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Podcast 688: tPA Before Thrombectomy

Emergency Medical Minute

Release Date: 07/05/2021

Podcast 836: Humming to get EJ show art Podcast 836: Humming to get EJ

Emergency Medical Minute

Contributor: Jared Scott, MD Educational Pearls: Two conventional ways to aid in external jugular vein (EJ) catheter placement are Trendelenburg’s position and Valsalva’s maneuver by patient  One study compared ultrasound visualization of cross sections of EJ and common femoral vein at baseline and with patients in Trendelenburg's position, Valsalva's maneuver, and while humming The study found all three conditions distended the veins from baseline, but there was no significant difference in diameter between the conditions   Humming may be a viable technique in distended EJ...

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Podcast 835: Syncope Review show art Podcast 835: Syncope Review

Emergency Medical Minute

Contributor: Meghan Hurley, MD Educational Pearls: Syncope is defined as a loss of consciousness with an immediate return to baseline Differential is broad Cardiogenic Structural (aortic stenosis, HOCUM, etc.) Electrical (long QT syndrome, Brugada, etc.) Neurogenic/neurovascular (brain bleed, etc.) Seizure Everything else Hypoglycemia, anemia, and bleeding into the abdominal cavity are some potential causes to rule out Vasovagal Diagnosis of exclusion Work Up EKG Good H&P Labs especially Hb and glucose References Morris J. Emergency department management of syncope. Emerg Med...

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Podcast 834:  Peds Buckle Fractures show art Podcast 834: Peds Buckle Fractures

Emergency Medical Minute

Contributor: Aaron Lessen, MD Educational Pearls: Torus (Buckle) fractures are a commonly encountered pediatric fracture pattern Typically presents as wrist pain secondary to a child falling on outstretched hand One edge of the bone “buckles” or bends because children’s bones are softer and more pliable Management Older studies have shown that short term immobilization with a velcro splint and primary care follow up is sufficient Recent randomized trial compared immobilization with Velcro splint with as needed wrist support using a gauze wrap No significant differences noted in...

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Podcast 833: NS vs LR show art Podcast 833: NS vs LR

Emergency Medical Minute

Contributor: Travis Barlock, MD Educational Pearls: Normal Saline (NS) contains 154 mEq of both Sodium (Na) and Chloride (Cl),  and has a pH of 5.5 Normal Na and Cl in adult humans are about 140 mEq/L and 103 mEq/L. respectively   Excess negative charge resulting from hyperchloremia is managed via bicarbonate excretion leading to loss of base Overall, administration of NS drives metabolic acidosis Lactated Ringers (LR) contains 130 mEq of Na and 109 mEq Cl, and has a pH of 6.5   LR components are closer to physiologic levels thus may generally be a more...

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CA Bridge Program and Health Disparities in the Opioid Epidemic show art CA Bridge Program and Health Disparities in the Opioid Epidemic

Emergency Medical Minute

Happy Thanksgiving EMM listeners, Mason here wanting to extend a special thank you to all of you for tuning in to our show. Today we are featuring a special episode on health disparities in the opioid epidemic and their intersection with the ER that we produced for the , a national initiative to provide comprehensive education on opioid stewardship and best practices.  In an effort to promote diversity, equity, and inclusion in Emergency Medicine, The Emergency Medical Minute is proud to present our 2nd annual Diversity and Inclusion Award. We support increasing the representation...

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Podcast 832: STD Checks show art Podcast 832: STD Checks

Emergency Medical Minute

Educational Pearls: Most common sexually transmitted disease (STD) in North America: Human Papillomavirus (HPV) From the emergency department patients should be connected to follow-up care and educated on vaccine series Most common non-viral STD in North America: Trichomonas Vaginalis   While men may be asymptomatic, they can transmit the disease to women who may experience irritation leading to increased likelihood of PID and contraction of other STDs and HIV Trichomonas is diagnosed via wet preparation with visualization of motile parasites  Similarly, men’s urine...

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Podcast 831: O2 Targets show art Podcast 831: O2 Targets

Emergency Medical Minute

Contributor: Aaron Lessen,MD Educational Pearls: Recent study looked at mechanically ventilated patients in ED and ICU to determine if O2 saturation level impacted patient outcomes 2541 patients randomized to one of three target O2 saturation levels Low: 90% (Range: 88-92%) Intermediate: 94% (Range: 92-96%) High: 98% (Range: 96-100%) Outcome indicators Primary: Number of days alive and ventilator free by day 28 of hospital admission Secondary: Mortality at 28 days No significant difference was seen for either primary or secondary outcomes between all three groups at 28 days This...

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Podcast 830: Peripheral IV Flow Rates show art Podcast 830: Peripheral IV Flow Rates

Emergency Medical Minute

Contributor: Travis Barlock, MD Educational Pearls: Gauge and length of catheter are determinants of flow rate  Smaller gauges produce higher flow rate Longer catheters reduce flow rate   Common IV gauges produce predictable rates of flow:  20 gauge = 60 cc/min 18 gauge = 105 cc/min 16 gauge = 220 cc/min  Central lines typically have two 18 gauge and one 16 gauge lumen, both with long catheters, producing the following slower flow rates:  18 gauge = 26 cc /min  16 gauge = 55 cc/min Sheath Introducers, such as Cordis brand catheters, are wider and...

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Podcast 829: Monkeypox show art Podcast 829: Monkeypox

Emergency Medical Minute

Contributor: Aaron Lessen, MD Educational Pearls: Monkeypox transmission is still occurring  in the United States Transmitted by contact to exposed lesion MSM are a high-risk group for monkeypox infection Symptoms include rash and flu like symptoms Monkeypox lesions are often described as blister-like, firm, clear, and rubbery Most commonly develop on the face and/or anogenital regions Patients with potential monkeypox infection should be moved to isolation to reduce risk of transmission Providers should use full PPE including N95, facial covering, gown, and gloves when interacting...

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Podcast 828: TXA Dosing Update show art Podcast 828: TXA Dosing Update

Emergency Medical Minute

Contributor: Nick Hatch, MD Educational Pearls: In the setting of traumatic injury, tranexamic acid (TXA) is given to stabilize clots which minimizes bleeding and decreases risk of hemorrhagic shock   Current TXA dose for trauma is 1 g bolus followed by a 1 g infusion; both doses should be given within 3 hours from time of injury  Due to the split dose and narrow window, patients with complicated care, particularly if they require transfer may miss the infusion dose  Various smaller studies have shown that dosing 2 g initially or 2 g followed by a 1 g infusion produces the...

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Contributor: Aaron Lessen, MD

Educational Pearls:

  • DEVT Trial, a recent non-inferiority study, looked at giving tPA prior to endovascular thrombectomy and was stopped early because there was no benefit shown to giving tPA before this intervention
  • Coupled with the SKIP and DIRECT MT trials corroborating these findings, it appears that giving tPA prior to thrombectomy is not indicated
  • Whether patients should receive tPA prior to transfer for thrombectomy (i.e. they are in a rural healthcare setting) is still unclear

References

Yang P, Treurniet KM, Zhang L, et al. Direct Intra-arterial thrombectomy in order to Revascularize AIS patients with large vessel occlusion Efficiently in Chinese Tertiary hospitals: A Multicenter randomized clinical Trial (DIRECT-MT)-Protocol. Int J Stroke. 2020;15(6):689-698. doi:10.1177/1747493019882837

Suzuki K, Matsumaru Y, Takeuchi M, et al. Effect of Mechanical Thrombectomy Without vs With Intravenous Thrombolysis on Functional Outcome Among Patients With Acute Ischemic Stroke: The SKIP Randomized Clinical Trial [published correction appears in JAMA. 2021 May 4;325(17):1795]. JAMA. 2021;325(3):244-253. doi:10.1001/jama.2020.23522

Zi W, Qiu Z, Li F, et al. Effect of Endovascular Treatment Alone vs Intravenous Alteplase Plus Endovascular Treatment on Functional Independence in Patients With Acute Ischemic Stroke: The DEVT Randomized Clinical Trial. JAMA. 2021;325(3):234-243. doi:10.1001/jama.2020.23523

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD