R&R In The FASTLANE 036

Welcome to the 36th 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

Chatterjee S et al. Thrombolysis for pulmonary embolism and risk of all-cause mortality, major bleeding, and intracranial hemorrhage: a meta-analysis. JAMA 2014; 311(23):2414-21. PubMed ID: 24938564

• This meta-analysis suggests potential mortality benefit in patients with haemodynamically stable pulmonary embolism with right ventricular dysfunction (intermediate-risk PE). However, this advantage must be tempered against the increased risk of major bleeding and intracranial haemorrhage associated with thrombolytic therapy, particularly for patients greater than 65yrs. Thrombolysis was also associated with a lower risk of recurrence of pulmonary embolism.
• Recommended by: Nudrat Rashid, Anand Swaminathan, Salim R. Rezaie, Chris Nickson

Stevens DL, Bisno a. L, Chambers HF, et al. Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2014. PMID: 24947530

• For a common emergency department complaint, management of skin and soft tissue infections (SSTIs) is rife with dogma and marginal quality evidence. The IDSA released updated guidelines once again urging physicians to target streptococcus (i.e. no MRSA coverage) in most non-severe cases of non-purulent cellulitis, use an initial 5 day course of antibiotics in cellulitis, and only give antibiotics after incision and drainage to moderate/severe purulent infections (defined by systemic symptoms). Take a gander at the article for some excellent theoretical algorithms, recommendations on less common SSTIs (bubonic plague), and read these updates yourself, since even the recommendations persisting from the 2005 iteration still haven’t made it into practice.
• Recommended by: Lauren Westafer

Noble S, Chitnis J. Case report: use of topical tranexamic acid to stop localised bleeding. Emerg Med J. 2013 Jun;30(6):509-10. PMID: 22833592.

• Tranexamic acid has become a popular drug for dealing with difficult to control areas of bleeding including epistaxis and oral mucosa bleeding. Here, the authors discuss a case of bleeding from a nipple after piercing in a patient with hemophilia.
• Recommended by: Sean Fox

Stiell IG et al. Clinical characteristics associated with adverse events in patients with exacerbation of chronic obstructive pulmonary disease: a prospective cohort study. CMAJ 2014. PMID: 24549125

• This study found that a high percentage (49%) of patients with serious adverse outcomes after an ED visit for COPD were not initially admitted to the hospital. The authors used logistic regression to derive a decision instrument to aid in determining which patients with COPD exacerbation should be admitted based on risk stratification. The study does not show that admission improves outcomes but the instrument may prove useful for risk stratification if it is prospectively validated.
• Recommended by: Anand Swaminathan

Barends CRM ,Absalom AR. Tied up in science: unknotting an old anaesthetic problem. BMJ 2013;347:f6735. PMID: 24335667

• Anyone who has transferred a patient – whether from ED to CT, between theatre & ICU or between institutions will be familiar with one of the universal laws of transfer medicine – cables and lines will inevitably become tangled.
• But why?
• Clever physicists and topological mathematicians have the answer, with knot formation a function of the length of lines and their movement. It’s not exactly string theory in the sense of cosmology and quantum physics – but it’s highly relevant to anyone caring for a critical patient with multiple lines…
• A deeper dive for the maths geeks can be found here
• “Based on the observation that long, stiff strings tend to form a coiled structure when confined, we propose a simple model to describe the knot formation based on random “braid moves” of the string end. Our model can qualitatively account for the observed distribution of knots and dependence on agitation time and string length.”
• Recommended by:Tim Leeuwenburg

Partyka C, Taylor B. Review article: ventricular assist devices in the emergency department. EMA 2014; 26(2):104-12 PMID: 24707998

• Great FOAM review article on trouble shooting and management of patients who present with left ventricular assist devices (LVADs).
• Recommended by: Anand Swaminathan, Chris Nickson
• Learn more: Part man, part machine… – thebluntdissection

Straus SE, Thorpe KE, Holroyd-Leduc J. How do I perform a lumbar puncture and analyze the results to diagnose bacterial meningitis? JAMA. 2006 Oct 25;296(16):2012-22. Review. PMID: 17062865

• Techniques that reduce Post LP Headaches: (a) Use small gauge, atraumatic needles (b) Re-insertion of stylet before removal of needle (c) Patients DO NOT need bed rest after LP
• Recommended by: Salim R. Rezaie

Lee JM, Bae W, Lee YJ, Cho YJ. The efficacy and safety of prone positional ventilation in acute respiratory distress syndrome: updated study-level meta-analysis of 11 randomized controlled trials.Crit Care Med. 2014 May;42(5):1252-62. PMID: 24368348

• This meta-analysis elucidated the effect of prone positioning on overall mortality and associated complications.Ventilation in the prone position and duration of proning significantly reduced overall mortality in patients with severe ARDS. The major complications were pressure ulceration and airway problems.
• Recommended by: Nudrat Rashid

Wang X et al. Ketamine does not increase intracranial pressure compared with opioids: meta-analysis of randomized controlled trials. J Anesth 2014; ePub. PMID: 24859931

• In this meta-analysis, ketamine was not shown to increase intracranial pressure in comparison to opiates in patients with ICP monitors. Although there were only 5 studies included and there was significant heterogeneity, the evidence showing that ketamine does not significantly raise ICP is far more robust than the evidence behind the old dogma.
• Recommended by: Anand Swaminathan

Nazerian P et al. Accuracy of point-of-care multiorgan ultrasonography for the diagnosis of pulmonary embolism. Chest 2014; 145(5):950-7 PMID: 24092475

• Point of care multi-organ ultrasound in the hands of experienced Emergency Medicine sonographers is a promising modality for the diagnosis or exclusion of pulmonary embolism in place of CT scan. In this study a negative multi-organ ultrasound (lungs looking for subpleural consolidation, the heart looking for RV dilation and the lower extremities looking for DVT) along with ultrasound revealing an alternative diagnosis had a sensitivity of 100% when compared to CT scan as the gold standard. The study shows that CT scanning could be reduced by 50% with application of this modality.
• Recommended by: Anand Swaminathan
• Learn more: Multi-Organ US for PE (Ultrasound Podcast)