R&R In The FASTLANE 118

Welcome to the 118th 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 6 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 : Overview; Archives and Contributors

This Edition’s R&R Hall of Famer

Kearon C,  et al. Antithrombotic Therapy for VTE Disease. Chest 2016. PMID: 22315268

• The new ACCP guidelines are out for venous thromboembolism and appear fairly progressive considering standard practice for much of the US. Subsegmental PEs get no anticoagulation in patients with no DVT and low risk for reoccurrence (i.e. Recent surgery). Oh, and send those low risk PE patients home on anticoagulation (or at least discharge them early). They are also very fond of the target specific anticoagulants.
• Recommended by: Lauren Westafer

Contenti J et al. Long-Term β-Blocker Therapy Decreases Blood Lactate Concentration in Severely Septic Patients. Crit Care Med 2015; 43(12):2616-22. PMID: 26427590

• Another article imploring clinicians to beware of patients on beta blockers in terms of using numbers to gauge severity of illness. We have seen previously how beta blocker use can mask shock by preventing the patient from mounting a tachycardia or exhibiting a positive shock index. This group demonstrates that patients with sepsis may not mount the higher lactate levels commonly thought to indicate severity. Bottom line, don’t rely on lab findings alone. Take in the entire picture of the patient in your assessment.
• Recommended by: Anand Swaminathan

Meyers HP et al. Validation of the modified Sgarbossa criteria for acute coronary occlusion in the setting of left bundle branch block: A retrospective case-control study. Am Heart J 2015; 170(6):1255-64. PMID: 26678648

• Identifying STEMI in patients with in patients with an underlying LBBB can be difficult. The original Sgarbossa criteria was a major step in aiding clinicians but had it’s own flaws. In 2012, Steve Smith and colleagues derived a new criteria including ST elevation/S wave ratio (in place of discordant elevation) to aid in diagnosis. This study provides validation of that approach. Although the study was retrospective and only included 45 patients with acute coronary occlusion, it provides valuable information on the utility of ST elevation/S wave ratio for diagnosis of acute MI in this subset of patients.
• Recommended by: Anand Swaminathan

Study of Maternal and Child Kissing (SMACK) Working Group. Maternal kisses are not effective in alleviating minor childhood injuries (boo-boos): a randomized, controlled and blinded study. J Eval Clin Pract 2015. PMID: 26711672

• This is kind of interesting in many ways, it appears that the paper was submitted as a joke (which is obvious reading the methods), but the Journal actually thought it was a real piece of research and published it. After the laugh and outcry, apparently the Journal is saying that the paper was publish as satire, despite the fact that there is no indication of it in the issue.
• Satire or Science, the research shows when 943 toddlers are induced minor injuries, and then treated with maternal kisses, third-party kisses or no treatment at all, there was no difference in the Toddler Discomfort Index at 1 and 5′. Actually the intervention group have a higher distress than placebo. The toddlers were blind to the intervention. Kissing boo-boos is not good.
• I think the only bottom line here is that the current publication/peer review system is not working.
• Recommended by: Daniel Cabrera

Robertson L, et al. Oral direct thrombin inhibitors or oral factor Xa inhibitors for the treatment of pulmonary embolism. Cochrane Database of Systematic Reviews 2015. PMID 26636644

• This is a Cochrane review analyzing the current evidence behind the use of novel anticoagulants (NOACs) in the treatment of pulmonary embolism (PE). The results are predictable and reflect the current understanding about NOACs: no better and no worse than warfarin. The study pooled more than 7800 patients in groups comparing anti-thrombin (dabigatran) versus antiXa (-xabans); although some heterogeneity exists, the quality of the analysis was felt to be good. No differences in recurrence of PE or DVT, mortality or major bleeding was found. It appears that NOACs are more convenient but in no case different than warfarin in patient oriented outcomes. Caveat is quality of life was not measured.
• Recommended by: Daniel Cabrera

C. Frerk and the Difficult Airway Society intubation guidelines working group. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J of Anaes 2015. PMID 26556848

• These new guidelines from the Difficult Airway Society provide a strategy to manage unanticipated difficulty with tracheal intubation. A simplified, single algorithm covers unanticipated difficulties in both routine intubation and rapid sequence induction. The guidelines promote “failure” in that advances in the understanding of crisis management emphasize the recognition, clear declaration of difficulty during airway management and planning for failed intubation should be part of the preparation for airway management. 
• The numbers of airway interventions are limited to 3 attemps (+ 1 by an more expirenced provider), If tracheal intubation fails, supraglottic airway devices are recommended to provide a route for oxygenation while reviewing how to proceed. Surgical cricothyroidotomy is recommended as the preferred rescue technique and should be practised by all anaesthetists. 
• Recommended by: Søren Rudolph