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Ischemic Stroke Guidelines from the ASA

Hot off the presses; the 2013 Ischemic Stroke Guidelines from AHA/ASA (Stroke 2013;44:870)

Want the full recommendations as written by the AHA/ASA?

Stroke Centers

* Comprehensive Stroke Centers are god

* Should have neurocritical care unit

* EMS should bypass hospitals that can’t care for stroke

* Should have tele-rads if no in-house radiologists

Initial Eval

* Door to Drug within 60 minutes (80% compliance)

* Use a Stroke Scale, preferably NIHSS

* Get labs, but glucose is the only one that needs to be done before tPa

* Get EKG and troponin, don’t delay tPA for this

 

ED-Based Care

Imaging

* Get either a NCCT or MRI to exclude hemorrhage prior to tPA

* tPA indicated even if ischemic signs, unless a frank hypodensity is noted

* A non-invasive intracranial vascular study is strongly recommended during initial imaging if IA tPA or mechanical thrombectomy is contemplated. This should not delay tPA administration

* In tPA candidates, the CT or MRI should be read within 45 minutes of arrival by a physician with expertise in reading CTs or MRIs of the brain

* Consider CT Perfusion or MRI perfusion in patients outside of the window for IV tPA

* If frank hypodensity involves more than 1/3 of the MCA territory, IV tPA should be withheld

TIAs

* They should get imaging of their cervical vasculature

* Noninvasive imaging by CTA or MRA of the intracranial vasculature is rec. to exclude proximal intracranial stenosis or occlusion. Intracranial lesions may need confirmatory angio if occlusion seen on CTA

* Pts with transient sx should receive imaging within 24 hours, preferably by MRI

Acute Treatment

* Cardiac Monitoring

* New BP meds allowed to get the pt <180/110. Shoot for 180/105 for first 24 hours

* Intubate airway compromise or bulbar dysfunction

* Shoot for pulse ox > 94%. Don’t give supplemental O2 in patients with normal RA pulse ox

* Lower temps >38 C

* Until further evidence, use the same BP goals for IA/mech treatments

* In Non-tPA, only treat if SBP>220 or DBP>120

* Treat hypovolemia with NS and treat CO-reducing dysrhythmias

* Treat hypoglycemia

* May restart home anti-hypertensives after 24 hours

* Treat hyperglycemia to achieve a Blood Sugar of 140–180 mg/dl

IV Fibrinolysis

* Give IV tPA in patients who meet 3 hour criteria (IA)

* Getting it within window is not enough, shoot for the <60 minutes timeframe

* Give IV tPA to pts who meet criteria within 4.5 hours (IB)

* Be prepared to treat complications including bleeding and angioedema

* tPA is reasonable if pt had a seziure if treating team feels deficit is from stroke and not post-ictal state (IIaC)

* Benefits of sono-thrombolysis are unknown at this time

* Other agents besides tPA should only be used in clinical trials

* Benefit of tPA unknown in patients in the 3–4.5 hr range with one of the additional contra-indications

* Use of tPA in pts with mild deficits, rapidly improving deficits, major surgery in prior 3 months, and recent MI may be considered and should be based on risk benefit assessment

* Don’t use streptokinase

* The use of intravenous rtPA in patients taking direct thrombin inhibitors or direct factor Xa inhibitors may be harmful and is not recommended unless sensitive laboratory tests such as aPTT, INR, platelet count, and ECT, TT, or appropriate direct factor Xa activity assays are normal, or the patient has not received a dose of these agents for >2 days (assuming normal renal metabolizing function). Similar consideration should be given to patients being considered ...

Paul Mayo and I seem to have established a tradition of debating each other at the annual Greater NY Hospital Association Critical Care Controversies Conference.

Last year, we debated whether paralytics should be used for emergent intubations.

This year, the topic was Should All Intubations be Performed with Video Laryngoscopy?

I think you will enjoy the debate, because we don't mind attacking our opponent.

If you enjoyed this podcast and the others on the EMCrit site, please consider supporting the show at CME.EMCrit.org.

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Right click here and choose save-as

Now, on to the debate...

 

As you know, my motto is maximally aggressive care, ALWAYS! Maximally aggressive curative care and maximally aggressive palliative care. I did a podcast episode on critical care palliation a year or so ago.

At this year's EMCrit Conference, Ashley Shreves gave the ultimate lecture on the topic. Twenty minutes jam-packed with goodness.

* The End-of-Life and Palliation Education Resource Center

A listener, Don Zweig, wrote with this summary:

* We (as in ED docs) in general deal with End of Life Care and palliative care situations poorly.

* Our job as physician is to understand the family goals and values and then give a professional recommendation- it is not to give a menu--they have no medical knowledge to reasonably make this choice.

* Three things we should never say:

*  "Do you want us to do everything?"  Of course they do, but if you offer "everything" who wouldn't want mom to get everything? Could they say…."no, whatever you do , don't do everything for mom!" This also makes the family feel that everything (whatever that entails) is reasonable or possible. Instead use the 'Pal Care' approach and say, "What would be most important to you and your mom now?"  On the basis of what you hear make a reasoned professional recommendation.

* "Do you want us to resuscitate her?"  This implies that we think it is possible or reasonable to do this!  Since you ask this it must be reasonable.  "You can just bring her back?  Great, go ahead!" Use natural death language.  So it sounds like your mom would want a natural death?  When her heart stops we will not interfere with that process

* " I am so sorry, there is nothing more we can do"  There is a lot that can be done and it involves maximizing comfort and minimizing suffering. They need palliative care or hospice.    So call a consult and give palliative meds.

* Try to get private room and take them off the monitor!  There is no place for monitor in the dying patient for which you are providing comfort care.

* Treat discomfort with morphine or dilaudid in very small doses.  Double every 15 minutes until decreased suffering.

Addendum

This amazing post on the blog Expensive Care is a must read on the topic of the ethics of CPR

Treating Pain in Palliative Patients

Survival of old intubated folks (J Am Geriat Soc 2018)

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Now on to the Vodcast...

I received a distressed email from a fan who was dismayed that other residents in her program were bashing medical podcasting; this is my response.

What is Tacit Knowledge?

* Wikipedia Entry

Slide Show on Tacit Knowledge and Wicked Problems

Social Media as a Transmission Tool for Tacit Knowledge

* Social Media and Tacit Knowledge Sharing

* Potentials of Social Media for Tacit Knowledge Sharing - Preliminary Findings

* Conceptual Model for Social Media and Tacit Knowledge

Next horizon is to answer the question of how to solve Wicked Problems and can social media and FOAM help?

* Wicked Problems

What do you think?

At the EMCrit 2013 Conference we had a Blast Competition. The BLAST rules are easy:

The winner this year was Salil Bhandari with an incredible presentation on peri-mortem caesarean section.

Here is an article:

Eur J Emerg Med. 2011 Aug;18(4):241-2. doi: 10.1097/MEJ.0b013e328344f2c5. Prehospital resuscitative hysterotomy.

Want to know more about peri-mortem c-section? Check out these insanely good posts:

* The post Perimortem C-section at St.Emlyn’s appeared first on St Emlyns.

* A personal take from a doc, Greg Press, who has performed two of these (2 more than me)

Update

Neonatal outcome: mean times from arrest to delivery were 14±11 min and 22±13 min in survivors and non-survivors respectively (Resuscitation. 2012 Oct;83(10):1191-200.)

And here is a simulator video:

Video on Vimeo

And the best video on the procedure I have seen on life-identical model

https://www.youtube.com/watch?v=1v9x4jPQwE8

Update:

In one case series, 12 of 20 women had return of spontaneous circulation immediately after delivery (EMCNA, Vol. 30, pg. 949). HT to emedhome.

Rob Bryant has another great video on resuscitative hysterotomy

Now on to the Wee...

If you have a comment or question about one of the podcasts, chuck it into the comments section.

But I get a ton of clinical cases and questions by email or the contact form that have not been covered on a podcast yet. I love this--it exposes me to some great cases I would never hear about otherwise. Problem is, up until this point, it has been a 1 on 1 conversation. This is sort of a waste because nobody else benefits except you and me. So in the future, when you have a  case or question like this, I would love it if you posted to the Google Plus EMCrit Community page. This allows a few things:

* it allows my answer to be seen by a much larger group of people

* it allows folks smarter than me to chime in as well

* it keeps a record of these case interactions so I can refer people to them in the future

So how do you do it? Easiest way to learn is to watch this video:

See Version 2

Intubation Checklist

Checklists

Since Peter Pronovost's landmark study on how a simple checklist can nearly abolish central line infections, checklists have been the darling of the medical literature. But central lines generally are for elective procedures, allowing us the time and patience to run through the list. Can we gain the same safety and cognitive benefits in an adrenaline-laden procedure like intubation? Hell yeah!

It all starts with the EMCrit Intubation Checklist

Download the checklist

The Components

HOp Killers

Here is the wee on the HOp Killers: Hemodynamic Kills, Oxygenation Kills, and pH Kills

* Intubating the Hemodynamically Unstable Patient

* Intubating the Patient at Risk for Critical Hypoxemia

* Intubating the Patient with Metabolic Acidosis

RSI or Awake? · DSI? · RSA? · ICP/Vascular?

* Awake Intubation Lecture

* More info on Delayed Sequence Intubation (DSI)

* Rapid Sequence Airway (RSA)

* ICP/Vascular Intubation

Are the peri-intubation medications ready?

Push-Dose Pressors

* Push-Dose Pressor Podcast and Mixing Sheet

What is the plan for unexpected difficult or failed airway?

* I use a modified version of the Shock Trauma Center Failed Airway Algorithm

* Cook Gas ILA (My preferred Extraglottic Airway)

Can the cricothyroid membrane be palpated?

* Cric-Con Approach to Cricothyrotomy Preparation

What is the plan for post-intubation sedation?

* A bad sedation package traps your patient in a nightmare

Is the patient positioned adequately?

from AirwayCam Site

Would the patient benefit from pre-intubation NGT?

* Intubating the GI Bleeder

Skills of Intubation

Laryngoscopy

http://vimeo.com/17542057

Video Laryngoscopy

Here are some tips

Cricothyrotomy

See this post for all things surgical airway

Post Intubation Management

* Ventilator Lecture

* The Package

Building Checklists

* The Checklist Project and their

This podcast was originally posted on the Practical Evidence Podcast

The 2012 SSC Guidelines were just published and I saw the preview in Puerto Rico

2012 Surviving Sepsis Campaign Guidelines

See the Guidelines at (CCM 2013;41(2):580)

Diagnosis of Sepsis

Diagnosis of Severe Sepsis

The New Bundles

A. Initial Resuscitation

* Protocolized, quantitative resuscitation of patients with sepsis- induced tissue hypoperfusion (defined in this document as hypotension persisting after initial fluid challenge or blood lactate concentration ? 4 mmol/L). Goals during the first 6 hrs of resuscitation:

* Central venous pressure 8–12 mm Hg

* Mean arterial pressure (MAP) ? 65 mm Hg

* Urine output ? 0.5 mL/kg/hr

* Central venous (superior vena cava) or mixed venous oxygen saturation 70% or 65%, respectively (grade 1C).

* In patients with elevated lactate levels targeting resuscitation to normalize lactate (grade 2C).

B. Screening for Sepsis and Performance Improvement

* Routine screening of potentially infected seriously ill patients for severe sepsis to allow earlier implementation of therapy (grade 1C).

* Hospital–based performance improvement efforts in severe sepsis (UG).

C. Diagnosis

* Cultures as clinically appropriate before antimicrobial therapy if no significant delay (> 45 mins) in the start of antimicrobial(s) (grade 1C). At least 2 sets of blood cultures (both aerobic and anaerobic bottles) be obtained before antimicrobial therapy with at least 1 drawn percutaneously and 1 drawn through each vascular access device, unless the device was recently (<48 hrs) inserted (grade 1C).

* Use of the 1,3 beta-D-glucan assay (grade 2B), mannan and anti-mannan antibody assays (2C), if available and invasive candidiasis is in differential diagnosis of cause of infection.

* Imaging studies performed promptly to confirm a potential source of infection (UG).

D. Antimicrobial Therapy

* Administration of effective intravenous antimicrobials within the first hour of recognition of septic shock (grade 1B) and severe sepsis without septic shock (grade 1C) as the goal of therapy.

* Initial empiric anti-infective therapy of one or more drugs that have activity against all likely pathogens (bacterial and/or fungal or viral) and that penetrate in adequate concentrations into tissues presumed to be the source of sepsis (grade 1B). Antimicrobial regimen should be reassessed daily for potential deescalation (grade 1B).

* Use of low procalcitonin levels or similar biomarkers to assist the clinician in the discontinuation of empiric antibiotics in patients who initially appeared septic, but have no subsequent evidence of infection (grade 2C).

* Combination empirical therapy for neutropenic patients with severe sepsis (grade 2B) and for patients with difficult-to-treat, multidrugresistant bacterial pathogens such as Acinetobacter and Pseudomonas spp. (grade 2B). For patients with severe infections associated with respiratory failure and septic shock, combination therapy with an extended spectrum beta-lactam and either an aminoglycoside or a fluoroquinolone is for P. aeruginosa bacteremia (grade 2B). A combination of beta-lactam and macrolide for patients with septic shock from bacteremic Streptococcus pneumoniae infections (grade 2B). Empiric combination therapy should not be administered for more than 3–5 days. De-escalation to the most appropriate single therapy should be performed as soon as the susceptibility profile is known (grade 2B).

* Duration of therapy typically 7–10 days; longer courses may be appropriate in patients who have a slow clinical response, undrainable foci of infection, bacteremia with S.

[featimage]

Aortic Dissection

Lower Dp/Dt and Blood Pressure

Control Pain with fentanyl

Control Heart Rate/Inotropy with esmolol

See the esmolol drip sheet (YOU MUST CHECK ALL NUMBERS WITH YOUR OWN PHARMACY)

Control Blood Pressure

With in order of preference: clevidipine, nicardipine, nitroprusside, nitroglycerin

What about if the patient can't get beta-blockers?

What about labetalol?

A-lines

Why is the Patient's Blood Pressure Low?

*

Myocardial Infarction

Andy Neill thankfully addressed my erroneous assumption that MIs in Dissection would only be right coronary infarctions

Does an anterior STEMI rule out dissection? - Emergency Medicine Ireland

and check out this article as well (J Emerg Trauma Shock 2011;4:273-278)

*

Site of Blood Pressure Measurement

*

Rupture of the Aorta

*

Aortic Insufficiency

*

Pericardial Tamponade

Neurodeficits

Intubation

Do a high-icp/vascular intubation (More to come on this)

Update

* Nicardipine and Esmolol are compatible and can be given through the same IV

Amal Mattu's Law of 4's

History

* Abrupt onset of Thorax Pain

* Ripping or Tearing

* Migrating Pain

* History of Aortic Problems (like TAA)

Physical

* Hypotension

* Pulse Deficit

* Neuro Deficit

* New Murmur

Aortic Dissection Score

Tsutsumi Y, Tsujimoto Y, Takahashi S, et al. Accuracy of aortic dissection detection risk score alone or with D-dimer: a systematic review and metaanalysis. Eur Heart J Acute Cardiovasc Care. 2020; https:// doi.org/10.1177/2048872620901831.

Now on to the Podcast...

 

See the Guidelines at (CCM 2013;41(2):580)

Diagnosis of Sepsis

Diagnosis of Severe Sepsis

The New Bundles

A. Initial Resuscitation

* Protocolized, quantitative resuscitation of patients with sepsis- induced tissue hypoperfusion (defined in this document as hypotension persisting after initial fluid challenge or blood lactate concentration ? 4 mmol/L). Goals during the first 6 hrs of resuscitation:

* Central venous pressure 8–12 mm Hg

* Mean arterial pressure (MAP) ? 65 mm Hg

* Urine output ? 0.5 mL/kg/hr

* Central venous (superior vena cava) or mixed venous oxygen saturation 70% or 65%, respectively (grade 1C).

* In patients with elevated lactate levels targeting resuscitation to normalize lactate (grade 2C).

B. Screening for Sepsis and Performance Improvement

* Routine screening of potentially infected seriously ill patients for severe sepsis to allow earlier implementation of therapy (grade 1C).

* Hospital–based performance improvement efforts in severe sepsis (UG).

C. Diagnosis

* Cultures as clinically appropriate before antimicrobial therapy if no significant delay (> 45 mins) in the start of antimicrobial(s) (grade 1C). At least 2 sets of blood cultures (both aerobic and anaerobic bottles) be obtained before antimicrobial therapy with at least 1 drawn percutaneously and 1 drawn through each vascular access device, unless the device was recently (<48 hrs) inserted (grade 1C).

* Use of the 1,3 beta-D-glucan assay (grade 2B), mannan and anti-mannan antibody assays (2C), if available and invasive candidiasis is in differential diagnosis of cause of infection.

* Imaging studies performed promptly to confirm a potential source of infection (UG).

D. Antimicrobial Therapy

* Administration of effective intravenous antimicrobials within the first hour of recognition of septic shock (grade 1B) and severe sepsis without septic shock (grade 1C) as the goal of therapy.

* Initial empiric anti-infective therapy of one or more drugs that have activity against all likely pathogens (bacterial and/or fungal or viral) and that penetrate in adequate concentrations into tissues presumed to be the source of sepsis (grade 1B). Antimicrobial regimen should be reassessed daily for potential deescalation (grade 1B).

* Use of low procalcitonin levels or similar biomarkers to assist the clinician in the discontinuation of empiric antibiotics in patients who initially appeared septic, but have no subsequent evidence of infection (grade 2C).

* Combination empirical therapy for neutropenic patients with severe sepsis (grade 2B) and for patients with difficult-to-treat, multidrugresistant bacterial pathogens such as Acinetobacter and Pseudomonas spp. (grade 2B). For patients with severe infections associated with respiratory failure and septic shock, combination therapy with an extended spectrum beta-lactam and either an aminoglycoside or a fluoroquinolone is for P. aeruginosa bacteremia (grade 2B). A combination of beta-lactam and macrolide for patients with septic shock from bacteremic Streptococcus pneumoniae infections (grade 2B). Empiric combination therapy should not be administered for more than 3–5 days. De-escalation to the most appropriate single therapy should be performed as soon as the susceptibility profile is known (grade 2B).

* Duration of therapy typically 7–10 days; longer courses may be appropriate in patients who have a slow clinical response, undrainable foci of infection, bacteremia with S. aureus; some fungal and viral infections or immunologic deficiencies, including neutropenia (grade 2C).

* Antiviral therapy initiated as early as possible in patients with severe sepsis or septic shock of viral origin (grade 2C).