R&R In The FASTLANE 050

Welcome to the 50th 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

Smith-Bindman R et al. Ultrasonography versus Computed Tomography for Suspected Nephrolithiasis. NEJM 2014; 371(12):1100-10 PMID: 25229916

• Renal colic is a common presentation that often ends in a patient having a CT of the abdomen and pelvis. This article attempts to demonstrate that Ultrasound, whether radiologist performed or POC by ED physicians, is at least equivalent to CT in terms of adverse patient events. Although the protocol was convoluted and multiple primary endpoints were described, the study demonstrated an equivalent serious adverse outcome rate suggesting that ultrasound may safely be used as an initial confirmatory test for ureterolithiasis when a confirmatory test is determined to be needed. (Ryan Radecki)
• A RCT for US – Yay! Almost 3000 pts compared ED US, Rad US and CT. Outcomes were – did we misdiagnose anything bad? And yes the docs missed a few bad things – but it was the same in all 3 groups so ED US doesn’t seem to be killing people with misdiagnosis. Interestingly (according to their gold standard of visualised stone passage or surgery) all 3 groups had the same sens/spec of 85/50% respectively
• We do a ton of CTs looking for renal tract stones and there has never been any evidence that this improves patient outcomes. (Andy Neill)
  People are going to pick up this paper expecting it to tell them that ultrasound is as good as CT for diagnosing these stones. Unfortunately that’s not what it says.
• This study compared bedside US by EPs vs radiology US vs CT as the INITIAL test in patients expected with nephrolithiasis. It found there was no difference in serious outcomes between the groups, but the rate of serious outcomes was overall very low.
• Obviously patients that got only an US had lower radiation exposure and lengths of stay. But what is interesting is that 40% of patients with an initial ED US went on to get a CT also.
• This study does not state that patients should ONLY undergo US, just that it should be the INITIAL test. If it cuts down on our CT ordering, it sounds like a good start. (Zack Repanshek)
• Recommended by: Ryan Radecki, Andy Neill, Zack Repanshek
• Read More: Farewell CT Stone Protocol (EM Literature of Note), RCT of ED Renal Ultrasound for renal colic (Emergency Medicine Ireland)

Marik P. Early management of severe sepsis: concepts and controversies. Chest 2014; 145(6):1407-18. PMID: 24889440

• A great review from Paul Marik on severe sepsis. Discusses our current understanding of sepsis and highlights a number of controversies including fluid resuscitation, CVP, ScvO2, lactate clearance and more.
• Recommended by: Anand Swaminathan

Mellick LB. Torsion of the Testicle It Is Time to Stop Tossing the Dice. Pediatr Emerg Care 2012; 28(1):80-6.PMID: 22217895

• Excellent literature review of a relatively uncommon but serious disease where time and rapidity of diagnosis matters. The bulk of the literature shows that no individual feature of the history or physical examination can be relied upon to definitively rule in or rule out the disease. Color Doppler commonly has false positives and the myth that symptoms for more than 6 hours indicates that the testicle will be non-salvageable is incorrect. The key is suspecting the disease and getting a urologic consultation immediately.
• Recommended by: Anand Swaminathan

Rochwerg B, Alhazzani W, Sindi A, Heels-Ansdell D, Thabane L, Fox-Robichaud A, et al. Fluid Resuscitation in Sepsis: A Systematic Review and Network Meta-analysis. Ann Intern Med. 2014;161:347-355. PMID: 25047428

• So you’re working on a septic patient and the med student in the corner of the room asks – “But Dr. Bigshot, why are you flooding the patient with so much “normal” saline?” Why indeed! This systematic review + meta-analysis tries to answer the age old question of optimal resus fluid selection, specifically in septic patients. The authors make a gallant effort, but most of the numbers are not particularly compelling. That said, their intro and discussion sections provide great background and are an illuminating, easy read even for the novice resuscitationist. This paper might even encourage you to tweak your practice.
• Recommended by: David Marcus, MD

Kirkland S1, Stiell I, AlShawabkeh T, Campbell S, Dickinson G, Rowe BH. The Efficacy of Pad Placement for Electrical Cardioversion of Atrial Fibrillation/Flutter: A Systematic Review. Acad Emerg Med. 2014 Jul;21(7):717-726. PMID: 25117151

• There’s a good deal of pathophysiologic theory that has created preference for pad placement in cardioversion of atrial fibrillation/flutter. This systematic review of 13 studies that evaluated pad placement in either the Anterior-Posterior (AP) fashion compared with the Antero-Lateral (AL) position for the cardioversion of atrial fibrillation and found no difference, with a signal towards better success in those with pads in the AL position receiving biphasic cardioversion. The studies they pooled had significant limitations – varying levels of energy, limited ED studies, and heterogeneity. However, this serves another example of how pathophysiologic explanation may not translate into changed patient outcomes.
• Recommended by: Lauren Westafer

Shapiro NI, Karras DJ, Leech SH, Heilpern KL. Absolute lymphocyte count as a predictor of CD4 count. Ann Emerg Med. 1998; 32:323-8. PMID: 9737494.

• Classic paper demonstrating that all you need is a CBC with diff to estimate a patient’s CD4 count. Simple calculation for absolute lymphocyte count (ALC, like doing an ANC for neutropenia): total WBC x % lymphs. ALC>2,000 = CD4>200. ALC<1,000 = CD4<200. Grey area in the middle, and not perfectly accurate, but certainly better than guessing at a CD4.
• Recommended by: Seth Trueger

Chu K et al. Spectrophotometry or Visual Inspection to Most Reliably Detect Xanthochromia in Subarachnoid Hemorrhage: Systematic Review. Ann Emerg Med 2014; 64(3):256-264. PMID: 24635988

• Xanthochromia has long been the gold-standard test in the diagnosis of subarachnoid hemorrhage after negative non-contrast head CT. However, the determination of xanthchromia is performed in two different ways: visual inspection and spectrophtometry. While it would seem that spectrophotometry would be a superior modality, this systematic review finds that the available evidence is inconclusive. These conclusions further call in to question the utility of LP after CT if the “gold-standard” itself is unclear.
• Recommended by: Anand Swaminathan

Mahoney BA et al. Emergency interventions for hyperkalaemia (Review). Cochrane Database Syst Rev. 2005; 18(2): PMID: 15846652

• This is a systematic review of hyperkalemia management done by the Cochrane group looking only at randomized evidence. The conclusions aren’t shocking but bear repeating. IV calcium is effective in treating dysrhythmias. Nebulized/Inhaled beta agonists (i.e. albuterol/salbutamol) and insulin (paired with dextrose) are first line therapies as well. While dialysis is effective, potassium absorbing resins (i.e. Kayexalate) was not effective at 4 hours and there was no longer follow up data for this intervention.
• Recommended by: Anand Swaminathan

Sinnaeve PR, Armstrong PW, Gershlick AH, Goldstein P, Wilcox R, Lambert Y, et al. STEMI Patients Randomized to a Pharmaco-Invasive Strategy or Primary PCI: The STREAM 1-Year Mortality Follow-Up. Circulation. 2014. PMID: 25161043

• The fine folks at Boehringer Ingelheim are trying to convince us to give more tenecteplase for STEMI – patients between 60 and 120 minutes out from primary PCI. But, there’s no evidence these patients do any better – and they probably do worse. Any small cost savings from deferring emergent off-hours cardiac catheterization are reduced by the added cost of the drug.
• Recommended by: Ryan Radecki
• Read More: Emergency PCI for STEMI is Dead? (EM Literature of Note)

Eskin B, Shih RD, Fiesseler FW, Walsh BW, Allegra JR, Silverman ME, Cochrane DG, Stuhlmiller DF, Hung OL, Troncoso A, Calello DP. Prednisone for emergency department low back pain: a randomized controlled trial. J Emerg Med. 2014 Jul;47(1):65-70. PMID: 24739318.

• Do steroids help for musculoskeletal back pain?
• Approximately 5% of patients with ED diagnosis of musculoskeletal back pain leave with a prescription for steroids, despite lack of evidence of any benefit.
  This was a randomized, double-blind, placebo controlled study with patients randomized to 5 days of prednisone or placebo after discharge, along with analgesic of doctor’s choosing. There was no difference in pain between the two groups 5-7 days after discharge.
• With the lack of any benefit and the risk of GI side effects, especially when used with NSAIDs, there is no role for the use of steroids in treatment for musculoskeletal back pain.
• Recommended by: Zack Repanshek