R&R In The FASTLANE 141 • LITFL • Research and Reviews

Research and Reviews in the Fastlane 600

Welcome to the 141st 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

Baharoglu MI,et al; PATCH Investigators. Platelet transfusion versus standard care after acute stroke due to spontaneous cerebral haemorrhage associated with antiplatelet therapy (PATCH): a randomised, open-label, phase 3 trial. Lancet. 2016. PMID: 27178479.

An important paper and the first randomized trial to examine the role of platelet transfusions in patients on anti-platelet agents who have intracerebral hemorrhage. Surprisingly, this small, well done study, found increased disability and death in the group given platelets. While there ended up being some baseline differences between the two groups which may have influenced the results, and there were many exclusion factors, such as patients planning to have a surgical intervention in the next 24 hours, this is the best evidence we have to date, and it demonstrates that we are potentially harming our patients by transfusing in this scenario. Future research will hopefully illuminate this topic further, or at least give us insight into the mechanism involved in this surprising finding.
Should patients with spontaneous ICH on antiplatelet agents be given platelet transfusions? This RCT (open-label) says no. Bad outcomes were increased in the group given platelets. However, the study was relatively small and the patients were fairly heterogenous. While this study is unlikely to put the question to rest for good, it’s the best evidence we have at this point.
Recommended by Jeremy Fried, Anand Swaminathan
Further reading Put the platelets away in ICH (EM Literature of Note)

Quershi A et al. Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage. NEJM 2016. PMID: 27276234.

Aggressively lowering blood pressure in patients with acute hemorrhagic stroke makes physiologic sense but the evidence has never shown a patient centered outcome benefit. The ATACH-2 study is no different. This study showed that while it’s feasible to acutely lower systolic blood pressure < 140 mm Hg, there’s no benefit to death or disability. Additionally, patients in the aggressive blood pressure treatment arm were more likely to have adverse renal events at 7 days. These results mirror those seen in the INTERACT-2 trial (prior to the statistical shenanigans used to spin the results positively). Based on the best available evidence, we can confidently say that it should not be standard care to aggressively drop blood pressure in these patients.

Recommended by Anand Swaminathan
Further reading The case of the differing perspectives (EM Nerd)

Boccio E, et al. Combining transtracheal catheter oxygenation and needle-based Seldinger cricothyrotomy into a single, sequential procedure. Am J Emerg Med 2015. PMID: 25791154

Can’t Intubate? Can’t Ventilate? Big problem! Remember the most important procedure may be the most simplistic – Transtracheal Ventilation. This paper, though, takes transtracheal ventilation one step further and may prove to be extremely valuable to you and your patient!

Recommended by Sean M. Fox
Further reading Can’t Intubate Can’t Ventilate (Pediatric EM Morsels)

Zitek T, et al. The Effect of Nebulized Albuterol on Serum Lactate and Potassium in Healthy Subjects. Academic emergency medicine 2016. PMID: 26857949

This is a tiny study of healthy volunteers that reminds us that nebulized albuterol increases lactate and decreases potassium. Here the lactate increased 0.77 mmol/L (95%CI = 0.52 -1.02 mmol/L) and decreased potassium 0.5 mEq/L (95% CI = −0.72 to −0.28 mEq/L), which turned up statistically significant p values. Of note, they used a dose of 10 mg, which, depending on local practice, could be a hefty dose. Looking to decrease the potassium? It’s not clear what effect smaller doses may have. See a slight lactate bump in a patient with an asthma exacerbation? It may be the albuterol.
Recommended by Lauren Westafer

Kisser U, et al. Bystander cricothyrotomy with ballpoint pen: a fresh cadaveric feasibility study. Emerg Med J 2016 PMID: 27095773.

This study is putting a nail in the coffin of the urban legend of ballpoint pen cricothyroitomy. Only using pens with an inner diameter sufficient to generate an airflow flow of more than 10 l/min 10 medical laypersons tried to penetrate the skin of anterior neck of fresh normal weight cadavers. Only one participant was able to do so but it took more than five minutes and there was extensive damage to surrounding tissues.
Recommended by Søren Rudolph

Kaplan RM, Irvin VL. Likelihood of Null Effects of Large NHLBI Clinical Trials Has Increased over Time. PLoS ONE. 2015;10(8):e0132382. PMID: 26244868

Once NIH-funded trials needed to register their primary outcomes with ClinicalTrials.gov, suddenly, all these studies with pharma co-sponsors stopped being universally positive.