Sickle Cell Disease and Stroke
Pediatric EM Morsels
APRIL 7, 2023
Unfortunately, it can cause so many other complications – Sepsis , acute chest syndrome , and hepatopathy.
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For undifferentiated strokes, should blood pressure be aggressively managed pre-hospital?
PulmCCM
MAY 27, 2024
Uncontrolled hypertension is a major risk factor for both ischemic and hemorrhagic strokes. Maintaining blood pressure at or near the normal range (again, over long periods) reduces the risk of stroke. Once an acute stroke is underway, however, the calculus changes.
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Blood Pressure Management in Neurologic Emergencies: What Does the Evidence Say?
EMDocs
JANUARY 29, 2024
This article will discuss blood pressure goals and preferred pharmacotherapy for non-traumatic ischemic and hemorrhagic strokes. Ischemic Strokes: Ischemic stroke is characterized by a blockage of a blood vessel in the brain. The BP targets for patients with ischemic strokes depend on the available therapeutic options.
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Grand Rounds Recap 7.10.24
Taming the SRU
JULY 25, 2024
Femoral nerve block case review - morbidity & mortality - community practice - r2 Clinical pathologic case - visual diagnosis - when time matters - operational aspects of stroke care Femoral nerve Block Case Review WITH dr. stolz Why do we care about regional anesthesia, specifically femoral nerve blocks? for obstructive CAD, OR 1.8
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emDOCs Videocast: EBM Update – IV BP Meds in NV Emergencies
EMDocs
SEPTEMBER 8, 2024
Study inclusion criteria: RCT or nonrandomized comparative observational studies Neurologic emergencies defined as: Hypertensive encephalopathy Ischemic stroke Hemorrhagic stroke Subarachnoid hemorrhage TBI Anti-hypertensive agents included nicardipine, clevidipine, labetalol, and nitroprusside. 2013 Jun 20;368(25):2355-65.
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SGEM#303: Two Can Make It – Less likely to have another stroke but more likely to have a bleed (THALES Trial)
The Skeptics' Guide to EM
OCTOBER 3, 2020
Ticagrelor and Aspirin or Aspirin Alone in Acute Ischemic Stroke or TIA. NEJM […] The post SGEM#303: Two Can Make It – Less likely to have another stroke but more likely to have a bleed (THALES Trial) first appeared on The Skeptics Guide to Emergency Medicine. Ticagrelor and Aspirin or Aspirin Alone in Acute Ischemic Stroke or TIA.
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2024 AHA Scientific Statement on Management of Elevated Blood Pressure
EMDocs
AUGUST 13, 2024
From 2006-2013, HTN emergencies occurred in approximately 2 of every 1000 adult ED visits. Background Hypertension (HTN) is significant issue globally and a leading risk factor for cardiovascular disease. HTN was the primary diagnosis in over 1 million ED visits in 2023, and rates of HTN emergencies have increased over the past 20 years.
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The Approach to Neuromuscular Weakness
Taming the SRU
SEPTEMBER 12, 2024
Neuromuscular (NM) weakness can have various causes, ranging from common and relatively easy to diagnose conditions (such as strokes and trauma) to less common and more difficult to diagnose ones (such as vascular pathologies, infections, autoimmune diseases, and neoplasms). Stroke: causes and clinical features. 80 , 711–721 (2013).
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The Latest in Critical Care, 7/10/23 (Issue #8)
PulmCCM
JULY 10, 2023
Read in JAMA When to start anticoagulation after ischemic stroke from atrial fibrillation It’s been unclear when to start anticoagulation after an ischemic stroke presumed due to thromboembolism from atrial fibrillation. Aspirin is sometimes given during the waiting period. Heparin infusions are usually avoided.
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REBEL Core Cast 97.0 – Acute Vision Loss II
RebelEM
MARCH 8, 2023
CRAO is a stroke of the eye; patients should be considered for a complete stroke work up. Philadelphia: Elsevier, 2013 (Ch) 26: p. CRAO is a stroke of the eye; patients should be considered for a complete stroke work up. Rapid diagnosis and emergency referral improves outcomes of ophthalmologic interventions.
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REBEL Cast Ep123: Reduced-Dose Systemic Peripheral Alteplase in Massive PE?
RebelEM
JANUARY 29, 2024
Am J Cardiol 2013. in the paper but 2.7% to ≈0.99 (p<0.001) Mean MPI/Tei Index≈ 0.47 in the paper but 2.7% to ≈0.99 (p<0.001) Mean MPI/Tei Index≈ 0.47 to 4.0mg/hr typically given in EKOS therapy (See Below). JACC Cardiovasc Interv 2018. PMID: 30025734 Sharifi M et al. PMID: 23102885 Aykan AC et al. Clin Exp Emerg Med 2023.
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STREAM-2: Half-Dose Tenecteplase vs Primary PCI in Older Patients with STEMI?
RebelEM
SEPTEMBER 28, 2023
neoplasm, aneurysm, intracranial or spinal surgery) or recent trauma to head or cranium (i.e. neoplasm, aneurysm, intracranial or spinal surgery) or recent trauma to head or cranium (i.e. PMID: 37439219 Armstrong P et al. Fibrinolysis or Primary PCI in ST-Segment elevation Myocardial Infarction.
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Heat-Related Illness
Pediatric Emergency Playbook
AUGUST 1, 2020
2013 Jul-Aug; 48(4): 546–553. Heat illness and heat stroke. J Athl Train. DeFranco MJ et al. Environmental issues for team physicians. Am J Sports Med. 2008 Nov;36(11):2226-37. Ishimine P. Hyperthermia. In: Pediatric Emergency Medicine, Baren JM, Rothrock SG, Brennan JA, Brown L (Eds), Saunders Elsevier, Philadelphia 2008. Jardine DS.
SGEM#182: Platelet Transfusions for Intracerebral Hemorrhage (PATCH) – Don’t Do It.
The Skeptics' Guide to EM
JUNE 11, 2017
Platelet transfusion versus standard care after acute stroke due to spontaneous cerebral haemorrhage associated with antiplatelet therapy (PATCH): a randomised, open-label, phase 3 trial. Non-contrast head CT shows a hemorrhagic stroke. [display_podcast] Date: June 5th, 2017 Reference: Baharoglu et al. Lancet 2016. Lancet 2016.
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SGEM#413: But Even You Cannot Avoid…Pressure – Intensive Care Bundle with Blood Pressure Reduction in Acute Cerebral Haemorrhage
The Skeptics' Guide to EM
AUGUST 19, 2023
I responded by posting the 2013 SGEM episode on INTERACT-2 ( SGEM#73 ) which showed no statistical difference between intensive (<140 mmHg) and guideline directed (<180 mmHg). CT reveals a hemorrhage in the right internal capsule, suggestive of acute hypertensive hemorrhagic stroke. Symptoms began just prior to presentation.
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Rapid Blood Pressure Lowering in Patients with Acute Intracerebral Hemorrhage
All Ohio EM
SEPTEMBER 16, 2019
While ordinal analysis of the modified Rankin score (assessing changes along the spectrum of the mRS, as opposed to a binary good/poor outcome based on a single cutoff) has become common in stroke trials, there are questions surrounding its use. June 30, 2013 by Rory Spiegel. Delusions of benefit in the International Stroke Trial.
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Annals of B Pod: Anti-Xa Overdose
Taming the SRU
FEBRUARY 12, 2024
DISCUSSION Epidemiology and Background Rivaroxaban, along with other direct oral anticoagulants (DOACs), has become a mainstay of treatment for pro-thrombotic conditions since 2011. [1] 3-5] From a patient perspective, DOACs are favorable for daily dosing, oral intake, and lack of frequent clinical visits for dosing adjustments. Apr; 30(3): 85–95.
The Higher Tech Kid in the ED
Pediatric Emergency Playbook
OCTOBER 1, 2017
Also used for severe MS, stroke, TBI, chronic pain. 2013; 49:138–144. 2013; 29:347–349. Are VNS safe in everyday life? Intrathecal Pumps Used to infuse basal rate of drug, usually baclofen for spasticity, but pump may contain morphine, bupivicaine, clonidine. Verify the medication and identify the toxidrome if symptomatic.
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SGEM#301: You Can’t Stop GI Bleeds with TXA
The Skeptics' Guide to EM
SEPTEMBER 19, 2020
The first visit was back in 2013 for SGEM#50 : Under Pressure – Vasopressin, Steroids and Epinephrine in Cardiac Arrest. The Lancet 2020 This was an SGEM Journal Club episode recorded live at McGill University Grand Rounds. This was the third time coming to McGill University Department of Emergency Medicine to give Grand Rounds.
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TXA in head injuries
Don't Forget the Bubbles
JUNE 30, 2023
CRASH 2 , published in 2013 – was huge. Again, there was no increase in thrombotic stroke in the TXA group – TXA looks safe. 2013 Mar;17(10):1-79. But, there’s always been a worry that giving TXA could cause clotting in the cerebral vessels. This is not good. There have been a couple of landmark trials.
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SGEM#322: TXA for SAH – Won’t Stop Me Now
The Skeptics' Guide to EM
MARCH 13, 2021
Jeff was actually on the SGEM as the guest skeptic discussing this clinical decision instrument way back in 2013 ( SGEM#48 ). Dr. Perry did publish a prospective implementation of the Ottawa SAH Rule ( Stroke 2019 ). Jeff Perry and his group in the development of the Ottawa SAH Rule.
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The Latest in Critical Care, 1/22/24 (Issue #26)
PulmCCM
JANUARY 22, 2024
Most large subsequent trials showed no beneficial effects of TTM: In 2013, a trial more than three times larger than the original trials (NEJM, n=950) showed no benefit of cooling to 33°C compared to maintenance at 36°C, in either survival or neurologic outcome.
Diagnostics and Therapeutics: The Who, What, Where, When and Why of Lumbar Punctures
Taming the SRU
FEBRUARY 5, 2024
Clin Infect Dis. 2018;66(3):321-328. doi:10.1093/cid/cix806 5. Glimåker, M., Johansson, B., Ericsson, M., Bläckberg, J., Lindquist, L., & Sjölin, J. Early lumbar puncture in adult bacterial meningitis--rationale for revised guidelines. Scandinavian journal of infectious diseases , 45 (9), 657–663. Heyderman, R.
The Current Status of Continuous-Seizure Management
ACEP Now
JULY 7, 2024
2 A study of routine EEG in the ED in 2013 found that five percent of ED patients with altered mental status had nonconvulsive seizures (of whom 75 percent were in nonconvulsive status epilepticus).
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Pediatric Status Epilepticus
Pediatric Emergency Playbook
SEPTEMBER 1, 2015
Case 3: Headache and Arteriovenous Malformation Unlike in adults, stroke in children is divided evenly between hemorrhagic and ischemic etiologies. Pediatric Seizures and Strokes: Beyond Benzos and Brain Scans. 2013; 54 Suppl 7:23-34 Chin RFM et al., Nonconvulsive seizures are common in critically ill children. Boston, MA.
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Diagnostics: Thromboembolic Disease in Pregnancy
Taming the SRU
OCTOBER 7, 2024
The contraindications are the same as for the non-pregnant patient including: prior ICH, known brain lesion/malignancy, ischemic stroke in the past three months, suspected aortic dissection, active bleeding, and closed head trauma in the past three months. 2013 Apr;98(4):545-8. Haematologica. doi: 10.3324/haematol.2012.072009.
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REBEL Core Cast 98.0 – AVNRT
RebelEM
MARCH 22, 2023
Resources REBEL EM: SVT with Aberrancy Versus VT Amal Mattu’s ECG Case of the Week: August 26th, 2013 ALiEM: Tricks of the Trade: Valsalva Maneuver By Using a 10cc Syringe Larry Mellick: Treating SVT with Adensoine ALiEM: Trick of the Trade: Combining Adenosine with the Flush References Brugada P et al.
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Pupil Disorders
Mind The Bleep
FEBRUARY 12, 2024
Examples of causes of each are listed below. Anisocoria – EyeWiki. online] EyeWiki. Available at: [link] Salmon, J. Kanski’s Clinical Ophthalmology / a Systematic Approach. Amsterdam: Elsevier. Simpson, A. Examination of the Eyes and Vision – OSCE Guide. online] Geeky Medics. Available at: [link] Sweeney, A.R., Prakalapakorn, S.G., and Lee, S.
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Targeted temperature management for post-cardiac arrest is officially over (for now)
PulmCCM
JANUARY 24, 2024
Most large subsequent trials showed no beneficial effects of TTM: In 2013, a trial more than three times larger than the original trials (NEJM, n=950) showed no benefit of cooling to 33°C compared to maintenance at 36°C, in either survival or neurologic outcome.
Doing statistics can be difficult but understanding them can be fairly simple
Sensible Medicine
MARCH 11, 2024
A couple of real-life examples A) The main outcome from the 2000 HOPE trial (ramipril versus placebo in higher cardiovascular risk patients) was the risk of heart attacks/strokes (CVD) over 5 years. if the risk of heart attacks/strokes in each group was the same, say, 10%, then the risk ratio, 10%/10% = 1. in favour of ramipril.
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Diagnostics: Inflammatory Markers
Taming the SRU
AUGUST 30, 2023
Similarly, a 2013 meta-analysis of 6 studies with 1,006 patients published in the American Journal of Emergency Medicine showed neither CRP nor PCT are sufficient to rule-in or rule-out infective endocarditis, with PCT having a pooled sensitivity of 64% and specificity of 73% and CRP having a pooled sensitivity of 75% and specificity of 73% [40].
Altered Mental Status in Children
Pediatric Emergency Playbook
MAY 1, 2016
For altered adults, use AEIOU TIPS (Alcohol-Epilepsy-Insulin-Overdose-Uremia-Trauma-Infection-Psychosis-Stroke). 2013; 28:145–284. Keep your mind open to the possibilities, and be ready to change it, when new information becomes available. Try this for altered children: remember that they need their VITAMINS! V – Vascular (e.g.
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Toxicology Answer: The Capsaicin Found in Hot Peppers and Chilis
ACEP Now
APRIL 2, 2024
Carolina Reaper, under whose effects I was suffering, is a cultivar of ( Capsicum chinense ) and was declared in 2013 to be the hottest chili pepper in the world with greater than 1.6 1 Adding more confusion, some countries refer to these fruits as ‘peppers’ when they are fresh and ‘chilies’ when they are dried. A habanero pepper.
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How To Manage Tracheo-Innominate Fistula
ACEP Now
MARCH 14, 2024
2013:1960-62. Tracheo-innominate artery fistula after stroke. The evolution of tracheal injury due to ventilatory assistance through cuffed tubes: a pathologic study. 169:334-48. Quereshi AZ. Fatal innominate artery hemorrhage in a patient with tetraplegia: case report and literature review. Ann Thorac Cardiovasc Surg. 10, 2023;21-5.
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ICU Physiology in 1000 Words: The Pulse
PulmCCM
SEPTEMBER 13, 2021
This is analogous to a left ventricle with constant stroke volume and heart rate, respectively. Tedford RJ: Determinants of right ventricular afterload (2013 Grover Conference series). However, the following model should dispel some of these half-truths. Investigative Ophthalmology & Visual Science 1965, 4(6):973-987.
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Contrast Media Shortage of 2022 – Lessons Learned
EMDocs
OCTOBER 30, 2023
3 A study of CT use trends in the ED has shown increasing use of CTs by almost 60% from 2005 to 2013. 3 A study of CT use trends in the ED has shown increasing use of CTs by almost 60% from 2005 to 2013. Reducing CECT performance, ICM dose reduction, and deferment of diagnostic imaging are strategies to combat contrast shortage.
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Episode 31 - Emergency Department Management of Patients Taking Direct Oral Anticoagulant Agents (Pharmacology CME)
EB Medicine
AUGUST 6, 2019
Nachi: Specifically, we’ll be focusing on the use of DOACs for the indications of stroke prevention in atrial fibrillation and the treatment and prevention of recurrent venous thromboembolisms. Jeff: Rivaroxaban, trade name Xarelto, the second FDA approved DOAC, is used for stroke prevention in those with nonvalvular afib and VTE treatment.
Do low tidal volumes harm people with acute brain injury?
PulmCCM
NOVEMBER 20, 2024
Patients with acute brain injuries due to strokes or trauma were generally excluded from trials testing low tidal volume ventilation, because of potential harms from elevated blood carbon dioxide levels or impairment of cerebral blood flow by high positive end-expiratory pressure (PEEP). 2013 Feb 28;2013(2):CD003844. 202409-1766ED.
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Big Labs, Little People
Pediatric Emergency Playbook
APRIL 1, 2016
Less common causes of troponemia are: Kawasaki disease, pediatric stroke, or neuromuscular disease. Cardiology in the Young; 2013. 2013; 88(10): 1127–1140. 2013; 29:715-719. 2013; 14(8): e380–e387. Don't go looking, if you won't do anything with the test. J Am Coll Cardiol. 2012; 60(23): 2427-2463. 23: 353–360.
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Pediatric Pain
Pediatric Emergency Playbook
JANUARY 1, 2017
The FPS-R uses more neutral and realistic faces and, unlike the Wong Baker scale, does not use smiling or crying faces to anchor the extremes of pain ( Tsze 2013 ). Use soothing sensory measures: speak softly, offer a pacifier, and stroke the skin softly. PAIN PHYSIOLOGY Pain includes two major components: generation and perception.
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Approach to Shock
Pediatric Emergency Playbook
JUNE 1, 2016
Conversely, is the heart rate too slow – even if the stroke volume is sufficient, if there is severe bradycardia, then cardiac output -- which is in liters/min – is decreased. 2013 Oct;132(4):663-7. 2013; 41:580-637. 2013; 17:R246. If so, use 1 J/kg to synchronize cardiovert. Chemically pace with atropine, 0.01
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MI in Children
Pediatric Emergency Playbook
JUNE 1, 2017
The previously well child now decompensated: undiagnosed thrombophilia Asymptomatic patent foramen ovale (PFO) is the cause of some cases of cryptogenic vascular disease, such as stroke and MI. 2013; 34(3):489-491. 2013; 34(4). 2013; 8(2):61-63. 2013; 6(5):752-761. 2013; 57:812-819. 2014; 5(4)L631-634.
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What does the angiogram show? The Echo? The CT coronary angiogram? How do you explain this?
Dr. Smith's ECG Blog
NOVEMBER 15, 2023
Stroke-volume:50 ml. Additional Points about MINOCA: I found it surprising to learn that the initial description of acute MI despite normal coronary vessels is not a new concept — having been first described ~80 years ago ( with eventual adoption of the term, "MINOCA" in 2013 ). Left ventricular end-diastolic volume: 99 ml.
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