R&R In The FASTLANE 172

Welcome to the 172nd 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

Friedman BW et al. Diazepam Is No Better Than Placebo When Added to Naproxen for Acute Low Back Pain. Ann Emerg Med 2017. DOI: http://dx.doi.org/10.1016/j.annemergmed.2016.10.002

• Should patients with acute low back pain be given a combination of NSAIDs and benzodiazepines? This RDCT looks at this question and finds no difference in functional impairment at 1 week or 3 months. Additionally, there was no difference in the secondary outcome of pain. Though the study is small (n = 114) it’s the best evidence available and it appears that, at least for now, NSAIDs alone are the way to go.
• Recommended by: Anand Swaminathan

Driver BE, McGill JW. Emergency Department Airway Management of Severe Angioedema: A Video Review of 45 Intubations. Ann Emerg Med 2017. PMID: 28110989.

• Fascinating case series reviewing 45 ED intubations for angioedema from Hennepin. Tons of interesting findings. Success on all of them without cric. Nasal FO first attempt on half, but only 57% successful. VL & DL both did pretty well, as did oral FO. Nasal FO and VL did pretty well as rescues; DL only 1 for 5 as a rescue (although it beat the simultaneous cric. remember: if you have an extra set of hands, have someone keep trying from above during cric!). Also nice to know intubating LMA was 5/5 as a rescue. And someone did a successful retrograde which I didn’t know was still a thing. Blind nasal: 4/10 initial, 0/3 as rescue. (So… I’m going to continue to not do blind nasals.) Lessons: know multiple approaches, know there is no silver bullet, plan plan plan and plan. Not a lot of oxygenation issues, and patients had a lot of time (median 33 min to tube) which is nice. Tons more in the manuscript, really a great read.
• Recommended by: Seth Trueger

Liu WC et al. Prognostic impact of restored sinus rhythm in patients with sepsis and new-onset atrial fibrillation. Crit Care 2016. PMID: 27855722

• It would be easy to get this paper wrong. I’ve seen the main figure floating around: in sepsis, if atrial fibrillation was converted to sinus rythm the mortality was 26%, and if it stayed in atrial fibrillation the mortality was 61%! Certainly sounds like we should be considering cardioversion, but that isn’t what this data shows. The fatal flaw is in how they defined these groups. It wasn’t patients they attempted to cardiovert versus those who they didn’t; it was patients who they were successful in cardioverting (or who converted spontaneously) versus those who they were unsuccessful or just didn’t try. In other words, your group was determined not by the medical management you received, but just by whether or not you happened to have any more atrial fibrillation over the following week. What that means is that we are just comparing a sicker group of patients to a healthier group, and not surprisingly, the sicker group has a higher mortality. This is confirmed by looking through the comparisons between the two groups: the group that remained in atrial fibrillation had a higher APACHE II score, higher SOFA score, more pressor use, and even more attempts at cardioversion than the group that returned to sinus rhythm.
• Recommended by: Justin Morgentern

Hess EP, et al. Shared decision making in patients with low risk chest pain: prospective randomized pragmatic trial. BMJ 2016. PMID: 27919865

• This is an interesting study exploring one piece of shared decision making: patient education. The authors sought to find out if they could increase patients comprehension of their risk and the options for assessment when they presented with low risk chest pain. The decision aid appears to have improved patient knowledge and also appears to have decreased the rate of admission for cardiac testing. However, as Ryan Radecki notes in his blog, we are still offering overtesting, and potentially overtreatment, as an option.
• Recommended by: Anand Swaminathan
• Further reading: The chest pain decision instrument trial (Emergency Medicine Literature of Note)

Carson SS, et al. Effect of Palliative Care-Led Meetings for Families of Patients With Chronic Critical Illness: A Randomized Clinical Trial. JAMA 2016. PMID: 27380343

• This multicenter randomized clinical trial randomized adult patients requiring 7 days or more of mechanical ventilation (and their family surrogate decision makers) to routine ICU family meetings or an intervention. The intervention included at least 2 structured family meetings led by palliative care specialists. At 3 months there was there was no significant differences in anxiety and depression symptoms but post-traumatic stress disorder symptoms were higher… in the intervention group! (don’t get too carries away though, the P value for this difference was 0.0495). Overall, I don’t think we can read too much into this result: end-of-life discussions are complex beasts and should probably be tailored to the individual circumstances. Furthermore, ICU settings vary considerably around the world. Nevertheless, I am reassured that Intensivists seem to be suitable professionals for leading family meetings and I maintain my belief that all clinical specialties should have palliative strings in their bows.
• Recommended by: Chris Nickson