Research and Reviews in the Fastlane 139

Research and Reviews in the Fastlane

Welcome to the 139th 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, Justin Morgenstern, 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
R&R Hall of Famer - You simply MUST READ this!
Arima H et al. Optimal achieved blood pressure in acute intracerebral hemorrhage: INTERACT2. Neurology 2014. PMID 25552575

  • This paper is creating noise since the mid of the year as it is pretending to change the current recommendations for the management of blood pressure in acute intracerebral hemorrhage (ICH). The original INTERACT2 study (N Engl J Med 2013; 368:2355-2365) did not show differences in mortality but improved functionality in patients with ICH when the BP goal was <140mmHG instead of the current 180mmHg.This study is a reanalysis of the data, attempting to identify the threshold where the benefit in functionality is produced, using ranges of <160, 160–169, 170–179, 180–189, and ≥190 mm Hg. The outcome was Rankin Scale at 90 days. Although the ranges proposed by the authors only include a <160 as the lowest, the linear analysis of SBP and Rankin Score shows a direct correlation going as low as 130-139mmHg, therefore the authors conclude that 130-139mmHg for SBP is the optimal range for management of patients with ICH.
  • The study is a post-hoc analysis of a previous large study (open and unblinded) making no claims about mortality but showing a consistent effect of better functional outcomes if the pressure is managed closer to SBP of 130-139mmHg.
  • Recommended by Daniel Cabrera

The Best of the Rest

R&R Mona Lisa -Brilliant writing or explanation” width=
Green SM et al. Sick Kids Look Sick. Ann Emerg Med 2014. PMID 25536869

  • Nice editorial on missing the sick child. – take home message: sick kids look sick and the authors reassures us that careful examination and trust in ones clinical judgment is still the best approach.
  • Recommended by Soren Rudolph

Surgery, Critical Care, respiratory
R&R Hot Stuff - Everyone’s going to be talking about this
Tyson AF et al. The Effect of Incentive Spirometry on Postoperative Pulmonary Function Following Laparotomy: A Randomized Clinical Trial. JAMA Surg 2015. PMID 25607594

  • A single centre randomised clinical trial from Malawi with 150 patients randomised in total. As suspected incentive spirometry for unmonitored patient use does not result in statistically significant improvement in pulmonary dynamics following laparotomy. Interestingly most of the patients were male and most of the procedure were emergency laparotomies.
  • Recommended by Nudrat Rashid

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

Alrajhi KN et al. Intracranial bleeds after minor and minimal head injury in patients on warfarin. J Emerg Med 2015. PMID 25440860

  • It’s well known that patients on warfarin have a high rate of intracranial hemorrhage after minor head trauma. This study found that 4.8% of those with minimal head trauma (GCS 15, no loss of consciousness, amnesia or confusion) had ICH as well. The study has limitations but suggests that all head trauma patients on warfarin should have a NCHCT regardless of severity of injury
  • Recommended by Anand Swaminathan

R&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 2015. PMID 25255427

  • This is another bullet in favor of etomidate for RSI. The authors of the paper did an extensive review and meta-analysis, pooling a total of 5552. Data shows that single use of etomidate for RRT does not increase mortality, despite increase in the incidence of adrenal insufficiency. Etomidate still appears to be a viable option for the RSI of critically ill patients.
  • Recommended by Daniel Cabrera

Ultrasound and imaging
R&R Hot Stuff - Everyone’s going to be talking about this
Russell FM et al. Diagnosing Acute Heart Failure in Patients With Undifferentiated Dyspnea: A Lung and Cardiac Ultrasound (LuCUS) Protocol. Acad Emerg Med 2015. PMID 25641227

  • POC Ultrasound has receive a lot of attention for it’s ability to improve diagnostic accuracy in patients with undifferentiated dyspnea. The LuCUS protocol looks at a combined lung and cardiac ultrasound approach to aid in rapidly diagnosing patients. This study showed that the LuCUS protocol had a (+) LR of 4.8 and a (-) LR of 0.20 for this objective. However, the study results will be difficult to apply. All examinations were performed by highly skilled US physicians with no other clinical duties at the time. The protocol includes non-standard imaging (assessment for pleural effusion, measuring diastolic function) that most providers have never performed. Additionally, the study did not set out to, and thus does not, show improved patient outcomes as a result of the LuCUS protocol.
  • 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.

Last update: Jun 23, 2016 @ 9:35 am

The post Research and Reviews in the Fastlane 139 appeared first on LITFL: Life in the Fast Lane Medical Blog.

JellyBean 038 with Shaun Walsh

So as we recover from SMACC in Dublin, which was a Wham Bam Shiny Mega Event with helicopters and REBOA and some other things that I will probably never do, I wanted to introduce you to someone thats doing something else that none of us will probably ever do.

Ever been to Elephant Island?
No? Ok.
Ever been to a Dentists?
How do we all feel about dentists?
Ever had a “moment” with a Plastic Surgeon?
How do we all feel about the Plastic Surgeons?
Okay I know how I feel about armies, you make up your own mind on that one.
Private sector medicine……?

Okay. So heres this chap that has done a whole bunch of stuff that either scares me or gives me the heebie jeebies. Yet I am extremely envious of his work/life balance and so many things he has managed to do.

This is a jellybean about another path.
A path through medicine that doesn’t get a lot of press.
A path that some people look down on.

Shaun is a “CMO” in a very big ICU in Sydney.
And he is a very happy man. (Despite working with @RogerRdharris.)
He stood out among a bunch of high achievers at the Bedside Critical Care Conference as possibly the most contented chap in the room and probably the one that has reached greater heights. (Physical ones.)

I hope Jellybeans shine a little light on the humans within Critical Care Medicine. It is a broad church. It includes @EMCrit and it includes Shaun Walsh. Both doing interesting stuff and doing it well.


JellyBean Large

Last update: Jun 23, 2016 @ 7:38 am

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LITFL Review 236

LITFL review

Welcome to the 236th 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


So for those of you that weren’t able to make it, or for the others that want to relive the greatness of SMACCDUB, the following FOAMed sites have published some fantastic podcasts summarising and discussing all that went on; ACPEducate, FOAMcast, St Emlyns,& PHEMCAST. [SL]

If you prefer your reflections in written form, Don’t Forget the Bubbles, Crit-iq, and the Resus Room have got you covered. [SO]

The Best of #FOAMcc Critical Care

  • Thanks to two recent RCTs, ELAIN and AKIKI, debate around the best timing to dialyse in acute kidney injury continues. The Bottom Line review ELAIN and discuss both trials in an editorial. [SO]
  • Rory Spiegel weighs in on both ELAIN and AKIKI in his excellent CCNerd blog post. [SO]

The Best of #FOAMus Ultrasound

  • Here’s an absolutely fantastic case of multi-organ ultrasound from Phillipe Rola. [SO]

The Best of Medical Education and Social Media

News from the Fast Lane

Reference Sources and Reading List

Brought to you by:

Last update: Jun 20, 2016 @ 5:51 am

The post LITFL Review 236 appeared first on LITFL: Life in the Fast Lane Medical Blog.

Funtabulously Frivolous Friday Five 150

Just when you thought your brain could unwind on a Friday, you realise that it would rather be challenged with some good old fashioned medical trivia FFFF…introducing Funtabulously Frivolous Friday Five 150

Question 1

The incredibly rare condition “immigration delay disease” tends only to live up to it’s name if you are travelling to the USA. What does this congential condition cause?

  • Adermatoglyphia – or an absence of fingerprints.
  • This is a problem as fingerprinting is an integral part of the entry process into the USA. Although thought to be autosomal dominant, the condition is very rare.. [Reference]

Question 2

The wording of this BMJ(1961) advert is particularly tragic. Distival is a brand name for which medication?

Question 3

Your gran phones you, horrified that the newest medication she has been prescribed is also used as “possum poison”. With a medical history of hypertension, dermatitis, osteoporosis, and Parkinson’s disease, which medication is she likely to be talking about?

    • Cholecalciferol
    • Used as a possum poison to cause lethal hypercalcaemia. [Reference]

Question 4

What is Bozzolo’s sign?

  • Pulsating vessels in the nasal mucous membrane.
  • Noted occasionally in an aneurysm of the thoracic aorta. [Reference]

Question 5

What does the patient with Fregoli delusion believe?

  • It is a rare disorder in which a person holds a delusional belief that different people are in fact a single person who changes appearance or is in disguise.
  • It is associated with L-dopa therapy and traumatic brain injury [Reference]


…and from the Banff Mountain Film Festival we bring you nature-rx, as recommended by your doctor.


Last update: Jun 17, 2016 @ 6:38 pm

The post Funtabulously Frivolous Friday Five 150 appeared first on LITFL: Life in the Fast Lane Medical Blog.

JellyBean 037 with Jaine Morris

There’s Remote and then there’s Really Remote.
When it’s Really Remote there are usually no doctors and if you are lucky there is a nurse like Jaine Morris.
She was working in Lockhart River and Lockhart River is pretty close to the end of the line.
It’s the last community on the east coast of Australia on the way to PNG.
Get your Google Maps Going!
This place is amazing. Iron Range National Park, Quintell beach, crocodiles, Portland Roads and Chilli Beach. This is the sort of area that holds pride of place on an outback adventurers “Bucket List”.
It is hard for me to articulate just how much respect I have for nurses that do that sort of thing. It is a level of immersion unlike any I have personally known.
So how do you deal with that?
We dive into how Jaine does it. (Which does NOT include diving into the water very often.) She is at the pointy end of an amazing system. She takes the calls, drives the ambulance, does the xrays, draws the bloods, sets the fractures, sews up the holes, washes out the wounds, blocks the nerves…. I could go on.
I love Lockhart River. It’s a community that is rising from a horrible history of some of the ugliest white interventions in black Australia. (J’accuse Joh Bjelke–Peterson! And the High Court of Australia agrees)
But Lockhart River is rising and fast. Despite being one of the most disadvantaged communities on the continent the stories that come from these days are about art and triumph and less about problems or violence.
There is much to do and fortunately some good people are doing it.
Quintell Beach

JellyBean Large

Last update: Jun 14, 2016 @ 9:31 pm

The post JellyBean 037 with Jaine Morris appeared first on LITFL: Life in the Fast Lane Medical Blog.