January 14, 2021

Background Information: Out-of-hospital cardiac arrest (OHCA) remains a diagnostic challenge to providers and a significant burden on healthcare systems globally. Despite the advancement of invasive medical therapies such as percutaneous coronary intervention (PCI) and extracorporeal membranous oxygenation (ECMO) at designated cardiac catherization centers, the majority of these patients sustain poor outcomes due to hypoxic brain injury. Clinical features of neurologic injury are typically delayed until 72 hours after admission. As a result, many neuro-prognostication tools have been developed to assist with clinical decision making as well as reduce expensive futile interventions.1 Some of these neuroprognostication tools include the Cardiac Arrest Hospital Prognosis (CAHP), OHCA and Targeted Temperature Management (TTM) risk tools. Unfortunately, these are complex and time consuming, thus limiting their use in the emergency department (ED). The authors of the following study sought out to develop and validate a point-based risk score to support clinical decision making and predict neurologic outcomes using the cerebral performance category (CPC) scale (Figure 1)

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 10, 2020

Background: Acute migraine headaches are a common presentation to emergency departments.  Treatment can be challenging: multiple medications are often required and allergies can limit options. Oral timolol maleate is approved by the FDA for migraine prophylaxis but is not typically effective once the migraine has started.  There are some case reports of topical timolol in the treatment of acute migraine headaches [2][3] and a research letter [4] describing the use of timolol eyedrops in the treatment of acute migraine headaches. The research letter was a randomized trial of 10 patients that was not masked and therefore no definitive conclusions could be made.

November 30, 2020

Background: Renal colic and migraine headaches are common emergency department presentations.  There are a wide range of medications available to treat pain from these disorders including opioids and non-steroidal anti-inflammatory drugs. Opioids have two major issues: dependency and side effects (i.e., apnea, vomiting, etc.). Having multiple medication options is essential in our efforts to reduce the use of opioids as first line therapy for pain control.

September 3, 2020

Background: The risk of a subsequent ischemic stroke in the first few months after an acute ischemic stroke or transient ischemic attack is approximately 5 to 10%. In these patients Aspirin has been used to prevent secondary ischemia, and trials have shown a reduced risk thereof when the P2Y12 receptor blocking antiplatelet agent Clopidogrel is added. Clopidogrel, however, requires hepatic conversion to its active form through a pathway that is inefficient in 25% of white and 60% of Asian patients and efficacy is uncertain in these patients. Not dependent on metabolic activation is the direct-acting ticagrelor with similar P2Y12 receptor blocking effect. While a trial of ticagrelor alone did not show benefit over aspirin; in their sub-group analysis of patients who had received aspirin within 7 days before randomization, treatment with ticagrelor may have reduced the risk of major vascular events. This finding suggested that the effect of aspirin received before entry into the trial might have persisted for several days after treatment and that the combination of ticagrelor and aspirin may prevent subsequent strokes.
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