July 27, 2020

Background: The scientific process in medicine is complicated. Obtaining high-quality data to guide management requires hypothesis formulation, data to support the hypothesis and study replication. Time and again beneficial findings in therapeutic studies fail to be replicated in subsequent studies. A single positive trial may cause some to feel it unethical to assign patients to a standard therapy that could potentially deprive them of benefit. Alternatively, pharmaceutical companies have little impetus to attempt or support collecting additional data that may jeopardize their product. In research, repetition is the pillar on which clinical trials results should be founded on. As this may not be feasible, complete transparency of all aspects of a trial are essential. One of the most hotly debated topics in emergency medicine is the use of systemic thrombolysis in acute ischemic stroke.  There are only two randomized clinical trials that demonstrate benefit in neurologic outcomes: NINDS-II and ECASS-III (see table below).  Methodological experts, however, have raised concerns that both studies had baseline imbalances in stroke severity that may have biased the trials final results. Both studies have undergone re-analysis taking these baseline differences into account.

July 22, 2020

Take Home Points
  • Spinal Epidural Abscess may present insidiously and patients often lack the classic triad of fever, back pain and neurologic symptoms
  • Empiric Antibiotics should cover Staphylococcus (including MRSA) and Gram negative Bacilli
  • All patients with clinical suspicion require rapid evaluation with MRI as the diagnostic study of choice
  • Although not all patients will go to the operating room, surgical consult (Neurosurgery or Orthopedics) should be obtained emergently

July 13, 2020

Background Information:

Headache is a common chief complaint that emergency physicians encounter almost every day and sometimes multiple times in each shift. In fact, headache is the fifth leading cause of patients presenting to the emergency department (ED).1 Current first-line treatment consists of a dopamine antagonist such as prochlorperazine or metoclopramide which are given in addition to diphenhydramine to mitigate any potential adverse effects. A recent study has shown that IV haloperidol, another dopamine antagonist, was equivalent to IV metoclopramide in the successful treatment of headaches in the ED.2 Additionally, haloperidol has been shown to be an effective rescue medication in the treatment of refractory migraine-pain.3 Unfortunately, the cardiovascular effects and reported QTc prolongation associated with haloperidol has limited its use in the ED. The authors of the following study sought to determine the effectiveness of low-dose IV haloperidol in the ED treatment of acute benign headache among patients aged 13 to 55 years old

July 8, 2020

Take Home Points
  • When approaching the patient with uspected seizure, focus on questions that matter in determining if the event was a seizure or not
  • Extensive lab work after a first time seizure is not necessary in patients who are back to baseline.  Focus on serum glucose, determining pregnancy/postpartum status, and in patients who continue to seize, check that sodium!
  • Get a CT of the Head on
    • First-time seizure patients
    • High-risk groups (alcoholics, immunocompromised, infants < 6 months of age)
    • Those with an abnormal neuro exam
    • Those presenting with focal seizures
  • Psychogenic non-epileptic seizures are difficulty to distinguish from true epilepsy and there is significant overlap between the two conditions.  Take all seizure activity seriously.
  • Give clear discharge instructions to your first-time seizure patients and close the loop on close neurology follow-up.

June 25, 2020

Definition: Suppurative infection enclosed within the epidural space

Epidemiology

  • Incidence: 2-3 cases per 10,000 hospitalized patients (Sendi 2008).
    • Rate is increasing given the rise in number of spinal procedures and anesthesia techniques
  • Mortality is low at 5%, however, if untreated paralysis may occur
  • Can occur at any age but most patients are between 50 and 70 years old.
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