R&R In The FASTLANE 074

Welcome to the 74th 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 7 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

Mahler A et al. The HEART Pathway Randomized Trial Identifying Emergency Department Patients With Acute Chest Pain for Early Discharge. Circ Cardiovasc Qual Outcomes. 2015. PMID: 25737484

• The study is a randomized trial comparing the HEART pathway (HEART score < 3 along with Tn negative at 0 and 3 hours) versus usual care in the treatment of low risk chest pain. At 30 days, the HEART pathway led to lower cardiac testing (12.1% absolute difference). Secondary outcomes of length of stay (9.9 vs 21.9 hours) and early discharge (39.7% vs. 18.4%) were improved with the HEART pathway as well. There was no difference in MACE at 30-days.
• This study is further evidence that the HEART pathway is a safe approach to the management of low risk chest pain and decreases unnecessary health care utilization.
• Recommended by Anand Swaminathan

Sanghavi BS et al. Outcomes After Out-of-Hospital Cardiac Arrest Treated by Basic vs Advanced Life Support. JAMA Intern Med. 2015;175(2):196-204. PMID: 25419698

• The OPALS trial, published in 2004, demonstrated the lack of added benefit of ACLS over BLS in out-of-hospital cardiac arrest (OHCA). ACLS continues to be standard care despite repeatedly demonstrating improved ROSC without improved RONF. This observational cohort sampling from Medicare beneficiaries in the US shows an association of BLS with better outcomes in comparison to ACLS (survival to hospital discharge 13.1% vs. 9.2%). Robust observational studies like this demonstrate the need for a true RDCT to definitively put the issue to rest.
• Recommended by Anand Swaminathan

Perry JJ et al.Differentiation between traumatic tap and aneurysmal subarachnoid hemorrhage: prospective cohort study. BMJ 2015. PMID: 25694274

• This study was a planned substudy from the Ottawa SAH rule derivation and validation studies. The authors investigated a way to definitively determine whether a lumbar puncture was traumatic or not. Ultimately, the authors states that an RBC < 2000 in the final tube AND the absence of xanthochromia defines a traumatic tap and the diagnosis of SAH is not present in this group. While the sensitivity was 100%, the lower CI was only 75% making this “rule” suboptimal.
• In spite of this weakness, there is some great information from this study which represents the largest prospective evaluation of traumatic LPs. Out of 631 patients who were CT negative with RBCs in the CSF, only 5 had a true aneurysmal SAH. 419 CTAs were performed to find those 5 patients. This data gives us a great look into the efforts required to identify aneurysmal SAH after a negative NCHCT.
• Recommended by Anand Swaminathan

Aguilera P, et al. Why does your dandruff smell like urine? Ann Emerg Med. 2015; 65(3): 342-4. PMID: 25702186

• Uremic frost?!? Who knew that existed? Another awesome pairing between Annals and EMRAP which provides both a visual, as well as intellectual picture of the sick uremic patient.Uremic frost are dandruff like uremic crystals which deposit on the skin in the severely uremic patient, nicely seen in the Annals image. The EMRAP group provides an excellent review of some of the critical, not-to-be-missed complications of uremia: encephalopathy, pericardial effusion (tamponnade), and platelet dysfunction in the bleeding patient. This concise summary also briefly covers the emergent treatment providers need to know.
• Behind the very catchy title this review has some easy to remember pearls on the management of the patients in end stage renal failure. In the ESRD patient with azotemia, remember “brain, heart, blood.”
  Altered mental status = Remember uremic encephalopathy; Dyspnea = Remember uremic pericardial effusion; Bleeding = Remember uremic platelet dysfunction; Altered mental status = Remember uremic encephalopathy; Dyspnea = Remember uremic pericardial effusion; Bleeding = Remember uremic platelet dysfunction
• Recommended by Jeremy Fried, Søren Rudolph

Ebell MH, et al. How long does a cough last? Comparing patients’ expectations with data from a systematic review of the literature. Ann Fam Med. 2013;11(1): 5-13. PMID: 23319500

• Great study looking at what patients expectations of cough duration is from viral illness versus what is published in a systematic review of the literature. Mean duration of cough in published literature was 17.8 days while patient expectations of cough duration was 7.2 – 9.3 days
• Recommended Salim Rezaie

Goyal M, et al; the ESCAPE Trial Investigators. Randomized Assessment of Rapid Endovascular Treatment of Ischemic Stroke. NEJM 2015.  PMID: 25671798.
Campbell BC, et al; the EXTEND-IA Investigators. Endovascular Therapy for Ischemic Stroke with Perfusion-Imaging Selection. NEJM 2015. PMID: 25671797

• Since the publication of MR CLEAN, two positive trials, EXTEND-IA and ESCAPE, were recently published in the NEJM.The first trial, Extending the Time for Thrombolysis in Emergency Neurological Deficits — Intra-Arterial (EXTEND-IA) trial, by Campbell et al, is a multi-center RCT that examined the efficacy of endovascular treatment in patients with CVA whose symptoms began within 4.5 hours of randomization. The second and far more statistically robust trial is the Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion with Emphasis on Minimizing CT to Recanalization Times (ESCAPE) trial, published by Goyal et al. In this trial, authors examined patients up to 12-hours after symptom onset.Like MR CLEAN both these trial were a stunning success. In fact their results far outpaced the, by comparison, paltry benefits found in MR CLEAN. Additionally both were stopped for overwhelming benefit. EXTEND-IA found the rate of significant improvement after 3 days (reduction in NIHSS > 8) was 80% vs 37% in the endovascular group and control group respectively. Likewise the rate of favorable outcome at 90-days (mRS of 0-2) was 71% vs 40% respectively, boasting an absolute difference of 31%.
• ESCAPE found the rate of functional independence at 90-days (mRS of 0-2) was 53.0% vs 29.3% in favor of the endovascular arm. With authors noting a 33.7% absolute increase in positive outcomes in patients who received endovascular therapy.Both EXTEND-IA and ESCAPE are impressively positive trials. Although small and methodologically flawed, with likely exaggerated effect sizes, when viewed in concert with MR CLEAN, these trials present endovascular therapy in a promising light. Most importantly EXTEND-IA and ESCAPE suggest we should strive to identify the small subset of stroke patients who will benefit from reperfusion therapy rather than the broad overreaching population in which such interventions are currently employed.
• Recommended by Rory Spiegel
• Read more: Christmas Comes Early for Endovascular Therapy in Stroke (EM Literature of Note)

Patel, MB, et al. Cervical spine collar clearance in the obtunded adult blunt trauma patient: A systematic review and practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma 2015; 78(2): 430-441. PMID: 25757133

• In many places, there’s a certain voodoo around cervical spine clearance after trauma – do you clear it after a CT? MRI? Never if an obtunded patient doesn’t regain meaningful consciousness? This guideline from EAST (US) recommends that cervical collars should be removed after a negative high-quality C-spine CT result alone in obtunded blunt trauma patients.
• This recommendation is based on low quality evidence but found that the risk is low and further testing produces clinically insignificant findings. The authors include this little gem to remind us that collars are not benign: “It should be acknowledged that cervical collar removal can result in neurologic change and even paralysis, although this may be underreported in the literature.”
• Recommended by Lauren Westafer