Research and Reviews in the Fastlane 092

Research and Reviews in the Fastlane

Welcome to the 92nd edition of Research and Reviews in the Fastlane. R&R in the Fastlane is a free resource that harnesses the power of social media to allow some of the best and brightest emergency medicine and critical care clinicians from all over the world tell us what they think is worth reading from the published literature.

This edition contains 7 recommended reads. The R&R Editorial Team includes Jeremy Fried, Nudrat Rashid, Soren Rudolph, Anand Swaminathan and, of course, Chris Nickson. Find more R&R in the Fastlane reviews in the R&R Archive, read more about the R&R project or check out the full list of R&R contributors

This Edition’s R&R Hall of Famer

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

Pickard R et al. Medical expulsive therapy in adults with ureteric colic: a multicentre, randomised, placebo-controlled trial. Lancet 2015. PMID: 25998582

  • The urology literature and guidelines has argued for the broad use of tamsulosin in the treatment of patients with renal colic to facilitate stone passage, reduce pain medication utilization and reduce interventions based on poor methodologic studies from the early 2000’s. This study, on the other hand, was a well done, RDCT comparing tamsulosin to nifedipine to placebo in 1136 patients and showed no statistically significant difference for the primary outcome (need for further intervention at 4 weeks). Subgroup analysis showed a slight benefit for lower tract stones and the issue of utility in larger stones (> 5 mm) remains unanswered. However, with the move to reduce CT use in renal colic, we won’t know stone location or size on many patients making this drug far less useful in the real world.

The Best of the Rest

Intensive CareNeuraz A et al. Patient Mortality Is Associated With Staff Resources and Workload in the ICU: A Multicenter Observational Study. Crit Care Med 2015; 43(8): 1587 – 94. PMID 25867907

  • This study aimed to assess the impact of the staffing-to-patient ratio and workload on ICU mortality. And what they found was the risk of death was increased by 3.5 when the patient-to-nurse ratio was greater than 2.5, and it was increased by 2.0 when the patient-to-physician ratio exceeded 14. High patient turnover (adjusted relative risk, 5.6) and the volume of life-sustaining procedures performed by staff (adjusted relative risk, 5.9) were also associated with increased mortality. Doesn’t this sound like a standard shift in the ED?
  • Incredibly important paper to help guide ICU directors & managers in staffing considerations for their ICU.Increased mortality risk associated with:
    – Nurse:patient > 2.5
    – Physician:patient > 14
    – High rates of turnover
    – Number of life saving interventionsBottom line – Intensive care requires INTENSIVE care.
  • Recommended by Salim R. Rezaie, John Greenwood

ResuscitationPanchal AR, et al. Efficacy of Bolus Dose Phenylephrine for Peri-intubation Hypotension. J Emerg Med 2015. PMID 26104846

  • Push dose vasopressors are commonly used in the emergency department, yet literature in this setting is scant. This is a retrospective study of use of phenylephrine in one ED over the course of a year. This study doesn’t look at patient centered outcomes but lays groundwork for future study in this area. The take home: emergency physicians use push-dose pressors in some hypotensive patients in the peri-intubation period and most patients given push dose pressors will end up on a vasopressor so be prepared to have a long-term fix for the hypotension.
  • Recommended by Lauren Westafer
  • Read More: Push dose pressors (EMCrit)

TraumaHale DF et al. Absence of clinical findings reliably excludes unstable cervical spine injuries in children 5 years or younger. J Trauma Acute Care Surg. 2015; 78(5): 943-8 PMID: 25909413

  • In this well done retrospective review of ~3,000 patients aged 5 years and younger who have imaging of their cervical spine, the authors give us some data and a common sense approach for the pre-elementary aged trauma patient’s c-spine evaluation. Essentially, in the words of the authors:“In those who were clinically evaluable (not in a coma), there were no asymptomatic patients who later were found to have unstable cervical spine injury”.So, if there is no neurologic deficit, and no pain or tenderness, there is no need to go crazy looking for an extremely rare, unlikely injury.
  • Recommended by Jeremy Fried
  • Further information: Pediatric C-spine Clearance (ERCAST); The Very Young Pediatric C-Spine Rarely Needs Radiologic Clearance (EM Literature of Note); Clearing the Pediatric C-Spine (PEM-ED)

AirwayL. Suppan et al. Alternative intubation techniques vs Macintosh laryngoscopy in patients with cervical spine immobilization: systematic review and meta-analysis of randomized controlled trials Br. J. Anaesth 2015. PMID 26133898

  • A well done review and meta-analysis with a skewed conclusion in my opinion. Even though the premise for the review is the well known problem with airway management in immobilised trauma patients and one of the keywords is “trauma”, none of the included 1866 patients (24 trials) were actual trauma patients intubated in emergency settings. Furthermore all intubations were done by “experienced” anaesthesiologist but with an amazingly high failure rate (20%) for direct laryngoscopy.
  • The authors present a thorough discussion on these and other limitations, but end up by concluding that the Airtraq device reduces the risk of intubation failure and that there is a lack of evidence for the usefulness of other intubation devices.
  • Recommended by Søren Rudolph

Emergency MedicinePollack CV et al. Idarucizumab for Dabigatran Reversal. NEJM 2015. PMID: 26095746

  • This article begs a number of questions most of which center on the quality of article being published by the NEJM and what their true motives are. This study is an interim analysis of an unblinded observational study looking at the ability of the antibody fragment idarucizumab to reverse the anticoagulant effect of dabigitran (a direct thrombin inhibitor). The study claims success of the new (an terribly expensive) drug but the endpoints are non-patient centered and the study suffers from a number of biases. Again, though, the real question is why the NEJM would publish such pharma sponsored drivel . . . except of course for the huge windfall from reprint proceeds for the article.
  • Recommended by Anand Swaminathan
  • Further reading: Let’s Reverse: Dabigtran (EM Literature of Note)

Emergency Medicine
Yu S, et al. Computed tomographic pulmonary angiography: clinical implications of a limited negative result. JAMA Intern Med 2015; 175(3): 447-9. PMID 25581389

  • I’m not sure why this is a research letter and not a paper but it’s what we have. The authors describe a chart review of all their CTPAs and looked at the 25% that were limited in their diagnostic ability (poor contrast etc…)
    They then looked at records of all those people with indeterminate scans (25% of the total). Very few had anything bad and no difference between the non diagnostic scans and those who had definitive negative scans.
  • This is just more evidence that we probably shouldn’t be diagnosing every VTE and a scan showing clear vessels to the lobar or segmental level is probably just fine.[someone linked to this on twitter, not sure who but cheers anyhow!]
  • Recommended by: Andy Neill

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 092 appeared first on LITFL: Life in the Fast Lane Medical Blog.

LITFL Review 189

LITFL review

Welcome to the 189th 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

The American College of Emergency Physicians made some pretty significant changes to its tPA clinical policy. Find out what they were and get comments from the experts on this week’s FOAMcast. [MG]

The Best of #FOAMed Emergency Medicine

  • How does eliminating the “zero-miss rate” for chest pain affect admission versus discharge decisions in the ED? EM Lit of Note discusses a recent article from Academic Emergency Medicine. [AS]
  • If you’ve heard of giving steroids instead of antibiotics for strep throat, you’ll want to read this thoughtful review of the evidence at Emergency Medicine PharmD. [MG]
  • What constitutes a “large bore IV”? Look at some real data at the ETMCourse. [MG]
  • Find out the details and background about Jehovah’s Witnesses beliefs regarding blood products at The Trauma Professional’s Blog. [MG]

The Best of #FOAMcc Critical Care

  • Not convinced that ATLS is for amateurs? Check out this post from ScanCrit on the many weaknesses of ATLS. [AS]
  • REBEL EM reviews the new ACC/AHA recommendations on which patients should go to cardiac catheterization post-ROSC. Excellent editorial highlighting major issues with this algorithm. [AS]
  • EMUpdates discusses a better way to place a central line with the wire through catheter technique. [AS]
  • Another step beyond basic ACLS: Cliff Reid discusses the role of inhaled nitric oxide in cardiac arrest patients with pulmonary hypertension. [AS]

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 189 appeared first on LITFL: Life in the Fast Lane Medical Blog.

Funtabulously Frivolous Friday Five 110

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…introducing Funtabulously Frivolous Friday Five 110

Question 1

A young fit male is out surfing, as he moves through the white water at waist depth another surfer hits in his chest and he goes into cardiac arrest. The life guards successfully defibrillate the surfer after one shock and he comes to your department sat up on the bed talking. What condition has he suffered from?

  • Commotio Cordis
  • Effectively ventricular fibrillation triggered by a blunt, non penetrating, and often innocent appearing unintentional blow to the chest without damage to the ribs, sternum or heart.
  • The latin translation is “agitation of the heart“.
  • A blow of approximately 30-50mph lands on the T wave creating an ‘R’ on ‘T’ phenomenon and VF. See our LITFL post on Commotio Cordis

Question 2

What causes a Sardonic Smile?

  • Derived from the Hemlock induced wry smiles peri-euthanasia…
  • Among the pre-Roman people of Sardinia they would euthanize their elderly. While doing so they would laugh loudly which is the origin of the sardonic laughter
  • However, the Sardoni believed that laughter during this killing would transform death into a new birth, and nullifies the murder.
  • Scientists in Italy theorised that the Sardoni used hemlock water dropwort that causes a sardonic grin before dropping the elders from a high rock or beating them to death.
  • Hemlock water dropwort contains Oenanthotoxin a toxin that acts as a noncompetitive gamma-aminobutyruc acid agonist.
  • However, if you are not killing your elders then you may see a Risus sardonicus – the apparent smile on a face of someone who either has tetanus or Strychnine poisoning – see tox conundrum 007.
  • Reference G. Appendino, F. Pollastro, L. Verotta, M. Ballero, A. Romano, P. Wyrembek, K. Szczuraszek, J. W. Mozrzymas, and O. Taglialatela-Scafati (2009). “Polyacetylenes from Sardinian Oenanthe fistulosa: A Molecular Clue to risus sardonicus”. Journal of Natural Products 72 (5): 962–965

Question 3

Why did van Gogh paint in yellow? What disease might this represent?van gogh

  • Xanthopsia
  • Arnold WN and Loftus LS reviewed the works of Van Gogh and his correspondence to answer this question…opinions vary, but possibilities to be excluded include
  • Digoxin toxicity is known to cause cataracts by blocking the sodium pump on the lens and thus causing a yellow hue.
  • Bilirubin deposition in the lens associated with jaundice
  • Congenital cataracts
  • Absinthe hallucinations.
  • However, there is no evidence that van Gogh was either jaundice or digoxin toxic. It is also unlikely that van Gogh had cataracts due to his youth. Hallucinations from absinthe may be an explanation for certain canvases but not for the majority.
  • So despite popular interesting theories about his health and drug abuse, his correspondence would indicate that he had a preference for the exaggerated yellow colours. [Reference PMID: 1794418]

Question 4

Where were cephalosporins discovered?

  • In the sewers of Sardinia.
  • It not all white lab coats, fancy conical glasses and staring at petri dishes. A large number of antibiotics have been discovered in rather gruesome circumstances.
  • Giuseppe Brotzu of Sardinia wondered why typhoid fever was less virulent in his city than elsewhere. He had many theories until one day while passing through the bay of “Su Siccu” he saw some young people swimming in the waters near a sewage outlet and wondered why they had not contracted this disease from contaminated faeces.
  • With haste he scooped up some sewer water, boiled up some placenta for medium and discovered a cure for this gram negative bacteria. [Reference]
Brendan Walsh diving in a sea of human waste.

I can taste a new antibiotic in here somewhere!!

Question 5

What is a Sister Mary Joseph Nodule?

  • It is a metastatic lesion involving the umbilicus.
  • Reportedly present in 1-3% of all intra-abdominal and/or pelvic malignancies (adenocarcinoma being the most common primary).
  • This lesion is likely to be reported on a CT scan but the ever observant Sister Mary Joseph (born Julia Dempsey 1856-1939) was surgical assistant to William Mayo of Mayo Clinics, and pointed out the frequent finding of a nodule in the umbilicus of patients with advanced cancer.
  • Other differentials of umbilical lesions include a paraumbilical hernia, surgical scar, endometriosis, granuloma, primary umbilical tumour and umbilical lint (aka belly button fluff). [Reference]

…and in other news

//www.youtube.com/watch?v=aS3xaXsh6vo

The post Funtabulously Frivolous Friday Five 110 appeared first on LITFL: Life in the Fast Lane Medical Blog.

TechTool Thursday 063 DxLogic

TechTool review DxLogic on iOS and website

DxLogic provides access to a database of likelihood ratios. Michael Garfinkle is a Nephrology Fellow from Canada, and has built up his database as a labour of love. The aim is to provide doctors with easy access to likelihood ratios to help them decide on whether or not a specific investigation is worthwhile, or whether a patient has a particular disease

Website: – iTunes – Website

Design

This is not the app’s best area. The app icon looks great, however you can’t help but feel a tad disappointed after opening the app.

It looks strange with some text in giant lettering and others at a regular size. The user interface is tricky to navigate – it would not have been possible for me to use the app without watching the five minute YouTube tutorial. An iOS app should be intuitive and able to be used without video instructions

User Interface

iphone1

iphone2

Clinical Content

The database contains over 700 likelihood ratios. You can:

  • Choose by specialty, disease, presentation, or investigation
  • View the positive or negative likelihood ratios
  • Change the pre-test probability and use the app’s suggestions for how to estimate this
  • View references and info about the articles used to derive the likelihood ratios

Cost

  • Free – there are some paid features but they are mysteriously difficult to access.
  • It is $2.49 to unlock the additional features, which isn’t too expensive

Room for Improvement

  • The font size could be reduced by 50% and we would still all be able to comfortably read it
  • There are clickable parts in the app that are well-disguised and I only found some of them from watching the YouTube tutorial – in iOS a button should look like a button
  • The unlock option and functionality needs to be improved as it was only with great persistence that I managed to work out how to upgrade

Overall

Michael Garfinkle must have spent rather a long time working on this and he has done a great job in putting together a database of likelihood ratios. There is a massive amount of useful stats information and references in this database.However, the app lets his hard work down by being clunky to use and not very pretty. A simple redesign of the app graphics would allow this app to do justice to his efforts.

From the stats point of view, I’m not sure how likely you would be to use this app on a regular basis – depends on your pre-test probability, I guess

//www.youtube.com/watch?v=ABEUSK0-Ouo

The post TechTool Thursday 063 DxLogic appeared first on LITFL: Life in the Fast Lane Medical Blog.

Research and Reviews in the Fastlane 091

Research and Reviews in the Fastlane

Welcome to the 91st edition of Research and Reviews in the Fastlane. R&R in the Fastlane is a free resource that harnesses the power of social media to allow some of the best and brightest emergency medicine and critical care clinicians from all over the world tell us what they think is worth reading from the published literature.

This edition contains 7 recommended reads. The R&R Editorial Team includes Jeremy Fried, Nudrat Rashid, Soren Rudolph, Anand Swaminathan and, of course, Chris Nickson. Find more R&R in the Fastlane reviews in the R&R Archive, read more about the R&R project or check out the full list of R&R contributors

This Edition’s R&R Hall of Famer

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

Rab T et al. Cardiac Arrest: A Treatment Algorithm for Emergent Invasive Cardiac Procedures in the Resuscitated Comatose Patient. JACC 2015; 66(1): 62 – 73. PMID: 26139060

  • Patients who are comatose after cardiac arrest continue to be a challenge, with high mortality. There is already an ACC/AHA Class I recommendation for angiography/PCI in patients with STEMI, but the new guidelines are now indicating that this should be done for patients with non-STEMI as well. There are some major issues with the use of observational studies and absolute cutoffs of lab values and age, but bottom line:Patient with cardiac arrest and ROSC who is comatose should have targeted temperature management and cath lab activated when appropriate regardless of ECG (i.e. STEMI or non-STEMI)

The Best of the Rest

AirwayBrainard A et al. A randomized trial on subject tolerance and the adverse effects associated with higher- versus lower-flow oxygen through a standard nasal cannula. Ann Emerg Med. 2015 Apr;65(4):356-61. PMID: 25458980

  • Great study by Andrew Brainard (Sharp End Crew) et al showing that “higher” flow nasal cannula (ie. 15 lpm used for preox & passive ox during laryngoscopy) is really not that annoying for the patient. Incidentally I trialed this myself a few years back and it made my nose tickle for a few minutes, but then again I didn’t get any induction agents & sedative drips and wasn’t acutely ill at the time.
  • Recommended by Seth Trueger

CardiologyStub D et al. Air Versus Oxygen in ST-Segment-Elevation Myocardial Infarction. Circulation. 2015; 131(24):2143-50. PMID 26002889

  • The Australian AVOID trial adressess the important question wether routine administration of oxygen to patients with STEMI is associated with increased infarction size as measured by cardiac enzymes and MRI at 6 months. I all 441 STEMI patients were randomized prehospital to oxygen (8 L/min) by face-mask or no oxygen from. Mean peak TnI was similar between the two groups but there was a significant increase in mean peak CK of 20% in the oxygen group. Although not all patients underwent MRI at 6 months, there was a significantly increase in myocardial infarct size on cardiac MRI in the oxygen group (n=139; 20.3 versus 13.1 g; P=0.04). Furthermore there was an increase in the rate of recurrent myocardial infarction in the oxygen group compared with the no oxygen group (5.5% versus 0.9%; P=0.006) and an increase in frequency of cardiac arrhythmia (40.4% versus 31.4%; P=0.05).This adds to the fact that oxygen is a drug a should be used only if indicated. The perception that oxygen is harmless and that you can’t get enough of a good thing seems to be running out of fashion.
  • Recommended by Søren Rudolph
  • Read More: July 2015 REBEL Cast (REBEL EM)

Critical CareCardenas-Garcia J, et al. Safety of peripheral intravenous administration of vasoactive medication. J Hosp Med 2015. PMID: 26014852.

  • Finally we have some prospective and real world data on the safety of peripheral vasopressors! Using a decent drip in a good vein resulted about a 2% extravasation rate with no significant limb injury in 700+ patients. Only 13% needed a CVC in this study.
    Single centre – but mounts a good case for cautious use of peripheral noradrenaline.
  • Recommended by Casey Parker

HematologyLitton E et al. Safety and efficacy of intravenous iron therapy in reducing requirement for allogeneic blood transfusion: systematic review and meta-analysis of randomised clinical trials. BMJ 2013;347:f4822.PMID: 23950195

  • We know that blood transfusions carry significant risks of allo-immunization, TACO, TRALI and have historically been over-utilized. This systematic review and meta-analysis of 75 trials looking at the efficacy and safety of IV iron as an alternative to blood transfusions, found that IV iron was associated with a mean increase in hemoglobin of 6.5g/L and reduced requirement for red cell transfusions (RR 0.74) at the cost of an increased risk of infection (RR 1.33). An ED-based RCT is desperately needed to assess the potential for IV iron as an alternative or adjunct to blood transfusions in patients with severe iron deficiency anemia.
  • Recommended by Anton Helman
  • Further reading: Episode 65: IV Iron for Anemia in Emergency Medicine (Emergency Medicine Cases)

Emergency MedicineSimerville JA et al. Urinalysis: a comprehensive review. Am Fam Physician. 2005; 71(6): 1153-62. Review. Erratum in: Am Fam Physician. 2006 Oct 1;74(7):1096. PMID: 15791892 (FREE OPEN ACCESS ARTICLE)

  • Found this via Jim Roberts (him with the Roberts and Hedges book) over at EM News.A wonderful review of all things for testing the wee wee. I learnt a lot reading this and given it’s such a common test we need to know it inside out.
  • Recommended by Andy Neill
  • Further reading: Urinalysis: Microscopy (Emergency Medicine News)

Emergency Medicine
Kline JA, Kabrhel C. Emergency Evaluation for Pulmonary Embolism, Part 1:Clinical Factors that Increase Risk. J Emerg Med. 2015; 48(6): 771-80. PMID: 25863772.
and
Kline JA, Kabrhel C. Emergency Evaluation for Pulmonary Embolism, Part 2: Diagnostic Approach. J Emerg Med. 2015; 49(1): 104-17. PMID: 25800524.

  • This two part series by the guru of all things thromboembolic is a MUST READ for all emergency providers.The first part focuses on the patient factors we must take into account as we evaluate for the possibility of a pulmonary embolism in our patients. The second is an outstanding summary of how best to apply the current state of knowledge to our clinical practice as we workup these same patients. If nothing else, Figure 1 of Part 2 is worth the time of picking up this paper to give you an evidence based, logical approach to the diagnostic evaluation of these patients. Highlights include the use of PERC, age adjusted D-dimer, and how to approach the pregnant patient with a possible PE.
  • 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 091 appeared first on LITFL: Life in the Fast Lane Medical Blog.

So you wanna speak at SMACC Dublin in 2016?

Got an idea for a SMACC talk?

Got an idea for a speaker?

We are willing to listen. No guarantees of course — places are limited, and there is a world of awesome people and awesome ideas out there.

Just fill in the form and help make SMACC Dublin uniquely fantastic.

The post So you wanna speak at SMACC Dublin in 2016? appeared first on LITFL: Life in the Fast Lane Medical Blog.