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?
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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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PulmCCM
MAY 3, 2024
While outcomes from acute ischemic stroke due to large vessel occlusion in the anterior circulation have improved substantially in the era of thrombolytics and mechanical thrombectomy, overall outcomes remain poor. ” However, that was in the era before mechanical thrombectomy. Along with endovascular thr… Read more
EM Ottawa
MAY 20, 2024
2023 Jun 29;388(26):2411-2421. Question and Methods: RCT at 103 sites to compare outcomes at 30 days for early versus late DOAC initiation among patients with ischemic stroke and atrial fibrillation. Methodology: 3/5 Usefulness: 2/5 Fischer U, et al. N Engl J Med.
EM Ottawa
MAY 6, 2024
2023 Jun 1;388(22):2025-2036. Editorial: Expanding Treatment for Acute Ischemic Stroke beyond Revascularization. N Engl J Med.
ACEP Now
OCTOBER 10, 2023
The CT scan reveals a hemorrhage in the right internal capsule, suggestive of acute hypertensive hemorrhagic stroke. Both INTERACT-2 and ATACH-2 showed no statistical difference in their primary outcome between intensively lowering the BP and a less-intensive strategy. Reference Ma LM, Hu X, Song L, et.
ACEP Now
MARCH 6, 2024
The Sisyphean task remains to try to keep up—and, in that vein—here is a light round of the emergency medicine literature from 2023. What’s New in Stroke Care? 4 Repeated trials have not shown alteplase to have any signal of better outcomes, nor tenecteplase to have an association with increased adverse events.
EMDocs
AUGUST 17, 2024
. #1: TNK Up to 24 Hours for Stroke? Source Tenecteplase for Ischemic Stroke at 4.5 Spoon Feed In ICU patients with traumatic brain injury (TBI) and anemia, transfusing blood to a liberal hemoglobin threshold (10 g/dL) compared to a restrictive threshold (7 g/dL) did not lead to better neurological outcomes at 6 months.
EMDocs
JANUARY 13, 2024
Spoon Feed High-dose nitroglycerin improves outcomes in patients with sympathetic crashing acute pulmonary edema (SCAPE) without significant side effects when compared to low-dose nitroglycerin. 2023 Nov 28:emermed-2023-213285. doi: 10.1136/emermed-2023-213285. 2023 Nov 28:emermed-2023-213285. Emerg Med J.
EMDocs
OCTOBER 21, 2023
Answer : Basilar Artery Occlusion Epidemiology:  Basilar artery occlusion (BAO) is a subset of the posterior circulation strokes. Posterior circulation strokes are estimated to account for 20% of all strokes, with BAO accounting for ~1% of all strokes. Symptoms may range from days to months prior to stroke onset.
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.
EMDocs
OCTOBER 14, 2023
. #1: What’s the BEST Target SBP Post-Embolectomy for Stroke? Spoon Feed More aggressive systolic blood pressure (SBP) goals, beyond keeping it <180 mmHg, probably don’t make much of a difference in outcomes for patients who have undergone endovascular therapy for ischemic stroke. 2023 Sep 5;330(9):821-831.
EMDocs
MAY 4, 2024
Epub 2023 Sep 17. 2: The Endovascular Therapy Train Continues Onward Spoon Feed This was an exploratory analysis of the recently published SELECT2 trial, which randomized 352 adults with acute ischemic stroke due to carotid or M1 MCA occlusion to endovascular thrombectomy (EVT) or medical management. . #2: Acad Emerg Med.
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? About two thirds of patients in each arm were vaccinated.
EMDocs
SEPTEMBER 2, 2023
. #1: Dual Antiplatelets or Lytics for Minor Stroke? Spoon Feed In minor acute ischemic stroke (AIS) patients presenting within 4.5 hours of onset, dual antiplatelet therapy (DAPT) is non-inferior to intravenous alteplase for excellent neurologic outcome at 90 days. 2023 Jun 27;329(24):2135-2144. 2023 Aug 14;e232900.
EMDocs
FEBRUARY 28, 2024
Code Stroke is called and he is seen by a neurologist within 10 minutes. He is admitted with a diagnosis of brainstem stroke and treated by the neurologist with ASA only. He undergoes a thrombectomy, but his outcome is poor. Plaintiff : The family’s concern is that a delay in appropriate treatment led to his poor outcome.
RebelEM
SEPTEMBER 14, 2023
bleeding, stroke, limb ischemia, and hemolysis). to 1.03) Poor Neurologic Outcome (CPC 3 or 4): 24.8% to 1.03) Poor Neurologic Outcome (CPC 3 or 4): 24.8% to 1.03) Poor Neurologic Outcome (CPC 3 or 4): 24.8% to 1.03) Poor Neurologic Outcome (CPC 3 or 4): 24.8% Zeymer HT et al. Control: 53.4% D ECLS: 18.2%
EMDocs
AUGUST 13, 2024
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. Background Hypertension (HTN) is significant issue globally and a leading risk factor for cardiovascular disease. From 2006-2013, HTN emergencies occurred in approximately 2 of every 1000 adult ED visits.
The Skeptics' Guide to EM
APRIL 8, 2023
Date: April 4th, 2023 Reference: Vaughan and Browne. 2023 Apr Guest Skeptics: Dr. Louella Vaugh is an internist practising as a hospitalist physician at an academic centre in London, UK with a special interest in smaller, rural and remote healthcare. Date: April 4th, 2023 Reference: Vaughan and Browne. BMJ Qual Saf.
The Skeptics' Guide to EM
JUNE 17, 2023
Date: June 15, 2023 Reference: Rees CA et al. Date: June 15, 2023 Reference: Rees CA et al. American Journal of Hematology Jan 2023 Guest Skeptic: Dr. Amy Drendel is a pediatric emergency medicine physician and physician scientist at Children’s Wisconsin.
RebelEM
JUNE 19, 2023
PMID: 37314244 Clinical Question: In advanced trauma systems, does prehospital administration of TXA increase the rate of survival with a favorable neurologic outcome in patients at risk for trauma-induced coagulopathy? 1.00 (0.9 – 1.12) Secondary Outcome Mortality 24h 9.7% Prehospital Tranexamic Acid for Severe Trauma.
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. Accessed August 8, 2023.
RebelEM
SEPTEMBER 28, 2023
STREAM-2: Half-Dose Tenecteplase or Primary Percutaneous Coronary Intervention in Older Patients With ST-Segment-Elevation Myocardial Infarction: A Randomized, Open-Label Trial. neoplasm, aneurysm, intracranial or spinal surgery) or recent trauma to head or cranium (i.e. Primary PCI: 95.7% Stents Placed: Pharmaco-Invasive Treatment: 97.4%
Don't Forget the Bubbles
JUNE 30, 2023
The primary outcome was 28-day mortality – TXA improved survival with no increased risk of cerebral clots. Survival was better, both at 24 hours and six months, in the TXA group, although the primary outcome, a quality of life score at six months, called the Glasgow Outcome Scale Extended (GOS-E), was the same in both groups ( 53.7%
RebelEM
MAY 18, 2023
These patients can have a vasodilated vascular bed and the initial use of fluids is hypothesized to serve two purposes: Augmenting the macrovascular system (stroke volume and cardiac output) and augmenting the microvascular perfusion (capillary blood flow). This resulted in better shock control by 6hrs (76.1% Liberal: 14.9% Liberal: 14.9%
Sensible Medicine
JULY 6, 2023
In the CLEAR Outcomes trial, it was found effective in modestly reducing cholesterol and cardiovascular outcomes in statin-intolerant patients. The authors have now published a subanalysis of the main CLEAR Outcomes study. Bempedoic Acid is a cholesterol-lowering drug. JMM Sensible Medicine is a reader-supported publication.
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.
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. Treasure Island (FL): StatPearls Publishing; January 30, 2023.
Taming the SRU
APRIL 22, 2023
If untreated, atrial fibrillation can increase clot formation and lead to an increased risk for heart attack and stroke as well as development of congestive heart failure. There were similar lengths of say overall and no significant difference in safety outcomes. There was no difference in safety outcomes.
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.
ACEP Now
OCTOBER 3, 2023
In April 2023, the third edition of the Brain Trauma Foundation’s evidence-based guidelines for the prehospital management of traumatic brain injury (TBI) was published in Prehospital Emergency Care. 2,3 TBI outcomes are profoundly linked to the timing and quality of care provided before patients reach the hospital. Prehosp Emerg Care.
AED Leader
AUGUST 15, 2023
An umbrella review published in BMJ in 2023 revealed that dietary sugar consumption is associated with 10 cardiovascular outcomes, a greater risk of coronary artery disease, and an increased risk of all-cause mortality. Clogged blood vessels leading to the brain can lead to a stroke or vascular dementia.
Taming the SRU
JUNE 3, 2024
Susan Wilcox Increasing regionalization due to: Growth of specialty centers Increasing development of healthcare systems Hub-and-spoke models Development of ECMO, trauma, transplant, and stroke centers The higher the acuity of the centers, the higher the acuity of the patient that needs to get there.
RebelEM
JULY 27, 2023
Background: Current stroke guidelines recommend IV alteplase for patients with acute ischemic stroke presenting within 4.5hrs of symptom onset based on the NINDS and ECASS III publications. Both NINDS and ECASS III excluded patients with mild stroke symptoms but failed to clearly define a threshold for mild stroke.
ACEP Now
MAY 9, 2024
These questionable practices led to a rash of bad outcomes. While both conditions rely on supportive care as the mainstay of treatment, plastic surgery literature suggests better outcomes with microscopic fat embolism. As a result, our current data on AFT complications likely underestimates the actual incidence.
PulmCCM
DECEMBER 11, 2023
Sepsis, infectious disease Managing septic shock with a restrictive-fluids approach (preferentially using vasopressors after a single liter crystalloid bolus) led to similar outcomes as the usual practice of bolusing large volumes of fluids first. Vitamin C did not improve outcomes among patients hospitalized with Covid-19.
Dr. Smith's ECG Blog
NOVEMBER 14, 2023
Here is that last post: A 90-something with acute stroke. Outcome: All 4 serial hs troponin I, out to 6 hours, were undetectable. link] = My Comment by K EN G RAUER, MD ( 11/14 /2023 ): = One of the most helpful clinical clues in support that an acute cardiac event is ongoing — is the finding of " dynamic " ECG changes.
EMDocs
NOVEMBER 20, 2023
For patients on VKAs to prevent stroke in nonvalvular atrial fibrillation who require reversal, 4-factor prothrombin complex concentrate (PCC) is preferred to fresh frozen plasma (FFP) because of the rapidity of INR reduction (Conditional recommendation, very low-quality evidence). 2023 Feb 1;118(2):208-231. Am J Gastroenterol.
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.
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. 1976 May 15;1(7968):1031-4.
RebelEM
JANUARY 29, 2024
Clin Exp Emerg Med 2023. REBEL Cast Ep123: Reduced-Dose Systemic Peripheral Alteplase in Massive PE? Click here for Direct Download of the Podcast Paper: Aykan AC et al. Reduced-Dose Systemic Fibrinolysis in Massive Pulmonary Embolism: A Pilot Study. in the paper but 2.7% to ≈0.99 (p<0.001) Mean MPI/Tei Index≈ 0.47 in the paper but 2.7%
ALiEM
JANUARY 29, 2024
It requires immediate consultation with ophthalmology as well as neurology as it is considered a stroke equivalent. Case Question: What treatments can you perform in the ED for this diagnosis and do they improve outcomes? This has the potential to expedite consultations with specialty teams and treatment. PMID: 23023446.
ACEP Now
JULY 7, 2023
2,3 In general, patients who develop cardiac arrest with an initial rhythm of VT or VF tend to have favorable outcomes compared to patients who develop cardiac arrest from either asystole or pulseless electrical activity. Heart disease and stroke statistics-2022 update: A report from the American Heart Association. Circulation.
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. Left ventricular end-diastolic volume: 99 ml. Left ventricular systolic volume: 49 ml. Left ventricular ejection fraction:50 %. Normal wall thickness. References: 1.
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