R&R In The FASTLANE 104

Welcome to the 104th 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

Youngquist ST et al. Use of Prehospital Variables to Predict Acute Coronary Artery Disease in Failed Resuscitation Attempts for Out-of-Hospital Cardiac Arrest. Resuscitation 2015; 92: 82-7. PMID 25936932

• Can a simple set of variables predict which OHCA patients suffer from CAD and thus may benefit from more advanced salvage therapies (i.e.ECMO with PCI)? In this retrospective analysis 151 cases of unsuccessful resuscitation where an autopsy was performed CAD (defined as thrombotic coronary occlusion with plaque rupture and myocardial) was found to be the likely cause of death in 43% of cases. An initial shockable rhythm was predictive of CAD as 77% of patients with VF/VT had coronary occlusion. By adding increasing age and male gender 75% of cases could be identified in this population. As time is paramount, early identification of potential salvageable patients of importance, so even though this is a small retrospective study is does provide important knowledge.
• Recommended by Soren Rudolph

Angus DC et al. A systematic review and meta-analysis of early goal-directed therapy for septic shock: the ARISE, ProCESS and ProMISe Investigators. Inten Care Med 2015. PMID 25952825

• The last year has seen a plethora of articles published pertaining to the management of septic shock. These authors performed a meta-analysis of 5 RDCTs including the ARISE, ProCESS and ProMISe trials and conclude that there was no benefit of EGDT over versus standard care in terms of mortality. Once again, it’s important to note that standard care has changed radically since Rivers published his EGDT trial in 2001.
• Recommended by Anand Swaminathan

Claessens YE et al. Early Chest CT-Scan to Assist Diagnosis and Guide Treatment Decision for Suspected Community-Acquired Pneumonia. Am J Respir Crit Care Med 2015. PMID 26168322

• I hesitate to even mention this paper, because I think the conclusions are so wrong. These authors enrolled 319 adult patients with clinically suspected community acquired pneumonia and subjected them to both a chest xray and a CT scan. Not surprisingly, the CT scan found what were interpreted as infiltrates in 33% of patients who had normal chest xrays. The CT findings were used to change management, both in terms of use of antibiotics as well as decision to admit, in a reasonable number of patients. However, it is not clear if any of those management changes were actually warranted. The authors want to use this data to conclude that patients suspected of community acquired pneumonia should all get CT scans. That is absolutely nutty. If we were missing 33% of clinically important pneumonias with current practice, our morgues would be full. Either these are tiny infiltrates that we fight off ourselves, they are false positives, or we catch the pneumonia on a follow up xray 2 days later with a substantially lower radiation burden. (As a side note, be prepared for a similar problem of overdiagnosis in the many studies I assume will soon be published about using ultrasound for pneumonia, even if it has the advantage of no radiation.)
• Recommended by Justin Morgenstern

Ilicki J. Safety of Epinephrine in Digital Nerve Blocks: A Literature Review. J Emerg Med 2015. PMID 26254284

• This is a deep dive literature review looking at the dogmatic teaching that you can’t use lidocaine with epinephrine for digital anesthesia. Any induced vasospasm is transient with a lack of reported complications. Bottom line – no restrictions in using epi in a digit without preexisting compromised circulation. Dogma lysed.
• Recommended by Anand Swaminathan

Ventura AM et al. Double-Blind Prospective Randomized Controlled Trial of Dopamine Versus Epinephrine as First-Line Vasoactive Drugs in Pediatric Septic Shock. Crit Care Med 2015. PMID 26323041

• It is well established that norepinephrine is the vasoactive agent of choice in adults with septic shock but dopamine continues to be widely used in pediatric septic shock. This RDCT compared dopamine to epinephrine and found that dopamine was associated with a higher rate of mortality at 28 days: 20.6% vs. 7%. The study was small (n = 120) and was stopped early due to increased mortality in the dopamine group (increased but not higher than the study was powered to detect) but is the best available evidence to date that dopamine should not be the vasopressor of choice in pediatric shock.
• Recommended by Salim Rezaie, Anand Swaminathan

Diercks DB et al. Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients With Suspected Acute Nontraumatic Thoracic Aortic Dissection. Annals of Emergency Medicine. 65(1):32–42.e12. PMID 25529153

• This is the current clinical policy about management or thoracic aortic dissection (TAD). The group did a solid appraisal of the literature and make some (conservative) recommendations:
  #1 Do not use CDR to rule-out or identify low risk patients for TAD
  #2 Do not use D-dimer to rule-out or identify low risk patients for TAD
  #3 CTA is the test of choice, similar performance to MRI and TTE
  #4 Do not make the diagnosis of TAD based on bedside EUS TTE
  #5 Treat tachycardia and hypertension, but goals are not clear
• Recommended by Daniel Cabrera