Welcome to the 44th 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

Nuotio I, Hartikainen JE, Grönberg T, Biancari F, Airaksinen KE. Time to cardioversion for acute atrial fibrillation and thromboembolic complications. JAMA. 2014 Aug 13;312(6):647-9. PMID: 25117135

  • This is an interesting research letter suggesting that we might be a little bit “button happy” with our defibs in the case of new onset AF. I’ve always been a big fan of DCC for new AF and assumed that the “within 48hrs” was a useful protection against stroke. This small research letter (with 5000 cardioversions) suggests the rate of thromboembolism might be as high as 1% in the first 30 days following unanticoagulated DCC. As it’s only a research letter there’s not much details in the way of methods but gives pause to think before you charge. Especially considering that rate control and anticoagulation seems to produce the same outcomes. Hat tip to @drjohnm for the link
  • This retrospective review challenges the widely accepted concept that patients with recent onset atrial fibrillation of less than 48 hours duration are safe for cardioversion without preceding anticoagulation. The authors report a 1.1% risk of thromboembolism after symptoms have been going for greater than 12 hours (vs 0.3% in the < 12 hour group). Before practice is completely changed, though, it should be noted that the rate of CVA after cardioversion in anticoagulated patients (3 weeks of therapeutic anticoagulation) may be as high as 0.8%. Additionally, this study suffers from the standard flaws of all retrospective studies. More research is needed to help answer this question and guide management.
  • Recommended by: Andy Neill, Anand Swaminathan
  • Read More: Shocking AF — What’s the rush? (Dr John M), Should the 48-hour Cardioversion Window Be Revised? (EM Literature of Note)

Courtney DM et al. Prospective multicenter assessment of interobserver agreement for radiologist interpretation of multidetector computerized tomographic angiography for pulmonary embolism. J Thromb Haem 2010; 8: 533-9. PMID 20015156

  • This study looks at the agreement between radiologists in reading CTPAs for pulmonary embolism. They found that more than 10% of studies initially read as positive were later read as either negative or indeterminate. Many of the change in read occurred in subsegmental embolisms. This study throws further doubt on starting patients on long term anticoagulation based on the presence of a subsegmental pulmonary embolism.
  • Recommended by: Anand Swaminathan

Raemer DB. Ignaz semmelweis redux? Simul Healthc. 2014 Jun;9(3):153-5. PMID: 24401925

  • As a rabid in situ simulationist it is good to be tempered now an then by a brilliant article. Dan Raemer, one of the many sim gurus from the Center for Medical Simulation and Harvard Medical School, writes about the pros and cons of in situ simulation. The cons provide food for thought.
  • Recommended by: Chris Nickson

Marik PE. Iatrogenic salt water drowning and the hazards of a high central venous pressure. Ann Intensive Care. 2014 PMID: 25110606

  • If the author doesn’t make you want to read this, then the title will. Paul Marik’s talk on EMCrit took the FOAMiverse by storm – this article is really the distillation of his ideas about over-resuscitation, chloride toxicity and the uselessness of the CVP for assessing euvolaemia. IT is typically iconoclastic and persuasive. A word of caution, ideas like chloride being toxic are far from proven and though they may well turn out to be true we should guard against creating new dogma before the truth is really known.
  • Recommended by: Chris Nickson
  • Listen to more: Fluids in Sepsis, A New Paradigm – Paul Marik (EMCrit)

Driver BE, Debaty G, Plummer DW, Smith SW. Use of esmolol after failure of standard cardiopulmonary resuscitation to treat patients with refractory ventricular fibrillation. Resuscitation. 2014 PMID: 25033747

Antonucci E, et al. Myocardial depression in sepsis: from pathogenesis to clinical manifestations and treatment. J Crit Care. 2014 Aug;29(4):500-11. PMID 24794044

  • An awesome bench to bedside review, summarizing the basics of the pathogenesis, diagnosis, and treatment of myocardial depression in sepsis.
  • Recommended by: Sa’ad Lahri

Heradstveit BE, Heltne JK. PQRST – A unique aide-memoire for capnography interpretation during cardiac arrest. Resuscitation 2014 PMID 25063372

  • End tidal CO2 monitoring has become a mainstay in resuscitation. This article gives a mnemonic device for applying capnography during resuscitation. This tool can help bridge the gap from theory to application for many practitioners.
    P – Position of the tube
    Q – Quality of compressions
    R – Return of spontaneous circulation
    S – Strategy for further treatment
    T – Termination of resuscitation
  • Recommended by: Anand Swaminathan

Rohde JM, et al. Health care-associated infection after red blood cell transfusion: a systematic review and meta-analysis. JAMA. 2014 PMID: 24691607

  • A meta analyses providing further evidence for a restrictive PRBC transfusion policy as those patients in liberal groups were more likely to acquire hospital associated infections. A goal of Hb <7 provided a NNT of 20 to reduce infection.
  • Recommended by: Jeremy Fried

Sezik S, Aksay E, Kılıç TY. The Effect of Fresh Frozen Plasma Transfusion on International Normalized Ratio in Emergency Department Patients.  J Emerg Med. 2014 Jul 26. pii: S0736-4679(14)00636-2. doi: 10.1016/j.jemermed.2014.04.042. [Epub ahead of print] PMID 25074780

  • Fresh frozen plasma (FFP) is commonly used to reverse elevated international normalized ratios (INRs) in patients with coagulopathy and trauma or anticipated procedures.  While prior studies and recommendations have demonstrated that FFP does not reduce the iNR below 1.7, FFP is often given to patients with minimally elevated INRs.  This cross-sectional retrospective study of 87 patients who received FFP and had their INR re-checked within 6 hours found that the degree of improvement in INR is greatest in those with the most elevated INRs. They found the following reductions in INR per unit of FFP:
    INR <2:  0.03
    INR 2-5: 0.77
    INR 5-9: 2.14
    INR 9-12: 4.63
    The study has limitations and correcting numbers isn’t the same as fixing patients, but it’s good to know the gains of an intervention, especially as transfusions have associated risks.
  • Recommended by: Lauren Westafer

Carpenter CR, et al. Adult scaphoid fracture. Acad Emerg Med 2014; 21: 102-121. PMID 24673666

  • In this systematic review, only the absence of snuff box tenderness to palpation had an adequate negative likelihood ratio (- LR = 0.15) to affect management. MRI was found to be better than bone scan, CT or ultrasound for the diagnosis. This is in stark contrast with traditional teaching that only MRI can rule out occult scaphoid fractures in the acute setting.
  • Recommended by: Anand Swaminathan

Emergency physician with interest in education and knowledge translation. #FOAMed Fan | @jdfried |

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