R&R In The FASTLANE 195

Welcome to the 195th 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

Weiser et al. Initial Electrical Frequency Predicts Survival And Neurological Outcome in Out Of Hospital Cardiac Arrest Patients with Pulseless Electrical Activity. Resuscitation. 2018. PMID: 29408228

• Maybe PEA isn’t all ‘doom and gloom’. There is already emerging awareness that ‘pseudo-PEA’ may have a better prognosis, now this observational study from Vienna suggests that OOHCA patients and a heart rate >60/min may do better. In this study, this group “showed a 30-days-survival rate of 22% and a good neurological outcome in 15% of all patients – comparable to shockable cardiac arrest rhythms”.
• Recommended by: Chris Nickson

Babl FE, et al. Accuracy of Clinician Practice Compared With Three Head Injury Decision Rules in Children: A Prospective Cohort Study Annals of Emergency Medicine. 2018. doi.org/10.1016/j.annemergmed.2018.01.015

• Personally, I love when clinical decision tools are compared to physician judgement. It’s rarely done, and helps us determine if these tools are helping or hurting us take care of our patients. In this setting of low CT utilization, the use of decision tools did not perform as well as physician judgement. Clinicians had better specificity and positive predictive value, and similar sensitivity and negative predictive value.
• One caveat, this was done in a setting where head CTs are performed at a low baseline rate (unlike the U.S.), so be sure to take your own baseline utilization rate into consideration when applying these findings to your practice.
• Recommended by: Jeremy Fried

Keijzers G, et al. Don’t just do something, stand there! The value and art of deliberate clinical inertia. Emergency medicine Australasia : EMA. 2018; PMID: 29327445

• This one is hot off the press, and the first of a three part series – look out for the rest… The article discusses the concept of ‘deliberate clinical inertia’, which is “the art of doing nothing as a positive response”. In particular, it talks about the barriers and strategies to overcome them. That’s right the 13th Law of the House of God wasn’t just a joke, often the best medicine really does involve doing as much nothing as possible. Should ‘doing nothing’ be a KPI?… A caveat is that the sicker the patient, the more likely intervention will be appropriate.
• Recommended by: Chris Nickson

Hughes PG, et al. Ten Tips for Maximizing the Effectiveness of Emergency Medicine Procedure Laboratories. The Journal of the American Osteopathic Association. 2016; 116(6):384-90. PMID: 27214775

• The world would be a better place if (1) we all had regular procedure labs and (2) we all followed the 10 tips in this article.
• Recommended by: Chris Nickson

Kawano et al. Intraosseous Vascular Access Is Associated With Lower Survival and Neurologic Recovery Among Patients With Out-of-Hospital Cardiac Arrest. Ann Emerg Med 2018 PMID: 29310869

• IO or IV in arrest? This study finds an association between IO use and worse neuro outcomes but, the data is extremely limited due to a host of biases. It’s unclear why IO was chosen as the route and the IO group was sicker overall. Additionally, with no evidence for benefit of any meds in cardiac arrest, there isn’t even a physiologic basis for why IO would be worse than IV. Ultimately, only a randomized trial can give us any useful information. We should continue to de-emphasize the importance of obtaining access in arrest.
• Recommended by: Anand Swaminathan