The Skeptics' Guide to EM

AUGUST 20, 2022

Fragility Index Meta-Analysis of Randomized Controlled Trials Shows Highly Robust Evidential Strength for Benefit of The post SGEM Xtra: Are tPA Stroke Trials Really Fragile? I knew about Jeff from his multiple publications in the stroke literature. first appeared on The Skeptics Guide to Emergency Medicine. This is an SGEM Xtra.

Stroke 52

Stroke Best Practices EMS Research 52

Emergency Medicine Cases

JANUARY 29, 2019

In this EM Cases main episode podcast, a follow up to our episode on TIA released in November 2018 with Walter Himmel and David Dushenski, we’ll try to simplify the confusing time-based and brain tissue-based options for stroke management. Which patients should be considered for lytic therapy? and many more.

Stroke 52

Stroke EMS 52

Sensible Medicine

JUNE 17, 2024

Stroke occurred in 7 patients (0.12%). Proponents wrote back in 2018 that longer-term safety studies are needed that specifically assess…”cerebral microemboli assessed by magnetic resonance imaging.” We really can’t say much about safety when only 600 patients are randomized. There is enough, though, to worry.

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Shock Stroke Operations Ultrasounds 130

RebelEM

SEPTEMBER 7, 2023

BACKGROUND: intracerebral hemorrhage (ICH) makes up 10-15% of all strokes and significantly contributes to overall stroke-related morbidity and mortality ( Hostettler 2019 ). About 30% of patients experience early seizures within seven days following the onset of a stroke ( Peter-Derex 2022 ). Epub 2018 Oct 6.

Seizures 133

Seizures Stroke Outcomes Research 133

The Skeptics' Guide to EM

MAY 15, 2021

Daniel Schwerin is employed with Prisma Health-Upstate as a clinical assistant professor, emergency medicine GME director for emergency medical services and medical director for several local EMS agencies and has lectured on prehospital stroke management. Background: We have discussed stroke so many times on the SGEM.

Stroke 52

Stroke EMS Outcomes 52

RebelEM

AUGUST 22, 2024

What They Did: Retrospective review of consecutive RAO cases managed as part of a remote ophthalmology consult protocol activated on May 1, 2021, at three stroke centers across a health system. The protocol involved collaboration between the ophthalmology service, ED, and stroke service, including neurology and neuroendovascular teams.

Stroke 85

Stroke Administration Outcomes Documentation/Coding 85

RebelEM

JANUARY 29, 2024

JACC Cardiovasc Interv 2018. 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). PMID: 30025734 Sharifi M et al. Moderate Pulmonary Embolism Treated with thrombolysis (from the “MOPETT” Trial).

Stroke 136

Stroke Outcomes Hospitals Administration 136

Don't Forget the Bubbles

JULY 5, 2023

The Kilifi algorithm includes five clinical situations that are common sickle cell presentations – clinical jaundice, severe anaemia, bone and joint infections, and stroke. What is the role of transcranial dopplers in primary prevention of strokes? What strategies are useful for secondary stroke prevention?

Blood Transfusions 126

Blood Transfusions Stroke Dehydration Sepsis 126

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.

Stroke 73

Stroke Outcomes EMS Seizures 73

ACEP Now

JULY 7, 2023

Heart disease and stroke statistics-2022 update: A report from the American Heart Association. Heart disease and stroke statistics—2018 update: A report from the American Heart Association. Heart disease and stroke statistics-2017 update: A report from the American Heart Association. References Tsao CW, et al.

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Resuscitation Shock Stroke Hospitals 98

ACEP Now

OCTOBER 9, 2023

The concept of rapid assessment for heart attacks and strokes is not foreign to the general public, but these emergencies do not include rapid destruction of clothing, private examinations performed in front of audiences, or a quick succession of invasive procedures. Chicago, IL: American College of Surgeons; 2018. 2017;152(9):843.

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Resuscitation Research Stroke Emergency Department 126

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.

Stroke 40

Stroke Emergency Department Research Wellness 40

PulmCCM

NOVEMBER 11, 2021

To focus matters, the hemodynamic variable under consideration is the stroke volume [SV]; in other words, how does a push of phenylephrine affect SV? ’ Diminished stroke volume? In the former group, stroke index [i.e., SV] increased significantly, while in the latter group, stroke index fell in response to phenylephrine.

Stroke 40

Stroke Sepsis Administration Wellness 40

RebelEM

FEBRUARY 29, 2024

3, 6 Among patients with stroke or traumatic brain injury (TBI), the risk may be as high as 28%-76% and 23%-60%, respectively. Post-stroke infection: a systematic review and meta-analysis. Tanaffos 2018 , 17 (2), 110-116. 4, 8 Paper: Dahyot-Fizelier, C., Infect Control Hosp Epidemiol 2014 , 35 (8), 915-936. Westendorp, W.

CDC 125

CDC Radiology Radiology Outcomes 125

RebelEM

JUNE 26, 2023

J Trauma Acute Care Surg 2018. Severe acute traumatic coagulopathy = PT >1.5 to 3.33; P = 0.72 NOT STATISTICALLY SIGNIFICANT Also no difference in individual components given Thromboembolic Events: 4F-PCC: 35% Placebo: 24% Absolute Diff: 11%; 95% CI 1 to 21% Relative Risk 1.48; 95% CI 1.04 to 2.10; P = 0.03 Lancet Haematol 2017.

Administration 145

Administration Outcomes Resuscitation Radiology 145

Downeast Emergency Medicine

OCTOBER 1, 2021

TNK is easier to prepare and administer (a rapid, single-bolus) which may mean faster door-to-needle times and faster door-in-door-out times for transport (and hopefully translate into less disability after stroke). AHA/ASA Guidelines: 2018: “Tenecteplase administered as a 0.4-mg/kg Holmes, MD References NOR-TEST Lancet Neurology.

Stroke 52

Stroke Administration Outcomes 52

Dr. Smith's ECG Blog

FEBRUARY 18, 2024

This could be easily overlooked since there is complete heart block, but recognizing the atrial arrhythmia may mean prescribing anticoagulation to prevent stroke. The January 30, 2018 post — for PTA. In this case, it is atrial fibrillation. The September 22, 2019 post — intermittent ST-T wave artifact.

EKG/ECG 97

EKG/ECG Stroke 97

RebelEM

MARCH 8, 2023

CRAO is a stroke of the eye; patients should be considered for a complete stroke work up. Philadelphia: Elsevier, 2018 (Ch) 61: p. CRAO is a stroke of the eye; patients should be considered for a complete stroke work up. Take Home Points: Assess patients with floaters or flashers for retinal or vitreous detachment.

Stroke 52

Stroke Emergency Department Ultrasounds Outcomes 52

Dr. Smith's ECG Blog

JULY 5, 2024

But the duration of symptoms was prolonged and so to avoid the risk of stroke, AV nodal blockade (rate control) was preferred. We want to avoid a stroke. They chose to give adenosine, and this is what happened: Adenosine to verify flutter: flutter waves made obvious Not actually from this case. What AV nodal blocker should we give?

EKG/ECG 104

EKG/ECG Stroke Administration Wellness 104

The Skeptics' Guide to EM

NOVEMBER 7, 2018

[display_podcast] Date: November 6th , 2018 Reference: Sprigg et al. 2018 Guest Skeptic: Dr. Robert Edmonds is an emergency physician in the US Air Force in Virginia. display_podcast] Date: November 6th , 2018 Reference: Sprigg et al. This is Bob’s eighth visit to the SGEM. This is Bob’s eighth visit to the SGEM.

Stroke 40

Stroke Outcomes 40

PulmCCM

JULY 10, 2023

A 2018 meta-analysis reviewed here suggested that prolonged infusion of antipseudomonal beta-lactams reduced mortality by 30% compared with shorter infusions, and more observational data has accumulated since that time. There’s a period of time after ischemic stroke when damaged cerebral blood vessels are susceptible to bleeding.

Stroke 52

Stroke Sepsis Infectious Diseases Outcomes 52

Sensible Medicine

SEPTEMBER 23, 2024

In 2018, three modern trials comparing asa vs placebo for primary prevention were published. The rate of the composite primary outcome of CV death, MI, unstable angina, stroke or transient attack was 4.29% with asa vs 4.48% with placebo. This was one of the trials that got aspirin use established as a preventive medicine.

Stroke 95

Stroke Academics Outcomes Shock 95

Don't Forget the Bubbles

JUNE 30, 2023

Again, there was no increase in thrombotic stroke in the TXA group – TXA looks safe. published in 2018, looked at 1900 matched pairs of injured children under 12, half of whom received TXA. 2018 Dec;19(12):e637-e642. in the TXA group vs 53.7% in the placebo group). This study moves trauma care beyond just ‘survival’.

Head Injuries 145

Head Injuries Seizures Outcomes Pediatrics 145

The Skeptics' Guide to EM

MAY 23, 2020

Endovascular thrombectomy with or without intravenous alteplase in acute stroke. Endovascular thrombectomy with or without intravenous alteplase in acute stroke. Background: The issue of thrombolytics for stroke has been debated since at least 1995. Date: May 19th, 2020 Reference: Yang P et al.

Stroke 40

Stroke EMS Administration Wellness 40

The Skeptics' Guide to EM

APRIL 6, 2019

He reports he has been taking apixaban to prevent stroke in the context of atrial fibrillation, which you easily recognize as one of the modern oral anti-Factor Xa inhibitors. The FDA granted accelerated approval for andexanet alfa (Andexxa) in May of 2018. You order a non-contrast CT to rule out hemorrhage.

Stroke 52

Stroke Administration EMS Wellness 52

Dr. Smith's ECG Blog

DECEMBER 24, 2023

And so was an appropriate anti-coagulant, since atrial flutter, like fibrillation, can result in thromboembolism and stroke. This could be a beta blocker such as metoprolol, or a calcium channel blocker such as diltiazem. Metoprolol was also on the medication list.

EKG/ECG 130

EKG/ECG Stroke Administration Wellness 130

The Skeptics' Guide to EM

SEPTEMBER 21, 2019

In uncomplicated patients with symptoms less than 48 hours and no stroke or TIA in the past six months, the 2018 Canadian Cardiovascular Society (CCS) guidelines permit rate or rhythm control (2).

Emergency Department 52

Emergency Department Stroke Academics Shock 52

Dr. Smith's ECG Blog

NOVEMBER 14, 2023

Here is that last post: A 90-something with acute stroke. For examples of this phenomenon — See My Comment in the February 14, 2018 — July 21, 2020 — and December 22, 2022 posts in Dr. Smith's ECG Blog ). She has no chest symptoms. What is the diagnosis? He stated he had never had this before.

EKG/ECG 115

EKG/ECG EMS Stroke Outcomes 115

Dr. Smith's ECG Blog

MAY 30, 2023

IV fluids for more preload are indicated, but not too much, as the RV can be overloaded with fluid, cause the septum to bow into the LV, and then harm LV stroke volume and cardiac output, leading to worsening hypotension, worse RV perfusion, worse RV function, and more RV failure. For review — GO TO: The June 4, 2018 post ( LA-LL reversal ).

Shock 86

Shock EKG/ECG Academics Stroke 86

Taming the SRU

FEBRUARY 5, 2024

2018) Epidemiology of lumbar punctures in hospitalized patients in the United States. A., & Koehler, P. The first lumbar puncture. Journal of the history of the neurosciences, 6(2), 147–153. Vickers A, Donnelly JP, Moore JX, Barnum SR, Schein TN, et al. PLOS ONE 13(12): e0208622. Glimåker M, Sjölin J, Åkesson S, Naucler P.

Infectious Diseases 97

Infectious Diseases Seizures Ultrasounds Sepsis 97

Mind The Bleep

JANUARY 11, 2024

Investigations include fundoscopy and fluorescein angiography. American Academy of Ophthalmology. National Institue for Health and Care Excellence. Hypertension in adults: diagnosis and management. Guidance NG136. GP notebook. Hypertension (malignant).

Stroke 52

Stroke Hospitals 52

Mind The Bleep

JANUARY 9, 2024

myocardial infarction, peripheral vascular disease, stroke ) and microvascular (e.g., Overview Diabetes mellitus can cause both macrovascular (e.g., nephropathy, neuropathy, retinopathy) complications. Diabetic Retinopathy detection through integration of Deep Learning classification framework. 10.1101/225508.

Stroke 52

Stroke Research 52

The Skeptics' Guide to EM

MAY 24, 2019

Dual antiplatelet therapy with aspirin and clopidogrel for acute high risk transient ischaemic attack and minor ischaemic stroke: a clinical practice guideline. BMJ Dec 2018 * Feld et al. Pediatrics Dec 2018 * Frey et al. Clinical Practice Guideline: Maintenance Intravenous Fluids in Children.

Domestic Violence 40

Domestic Violence Sexual Assault Research Diabetic Emergencies 40

Taming the SRU

AUGUST 30, 2023

A 2018 USA multi-center prospective RCT involving 1,656 adult patients published in NEJM used varying PCT cut-offs to guide antibiotic initiation in the emergency department. 2018 Aug 1;10(8):a028456. Epub 2018 Oct 19. 2018 Jul 31;138(5):e78-e79. 2018 May;18(5):496-497. ng/mL, 0.25-0.5 ng/mL, and >0.5

Infectious Diseases 88

Infectious Diseases Sepsis Emergency Department Point-of-Care Testing 88

Northwestern EM Blog

JUNE 16, 2024

The most common symptoms include: Lightheadedness Syncope Chest pain Exercise intolerance Fatigue **Important note: The heart rate at which patients experience symptoms may vary based on their ability to increase stroke volume. Joglar, J. Marine, J. McLeod, C. Patton, K. Pellegrini, C. Selzman, K. Thompson, A., & Varosy, P.

Hyperthermia / Hypothermia 52

Hyperthermia / Hypothermia Infectious Diseases Stroke Poisoning 52

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. May 2; 19(1): 19.

Administration 79

Administration Fractures Anaphylaxis Head Injuries 79

Sensible Medicine

FEBRUARY 28, 2024

JMM Although the skeptical cardiologist questions the value of many procedures and diagnostic tests in cardiology, he remains an enthusiastic advocate of the use of coronary artery calcium (CAC) testing to better personalize each individual's risk of heart attack and stroke.

Stroke 48

Stroke Documentation/Coding Outcomes Wellness 48