Welcome to the 100th 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
Kelley AS, Morrison RS. Palliative Care for the Seriously Ill. NEJM 2015; 373:747-755. PMID: 26287850
- This excellent review article emphasizes palliative care being interdisciplinary care involving multiple specialities e.g. medicine, nursing, social work, chaplaincy, etc which focuses on improving quality of life for persons of any age who are living with any serious illness and for their families. Core components of palliative care include the assessment and treatment of physical and psychological symptoms, identification of and support for spiritual distress, expert communication to establish goals of care and assist with complex medical decision making, and coordination of care. Excellent cognitive road maps for Breaking Bad News such as SPIKES (setting up the interview, assessing the patient’s perception, obtaining the patient’s invitation, giving knowledge and information, responding to emotion, and summarizing the discussion), and others to express empathy with the use of NURSE (naming, understanding, respecting, supporting, and exploring) are described and could be utilised in our practise.
- Recommended by: Nudrat Rashid
Gaeta F et al. Tolerability of aztreonam and carbapenems in patients with IgE-mediated hypersensitivity to penicillins. J Allergy Clin Immunol. 2015;135(4):972-6. PMID: 25457154
- True penicillin allergy can potentially limit antibiotic options as many antibiotics from cephalosporins to carbapenems to aztreonam have reported cross-reactivity. A number of publications have shown low cross-reactivity (1-3%) between penicillins and cephalosporins as well as low cross-reactivity between penicillins and imipenem/meropenem (~ 1%). This study, using skin tests, found that 0 out of 211 patients demonstrated cross-reactivity between penicillin and aztreonam. The authors recommend skin testing prior to administration and skin testing isn’t a perfect surrogate for a systemic reaction upon IV administration but the best evidence we have shows that cross-reactivity is highly unlikely.
- Recommended by: Anand Swaminathan
Park G et al. Randomized single-blinded clinical trial on effects of nursery songs for infants and young children’s anxiety before and during head computed tomography. Am J Emerg Med. 2015. PMID: 26314215
- This RCT randomized children aged <4 years who were undergoing CT scans to receive either nursery rhymes (via musical CD) or standard care (with no music). The children who received the music had significantly lower agitation scores measured using a visual analogue scale (absolute difference 2.4 cm, p=0.03). The paper has some weaknesses. For example, even though the research associate assessing agitation wore earphones to block out any music, they seem unlikely to have been truly blinded to allocation because they’ll have seen the child’s reaction. What’s more, the difference is modest. Still, it’s a nice idea and gives us some evidence (even if it does have weaknesses) to suggest that music might be helpful in this situation.
- Recommended by: Rick Body
Un, et al. Novel Vagal Maneuver Technique for Termination of Supraventricular Tachycardias. AJEM 2015 PMID: 26209466
- A brief case series that describes the success of a new vagal maneuver for termination of SVT in the emergency setting. Basically, the authors describe moving patients quickly from a sitting to a supine position, and their success with 5 different patients. This is certainly a benign enough procedure without significant foreseeable harm, so well worth attempting before placing an IV and pushing adenosine. Another arrow in the quiver!
- Recommended by: Jeremy Fried
Kosova E, Bergmark B, Piazza G. Fat embolism syndrome. Circulation 2015;131(3):317-20. PMID: 25601951
- Although a review, this article highlights a rare, but important and often misdiagnose entity: Fat Embolism Syndrome (FES). FES is defined as the presence of fat globules in pulmonary circulation. Common affected population are young (10-40) patients with long bong trauma but it can be seen in pathological fractures or bone marrow disease. The pathophysiology is thought to be related to a mechanical obstruction plus a sever inflammatory process (similar to amniotic fluid emboli). Classic presentation is respiratory failure, neurological abnormalities and petechiae. Diagnosis is challenging and based on clinical presentation, isolation of fat particles in wedge circulation appears not to be of great help for the diagnosis, the authors recommend the use of Gurd criteria (http://bit.ly/1umarLp). Treatment consists in general aggressive intensive care support.
- Recommended by: Daniel Cabrera
Asch DA, Rosin R. Innovation as Discipline, Not Fad. NEJM 2015; 373(7):592-594. PMID: 26267619
- Most of us have a bunch of ideas that we think might make our hospital work better.Most of us do not implement those ideas.This is because full implementation would take a bunch of money or resources to build a whole system. So we are stuck unable to implement a fix because we cannot get the resources; unable to get the resources because we do not have evidence it will work; and unable to get the evidence it will work because we cannot implement the fix.Asch and Rosin provide a set of ingenious solutions for breaking out of this bind. They describe a set of strategies stolen from the technology industry but that they are implementing in healthcare. (Rosin used to work for Quicken, of tax accounting fame.)Pertinently, they provide pragmatic strategies for being able to develop a test-able fix without making most of the investment needed to make a permanent fix. If the test-able fix works, one has evidence to command the resources to make in permanent. If it does not, no harm done, one can move on quickly to a new test-able fix.Particularly for people early in their careers—or in resource-poor environments—these strategies seem enormously useful. The article prompted a bunch of ideas for me, anyway. The bottom line: don’t wait until everything can be done perfectly; find the critical part of a potential solution, find a way that might be good enough to make it better, objectively evaluate it in a real situation, and learn from the result.
- Recommended by: Jack Iwashyna