In contrast, more is almost certainly better when treating devastating large-vessel occlusions (LVO). Early trials testing endovascular treatment of LVO enrolled primarily patients with very small core infarcts surrounded by large viable penumbra. The “SELECT-2” trial looked at occlusions of the internal carotid and proximal middle cerebral artery resulting in larger core infarcts.⁶ The outcomes were dismal whether treated with endovascular therapy or conservative medical care, but 20 percent achieved a modified Rankin score of 0 to 2 with the former, compared with only seven percent of the latter.

The Right Way to Airway

Video largyngoscopy (VL) is simply, in most situations, the better tool for the job. Expertise with direct visualization is still necessary, but the “DEVICE” trial adds another feather to the cap favoring VL.⁷ The operators involved in the trial were mostly emergency medicine residents or critical care fellows, but this fact does not diminish the generalizability of these observations. Many clinicians staffing emergency departments intubate infrequently, as well, and these results are likely applicable to a wide scope of practice.

More commonly asked than how to intubate, the more challenging question is whether to intubate. It may be conveniently glib to base clinical practice on the charming rhyme of “less than eight, intubate,” but accumulated wisdom teaches many patients with depressed Glasgow coma scores (GCS) improve spontaneously without adverse consequences. Now, a randomized, controlled trial clearly demonstrates some patients with low GCS are far more likely to be harmed by an aggressive approach to airway management.⁸ Enrolling patients with depressed GCS thought to be from substance abuse and misuse, including nearly a quarter in each cohort with GCS 3, a conservative approach to airway management avoided both intubation-related risks and intensive care unit admissions.

Finally, the “EXACT” trial examined whether, in patients with return of spontaneous circulation after an out of hospital cardiac arrest, a peripheral oxygenation target of 90–94 percent conferred a survival benefit, as compared with the typical 98–100 percent.⁹ Unfortunately, this trial can be added to the heap of things ruined by the COVID-19 pandemic, as the arrival of COVID necessitated early termination. Only 425 of the planned 1,416 were enrolled, leaving the primary and secondary outcomes grossly imprecise. Survival to hospital discharge favored the “standard care” group, 47.9 percent to 38.3 percent, leaving little chance the lower oxygen target would have become a preferred strategy.

A Myriad of Infectious Disease Papers

The use of steroids in severe sepsis remains challenging, primarily as proper patient selection is necessary to tease out those with the greatest likelihood of benefit. One consistent signal for potential benefit has been community-acquired pneumonia, and the “CAPE COD” trial very clearly identifies those patients admitted to the intensive care unit as candidates for steroids.¹⁰ The trial was stopped due to superiority due to both its overall mortality benefit, as well as a reduction in the need for mechanical ventilation.