R&R In The FASTLANE 059

Welcome to the 59th 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

Makam AN, et al. Use of Cardiac Biomarker Testing in the Emergency Department. JAMA Intern Med 2014. PMID: 25401720

• This study looked at national survey data from 2009-2010 of patients >18 y/o presenting to the ED (n=44,448 visits) and found that cardiac enzyme testing was performed in 16.9% of visits, including in 8.2% of visits lacking ACS-related symptoms (which includes things like nausea, vomiting, abdominal pain, dyspnea, etc).
• This begs the question, why then, was a troponin (or ck-mb) ordered? It’s probably not changing management. In an era in which we’re discovering that there are harms to downstream testing, this study calls out just how trigger happy we may be. As more sensitive cardiac assays are used, this may mean even more for our patients.
• Recommended by: Lauren Westafer

Curtis JR, et al. The importance of word choice in the care of critically ill patients and their families. Intensive Care Med. 2014; 40(4): 606-8. PMID: 24441669.

• Word choice in critical care is critically important. This article shows why, and gives you alternatives to these shockers: “Withholding or withdrawing care”, “there is nothing more that we can do”, “Withholding and withdrawing life-sustaining measures are morally equivalent”, “consider an end-of-life decision” and “no escalation of treatment”.
• Recommended by: Chris Nickson

Waxman DA, et al. The effect of malpractice reform on emergency department care. NEJM 2014; 371(16): 1518-25. PMID: 25317871

• This large study looking at Medicare claims looks at the effect of tort reform on emergency physician practice. By examining advanced imaging (CT and MRI) rates as well as ED charges and admission rates, they determined whether there was a correlation of these factors and states which enacted stricter malpractice language. No such relationship of significance was found. This study does a great job of demonstrating that resource intensive practice of the ED is due to more than simple fear of legal repercussions, but likely to other behavioral and cultural motives.
• Recommended by:  Jeremy Fried

Scotter J et al. Prognosis of patients with bilateral fixed dilated pupils secondary to traumatic extradural or subdural haematoma who undergo surgery: a systematic review and meta-analysis. Emerg Med J 2014. PMID: 25385844

• Don’t give up on patients with epidural hematomas and fixed and dilated pupils. In this systematic review, patients with bilateral fixed and dilated pupils with an epidural hematoma, the mortality was 29.7%. More importantly, 54.3% of them had favorable outcomes. Unfortunately, the presence of bilateral fixed and dilated pupils with subdural hematomas did not fare as well (6.6% favorable outcomes).
• Recommended by: Cliff Reid
• Read More: Bilateral Fixed Dilated Pupils? Operate if Extradural! (Resus.me)

Hall N. The Kardashian index: a measure of discrepant social media profile for scientists. Genome Biol. 2014; 15(7):424. PMID: 25315513

• How do you know if a scientist is a social media loudmouth or just a quiet achiever? Calculate his or her ‘Kardashian Index’. The K-index is a a measure of discrepancy between a scientist’s social media profile and publication record based on the direct comparison of numbers of citations and Twitter followers.
• Surely a scientist doesn’t want to score too high, nor too low, but what is the ideal number? Most FOAM creators will score on the high side, should we just shut up?
• Recommended by: Chris Nickson

Mounsey A, et al. 7 questions to ask when evaluating a noninferiority trial. J Fam Pract. 2014; 63(3): E4-8. PMID: 24701606

• As this article says, “review of 116 noninferiority trials and 46 equivalence trials found that only 20% fulfilled generally accepted quality criteria”. Read this, if your understanding of non-inferiority trials is, well, inferior. (Hat tip to EMU’s Yosef Liebman).
• Recommended by: Chris Nickson

Bennett C, et al. Tranexamic acid for upper gastrointestinal bleeding. Cochrane Database of Systematic Reviews 2014, Issue 11. PMID 25414987

• This is systematic review appraising the evidence around the use of TXA for gastrointestinal bleeding. Unfortunately the quality of the available evidence is moderate to poor. TXA vs. no standard interventions (ie, no PPI or EGD) appears to be beneficial, however compared to standard interventions, the effect is lost, suggesting minimal or no effect in real clinical practice where patients tend to go under emergent endoscopy for evaluation and treatment.
• Current evidence does not support use of TXA for GI bleeding when other interventions are available. Evidence may change once ongoing studies (ie, HALT-IT) are publish.
• Recommended by: Daniel Cabrera

Kelly AM et al. Sensitivity of proposed clinical decision rules for subarachnoid haemorrhage: An external validation study. Emerg Med Austral 2014. PMID 25381840

• This is a retrospective validation study of the Ottawa SAH decision instrument published by Perry et al in JAMA last year (link – http://www.ncbi.nlm.nih.gov/pubmed/24065011). This group found that the instrument performed well in a small population and that while it probably wouldn’t reduce the rate of CT scanning, it may be helpful in further risk stratification. Unfortunately, the study was retrospective and rather small (n = 59).
• Recommended by: Anand Swaminathan

Ownbey M et al. Prevalence and interventional outcomes of patients with resolution of ST-segment elevation between prehospital and in-hospital ECG. Prehosp Emerg Care 2014;18(2):174-9. PMID 24400994

• What to do with the patient with prehospital ST elevations that resolve after treatment in the field? This article has a number of mehodologic issues due to difficulties in obtaining full records but suggests that dynamic ST elevations should still have cardiology consultation with strong consideration for emergent catheterization.
• Recommended by: Anand Swaminathan
• Further information: STEMI with resolved STE…What do you do? (Amal Mattu’s Emergency ECG of the Week)

Hughes NT, et al. Damage control resuscitation: permissive hypotension and massive transfusion protocols. Pediatr Emerg Care. 2014 Sep;30(9):651-6. PMID 25186511

• Damage Control Resuscitation is the talk of the town (or the ED at least)… but does it really apply to children? Remember that children have different physiologic tolerances and responses… so perhaps not. The hypotensive child is at a different place compared to the hypotensive adult.
• Recommended by: Sean Fox