R&R In The FASTLANE 131

Welcome to the 131st 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

Kudenchuk PJ et al. Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest. NEJM 2016. PMID: 27043165

• In past iterations of ACLS, drugs played a central role in resuscitation. However, recent years have seen many of them (atropine, vasopressin, epinephrine) take a hit. This article further stresses the limited (if any) role for medications. The study investigators performed a 3-arm, RDCT comparing amiodarone to lidocaine to placebo in refractory VF/VT arrest. The results? No significant difference in survival to discharge or survival with good neurologic outcome between the meds. In a small subgroup (those with witnessed arrest) both amiodarone and lidocaine outperformed placebo but this is simply exploratory data for generating a hypothesis. Even if it turns out to be accurate, there doesn’t seem to be much reason to give the more expensive, more side effect amiodarone over the tried and true, dirt cheap lidocaine.
• Bottom line: Stop focusing on the drugs and keep your attention on maintaining a high-compression fraction + delivering electricity when indicated. (Swaminathan)
• This high quality study performed by the Resuscitation Outcomes Consortium (ROC) Investigators examined the efficacy of amiodarone and lidocaine in out of hospital cardiac arrest, specifically in patients with pulseless ventricular tachycardia or ventricular fibrillation. Patients were randomized to receive either placebo, amiodarone, or lidocaine. A well done trial with many layers to it, the main finding, in brief, is that no benefit to survival to hospital discharge or favorable neurological outcome was found. Importantly, when the relationship to witnessed arrest was examined, a pre-specified subgroup, a statistically and clinically significant 5% survival advantage with amiodarone and lidocaine was present. While this study likely demonstrates the futility of these drugs for patients after arrival in the ED, their use in the prehospital setting may be beneficial for those whose arrest is witnessed. An important contribution to the resuscitation literature of which we all must be aware. (Fried)
• Recommended by: Jeremy Fried, Anand Swaminathan
• Read More: Push Hard and Fast – And Say No to Drugs (ScanCrit)

Ridgeon EE et al. The Fragility Index in Multicenter Randomized Controlled Critical Care Trials. Crit Care Med 2016. PMID: 26963326

• There is a real danger of fixating on ‘significant’ p-values when interpreting the results of clinical trials. How robust are these ‘significant’ results really? The ‘Fragility Index’ is a useful, simple metric for answering this question.It is the minimum number of patients whose status would have to change from a nonevent to an event that is required to turn a statistically significant result to a nonsignificant result. Following on from Walsh et al, 2014 (see: http://intensiveblog.com/fragility-index-walsh-et-al-2014/), these authors demonstrate that much of the evidence-base in critical care trials is worryingly ‘fragile’: >40% of multi-center RCTs had a Fragility Index of less than or equal to 1! Learn more about ‘The Fragility Index’ here: https://litfl.com/fragility-index/
• Recommended by: Chris Nickson

Body R et al. Chest pain: if it hurts a lot, is heart attack more likely? Eur J Emerg Med 2016; 23(2):89-94. PMID: 25340995

• If a patient is in a lot of pain, does that make it more likely that they are having an MI? According to this prospective data-set (collected for a different study): no. Patients diagnosed with MI rated their pain as 8/10 as compared to an average of 7/10 pain in the patients who ruled out – not diagnostically helpful. Of course, physicians may have been more likely to enroll patients with higher pain scores, which would skew the numbers, much like the research indicating that pain radiating to the right shoulder is more specific than pain radiating to the left shoulder.
• Recommended by: Justin Morgenstern

Beadle KL et al. Isopropyl alcohol nasal inhalation for nausea in the Emergency Department: A randomized controlled trial. Ann Emerg Med 2015. PMID: 26679977

• This is a small double-blinded RCT comparing inhaled isopropyl alcohol to saline placebo for short-term relief of nausea in the ED. Although it is hard to believe patients (and possibly investigators) were truly blinded to the odor of isopropanol, this study found isopropanol superior to placebo for improvement of nausea at ten minutes.
• This effect may be short lived however, as there was no difference in subsequent use of antiemetics between the two groups. In light of recent attention to possible side effects of existing medications, including prolongation of the QT interval with ondansetron, isopropyl alcohol pads offer an intriguing option for short-term relief of nausea in the ED.
• Recommended by: Meghan Spyres

Joseph B et al. Traumatic brain injury advancements. Curr Opin Crit Care. 2015; 21(6):506-11. PMID 26539924

• We are increasingly aware of the role that inflammation plays in development of secondary traumatic brain injury. Several newer strategies aimed at reducing inflammation are highlighted in this review paper. Strong evidence is still pending for most of these treatment strategies but we are awaiting several clinical trials on the use of Glibenclamide, statins, beta blockers, hypothemia and remote ascetic conditioning. Furthermore more tailored treatment of TBI coagulopathy using bedside viscoelastic essays may have profound effects on secondary brain injury.
• Recommended by: Soren Rudolph

Patanwala AE et al. Succinylcholine Is Associated with Increased Mortality When Used for Rapid Sequence Intubation of Severely Brain Injured Patients in the Emergency Department. Pharmacotherapy. 2016; 36(1):57-63. PMID: 26799349

• Should we use succinycholine or rocuronium as our 1st line paralytic in patients with head trauma? This retrospective cohort study found equal overall mortality but a higher mortality rate in patients with more severe head injury if they got succinycholine. This study only shows an association and not causality and will need further prospective studies to elucidate the truth. However, in the absence of better evidence, either agent appears reasonable as the first line but rocuronium has a number of advantages (absence of contraindications, longer paralysis).
• Recommended by: Anand Swaminathan
• Read More: Does Succinylcholine Increase Mortality in Severe TBI Patients? (UMEM Education Pearls), Rocuronium vs. Succinycholine (Core EM)