Research and Reviews in the Fastlane 600

Welcome to the 48th 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

RR Hall of FAMER

Mal S et al. Effect of Out-of-Hospital Noninvasive Positive-Pressure Support Ventilation in Adult Patients With Severe Respiratory Distress: A Systematic Review and Meta-analysis. Ann of EM 2014; 63(5):600-607. PMID: 24342819

  • Over the last decade, health care providers have been increasingly aggressive in starting NIPPV early in management. Numerous studies demonstrate decreased ICU admissions and decreased intubation rates when NIPPV is used in the ED in patients with COPD exacerbations and acute decompensated heart failure. This systematic review and meta-analysis demonstrates significant reductions in in-hospital mortality (NNT = 18) and invasive ventilation (NNT = 8) when NIPPV is applied in the prehospital setting.
  • Recommended by: Salim Rezaie, Anand Swaminathan
  • Read More: September REBEL Cast (Salim Rezaie)

Del Pizzo J1, Callahan JM. Intranasal medications in pediatric emergency medicine. Pediatr Emerg Care. 2014;30(7):496-501. PMID: 24987995

  • This is a really helpful review of intranasal administration of medications in the Peds ED. This route is often underutilized and may be a means by which you can optimize your door to analgesic administration time. Despite our best intentions, kids with significantly painful processes (like a long bone fracture) often go for prolonged periods without appropriate (or any) analgesics. (See article PMID: 22270501). Using the intranasal route can help hasten the delivery of pain medications! Consider this the next time you see the kid with the obviously deformed extremity… yes, you will likely still need an IV, but that intranasal fentanyl can make getting the IV and those important xrays much more humane.
  • Recommended by: Sean Fox
  • Read More: Intranasal Analgesia (Sean Fox)

McPhee LC et al. Single-dose etomidate is not associated with increased mortality in ICU patients with sepsis: analysis of a large electronic ICU database. Crit Care Med. 2013;41(3):774-83. PMID: 23318491

  • The use of etomidate for RSI has been much maligned in recent years for it’s side effect of transient adrenal suppression. However, there has been little, if any, if any evidence of its effect on patient centered outcomes. In this retrospective analysis, etomidate was not associated with increased mortality or other adverse outcomes in patients with shock or the subgroup with septic shock. Until a large, well-done RDCT is performed, the issue will not be put to rest but for now, etomidate is a viable option for RSI.
  • Recommended by: Anand Swaminathan
RR Game Changer

Campagna JD et al. The Use of Cephalosporins in Penicillin-allergic Patients: A Literature Review. J Emerg Med. 2012;42(5):612-20. PMID: 21742459

  • Although a myth persists that approximately 10% of patients with a history of penicillin allergy will have an allergic reaction if given a cephalosporin, the overall cross-reactivity rate is approximately 1% when using first-generation cephalosporins or cephalosporins with similar R1 side chains. For penicillin-allergic patients, the use of third- or fourth-generation cephalosporins or cephalosporins with dissimilar side chains than the offending penicillin carries a negligible risk of cross allergy.
  • Recommended by: Salim Rezaie
RR Game Changer

Smith-Bindman R et al. Radiation dose associated with common computed tomography examinations and the associated lifetime attributable risk of cancer.  Arch Intern Med. 2009;169(22): 2078-86. PMID: 20008690

  • Quantifying risks of ionizing radiation is tough. This article shows that many patients get more radiation than studies using phantoms would imply. There was also a wide variation in the dose each patient received.
    You might be able to use this to dial back the number of not-absolutely-necessary CTs performed in the ED.
  • Recommended by: Justin Hensley
RR Trash

Doss M. Radiation dose justification and optimization should not be applied to medical imaging in emergency medicine. Ann Emerg Med 2014; 64(3):332-3. PMID: 25149970

  • Editorial that discusses the idea that what we know about radiation and risks of malignancy is wrong. The author reviews recent literature and argues that the estimates of medical imaging induced malignancy are off base as they are based on an incorrect risk projection model. Furthermore, he goes on to state there is reason to suspect that low dose radiation may, in fact, be beneficial and reduce cancer risk. While it’s clear that we don’t fully comprehend the impact of medical radiation, this editorial adds little to the discussion. The author only cites his own research on the topic. The claims of reducing cancer are particularly short on data to support them.
  • Recommended by: Jeremy Fried, Reuben Strayer
RR Boffintastic

Blood pressure-lowering treatment based on cardiovascular risk: a meta-analysis of individual patient data. The Blood Pressure Lowering Treatment Trialists’ Collaboration. Lancet 2014; 384 (9943): 591-598. PMID: 25131978

  • OK its preventative care – not sexy. But a great look at risk and the way we get carried away with numbers.
    Does lowering a pts BP help reduce their CVD risk?
    Well… yes
    Relative risk benefits for all CVD risk groups fell with BP reduction – but, it is really only in the higher risk groups where you get a useful ABSOLUTE risk reduction.
    So most importnat to target therapy at pts who will derive the benefits
  • Recommended by: Casey Parker
RR Eureka

Petinaux B et al. Accuracy of radiographic readings in the emergency department. Am J Emerg Med 2011; 29(1):18-25. PMID: 20825769

  • Many emergency physicians read their own plain films in real time and make clinical decisions based on their own reads.
    This study looked at one institution’s discrepancy rate between EP and radiologist plain film reads over 10 years. They found overall an ~3% discrepancy rate on all plain films. This of course does not mean the radiologist was correct in every discrepancy. But it does show we agree most of the time.
    Most interestingly, the rate of discrepancies requiring emergent change in management was a mere 0.056%!
  • Recommended by: Zack Repanshek
RR Game Changer

Williams BT et al. Emergency department identification and critical care management of a Utah prison botulism outbreak. Ann Emerg Med 2014; 64(1):26-31. PMID: 24331717

  • This article reviews an outbreak of botulism in a US prison system resulting from consumption of pruno (jailhouse wine). Food borne botulism is infrequent (20 cases/year in US) and outbreaks like this (8 cases) are critical in learning more about the disease. The authors provides information about time from consumption to onset of symptoms and severity of symptoms that are critical in understanding and recognizing this rare and potentially devastating disease. 
  • Recommended by: Anand Swaminathan

Braude D et al. Air Transport of Patients with Pneumothorax: Is Tube Thoracostomy Required Before Flight? Air Med J. 2014 Jul-Aug;33(4):152-6. PMID: 25049185

  • Conventional teaching dictates that all patients with any pneumothorax (PTX) should have a tube thoracostomy placed prior to air medical transport. However, this “rule” may delay transfer for definitive management of injuries and has not been shown to decrease the risk of adverse outcomes. This article is a retrospective review of trauma patients transported to a single trauma center with confirmed PTX who did not have a tube thoracostomy placed prior to transport. They found a low complication rate (6%) and all patients were successfully treated with needle decompression. Although prospective validation is required, this article challenges the conventional dogma.
  • Recommended by: Anand Swaminathan
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New Jersey Emergency Physician with academic focus on resident education and critical care in the ED. Strong supporter of FOAMed and its role in cutting down knowledge translation | @EMSwami |

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