Research and Reviews in the Fastlane 048

Research and Reviews in the Fastlane

Welcome to the 48th 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

Prehospital/Retrieval, Resuscitation

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

R&R Game Changer? Might change your clinical practice

Mal S et al. Effect of Out-of-Hospital Noninvasive Positive-Pressure Support Ventilation in Adult Patients With Severe Respiratory Distress: A Systematic Review and Meta-analysis. Ann of EM 2014; 63(5):600-607. PMID: 24342819

  • Over the last decade, health care providers have been increasingly aggressive in starting NIPPV early in management. Numerous studies demonstrate decreased ICU admissions and decreased intubation rates when NIPPV is used in the ED in patients with COPD exacerbations and acute decompensated heart failure. This systematic review and meta-analysis demonstrates significant reductions in in-hospital mortality (NNT = 18) and invasive ventilation (NNT = 8) when NIPPV is applied in the prehospital setting.
  • Recommended by: Salim Rezaie, Anand Swaminathan
  • Read More: September REBEL Cast (Salim Rezaie)

The Best of the Rest

Emergency Medicine, Pediatrics

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

Del Pizzo J1, Callahan JM. Intranasal medications in pediatric emergency medicine. Pediatr Emerg Care. 2014;30(7):496-501. PMID: 24987995

  • This is a really helpful review of intranasal administration of medications in the Peds ED. This route is often underutilized and may be a means by which you can optimize your door to analgesic administration time. Despite our best intentions, kids with significantly painful processes (like a long bone fracture) often go for prolonged periods without appropriate (or any) analgesics. (See article PMID: 22270501). Using the intranasal route can help hasten the delivery of pain medications! Consider this the next time you see the kid with the obviously deformed extremity… yes, you will likely still need an IV, but that intranasal fentanyl can make getting the IV and those important xrays much more humane.
  • Recommended by: Sean Fox
  • Read More: Intranasal Analgesia (Sean Fox)

Emergency Medicine, Resuscitation

R&R Hot Stuff - Everyone’s going to be talking about this
McPhee LC et al. Single-dose etomidate is not associated with increased mortality in ICU patients with sepsis: analysis of a large electronic ICU database. Crit Care Med. 2013;41(3):774-83. PMID: 23318491

  • The use of etomidate for RSI has been much maligned in recent years for it’s side effect of transient adrenal suppression. However, there has been little, if any, if any evidence of its effect on patient centered outcomes. In this retrospective analysis, etomidate was not associated with increased mortality or other adverse outcomes in patients with shock or the subgroup with septic shock. Until a large, well-done RDCT is performed, the issue will not be put to rest but for now, etomidate is a viable option for RSI.
  • Recommended by: Anand Swaminathan

Emergency Medicine

R&R Game Changer? Might change your clinical practice
Campagna JD et al. The Use of Cephalosporins in Penicillin-allergic Patients: A Literature Review. J Emerg Med. 2012;42(5):612-20. PMID: 21742459

  • Although a myth persists that approximately 10% of patients with a history of penicillin allergy will have an allergic reaction if given a cephalosporin, the overall cross-reactivity rate is approximately 1% when using first-generation cephalosporins or cephalosporins with similar R1 side chains. For penicillin-allergic patients, the use of third- or fourth-generation cephalosporins or cephalosporins with dissimilar side chains than the offending penicillin carries a negligible risk of cross allergy.
  • Recommended by: Salim Rezaie

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

Smith-Bindman R et al. Radiation dose associated with common computed tomography examinations and the associated lifetime attributable risk of cancer.  Arch Intern Med. 2009;169(22): 2078-86. PMID: 20008690

  • Quantifying risks of ionizing radiation is tough. This article shows that many patients get more radiation than studies using phantoms would imply. There was also a wide variation in the dose each patient received.
    You might be able to use this to dial back the number of not-absolutely-necessary CTs performed in the ED.
  • Recommended by: Justin Hensley

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

 

Doss M. Radiation dose justification and optimization should not be applied to medical imaging in emergency medicine. Ann Emerg Med 2014; 64(3):332-3. PMID: 25149970

  • Editorial that discusses the idea that what we know about radiation and risks of malignancy is wrong. The author reviews recent literature and argues that the estimates of medical imaging induced malignancy are off base as they are based on an incorrect risk projection model. Furthermore, he goes on to state there is reason to suspect that low dose radiation may, in fact, be beneficial and reduce cancer risk. While it’s clear that we don’t fully comprehend the impact of medical radiation, this editorial adds little to the discussion. The author only cites his own research on the topic. The claims of reducing cancer are particularly short on data to support them.
  • Recommended by: Jeremy Fried, Reuben Strayer

Cardiology

R&R Boffintastic - High quality research

Blood pressure-lowering treatment based on cardiovascular risk: a meta-analysis of individual patient data. The Blood Pressure Lowering Treatment Trialists’ Collaboration. Lancet 2014; 384 (9943): 591-598. PMID: 25131978

  • OK its preventative care – not sexy. But a great look at risk and the way we get carried away with numbers.
    Does lowering a pts BP help reduce their CVD risk?
    Well… yes
    Relative risk benefits for all CVD risk groups fell with BP reduction – but, it is really only in the higher risk groups where you get a useful ABSOLUTE risk reduction.
    So most importnat to target therapy at pts who will derive the benefits
  • Recommended by: Casey Parker

Toxicology, Emergency Medicine

R&R Game Changer? Might change your clinical practice
Williams BT et al. Emergency department identification and critical care management of a Utah prison botulism outbreak. Ann Emerg Med 2014; 64(1):26-31. PMID: 24331717

  • This article reviews an outbreak of botulism in a US prison system resulting from consumption of pruno (jailhouse wine). Food borne botulism is infrequent (20 cases/year in US) and outbreaks like this (8 cases) are critical in learning more about the disease. The authors provides information about time from consumption to onset of symptoms and severity of symptoms that are critical in understanding and recognizing this rare and potentially devastating disease. 
  • Recommended by: Anand Swaminathan

Emergency Medicine

R&R Eureka - Revolutionary idea or concept
Petinaux B et al. Accuracy of radiographic readings in the emergency department. Am J Emerg Med 2011; 29(1):18-25. PMID: 20825769

  • Many emergency physicians read their own plain films in real time and make clinical decisions based on their own reads.
    This study looked at one institution’s discrepancy rate between EP and radiologist plain film reads over 10 years. They found overall an ~3% discrepancy rate on all plain films. This of course does not mean the radiologist was correct in every discrepancy. But it does show we agree most of the time.
    Most interestingly, the rate of discrepancies requiring emergent change in management was a mere 0.056%!
  • Recommended by: Zack Repanshek

Prehospital/Retrieval

R&R Hot Stuff - Everyone’s going to be talking about thisR&R Game Changer? Might change your clinical practice

Braude D et al. Air Transport of Patients with Pneumothorax: Is Tube Thoracostomy Required Before Flight? Air Med J. 2014 Jul-Aug;33(4):152-6. PMID: 25049185

  • Conventional teaching dictates that all patients with any pneumothorax (PTX) should have a tube thoracostomy placed prior to air medical transport. However, this “rule” may delay transfer for definitive management of injuries and has not been shown to decrease the risk of adverse outcomes. This article is a retrospective review of trauma patients transported to a single trauma center with confirmed PTX who did not have a tube thoracostomy placed prior to transport. They found a low complication rate (6%) and all patients were successfully treated with needle decompression. Although prospective validation is required, this article challenges the conventional dogma.
  • Recommended by: Anand Swaminathan

The R&R iconoclastic sneak peek icon key

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

That’s it for this week…

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

The post Research and Reviews in the Fastlane 048 appeared first on LITFL.

The LITFL Review 151

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 151st edition, brought to you by:

The Most Fair Dinkum Ripper Beaut of the Week

resizer

Its shared by these four beauties this week…..

Simon Finfer (@icuresearch) should need no introduction… His talk on ICN is essential listening if you want to understand the importance of critical care research and how it works. Listen to Finfer: The Dark Side of Research NOW. [CN]

Last week marked the 5 year anniversary of LITFL and Mike Cadogan shares with the FOAM world 5 lessons he’s learned over the last 5 years. Mike’s contributions to FOAM have been limitless and impossible to quantify. The tips here are critical to all the educators out there looking to make an impact. [AS]

What exactly is “pseudo PEA”? The ED ECMO podcast tackles this question, and suggests a new way to think about PEA arrest. [MG]

Unthinkably awesome- the “establishment” are embracing FOAMed! The UK College of Emergency Medicine has launched its rather excellent FOAMed website, with weekly updates of FOAMy goodness- and mapped out to the UK EM curriculum. This really sets the bar high. Other colleges please take note… [SO]

The Best of #FOAMed Emergency Medicine

The Best of #FOAMcc Critical Care

#FOAMTox Toxicology

#FOAMPed Paediatrics

  • KIDS (Kids Intensive care and Decision Support) is a 24 hour referral, coordination, advice and transport service working out of the West Midlands in Birmingham, UK. All of their guidelines and SOPS are available via an awesome free app here. [SO]
  • More fantastic resources from the Severn Emergency Medicine team on paediatric acute presentations. [SL]
  • Don’t Forget the Bubbles looks at thrombocytosis in children – is it just benign? [TRD]

#FOAMus Ultrasound

#MedEd Education and Social Media

News from the Fast Lane

Reference Sources and Reading List

The post The LITFL Review 151 appeared first on LITFL.

Research and Reviews in the Fastlane 047

Research and Reviews in the Fastlane

Welcome to the 47th 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, Resuscitation

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

Ferrer R et al. Empiric antibiotic treatment reduces mortality in severe sepsis and septic shock from the first hour: results from a guideline-based performance improvement program. Crit Care Med 2014; 42: 1749-55. PMID: 24717459

  • This retrospective analysis of prospective surviving sepsis data of patients admitted to the ICU with severe sepsis found that delays in antibiotic administration resulted in a concomitant increase in hospital mortality. Though the results are compelling with a linear relationship between time to administration and hospital mortality discovered it is key to interpret this study with caution as the data are uncontrolled for the antibiotic administration to time metric primarily studied by this paper. Multiple potential confounders exist that might account for the observed relationship that should be studied prospectively. In the meantime it makes reasonable sense to administer antibiotics as soon as possible after the actual discovery of real sepsis.  
  • Recommended by: William Paolo

The Best of the Rest

Emergency Medicine, Administration

R&R Landmark paper that will make a difference

Viccellio P et al. Patients overwhelmingly prefer inpatient boarding to emergency department boarding. J Emerg Med. 2013; 45(6):942-6. PMID: 24063879

  • From the category of “you really had to study this to prove it?!?”Turns out when awaiting a real bed in the hospital patients would much rather do this in the hallway of a hospital ward rather than the hallway of the ED. One can only imagine this is because you’re much less likely to be coughed/urinated/vomited on in the ward than the ED.Of note this is written by Peter Vicellio, the chap who came up with the full capacity protocols that spread crowding across the hospital instead of locating it all in the ED
  • Recommended by: Andy Neil

Emergency Medicine

R&R Game Changer? Might change your clinical practice
Wulf NR, Matuszewski KA. Sulfonamide cross-reactivity: is there evidence to support broad cross-allergenicity? Am J Health Syst Pharm. 2013 Sep 1;70(17):1483-94. PMID: 23943179

  • Traditional teaching cautions of allergic cross-reactivity of non-antibiotic sulfa containing drugs (acetazolamide, furosemide) in patients allergic to sulfonamides. This review of over 50 years of literature and manufacturer data found a whopping 9 case reports, none of which were confirmed with testing. Yet another medical myth, propagated in classrooms and many computerized provider entry programs, busted.
  • Recommended by: Lauren Westafer

Pediatrics, Cardiology

R&R Eureka - Revolutionary idea or concept
Tester DJ et al. Unexplained drownings and the cardiac channelopathies: a molecular autopsy series. Mayo Clin Proc. 2011;86(10):941-7. PMID: 21964171

  • This is interesting! Consider the possibility of Prolonged QTc in the patient presenting with a submersion injury… ask about family history of sudden death or other submersion events.
  • Recommended by: Sean Fox
  • Read More: Prolonged QTc and Submersion Injury (Sean Fox)

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

Holley A et al. Frozen blood products: clinically effective and potentially ideal for remote Australia. Anaesth Intensive Care 2013; 41(1): 10-19. PMID: 23362885

  • An exploration of the feasibilty of cryopreservation to extend the shelf life and facilitate the transport of blood products, while minimising post-thawing complications. Particularly relevant for remote and regional centres facing the challenge of occasional need for massive blood transfusion.
  • Recommended by: Matt MacPartlin

Critical Care, Anaesthetics
R&R Game Changer? Might change your clinical practice

Tanaka LM et al. Early sedation and clinical outcomes of mechanically ventilated patients: a prospective multicenter cohort study. Crit Care 2014; 18(4): R156. PMID: 25047960

  • Further evidence that early sedation depth is associated with worse outcomes in patients. This multi center study found it to be an independent predictor of in hospital mortality, although complicated by multiple issues, such as the increased use of benzos and sicker patients in the deep sedation group. Although not definitive, it does make sense to limit ourselves to lighter sedation in patients when able.
  • Recommended by: Jeremy Fried

Resuscitation, Critical Care

R&R Boffintastic - High quality research

Dhanani S et al. Vital Signs After Cardiac Arrest Following Withdrawal of Life-Sustaining Therapy: A Multicenter Prospective Observational Study. Crit Care Med. 2014  [Epub ahead of print] PMID: 24810533

  • The Canadians and the French run great trials. This one is Canadian and is essentially a feasibility study looking at recording continuous physiological data before and after the determination of death to explore “Lazarus” fears in the setting of withdrawl of life-sustaining support in anticipation of proceeding to DCD.A small trial, but if a recordable BP failed to reappear by 90 seconds after the determination of death, it didn’t return at all. And in the 4 cases where a recordable BP was detected it was transient and of no longer duration than 3 minutes.
  • Recommended by: Matt MacPartlin

Toxicology

R&R WTF Weird, transcendent or funtabulous!” width=
Archer JR et al. Trend analysis of anonymised pooled urine from portable street urinals in central London identifies variation in the use of novel psychoactive substances. Clin Toxicol (Phila). 2014 Mar;52(3):160-5. PMID: 24506433

  • In this study, the research team collected pooled urine (read many people used the urinal they collected from) from a popular nightclub area in London and analyzed the specimens for the presence of illicit drug compounds. The goal was to determine whether this method could be used to track patterns and monitor trends in recreational drug use. 
  • Recommended by: Anand Swaminathan

Emergency Medicine, Critical Care, Anaesthetics

R&R Eureka - Revolutionary idea or concept
Hindman BJ et al. Intubation Biomechanics: Laryngoscope Force and Cervical Spine Motion during Intubation with Macintosh and Airtraq Laryngoscopes. Anesthesiology. 2014; 121(2):260-71. PMID: 24739996

  • Interesting and technical analysis of laryngoscope force comparing Mac 3 to Airtraq in the OR. To be honest, this study is essentially a small OR “bench research” study, but they raise an interesting question, finding “the relationship between laryngoscope force and cervical spine motion is nonlinear,” so “cervical spine motion during endotracheal intubation is not directly proportional to force” and therefore “low-force laryngoscopes cannot be assumed to result in proportionally low cervical spine motion.”Basically, this questions the idea that we can be “gentle” during laryngscopy to minimize c-spine movement.I certainly classify this as “hypothesis generating” (at best). We certainly wouldn’t want to change practice based on a lab study of 14 healthy OR subjects (or 9 female sheep).
  • Recommended by: Taylor Zhou

End of Life Care

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

Shaw AB. Acts of commission, omission, and demission or pulling the plug. J R Soc Med. 1995 Jan;88(1):18-9. PubMed PMID: 7884762; PubMed Central PMID: 1295067

  • I stumbled across this 1995 paper recently. It is a brief, cogent discussion of why withdrawal of care is ethically and legally correct when a life of value is no longer realistic for the patient.
  • Recommended by: Chris Nickson

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 047 appeared first on LITFL.

Research and Reviews in the Fastlane 047

Research and Reviews in the Fastlane

Welcome to the 47th 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, Resuscitation

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

Ferrer R et al. Empiric antibiotic treatment reduces mortality in severe sepsis and septic shock from the first hour: results from a guideline-based performance improvement program. Crit Care Med 2014; 42: 1749-55. PMID: 24717459

  • This retrospective analysis of prospective surviving sepsis data of patients admitted to the ICU with severe sepsis found that delays in antibiotic administration resulted in a concomitant increase in hospital mortality. Though the results are compelling with a linear relationship between time to administration and hospital mortality discovered it is key to interpret this study with caution as the data are uncontrolled for the antibiotic administration to time metric primarily studied by this paper. Multiple potential confounders exist that might account for the observed relationship that should be studied prospectively. In the meantime it makes reasonable sense to administer antibiotics as soon as possible after the actual discovery of real sepsis.  
  • Recommended by: William Paolo

The Best of the Rest

Emergency Medicine, Administration

R&R Landmark paper that will make a difference

Viccellio P et al. Patients overwhelmingly prefer inpatient boarding to emergency department boarding. J Emerg Med. 2013; 45(6):942-6. PMID: 24063879

  • From the category of “you really had to study this to prove it?!?”Turns out when awaiting a real bed in the hospital patients would much rather do this in the hallway of a hospital ward rather than the hallway of the ED. One can only imagine this is because you’re much less likely to be coughed/urinated/vomited on in the ward than the ED.Of note this is written by Peter Vicellio, the chap who came up with the full capacity protocols that spread crowding across the hospital instead of locating it all in the ED
  • Recommended by: Andy Neil

Emergency Medicine

R&R Game Changer? Might change your clinical practice
Wulf NR, Matuszewski KA. Sulfonamide cross-reactivity: is there evidence to support broad cross-allergenicity? Am J Health Syst Pharm. 2013 Sep 1;70(17):1483-94. PMID: 23943179

  • Traditional teaching cautions of allergic cross-reactivity of non-antibiotic sulfa containing drugs (acetazolamide, furosemide) in patients allergic to sulfonamides. This review of over 50 years of literature and manufacturer data found a whopping 9 case reports, none of which were confirmed with testing. Yet another medical myth, propagated in classrooms and many computerized provider entry programs, busted.
  • Recommended by: Lauren Westafer

Pediatrics, Cardiology

R&R Eureka - Revolutionary idea or concept
Tester DJ et al. Unexplained drownings and the cardiac channelopathies: a molecular autopsy series. Mayo Clin Proc. 2011;86(10):941-7. PMID: 21964171

  • This is interesting! Consider the possibility of Prolonged QTc in the patient presenting with a submersion injury… ask about family history of sudden death or other submersion events.
  • Recommended by: Sean Fox
  • Read More: Prolonged QTc and Submersion Injury (Sean Fox)

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

Holley A et al. Frozen blood products: clinically effective and potentially ideal for remote Australia. Anaesth Intensive Care 2013; 41(1): 10-19. PMID: 23362885

  • An exploration of the feasibilty of cryopreservation to extend the shelf life and facilitate the transport of blood products, while minimising post-thawing complications. Particularly relevant for remote and regional centres facing the challenge of occasional need for massive blood transfusion.
  • Recommended by: Matt MacPartlin

Critical Care, Anaesthetics
R&R Game Changer? Might change your clinical practice

Tanaka LM et al. Early sedation and clinical outcomes of mechanically ventilated patients: a prospective multicenter cohort study. Crit Care 2014; 18(4): R156. PMID: 25047960

  • Further evidence that early sedation depth is associated with worse outcomes in patients. This multi center study found it to be an independent predictor of in hospital mortality, although complicated by multiple issues, such as the increased use of benzos and sicker patients in the deep sedation group. Although not definitive, it does make sense to limit ourselves to lighter sedation in patients when able.
  • Recommended by: Jeremy Fried

Resuscitation, Critical Care

R&R Boffintastic - High quality research

Dhanani S et al. Vital Signs After Cardiac Arrest Following Withdrawal of Life-Sustaining Therapy: A Multicenter Prospective Observational Study. Crit Care Med. 2014  [Epub ahead of print] PMID: 24810533

  • The Canadians and the French run great trials. This one is Canadian and is essentially a feasibility study looking at recording continuous physiological data before and after the determination of death to explore “Lazarus” fears in the setting of withdrawl of life-sustaining support in anticipation of proceeding to DCD.A small trial, but if a recordable BP failed to reappear by 90 seconds after the determination of death, it didn’t return at all. And in the 4 cases where a recordable BP was detected it was transient and of no longer duration than 3 minutes.
  • Recommended by: Matt MacPartlin

Toxicology

R&R WTF Weird, transcendent or funtabulous!” width=
Archer JR et al. Trend analysis of anonymised pooled urine from portable street urinals in central London identifies variation in the use of novel psychoactive substances. Clin Toxicol (Phila). 2014 Mar;52(3):160-5. PMID: 24506433

  • In this study, the research team collected pooled urine (read many people used the urinal they collected from) from a popular nightclub area in London and analyzed the specimens for the presence of illicit drug compounds. The goal was to determine whether this method could be used to track patterns and monitor trends in recreational drug use. 
  • Recommended by: Anand Swaminathan

Emergency Medicine, Critical Care, Anaesthetics

R&R Eureka - Revolutionary idea or concept
Hindman BJ et al. Intubation Biomechanics: Laryngoscope Force and Cervical Spine Motion during Intubation with Macintosh and Airtraq Laryngoscopes. Anesthesiology. 2014; 121(2):260-71. PMID: 24739996

  • Interesting and technical analysis of laryngoscope force comparing Mac 3 to Airtraq in the OR. To be honest, this study is essentially a small OR “bench research” study, but they raise an interesting question, finding “the relationship between laryngoscope force and cervical spine motion is nonlinear,” so “cervical spine motion during endotracheal intubation is not directly proportional to force” and therefore “low-force laryngoscopes cannot be assumed to result in proportionally low cervical spine motion.”Basically, this questions the idea that we can be “gentle” during laryngscopy to minimize c-spine movement.I certainly classify this as “hypothesis generating” (at best). We certainly wouldn’t want to change practice based on a lab study of 14 healthy OR subjects (or 9 female sheep).
  • Recommended by: Taylor Zhou

End of Life Care

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

Shaw AB. Acts of commission, omission, and demission or pulling the plug. J R Soc Med. 1995 Jan;88(1):18-9. PubMed PMID: 7884762; PubMed Central PMID: 1295067

  • I stumbled across this 1995 paper recently. It is a brief, cogent discussion of why withdrawal of care is ethically and legally correct when a life of value is no longer realistic for the patient.
  • Recommended by: Chris Nickson

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 047 appeared first on LITFL.

Research and Reviews in the Fastlane 047

Research and Reviews in the Fastlane

Welcome to the 47th 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, Resuscitation

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

Ferrer R et al. Empiric antibiotic treatment reduces mortality in severe sepsis and septic shock from the first hour: results from a guideline-based performance improvement program. Crit Care Med 2014; 42: 1749-55. PMID: 24717459

  • This retrospective analysis of prospective surviving sepsis data of patients admitted to the ICU with severe sepsis found that delays in antibiotic administration resulted in a concomitant increase in hospital mortality. Though the results are compelling with a linear relationship between time to administration and hospital mortality discovered it is key to interpret this study with caution as the data are uncontrolled for the antibiotic administration to time metric primarily studied by this paper. Multiple potential confounders exist that might account for the observed relationship that should be studied prospectively. In the meantime it makes reasonable sense to administer antibiotics as soon as possible after the actual discovery of real sepsis.  
  • Recommended by: William Paolo

The Best of the Rest

Emergency Medicine, Administration

R&R Landmark paper that will make a difference

Viccellio P et al. Patients overwhelmingly prefer inpatient boarding to emergency department boarding. J Emerg Med. 2013; 45(6):942-6. PMID: 24063879

  • From the category of “you really had to study this to prove it?!?”Turns out when awaiting a real bed in the hospital patients would much rather do this in the hallway of a hospital ward rather than the hallway of the ED. One can only imagine this is because you’re much less likely to be coughed/urinated/vomited on in the ward than the ED.Of note this is written by Peter Vicellio, the chap who came up with the full capacity protocols that spread crowding across the hospital instead of locating it all in the ED
  • Recommended by: Andy Neil

Emergency Medicine

R&R Game Changer? Might change your clinical practice
Wulf NR, Matuszewski KA. Sulfonamide cross-reactivity: is there evidence to support broad cross-allergenicity? Am J Health Syst Pharm. 2013 Sep 1;70(17):1483-94. PMID: 23943179

  • Traditional teaching cautions of allergic cross-reactivity of non-antibiotic sulfa containing drugs (acetazolamide, furosemide) in patients allergic to sulfonamides. This review of over 50 years of literature and manufacturer data found a whopping 9 case reports, none of which were confirmed with testing. Yet another medical myth, propagated in classrooms and many computerized provider entry programs, busted.
  • Recommended by: Lauren Westafer

Pediatrics, Cardiology

R&R Eureka - Revolutionary idea or concept
Tester DJ et al. Unexplained drownings and the cardiac channelopathies: a molecular autopsy series. Mayo Clin Proc. 2011;86(10):941-7. PMID: 21964171

  • This is interesting! Consider the possibility of Prolonged QTc in the patient presenting with a submersion injury… ask about family history of sudden death or other submersion events.
  • Recommended by: Sean Fox
  • Read More: Prolonged QTc and Submersion Injury (Sean Fox)

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

Holley A et al. Frozen blood products: clinically effective and potentially ideal for remote Australia. Anaesth Intensive Care 2013; 41(1): 10-19. PMID: 23362885

  • An exploration of the feasibilty of cryopreservation to extend the shelf life and facilitate the transport of blood products, while minimising post-thawing complications. Particularly relevant for remote and regional centres facing the challenge of occasional need for massive blood transfusion.
  • Recommended by: Matt MacPartlin

Critical Care, Anaesthetics
R&R Game Changer? Might change your clinical practice

Tanaka LM et al. Early sedation and clinical outcomes of mechanically ventilated patients: a prospective multicenter cohort study. Crit Care 2014; 18(4): R156. PMID: 25047960

  • Further evidence that early sedation depth is associated with worse outcomes in patients. This multi center study found it to be an independent predictor of in hospital mortality, although complicated by multiple issues, such as the increased use of benzos and sicker patients in the deep sedation group. Although not definitive, it does make sense to limit ourselves to lighter sedation in patients when able.
  • Recommended by: Jeremy Fried

Resuscitation, Critical Care

R&R Boffintastic - High quality research

Dhanani S et al. Vital Signs After Cardiac Arrest Following Withdrawal of Life-Sustaining Therapy: A Multicenter Prospective Observational Study. Crit Care Med. 2014  [Epub ahead of print] PMID: 24810533

  • The Canadians and the French run great trials. This one is Canadian and is essentially a feasibility study looking at recording continuous physiological data before and after the determination of death to explore “Lazarus” fears in the setting of withdrawl of life-sustaining support in anticipation of proceeding to DCD.A small trial, but if a recordable BP failed to reappear by 90 seconds after the determination of death, it didn’t return at all. And in the 4 cases where a recordable BP was detected it was transient and of no longer duration than 3 minutes.
  • Recommended by: Matt MacPartlin

Toxicology

R&R WTF Weird, transcendent or funtabulous!” width=
Archer JR et al. Trend analysis of anonymised pooled urine from portable street urinals in central London identifies variation in the use of novel psychoactive substances. Clin Toxicol (Phila). 2014 Mar;52(3):160-5. PMID: 24506433

  • In this study, the research team collected pooled urine (read many people used the urinal they collected from) from a popular nightclub area in London and analyzed the specimens for the presence of illicit drug compounds. The goal was to determine whether this method could be used to track patterns and monitor trends in recreational drug use. 
  • Recommended by: Anand Swaminathan

Emergency Medicine, Critical Care, Anaesthetics

R&R Eureka - Revolutionary idea or concept
Hindman BJ et al. Intubation Biomechanics: Laryngoscope Force and Cervical Spine Motion during Intubation with Macintosh and Airtraq Laryngoscopes. Anesthesiology. 2014; 121(2):260-71. PMID: 24739996

  • Interesting and technical analysis of laryngoscope force comparing Mac 3 to Airtraq in the OR. To be honest, this study is essentially a small OR “bench research” study, but they raise an interesting question, finding “the relationship between laryngoscope force and cervical spine motion is nonlinear,” so “cervical spine motion during endotracheal intubation is not directly proportional to force” and therefore “low-force laryngoscopes cannot be assumed to result in proportionally low cervical spine motion.”Basically, this questions the idea that we can be “gentle” during laryngscopy to minimize c-spine movement.I certainly classify this as “hypothesis generating” (at best). We certainly wouldn’t want to change practice based on a lab study of 14 healthy OR subjects (or 9 female sheep).
  • Recommended by: Taylor Zhou

End of Life Care

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

Shaw AB. Acts of commission, omission, and demission or pulling the plug. J R Soc Med. 1995 Jan;88(1):18-9. PubMed PMID: 7884762; PubMed Central PMID: 1295067

  • I stumbled across this 1995 paper recently. It is a brief, cogent discussion of why withdrawal of care is ethically and legally correct when a life of value is no longer realistic for the patient.
  • Recommended by: Chris Nickson

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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CCC Update 008

As you know, the LITFL Critical Care Compendium is a living resource built around the knowledge base needed for the FCICM exam, but extends far beyond those conservative boundaries. Plugging away on this project is where I spend most of my time ‘living in the fast lane’. The pages are built into the back end of LITFL — they don’t enter the blog feed — hence the need for updates to make sure you are not missing out on anything important… like leptospirosis, which featured in CCC Update 007 and within 2 weeks appeared in the FCICM Part II exam (or so I have been told)…

Here is what is new or undergone a major overhaul recently:

Endotracheal tube cuff leak

A problem that may be trivial, or life-threatening – as is the treatment!

Hemolytic anaemia

Few areas of medicine are funkier than hemoytic anaemia. The myriad causes, investigations and potential complications (respect cold agglutination is all I can say…) might even cause a bead of sweat to form on Dr. House’s furrowed brow. Here is my distillation of this challenging critical care problem.

In Situ Simulation

This page may be biased, as I think in situ simulation is the greatest thing since the laryngoscope blade bottle opener. The pros, the cons, the safety issues, how to ensure success and the evidence – it is all here.

Rivaroxaban and bleeding

Based on a clinical update by James Hayes, this page outlines the clinical issues regarding the new oral anticoagulant rivaroxaban, an orally active Factor IXa inhibitor.

Statins in the critically ill

Statins have pleiotropic effects and are being studied for numerous conditions in intensive care. Here is another excellent ‘critical evaluation’ of a putative therapy for the critically ill by Sarah Yong.

Vitamin D in critical illness

Vitamin D also has pleiotropic (the word of the day) effects and is often low in the critically ill. So should we be replacing it? Could this be a future ‘critically evaluate’ question in the FCICM Part II exam? This is a great overview by Sarah Yong.

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