Latest Updates

Acute Ischemic Stroke and Transient Ischemic Attack

    • Endovascular treatment of acute ischemic stroke (AIS) enables access to occluded intracranial vessels for local administration of thrombolytics, mechanical embolectomy, and/or angioplasty. There are currently four mechanical devices cleared by the Food and Drug Administration (FDA) for recanalization of arterial occlusion in patients with AIS; however, despite being cleared by the FDA, none of these devices have an FDA clinical indication due to the need for randomized comparison with medical therapy devices. Endovascular interventions are extremely time dependent, and reduced time from symptom onset to reperfusion is highly correlated with better clinical outcomes.
    • CTA with CT perfusion or MRA with diffusion-weighted MRI with or without MR perfusion is recommended for certain patients (2019 AHA/ASA recommendation on head imaging).
    • 2019 AHA/ASA updates on IV alteplase indications and management in acute ischemic stroke patients.

Shock: Pathophysiology and Management

Paige Armstrong, MD, MHS, Hamid Shokoohi, MD, MPH, RDMS, RDCS
    • The importance of prompt administration of intravenous fluids and vasoactive medications (norepinephrine or dopamine as the first choice) and the limitations of protocol-based therapy, as guided by recent evidence, should be emphasized.
    • There is significant controversy surrounding Early Goal-Directed Therapy (EGDT) in the management of severe sepsis and septic shock. Recently, a few, large, multicenter randomized trials, including ProCESS (Protocolized Care for Early Septic Shock), ARISE (Australasian Resuscitation in Sepsis Evaluation), and ProMISe (Protocolised Management In Sepsis) failed to provide similar conclusive supporting evidences.

Panic Attacks and Anxiety Disorders

Curtis Wittmann, MD
    • A patient with posttraumatic stress disorder (PTSD) is more likely to initially present for treatment in a medical, rather than mental health, setting; however, primary care physicians recognize symptoms of PTSD in these patients only approximately 50% of the time, and often do not make the diagnosis. Patients presenting to the emergency department for physical trauma are at risk, as are combat veterans and victims of rape or domestic violence. In addition, patients undergoing frightening, painful or life-threatening medical illnesses or procedures may develop PTSD. The provision of support and information about PTSD to patients in the emergency department may enable early recognition of the symptoms and may prevent the development of full-blown PTSD.

Seizure

    • Status epilepticus has a distinct pathophysiology that remains poorly understood; interestingly, in animal models, many of the basic underlying mechanisms appear to be common regardless of how seizures are initiated. A single seizure is transformed into a self-perpetuating and pharmacoresistant disorder through a cascade of extrinsic signaling followed by intrinsic nuclear events.
    • Detailed treatment approaches for status epilepticus, delineating first-line, second-line, and third-line antiepileptic drugs.
    • STESS prognostication scores primarily being used for research purposes but may have indication in clinical settings.

Appendicitis

    • Bedside right lower quadrant ultrasonography to assess for acute appendicitis is rapid and noninvasive and does not involve ionizing radiation. Studies have validated that nonradiologist clinicians, when trained properly, can safely and accurately perform this examination, with sensitivities and specificities similar to those achieved by radiologists.
    • Ultrasonographic detection of either a complex fluid collection or abscess is reported to be 99% specific for diagnosis of a perforated appendix but only 36% sensitive.
    • A recent randomized controlled trial of amoxicillin-clavulanate versus appendectomy demonstrated the noninferiority of antibiotics for treatment of acute noncomplicated appendicitis but did not demonstrate an increased rate of complications in the appendectomy group. However, a Cochrane review of antibiotic therapy versus operative management did not find conclusive data to support antibiotic therapy and concluded that appendectomy remains the gold standard treatment.

Hypertensive Crises

    • New definitions of hypertension have been established. Normal blood pressure is SBP < 120 mm Hg and DBP < 80 mm Hg. Elevated blood pressure is defined as SBP 120-129 mm Hg and DBP < 80 mm Hg. Stage 1 hypertension is defined as SBP 130-139 mm Hg or DBP 80-89 mm Hg, and stage 2 hypertension is defined as SBP ≥ 140 mm Hg or DBP ≥ 90 mm Hg.
    • The ATACH-2 trial showed that intensive blood pressure lowering in patients with intracranial hemorrhage leads to increased adverse events without substantial benefit.
    • ENCHANTED study did not show benefit in intensive blood pressure reduction in patients with acute ischemic stroke who have received intravenous thrombolysis.

General Approach to the Poisoned Patient

Steven B Bird, MD , Emily Gordon, MD
    • Intravenous lipid emulsion (ILE) therapy is a more recent addition to the armamentarium employed to increase toxin elimination. Most data are in the form of case reports, and a recent review of ILE was unable to provide absolute indications for its use. However, ILE was reported to be most useful in overdoses of local anesthetics (e.g., bupivacaine, ropivacaine, mepivacaine), haloperidol, lipophilic tricyclic antidepressants and beta blockers, some calcium channel blockers, and bupropion. ILE is recommended in the resuscitation of patients exhibiting hemodynamic instability in the setting of an acute overdose of lipophilic substances.

Pediatric Seizures and Status Epilepticus

Lindsey Retterath, MD , Dale Woolridge, MD
    • Pediatric seizures between the ages of 6 months and 6 years are most commonly febrile seizures. The majority are simple and do not require further workup or admission, however, non-CNS and CNS infections can also cause seizures and must be considered in the setting of seizure and fever. LP should be considered in all patients who either are < 1 year of age, demonstrate meningismus or  have a prolonged seizure or post-ictal period, or appear toxic without a known source.
    • Benzodiazepines remain the mainstay for first-line seizure management. Multiple studies demonstrate non-inferiority of early IM and intransalal midazolam and rectal diazepam to the historic standard, IV lorazepam.
    • Levetiracetam may be a safe alternative as first or second-line therapy. Current studies demonstrate its safety and efficacy. Non-inferiority studies are lacking, however, it is a generally safe medication with fewer side effects and interactions than fosphenytoin and phenobarbital, which are the current standard for second line seizure medication.
    • Medication non-compliance or under-dosing is the a common cause of seizures in patients with known epilepsy, rendering it useful to check antiepileptic serum drug levels.

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