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practice updates

Neuro Intubation Highlights

You are working a busy shift when you receive a phone call from EMS that they are bringing in a “sick trauma patient.” As you prepare the trauma bay, the patient arrives. He is the victim of an assault and in clear need of intubation. He is unconscious with a GCS of 5, HR 125, BP 180/11, Sp02 88% on NRB 15 lpm, RR 22. As you prepare your medications, what are the best options for this scenario? Pre-treatment with lidocaine, fentantyl or esmolol? Is it okay to use ketamine in trauma patients in traumatic brain injury (TBI)?

clinical cases

Bounceback: An Unrelenting Headache

CC: Headache First visit HPI: 29 year old female with a prior history of headaches, presented with two days of gradual onset, atraumatic, right sided headache that is throbbing in nature. The patient reported heaviness about the eye but no visual changes or disturbances. No neck pain, fevers, chills. She described feeling slightly light-headed but no balance loss. She had a mechanical trip and fall yesterday without head trauma, and her headache had been present for a day prior to the fall. ROS: otherwise normal. PMH/PSH: headaches, depression, anxiety, asthma SH: no smoking, no etoh, no drugs Allergies: Penicillin (rash) Pertinent Exam Vitals: 98.6F, BP: 156/85 P: 101, RR: 16, O2: 98%RA Gen: A&Ox3, well-developed, well-nourished HEENT: normocephalic, atraumatic, conjunctiva wnl, EOM wnl, PERRL, normal fundoscopic exam, crisp optic discs, normal ROM neck/supple Chest: wnl Abd: wnl Musculoskeletal: wnl Neuro: CN2-12 intact, normal reflexes, normal muscle tone, normal coordination Labs: Serum HCG negative Imaging: None ordered ED Course: The patient was believed to be experiencing a migraine headache. She had no evidence of head trauma, no signs of infectious etiology, and had no clinical findings or hx for SAH. She was administered Toradol, IVF and Reglan, and discharged with instructions to follow up with neurology and possibly have an outpatient MRI. Discharge Dx: Headache [...]

practice updates

How To Be A Clinical Rock Star Managing Subarachnoid Hemorrhages

A New Way to Think About Subarachnoid Hemorrhage: It is helpful to remember that while a subarachnoid hemorrhage is in fact a “bleed”, it is also a stroke.  When compared to ischemic strokes, hemorrhagic strokes tend to have an increased risk death in the acute phase, but for those patients that don’t die, their overall prognosis for return-to-baseline is somewhat better than ischemic events.  Why is this?  During hemorrhagic strokes (i.e. bleeds), an artery bursts, bathing brain cells in blood.  The cells become “stunned”, but there is rarely significant cell death surrounding these events.  If the total volume of hemorrhage is small, a patient has a chance at making a full, or near-full recovery (depending on extent of injury and any herniation symptoms). In ischemic events, lack of blood flow to brain cells causes cellular destruction, and a watershed “penumbra” effect can cause large swaths of brain cell death relative to the small area of initial ischemia.  In ischemic cell death, brain cells don’t remodel or regain function, which is why ischemic stroke patients have a high likelihood of residual neurologic deficit.  This terminal cell death is also why there is such a push for early identification of ischemic stroke, and why thrombolytics and other neurologic intervention procedures have gained such momentum. Patients presenting with headaches are worrisome because it can be difficult to sift through so many associated symptoms to determine who has benign pathology and who has a catastrophe brewing in their brain.  It is my goal to give you the needed strategy to be a rock star when it comes to evaluating headache patients. [...]

practice updates

ICP Management Update

Author: Albert Arslan, MD and Anthony Scoccimarro, MD (Resident Physicians, Lincoln Emergency Medicine) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital)   Prevent and Identify – the ED’s equivalent of Search & Rescue when managing elevated Intracranial Pressures (ICP). The causes of elevated ICP are typically described in the context […]

practice updates

Concussion Update

Concussion is a type of mild traumatic brain injury (TBI) that classically occurs in sports-related incidents but can be due to any traumatic force to the brain. The term concussion stems from the Latin word, concussus, which means “to shake violently." While sport is the most common cause of concussion in children, the most common causes of concussion in adults are falls and motor vehicle accidents. Young children have the highest rate of concussions in all age groups. [...]

practice updates

Aggressive BP Management in Patients with ICH

"The patient was hypertensive with SBP in 220s...a stat CT scan revealed a large intraparenchymal hemorrhage"
What's the goal BP in a patient with ICH? How quickly should that target be reached? What's the evidence? Ben Cooper, MD addresses these questions and more in this review of the recent literature.

practice updates

Cauda Equina Syndrome

"Recent studies have suggested that the timing of surgery may be less important for overall outcomes. Rather, outcomes may be more related to the extent of cord compression at presentation"

Jennifer Robertson, MD, MSEd brings us an update on cauda equina syndrome, including making the diagnosis, timing of surgery, and medicolegal risks.