R&R In The FASTLANE 041

Welcome to the 41st 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

Laursen CB, et al. Point-of-care ultrasonography in patients admitted with respiratory symptoms: a single-blind, randomized controlled trial. The Lancet Respiratory Medicine – July 2014 PMID: 24998674

• One of the first RCTs examining the utility of POCUS for ED patients presenting with dyspnea. Using a POCUS protocol performed by a single experienced provider, examining the heart, lungs, and deep veins of the LE, authors found significant improvement in their primary endpoint – the rate of correct diagnoses made at 4 hours. Though promising, these benefits did not translate into improvements in hospital or 30 day mortality, length of stay or hospital free days. Furthermore there was a significant increase in downstream testing in patients randomized to the POCUS group indicating there may be a degree of over-diagnosis that occurs with the introduction of such a protocol. (Rory Spiegel)
• This is further evidence that POCUS of the chest may be of benefit in the ED. However, although this is an RCT there are some significant biases within it. Whilst I personally agree with the results and in all honesty I wish them to be true, there is not evidence here to firmly change practice. For me I would like to see more studies using a broader population base, multiple USS operators and larger numbers. (Simon Carley)
• Recommended by: Rory Spiegel, Simon Carley
• Read More: POCUS for the Breathless Patient (St. Emlyn’s) and ED Hocus POCUS . . . or Just a Hoax (EM Literature of Note)

Singleton T et al.Emergency department care for patients with hemophilia and von Willebrand disease. J Emerg Med. 2010 Aug;39(2):158-65. PMID: 18757163 [JEM Full Text]

• Heriditary bleeding disorders are reletively rare and most often are treated in out-patients-clinics. Emergency physicians rarely encounter them with the potiential for delays in diagnosis and administration of replacement therapy. In this great review of ED evaluation and management of hemophilia and Von Willebrand disease to outline some of the issues facing emergency physicians and the options available for the treatment of these patients.
• Recommended by: Sean Fox

Harvey V, Perrone J, Kim P.Does the Use of Tranexamic Acid Improve Trauma Mortality? Ann Emerg Med 2014; 63(4):460-462. PMID 24095056 [Annals Full Text]

• This is a review of the literature regarding tranexamic acid use in traumatic hemorrhage showing that tranexamic acid significantly decrease mortality in bleeding trauma patients, without significantly increasing serious prothrombotic complications if administered within 3 hours of injury. There is, however, no evidence of benefit in patients with traumatic brain injury. The authors recommend early treatment with tranexamic acid in trauma patients without isolated brain injuries who have or are at risk for significant hemorrhage and in patients who receive resuscitation with blood products, particularly if they require massive transfusion or have a high risk of death at baseline.
• Recommended by: Anand Swaminathan

Righini M et al.Age-adjusted D-dimer cutoff levels to rule out pulmonary embolism: the ADJUST-PE study.JAMA. 2014 Mar 19;311(11):1117-24. PubMed PMID: 24643601. [JAMA Full Text]

• This study prospectively validated whether an age-adjusted D-dimer cutoff was associated with an increased diagnostic yield of D-dimer in elderly patients with suspected PE. Compared with a fixed D-dimer cutoff, the combination of pretest clinical probability assessment with age-adjusted D-dimer cutoff was associated with a larger number of patients in whom PE could be considered ruled out with a low likelihood of subsequent clinical venous thromboembolism. So if this is not your clinical practice already, maybe time to use age adjust d-dimer values?
• Recommended by: Jerremy Fried
• Read More: Age Adjusted D-Dimer Testing (REBEL EM)

Kelleher DC et al.Factors affecting team size and task performance in pediatric trauma resuscitation. Pediatr Emerg Care. 2014 Apr;30(4):248-53. PMID 24651216

• This study investigates factors associated with varying team size and task completion during trauma resuscitation. Video of 201 pediatric trauma resuscitations were reviewed and task completion was then analyzed in relation to team size using best-fit curves. Having 7 people at the bedside during a pediatric trauma resuscitation was optimal in patient management. Beyond this number, the investigators saw diminishing returns.
• Recommended by: Cliff Reid
• Read More: Resus Team Size and Productivity (Resus.Me)

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Allon M et al.Effect of bicarbonate administration on plasma potassium in dialysis patients: interactions with insulin and albuterol. Am J Kidney Dis. 1996 Oct;28(4):508-14. PMID: 8840939 [AJKD Full Text]

• This is the paper that should have pushed people away from using bicarb in hyperkalemia, or at least started them towards researching it. Whereas insulin and albuterol are effective temporizing measures to shift potassium rapidly from the extracellular to the intracellular fluid compartments and thereby lowering plasma potassium acutely, bicarbonate by itself is not. But bicarbonate is believed to have a potentiating effect on albuterol and insulin. Using a prospective cross-over design, 6 treatment protocols combining bicarbonate, albuterol, insulin and saline respectively were investigated for acute effects on plasma potassium as well as blood bicarbonate and pH in nondiabetic hemodialysis patients. The resulst observations suggest that bicarbonate administration does not potentiate the potassium-lowering effects of insulin or albuterol in this patient population.
• Recommended by: Justin Hensley

Hwang V et al.Prevalence of traumatic injuries in drowning and near drowning in children and adolescents. Arch Pediatr Adolesc Med. 2003 Jan;157(1):50-3. PMID: 12517194 [JAMA Full text]

• In this ten-year retrospective review of pediatric drowning and near drowning the prevalence of traumatic injury was low. In fact the authors only identified cervical spine injuries, and all but 1 patient had a clear history of diving. Use of specialized trauma evaluations may not be warranted for patients in drowning and near-drowning accidents without a clear history of traumatic mechanism. So not all submersion victims are trauma victims! If they are not a trauma victim, then do you and the patient a favor and remove the C-Collar.
• Recommended by: Sean Fox

Nishijima DK et al. Utility of platelet transfusion in adult patients with traumatic intracranial hemorrhage and preinjury antiplatelet use: A systematic review. J Trauma Acute Care Surg: 2012;72:1658Y1663. PMID 22695437

• Preinjury use of antiplatelet agents (i.e. aspirin, clopidogrel) is common. Patients with ICH on these agents have higher morbidity and mortality. this systematic review reveals the lack of evidence to support or refute the utility of platelet transfusion in these patients. Physicians must weight the risks and benefits of a platelet transfusion in patients on antiplatelet agents who present with traumatic ICH.
• Recommended by: Anand Swaminathan

Dries DJ and Endorf FW.Inhalation injury: epidemiology, pathology, treatment strategies. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013, 21:31 .PMID 23597126

• Relatively few diagnosis-specific therapeutic options have been identified for patients with inhalation injury or chemical products of combustion. In this paper, pathophysiology current treatment strategies and medical strategies under investigation for specific treatment of smoke inhalation (beta-agonists, pulmonary blood flow modifiers, anticoagulants and anti-inflammatory strategies) are reviewed
• Recommended by: Soren Steemann Rudolph

Shokoohi H et al.Ultrasound-guided peripheral intravenous access program is associated with a marked reduction in central venous catheter use in noncritically ill emergency department patients. Ann Emerg Med. 2013 Feb;61(2):198-203. PMID 23141920 [Annals Full Text]

• A well-instituted US-guided peripheral IV program will indeed decrease rates of central line insertion. Among of 401,532 patients, 1,583 (0.39%) received a central venous catheter. During a 5-year study period the rate of central line placement decreased by 80% The decrease in the rate was significantly greater among non-critically ill patients than critically ill patients. Not groundbreaking but nice to have some solid evidence.
• Recommended by: Seth Trueger