R&R In The FASTLANE 062

Welcome to the 62nd 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

Brindley PG, Reynolds SF. Improving verbal communication in critical care medicine. J Crit Care. 2011;26(2):155-9. PMID: 21482347.

  • I saw a tweet from the recent Intensive Care Society meeting with a quote from Peter Brindley: “communication is the most dangerous procedure in the hospital”. Following the strategies outlined in this review will go a long way to making it safe.
  • Recommended by: Chris Nickson
  • Read More: Communication in a Crisis (LITFL)

Pitts SR et al. Emergency Department Resource Use by Supervised Residents vs Attending Physicians Alone. JAMA 2014; 312(22):2394-2400. PMID: 25490330

  • This was a cross-sectional study looking at the resource utilization in patients seen by residents versus those seen by attendings alone. The study finds that resident supervised cases were more likely to be admitted to the hospital, had a greater use of imaging and longer ED length of stay. No causality can be shown here and there are numerous explanations to these findings including that residents are more likely to see sicker patients. Increased use of imaging and LOS should be expected as trainees are developing their clinical skills and acumen but better (not necessarily more) faculty supervision may be helpful in reducing admissions.
  • Recommended by: Anand Swaminathan

Mantokoudis G et al. VOR Gain by Head Impulse Video-Oculography Differentiates Acute Vestibular Neuritis From Stroke. Otol Neurotol. 2014. PMID: 25321888

  • Should we reconsider HINTS and HIT as the gold standard for posterior circulation stroke diagnosis? This paper from an otoneurology group (including Newman-Toker, the lead author of the HINTS paper) shows a diagnostic accuracy of 90% (sens 88% and spec 92%). The other corollary from this paper is that assessing HIT correctly probably requires a video HIT device instead of just plain physical exam. Apparently doing HIT in our patients is not as easy and not as good as we thought it was.
  • Recommended by: Daniel Cabrera

Spahn DR et al. Management of bleeding and coagulopathy following major trauma: an updated European guideline. Critical Care 2013, 17:R76. PMID: 23601765

  • These are a well written evidence-based recommendations to guide the acute management of the bleeding trauma patient by the multidisciplinary Task Force for Advanced Bleeding Care in Trauma.
    The paper represents an updated version of the guideline published by the group in 2007 and updated in 2010.
  • Recommended by:< Soren 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

Oddo M et al. Management of mechanical ventilation in acute severe asthma: practical aspects. Intensive Care Med. 2006 Apr;32(4):501-10. PMID: 16552615

  • Look, obviously the goal is to not intubate the patient presenting with a severe asthma exacerbation… but our jobs often place us between the rock and the hard place. This article describes how best to deal with the uncomfortable position and benefit the patient the most.
  • Recommended by: Sean Fox
  • Read More: Mechanical Ventilation for Severe Asthma (Pediatric EM Morsels)

Poonai N et al. Oral administration of morphine versus ibuprofen to manage postfracture pain in children: a randomized trial. CMAJ 2014. PMID: 25349008

  • This parallel-group, randomized, blinded superiority trial compared oral ibuprofen with oral morphine in pediatric patients (n=134) discharged from a pediatric ED after a non-operative extremity fracture. They found no statistically significant difference in analgesia between the two. Oral morphine isn’t the go-to analgesia in many pediatric patients and, even with the fight against pediatric oligoanalgesia, it doesn’t appear that it should be. Treat pain; proper splinting and ibuprofen should be sufficient in cases like those in this study.
  • Recommended by: Lauren Westafer

Tessaro MO et al. Tracheal rapid ultrasound saline test (T.R.U.S.T.) for confirming correct endotracheal tube depth in children. Resuscitation 2014. PMID: 25238740

  • Inadvertent bronchial intubation can occur in up to 30% of paeds emergency intubations often with disastrous consequences if unrecognised. In this study, the authors evaluated the accuracy of tracheal ultrasonography of a saline-inflated endotracheal tube
    (ETT) cuff for confirming correct ETT insertion depth. There are numerous advantages to this approach including not waiting for the xray and no interruptions to chest compressions.The authors look at point of care tracheal ultrasound at the suprasternal notch to confirm tube placement. They found a sensitivity of 98.8% and specificity of 96.4% giving a (+) LR = 32 for confirming tube placement. Although the study wasn’t done in an ED population, this technique may be employed to prevent delays in recognition of mainstem intubation and cut time to initiation of management.
  • Recommended by: Sa’ad Lahri, Anand Swaminathan
  • Read More: Quit Mainstemming Kids 30% of the Time! (The Ultrasound Podcast)

Zahir H et al. Edoxaban Effects on Bleeding Following Punch Biopsy and Reversal by a 4-Factor Prothrombin Complex Concentrate. Circulation. 2014. PMID: 25403645

  • Healthy volunteers taking edoxaban (an oral Factor Xa inhibitor) had their bleeding time after punch biopsy effectively attenuated by 4-factor prothrombin concentrate complex. Probably your go-to agent in the setting of life-threatening bleeding for these agents: edoxaban, apixaban, and rivaroxiban.
  • Recommended by: Ryan Radecki
  • Read More: 4-Factor Works for Factor Xa Inhibitors (Emergency Medicine Literature of Note)

Johansson PI et al. How I treat patients with massive hemorrhage. Blood. 2014. PMID: 25293771

  • The optimal way to resuscitate the massive bleeding patient remains elusive. In this paper two of the most prominent concepts are presented. The Copenhagen concept uses transfusion packs, TXA and viscoelastic assays (VHA) to guide resuscitation in a goal directed fashion along the resuscitation phase. Activation of a massive bleeding protocol is based on clinical evaluation. In the Houston concept VHA is obtained early and activation of MTP is based on the ABC scoring system.
  • Recommended by: Soren Rudolph

New Jersey Emergency Physician with academic focus on resident education and critical care in the ED. Strong supporter of FOAMed and its role in cutting down knowledge translation | @EMSwami |

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