Emergency Medicine Literature of Note
Musings on Emergency Medicine, Clinical Informatics, & High-Value Care.
With all the various competing interests for time, it’s rare to find an article of sufficient note to warrant its own blog post. A notable publication might get a short tweet thread. Collections of other literature find their way into ACEPNow articles or the odd Annals of Emergency Medicine Journal Club. But, every once in … Continue reading “It’s Not OK To Let 25% of tPA Cases Be Stroke Mimics”
A couple months back, this little report – MaRISS – was published with minimal fanfare in Stroke. Considering the effort necessary to fund and conduct a prospective study, it’s rather remarkable these data are so uninformative. The stated purpose of this study: “The objective of this study is to describe multidimensional outcomes, identify predictors of … Continue reading “Why Isn’t tPA in Minor Stroke Questioned?”
The original argument: tPA helps all strokes, we must give it to everyone as quickly as possible!The updated argument: tPA doesn’t not help all strokes, so it should still be given! Specifically, as applies to the cohort of patients with large vessel occlusions being considered for mechanical thrombectomy. This small, pooled registry sample looked at … Continue reading “Who Recanalizes with Just tPA?”
In my book, “safe” translates to a lack of attributable harm. Therefore, going as fast as possible while still claiming safety – should mean no excess harms resulting from the rush. There’s no way to precisely tell whether or not this is the case here in Helsinki, where the stroke neurologists have cut their door-to-needle … Continue reading “tPA in Under 20 Minutes is Recklessness”
Most of the unhinged ramblings on this blog involve lamenting the excessive sensitivity of CT pulmonary angiograms for the diagnosis of pulmonary embolism. “Excessively sensitive for PEs of uncertain clinical signifiance!” and “Too many false positives in an inappropriately selected population!” gloomily drones the author (We can’t all, and some of us don’t). Now, again, … Continue reading “Again With the Failings of CTPA”
What happens when you wake up and you’re paralyzed from a stroke? Well, usually nothing. “Unknown time of onset” takes you – for better or worse – out of the game for alteplase, but not necessarily for endovascular therapy should a large-vessel occlusion be identified. Those large vessel occlusions, in the setting of a favorable … Continue reading “Wake Up and Smell the tPA”
Indiscriminate use of tPA in those with undifferentiated stroke is a low-value proposition – even if you find the evidence reliable. The utility of tPA for stroke depends on anatomy, time, and tissue status – information the traditional non-contrast head CT does not usually provide. Unfortunately, one of the latest “innovations” in stroke care is … Continue reading “All Aboard the tPA Hype Bus”
It’s medical news nonsense time again – this time featuring our old favorite, tPA for stroke. “Tissue Plasminogen Activators Safe for Patients Who Wake Up with Stroke Symptoms” reports HCP Live, and featured in the ACEP daily e-mail newsletter. Oddly enough, this article was actually initially published back in July before being picked up by … Continue reading “tPA For Wake-Up Strokes – “Safe!””
Many institutions are starting to see roll-out of some sort of clinical decision-support for imaging utilization. Whether it be NEXUS, Canadian Head CT, or Wells for PE, there is plenty of literature documenting improved yield following implementation. This retrospective evaluation looks at what happens when you don’t obey your new robot overlords – and perform CTPA … Continue reading “Don’t CTPA With Your Gut Alone”
This is an abstract that sucked me in – not because of the concept of the study – but because of its quoted incidence of adverse outcomes. 23.7% incidence of contrast-induced nephropathy following a CT pulmonary angiogram! 12.5% incidence of renal failure! 12.8% in-hospital mortality! But, no. The study itself is a comparison between three … Continue reading “An Oddly Dire Look at CIN after CTPA”