R&R In The FASTLANE 146

Research and Reviews in the Fastlane 600

Welcome to the 146th 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 5 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

Sierink JC et al. Immediate total-body CT scanning versus conventional imaging and selective CT scanning in patients with severe trauma (REACT-2): a randomised controlled trial. Lancet 2016. PMID: 27371185

  • Whole body CT is commonly performed in trauma patients in order to find all injuries. However, it’s unclear whether this benefits the patient. In this unblinded, multicenter randomized trial, there was no benefit to immediate whole body CT in severe trauma when compared to selective imaging. Total radiation dose and cost were only minimally lower in the selective imaging group but there are difficult to assess benefits as well (time to CT for all the other patients in your department, for instance). If there’s no benefit, there’s only room for harm. Time to stop reflexively pan-scanning.
  • Recommended by Anand Swaminathan
  • Read more:  The case of the anatomic injury II; A case of central tendencies (EM Nerd) and  Do we always need a whole body CT in trauma? (St. Emlyn’s)

RR Trash

Grissa MH, et al. Acupuncture vs intravenous morphine in the management of acute pain in the ED. Am J Emerg Med 2016 PMID:27475042

  • Time to page for a stat acupuncture consult in the ED? No. Just, no.
    While the desire to avoid or minimize opioids is, for good reason, a hot topic in emergency medicine, this is one study that should never have been published. The authors compared the use of acupuncture to IV morphine in the relief of acute pain. They found that acupuncture significantly reduced the time to relief as well as a statistical (but not clinically relevant) reduction in patients’ pain score. Unfortunately, this study is so flawed that I find it surprising it was published. Some of the biggest issues include: lack of a flow diagram to describe subject allocation, dropout rates, and analysis;  lack of blinding (sham acupuncture can be used to minimize placebo effect and determine actual efficacy); and, in the words of the authors “our population represents…predominantly young and healthy participants for whom acupuncture is a culturally accepted practice, which would augment any placebo effect.”
  • Recommended by Jeremy Fried
  • Read more:  Dawn of the stat acupuncture consult (EM lit of note) and  On the pointlessness of acupuncture in the emergency room… or anywhere else (Science-based Medicine)

RR Mona Lisa

Ranji SR et al. Do opiates affect the clinical evaluation of patients with acute abdominal pain? JAMA 2006. PMID: 17032990

  • Systematic review on whether opioid analgesia obscures our abdominal exam. The short answer is no. The more nuanced answer is that it can change specific elements of the exam but not in a way that impacts care meaningfully, so do not withhold pain medicine in order to “follow the exam.” This makes sense as doses of morphine used “back in the day” that obscured exams were the equivalent of 30-60mg.
  • Recommended by Seth Trueger

RR Eureka

Miotto R et al. Deep Patient: An Unsupervised Representation to Predict the Future of Patients from the Electronic Health Records. Sci Rep 2016. PMID:27185194

  • Soon, the robots will use Big Data to prognosticate all the outcomes for your patients. Then, you wont have to worry about the medicine anymore, and you can focus on your patient satisfaction scores.
  • Recommended by RPR
  • Read more:  Better living through better prediction (EM lit of note)


RR HOT STUFF

Jie KE, et al. Isolated fat pad sign in acute elbow injury: is it clinically relevant? European journal of emergency medicine 2016. PMID:26153882

  • The importance of the isolated elbow fat pad might also be a myth!? This is a subset of a prospective observational trial, in which 587 adults with acute isolated elbow injuries all had x-rays done. This study looked at the 111 (19%) that had an isolated fat pad (anterior sail sign and/or posterior fat pad) but no other injuries seen on the x-ray. The standard practice for these patients was an elastic bandage and a sling, with orthopaedics follow-up in 1 week. (Where I work, children generally get a plaster splint, as we are concerned about occult supracondylar fractures.) At the 1 week follow up, there were no significant injuries identified, although they did not routinely get follow-up x-rays. Only 1 patients was transitioned to a cast because of ongoing pain. Unfortunately, they did lose 17% of the patients to follow-up at 1 week. They had long term follow up (phone calls 22 months later) on 90% of the patients, and there were no patients with persistent symptoms that prevented them from carrying out their daily activities.
  • Recommended by Justin Morgentern

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Community emergency physician with a passion for education, evidence based medicine, and life, working in the Greater Toronto Area (that’s in Canada) | @First10EM | Website |

2 Comments

  1. I would respectfully disagree that the paper: Jie KE, et al. Isolated fat pad sign in acute elbow injury: is it clinically relevant? European journal of emergency medicine 2016 is NOT a “game changer”.
    Unfortunately behind a paywall so I wasn’t able to fully critically appraise this paper, but there is not enough here to convince me to change my practice. The authors do not differentiate anterior vs posterior fat pad (small anterior fat pads are usually normal), and without all patients receiving standardized follow up imaging and clinical assessment, this study lacks the rigour of a true diagnostic test accuracy study (DTA). I also get the impression it is a single centre, small prospective cohort.
    These findings will need to be repeated in a more rigorous and multi-centre fashion before they can be adopted in daily practice.

    • Thanks for the comment.
      I agree with you that the banner “game changer” is is probably too much for a single centre observational trial. You should not immediately stop splinting all children based solely on this trial. The study is included because it is interesting, but it definitely needs more studies with larger numbers of patients.
      That being said, this paper will change my practice for some patients, so the label might still apply. As you said, there is a clinical spectrum of these injuries. My training was that everyone should be put in a plaster splint. For low energy injuries, where I have a low clinical suspicion, I will probably discuss sling only versus full plaster with parents, but still get everyone reassessed by ortho in a few days.
      Finally, although I agree this study doesn’t have a diagnostic gold standard test, I think the outcome they use is exactly what future studies should use. I don’t care what an MRI shows. I care about patient oriented outcomes like pain and long term function, and whether my management affects those outcomes.

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