R&R In The FASTLANE 081

Welcome to the 81st 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

Brown CA et al. Techniques, success, and adverse events of emergency department adult intubations. Ann Emerg Med 2015; 65(4):363-370. PMID: 25533140

• This article reviewed 17,583 adult ED intubations over 10 years at 13 different centers.
  The study found 95% of intubations were performed by ED physicians with good results: 99% of intubations were successful within 3 attempts.
• Orotracheal intubation with RSI was, of course, the most common technique, with 85% first pass success rate with this technique. And first pass success rates increased over time during the 10 year period, showing that we are continuing to get better!
• Interestingly, senior residents had 85% first pass rate, compared to just 72% for attendings.
• For drugs, etomidate was overwhelmingly the most commonly used induction agent, while succinylcholine ruled as a paralytic, although a notable increase in rocuronium was noted in the later years studied.
• Finally, VL use, as could be expected, increased substantially during the time of the study.
• Recommended by: Zack Repanshek

Kang BJ et al. Failure of high-flow nasal cannula therapy may delay intubation and increase mortality. Intensive Care Med. 2015;41(4):623-32. PMID: 25691263

• Here we go again! A nice reminder of how prolonged non-invasive oxygenation strategies are potentially harmful to patients with non-rapidly reversible causes of hypoxemic respiratory failure. In this study, patients who failed high-flow nasal cannula (HFNC) after 48 hours had significantly higher overall ICU mortality, poorer extubation success and ventilator weaning, and fewer ventilator-free days.
• Recommended by: John Greenwood

Reichlin T et al. Prospective validation of a 1-hour algorithm to rule-out and rule-in acute myocardial infarction using a high-sensitivity cardiac troponin T assay. CMAJ 2015. PMID: 25869867 (FREE OPEN ACCESS ARTICLE)

• Every day a faster rule-out for acute myocardial infarction – this time, only one hour. Every day a caveat – requires new highly-sensitive troponin assays, and generated a fair number of “observation zone” results or false positives.
• Recommended by: Ryan Radecki
• Read More: The 1-Hour Rule Out (EM Lit of Note)

Putera M et al. Translation of acute coronary syndrome therapies: From evidence to routine clinical practice. Am Heart J 2015; 169(2):266-73. PMID: 25641536

• We often bemoan the snail-like pace of knowledge translation (KT) and this article backs up our complaints. The authors investigated the time from publication of critical articles contributing to level 1A AHA recommendations to incorporation in guidelines and translation to clinical practice. They find that translation is delayed up to 30 years in some cases. For aspirin, the time from key article publication to 90% adoption of guidelines was 16 years. There are some worrisome rapid adoptions as well. Adoption of agents like clopidogrel, prasurgel and bivalarudin into guidelines was quite rapid. Perhaps there is a role for delayed translation to allow time for safety data and subsequent validating studies to emerge.
• Recommended by: Anand Swaminathan

Steiner ME et al. Effects of red-cell storage duration on patients undergoing cardiac surgery. N Engl J Med. 2015; 372:(15)1419-29. PMID: 25853746 (FREE OPEN ACCESS ARTICLE)

• Prior literature suggests transfusion with fresher red blood cells (PRBCs) may be better. The RECESS trial, a prospective, multi-centered study, looked at 1098 adults undergoing cardiac surgery randomized the patients to receive blood stored for <10 days or > 21 days. Patients received a median of 3 units in the first post-op week with no significant difference in multi-organ dysfunction (MODS) or all-cause mortality at 7 or 28 days between groups. The study was only powered to look at a change in the MODS but, in conjunction with the ABLE trial, supports the efficient use of PRBCs for most patients – first in, first out.
• Recommended by: Lauren Westafer
• Read More: Special (Medical) Transfusion Situations (The Short Coat)

Blok KM et al. CT within 6 hours of headache onset to rule out subarachnoid hemorrhage in nonacademic hospitals. Neurology 2015. PMID: 25862794

• This paper is a solid contribution to the concept of SAH rule out with a CT within 6h of onset. This group evaluated patients presenting with concern for SAH and a normal physical exam. All patients underwent head CT and LP. The rate of SAH in the population was 7% (52/760) and of this group, only one patient was not detected by CT; a patient with a perimesencephalic bleed and not an aneurysmal SAH. The beauty of this study is that it was performed in a community setting (not a large tertiary center) and CT were reviewed by staff radiologist, making the concept of 6h rule out also more externally valid. The NPV for SAH with a negative CT within 6h of headache onset was 99.9% (1:1000)
• Recommended by: Daniel Cabrera

Horst JA et al. Can Children With Uncomplicated Acute Appendicitis Be Treated With Antibiotics Instead of an Appendectomy? Ann Emerg Med 2015. PMID: 25724624

• Non-surgical treatment of appendicitis continues to gain traction in many countries around the world. This article reviews the scant pediatric literature looking at this management approach. The evidence shows that this strategy may be safe in carefully selected patients but larger, well-done studies are necessary prior to adoption.
• Recommended by: Anand Swaminathan
• Read More: SGEM #115: Complicated – Non-Operative Treatment of Appendicitis (NOTA) (The SGEM)