The Skeptics' Guide to EM

APRIL 25, 2020

Effectiveness of emergency physician determinations of the need for thrombolytic therapy in acute stroke. Effectiveness of emergency physician determinations of the need for thrombolytic therapy in acute stroke. She was last seen well two hours prior. There is no previous history of stroke. Reference: Juergens et al.

Stroke 40

Stroke Emergency Department Outcomes Administration 40

RebelEM

JUNE 8, 2023

They can be associated with side effects such as reflex bradycardia, decreased stroke volume in phenylephrine, tachycardia and hypertension associated with epinephrine. However, peripherally dosed push dose pressors, (PDPs), are beginning to be administered more frequently for management of acute hypotension.

Administration 98

Administration Emergency Department Outcomes Documentation/Coding 98

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. That would likely slow the ventricular rate as well, but would have a higher likilihood of converting to sinus. We want to avoid a stroke. What AV nodal blocker should we give? How about amiodarone?

EKG/ECG 112

EKG/ECG Stroke Administration Ultrasounds 112

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

Emergency Medicine Ireland

APRIL 29, 2024

Hopefully what follows will provide enough broad brush strokes to get you through a night on call or even worse a viva. The sodium rises, the patient stops seizing everyone relaxes but then the Na continues to rise, well above the 5mmol we wanted and a panic ensues. We’ll start with truly emergent situations. Christopher, K.,

Seizures 75

Seizures Sepsis Stroke Administration 75

ACEP Now

SEPTEMBER 6, 2024

This comes out of INTERACT-4, a trial testing the efficacy of blood pressure reduction in undifferentiated acute stroke syndromes. Without delving into too much detail, approximately half of the over 2,300 patients in the trial suffered ischemic stroke, and the remainder hemorrhagic stroke.

Research 49

Research Stroke Outcomes Sepsis 49

Dr. Smith's ECG Blog

DECEMBER 26, 2020

They called their transfer center cardiologist on call, who reviewed the case on the phone with them, as well as the ECG. The case was reviewed by the receiving team who had concerns for acute stroke or other cause of acute altered mental status. The patient was admitted for stroke management. Serial troponins were negative.

EKG/ECG 52

EKG/ECG Stroke Administration Seizures 52

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. hours of right sided weakness as well as slurred speech. hours of right sided weakness as well as slurred speech. Date: May 19th, 2020 Reference: Yang P et al.

Stroke 40

Stroke EMS Administration Wellness 40

Dr. Smith's ECG Blog

OCTOBER 12, 2024

CTA head and neck were obtained and showed no evidence of intracranial hemorrhage, large vessel occlusion stroke (what a helpful and apt name for an acute arterial occlusion paradigm, by the way.), Vital signs were within normal limits on arrival to the Emergency Department. Blood glucose was not low at 162 mg/dL. or basilar ischemia.

EKG/ECG 115

EKG/ECG Documentation/Coding Emergency Department COPD 115

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. This changed in 2015 when the Food and Drug Administration (FDA) approved idarucizumab for the reversal of dabigatran. Dabigatran is a direct thrombin inhibitor.

Stroke 52

Stroke Administration EMS Wellness 52

EMDocs

OCTOBER 30, 2023

Some institutions developed a tier-based system for outpatient imaging as well which was updated in real-time. Contrast Media, Iodinated, Dose, and Administration. 3 A study of CT use trends in the ED has shown increasing use of CTs by almost 60% from 2005 to 2013. J Am Coll Radiol. doi:10.1016/j.jacr.2023.06.032 In: Baert, A.L.

Radiology 101

Radiology Radiology Emergency Department Hospitals 101

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. Nachi: Well, I’m sure more of those studies are still coming. Show More v Jeff: Fair enough, we’ll take what we can get. Jeff: Agree.

Emergency Department 40

Emergency Department Stroke Wellness Outcomes 40

PulmCCM

DECEMBER 11, 2024

It’s a wonderful contribution to the literature and well worth reading. These are nonfalsifiable claims that illustrate the problem well. An excellent review article titled “Sepsis and Septic Shock” was published 4 December 2024 in the New England Journal of Medicine.

Sepsis 45

Sepsis Shock Research Wellness 45

PulmCCM

JANUARY 4, 2022

For example, should a fluid challenge fail to raise stroke volume [SV], a state of physiological preload intolerance exists and additional volume is arguably harmful ; further attempts to increase tissue perfusion might then be best achieved with vasoactives. For what are intravenous fluids diagnostic? the Frank-Starling mechanism].

Wellness 40

Wellness Outcomes Sepsis Stroke 40

Dr. Smith's ECG Blog

JULY 3, 2018

No data exists to suggest or refute that opioid administration leads to longer time to cath in patients with ongoing ACS; however, it makes logical sense that it would, since one of the qualifying factors for emergent cardiac cath is ongoing chest pain. He reports nausea as well. No further echocardiograms were available after cath.

EKG/ECG 52

EKG/ECG Documentation/Coding Administration Outcomes 52

ACEP Now

JULY 6, 2023

Now, many PID patients are treated and released after ED administration of appropriate antibiotics to eradicate possible infection by Neisseria gonorrhea and Chlamydia trachomatis , often with added treatment for anaerobic microbes. Acute pyelonephritis has become a disease for which outpatient management is often feasible and appropriate.

Head Injuries 52

Head Injuries Emergency Department Research Pediatrics 52

EMDocs

JUNE 8, 2023

This week we cover the EXTEND trial looking at thrombolysis up to 9 hours after stroke onset. and 9 hours after onset of symptoms, with non-infarcted brain tissue, does the administration of alteplase improve functional outcome at 90 days? Intervention: Alteplase 0.9 in alteplase group versus 0.9% to 53.54, p=0.053).

Stroke 98

Stroke Administration Documentation/Coding Outcomes 98

EMDocs

JULY 20, 2023

Patient had to be able to be randomized between 6-24 hours after last known well. Pre-stroke disability had to be insignificant measured by mRS (modified Rankin Scale) of 0 or 1. Take away: Positive trial The study used superior imaging techniques and extensive stroke care that may not be readily available at smaller facilities.

Stroke 97

Stroke Outcomes Head Injuries Psychiatric 97

RebelEM

JUNE 26, 2023

Interventions such as early application of hemorrhage control, tranexamic acid, reduction of crystalloid fluid administration and balanced ratio blood product transfusion have improved many patients’ outcomes. 4F-PCC contains factors II, VII, IX, X as well as Proteins S and C. Severe acute traumatic coagulopathy = PT >1.5

Administration 145

Administration Outcomes Resuscitation Radiology 145

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. Patient data anonymized when presented to adjudication committee to avoid detection bias Well-balanced patient characteristics between groups. Post-stroke infection: a systematic review and meta-analysis.

CDC 122

CDC Radiology Radiology Head Injuries 122

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. She did well. The above said — WHY did the atrial rate become faster after administration of an IV ß-blocker? Metoprolol was also on the medication list. Smith : there is something missing here!

EKG/ECG 126

EKG/ECG Stroke Administration Wellness 126

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. Primary PCI: 95.7% Stents Placed: Pharmaco-Invasive Treatment: 97.4% Primary PCI: 95.7% ECG Results: Repeat ECG 90min after tenecteplase indicated 70.3%

EKG/ECG 138

EKG/ECG Allergic Reactions Shock Stroke 138

ACEP Now

MARCH 6, 2024

The PATCH-Trauma trial took a critical look at TXA in major trauma in the advanced trauma systems of Australia and found a mixed result: a slightly greater number of patients were still alive six months following TXA administration, but there was no difference in survival with a good functional outcome. What’s New in Stroke Care?

Research 52

Research Airway Management Stroke Outcomes 52

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? Demographics were well balanced in the two groups. Prehospital Tranexamic Acid for Severe Trauma.

Blood Transfusions 105

Blood Transfusions Outcomes Administration Hyperthermia / Hypothermia 105

Taming the SRU

FEBRUARY 24, 2024

non-invasive positive pressure ventilation and IV nitroglycerin infusion have been shown to reduce morbidity (intubation rates, ICU admission) & mortality. non-invasive positive pressure ventilation and IV nitroglycerin infusion have been shown to reduce morbidity (intubation rates, ICU admission) & mortality.

Leadership 94

Leadership EMS Pediatrics Stroke 94

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). Liberal: 14.9% Estimated Difference: -0.9%; 95% CI 04.4 Liberal: 14.9% Read more

Sepsis 104

Sepsis Shock Resuscitation Outcomes 104

Dr. Smith's ECG Blog

SEPTEMBER 2, 2024

She stabilized after electrolyte administration with no further episodes of TdP. Regarding my Systematic assessment of ECG #1: There is significant baseline artifact , as well as baseline wander. Potassium chloride drip was also started. Potassium on admission was 3.5mmol/L (Ref 3.6-4.6) and magnesium 0.88 mmol/L (Ref 0.71-0.94).

Seizures 113

Seizures EKG/ECG EMS Stroke 113

ACEP Now

OCTOBER 3, 2023

Confounders to the GCS such as seizure and post-ictal phase, ingestions and drug overdose, as well as medications administered in the prehospital setting that impact GCS score should be documented. The GCS must be obtained through interaction with the patient (i.e., References Lulla A, et al.

Fluid Resuscitation 98

Fluid Resuscitation Documentation/Coding Resuscitation Pediatrics 98

EM Literature of Note

SEPTEMBER 9, 2021

It has apparently become time for the mobile stroke unit to go from niche to prime-time. Previously consigned to the pages of Stroke and similar journals, the latest and most comprehensive trial now graces the pages of the New England Journal of Medicine. A flagship study for a flagship journal.

Stroke 40

Stroke Telemedicine EMS Administration 40

The Skeptics' Guide to EM

SEPTEMBER 28, 2019

This was because of a well-known critical care physician Dr. Paul Marik. Clinical Question: Does the administration of vitamin C to an adult critically ill ICU patient or cardiac surgery patients decrease mortality? Reference: Putzu et al.

Sepsis 52

Sepsis Shock Outcomes Stroke 52

Don't Forget the Bubbles

JUNE 30, 2023

Again, there was no increase in thrombotic stroke in the TXA group – TXA looks safe. Well, one study in Kornelson’s systematic review and meta-analysis is interesting. Tranexamic acid administration to pediatric trauma patients in a combat setting: the pediatric trauma and tranexamic acid study (PED-TRAX). doi: 10.1097/TA.0000000000000443.

Head Injuries 145

Head Injuries Seizures Pediatrics Outcomes 145

Taming the SRU

MAY 3, 2023

She was noted to have improvement in her underlying respiratory status as well and was extubated approximately three weeks later. This targeted pulmonary vasodilation is thought to improve underlying ventilation-perfusion mismatch, leading to increased blood flow to already well-ventilated lung tissue (3).

Wellness 52

Wellness Hospitals Shock Outcomes 52

Downeast Emergency Medicine

APRIL 26, 2021

2][3] If earlier treatment with TXA is better, would there be benefit in its administration in the prehospital setting? Association between prehospital tranexamic acid administration and outcomes of severe traumatic brain injury. MI or stroke). If so, could this be done safely? JAMA Neurol. 2021;78(3):338–345.

Head Injuries 52

Head Injuries Administration Outcomes Seizures 52

EB Medicine

AUGUST 1, 2018

Jeff: Because the current DEA controlled substances schedule designations are based on original chemical names, synthetics have gained popularity as manufacturers are able to produce newer compounds and circumvent DEA designation as well as routine urine drug screening tests. First up is the link between cannabis use and stroke or TIA.

Seizures 40

Seizures Hyperthermia / Hypothermia Administration Dehydration 40

Northwestern EM Blog

MAY 16, 2022

The above study was well summarized and bears repeating that, in this multicenter randomized study assessing CT vs POCUS vs radiology performed US in patients with suspected renal colic in the ED setting, initial US reduced radiation exposure without adversely affecting patient-centered outcomes. J Urol 2019. 202(3):475-483.

Ultrasounds 52

Ultrasounds Radiology Radiology Outcomes 52

Mind The Bleep

DECEMBER 6, 2023

For example: in a study on stroke, if the mean age of participants in the treatment arm is 25 years, compared to 75 years in the placebo arm, are the results going to be valid? Was the administration difficult? Outcome measures are well and good, but often there is no significant difference measured in the primary outcome.

Outcomes 52

Outcomes Evidence-Based Practice Research Stroke 52

Taming the SRU

MARCH 31, 2023

of emergency medicine residents report 1 or more dimensions of burnout (Lin Annals Emerg Med 2019) Moral Injury with COVID “We pushed aside our fear and frustration to focus on saving the patients in front of us; we kept our eyes open, and our feelings closed.

Allergic Reactions 40

Allergic Reactions Seizures Anaphylaxis Leadership 40