R&R In The FASTLANE 139

Welcome to the 139th 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

Arima H et al. Optimal achieved blood pressure in acute intracerebral hemorrhage: INTERACT2. Neurology 2014. PMID 25552575

• This paper is creating noise since the mid of the year as it is pretending to change the current recommendations for the management of blood pressure in acute intracerebral hemorrhage (ICH). The original INTERACT2 study (N Engl J Med 2013; 368:2355-2365) did not show differences in mortality but improved functionality in patients with ICH when the BP goal was <140mmHG instead of the current 180mmHg.This study is a reanalysis of the data, attempting to identify the threshold where the benefit in functionality is produced, using ranges of <160, 160–169, 170–179, 180–189, and ≥190 mm Hg. The outcome was Rankin Scale at 90 days. Although the ranges proposed by the authors only include a <160 as the lowest, the linear analysis of SBP and Rankin Score shows a direct correlation going as low as 130-139mmHg, therefore the authors conclude that 130-139mmHg for SBP is the optimal range for management of patients with ICH.
• The study is a post-hoc analysis of a previous large study (open and unblinded) making no claims about mortality but showing a consistent effect of better functional outcomes if the pressure is managed closer to SBP of 130-139mmHg.
• Recommended by Daniel Cabrera

Green SM et al. Sick Kids Look Sick. Ann Emerg Med 2014. PMID 25536869

• Nice editorial on missing the sick child. – take home message: sick kids look sick and the authors reassures us that careful examination and trust in ones clinical judgment is still the best approach.
• Recommended by Soren Rudolph

Tyson AF et al. The Effect of Incentive Spirometry on Postoperative Pulmonary Function Following Laparotomy: A Randomized Clinical Trial. JAMA Surg 2015. PMID 25607594

• A single centre randomised clinical trial from Malawi with 150 patients randomised in total. As suspected incentive spirometry for unmonitored patient use does not result in statistically significant improvement in pulmonary dynamics following laparotomy. Interestingly most of the patients were male and most of the procedure were emergency laparotomies.
• Recommended by Nudrat Rashid

Alrajhi KN et al. Intracranial bleeds after minor and minimal head injury in patients on warfarin. J Emerg Med 2015. PMID 25440860

• It’s well known that patients on warfarin have a high rate of intracranial hemorrhage after minor head trauma. This study found that 4.8% of those with minimal head trauma (GCS 15, no loss of consciousness, amnesia or confusion) had ICH as well. The study has limitations but suggests that all head trauma patients on warfarin should have a NCHCT regardless of severity of injury
• Recommended by Anand Swaminathan

Gu WJ et al. Single-Dose Etomidate Does Not Increase Mortality in Patients With Sepsis: A Systematic Review and Meta-analysis of Randomized Controlled Trials and Observational Studies. Chest 2015. PMID 25255427

• This is another bullet in favor of etomidate for RSI. The authors of the paper did an extensive review and meta-analysis, pooling a total of 5552. Data shows that single use of etomidate for RRT does not increase mortality, despite increase in the incidence of adrenal insufficiency. Etomidate still appears to be a viable option for the RSI of critically ill patients.
• Recommended by Daniel Cabrera

Russell FM et al. Diagnosing Acute Heart Failure in Patients With Undifferentiated Dyspnea: A Lung and Cardiac Ultrasound (LuCUS) Protocol. Acad Emerg Med 2015. PMID 25641227

• POC Ultrasound has receive a lot of attention for it’s ability to improve diagnostic accuracy in patients with undifferentiated dyspnea. The LuCUS protocol looks at a combined lung and cardiac ultrasound approach to aid in rapidly diagnosing patients. This study showed that the LuCUS protocol had a (+) LR of 4.8 and a (-) LR of 0.20 for this objective. However, the study results will be difficult to apply. All examinations were performed by highly skilled US physicians with no other clinical duties at the time. The protocol includes non-standard imaging (assessment for pleural effusion, measuring diastolic function) that most providers have never performed. Additionally, the study did not set out to, and thus does not, show improved patient outcomes as a result of the LuCUS protocol.
• Recommended by Anand Swaminathan