R&R In The FASTLANE 091

Welcome to the 91st 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

Rab T et al. Cardiac Arrest: A Treatment Algorithm for Emergent Invasive Cardiac Procedures in the Resuscitated Comatose Patient. JACC 2015; 66(1): 62 – 73. PMID: 26139060

• Patients who are comatose after cardiac arrest continue to be a challenge, with high mortality. There is already an ACC/AHA Class I recommendation for angiography/PCI in patients with STEMI, but the new guidelines are now indicating that this should be done for patients with non-STEMI as well. There are some major issues with the use of observational studies and absolute cutoffs of lab values and age, but bottom line:Patient with cardiac arrest and ROSC who is comatose should have targeted temperature management and cath lab activated when appropriate regardless of ECG (i.e. STEMI or non-STEMI)
• Recommended by Salim R. Rezaie
• Further reading: Beyond ACLS: From CPR to Cath: The new ACC/AHA Cardiac Arrest Algorithm (R.E.B.E.L. EM)

Brainard A et al. A randomized trial on subject tolerance and the adverse effects associated with higher- versus lower-flow oxygen through a standard nasal cannula. Ann Emerg Med. 2015 Apr;65(4):356-61. PMID: 25458980

• Great study by Andrew Brainard (Sharp End Crew) et al showing that “higher” flow nasal cannula (ie. 15 lpm used for preox & passive ox during laryngoscopy) is really not that annoying for the patient. Incidentally I trialed this myself a few years back and it made my nose tickle for a few minutes, but then again I didn’t get any induction agents & sedative drips and wasn’t acutely ill at the time.
• Recommended by Seth Trueger

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Stub D et al. Air Versus Oxygen in ST-Segment-Elevation Myocardial Infarction. Circulation. 2015; 131(24):2143-50. PMID 26002889

• The Australian AVOID trial adressess the important question wether routine administration of oxygen to patients with STEMI is associated with increased infarction size as measured by cardiac enzymes and MRI at 6 months. I all 441 STEMI patients were randomized prehospital to oxygen (8 L/min) by face-mask or no oxygen from. Mean peak TnI was similar between the two groups but there was a significant increase in mean peak CK of 20% in the oxygen group. Although not all patients underwent MRI at 6 months, there was a significantly increase in myocardial infarct size on cardiac MRI in the oxygen group (n=139; 20.3 versus 13.1 g; P=0.04). Furthermore there was an increase in the rate of recurrent myocardial infarction in the oxygen group compared with the no oxygen group (5.5% versus 0.9%; P=0.006) and an increase in frequency of cardiac arrhythmia (40.4% versus 31.4%; P=0.05).This adds to the fact that oxygen is a drug a should be used only if indicated. The perception that oxygen is harmless and that you can’t get enough of a good thing seems to be running out of fashion.
• Recommended by Søren Rudolph
• Read More: July 2015 REBEL Cast (REBEL EM)

Cardenas-Garcia J, et al. Safety of peripheral intravenous administration of vasoactive medication. J Hosp Med 2015. PMID: 26014852.

• Finally we have some prospective and real world data on the safety of peripheral vasopressors! Using a decent drip in a good vein resulted about a 2% extravasation rate with no significant limb injury in 700+ patients. Only 13% needed a CVC in this study.
  Single centre – but mounts a good case for cautious use of peripheral noradrenaline.
• Recommended by Casey Parker

Litton E et al. Safety and efficacy of intravenous iron therapy in reducing requirement for allogeneic blood transfusion: systematic review and meta-analysis of randomised clinical trials. BMJ 2013;347:f4822.PMID: 23950195

• We know that blood transfusions carry significant risks of allo-immunization, TACO, TRALI and have historically been over-utilized. This systematic review and meta-analysis of 75 trials looking at the efficacy and safety of IV iron as an alternative to blood transfusions, found that IV iron was associated with a mean increase in hemoglobin of 6.5g/L and reduced requirement for red cell transfusions (RR 0.74) at the cost of an increased risk of infection (RR 1.33). An ED-based RCT is desperately needed to assess the potential for IV iron as an alternative or adjunct to blood transfusions in patients with severe iron deficiency anemia.
• Recommended by Anton Helman
• Further reading: Episode 65: IV Iron for Anemia in Emergency Medicine (Emergency Medicine Cases)

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Simerville JA et al. Urinalysis: a comprehensive review. Am Fam Physician. 2005; 71(6): 1153-62. Review. Erratum in: Am Fam Physician. 2006 Oct 1;74(7):1096. PMID: 15791892 (FREE OPEN ACCESS ARTICLE)

• Found this via Jim Roberts (him with the Roberts and Hedges book) over at EM News.A wonderful review of all things for testing the wee wee. I learnt a lot reading this and given it’s such a common test we need to know it inside out.
• Recommended by Andy Neill
• Further reading: Urinalysis: Microscopy (Emergency Medicine News)

Kline JA, Kabrhel C. Emergency Evaluation for Pulmonary Embolism, Part 1:Clinical Factors that Increase Risk. J Emerg Med. 2015; 48(6): 771-80. PMID: 25863772.
and
Kline JA, Kabrhel C. Emergency Evaluation for Pulmonary Embolism, Part 2: Diagnostic Approach. J Emerg Med. 2015; 49(1): 104-17. PMID: 25800524.

• This two part series by the guru of all things thromboembolic is a MUST READ for all emergency providers.The first part focuses on the patient factors we must take into account as we evaluate for the possibility of a pulmonary embolism in our patients. The second is an outstanding summary of how best to apply the current state of knowledge to our clinical practice as we workup these same patients. If nothing else, Figure 1 of Part 2 is worth the time of picking up this paper to give you an evidence based, logical approach to the diagnostic evaluation of these patients. Highlights include the use of PERC, age adjusted D-dimer, and how to approach the pregnant patient with a possible PE.
• Recommended by: Jeremy Fried