Research and Reviews in the Fastlane 167

Research and Reviews in the Fastlane

Welcome to the 167th 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 5 recommended reads. The R&R Editorial Team includes Jeremy Fried, Nudrat Rashid, Soren Rudolph, Justin Morgenstern 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

Education                                                            R&R Hall of Famer - You simply MUST READ this!


Myles PS et al. ATACAS study. Tranexamic Acid in Patients Undergoing Coronary-Artery Surgery. N Engl J Med 2016. PMID: 27774838.

  • The ATACAS study was a large, multi-centre, double blind study with a 2 by 2 factorial design. Patients undergoing coronary artery surgery that were considered “at risk for peri-operative complications” were assigned to either receiving aspirin or placebo and tranexamic acid or placebo. The group that received tranexamic acid had a lower risk of bleeding compared to placebo. Even though there wasn’t a higher risk of death or thrombotic complications, there was a higher risk of post-operative seizures observed within the tranexamic acid group.
  • Recommended by: Nudrat Rashid

The Best of the Rest

R&R Hot Stuff - Everyone’s going to be talking about thisWillman MW, et al. Do heroin overdose patients require observation after receiving naloxone? Clin Toxicol 2016. PMID: 27849133

  • There has been recent interest in a policy of decreased or no observation time for patients receiving naloxone after heroin overdose. This article summarizes several retrospective reviews, concluding that patients with heroin overdose typically do well after EMS treat-and-release naloxone administration, and that they can be safely discharged from the ED after a period of one-hour observation. Considerable limitations in the retrospective nature of such reviews and significant impact of new adulterants such as fentanyl and U-47700 on current “heroin” overdoses seriously limit interpretation and applicability of these studies to today’s clinical practice. Strong caution should be taken in making practice changes based on retrospective and potentially outdated data.
  • Recommended by: Meghan Spyres
  • Further reading: Treating “heroin” overdose: The past is no guide (The Poison Review)

Emergency Medicine
R&R Game Changer? Might change your clinical practiceTaylor DM, et al. Midazolam-Droperidol, Droperidol, or Olanzapine for Acute Agitation: A Randomized Clinical Trial. Ann Emerg Med 2016. PMID: 27745766

  • This was a well executed RCT that found midazolam 5 mg/droperidol 5 mg IV was superior to droperidol 10mg IV or olanzapine 10 mg IV for agitated patients. The 2-drug combo worked in 75% of patients at ten minutes vs ~50% in the other two groups. Also, fewer repeat sedative doses were needed when the drugs were combined. Median time to sedation was only 5 minutes for the combo vs. 11 minutes for the other two individual drugs. Adverse events were statistically similar in all groups, but the midazolam/droperidol group had a higher percentage temporarily needing jaw thrust or supplemental oxygen. For agitation, the combination of midazolam 5 mg/droperidol 5 mg IV was better and faster onset than droperidol 10 mg IV or olanzapine 10 mg IV. 
  • Recommended by: Clay Smith

R&R Eureka - Revolutionary idea or conceptPengel KB. Common overuse injuries in the young athlete. Pediatr Ann 2014. PMID: 25486038

  •  We constantly want kids to be more active… but that can lead to some injuries. The knee is very susceptible to overuse injuries, but before you simply label it a “Sprain” consider a few other ominous entities.
  • Recommended by: Sean Fox

Pediatrics                                                                                                                                                               R&R Eureka - Revolutionary idea or concept
R&R Hot Stuff - Everyone’s going to be talking about thisHoreczko T, et al. The Pediatric Assessment Triangle: Accuracy of its application by nurses in the triage of children. J Emerg Nurs 2013. PMID: 22831826

  •  This prospective observational trial looked at the outcomes of 528 children for whom the triage nurse had performed an assessment using the pediatric assessment triangle (PAT) at a large academic pediatric emergency department. Two pediatricians, blinded to that triage assessment, retrospectively reviewed the chart to determine the final diagnosis (of stable versus unstable). The biggest weakness of this data is that although 1002 charts were selected for review, only 528 contained adequate data for inclusion. The PAT did a good job screening for instability (97.3% sensitive 95%CI 64.6-98.8%), although like most screening tools it does over call (specificity of 22.9% with 95%CI 17.0-30.0%). The triangle was reasonable for identifying respiratory distress (LR+ 4, 95% CI 3.1-4.8), respiratory failure (LR+ 12, 95% CI 4.0-37), shock (LR+ 4.2, 95% CI 3.1-5.6), central nervous system/metabolic disorder (LR+ 7, 95% CI 4.3-11), and cardiopulmonary failure (LR+ 49, 95% CI 20-120). Perfect identification of the final assessment is not the role of a triage tool, like the PAT. The PAT tool performed well here, but perhaps a more appropriate measure would have been something like the number of children who become unstable within the first hour who were missed by the PAT? Bottom line: The pediatric assessment triangle is an excellent triage tool, but you still have to follow it with a complete medical assessment.
  • Recommended by: Justin Morgenstern

The R&R iconoclastic sneak peek icon key

Research and ReviewsThe list of contributorsR&R in the FASTLANE 009 RR Vault 64 The R&R ARCHIVE
R&R in the FASTLANE Hall of FamerR&R Hall of famer You simply MUST READ this!R&R Hot Stuff 64R&R Hot stuff! Everyone’s going to be talking about this
R&R in the FASTLANELandmark PaperR&R Landmark paper A paper that made a differenceR&R Game Changer 64R&R Game Changer? Might change your clinical practice
R&R Eureka 64R&R Eureka! Revolutionary idea or conceptR&R in the FASTLANE RR Mona Lisa R&R Mona Lisa Brilliant writing or explanation
R&R in the FASTLANE RR Boffin 64 R&R Boffintastic High quality researchR&R in the FASTLANE RR Trash 64 R&R Trash Must read, because it is so wrong!
R&R in the FASTLANE 009 RR WTF 64 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.

Last update: Jan 5, 2017 @ 9:57 am

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