R&R In The FASTLANE 046

Welcome to the 46th 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

Schuh S et al. Effect of oximetry on hospitalization in bronchiolitis: a randomized clinical trial. JAMA. 2014 Aug 20;312(7):712-8. PMID: 25138332.

• This paper reports on a study with a remarkable methodology: infants with mild or moderate bronchiolitis were randomized to have their actual oxygen saturation displayed, or a saturation increased by 3%. 26 of 105 (25%) of patients with falsely raised saturation were admitted,  44 or 108 (41%) of patients in the true saturation group were admitted, no difference in follow-up outcomes. The message is that we over-rely on pulse oximetry in our disposition decisions.
• Recommended by: Reuben Strayer

Palazuolli A et al. Continuous versus bolus intermittent loop diuretic infusion in acutely decompensated heart failure: a prospective randomized trial. Crit Care 2014; 8(3):R134. PMID: 24974232

• Despite evidence that loop diuretics are harmful (or at least not helpful) in the initial management of most patients with acute decompensated heart failure (ADHF), they continue to be widely used. Recently, treatment has shifted towards the idea of continuous loop diuretic infusion instead of bolus dosing. In this RCT, continuous infusion of loop diuretic (compared to bolus dosing) was found to worsen GFR, increase the rate of rescue therapy and increase mortality at 6 months.
• Recommended by: Anand Swaminathan

Lenhardt R et al. Is video laryngoscope-assisted flexible tracheoscope intubation feasible for patients with predicted difficult airway? A prospective, randomized clinical trial. Anesth Analg. 2014 Jun;118(6):1259-65. PMID: 24842175

• The authors describe using a flexible endoscope (akin to a fiberoptic bronchoscope) IN COMBINATION with a glidescope to facilitate intubation in patients with predicted difficult airway. With hyperangulated blades, you will almost always see the glottis, the problem is getting the tube around the bend to deliver it to the glottis. Using the flexible endoscope (they used an aScope) addresses this problem. This approach makes a lot of sense in patients who are predicted or known to have difficult airways and need to intubated urgently but not emergently, i.e. in the next 10 minutes but not in the next 10 seconds, because it will take a little time to set this up and carry it out.
• Recommended by: Reuben Strayer

Chagnon SL et al. Child neurology: tick paralysis: a diagnosis not to miss. Neurology. 2014 Mar 18;82(11):e91-3.

• Weakness in a child can be very perplexing… is it a stroke? Really? Should we get a MRI? Well, strokes happen in kids… but before you go ordering a million dollar work-up, check the child’s skin for a tick! Tick Paralysis seems like something out of a science fiction novel (do people still read books – just curious), but it is not fiction and your detective work can make a huge difference!
• Recommended by: Sean Fox
• Read More: Tick Paralysis (Sean Fox)

Soult MC et al. Thoracic ultrasound can predict safe removal of thoracostomy tubes. J Trauma Acute Care Surg. 2014 Aug;77(2):256-61. PMID: 25058251

• This is a real game changer. We insert about 20 Intercostal drains per weekend and then often have a severe ED boarding issue on the Monday and Tuesday. US is safe and effective for the rapid diagnosis of PTX and now great for removal of intercostal drains. Also less radiation… looks like a win-win!
• Recommended by: Sa’ad Lahri

van Dongen TMA et al. A trial of treatment for acute otorrhea in children with tympanostomy tubes. NEJM 2014; 370: 723-33. PMID: 24552319

• In children with tympanostomy tubes and acute otorrhea without fever, topical antibiotics with glucocortocoids were superior to oral antibiotics. Just one more disease that we now recognize we’re over-treating with oral antibiotics.
• Recommended by: Anand Swaminathan

Aguilera AL et al. Radiography of cardiac conduction devices: a comprehensive review. Radiographics. 2011 Oct;31(6):1669-82. PMID: 21997988

• A well-written guide to detecting CCD (PPMs & ICDs) problems on plain films, with lots of helpful images and clear explanations. Gold for fellowship candidates.
• Recommended by: Matt MacPartlin

Costa EL et al. Electrical impedance tomography. Curr Opin Crit Care. 2009 Feb;15(1):18-24. Review. PMID: 19186406.

• Electrical impedance tomography. (EIT) is seriously cool. If you look after mechanically ventilated patients you’ll be amazed at the potential this technology has for real-time assessment of lung ventilation and perfusion. Time will tell if use becomes widespread.
• Recommended by: Chris Nickson

Hunt BJ. Bleeding and coagulopathies in critical care. N Engl J Med. 2014 Feb 27;370(9):847-59. PMID: 24571757

• Excellent review of the hemorrhaging and coagulopathic patient. Also provides further support to the use of TXA in trauma to those looking for it.
• Recommended by: Jeremy Fried

Kim F et al. Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest: a randomized clinical trial. JAMA 1014; 311: 45-52. PMID: 24240712

• Post-arrest cooling improves neurologic outcomes, and the sooner we can cool after ROSC the better, right? This study looked at initiating cooling prehospital after out of hospital cardiac arrest with resuscitation. No surprise, these patients cooled faster, reaching 34 degrees > 1 hour faster! Unfortunately, this early cooling did not show a benefit in survival or neurologic outcome. This was true for both VF and non-VF arrest. Prehospital cooling reduced core temperature by hospital arrival and reduced the time to reach a temperature of 34°C, but did not improve survival or neurological status among patients resuscitated from prehospital VF or those without VF
• Recommended by: Salim Rezaie, Zach Repanshek