R&R In The FASTLANE 043

Welcome to the 43rd 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

Cohen L, et al. The Effect of Ketamine on Intracranial and Cerebral Perfusion Pressure and Health Outcomes: A Systematic Review. Ann Emerg Med. 2014 Jul 16. pii: S0196-0644(14)00529-0. doi: 10.1016/j.annemergmed.2014.06.018. [Epub ahead of print] PMID: 25064742.

• Despite the widespread use of ketamine for decades the dogma persists that the drug increases intracranial pressure and should not be used in patients with head injuries. However, the evidence continues to mount against this idea. This is another systematic review of the available literature demonstrating that ketamine in the critically ill patient does not appear to adversely affect any patient centered outcomes. Ketamine theoretically may be neuroprotective in these patients and should be considered safe for use.
• A thorough systematic review demonstrates what the FOAM community has been advocating for years: Ketamine is a safe and reasonable sedation/induction agent choice for the undifferentiated patient in the emergency department.
• Recommended by: Anand Swaminathan, Jeremy Fried

Sklansky M, Nadkarni N, Ramirez-Avila L. Banning the Handshake From the Health Care Setting. JAMA. 2014 May 15. doi: 10.1001/jama.2014.4675. [Epub ahead of print] PMID: 24833502

• Ban the handshake! Long live the fist bump! A clarion call from JAMA to reduce infection transmission. This editorial expounds the connection between handshakes and infection in the hospital with a directive to ban the handshake altogether from the health care setting. They draw a link between the social acceptance of smoking in the 1950s and 60s and the current use of grasping hands in greeting today. Alternative greetings suggested include, among others, waving, hand-over-heart, and bowing.
• Recommended by: Jeremy Fried

Charlton B, Redberg R. The trouble with dabigatran. BMJ. 2014 Jul 23;349:g4681. doi: 10.1136/bmj.g4681. PMID: 25055830

• Once again, due to the lack of transparency from drug company research, we find ourselves discovering the dangers of a drug long after it’s been released. This editorial briefly outlines the current state of knowledge regarding the knowns and unknowns of dabigatran use. Briefly, use caution in the elderly and renal impaired. As the authors comment: “In effect, the current situation leaves clinicians and patients the choice between the devil they know and the one they don’t.”
• Recommended by: Jeremy Fried

Golan E et al. Predicting Neurologic Outcome After Targeted Temperature Management for Cardiac Arrest: Systematic Review and Meta-Analysis. Crit Care Med 2014; 42:1919–1930. PMID 24717465

• Predicting poor neurologic outcome after ROSC with TTM is challenging. This article is a meta-analysis and systematic review looking at the utility of different tests used in this determination. Bilateral absence of pupillary reflexes (+ LR = 10.45) and bilateral absence of somatosensory-evoked potential (+ LR = 12.79) were the most useful in predicting poor neurological outcome. The authors recommend waiting 72 hours to make evaluations. The authors also state a major caveat that is perhaps the biggest take home point: “clinicians should use caution with these predictors as they carry the inherent risk of becoming self-fulfilling.”
• Recommended by: Anand Swaminathan

Lee LK, Monroe D, Bachman MC, et al. Isolated Loss of Consciousness in Children With Minor Blunt Head Trauma. JAMA Pediatr. 2014;02115. doi:10.1001/jamapediatrics.2014.361. PMID 25003654

• The PECARN clinical decision tool for detecting clinically important brain injury in pediatric blunt head trauma has been widely adopted. Loss of consciousness (LOC) is one of the components of this tool and has been demonstrated to be of debatable utility and accuracy in previous studies (kappa 0.54 for children <2 in this paper). This paper is a sub-group analysis of the data used to form the initial tool.
• The authors look at isolated LOC and found that, alone, it does not represent significant risk for clinically important TBI. The tool has recommended observation vs CT scan at the discretion of the physician but, as most of these subgroup analyses have demonstrated, an isolated risk factor (vomiting or LOC) is most often not a harbinger of badness. Use judgment, recognize the limitation of reported LOC, and embrace observation.
• Recommended by: Lauren Westafer
• Read More: REBEL Cast August 2014 (Salim Rezaie)

Perry JJ, Stiell IG, et al. Sensitivity of computed tomography performed within six hours of onset of headache for diagnosis of subarachnoid haemorrhage: prospective cohort study. BMJ. 2011 Jul 18;343:d4277. doi: 10.1136/bmj.d4277. PMID: 21768192

• 3rd generation CT scanners are extremely sensitive in identifying SAH when it is carried out within six hours of headache onset and interpreted by a qualified radiologist. This study claimed a sensitivity and specificity of 100% in this group of patients questioning the traditional “CT, LP” approach to managing patients with clinical suspicion for SAH. However, the study has flaws and we eagerly await external validation.
• Recommended by: Salim R. Rezaie

Williams CM, Maher CG, Latimer J et al. Efficacy of paracetamol for acute low-back pain: a double-blind, randomised controlled trial. Lancet. 2014 Jul 23. pii: S0140-6736(14)60805-9. doi: 10.1016/S0140-6736(14)60805-9. PMID 25064594

• Should we continue to give paracetamol for lower back pain? In this Australian multicentre, double-dummy, randomised, placebo controlled trial 1652 patients with acute lower back pain were randomly allocated either to regular doses of paracetamol, as-needed doses of paracetamol or placebo. The primary outcome was time until recovery from low-back pain. Surprisingly the regular or as-needed dosing with paracetamol did not affect recovery time compared with placebo.
• Recommended by: Søren Rudolph

Borst GM, Davies SW, Waibel BH, Leonard KL, Rinehart SM, et al. When birds can’t fly: An analysis of interfacility ground transport using advanced life support when helicopter emergency medical service is unavailable. J Trauma Acute Care Surg. 2014 Aug;77(2):331-7. PMID 25058262

• A novel contribution to the ongoing debate over utilization of helicopter EMS in trauma, demonstrating no survival benefit associated with HEMS transport. However, this retrospective analysis is limited by missing data and between-group differences.
• Recommended by: Ryan Radecki
• Read more: Get to the Choppa! Or … Maybe Not? (EM Literature of Note)

Lu MT, Tellis WM, Avrin DE. Providing formal reports for outside imaging and the rate of repeat imaging. AJR Am J Roentgenol. 2014 Jul;203(1):107-10. doi: 10.2214/AJR.13.10617. PMID: 24951202.

• Health care expenditures continue to climb for a multitude of disparate reasons across specialties. Often the ED is the department that receives transfers from other institutions and is frequently asked to repeat imaging or laboratory examinations. This retrospective chart review found that when radiologists provided second reads on abdomen and pelvic CTs the overall usage of repeat CTs decreased thereby decreasing effective radiation doses and overall costs to each patient. This obvious study reiterates that we should minimize repeated studies by enlisting our radiology colleagues to aid us in interpreting studies from outside hospitals.
• Recommended by: William Paolo

Mueller SW, et al. A randomized, double-blind, placebo-controlled, dose range study of dexmedetomidine as adjunctive therapy for alcohol withdrawal. Crit Care Med 2014;42(5):1131-9. PMID 24351375

• First RCT to evaluate dexmedetomidine in severe ethanol withdrawal. Dexmedetomidine reduced short-term benzodiazepine requirements, but not long-term when using symptom-triggered approach. Monitor for bradycardia when using dexmedetomidine.
• Recommended by: Bryan Hayes
• Read more: Dexmedetomidine (Precedex) as an Adjunct to Benzodiazepines for Ethanol Withdrawal (ALiEM)