R&R In The FASTLANE 075

Welcome to the 75th 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

Newman DH, et al. Quantifying Patient-Physician Communication and Perceptions of Risk During Admissions for Possible Acute Coronary Syndromes. Ann Emerg Med 2015 PMID: 25748480.

• A fascinating article which examines how we in the ED communicate with our admitted low risk chest pain patients. The authors gave surveys to both patients and physicians, asking why the patient was staying in the hospital, and what the chances were of a possible adverse outcome. In this low risk cohort, with a collective risk of <2% for death/MI in 30 days, communication was, unsurprisingly, poor.A discussion regarding the possible risks to patients and reasons for remaining in the hospital only occurred 2/3 of the time. Patients and their physicians only agreed on the patient’s risk 36% of the time. Additionally, patient estimation of MI mortality at home versus in the hospital was 80% v 10%; while physician estimation was 15% and 10%The accompanying editorial (PMID 25749403) accurately describes this as a state of “collective statistical illiteracy.” As we incorporate shared decision making into our practice for low risk patient populations, it’s imperative that we provide accurate information.
• Recommended by Jeremy Fried

Fermann GJ et al. Treatment of Pulmonary Embolism With Rivaroxaban: Outcomes by Simplified Pulmonary Embolism Severity Index Score from a Post Hoc Analysis of the EINSTEIN PE Study. Acad Emerg Med 2015; 22(3):299-307. PMID: 25716463

• In this retrospective analysis of the EINSTEIN PE trial (comparing rivaroxaban to standard PE therapy) the authors found that patients with an sPESI score of 0 or 1 had extremely low rates of major adverse outcomes at 7, 14 and 30 days. With an sPESI of 0, there were no cases of fatal PE at 7 days and a recurrent VTE rate < 1% at 30 days with rivaroxaban treatment. A prospective, randomized trial is needed but this study further supports the practice of discharge home from the ED on oral anticoagulation therapy in patients who are low risk.
• Recommended by Anand Swaminathan
• Read more: Adverse Outcomes are Very Rare After Pulmonary Embolism (EM Lit of Note)

Dugas AF et al. Clinical Diagnosis of Influenza in the Emergency Department. Am J Emerg Med 2015. DOI: http://dx.doi.org/10.1016/j.ajem.2015.03.008.

• This article evaluates emergency provider’s ability to diagnose influenza based on history and physical examination. The authors find that sensitivity and specificity is poor (36% and 78% respectively) in comparison to the gold standard of influenza PCR testing. The authors go to great lengths to explain the importance of diagnosing influenza based on their perceived benefits of antiviral medication initiation early in the course of disease. However, no such benefit exists when all the data is reviewed. Only a modest curtailing of length of symptoms has been shown (~ 16-17 hours) at the trade off of increased nausea, vomiting and psychiatric complications. The authors repeated claims at improved mortality, particularly in the sickest subset of influenza patients, is unsubstantiated in the literature.
• Despite these issues, the poor sensitivity and specificity of clinical exam further contribute to the limitations of prescribing these medications since even if there was a significant benefit, identifying those with the disease is difficult in the absence of expensive tests. Fortunately, the benefit is so minimal as to obviate the need for testing or antiviral treatment.
• Recommended by Anand Swaminathan

Munro AR et al. Use of an Accelerated Diagnostic Pathway allows rapid and safe discharge of 70% of chest pain patients from the Emergency Department 2015: 128(1408); 62-71. PMID: 25662380

• Accelerated diagnostic protocols in low risk chest pain are all the rage. This article is a prospective observational cohort study of 452 patients presenting with chest pain to one New Zealand ED. The authors split patients into either high-risk or non-high risk groups based on EKG, clinician “gestalt” and serial high-sensitivity troponin assay (or single enzyme if symptoms for more than 6 hours). This group classified 75% of patients as non-high risk with a 0% rate of acute MI or death at 30 days (100% follow up!). 1.2% of non-high risk patients required urgent revascularizaton (part of MACE but a soft endpoint) at 30 days. This study further defends the pathway of early discharge from the ED without evocative testing in subsets of patients with low risk chest pain.
• Recommended by Anand Swaminathan

Edwards C, et al. Residency Training: A failed lumbar puncture is more about obesity than lack of ability. Neurology 2015; 84(10):e69-72. PMID: 25754807

• This is an interesting article exploring the reasons for LP failure. The authors reviewed all elective LPs done by Neurology residents in a LP clinic. They recorded all the demographic of the patient and the characteristics of the proceduralist. The overall LP failure rate was 19% and it was associated with a high patient BMI, other variables such as the level of the training of the resident did not have an effect. The authors made the recommendation that in patients with a high BMI (>35) an image-guided LP is recommended.
• Recommended Daniel Cabrera

De Lange DW et al. Extracorporeal membrane oxygenation in the treatment of poisoned patients. Clin Toxicol 2013; 51: 385-393. PMID 23697460

• Improved technology and advances in emergency critical care have made it feasible at some institutions to initiate extracorporeal membrane oxygenation (ECMO) in the Emergency Department. As a “Bridge to Recovery” ECMO has potential to benefit the crashing toxicology patient, buying time while the body (perhaps aided by hemodialysis or another enhanced elimination technique) rids itself of the poison. Veno-arterial ECMO can provide circulatory support in cases of severe cardiotoxicity. This literature review covers techniques, indications, contraindications,complications, and clinical case reports. It will get you thinking about the possibilities.
• Recommended by Leon Gussow

Grailey K et al. Diagnostic Accuracy of Nitroglycerine as a ‘Test of Treatment’ for Cardiac Chest Pain: A Systematic Review. Emerg Med J 2012; 29(3):173-6. PMID: 21511974.

• This study evaluated the diagnostic accuracy of nitroglycerine relieving chest pain as a predictor of the pain being cardiac/ACS in etiology. The combined sensitivity was 0.52 (95% CI 0.48 to 0.56) and combined specificity was 0.49 (95% CI 0.46 to 0.52) meaning that the use of nitroglycerine as a diagnostic modality in chest pain is not useful.
• Recommended by Salim R. Rezaie