R&R In The FASTLANE 179

Welcome to the 179th 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

The PRISM Investigators. Early, Goal-Directed Therapy for Septic Shock — A Patient-Level Meta-Analysis. NEJM 2017. PMID: 28320242

• The Protocolized Resuscitation in Sepsis Meta-Analysis [PRISM] study was a meta-analysis of individual patient data from The ProCESS, ARISE, and ProMISe trials and aimed at providing greater statistical power to identify subgroup effects. It was planned prospectively prior to enrolment of the first patient into the first trial. Unsuprisingly no evidence was found that EGDT resulted in lower mortality than usual care. Average costs were higher in those who received EGDT. In subgroup analysis those patients with worse shock or those with combined hypotension or hyperlactataemia did not show benefit from EGDT. Is this the final nail in the EGDT coffin?
• Recommended by: Nudrat Rashid

Leone MA, et al. Immediate antiepileptic drug treatment, versus placebo, deferred, or no treatment for first unprovoked seizure. Cochrane Database Syst Rev. 2016. PMID: 27150433

• Should we be starting anticonvulsants for first time unprovoked seizures in the emergency department? This is a cochrane review looking at immediate versus delayed treatment for patients of any age after their first unprovoked seizure. They identified a total of 6 trials that included 1600 patients. Overall, starting anticonvulsants early was associated with a lower risk of early seizure recurrence. You were less likely to have a seizure in the first 5 years if you were treated, but there was no difference in the likelihood of obtaining any 5 year seizure free period. Obviously, adverse events were higher in the treatment group. At 5 years, 45% of the control group had a seizure, as compared to only 35% of the treatment group. However, this has to be weighed against the 30% of patients in the treatment group who had adverse effects (not very well described here) from these medications. Bottom line: This is all about shared decision making to me. There isn’t a clear answer, so I will probably still leave this decision to the neurologists in follow up.
• Recommended by: Justin Morgenstern

Giordano P, et al. Recommendations for the use of long-term central venous catheter (CVC) in children with hemato-oncological disorders: management of CVC-related occlusion and CVC-related thrombosis.  (AIEOP). Ann Hematol. 2015. PMID: 26300457

• Occluded central vascular catheters are more than a nuisance to children who need them. This article is robust, but boils down some salient points about how we can evaluate and manage these occluded CVCs in the ED.
• Recommended by: Sean M. Fox

Sunden-Cullberg J, et al. Fever in the Emergency Department Predicts Survival of Patients With Severe Sepsis and Septic Shock Admitted to the ICU. Crit Care Med. 2017. PMID: 28141683

• It is the patients with severe sepsis and septic shock who DO NOT have fever, that we must pay more attention to. Currently, the qSOFA score does not use temperature as a predictor of mortality and in this study, temperature was the vital sign that had the best prediction of in-hospital mortality.
• Recommended by: Salim R. Rezaie

Levine M, et al. Critical care management of verapamil and diltiazem overdose with a focus on vasopressors: a 25-year experience at a single center. Ann Emerg Med. 2013. PMID: 23642908

• Significant debate surrounding the use of vasopressors vs. high dose insulin (HIE) for calcium channel blocker (CCB) poisoning exists in the toxicology community. Existing animal data often favors use of HIE and clinicians often fear ischemic complications subsequent to heavy use of vasopressors. This retrospective study of CCB poisoning, conversely, found good results (only one death in 48 patients, this death was not attributable to CCB toxicity) without significant complications with the use of vasopressors alone. No digital or limb ischemia was reported and remaining ischemic events were thought to be due to CCB toxicity, not vasopressor use. This study is limited by its retrospective methods and by data originating from a single center with a bedside medical toxicology service.
• Recommended by: Meghan Spyres