Blog

Thunderclap headache, but negative CT: now what?

A 45 year old male comes into the ED with a sudden, severe headache. It started while he was at work yesterday and was the worst of his life. It started feeling a little better, but hasn’t totally gone away and his wife made him come to get checked out. There are enough concerning featuresRead more

The Neuroprotective Intubation

Bottom line up front: (1) Intubating those with TBI or spontaneous ICH is dangerous. You want to prevent increased ICP that is caused by laryngoscopy. (2) Pre-treat with fentanyl if time and the pt’s BP allow. The dose of fentanyl is larger than we are used to, dose 3 mcg/kg (or ~150-200mcg). (3) It isRead more

DAWN of a new era in stroke care

Thrombectomy performed within 6 hours of symptom onset has been demonstrated to significantly improve clinical outcomes after stroke. Though there is generally diminishing benefit with increased time interval from last known well to the time of intervention, some previous data suggested that patients with “salvageable” brain tissue on diffusion weighted imaging (DWI) may still benefitRead more

The 52 in 52 review: Thrombolysis with Alteplase 3 to 4.5 Hours after Acute Ischemic Stroke

Article Citation                                                                                                                             Hacke W, Kaste M, Bluhmki E, Brozman M, et al; ECASS Investigators. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med. 2008 Sep 25;359(13):1317-29. PMID: 18815396   What we already know about the topic  Last week we reviewed the 1995 NINDS trial that showed that t-PA givenRead more

Is there anyway to differentiate between a traumatic tap and an aneurysmal SAH?

There may be.     Traumatic lumbar punctures occur in up to 30% of lumbar punctures. An observational, multicenter cohort study by Jeffrey Perry et. al. attempted to answer this question and enrolled sequential patients with acute non-traumatic headaches who: had a GCS of 15, were neurologically intact, and whose headache reached a peak intensityRead more

Is the LP really necessary?

Concerned about a SAH?  The thunderclap worst headache of your patient’s life?  Recent data suggests that a negative head CT within 6 hours of symptom onset in a neurologically intact patient doesn’t warrant an LP. Perry et al: Multicenter prospective cohort study 240/3132 (7.7%) had SAH overall SAH defined as: visualized on noncontrast head CT,Read more

Sphenopalantine Ganglion Block for Migraines

Patients presenting to the ED with migraine pain can often present a challenge in terms of pain control. For patients who have pain refractory to NSAIDs, IV fluids, and migraine abortive therapies, or those who would prefer not to receive an IV, what other options can we turn to? The sphenopalatine ganglion (SPG) plays aRead more

ACEP Clinical Policy: TIA

In 2016, ACEP published “Clinical Policy: Critical Issues in the Evaluation of Adult Patients with Suspected Transient Ischemic Attack (TIA) in the Emergency Department” in the Annals of EM. Here is a brief refresher. Transient ischemic attack (TIA) is a part of a spectrum of ischemia affecting the central nervous system. “Transient episode of neurologicRead more

Giving tPA to a patient on aspirin? What about aspirin and Plavix?

Does it matter if my patient getting tPA is on prestroke antiplatelets?   The neurology and ED teams have decided to give tissue plasminogen activator (tPA). As an outpatient, the patient is on aspirin and clopidogrel dual antiplatelet therapy. Does it matter that they’re on aspirin and Plavix? Does prestroke antiplatelet therapy in acute ischemicRead more

Hypertonic Saline or Mannitol for Head Injury?

Traumatic Brain Injury & Neurocritical Care You’ve just intubated your traumatic brain injury patient and the repeat pupil exam shows signs of herniation. In addition to your other interventions (e.g., Reverse Trendelenburg positioning, optimization of sedation/analgesia), do you reach for the hypertonic saline or mannitol as osmotherapy? What risks and benefits come with either therapy?Read more