EM@3AM: Brainstem Strokes
EMDocs
MAY 11, 2024
Answer : Brainstem stroke specifically in the pons resulting in locked in syndrome. CT head without contrast 1 is performed and reveals the following: Question: What is the diagnosis?
2021 Outcomes Stroke 
What's the ideal blood pressure target after ischemic stroke?
PulmCCM
SEPTEMBER 21, 2023
Blood pressure often rises during acute ischemic strokes, in what is widely held to be a natural protective mechanism: increased blood pressure pushes more blood through and around stenotic blood vessels into areas of injured, oxygen-starved brain.
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Glasgow Coma Scale in Children
Pediatric EM Morsels
JULY 21, 2023
Motor Fingernail bed pressure with a pencil first If flexion outcome, then apply painful stimulus to neck or head (trapezius or supraorbital notch) to look for localization Spinal reflex can result in a falsely elevated score if lower extremity pain induced Verbal Orientated- Able to answer all questions. A practical scale. PMID: 4136544.
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Non-significant Studies Can Teach A Lot
Sensible Medicine
NOVEMBER 6, 2023
Many doctors believe that closing the left atrial appendage (with a device) will help reduce stroke and bleeding. The idea behind stroke reduction is that occluding the appendage takes away a common area where clots form. The original SWISS APERO trial results came in 2021. This study report included only 45-day outcomes.
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Unpacking the PEACH Trial: What is Levetiracetam’s Role in Spontaneous Intracerebral Hemorrhage?
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 ). However, guidelines offer no strong recommendations for its use, specifically in spontaneous ICH ( Fang 2021 ).
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EM@3AM: Stercoral Colitis
EMDocs
JANUARY 11, 2025
A 75-year-old woman who is bedridden after a stroke presents to the ED from a nursing facility with abdominal pain and constipation. Stercoral Colitis in the Emergency Department: A Retrospective Review of Presentation, Management, and Outcomes. Fecal Impaction and Nonperforated Stercoral Colitis: Red Flags for Poor Outcomes.
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Remote Consult Protocols for Retinal Artery Occlusion: A Visionary Approach in Emergency Care?
RebelEM
AUGUST 22, 2024
hours of symptom onset appears to be the most promising approach for improving visual outcomes, supported by multiple studies and meta-analyses. 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.
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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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SGEM#330: Should You Be Going Mobile to Treat Acute Ischemic Stroke?
The Skeptics' Guide to EM
MAY 15, 2021
Date: May 6th, 2021 Guest Skeptic: Dr. 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. Reference: Fatima et al.
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SGEM Xtra: The NNT is Mellow Yellow for tPA in Acute Ischemic Stroke
The Skeptics' Guide to EM
MAY 1, 2021
Date: April 30th, 2021 Guest Skeptic: Dr. Justin Morgenstern is an emergency physician and the creator of the excellent #FOAMed project called First10EM.com. Date: April 30th, 2021 Guest Skeptic: Dr. Justin Morgenstern is an emergency physician and the creator of the excellent #FOAMed project called First10EM.com.
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Sepsis alerts work! Just not in the patients who fire the alerts
PulmCCM
JANUARY 6, 2025
A 2021 analysis of Epic’s sepsis model revealed atrocious false positive and negative rates. A cluster randomized trial using all-cause mortality as an outcome was always needed to determine whether EMR alerts improve outcomes for suspected severe infection. And have they fired. But for whom, and to what end?
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2021 Wrap-Up
EM Literature of Note
JANUARY 9, 2022
The Annals of Emergency Medicine Podcast continues apace, with free monthly updates from the original research published in the journal: iTunes Link SoundCloud Link Likewise, the Annals of Emergency Medicine Journal Club has published several monthly installments: Predicting Outcomes in Pediatric Pneumonia: Are We Omnipotent or Incompetent?
SGEM#354: Everybody Walk the Dinosaur and Not Take the MSU
The Skeptics' Guide to EM
JANUARY 1, 2022
Date: December 21st, 2021 Guest Skeptic: Dr. Howard “Howie” Mell began his career as a firefighter / paramedic in Chicago. Prospective, multicenter, controlled trial of mobile stroke units. NEJM 2021 […] The post SGEM#354: Everybody Walk the Dinosaur and Not Take the MSU first appeared on The Skeptics Guide to Emergency Medicine.
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Non-Invasive Blood Pressure Monitoring in Critically Ill Adults?
RebelEM
FEBRUARY 8, 2024
patients with more discrepant readings had NIBP checked more frequently) Some patients were on multiple vasopressors, but for an unclear reason the authors decided to only evaluate the dose of norepinephrine MAP discrepancy is not a patient oriented outcome (i.e. to 1.12; p = 0.03 to 0.99; p <0.01 to 1.09; p = 0.01 to 1.37; p <0.01
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EM Quick Hits 35 – 10 Best Papers of 2021, Peripartum Cardiomyopathy, Crashing Asthmatic, Febrile Neutropenia, Anaphylaxis update
Emergency Medicine Cases
JANUARY 18, 2022
The post EM Quick Hits 35 – 10 Best Papers of 2021, Peripartum Cardiomyopathy, Crashing Asthmatic, Febrile Neutropenia, Anaphylaxis update appeared first on Emergency Medicine Cases.
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SGEM#333: Do you gotta be starting something – like tPA before EVT?
The Skeptics' Guide to EM
JUNE 5, 2021
Date: May 25th, 2021 Guest Skeptic: Dr. Garreth Debiegun is an emergency physician at Maine Medical Center in Portland, ME and clinical assistant professor with Tufts University School of Medicine. JAMA 2021 * Zi et al. JAMA 2021 Case: A 74-year-old woman presents to your emergency department with 1.5
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SGEM#349: Can tPA Be A Bridge Over Trouble Waters to Mechanical Thrombectomy?
The Skeptics' Guide to EM
NOVEMBER 6, 2021
Date: November 1st, 2021 Reference: Katsanos et al. Utility of Intravenous Alteplase Prior to Endovascular Stroke Treatment: A Systematic Review and Meta-analysis of RCTs. Neurology 2021 Guest Skeptic: Dr. Michal Krawczyk is in his fifth year of neurology residency at Western University in London, Ontario, Canada.
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Intranasal Fentanyl for Sickle Cell Vaso-Occlusive Pain
ACEP Now
AUGUST 25, 2023
Primary Outcome: Discharged home from the ED Secondary Outcomes: There were several secondary outcomes. Another interesting secondary outcome that could confound the results is that children who received IN fentanyl received higher overall total parenteral opioid morphine equivalents. link] Published May 2021.
A Beginner’s Guide to Vasoactive Drug use in Children with Septic Shock
Don't Forget the Bubbles
NOVEMBER 27, 2023
The amount of blood that comes from the heart with each contraction is the stroke volume (SV). The stroke volume is the difference between how full it is at the start and how full it is after a contraction. The next element of stroke volume is the emptying. Published 2021 Apr 16. 2021;25(1):146. link] Roland D.
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Is a Cuff Enough?
Taming the SRU
APRIL 17, 2024
The primary outcome was defined as agreement of less than 10 % of the mean arterial pressure (MAP) between simultaneously recorded IABP and NIBP measurements. Surviving sepsis campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. References Evans L, Rhodes A, Alhazzani W, et al. Crit Care Med.
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The Latest in Critical Care, 1/22/24 (Issue #26)
PulmCCM
JANUARY 22, 2024
Background Therapeutic hypothermia, later rebranded as targeted temperature management, became a standard post-cardiac arrest therapy for comatose patients after two 2002 NEJM trials ( n=273 and n=77 ) suggested reducing core temperature to 32°C to 34°C markedly improved neurologic outcomes and survival.
Ventricular Fibrillation, ICD, LBBB, QRS of 210 ms, Positive Smith Modified Sgarbossa Criteria, and Pacemaker-Mediated Tachycardia
Dr. Smith's ECG Blog
APRIL 2, 2024
Angiogram in 2021 was normal. No wall motion abnormality Decreased left ventricular systolic performance, severe Left ventricular enlargement, marked Dilated cardiomyopathy severe Est. stroke volume 52 cc at HR 70 = 3.64 The patient awoke and had a good outcome! "Old records still had not appeared. Initial trop ~200.
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The Case to Replace Alteplase
Downeast Emergency Medicine
OCTOBER 1, 2021
This lecture was presented at the 2021 Maine Medical Center Winter Symposium. 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). 2019 Aug;50(8):2156-2162.[ Full Print ]
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Targeted temperature management for post-cardiac arrest is officially over (for now)
PulmCCM
JANUARY 24, 2024
Background Therapeutic hypothermia, later rebranded as targeted temperature management, became a standard post-cardiac arrest therapy for comatose patients after two 2002 NEJM trials ( n=273 and n=77 ) suggested reducing core temperature to 32°C to 34°C markedly improved neurologic outcomes and survival.
The Latest in Critical Care, 3/18/24 (Issue #34)
PulmCCM
MARCH 18, 2024
PROPHY-VAP) Patients with strokes and traumatic brain injuries who require mechanical ventilation due to coma are at very high risk for developing ventilator associated pneumonia. These results line up with a 2021 meta-analysis, which found both midlines and PICCs had a CRBSI rate of about 0.5%.
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SGEM#322: TXA for SAH – Won’t Stop Me Now
The Skeptics' Guide to EM
MARCH 13, 2021
Date: March 11th, 2021 Guest Skeptic: Dr. Robert Edmonds is an emergency physician in the US Air Force in Ohio. Lancet 2021 Case: You’re […] The post SGEM#322: TXA for SAH – Won’t Stop Me Now first appeared on The Skeptics Guide to Emergency Medicine. Reference: Post et al. Reference: Post et al.
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Journal Club - Tranexamic Acid in Trauma
Downeast Emergency Medicine
APRIL 26, 2021
4] We also know that severe TBI is commonly associated with the development of intracranial hemorrhage where the presence and volume of blood are associated with increased mortality and poor outcomes.[5] Association between prehospital tranexamic acid administration and outcomes of severe traumatic brain injury. 2021 Jan 1;32(1):37-43.
Major Trauma – Injuries by Assault
Don't Forget the Bubbles
FEBRUARY 5, 2025
There is significant evidence in adults and developing in the paediatric population that TXA results in better outcomes if given early in patients with mild to moderate traumatic brain injury (TBI) and does not cause harm. Disability – Altered mentation, seizure, stroke symptoms, severe headache, neurological deficit, visual symptoms.
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. Medical Therapy for Secondary Prevention and Long-Term Outcome in Patients With Myocardial Infarction With Nonobstructive Coronary Artery Disease. Figure-2: Classification of Underlying Diagnoses in Patients with MINOCA ( Adapted from Table-1 in Sykes et al: Interventional Cardiology Review: 16:e10, 2021 ).
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Brazilian Butt Lift Procedure Can Result in Emergency Department Visits
ACEP Now
MAY 9, 2024
The procedure has soared in popularity as beauty standards have shifted and cosmetic surgery has become increasingly transparent on social media platforms, with reported cases in the United States increasing from 614 in 2002 to 61,387 by 2021, a nearly 10,000 percent increase. These questionable practices led to a rash of bad outcomes.
Diagnostics: Inflammatory Markers
Taming the SRU
AUGUST 30, 2023
Significantly elevated CRP (>122mg/L) and PCT (>0.5ng/mL) levels are predictors of bad outcomes, and are useful for tracking therapy progress, but are not specific enough to rule-in infectious endocarditis [38-39]. 2021; 93: 4358–4369. 2021 Jan;25(1):466-479. Epub 2021 Oct 1. J Med Virol. Medicine (Baltimore).
Chest pain and shock: Is there a right ventricular OMI on this ECG? And should he undergo trancutaneous pacing?
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. The November 27, 2021 post ( LA-RA reversal ).
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Subarachnoid hemorrhage: ED presentation, evaluation, and management
EMDocs
JULY 3, 2023
National Institutes of Health Stroke Scale (NIHSS) is 13; vital signs include pulse 86 beats/minute (bpm), blood pressure 164/94 mmHg, and saturation of 98% on room air. Introduction SAH has the potential for rapid progression and devastating outcomes. Short- and long-term outcome of patients with aneurysmal subarachnoid hemorrhage.
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Testicular torsion
Don't Forget the Bubbles
FEBRUARY 7, 2024
This week, NCEPOD (National Confidential Enquiry into Patient Outcomes and Death) produced a much-anticipated report on how we manage acute testicular torsion in young people. “Time is brain” urges us to think about thrombolysis or clot retrieval in acute strokes. Pediatric radiology , 48 , pp.735-744. Barbosa, J.A.,
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EM@3AM: Hyperthermia
EMDocs
DECEMBER 16, 2023
Both can result in heat exhaustion and heat stroke and have many overlapping symptoms. Patients with heat stroke have hot, dry skin and altered mental status (e.g., C, and heat stroke occurs at a core temperature > 40°C. C, and heat stroke occurs at a core temperature > 40°C. Temps greater than 41.5C Bendall, J.
Dilated Cardiomyopathy in Children
Don't Forget the Bubbles
AUGUST 21, 2023
Stimulation of baroreceptors results in a catecholamine-mediated increase in heart rate , stroke volume, contractility, and systemic vascular resistance (SVR). What are the long-term outcomes for children with dilated cardiomyopathy? Outcomes at 1 year seem to be influenced by the severity of illness at presentation.
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SGEM#325: Thin Ice – Subgroup Analysis of the THAWS Trial
The Skeptics' Guide to EM
APRIL 3, 2021
Date: March 31st, 2021 Guest Skeptic: Prof Daniel Fatovich is an emergency physician and clinical researcher based at Royal Perth Hospital, Western Australia. Date: March 31st, 2021 Guest Skeptic: Prof Daniel Fatovich is an emergency physician and clinical researcher based at Royal Perth Hospital, Western Australia. THAWS RCT Substudy.
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CT Angiography Head and Neck: Indications and Limitations
EMDocs
NOVEMBER 13, 2023
2 Outcomes of patients presenting with ischemic stroke who received MRI as initial imaging modality have demonstrated similar outcomes to those with initial CTA, with Kim et al. demonstrating that functional outcome at 3 months did not differ between the CTA and MRI groups (38.5% 8 The data in Mayer et al.
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Pain Management of Common Chief Complaints in the ED
EMDocs
NOVEMBER 4, 2024
80 It can be caused by traumatic nerve, spinal cord, or brain injury (including stroke) or can be a sequela of conditions like diabetes, HIV/AIDS, postherpetic neuropathies, multiple sclerosis, cancer, or chemotherapies. 2021 Apr;28(4):444-454. Epub 2021 Jan 2. 2021 Feb;60(2):165-174. 2021 Feb;60(2):165-174.
The Latest in Critical Care, 2/26/24 (Issue #31)
PulmCCM
FEBRUARY 26, 2024
Tenecteplase for acute ischemic stroke presenting after 4.5 Because it can be infused more rapidly than alteplase, TNK is gaining prominence as thrombolytic treatment for acute ischemic stroke, in patients presenting within 4.5 hours post-stroke, but those trials were conducted before mechanical thrombectomy (performed a.s.a.p.
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The Latest in Critical Care, 9/28/23 (Issue #15)
PulmCCM
SEPTEMBER 28, 2023
Systemic corticosteroids (such as intravenous dexamethasone) improve outcomes in severe pneumonia due to SARS-CoV-2 infection. It makes sense that inhaled steroids might improve outcomes from less severe infections. Do inhaled steroids improve Covid pneumonia? This study included a true blinded placebo control arm.
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PRINCIPLE Investigators Study Inhaled Budesonide for COVID-19
PulmCCM
NOVEMBER 18, 2021
heart disease, hypertension, asthma or lung disease, diabetes, hepatic impairment, stroke or neurological problems, immunocompromise, self-reported obesity or body-mass index of at least 35 kg/m² were enrolled. Inclusion criteria were outpatients at least 65 years of age, or at least 50 years of age with comorbidities [i.e.,
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emDOCs Podcast – Episode 117: Cavernous Sinus Thrombosis
EMDocs
APRIL 1, 2025
Pneumonia and empyema may occur; intracranial involvement may lead to stroke, brain abscess, subdural empyema, meningitis, encephalitis. Several studies have found reduced mortality and improved neurologic outcomes with anticoagulation (UFH or LMWH) (4-6). 2021 Nov-Dec;66(6):1021-1030. 2021 Nov-Dec;66(6):1021-1030.
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95 Systemic Lupus Erythematosus: ED presentations, evaluation, and management
EMDocs
FEBRUARY 3, 2025
These complications affect both the central and peripheral nervous systems and encompass a wide range of conditions, including transient ischemic attacks (TIA), stroke, headaches, mood disorders, seizures, psychosis, neuropathy, and cognitive dysfunction (1,6,7). Khan A, Shamim R, Wagan AA, Khan SM, Nazeer Ahmed S, Haroon M. Egypt Rheumatol.
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