First EDition: News for and about the practice of Emergency Medicine
Magnesium given at stroke onset didn’t improve functional outcomes; Glucose level may predict mortality in acute heart failure; In severe trauma, 1:1:1 transfusion protocol linked to less exsanguination; Stress tests in ED lead to unneeded cardiac interventions; New treatment options outlined for acute-onset, severe hypertension in pregnancy; “Drip-and-ship” thrombolysis remains common for ischemic stroke; Three trials cement embolectomy for acute ischemic stroke; Views on the News - Results warrant embolectomy scale-up
BY NICOLA GARRETT
FROM OBSTETRICS AND GYNECOLOGY
The American College of Obstetricians and Gynecologists has added nifedipine as a first-line treatment for acute-onset severe hypertension during pregnancy and the postpartum period in an updated opinion from its Committee on Obstetric Practice.
,The update, released on Jan. 22, points to studies showing that women who received oral nifedipine had their blood pressure lowered more quickly than with either intravenous labetalol or hydralazine – the traditional first-line treatments – and had a significant increase in urine output. Concerns about neuromuscular blockade and severe hypotension with the use of nifedipine and magnesium sulphate were not borne out in a large review, the committee members wrote, but they advised careful monitoring since both drugs are calcium antagonists.
The committee opinion includes model order sets for the use of labetalol, hydralazine, and nifedipine for the initial management of acute onset severe hypertension in women who are pregnant or post partum with preeclampsia or eclampsia (Obstet. Gynecol. 2015;125:521-5).
While all three medications are appropriate in treating hypertensive emergencies during pregnancy, each drug has adverse effects.
For instance, parenteral hydralazine can increase the risk of maternal hypotension. Parenteral labetalol may cause neonatal bradycardia and should be avoided in women with asthma, heart disease, or heart failure. Nifedipine has been associated with increased maternal heart rate and overshoot hypotension.
“Patients may respond to one drug and not another,” the committee noted.
The ACOG committee also called for standardized clinical guidelines for the management of patients with preeclampsia and eclampsia.
“With the advent of pregnancy hypertension guidelines in the United Kingdom, care of maternity patients with preeclampsia or eclampsia improved significantly and maternal mortality rates decreased because of a reduction in cerebral and respiratory complications,” they wrote. “Individuals and institutions should have mechanisms in place to initiate the prompt administration of medication when a patient presents with a hypertensive emergency.”
The committee recommended checklists as one tool to help standardize the use of guidelines.
“Drip-and-ship” thrombolysis remains common for ischemic stroke
BY MICHELE G. SULLIVAN
AT THE INTERNATIONAL STROKE CONFERENCE
NASHVILLE, TENN. – About 25% of patients with ischemic stroke who receive thrombolytic therapy get it in the field before hospital transfer with the “drip-and-ship” paradigm. While there were only modest differences in clinical outcomes between these patients and those treated when admitted to an emergency department, drip-and-ship may actually increase the overall use of tissue plasminogen activator (TPA), Dr. Kevin N. Sheth said at the International Stroke Conference, sponsored by the American Heart Association.
The retrospective analysis, which was simultaneously published in Stroke (2015 Feb. 11 [doi:10.1161/STROKEAHA.114.007506]), plumbed the Get With the Guidelines registry for data to describe trends in the use of TPA and drip-and-ship administration across the United States over time. The study involved 1,440 hospitals and 44,667 patients who had an ischemic stroke during 2003-2010 and received TPA. Of these, 10,475 (23.5%) received it in the field before optional admission and within 3 hours of symptom onset.
Vitals Key clinical point: The rate of thrombolysis for ischemic stroke via drip-and-ship has remained steady over the past 12 years. Major finding: About a quarter of ischemic stroke patients eligible for TPA are getting it in the field, via the “drip-and-ship” paradigm. Data source: A retrospective study comprising 44,667 patients with ischemic stroke. Disclosures: Dr. Sheth is a member of the Get with the Guidelines (GWTG) Stroke Clinical Workgroup, and he is a coinvestigator and executive committee member for Glyburide Advantage in Malignant Edema and Stroke-Remedy Pharmaceuticals (GAMES-RP), a phase II trial to prevent swelling in patients with large stroke, funded by Remedy Pharmaceuticals. |
Baseline characteristics were similar between the treatment groups. The patients’ mean age was 70 years, and the sex distribution was evenly split. More than 75% of each group was white.
The National Institutes of Health Stroke Scale (NIHSS) score was significantly higher among those who presented for hospital treatment (12.9 vs. 11). However, these patients were seen before TPA administration, while the drip-and-ship group had already been treated, a temporal difference that could have accounted for the score finding, cautioned Dr. Sheth, director of the neuroscience ICU and chief of clinical research at Yale University, New Haven, Conn.
In hospitals that employed drip-and-ship, there were significantly higher rates of stroke patients treated each year as well as more beds. Those hospitals also were more often teaching facilities and were designated as a primary stroke center.
Drip-and-ship frequency remained fairly steady over the study period – about 25% of all eligible patients had it in both 2003 and 2010. Among those treated at the hospital, the frequency of TPA administration within 3 hours of stroke onset rose sharply over the study period, from about 11% in 2003 to 25% in 2010. In contrast, the percentage of timely thrombolysis in drip-and-ship patients moved very little, from about 5% to 9% over the same period.
