R&R In The FASTLANE 157

Welcome to the 157th 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

Prandoni P, et al. Prevalence of Pulmonary Embolism among Patients Hospitalized for Syncope. N Engl J Med 2016. doi: 10.1056/NEJMoa1602172

• Reports of the PESIT study claim 1 in 6 patients admitted to the hospital with syncope have pulmonary embolism. However, this data is misleading. These patients are not the typical syncope patients in the US. These patients were elderly (>75% over 75 y/o). Further, 42% of the imaging was positive for PE which is quite different than the typical 20-30% yield of CTPAs performed in the US, especially considering 25% of the PE+ patients had no clincial evidence of PE. Certainly, PE can cause syncope. However, given many of these patients had an alternative explanation for the syncope and had no clinical signs or symptoms of PE, one must wonder, is this the baseline rate for PEs in the elderly population? This study appears to be an example of overdiagnosis but is being interpreted as a call to change practice. Caution.
• Recommended by Lauren Westafer

Sista AK et al. Persistent right ventricular dysfunction, functional capacity limitation, exercise intolerance, and quality of life impairment following pulmonary embolism: Systematic review with meta-analysis. Vasc Med 2016. PMID: 27707980

• Functional impairment after pulmonary embolism is more common than most of us believe. In this systematic review, the authors found that at 33% of patients had mild functional impairment and 11% had moderate impairment. Overall, thrombolysis had improved outcomes but not statistically significantly better ones further questioning their role in PE management. This article gives us a better idea of morbidity but raises more questions than it answers in terms of improving outcomes.
• Recommended by Anand Swaminathan

Schriger DL. Does Everything Need to Be “Scientific”? Ann Emerg Med 2016. PMID: 27553480

• This is an excellent editorial framed against the publication in Annals of a system for rating FOAM posts from Chan et al. Schriger asks a number of important questions about whether we need a scientific evaluation of blogs and podcasts or if we simply need to trust the end user to use their judgement and knowledge when reading these resources.
  “The seemingly benign act of formally rating the secondary medical literature may have similar unintended consequences if it is heard as “turn off your brain,” “don’t use your own judgment,” or “be a good sheep and follow the herd.””
• Recommended by Anand Swaminathan

Friedman BW. Managing Migraine. Ann Emerg Med. 2016 PMID: 27510942.

• A really nice review by a leading EM headache researcher. Covers a huge amount of the literature. Emphasizes that migraine is a clinical not an imaging diagnosis and the the IHS criteria can be very helpful. In his treatment algorithm he has anti-dopaminergics repeated up to 3 times with NSAID and then ergotamine if possible. I’ve never used the ergotamine… His final tiers of treatment are bilateral occipital nerve blocks with opiates as last resource.
• Recommended by Andy Neill
• Read more: Managing Migraine Headaches in Complicated Patients (ALiEM)

Edlow JA. Managing nontraumatic acute back pain. Ann Emerg Med 2015. PMID: 25578887

• This is an excellent, common sense approach to the evaluation of nontrauamtic acute low back pain in the ED. There is an extensive flow chart included which can serve as a guideline to management. The key is to focus on finding red flags (steroid use, history of cancer, new neurologic findings, fever, IV drug use) and image aggressively in those patients (MRI). In all others, imaging is unlikely to be helpful.
• Recommended by Anand Swaminathan