Medicine News: Research and Reviews in the Fastlane 092

Welcome to the 92nd 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 7 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 R&R Archive, read more about the R&R project or check out the full list of R&R contributors

This Edition’s R&R Hall of Famer

Urology

Pickard R et al. Medical expulsive therapy in adults with ureteric colic: a multicentre, randomised, placebo-controlled trial. Lancet 2015. PMID: 25998582

The urology literature and guidelines has argued for the broad use of tamsulosin in the treatment of patients with renal colic to facilitate stone passage, reduce pain medication utilization and reduce interventions based on poor methodologic studies from the early 2000’s. This study, on the other hand, was a well done, RDCT comparing tamsulosin to nifedipine to placebo in 1136 patients and showed no statistically significant difference for the primary outcome (need for further intervention at 4 weeks). Subgroup analysis showed a slight benefit for lower tract stones and the issue of utility in larger stones (> 5 mm) remains unanswered. However, with the move to reduce CT use in renal colic, we won’t know stone location or size on many patients making this drug far less useful in the real world.

Recommended by Anand Swaminathan
Read More: The Adventure of the Impassible Stone (EM Nerd); Finally an End to Tamsulosin for Renal Colic? (EM Lit of Note)

The Best of the Rest

Intensive Care

Neuraz A et al. Patient Mortality Is Associated With Staff Resources and Workload in the ICU: A Multicenter Observational Study. Crit Care Med 2015; 43(8): 1587 – 94. PMID 25867907

This study aimed to assess the impact of the staffing-to-patient ratio and workload on ICU mortality. And what they found was the risk of death was increased by 3.5 when the patient-to-nurse ratio was greater than 2.5, and it was increased by 2.0 when the patient-to-physician ratio exceeded 14. High patient turnover (adjusted relative risk, 5.6) and the volume of life-sustaining procedures performed by staff (adjusted relative risk, 5.9) were also associated with increased mortality. Doesn’t this sound like a standard shift in the ED?
Incredibly important paper to help guide ICU directors & managers in staffing considerations for their ICU.Increased mortality risk associated with:
– Nurse:patient > 2.5
– Physician:patient > 14
– High rates of turnover
– Number of life saving interventionsBottom line – Intensive care requires INTENSIVE care.
Recommended by Salim R. Rezaie, John Greenwood

ResuscitationPanchal AR, et al. Efficacy of Bolus Dose Phenylephrine for Peri-intubation Hypotension. J Emerg Med 2015. PMID 26104846

Push dose vasopressors are commonly used in the emergency department, yet literature in this setting is scant. This is a retrospective study of use of phenylephrine in one ED over the course of a year. This study doesn’t look at patient centered outcomes but lays groundwork for future study in this area. The take home: emergency physicians use push-dose pressors in some hypotensive patients in the peri-intubation period and most patients given push dose pressors will end up on a vasopressor so be prepared to have a long-term fix for the hypotension.
Recommended by Lauren Westafer
Read More: Push dose pressors (EMCrit)

TraumaHale DF et al. Absence of clinical findings reliably excludes unstable cervical spine injuries in children 5 years or younger. J Trauma Acute Care Surg. 2015; 78(5): 943-8 PMID: 25909413

In this well done retrospective review of ~3,000 patients aged 5 years and younger who have imaging of their cervical spine, the authors give us some data and a common sense approach for the pre-elementary aged trauma patient’s c-spine evaluation. Essentially, in the words of the authors:“In those who were clinically evaluable (not in a coma), there were no asymptomatic patients who later were found to have unstable cervical spine injury”.So, if there is no neurologic deficit, and no pain or tenderness, there is no need to go crazy looking for an extremely rare, unlikely injury.
Recommended by Jeremy Fried
Further information: Pediatric C-spine Clearance (ERCAST); The Very Young Pediatric C-Spine Rarely Needs Radiologic Clearance (EM Literature of Note); Clearing the Pediatric C-Spine (PEM-ED)

AirwayL. Suppan et al. Alternative intubation techniques vs Macintosh laryngoscopy in patients with cervical spine immobilization: systematic review and meta-analysis of randomized controlled trials Br. J. Anaesth 2015. PMID 26133898

A well done review and meta-analysis with a skewed conclusion in my opinion. Even though the premise for the review is the well known problem with airway management in immobilised trauma patients and one of the keywords is “trauma”, none of the included 1866 patients (24 trials) were actual trauma patients intubated in emergency settings. Furthermore all intubations were done by “experienced” anaesthesiologist but with an amazingly high failure rate (20%) for direct laryngoscopy.
The authors present a thorough discussion on these and other limitations, but end up by concluding that the Airtraq device reduces the risk of intubation failure and that there is a lack of evidence for the usefulness of other intubation devices.
Recommended by Søren Rudolph

Emergency MedicinePollack CV et al. Idarucizumab for Dabigatran Reversal. NEJM 2015. PMID: 26095746

This article begs a number of questions most of which center on the quality of article being published by the NEJM and what their true motives are. This study is an interim analysis of an unblinded observational study looking at the ability of the antibody fragment idarucizumab to reverse the anticoagulant effect of dabigitran (a direct thrombin inhibitor). The study claims success of the new (an terribly expensive) drug but the endpoints are non-patient centered and the study suffers from a number of biases. Again, though, the real question is why the NEJM would publish such pharma sponsored drivel . . . except of course for the huge windfall from reprint proceeds for the article.
Recommended by Anand Swaminathan
Further reading: Let’s Reverse: Dabigtran (EM Literature of Note)

Emergency Medicine
Yu S, et al. Computed tomographic pulmonary angiography: clinical implications of a limited negative result. JAMA Intern Med 2015; 175(3): 447-9. PMID 25581389

I’m not sure why this is a research letter and not a paper but it’s what we have. The authors describe a chart review of all their CTPAs and looked at the 25% that were limited in their diagnostic ability (poor contrast etc…)
They then looked at records of all those people with indeterminate scans (25% of the total). Very few had anything bad and no difference between the non diagnostic scans and those who had definitive negative scans.
This is just more evidence that we probably shouldn’t be diagnosing every VTE and a scan showing clear vessels to the lobar or segmental level is probably just fine.[someone linked to this on twitter, not sure who but cheers anyhow!]
Recommended by: Andy Neill

The R&R iconoclastic sneak peek icon key

	The list of contributors		The R&R ARCHIVE
	R&R Hall of famer You simply MUST READ this!		R&R Hot stuff! Everyone’s going to be talking about this
	R&R Landmark paper A paper that made a difference		R&R Game Changer? Might change your clinical practice
	R&R Eureka! Revolutionary idea or concept		R&R Mona Lisa Brilliant writing or explanation
	R&R Boffintastic High quality research		R&R Trash Must read, because it is so wrong!
	R&R WTF! Weird, transcendent or funtabulous!

That’s it for this week…

That should keep you busy for a week at least! Thanks to our wonderful group of editors and contributors Leave a comment below if you have any queries, suggestions, or comments about this week’s R&R in the FASTLANE or if you want to tell us what you think is worth reading.

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