R&R In The FASTLANE 066

Welcome to the 66th 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 6 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

Sandroni C et al. Prognostication in comatose survivors of cardiac arrest: an advisory statement from the European Resuscitation Council and the European Society of Intensive Care Medicine. Intensive Care Med 2014; 40(12):1816-31. PMID: 25398304

• This is a question that plagues most Critical Care Doctor’s. Unfortunately the quality of evidence remains poor. The author’s suggest a multimodal prognostication approach in all patients. The most robust predictor’s remain bilateral absence of either pupillary and corneal reflexes or N20 wave of short-latency somatosensory evoked potentials in patients who are comatose with absent or extensor motor response at ≥ 72 h from arrest, either treated or not treated with controlled temperature.
• Recommended by: Nudrat Rashid

Vaillancourt S et al. Repeated Emergency Department Visits Among Children Admitted With Meningitis or Septicemia: A Population-Based Study. Ann Emerg Med 2014. PMID: 25458981

• This is a retrospective cohort study looking at all kids within a database who were identified as having bacteremia or meningitis. The authors sought to look at whether there was a difference in outcomes between patients who were identified on first presentation or in those discharged home initially. Although it would make sense that patients with these diseases would do worse if sent home, the authors did not find evidence of this. Bottom line is that it’s unlikely we can detect all kids with occult bactermia or meningitis and if they look good on initial presentation, delayed diagnosis is unlikely to lead to bad outcomes.
• Recommended by: Anand Swaminathan

Snell JA, et al.: Clinical review: The critical care management of the burn patient. Critical Care 2013; 17(5):241. PMID: 24093225 (FREE OPEN ACCESS ARTICLE)

• This review goes through important concepts such as fluid creep, nutrition and hypermetabolism. Having looked after three burns patients recently in an ED for >48hrs, it is extremely important to be fully informed and have a sophisticated knowledge of all aspects of Emergency Care including taking care of critically ill patients for prolonged periods of time.
• Recommended by: Sa’ad Lahri

Van Gelder IC et al. Lenient versus strict rate control in patients with atrial fibrillation. NEJM 2010; 362(15):1363-73. PMID: 20231232 (FREE OPEN ACCESS ARTICLE)

• What’s your goal rate in AFib with RVR? This paper doesn’t answer it definitively, but helps remind us that people with AFib aren’t people in sinus rhythm. Like AFFIRM (rate vs rhythm control) this is a long-term, outpatient study about rate control in AFib — not exactly what we see in the ED with acute RVR. But like AFFIRM, it will probably be a while before we have the right answer to our question. Don’t go for euboxia, go for what helps your patient — we don’t have a precise answer but I think it’s likely reasonable to aim for rate in the 110s.
• Recommended by:  Seth Trueger

Jena AB et al. Mortality and Treatment Patterns Among Patients Hospitalized With Acute Cardiovascular Conditions During Dates of National Cardiology Meetings. JAMA Intern Med 2014. PMID: 25531231

• In this retrospective chart review, the authors looked at change in mortality of patients with primary cardiac issues who were admitted at the same time as national cardiology conferences. They found that high-risk patients with heart failure and cardiac arrest had lower mortality during the national conferences. Intuitively, less cardiac procedures (specifically PCI) were performed. No conclusions can be drawn from this study and, obviously, the study is ripe with limitations from its design. However, the study again questions the idea that more is better.
• Recommended by: Anand Swaminathan

Kraut JA, Madias NE. Lactic Acidosis. NEJM. 2014; 371(24):2309-2319. PMID: 25494270.

• Important review for all EM and critical care docs of all things lactic acidosis related. Some important points made in the review include:
  “Randomized, controlled studies are needed to determine the most effective and safe crystalloid. Red-cell transfusions should be administered to maintain the hemoglobin concentration at a level above 7 g per deciliter. Resuscitative efforts should be complemented by measures targeting the cause or causes of lactic acidosis. . . the value of bicarbonate therapy in reducing mortality or improving hemodynamics remains unproven.”
• Recommended by: Jeremy Fried