December 17, 2020

Background: Intravenous alteplase is the current standard care for treatment of acute ischemic stroke (AIS) despite active debate on the research supporting its use.  The window for its use has been restricted to <3h of symptom onset based on the results of the NINDS trial and extended to a time window of <4.5h based on the results of the ECASS-3 trial. Both studies excluded patients with unknown time of onset and these patients are excluded from consideration for thrombolytics in real life as well. These trials are the only randomized studies showing benefit of intravenous alteplase vs placebo in acute ischemic stroke to date.  Of note, both of these trials have undergone reanalysis calling the validity of their results into question.  Despite which side of the debate you fall on, stroke care has moved on with advanced perfusion imaging and thrombectomy in large vessel occlusion strokes. Increased use of perfusion imaging has challenged the idea that time is a critical determinant of which patients should be considered for thrombolytics.

December 16, 2020

Background: Throughout the COVID-19 pandemic, numerous therapeutic agents have been repurposed and applied empirically and within clinical trials. Prophylactic medications for COVID-19 could have a huge benefit, but studies to date haven’t panned out. Initially many therapeutic medications were used late in illness, and one of the criticisms of these negative studies was that the drugs were applied too late in the disease and therefore did not show any benefit. There were also numerous studies showing associations of benefit, but subsequent randomized clinical trials have failed to prove effectiveness in reducing mortality (i.e. Remdesivir, hydroxychloroquine, lopinavir/ritonavir, convalescent plasma, monoclonal antibody therapy). Ivermectin is an interesting medication that had fallen off my radar until recently.  It is an anti-parasitic medication, with potential anti-viral, and anti-inflammatory properties against SARS-CoV-2 and COVID-19. In this post we will review some of the current evidence in using Ivermectin as a prophylactic and therapeutic agent in COVID-19.

December 16, 2020

Take Home Points
  • This is a resuscitative hysterotomy - focus is on saving the mother first. Delivering the fetus can improve venous return thus increasing chance to save mom
  • Don’t focus on gestational age to make the decision - if you think the belly is big enough to be causing compression of vascular structures, the procedure is indicated
  • Once you’ve made the decision - it’s go time. The faster you do it, the more likely you can salvage mom and the fetus
  • Large vertical incision to maximize exposure, locate uterus, vertical incision with scalpel and extend with scissors

December 15, 2020

Background: The COVID-19 Pfizer BNT162b2 vaccine, let’s just call it the COVID-19 Pfizer vaccine (so I don’t have to keep writing BNT162b2) is a novel mRNA vaccine developed to give immunity against the SARS CoV2 virus. It is synthesized mRNA packaged in small lipid nanoparticles but must be stored at extremely low temperatures (-70 C and 2 - 8 C for 5 days ) to prevent degradation.  The mRNA encodes for a small portion of the SARS CoV2 virus known as the spike protein and does not encode for the entire virus itself. This small lipid nanoparticle is injected into your body and then enters the cell. The lipid nanoparticles serve to protect and preserve the mRNA from degradation and allows it to enter cells readily.  After the mRNA enters the cells, the ribosomes will then take the mRNA and begin to synthesize this information to produce the spike protein portion of the SARS CoV-2 virus. The spike protein is what is believed to help the SARS CoV-2 virus enter human cell, replicate, and then lead to the syndrome known as COVID-19. This spike protein is believed to be the immunogenic portion of the virus that the body will then recognize as foreign and begin to develop an immune response against. The vaccine is given in 2 doses that are to be administered 3 weeks apart.

December 14, 2020

Background: In the US out-of-hospital cardiac arrest (OHCA) has an estimated survival rate of <10% overall, but slightly better survival rates with shockable rhythms of approximately 30% [2]. A small proportion of these patients will have refractory VF/VT OHCA not treatable by standard ACLS guidelines.  One possible modality for these patients is extracorporeal membrane oxygenation (ECMO, followed by immediate coronary angiography and percutaneous coronary intervention (PCI).  How would this ECMO-facilitated resuscitation strategy fair when applied in a US metropolitan community?