R&R In The FASTLANE 159

Welcome to the 159th 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

Kim JW. et al. Video laryngoscopy vs. direct laryngoscopy: Which should be chosen for endotracheal intubation during cardiopulmonary resuscitation? A prospective randomized controlled study of experienced intubators. Resuscitation 2016. PMID 27095126

• Yet another study comparing VL and DL … and …once again finds no difference in overall success rate, “first pass” success, time and esophageal intubation.But it’s not the interesting thing about this study!In a prospective randomized design experienced airway providers (> 50 endotracheal intubations) intubated patients with cardiac arrest and ongoing CPR, either with GildeScope® (VL) or direct laryngoscopy (DL).
• All procedure was filmed and subsequently analyzed for time, complications and interruption of chest compressions.A total of 140 intubations, DL (n = 69) and VL (n = 71) respectively were analyzed and there were no differences in the success rate, etc….not very interesting!The authors found an average interruptions of chest compressions using DL of 4.0 sec. (1.0 to 11.0 seconds) compared to VL 0.0 sec (0.0-1.0 sec.)
• And a significantly higher rate of prolonged interruptions > 10 sec. using DL (18/69 [26.1%]), compared to the VL (0/71) (p <0.001) – a difference which was also present for the more experienced airway providers (> 80 endotracheal intubation), with DL (14/55 [25.5%] compared to 0/57 using VL.The Importance of effective chest compressions without interruption is well known as well as secondary role of intubation during CPR, which should ideally not interrupt chest compressions> 10 seconds. With this in mind the I find this to be the important take home message of the current study.
• Recommended by Soren Rudolph

Ray JG, et al. Association Between MRI Exposure During Pregnancy and Fetal and Childhood Outcomes. JAMA 2016. PMID 27599330

• MRI in the first trimester appeared safe, based on this enormous healthcare database study from Ontario. However, exposure to gadolinium contrast should be avoided, as it increased risk for skin problems, stillbirth, and neonatal death.This matters because CT during pregnancy gives a large fetal radiation dose. Assuming it accomplishes the imaging goals, MRI without contrast is now a proven, safe option for pregnant women in the first trimester.
• Recommended by Clay Smith
• Read more: Safety of First Trimester MRI (EM Topics)

Bonadio W. Pediatric lumbar puncture and cerebrospinal fluid analysis. J Emerg Med 2014. PMID: 24188604

• Pediatric Lumbar Punctures are a common procedure in the ED, but they are often complicated by “traumatic” results. Help minimize that risk by knowing the anatomy a little better and by not continually reinserting the stylet as you advance the needle. Simple strategy to help make your job easier!
• Recommended by SMF

Perez MR, et al. Sternal fracture in the age of pan-scan. Injury 2015. PMID: 25817167

• Classic teaching is that sternal fractures are signs of other badness. But in this case, “classic” predates CT, so what does an otherwise-occult sternal fracture mean? In this study of patients in the NEXUS cohort, aptly titled “Sternal fracture in the age of pan-scan,” they find that otherwise-occult sternal fractures just aren’t that big a deal. Takeaway: if the patient has substantial chest pain, sternal fracture on CXR, or other signs of cardiac contusion, be worried. But, a sternal fracture found incidentally on a panscan is just that.
• Recommended by Seth Trueger

Heard A, et al. Apneic Oxygenation During Prolonged Laryngoscopy in Obese Patients: A Randomized, Controlled Trial of Buccal RAE Tube Oxygen Administration. Anesth and Analg 2016. PMID: 27655276

• In this exciting RCT, they took a modified 3.5mm oral RAE tube (designed to make a sharp bend without kinking) and put it in the mouth, along the buccal mucosa at 10 L/min while lifting the tongue with a laryngoscope to a grade III equivalent view. The 20 who got buccal O2 were much more likely than the 20 who did not to have 12.5 minutes of apnea without desaturation to <95% (Hazard ratio 0.159). Median apnea time in the buccal O2 group was 750 seconds (12.5 minutes) vs. 296 seconds (~5 minutes) in the standard group.Delivery of high flow buccal O2 is an easy, affordable way to make ETT placements in obese patients safer by prolonging apnea times without desaturation. This article is one I highly recommend you find full text and read the methods.
• Recommended by Clay Smith
• Read more: Buccal O2 in Obese Patients: 12.5 Minutes of Apnea (EM Topics)