Research and Reviews in the Fastlane 080

Research and Reviews in the Fastlane

Welcome to the 80th 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

Infectious Diseases
R&R Hall of Famer - You simply MUST READ this!
Potsma DF et al. Antibiotic Treatment Strategies for Community-Acquired Pneumonia in Adults. NEJM 2015; 72(14):1312-23. PMID: 25830421

  • Most community acquired pneumonia guidelines recommend a beta-lactam plus a macrolide or fluoroquinolone monotherapy in the treatment of non-ICU patients. But the evidence behind these recommendations is not clear. This non-inferiority study looked at the 90 day mortality rates of beta-lactam monotherapy as compared to the current recommendations, and found the monotherapy was not inferior. This study calls into question the current guidelines and will hopefully lead to more evidence-based recommendations in the future.
  • Recommended by: Zack Repanshek
  • Read More: Antibiotics for community-acquired pneumonia: Is azithromycin out? (Pulm CCM)

The Best of the Rest

Ophthalmology, Ultrasound
R&R Hot Stuff - Everyone’s going to be talking about this
Vrablik ME et al. The diagnostic accuracy of bedside ocular ultrasonography for the diagnosis of retinal detachment: a systematic review and meta-analysis. Ann Emerg Med 2015; 65(2):199-203. PMID: 24680547

  • Nice meta-analysis of bedside US for retinal detachment in Annals of EM showing 97-100% sensitivity, 83-100% specificity, based on 3 small studies (201 patients). Certainly not perfect but in the right patients should be useful — can certainly make a middle-of-the-night phone call to a sleeping ophthalmologist much easier.
  • Recommended by: Seth Trueger

Critical CareR&R Mona Lisa -Brilliant writing or explanation” width=

Marik PE. Enteral nutrition in the critically ill: myths and misconceptions. Crit Care Med. 2014;42:(4)962-9. PMID: 24296860

  • If a paper can make anyone interested in nutrition in the critically ill, it is this review by Dr. Paul Marik. The key, myth busting take-homes in this evidence review:
    *Nutrition should be a priority in the critically ill
    *Enteral nutrition is safe in patients on vasopressors.
    *Gastric residuals are not a reliable indicator of aspiration risk. Studies looking at interrupting feeds with gastric residual volumes >200-250 mL vs > 400-500 mL show no difference in pneumonia/mortality.
    *Ileus is not a contraindication to feeds. In ICU patients “neither the presence nor the absence of bowel sounds nor evidence of the passage of flatus or stool is required for the initiation of enteral feeding”
  • Recommended by: Lauren Westafer

Education, Trauma
R&R Eureka - Revolutionary idea or concept

Lorello GR et al. Mental practice: a simple tool to enhance team-based trauma resuscitation. Can J Emerg Med 2015. PMID: 25860822 (FREE OPEN ACCESS ARTICLE)

  • Can mental practice (MP) and visualization improve patient care? The authors of this study show that MP improves the performance of trainees in simulated trauma care in comparison to traditional ATLS training specifically in the realm of team dynamics. Continued research in this area is needed but MP is cheap (read: free), can be done anytime, anywhere and should be more widely used.
  • Recommended by: Anand Swaminathan

Trauma
Salibi A, Barabas A. The ‘pole and tent’ pressure dressing. Emerg Med J 2015;32(3):254. PMID: 25239952

  • Who doesn’t want another tool in their kit for controlling bleeding? This short letter to EMJ describes (with pictures) a “tent and pole” technique for applying point pressure while minimizing distal ischemia and venous congestion. This technique is likely most helpful in the prehospital setting where more definitive management tools may not be available.
  • Recommended by: Jeremy Fried

Psychiatry and Mental Health, Emergency Medicine
Ryan C et al. Clinical decisions in psychiatry should not be based on risk assessment. Australas Psychiatry 2010; 18(5): 398-403. PMID: 20863176

  • Risk assessment of violence / self-harm is a cornerstone of ED decision-making. But does it actual help? Can we predict risk or are the commonly used tools unable to assist us in making these often difficult decisions.
  • Recommended by: Casey Parker

Resuscitation, Emergency Medicine
R&R Hot Stuff - Everyone’s going to be talking about this

Fuller BM, et al. Mechanical Ventilation And Acute Respiratory Distress Syndrome In The Emergency Department: A Multi-Center, Observational, Prospective, Cross-Sectional Study. Chest 2015. PMID: 25742126

  • This is a small, multicenter study of US emergency departments assessing the utilization of lung protection strategies (LPS) in ventilated patients. ARDSNet recommendations of low tidal volumes were only used in 58% of overall patients and less than 50% in patients with actual ARDS. It appears that a significant number of patients who may benefit from LPS are not receiving the intervention.
  • Recommended by: Daniel Cabrera

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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EMA Journal April 2015

Issue 2 (Vol. 28) of EMA Journal for 2015 was published online on 25th March. Editorial overview by Andrew Gosbell & Geoff Hughes

ED Models of Care  (Abstract)

A range of models of care (MOCs) have been implemented in order to improve the key ED functions of patient evaluation, treatment and/or discharge/admission. This systematic review, from Wylie et al, examined ED MOCs in terms of quality/effectiveness of care and cost, with reference to the 3 phases of emergency care: input, throughput and output. There is an absence of cost benefit analysis for MOCs to reduce ED inputs. In addition, there is substantial variation in how available resources are valued in respect of the MOCs implemented by EDs to address throughput and optimal patient disposition, and no cost-effectiveness analysis. Research into cost benefits and clinical outcomes of MOCs and ED staff mix is needed in order for reliable assessments of their impact on safety, clinical effectiveness and cost effectiveness. This is important as public hospital budgets continue to remain under pressure

Lessons from the history of Australasian disasters  (#FOAMed)

In the current context of devastating natural disasters experienced across Australasia, Bradt and colleagues examined disaster management in Australasia, by undertaking an epidemiological analysis of Australasian disasters that have occurred since 1900. Timeline analysis revealed an increasing incidence in natural disasters over the last fifteen years, with the disasters occurring in most recent years having the highest death toll and greatest economic losses. The response to most disasters of national significance, and all terrorist acts, has been the introduction of reactive hazard-specific legislation. However, the increasing vulnerability of Australasia to disaster suggests that a comprehensive all hazards model of legislation is required to improve future resilience.

Diagnostic error – missed fractures  (#FOAMed)

This case study from Australasian Emergency Medicine Events Register, EMER, by Deakin et al, describes the failure of a registrar to correctly identify a triquetral fracture on X-ray. It highlights the system issue of lack of timely radiological reporting that could potentially result in significant patient harm. Emergency Medicine Events Register (EMER) is an anonymous, confidential and protected incident-reporting system, supported by ACEM. Anyone working in emergency medicine can enter a near miss or error by following the link to EMER. Reporting takes 5 min and will help to inform practice and improve patient safety in emergency medicine.

CLINICAL PROCEDURES: Paediatric ENT foreign bodies  (#FOAMed)

Children seem to be able to find a seemingly inexhaustible variety of objects to stick into all sorts of places they were not supposed to go! In this clinical procedures, Craig and colleagues give advice on managing common paediatric ED presentations due to aural and nasal foreign bodies, including suggestions on non-invasive techniques that can be useful; tips on analgesia and sedation; and options on the specific types of instruments that are suitable for particular types of foreign bodies. Specific mention is made on button batteries, due to the potential for significant complications, which need urgent removal.

TRAINEE FOCUS: role of short courses in EM training  (#FOAMed)

A growing number of short courses are available to emergency medicine clinicians, covering a variety of areas such as trauma, resuscitation, ultrasound, paediatric emergencies and research methods. This Trainee Focus considers whether such short courses should be mandatory requirements for ACEM trainees (Reference 1). There’s no dispute that there are many benefits in undertaking short courses and Williams contends that accredited compulsory courses provide clarity on the standards to which emergency physicians are trained (Reference 2). However, MacKenzie argues that rather than mandating courses, adult learning approaches, with individual learning goals, developed against the new ACEM curriculum, should be encouraged to enable trainees to proactively identify their own training needs (Reference 3). Twitter feedback on this topic is also provided. An accompanying interview with Director of the Emergency Trauma Management course, Andy Buck (@edexam), explores the rationale for developing a new EM-focused course, the underlying educational theory and the role of external courses in the FOAMed era.

Further reading:

EMA Journal Banner

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JellyBean 018 with Paul Young

So SMACC is nearly upon us.
I wouldn’t like to be organising it. Paul Young is going and he is hilarious. And very smart. And a research rising star. I certainly have all his mind maps via LITFL.
He knows how to put a meeting together having recently been the Medical Convener of the ASM of the worlds first College of Intensive Care Medicine. (He is, however, rather humble about how hard it was to dream it all up.)And he controls the weather. Is there anything he cannot do? Well, he couldn’t comment when he was asked comment on the goings on at the notorious Boogie Wonderland Night Club late one night in Wellington. The plot thickens

JellyBean Large

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LITFL Review 178

LITFL review

Welcome to the 178th 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 week, the EMCrit podcast features part 2 of “Who Needs an Acute PCI” with Dr Steve Smith. This, along with part 1, is a must listen for all providers. [MG]

 

The Best of #FOAMed Emergency Medicine

  • Does CAP therapy need to included coverage of atypical microbes? PulmCCM reviews the NEJM article bringing traditional care into question. [AS]
  • EM Lyceum reviews debatable issues in the management of potential spinal cord injuries. [AS]
  • Dave Schriger discusses “Whose Risk are You Managing?” at Essentials of Emergency Medicine. [AS]
  • A really useful introduction to pressors and inotropes in the ED from the HEFTEMcast guys this week. [CC]
  • St. Emlyn’s journal club covers an article comparing subdissociative ketamine to morphine for acute pain management. Natalie May blogs about the virtues of ketamine as an analgesic and takes the opportunity to discuss the difference between superiority, non-inferiority, no difference and equivalence. Now we just have to wait for the ‘drought to end’….[CC, AS]

The Best of #FOAMcc Critical Care

  • Amazing video capture of an open cric performed on an arresting patient via Reuben Strayer using the scalpel, finger, bougie technique. [AS]

The Best of #FOAMtox Toxicology

  • Can you predict which of your withdrawing alcohol dependent patients will develop DTs?  There may be some predictive tests out there, but then again…..[CC]

News from the Fast Lane

Reference Sources and Reading List

Brought to you by:

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Research and Reviews in the Fastlane 079

Research and Reviews in the Fastlane

Welcome to the 79th 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

Trauma, Resuscitation
R&R Hall of Famer - You simply MUST READ this!
Hunt H et al. Thromboelastography (TEG) and rotational thromboelastometry (ROTEM) for trauma-induced coagulopathy in adult trauma patients with bleeding. Cochrane Database of Systematic Reviews 2015, Issue 2. PMID: 25686465

  • The use of thromboelastography (TEG) and rotational thromboelastometry (ROTEM) has became standard in many trauma systems to assess for Trauma induced coagulopathy (TIC). This systematic review searched and analyzed the current available literature about the accuracy of ROTEM/TEG to assess for TIC. Surprisingly high quality evidence is scant. None of the identified studies had as primary end-point to assess for accuracy and there are some concerns from the researchers about bias about the gold-standard. From the parameters evaluated, only clot amplitude have same relation with TCI, but with not enough power. The authors conclude that TEG/ROTEM is not ready for clinical prime-time use.
  • Recommended by: Daniel Cabrera

The Best of the Rest

Airway, Resuscitation

Barnard EB et al. Rapid sequence induction of anesthesia via the intraosseous route: a prospective observational study. Emerg Med J 2014. PMID: 24963149

  • Lung US has pretty impressive test characteristics for the diagnosis of Pads pneumonia.
    Here is the latest metanalysis to show it works.
  • Recommended by: Salim Rezaie
  • Read More: February 2015 REBEL Cast (REBEL EM)

Infectious Diseases
R&R Trash - Must read, because it is so wrong!

Dobson J et al. Oseltamivir treatment for influenza in adults: a meta-analysis of randomised controlled trials. Lancet 2015. PMID: 25640810

  • This is another Roche pharmaceutical sponsored study looking at individual patient level data to find a benefit for oseltamivir in the treatment of influenza. Overall, the MUGAS foundation (unrestricted grant from Roche) found that oseltamivir shortened symptoms of influenza by about 18 hours. This was in comparison to placebo (no supportive care with acetaminophen or NSAIDs) and came at the cost of increased nausea and vomiting. Additionally, there was no benefit in patients with flu-like symptoms that did not have influenza based on testing. The question we have to ask is whether 18 hours of less symptoms is worth the cost of the drug, testing and the increased side effects.
  • Recommended by: Anand Swaminathan

Pediatrics, Trauma
R&R Eureka - Revolutionary idea or conceptDayan PS et al. Headache in Traumatic Brain Injuries From Blunt Head Trauma. Pediatrics 2015;135(3): 504-12. PMID: 25647678

  • This is another analysis of the PECARN head injury data in which the authors look at the effects of single components of the decision aid and, in this case, it’s headache. Most kids with an injury and headache did not receive CT scans and, of those who did, most with PECARN isolated headache did not have clinically significant TBI (3/209, 1.4%). With this decision aid, it seems the key is the ‘observation vs CT component” and the former may often be reasonable for isolated positive findings. Recall, the vital component to all decision tools remains- clinical gestalt.
  • Recommended by: Lauren Westafer

Pediatrics, Toxicology
Whitney RE, et al. Diffuse corneal abrasion after ocular exposure to laundry detergent pod. Pediatr Emerg Care. 2015; 31(2): 127-8. PMID: 25422858

  • Many of us are aware, or at least becoming aware, of the unique hazards that Laundry Detergent Pods can cause. For as yet poorly understood reasons, the pods can cause altered mental status and this, naturally makes us worry; however, don’t be cavalier if they are alert and crying about their eye pain! These pods can lead to serious eye injuries due to their alkali contents.
  • Recommended by: Sean Fox
  • Read More: Laundry Detergent Pod Toxicity (Pediatric EM Morsels)

Pediatrics, Toxicology
Russell JL, et al. Significant chemical burns associated with dermal exposure to laundry pod detergent. J Med Toxicol. 2014; 10(3): 292-4. PMID: 24526400

  • We just mentioned how the laundry detergent pods can lead to eye injuries… well, apparently they can cause dermal burns as well! Make sure you expose the patients, remove contaminated clothing, and irrigate the exposed areas!
  • Recommended by: Sean Fox

Airway, Ultrasound
R&R Hot Stuff - Everyone’s going to be talking about thisDas SK et al. Transtracheal ultrasound for verification of endotracheal tube placement: a systematic review and meta-analysis. Can J Anes 2014. PMID: 25537734 

  • There are many techniques to confirm that an ETT is in the correct location (trachea versus esophagus): bilateral breath sounds, chest rise, chest X-ray and End Tidal CO2. This article is a meta-analysis looking at a relatively new technique: POC Ultrasound. This review found that for ED intubations, US had a sensitivity of 98% and a specificity of 94%. The question, however, should be whether this technique is faster than End Tidal CO2, which is extremely reliable.
  • Recommended by: Anand Swaminathan
  • Read More: Ultrasound for Verification of Endotracheal Tube Location (ALiEM)

The R&R iconoclastic sneak peek icon key

Research and Reviews The list of contributors R&R in the FASTLANE 009 RR Vault 64 The R&R ARCHIVE
R&R in the FASTLANE Hall of Famer R&R Hall of famer You simply MUST READ this! R&R Hot Stuff 64 R&R Hot stuff! Everyone’s going to be talking about this
R&R in the FASTLANELandmark Paper R&R Landmark paper A paper that made a difference R&R Game Changer 64 R&R Game Changer? Might change your clinical practice
R&R Eureka 64 R&R Eureka! Revolutionary idea or concept R&R in the FASTLANE RR Mona Lisa R&R Mona Lisa Brilliant writing or explanation
R&R in the FASTLANE RR Boffin 64 R&R Boffintastic High quality research R&R in the FASTLANE RR Trash 64 R&R Trash Must read, because it is so wrong!
R&R in the FASTLANE 009 RR WTF 64 R&R WTF! Weird, transcendent or funtabulous!

That’s it for this week…

That should keep you busy for a week at least! Thanks to our wonderful group of editors and contributors Leave a comment below if you have any queries, suggestions, or comments about this week’s R&R in the FASTLANE or if you want to tell us what you think is worth reading.

 

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JellyBean 017 with Prof Derek Angus

Derek Angus; 15/15 on the Glasgow Conversational Scale.Derek was in the headlines recently being the lead author of the PROCESS trial. You may have heard him on EMCrit talking about that study. But where does he come from, how did he get here?

I caught up with Derek in Wellington, New Zealand at the Paul Young curated “Down with Dogma” College of Intensive Care Medicine Annual Scientific Meeting and I won’t pretend; I really like him. Angus is a Prince of research. Do a Pubmed search for him if you don’t believe me; there are literally hundreds of papers.

He started out at Glasgow University. (I seem to have a thing for Glaswegians a.k.a. “Weegies”) He was aiming at neurosurgery but after his MRCP and became the first Commonwealth citizen to work for MSF back when MSF were much, much smaller. This conversation was just too interesting to stop around 10 minutes as Jellybeans usually are. Have a listen. I think you’ll like it.
Well he was dancing with Steve Webb of the ANZICS CTG around 2am in Wellington, so the chances are good.

Maybe research and researchers are sexy?

JellyBean Large

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