R&R In The FASTLANE 160

Welcome to the 160th 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

DePeter KC, et al. Does the Use of Ibuprofen in Children with Extremity Fractures Increase their Risk for Bone Healing Complications? J Emerg Med 2016. PMID: 27751698

• Many orthopedists recommend steering clear of NSAIDS for analgesia in acute fracture due to concern for fracture malunion. This dogma persists despite mixed evidence and a paucity of evidence of harm in kids. This is a retrospective study, limited by typical issues with that design, who found no association between exposure to ibuprofen during initial ED visit for acute fracture of bones at high risk of malunion (OR 0.8 0.4-1.8). Note: they excluded patient support with osteogenesis imperfecta, recent chemo or steroids, and other systemic reasons for delayed union. Do not withhold a fantastic analgesic in otherwise healthy kids with fracture.
• Recommended by Lauren Westafer
• Read more: A Disunion of the Literature: NSAIDS and Fracture (The Short Coat)

Martsolf, G, et al. Association Between the Opening of Retail Clinics and Low-Acuity Emergency Department Visits. Ann Emerg Med 2016. DOI: http://dx.doi.org/10.1016/j.annemergmed.2016.08.462

• A fascinating and empirical look at the claim that the opening of “convenience care” retail clinics in the US would result in fewer low acuity ED visits. Not surprising to those of us working daily in those EDs, no such effect was found. A small effect was found among those patients with private insurance, but this is clearly not the “solution” to decreasing low acuity ED visits that many of the proponents of these clinics are hoping. The accompanying editorial by Jesse Pines (http://dx.doi.org/10.1016/j.annemergmed.2016.09.047) is an insightful examination of the results and the broader implications. Well worth the read for anyone interested in the role of emergency care in society.
• Recommended by Jeremy Fried

Bentzer P, et al. Will This Hemodynamically Unstable Patient Respond to a Bolus of Intravenous Fluids? JAMA 2016. PMID: 27673307

• No physical findings predicted fluid responsiveness. This includes: “dry mucous membranes, dry axilla, decreased tissue turgor, capillary refill time greater than 2 seconds, tachycardia, and low jugular venous pressure.” Low CVP had a positive likelihood ratio (LR+) of 2.6; high CVP had a negative likelihood ratio (LR -) or 0.5. IVC respiratory variation on ultrasound in ventilated patients (distensibility index >15%) had LR+ 5.3; LR- 0.27 if the IVC was less distensible. But the strongest predictor of fluid responsiveness was increased cardiac output with passive leg raise of >10% (by Swan-Ganz thermodilution or echo), LR+ 11; LR- with no change in cardiac output was 0.13.In summary, physical findings to assess for fluid responsiveness are not reliable, IVC distensibility on ultrasound in ventilated patients is pretty good. Increased cardiac output with passive leg raise is the best marker of fluid responsiveness.
• Recommended by Clay Smith
• Read more Best Tests for Fluid Responsiveness (EM Topics)

Carel H, et al. Illness as transformative experience. The Lancet 2016. PMID: 27672725

• Some experiences in life are transformative. You can’t know what it’s like to be a parent until you already are one. More importantly the simple act of becoming a parent is likely to transform you in ways you cannot predict, so that your values and preferences will not be the same. This is true also of being ill. We cannot predict the ways that illness will change us, which makes discussions about a future with illness and therefore shared decision making more complicated. Perhaps the most important message is that most people adapt. Although being blind seems horrible to those with their vision, it is consistently rated as less bad by those without their vision. This is an excellent message for patients at the beginning of their journey into chronic illness – although difficult, most people adapt and continue living meaningful and mostly happy lives.
• Recommended by Justin Morgenstern

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Kitamura T, et al. Public-Access Defibrillation and Out-of-Hospital Cardiac Arrest in Japan. N Engl J Med 2016. PMID: 27783922

• Automated electronic defibrillators profoundly increase survival when used by lay bystanders and a shock is provided. However, it took an installed base of half a million AEDs in Japan to save ~200 lives per year.
• Recommended by RPR
• Read more: Just how many lives do AEDs save? (Emergency Medicine Literature of Note)