JournalFeed Weekly Wrap-Up

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: MRI-Guided Alteplase for Wake-Up Stroke

Spoon Feed
For patients with unknown time of stroke onset, MRI characteristics may be able to discern the timing of the stroke and allow for thrombolytic therapy.  Overall, outcomes were better with thrombolysis but at the possible cost of higher mortality and risk of intracranial bleed.

Why does this matter?
If a patient wakes up with stroke symptoms, there is no way to know an accurate time of onset, which precludes use of thrombolytic therapy.  But if we estimate timing using MRI, lytics might still be helpful.

Better or bleed – tough choice
This was a RCT with 503 patients total that was stopped early because they ran out of money…seriously.  They intended to enroll 800.  For patients with unknown time of stroke onset (most occurred while asleep), MRI was performed and patients were randomized to receive alteplase or placebo if the MRI showed an, “ischemic lesion that was visible on MRI diffusion-weighted imaging but no parenchymal hyperintensity on fluid-attenuated inversion recovery (FLAIR), which indicated that the stroke had occurred approximately within the previous 4.5 hours.”  For the primary outcome of favorable neurological outcome at 90 days (modified Rankin scale 0-1), the alteplase group was better: 131/246 (53.3%) for alteplase; 102/244 patients (41.8%) for placebo (adjusted OR, 1.61; 95% CI 1.09 to 2.36).  A familiar refrain with lytics in stroke; there was slightly higher mortality in the alteplase group and more intracranial bleeding, both of which were not statistically significant but may have been had they recruited enough patients.  It appears MRI features may be able to guide lytic therapy for stroke patients with unknown time of onset and lead to a better outcome in more patients, assuming they are lucky enough not to have a head bleed and die.

Source
MRI-Guided Thrombolysis for Stroke with Unknown Time of Onset.  N Engl J Med. 2018 May 16. doi: 10.1056/NEJMoa1804355. [Epub ahead of print]

Another Spoonful
emDocs took an in-depth look at the new 2018 stroke guidelines

#2: IOTA – Oxygen, Less Is More

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For adults with varied acute illnesses, use of supplemental oxygen in patients with room air SpO2 of 94% or greater was associated with increased short and longterm mortality.

Why does this matter?
Patients who are acutely ill, with normal or slightly low SpO2 are often placed on oxygen to keep saturations at or near 100%.  But several studies have called this practice into question for acute MI, stroke, and critical illness.  What does a broader look at the literature show?

IOTA avoid giving too much oxygen
This was a meta-analysis of 25 RCTs including 16,037 acutely ill adult patients of various types (sepsis, critical illness, stroke, trauma, myocardial infarction, cardiac arrest, or emergency surgery) that received either a liberal or conservative oxygen strategy.  Those who received a more liberal oxygen strategy, median SpO2 96% or more, fared worse, with increased in-hospital, 30-day, and longterm mortality.  Overall, 11 more people per 1000 would die in-hospital with a liberal oxygen strategy.  In critically ill patients, 40 more patients per 1000 would die from excessive supplemental oxygen.  In practical terms, if a patient has a room air SpO2 of 94% or greater, avoid supplemental oxygen.

Source
Mortality and morbidity in acutely ill adults treated with liberal versus conservative oxygen therapy (IOTA): a systematic review and meta-analysis.  Lancet. 2018 Apr 28;391(10131):1693-1705. doi: 10.1016/S0140-6736(18)30479-3. Epub 2018 Apr 26.
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#3: Bougie vs Stylet – The BEAM Trial

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First attempt success was higher in the bougie group vs stylet group (98% vs 87% in all comers, 96% vs 82% in patients with at least one difficult airway characteristic). The median duration of the first-attempt as well as incidence of hypoxemia was similar between bougie and stylet groups.

Why does this matter?
We often use the bougie as an adjunct device for challenging airways. This study looks at the utility of a bougie for all comers and whether that extra step improves outcomes without increasing time to intubation or complications.

BEAM me up, Scotty!
This was a RCT conducted at Hennepin County Medical Center with 757 patients. They randomized patients to either bougie or ETT+stylet for initial attempt. Intubations were performed by mostly senior ED residents or fellows using a Macintosh blade (majority with C-MAC).

First-attempt success was better in the bougie group, with no statistically significant difference in terms of the duration of the attempt. Overall, rates of hypoxemia were similar between bougie and stylet groups (13% vs 14%); however, there was less hypoxemia during the first-attempt in the bougie group.

This study gives the first RCT data on the utility of the bougie as a primary intubation device. These results may not be generalizable if you do not have a similar set-up in your hospital or are not comfortable using the bougie. I would like to see this study repeated in more centers, but this is pretty compelling data in support of using the bougie first.

Source
Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients With Difficult Airways Undergoing Emergency Intubation: A Randomized Clinical Trial.  JAMA. 2018 May 16. doi: 10.1001/jama.2018.6496. [Epub ahead of print]
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For more on bougie, see this great posts: EMCrit, REBEL EM, and First10EM