R&R In The FASTLANE 008

Research and Reviews in the Fastlane 600

Welcome to the 8th 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

RR Hall of FAMER

Abd-el-Maeboud KH, el-Naggar T, el-Hawi EM, Mahmoud SA, Abd-el-Hay S. Rectal suppository: commonsense and mode of insertion. Lancet. 1991 Sep 28;338(8770):798-800. PMID: 1681170

  • This little known classic has never been repeated, but it has sparked a debate that continues to this day: What is the best direction to place a suppository – pointy or blunt end first? The authors challenged conventional wisdom as well as manufacturer instructions and tested their theory – that blunt end was best – on 100 unwitting patients. The rate of needing to insert a digit in the anal canal to push the suppository further in was 1% in the blunt end group versus 83% for pointy end first. Unwanted suppository expulsion rate was also lower in the blunt end group.
  • Since this is the only study of its kind, questions have been raised as to whether it should be practice changing.
  • It is for me. That’s all I can say.
  • Recommended by: Rob Orman

RR Eureka

Kumar RD, Hirsch NP. Clinical evaluation of stethoscope-guided inflation of tracheal tube cuffs. Anaesthesia. 2011 Nov;66(11):1012-6. doi: 10.1111/j.1365-2044.2011.06853.x. Epub 2011 Aug 18. PMID: 21851343.

  • A cool, practical study although patient numbers are small.
  • Recommended by: Sa’ad Lahri

RR Game Changer

Bershad EM, Suarez JI. Prothrombin complex concentrates for oral anticoagulant therapy-related intracranial hemorrhage: a review of the literature. Neurocrit Care. 2010 Jun;12(3):403-13. Review. PMID: 19967567.

  • PCC Review:  PCCs ARE AVAILABLE IN THE US!!!  PRofilNine SD is roughly equivalent to Octaplex!
  • Recommended by: Mike Jasumback

RR Game Changer

Latronico N, Bolton CF. Critical illness polyneuropathy and myopathy: a major cause of muscle weakness and paralysis. Lancet Neurol. 2011 Oct;10(10):931-41. Review. PMID: 21939902.

  • Go the early rehab. A good review of a classic topic.
  • Recommended by: Oliver Flower

RR Mona Lisa

Armfield DR, Kim DH, Towers JD, Bradley JP, Robertson DD. Sports-related muscle injury in the lower extremity. Clin Sports Med. 2006 Oct;25(4):803-42. PMID: 16962427

  • We see lots of muscle strains and soft tissue injuries. This is a good review of what specific anatomic injuries are occurring.
  • Recommended by: Andy Neill

RR Game Changer

Hudson ML, Moore GP. Defences to Malpractice: What Every Emergency Physician Should Know. J Emerg Med 2011;41:598-606. PMID: 21094012

  • A medical malpractice suit must contain four elements: duty; breach of standard of care (negligence); injury; and proximate cause. However, even if all these factors exists, there are additional specific defences that physician can claim: including contributory negligence, comparative fault, respectable minority, clinical innovation, and Good Samaritan exclusion.
  • Although most of these specific defences seem to me included in the original 4 elements, the authors give a good summary of this topic.
  • Recommended by: Leon Gussow

RR Game Changer

Nguyen-Khac E, Thevenot T, Piquet MA, Benferhat S, Goria O, Chatelain D, Tramier B, Dewaele F, Ghrib S, Rudler M, Carbonell N, Tossou H, Bental A, Bernard-Chabert B, Dupas JL; AAH-NAC Study Group. Glucocorticoids plus N-acetylcysteine in severe alcoholic hepatitis. N Engl J Med. 2011 Nov 10;365(19):1781-9. PMID: 22070475.

  • NAC – is there anything we can’t try it for. Negative trial statistically but results all leaning toward benefit. 8% v 24% mortality at 1 month vs placebo
  • Recommended by: Andy Neill
  • Learn more: Emergency Medicine Ireland – NAC for alcoholic hepatitis

RR Eureka

Mellick LB. Torsion of the Testicle: It Is Time to Stop Tossing the Dice. Pediatr Emer Care 2012;28:80-86. PMID: 22217895

  • Great in-depth discussion of the myths and misconceptions related to the presentation and diagnosis of testicular torsion. Bottom line recommendation: image every patient with scrotal or testicular pain whose history and physical is not consistent with torsion. Clinically obvious torsion should go directly to urology for exploration.
  • Recommended by: Leon Gussow

RR Game Changer

Vazirani J, Knott JC. Mandatory Pain Scoring at Triage Reduces Time to Analgesia. Ann Emerg Med. 2011 Sep 9. PMID: 21908072

  • If you want your patients to get analgesia quicker… ask the triage nurse to do analgesia scores. Will it affect the ATS category as well??
  • Recommended by: Ioana Vlad

RR WTF

Doyal L. Should the skeleton of “the Irish giant” be buried at sea?. BMJ 2011; 343. PMID: 22187392

  • A story from a time when ethics was not a word.
  • Recommended by: Ioana Vlad

Research and Reviews icon glossary

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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