Welcome to the 77th 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
Grunau BE, et al. Emergency Department Corticosteroid Use for Allergy or Anaphylaxis Is Not Associated With Decreased Relapses. Ann Emerg Med. 2015. PMID 25820033.
- The treatment for anaphylaxis is epinephrine but steroids are commonly prescribed for allergic reactions of all severities. This observational chart review seeks to add some data to this practice (there are no RCTs) and found no difference in rate of return visit/biphasic reaction in patients with anaphylaxis/allergic reaction who were prescribed steroids (or received steroids in the ED) and those who received no steroids. There’s little data in this area and, it seems, there may not be much behind the practice of giving steroids in allergic reactions.
- Corticosteroids are traditionally prescribed to patients who present with anaphylactic reactions. However, the benefit of these drugs in preventing the rare complication of biphasic anaphylaxis is poorly understood. These authors do a retrospective review of 5 years worth of patients presenting with allergic reactions. They find no significant difference in the rate of biphasic reactions whether steroids are given or not. Even short courses of steroids have potential deleterious effects. While this study has the inherent flaws of any retrospective review, this study argues that we carefully weigh the harms and benefits.
- Whilst this is a retrospective trial, it is useful at least in allowing a patient with contraindications to steroid to be given the option of not having them. As someone who has seen thousands of ED referrals regarding acute allergy, I don’t think steroids make any difference to acute reactions, though if urticaria has persisted for more than three days, and there has been angioedema, then steroids do make a difference. This opinion though and not addressed in this study. The authors call for a RCT which is exceptionally unlikely to ever be done.In my practice, when i induce severe allergy (during challenges: food/drugs) i rarely use steroids; Adrenaline is key.
- Recommended by: Lauren Westafer, Anand Swaminathan, Daman Langguth
Miller LG, et al. Clindamycin versus trimethoprim-sulfamethoxazole for uncomplicated skin infections. N Engl J Med 2015; 372(12): 1093-103. PMID: 25785967
- This was a randomized controlled trial in uncomplicated skin infections comparing Clindamycin 300mg TID to Bactrim BID in order to determine the ideal coverage for these infections within the emergency department. All individuals either had strictly defined cellulitis or abscess and were treated in a randomized double blinded fashion. The primary outcome, cure, was not statistically significantly different between the two groups and Staph aureus (with MRSA being preponderant) was responsible for the majority of identifiable infections.
- Though this study is intriguing there are several questions raised by its findings. Greater than 30% of the entire cohort had abscesses and all underwent incision and drainage. While the study found no difference between these two groups in terms of antibiotic cure a priori evidence suggests that the act of incision and drainage and not the administered antibiotic, regardless of type, is solely responsible for cure and therefore the finding of no difference.
- Further the authors theorize that there may be susceptibility to Bactrim in strep species and this is responsible for the lack of difference in cellulitis cure rates in spite of general resistance to the antimicrobial within the bacterial species. However there were a minimal amount of strep species in either group represented making this a difficult recommendation to generalize from this study.
- Recommended by: William Paolo
Asha SE, et al. A Systematic Review and Meta-analysis of D-dimer as a Rule-out Test for Suspected Acute Aortic Dissection. Ann Emerg Med 2015. PMID: 25805111
- The role of d-Dimer in the exclusion of acute aortic dissection has been argued back and forth for years. This meta-analysis and systematic review reveals a high sensitivity and poor specificity. This is no surprise. The discussion section, though is very thought provoking as to targeted d-Dimer use in risk stratification. The included articles for this systematic review have a number of flaws and so the authors issue a call for well-done, ED based prospective studies prior to adoption of this approach.
- Recommended by: Anand Swaminathan
Holst Lars B, et al. Restrictive versus liberal transfusion strategy for red blood cell transfusion: systematic review of randomised trials with meta-analysis and trial sequential analysis BMJ 2015; 350: h1354. PMID: 25805204
- This is a systematic review analyzing transfusion strategies in the setting of acute blood loss, where a threshold was use to decide in transfusion (including post surgical, active malignancy, GI bleedings, trauma, etc.). A total of 31 studies included, with 9813 total pooled patients, the risk of bias was low. The data shows that a restrictive strategy (heterogeneous definition) was not associated with increased mortality and therefore is as safe as a liberal approach. The number of units transfused was not surprisingly lower in the restricted approach. The findings apply to trauma, post-op, acute medical bleeding.
- Recommended by: Daniel Cabrera
Wares CM, et al. Emergency Department Prognostication of Comatose Cardiac Arrest Patients Undergoing Therapeutic Hypothermia is Unreliable. Am J Emerg Med 2015. DOI: http://dx.doi.org/10.1016/j.ajem.2014.12.033
- This small, but important, study reminds us to not be so fatalistic in our post resuscitation prognostication. With the advent of therapeutic hypothermia (and early PCI) post arrest patients are doing considerably better than we believe. In this small study, ED providers did poorly in predicting those whom had a good neurological outcome (40% in both the study sample as well as the site’s therapeutic hypothermia registry data).
- Recommended by: Jeremy Fried
Kaukonen KM et al. Systemic Inflammatory Response Syndrome Criteria in Defining Severe Sepsis. NEJM 2015. PMID: 25776936 (FREE OPEN ACCESS ARTICLE)
- Although it’s widely understood that the systemic inflammatory response syndrome criteria are poorly specific (i.e. lots of false positives) for sepsis, it was thought that this lack of specificity came with high sensitivity. This article sheds some light on the issue. In this study of ICU patients in Australia and New Zealand, the standard SIRS criteria missed 1 in 8 patients who went on to severe sepsis. These results call into question the reliability of the SIRS criteria.
- Recommended by: Anand Swaminathan