R&R In The FASTLANE 055

Welcome to the 55th 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

Weingart SD et al. Delayed Sequence Intubation: A Prospective Observational Study. Ann Emerg Med. 2104 PMID

• Viva FOAMed – The concept of Delayed Sequence Intubation (DSI) was introduced to world via FOAMEd/Social media networks and has now been formally studied and peer reviewed in a publication. DSI essentially procedural sedation, with the procedure being pre oxygenation. In this prospective, observational, multicenter study 62 patients whose medical condition led them to impede optimal pre oxygenation were enrolled. The primary outcome was the difference in oxygen saturations after maximal attempts at preoxygenation before delayed sequence intubation compared with saturations just before intubation.
• This is essentially a “proof of concept”. DSI could offer a safe alternative to rapid sequence intubation in the “can’t pre oxygenate patient”
• Recommended by Anand Swaminathan and Søren Rudolph (co-author)
• Read More: EMCrit Podcast 40 – Delayed Sequence Intubation (DSI)

Aquino CC et al. Restless Genital Syndrome in Parkinson Disease. JAMA Neurol. 2014. PMID 25285600

• Who would have thought there is such a thing as “Restless Genital Syndrome”.The authors describe a case of a woman with disabling discomfort in the genital region which resolved with dopamine agonists.
• Recommended by: Nudrat Rashid

Fragou M et al. Real-time ultrasound-guided subclavian vein cannulation versus the landmark method in critical care patients: a prospective randomized study. Crit Care Med 2011;  39(7): 1607-12. PMID 21494105

• Ultrasound has been used for years to guide placement of internal jugular vein central lines but has not been as widely adopted in the placement of infraclaviular subclavian lines. This study demonstrates a higher success rate (100% vs. 88%) and lower pneumothorax rate (0% vs. 5%) in comparing ultrasound guided versus landmark technique for placement. Although the ultrasound guided method may be technically difficult to learn and take some time investment, that time is repayed in the shorter time to accessing the vessel and lower complication rate.
• Recommended by: Anand Swaminathan

Matijevic, N et al. Better hemostatic profiles of never-frozen liquid plasma compared with thawed fresh frozen plasma. J Trauma Acute Care Surg 2013; 74(1): 84-90. PMID 23271081

• Small lab study of thawed fresh frozen plasma (FFP) vs liquid plasma (LQP) showing LQP to have a better hemostatic profile. An effect that was sustained over time. LQP seems to be a good first line resuscitative fluid both in- and prehospitally when also considering the five times longer storage time compared to FFP.
• Recommended by: Søren Rudolph

Arora S et al.. Myth: interpretation of a single ammonia level in patients with chronic liver disease can confirm or rule out hepatic encephalopathy. CJEM. 2006; 8(6): 433-5. PMID 17209493

• Very nice review of the utility (read: the lack thereof) of ammonia as a diagnostic test for hepatic encephalopathy. The statistical correlation is only 0.6-0.7 which is not very strong, plus quite a few study subjects with levels that simply do not correlate with the clinical picture. The conclusion is that the acute ammonia simply doesn’t tell you whether or not your patient is encephalopathic. My take is that it’s like uric acid in gout — gouty patients probably have higher levels overall, but a single serum uric acid level doesn’t help us diagnose *this* episode.
• Recommended by: Seth Trueger

aghavi S et al. ”Permissive hypoventilation” in a swine model of hemorrhagic shock. J Trauma Acute Care Surg. 2014; 77(1): 14-9. PMID 25295709

• Even though this is a small animal study, it’s another arguement for a ”scoop ’n run” practice in penetrating trauma. Anesthesized pigs were either intubated (n=6), BVM ventilated (n=7) or passively oxygenated (n=6) and then exsanguinated using a carotid lesion. Primary outcome was time until death. On average the non ventilated pigs survive 50 minutes, which was 1,5 minutes longer (non significant) with more favourable hemodymamic profiles than both groups of ventilated pigs.
• Recommended by: Søren Rudolph

Rosen P. The biology of emergency medicine. JACEP. 1979 Jul;8(7):280-3. PubMed PMID 449164

• Peter Rosen has called this ‘the only good article I have ever written’. This is Rosen’s rationale, published in 1979, for the need for emergency medicine as a specialty and his way of silencing the doubters. Well worth reading to see how far the specialty has come – or not come – and for an insight into what our international colleagues are facing as they fight to create the specialty in far flung places. The article is packed with specialty-defining quips and quotations, such as “The hardest mental change to create in new residents is to “assume the worst even if statistically improbable.” Nowhere in inpatient medicine does one learn that in early disease states, the threat to life, or well-being, hides itself. The responsibility is to describe or to deny that life threat rather than to place a specific label on a patient.”… and “We are poorly taught in medical school and residencies to distinguish sick from well. There are two great shocks for every emergency medicine resident: one, not every patient is sick, and two, many patients are much sicker than they first appear.” Oh, and perhaps I’m misquoting him, but did Rosen envisage the rise of FOAM when he wrote “There is no substitute for online experience.”? 😉
• Recommended by: Chris Nickson

Shehabi Y et al. Procalcitonin Algorithm in Critically Ill Adults with Undifferentiated Infection or Suspected Sepsis: A Randomized Controlled Trial. Am J Respir Crit Care Med. 2014. PMID 25295709

• Yet another paper demonstrating the lack of utility of procalcitonin in guiding antibiotic therapy in the critically ill. Another helpful reminder that bad tests do not replace good clinical judgment.
• Recommended by: Rory Spiegel

De Jong. Video laryngoscopy versus direct laryngoscopy for orotracheal intubation in the intensive care unit: a systematic review and meta-analysis. Intensive Care Med. 2014; 40(5): 629-39. PMID 24556912

• The aim of this study was to critically review the literature to investigate whether video laryngoscopy (VL) reduces difficult orotracheal intubation rate, first-attempt success, and complications related to intubation in ICU patients, compared to standard therapy, defined as direct laryngoscopy. In a total of 2,133 participants VL in the ICU was associated with reduced risk of difficult intubation and esophogeal intubation while increasing first pass success.
• Recommended by: Anand Swaminathan

Gu WJ. Single-dose etomidate does not increase mortality in patients with sepsis: A systematic review and meta-analysis of randomized controlled trials and observational studies. Chest. 2014 Sep 25. PMID 25255427

• Perhaps the “etomidate drama” can be put to rest based on the current evidence. There is no credible evidence that Etomidate leads to higher mortality in Sepsis than Ketamine. In the end we need high-quality, adequately powered RCT’s to put this matter to rest.
• Recommended by: Sa’ad Lahri