Welcome to the 181st 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
WOMAN Trial Collaborators. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. Lancet 2017. PMID: 28456509
- The WOMAN trial has already been widely discussed. Some tout it is a game changer; others refer to it as a disappointingly negative trial. Some focus on a decrease in bleeding deaths; others emphasize the importance of all cause mortality. This is one of those times that you aren’t going to be able to rely on the FOAM community to make up your mind for you. Grab the paper (its free), give it a read, and see what you think.
- Recommended by: Justin Morgenstern
- Read more: Thoughts on the WOMAN trial (Broome Docs)
Olaussen A, et al. Consciousness induced during cardiopulmonary resuscitation: An observational study. Resuscitation 2017. PMID: 28161214
- I have had this happen to me. Start chest compressions, the patient is awake; stop, and he is dead. I have struggled with this throughout a 2 hour code, and have discussed it with the patient months later. Thankfully he is alive. Unfortunately, he still suffers from nightmares and flashbacks to that resuscitation. This is a retrospective registry-based study from Australia looking at more than 16,000 EMS based resuscitation. There were 112 (0.7%) cases of CPR induced consciousness identified. The incidence increased from 2003 to 2014. The outcomes in these patients were excellent (43% survival to hospital discharge), despite the fact that CPR was presumably stopped repeatedly in the face of consciousness. There are a ton of problems with this data, as identifying these cases retrospectively is fraught with error, but the point is this happens and you need to have a plan. In the future, I would use ketamine as my sedative of choice here. Bottom line: Good quality CPR can result in consciousness. The outcomes are good, but have a plan to manage this awareness.
- Recommended by: Justin Morgenstern
Levine M et al. Estimating the impact of adopting the revised Uited Kingdom acetaminophen treatment nomogram in the U.S. population. Clin Toxicol. 2017; doi: 10.1080/15563650.2017.1291945
- Acetaminophen poisoning is extremely common. Recently, European guidelines have lowered the treatment threshold, resulting in a significant increase in the number of patients treated, without clear clinical benefit. This retrospective study looked at the potential cost to the health care system if such a policy change was enacted in the United States. Based on extrapolation from patients identified at 8 participating centers, this study estimates an additional 4500 patients would be treated annually, to a cost of $45 million. Although there is significant interest in re-thinking the management of acetaminophen toxicity in the Tox and EM community, before adopting a policy not clearly founded in a clinical concern, the risks and consequences of such a policy should be seriously considered.
- Recommended by: Meghan Spyres
Beitler JR, et al. Favorable Neurocognitive Outcome with Low Tidal Volume Ventilation After Cardiac Arrest. American journal of respiratory and critical care medicine 2017. PMID: 28267376
- Low tidal volume was neuroprotective post-arrest.
Odds of neurologically-intact survival after cardiac arrest increased 60% for every 1 mL/kg decrease in tidal volume (Vt) (obviously with a lower limit around 6mL/kg…don’t crank it down to zero) compared with patients ventilated at >8 mL/kg. Those with Vt <8 mL/kg had a cerebral performance category 1 or 2 (CPC 1 or 2 = good outcome) 27% of the time; only 12% with Vt >8 mL/kg had a CPC 1 or 2. That’s a NNT of 7. They used propensity-adjusted analysis to account for potential confounders. Lower Vt was also associated with improvement in several other secondary outcomes and didn’t appear to have any adverse effects. Based on this rigorous analysis, I think the results are probably true. This is big news and easy to implement immediately.
If there was a drug that made this big an impact on cognitive outcome post-arrest, Big Pharma would bottle and sell it for billions.
- Recommended by: Clay Smith
- Read more: Low Tidal Volume Neuroprotective Post-Arrest (EM Topics)
Moayedi S et al. Safety and Efficacy of the “Easy Internal Jugular (IJ)”: An Approach to Difficult Intravenous Access. JEM 2016. PMID: 27658558
- In stable patients, who have had failed attempts at establishing peripheral or external jugular vein access, the Easy IJ is a rapid method of achieving short-term IV access with no major adverse patient oriented outcomes.
- Recommended by: Salim R. Rezaie