R&R in the FASTLANE 025

• Weingart GS, Carlson JN, Callaway CW, Frank R, Wang HE. Estimates of sedation in patients undergoing endotracheal intubation in US EDs. Am J Emerg Med. 2012 Jul 4. [Epub ahead of print] PubMed PMID: 22770915.

Less than one-half of patients undergoing ETI in the ED receive sedative drugs while in the ED. These findings are congruent with prior smaller studies from single academic centers. Now I’m not sure if some of these patients were so deeply comatose that the team felt no sedation was necessary, but I can’t imagine it is a huge fraction of the patients that did not get sedation. This makes me so sad. The relief of pain and suffering should be our first priority as doctors. How can this still be going on?

Recommended by Scott Weingart (NB. no connection to the first author of the paper)

• Reilly BM. Inconvenient truths about effective clinical teaching. Lancet. 2007 Aug 25;370(9588):705-11. PubMed PMID: 17720022.

30 years of teaching reduced to two great mnemonics: ‘TALK’ the talk and ‘WALK’ the walk. In the absence of a solid body of research telling us what make effective clinical teaching, this is gold. The inconvenient truth remains – we don’t really know how effective our clinical teaching is, or what really works. Infused with practical philosophy and hard earned wisdom this is a must read for all who teach on the floor or in the wards.

Recommended by Joe Lex and Chris Nickson

• Cooper RJ, Green SM. Don’t Hyperventilate Over Triage Respiratory Rates. Ann Emerg Med. 2012 Jul 26. [Epub ahead of print] PubMed PMID: 22841175.

Respiratory rates measured in ED triage are inaccurate – missing 77% of tachypnoea. This editorial discusses many of the issues surrounding this. It concludes stating that it probably doesn’t matter. This conclusion makes me uneasy – of all the vital signs, RR probably best correlates with need for ICU admission when patients are reviewed by the upstairs team. We need to find a way to get this right.

Recommended by Chris Nickson

• Ater D, Shai H, Bar BE, Fireman N, Tasher D, Dalal I, Ballin A, Mandelberg A. Hypertonic saline and acute wheezing in preschool children. Pediatrics. 2012 Jun;129(6):e1397-403. Epub 2012 May 21. PubMed PMID: 22614767.

After years of bad press, salt is making a comeback! This is the first RCT of nebulized hypertonic saline in preschool viral induced wheeze. The study design is pragmatic and reflects current practice. The addition of 5% saline to albutamol nebs reduced both need for admission and length of stay.

Recommended by Michael Baker

• Easter JS, Vinton DT, Haukoos JS. Emergent pediatric thoracotomy following traumatic arrest. Resuscitation. 2012 Jun 13. [Epub ahead of print] PubMed PMID: 22705411.

This case series of ED thoracotomy in paediatric blunt or penetrating trauma is the second largest ever and the only study published in the last 20 years. The conclusions are similar to adult studies, with no survivors in the blunt trauma group or if there were no signs of life. Overall 19% of patients survived in the penetrating trauma group, all neurologically intact.

Recommended by Michael Baker

• Perner A, et al; 6S Trial Group; Scandinavian Critical Care Trials Group. Hydroxyethyl starch 130/0.42 versus Ringer’s acetate in severe sepsis. N Engl J Med. 2012 Jul 12;367(2):124-34. Epub 2012 Jun 27. Erratum in: N Engl J Med. 2012 Aug 2;367(5):481. PubMed PMID: 22738085.

You don’t still use starch do you? Patients with severe sepsis who undergo fluid resuscitation with HES 130/0.42 are more likely die and need renal replacement therapy compared to those receiving Ringer’s acetate.

Recommended by Chris Curry

• Fertel BS, Nelson LS, Goldfarb DS. Extracorporeal removal techniques for the poisoned patient: a review for the intensivist. J Intensive Care Med. 2010 May-Jun;25(3):139-48. Epub 2010 May 5. Review. PubMed PMID: 20444738.

This paper is by far the best thing I’ve seen on the topic. The authors (Baruch Fertel, Lewis Nelson, and David Goldfarb) represent emergency medicine, medical toxicology, and nephrology. The paper is so full of pearls that it is impossible to summarize — I found myself underlining and highlighting almost every paragraph.

Recommended by Leon Gussow
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