Research and Reviews in the Fastlane 600

Welcome to the 70th 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

RR Hall of FAMER

Shah VP et al. Prospective Evaluation of Point-of-Care Ultrasonography for the Diagnosis of Pneumonia in Children and Young Adults. JAMA Peds 2013; 167(2): 119-25. PMID 23229753

  • A number of studies demonstrate the utility of POC US for the diagnosis of pneumonia. This study demonstrated a high sensitivity (86%) and very high specificity (97%) when looking for consolidations > 1 cm on US compared to chest X-ray as the standard. The study was done quickly (mean 7 minutes) and by non-experts (1 hour of training) increasing the likelihood that the findings can be generalized to non-study settings.
  • Recommended by: Anand Swaminathan

Olaussen A, et al. Return of consciousness during ongoing Cardiopulmonary Resuscitation: A systematic review, Resuscitation 2014; 86: 44-48. PMID 25447435

  • After introduction of mechanical CPR device CPR induced consciousness seems more prevalent. Though CPR induced consciousness may be distressing for the rescuers (and maybe the patient) it is often percieved as a good prognostic sign of outcome. The current guidelines on advanced cardiopulmonary resuscitation focus on delivering high quality chest compressions with minimal interruptions only pausing for rhythm check or if the patient shows signs of life. Thus CPR induced consciousness may be mistanken for signs of life interupting the sequence of CPR and influence the quality of care. This systematic review only identified reports on 10 patients. The incidence, implications and prognostic value of CPR-induced consciousness remains unknown and should be eveluated.
  • Recommended by: Søren Rudolph
RR Eureka

Eckert MJ et al. Tranexamic acid administration to pediatric trauma patients in a combat setting: The pediatric trauma and tranexamic acid study (PED-TRAX). J Trauma Acute Care Surg 2014; 77(6): 852-8. PMID: 25423534

  • The use of TXA in severe trauma is current standard practice, but its benefit in Peds trauma is not clear. This study is a retrospective review of TXA use in pediatric civilian victims managed by NATO in Afghanistan. From 766 patients, 66 received TXA; this patients had severe torso or extremity trauma. The TXA group was significantly sicker than control (ISS 18 vs 10). The unadjusted mortality was not statically significant but higher in the TXA group (15 vs 8%), however the severity adjusted mortality was lower in TXA with an OR 0.27; with no adverse events. The study has several limitations, particularly a relatively low number of events and the differences between TXA and control (being the TXA way sicker), but appears to show TXA is beneficial is severe pediatric trauma.
  • Recommended by Daniel Cabrera
RR Game Changer

Hoppe JA et al. Association of Emergency Department Opioid Initiation With Recurrent Opioid Use. Ann Emerg Med 2014. PMID 25534654

  • A retrospective observational study which examines the link between opioid prescriptions given in the ED to opioid naive patients (as defined by no filled rx in the past year) and opioid use one year later. A well done study which used the state prescription monitoring program to determine opioid use, and found an important link between filled ED prescriptions and later use. An adjusted odds ratio of 1.8 for recurrent use was found. Limited by the design of the study, this is still important information for ED providers as we consider the implications of providing opioids to our patients for their acute pain issues.
  • Recommended by Jeremy Fried

Rowell AE et al. Moderate elevations in international normalized ratio should not lead to delays in neurosurgical intervention in patients with traumatic brain injury. J Trauma Acute Care Surg 2014; 77(6): 846-51. PMID 25423533

  • Should we delay neurosurgical intervention in patients with traumatic intracranial bleeds due to slight INR elevations? This study looks at the delays that occur from mild elevations and found that patients with INR < 1.4 had their neurosurgical intervention 174 minutes earlier on average than those with an elevated INR. Additionally, they found that mild INR elevations were not correlated with abnormal coagulation based on TEG measurement. Although patient outcomes were not a primary outcome, this study should make us reconsider the utility of INR and delayed intervention based on it.
  • Recommended by Anand Swaminathan
RR Trash

Tapiainen T et al. Effect of antimicrobial treatment of acute otitis media on the daily disappearance of middle ear effusion: a placebo-controlled trial. JAMA Pediatr. 2014;168:(7)635-41. PMID 24797294

  • This RCT compared amoxicillin-clavulanate with placebo in children 6mo – 15 years old with acute otitis media (AOM) (n=84). The authors conclude “antimicrobial treatment of AOM in children is beneficial because it significantly reduces the duration of Middle Ear Effusion (MEE).” These findings seemingly contradict the AAP and Cochrane recommendations against antibiotics for most cases of AOM. Why? The primary and secondary outcomes were not clinically relevant, MEE and time to improved tympanogram findings, respectively. Let’s stop looking for small improvement in surrogate measures, particularly when the intervention (antibiotics) is associated with harm (NNH 1 in 9 for diarrhea).
  • Recommended by Lauren Westafer

Raymondos K et al. The intubation scoop (i-scoop) – a new type of laryngoscope for difficult and normal airways. Anaesthesia. 2014; 69(9): 990-1001. PMID: 24894025

  • The evolution of laryngoscopy began with devices designed to maximally displace the tongue and other soft tissues of the mouth to establish a direct line of sight between the operator’s eye and the patient’s glottis. Video laryngoscopy allows for less tissue displacement, by eliminating the need for direct line of sight, but because of the distance between the camera and the tip of the blade, and the absence of a channel for delivering the ETT, varying degrees of tissue displacement is still needed. The authors of this paper developed a laryngoscope shaped to follow the curve of the airway, with an ETT channel and the camera mounted at the tip of the blade, which allows for visualization of the glottis and delivery of the tube without tissue displacement. It worked extremely well in this small manikin study, though the failure rates they report with other devices are incongruous with the rest of the literature and undermine face validity. I am also concerned about how this device will perform with soiled airways, common in EM. Though this paper only describes a prototype, this may be the shape of things to come in laryngoscopy.
  • Recommended by Reuben Strayer
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Senior Consultant Anesthesiologist, Traumemanager and PHEM doctor. Dedicated to trauma resuscitation, prehospital care and airway management. Barometerbarn | @SorenRudolph |

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