Journal Feed Weekly Wrap-Up

Dec 21st, 2019
Clay Smith
categories:
In the Literature

We always work hard, but we may not have time to read through a bunch of journals. It’s time to learn smarter.

Originally published at JournalFeed, a site that provides daily or weekly literature updates.

Follow Dr. Clay Smith at @spoonfedEM, and sign up for email updates here.

#1: Managing Acute Severe Hypertension

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We need to know hypertension (HTN) and be expert in not only management of hypertensive emergency but urgency as well. Here is a quick review for you.

Why does the matter?
We see elevated BP all the time in the ED. We often see asymptomatic patients referred for BP elevation from clinics from those who should know better. This is a review article with several best practices. Make sure to review our prior post on the latest AHA HTN guidelines.

Under pressure…
The key take home points were:

Acute severe HTN with end organ damage is called hypertensive emergency and should be managed in the hospital with IV medications. What is end-organ damage?
- Brain: stroke, ICH, PRES
- Eye: retinal hemorrhage, exudate, papilledema
- CV: ACS, heart failure, aortic dissection
- Renal: AKI
- Microvascular: microangiopathic hemolytic anemia and “malignant HTN”
This next point is so important, I am going to quote it in full.
“Acute severe hypertension without acute target-organ damage (hypertensive urgency) is not associated with adverse short-term outcomes and can be managed in the ambulatory setting.”
To recap, HTN urgency does not impact short-term outcomes and can be managed in clinic. Generally, these patients should not be referred to the ED. They need oral medication started (or restarted) and close follow up.
Stopping previously prescribed medication is the most common reason for HTN urgency.
Due to autoregulation in patients with chronic HTN, the pace of BP lowering should be slow – 25% max in the first hour.
The type of IV medication for HTN emergency should be guided by the type of end organ damage. Here is a simplified way to think about this. For the brain, use nicardipine. For the heart or vessels, use nitroglycerin.
- Nicardipine – Use for diffuse microvascular injury (malignant HTN), HTN encephalopthy, ICH, or ischemic stroke.
- Nitroglycerin – Use for ACS, CHF, or aortic dissection (add esmolol for dissection).
- Goal decrease for most patients is usually 20-25% in hour one; a SBP of 160 is not a bad general target over hours 2-6. Dissection should target 120.

Source
Acute Severe Hypertension. N Engl J Med. 2019 Nov 7;381(19):1843-1852. doi: 10.1056/NEJMcp1901117.

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#2: Guidelines for Nonvariceal Upper GI Bleeding

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These guidelines for nonvariceal upper GI bleeding are important for us to know from start to finish.

Why does the matter?
This is an update of similar guidelines from 2010. We need to know all aspects of management, including endoscopic management, to understand their individual risk when they bounce back to the ED after hospital discharge.

Turn off the hose
These guidelines were based on the best available evidence from extensive literature review and recommendation of a multidisciplinary panel.

Preendoscopic management

Resuscitation should be initiated in patients with hemodynamic instability. Did they really need to say this?
A Glasgow Blatchford score of ≤1 may allow for safe discharge home.
They determined the transfusion trigger for patients without cardiovascular disease should be 8 g/dL; higher in patients with CV disease.
Endoscopy should not be delayed for anticoagulated patients.
Promotility agents should be used to improve endoscopic yield.
If endoscopy finds low risk features, patients may be discharged home right away.
PPIs may be used pre-endoscopy to “downstage the endoscopic lesion and decrease the need for endoscopic intervention but should not delay endoscopy.”

Endoscopic management

Endoscopy should occur within 24 hours.
It should be done with thermocoagulation, sclerosant, or clips. Clips are used only if high risk stimata, i.e. active bleeding or visible vessel in ulcer base.
TC-325 can temporize when other endoscopic methods fail. It is also called Hemospray and is a mineral based compound that coheres and adheres when wet, which promotes clotting. It should not be used as the sole bleeding control method.

Post-endoscopy

H2 blockers should not be used for active bleeding.
Somatostatin/octreotide are not recommended for nonvariceal bleeds.
For high risk stigmata on endoscopy, IV PPI loading and infusion are indicated.
An ulcer requiring endoscopic therapy should get twice daily PPI oral treatment for 2 weeks, then daily.

Hospital management

Patients may eat 24h after endoscopy.
Most patients with high risk stigmata should stay in the hospital for 72 hours at least.
Embolization or surgery are options after failed endoscopy.

Prevention

Patients with prior bleeding ulcer who need an NSAID should get a COX-2 inhibitor + a PPI.
Aspirin or anticoagulants for CV disease may be restarted as soon as benefit outweighs risk but should be given with a PPI.

Source
Management of Nonvariceal Upper Gastrointestinal Bleeding: Guideline Recommendations From the International Consensus Group. Ann Intern Med. 2019 Oct 22. doi: 10.7326/M19-1795. [Epub ahead of print]

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#3: Stroke Guidelines – 2019 Update From the AHA

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This is an update to the Stroke Guidelines released in 2018. We will focus on what’s new since last year.

Why does the matter?
Several new studies have resulted in the need for an update already. The field of stroke care is in the process of rapid change. Here is what’s new. This post is much longer than usual. The guidelines were 75 pages long.

Faster than reading 75 pages…

Public education and hospital personnel education should focus on having patients call 911 sooner in order to allow more patients to receive treatment, especially thrombectomy.
It is not clear if bypassing the nearest stroke center with thrombolysis capability in favor of one with both thrombolysis and thrombectomy is beneficial to patients. Procedures should be developed to help EMS better determine if a stroke could be a large vessel occlusion (LVO) to decide such things. Rob Orman just did a great podcast on this.
QI, including ED education to safely increase fibrinolytic treatment is recommended. This includes feedback, setting and monitoring goal times, such as time to CT, time to tPA.
Telemedicine can make a big impact on stroke care in remote locations by assessing tPA eligibility, advising administration, or determining if a patient may be a thrombectomy candidate, especially when local stroke teams are not available.
Systems should optimize the speed and efficiency of obtaining brain imaging.
An MRI to assess for microbleeds prior to tPA is not recommended.
Multimodal CT or MR imaging is not needed prior to tPA if the non-contrast CT is negative.
WAKE-UP led to this recommendation: “In patients with AIS who awake with stroke symptoms or have unclear time of onset > 4.5 hours from last known well or at baseline state, MRI to identify diffusion-positive FLAIR-negative lesions can be useful for selecting those who can benefit from IV alteplase administration within 4.5 hours of stroke symptom recognition.”
If LVO is suspected, a CTA may be performed without a serum creatinine.
If patients may be candidates for thrombectomy, it is reasonable to image the extracranial vertebrals and carotids for pre-procedural planning purposes.
DAWN and DEFUSE 3 led to this change: “When selecting patients with AIS within 6 to 24 hours of last known normal who have LVO in the anterior circulation, obtaining CTP or DW-MRI, with or without MRI perfusion, is recommended to aid in patient selection for mechanical thrombectomy, but only when patients meet other eligibility criteria from one of the RCTs that showed benefit from mechanical thrombectomy in this extended time window.”
Hypotension and hypovolemia should be corrected to maintain systemic perfusion.
Most tPA recommendations were the same except this: “IV alteplase (0.9 mg/kg, maximum dose 90 mg over 60 minutes with initial 10% of dose given as bolus over 1 minute) administered within 4.5 hours of stroke symptom recognition can be beneficial in patients with AIS who awake with stroke symptoms or have unclear time of onset >4.5 hours from last known well or at baseline state and who have a DW-MRI lesion smaller than one-third of the MCA territory and no visible signal change on FLAIR.”
Also related to tPA, it may be reasonable for mild disabling stroke from 3-4.5 hours but should not be given for mild non-disabling stroke at all. Also, tPA may be given to patients with sickle cell anemia and stroke as well as those with dense MCA sign.
Patients with 1-10 cerebral microbleeds on MRI may still receive tPA, but those with >10 are at greater risk for major bleed and likely should not.
Do not give IV ASA within 90 minutes of tPA.
Tenecteplace may be used instead of alteplase.
“In selected patients with AIS within 6 to 16 hours of last known normal who have LVO in the anterior circulation and meet other DAWN or DEFUSE 3 eligibility criteria, mechanical thrombectomy is recommended.” I A recommendation and “In selected patients with AIS within 16 to 24 hours of last known normal who have LVO in the anterior circulation and meet other DAWN eligibility criteria, mechanical thrombectomy is reasonable.” IIa LOE B-R
In the 6-24h window, evaluation and treatment should proceed as quickly as possible.
Brief hyperventilation to a PCO2 of 30-34 for severe edema is reasonable as a bridge to more definitive treatment.
There were many more new recommendations, but this is enough and covers the most important for EM.

Source
Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2019 Dec;50(12):e344-e418. doi: 10.1161/STR.0000000000000211. Epub 2019 Oct 30.

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Journal Feed Weekly Wrap-Up

#1: Managing Acute Severe Hypertension

#2: Guidelines for Nonvariceal Upper GI Bleeding

#3: Stroke Guidelines – 2019 Update From the AHA

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