R&R In The FASTLANE 072
Welcome to the 72nd 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
Vincent JL et al. Ten big mistakes in intensive care medicine. Intensive Care Med. 2014. PMID 25502093
- From one of the absolute masters of critical care Dr. Vincent, here’s ten important challenges in the care of critically ill that we should all reflect on and strive to overcome.
- Recommenced by: Chris Nickson
Sheren PB et al. Development of a standard operating procedure and checklist for rapid sequence induction in the critically ill. Scand J Trauma Resusc Emerg Med. 2014; 22(1): 41. PMID 25209044
- An excellent, evidence based review of the critical components of RSI. The authors use this evidence to build a standard operating procedure with an airway checklist and kit dump that can aid in building team dynamics and decrease the incidence of adverse events.
- Recommended by Anand Swaminathan
BMJ. 2014 Oct 31;349:g6557. PMID 25361576
- This is really just to highlight the excellent series that Phillip Sedgwick [@statistics_man] writes for the BMJ. Sadly not #FOAMed but a great resource for those looking to learn for the UK FCEM exam. Here’s a link to every single one below.
- Recommended by: Andy Neil
Adelgais KM et al. Intra-Abdominal Injury Study Group of the Pediatric Emergency Care Applied Research Network (PECARN). Accuracy of the abdominal examination for identifying children with blunt intra-abdominal injuries. J Pediatr. 2014; 165(6):1230-1235. PMID 25266346
- The leading cause of mortality in children is accidental injuries. Fortunately, the majority of kids that you see after injuries will not have severe trauma, but sorting out those who are at risk of serious abdominal trauma can be difficult. This is a reminder that you can rely on your exam… when the child has a normal GCS. As the GCS declines, the reliability of your exam declines as well.
- Recommended by Sean Fox
Loubani OM, Green RS. A Systematic Review of Extravasation and Local Tissue Injury from Administration of Vasopressors through Peripheral Intravenous Catheters and Central Venous Catheters. J Crit Care 2015. PMID 25669592
- We’re taught to administer vasopressors through central lines and this may delay these medications. These authors searched the literature to find extravasation and local tissue complications of vasopressors and came up with case reports (n=305 from 270 patients). They found that local tissue injury attributable to peripheral administration tends to occur in distal IV sites following long durations of infusions (average infusion duration before extravasation: 35.2 h). If a patient needs a pressor, they can get it peripherally temporarily while you’re obtaining central access.
- Recommended by Lauren Westafer
Mutschler M et al. The ATLS(®) classification of hypovolaemic shock: A well established teaching tool on the edge?.Injury 2014; 45 Suppl 3:S35-8. PMID 25284231
- The ATLS shock classification has been taking a beating lately. The classification in it self has very little scientific back up – studies have shown that more than 90% of all trauma patients could not be classified according to system. Irrespective of mechanism of injury the classification it may overestimate the degree of tachycardia associated with hypotension and underestimate mental disability in the presence of hypovolaemic shock. Does the ATLS faculty believe it? – Doesn’t seem so. In a survey among 383 European ATLS course instructors and directors the actual appreciation and confidence in this tool during daily clinical trauma care was assessed. Less than half (48%) of all respondents declared that they use the system in their own practice. Overall it seems that the ATLS shock classification today serves only on purpose – namely to test the students attending the course. Hopefully future ATLS manuals will revise the current classification.
- Recommended by Søren Rudolph
Senior Consultant Anesthesiologist, Traumemanager and PHEM doctor. Dedicated to trauma resuscitation, prehospital care and airway management. Barometerbarn | @SorenRudolph |
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I’ve got to say, the paper by Loubani cannot be regarded as changing anything, let alone the game. It is fundamentally not equipped to address the question of safety of peripheral inotropes by its very design as it disregards any paper not reporting an adverse event. How many papers did they pass over to obtain the 85 articles used? 6209. That’s the number of papers which either did not have the outcome of interest (a complication) or did not have vasopressors administered IV (ie IM or otherwise). Both groups of papers are crucial in determining safety of a drug and, if numbers could be weighed on face value, this would suggest we have 6209 articles not documenting any adverse outcome, some even if given IM or otherwise, versus 85 articles documenting complications. This alone suggests that the premise of using this article as ammunition against peripheral inotropes is laughable.
Additionally, the paper itself documents 114 extravasation events, during which 75% had no soft tissue complication! the question must be asked: if the vasopressor comes out of the vein and there is no soft tissue complication – do we care?
Obviously there IS lab data which show vasopressors like noradrenaline can cause tissue necrosis – this is not in dispute. However to cite such a paper as evidence that central access must be obtained immediately when administering inotropes is a false use of the evidence.