Research and Reviews in the Fastlane 600

Welcome to the 124th 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

Gaeta F et al. Tolerability of aztreonam and carbapenems in patients with IgE-mediated hypersensitivity to penicillins. J Allergy Clin Immunol. 2015;135(4):972-6. PMID 25457154

  • True penicillin allergy can potentially limit antibiotic options as many antibiotics from cephalosporins to carbapenems to aztreonam have reported cross-reactivity. A number of publications have shown low cross-reactivity (1-3%) between penicillins and cephalosporins as well as low cross-reactivity between penicillins and imipenem/meropenem (~ 1%). This study, using skin tests, found that 0 out of 211 patients demonstrated cross-reactivity between penicillin and aztreonam. The authors recommend skin testing prior to administration and skin testing isn’t a perfect surrogate for a systemic reaction upon IV administration but the best evidence we have shows that cross-reactivity is highly unlikely.
  • Recommended by Anand Swaminathan

Minneci PC et al. Effectiveness of Patient Choice in Nonoperative vs Surgical Management of Pediatric Uncomplicated Acute Appendicitis. JAMA Surg 2015:1-8. PMID 26676711

  • Surgeons at a children’s hospital offered patients a choice between immediate surgery and antibiotic therapy for appendicitis, and about 75% in the no-surgery group ultimately avoided an operation during median 18 month follow-up.
  • Read more: The New “Standard of Care” for Appendicitis (EM Lit of Note)
  • Recommended by: Ryan Radecki
RR Mona Lisa

Böttiger et al. Influence of EMS-physician presence on survival after out-of-hospital cardiopulmonary resuscitation: systematic review and meta-analysis. Crit Care 2016; 20:4. PMID 26747085

  • The never ending battle between EMS physians and paramedics rages on. In this meta analysis based on 14 studies and a huge number of patients (126829) the authors suggests that EMS-physician-guided CPR in out-of-hospital cardiac arrest is associated with improved survival outcomes. Although meta analysis are only as good as the data allows, and in this meta analysis no RCTs where included (as they do not exist), this represents the best evidens available.
  • Recommended by Søren Rudolph
RR Game Changer

Zuckerman M et al. A review of the toxicologic implications of obesity. J Med Toxicol 2015; 11:342-354. PMID 26108709

  • The management of drug overdose in the setting of obesity is complicated by alterations in physiology, pharmacokinetics and comorbidities, potentially placing this patient population at increased risk of drug-related death. This article provides an excellent in-depth dive into these factors and discusses alterations in utilization and dosing of antidotes. Importantly, the authors highlight an overdue need for inclusion of obese subjects in clinical research to better understand drug toxicity in this growing patient population.
  • Recommended by Meghan Spyres
RR Game Changer

Nehme Z et al Effect of supplemental oxygen exposure on myocardial injury in ST-elevation myocardial infarction. Heart 2016. PMID 26740484

  • More on the potential harm from supplemental oxygen in MI patients. This study examines the dose-relationship of oxygen therapy and infarct size assess by biomarkers. Excluding hypoxic patients and those with cardiogenic shocks 441 patients with STEMI were randomized to oxygen or room air. Every 100 L increase in oxygen exposure in the first 12 h was associated with significantly increased cTnI and CK of 1,4% and 1,2% respectively.As the median supplemental oxygen exposure was 1746 L this would result in a 21% increase in infarct size.
  • Recommended by Søren Rudolph

Debaty G et al. Impact of intra-arrest therapeutic hypothermia in outcomes of prehospital cardiac arrest: a randomized controlled trial. Intensive Care Med 2014;40(12):1832-42. PMID 25348858

  • This appears to be another nail in the coffin of hypothermia and even targeted temperature management. The study consisted in infusion cold saline and cooling devices vs. no hypothermic interventions in patients with out-of-hospital cardiac arrest. The first endpoint was level of neuron-specific enolase, with secondary endpoint being the levels of various ILs and clinical outcome. The results showed absolutely no difference between interventions. Pre-hospital, intra cardiac arrest initiation of TTM does not improve any outcomes.
  • Recommended by Daniel Cabrera
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Senior Consultant Anesthesiologist, Traumemanager and PHEM doctor. Dedicated to trauma resuscitation, prehospital care and airway management. Barometerbarn | @SorenRudolph |

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