ACEP Now

APRIL 2, 2024

Posterior circulation strokes make up 20 percent of all strokes but account for 40 percent of stroke misdiagnoses. Dizziness is especially tricky, with up to 40 percent of strokes presenting with dizziness being missed. His neurological exam on arrival is documented as normal. His blood pressure is 190 over 115.

Stroke 40

Stroke Documentation/Coding Poisoning Emergency Department 40

Emergency Medicine Journal

MARCH 21, 2024

Background In 2019, the emergency medical services (EMS) covering the western Norway Regional Health Authority area implemented its version of the prehospital clinical criteria G-FAST (Gaze deviation, Facial palsy, Arm weakness, Visual loss, Speech disturbance) to detect acute ischaemic stroke (AIS) with large vessel occlusion (LVO).

Stroke 52

Stroke Documentation/Coding EMS Hospitals 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 of symptom onset; stroke symptoms that started during sleep were assumed to have started halfway between the actual last known well and the time of wake-up. Analyses were not adjusted for multiple comparisons.

Stroke 77

Stroke Administration Outcomes Documentation/Coding 77

EMDocs

MAY 4, 2024

. #1: Emergent Cath Lab Activations with “Normal” Computer ECG Interpretations Spoon Feed A significant minority of code STEMI patients have an initial normal computer ECG interpretation. Source Endovascular Thrombectomy for Large Ischemic Stroke Across Ischemic Injury and Penumbra Profiles.

Documentation/Coding 77

Documentation/Coding Stroke Emergency Department Pediatrics 77

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

PulmCCM

SEPTEMBER 17, 2023

Fully implemented, CDC’s toolkit would promote sepsis into the major leagues of “code strokes” and “code STEMIs” — highly prioritized system-wide operational programs enjoying executive sponsorship and significant financial and human resources. ” What is that, a sepsis Stasi?

CDC 98

CDC Sepsis Hospitals Documentation/Coding 98

Emergency Medicine Cases

JULY 4, 2017

In this two part EM Cases Journal Jam podcast Justin Morgenstern, Rory Spiegel and Anton Helman do a deep dive into the world's literature on systemic thrombolysis for ischemic stroke followed by an analysis of endovascular therapy for stroke.

Stroke 52

Stroke Documentation/Coding EMS 52

The Skeptics' Guide to EM

AUGUST 10, 2024

A code stroke is activated, and a CT head shows a left basal ganglia hemorrhage with no vascular lesions on CT angiography. Initial evaluation by medics revealed right arm weakness, a right facial droop, and decreased responsiveness. When he arrives at your ED, the family tells you he was doing fine until dinner.

Stroke 70

Stroke Airway Management Documentation/Coding Outcomes 70

Ken Grauer, MD

JUNE 22, 2024

As another alternative consideration — Diffuse ST-T wave abnormalities ( including T wave inversion ) as are seen in ECG #1 could be the result of a non -cardiac condition — including marked metabolic and/or electrolyte disturbance, CNS catastrophe (ie, stroke, intracerebral or subarachnoid bleed, trauma, tumor ), severe anemia, "sick" patient, etc.

EKG/ECG 433

EKG/ECG Stroke Documentation/Coding Wellness 433

Board Bombs

AUGUST 16, 2020

Check out our interactive question bank podcast- the FIRST of its kind here: emrapidfire.supercast.tech Code Stroke? Check out our interactive question bank podcast- the FIRST of its kind here: emrapidfire.supercast.tech Code Stroke? JK its just Bells Palsy. JK its just Bells Palsy. or is it?

Documentation/Coding 52

Documentation/Coding Stroke 52

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?

Stroke 97

Stroke Fractures Outcomes Operations 97

EMDocs

JUNE 28, 2023

EMS report includes concern for CVA, with variable documentation of face and extremity weakness. Nursing documentation includes the presence of a facial droop. There, his initial neuro exam is documented as normal, but a head CT reveals evidence of a possible acute CVA in the right hemisphere. a stroke or cardiac event).

Documentation/Coding 67

Documentation/Coding EMS Stroke Patient Safety 67

EMDocs

SEPTEMBER 19, 2023

Also think about NCSE in patients with prior cerebral pathology (ie, ischemic stroke); a patient who was seizing, was treated, and is not coming out of their post ictal state; and in patients with unexplained altered mental status with no other cause. Official diagnosis requires EEG, which is not something we can typically obtain in the ED.

Seizures 72

Seizures Documentation/Coding EKG/ECG Emergency Department 72

Mind The Bleep

NOVEMBER 21, 2023

Unless you’re documenting something hilarious, please keep it brief and to the point. History of Presenting Complaint In this section use SOCRATES to document the pain. Drugs/Allergies When documenting drugs – try to get the dose and frequency (this can be found on Summary Care Records from the GP if you have access).

Documentation/Coding 52

Documentation/Coding COPD EKG/ECG Wellness 52

ACEP Now

OCTOBER 29, 2024

Our nurse did not study Paul Ekman’s Facial Action Coding System for Action Units to code “fear” in the patient’s face. Passively, I watch another clinician’s cursory examination of a critically ill patient to determine how they deem a patient “toxic-appearing” or their bedside neurological assessment to activate a code stroke.

Emergency Department 59

Emergency Department Mass Casualty Incidents Documentation/Coding Sepsis 59

RebelEM

JANUARY 29, 2024

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).

Stroke 137

Stroke Outcomes Hospitals Administration 137

ACEP Now

JANUARY 30, 2024

Live and in person for the first time in three years, the PEM Assembly is part of this year’s ACEP Accelerate, where you can fuel your future with four different, professional, enhancing tracks, including the ED Director’s Academy and the Reimbursement and Coding Conferences. Learn more at acep.org/accelerate.

Pediatrics 52

Pediatrics EMS Documentation/Coding Stroke 52

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

RebelEM

MARCH 13, 2024

This was not a Code 3 respiratory distress, fentanyl overdose with minimal response to Narcan or even an unconscious stroke patient with the blood pressure of a giraffe. The patient came in working hard to breath, had minimal improvement after meds and treatments and was clearly tiring.

Documentation/Coding 59

Documentation/Coding Outcomes EMS Stroke 59

ACEP Now

OCTOBER 3, 2023

This document is an update of guidelines first published in 2000, and then updated in 2007. 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. 2019;154(7):e191152.

Fluid Resuscitation 98

Fluid Resuscitation Documentation/Coding Resuscitation EMS 98

The Skeptics' Guide to EM

DECEMBER 5, 2020

You’re about to call in your MRI tech from home, but then you remember reading that the HINTS exam is more sensitive than early MRI for diagnosis of posterior stroke. You wonder, “Why can’t I just rule out stroke with the HINTS exam? Posterior circulation strokes account for approximately up to 25% of all ischemic strokes [1].

Stroke 40

Stroke Documentation/Coding Emergency Department Hospitals 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.), Preliminary findings documented in the cath lab were “Anterior STEMI and no significant coronary artery disease.” (!!!) ng/mL and 0.10

EKG/ECG 98

EKG/ECG Documentation/Coding Emergency Department COPD 98

Taming the SRU

JULY 31, 2024

Barometric pressure, humidity, and temperature changes may influence stroke and fall incidence (especially in elderly patients with cardiovascular risk factors). Nice people are not more likely to get cancer. Black clouds don’t exist (but I still sort of think they do).

EKG/ECG 52

EKG/ECG Sepsis Documentation/Coding Stroke 52

JournalFeed

MARCH 26, 2022

High-dose IN Fentanyl Spoon Feed: Higher doses of intranasal (IN) fentanyl for pain ranging from 2-5 μg/kg (with a maximum of 200 μg) were given in a pediatric emergency department, with no documented episodes of apnea, hypotension, or respiratory failure.

Stroke 40

Stroke Documentation/Coding Emergency Department Resuscitation 40

ACEP Now

JUNE 6, 2023

Notoriously elusive, with a high misdiagnosis rate, thoracic aortic dissection (AD) can mimic many conditions, including acute coronary syndrome (ACS, the most common), gastroesophageal reflux disease (GERD), stroke, and spinal-cord compression. 1 Opioids or anxiolytics are often given to patients whose diagnosis of AD is missed or delayed.

EKG/ECG 85

EKG/ECG Stroke Documentation/Coding Operations 85

Mind The Bleep

JUNE 18, 2023

ICD-10 codes: F00-03 are the ICD codes for dementia and its subtypes F02. – One stroke is prevented for every 37 patients with dementia who avoid 2-3 months of antipsychotic symptoms for their BPSD. This article outlines the main factors related to the presentation, aetiology, and treatment of BPSD.

Psychiatric 52

Psychiatric Documentation/Coding Stroke Fractures 52

Taming the SRU

SEPTEMBER 1, 2023

for detecting major injuries Abnormal CXR Rapid deceleration mechanism Presence of a distracting injury Chest wall tenderness Sternal/thoracic spine/scapular tenderness There are limited decision-making rules for thoracic spine imaging Yet a study (Inaba et al., 2015) reported a sensitivity of 98.9%

Sepsis 94

Sepsis Documentation/Coding Administration Fractures 94

Taming the SRU

AUGUST 4, 2024

Know your audience, and tailor your presentation to them in terms of humor, pop culture references, and dress code Err on the side of making your presentation slightly shorter than the alloted time to allow room for questions. It is better to finish early than rushing through your presentation

Emergency Department 84

Emergency Department Dislocations Documentation/Coding Burns 84

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.

Shock 90

Shock Seizures Airway Management Stroke 90

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. A subset of these patients develop an accelerated rate either primarily or due to other factors known as rapid ventricular response.

Outcomes 52

Outcomes Stroke Documentation/Coding Fractures 52

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. For many individuals, this is life-transforming.

Stroke 45

Stroke Documentation/Coding Outcomes Wellness 45

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

Sensible Medicine

DECEMBER 1, 2023

This is the doctor who explains why, at age 80, it would be crazy to be “full code.” When I first learned about shared decision making, I was taught that when patient and doctor stay in their lanes – doctors say what is or is not indicated and patients express their preferences – things tend to go well.

Wellness 83

Wellness Documentation/Coding Outcomes Stroke 83

Dr. Smith's ECG Blog

SEPTEMBER 2, 2024

I therefore feel it relevant to document ( in your dictation/on the medical chart ) when significant artifact potentially impairs the accuracy of your interpretation. Regarding my Systematic assessment of ECG #1: There is significant baseline artifact , as well as baseline wander.

Seizures 104

Seizures EKG/ECG EMS Stroke 104

Taming the SRU

FEBRUARY 5, 2024

1) However, it wasn’t until the 1890s that purposeful, successful, and safe attempts to access this fluid were documented (2). Metropolitan Museum of Art, CC0, via Wikimedia Commons The ancient Egyptian physician Imhotep is often credited with the discovery of cerebral spinal fluid (CSF) —over 5,000 years ago! (1)

Infectious Diseases 96

Infectious Diseases Seizures Ultrasounds Sepsis 96

Downeast Emergency Medicine

APRIL 26, 2021

Trauma patients between the ages of 18-90 years had to have either had one documented episode of hypotension (defined as a systolic BP <90 mmHg) or tachycardia (>100 beats/minute) to be included in the study. MI or stroke). TXA does not increase the incidence of thromboembolic events such as DVT/PE, stroke, or MI.

Head Injuries 52

Head Injuries Administration Outcomes Seizures 52

All Ohio EM

FEBRUARY 11, 2019

Dr. Mike Pallaci covered endovascular therapy for stroke with a quick review of some very relevant studies that put endovascular therapy on the map. Based on data from MR CLEAN, merely 1/110 screened strokes would meet inclusion criteria. Even once it arrives, it will cost upwards of $25k per dose! Image from R.E.B.E.L

EMS 52

EMS Stroke Leadership Documentation/Coding 52