R&R In The FASTLANE 167

Welcome to the 167th 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

Myles PS et al. ATACAS study. Tranexamic Acid in Patients Undergoing Coronary-Artery Surgery. N Engl J Med 2016. PMID: 27774838.

• The ATACAS study was a large, multi-centre, double blind study with a 2 by 2 factorial design. Patients undergoing coronary artery surgery that were considered “at risk for peri-operative complications” were assigned to either receiving aspirin or placebo and tranexamic acid or placebo. The group that received tranexamic acid had a lower risk of bleeding compared to placebo. Even though there wasn’t a higher risk of death or thrombotic complications, there was a higher risk of post-operative seizures observed within the tranexamic acid group.
• Recommended by: Nudrat Rashid

Willman MW, et al. Do heroin overdose patients require observation after receiving naloxone? Clin Toxicol 2016. PMID: 27849133

• There has been recent interest in a policy of decreased or no observation time for patients receiving naloxone after heroin overdose. This article summarizes several retrospective reviews, concluding that patients with heroin overdose typically do well after EMS treat-and-release naloxone administration, and that they can be safely discharged from the ED after a period of one-hour observation. Considerable limitations in the retrospective nature of such reviews and significant impact of new adulterants such as fentanyl and U-47700 on current “heroin” overdoses seriously limit interpretation and applicability of these studies to today’s clinical practice. Strong caution should be taken in making practice changes based on retrospective and potentially outdated data.
• Recommended by: Meghan Spyres
• Further reading: Treating “heroin” overdose: The past is no guide (The Poison Review)

Pengel KB. Common overuse injuries in the young athlete. Pediatr Ann 2014. PMID: 25486038

•  We constantly want kids to be more active… but that can lead to some injuries. The knee is very susceptible to overuse injuries, but before you simply label it a “Sprain” consider a few other ominous entities.
• Recommended by: Sean Fox

Taylor DM, et al. Midazolam-Droperidol, Droperidol, or Olanzapine for Acute Agitation: A Randomized Clinical Trial. Ann Emerg Med 2016. PMID: 27745766

• This was a well executed RCT that found midazolam 5 mg/droperidol 5 mg IV was superior to droperidol 10mg IV or olanzapine 10 mg IV for agitated patients. The 2-drug combo worked in 75% of patients at ten minutes vs ~50% in the other two groups. Also, fewer repeat sedative doses were needed when the drugs were combined. Median time to sedation was only 5 minutes for the combo vs. 11 minutes for the other two individual drugs. Adverse events were statistically similar in all groups, but the midazolam/droperidol group had a higher percentage temporarily needing jaw thrust or supplemental oxygen. For agitation, the combination of midazolam 5 mg/droperidol 5 mg IV was better and faster onset than droperidol 10 mg IV or olanzapine 10 mg IV. 
• Recommended by: Clay Smith

Horeczko T, et al. The Pediatric Assessment Triangle: Accuracy of its application by nurses in the triage of children. J Emerg Nurs 2013. PMID: 22831826

•  This prospective observational trial looked at the outcomes of 528 children for whom the triage nurse had performed an assessment using the pediatric assessment triangle (PAT) at a large academic pediatric emergency department. Two pediatricians, blinded to that triage assessment, retrospectively reviewed the chart to determine the final diagnosis (of stable versus unstable). The biggest weakness of this data is that although 1002 charts were selected for review, only 528 contained adequate data for inclusion. The PAT did a good job screening for instability (97.3% sensitive 95%CI 64.6-98.8%), although like most screening tools it does over call (specificity of 22.9% with 95%CI 17.0-30.0%). The triangle was reasonable for identifying respiratory distress (LR+ 4, 95% CI 3.1-4.8), respiratory failure (LR+ 12, 95% CI 4.0-37), shock (LR+ 4.2, 95% CI 3.1-5.6), central nervous system/metabolic disorder (LR+ 7, 95% CI 4.3-11), and cardiopulmonary failure (LR+ 49, 95% CI 20-120). Perfect identification of the final assessment is not the role of a triage tool, like the PAT. The PAT tool performed well here, but perhaps a more appropriate measure would have been something like the number of children who become unstable within the first hour who were missed by the PAT? Bottom line: The pediatric assessment triangle is an excellent triage tool, but you still have to follow it with a complete medical assessment.
• Recommended by: Justin Morgenstern