REBEL REVIEW 102: Confusion Assessment Method Algorithm (CAM-ICU)

Created March 27, 2021 | Neurology | DOWNLOAD

March 18, 2021

Background: The publication of the MR CLEAN trial in January 2015 changed the face of ischemic stroke care. This was the first study demonstrating a benefit to endovascular treatment of a specific subset of ischemic stroke patients: those with a large vessel occlusion (LVO) presenting within 6 hours of symptom onset. MR CLEAN was followed by a flurry of publications seeking to replicate and refine treatment as well as expand the window for treatment. The REBEL EM team reviewed this literature back in 2018 and, with the help of Dr. Evie Marcolini, created a workflow (see CVA Workflow below).

One major component of LVO management is the use of systemic thrombolytics in patients presenting within the current thrombolytic treatment window prior to endovascular intervention. However, it’s unclear if systemic thrombolytic administration results in better outcomes or if it simply exposes the patient to increased risks at a higher cost. Limited evidence questions the utility of the current approach with lytics + endovascular therapy (Phan 2017, Rai 2018).  In 2020, we reviewed an article by Yang and colleagues that demonstrated non-inferiority to an endovascular intervention only approach (with a 20% non-inferiority lower limit) (REBEL EM). Recently, two more studies have been published on this topic.

March 11, 2021

Background: Patients who present with a transient ischemic attack (TIA) are at higher risk of subsequent stroke, especially in the short term (< 7 days). However, the majority of these patients do not experience strokes which leads to a clinical conundrum; should all TIAs be admitted for evaluation? Comprehensive investigation, aggressive treatment, and/or hospital admission is not feasible for all patients and being able to risk stratify these patients to those who would most likely benefit is crucial.

February 18, 2021

Background:  Headache was the 5th most common reason for patients to present to the emergency department in the US in 2016.  Often ED providers include IV fluid boluses in their headache treatment cocktail, with prior research demonstrating IV fluids are included approximately 40% of the time (Jones).  While dehydration may precipitate some headaches, there is little evidence to support the use of IV fluids for their treatment.

February 15, 2021

Background: Alteplase has been the accepted thrombolytic for acute ischemic stroke (AIS) for 25 years. However, recent data has emerged regarding tenectaplase as an alternative.  Tenecteplase is a modified form of alteplase, with a lower cost and more favorable pharmacokinetic profile allowing for bolus injection.  Specifically, it has a higher fibrin specificity and lower affinity to plasminogen activator inhibitor (PAI-1) with a slightly longer half-life.