R&R In The FASTLANE 042

Welcome to the 42nd 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 : Overview; Archives and Contributors

This Edition’s R&R Hall of Famer

Braunwald E, Morrow DA. Unstable angina: Is it time for a requiem? Circulation 2013; 127: 2452-2457. PMID 23775194

• An editorial from one of the most respected members of the cardiology world questioning the continued use of the term “unstable angina”. With the development of more and more sensitive troponin assays, it is possible that the clinical entity of unstable angina no longer exists.
• Recommended by: Anand Swaminathan

Quinn JV, Polevoi SK, Kohn MA. Traumatic lacerations: what are the risks for infection and has the ‘golden period’ of laceration care disappeared? Emerg Med J 2014; 31(2): 96-100. PMID 23314208

• This article challenges the notion that lacerations need to be closed within a specific “golden period” lest they become infected. The authors find that diabetes, wound contamination, length greater than 5 cm and location on the lower extremity are important risk factors for wound infection. Time from injury to wound closure is not as important as previously thought.
• Recommended by: Anand Swaminathan
• Read More: Goldfinger (More Dogma of Wound Care) (SGEM)

Green SM, Andolfatto G. Managing Propofol-Induced Hypoventilation. Ann Emerg Med. 2014 Jul 11. pii: S0196-0644(14)00588-5. PMID 25017824

• Great review on all practical aspects of propofol use in the ED setting. A wonderful primer for those in training and an outstanding review for those using it for years.
• Recommended by: Jeremy Fried

Body R et al. Can emergency physicians ‘rule in’ and ‘rule out’ acute myocardial infarction with clinical judgement? Emerg Med J 2014. PMID 25016388

• Gestalt takes another hit. Simon, Rick and their team of researchers look at the utility of physician gestalt in “ruling-in” and “ruling-out” MI. What they find is surprising. Two findings stand out. 1) in patients who were placed in the “definitely ACS” category, only 50.9% had ACS. 2) Gestalt barely improved with increasing clinical experience. In patients with the lower 3 risk categories by gestalt, a normal ECG and negative hsTnT, sensitivity was 100% for “ruling-out” MI. These results need to be validated and it’ll be interesting to find out how much hsTnT added to gestalt + ECG.
• Recommended by: Anand Swaminathan
• Read More: How accurate is clinical judgement for acute coronary syndromes? (St. Emlyn’s)

Lemkin DL, Witting MD, Allison M, Farzad A, Bond MC, Lemkin MA. Electrical exposure risk associated with hands-on defibrillation. Resuscitation. 2014 Jun 30. pii: S0300-9572(14)00631-5. doi: 10.1016/j.resuscitation.2014.06.023. [Epub ahead of print] PMID: 24992873

• An excellent cadaveric study examining the safety of hands on defibrillation. As a provider who has performed hands on defibrillation in the past and felt a numbing shock up my arm lasting several minutes, this study confirms that this practice is likely not safe. For now, keep your hands off during the shock phase of your resuscitation.
• Recommended by: Jeremy Fried

Chamberlain JM, et a;; Pediatric Emergency Care Applied Research Network (PECARN). Lorazepam vs diazepam for pediatric status epilepticus: a randomized clinical trial. JAMA. 2014 Apr 23-30;311(16):1652-60. PubMed PMID: 24756515

• This is a double blind randomized controlled trial utilizing the PECARN hospitals of individuals from 3 months to 18 years with defined status epileptics to determine the efficacy and safety of diazepam versus lorazepam.  The study found no distinction between either intervention in the primary efficacy outcome however it did that lorazepam had a slightly longer sedative effect.  Though diazepam is primarily associated with pediatric seizure it appears that there is no particular reason to believe that it is the primary benzodiazepine to be utilized in pediatric status epileptics.  The longer sedating effects of lorazepam may in fact have no demonstrable clinical ramifications though it may affect the time to patient disposition.
• Recommended by: William Paolo

Lee LK, Monroe D, Bachman MC, et al. Isolated Loss of Consciousness in Children With Minor Blunt Head Trauma. JAMA Pediatr. Published online July 07, 2014. doi:10.1001/jamapediatrics.2014.361. PMID 25003654

• This re-examination of the PECARN cohort investigated the utility of isolated LOC, in an otherwise well appearing child, for predicting clinically important TBI. The authors found that LOC in isolation of other concerning exam findings was not a predictor of TBI, proving once again that a statistical association demonstrated by multi-factorial regression does not necessarily translate into a clinically relevant decision point.
• Recommended by: Rory Spiegel

Villanueva C, et al. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med. 2013 Jan 3;368(1):11-21. doi: 10.1056/NEJMoa1211801. Erratum in: N Engl J Med. 2013 Jun 13;368(24):2341. PubMed PMID: 23281973

• In a large randomized trial, patients in the restrictive transfusion group (Hb < 7) had a significantly higher probability of survival, less further bleeding, and fewer adverse events than those in the liberal transfusion group (Hb < 9).
• Recommended by: Salim R. Rezaie

Taylor MR, Lalani N. Adult small bowel obstruction. Acad Emerg Med. 2013;20(6):528–44. doi:10.1111/acem.12150. PMID 23758299

• Distended, tympanic abdomen in a patient that hasn’t passed gas in two days?  This is a classic presentation for Small Bowel Obstruction (SBO) and most providers are ordering a plain film of the abdomen.  Yet, this systematic review calls attention to the data demonstrating that the clinical features we love to hone in on are not consistently found in patients with SBO.  Furthermore, they call for abandonment of the abdominal x-ray due to poor performance (+LR 1.55, -LR 0.59) and instead, recommend bedside ultrasound for a quick screening (+LR 9.8, -LR 0.04). Oh, and while CT remains the test that most surgeons want because it can identify transition points well, even the EAST clinical practice guidelines in 2012 recognize the value of ultrasound in SBO.
• Recommended by: Lauren Westafer
• Read More:Small Bowel Obstruction – A Likely Story? (The Short Coat)

Shinar Z, Stahovich M, Bellezzo J, Cheskes S, Chillcott S, Dembitsky W. Chest compressions may be safe in arresting patients with left ventricular assist devices (LVADs). Resuscitation 2014. PMID 24472494

• Chest compressions may be safe in the arresting patient with an LVAD. In this case series, none of the patients who received chest compressions had dislodgement of their LVAD.
• Recommended by: Anand Swaminathan
• Read More: No LVADs Were Harmed in the Making of This Blog Post (Emergency Medicine Literature of Note)