Welcome to the 107th 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
Badhiwala, JH et al. Endovascular Thrombectomy for Acute Ischemic Stroke A Meta-analysis. JAMA 2015. PMID 26529161
- Badhiwala conducted a systematic review and meta-analysis of RCTs examining the efficacy of endovascular treatment for acute ischemic stroke (8). Published in JAMA, the authors included the five most recent positive trials, as well as the three negative trials published in the NEJM in February of 2013. The primary, an ordinal analysis of functional status (mRS) at 90-days was in favor of endovascular therapy with an odds ratio of 1.56 (1.14–2.13 p = 0.005). No difference was observed in the 90-day mortality (15.8% vs. 17.8%) or the rate of symptomatic intracranial hemorrhage (5.7% vs. 5.1%).Despite its methodologic rigor, Badhiwala et al’s meta-analysis brings us no closer to certitude.
- It serves to place an objective number on the current ambiguous state of the data concerning endovascular therapy for acute ischemic stroke. But the inherent value of its statistical manipulations in a pooled data set is unclear. This analysis provides little utility over our unstructured judgment of each respective trial’s importance. By combining these trials, Badhiwala et al have attempted to augment statistical power in a dataset that already boasts effect sizes well below statistical significance. When truly, what is required, is a clinical homogeneity that no amount of statistical manipulations can supplant.
- Recommended by Rory Spiegel
Lim SH, et al. Slow infusion of calcium channel blockers compared with intravenous adenosine in the emergency treatment of supraventricular tachycardia. Resuscitation 2009. PMID: 19261367
- I almost never use adenosine in SVT. This paper helps to explain why.
- This is a RCT of 206 adult patients with SVT randomized to either adenosine or a calcium channel blocker. The dosing of the CCBs was either verapamil 1mg/min to a max of 20 mg or diltiazem 2.5mg/min to a max of 50mg. Adenosine dosing was 6mg followed by 12 mg if needed. Calcium channel blockers did a better job converting to sinus rhythm (98% vs 86.5% p=0.002). 1 patient in the CCB group developed transient hypotension as compared to none in the adenosine group.
- Bottom line: Calcium channel blockers may be more effective than adenosine and don’t have the horrible side effects. I always start with a CCB, and my patients have thanked me every single time for not exposing them to the horrors of adenosine.
- Recommended by Justin Morgenstern
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
- This is a double-blind, prospective, randomized controlled trial of 120 children with fluid refractory septic shock from a pediatric ICU in Brazil. Patients were randomized to dopamine (5 – 10 ug/kg/min) or epinephrine (0.1 – 0.3 ug/kg/min). The primary outcome was death from any cause by 28 days. Death occurred in 13 (20.6%) of patients int he dopamine group vs 4 (7%) of patients in the epinephrine group. The survival OR for children on epinephrine vs dopamine was 6.49. The results must be balanced with some caveats.
- First, this is a single center study and we all remember how the EGDT Rivers study turned out (i.e. we still need an external validation study).
- Secondly, although not statistically significant the Vasoactive Inotropic Scores (VIS), a predictor of morbidity/mortality, were higher in the dopamine group vs the epinephrine group. Ultimately, this is the 1st prospective, controlled randomized trial to compare epi vs dopamine and in this study: Dopamine was associated with an increased risk of death and healthcare-associated infection when compared to epinephrine in pediatric patients with septic shock.
- Recommended by Salim R. Rezaie
Morton MJ. Should Patients Who Receive a Diagnosis of Acute Pulmonary Embolism and Have Evidence of Right Ventricular Strain Be Treated With Thrombolytic Therapy? Ann Emerg Med 2015. PMID: 26475245.
- A difficult clinical scenario: should hemodynamically stable patients with evidence of RV strain be given thrombolytics for their acute pulmonary embolism?
This Systematic Review Snapshot summarizes a meta analysis performed examining this issue, and find, unsurprisingly, that the answer is a nuanced one and must be individualized for each patient. They find a small mortality benefit with a NNT of 65, balanced with a major hemorrhagic event with a NNH of 18. Importantly, the risk of major bleeding increased significantly in patients over age 65. While clearly not providing a definitive answer, it does give those of us caring for patients at the bedside some guidance on how best to treat these patients and discuss the risks and benefits with patients.
- Recommended by Jeremy Fried
Muller MP, et al. Hand Hygiene Compliance in an Emergency Department: The Effect of Crowding. Acad Emerg Med 2015. PMID 26356832
- Sometimes referred to as the biggest knowledge translation failure, hand washing is something that we are expected to do before and after touching patients, before procedures, and after touching body fluids. Seems easy enough yet this ED study from a Canadian ED shows that we are still terrible, physicians had 34% compliance – when they were being watched! Shockingly, compliance was only 26% “after body fluid exposure.”
- Sometimes simple things can make a big difference.
We know hand hygiene is essential, and we also know we’re bad at it. This study suggests we’re even worse at it when the ED is busy. Researchers looked at 1116 hand hygiene opportunities presented to nurses, physicians and other healthcare professionals and used time to physician assessment as a marker of ED crowding. Mean hand hygiene compliance was only 29% but more worryingly longer mean time to physician assessment and higher nursing hours were associated with even lower compliance (24%). The bottom line? No matter how busy you are, WASH YOUR HANDS!
- Recommended by Lauren Westafer, Natalie May
Tseng HJ et al. Imaging Foreign Bodies: Ingested, Aspirated, and Inserted. Ann Emerg Med 2015. PMID: 26320521
- An excellent, in depth review of finding and managing foreign bodies that are ingested, aspirated or inserted. The authors create some great tables that can act as rapid access guides on your smart device for just in time clinical guidance.
- Recommended by Anand Swaminathan