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 27, 2020

Background: Acute gastrointestinal bleeding (GIB) is a common diagnosis dealt with by emergency clinicians.  Definitive therapy for acute GIB often includes endoscopy or surgery. However, there is a myriad of pharmaceutical options (i.e. PPI, Somatostatin Analogues, Antibiotics, etc.) as well as blood products that may be instituted as part of the acute resuscitation of these patients. The role of tranexamic acid (TXA) in resuscitation of this condition is unknown.

TXA has become one of the darling medications of emergency medicine, with numerous indications, minimal side effect profile and low cost. TXA works by inhibiting blood clot breakdown (i.e. fibrinolysis).  TXA has been shown to decrease death from bleeding in other conditions (Trauma, Postpartum hemorrhage) but there is limited evidence for its use in GIB.  A systematic review and meta-analysis of seven randomized trials with just over 1600 patients [2] showed a reduction in all-cause mortality.  However, the individual trials were small and prone to a myriad of biases making these conclusions hypothesis generating at best.

June 24, 2020

Take Home Points
  • Heat stroke is a life-threatening disorder characterized by elevated core temperature, compromise to neurologic function and multi-system organ dysfunction
  • The keystone of treatment is rapid cooling within 30 minutes of presentation preferably with ice water immersion
  • Patients with heat stroke should be investigated for rhabdomyolysis, AKI, liver failure and concomitant infection

June 18, 2020

Background: Here we go again with another “Time is Brain,” acute ischemic stroke study.  The authors start out by saying that earlier administration of intravenous tPA in acute ischemic stroke is associated with reduced mortality by the time of hospital discharge and better functional outcomes at 3 months.  These statements are based on flawed studies [3][4] (Check out Ken Milne discussing these issues HERE). Additionally, tPA has not been demonstrated to decrease mortality in any randomized clinical trial though it does increase early mortality. If you can’t tell, I am very skeptical about the spin of this trial.

May 31, 2020

I am fortunate to work in a hospital system that is very forward thinking.  We have a phenomenal relationship with our intensivists, and I have been fortunate enough to have several discussions with them about how we are managing COVID-19 in our ICUs.  For full transparency, I don’t work up in the ICU, but had the opportunity to discuss what we are doing in our ICUs with one of our intensivists (ECMO, steroids, Remdesivir, etc...).  We are doing something different in San Antonio that I thought was worth discussing on this podcast that may be a feasible option for some institutions and some patients, but not all. If there is one thing this disease has taught me, that is one size does not fit all.