R&R In The FASTLANE 170

Welcome to the 170th 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

Bexkens R, et al. Effectiveness of reduction maneuvers in the treatment of nursemaid’s elbow: A systematic review and meta-analysis. The American journal of emergency medicine 2017. PMID: 27836316

• This paper has already gather a lot of attention. Are you using the best technique to reduce pulled elbows? This is a systematic review and meta-analysis that includes 7 trials covering a total of 701 patients. None of the trials were high quality. According to their results, hyperpronation is better than the traditional technique of supination-flexion (risk ratio, 0.34; 95% CI, 0.23 to 0.49). Absolute risk difference between maneuvers was 26.4%, which results in a number needed to treat of 3.8.That might be true, but something seems really wrong with this data. To have an absolute difference of 26% you have to be failing AT LEAST 26% of the time on a reduction that I have very close to a 100% success rate using supination-flexion technique. So this paper doesn’t really pass the sniff test. I guess if you are just starting out or if you have had a number of failures, you could choose the hyperpronation technique, but if you are getting close to 100% success with supination-flexion like I am, this data should not make you change your practice. They do comment about pain, but honestly kids cry with both techniques and stop in seconds either way, so I’m not sure how they would accurately assess this.
  Bottom line: Hyperpronation works for pulled elbows (but so does pronation-supination, or almost anything in my experience).
• Recommended by: Justin Morgenstern

Robertson JJ, et al. Myths in the Evaluation and Management of Ovarian Torsion. J Emerg Med 2016. PMID: 27988260

• A great review of myths associated with ovarian torsion evaluation and management. A collection of the clinical bottom lines, includes:
  • Ovarian torsion affects women of all ages.
  • The classic presentation of ovarian torsion is not always present. Patients may have gradual onset pain, intermittent pain, or very mild pain.
  • Do not rely on a normal pelvic or bimanual examination to rule out torsion.
  • Normal arterial flow on Doppler US cannot rule out torsion. Consider using a combination of ultrasound findings.
  • A normal abdominal/pelvic CT significantly decreases likelihood of torsion. Other findings on CT with ovarian torsion warrant further evaluation for the condition.
  • Pregnant women can experience ovarian torsion, with increased risk if they are undergoing fertility treatment or have had prior torsion.
  • Patients may have symptoms for several days and still have viable ovaries after surgery.
• Recommended by: Jeremy Fried

Dlamini N, et al. Cerebral venous sinus (sinovenous) thrombosis in children. Neurosurg Clin N Am 2010. PMID: 20561500

• Cerebral Venous Thrombosis (CVT) is a difficult diagnosis to make in adults because it presents with nonspecific symptoms. In children, it is even more challenging to make the diagnosis of CVT, yet still can lead to significant morbidity and mortality. This article helps outline the presentation, risk factors, and management of CVT in children.
• Recommended by: SMF
• Further reading: Cerebral Venous Thrombosis (Pediatric EM Morsels)

Lamontagne, et al. qSOFA for Identifying Sepsis Among Patients With Infection. JAMA 2017. PMID: 28114531

• Since the release of Sepsis-3, the discussion around qSOFA has generated vast amount of strong opinions, and perhaps more heat than light. In just two pages, this group does an extraordinary job of reviewing the facts as they actually stand on the ground, and providing a balanced perspective on what we know and what we do not.
• Recommended by: Jack Iwashyna

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Girardis M, et al. Effect of Conservative vs Conventional Oxygen Therapy on Mortality Among Patients in an Intensive Care Unit: The Oxygen-ICU Randomized Clinical Trial. JAMA 2016. PMID: 27706466

• We knew hyperoxia was bad. Here is RCT data that helps prove causation, although it was stopped early due to sluggish recruitment. It showed that patients randomized to a conservative oxygenation approach (PaO2 70-100mm Hg or SpO2 94-97%) vs conventional (PaO2 up to 150mm Hg or SpO2 97-100%) had lower mortality, RR 0.57 (95% CI, 0.37-0.90). NNT = 12. Other secondary outcomes were better as well.
  Summary: Target SpO2 94-97% in critically ill patients. This study adds more evidence that hyperoxia is bad for patients.
• Recommended by: Clay Smith
• Furhter reading: Hyperoxia kills: Oxygen-ICU RCT (EM Topics)