R&R In The FASTLANE 122

Welcome to the 122nd 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

Mosier et al. The Physiologically Difficult Airway. West J Emerg Med. 2015; 16(7):1109-1117. PMID 26759664

• The difficult airway is well recognized as a clinical entity and is classically based on anatomic considerations. In this paper another aspect of the difficult airway that involves physiologic abnormalities are considered. Derangement such as hypoxemia, hypotension, severe metabolic acidosis, and right ventricular failure must be considered in developing an airway plan. The authors provide recommendations based on clinical experience and, where possible, based on available evidence.
• Recommended by Søren Rudolph

Bugden S et al. Skin Glue Reduces the Failure Rate of Emergency Department–Inserted Peripheral Intravenous Catheters: A Randomized Controlled Trial. Ann Emerg Med 2015. PMID 26747220

• This study looked at reducing the rate of peripheral IV (PIV) failure by applying a drop of cyanoacrolate to the PIV site. In this nonblinded, randomized trial, failure rates were 10% lower in the cyanoacrolate group. This difference was mostly due to decreased dislodgement rate (7% vs. 14%). Although this looks impressive, the absence of blinding biases the results towards the cyanoacrolate group making this intervention look better than it may be in real life. Also, let’s not remember that cyanoacrolate isn’t cheap. Is the added cost worth the savings from PIV replacement? A multi-center study with cost-analysis is needed.
• Recommended by Anand Swaminathan

Drennan IR et al. Out-of-hospital cardiac arrest in high-rise buildings: delays to patient care and effect on survival. Can Med Assoc J 2016. PMID 26783332

• Looking for a new home? You might want to avoid high rises. This registry study found that living on or above the 3rd floor of a building is associated with a decreased survival as compared to living on the lower floors. No one who lived above the 25th floor survived!
• Recommended by Justin Morgenstern

Skaugset LM et al.  Can You Multitask? Evidence and Limitations of Task Switching and Multitasking in Emergency Medicine. Ann Emerg Med 2015. PMID 26585046

• Emergency physicians are masters of multitasking – or so we think. This review explains that most of what we think of as multitasking is really rapidly switching between tasks, and even if you are good at it, this task switching slows you down and results in error. Unfortunately, the solution promoted in most other fields – limiting interruptions – just isn’t feasible in emergency medicine. Some suggestions to help: prioritize tasks according to acuity, recognize when interruptions can be delayed or redirected, practice skills so they become automatic (and don’t add to cognitive load), and use mental frameworks or external brains to limit cognitive work. Of course, optimizing your departmental workflow to limit interruptions, especially at critical times, is also important.
• Recommended by Justin Morgenstern

Bates SM et al. Rapid Quantitative D-dimer to Exclude Pulmonary Embolism: A Prospective Cohort Management Study. J Thromb Haemost. 2015. PMID 26707364

• Current guidelines and and common practice uses a combination of low pre-test probability and a ‘normal’ d-dimer to exclude PE as a diagnosis. These authors used a d-dimer beneath their standard threshold alone to exclude PE in all comers (mostly ED patients). Of greater than 800 patients, there was only one possible missed PE. While the authors tout their incredible negative predictive value (their primary outcome), the study was terminated prematurely due to the unavailability of that d-dimer assay. Further, only 58(7%) of patients fell into the high-risk category. Regardless, with future studies we may find that a normal d-dimer could exclude PE in higher probability patients.
• Recommended by Lauren Westafer

Wells M et al. The PAWPER tape: A new concept tape-based device that increases the accuracy of weight estimation in children through the inclusion of a modifier based on body habitus. Resuscitation 2013; 84(2): 227-32. PMID 22796544

• Recent studies have revealed the short-comings of the Broselow tape for estimating weights both in the western world, where obesity is rampant, and in developing worlds, where malnutrition is common. This study looks at adding an adjustment to the Broselow tape to increase accuracy of weight estimates and it appears to work. The PAWPER method estimate weight to within 10% in 90% of patients vs just 63.6% with Broselow tape only. Kappa was good between two raters as well. This tool may add in preventing dosing errors of weight-based medications but requires external validation.
• Recommended by Anand Swaminathan