R&R In The FASTLANE 051

Research and Reviews in the Fastlane 600

Welcome to the 51st 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

The ARISE Investigators and the ANZICS Clinical Trials Group, Goal-Directed Resuscitation for Patients with Early Septic Shock. NEJM 2014. PMID: 25272316

  • Early Goal Directed Therapy (EGDT) has already come under fire after publication of the ProCESS trial. ARISE goes even further. This multinational RCT demonstrates that modern usual care is equivalent to EGDT in terms of outcomes (90-day all cause mortality). The usual care arm had lower rates of CVL placement and blood transfusion. ARISE is important because unlike ProCESS, all of the participating centers were not academic institutions. EGDT was practice changing but putting it to pasture will hopefully allow us to focus in the critical pieces of management that make the difference: early recognition of sepsis, source control, antibiotics and fluids.
  • Recommended by: Nudrat Rashid, Anand Swaminathan
  • Read More: ARISE, and Cast Off the Shackles of EGDT (EM Lit of Note), Podcast 134 – ARISE has arisen; now where do we stand on Severe Sepsis in 2014 (EMCrit)

RR HOT STUFF

Al Deeb M. Point-of-care Ultrasonography for the Diagnosis of Acute Cardiogenic Pulmonary Edema in Patients Presenting With Acute Dyspnea: A Systematic Review and Meta-analysis. Acad Emerg Med 2014; 21(8):843-852. PMID: 25176151

  • Point of Care Ultrasound (POCUS) is a hot topic for research currently. This systematic review and meta-analysis looks at it’s use in the diagnosis of acute cardiogenic pulmonary edema. The evidence demonstrates that in patients with a high pre-test probability and b-lines on lung US, the diagnosis of acute cardiogenic pulmonary edema is clinched. Conversely, a low pretest probability along with a negative study virtually rules out the disease.
  • Recommended by: Anand Swaminathan

RR Game Changer

Bro-Jeppesenemail, J et al. The inflammatory response after out-of-hospital cardiac arrest is not modified by targeted temperature management at 33 °C or 36 °C. Resuscitation 2014. PMID: 25150183

  • Post arrest hypothermia at 33 degrees takes another hit ? 168 Patients from the TTM trial were analyzed for inflammatory markers and correlated to SOFA. IL-6 levels were most consistently organ failure and even more than traditional markers like CRP and PCT. TTM at 33 °C did not modify SIRS.
  • Recommended by: Soren Rudolph

RR Game Changer

Jacob S et al. Cardiac Rhythm Device Identification Algorithm using X-Rays: CaRDIA-X. Heart Rhythm. 2011;8(6):915-22. PMID: 21220049

  • Implantable cardiac devices (AICDs, pacemakers etc) are becoming more and more common as are the complications of these devices. Often, patients presenting to the ED will require interrogation. Although all patients are supposed to carry device ID cards, the cards are often missing when most needed leading to diagnostic and management delays. These authors create a complicated but comprehensive and ultimately successful algorithm guiding clinicians through the process of identifying the device based on appearance on a chest X-ray.
  • Recommended by: Anand Swaminathan

RR Game Changer

Tenner S, et al. American College of Gastroenterology guideline: management of acute pancreatitis. Am J Gastroenterol. 2013; 108(9): 1400-15. PMID: 23896955

  • The American College of Gastroenterology updated their guidelines for the acute management of pancreatitis and there’s a smattering of dogmalysis. Antibiotics, while good if the patient has a bacteremia or cholangitis, are largely out in these guidelines, and are notably discouraged for prophylaxis. Some other notable pearls: they say “no” to the routine use of CT and recommend ultrasound and enteral feeds in nearly all cases. They also emphasize that the severity of pancreatitis is best picked up by seeing how patients respond over time to treatment, not a simple clinical score.
  • Recommended by: Lauren Westafer

RR Boffintastic

Lars B. Holst et al. Lower versus Higher Hemoglobin Threshold for Transfusion in Septic Shock. NEJM 2014. PMID: 25270275

  • This multicenter RCT addresses the gap between clinical practice and the lack of efficacy and safety data on RBC transfusion in septic shock patients. The authors didn’t find differences in mortality, organ failure or ischaemic events when comparing patients assigned to blood transfusion at a higher hemoglobin threshold to those assigned to blood transfusion at a lower threshold.
  • Recommended by: Soren Rudolph, Nudrat Rashid

RR Eureka

Gray RM, Rode H. Intra-operative endotracheal tube stabilisation for facial burns. Burns. 2010; 36(4): 572-5. PMID: 20061089

  • A trick to help secure an ETT in a patient with facial burns. Although used on 12 patients, it is still awesome, especially if you have to transfer a patient.
  • Recommended by: Sa’ad Lahri

RR HOT STUFF

HARP-2 Investigators, for the Irish Critical Care Trials Group. Simvastatin in the Acute Respiratory Distress Syndrome. NEJM 2014. PMID: 25268516

  • This was a large, multicenter, double-blind, randomized, placebo-controlled clinical trial involving patients with ARDS and showed that simvastatin, as compared with placebo, did not improve clinical outcomes. It looked at a larger population that the recent SAILS study which looked at rosuvastatin in sepsis associated ARDS and together they add to the increasing evidence that shows that statins do not have a routine role in ARDS.
  • Recommended by: Nudrat Rashid

RR Game Changer

Hayward G et al. Corticosteroids as standalone or add-on treatment for sore throat. Cochrane Database Syst Rev 2012 PMID: 23076943

  • Do steroids work for sore throat?
    This Cochrane Review included 8 articles comparing steroids vs placebo in patients with sore throat who were also treated with antibiotics.
    The steroid group showed a significant decrease in pain at 24 hours and an overall decrease in time to resolution of pain. This was true for both oral and IM routes with an NNT = 4.
    It appears that patients with sore throat is one place where steroids are useful!
  • Recommended by: Zack Repanshek

RR WTF

Barnung S,  A prehospital use of ITClamp for haemostatic control and fixation of a chest tube. Acta Anaesthesiol Scand 2014; 58: 251–253.PMID: 24325619

  • The ITClamp – a smart little device – here’s 3 cases where it was used for haemostatic control and immediate securing of a chest tube.
  • Recommended by: Soren Rudolph

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Intensivist and Donation Medical Specialist, Australia  | @NudratRashid |

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