Tenecteplase vs. Alteplase For … Stroke Mimics?

Bless their little hearts.

It’s almost as though this is a submission fo the IgNobel Prize, rather than a serious scientific manuscript. “How well does a medicine work when the patient doesn’t have the disease?” is basically a joke, right?

Not in the magical world of stroke neurology, replete with its array of meretricious interventions.

This is a secondary analysis of NOR-TEST, a phase III trial comparing alteplase with tenecteplase. A few folks believe tenecteplase has superior fibrinolysis to alteplase, and therefore ought to be potentially favored in acute ischemic stroke. NOR-TEST, for what it’s worth, could not detect any statistically significant difference between the two.

What is notable in this trial, of course, is the 17% rate of stroke mimics. And, this is a Very Important publication comparing the safety of these two medications when given to patients inappropriately. And, of course, there is no difference. There were three cases of intracerebral hemorrhage and three cases of extracranial bleeding, none of whom – you know – died, but were clearly all unnecessary iatrogenic injury.

Some more interesting notes, at least, from their analysis of stroke mimics. The average NIHSS in this entire study was 4, with the IQR for mimics 2-6 and for acute ischemia 2-8. There’s no useful evidence to suggest thrombolysis is superior to placebo in this sort of mild stroke cohort, but, here we are. Absent this evidence, some neurologists make an argument based on the Get With the Guidelines-Stroke registry, observing many patients with mild stroke are ultimately unable to be discharged to home due to persistent disability. In the NOR-TEST cohort of mimics, however, only 79% were assessed to have mRS 0-1 at 3 months, while their treated stroke cohort achieved mRS 0-1 only 60% of the time.  It would seem the base rate of mimic- or mild-stroke disability is effectively as observed in the GWTG-Stroke registry, regardless of treatment.

In sum, these authors have basically provided us with an unwitting glimpse into how acute stroke treatment has gone utterly off the rails in Norway.  Now, I wonder if they’re related to the group trying to push tPA in less than 20 minutes ….

“Safety and predictors of stroke mimics in The Norwegian Tenecteplase Stroke Trial (NOR-TEST)”

https://www.ncbi.nlm.nih.gov/pubmed/30019629

Central Line Wizardry

I was scrolling through twitter this morning when I came across a quick video from @CriticalCareNow for an awesome central line trick. And then I went to his feed and found some more.

They are pretty genius and I think I’ll start using a few.

Check out Dr. Haney Mallemat’s twitter at @CriticalCareNow for video demonstrations! Link below.

 

Trick #1: Stop running out of sterile flushes. Use a saline bag!

You finally get your line in, go to reach for a flush, and realize you’ve used them all. Or you dropped one. Or a consultant is doing a procedure and starts asking for your entire ED supply of sterile flushes (based on true, recent events). Never again!

-hang a saline bag prior to starting (grab a 250-500cc one if available, you won’t need a full liter)

-open IV tubing onto your sterile field

-hand off the spike end to an assistant

-leave the connector end on your field for PRN use

 

Trick #2: Lost your plastic sheath on the guidewire? Straighten it out!

It happens. Despite your most cautious approach, things drop on the floor during your sterile procedures. Did you know you can straighten the J-tip of the wire out?

-pinch the the straight part of the J-tip between your thumb and first finger and slide them over one another, which should straighten the tip out enough for you to insert the wire

 

Trick #3: Be neat with that blood-covered guidewire!

If you’ve ever pulled out a guidewire, you know that it’s covered in blood and usually very floppy, which can send blood flying everywhere. It also has a tendency to roll off which every surface you put it on–mayo stand, patient drapes, etc. A slick way to tidy up you guidewire like a pro is to put it back where it came from.

-once your central line is inside the patient, simply guide the wire tip back into the plastic tubing it came from.

 

If you want some more, dive into the TR Pearl archives for  Dr. Brendan Milliner’s post:

http://sinaiem.org/tips-for-being-a-pro-lineman-central-line-edition/

 

Source:

https://twitter.com/CriticalCareNow

Ondes Q à l’ECG – pathologiques ou non ?

 

Combien de fois voyons-nous un ECG lu par la machine comme « présence d’un infarctus ancien » ?  Tout bonnement parce que la machine détecte des ondes Q sur le tracé, dans un des territoires.  La vaste majorité du temps, le patient est asymptomatique, non connu cardiaque.  Parfois, l’ECG a été demandé dans un contexte de dépistage, en pré-op, ou pour suivre les guides de pratique de l’hypertension ou du diabète.  Que faire avec une telle anomalie sous nos yeux ? On ferme les yeux ? Ou au contraire, on commande une panoplie de tests, à la recherche d’anomalies régionales pour prouver un ancien infarctus (écho cardiaque, IRM cardiaque, etc.) ?

 

Je vous réfère cette semaine à l’excellent billet de Dr Larose et de Dr Vadeboncoeur sur le sujet.  Publié sur le site de l’AMUQ, vous y trouverez la nouvelle définition de l’onde Q, selon les guides du « Fourth Universal Definition of Myocardial Infarction », publiée le 25 août 2018 dans l’European Heart Journal.  Vous apprendrez aussi  un truc pratique pour éviter un « faux positif », en répétant immédiatement l’ECG avec une variante…

https://www.amuq.qc.ca/membres/l-urgentiste/chronique-ecg-u/#O2018

 

 

Aussi, j’aimerais faire un rappel des lingettes d’alcool à inhaler pour soulager rapidement les nausées de vos patients à l’urgence.  On en avait parlé le printemps dernier : (https://docsdurgence.com/2018/03/02/traiter-la-nausee-rapidement-a-lurgence-sans-solute-sans-avaler-de-comprimes/)

 

Cette semaine, l’équipe TopMU présente l’étude en détail, pour vous aider à vous faire votre idée.  Seront-ils d’accord avec moi ? Est-il trop tôt pour aller de l’avant ?  Même si cela nécessite un abonnement, pour 25 $ par an pour vous, collègues infirmiers et infirmières, ça vaut le coup pour rester à jour… et pour en apprendre à vos collègues médecins et autres professionnels. https://topmu.ca/courses/tt02_09_aromatherapie-et-nausee/

 

Bonne lecture !

Frédéric Picotte, MD

Professeur adjoint de clinique au Département de médecine de famille et médecine d’urgence

Université de Montréal

Éditeur TopMU

Docsdurgence.com