Welcome to the 169th 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
Motov S et al. Comparison of Intravenous Ketorolac at Three Single-Dose Regimens for Treating Acute Pain in the Emergency Department: A Randomized Controlled Trial. Ann Emerg Med 2016. PMID: 27993418
- What’s the therapeutic ceiling for ketorlac? According to this high-quality RDCT it’s just 10 mg IV, not the 30 mg that we typically use. Without added benefit at higher doses, all we’re left with is the increased risk of side effects and harm. Without any good evidence speaking to the necessity of higher doses, it’s time to drop our dose down when using this drug.
- This well done study examined the analgesic effect of ketorolac at 3 different doses for patients presenting to the emergency department with abdominal pain, flank pain, musculoskeletal pain, or headache. Doses of 10mg, 15mg, or 30mg were administered in a convenience sample, and the authors found no difference in pain relief. In the absence of any increased benefit, all that is left is potential harm in providing doses higher than the apparent analgesic ceiling of 10mg and all practitioners should consider using that as their standard dose in the future.
- The ceiling analgesic dose of ketorolac is 10 mg – IV or IM. This study confirms this dosage for acute pain in the ED. This was an RCT of ED patients with acute (<30 days) of musculoskeletal, flank, abdominal, or head pain rated at least 5/10. The authors set out to examine mean difference in pain scores between 10mg IV, 15 mg IV, and 30 mg IV and, unsuprisingly, they found no significant difference between mean pain scores. These results are consistent with prior literature and, given side effects of NSAIDs tend to increase in a dose related fashion, it’s a good idea to give the 10mg dose a try.
- Recommended by: Anand Swaminathan, Jeremy Fried, Lauren Westafer
Freund Y et al. Prognostic Accuracy of Sepsis-3 Criteria for In-Hospital Mortality Among Patients With Suspected Infection Presenting to the Emergency Department. JAMA 2016. doi:10.1001/jama.2016.20328
- In 2016, the Sepsis-3 criteria were launched shifting our definition of sepsis to life-threatening organ dysfunction caused by a dysregulated host response to infection. Along with this shift was the change from SIRS to SOFA and qSOFA to predict mortality in septic patients. This article looks to prospectively validate the qSOFA score. Although the study is multinational, it was primarily performed in France (27 out of 30 centers) and found that patients with a qSOFA < 2 had a mortality rate of just 3% versus 24% in the qSOFA >/= 2. The article concludes that this study validates qSOFA and that this tool is more specific than SIRS without unacceptable decrease in sensitivity. However, some caution should be taken. The overall mortality rate was very low (~ 8%) and a much larger retrospective study published in the same issue from the ANZICS group showed that qSOFA was no better than SIRS but that SOFA was superior. Clearly, this isn’t the last we’ll hear on Sepsis-3.
- Recommended by: Anand Swaminathan
- Read more: Alfred researchers validate new sepsis criteria – with a catch (Intensive)
Stanley Adrian J, et al. Comparison of risk scoring systems for patients presenting with upper gastrointestinal bleeding: international multicentre prospective study. BMJ 2017. PMID: 28053181
- This paper is a comparison for the performance of the most used pre-EGD scores to predict important outcomes (mortality, rebleeding, intervention and hospital LOS) in patients with GI bleeding. The Glasgow Blatchord scale outperformed all others in all categories except on 30-day mortality. En general the disposition of patients with upper GI bleeding is straightforward, but when in doubt (close outpatient follow-up vs. admission) the use of the GBS may be helpful in determining the dispo and level of care.
- Recommended by: Daniel Cabrera
Magana JN, Kuppermann N. The PECARN TBI rules do not apply to abusive head trauma. Acad Emerg Med 2016. PMID: 28039943
- An excellent commentary which examines the findings of Ide et al (PMID: 27862642) in their retrospective review validation of the PECARN head trauma decision tool. The authors remind us that the PECARN traumatic brain injury rules are not intended to be utilized in cases of suspected child abuse, and that in those cases the threshold to image should be low, as “The morbidity and mortality and social implications of abusive head trauma demand a different screening approach.”
- Recommended by: Jeremy Fried
Simone JV. Understanding academic medical centers: Simone’s Maxims. Clinical cancer research 1999. PMID: 10499593
- This is a great read for anyone hanging from the leadership chain in a complex organisation, especially so if the organisation is an academic medical center. Born from hard won experience, these are “Simone’s Maxims”:
- Institutions Don’t Love You Back
- Institutions Have Infinite Time Horizons to Attain Goals, But an Individual Has a Relatively Short Productive Period.
- Members of Most Institutional Committees Consist of About 30% Who Will Work at It, Despite Other Pressures, and 20% Who Are Idiots, Status Seekers, or Troublemakers.
- Institutional Incompetents and Troublemakers Are Often Transferred to Another Area, Where They Continue to Be Incompetent or Troublemakers.
- 5. Leadership Does Matter
- 6. Leaders Are Often Chosen Primarily for Characteristics That Have Little or No Correlation with a Successful Tenure as Leader.
- 7. For Academic Leaders, the Last 10% of Job Accomplishment May Take as Much Time as the First 90% and May Not Be Worth the Effort.
- 8. With Rare Exceptions, the Appropriate Maximum Term for an Academic Leader/Administrator Is 10 Years, Plus or Minus 3 Years.
9. In Academic Institutions, Muck Flows Uphill.
- 10. In Recruiting, First-Class People Recruit First-Class People; Second-Class People Recruit Third-Class People.
- 11. Personal Attitude and Team Compatibility Is Grossly Underrated in Faculty Recruiting.
- 12. The Longer and More Detailed the Written Offer to a New Faculty Recruit, the More Likely Both Sides Will End Up Unhappy.
- 13. Faculty Fired for Incompetence Will Almost Always Land a Better Job at Higher Pay.
- JOB CHANGES
- 14. One Should Consider an Academic Move Only for an Improvement in Anticipated Opportunity and Environment of 50% or More.
- 15. Every Job Relocation Is Due to a Combination of “Push and Pull”; However, the More “Push” Dominates the Decision, the More Unlikely the Move Will Be Satisfactory.
- 16. The “Fit” in a New Job Often Is Not Apparent for at Least 18 Months.
- 17. The Time Course of Academic Jobs Is Like the Classic Sigmoid Growth Curve of Bacteria in Culture, with a Lag Phase, Log Growth Phase, and Plateau.
- 18. Academic Battles Are Recurring and Continuous, and No One Can Win Them All.
- 19. Academic Success, Ironically, Depends on Recognizing and Adapting to the Dominant Cultural and Financial Features of One’s Academic Era.
- 20. There Are Strong Temptations to Compromise One’s Academic Mission by Unhealthy Alliances with Sources of Power or Dollars
- 21. Academic Medicine Is a Noble Calling.Read the full article to learn more about them.Hat tip to Daniel Cabrera for sharing this one on Twitter!
- Recommended by: Chris Nickson