Research and Reviews in the Fastlane 076

Research and Reviews in the Fastlane

Welcome to the 76th 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

Infectious Disease
R&R Hall of Famer - You simply MUST READ this!
Mouncey PR et al. Trial of Early, Goal-Directed Resuscitation for Septic Shock (The ProMISe Trial) NEJM 2015. PMID: 25776532 (FREE OPEN ACCESS ARTICLE)

  • The ProMISe trial is the third of the trio of studies comparing contemporary standard resuscitation of septic shock patients to EGDT. Like ARISE and ProCESS, ProMISe found no difference between usual care and EGDT for the primary endpoint of mortality. However, EGDT patients were more likely to get any central line (92.1% vs. 50.9%) central lines with SCVO2 monitoring capability (87.3% vs. 0.3%) and to get inotropes (i.e. dobutamine) (18.1% vs. 3.8%). Once again, the bottom line is that EGDT has changed our usual care from what it was 20 years ago. Aggressive management doesn’t require SCVO2 monitoring, CVP or hard triggers for interventions. Early antibiotics, fluids, source control with frequent reassessment triggering escalation of care is what we should focus on.
  • Recommended by Anand Swaminathan
  • Read more: The ProMISe Study: EGDT RIP? (St. Emlyn’s); Trial of Early, Goal-Directed Resuscitation for Septic Shock (The Bottom Line); The Protocolised Management in Sepsis (ProMISe) Trial (REBEL EM); Keep your ProMISe (MD Aware)

The Best of the Rest

Infectious Disease

Contenti J, et al. Effectiveness of arterial, venous,and capillary blood lactate as a sepsis triage tool in ED patients. Am J Emerg Med. 2014. PMID: 25432592.

  • The practice of arterial blood gas and lactate measurement continues despite evidence that most values in venous samples correlate adequately in most scenarios. This paper describes a 117 patients prospectively subjected to simultaneous arterial, venous, and capillary lactate measurement. The authors conclude, “…peripheral venous blood lactate appears to be more effective in assessing initial severity of sepsis than arterial lactate.”
  • Recommended by Reuben Strayer

Respiratory

Woods M, et al. BET 2: In patients presenting with an exacerbation of COPD can a normal venous blood gas pCO2 rule out arterial hypercarbia? Emerg Med J 2015; 32(3):251-3. PMID: 25694499.

  • Likely old news to many, but a nice summary of the studies demonstrating that, once again, we don’t need to subject our patients to the pain and potential complications of an arterial stick to obtain needed clinical information. In the words of the authors: “The clinical bottom line is that a normal venous pCO2 effectively rules out arterial hypercarbia.”
    Please, protect patients from unnecessary painful procedures!
  • Recommended by Jeremy Fried

Cardiology
R&R Hot Stuff

Stiell IG, et al. Safety of Urgent Cardioversion for Patients With Recent-Onset Atrial Fibrillation and Flutter Can J Cardiol 2015; 31(3):239-41. PMID: 25592853

  • The safety of cardioversion of recent-onset atrial fibrillation of < 48 hours duration has recently been called in to question in a Finish study published in 2013 and a secondary analysis of this data in 2014. In this viewpoint piece, Stiell and colleagues review the strengths and weaknesses of this recent data. They conclude that cardioversion should still be strongly considered in recent-onset atrial fibrillation < 48 hours in duration in patients without known valvular heart disorders (including mechanical valves) or recent thromboembolic events (TIA/CVA). Additionally, TEE should be considered prior to cardioversion in patients with high CHADS2 or CHA2DS2-VASc, age > 65, and as the onset time approaches 48 hours.
  • Recommended by Anand Swaminathan

Gastroenterology
R&R BoffintasticR&R Mona Lisa

Kessel B, et al. Evaluation of nasogastric tubes to enable differentiation between upper and lower gastrointestinal bleeding in unselected patients with melena. Eur J Emerg Med 2015. PMID: 25747792

  • More data on the lack of utility of NGL for UGIB. 386 patients admitted for melena; 279 had a negative lavage. Sensitivity for upper GI source was 28%. NPV was <1%.That means for patients with melena, >99% with a negative NG lavage still have an upper source of their bleed. And patients consistently rate NG as one of the most miserable interventions we do. So don’t.
  • Recommended Seth Trueger

Resuscitation

Sheak KR, et al. Quantitative relationship between end-tidal carbon dioxide and CPR quality during both in-hospital and out-of-hospital cardiac arrest. Resuscitation 2015; 89:149-154. PMID: 25643651.

  • This study is important to confirm what many of us already do, use ETCO2 as a marker of CPR quality. While limited by the manner in which the data was collected, and multiple potential confounders such as lack of medication administration and ventilation details, the authors provide us with a positive correlation between chest compression depth and ETCO2 levels. For every 10mm increase in depth, there was a 1.4mm Hg increase in ETCO2. While statistically significant, there is likely limited clinical importance of such a small difference. Nevertheless, as quality of CPR is the known most important factor in resuscitation, any small improvement should be utilized to its maximum.
  • Resuscitation leaders – Using EtCO2 to guide CPR effectiveness? First rule of Resus – Optimize execution. Remember, it’s not just CPR quality affecting your EtCO2, respiratory rate (watch your bagger!) can significantly impact your EtCO2 value. Interestingly, chest compression rate did not significantly impact EtCO2….
  • Recommended by John Greenwood, 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&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.

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LITFL Review 174

LITFL review

Welcome to the 174th LITFL Review. 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.

The Most Fair Dinkum Ripper Beauts of the Week

resizerThe 15th International Symposium on Intensive Care and Emergency Medicine (ISICEM-15) took place from the 17th to the 20th of March. Lots of FOAMy goodness bubbled up from the event, including:

Three big studies (ProMISe, ABLE, and a study on SIRS criteria) were presented. More info on these later in the review… [SO]

The Best of #FOAMed Emergency Medicine

The Best of #FOAMcc Critical Care

The Best of #FOAMtox Toxicology

  • Maybe it’s scorpion venom…maybe it’s methamphetamine? The Poison Review looks at a recently published case with a link to a nice review on scorpion envenomation [JAR]
  • Tox Talks next section on the Intralipid Toxoversy is out. Listen in! [JAR]
  • Take a toke, or munch on a Keef Kat or Boddahfinger bar??? Leon Gussow discusses a recent NEJM paper on marijuana edibles [JAR]

The Best of #FOAMPed Pediatrics

  • What’s more important in a peds ER than sex, drugs and psychosis? Sex, drugs and psychosis in teens. Ilene Claudius discusses a number of issues on the topic at Essentials of EM 2014 [ML]

The Best of Medical Education and Social Media

News from the Fast Lane

Reference Sources and Reading List

Brought to you by:

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The Deteriorating Patient

ANZICS PS&Q Meeting

If you want to know all there is to know about ‘The Deteriorating Patient‘, the Gold Coast is the place to be on July 6th and 7th 2015:

Approximately 10% of hospitalised patients will experience a serious adverse event.   To improve the detection, recognition and response to deteriorating ward patients Australian and New Zealand clinicians pioneered Rapid Response Teams (RRTs) and Medical Emergency Teams.   Two thirds of ICUs in Australia and New Zealand are involved in Rapid Response Systems. Rapid Response Systems are an essential part of our hospital patient safety system.In 2015, ANZICS will again host a conference on RRTs and broader aspects of deteriorating ward patients. The program be designed to appeal to a multi-disciplinary audience featuring original research and an entire one day stream devoted to practical aspects of Rapid Response Team training.  There will be an opportunity for delegates to meet experts to obtain advice about RRTs and safety strategies for deteriorating patients for delegates to take back to their local hospital. The program will also contain sessions related to RRTs in specific settings as well as a dedicated paediatric session.  The social functions will again provide opportunities for delegates to catch up with friends and colleagues and will feature an inspiring speaker talking about aspects of teamwork.

Of particular interest are novel sessions focussed on the education and training of RRT members, including debriefing and assessment of videos of mock RRT calls and live RRT performances (some plus, some delta!)…

Here is the programme:

For a taster, here is my talk from last year’s conference, “Rapid Response Teams: The Registrars’ Perspective” (originally published on INTENSIVE):

REGISTER HERE!

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Research and Reviews in the Fastlane 075

Research and Reviews in the Fastlane

Welcome to the 75th 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 7 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

Cardiology
R&R Hall of Famer - You simply MUST READ this!
Newman DH, et al. Quantifying Patient-Physician Communication and Perceptions of Risk During Admissions for Possible Acute Coronary Syndromes. Ann Emerg Med 2015 PMID: 25748480.

  • A fascinating article which examines how we in the ED communicate with our admitted low risk chest pain patients. The authors gave surveys to both patients and physicians, asking why the patient was staying in the hospital, and what the chances were of a possible adverse outcome. In this low risk cohort, with a collective risk of <2% for death/MI in 30 days, communication was, unsurprisingly, poor.A discussion regarding the possible risks to patients and reasons for remaining in the hospital only occurred 2/3 of the time. Patients and their physicians only agreed on the patient’s risk 36% of the time. Additionally, patient estimation of MI mortality at home versus in the hospital was 80% v 10%; while physician estimation was 15% and 10%The accompanying editorial (PMID 25749403) accurately describes this as a state of “collective statistical illiteracy.” As we incorporate shared decision making into our practice for low risk patient populations, it’s imperative that we provide accurate information.
  • Recommended by Jeremy Fried

The Best of the Rest

Pulmonary
R&R Hot Stuff - Everyone’s going to be talking about this
Fermann GJ et al. Treatment of Pulmonary Embolism With Rivaroxaban: Outcomes by Simplified Pulmonary Embolism Severity Index Score from a Post Hoc Analysis of the EINSTEIN PE Study. Acad Emerg Med 2015; 22(3):299-307. PMID: 25716463

  • In this retrospective analysis of the EINSTEIN PE trial (comparing rivaroxaban to standard PE therapy) the authors found that patients with an sPESI score of 0 or 1 had extremely low rates of major adverse outcomes at 7, 14 and 30 days. With an sPESI of 0, there were no cases of fatal PE at 7 days and a recurrent VTE rate < 1% at 30 days with rivaroxaban treatment. A prospective, randomized trial is needed but this study further supports the practice of discharge home from the ED on oral anticoagulation therapy in patients who are low risk.
  • Recommended by Anand Swaminathan
  • Read more: Adverse Outcomes are Very Rare After Pulmonary Embolism (EM Lit of Note)

Infectious Disease

Dugas AF et al. Clinical Diagnosis of Influenza in the Emergency Department. Am J Emerg Med 2015. DOI: http://dx.doi.org/10.1016/j.ajem.2015.03.008.

  • This article evaluates emergency provider’s ability to diagnose influenza based on history and physical examination. The authors find that sensitivity and specificity is poor (36% and 78% respectively) in comparison to the gold standard of influenza PCR testing. The authors go to great lengths to explain the importance of diagnosing influenza based on their perceived benefits of antiviral medication initiation early in the course of disease. However, no such benefit exists when all the data is reviewed. Only a modest curtailing of length of symptoms has been shown (~ 16-17 hours) at the trade off of increased nausea, vomiting and psychiatric complications. The authors repeated claims at improved mortality, particularly in the sickest subset of influenza patients, is unsubstantiated in the literature.
    Despite these issues, the poor sensitivity and specificity of clinical exam further contribute to the limitations of prescribing these medications since even if there was a significant benefit, identifying those with the disease is difficult in the absence of expensive tests. Fortunately, the benefit is so minimal as to obviate the need for testing or antiviral treatment.
  • Recommended by Anand Swaminathan

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

Munro AR et al. Use of an Accelerated Diagnostic Pathway allows rapid and safe discharge of 70% of chest pain patients from the Emergency Department 2015: 128(1408); 62-71. PMID: 25662380

  • Accelerated diagnostic protocols in low risk chest pain are all the rage. This article is a prospective observational cohort study of 452 patients presenting with chest pain to one New Zealand ED. The authors split patients into either high-risk or non-high risk groups based on EKG, clinician “gestalt” and serial high-sensitivity troponin assay (or single enzyme if symptoms for more than 6 hours). This group classified 75% of patients as non-high risk with a 0% rate of acute MI or death at 30 days (100% follow up!). 1.2% of non-high risk patients required urgent revascularizaton (part of MACE but a soft endpoint) at 30 days. This study further defends the pathway of early discharge from the ED without evocative testing in subsets of patients with low risk chest pain.
  • Recommended by Anand Swaminathan

Neurology

Edwards C, et al. Residency Training: A failed lumbar puncture is more about obesity than lack of ability. Neurology 2015; 84(10):e69-72. PMID: 25754807

  • This is an interesting article exploring the reasons for LP failure. The authors reviewed all elective LPs done by Neurology residents in a LP clinic. They recorded all the demographic of the patient and the characteristics of the proceduralist. The overall LP failure rate was 19% and it was associated with a high patient BMI, other variables such as the level of the training of the resident did not have an effect. The authors made the recommendation that in patients with a high BMI (>35) an image-guided LP is recommended.
  • Recommended Daniel Cabrera

Toxicology

De Lange DW et al. Extracorporeal membrane oxygenation in the treatment of poisoned patients. Clin Toxicol 2013; 51: 385-393. PMID 23697460

  • Improved technology and advances in emergency critical care have made it feasible at some institutions to initiate extracorporeal membrane oxygenation (ECMO) in the Emergency Department. As a “Bridge to Recovery” ECMO has potential to benefit the crashing toxicology patient, buying time while the body (perhaps aided by hemodialysis or another enhanced elimination technique) rids itself of the poison. Veno-arterial ECMO can provide circulatory support in cases of severe cardiotoxicity. This literature review covers techniques, indications, contraindications,complications, and clinical case reports. It will get you thinking about the possibilities.
  • Recommended by Leon Gussow

 Cardiology

Grailey K et al. Diagnostic Accuracy of Nitroglycerine as a ‘Test of Treatment’ for Cardiac Chest Pain: A Systematic Review. Emerg Med J 2012; 29(3):173-6. PMID: 21511974.

  • This study evaluated the diagnostic accuracy of nitroglycerine relieving chest pain as a predictor of the pain being cardiac/ACS in etiology. The combined sensitivity was 0.52 (95% CI 0.48 to 0.56) and combined specificity was 0.49 (95% CI 0.46 to 0.52) meaning that the use of nitroglycerine as a diagnostic modality in chest pain is not useful.
  • Recommended by Salim R. Rezaie

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 075 appeared first on LITFL.

Why Australia and New Zealand Intensive Care Rocks!

Here is one possible reason:

From Bellomo et al, 2007

From Bellomo et al, 2007

Hats off to the ANZICS CTG and all the clinicians across Australia and New Zealand who enrol their patients in trials as we strive to learn more about how to help our patients.

Bellomo R, Stow PJ, Hart GK. Why is there such a difference in outcome between Australian intensive care units and others? Curr Opin Anaesthesiol. 2007 Apr;20(2):100-5. Review. PubMed PMID: 17413391.

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Interested in Toxicology? APAMT and TAPNA

You took WHAT???

The more you know, the less you know about a poison…. just look at paracetamol! And if your patient took something you knew a little bit about…. it is always combined with a new chemical name that you have never heard about! Not to mention the forever changing and amazing routes to administer it!

If you would like to know more about Toxicology, there will be two amazing Toxicology conferences in Australia this year.

On 1st and 2nd of May 2015 there is the TAPNA (Toxicology and Poisons Network Australasia) scientific meeting in Sydney. Since it is closely linked with Emergency Medicine and the poisonings are all kind of acute by the time they come to medical attention, the topic of the conference is Toxicology issues in acute care. The first day will be a conference with a few notable Australian speakers (Prof Nick Buckley on evidence and controversies in Toxicology, Dr Simone Strasser on drug induced hepatotoxicity, Dr Geoof Isbister on toxicokinetics, Dr Deirdre Murphy from INTENSIVE on ECMO use in the poisoned patient). The second day is an educational session on common Toxicology presentations, useful for anybody working in an Emergency Department, wanting to start a career in Toxicology or simply with an interest in Toxicology. The presenters will be Dr Andrew Dawson (@lankatox), Dr Colin Page, Dr Michael Downes (@ToxTalks), Dr Kate Sellors (@katesellors) and Dr Zeff Koutsogiannis (@zeff65) and myself (@ivyswonders).

Then on 1st to 4th December 2015 WATS (Western Australian Toxicology Service) will hold the Asia Pacific Association of Medical Toxicology (APAMT) conference in Perth.

Western Australia might be on the far and forgotten side of Australia, but it is not exactly a small state. Poisoned patients often wait hours before they are transferred to tertiary centres if they require specialist care. So the theme was appropriately chosen as Remote, Resource and Retrieval Challenges in Toxicology. There will be a preconference symposium run by TAPNA with workshops and lectures on various poisons and toxic exposures. And among the confirmed guest speakers we have so far Prof Bruno Megarbane from France, Dr Dag Jacobsen and Dr Knut Erik Hovda from Norway, Dr Michael Eddleston and Dr Paul Dargan from the UK.

I hope to see you either in Syndey or Perth or both!

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