R&R In The FASTLANE 076

Welcome to the 76th 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

Mouncey PR et al. Trial of Early, Goal-Directed Resuscitation for Septic Shock (The ProMISe Trial) NEJM 2015. PMID: 25776532 (FREE OPEN ACCESS ARTICLE)

• The ProMISe trial is the third of the trio of studies comparing contemporary standard resuscitation of septic shock patients to EGDT. Like ARISE and ProCESS, ProMISe found no difference between usual care and EGDT for the primary endpoint of mortality. However, EGDT patients were more likely to get any central line (92.1% vs. 50.9%) central lines with SCVO2 monitoring capability (87.3% vs. 0.3%) and to get inotropes (i.e. dobutamine) (18.1% vs. 3.8%). Once again, the bottom line is that EGDT has changed our usual care from what it was 20 years ago. Aggressive management doesn’t require SCVO2 monitoring, CVP or hard triggers for interventions. Early antibiotics, fluids, source control with frequent reassessment triggering escalation of care is what we should focus on.
• Recommended by Anand Swaminathan
• Read more: The ProMISe Study: EGDT RIP? (St. Emlyn’s); The Protocolised Management in Sepsis (ProMISe) Trial (REBEL EM); Keep your ProMISe (MD Aware)

Contenti J, et al. Effectiveness of arterial, venous,and capillary blood lactate as a sepsis triage tool in ED patients. Am J Emerg Med. 2014. PMID: 25432592.

• The practice of arterial blood gas and lactate measurement continues despite evidence that most values in venous samples correlate adequately in most scenarios. This paper describes a 117 patients prospectively subjected to simultaneous arterial, venous, and capillary lactate measurement. The authors conclude, “…peripheral venous blood lactate appears to be more effective in assessing initial severity of sepsis than arterial lactate.”
• Recommended by Reuben Strayer

Woods M, et al. BET 2: In patients presenting with an exacerbation of COPD can a normal venous blood gas pCO2 rule out arterial hypercarbia? Emerg Med J 2015; 32(3):251-3. PMID: 25694499.

• Likely old news to many, but a nice summary of the studies demonstrating that, once again, we don’t need to subject our patients to the pain and potential complications of an arterial stick to obtain needed clinical information. In the words of the authors: “The clinical bottom line is that a normal venous pCO2 effectively rules out arterial hypercarbia.”
  Please, protect patients from unnecessary painful procedures!
• Recommended by Jeremy Fried

Stiell IG, et al. Safety of Urgent Cardioversion for Patients With Recent-Onset Atrial Fibrillation and Flutter Can J Cardiol 2015; 31(3):239-41. PMID: 25592853

• The safety of cardioversion of recent-onset atrial fibrillation of < 48 hours duration has recently been called in to question in a Finish study published in 2013 and a secondary analysis of this data in 2014. In this viewpoint piece, Stiell and colleagues review the strengths and weaknesses of this recent data. They conclude that cardioversion should still be strongly considered in recent-onset atrial fibrillation < 48 hours in duration in patients without known valvular heart disorders (including mechanical valves) or recent thromboembolic events (TIA/CVA). Additionally, TEE should be considered prior to cardioversion in patients with high CHADS2 or CHA2DS2-VASc, age > 65, and as the onset time approaches 48 hours.
• Recommended by Anand Swaminathan

Kessel B, et al. Evaluation of nasogastric tubes to enable differentiation between upper and lower gastrointestinal bleeding in unselected patients with melena. Eur J Emerg Med 2015. PMID: 25747792

• More data on the lack of utility of NGL for UGIB. 386 patients admitted for melena; 279 had a negative lavage. Sensitivity for upper GI source was 28%. NPV was <1%.That means for patients with melena, >99% with a negative NG lavage still have an upper source of their bleed. And patients consistently rate NG as one of the most miserable interventions we do. So don’t.
• Recommended Seth Trueger

Sheak KR, et al. Quantitative relationship between end-tidal carbon dioxide and CPR quality during both in-hospital and out-of-hospital cardiac arrest. Resuscitation 2015; 89:149-154. PMID: 25643651.

• This study is important to confirm what many of us already do, use ETCO2 as a marker of CPR quality. While limited by the manner in which the data was collected, and multiple potential confounders such as lack of medication administration and ventilation details, the authors provide us with a positive correlation between chest compression depth and ETCO2 levels. For every 10mm increase in depth, there was a 1.4mm Hg increase in ETCO2. While statistically significant, there is likely limited clinical importance of such a small difference. Nevertheless, as quality of CPR is the known most important factor in resuscitation, any small improvement should be utilized to its maximum.
• Resuscitation leaders – Using EtCO2 to guide CPR effectiveness? First rule of Resus – Optimize execution. Remember, it’s not just CPR quality affecting your EtCO2, respiratory rate (watch your bagger!) can significantly impact your EtCO2 value. Interestingly, chest compression rate did not significantly impact EtCO2….
• Recommended by John Greenwood, Jeremy Fried