June 3, 2019

Background: Despite the lack of replication of the NINDS & ECASS-3 trials, guidelines recommend the use of tPA in the ≤4.5hr window after the onset of symptoms of acute ischemic stroke [2]. These recommendations used non-contrast computed tomography (NCHCT) for the selection of patients.  More recent endovascular studies have shown that perfusion-based imaging can show potential viable brain tissue beyond the 4.5 hour mark in patients with large vessel occlusions and result in good neurologic outcomes.  This advance has prompted investigators to look at perfusion-based technology to identify a larger cohort of patients without large vessel occlusion that may be candidates for systemic thrombolysis.  One of the big fears in stroke management is the concept of indication creep: finding more uses for a medication or product without strong evidence to support its use. The bigger question is, does this increase in use help the company’s bottom line or the patient? It is no wonder physicians are skeptical of industry sponsored trials, as we sometimes question the motives behind the study.  Now we have another industry sponsored trial: EXTEND. In this trial.

May 15, 2019

Essentials of Emergency Medicine 2019 is taking place at the Cosmopolitan Hotel/Casino in Las Vegas, NV. I was asked to give five lectures on varying topics and wanted to share what was discussed at each of these sessions.  If you haven't been to Essentials of Emergency Medicine, you need to add this conference to your list of conferences to attend.  The organizers pride themselves in discussing the latest practice-changing research and have meticulously designed content to maximize enjoyment and retention. In my humble opinion this conference is the quintessential medutainment extravaganza that applies learning theory principles, with amazing speakers, to provide you with the latest and greatest for clinical practice.

April 11, 2019

The shiny new toy in stroke treatment is endovascular therapy.  There have now been 12 randomized controlled trials (RCTs) on endovascular stroke therapy (EST), with eight of the last nine showing positive results – stunningly positive.  This flood of positive trials has led to new guidelines from the American Heart Association (AHA) and American Stroke Association (ASA)that extend the treatment window potentially as far out as 24 hours after last known well, and has spawned a movement to completely overhaul how we deliver care for patients with acute ischemic stroke (AIS). With all of the enthusiasm for EST, it is important to review the evolution of this new approach, to review and critique the evidence, and to evaluate what this means in clinical practice.

April 1, 2019

Background: No matter which side of the debate you sit on in regard to systemic thrombolysis in acute ischemic stroke (AIS), there is one truth: systems have undergone major changes to ensure tPA is offered to patients in the ≤4.5-hour window.  The debate surrounding tPA in AIS lies in the equipoise surrounding benefits while there are very real harms.  Advocates of tPA in AIS hang on to two trials that have never been replicated (i.e. NINDS and ECASS-III), and both have major methodological issues. Skeptics of tPA in AIS appropriately argue that there are 11 other randomized clinical trials which have shown almost no benefit, but come at the cost of early increased early mortality and symptomatic intracranial hemorrhage (sICH) (Nice breakdown of individual trials of thrombolysis in stroke can be found at First10EM).  Now there is a push to extend the window of tPA out to 9 hours in AIS with newer imaging modalities such as MRI diffusion-weighted studies in patients with unknown onset of symptoms. The push for this stems from the fact that patients with a visible ischemic lesion on diffusion-weighted imaging, combined with the absence of a clearly visible hyperintense signal in the same region on fluid-attenuated inversion recovery (FLAIR) is predictive of symptom onset within 4.5 hours before imaging.

March 29, 2019

On the last day of the last SMACC conference, Dr. Ken Milne (The SGEM) and I had a cage match debating four critical care controversies. It was all done in good fun with both of us taking our opportunities to poke a little fun at each other. While we took a pro vs con approach to the presentation, our positions are much closer than the debate demonstrates. Although the literature is far from perfect, development of critical appraisal skills and application of evidence-based medicine to the literature is what we should be using to inform our care but not dictate our care. It is equally as important to incorporate clinical judgment and ask our patients what their values and preferences are before making decisions about care.
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