R&R in the FASTLANE 015

The fifteenth edition of our series of eminence-based evidence:

R&R in the FASTLANE 010 RR IN THE FASTLANE LOGO 21 590x213

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 8 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

  • Crash-2 trial collaborators. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet. 2010 Jul 3;376(9734):23-32. Pubmed PMID: 20554319
R&R in the FASTLANE 009 RR Hall of fame 64 R&R in the FASTLANE 009 RR Hot Stuff 64 R&R in the FASTLANE 009 RR Landmark 64 R&R in the FASTLANE 009 RR GameChanger 64 R&R in the FASTLANE 009 RR Boffin 64 The paper that started the debate on TXA in trauma, sparked several subgroup analysis papers and is slowly finding it’s way into clinical practice.

Recommended by John Larkin
Learn more:
EMCrit Podcast 67 – Tranexamic Acid (TXA), Crash 2, & Pragmatism with Tim Coats
Emergency Medicine Ireland — Crash-2
Emergency Medicine Literature of Note — Critique of Crash-2
ICU Rounds Podcast — EARLY use of Tranexamic Acid may improve survival from bleeding in trauma
The Lancet — Crash-2: Tranexamic Acid and Trauma Patients (includes link to fulltext pdf)
The NNT — Tranexamic acid for Trauma

  • Krumholz SD et al. Study of Neurontin: Titrate to Effect, Profile of Safety (STEPS) Trial. Arch Intern Med ;2011 Jun 27;171:1100-1107. Pubmed PMID: 21709111
R&R in the FASTLANE 009 RR Hall of fame 64 R&R in the FASTLANE 009 RR Mona Lisa 64 So-called seeding trials are framed as phase 4 research, but are often designed and partially carried out by drug firms’ marketing departments to promote increased use of a specific drug. Disclosure of the true goal is made neither to the patients nor to participating clinicians. This must-read paper uses internal company memos obtained during product liability litigation to describe the whole sordid process.

Recommended by Leon Gussow

This week’s R&R recommendations

  • Bellomo R. The dangers of dogma in medicine. Med J Aust. 2011 Oct 3;195(7):372-3. PubMed PMID: 21978331.
R&R in the FASTLANE 009 RR Mona Lisa 64 R&R in the FASTLANE 009 RR Eureka 64 Written by an intensivist who has few rivals in his quest to bring light where there is darkness in medicine.
An excerpt: “Doctors would do well to maintain a degree of cautious skepticism for both bold new fashions and received wisdom, whether generated by the world or by the self. They would do even better to question what they do and see such questioning as an asset. It is everyone’s responsibility to find out how to ask questions systematically, find answers from searching the literature, critically appraise the literature and apply the results to practice.”

Recommended by Chris Nickson

  • Berger E. Web 2.0 in Emergency Medicine: Specialty Embracing the Future of Medical Communication. Ann Emerg Med. 2012; 59(4) A21-A23
R&R in the FASTLANE 009 RR GameChanger 64 R&R in the FASTLANE 009 RR Hot Stuff 64 A sign that Web 2.0 is on the road to becoming mainstream for emergency phyisicians?

Recommended by Mike Cadogan
Fulltext

  • Krumholz SD et al. Study of Neurontin: Titrate to Effect, Profile of Safety (STEPS) Trial. Arch Intern Med ;2011 Jun 27;171:1100-1107. Pubmed PMID: 21709111
R&R in the FASTLANE 009 RR Hall of fame 64 R&R in the FASTLANE 009 RR Mona Lisa 64 So-called seeding trials are framed as phase 4 research, but are often designed and partially carried out by drug firms’ marketing departments to promote increased use of a specific drug. Disclosure of the true goal is made neither to the patients nor to participating clinicians. This must-read paper uses internal company memos obtained during product liability litigation to describe the whole sordid process.

Recommended by Leon Gussow

  • Parsons M, Spratt N, Bivard A, et al. A randomized trial of tenecteplase versus alteplase for acute ischemic stroke. N Engl J Med. 2012 Mar 22;366(12):1099-107. Pubmed PMID: 22435369
R&R in the FASTLANE 009 RR Hot Stuff 64 There’s a new (old) TPA on the block – and 25 patients worth of data says it’s better than the old TPA. Good enough for the NEJM!

Recommended by Ryan Radecki
Learn more: Emergency Medicine Literature of Note — TPA is dead! Long live TPA!

  • Hagihara A, Hasegawa M, Abe T, Nagata T, Wakata Y, Miyazaki S. Prehospital epinephrine use and survival among patients with out-of-hospital cardiac arrest.  JAMA. 2012 Mar 21;307(11):1161-8. PubMed PMID: 22436956
R&R in the FASTLANE 009 RR Hot Stuff 64 R&R in the FASTLANE 009 RR Boffin 64 This massive Japanese observational study, like the brilliant Jacobs et al study finds that adrenaline (aka epi) increases ROSC. But it is associated (no causation implied by an observational study, remember) with worse outcomes in the longer term (survival AND neurological outcomes). Do we need a really big RCT? Can it be done? Are you going to stop giving epi? (But what else is there to give… SNP?)

Recommended by Chris Nickson, Ryan Radecki
Learn more:
Emergency Medicine Literature of Note — More Nails In the Coffin For Epinephrine
EMCrit Wee — Abandon Epinephrine?

  • Jacobs IG, Finn JC, Jelinek GA, Oxer HF, Thompson PL. Effect of adrenaline on survival in out-of-hospital cardiac arrest: A randomised double-blind placebo-controlled trial. Resuscitation. 2011 Sep;82(9):1138-43. Epub 2011 Jul 2. PubMed PMID: 21745533.
R&R in the FASTLANE 009 RR Eureka 64 R&R in the FASTLANE 009 RR Hot Stuff 64 R&R in the FASTLANE 009 RR Boffin 64 By now everyone knows this paper, but it needs to be on R&R… and not just because its from Western Australia (all power to Jacobs and Jelinek!). Commentators like John Marx on Journal Watch interpreted this as evidence of benefit for adrenaline as although it was underpowered, it found an increase in ROSC with epi that was not statistically significant. That’s all well and good but even if it was statistically significant, would it be clinically significant? Or could it even make things worse down the track?

Recommended by Chris Nickson
Learn more:
EMRAP — PACA Study — Epinephrine (Mel Herbert talks to Ian Jacobs; subscription required)
EMCrit Wee — Abandon Epinephrine?

  • Casey SJ, de Alwis WD. Review article: Emergency department assessment and management of stab wounds to the neck. Emerg Med Australas. 2010 Jun;22(3):201-10 PubMed PMID: 20497212.
R&R in the FASTLANE 009 RR GameChanger 64 R&R in the FASTLANE 009 RR Mona Lisa 64 Avoid a trauma tribulation when faced with penetrating neck injuries.This is an excellent overview of the assessment and management of stab wounds to the neck.

Recommended by John Larkin

  • Crash-2 trial collaborators. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet. 2010 Jul 3;376(9734):23-32. Pubmed PMID: 20554319
R&R in the FASTLANE 009 RR Hall of fame 64 R&R in the FASTLANE 009 RR Hot Stuff 64 R&R in the FASTLANE 009 RR Landmark 64 R&R in the FASTLANE 009 RR GameChanger 64 R&R in the FASTLANE 009 RR Boffin 64 The paper that started the debate on TXA in trauma, sparked several subgroup analysis papers and is slowly finding it’s way into clinical practice.

Recommended by John Larkin
Learn more:
EMCrit Podcast 67 – Tranexamic Acid (TXA), Crash 2, & Pragmatism with Tim Coats
Emergency Medicine Ireland — Crash-2
Emergency Medicine Literature of Note — Critique of Crash-2
ICU Rounds Podcast — EARLY use of Tranexamic Acid may improve survival from bleeding in trauma
The Lancet — Crash-2: Tranexamic Acid and Trauma Patients (includes link to fulltext pdf)
The NNT — Tranexamic acid for Trauma

The R&R iconoclastic sneak peek icon key

R&R in the FASTLANE 009 RR Authors 64 The list of contributors R&R in the FASTLANE 009 RR Vault 64 The R&R ARCHIVE
R&R in the FASTLANE 009 RR Hall of fame 64 R&R Hall of fame
You simply MUST READ this!
R&R in the FASTLANE 009 RR Hot Stuff 64 R&R Hot stuff!
Everyone ‘s going to be talking about this
R&R in the FASTLANE 009 RR Landmark 64 R&R Landmark paper
A paper that made a difference
R&R in the FASTLANE 009 RR GameChanger 64 R&R Game Changer?
Might change your clinical practice
R&R in the FASTLANE 009 RR Eureka 64 R&R Eureka!
Revolutionary idea or concept
R&R in the FASTLANE 009 RR WTF 64 R&R WTF!
Weird, transcendent or funtabulous!
R&R in the FASTLANE 009 RR Boffin 64 R&R Boffintastic
High quality research
R&R in the FASTLANE 009 RR Trash 64 R&R Trash
Must read, because it is so wrong!
R&R in the FASTLANE 009 RR Mona Lisa 64 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.

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Comments

  1. says

    Both the Hagihara and Jacobs papers on pre-hospital adrenalin (epinephrine) get a good summary review by Scott Weingart on a recent EMCrit Wee. The Jacobs trial was terminated prematurely and there were seemingly a fair proportion of protocol violations. The Hagihara trial appears in essence to be a retrospective document audit that offers association only. As Scott suggests, perhaps there is now enough evidence of evidential equipoise to justify looking for evidence -- So bring on the multicetre, placebo controlled RCT in multiple countries.

    • says

      I think Ian Jacobs and colleagues showed that it may be impossible to perform a multi-center randomised controlled trial on this in a country like Australia. Could it be done in Japan or elsewhere? Perhaps.

      I’ve added links to Scott’s great comments on this topic. Thanks for the heads up!

      C

      • says

        The editorial accompanying the Hagihara paper was by Dr. Clifton W. Callaway, one of the listed authors for the AHA ACLS guidelines. He states that there is equipoise between placebo and epinephrine.

        It wasn’t the IRBs that prevented the Jacobs trial from reaching significance, but politicians misinforming the public.

        Even the doctors who were opposed to studying epinephrine in a randomized placebo-controlled trial will have a hard time claiming that there is anything unethical about an epinephrine vs. placebo study.

        Even the AHA does not “require” administration if epinephrine.

        “It is reasonable to consider administering a 1 mg dose of IV/IO epinephrine every 3 to 5 minutes during adult cardiac arrest (Class IIb, LOE A).”
        http://circ.ahajournals.org/content/122/18_suppl_3/S729.full#sec-25

        “Deemphasis on Devices and Advanced Cardiovascular Life Support Drugs During Cardiac Arrest
        At the time of the 2010 International Consensus Conference there were still insufficient data to demonstrate that any drugs or mechanical CPR devices improve long-term outcome after cardiac arrest.45 Clearly further studies, adequately powered to detect clinically important outcome differences with these interventions, are needed.”
        http://circ.ahajournals.org/content/112/22_suppl/III-133.full

        .

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