LITFL Review 152

LITFL review

The LITFL Review is 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.

Welcome to the 152nd edition, brought to you by:

The Most Fair Dinkum Ripper Beaut of the Week

resizerA real Ripper from SMACC Gold- Casey Parker reminds us what makes us human. Our ability to feel and empathise is more important than ever. Learn more in his talk “Hard Lessons Learned”. [SO]

If you have just a few seconds to spare, read this touching post from Katrin Huska. It may be time you had that talk with your patient, too. [SO]

One of the most famous airway tragedies in recent history- the Elaine Bromiley case- receives a real-time reconstruction courtesy of Nicholas Chrimes. Harrowing and essential- anyone involved in airway management should watch this. [SO]

The second in the trilogy of trials reassessing Early Goal-Directed Therapy- the ARISE trial- has been released to great fanfare. Hear the original presentation here and Scott Weingart’s awesome summary here. Emergency Medicine Literature of Note also posted their commentary here, The Bottom Line has a great review as well, and the Intensive Care Network has interviewed the lead author here. [SO,MG, AS]

The Best of #FOAMed Emergency Medicine

  • We won’t be fooled again! Ken Milne and Ryan Radecki review the questionable veracity of the  conclusions of the Cochrane Collaboration systematic review of thrombolysis in acute ischemic stroke. [AS]
  • Looking to improve your skills as a trauma provider? The Anaesthesia Trauma and Critical Care (ATACC) Course, hosted multiple times a year in the UK, is widely lauded as one of the best courses available for up-to-date trauma practice. The ENTIRE course manual is available entirely FREE- via PDF and iTunes, and will be updated regularly.Just let that sink in. A free, up-to-date (and constantly updated), and concise trauma manual.(Thanks to Tim Leeuwenburg for the tip) [SO]
  • Didn’t make the UK’s College of Emergency Medicine Conference this week? Check out this fantastic resource of short summaries of the key points from the lead lecturers. CEM going FOAMed! With a huge range of topics including from traumatic arrest, sedation, gestalt and much much more. [SL]
  • The September edition of the Annals of Emergency Medicine Audio Summary, hosted by Drs David Newman and Ashley Shreves has been released. [MG]
  • Which c-spine rule is better: NEXUS or Canadian C-spine rule? BoringEM reviews the literature, and helps us understand their best uses. [MG]
  • Do you understand axis as well as you’d like? The EMS 12-Lead blog gives us the first in a new series on understanding axis on the ECG. [MG]
  • Damian Roland writes a touching post on a recent campaign to help reduce the incidence of suicide and improve general wellbeing by connecting with others. The 17th part of his “What I learnt this week” series, on #connectingwith, is here. [SO]
  • Pre hospital Intubation and Failure recognise (o)esophageal intubation.  An ED nurse and Mother blogs about her the death of her daughter and the scholarship fund set up in her memory.  [CC]
  • We all would like a smart doctor but I think most of us would agree that toughness, resilience and “grit” are vital characteristics. John Greenwood discusses the concept of “grit” and why we should identify and foster it. [AS]
  • Not only is half of what we learn in medical school wrong, but more than half of research is wrong as well. Ryan Radecki implores that we open the data up for external analysis and verification. [AS]
  • A wonderful reminder from Amal Mattu that flipped T-waves in the inferior and anteriorseptal leads is a PE until proven otherwise. Don’t be mislead into the ischemia pathway! [AS]
  • Takotsubo can be one of the most difficult STEMI mimics to differentiate. Learn how this week from Dr Steve Smith. [MG]
  • The AHA/ACC guidelines on the management of NSTEMI are out and Ryan Radecki highlights some important, and long awaited, changes including addition of the HEART score, dropping of CK-MB and Myoglobin, a place for single troponins and shared decision making. [AS]
  • In the latest edition of the MEdIC series, the ALiEM team discusses the use of and role for black humour and slang terminology. This post is a great example of crowdsourcing with over 120 comments and has wonderful expert peer review. [AS]

The Best of #FOAMcc Critical Care

  • Really wide QRS > 200 msec? Amal Mattu reminds us to think more about toxic effects of medications and metabolic issues like hyperkalemia and treat with Calcium and Bicarbonate. [AS]
  • Rory Spiegel offers a passionate argument for the use of Midline catheters for deep peripheral veins instead of traditional intravenous catheters. Time to adapt our “ideology, methods and tools accordingly.” [AS]
  • The Neuro ICM and EM blog have a wonderful summary on a recent consensus statement on MultiModality Monitoring in Neurocritical Care. [SO]
  • The absence of intracranial hemorrhage in a head trauma patient does not mean critical care management is unnecessary. St. Emlyn’s discusses the critical care management of patients with diffuse axonal injury this week on their podcast. [SL, AS]
  • We’ve all been wondering about Rob Mac Sweeney. Full time consultant in Intensive Care and anaesthesia, producer of some of the best #FoamCC with the Critical Care Reviews newsletter, editor of a new open access critical care journal- how does he do it all? ALiEM’s “How I work Smarter” series has the answer. [SO]
  • UMEM have a great critical care pearl on Goal-directed resuscitation during Cardiac arrest using CPP, DBP, and ETCO2. [SO]
  • Tachydysrhythmia diagnosis and management is bread and butter EM. John Greenwood reviews pearls and pitfalls from Amal Mattu on the University of Maryland Emergency Medicine site. This simple approach makes management straightforward. [AS]
  • PulmCrit features some dogmalysis, explaining that Lactated Rings is not only safe, but superior to normal saline in the setting of hyperkalaemia. [MG]
  • “Panscanning” has become a common practice for evaluation of trauma patients without any evidence of benefit. ALiEM gives a great critique of this practice. A must read for anyone caring for trauma patients. [AS]
  • Emergency Physicians MUST be the expert in EKGs. Steve Smith recounts a case to remind us that not all cardiologists are up to date on the literature.

#FOAMTox Toxicology

#FOAMus Ultrasound

  • Ultrasound continues to challenge CT scan for radiographic diagnostic supremacy. ALiEM shares a great post reviewing the utility of ultrasound in the diagnosis of small bowel obstruction. [AS]
  • Academic Life in Emergency Medicine release two new Paucis Verbis cards this week for focused abdominal aortic ultrasound, and FAST exam. [MG]
  • Ultrasound of The Week has a superb case of an 87 year old male with collapse. Brilliant images? [SO]
  • Have you been following the Intensive Care Network’s Lung Ultrasound Case series? Why not? Please check it out now- Case 5 is now up. [SO]
  • Matt and Mike from the Ultrasound Podcast discuss the recent paper on  point-of-care ultrasound in patients with respiratory symptoms- with Vicki Noble, Andrew Liteplo, and the first author Christian Laursen in a great two-part journal club. Part 1  Part 2 [SO]
  • The recent NEJM article on CT vs. Ultrasound in renal colic has gotten a lot of press on FOAM. St. Emlyn’s weighs in as well with a critical review of the article.

#FOAMPed Paediatrics

  • What is the relevance of mildly subnormal oxygen levels in bronchiolitis?  Don’t Forget the Bubbles discusses this question in The Effects of Oximetry on Hospital Admission in Bronchiolitis. [AS]
  • SonoKids discusses the benefits of a bedside ultrasound in a 9 year old trauma patient with flank pain – Not so FAST? [TRD]
  • Never mind faffing around trying to get IV access while your paediatric patient writhes in agony – Pediatric EM Morsels sells us the benefits of using intranasal fentanyl. [TRD]
  • Brilliant discussion of strep pharyngitis from Casey Parker asking tough questions about who should be tested (almost no one) and who should be treated (surprise – it’s not what you think). [AS]

Reference Sources and Reading List

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Research and Reviews in the Fastlane 052

Research and Reviews in the Fastlane
Welcome to the 52nd edition of Research and Reviews in the Fastlane. R&R in the Fastlane is a free resource that harnesses the power of social media to allow some of the best and brightest emergency medicine and critical care clinicians from all over the world tell us what they think is worth reading from the published literature.
This edition contains 10 recommended reads. The R&R Editorial Team includes Jeremy Fried, Nudrat Rashid, Soren Rudolph, Anand Swaminathan and, of course, Chris Nickson. Find more R&R in the Fastlane reviews in the R&R Archive, read more about the R&R project or check out the full list of R&R contributors

This Edition’s R&R Hall of Famer

Infectious Diseases, Epidemiology, Critical Care

R&R Hall of Famer - You simply MUST READ this!R&R Hot Stuff - Everyone’s going to be talking about thisWHO Ebola Response Team. Ebola Virus Disease in West Africa — The First 9 Months of the Epidemic and Forward Projections. NEJM 2014 PMID: 25244186

  • Since the onset of the Ebola Virus Disease epidemic 7 months ago a total of 4507 confirmed and probable cases, as well as 2296 deaths from the virus had been reported from five countries in West Africa — Guinea, Liberia, Nigeria, Senegal, and Sierra Leone. The disease is rapidly spreading with a case diagnosed in the United States this week. This is an excellent report on the clinical and epidemiologic characteristics of the epidemic and the analyses in this paper can be used to inform recommendations regarding control measures. Unfortunately the current epidemiologic outlook is bleak especially in Guinea, Liberia, and Sierra Leone. Control measures which include improvements in contact tracing, adequate case isolation, increased capacity for clinical management, safe burials, greater community engagement, and support from international partners need to improve quickly otherwise these countries will be reporting thousands of deaths each week. Experimental therapeutics and Vaccines are not available at present and certainly not in the quantities that are required. We must also face the prospect that Ebola Virus Disease may become Endemic to the human population in West Africa.
  • Recommended by: Nudrat Rashid

The Best of the Rest

Emergency Medicine

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

Hwang V et al. Are pediatric concussion patients compliant with discharge instructions? J Trauma Acute Care Surg 2014. PMID: 24977765

  • The short and long term morbidity associated with pediatric concussions is becoming better recognized. This study looked at compliance with discharge instructions. Surprisingly (or maybe not so), 39% of pediatric patients returned to play (RTP) on the day of the injury. RTP is widely recognized as a risk for recurrent and more severe concussions as well as significant morbidity. It is the duty of the Emergency Physician to stress the importance of discharge instructions as well as the importance of appropriate follow up.
  • Recommended by: Anand Swaminathan

PediatricsR&R Mona Lisa -Brilliant writing or explanation” width=Singleton T et al. Emergency department care for patients with hemophilia and von Willebrand disease. J Emerg Med. 2010; 39(2): 158-65. PMID: 18757163

  • Bleeding always catches our attention in the ED… especially when it won’t stop. Von Willebrand disease is often encountered in the Peds ED. Make sure that the patient and their family don’t know more about it than you do.
  • Recommended by: Sean Fox
  • Read More: Von Willebrand Disease (PED EM MORSELS)

Emergency MedicineR&R Game Changer? Might change your clinical practiceR&R Eureka - Revolutionary idea or conceptGorchynski J et al. The “Syringe” Technique: A Hands-Free Approach for the Reduction of Acute Nontraumatic Temporomandibular Dislocations in the Emergency Department. J Emer Med 2014. PMID: 25278137

  • Reduction of temporomandibular joint (TMJ) dislocations is difficult, time consuming and often requires procedural sedation. This article describes a novel method for reduction of atraumatic TMJ dislocations in the ED. The “syringe” technique successfully reduced 97% (30/31) of dislocations. 77% (24/31) reductions were completed in less than 1 min. While this is not proof of superiority to other techniques, the time to reduction here is stunning and it’s always nice to have another arrow in the quiver
  • Recommended by: Anand Swaminathan

Pediatrics
R&R Game Changer? Might change your clinical practiceHalm BM. Reducing the time in making the diagnosis and improving workflow with point-of-care ultrasound. Pediatr Emerg Care. 2013; 29(2): 218-21. PMID: 23546429

  • Ok, so this isn’t hard core research, but I wanted to use it to highlight the fact that intussusception does not commonly present in the “classic” fashion and that by using point of care ultrasound, you can augment your physical exam to help diagnosis the condition in the child who presents with “altered mental status.”
  • Recommended by: Sean Fox
  • Read More: Intussusception & Altered Mental Status (PED EM MORSELS)

ResuscitationR&R Eureka - Revolutionary idea or conceptHeidlebaugh M et al. Full Neurologic Recovery and Return of Spontaneous Circulation Following Prolonged Cardiac Arrest Facilitated by Percutaneous Left Ventricular Assist Device. Ther Hypothermia Temp Manag. 2014. PMID: 25184627

  • Case report of a novel solution to a patient who sustained intra-cardiac catheterization cardiac arrest. An Impella device (an intraventricular LVAD) was placed into the left ventricle to provide adequate forward flow. Case report only but may offer an alternative to ECLS.
  • Recommended by: Cliff Reid
  • Read More: Left Ventricular Assist Device for Cardiac Arrest? (RESUS.ME)

Emergency Medicine, ObstetricsR&R Hot Stuff - Everyone’s going to be talking about thisKline JA et al. Systematic Review and Meta-analysis of Pregnant Patients Investigated for Suspected Pulmonary Embolism in the Emergency Department. Acad Emerg Med. 2014; 21(9): 949-959. PMID: 25269575

  • This systematic review and meta analysis looked at the literature (and gray lit) for pregnant patients undergoing work-up for pulmonary embolism, a cohort historically classified as high risk. The shocking take-home: we probably over-investigate PE in pregnant patients. The VTE rate in pregnant patients was 4.1%, compared with a rate of 12.4% in non-pregnant patients. The pooled RR of pregnancy VTE was 0.60 (95% CI 0.41-0.87) and patients of childbearing age (≤45 years) had RR 0.56 (95% CI 0.34-0.93). Of note, this study highlights the miniscule number of pregnant patients included in PE studies (n=506) and the tiny number of these who actually had VTE (n=29).
  • Recommended by: Lauren Westafer

Education

Cheston CC et al. Social media use in medical education: a systematic review. Acad Med. 2013; 88(6): 893-901. PMID: 23619071

  • Systematic review of social media in medical education. They found 12 studies, mostly small, a lot of reflective work. Good to see a growing evidence base for integrating FOAM into formal curricula.
  • Recommended by: Seth Trueger

Resuscitation, Critical CareR&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 2014. PMID: 25255427

  • Etomidate, once the only available induction agent for RSI in US Emergency Departments, has long been maligned for its transient adrenal suppression in spite of the absence of any detrimental patient oriented outcomes. This systematic review and meta-analysis including 18 studies (only 2 RCTs) and > 5,500 patients demonstrated no difference in mortality in septic patients. For now, at least, etomidate is a viable option as an induction agent in patients with sepsis.
  • Recommended by: Anand Swaminathan

Emergency Medicine, OpthalmologyR&R WTF Weird, transcendent or funtabulous!” width=Moradi P et al. Sudden pseudoproptosis. Emerg Med J 2013; 31(8): 624. PMID: 24136120

  • Who knew there was such as thing as “Floppy eyelid syndrome”! Described in overweight middle-aged men. Interesting case with pictures described here. A disorder of unknown origin manifested by an easily everted, floppy upper eyelid and upper palpebral conjunctivitis. The upper eyelid everts during sleep, resulting in irritation, conjunctivitis and conjunctival keratinisation.
  • 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

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Help African Emergency Medicine Now!

aka Postcards from the Edge 010

This ‘postcard from the edge’ is by Swedish Emergency Physician Dr Katrin Hruska (@akutdoktorn), who writes a Swedish/ English language language blog called akutdoktorn.

Immaculate Nagaddya is a registered nurse, working in Lugada Hospital in Uganda. It is a small hospital with about 10 000 visits per year, where she receives critically ill patients, presenting with conditions like status asthmatics, status epilepticus and severe dehydration from watery diarrhoea. Together with seven other nurses and between one and three doctors she keeps this emergency department open day and night, all year round.

Immaculate Nagaddya

Immaculate Nagaddya

Equipment is scarce in Immaculate’s emergency department: 2 blood pressure cuffs, 2 monitors, 2 pulse oximeters and 1 digital thermometer. But there is oxygen for all eleven beds and the hospital offers x-ray and ultrasound scans. Even though it is a 270 bed hospital, the emergency room has only been in place since August 2013. Immaculate and her colleagues are working hard to improve the quality of emergency care they can provide. That is why Immaculate was chosen by her hospital to go to the AFCEM conference in Addis Ababa in November. But Immaculate is not going.

AFCEM is the biannual meeting of the African Federation of Emergency Medicine (http://www.afcem2014.com). It covers the same kind of topics any emergency conference would: Closed head injury, stroke, the acute abdomen, airway management etc. Yet the information and recommendations conveyed will be very different from what one can hear on podcasts or learn from blogs. Good quality emergency medicine in low and middle income countries is just as evidence based as anywhere else. It just needs to be based on evidence that is applicable to a low resource setting. And this is what the AFCEM meeting is about.

The organizers of AFCEM were hoping that registration fees from American and European delegates would finance a sponsorship program covering half the cost for registration and accommodation for 30 doctors and nurses from African hospitals. But the Ebola outbreak is keeping the foreign doctors away and 23 of the planned sponsorships have been cancelled. Immaculate is number 16 on that list. There is no way she is going to go.

Dr Jeremiah Njenga wants to bring the specialty of emergency medicine to Kenya together with his mentor Dr. Wachira Benjamin. Jeremiah is the first name on the list of people waiting for sponsorship. I felt certain that it wouldn’t be difficult to raise money for him to go, so I launched a Twitter and Facebook campaign. Many people supported this campaign and started spreading the word. Therefor I was surprised to see that the only ones who had actually donated money, were two of my personal friends.

jeremiah A&E

Dr Jeremiah Njenga

I’m saddened by the irony of Ebola impeding the development of a sustainable healthcare structure, the very lack of which is the reason Ebola has been able to spread so rapidly. From my own, very limited and immensely frustrating, experience of working in a resource limited setting, I know that it requires highly dedicated people. These people need to be encouraged. They need to be selected by their hospitals to go to meetings where they can learn more, interact with others and get inspired to keep improving emergency care for their patients.

I don’t believe that most of you who read this blog post wouldn’t be willing to donate 25 or 50 dollars just so send a clear signal to Immaculate and Jeremiah that their hard work and engagement is important to all of us. I do, however, believe that some are put off by the rather complicated process of donating through the Givengain website. I wish it would be less tedious to contribute, but this is the only option AFEM has, since they are based in Africa.

There is no quick fix for emergency care in Africa. It is not the lack of equipment, and definitely not of knowledge, that are the biggest obstacles to improving care. In the long run, only dedicated people like Immaculate and Jeremiah can make this happen. As an advocate for emergency care in my own country I know the commitment and perseverance it takes and how important it is to meet others, fighting the same battle, to keep you motivated. I will personally make sure that Jeremiah goes to the AFCEM meeting in November. But Immaculate is not going.

Before you like or share this post, make sure you have donated at least a small contribution to AFEM here.

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Research and Reviews in the Fastlane 051

Research and Reviews in the Fastlane

Welcome to the 51st edition of Research and Reviews in the Fastlane. R&R in the Fastlane is a free resource that harnesses the power of social media to allow some of the best and brightest emergency medicine and critical care clinicians from all over the world tell us what they think is worth reading from the published literature.

This edition contains 10 recommended reads. The R&R Editorial Team includes Jeremy Fried, Nudrat Rashid, Soren Rudolph, Anand Swaminathan and, of course, Chris Nickson. Find more R&R in the Fastlane reviews in the R&R Archive, read more about the R&R project or check out the full list of R&R contributors

This Edition’s R&R Hall of Famer

Emergency Medicine, Critical Care, Resuscitation

R&R Hall of Famer - You simply MUST READ this!R&R Hot Stuff - Everyone’s going to be talking about thisR&R Game Changer? Might change your clinical practiceThe ARISE Investigators and the ANZICS Clinical Trials Group, Goal-Directed Resuscitation for Patients with Early Septic Shock. NEJM 2014. PMID: 25272316

The Best of the Rest

Emergency MedicineR&R Hot Stuff - Everyone’s going to be talking about thisAl Deeb M. Point-of-care Ultrasonography for the Diagnosis of Acute Cardiogenic Pulmonary Edema in Patients Presenting With Acute Dyspnea: A Systematic Review and Meta-analysis. Acad Emerg Med 2014; 21(8):843-852. PMID: 25176151

  • Point of Care Ultrasound (POCUS) is a hot topic for research currently. This systematic review and meta-analysis looks at it’s use in the diagnosis of acute cardiogenic pulmonary edema. The evidence demonstrates that in patients with a high pre-test probability and b-lines on lung US, the diagnosis of acute cardiogenic pulmonary edema is clinched. Conversely, a low pretest probability along with a negative study virtually rules out the disease.
  • Recommended by: Anand Swaminathan

Resuscitation, Critical CareR&R Game Changer? Might change your clinical practiceBro-Jeppesenemail, J et al. The inflammatory response after out-of-hospital cardiac arrest is not modified by targeted temperature management at 33 °C or 36 °C. Resuscitation 2014. PMID: 25150183

  • Post arrest hypothermia at 33 degrees takes another hit ? 168 Patients from the TTM trial were analyzed for inflammatory markers and correlated to SOFA. IL-6 levels were most consistently organ failure and even more than traditional markers like CRP and PCT. TTM at 33 °C did not modify SIRS.
  • Recommended by: Soren Rudolph

Emergency Medicine, CardiologyR&R Game Changer? Might change your clinical practiceR&R Eureka - Revolutionary idea or conceptJacob S et al. Cardiac Rhythm Device Identification Algorithm using X-Rays: CaRDIA-X. Heart Rhythm. 2011;8(6):915-22. PMID: 21220049

  • Implantable cardiac devices (AICDs, pacemakers etc) are becoming more and more common as are the complications of these devices. Often, patients presenting to the ED will require interrogation. Although all patients are supposed to carry device ID cards, the cards are often missing when most needed leading to diagnostic and management delays. These authors create a complicated but comprehensive and ultimately successful algorithm guiding clinicians through the process of identifying the device based on appearance on a chest X-ray.
  • Recommended by: Anand Swaminathan

Emergency Medicine, Gastroenterology
R&R Game Changer? Might change your clinical practiceTenner S, et al. American College of Gastroenterology guideline: management of acute pancreatitis. Am J Gastroenterol. 2013; 108(9): 1400-15. PMID: 23896955

  • The American College of Gastroenterology updated their guidelines for the acute management of pancreatitis and there’s a smattering of dogmalysis. Antibiotics, while good if the patient has a bacteremia or cholangitis, are largely out in these guidelines, and are notably discouraged for prophylaxis. Some other notable pearls: they say “no” to the routine use of CT and recommend ultrasound and enteral feeds in nearly all cases. They also emphasize that the severity of pancreatitis is best picked up by seeing how patients respond over time to treatment, not a simple clinical score.
  • Recommended by: Lauren Westafer

Airway, AnesthesticsR&R Eureka - Revolutionary idea or conceptGray RM, Rode H. Intra-operative endotracheal tube stabilisation for facial burns. Burns. 2010; 36(4): 572-5. PMID: 20061089

  • A trick to help secure an ETT in a patient with facial burns. Although used on 12 patients, it is still awesome, especially if you have to transfer a patient.
  • Recommended by: Sa’ad Lahri

Critical Care, RespiratoryR&R Hot Stuff - Everyone’s going to be talking about thisHARP-2 Investigators, for the Irish Critical Care Trials Group. Simvastatin in the Acute Respiratory Distress Syndrome. NEJM 2014. PMID: 25268516

  • This was a large, multicenter, double-blind, randomized, placebo-controlled clinical trial involving patients with ARDS and showed that simvastatin, as compared with placebo, did not improve clinical outcomes. It looked at a larger population that the recent SAILS study which looked at rosuvastatin in sepsis associated ARDS and together they add to the increasing evidence that shows that statins do not have a routine role in ARDS.
  • Recommended by: Nudrat Rashid

Critical CareR&R Game Changer? Might change your clinical practiceR&R Boffintastic - High quality researchLars B. Holst et al. Lower versus Higher Hemoglobin Threshold for Transfusion in Septic Shock. NEJM 2014. PMID: 25270275

  • This multicenter RCT addresses the gap between clinical practice and the lack of efficacy and safety data on RBC transfusion in septic shock patients. The authors didn’t find differences in mortality, organ failure or ischaemic events when comparing patients assigned to blood transfusion at a higher hemoglobin threshold to those assigned to blood transfusion at a lower threshold.
  • Recommended by: Soren Rudolph, Nudrat Rashid

Emergency Medicine, Infectious DiseasesR&R Game Changer? Might change your clinical practiceHayward G et al. Corticosteroids as standalone or add-on treatment for sore throat. Cochrane Database Syst Rev 2012 PMID: 23076943

  • Do steroids work for sore throat?
    This Cochrane Review included 8 articles comparing steroids vs placebo in patients with sore throat who were also treated with antibiotics.
    The steroid group showed a significant decrease in pain at 24 hours and an overall decrease in time to resolution of pain. This was true for both oral and IM routes with an NNT = 4.
    It appears that patients with sore throat is one place where steroids are useful!
  • Recommended by: Zack Repanshek

Retrieval, Prehospital and DisasterR&R WTF Weird, transcendent or funtabulous!” width=Barnung S,  A prehospital use of ITClamp for haemostatic control and fixation of a chest tube. Acta Anaesthesiol Scand 2014; 58: 251–253. PMID: 24325619

  • The ITClamp – a smart little device – here’s 3 cases where it was used for haemostatic control and immediate securing of a chest tube.
  • Recommended by: Soren Rudolph

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

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Research and Reviews in the Fastlane 050

Research and Reviews in the Fastlane

Welcome to the 50th edition of Research and Reviews in the Fastlane. R&R in the Fastlane is a free resource that harnesses the power of social media to allow some of the best and brightest emergency medicine and critical care clinicians from all over the world tell us what they think is worth reading from the published literature.

This edition contains 10 recommended reads. The R&R Editorial Team includes Jeremy Fried, Nudrat Rashid, Soren Rudolph, Anand Swaminathan and, of course, Chris Nickson. Find more R&R in the Fastlane reviews in the R&R Archive, read more about the R&R project or check out the full list of R&R contributors

This Edition’s R&R Hall of Famer

Emergency Medicine, Ultrasound and Imaging

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

R&R Hot Stuff - Everyone’s going to be talking about thisR&R Game Changer? Might change your clinical practiceSmith-Bindman R et al. Ultrasonography versus Computed Tomography for Suspected Nephrolithiasis. NEJM 2014; 371(12):1100-10 PMID: 25229916

  • Renal colic is a common presentation that often ends in a patient having a CT of the abdomen and pelvis. This article attempts to demonstrate that Ultrasound, whether radiologist performed or POC by ED physicians, is at least equivalent to CT in terms of adverse patient events. Although the protocol was convoluted and multiple primary endpoints were described, the study demonstrated an equivalent serious adverse outcome rate suggesting that ultrasound may safely be used as an initial confirmatory test for ureterolithiasis when a confirmatory test is determined to be needed. (Ryan Radecki)
  • A RCT for US – Yay! Almost 3000 pts compared ED US, Rad US and CT. Outcomes were – did we misdiagnose anything bad? And yes the docs missed a few bad things – but it was the same in all 3 groups so ED US doesn’t seem to be killing people with misdiagnosis. Interestingly (according to their gold standard of visualised stone passage or surgery) all 3 groups had the same sens/spec of 85/50% respectively
  • We do a ton of CTs looking for renal tract stones and there has never been any evidence that this improves patient outcomes. (Andy Neill)
    People are going to pick up this paper expecting it to tell them that ultrasound is as good as CT for diagnosing these stones. Unfortunately that’s not what it says.
    This study compared bedside US by EPs vs radiology US vs CT as the INITIAL test in patients expected with nephrolithiasis. It found there was no difference in serious outcomes between the groups, but the rate of serious outcomes was overall very low.
    Obviously patients that got only an US had lower radiation exposure and lengths of stay. But what is interesting is that 40% of patients with an initial ED US went on to get a CT also.
    This study does not state that patients should ONLY undergo US, just that it should be the INITIAL test. If it cuts down on our CT ordering, it sounds like a good start. (Zack Repanshek)
  • Recommended by: Ryan Radecki, Andy Neill, Zack Repanshek
  • Read More: Farewell, CT Stone Protocol (EM Literature of Note), RCT of ED Renal Ultrasound for renal colic (Emergency Medicine Ireland)

The Best of the Rest

Resuscitation, Emergency Medicine

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

Marik P. Early management of severe sepsis: concepts and controversies. Chest 2014; 145(6):1407-18. PMID: 24889440

  • A great review from Paul Marik on severe sepsis. Discusses our current understanding of sepsis and highlights a number of controversies including fluid resuscitation, CVP, ScvO2, lactate clearance and more.
  • Recommended by: Anand Swaminathan

Emergency Medicine

R&R Game Changer? Might change your clinical practice
Mellick LB. Torsion of the Testicle It Is Time to Stop Tossing the Dice. Pediatr Emerg Care 2012; 28(1):80-6.PMID: 22217895

  • Excellent literature review of a relatively uncommon but serious disease where time and rapidity of diagnosis matters. The bulk of the literature shows that no individual feature of the history or physical examination can be relied upon to definitively rule in or rule out the disease. Color Doppler commonly has false positives and the myth that symptoms for more than 6 hours indicates that the testicle will be non-salvageable is incorrect. The key is suspecting the disease and getting a urologic consultation immediately.
  • Recommended by: Anand Swaminathan

Emergency Medicine, Resuscitation

R&R Game Changer? Might change your clinical practice
Rochwerg B, Alhazzani W, Sindi A, Heels-Ansdell D, Thabane L, Fox-Robichaud A, et al. Fluid Resuscitation in Sepsis: A Systematic Review and Network Meta-analysis. Ann Intern Med. 2014;161:347-355. PMID: 25047428

  • So you’re working on a septic patient and the med student in the corner of the room asks – “But Dr. Bigshot, why are you flooding the patient with so much “normal” saline?” Why indeed! This systematic review + meta-analysis tries to answer the age old question of optimal resus fluid selection, specifically in septic patients. The authors make a gallant effort, but most of the numbers are not particularly compelling. That said, their intro and discussion sections provide great background and are an illuminating, easy read even for the novice resuscitationist. This paper might even encourage you to tweak your practice.
  • Recommended by: David Marcus, MD

Emergency Medicine, Cardiology
R&R Game Changer? Might change your clinical practiceKirkland S1, Stiell I, AlShawabkeh T, Campbell S, Dickinson G, Rowe BH. The Efficacy of Pad Placement for Electrical Cardioversion of Atrial Fibrillation/Flutter: A Systematic Review. Acad Emerg Med. 2014 Jul;21(7):717-726. PMID: 25117151

  • There’s a good deal of pathophysiologic theory that has created preference for pad placement in cardioversion of atrial fibrillation/flutter. This systematic review of 13 studies that evaluated pad placement in either the Anterior-Posterior (AP) fashion compared with the Antero-Lateral (AL) position for the cardioversion of atrial fibrillation and found no difference, with a signal towards better success in those with pads in the AL position receiving biphasic cardioversion. The studies they pooled had significant limitations – varying levels of energy, limited ED studies, and heterogeneity. However, this serves another example of how pathophysiologic explanation may not translate into changed patient outcomes.
  • Recommended by: Lauren Westafer

Emergency Medicine, Infectious Disease

R&R Eureka - Revolutionary idea or conceptShapiro NI, Karras DJ, Leech SH, Heilpern KL. Absolute lymphocyte count as a predictor of CD4 count. Ann Emerg Med. 1998; 32:323-8. PMID: 9737494.

  • Classic paper demonstrating that all you need is a CBC with diff to estimate a patient’s CD4 count. Simple calculation for absolute lymphocyte count (ALC, like doing an ANC for neutropenia): total WBC x % lymphs. ALC>2,000 = CD4>200. ALC<1,000 = CD4<200. Grey area in the middle, and not perfectly accurate, but certainly better than guessing at a CD4.
  • Recommended by: Seth Trueger

Emergency Medicine

R&R Hot Stuff - Everyone’s going to be talking about this
Chu K et al. Spectrophotometry or Visual Inspection to Most Reliably Detect Xanthochromia in Subarachnoid Hemorrhage: Systematic Review. Ann Emerg Med 2014; 64(3):256-264. PMID: 24635988

  • Xanthochromia has long been the gold-standard test in the diagnosis of subarachnoid hemorrhage after negative non-contrast head CT. However, the determination of xanthchromia is performed in two different ways: visual inspection and spectrophtometry. While it would seem that spectrophotometry would be a superior modality, this systematic review finds that the available evidence is inconclusive. These conclusions further call in to question the utility of LP after CT if the “gold-standard” itself is unclear.
  • Recommended by: Anand Swaminathan

Emergency Medicine

R&R Game Changer? Might change your clinical practice
Mahoney BA et al. Emergency interventions for hyperkalaemia (Review). Cochrane Database Syst Rev. 2005; 18(2): PMID: 15846652

  • This is a systematic review of hyperkalemia management done by the Cochrane group looking only at randomized evidence. The conclusions aren’t shocking but bear repeating. IV calcium is effective in treating dysrhythmias. Nebulized/Inhaled beta agonists (i.e. albuterol/salbutamol) and insulin (paired with dextrose) are first line therapies as well. While dialysis is effective, potassium absorbing resins (i.e. Kayexalate) was not effective at 4 hours and there was no longer follow up data for this intervention.
  • Recommended by: Anand Swaminathan

Emergency Medicine


Sinnaeve PR, Armstrong PW, Gershlick AH, Goldstein P, Wilcox R, Lambert Y, et al. STEMI Patients Randomized to a Pharmaco-Invasive Strategy or Primary PCI: The STREAM 1-Year Mortality Follow-Up. Circulation. 2014. PMID: 25161043

  • The fine folks at Boehringer Ingelheim are trying to convince us to give more tenecteplase for STEMI – patients between 60 and 120 minutes out from primary PCI. But, there’s no evidence these patients do any better – and they probably do worse. Any small cost savings from deferring emergent off-hours cardiac catheterization are reduced by the added cost of the drug.
  • Recommended by: Ryan Radecki
  • Read More: Emergency PCI for STEMI is Dead? (EM Literature of Note)

Emergency Medicine

R&R Game Changer? Might change your clinical practice

Eskin B, Shih RD, Fiesseler FW, Walsh BW, Allegra JR, Silverman ME, Cochrane DG, Stuhlmiller DF, Hung OL, Troncoso A, Calello DP. Prednisone for emergency department low back pain: a randomized controlled trial. J Emerg Med. 2014 Jul;47(1):65-70. PMID: 24739318.

  • Do steroids help for musculoskeletal back pain?
    Approximately 5% of patients with ED diagnosis of musculoskeletal back pain leave with a prescription for steroids, despite lack of evidence of any benefit.
    This was a randomized, double-blind, placebo controlled study with patients randomized to 5 days of prednisone or placebo after discharge, along with analgesic of doctor’s choosing. There was no difference in pain between the two groups 5-7 days after discharge.
    With the lack of any benefit and the risk of GI side effects, especially when used with NSAIDs, there is no role for the use of steroids in treatment for musculoskeletal back pain.
  • Recommended by: Zack Repanshek

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!

 

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Research and Reviews in the Fastlane 049

Research and Reviews in the Fastlane

Welcome to the 49th edition of Research and Reviews in the Fastlane. R&R in the Fastlane is a free resource that harnesses the power of social media to allow some of the best and brightest emergency medicine and critical care clinicians from all over the world tell us what they think is worth reading from the published literature.

This edition contains 10 recommended reads. The R&R Editorial Team includes Jeremy Fried, Nudrat Rashid, Soren Rudolph, Anand Swaminathan and, of course, Chris Nickson. Find more R&R in the Fastlane reviews in the R&R Archive, read more about the R&R project or check out the full list of R&R contributors

This Edition’s R&R Hall of Famer

Emergency Medicine, Cardiology

R&R Hall of Famer - You simply MUST READ this!R&R Eureka - Revolutionary idea or concept

Stolker JM et al. Re-Thinking Composite Endpoints in Clinical Trials: Insights from Patients and Trialists. Circulation. 2014. PMID: 25200210

  • Composite endpoints are commonplace, especially in cardiology literature. It takes massive power to find mortality/major mobidity benefits for many interventions; thus, many studies are powered for a primary composite outcome, often: death, myocardial infarction (MI), and revascularization. This cardiology survey data highlights that both patients and trial researchers appreciate the inequity between death and revascularization. The shocker? Patients rated MI and stroke worse than death, whereas researchers rated MI and stroke as 1/3 to 1/2 as important as death. Both clinical trialists and patients rated revascularization as a minor event, in contradistinction to the equal weight placed in the composite primary outcome in many trials.
  • Recommended by: Lauren Westafer, Anand Swaminathan
  • Read More: Would You Rather . . . (Lauren Westafer)

The Best of the Rest

Resuscitation, Emergency Medicine

R&R Game Changer? Might change your clinical practice

Hernandez, C et al. C.A.U.S.E.: Cardiac arrest ultra-sound exam–a better approach to managing patients in primary non-arrhythmogenic cardiac arrest.Resuscitation. 2008 Feb;76(2):198-206. PMID: 17822831

  • Having a practical approach to managing a PEA is crucial. This paper has used the C.A.U.S.E. mnemonic (appropriately termed) to find reversible causes. In addition this protocol has the potential to reduce the time required to determine the etiology of a cardiac arrest and thus decrease the time between arrest and appropriate therapy.
  • Recommended by: Sa’ad Lahri

Emergency Medicine

R&R Landmark paper that will make a difference
Calder KK et al. The mortality of untreated pulmonary embolism in emergency department patients. Ann Emerg Med. 2005 Mar;45(3):302-10. PMID: 15726055

  • This 2005 paper questions the mortality rate of untreated PE — they find only 5%. Scary numbers from PE probably represent old data when the only PEs we found were big, bad… and obvious.
  • Recommended by: Seth Trueger

Emergency Medicine, Cardiology

R&R Hot Stuff - Everyone’s going to be talking about this
Thiruganasambandamoorthy V et al. Outcomes in Presyncope Patients: A Prospective Cohort Study. Ann Emerg Med 2014. PMID: 25182542

  • Pre-syncope is often thought of as a benign occurrence but in this prospective study, the authors found that 5.1% of patients with presyncope had serious outcomes at 30 days. This rate was only 1.9% in the group sent home from the Emergency Department. Emergency Physicians had a tough time determining which patients with presyncope were at risk for serious outcomes after discharge. This area needs more research but it is clear that we should take presyncope seriously.
  • Recommended by: Anand Swaminathan

Pre-hospital/Retrieval, Resuscitation
R&R Game Changer? Might change your clinical practice

Jabre P et al. Family presence during cardiopulmonary resuscitation. NEJM 2013; 368(11):1008-18. PMID: 23484827 (OPEN ACCESS ARTICLE)

  • Should the family watch? In this study, home CPR was performed by responding EMS units, half offered the family the opportunity to be present for resuscitation, half did not. Post-surveys were conducted 90 days later on family and health care workers.
    PTSD and anxiety symptoms were less in the family members who witnessed the resuscitation. Health care workers did not report increased stress levels or that family interfered with resuscitation.
  • Application to emergency department and critical care setting is questionable given this was a French pre-hospital study, but it suggests that family presence in resuscitation may be good for family members and does not hinder the care provided.
  • Recommended by: Zack Repanshek

Pediatrics, Emergency Medicine
R&R Game Changer? Might change your clinical practice

Cohen HA et al. Effect of honey on nocturnal cough and sleep quality: a double-blind, randomized, placebo-controlled study. Pediatrics. 2012 Sep;130(3):465-71. PMID: 22869830 (OPEN ACCESS ARTICLE)

  • If you aren’t using honey for cough in kids (>!yr old only!), then you should be. Not many drugs are effective, and this RCT shows that it wasn’t simply sticky sweet syrup, but something specific about honey as yet unidentified.
  • Recommended by: Justin Hensley

Emergency Medicine

R&R Eureka - Revolutionary idea or concept

Rising KL et al. Return Visits to the Emergency Department: The Patient Perspective. Ann Emerg Med 2014. PMID: 25193597

  • New article in Annals looking at 60 bouncebacks — great qualitative research with patient perspectives on why they had to come back. A lot of uncertainty, worry, poor explanation. And, not surprisingly, patients thought blood work or imaging would have been necessary (would be nice to see the physicians’ perspectives!)
  • Recommended by: Seth Trueger

Emergency Medicine

R&R Eureka - Revolutionary idea or concept
Sheehy AM et al. The Role of Copy-and-Paste in the Hospital Electronic Health Record. JAMA Intern Med. 2014 Aug 1;174(8):1217-8. PMID: 24887572

  • We are seeing more attention paid to how we use electronic health records (EHRs), and this paper addresses one the most contentious issues in the EHR era, the use of “macros” or templates to document care. The authors outline the problem (documenting what you did not do, i.e. fraud) and propose user-based and systems-based solutions. Ultimately they conclude the force that drives inappropriate documentation is the perverse ways in which hospitals and physicians are reimbursed (e.g. by documenting a “complete” review of systems) and that without changing these incentives, progress on the copy & paste front will be difficult.
  • Recommended by: Reuben Strayer

Pediatrics, Resuscitation

R&R Game Changer? Might change your clinical practice
Tibballs J, Russell P. Reliability of pulse palpation by healthcare personnel to diagnose paediatric cardiac arrest. Resuscitation. 2009 Jan;80(1):61-4. PMID: 18992985

  • In the healthy child, finding a pulse is not a problem. Unfortunately, our management is not usually contingent upon finding a pulse in the healthy kid, whereas it is vital in the sick one… especially if they are unresponsive. “Do you feel a pulse?” “Hmmm… I think so… well, maybe not…” “Does anyone feel a pulse?” This paper essentially points out that we are not perfect at determining whether there is a pulse present or not. When time is of the essence, wasting time trying to be perfect is unwise. This helps advocate for two things in my mind: 1) More liberal use of chest compressions in the patient who is unresponsive , lacks movement, or has poor respirations and (2) more liberal use of bedside ultrasound (although not right away… as you only have 10 seconds to make a decision).
  • Recommended by: Sean Fox
  • Read More: Palpation of Pulse for Cardiac Arrest (Sean Fox)

Obstetrics/Gynecology, Emergency Medicine

R&R Game Changer? Might change your clinical practice

Glasier A et al. Can we identify women at risk of pregnancy despite using emergency contraception? Data from randomized trials of ulipristal acetate and levonorgestrel. Contraception 2011; 84: 363-7. PMID: 21920190

  • Not all women respond to emergency contraception medications the same. This study found that women with higher BMI (> 25) were at an increased risk for medication failure (OR 3.60). The authors recommend that women with higher BMIs should be offered copper IUDs (not realistic in most EDs). Alternatively, some agents are more effective and may be viable options.
  • 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!

 

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