Research and Reviews in the Fastlane 061

Research and Reviews in the Fastlane

Welcome to the 61st 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 Medicine, Trauma, ResuscitationR&R Hall of Famer - You simply MUST READ this!
Slessor D, et al. To be blunt: Are we wasting our time? Emergency department thoracotomy following blunt trauma: A systematic review and meta-analysis. Ann Emerg Med 2014. PMID: 25443990

  • Should we be performing ED thoracotomies in patients with blunt traumatic arrest? This systematic review and meta-analysis looked at 27 studies and concluded that while good outcomes were rare (1.5%), the patients that had good outcomes all had vitals on admission and received ED thoracotomy within 15 minutes of cardiac arrest. The primary literature is limited but their proposed algorithm on which patients to consider thoracotomy aids in providing guidance to care.
  • Recommended by: Sa’ad Lahri, Anand Swaminathan, Jeremy Fried

The Best of the Rest

Airway
Hamaekers AE, et al. Equipment and strategies for emergency tracheal access in the adult patient. Anaesthesia. 2011 Dec;66 Suppl 2:65-80. PMID: 22074081

  • How to access the cricothyroid membrane….or not! – a great review of the literature for different ways of gaining emergency airway access via the cricothyroid membrane. Importantly, the authors remind us that “Avoiding delay in initiating rescue techniques is at least as important as choice of device in determining outcome.”
  • Recommended by: Søren Rudolph

Emergency Medicine, CardiologyR&R Game Changer? Might change your clinical practice
Collins SP et al. Early Management of Patients With Acute Heart Failure: State of the Art and Future Directions A Consensus Document from the SAEM/HFSA Acute Heart Failure Working Group. Acad Emerg Med. 2014. PMID: 25423908.

  • This consensus statement provides a great summary of what we know, and more importantly, don’t know about the acute heart failure patient in the ED. The importance of future research on the ED population for treatment and disposition issues is stressed. What do we know? POCUS has the best diagnostic criteria for the acute presentation with LR– of 0.01–0.14 and LR+ of 17.2–49.5, significantly outperforming other diagnostic testing. If you’re not using ultrasound at the bedside for the dyspneic already, time to pick up the probe. The authors also present a common sense treatment modality for acute patients based on their blood pressure. Although limited by lack of data in this area, it makes sense and is based on best available evidence.
  • Recommended by: Jeremy Fried

Emergency Medicine, ImmunologyR&R Hot Stuff - Everyone’s going to be talking about this
Campbell RL et al. Emergency department diagnosis and treatment of anaphylaxis: a practice parameter.  Annals of Allergy, Asthma & Immunology 2014; 113(6):  599 – 608. PMID 25466802

  • This paper is a practice parameter statement from The American Academy of Allergy, Asthma and Immunology (AAAAI) and the American College of Allergy, Asthma and Immunology (ACAAI). However, the first and senior authors are Emergency Physicians.
    The recommendations are mostly to be aggressive about diagnosis and monitoring: immediate IM Epi and if refractory, proceed with Epi drip, if access issues jump into IO, low threshold for airway management, aggressive volume administration, consider glucagon if refractory, consider B-agonist for bronchospasm, consider ECMO if failure to respond to medical therapy, observe for at least 4h or longer if high risk, plus some outpatient treatment guidelines. Bottom line is very aggressive management is recommended.
  • Recommended by: Daniel Cabrera

Critical Care
McDermid RC et al. Controversies in fluid therapy: Type, dose and toxicity. World J Crit Care Med. 2014;3(1):24-33. PMID: 24834399

  • An overview and review of the evidence underpinning key controversies in fluid management of the critically ill. Ultimately it supports the current (not completely unproven) balanced salt solution (anti-colloid, anti-chloride) zeitgeist. The paper includes useful expositions of the 3 phases of fluid management (resuscitation, maintenance/ homeostasis and ‘de-resuscitation’) as well as quantitative (volume effects) and qualitative (type of fluid) toxicities. Fluids are a ubiquitous in critical care and they are drugs – we should treat them as such and continue the search for answers.
  • Recommended by:  Chris Nickson

Emergency Medicine, CardiologyR&R Hot Stuff - Everyone’s going to be talking about thisR&R Game Changer? Might change your clinical practice
Mahler SA et al. Can the HEART Score Safely Reduce Stress Testing and Cardiac Imaging in Patients at Low Risk for Major Adverse Cardiac Events? Crit Pathw Cardiol 2011; 10(3):128-33 PMID: 21989033

  • This was a cohort study of patients presenting with chest pain who had the HEART score applied. The authors found that in patients with a HEART score < 3 only 5/1070 of had a MACE at 30 days. Application of the rule would have reduced cardiac testing by 84.5% in low risk patients. Excluding patients with any positive troponin (you can have a positive troponin and a HEART score < 3) raises sensitivity to 100% and would still save 82% of cardiac testing. The HEART score was derived and validated in the ED and appears ready for prime time.
  • 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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LITFL Review 159

LITFL review

Welcome to the 159th 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

resizerThis Will Revolutionize Education is a much-watch video for all educators at any level, on the role of innovation and the role of the teacher. [AS]

The Best of #FOAMed Emergency Medicine

  • Amal Mattu reviews a case of a 17-year-old with a wide irregular rhythm and discusses the proper management, as well as changes to the ACC/AHA guidelines, for the treatment of atrial fibrillation. [AS}
  • Should every patient who presents to the ED with chest pain get an US? Steve Smith argues that the answer may be yes. [AS]
  • Mucormycosis is rare but deadly; the perfect storm of Emergency Medicine diseases. Andy Neill reviews the basics of the disease and some features that can help with diagnosis. [AS]
  • Here’s a great review of Ludwig’s angina from the Mayo Clinic’s EMBlog. [SO]

The Best of #FOAMcc Critical Care

The Best of #FOAMus Ultrasound

#The Best of #FOAMtox Toxicology

News from the Fast Lane

Reference Sources and Reading List

Brought to you by:

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This Will Revolutionise Education

In this short Veratisium video it is argued that no technology is superior to another for education. Despite repeated claims, no technology has revolutionised education.

Is this because what limits education is what happens in the learner’s mind?

Gradually we are finding out more about how to make technology-assisted learning work more effectively (such as avoiding the split attention effect and other principles of multimedia learning). Yet some things ring true – the effective teacher, as always, is not the font of all knowledge, but the facilitator of experiences that lead to individual discovery, usually within a social context. Which begs the question, where does social media and FOAM fit into this?

Hat tip to Jason Frank (@drjfrank)

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The Devil is in the Details

This is the first in a series of posts I intend to write about some of the nuances of clinical research and statistical techniques. The introduction is long winded, but I think it’s useful to try and explain why I think this is so important.

Our current approach to clinical research has fundamental flaws

In 2014 clinical research forms the backbone of our medical practice. Unfortunately there is an increasing feeling that our systems of research have not been serving us as well as we think. Amongst the many excellent talks that came out of smaccGOLD in 2014 were a number of speakers highlighting the limitations and conflicts of interest that are a widespread problem in the conduct and publication of clinical trials.

Journals are often motivated to publish for reasons other than the quality of the paper, the influence of industry is often perverse and not obviously apparent, and the safeguards meant to prevent fraudulent publication have proven to be fallible. This has lead to important journals publishing inaccurate and even fabricated data, potentially causing irreconcilable harm to patients.

One of the potential solutions is open access publication. All trials conducted should be published and made available for free, including the publication of trial data. This is the motivation behind Rob McSweeney’s exciting new online journal Critical Care Horizons.

There are an increasing number of open access journals in many fields that appear to follow this principal. It is important to understand the financial motivation behind many of these journals. Unlike Critical Care Horizons they often charge authors for publication. Authors maybe motivated by the ease of publication and the journal is publishing simply because the fee has been paid. This means the quality is often not of the same standard as established journals.

The main concern about open access publication is the removal of the peer review process. Whilst in many ways peer review is a flawed technique, it is the accepted method for ensuring only research of sufficient quality makes it to clinicians for wide spread appraisal and potentially to change practice.

Critics would argue that peer review has failed on a number of occasions and a more transparent process is required. Currently no one is offering an ideal solution.

Both sides of this argument are best summarised by Professor Simon Finfer’s fantastic talk on The Dark Side of Research given to the Sydney Intensive Care Network earlier this year.

What can we do as medical professionals?

What ever the source and format of clinical research, the only way we can prevent ourselves from being mislead or lied to is by being savvy consumers. This means we require an understanding of increasingly complex methodological and statistical techniques. To date our medical education and training has not provided a good foundation for acquiring these skills.

Public health, statistics and epidemiologically classes are, in my opinion, amongst the most tedious and often poorly attended at university (at least when I was a student.)

Critical care colleges test a basic understanding of statistical techniques in primary or fellowship exams, but knowing the difference between sensitivity and specificity is no longer sufficient in a world were regression models are king.

All the colleges require conduct of a research project or similar. Unfortunately the format for these projects often renders them little more than a barrier to completing training without ensuring they provide the skills to assess and interpret publications to guide practice. The recent move towards accepting approved courses from recognized universities are hopefully a step in the right direction.

What does FOAM have to offer?

FOAM has filled the gap in medical education when more established formats have failed to move quickly enough to assimilate new ideas into current practice. In terms of clinical research, many blogs function as online journal clubs publishing breakdown and interpretations of major trials. Several websites, such as StEmlyns,  have talked about different statistical techniques, although this is not an easy subject to write about. It is extremely dry and the benefits of a more detailed understanding are not always apparent.

Whilst I am by no means an expert in clinical research, I have a particular interest in trials and their design. My aim is to write a series of posts about some of the finer details of research and statistical techniques. The hope is that this will make it easier to understand the language and techniques used in publications. My general approach will be to concentrate on key practical points, keep posts short(ish) and where possible use well known trials to highlight these ideas.

With that in mind I wanted to make my first post about CONSORT (Consolidated Standards of Reporting Trials).

CONSORT Statement and the CONSORT Flow Diagram

CONSORT is a group of researchers that published a 25 point check-list in 2010. This highlighted the key points that should be included in the write up of a clinical trial. They are an excellent framework for structuring and writing a paper and I would encourage anyone in the process of conducting clinical research to use them.

Occasionally they are presented as a way to critique published papers. This is generally a flawed idea as you end up assessing the write up rather than the experiment.

The same group also produced a similar statement for systematic reviews called PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). Both checklists detail what should be in a write up and where it is appropriately located.

Part of this checklist is a flow diagram. The CONSORT Flow Diagram is a simple box diagram that details the passage of participants (or papers in the case of PRISMA) through the trial from initial screening, all the way to follow up. Every published article should produce one of these flow diagrams; they will likely be located somewhere within the published material and are a useful source of information when assessing a paper.

This diagram details patient numbers at each stage of the process, allowing assessment of components of the conduct of the trial such as those receiving intended allocation, those lost to follow up and the numbers included in the final analysis. In it’s best form the flow diagram will include an explanation as to why patient numbers changed at each stage such as reasons for patient exclusion after screening.

One of the main benefits is that it allows readers to assess external validity in more detail. One of the fundamental aspects of external validity is the inclusion/exclusion criteria. The problem is that it can often be hard to understand the effect that they have on the size and make up of the final trial population, and how relevant the trial patients are to the broader population. An excellent example of the benefits of the flow diagram can be found in the DECRA study.

DECRA (Decompressive Craniectomy in Diffuse Traumatic Brain Injury)

DECRA was published in NEJM in 2011 and is an exceptional study. The fact that they were able to conduct an RCT on such an invasive procedure is impressive enough, but it was also well conducted with robust methodology.

In the DECRA trial researchers assessed the difference between a conservative approach to craniotomy with a very aggressive one in the management of elevated ICP (>20mmHg sustained for more than 15 minutes) in the first 72 hours following closed traumatic brain injury.

The primary outcome measure was revised to disability level at 6 months as defined by the Extended Glasgow Outcome Score. Their findings were in favour of a conservative approach. 70% in the surgical group had unfavourable outcomes compared with 51% in the conservative group. This has lead to many clinicians being more cautious with the use of this surgical procedure than they would have been before its publication.

There are several remaining controversies with DECRA regarding surgical technique, timing of intervention, trigger of ICP and how these findings should be extrapolated into clinical practice.

One of the concerns was how applicable the results are to all patients with significant brain injury. This is a test of the external validity. Inclusion and exclusion criteria were as follows.

Inclusion Criteria:

  • Age 15-59y
  • Suffering severe, non penetrating traumatic brain injury defined as GCS 3-8 or Marshall class III on CT

Exclusion Criteria:

  • Not suitable for full active treatment
  • Had dilated, un-reactive pupils
  • Mass lesions (unless too small to require surgery)
  • Spinal cord injury
  • Cardiac arrest at the scene

The write up states that of the 3478 patients assessed (likely to meet inclusion criteria) only 155 patients were enrolled in the study. This already suggests findings are only directly applicable too a small percentage of severe head injuries. However this doesn’t give much of an idea as to why patients were excluded, e.g. refused consent, age, spinal injury etc.

In the supplement, made freely available online, the authors included a CONSORT Flow Diagram.

This provides a lot of information about the patients screened and those included in the study, in a simple format.

The first point to note is that only 21 patients’ families declined consent. For such an invasive procedure, in such sick patients, this is a staggering achievement. I would love to know what information was provided to families as getting patients to consent to comparatively simple treatments for a study can often be challenging.

The second point is that the majority of patients were either excluded on the basis of mass lesions (sub or extradural haematoma) or their ICP was controlled with medical therapy alone. This means that the findings are harder to extrapolate to patients who have a craniectomy for removal of a mass lesion or patients that have sustained elevated ICPs after the first 72 hour period (although this isn’t particularly common). It does not mean that the study findings are irrelevant to these patients, just that we have to think more carefully about how they should be applied.

It is also worth noting that the trial team did an excellent job of maintaining study protocol with only 7 of the 155 patients receiving the incorrect treatment, in very difficult circumstances. All patients enrolled in the study completed it with no losses to follow up.

Summary

DECRA demonstrated that not every patient with a raised ICP benefits from this form of craniectomy, and those that receive it require ongoing medical management. The effects of DECRA have been a more holistic approach to the management of ICP in the severely brain injured patient. Rather than simply lifting the lid, we now concentrate on optimal medical therapy and a more detailed consideration as to why the patient may have an elevated ICP. This can only be of benefit to our patients.

The CONSORT diagram demonstrates which patients we should be more cautious about blindly applying the findings of DECRA to. Hopefully RESCUE ICP will answer some of the remaining questions more clearly when it finally meets its recruitment targets.

CONSORT diagrams are increasingly included as part of the main publication but they are often found in the supplemental material. I would encourage people to look for them in any publication of significance as they highlight a lot of information in a very accessible format.

The CONSORT and PRISMA checklists are an excellent resource and freely available online.

References

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TechTool Thursday 060 Piktochart

TechTool review Piktochart Infographic Website

Piktochart is a website that makes it easy for you to build your own infographics. These can be used for presentations, posters, and in fact for anything you might want to share with others. It has great potential for improving the visual appeal of medical education both online and in hospitals

Website: – Website – Twitter

How does it work?

When starting a new project, choose whether you want to design a banner, report, infographic, or presentation. You are then offered templates to choose from which will be the basis of your project. The site has almost 600 templates so it’s not hard to find something that you like.
Then adapt the template to your needs. There are loads of icons, shapes, and designs to use. Everything can be customised, colours changed to match your theme, and fonts adjusted

Is it fiddly to use?

It does take a while to get the hang of, but once you’ve produced your first poster it becomes second nature. There is a good tutorial and help section in case you run into difficulties.

User Interface

Piktochart 1

Piktochart 2

How much does it cost?

There is a free account option, which allows you to use the full features of Piktochart but with only limited templates. The free account will also mean that there is a Piktochart logo at the bottom of all your creations.
The full version costs $29 per month or $290 per year. They have a special discount for educators (using your university email) and students at $39.99 per year, which is a great deal. I used the free version for a while, but found I was using it lots, so have signed up for the full version now.

Is it useful?

So far, I’ve managed to use it quite broadly.
I’ve produced a poster for the hospital about managing febrile neutropenia; a teaching presentation about a QI project progress; an explainer infographic about a teaching course in development; and a redesign of the old-fashioned junior doctor newsletter sent out by our hospital

How could it be improved?

Once you delete a section from your template, you can’t access these deleted template features/graphics later. It would be nice to have each template asset in an accessible place so they can be pulled into your customised version.
Also, the website can sometimes be a bit slow, which gets a touch frustrating

What’s the overall verdict?

Medical education within institutions can often be dry – with the same old posters on the wall, and the same teaching slides that have been used for the last 20 years. Piktochart offers an easy way for people to produce visually appealing content without having to employ a graphic designer, or work out how to use Adobe Illustrator.

Plus there’s a free option, so have a play and see for yourself…

//www.youtube.com/watch?v=SzI9RzvnwZA

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Research and Reviews in the Fastlane 060

Research and Reviews in the Fastlane

Welcome to the 60th 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 8 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!
January CT et al. 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: Executive Summary. Circulation 2014. PMID 24682348

  • This document is the updated ACC/AHA recommendations for the management of atrial fibrillation. There are a number of pearls in here but one of the big game changers is that amiodarone is now listed as a harmful medication in the treatment of patients with WPW who present in atrial fibrillation. This recommendation limits options and as a result, pushes electrical cardioversion higher up in the algorithm.
  • Recommended by: Anand Swaminathan
  • Read More: 17 yo man with palpitations. What drugs are deadly? (Amal Mattu)

The Best of the Rest

ResuscitationR&R Hot Stuff - Everyone’s going to be talking about this
Sutton RM, et al. Patient-Centric Blood Pressure Targeted CPR Improves Survival from Cardiac Arrest. Am J Respir Crit Care Med. 2014. PMID: 25321490

  • An animal/basic science paper but important because it shows the benefits of goal-oriented resuscitation.
    Swines underwent VF arrest and later were resuscitated using the standard ACLS guidelines versus a goal oriented approach aiming to SBP of 100 mmHg and coronary perfusion pressure of 20 mmHg. The goal-oriented group had a survival of 80% at 24h, while the standard-group 0%. This paper supports the need for further investigation into a resuscitation protocol oriented to hemodynamic goals.
  • Recommended by: Daniel Cabrera

PrehospitalR&R Hot Stuff - Everyone’s going to be talking about this
Scheppke, et al. Prehospital Use of IM Ketamine for Sedation of Violent and Agitated Patients. West J Emerg Med 2014; 15(7). Retrieved from: https://escholarship.org/uc/item/64p9m3xt (OPEN ACCESS ARTICLE)

  • Not for routine agitation but for the uncontrollably violent patient, especially one that may have a dangerous medical condition, effecting immediate control is both a patient and staff safety mandate. This prehospital case series describes how ketamine is uniquely suited to this purpose and reports on 52 patients who received between 200 and 400 mg IM ketamine. 50/52 were quickly sedated in about two minutes. 3/52 developed respiratory depression, 1 managed with bag mask ventilation and 2 managed with endotracheal intubation. This series supports the bulk of the evidence suggesting that dissociative dose ketamine (no reason to go small – I would use 6 or 7 mg/kg or, to make it easy, 500 mg) is very effective for immediate control of agitation, but that these patients must be managed like procedural sedation patients – with specific attention to ventilation and readiness to intubate, along with identification and management of the underlying causes (and effects) of agitation.
  • Recommended by: Reuben Strayer

Emergency Medicine, Neurology, Infectious DiseaseR&R Game Changer? Might change your clinical practice
Jhun P et al. Don’t Let Herpes Melt Your Brain. Ann Emerg Med 2014; 64(6): 589 – 590 PMID: 25454563

  • In a partnership between Annals and EM:RAP, this commentary is a mini review of herpes encephalitis and refers to an image in emergency medicine article. A great quick review of a potentially devastating disease that can often be missed in the ED. Did you know that 1/3 of patients can present with stroke like focal neurological deficits? And that early in the disease 1/10 will have normal CSF and MRI findings? Scary stuff, especially when you consider the consequences of not catching this early.
  • Recommended by:  Jeremy Fried
  • Further information: Best Case Ever 30: Rob Roger’s Mother (Emergency Medicine Cases)

AirwayR&R Game Changer? Might change your clinical practice
Patel A et al. (THRIVE): a physiological method of increasing apnoea time in patients with difficult airways. Anaesthesia. 2014. PMID 25388828

  • Conceptualizing apnoeic oxygenation during emergency and difficult tracheal intubations – THIRIVE – Transnasal Humidified Rapid-Insufflation Ventilatory Exchange.
    In this study continuous delivery of transnasal high-flow humidified oxygen using the OptiFlow system and jawthrust extended the apnoea times (median apnoea time 14 min (9–19 [IQR 5–65])) in 25 patients with known difficult airways (Mean Mallampati grade 3 and/or obesity and/or stridor and/or mean Cormack-Lehane score 3) who were undergoing general anaesthesia for hypopharyngeal or laryngotracheal surgery. No patient experienced arterial desaturation.
  • Recommended by:  Søren Rudolph

Emergency MedicineR&R Hot Stuff - Everyone’s going to be talking about this
Packham et al. Sodium Zirconium Cyclosilicate in Hyperkalemia. N Engl J Med 2014;2(21):2223-2233. PMID 25415807

  • This is an industry sponsored study where outpatients with asymptomatic hyperkalemia were randomized to placebo or different doses of Sodium Zirconium Cyclosilicate (ZS-9) in a 2-stage model (ZS-9 and then ZS9/placebo). Patients with severe hyperkalemia and requiring emergent interventions were excluded. The goal was the ability to decrease serum K levels within 8 hours. Benefit was dose dependent, being max at 10mg with a decrease of 0.7mEq. The number of adverse effects were no statistically different. In the highest dose group, ZS-9 was able to reduce K at a rate of 0.3% per hour while 0.09% in the placebo group.
    The use of ZS-9 is probably designed to be use in outpatient nephrology units or inter-dialysis runs, but given the design study excluding acute/emergent patients and the temporary profile of the drug, at this point, ZS-9 probably has no role in acute care medicine.
  • Recommended by: Daniel Cabrera
  • Further reading: A Brave New Kayexalate Free World (Emergency Medicine Literature of Note)

Emergency Medicine, Ultrasound and ImagingR&R Game Changer? Might change your clinical practice
Adhikari S, et al. Isolated Deep Venous Thrombosis: Implications for 2-Point Compression Ultrasonography of the Lower Extremity. Ann Emerg Med 2014. Available from: http://www.annemergmed.com/article/S0196-0644(14)01419-X/abstract

  • Traditional EM bedside US for the detection of lower extremity DVT is based in a 2-point system, scanning femoral and popliteal veins for the presence of clinically significant thrombi. This study enrolled 2500+ from whom 362 had a DVT, among them 6.3% have proximal DVT not located in common femoral or popliteal locations. This study shows a significant number of patients with proximal DVTs that a 2-point scan would miss.
  • Recommended by: Daniel Cabrera

Emergency Medicine, AdminstrationR&R Hot Stuff - Everyone’s going to be talking about this
Gupta, M. Happy Meals for Everyone? Ann Emerg Med 2014; 64(6): 609 – 611. PMID: 25454564

  • This excellent editorial points out the positive and negative aspects of an accompanying study (PMID: 25182541) which examined the patient and ED characteristics associated with patient satisfaction scores. Obviously, a growing issue in the U.S. as administrative decisions and payment are increasingly being tied to these scores. The editorial goes further than the current article to discuss the larger issues at stake and is well worth a read for all practitioners who have to hand out “happy meals” to their patients.
  • Some highlights:
    • Low Press Ganey response rate ensures that only ~2% of ED patients account for the entirety of satisfaction information that EDs use to gauge performance
    • Press Ganey uses comparator groups based solely on census and does not adjust for or provide data on other factors such as sociodemographics that may affect patient satisfaction scores
    • Press Ganey’s ED-specific analyses display a relative percentage rank when comparing that ED within each comparator group, but reports do not accessibly provide additional context such as corresponding confidence intervals
    • When and to what extent is it appropriate to equate patient (consumer?) satisfaction scores with quality of care like other service industries do?
  • 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.

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