Research and Reviews in the Fastlane 600

Welcome to the 112th 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

RR Hall of FAMER

Bischof JE et al. ST Depression in Lead aVL Differentiates Inferior ST-Elevation Myocardial Infarction From Pericarditis. AM J Emerg Med 2015. PMID: 26542793

  • In the presence of inferior ST-segment elevation (Leads II, III, aVF), the presence of any ST depression in lead aVL (high lateral lead) is highly sensitive for coronary occlusion (i.e. Inferior STEMI) and very specific for differentiating inferior STEMI vs pericarditis.
  • Recommended by: Salim Rezaie, Justin Morgenstern
  • Read More: New Paper Published on Significance of Reciprocal ST Depression in Lead aVL (Dr. Smith’s ECG Blog)

Milcent K et al. Use of Procalcitonin Assays to Predict Serious Bacterial Infection in Young Febrile Infants. JAMA Pediatr. 2015. PMID: 26595253

  • Another article touting the performance of procalcitonin, this time in infants presenting to the pediatric ED with fever <3 months of age(I.e. the ones we really worry about). The authors show that the procalcitonin outperforms CRP, WBC, and ANC with an OR of 30 for invasive bacterial infections (all likelihood ratios except PCT >2 ng/dL were not very helpful). Yet, this study compares a newer biomaker to markers that we have accepted as mediocre at best. Further, while the authors assessed clinician perception of how sick the kid was, this wasn’t reported but is the most important comparator.
  • Recommended by: Lauren Westafer

Chiang WC et al. Prehospital intravenous epinephrine may boost survival of patients with traumatic cardiac arrest: a retrospective cohort study. Scand J Trauma Resusc Emerg Med 2015; 23(1): 102. PMID 26585517

  • This group explores the administration of epinephrine in patients with traumatic cardiac arrest (TCA). In a retrospective observational study they enrolled 514 adult patients with TCA. Epinephrine was administered in 43 (8.4 %) cases at the discretion of the EMS crew. Outcomes measures were sustained (≥2 h) recovery of spontaneous circulation (ROSC) and survival to discharge. The epinephrine group vs the non-epinephrine group had higher sustained ROSC (41.9 % vs. 17.6 %, p < 0.01) and survival to discharge (14.0 % vs. 3.0 %, p < 0.01).
  • The adjusted odds ratios (ORs) of epinephrine effect were 2.24 (95 % confidence interval (CI) 1.05-4.81) on sustained ROSC, and 2.94 (95 % CI 0.85-10.15) on survival to discharge.
  • The results of this study must be interpreted with caution. Epinephrine was administered in a non-randomized fashion outside a treatment protocol in a non-physician lead prehospital system. The mechanism (and underlying injuries) are largely unreported as are most other prehospital interventions. We are increasingly aware that TCA is heterogenous entity where rapid meaningful interventions according to the mechanism of injury may save lives.
  • Recommended by: Soren Rudolph
RR Game Changer

Wilmer I et al. Air ambulance tasking: mechanism of injury, telephone interrogation or ambulance crew assessment? Emerg Med J 2015; 32(10):813-6. PMID: 25527473

  • Everyone loves a good pre-hospital chopper paper… well this one is all about how you task your crew. How do you decide when to send the helicopter? London HEMS have a paramedic in the control room screening 1000s of calls to find the right ones. Here they compared the 3 things they use to control dispatch. 1) Mechanism of injury (MOI) (a very short list), 2) London Air Ambulance control room interrogation of the call, 3) secondary activation by ground paramedics.
  • Of 2000 calls:
    20% activated by MOI (60% accurate)
    60% activated by London Air Ambulance dispatcher joining the call (70% accurate)
    20% activated by request by ground paramedics (72% accurate)
  • As always MOI is a bit crap. If you’re thinking of setting up or improving a service maybe this might help.
  • Recommended by: Andy Neill
RR Eureka

Riddell M et al. Use of Femoral Nerve Blocks to Manage Hip Fracture Pain among Older Adults in the Emergency Department: A Systematic Review. CJEM 2015. PMID: 26354332

  • This is a systematic review of randomized control trials asking the question: does the use of a femoral nerve block reduce pain, opioid use, delirium, or improve function in adults over 65 with an acute hip fracture. They found 7 RCTs covering a total of 224 patients – so the studies were small. The authors appropriately did not perform a meta-analysis, as the studies were heterogenous, so a single numerical summary is not possible.
  • Overall, nerve block groups consistently had both statistically and clinically significant reduction in their pain scores as compared to placebo, used less opioid, and had fewer complications.
  • Recommended by: Justin Morgenstern

Lee CW et al. Development of a Fluid Resuscitation Protocol Using Inferior Vena Cava and Lung Ultrasound. J Crit Care 2015. PMID: 26475100

  • This is a wonderful article that reviews the current literature on point of care ultrasound (POCUS) of the IVC and lungs for assessment of fluid status in critically ill patients. Additionally, the authors create an algorithm based on POCUS findings to sort patients into three categories: fluid resuscitate, fluid test and fluid restrict. While this is not evidence, it is a practical approach based on current understanding.
  • Recommended by: Anand Swaminathan
  • Read More: Ultrasound Guided Fluid Assessment Protocol (Core EM)
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New Jersey Emergency Physician with academic focus on resident education and critical care in the ED. Strong supporter of FOAMed and its role in cutting down knowledge translation | @EMSwami |

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