R&R In The FASTLANE 086

Welcome to the 86th 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

Weinstock MB, et al. Risk for Clinically Relevant Adverse Cardiac Events in Patients With Chest Pain at Hospital Admission. JAMA Intern Med 2015. PMID: 25985100

• An incredibly important contribution to the literature looking at outcomes of patients who remain in the hospital (admitted and observed) after a negative ED evaluation for chest pain. Excluding patients with abnormal vital signs, electrocardiographic ischemia, left bundle branch block, or a pacemaker rhythm, the authors found that 1 in 1817 had a clinically relevant adverse cardiac event (defined by inpatient ST-segment elevation myocardial infarction, life-threatening arrhythmia, cardiac or respiratory arrest, or death). This article is one more piece of the mounting evidence demonstrating a clear call to change what is the usual care in many  institutions in the U.S. Stop the madness!
• Chest pain is tough — it’s the second most ED common chief complaint, and it scares the heck out of us and our patients – partially because missed MI is one one of the top causes of litigation. But we also see a ton of resources spent on a terribly low yield from chest pain workups. This new study in JAMA-IM including Mike Weinstock (of Bounceback fame), Scott Weingart and David Newman looked at the bad outcomes of patients with normal ECGs and 2 negative troponins admitted for chest pain, and found only 20 bad outcomes in 11k patients (4 in 7000 with appropriate exclusions like abnormal vital signs). Maybe it’s time to change our approach to chest pain?
• Recommended by Jeremy Fried & Seth Trueger

Croskerry P. ED cognition: any decision by anyone at any time. CJEM 2014;16(1): 13-9. PMID: 24423996

• Anything by Pat Croskerry on decision making is gold. Here he gives a great overview of some of the challenges to good decision making in the ED with reference to Kahneman’s book “thinking fast and slow”. Both should be required reading for all trainees and EPs. Free pdf too.
• Recommended by Andy Neill

Fromm C et al. Diltiazem vs. Metoprolol in the Management of Atrial Fibrillation or Flutter with Rapid Ventricular Rate in the Emergency Department. J Emerg Med 2015. PMID 25913166

• Are you a calcium channel blocker person or beta-blocker person? This is one of EM providers’ favorite debates in the management of atrial fibrillation with RVR. This prospective, randomized, double-blind study randomized a convenience sample of 52 patients with atrial fibrillation with RVR to diltiazem 0.25 mg/kg (max dose of 30 mg) or metoprolol administered at a dose of 0.15 mg/kg (max dose of 10 mg). Controlling for age, sex, baseline HR and blood pressure, patients randomized to the diltiazem group were more likely to achieve rate control HR 4.65 (95% CI 2.09-10.36; p = 0.0001). No difference in bradycardia or hypotension.
• Recommended by Lauren Westafer

Capps E et al. Beyond broken spines-what the radiologist needs to know about late complications of spinal cord injury. Insights Imaging. 2015;6(1):111-22. PMID: 25503997

• This is a nice review of a fairly niche topic but something we do see with regularity. Lots of GU problems to find (with no symptoms often). And remember autonomic dysreflexia and fourniers and osteo too!
• Recommended by Andy Neill

Lacroix J et al. Age of Transfused Blood in Critically Ill Adults. NEJM 2015;372(15): 1410-8. PMID 25853745

• In this international multicenter RCT 2430 ptts were randomized (1211/1219 ptts) to received either old (22.0±8.4) or fresh (6.1±4.9 days) PRBC. Patients were transfused for various reasons but according to at restrictive strategy lasting the entire duration of their hospitalisation. The primary outcome measure was 90-day mortality.The signal from this study is clear – NO DIFFERENCE!
• Recommended by Søren Rudolph

Dean DB. Field management of displaced ankle fractures: techniques for successful reduction. Wilderness Environ Med. 2009;20(1): 57-60. PMID: 19364168

• Hematoma block of the ankle? Where has this technique been hiding? Useful in both the ED and the wilderness.
• Recommended by Justin Hensley