R&R In The FASTLANE 103

Welcome to the 103rd 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

Appelboam A et al. Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial. Lancet 2015. PMID 26314489

• This well done randomized control trial adds a slight modification to the traditional Valsalva maneuver (dropping patient into supine position with legs up) and increases the response rate from 17% to 43%. A no cost way to potentially avoid adenosine, verapamil, and electricity makes for happy patients . . . but unhappy trainees.
• Recommended by Anand Swaminathan

Bruder EA et al. Single induction dose of etomidate versus other induction agents for endotracheal intubation in critically ill patients. Cochrane Database of Systematic Reviews 2015. PMID 25568981

• This is another brick of information into the issue of etomidate for RSI in the ED for critically ill patients. The authors performed a systematic review and meta-analysis looking for etomidate vs. other induction agent on ED RSI. They identified 1666 studies but only 7 of them including 722 were able to be included. There was NO evidence of etomidate affecting mortality, ventilator use, vasopressor use or time in the ICU. There was a significant suppression of adrenal function in the short period after (4-6h) and a non-significant increase on the patients SOFA scores.
• Recommended by Daniel Cabrera

Hunold KM et al. Constipation Prophylaxis Is Rare for Adults Prescribed Outpatient Opioid Therapy From U.S. Emergency Departments. Acad Emerg Med 2015. PMID 26291177

• Emergency physicians prescribe a fair amount of opioids. Amongst the medication class’s known side effects – constipation. Major medical societies recommend bowel regimens before patients become constipated yet according to this retrospective study from the National Hospital Ambulatory Medical Care Survey, most opioid prescriptions from the ED are not accompanied by a prescription for a laxative (0.9% were prescribed laxatives). This study is quite limited as it doesn’t include potential recommendations for these over the counter medications but is a good reminder to prescribe stool softeners/laxatives with opioids.
• Recommended by Lauren Westafer

Rodrigo GJ et al. Assessment of acute asthma severity in the ED: are heart and respiratory rates relevant? Am J Emerg Med 2015. PMID 26233619

• The authors of this paper want to tell us that vitals signs aren’t helpful in asthma, but I think their conclusions are entirely backwards.
  This is a retrospective look at data that was collected prospectively as part of 7 other asthma trials done at a single Emergency Department. In total, 1192 adult patients were included. They compared heart rate and respiratory rate between two predefined groups: severe asthma (defined as an FEV1 31-50% of expected) and life threatening asthma (defined as an FEV1 <= 30% expected). The HR and RR were not different between the groups (mean of 102 and 22 respectively). They then use logistic regression to show that only FEV1 and O2 saturation were related to the outcome of admission to hospital. Based on this, they conclude that HR and RR are not determinants of acute asthma severity. I think this is probably the wrong interpretation. They use FEV1 as their definition of illness severity rather than hard outcomes. The lack of correlation between FEV1 and vital signs in this study might equally indicate that FEV1 is not a good indicator of disease severity. (It is a disease oriented, not a patient oriented outcome.) Although FEV1 was correlated with admission rates at this hospital, I imagine this just represents the local practices of the hospital: they believe in FEV1 and therefore admit you to hospital if your FEV1 is low, even if you had no other indications for admission.
• Bottom line: I would still strongly suggest assessing patients clinically, including vital signs. Don’t let surrogate outcomes like the FEV1 or peak flow rates confuse you in asthma.
• Recommended by Justin Morgenstern

Cohn B. Can Bedside Oculomotor (HINTS) Testing Differentiate Central From Peripheral Causes of Vertigo? Ann Emerg Med 2014. PMID 24530107

• Differentiating peripheral and central vertigo in patients with continuous symptoms is not only difficult but critical as those with central vertigo may have serious, life-threatening pathology. MRI continues to be the gold standard for finding posterior circulation abnormalities but the HiNTS examination has gained popularity in recent years. This article reviews the literature behind this procedure and contains links to videos demonstrating it’s use.
• Recommended by Anand Swaminathan

Martindale JL et al. β-Blockers versus calcium channel blockers for acute rate control of atrial fibrillation with rapid ventricular response: a systematic review. Eur J Emerg Med 2015. PMID: 25564459

• Rate control of rapid atrial fibrillation is a common ED scenario without a clear best medication (calcium channel blocker or beta blocker) recommendation available from the literature. This systematic review finds that the available RDCT evidence (2 studies) supports the use of diltiazem over metoprolol for acute rate control but notes the absence of adequate high-quality studies to settle the debate.
• Recommended by Anand Swaminathan