Research and Reviews in the Fastlane 084

Research and Reviews in the Fastlane

Welcome to the 84th 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

Resuscitation
R&R Hall of Famer - You simply MUST READ this!
Perkins GD et al. Mechanical versus manual chest compression for out-of-hospital cardiac arrest (PARAMEDIC): a pragmatic, cluster randomised controlled trial. Lancet 2015; 385(9972): 947-55. PMID: 25467566

  • In this british trial prehospital use of mechanical chest compression (LUCAS-2 device) vs manual chest compression was studied. The primary outcome was survival to 30 days after the cardiac arrest event. During the study period 4471 patients was assigned to the study group (1652 ptts) or control group (2819 ptts). Only 60% (985) of patients actually received mechanical chest compression in the study group, and <1% (11) of patients in the control group received mechanical compressions.In the intention-to-treat analysis, 30 day survival was similar between the two groups – 6% vs 7%; adjusted odds ratio [OR] 0·86, 95% CI 0·64–1·15).Together with the LINC trial the PARAMEDIC study provides evidence that mechanical chest compressions does not provide improvements in survival after OHCA and widespread routine use is not warranted. Still mechanical chest compression devices may be of benefit in special circumstances as a bridge to more advanced therapies like ECMO supported PCI in selected patients.
  • Recommended by: Søren Rudolph

The Best of the Rest

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

Chan KE et al. Dabigatran and Rivaroxaban Use in Atrial Fibrillation Patients on Hemodialysis.  Circulation 2015. PMID: 25595139

  • The use of novel anticoagulants (NOAC), such as Dabigatran and Rivaroxaban, is contraindicated in patients with reduced renal function. This papers examines the use and outcomes of NOACs in patients on dialysis. Not surprisingly the risk of bleeding, hospitalization and death are very high. The risk of hemorrhagic death is 71-78% higher compared to Warfarin. The bottom line is pretty simple, they are contraindicated and are clearly associated to death. Stop doing it!
  • Recommended by: Daniel Cabrera

Critical Care, Simulation
R&R Hot Stuff - Everyone’s going to be talking about thisHoskote SS et al. Simulation-based Training for Emergency Medicine Residents in Sterile Technique During Central Venous Catheterization: Impact on Performance, Policy, and Outcomes. Acad Emerg Med 20152(1):81-7. PMID: 25556399

  • Reducing catheter related bloodstream infections (CRBIs) is an important initiative. Anecdotally, Emergency Department placed lines are thought to be inherently “dirty” as they are often placed in emergent situations where rapid access is essential. This leads to their removal later in the ICU with replacement under more sterile conditions. This study demonstrated that using a simulation program, EM residents could be brought up to speed on proper sterile technique and that these lessons could be applied clinically. The authors of this study found identical CRBI rates between ED and MICU placed central lines after this educational intervention.
  • Recommended by: Anand Swaminathan

Trauma
Hildebrand DR et al. Modern management of splenic trauma. BMJ. 2014; 348. PMID: 24696170

  • Pediatric patients with abdominal trauma can be a challenge to assess. Naturally, we often are concerned for potential splenic injury. What is the most current approach to managing splenic injury? Find out.
  • Recommended by: Sean Fox

Airway
R&R WTF Weird, transcendent or funtabulous!” width=Chang YH et al. Cyanoacrolate glue ingestion with formation of a laryngeal cast. Resuscitation 2011; 82(5): 507. PMID: 21324579

  • I know we all love airway models but don’t try this at home: very cool yet extremely scary case report of a superglue ingestion causing a nice but occlusive airway cast.
  • Recommended by: Seth Trueger

Toxicology
R&R Mona Lisa -Brilliant writing or explanation” width=Berger FH et al. Body packing: a review of general background, clinical and imaging aspects. Radiol Med 2015; 120(1): 118-32. PMID: 25300715

  • This is a lovely paper with huge numbers of great images on how to image the body packer. (short answer, probably CT without oral contrast, quelle surprise…). There’s also some interesting images of money concealed in remarkable orifices…
  • Recommended by: Andy Neill
  • Read More: Best Paper Yet on Screening Suspected Body Packers (The Poison Review)

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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JellyBean 022 with MedSTAR

Ben and Dave at “AeroMed” in Melbourne
Critical Care Medicine is not just about hospitals and doctors. It’s about the entire team. It’s also about the people who are at the heart of the process before you get to hospital. The nurses and paramedics that I have worked with are some of the most amazing people who I have ever met.
Ben and Dave are two such people; a nurse and a paramedic that are pushing the boundaries of what we can expect from these professions.
They were both speaking at AeroMed, the combined ASA/FNA (Aeromedical Society of Australia and Flight Nurses Australia) Conference a while back in Melbourne. Check it out this year in Darwin…These guys are both working for MedSTAR doing new stuff; Nurse/Paramedic led U/S in pre-hospital medicine and Nurse Only Intra Aortic Balloon Pump transfers. That is not the norm in Australia.

It’s nice to hear about the positive experience these guys are having with the multi-disciplinary approach at the South Australian system. A lesson for us all.

Then they published on it and presented it at a major conference. Of course they did.

JellyBean MEDSTAR
JellyBean Large

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LITFL Review 182

LITFL review

Welcome to the 182nd 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

resizer Essentials of Emergency Medicine is offering a US resident scholarship in partnership with ALiEM and EMCrit for the October Essentials course in Las Vegas. Check it out and apply now! [AS]

 

The Best of #FOAMed Emergency Medicine

  • Great pearl from the University of Maryland on the significance of discordant U waves in relation to cardiac ischemia. [AS]
  • Rich Carden reminds us of an often-neglected area of EM with this great blog on St Emlyns; Are we doing all we can for Mental Health? [SL]
  • Are hyperacute T-waves diagnostic of infarction in the setting of a paced rhythm? Find out at Dr Smith’s ECG Blog. [MG]
  • The May edition of the Annals of Emergency Medicine audio summary is now available! [MG]

The Best of #FOAMcc Critical Care

The Best of #FOAMtox Toxicology

  • The Maryland Critical Care Project has a great talk on toxic haemoglobinopathies, specifically carbon monoxide and methaemoglobinaemia. [SO]

The Best of #FOAMus Ultrasound

  • Excellent vodcast from Matt, Mike and Mike on POCUS for DVT diagnosis with step by step demonstration (feat. Jacob Avila). [AS]
  • Even inexperienced trainees can rapidly learn to assess patients for the presence of B-lines on POCUS according the this weeks SGEM podcast. [AS]

The Best of #FOAMim Internal Medicine

  • The Centre of Evidence-based medicine has put up a wonderful set of video lectures debating the value of evidence-based medicine. All come from the recent “Evidence Live” event, and are definitely worth a listen. [SO]
  • Everything you ever wanted to know about urinary tract infections,  this week’s Louisville Lecture. [ML]

The Best of Medical Education and Social Media

  • The EM Mindset series from EMDocs.net continues with Andy Sloas discussing the role of the Emergentologist. [AS]
  • Excellent basic overview from BoringEM of a critical statistical concept in decision making: the Likelihood Ratio. [AS]
  • Talking about the elephant in the room, Howard Ovens discusses the ‘Free’ in FOAMed and investigates the idea of funding FOAMed to achieve sustainability. [SL]

News from the Fast Lane

Reference Sources and Reading List

Brought to you by:

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Research and Reviews in the Fastlane 083

Research and Reviews in the Fastlane

 

Welcome to the 83rd 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

Resuscitation, Paediatrics, Critical Care
R&R Hall of Famer - You simply MUST READ this!
Moler FW et al THAPCA Trial Investigators. Therapeutic Hypothermia after Out-of-Hospital Cardiac Arrest in Children. NEJM 2015. PMID: 25913022

  • More evidence to support not cooling patients. This trial involving 295 comatose children who survived after an Out of Hospital Cardiac Arrest showed that therapeutic hypothermia as compared to therapeutic normothermia did not confer a survival benefit with a good functional outcome at  1 year. Rates of infections and arrhythmias were similar between groups. Questions remain about the role of targeted temperature management in children.
  • Recommended by: Nudrat Rashid

The Best of the Rest

Trauma R&R Boffintastic - High quality research

Duch P1, Møller MH. Epidural analgesia in patients with traumatic rib fractures: a systematic review of randomised controlled trials. Acta Anaesthesiol Scand 2015. PMID: 25683770

  • Pain following traumatic rib fractures is often managed by continuous epidural analgesia (CEA). In this systematic review of randomised controlled trials the benefit and harm of CEA is compared with other analgesic interventions in patients with traumatic rib fractures.
    In 223 trials all with high risk of bias the authors found quality and quantity of evidence in support of CEA to be low, and there is no firm evidence for benefit or harm of CEA compared with other analgesic interventions.
  • Recommended by: Søren Rudolph

Emergency Medicine

Vali Y et al. Investigating and managing suspected pulmonary embolism in an outpatient setting: the Leicester experience. Thorax 2015; 70(3): 291-3. PMID: 24764115

  • A hospital in Leicester, UK set up an ambulatory management program for patients with low risk PE (HR <110 bpm, SBP >100 mm Hg, O2 sat >92% on RA, RR <30 bpm, no syncope, normal troponin, and no large central clot or right heart strain on CTPA) and looked at their results over two years.They discharged 70/96 (73%!!) of PE patients. They report that no discharged patients died from causes related to PE or the treatment of PE.Of course this is just one hospital with a relatively small sample size. But the study does suggest that with appropriate selection criteria and the right outpatient resources, ambulatory management of PE is a feasible and practical route.
  • Recommended by: Zack Repanshek

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

Debaty G et al. Impact of intra-arrest therapeutic hypothermia in outcomes of prehospital cardiac arrest: a randomized controlled trial. Inten Care Med 2014. PMID: 25348858

  • How early after ROSC should cooling start? Upon reaching the hospital or prehospital? How about before ROSC? This study looks at intra-arrest cooling in the prehospital setting. No benefit was found for either the surrogate markers or the most important patient centered outcome of survival. Interestingly, the median temperature upon hospital presentationin the group that did not get intra-arrest cooling was 35 degrees (below the 36 degrees recommended in the TTM trial conclusions). Intra-arrest cooling may simply be a lot of money and effort spent without noticeable differences in outcomes.
  • Recommended by: Anand Swaminathan
  • Read More: JC: Getting Chilly Quickly 3. Hypothermia at St.Emlyn’s (St Emlyn’s)

Critical CareR&R Eureka - Revolutionary idea or concept

Walkey AJ. Long-term Outcomes Following Development of New-Onset Atrial Fibrillation During Sepsis. Chest 2014; 146(5):1187-95. PMID: 24723004

  • This is an interesting observational study using secondary data analysis, in this case claims data. The aim was to study incidence and outcomes of new onset Afib during sepsis. It happens to be common (7%) with recurrence being very common (55%). Patient with new-onset Afib during sepsis have a higher risk of death, heart failure and stroke compared with patients without it.
  • Recommended by: Daniel Cabrera

Wilderness Medicine

Brown DJ. Accidental hypothermia. NEJM 2012; 367(20): 1930-8. PMID: 23150960

  • This article provides a wonderful summary of the current recommendations of how to best care for the cold patient, and also provides some amazing information on some extreme cases. For example, the longest reported duration of CPR with full neurological recovery after extracorporeal rewarming is 190 minutes! Additionally, the importance of ECMO or bypass is stressed as an important aspect of care for the severely hypothermic patient as survival rates with full neurological recovery can be altered from less than 37% to as high as 63%. Other useful numbers are also provided, such as consideration of cessation of CPR for patient with Potassium levels greater than 12 mmol/L.
  • 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 083 appeared first on LITFL.

JellyBean 021 with Michael Parr

Michael Parr has had the kind of career that most of us can only dream of.
Co-Editor of Resuscitation. Australian Rep on ILCOR. Director of ICU in one of the biggest hospitals in Sydney.
It’s a great story starting in Liverpool, via Yorkshire, London, Baltimore and ending in, well, Liverpool.
I wouldn’t even dream of looking back on something similar at the end of my career. And he is far from done yet.
He has a very interesting story and he credits his mentor, Peter Baskett, for so much of it. I think there’s at least a little credit due to Michael himself but he is rather humble about it.
(Lucky he wasn’t mentored by Peter Safar whose name I got wrong early in the chat; but whoever Peter Sagar is, I’m sure he is a good mentor too.)
Michael is a big man, I didn’t want to make him angry. He is a big character too and he is married to an even bigger character, Dr Cynthia Parr the Palliative Care Specialist. This fortunately means that he returned to Liverpool, Australia after a second stint in Bristol.
This conversation was recorded before the most recent ILCOR update and I had asked Prof Parr if he would give us a sneak preview. Interestingly we focused on therapeutic hypothermia and the TTM trial was not yet out.
Of course despite our interest in resuscitation we cannot really hold our own in the company of Renowned Urologist Dr V. Jones

//www.youtube.com/watch?v=ILxjxfB4zNk

JellyBean Large

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Stu Marshall on Airway Strategies

Stuart Marshall is an anaesthetist with a PhD in Human Factors and is the Clinical Director of Simulation Education at The Alfred (based at the Australian Centre for Health Innovation). In this FOAM video, created for the Critically Ill Airway (CIA) course, Stu provides an interactive guide to how an airway expert develops a strategies for airway management.

CIA airway strategy from Stu Marshall on Vimeo.

Feel free to discuss your plans for the scenarios presented in the video. Depending on your context, your plans may be quite different to those described…

The next CIA course is December 8th and 9th 2015, registrations are now open.CIA Alfred Monash logo

 

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