MICU Follow Up – Hypothermia

-ECMO (if available) may be best way to rewarm, 7-10 ⁰C /hr

-Thoracic lavage up to 6 ⁰C/hr

-If coding, can attempt defibrillation x 3; rewarm to at least 86 ⁰ F

-Try to avoid stimulating heart, if need central access, fem line is best

-Rewarming complications include several electrolyte/coag abnormalities; check frequently

-Goal rewarm temp is 86-89 ⁰F

Neuro Cases

1. Stroke in Sickle Cell

-Neuro/hem consults early

-Exchange transfusion as treatment

-Can use upper motor neuron/lower motor neuron signs to help delineate where problem is

ex. UMN: +Babinski, spasticity, hyperreflexia ; LMK: Fasciculations, hypotonia, hypo/areflexia

2. Posterior Circulation Strokes

-Several symptoms: vertigo/dizziness, imbalance, unilateral limb weakness, dysarthria, diplopia, nystagmus, n/v, dysphagia

-HINTS exam can be used if symptomatic (Head Impulse, Nystagmus, Test of Skew)

-Subclavian Steal Syndrome: suspect in a patient with vertebrobasilar territory neuro sxs, arm claudication (exercise-induced arm pain or fatigue; coolness or paresthesias in extremity)

3) tPA

-BP goals for tPA administration <180/110 – may use Labetalol/Nicardipine for BP control

-Know some of the absolute contraindications; ex: any hx of intracranial hemorrhage, BP >180/110, known bleeding diathesis (platelet count <100,000; use of warfarin with INR > 1.7, use of DOACs) Can use MDCALC to run absolute/relative contraindications

-tPA symptom onset < 4.5 hours (prefer <3 hours esp in those >80 years)

Geriatrics Lecture

4 M’s for the ED: Medications

-Medications/polypharmacy should be high on differential for acute change in elderly

-1/3 of elderly patients lose independence in at least 1 activity when admitted

-Several meds are problematic; warfarin, ASA, plavix, digoxin, metformin and other diabetic medications, antibiotics

Room 9 Follow Up Case – Massive Hemoptysis

-Massive hemoptysis, no clear consensus definition. 100-1,000 mL/24 hours or >50 mL in a single event – really any bleed that is life threatening due to airway obstruction, hypotension, or blood loss

-Usually arises from bronchial circulation; MCC usually TB, bronchiectasis, lung abscess, bronchogenic carcinomas

-Airway protection: if having difficulty clearing airway or hypoxic/dyspneic, prepare for difficult intubation; intubation of mainstem of the good lung; can do this via going past the cords and turning ET 90 degrees; have patient lay on side of the bad lung

-TXA: nebulized TXA with 1 g TXA in 10 cc saline. Can also do 500 mg TID. Systemic route also an option, 1gm load in 100 mL NS over 10 minutes and 1 gm over 8 hours.

-Bronchoscopy and CT; CTA may help identify source; consults to consider early: Pulm, IR or CT surgery

EMS Lecture- PreHospital Stroke

-Several scoring systems (RACE, Stroke VAN, FAST-ED, CSTAT, LAMS) to help guide pre-arrival notification and transport to comprehensive stroke center

-CSTAT: Cincinnati Stroke Triage Assessment Tool, Screen for Large Occlusion Strokes >/= 2 is positive

Conjugate Gaze Deviation 2 points

Incorrectly Answers Age or Month and Does not follow at least one command (close your eyes, open and close your hand) 1 point

Arm (right, left or both) falls to the bed within 10 seconds 1 point

-Mobile stroke units – can decrease time to stroke tx by 50%, 20 units worldwide, CT scanner in back; tremendous expense without great improvement in outcomes

-tPA goal 60 minutes door to drug.

Hey I was going over some articles with a friend for Board Prep. Check out a few valuable figures from the papers:

• TIA Management. Think about the mimics. High risk for stroke if true TIA.

Edlow JA. Managing patients with transient ischemic attack. Ann Emerg Med 2018 Mar;71(3):409-15.

• Cord Compression Diagnosis and Treatment. Steroids only for malignancy. Keep BP up, ABx when indicated, and call the surgeon!

Ropper AE, Ropper AH. Acute spinal cord compression. N Engl J Med 2017 Apr;376(14):1358-69.

• Algorithm approach for New Onset Seizure. Anticonvulsants recommended even for first time IF epilepsy diagnosed.

Gavvala JR, Schuele SU. New-onset seizure in adults and adolescents: a review. JAMA 2016 Dec;316(24):2657-68

• Outcomes with Endovascular stroke therapy in hours 6-16. This is why we room 9 strokes outside of the tPA window.

DEFUSE 3 Investigators. Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging. N Engl J Med 2018 Feb;378(8):708-18