R&R in the FASTLANE 008

The eighth edition of our weekly series of eminence-based evidence:

A free weekly 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 14 recommended reads. Find out more about the R&R in the FASTLANE project here and check out the team of contributors from all around the world.

This week’s ‘R&R Hall of Famers’

Abd-el-Maeboud KH, el-Naggar T, el-Hawi EM, Mahmoud SA, Abd-el-Hay S. Rectal suppository: commonsense and mode of insertion. Lancet. 1991 Sep 28;338(8770):798-800. PMID: 1681170

This little known classic has never been repeated, but it has sparked a debate that continues to this day: What is the best direction to place a suppository – pointy or blunt end first? The authors challenged conventional wisdom as well as manufacturer instructions and tested their theory – that blunt end was best – on 100 unwitting patients. The rate of needing to insert a digit in the anal canal to push the suppository further in was 1% in the blunt end group versus 83% for pointy end first. Unwanted suppository expulsion rate was also lower in the blunt end group. Since this is the only study of its kind, questions have been raised as to whether it should be practice changing. It is for me. That’s all I can say.

Recommended by Rob Orman
Learn more: ERCAST – The Suppository Conundrum

Hudson ML, Moore GP. Defenses to Malpractice: What Every Emergency Physician Should Know. J Emerg Med 2011;41:598-606. PMID: 21094012

A medical malpractice suit must contain four elements: duty; breach of standard of care (negligence); injury; and proximate cause. However, even if all these factors exists, there are additional specific defenses that physician can claim: including contributory negligence, comparative fault, respectable minority, clinical innovation, and Good Samaritan exclusion. Although most of these specific defenses seem to me included in the original 4 elements, the authors give a good summary of this topic.

Recommended by Leon Gussow

This week’s R&R recommendations

Airway

Kumar RD, Hirsch NP. Clinical evaluation of stethoscope-guided inflation of tracheal tube cuffs. Anaesthesia. 2011 Nov;66(11):1012-6. doi: 10.1111/j.1365-2044.2011.06853.x. Epub 2011 Aug 18. PMID: 21851343.

A cool, practical study although patient numbers are small.
Recommended by Sa’ad Lahri

Critical care

Bershad EM, Suarez JI. Prothrombin complex concentrates for oral anticoagulant therapy-related intracranial hemorrhage: a review of the literature. Neurocrit Care. 2010 Jun;12(3):403-13. Review. PMID: 19967567.

PCC Review: PCCs ARE AVAILABLE IN THE US!!! PRofilNine SD is roughly equivalent to Octaplex!

Recommended by Mike Jasumback

Latronico N, Bolton CF. Critical illness polyneuropathy and myopathy: a major cause of muscle weakness and paralysis. Lancet Neurol. 2011 Oct;10(10):931-41. Review. PMID: 21939902.

Go the early rehab. A good review of a classic topic.

Recommended by Oliver Flower

Emergency medicine

Armfield DR, Kim DH, Towers JD, Bradley JP, Robertson DD. Sports-related muscle injury in the lower extremity. Clin Sports Med. 2006 Oct;25(4):803-42. PMID: 16962427

We see lots of muscle strains and soft tissue injurys. This is a good review of what specific anatomic injuries are occurring.

Recommended by Andy Neill

Hudson ML, Moore GP. Defenses to Malpractice: What Every Emergency Physician Should Know. J Emerg Med 2011;41:598-606. PMID: 21094012

A medical malpractice suit must contain four elements: duty; breach of standard of care (negligence); injury; and proximate cause. However, even if all these factors exists, there are additional specific defenses that physician can claim: including contributory negligence, comparative fault, respectable minority, clinical innovation, and Good Samaritan exclusion. Although most of these specific defenses seem to me included in the original 4 elements, the authors give a good summary of this topic.

Recommended by Leon Gussow

Nguyen-Khac E, Thevenot T, Piquet MA, Benferhat S, Goria O, Chatelain D, Tramier B, Dewaele F, Ghrib S, Rudler M, Carbonell N, Tossou H, Bental A, Bernard-Chabert B, Dupas JL; AAH-NAC Study Group. Glucocorticoids plus N-acetylcysteine in severe alcoholic hepatitis. N Engl J Med. 2011 Nov 10;365(19):1781-9. PMID: 22070475.

NAC – is there anything we can’t try it for. Negative trial statistically but results all leaning toward benefit. 8% v 24% mortality at 1 month vs placebo

Recommended by Andy Neill
Learn more: Emergency Medicine Ireland – NAC for alcoholic hepatitis

Vazirani J, Knott JC. Mandatory Pain Scoring at Triage Reduces Time to Analgesia. Ann Emerg Med. 2011 Sep 9. PMID: 21908072

If you want your patients to get analgesia quicker… ask the triage nurse to do analgesia scores. Will it affect the ATS category as well??

Recommended by Ioana Vlad

Pediatrics

Mellick LB. Torsion of the Testicle: It Is Time to Stop Tossing the Dice. Pediatr Emer Care 2012;28:80-86. PMID: 22217895

Great in-depth discussion of the myths and misconceptions related to the presentation and diagnosis of testicular torsion. Bottom line recommendation: image every patient with scrotal or testicular pain whose history and physical is not consistent with torsion. Clinically obvious torsion should go directly to urology for exploration.

Recommended by Leon Gussow

Quirky, weird and wonderful

Abd-el-Maeboud KH, el-Naggar T, el-Hawi EM, Mahmoud SA, Abd-el-Hay S. Rectal suppository: commonsense and mode of insertion. Lancet. 1991 Sep 28;338(8770):798-800. PMID: 1681170

This little known classic has never been repeated, but it has sparked a debate that continues to this day: What is the best direction to place a suppository – pointy or blunt end first? The authors challenged conventional wisdom as well as manufacturer instructions and tested their theory – that blunt end was best – on 100 unwitting patients. The rate of needing to insert a digit in the anal canal to push the suppository further in was 1% in the blunt end group versus 83% for pointy end first. Unwanted suppository expulsion rate was also lower in the blunt end group. Since this is the only study of its kind, questions have been raised as to whether it should be practice changing. It is for me. That’s all I can say.

Recommended by Rob Orman
Learn more: ERCAST – The Suppository Conundrum

Doyal L. Should the skeleton of “the Irish giant” be buried at sea?. BMJ 2011; 343. PMID: 22187392

A story from a time when ethics was not a word.

Recommended by Ioana Vlad

Retrieval, prehospital and disaster

Weber JM et al. Can Nebulized Naloxone Be Used Safely and Effectively by Emergency Medical Services for Suspected Opioid Overdose? Prehosp Emerg Care 2011 Dec 22. [Epub ahead of print] PMID: 22191727

Nebulized naloxone appears to be a safe and effective option for prehospital treatment of the non-emergent patient with suspected opiate toxicity.

Recommended by Leon Gussow

Toxicology

Nielsen AS, Damek DM. Window of opportunity: Flexion myelopathy after drug overdose. J Emerg Med. 2008 Dec 10. PMID: 19081699

One question you probably haven’t thought to ask the paramedics!

Recommended by Ioana Vlad

Trauma

James MF, Michell WL, Joubert IA, Nicol AJ, Navsaria PH, Gillespie RS. James MF, Michell WL, Joubert IA, Nicol AJ, Navsaria PH, Gillespie RS. Resuscitation with hydroxyethyl starch improves renal function and lactate clearance in penetrating trauma in a randomized controlled study: the FIRST trial (Fluids in Resuscitation of Severe Trauma). Br J Anaesth. 2011 Nov;107(5):693-702. PMID: 21857015

This is the first randomized, controlled, double-blind study comparing crystalloids with isotonic colloids in trauma.
Recommended by Cliff Reid
Learn more: Resus.ME – FIRST: Fluid Resuscitation in Severe Trauma

Rosenberg H, Rosenberg H, Hickey M. Emergency management of a traumatic tooth avulsion. Ann Emerg Med. 2011 Apr;57(4):375-7. PMID: 20817349

Got an avulsed tooth at 3 am, but no dentist/ oral surgeon on call? How do you temporarily stabilize the tooth once reimplanted? Dermabond + nasal bridge of N95 mask = stabilized tooth!

Recommended by Michelle Lin
Learn more: Academic Life in Emergency Medicine – Trick of the Trade: Dental Injury

The R&R iconoclastic sneak peek icon key

The list of contributors The R&R ARCHIVE
R&R Hall of fame
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 WTF!
Weird, transcendent or funtabulous!
R&R Boffintastic
High quality research R&R Trash
Must read, because it is so wrong!
R&R Mona Lisa
Brilliant writing or explanation

That’s it for now…

That should keep you busy for a week at least… 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.

	The list of contributors		The R&R ARCHIVE
	R&R Hall of fame 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 WTF! Weird, transcendent or funtabulous!
	R&R Boffintastic High quality research		R&R Trash Must read, because it is so wrong!
	R&R Mona Lisa Brilliant writing or explanation

This week’s ‘R&R Hall of Famers’

This week’s R&R recommendations

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