R&R In The FASTLANE 127

Welcome to the 127th 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

Talan DA et al. Trimethoprim–Sulfamethoxazole versus Placebo for Uncomplicated Skin Abscess. NEJM 2016; 374:823-832. PMID: 26962903

• For thousands of years, the treatment of simple abscesses has been incision and drainage. This article, though, may change that paradigm. In this RDCT, half of the patients were given TMP-SMX and half were given placebo after I+D was performed. They found a 7% difference in their primary outcome of cure rate. This was below the stated difference (7.5%) they sought to find but, pretty close. Reading the headline alone will lead many providers to either change their care or, justify their current practice pattern. However, a deeper dive into the paper shows that many of the patients did not have simple abscesses. The authors state, “However, most participants had a total lesion size, including associated erythema, of more than 5 cm, and many met other guideline criteria for antibiotic treatment.” This study didn’t look at simple abscesses but rather at ones that most clinicians would have given antibiotics to and in spite of that, they found only a relatively modest benefit. Despite the headline, this is NOT practice changing.
• Recommended by: Anand Swaminathan
• Further reading: Are Antibiotics Back in Favor for Abscesses? (EM Literature of Note), Trimethoprim-Sulfamethoxazole for Uncomplicated Skin Abscesses? (R.E.B.E.L. EM)

Martin SP, et al. Double-dorsal single-volar digital subcutaneous anaesthetic injection for finger injuries in the emergency department: A randomised controlled trial . Emergency Medicine Australasia. 2016. PMID 26991958

• Intuitively, most of us would prefer one injection over two injections, particularly if outcomes were essentially the same. Traditional nerve blocks involve two dorsal injections, one on either side of the digit. Yet, previous literature shows a single subcutaneous injection on the volar aspect works quite well as a digital block. This randomized study of 86 ED patients again reminds us that we should be employing this nerve block more.
• Recommended by: Lauren Westafer
• Further reading: Trick of the trade: Single digital block (ALiEM)

Khandelwal N, et al. Head-Elevated Patient Positioning Decreases Complications of Emergent Tracheal Intubation in the Ward and Intensive Care Unit. Anesth Analg. 2016 PMID: 26866753

• Is intubating patients in the supine position no longer recommended?Previous studies in the OR environment have demonstrated that a bed up head elevated (BUHE) position improves preoxygenation and prolongs apnea time. This study looked at emergent intubations by anesthesiologists outside of the OR, and had a primary composite endpoint of any occurrence of: difficult intubation, hypoxemia, esophageal intubation, or pulmonary aspiration. After adjusting for several factors (such as obesity, predicted difficulty of intubation, & experience of provider), the authors found a significantly decreased chance of the composite endpoint in the BUHE position (OR = 0.47). While limited by the exclusion of ED patients, the use of a composite endpoint, and the retrospective nature of the study, this study, along with others looking at best positioning for intubation, demonstrates that it may be time to re-examine our routine use of the supine position for intubation.
• Recommended by: Jeremy Fried

---

Downar J, et al. Mandate to obtain consent for withholding nonbeneficial cardiopulmonary resuscitation is misguided. CMAJ. 2016. PMID: 26728846

• Although this editorial is provoked by a local mandate that consent be obtained before withholding CPR, there are many good points about decision making at the end of life that make it a worthwhile read. It is strange that for all other medical interventions we require consent to act, but in the case of CPR the standard seems to be swinging towards consent not to act, even when CPR is clearly futile. General understanding of CPR, as well as our own discussions about the end of life, need to be improved.
• Recommended by: Justin Morgenstern

Sackles, JC et al. First Pass Success without Hypoxemia is Increased with the Use of Apneic Oxygenation During RSI in the Emergency Department. Acad Emerg Med 2016. PMID: 26836712

• 635 patients randomized to ApOx vs no ApOx. Patients who got RSI with ApOx had a first pass success without hypoxemia was 82% vs 69% in the cohort of patients who got RSI Without ApOx. The use of ApOx during the RSI of adult patients in the ED was associated with a significant increase in first pass success without hypoxemia.
• Recommended by: Salim R. Rezaie
• Further reading: Should we be Using Apneic Oxygenation (ApOx) in the ED? (R.E.B.E.L. EM)

Friedman BW, et al. The association between headache and elevated blood pressure among patients presenting to an ED. Am J Emerg Med. 2014 PMID: 24993684.

• More data that BP & HA aren’t related. To be fair, the patients with headaches had higher BPs, but lowering BPs didn’t make a difference. One more reason to explain to the patient, the referring doc, the floor staff, etc, that no, their head is not about to explode.
• Recommended by Seth Trueger