Welcome to the 60th 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 8 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

January CT et al. 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: Executive Summary. Circulation 2014. PMID 24682348

  • This document is the updated ACC/AHA recommendations for the management of atrial fibrillation. There are a number of pearls in here but one of the big game changers is that amiodarone is now listed as a harmful medication in the treatment of patients with WPW who present in atrial fibrillation. This recommendation limits options and as a result, pushes electrical cardioversion higher up in the algorithm.
  • Recommended by: Anand Swaminathan

Sutton RM, et al. Patient-Centric Blood Pressure Targeted CPR Improves Survival from Cardiac Arrest. Am J Respir Crit Care Med. 2014. PMID: 25321490

  • An animal/basic science paper but important because it shows the benefits of goal-oriented resuscitation.
    Swines underwent VF arrest and later were resuscitated using the standard ACLS guidelines versus a goal oriented approach aiming to SBP of 100 mmHg and coronary perfusion pressure of 20 mmHg. The goal-oriented group had a survival of 80% at 24h, while the standard-group 0%. This paper supports the need for further investigation into a resuscitation protocol oriented to hemodynamic goals.
  • Recommended by: Daniel Cabrera

Scheppke, et al. Prehospital Use of IM Ketamine for Sedation of Violent and Agitated Patients. West J Emerg Med 2014; 15(7). Retrieved from: https://escholarship.org/uc/item/64p9m3xt (OPEN ACCESS ARTICLE)

  • Not for routine agitation but for the uncontrollably violent patient, especially one that may have a dangerous medical condition, effecting immediate control is both a patient and staff safety mandate. This prehospital case series describes how ketamine is uniquely suited to this purpose and reports on 52 patients who received between 200 and 400 mg IM ketamine. 50/52 were quickly sedated in about two minutes. 3/52 developed respiratory depression, 1 managed with bag mask ventilation and 2 managed with endotracheal intubation.
  • This series supports the bulk of the evidence suggesting that dissociative dose ketamine (no reason to go small – I would use 6 or 7 mg/kg or, to make it easy, 500 mg) is very effective for immediate control of agitation, but that these patients must be managed like procedural sedation patients – with specific attention to ventilation and readiness to intubate, along with identification and management of the underlying causes (and effects) of agitation.
  • Recommended by: Reuben Strayer

Jhun P et al. Don’t Let Herpes Melt Your Brain. Ann Emerg Med 2014; 64(6): 589 – 590 PMID: 25454563

  • In a partnership between Annals and EM:RAP, this commentary is a mini review of herpes encephalitis and refers to an image in emergency medicine article. A great quick review of a potentially devastating disease that can often be missed in the ED. Did you know that 1/3 of patients can present with stroke like focal neurological deficits? And that early in the disease 1/10 will have normal CSF and MRI findings? Scary stuff, especially when you consider the consequences of not catching this early.
  • Recommended by:  Jeremy Fried
  • Further information: Best Case Ever 30: Rob Roger’s Mother (Emergency Medicine Cases)

Patel A et al. (THRIVE): a physiological method of increasing apnoea time in patients with difficult airways. Anaesthesia. 2014. PMID 25388828

  • Conceptualizing apnoeic oxygenation during emergency and difficult tracheal intubations – THIRIVE – Transnasal Humidified Rapid-Insufflation Ventilatory Exchange.
  • In this study continuous delivery of transnasal high-flow humidified oxygen using the OptiFlow system and jawthrust extended the apnoea times (median apnoea time 14 min (9–19 [IQR 5–65])) in 25 patients with known difficult airways (Mean Mallampati grade 3 and/or obesity and/or stridor and/or mean Cormack-Lehane score 3) who were undergoing general anaesthesia for hypopharyngeal or laryngotracheal surgery. No patient experienced arterial desaturation.
  • Recommended by:  Søren Rudolph

Packham et al. Sodium Zirconium Cyclosilicate in Hyperkalemia. N Engl J Med 2014;2(21):2223-2233. PMID 25415807

  • This is an industry sponsored study where outpatients with asymptomatic hyperkalemia were randomized to placebo or different doses of Sodium Zirconium Cyclosilicate (ZS-9) in a 2-stage model (ZS-9 and then ZS9/placebo). Patients with severe hyperkalemia and requiring emergent interventions were excluded. The goal was the ability to decrease serum K levels within 8 hours. Benefit was dose dependent, being max at 10mg with a decrease of 0.7mEq. The number of adverse effects were no statistically different. In the highest dose group, ZS-9 was able to reduce K at a rate of 0.3% per hour while 0.09% in the placebo group.
  • The use of ZS-9 is probably designed to be use in outpatient nephrology units or inter-dialysis runs, but given the design study excluding acute/emergent patients and the temporary profile of the drug, at this point, ZS-9 probably has no role in acute care medicine.
  • Recommended by: Daniel Cabrera
  • Further reading: A Brave New Kayexalate Free World (Emergency Medicine Literature of Note)

Adhikari S, et al. Isolated Deep Venous Thrombosis: Implications for 2-Point Compression Ultrasonography of the Lower Extremity. Ann Emerg Med 2014. Available from: http://www.annemergmed.com/article/S0196-0644(14)01419-X/abstract

  • Traditional EM bedside US for the detection of lower extremity DVT is based in a 2-point system, scanning femoral and popliteal veins for the presence of clinically significant thrombi. This study enrolled 2500+ from whom 362 had a DVT, among them 6.3% have proximal DVT not located in common femoral or popliteal locations. This study shows a significant number of patients with proximal DVTs that a 2-point scan would miss.
  • Recommended by: Daniel Cabrera

Gupta, M. Happy Meals for Everyone? Ann Emerg Med 2014; 64(6): 609 – 611. PMID: 25454564

  • This excellent editorial points out the positive and negative aspects of an accompanying study (PMID: 25182541) which examined the patient and ED characteristics associated with patient satisfaction scores. Obviously, a growing issue in the U.S. as administrative decisions and payment are increasingly being tied to these scores. The editorial goes further than the current article to discuss the larger issues at stake and is well worth a read for all practitioners who have to hand out “happy meals” to their patients.
  • Some highlights:
    • Low Press Ganey response rate ensures that only ~2% of ED patients account for the entirety of satisfaction information that EDs use to gauge performance
    • Press Ganey uses comparator groups based solely on census and does not adjust for or provide data on other factors such as sociodemographics that may affect patient satisfaction scores
    • Press Ganey’s ED-specific analyses display a relative percentage rank when comparing that ED within each comparator group, but reports do not accessibly provide additional context such as corresponding confidence intervals
    • When and to what extent is it appropriate to equate patient (consumer?) satisfaction scores with quality of care like other service industries do?
  • Recommended by: Jeremy Fried

Emergency physician with interest in education and knowledge translation. #FOAMed Fan | @jdfried |

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