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 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
Starmer AJ, et al. Changes in Medical Errors after Implementation of a Handoff Program. NEJM 2014; 371(19): 1803–12. 25372088
- Despite a significant impetus about its use in healthcare, there was no good evidence that a standard handoff tool at the moment of patient transfer or care improved outcomes. This is a multicenter study (9 sites) where they used the I-PASS mnemonic for transitions of care. The use of the tool decrease errors in a 23% and adverse events in a 30%. The participants in this study did not experience increase workload.
- In the best study to date examining patient safety consequences with standardized handoffs, these authors found a reduction of 1.4 preventable adverse patient events per 100 patient admissions (4.7 vs. 3.3 events per 100 admissions). Nine different pediatric training sites were included in the study. Also of note, direct observation by research assistants found no change in resident workflow or amount of time with patients and family with the institution of the standardized handoff.
- Recommended by: Daniel Cabrera, Jeremy Fried
- Further reading: It’s a Patient Hand-Off Miracle (Emergency Medicine Literature of Note)
The Best of the Rest
Rubano E et al. Systematic Review: Emergency Department Bedside Ultrasonography for Diagnosing Suspected Abdominal Aortic Aneurysm. Acad Emerg Med 2013;20(2): 128-38. PMID: 23406071
- You better think ultrasound if you are thinking acute abdominal aneurysm (Triple A).
The prevalence of triple A is 1.3-15% in emergency department adults and increases with age. It’s greatest in males over 65 with a history of smoking and hypertension.
These are patients that are the absolute definition of “can’t miss”. The mortality with rupture approximately 90 percent. There is no combination of history or physical findings that can reliably exclude acute abdominal aneurysm. Adult emergency department patients with any presentation consistent with potential triple A should be scanned.
This paper is part of evidence based diagnostic series in Academic Emergency Medicine. The decision editor for this is the same guy who wrote the book on Evidence Based Emergency Care, Dr. Chris Carpenter.
The positive likelihood ratio (+LR) was 10.8-infinity
The negative likelihood ratio (-LR) was 0.00-0.025
Bottom Line: Emergency department ultrasound, when applied by “trained” emergency physicians, is an excellent accurate diagnostic modality to detect triple A’s in symptomatic adult patients.
- Recommended by: Ken Milne, Mike Mallin and Matt Dawson
- Further reading: You better think ultrasound for acute abdominal aneurysm (Skeptic’s Guide to Emergency Medicine)
Cheskes S et al. The impact of peri-shock pause on survival from out-of-hospital shockable cardiac arrest during the Resuscitation Outcomes Consortium PRIMED trial. Resuscitation 2014; 18(3): 336-42. PMID: 24513129
- The length of the pre-shock pause is strongly associated with the rate of good outcomes after cardiac arrest. This is the largest study investigating the topic. Reducing the pre-shock and post-shock pause is easy too: continue compressions while the defibrillator charges and immediately resume compressions after discharge. It’s small alterations in our methods that often lead to the biggest outcome changes.
- Recommended by: Anand Swaminathan
Bangalore S, et al. Clinical Outcomes with β-Blockers for Myocardial Infarction: A Meta-analysis of Randomized Trials. Am J Med 2014; 127(10): 939-53. PMID: 24927909.
- Outstanding meta analysis that looks at the effect of beta blockers in myocardial infarction before and after the modern reperfusion era. This paper is full of multiple data points that will significantly inform cardiology practice, to the point that the authors recommend that guidelines re-examine the recommendation for beta blockers in MI in patients undergoing contemporary treatment. Most significantly for emergency practitioners, no mortality or cardiovascular mortality benefit was found for the use of IV beta blockers in the acute phase. The COMMIT trial drives most of the findings, but no differences were found when that data was excluded in the analysis.
- Recommended by: Jeremy Fried
Marquié JC, et al. Chronic effects of shift work on cognition: findings from the VISAT longitudinal study. Occup Environ Med. 2014. PMID: 25367246
- This is french study using a large (3000+) cohort of workers from multiple areas of industry. The population was separated in shift workers (defined broadly as going to bed after midnight, waking up before 5am, alternating schedule or not able to sleep overnight). The applied cognitive tests to each patient in a yearly basis. The results showed chronic cognitive impairment in the shift-worked population compared to non-shift worked. There were small but statistically significant differences between the groups that were more marked if the shift-work was longer that 10 years. After 5 years of non-shift work, there was no difference suggesting recovery.
- Recommended by: Daniel Cabrera
Beaudoin FL, et al. Low-dose Ketamine Improves Pain Relief in Patients Receiving Intravenous Opioids for Acute Pain in the Emergency Department: Results of a Randomized, Double-blind, Clinical Trial. Acad Emerg Med. 2014;21(11):1193–1202. PMID: 25377395
- This study (n=60) randomized patients in the ED getting IV opioids to morphine (0.1 mg/kg) + placebo or morphine (0.1 mg/kg) + ketamine (group 1 0.15 or group 2 0.30 mg/kg). Patients in the ketamine arm had significantly decreased pain without significant adverse effects, although the group with the higher dose of ketamine had a seeming increase in side effects without added analgesic benefit. The literature is mounting that low dose ketamine has utility in the acute analgesia armamentarium but selecting the right population will likely be key (and more is not better).
- Recommended by: Lauren Westafer
- Further Listening: Cliff Reid shares his experience on “sub-dissociative” ketamine for analgesia –NeuroRAGE Special Edition (RAGE podcast)
Emergency Medicine, Cardiology, Neurology
Ge Coll-Vinent B et al. Stroke Prophylaxis in Atrial Fibrillation: Searching for Management Improvement Opportunities in the Emergency Department: The HERMES-AF Study. Ann Emerg Med 2014. PMID: 25182543
- While it’s clear that atrial fibrillation raises the risk of stroke in patients, selecting the right prophylaxis regimen continues to be challenging. In this observational study performed in Spain, the authors found that many patients that were moderate to high-risk for stroke were not discharged on the appropriate prophylaxis. Whether this is the Emergency Providers role or not is debatable but it is vital for us to consider starting the right medications upon discharge or ensuring close follow up where this can be done.
- Recommended by: Anand Swaminathan
Ralston SL, et al. Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis. Pediatrics. 2014. PMID: 25349312.
- Can we stop doing the wrong things for bronchiolitis, and start doing the right things? Don’t test for virus, order bloodwork, or get X rays. This also means don’t give steroids, albuterol, epinephrine, antibiotics, or CPT. Hypertonic saline is recommended against in ED, but maybe you can use in hospitalized patients.
You should hydrate all patients with bronchiolitis. Start at their mouth if possible.
- Recommended by: Justin Hensley
Leidel BA et al. Comparison of intraosseous versus central venous vascular access in adults under resuscitation in the emergency department with inaccessible peripheral veins. Resuscitation 2012; 83(1):40-5. PMID: 21893125
- There continues to be an ongoing debate on the vascular access method of choice in patients in whom peripheral access has failed. This article demonstrates that IO access is more likely to have 1st pass success (85 vs. 60%) than central line insertion and is faster (2 vs. 8 min). A difference of 6 minutes is critical for interventions like airway management but may be negated by rapidity of infusion for procedures like blood transfusion or fluid administration.
- Recommended by: Anand Swaminathan
Emergency Medicine, Infectious Disease
Singer AJ, Thode HC Jr. Systemic antibiotics after incision and drainage of simple abscesses: a meta-analysis. Emerg Med J. 2013. PMID: 23686731
- Treatment for an uncomplicated cutaneous abscess is usually just incision and drainage. However, patients still routinely get prescribed oral antibiotics?
An earlier 2007 systematic review in Annals of Emergency Medicine by Hanki and Everett looked at this issue. Their closing line was “A conclusive, multicenter, double-blind, randomized, placebo-controlled clinical trial is lacking and sorely needed.”
This new SR identified only 4 studies (2 from 2010) and included almost 600 patients. The conclusion was adding antibiotics after I&D did not significantly improve early cure or recurrence rates for uncomplicated cutaneous abscesses.
- Recommended by: Ken Milne
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…