October 30, 2019

Background: Currently, alteplase is the mainstay of treatment of acute ischemic stroke.  Advocates of alteplase suggest that the benefit of alteplase is greatest when given early and declines with increasing time from stroke symptom onset (i.e. time is brain).  Therefore, the AHA/ASA guidelines recommend intravenous alteplase within 4.5 hours after stroke onset, which is based on very weak evidence (i.e. NINDS & ECASS III). Due to weak evidence in support of it’s use and significant patient risks associated with alteplase, it’s use in acute ischemic stroke remains controversial.  One of the big issues is that by decreasing the time for evaluation and treatment, there is an increased risk of administrating alteplase to patients presenting with noncerebrovascular conditions that can resemble an acute ischemic stroke (i.e. stroke mimics).  This puts patients with no chance of improvement with alteplase at risk for increased mortality and symptomatic ICH.  There is some limited data on the safety of alteplase in stroke mimics and this study adds to that knowledge.

October 9, 2019

Take Home Points 
  • Acute closed angle glaucoma is an ophthalmologic emergency that usually presents with sudden, painful, monocular vision loss.
  • Physical exam will reveal conjunctival redness, corneal haziness or cloudiness due to edema and a pupil that is mid sized and minimally reactive to light, a rock hard globe and IOP >/= 21.
  • These patients require emergent ophthalmology evaluation but treatment should be started empirically while waiting for the evaluation. Initial treatment to decrease IOP usually includes a topical BB such as timolol and topical AB such as apraclonidine and either IV or PO acetazolamide.  
 

September 25, 2019

Take Home Points
  • When looking at pH and bicarb, the differences between VBG and ABG are miniscule. For DKA patients, stick with the VBG as is less painful and has fewer complications. 
  • LR is probably a better fluid for the large volume resuscitation required in DKA. Start with a 20 cc/kg bolus and then reassess the patient’s perfusion status.
  • Stay on top of your electrolyte repletion. If the patient has a working gut, you can aggressively replete potassium orally and don’t forget that when you are repleting potassium you also must replete magnesium.
  • Bolus dose insulin gets the patient to super-physiologic levels and has been associated with higher potassium requirements and more episodes of hypoglycemia. It’s probably fine to skip the bolus and stick with a drip alone
  • Don’t forget to think of all possible etiologies of DKA, while we most often find this in patients who have not been taking their home meds for whatever reason, don’t forget a good history to look for sources such as infection and ischemia. 

September 11, 2019

Take Home Points:

  • Get definitive airway control when necessary
    • Use modality you’re most comfortable with
  • Hard signs -  pulsatile bleeding, bruit or thrill, expanding hematoma, airway compromise, massive hemoptysis (think airway injury), hematemesis (think esophageal injury), grossly injured trachea, neurologic deficit, subcutaneous emphysema.
  • Soft Signs are hypotension that resolves, stable hematoma, wound in proximity to major vascular structure, minor hemoptysis, dyspnea, dysphagia, chest tube air leak, vascular bruit or thrill (depends on surgeon).
  • Hard Sign on presentation goes straight to the OR. Soft Sign on presentation gets some imaging done
  • Resuscitate with blood products -> Activate massive transfusion protocol
  • Most hemorrhage will respond to direct pressure
  • Don't miss other injuries!

September 2, 2019

Background: Convulsive status epilepticus is the most common pediatric neurological emergency worldwide.  Currently, phenytoin (UK & Europe) or fosphenytoin (USA) is the recommended second-line IV anticonvulsant for the treatment of pediatric status epilepticus.  Some evidence and providers however suggest that levetiracetam could be an effective and safer alternative. Recently not one, but two RCTs were published trying to figure out whether levetiracetam or phenytoin should be second-line treatment of pediatric status epilepticus.