R&R In The FASTLANE 049

Welcome to the 49th 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

Stolker JM et al. Re-Thinking Composite Endpoints in Clinical Trials: Insights from Patients and Trialists. Circulation. 2014. PMID: 25200210

• Composite endpoints are commonplace, especially in cardiology literature. It takes massive power to find mortality/major mobidity benefits for many interventions; thus, many studies are powered for a primary composite outcome, often: death, myocardial infarction (MI), and revascularization. This cardiology survey data highlights that both patients and trial researchers appreciate the inequity between death and revascularization. The shocker? Patients rated MI and stroke worse than death, whereas researchers rated MI and stroke as 1/3 to 1/2 as important as death. Both clinical trialists and patients rated revascularization as a minor event, in contradistinction to the equal weight placed in the composite primary outcome in many trials.
• Recommended by: Lauren Westafer, Anand Swaminathan
• Read More: Would You Rather . . . (Lauren Westafer)

Hernandez, C et al. C.A.U.S.E.: Cardiac arrest ultra-sound exam–a better approach to managing patients in primary non-arrhythmogenic cardiac arrest.Resuscitation. 2008 Feb;76(2):198-206. PMID: 17822831

• Having a practical approach to managing a PEA is crucial. This paper has used the C.A.U.S.E. mnemonic (appropriately termed) to find reversible causes. In addition this protocol has the potential to reduce the time required to determine the etiology of a cardiac arrest and thus decrease the time between arrest and appropriate therapy.
• Recommended by: Sa’ad Lahri

Calder KK et al. The mortality of untreated pulmonary embolism in emergency department patients. Ann Emerg Med. 2005 Mar;45(3):302-10. PMID: 15726055

• This 2005 paper questions the mortality rate of untreated PE — they find only 5%. Scary numbers from PE probably represent old data when the only PEs we found were big, bad… and obvious.
• Recommended by: Seth Trueger

Thiruganasambandamoorthy V et al. Outcomes in Presyncope Patients: A Prospective Cohort Study. Ann Emerg Med 2014. PMID: 25182542

• Pre-syncope is often thought of as a benign occurrence but in this prospective study, the authors found that 5.1% of patients with presyncope had serious outcomes at 30 days. This rate was only 1.9% in the group sent home from the Emergency Department. Emergency Physicians had a tough time determining which patients with presyncope were at risk for serious outcomes after discharge. This area needs more research but it is clear that we should take presyncope seriously.
• Recommended by: Anand Swaminathan

Jabre P et al. Family presence during cardiopulmonary resuscitation. NEJM 2013; 368(11):1008-18. PMID: 23484827 (OPEN ACCESS ARTICLE)

• Should the family watch? In this study, home CPR was performed by responding EMS units, half offered the family the opportunity to be present for resuscitation, half did not. Post-surveys were conducted 90 days later on family and health care workers.
  PTSD and anxiety symptoms were less in the family members who witnessed the resuscitation. Health care workers did not report increased stress levels or that family interfered with resuscitation.
• Application to emergency department and critical care setting is questionable given this was a French pre-hospital study, but it suggests that family presence in resuscitation may be good for family members and does not hinder the care provided.
• Recommended by: Zack Repanshek

Cohen HA et al. Effect of honey on nocturnal cough and sleep quality: a double-blind, randomized, placebo-controlled study. Pediatrics. 2012 Sep;130(3):465-71. PMID: 22869830 (OPEN ACCESS ARTICLE)

• If you aren’t using honey for cough in kids (>!yr old only!), then you should be. Not many drugs are effective, and this RCT shows that it wasn’t simply sticky sweet syrup, but something specific about honey as yet unidentified.
• Recommended by: Justin Hensley

Rising KL et al. Return Visits to the Emergency Department: The Patient Perspective. Ann Emerg Med 2014. PMID: 25193597

• New article in Annals looking at 60 bouncebacks — great qualitative research with patient perspectives on why they had to come back. A lot of uncertainty, worry, poor explanation. And, not surprisingly, patients thought blood work or imaging would have been necessary (would be nice to see the physicians’ perspectives!)
• Recommended by: Seth Trueger

Sheehy AM et al. The Role of Copy-and-Paste in the Hospital Electronic Health Record. JAMA Intern Med. 2014 Aug 1;174(8):1217-8. PMID: 24887572

• We are seeing more attention paid to how we use electronic health records (EHRs), and this paper addresses one the most contentious issues in the EHR era, the use of “macros” or templates to document care. The authors outline the problem (documenting what you did not do, i.e. fraud) and propose user-based and systems-based solutions. Ultimately they conclude the force that drives inappropriate documentation is the perverse ways in which hospitals and physicians are reimbursed (e.g. by documenting a “complete” review of systems) and that without changing these incentives, progress on the copy & paste front will be difficult.
• Recommended by: Reuben Strayer

Tibballs J, Russell P. Reliability of pulse palpation by healthcare personnel to diagnose paediatric cardiac arrest. Resuscitation. 2009 Jan;80(1):61-4. PMID: 18992985

• In the healthy child, finding a pulse is not a problem. Unfortunately, our management is not usually contingent upon finding a pulse in the healthy kid, whereas it is vital in the sick one… especially if they are unresponsive. “Do you feel a pulse?” “Hmmm… I think so… well, maybe not…” “Does anyone feel a pulse?” This paper essentially points out that we are not perfect at determining whether there is a pulse present or not. When time is of the essence, wasting time trying to be perfect is unwise. This helps advocate for two things in my mind: 1) More liberal use of chest compressions in the patient who is unresponsive , lacks movement, or has poor respirations and (2) more liberal use of bedside ultrasound (although not right away… as you only have 10 seconds to make a decision).
• Recommended by: Sean Fox
• Read More: Palpation of Pulse for Cardiac Arrest (Sean Fox)

Glasier A et al. Can we identify women at risk of pregnancy despite using emergency contraception? Data from randomized trials of ulipristal acetate and levonorgestrel. Contraception 2011; 84: 363-7. PMID: 21920190

• Not all women respond to emergency contraception medications the same. This study found that women with higher BMI (> 25) were at an increased risk for medication failure (OR 3.60). The authors recommend that women with higher BMIs should be offered copper IUDs (not realistic in most EDs). Alternatively, some agents are more effective and may be viable options.
• Recommended by: Anand Swaminathan