R&R In The FASTLANE 147

Research and Reviews in the Fastlane 600

Welcome to the 147th 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

RR Hall of FAMER

Carrick MM et al. Intraoperative hypotensive resuscitation for patients undergoing laparotomy or thoracotomy for trauma: Early termination of a randomized prospective clinical trial. J Trauma Acute Care Surg. Volume 80, Number 6 PMID: 27015578

  • Hypotensive resuscitation is one of the pillars of damage control resuscitation in the bleeding trauma patient. Maintaining a just sufficient mean arterial pressure (MAP) with limited fluid resuscitation until hemorrhage control is considered standard of care although this practice is largely based on animal studies with no high level evidence other than a non-blinded semi-randomized study by Bickell et al in 1994 (also known as the “Mattox trial”). In a single-institution RCT the Mattox group extended the limited fluid resuscitation beyond the trauma bay into the OR. The study was originally including both blunt and penetrating trauma patients, but at interim analysis concerns were raised about a disproportionate number of blunt trauma patients being randomized. To eliminate this confounding effect, the decision was made to stop enrolling blunt trauma patients.  
  • A total of 168 patients undergoing laparotomy or thoracotomy for penetrating trauma with SBP of 90 mm Hg or lower were randomized to either a minimum MAP of 50 mmHg (LMAP) or MAP of 65 mmHg (HMAP) at which further specific resuscitative interventions (e.g., fluids, transfusions or vasopressors) were administered. Primary outcome was 30-day mortality.  The trial was terminated early and therefore was underpowered and failed to demonstrate that a MAP of 50 mmHg could significantly improve 30-day mortality. Despite the lack of statistical significance there was a 5% difference in mortality favoring the hypotensive group. Furthermore the study suggests that maintaining a MAP of greater than 50mmHg is far easier than to maintain one that is greater than 65 mm Hg supporting the theory of autoregulation as proposed by Dutton.  
  • The authors concluded that hypotensive resuscitation is safe in the penetrating trauma population and it does not increase end organ damage, infectious complications or coagulopathy.
  • Recommended by Soren Rudolph

RR HOT STUFF

Schou-Jensen K et al. [An ordinary condom can be used for removing encircling metallic objects around penis]. Ugeskrift for laeger. 178(32):. 2016. PMID: 27507030

  • Self- insertion of the penis in various ring shaped foreign bodies, usually for sexual gratification and auto-eroticism especially during male masturbation, is an unusual but important condition which EM docs and urologists will encounter. In this report two cases where a new method for removing encircling objects from the penis using a ordinary condom was applied. The article in danish with a short abstract, but sufficient self explanatory images are provided.
  • Recommended by Soren Rudolph

RR HOT STUFF

Laina A et al. Amiodarone and cardiac arrest: Systematic review and meta-analysis. Internat J Cardiol 2016; 221: 780-8. PMID: 27434349

  • Amiodarone is dead in the dead! The recent ALPs trial in the NEJM grabbed headlines showing that there was no difference in survival to discharge in OHCA patients who got amiodarone versus lidocaine versus placebo. This systematic review and meta-analysis looked at 4 RCTs and 6 observational studies and found that while amiodarone increases survival to hospital admission, it doesn’t change survival to discharge or good neurologic outcomes. Another nail in the coffin for amiodarone.
  • Recommended by Anand Swaminathan

RR Game Changer

Coorg et al. Clinical presentation and outcomes associated with different treatment modalities for pediatric back scorpion envenomation. J Med Tox 2016. PMID: 27487782

  • The high cost of scorpion antivenom has led some PEM physicians to treat with supportive care alone or to use off label dosing in single vial increments instead of the recommended three vial loading dose. This retrospective review showed no difference in outcomes between these strategies. Significant differences in envenomation severity between the groups, however, suggests that this most likely reflects the ability of experienced PEM physicians to select the appropriate patient for each strategy.
  • Recommended by Meghan Spyres

RR HOT STUFF

Sheridan RL. Fire-Related Inhalation Injury. N Engl J Med. 375(5):464-469. 2016.

  • A great review of all things related to fire inhalation injury, for both the clinician in the emergency department as well as the ICU.  Key points included:
    • Remember to consider concomitant carbon monoxide and cyanide exposure
    • And contrary to what I was often told early in training, “The presence of inhalation injury does not mandate intubation.” The authors instead remind us that intubation should be immediately considered in patients “who have facial edema, hoarseness, or stridor or in patients with large cutaneous burns in whom facial edema is likely to develop with resuscitation.”
  • Recommended by Jeremy Fried

RR Game Changer

Welch JL, Cooper DD. Should I Use Lidocaine With Epinephrine in Digital Nerve Blocks? Annals of emergency medicine. 2016. PMID:27125816

  • By now, most people have heard that epinephrine is safe in digital blocks – but a common question is why would you want to use it? In this systematic review, they found that using epinephrine resulted in longer anaesthesia and less bleeding. Although not critical, those advantages have me routinely reaching for the epi when working with digits.
  • 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 |

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