R&R In The FASTLANE 176

Welcome to the 176th 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 5 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

Stiell IG et al. Outcomes for Emergency Department Patients with Recent-Onset Atrial Fibrillation and Flutter Treated in Canadian Hospitals. Ann Emerg Med 2017. PMID: 28110987

• To cardiovert or not to cardiovert recent onset atrial fibrillation? It’s a question that plagues EM. While this doesn’t give us a definitive answer on safety, it’s an excellent prospective study demonstrating that taking an aggressive approach to the management of recent-onset AF/AFl in the ED. Based on this evidence it appears reasonable to adopt an approach focused on restoring sinus rhythm in the ED.
• Recommended by: Anand Swaminathan
• Further reading: Outcomes after aggressive management of recent-onset atrial fibrillation in the ED (REBEL EM)

Moayedi S, Witting M, Pirotte M. Safety and Efficacy of the “Easy Internal Jugular (IJ)”: An Approach to Difficult Intravenous Access. The Journal of emergency medicine. 51(6):636-642. 2016. PMID: 27658558

• This is a prospective look at the use of an “easy IJ” in 74 patients with difficult vascular access in three emergency departments. The easy IJ is a technique of placing a peripheral IV (in this case they used 4.8 cm long 18 gauge catheters) into the internal jugular using ultrasound guidance and limited sterile technique (not a full drape). Overall, this is relatively successful with 88% of patients getting a usable line. It was quick, with total procedure time clocking in under 5 minutes (although it takes that long for our ultrasound to boot up sometimes). It also looked pretty safe in this small cohort, with no cases of pneumothorax, line infection, or arterial puncture. The lines were used for up to 24 hours before being removed. There are a numer of other techniques (IOs and ultrasound guided peripheral IVs) that I would go to first, but it is important to have multiple backup strategies. Although we would need a much larger trial to really assess the safety of this procedure, and I would love to see a controlled trial comparing this to other rescue vascular access options, this is clearly a reasonable option when urgent vascular access is required. Bottom line: I will definitely keep this procedure in mind in patients with difficult vascular access
• Recommended by: Justin Morgenstern

Patterson T et al. A Randomised Trial of Expedited transfer to a cardiac arrest centre for non-ST elevation ventricular fibrillation out-of-hospital cardiac arrest: The ARREST pilot randomised trial. Resuscitation. 2017 PMID: 28174052

• While the trend is towards PCI for all post arrest patients, let’s be honest there isn’t good controlled data to support that as yet. This trial is a pilot trial to assess feasibility of running such an RCT. They randomised patients with VT/VF to either go straight to a PCI centre similar to existing STEMI pathways whereas the control group got standard ACLS and transport to closest ED. They randomised 40 patients and overall about a 50% survival at 30 days in each group. Of note there was only a 30 minute difference in time to PCI suggesting that the control patients were all getting early PCI anyhow. The same group is now planning a larger RCT to hopefully definitively answer the question.
• Recommended by: Andy Neil

Kongbunkiat K et al. Leukoaraiosis, intracerebral hemorrhage, and functional outcome after acute stroke thrombolysis. Neurology. 2017;88(7):638-645.

• If you give tPA, you might as well give it as safely as possible – and ICH rates begin to exceed 10% when an elderly patient has chronic vascular damage to the brain as evidenced by moderate or severe leukoaraiosis.
• Recommended by: Ryan Radecki

Barends EGR, Briner RB. Teaching Evidence-Based Practice: Lessons From the Pioneers: An Interview With Amanda Burls and Gordon Guyatt. Academy of Management Learning & Education. 13(3):476-483. 2014. [article]

• This interview with Gordon Guyatt and Amanda Burls is a great read. They detail the struggles faced when starting the evidence based movement, many of which are probably ongoing, as well as the future of evidence based medicine.
• Recommended by: Justin Morgenstern