews in the Fastlane 053 appeared first on LITFL.

LITFL Review 152

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 152nd edition, brought to you by:

The Most Fair Dinkum Ripper Beaut of the Week

resizerA real Ripper from SMACC Gold- Casey Parker reminds us what makes us human. Our ability to feel and empathise is more important than ever. Learn more in his talk “Hard Lessons Learned”. [SO]

If you have just a few seconds to spare, read this touching post from Katrin Huska. It may be time you had that talk with your patient, too. [SO]

One of the most famous airway tragedies in recent history- the Elaine Bromiley case- receives a real-time reconstruction courtesy of Nicholas Chrimes. Harrowing and essential- anyone involved in airway management should watch this. [SO]

The second in the trilogy of trials reassessing Early Goal-Directed Therapy- the ARISE trial- has been released to great fanfare. Hear the original presentation here and Scott Weingart’s awesome summary here. Emergency Medicine Literature of Note also posted their commentary here, The Bottom Line has a great review as well, and the Intensive Care Network has interviewed the lead author here. [SO,MG, AS]

The Best of #FOAMed Emergency Medicine

  • We won’t be fooled again! Ken Milne and Ryan Radecki review the questionable veracity of the  conclusions of the Cochrane Collaboration systematic review of thrombolysis in acute ischemic stroke. [AS]
  • Looking to improve your skills as a trauma provider? The Anaesthesia Trauma and Critical Care (ATACC) Course, hosted multiple times a year in the UK, is widely lauded as one of the best courses available for up-to-date trauma practice. The ENTIRE course manual is available entirely FREE- via PDF and iTunes, and will be updated regularly.Just let that sink in. A free, up-to-date (and constantly updated), and concise trauma manual.(Thanks to Tim Leeuwenburg for the tip) [SO]
  • Didn’t make the UK’s College of Emergency Medicine Conference this week? Check out this fantastic resource of short summaries of the key points from the lead lecturers. CEM going FOAMed! With a huge range of topics including from traumatic arrest, sedation, gestalt and much much more. [SL]
  • The September edition of the Annals of Emergency Medicine Audio Summary, hosted by Drs David Newman and Ashley Shreves has been released. [MG]
  • Which c-spine rule is better: NEXUS or Canadian C-spine rule? BoringEM reviews the literature, and helps us understand their best uses. [MG]
  • Do you understand axis as well as you’d like? The EMS 12-Lead blog gives us the first in a new series on understanding axis on the ECG. [MG]
  • Damian Roland writes a touching post on a recent campaign to help reduce the incidence of suicide and improve general wellbeing by connecting with others. The 17th part of his “What I learnt this week” series, on #connectingwith, is here. [SO]
  • Pre hospital Intubation and Failure recognise (o)esophageal intubation.  An ED nurse and Mother blogs about her the death of her daughter and the scholarship fund set up in her memory.  [CC]
  • We all would like a smart doctor but I think most of us would agree that toughness, resilience and “grit” are vital characteristics. John Greenwood discusses the concept of “grit” and why we should identify and foster it. [AS]
  • Not only is half of what we learn in medical school wrong, but more than half of research is wrong as well. Ryan Radecki implores that we open the data up for external analysis and verification. [AS]
  • A wonderful reminder from Amal Mattu that flipped T-waves in the inferior and anteriorseptal leads is a PE until proven otherwise. Don’t be mislead into the ischemia pathway! [AS]
  • Takotsubo can be one of the most difficult STEMI mimics to differentiate. Learn how this week from Dr Steve Smith. [MG]
  • The AHA/ACC guidelines on the management of NSTEMI are out and Ryan Radecki highlights some important, and long awaited, changes including addition of the HEART score, dropping of CK-MB and Myoglobin, a place for single troponins and shared decision making. [AS]
  • In the latest edition of the MEdIC series, the ALiEM team discusses the use of and role for black humour and slang terminology. This post is a great example of crowdsourcing with over 120 comments and has wonderful expert peer review. [AS]

The Best of #FOAMcc Critical Care

  • Really wide QRS > 200 msec? Amal Mattu reminds us to think more about toxic effects of medications and metabolic issues like hyperkalemia and treat with Calcium and Bicarbonate. [AS]
  • Rory Spiegel offers a passionate argument for the use of Midline catheters for deep peripheral veins instead of traditional intravenous catheters. Time to adapt our “ideology, methods and tools accordingly.” [AS]
  • The Neuro ICM and EM blog have a wonderful summary on a recent consensus statement on MultiModality Monitoring in Neurocritical Care. [SO]
  • The absence of intracranial hemorrhage in a head trauma patient does not mean critical care management is unnecessary. St. Emlyn’s discusses the critical care management of patients with diffuse axonal injury this week on their podcast. [SL, AS]
  • We’ve all been wondering about Rob Mac Sweeney. Full time consultant in Intensive Care and anaesthesia, producer of some of the best #FoamCC with the Critical Care Reviews newsletter, editor of a new open access critical care journal- how does he do it all? ALiEM’s “How I work Smarter” series has the answer. [SO]
  • UMEM have a great critical care pearl on Goal-directed resuscitation during Cardiac arrest using CPP, DBP, and ETCO2. [SO]
  • Tachydysrhythmia diagnosis and management is bread and butter EM. John Greenwood reviews pearls and pitfalls from Amal Mattu on the University of Maryland Emergency Medicine site. This simple approach makes management straightforward. [AS]
  • PulmCrit features some dogmalysis, explaining that Lactated Rings is not only safe, but superior to normal saline in the setting of hyperkalaemia. [MG]
  • “Panscanning” has become a common practice for evaluation of trauma patients without any evidence of benefit. ALiEM gives a great critique of this practice. A must read for anyone caring for trauma patients. [AS]
  • Emergency Physicians MUST be the expert in EKGs. Steve Smith recounts a case to remind us that not all cardiologists are up to date on the literature.

#FOAMTox Toxicology

#FOAMus Ultrasound

  • Ultrasound continues to challenge CT scan for radiographic diagnostic supremacy. ALiEM shares a great post reviewing the utility of ultrasound in the diagnosis of small bowel obstruction. [AS]
  • Academic Life in Emergency Medicine release two new Paucis Verbis cards this week for focused abdominal aortic ultrasound, and FAST exam. [MG]
  • Ultrasound of The Week has a superb case of an 87 year old male with collapse. Brilliant images? [SO]
  • Have you been following the Intensive Care Network’s Lung Ultrasound Case series? Why not? Please check it out now- Case 5 is now up. [SO]
  • Matt and Mike from the Ultrasound Podcast discuss the recent paper on  point-of-care ultrasound in patients with respiratory symptoms- with Vicki Noble, Andrew Liteplo, and the first author Christian Laursen in a great two-part journal club. Part 1  Part 2 [SO]
  • The recent NEJM article on CT vs. Ultrasound in renal colic has gotten a lot of press on FOAM. St. Emlyn’s weighs in as well with a critical review of the article.

#FOAMPed Paediatrics

  • What is the relevance of mildly subnormal oxygen levels in bronchiolitis?  Don’t Forget the Bubbles discusses this question in The Effects of Oximetry on Hospital Admission in Bronchiolitis. [AS]
  • SonoKids discusses the benefits of a bedside ultrasound in a 9 year old trauma patient with flank pain – Not so FAST? [TRD]
  • Never mind faffing around trying to get IV access while your paediatric patient writhes in agony – Pediatric EM Morsels sells us the benefits of using intranasal fentanyl. [TRD]
  • Brilliant discussion of strep pharyngitis from Casey Parker asking tough questions about who should be tested (almost no one) and who should be treated (surprise – it’s not what you think). [AS]

Reference Sources and Reading List

The post LITFL Review 152 appeared first on LITFL.

Research and Reviews in the Fastlane 052

Research and Reviews in the Fastlane
Welcome to the 52nd 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

Infectious Diseases, Epidemiology, Critical Care

R&R Hall of Famer - You simply MUST READ this!R&R Hot Stuff - Everyone’s going to be talking about thisWHO Ebola Response Team. Ebola Virus Disease in West Africa — The First 9 Months of the Epidemic and Forward Projections. NEJM 2014 PMID: 25244186

  • Since the onset of the Ebola Virus Disease epidemic 7 months ago a total of 4507 confirmed and probable cases, as well as 2296 deaths from the virus had been reported from five countries in West Africa — Guinea, Liberia, Nigeria, Senegal, and Sierra Leone. The disease is rapidly spreading with a case diagnosed in the United States this week. This is an excellent report on the clinical and epidemiologic characteristics of the epidemic and the analyses in this paper can be used to inform recommendations regarding control measures. Unfortunately the current epidemiologic outlook is bleak especially in Guinea, Liberia, and Sierra Leone. Control measures which include improvements in contact tracing, adequate case isolation, increased capacity for clinical management, safe burials, greater community engagement, and support from international partners need to improve quickly otherwise these countries will be reporting thousands of deaths each week. Experimental therapeutics and Vaccines are not available at present and certainly not in the quantities that are required. We must also face the prospect that Ebola Virus Disease may become Endemic to the human population in West Africa.
  • Recommended by: Nudrat Rashid

The Best of the Rest

Emergency Medicine

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

Hwang V et al. Are pediatric concussion patients compliant with discharge instructions? J Trauma Acute Care Surg 2014. PMID: 24977765

  • The short and long term morbidity associated with pediatric concussions is becoming better recognized. This study looked at compliance with discharge instructions. Surprisingly (or maybe not so), 39% of pediatric patients returned to play (RTP) on the day of the injury. RTP is widely recognized as a risk for recurrent and more severe concussions as well as significant morbidity. It is the duty of the Emergency Physician to stress the importance of discharge instructions as well as the importance of appropriate follow up.
  • Recommended by: Anand Swaminathan

PediatricsR&R Mona Lisa -Brilliant writing or explanation” width=Singleton T et al. Emergency department care for patients with hemophilia and von Willebrand disease. J Emerg Med. 2010; 39(2): 158-65. PMID: 18757163

  • Bleeding always catches our attention in the ED… especially when it won’t stop. Von Willebrand disease is often encountered in the Peds ED. Make sure that the patient and their family don’t know more about it than you do.
  • Recommended by: Sean Fox
  • Read More: Von Willebrand Disease (PED EM MORSELS)

Emergency MedicineR&R Game Changer? Might change your clinical practiceR&R Eureka - Revolutionary idea or conceptGorchynski J et al. The “Syringe” Technique: A Hands-Free Approach for the Reduction of Acute Nontraumatic Temporomandibular Dislocations in the Emergency Department. J Emer Med 2014. PMID: 25278137

  • Reduction of temporomandibular joint (TMJ) dislocations is difficult, time consuming and often requires procedural sedation. This article describes a novel method for reduction of atraumatic TMJ dislocations in the ED. The “syringe” technique successfully reduced 97% (30/31) of dislocations. 77% (24/31) reductions were completed in less than 1 min. While this is not proof of superiority to other techniques, the time to reduction here is stunning and it’s always nice to have another arrow in the quiver
  • Recommended by: Anand Swaminathan

Pediatrics
R&R Game Changer? Might change your clinical practiceHalm BM. Reducing the time in making the diagnosis and improving workflow with point-of-care ultrasound. Pediatr Emerg Care. 2013; 29(2): 218-21. PMID: 23546429

  • Ok, so this isn’t hard core research, but I wanted to use it to highlight the fact that intussusception does not commonly present in the “classic” fashion and that by using point of care ultrasound, you can augment your physical exam to help diagnosis the condition in the child who presents with “altered mental status.”
  • Recommended by: Sean Fox
  • Read More: Intussusception & Altered Mental Status (PED EM MORSELS)

ResuscitationR&R Eureka - Revolutionary idea or conceptHeidlebaugh M et al. Full Neurologic Recovery and Return of Spontaneous Circulation Following Prolonged Cardiac Arrest Facilitated by Percutaneous Left Ventricular Assist Device. Ther Hypothermia Temp Manag. 2014. PMID: 25184627

  • Case report of a novel solution to a patient who sustained intra-cardiac catheterization cardiac arrest. An Impella device (an intraventricular LVAD) was placed into the left ventricle to provide adequate forward flow. Case report only but may offer an alternative to ECLS.
  • Recommended by: Cliff Reid
  • Read More: Left Ventricular Assist Device for Cardiac Arrest? (RESUS.ME)

Emergency Medicine, ObstetricsR&R Hot Stuff - Everyone’s going to be talking about thisKline JA et al. Systematic Review and Meta-analysis of Pregnant Patients Investigated for Suspected Pulmonary Embolism in the Emergency Department. Acad Emerg Med. 2014; 21(9): 949-959. PMID: 25269575

  • This systematic review and meta analysis looked at the literature (and gray lit) for pregnant patients undergoing work-up for pulmonary embolism, a cohort historically classified as high risk. The shocking take-home: we probably over-investigate PE in pregnant patients. The VTE rate in pregnant patients was 4.1%, compared with a rate of 12.4% in non-pregnant patients. The pooled RR of pregnancy VTE was 0.60 (95% CI 0.41-0.87) and patients of childbearing age (≤45 years) had RR 0.56 (95% CI 0.34-0.93). Of note, this study highlights the miniscule number of pregnant patients included in PE studies (n=506) and the tiny number of these who actually had VTE (n=29).
  • Recommended by: Lauren Westafer

Education

Cheston CC et al. Social media use in medical education: a systematic review. Acad Med. 2013; 88(6): 893-901. PMID: 23619071

  • Systematic review of social media in medical education. They found 12 studies, mostly small, a lot of reflective work. Good to see a growing evidence base for integrating FOAM into formal curricula.
  • Recommended by: Seth Trueger

Resuscitation, Critical CareR&R Hot Stuff - Everyone’s going to be talking about this Gu WJ et al. Single-Dose Etomidate Does Not Increase Mortality in Patients with Sepsis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials and Observational Studies. Chest 2014. PMID: 25255427

  • Etomidate, once the only available induction agent for RSI in US Emergency Departments, has long been maligned for its transient adrenal suppression in spite of the absence of any detrimental patient oriented outcomes. This systematic review and meta-analysis including 18 studies (only 2 RCTs) and > 5,500 patients demonstrated no difference in mortality in septic patients. For now, at least, etomidate is a viable option as an induction agent in patients with sepsis.
  • Recommended by: Anand Swaminathan

Emergency Medicine, OpthalmologyR&R WTF Weird, transcendent or funtabulous!” width=Moradi P et al. Sudden pseudoproptosis. Emerg Med J 2013; 31(8): 624. PMID: 24136120

  • Who knew there was such as thing as “Floppy eyelid syndrome”! Described in overweight middle-aged men. Interesting case with pictures described here. A disorder of unknown origin manifested by an easily everted, floppy upper eyelid and upper palpebral conjunctivitis. The upper eyelid everts during sleep, resulting in irritation, conjunctivitis and conjunctival keratinisation.
  • Recommended by: Jeremy Fried

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

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