R&R In The FASTLANE 089

Welcome to the 89th 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

Mendelow AD et al. Early surgery versus initial conservative treatment in patients with traumatic intracerebral haemorrhage [STITCH(Trauma)]: the first randomised trial. J Neurotrauma. 2015. PMID 25738794

• This had the making of a great RCT to answer a really important question. Does early surgery improve outcomes for those traumatic intracerebral contusions and haematomas? It had a pragmatic design and you got into the trial if the surgeon had equipoise on whether or not to operate. (the roughly GCS9-12 range). Collapsed due to poor recruitment with about 20% of their needed numbers. Glasgow Outcome Scale of 60% v 50% favouring early surgery (almost exactly what they predicted in their power calculation but due to low numbers not significant). Mortality was 15% v 33% favouring early surgery and the kaplan meier curves look lovely. All in all a great trial that never was. The authors interpret it positively and sound like they lean toward early surgery. Is this a move away from the neurosurgical nihilism? Worth noting that 85% in the trial didn’t have ICP monitoring likely due to the fact that most patients came from india and china
• Recommended by Andy Neill

Fang R. An artificial pneumoperitoneum created by injection of oxygen may prevent acute mountain sickness. Am J Emerg Med 2015. PMID 25910671

• This may be the future of the treatment of Acute Mountain Sickness, but I don’t think a lot of people will be in line to get this treatment. The authors of this paper recommends the theoretical use of a pneumoperitoneum to prevent AMS. They believe it is a consideration in patients who need to ascend rapidly (like rescuers).
• Recommended by Daniel Cabrera

Joseph B et al. Validating Trauma-Specific Frailty Index for Geriatric Trauma Patients: A Prospective Analysis. J Am Coll Surg. 2014; 219(1): 10-17. PMID 24952434

• In this study the authors modified an extensive and time consuming 50-variable Frailty Index to a 15-variable Trauma-Specific Frailty Index (TSFI) by selecting the 15 variables with the strongest association for development of unfavorable discharge disposition. The TSFI was then prospective validated in 200 consecutive severly injured (median ISS score 15 (IQR 9 to 20)) geriatric (>65 years , mean age 77 +/- 12,1) in a Level 1 trauma center. Favorable discharge was defined as discharge to home or rehabilitation center and unfavorable defined as discharge to a skilled nursing facility or in-hospital morality.
• By assigning points in the following categories (cancer history, coronary heart disease, dementia, help with grooming , help managing money, help doing household work, help toileting, help walking, feel less useful , feel sad, feel effort to do everything , falls , feel lonely,f function, sexually active and nutrition, albumin) the authors did ROC curve analysis and found that a TSFI cutoff point of 0.27 was optimal, with sensitivity of 85% and specificity of 75% in predicting unfavorable discharge disposition in geriatric trauma patients. A TSFI score >0.27 was an independent predictor of unfavorable outcomes after trauma.
• Recommended by Soren Rudolph

Colman et al. CARTOONS KILL: casualties in animated recreational theater in an objective observational new study of kids’ introduction to loss of life. BMJ. 2014. PMID 25515715

• Supposedly “family friendly” children’s’ programming is a lot more objectively violent than movies geared for adults. Basically, characters in kids’ movies die a lot.
• Recommended by Seth Trueger

Cook TM et al. Fourth National Audit Project. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 2: intensive care and emergency departments. Br J Anaesth. 2011; 106(5): 632-42. PMID 21447489

• NAP4 was a huge undertaking – a national audit of UK airway errors and incidents – and it’s findings are an education in airway management. This paper concerns airway events in the ED and ICU. Probable under-reporting bias is a major drawback and trying to figure out the real cause for events in studies such as these is always problematic. A landmark article nevertheless.
• Results from the entire NAP 4 study are published in this PODCAST series
• Recommended by Chris Nickson

Nightingale CE et al. Peri-operative management of the obese surgical patient 2015. Anaesthesia 2015. PMID 25950621

• STOP BANG, OSA, OHS, AAGA,SOBA?!…..how to manage the obese patient. Solid and easily read British recommendations on perioperative management of the obese patient applicable to most aspects of critical care.
• See also this easy read in Aneshesiology News on the same topic and the SOBA website
• Recommended by Soren Rudolph

Schnell F et al. The Recognition and Significance of Pathological T-Wave Inversions in Athletes. Circulation 2015; 131(2):165-73. PMID 25583053

• Athletes are known to have atypical physiology but what about TWI. This study found that athletes with pathologic TWI (except those in aVR, III, V1) were likely to have underlying cardiac pathology (45% of patients). Hypertrophic cardiomyopathy was the most common finding (81% of cardiac pathology). These authors recommend that all athletes with pathologic TWI be referred for further cardiac testing.
• Recommeded by Anand Swaminathan