Research and Reviews in the Fastlane 600

Welcome to the 34th 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

Canto JG et al. Association of age and sex with myocardial infarction symptom presentation and in-hospital mortality. JAMA. 2012 Feb 22;307(8):813-22. PubMed ID: 22357832

  • A tweet from a talk by Amal Mattu led me to this study based on a registry of over 1 million American patients. It is important because of this finding: “The proportion of MI patients who presented without chest pain was significantly higher for women than men (42.0% [95% CI, 41.8%-42.1%] vs 30.7% [95% CI, 30.6%-30.8%]; P < .001).”
    The rates of MI without chest pain are even higher in women <45 years of age. Burn your textbooks and reflect on the external validity of the historical mass of medical literature based on studies of white anglo-saxon males.
  • Recommended by: Chris Nickson

Grunau BE et al. Incidence of Clinically Important Biphasic Reactions in Emergency Department Patients with Allergic Reactions or Anaphylaxis. Ann Emerg Med 2014 Jun;63(6):736-744 PubMed ID: 24239340

  • The study was a retrospective review over 5 years. Of the 2800 patients with diagnoses of allergic reaction or anaphylaxis, 5 or 0.18% had clinically important biphasic reactions. 2 of these reactions occurred during the index visit. The other 3 biphasic reactions occurred up to 6 days after initial visit. This article raises the question about whether standard monitoring for 6-8 hours is necessary after resolution of symptoms or if observation is simply a waste of resources.
  • Recommended by: Anand Swaminathan

Coskun A et al. Management of Rectal Foreign Bodies. World J Emerg Surg 2013; 8: 11-24 PMCID: 3601006

  • A retrospective review of 10 years from a single hospital of rectal foreign bodies. This article reviews the presentation and step by step management. While most foreign bodies can be removed under local anesthesia in the Emergency Department, laparotomy is occasionally required. After removal of the foreign body, the authors suggest a period of observation, a rigid or flexible endoscopy to evaluate for rectal injury, and repeat plain films to examine for evidence of injury and perforation that may have occurred during the extraction process.
  • Recommended by: Tim Leeuwenburg

Dayan PS et al. Association of traumatic brain injuries with vomiting in children with blunt head trauma. Ann Emerg Med 2014; 63(6):657-65. PubMed ID: 24559605

  • Significant TBI is extremely rare in children with minor head injury and vomiting as their only sign or symptom. Observation is appropriate for these children instead of immediate head CT. Although observation requires time and effort, it reduces exposure to radiation as well as the occasional need for procedural sedation.
  • Recommended by: Anand Swaminathan
RR Trash

Valle EJ et al. Do all trauma patients benefit from tranexamic acid? J Trauma Acute Care Surg 2014; 76(6):1373-8. PubMed ID: 24854303

  • In this study, the authors question the use of TXA in all patients with trauma. Using an observational design, they concluded that in the most severe trauma patients, TXA was associated with an increased mortality. However, the study suffers from a number of major flaws that start with the study design. The findings here do nothing to contest the utility of this drug in trauma as found in superior trials like CRASH-2.We should not go back in embracing the use of this drug in trauma.
  • Recommended by: Simon Carley
  • Read More: JC: Tranexamic Acid – does the evidence stack up?

Kovacks G. Airway management: “the times they are a-changin.” CJEM 2013; 15: 1-4. PubMed ID: 23721950

  • Having trouble getting a grip on all the different airway devices? This editorial gives a succinct overview of the different modalities currently in practice.
  • Recommended by: Søren Rudolph
RR Game Changer

Cai Q, Mehta N, Sgarbossa EB, et al. The left bundle-branch block puzzle in the 2013 ST-elevation myocardial infarction guideline: From falsely declaring emergency to denying reperfusion in a high-risk population. Are the Sgarbossa Criteria ready for prime time? American Heart Journal. 2013;166(3):409–413. PubMed ID: 24016487

  • This article gives an algorithm for diagnosing STEMI in the setting of new and presumed new LBBB. This article builds on Stephen Smith’s article on the modified Sgarbossa criteria and gives a pathway for catheterization lab activation or thrombolytic administration.
  • Recommended by: Anand Swaminathan

Vedovati MC et al. Multidector CT scan for acute pulmonary embolism: embolic burden and clinical outcome. Chest 2012; 142(6): 1417-24. PubMed ID: 22628491

  • Embolus localization, rather than burden, may have a role in risk stratifying the haemodynamically stable acute PE with regard to subsequent all-cause mortality and clinical deterioration. The strongest signal was for central PE in patients that were hemodynamically stable at presentation. The absolute results and confidence intervals suggest sample size might have been too small however. Not commented upon in the paper, but numbers also make you wonder if you believe the conclusion then should patients with central or lobar PE should be kept for 10 days to capture all deteriorations?
  • Recommended by:  Matthew Mac Partlin
RR Game Changer

Traub SJ et al. N-acetylcysteine plus intravenous fluids versus intravenous fluids alone to prevent contrast-induced nephropathy in emergency computed tomography. Ann Emerg Med. 2013; 62(5):511-520 PubMed PMID: 23769807.

  • This study was hoping to show that NAC will keep all those contrast CTs from giving our patients contrast induced nephropathy (CIN). It did not. It looks like the real answer is fluids (and that maybe we are not killing off so many kidneys anyway).
  • Recommended by: Zack Repanshek
RR Game Changer

Wang J, Xu E, Xiao Y. Isotonic versus hypotonic maintenance IV fluids in hospitalized children: a meta-analysis. Pediatrics. 2014 Jan;133(1):105-13 PubMed PMID: 24379232

  • Meta-analysis of 10 RCTs looking at maintenance IV fluids in hospitalized pediatric patients. The study found a RR = 2.24 for hyponatremia in comparing hypotonic fluids with isotonic fluids. They concluded that isotonic fluids are safer for this indication. Proper maintenance fluid choice in children just got turned on its head.
  • Recommended by: Justin Hensley
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New Jersey Emergency Physician with academic focus on resident education and critical care in the ED. Strong supporter of FOAMed and its role in cutting down knowledge translation | @EMSwami |

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