R&R In The FASTLANE 065

Research and Reviews in the Fastlane 600

Welcome to the 65th 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

RR Hall of FAMER

Hess EP et al. The Chest Pain Choice Decision Aid;A Randomized Trial. Circ Cardiovasc Qual Outcomes 2012; 5(3):251-9. PMID: 22496116

  • This study looked at how patients and doctors can use shared decision making to reduce in patient work ups for low risk chest pain. Using a chest pain decision aid, they reduced in patient work ups by 19%. The brilliance here is in the application of the theory of shared decision making and the knowledge transfer to patients using this system.
  • Recommended by: Anand Swaminathan

RR Game Changer

Bangalore S et al. Clinical outcomes with β-blockers for myocardial infarction: a meta-analysis of randomized trials. Am J Med. 2014;127(10):939-53. PMID: 24927909

  • The pendulum for beta blockers in MI keeps swinging around. In this systematic review, they find a decrease in recurrent MI but no mortality difference since we entered the “reperfusion era.” There might be some benefit, but in the first 90 minutes in the ED, my nurses & I probably have more important things to do.
  • Recommended by: Seth Trueger

RR HOT STUFF

Nørgaard BL et al. Diagnostic performance of noninvasive fractional flow reserve derived from coronary computed tomography angiography in suspected coronary artery disease: the NXT trial (Analysis of Coronary Blood Flow Using CT Angiography: Next Steps). J Am Coll Cardiol. 2014; 63(12):1145-55. PMID: 24486266

  • A look at what is next in line for non-invasive to evaluate ED low-risk chest pain patients. FFTct seems to be a mediocre test assessed using a questionably benign definition of disease as the gold standard, in a remarkably healthy population (only 11% with significant stenosis), to identify a cohort that likely does not benefit from stent placement in the first place..
  • Recommended by: Rory Spiegel

RR Game Changer

Cappato R et al. Rivaroxaban vs. vitamin K antagonists for cardioversion in atrial fibrillation. Eur Heart J. 2014. PMID: 25182247

  • Rhythm vs rate and optimal anticoagulation is still a significant point of discussion in the management of A-fib in the ED. This paper evaluates the use of Rivaroxaban in patients with atrial fibrillation vs. Vitamin K antagonists (VKAs). In this study Rivaroxaban was non-inferior to VKAs in all groups, and remarkably an early cardioversion strategy with Rivaroxaban 4 hours prior to cardioversion plus 6 weeks after the procedure was similar to the conservative strategy, i.e., 3 weeks of ACO prior to the procedure.
  • Recommended by:  Daniel Cabrera

RR Game Changer

Johnson RW, Rice AS. Clinical practice. Postherpetic neuralgia. NEJM 2014;371(16):1526-33. PMID: 25317872.

  • An excellent review of all things postherpetic neuralgia. The importance of the zoster vaccine is apparent as the futility of other treatments is demonstrated in the article. Of important note, opioids are relegated to use as a third line agent, after gabapentine/pregabalin and TCAs.
  • Recommended by: Jeremy Fried

RR HOT STUFF

Wilcox SR et al. Emergency Medicine Residents’ Knowledge of Mechanical Ventilation. J Emerg Med. 2014. PMID: 25497896

  • The Free Open Access Medical Education (FOAM) world is filled with airway and critical care pearls; yet this survey study and knowledge test demonstrate a discrepancy. Of surveyed emergency medicine residents (n=210), 44.5% never or rarely feel comfortable troubleshooting vents in the ED. The average score on the knowledge tool was 73.3% and 61.5% of participants scored at least 70%. It seems that residents have limited formal training with vents, feel insecure, and may have knowledge gaps surrounding ventilator management as well. Time to bridge the gap.
  • Recommended by: Lauren Westafer

RR Game Changer

Gex G et al. Is atrial fibrillation associated with pulmonary embolism? J Thromb Haemost. 2012 Mar;10(3):347-51. PMID: 22212132

  • Patients with AFib get clots. Patients with AFib get tachycardia. Certainly seems like patients with AFib should be higher risk for PE… but according to this paper based on nearly 2500 patients worked up for PE, there was no association. If anything, if they are dyspneic and in AFib, that may sufficiently account for their symptoms and they shouldn’t get a PE workup (although the numbers aren’t that big). Not surprisingly, I heard of this paper through Jeff Kline (@klinelab).
  • Recommended by: Seth Trueger

RR HOT STUFF

Goodacre S et al. Intravenous or nebulised magnesium sulphate versus standard therapy for severe acute asthma (3Mg trial): a double-blind, randomised controlled trial. Lancet Respir Med 2013; 1: 293–300. PMID: 24429154

  • This well-done RDCT investigates the role of magnesium in the treatment of asthma. Intravenous magnesium was only slightly better than placebo in this study. Additionally, there appears to be no role for nebulized magnesium therapy. .
  • Recommended by: Soren Rudolph

RR Game Changer

Bennett C et al.Bynum WE et al. Shame, guilt, and the medical learner: ignored connections and why we should care. Med Educ. 2014 Nov; 48(11): 1045-54. PMID: 25307632

  • Medical errors are inevitable as is the shame response when these errors occur. That shame can fester and lead to burnout, dropout and overall dissatisfaction with our work. Therefore, it is critical that we both learn to deal with our shame and to teach our trainees to do the same. Discussion of errors in protected settings, effective feedback and behavior modeling are the first steps in improving our abilities to deal with these emotions.
  • Recommended by: Anand Swaminathan

RR Game Changer

Isbister GK et al. Randomized Controlled Trial of Intravenous Antivenom Versus Placebo for Latrodectism: The Second Redback Antivenom Evaluation (RAVE-II) Study. Ann Emerg Med 2014; 64(6):620-628. PMID: 24999282

  • This is an RDCT looking at the use of Latrodectus (e.g. Black Widow Spider) antivenom versus placebo after treatment. The group found no statistically significant difference in pain improvement or resolution of systemic effects with antivenom. Additionally, antivenom caused hypersensitivity reactions in 3.6% of patients.
  • Recommended by: Anand Swaminathan

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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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