Research and Reviews in the Fastlane 067

Research and Reviews in the Fastlane

Welcome to the 67th 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

Emergency MedicineR&R Hall of Famer - You simply MUST READ this!
DRAFT Clinical Policy: Use of Intravenous tPA for the Management of Acute Ischemic Stroke in the Emergency Department.  The draft is now open for comments until March 13, 2015. To view the draft policy and comment form, Click Below: Clinical Policy Comment Form-Intravenous tPA 

  • ACEP has revamped it’s recommendations for the most controversial topic in Emergency Medicine: the use of tPA in acute ischemic strokes. The draft for the new clinical policy is available online, and importantly, there is a comment period open for 60 days (until March 13th). While there are strong feelings on both sides of this debate, the ability to make our voices heard within the organization is an important opportunity, and not to be missed.Briefly, the new policy examines the same two questions as the one from 2012:
  • 1. Is IV tPA safe and effective for acute ischemic stroke patients if given within 3 hours of symptom onset
  • 2. Is IV tPA safe and effective for acute ischemic stroke patients treated between 3 to 4.5 hours after symptom onset?Important changes in the policy include
    • A new emphasis on a shared decision making model with the physician and patient as a Level C recommendation
    • The specific mention of consideration of the increased risk of symptomatic intracerebral hemorrhage as the ONLY Level A recommendation
    • The strength of the recommendation for tPA toned down from “should be offered” and “should be considered” in the 2012 policy to “may be given to carefully selected acute ischemic stroke patients” in the new one.
    • Overall, a must read piece for EM practitioners, not only to inform their own decision making, but also to give voice to our own thoughts on the issue prior to publication of the policy.
  • Recommended by: Jeremy Fried
  • Read More: The Wholesale Revision of ACEP’s tPA Clinical Policy (EM Lit of Note)
  • Read More: Reflections on ACEP tPA Clinical Policy Update Draft (FOAMCast)

The Best of the Rest

EducationR&R Hot Stuff - Everyone’s going to be talking about thisFraser K et al. The Emotional and Cognitive Impact of Unexpected Simulated Patient Death A Randomized Controlled Trial. Chest. 2014; 145(5): 958-63. PMID: 24158305

  • What is the effect of simulation patient death on trainees? This study looks into the question and finds that medical students randomized to having their simulated patient die report increased cognitive load and had poorer learning outcomes. The authors caution that this doesn’t mean we shouldn’t have simulated patients die but that we need to plan for this outcome intelligently.
  • Recommended by: Anand Swaminathan

PediatricsR&R Game Changer? Might change your clinical practiceMaffei FA et al. Duration of mechanical ventilation in life-threatening pediatric asthma: description of an acute asphyxial subgroup. Pediatrics 2004; 114(3):762-7. PMID: 15342851

  • Interestingly, while we often preach to not intubate the asthmatic… there may be a sub-population of patients with Acute Asphyxial Asthma who have brief, albeit severe, exacerbations that require intubation, but then do fairly well. These patients may present to you with no other option than to intubate.
  • Recommended by:  Sean Fox

 Critical CareR&R Game Changer? Might change your clinical practiceR&R Boffintastic - High quality researchPener A et al. Scandinavian clinical practice guideline on choice of fluid in resuscitation of critically ill patients with acute circulatory failure. Acta Anaesthesiol Scand. 2014. PMID: 25363535

  • Scandinavian guidelines for fluid resusciation in critically ill patients. For general ICU patients, those with sepsis and trauma patients crystalloids rather than hydroxyethyl starch, gelatin and albumin are recommended . Unfortunately no recommendations are provided for burns as there are very limited data from randomised trials on fluid resuscitation in this patient population.
  • Recommended by: Soren Rudolph

Cardiology, Emergency Medicine, Resuscitation
R&R Hot Stuff - Everyone’s going to be talking about thisCalle PA et al.  Inaccurate treatment decisions of automated external defibrillators used by emergency medical services personnel: Incidence, cause and impact on outcome. Resuscitation 2015. PMID: 25556589

  • This is an interesting and concerning paper. Two authors reviewed all rhythm analysis algorithm (RAA) from patients who had an AED activated secondary to cardiac arrest. The authors found that in 16% of shockable rhythms (23 of 148) the AED did not advise shock, often secondary to artifacts or “fine V-fib”.This article shows a concerning incidence of “failure to defibrillate” among OHCA receiving AEDs.
  • Recommended by: Daniel Cabrera

AirwayR&R Hot Stuff - Everyone’s going to be talking about thisPatel A, Nouraei SAR. Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE): a physiological method of increasing apnoea time in patients with difficult airways. Anaesthesia. 2014 Nov 10. PMID: 25388828

  • Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE) is a form of high flow nasal cannula – provided oxygen therapy. High flow rates, a degree of PEEP, and potentially some CO2 clearance can be achieved, and so it might be a more effective alternative to routine nasal prong oxygenation during apnoea after RSI (ie. an alternative form of NODESAT). The bulkiness of the apparatus can make it difficult to provide mask ventilation and more studies are needed to define patients who might benefit, but this small elective anaesthesia study on patients with difficult airways provides an interesting overview of the technique.
  • Recommended by: Cliff Reid
  • Read More: High flow systems for apnoeic oxygenation (RESUS.ME)

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 067 appeared first on LITFL.

Warm summer nights

It was summer 2006, the days long and the nights warm, and I was an intern, living by the beach and working a rotation in emergency. My memories of this time are like those of childhood holidays, a jumble of sensation and moments, rounded out and glossed by time and nostalgia, but I can say with certainty that it was a golden period.

I was beginning to find my feet within the world of medicine, finally feeling like a real doctor. We were still in the old department in those days, poorly designed and hopelessly undersized for our growing patient load, yet warm and friendly, the glass walled doctor station affectionately known as “the fishbowl” a hive of social activity. My wins were simple things; a growing success rate in IV cannulation, mastering the art of plastering and suturing, independently managing common emergency presentations such as pneumonia and Colles’ fractures, my first shoulder joint reduction (a modified Kocher’s technique with traction).

Hours outside work felt like one long holiday. The junior doctor ED roster, weekend and evening heavy, can be a lonely one when everyone else is at work in the depths of a southern state winter. Over summer, however, a 4pm shift start feels like a day off, and a 5.30pm finish leaves hours of daylight. The small unit I shared with two friends was walking distance from both the beach and the pub, ensuring a constant stream of Melbourne guests and an ongoing vibe of festivity.

And then there was surfing, always surfing. Anyone can surf on a Queensland holiday, but there is a distinct joy in punctuating a satisfying day’s work with a splash in the ocean. Surfing alone or with friends, a quick sunrise dip on a still morning before work, or east coast odysseys on runs of days off. Storing my board in the residents’ quarters on hot days to stop the wax melting in the car, leaving nightshift and heading straight to the beach, followed by eggs and a cold beer at a favourite cafe before heading home to sleep. Surely this was a magnificent life.

More summers came and went, and friends moved on. I have no recollection of making a formal decision to stay in both emergency medicine and my home by the beach, it simply became evident I wouldn’t leave. Then a romance led to the intertwining of two lives and blossomed into a family. We all moved into an old house on a large block with glimpses of the ocean from the neglected backyard, and slowly set about making it ours. I am now part of my family unit first, myself second. I drive the same highway to work that I did as an intern, detouring along the coast on my way home to check the surf, but these days I don’t stop. Family, work, study, the house and garden, so many forces keeping me land bound, so many good reasons not to plunge in. Yet it often feels that a little piece of me is missing.

It’s not just the relinquishing of personal freedom I struggle with, but the recurrent little deaths of youthful possibility. Raising a family and completing a formal training program are noble and rewarding pursuits, but they are also ruthless dream slayers. We cannot live all potential lives, and will do ourselves an injustice if we try. I have never lived in Paris for six months and become fluent in french, nor toured the Californian longboard circuit. We all have these, I dare say, the dreams we have let go by yet carry around with us, packed tidily into a secret little backpack.

Nine years have passed and I am working a busy shift on a hot, sticky day, when it feels like the whole state is holidaying in our town. I am well on my way to becoming a competent emergency physician and still love the never ending challenge. My small wins are a smoothly executed intubation, wrestling a rampaging department into submission overnight, pulling off a novel procedure or tactfully solving a disposition issue. We have been in the new department for years now. It was the right move, but at times I still miss the cramped coziness of the old place.

I hear the loudspeaker call of a resus patient, and walk in to see a young man, clad only in boardshorts, sand clinging to his legs, face contorted in pain, gingerly supporting the weight of his left arm. What happened, I ask. He was paddling for a wave and his shoulder just popped out. I enquire as to which break, and it is one of my favourites, a rolling point situated on a scenic bluff, far enough out of town to keep the crowds down. It would be offshore today. For a moment I forget his pain and I am there, on that wave, the sharp sting of spray in my face, weight of water between my fingers, gliding down the face and springing to my feet, my longing so strong I can taste it, like an unexpected mouthful of salty water. How I want to go back to a time when I would arrive at work with grains of sand in my hair, euphoric with surfing and emergency, the two somehow forever wedded for me that first year. The moment passes and I drag myself back to the present, where I belong. I do shoulders differently now. Some nitrous and gentle external rotation with a flexed elbow, and with a sudden clunk the rounded humeral head is also back where it belongs, the procedure familiar and satisfying in my hands.

The next day we take our children to the beach, low tide with a forgiving swell. We rarely battle with a board on family visits any more, the finite resource of adult upper limbs already allocated to towels, buckets, other miscellaneous beach paraphernalia and a rather sturdy toddler whose preferred mode of transport is balanced on my hip, like a chubby-cheeked, divine smelling bag of lead. But today I grab a board from my teenage nephew, and suddenly I am paddling, gliding, standing, trimming, waving enthusiastically to my daughter playing on the shore. I am not that intern girl anymore, nor would I want to be, but for the duration of that wave I capture something of the sense of freedom and possibility of my glorious first summer by the beach, and realise that perhaps it is play that is the missing element in my crowded life these days. And as I drive down the highway to work this evening, window down, breathing in the warm summer night, I will be thinking of that wave, all that came before, and the many more still to come.

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LITFL Review #165

LITFL review

Welcome to the 165th 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

resizerDo you re-spike IV fluid bags? The case of Ruby Chen from gravelessons.com should make us all re-think this. [SO]

 

The Best of #FOAMed Emergency Medicine

The Best of #FOAMcc Critical Care

  • Great review of the pathophysiology and treatment of severe alcohol withdrawal and delerium tremens from PulmCrit. The review focuses on the potential role of phenobarbital as the first agent in treatment. [AS]
  • The evidence continues to mount that esmolol may be a useful therapy in patients with refractory VFib arrest. Resus.me reviews some recent lit on the subject. [AS]
  • Megan Brenner discusses the ins and outs of REBOA on the Maryland CC Project and shares a nice flow diagram for application of the device. [AS}
  • We rarely discuss our errors in management. On EM Cases, Andy Sloas discusses one and what he learned from the case to improve care in the future. [AS]
  • Charles Bruen reviews the rare but deadly Arrhythmogenic Right Ventricular Dysplasia (ARVD) with a focus on EKG findings and management. [AS]
  • More great reviews from The Bottom Line. This week the CHEST trial; starch vs saline for fluid resuscitation. [SL]
  • Josh Farkas continues his excellent series on Toxic Shock syndrome with advice on management in “A tale of two patients”. Don’t forget the clindamycin and IVIg….[SO]
  • John Greenwood from the Maryland Critical Care projects gives some thoughts on Jean-Luis Vincent’s recent paper, “10 big mistakes in Intensive Care Medicine”. Both the original article and John’s thoughts are humbling indeed. Check it out! [SO]
  • In our rush to resuscitate people, human aspects like empathy and compassion can get left behind. The Humanizing ICU project once again come to our rescue with a great video (submitted for SMACC EVO) reminding us all to “Be Sweet”. [SO]

The Best of #FOAMtox Toxicology

  • The Poison Review podcast has a great interview with Dr Guy Weinberg, known for developing the use of intralipid for treating local anaesthetic toxicity. Intralipid has also been used for other lipid soluble drug overdoses. Have a listen. [SO]

The Best of #FOAMus Ultrasound

  • Justin Mandeville from ICMWK reviews an article by Paul Mayo looking at critical care echo myths, and leaves us with some great pearls. [SO]
  • Here are some wonderful tips from echo.guru on measuring pericardial effusions. [SO]
  • Echoanaesthesiatoday.com is a great online resource for learning ultrasound nerve blocks. They have an amazing app called “Echo-blocks” which lists surgical procedures by site with the corresponding nerve block, complete with tutorial and video! One for the anaesthetists among us, or anyone else interested in regional anaesthesia. [SO]

The Best of Medical Education and Social Media

  • Check out this hilarious primer for SMACCFORCE. I have no idea who to credit it to, but I doff my cap to thee, sir or lady. (Thanks to Minh Le Cong for archiving) [SO]

News from the Fast Lane

Reference Sources and Reading List

Brought to you by:

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Research and Reviews in the Fastlane 066

Research and Reviews in the Fastlane

Welcome to the 66th 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

Critical Care

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

Sandroni C et al. Prognostication in comatose survivors of cardiac arrest: an advisory statement from the European Resuscitation Council and the European Society of Intensive Care Medicine. Intensive Care Med 2014; 40(12):1816-31. PMID: 25398304 (FREE OPEN ACCESS ARTICLE)

  • This is a question that plagues most Critical Care Doctor’s. Unfortunately the quality of evidence remains poor. The author’s suggest a multimodal prognostication approach in all patients. The most robust predictor’s remain bilateral absence of either pupillary and corneal reflexes or N20 wave of short-latency somatosensory evoked potentials in patients who are comatose with absent or extensor motor response at ≥ 72 h from arrest, either treated or not treated with controlled temperature.
  • Recommended by: Nudrat Rashid

The Best of the Rest

PediatricsR&R Hot Stuff - Everyone’s going to be talking about thisVaillancourt S et al. Repeated Emergency Department Visits Among Children Admitted With Meningitis or Septicemia: A Population-Based Study. Ann Emerg Med 2014. PMID: 25458981

  • This is a retrospective cohort study looking at all kids within a database who were identified as having bacteremia or meningitis. The authors sought to look at whether there was a difference in outcomes between patients who were identified on first presentation or in those discharged home initially. Although it would make sense that patients with these diseases would do worse if sent home, the authors did not find evidence of this. Bottom line is that it’s unlikely we can detect all kids with occult bactermia or meningitis and if they look good on initial presentation, delayed diagnosis is unlikely to lead to bad outcomes.
  • Recommended by: Anand Swaminathan

Critical CareSnell JA, et al.: Clinical review: The critical care management of the burn patient. Critical Care 2013; 17(5):241. PMID: 24093225 (FREE OPEN ACCESS ARTICLE)

  • This review goes through important concepts such as fluid creep, nutrition and hypermetabolism. Having looked after three burns patients recently in an ED for >48hrs, it is extremely important to be fully informed and have a sophisticated knowledge of all aspects of Emergency Care including taking care of critically ill patients for prolonged periods of time.
  • Recommended by: Sa’ad Lahri

Resuscitation, Critical Care, CardiologyR&R Game Changer? Might change your clinical practiceR&R LandmarkVan Gelder IC et al. Lenient versus strict rate control in patients with atrial fibrillation. NEJM 2010; 362(15):1363-73. PMID: 20231232 (FREE OPEN ACCESS ARTICLE)

  • What’s your goal rate in AFib with RVR? This paper doesn’t answer it definitively, but helps remind us that people with AFib aren’t people in sinus rhythm. Like AFFIRM (rate vs rhythm control) this is a long-term, outpatient study about rate control in AFib — not exactly what we see in the ED with acute RVR. But like AFFIRM, it will probably be a while before we have the right answer to our question. Don’t go for euboxia, go for what helps your patient — we don’t have a precise answer but I think it’s likely reasonable to aim for rate in the 110s.
  • Recommended by:  Seth Trueger

CardiologyR&R WTF Weird, transcendent or funtabulous!” width=Jena AB et al. Mortality and Treatment Patterns Among Patients Hospitalized With Acute Cardiovascular Conditions During Dates of National Cardiology Meetings. JAMA Intern Med 2014. PMID: 25531231

  • In this retrospective chart review, the authors looked at change in mortality of patients with primary cardiac issues who were admitted at the same time as national cardiology conferences. They found that high-risk patients with heart failure and cardiac arrest had lower mortality during the national conferences. Intuitively, less cardiac procedures (specifically PCI) were performed. No conclusions can be drawn from this study and, obviously, the study is ripe with limitations from its design. However, the study again questions the idea that more is better.
  • Recommended by: Anand Swaminathan

Critical Care, Emergency MedicineR&R Hot Stuff - Everyone’s going to be talking about thisKraut JA, Madias NE. Lactic Acidosis. NEJM. 2014; 371(24):2309-2319. PMID: 25494270.

  • Important review for all EM and critical care docs of all things lactic acidosis related. Some important points made in the review include:
    “Randomized, controlled studies are needed to determine the most effective and safe crystalloid. Red-cell transfusions should be administered to maintain the hemoglobin concentration at a level above 7 g per deciliter. Resuscitative efforts should be complemented by measures targeting the cause or causes of lactic acidosis. . . the value of bicarbonate therapy in reducing mortality or improving hemodynamics remains unproven.”
  • 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&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 066 appeared first on LITFL.

LITFL Review #164

LITFL review

Welcome to the 164th 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 journal Critical Care has always been an online source of excellent resuscitation information… and has now become 100% OPEN ACCESS. You heard that right, folks. Dive in! [SO]

 

The Best of #FOAMed Emergency Medicine

  • The Skeptics Guide discusses the utility of antiemetics in undifferentiated vomiting in the Emergency Department. [AS]
  • Excellent review of CT Coronary Angiogram (CTCA) from ERCast with Rob Orman interviewing Judd Hollander. [AS]
  • Another great case of a developing STEMI and the importance of serial ECGs shared by Amal Mattu from a new location for the ECG Weekly Vidcast. [AS]

The Best of #FOAMcc Critical Care

  • Rory Spiegel reviews the (lack of) evidence for the use of balanced solutions over normal saline in resuscitation of the critically ill patient. [AS]
  • Gareth Davies and Iain Beardsell discuss brain apnea and some of the nuances of managing these patients on the St. Emlyn’s podcast. [AS]
  • The Bottom Line dissects the CHEER trial (Mech CPR, Hypothermia, ECMO + Early Reperfusion. [AS]
  • What is ischemic conditioning? How might it be used in managing a cardiac arrest patient? Find on on the ED ECMO podcast. [MG]
  • David Tripp from the Wellington ICU shared an excellent collection of revision notes for the Australian College of Intensive Care Medicine exam. Also on the page are revision notes on critical care ultrasound, child health, and Fellowship of the Royal Australian College of Physicians. Worth a long, deep dive… [SO]
  • Josh Farkas has a very humbling post on the diagnosis of toxic shock shock syndrome. Are you suspicious enough? I certainly haven’t been in the past…[SO]

The Best of #FOAMus Ultrasound

The Best of Medical Education and Social Media

News from the Fast Lane

Reference Sources and Reading List

Brought to you by:

The post LITFL Review #164 appeared first on LITFL.

Research and Reviews in the Fastlane 065

Research and Reviews in the Fastlane

Welcome to the 65th 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, CardiologyR&R Hall of Famer - You simply MUST READ this!R&R EurekaHess EP et al. The Chest Pain Choice Decision Aid A Randomized Trial. Circ Cardiovasc Qual Outcomes 2012; 5(3):251-9. PMID: 22496116

  • This study looked at how patients and doctors can use shared decision making to reduce in patient work ups for low risk chest pain. Using a chest pain decision aid, they reduced in patient work ups by 19%. The brilliance here is in the application of the theory of shared decision making and the knowledge transfer to patients using this system.
  • Recommended by: Anand Swaminathan

The Best of the Rest

Cardiology, Emergency MedicineR&R Game Changer? Might change your clinical practiceBangalore S et al. Clinical outcomes with β-blockers for myocardial infarction: a meta-analysis of randomized trials. Am J Med. 2014;127(10):939-53. PMID: 24927909

  • The pendulum for beta blockers in MI keeps swinging around. In this systematic review, they find a decrease in recurrent MI but no mortality difference since we entered the “reperfusion era.” There might be some benefit, but in the first 90 minutes in the ED, my nurses & I probably have more important things to do.
  • Recommended by: Seth Trueger

CardiologyR&R Hot Stuff - Everyone’s going to be talking about thisNørgaard BL et al. Diagnostic performance of noninvasive fractional flow reserve derived from coronary computed tomography angiography in suspected coronary artery disease: the NXT trial (Analysis of Coronary Blood Flow Using CT Angiography: Next Steps). J Am Coll Cardiol. 2014; 63(12):1145-55. PMID: 24486266

  • A look at what is next in line for non-invasive to evaluate ED low-risk chest pain patients. FFTct seems to be a mediocre test assessed using a questionably benign definition of disease as the gold standard, in a remarkably healthy population (only 11% with significant stenosis), to identify a cohort that likely does not benefit from stent placement in the first place..
  • Recommended by: Rory Spiegel

Emergency Medicine, CardiologyR&R Hot Stuff - Everyone’s going to be talking about thisR&R Game Changer? Might change your clinical practiceCappato R et al. Rivaroxaban vs. vitamin K antagonists for cardioversion in atrial fibrillation. Eur Heart J. 2014. PMID: 25182247

  • Rhythm vs rate and optimal anticoagulation is still a significant point of discussion in the management of A-fib in the ED. This paper evaluates the use of Rivaroxaban in patients with atrial fibrillation vs. Vitamin K antagonists (VKAs). In this study Rivaroxaban was non-inferior to VKAs in all groups, and remarkably an early cardioversion strategy with Rivaroxaban 4 hours prior to cardioversion plus 6 weeks after the procedure was similar to the conservative strategy, i.e., 3 weeks of ACO prior to the procedure.
  • Recommended by:  Daniel Cabrera

NeurologyR&R Game Changer? Might change your clinical practiceJohnson RW, Rice AS. Clinical practice. Postherpetic neuralgia. NEJM 2014;371(16):1526-33. PMID: 25317872.

  • An excellent review of all things postherpetic neuralgia. The importance of the zoster vaccine is apparent as the futility of other treatments is demonstrated in the article. Of important note, opioids are relegated to use as a third line agent, after gabapentine/pregabalin and TCAs.
  • Recommended by: Jeremy Fried

Resuscitation, Emergency MedicineR&R Hot Stuff - Everyone’s going to be talking about thisWilcox SR et al. Emergency Medicine Residents’ Knowledge of Mechanical Ventilation. J Emerg Med. 2014. PMID: 25497896

  • The Free Open Access Medical Education (FOAM) world is filled with airway and critical care pearls; yet this survey study and knowledge test demonstrate a discrepancy. Of surveyed emergency medicine residents (n=210), 44.5% never or rarely feel comfortable troubleshooting vents in the ED. The average score on the knowledge tool was 73.3% and 61.5% of participants scored at least 70%. It seems that residents have limited formal training with vents, feel insecure, and may have knowledge gaps surrounding ventilator management as well. Time to bridge the gap.
  • Recommended by: Lauren Westafer

Emergency Medicine, CardiologyR&R Game Changer? Might change your clinical practiceGex G et al. Is atrial fibrillation associated with pulmonary embolism? J Thromb Haemost. 2012 Mar;10(3):347-51. PMID: 22212132

  • Patients with AFib get clots. Patients with AFib get tachycardia. Certainly seems like patients with AFib should be higher risk for PE… but according to this paper based on nearly 2500 patients worked up for PE, there was no association. If anything, if they are dyspneic and in AFib, that may sufficiently account for their symptoms and they shouldn’t get a PE workup (although the numbers aren’t that big). Not surprisingly, I heard of this paper through Jeff Kline (@klinelab).
  • Recommended by: Seth Trueger

Medical EducationR&R Game Changer? Might change your clinical practiceBennett C et al.Bynum WE et al. Shame, guilt, and the medical learner: ignored connections and why we should care. Med Educ. 2014 Nov; 48(11): 1045-54. PMID: 25307632

  • Medical errors are inevitable as is the shame response when these errors occur. That shame can fester and lead to burnout, dropout and overall dissatisfaction with our work. Therefore, it is critical that we both learn to deal with our shame and to teach our trainees to do the same. Discussion of errors in protected settings, effective feedback and behavior modeling are the first steps in improving our abilities to deal with these emotions.
  • Recommended by: Anand Swaminathan

Emergency Medicine, RespiratoryR&R Hot Stuff - Everyone’s going to be talking about thisGoodacre S et al. Intravenous or nebulised magnesium sulphate versus standard therapy for severe acute asthma (3Mg trial): a double-blind, randomised controlled trial. Lancet Respir Med 2013; 1: 293–300. PMID: 24429154

  • This well-done RDCT investigates the role of magnesium in the treatment of asthma. Intravenous magnesium was only slightly better than placebo in this study. Additionally, there appears to be no role for nebulized magnesium therapy. .
  • Recommended by: Soren Rudolph

Wilderness Medicine, ToxicologyR&R Game Changer? Might change your clinical practiceIsbister GK et al. Randomized Controlled Trial of Intravenous Antivenom Versus Placebo for Latrodectism: The Second Redback Antivenom Evaluation (RAVE-II) Study. Ann Emerg Med 2014; 64(6):620-628. PMID: 24999282

  • This is an RDCT looking at the use of Latrodectus (e.g. Black Widow Spider) antivenom versus placebo after treatment. The group found no statistically significant difference in pain improvement or resolution of systemic effects with antivenom. Additionally, antivenom caused hypersensitivity reactions in 3.6% of patients.
  • 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.

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