R&R In The FASTLANE 105

Welcome to the 105th 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

Sikorski R et al. Choice of General Anesthetics for Trauma Patients. Cur Anes Reports 2014; 4(3): doi 10.1007/s40140-014-0066-5 

• This paper is an absolute ‘must read’ for anyone providing anaesthesia for the severely injured. The authors convey years of anaesthetic experience from R Adams Cowley Shock Trauma in Baltimore with practical tips on how provide anaesthesia alongside massive transfusion and damage control surgery. The aim not only being optimised hemodynamics but also to improve micro circulatory flow and prevent endothelial damage, glycocalyx break down and fibrinolysis.
• Recommended by Soren Rudolph

Silver SA et al. Risk prediction models for contrast induced nephropathy: systematic review. BMJ. 2015; 27;351: h4395. PMID: 26316642

• This is a large systematic review exploring the ability of models to predict iodinated contrast induced nephropathy (CIN). Twelve prediction models were identified with varying degrees of validation. Most of these included similar risk factors as baseline renal dysfunction, diabetes, heart failure and hemodynamic compromise at the moment of the contrast administration.
• As bottom line, we still don’t know and can’t predict who is going to develop CIN from a regular CT (versus angiography), but probably patients with GFR <30 are at increased risk.
• Recommended by Daniel Cabrera

Theodoro D et al. Emergency Department Central Line–associated Bloodstream Infections (CLABSI) Incidence in the Era of Prevention Practices. Acad Emerg Med 2015; 22(9): 1048-1055. PMID: 26336036

• ED placed central lines are often maligned as being “dirty” and the source of infection. This study looked at the rate of central line-associated bloodstream infections (CLABSI) in ED placed lines and found the rate (2.0/1000 catheter days) to be the same as that in ICU placed lines (2.3/1000 catheter days). Additionally, they found that the introduction of a central line bundle aimed at standardizing practice was associated with a reduction in CLABSI in the ED (3.0/1000 before the bundle to 0.5/1000 after the bundle).
• Recommended by Anand Swaminathan

Reitsma S et al. The endothelial glycocalyx: composition, functions, and visualization. Pflugers Arch 2007; 454(3): 345-59. PMID 17256154

• We are increasingly aware of the endothelial glycocalyx and it’s central role in different pathophysiological steates. This “intricate self-assembling 3D mesh of polysaccharides” is really hard to get a real grip on. In trying to get educated I came across brilliant piece of explanatory paper. Although somewhat old it presents the reader with an in-depth explanation of the construction and function of the glycocalyx in vascular physiology and pathology, including mechanotransduction, hemostasis, signaling, and blood cell-vessel wall interactions.
• Recommended by Soren Rudolph

Gun G. et al. What Do We Miss Without Contrast In Patients With Flank Pain? Am J Emerg Med 2015. PMID 26439094

• A nicely written report of two cases of renal arterial infarction causing acute flank pain in patients presenting to the ED reminds us that not all flank pain is kidney stone. While this is obviously a rare entity, the article serves as a good reminder that for patients with recurrent pain and no stone on imaging, it might be worthwhile to obtain a CT WITH contrast to assess the vasculature.
• Recommended by Jeremy Fried

Tucci V. Down the Rabbit Hole. Emergency Department Medical Clearance of Patients with Psychiatric or Behavioral Emergencies. Emerg Med Clin 2015. doi:10.1016/j.emc.2015.07.002

• A comprehensive review of the complex topic of “medical clearing” psychiatric patients. Of particular note, the authors delineate the different recommendations of the American College of Emergency Physicians and American Psychiatric Association regarding alcohol levels and urine toxicology screening tests on patients. They also provide a helpful reminder of features which make an organic etiology more likely
  -age <12 or >40 without previous h/o psychiatric disease
  -sudden onset of symptom
  -visual or tactile hallucinations
  -h/o substance abuse
  -new medications
  -seizure
  -no family history of psychiatric disorders                                                                                                                                   
  A worthwhile read for all providers caring for psychiatric patients in the acute setting.
• Recommended by Jeremy Fried