Welcome to the BEST of 2015 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 10 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
Mouncey PR et al. Trial of Early, Goal-Directed Resuscitation for Septic Shock (The ProMISe Trial) NEJM 2015; 372(14): 1301-11. PMID: 25776532
- The ProMISe trial is the third of the trio of studies comparing contemporary standard resuscitation of septic shock patients to EGDT. Like ARISE and ProCESS, ProMISe found no difference between usual care and EGDT for the primary endpoint of mortality. However, EGDT patients were more likely to get any central line (92.1% vs. 50.9%) central lines with SCVO2 monitoring capability (87.3% vs. 0.3%) and to get inotropes (i.e. dobutamine) (18.1% vs. 3.8%). Once again, the bottom line is that EGDT has changed our usual care from what it was 20 years ago. Aggressive management doesn’t require SCVO2 monitoring, CVP or hard triggers for interventions. Early antibiotics, fluids, source control with frequent reassessment triggering escalation of care is what we should focus on.
- Recommended by Anand Swaminathan
- Read more: The ProMISe Study: EGDT RIP? (St. Emlyn’s); The Protocolised Management in Sepsis (ProMISe) Trial (REBEL EM); Keep your ProMISe (MD Aware)
Loubani OM, Green RS. A Systematic Review of Extravasation and Local Tissue Injury from Administration of Vasopressors through Peripheral Intravenous Catheters and Central Venous Catheters. J Crit Care 2015; 30(3): 653.e9-17. PMID 25669592
- We’re taught to administer vasopressors through central lines and this may delay these medications. These authors searched the literature to find extravasation and local tissue complications of vasopressors and came up with case reports (n=305 from 270 patients). They found that local tissue injury attributable to peripheral administration tends to occur in distal IV sites following long durations of infusions (average infusion duration before extravasation: 35.2 h). If a patient needs a pressor, they can get it peripherally temporarily while you’re obtaining central access.
- Recommended by Lauren Westafer
Leeuwenburg T. Airway management of the critically ill patient: modifications of traditional rapid sequence induction and intubation. Crit Care Horizons 2015; 1: 1-10. Free Open Access Link
- This is the first published article in the incredible free open access critical care journal launched by Rob MacSweeney
- Variations in RSI technique exist between individuals, specialties, institutions and countries. This paper by Kangaroo islands finest explores these variations practice and highlights specific measures for consideration in the critically ill. No specific recommendations are made but this paper may serve as basis for development of standard operation procedures at an institutional level.
- Recommended by:Soren Rudolph
Hilton AK, Bellomo R. A critique of fluid bolus resuscitation in severe sepsis. Crit Care 2012; 16(1): 302. PMID: 22277834
- The concept of the fluid bolus in resuscitation of the critically ill, especially in septic shock, is almost sacrosanct. Hilton and Bellomo tear down the facade that underpins this dogma. Read this and you will be left wondering what to believe… Is it time for a FEAST trial in adults in the developed world? In the meantime, continue to take the middle road in septic shock – judicious use of resuscitation fluids (e.g. 2-3 L at most in most adult patients) and early use of noradrenaline.
- Recommended by Chris Nickson
Bouhemad B et al Ultrasound for ʺlung monitoringʺ of ventilated patients. Anesthesiology 2015; 122(2):437-47. PMID 25501898
- The use of lung ultrasound (LUS) is ever expanding. Today we know several specific LUS patterns corresponding to lung pathology and for some of these we have couple specific treatments. However the problem with LUS has mostly been how to communicate findings between clinicians and to monitor these over time. This paper offers a scoring system to monitor degree of lung aeration over time and as response to specific treatments, ie PEEP and prone position, in the ventilated patient.
- Recommended by: Søren Rudolph
Weinstock MB, et al. Risk for Clinically Relevant Adverse Cardiac Events in Patients With Chest Pain at Hospital Admission. JAMA Intern Med 2015; 175(7): 1207-12. PMID: 25985100
- An incredibly important contribution to the literature looking at outcomes of patients who remain in the hospital (admitted and observed) after a negative ED evaluation for chest pain. Excluding patients with abnormal vital signs, electrocardiographic ischemia, left bundle branch block, or a pacemaker rhythm, the authors found that 1 in 1817 had a clinically relevant adverse cardiac event (defined by inpatient ST-segment elevation myocardial infarction, life-threatening arrhythmia, cardiac or respiratory arrest, or death). This article is one more piece of the mounting evidence demonstrating a clear call to change what is the usual care in many institutions in the U.S. Stop the madness!
- Chest pain is tough — it’s the second most ED common chief complaint, and it scares the heck out of us and our patients – partially because missed MI is one one of the top causes of litigation. But we also see a ton of resources spent on a terribly low yield from chest pain workups. This new study in JAMA-IM including Mike Weinstock (of Bounceback fame), Scott Weingart and David Newman looked at the bad outcomes of patients with normal ECGs and 2 negative troponins admitted for chest pain, and found only 20 bad outcomes in 11k patients (4 in 7000 with appropriate exclusions like abnormal vital signs). Maybe it’s time to change our approach to chest pain?
- Recommended by Jeremy Fried & Seth Trueger
Friedman, B.D, et al. Naproxen With Cyclobenzaprine, Oxycodone/Acetaminophen, or Placebo for Treating Acute Low Back Pain A Randomized Clinical Trial. JAMA 2015; 314(15): 1572-80. PMID 26501533
- An outstanding study which examines how we can best care for our patients who present with low back pain. The authors included patients with acute, non traumatic back pain without radicular symptoms; and examined the effect of naproxen with either placebo, cyclobenzaprine, or oxycodone/acetaminophen. At 7 days and 3 months, there was no significant difference in disability or pain control between placebo and use of the other medications. If you’re currently providing your patients with muscle relaxants or opioids in addition to NSAIDs, this study demonstrates the futility of that approach for the majority of your patients.
- Recommended by Jeremy Fried
Stub D et al. Air Versus Oxygen in ST-Segment-Elevation Myocardial Infarction. Circulation. 2015; 131(24):2143-50. PMID 26002889
- The Australian AVOID trial adressess the important question wether routine administration of oxygen to patients with STEMI is associated with increased infarction size as measured by cardiac enzymes and MRI at 6 months. I all 441 STEMI patients were randomized prehospital to oxygen (8 L/min) by face-mask or no oxygen from. Mean peak TnI was similar between the two groups but there was a significant increase in mean peak CK of 20% in the oxygen group. Although not all patients underwent MRI at 6 months, there was a significantly increase in myocardial infarct size on cardiac MRI in the oxygen group (n=139; 20.3 versus 13.1 g; P=0.04).
- Furthermore there was an increase in the rate of recurrent myocardial infarction in the oxygen group compared with the no oxygen group (5.5% versus 0.9%; P=0.006) and an increase in frequency of cardiac arrhythmia (40.4% versus 31.4%; P=0.05).This adds to the fact that oxygen is a drug a should be used only if indicated. The perception that oxygen is harmless and that you can’t get enough of a good thing seems to be running out of fashion.
- Recommended by Søren Rudolph
- Read More: July 2015 REBEL Cast (REBEL EM)
Hutchinson BD et al. Overdiagnosis of Pulmonary Embolism by Pulmonary CT Angiography. Am J Roentgenol. 2015; 205(2): 271-7. PMID: 6204274
- Pulmonary embolism (PE) is a favorite topic among emergency providers and recent efforts have focused on evidence based practices to combat overtesting. This retrospective, single center study from Ireland had 3 chest radiologists, blinded to clinical data and prior reads, look at 174 CTPAs positive for PE. These radiologist read 45 of these positive scans (25.9%) as negative, with excellent interrater reliability (k=0.83). False positive scans were more often solitary PE. Our “gold standard” is not imperfect and overtesting with an imperfect test is a good setup for downstream consequences.
- Recommended by:Lauren Westafer
Atir S et al. When Knowledge Knows No Bounds: Self-Perceived Expertise Predicts Claims of Impossible Knowledge. Psychol Sci 2015; 26(8): 1295-303. PMID: 26174782
- This article has little to do with clinical EM or critical care but gives us insight into how we think. The last author on this piece is psychologist David Dunning (he of the Ig Nobel Prize winning Dunning-Kruger Effect). This article reveals not only that we overestimate our abilities but that when our perceived expertise in an area is high, we overestimate our abilities even more. What do we do with this information? Continually question our abilities and our confidence so as not to be sucked in to this trap. This is an enlightening read for those interested in social sciences and how we think..
- Recommended by Anand Swaminathan