R&R In The FASTLANE 057

Welcome to the 57th 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

Rodriguez RM et al. NEXUS chest: validation of a decision instrument for selective chest imaging in blunt trauma. JAMA Surg 2013; 148(10): 940-6. PMID 23925583

• Chest trauma is common and the work-up has become controversial. There are many conflicting opinions regarding the need to catch all important injuries vs a desire to reduce radiation exposure to our patients. Therefore, it is critically important to be aware of new literature that addresses this issues. This is the validation of the NEXUS Chest Decision Instrument (DI) which looks to reduce chest imaging while having a near perfect sensitivity. The DI was 98.8% sensitive but the specificity was low (13.3%) raising the concerns that it will have minimal impact on imaging reduction.
• Recommended by: Eric Morley

Altgärde J, Redéen S, Hilding N, Drott P. Horse-related trauma in children and adults during a two year period. Scand J Trauma Resusc Emerg Med. 2014 Jul 17;22(1):40. PMID 25030979

• A colleague of mine once said “never ride an 500 kg animal with a brain the size of a walnut”. In this 2-year review of horse related injuries in a Swedish University Hospital. To no surprise most injuries were orthopedic and minor, but among 188 patients (147 children), 19 were considered having a serious injury, four patients needed treatment in intensive care units, none died.
• Recommended by: Søren Rudolph

Malo C et al. Tamsulosin for treatment of unilateral distal ureterolithiasis: a systematic review and metaanalysis. CJEM 2013; 15(0):1-14 PMID 23870675

• This study is a meta-analysis looking at whether tamsulosin increases the rate of spontaneous stone passage in patients with renal colic. The authors report a benefit to the drug with a RR for passage of 1.50. However, this meta-analysis is significantly flawed as the studies entered into it had significant bias mainly due to issues with randomization as well as a high level of heterogeneity. This meta-analysis typifies the issue of garbage in equals garbage out and does not change the fact that tamsulosin has little good evidence to defend its use in these patients.
• Recommended by: Anand Swaminathan

Shahzad A, Kemp I, Mars C et al for the HEAT-PPCI trial investigators. Unfractionated heparin versus bivalirudin in primary percutaneous coronary intervention (HEAT-PPCI): an open-label, single centre, randomised controlled trial. Lancet. 2014 Jul 4. pii: S0140-6736(14)60924-7. PMID 25002178

• Although primary PCI is the preferred approach to treatment of STEMI, the optimal concomitant antithrombotic regimen is unknown. This study compared bivalirudin to unfractionated heparin with the primary combined endpoint of death, CVA, reinfarction and target lesion revascularization. In spite of the fact that the trial was designed to favor bivalirudin (open-label), the authors found an increased rate in the primary outcome in the bivalirudin group (8.7% vs. 5.7%). Further proof that just because a drug is new, doesn’t mean it’s better.
• Recommended by: Anand Swaminathan

(1) Anter E, Callans DJ, Wyse DG. Pharmacological and electrical conversion of atrial fibrillation to sinus rhythm is worth the effort. Circulation. 2009 Oct 6;120(14):1436-43. PMID: 19805660

(2) Wyse DG, Anter E, Callans DJ. Cardioversion of atrial fibrillation for maintenance of sinus rhythm: a road to nowhere. Circulation. 2009 Oct 6;120(14):1444-52. PMID: 19805661

• Pros:
  • Provides improvement in quality of life and exercise performance to symptomatic patients
  • May help to determine the true impact of AF in patients with vague or potentially absent symptoms
  • May result in reasonable freedom from recurrence, even without antiarrhythmic drug treatment
  • Prevents inexorable AF-induced atrial remodeling
• Paired editorials which together with R&R 044’s Hall of Famer article (https://litfl.com/rr-in-the-fastlane-044/) sparked a twitter discussion re the benefits and risks of cardioversion for acute atrial fibrillation.
  Per the authors,
• Cons:
  • Immediate or early recurrence of AF is more common the sooner after the onset of AF that one is electrically cardioverted
  • No advantage of immediate cardioversion in terms of progression to permanent AF
• Important to remember, is that the acute onset or paroxysmal patient presenting to the ED is different than one with persistent or permanent afib. As Dr Wyse himself stated within his argument against cardioversion: “It is true that AF in some instances is “situational,” particularly first episodes, and conversion in itself is a means to an end. For these patients, correction or removal of the circumstances leading to AF may leave the patient free of further episodes of AF for months or years or perhaps forever.” Thanks to Dr Hamilton (@RJHamiltonMD) for the initial reference.
• Recommended by: Jeremy Fried

Stub D et al. Refractory cardiac arrest treated with mechanical CPR, hypothermia,ECMO and early reperfusion (the CHEER trial). Resuscitation 2014 Oct 2. pii: S0300-9572(14)00751-5. PMID 25281189

• Despite extensive research, good neurologic outcomes after cardiac arrest continue to be poor. This prospective, observational trial incorporates a combination of four interventions in patients with refractory cardiac arrest – mechanical CPR, Hypothermia, ECMO + Early Reperfusion (where indicated). 26 patients were enrolled, 24 placed on ECMO and 14/26 (54%) patients had good neurologic outcomes. Although there is no comparator group here, outcomes of refractory cardiac arrest are dismal. This single-center protocol will have to be externally replicated but the CHEER trial shows great promise for these patients.
• Recommended by: Anand Swaminathan

Ge PS, Runyon BA. Serum ammonia level for the evaluation of hepatic encephalopathy. JAMA. 2014 Aug 13;312(6):643–4. PMID 25117134

• Classic teaching tell us that the diagnosis of hepatic encephalopathy (HE) is based on serum ammonia levels, but not really. Ammonia levels can be very important in assessment and prognosis for acute liver failure, but they can not be used to rule out or rule in HE. Surprisingly the diagnosis of HE is clinical, based on history and physical exam.
• Recommended by: Daniel Cabrera

Caputo ND et al. Whole-body computed tomographic scanning leads to better survival as opposed to selective scanning in trauma patients: A systematic review and meta-analysis. J Trauma Acute Care Surg 2014; 77(4):534-9. PMID 25250591

• Another example of the false notion that systematic reviews and meta-analyses are the highest level of publication. This study concludes that the evidence indicates an advantage to whole body CT (WBCT) over selective imaging in trauma noting that even patients with higher ISS trauma scores had a lower mortality rate. However, a systematic review is only as good as the individual trials that go into it. The quality of contributing evidence in this article is heterogenous and when the retrospective trials with significant bias are removed, no difference is seen.
• Recommended by: Anand Swaminathan

Kharbanda AB. Appendicitis: do clinical scores matter? Ann Emerg Med. 2014 Oct;64(4):373-5. PMID 24882663

• Appendicitis scores? There are plenty of them around. Which one works better? Does it matter? I like to think that the utility of a scoring system is inversely related to the number of other scoring systems attempt to evaluate the same thing. If we had one that was useful, we wouldn’t need anymore.
• This short article is written as commentary to another good article about two of the more prominent Appendicitis Scoring systems:
• Ebell MH, Shinholser J. What Are the Most Clinically Useful Cutoffs for the Alvarado and Pediatric Appendicitis Scores? A Systematic Review. Ann Emerg Med. 2014 Oct;64(4):365-372. PMID 24731432
• Recommended by: SMF

Hilmo J, Naesheim T, Gilbert M. “Nobody is dead until warm and dead”: prolonged resuscitation is warranted in arrested hypothermic victims also in remote areas–a retrospective study from northern Norway. Resuscitation. 2014 Sep;85(9):1204-11. PMID 24882104

• We’ve been told that they have to be warm and dead before we can pronounce patients. But obviously many patients are dead when they’re cold, and they’re still dead when they’re warm. Figuring out which patients need resuscitation is worth studying, so this group set out to determine which ones need it. After much analysis, the only factor that determined survival was potassium level <5.9 mmol/L. This should lead to changes in protocols that say patients with K <12 should be resuscitated.
• Recommended by: Justin Hensley