““Six Publications That Six Publications That Influence Neurological Influence Neurological

Emergency Patient Emergency Patient Resuscitation in 2010”Resuscitation in 2010”

2010 Clinical Decision Making in Emergency Medicine

Ponte Vedra Beach, FLPonte Vedra Beach, FL

June 24, 2010June 24, 2010

Clinical Decision Making in Emergency Medicine –

A N  E V I D EN C E - B A S E D  C O N F E R E N C E

Edward P. Sloan, MD, MPH FACEP

Professor

Department of Emergency MedicineUniversity of Illinois College of Medicine

Chicago, IL

Attending PhysicianEmergency Medicine

University of Illinois HospitalSwedish American Belvidere Hospital

Chicago, IL

DisclosuresDisclosures• FERNE Chairman and PresidentFERNE Chairman and President• FERNE advisory board for The Medicine FERNE advisory board for The Medicine

Company in May 2007Company in May 2007• Dr. Sloan has been approved to study PCC Dr. Sloan has been approved to study PCC

(Beriplex) through an industry contract (Beriplex) through an industry contract with the University of Illinois at Chicago.with the University of Illinois at Chicago.

Thank YouThank You

• Clinical Decisions in EM Clinical Decisions in EM ConsortiumConsortium

• Well assembled staffWell assembled staff• FERNE staffFERNE staff

OverviewOverview• Emergency physicians must be Emergency physicians must be

able to quickly and effectively able to quickly and effectively resuscitate patients with varied resuscitate patients with varied neurological emergencies in order neurological emergencies in order to prevent long term adverse to prevent long term adverse neurological outcomes in patients neurological outcomes in patients who present to the Emergency who present to the Emergency Department. Department.

Learning ObjectivesLearning Objectives• Assess relevant medical literature Assess relevant medical literature

to neurological emergency to neurological emergency resuscitation.resuscitation.

• Establish how ED clinical practice Establish how ED clinical practice might change with recent might change with recent publications.publications.

Learning ObjectivesLearning Objectives• Discuss the implications of Discuss the implications of

changes on ED patient outcomes & changes on ED patient outcomes & resource use.resource use.

• Review guidelines that may impact Review guidelines that may impact decision making when decision making when resuscitating patients with acute resuscitating patients with acute neurological emergencies.neurological emergencies.

Case PresentationsCase Presentations• Acute ischemic stroke: tPA at the Acute ischemic stroke: tPA at the

4.5 hour time point?4.5 hour time point?• Status epilepticus: therapy after Status epilepticus: therapy after

benzodiazepines and phenytoins?benzodiazepines and phenytoins?• Hypothermic resuscitation s/p Hypothermic resuscitation s/p

cardiac arrest: standard of care?cardiac arrest: standard of care?

Case PresentationsCase Presentations• Transient ischemic attack: Transient ischemic attack:

outpatient ED management?outpatient ED management?• ICH in coagulopathic patients: ICH in coagulopathic patients:

INR reversal strategies?INR reversal strategies?• Severe hypertension and ICH: Severe hypertension and ICH:

aggressive continuous infusion aggressive continuous infusion Rx?Rx?

Acute Ischemic StrokeAcute Ischemic StrokeCase Presentation Case Presentation • 62 year old patient with HTN history 62 year old patient with HTN history

presents with acute middle cerebral presents with acute middle cerebral artery distribution stroke at four artery distribution stroke at four hours. hours. 

Key Clinical QuestionKey Clinical Question• Should IV tPA be given at or beyond Should IV tPA be given at or beyond

the 4.5 hour window?the 4.5 hour window?

Acute Ischemic StrokeAcute Ischemic Stroke• IV tPA should not be given at or IV tPA should not be given at or

beyond the 4.5 hour window beyond the 4.5 hour window because of increased ICH risk and because of increased ICH risk and loss of potential benefit at and loss of potential benefit at and beyond this 270 minute time point. beyond this 270 minute time point.

• IV tPA should be given as quickly as IV tPA should be given as quickly as possible, since benefit is related to possible, since benefit is related to the speed with which it can be the speed with which it can be given. given.

Acute Ischemic StrokeAcute Ischemic Stroke• TimeTime OROR NNT NNT PP• 0-90 min0-90 min 2.552.55 4.5 4.5 .0001.0001• 91-180 min91-180 min 1.641.64 9.0 9.0 .0119.0119• 181-270 min181-270 min 1.341.34 14.114.1 .0054.0054• 271-360 min271-360 min 1.221.22 21.421.4 .1057.1057• 0-360 min0-360 min 1.401.40 12.612.6 .0001.0001

• Other therapies for thrombus lysis or clot Other therapies for thrombus lysis or clot removal should be considered near or at the removal should be considered near or at the 270 minute (4.5 hour) IV tPA time limit.270 minute (4.5 hour) IV tPA time limit.

Status EpilepticusStatus EpilepticusCase Presentation Case Presentation • 37 year old patient with seizure, SE 37 year old patient with seizure, SE

history presents with SE that is history presents with SE that is refractory to ED benzodiazepine and refractory to ED benzodiazepine and phenytoin therapy.phenytoin therapy.

Key Clinical QuestionKey Clinical Question• What is the best next Rx that offers the What is the best next Rx that offers the

best chance for this refractory SE to be best chance for this refractory SE to be terminated?terminated?

Status EpilepticusStatus Epilepticus• The therapies that offer the best The therapies that offer the best

chance for terminating GCSE that is chance for terminating GCSE that is refractory to benzodiazepines & refractory to benzodiazepines & phenytoins Rx include anesthetic phenytoins Rx include anesthetic doses of barbiturates, midazolam, or doses of barbiturates, midazolam, or propofol. propofol.

Status EpilepticusStatus Epilepticus• Ketamine: an alternative in Ketamine: an alternative in

hypotensive refractory SE patients. hypotensive refractory SE patients. • Rx such as IV valproic acid or IV Rx such as IV valproic acid or IV

levetiracetam: may be effective in levetiracetam: may be effective in terminating complex partial SE, buy terminating complex partial SE, buy not likely to effectively Rx refractory not likely to effectively Rx refractory GCSE.GCSE.

Hypothermic Resus s/p Hypothermic Resus s/p Cardiac ArrestCardiac Arrest

Case Presentation Case Presentation • 59 year old patient sustains a cardiac 59 year old patient sustains a cardiac

arrest and is defibrillated out of arrest and is defibrillated out of ventricular fibrillation in a sinus rhythm ventricular fibrillation in a sinus rhythm with pulses.with pulses.

Key Clinical QuestionKey Clinical Question• Is it SOC to implement hypothermic Is it SOC to implement hypothermic

resuscitation in order to maximize resuscitation in order to maximize neurological outcome?neurological outcome?

Hypothermic Resus s/p Hypothermic Resus s/p Cardiac ArrestCardiac Arrest

• It is the standard of care to implement It is the standard of care to implement cooling methods in cardiac arrest cooling methods in cardiac arrest patients who survive the initial patients who survive the initial resuscitation in order to maximize the resuscitation in order to maximize the chance for a good neurological outcome. chance for a good neurological outcome.

• ““The data from the studies reviewed by The data from the studies reviewed by the Cochrane Collaboration supports the the Cochrane Collaboration supports the current best medical practice as current best medical practice as recommended by the International recommended by the International Resuscitation Guidelines.”Resuscitation Guidelines.”

Hypothermic Resus s/p Hypothermic Resus s/p Cardiac ArrestCardiac Arrest

• Cooling should take place in the ED Cooling should take place in the ED following a successful resuscitation from following a successful resuscitation from Vfib using whatever means are Vfib using whatever means are necessary to reduce core temperature.necessary to reduce core temperature.

• Definitive protocols for hypothermia Definitive protocols for hypothermia resuscitation patients need to be resuscitation patients need to be implemented in the critical care units so implemented in the critical care units so that sustained hypothermia can be that sustained hypothermia can be provided and complications minimized provided and complications minimized after ED resuscitation.after ED resuscitation.

Transient Ischemic AttackTransient Ischemic AttackCase Presentation Case Presentation • 71 year old patient with DM, HTN presents with 71 year old patient with DM, HTN presents with

loss of the use of R hand, unsteady gait, and loss of the use of R hand, unsteady gait, and poor vision for 20 minutes. The CT scan is poor vision for 20 minutes. The CT scan is negative and the current neurological exam is negative and the current neurological exam is normal.normal.

Key Clinical QuestionKey Clinical Question• Can an outpatient ED observation strategy for Can an outpatient ED observation strategy for

easily identified ED TIA patients provide easily identified ED TIA patients provide outcomes comparable to those of similar TIA outcomes comparable to those of similar TIA patients admitted to the hospital?patients admitted to the hospital?

Transient Ischemic AttackTransient Ischemic Attack• An outpatient ED observation strategy can be An outpatient ED observation strategy can be

utilized in way that provides comparable utilized in way that provides comparable patient outcomes to patients who are admitted patient outcomes to patients who are admitted to the hospital for the evaluation of their TIA.to the hospital for the evaluation of their TIA.

• The ABCD2 score was best predictive of The ABCD2 score was best predictive of patients at risk for recurrent TIAs or major patients at risk for recurrent TIAs or major strokes. Patients with a low ABCD2 score are strokes. Patients with a low ABCD2 score are more likely to have a recurrent TIA, and those more likely to have a recurrent TIA, and those with a high ABCD2 score are at greatest risk with a high ABCD2 score are at greatest risk for a subsequent moderate or severe stroke.for a subsequent moderate or severe stroke.

Transient Ischemic AttackTransient Ischemic Attack• Patients with an ABCD2 score of 0-3 are at the Patients with an ABCD2 score of 0-3 are at the

lowest risk for a stroke within 7 days. lowest risk for a stroke within 7 days. • The diagnostic evaluation of ED TIA patients The diagnostic evaluation of ED TIA patients

can be performed in an observation unit with can be performed in an observation unit with outcomes comparable to ED TIA patients who outcomes comparable to ED TIA patients who are admitted for their subsequent care. This are admitted for their subsequent care. This accelerated ED protocol care can be provided accelerated ED protocol care can be provided more quickly and at less cost than routine more quickly and at less cost than routine hospital care.hospital care.

Transient Ischemic AttackTransient Ischemic Attack• The tests which need to be performed in order The tests which need to be performed in order

to adequately evaluate ED TIA patients include: to adequately evaluate ED TIA patients include: routine laboratory tests, a non-contrast CT, routine laboratory tests, a non-contrast CT, ECG, and cardiac monitoring during the initial ECG, and cardiac monitoring during the initial ED visit, as well as carotid ultrasonography ED visit, as well as carotid ultrasonography and/or CT or MR angiography on an urgent and/or CT or MR angiography on an urgent basis. Echocardiography should be performed basis. Echocardiography should be performed if no large vessel disease is identified on the if no large vessel disease is identified on the imaging studies performed.imaging studies performed.

ICH in Coagulopathic PtsICH in Coagulopathic PtsCase Presentation Case Presentation • 80 year old patient with atrial fibrillation 80 year old patient with atrial fibrillation

hx on Coumadin presents with headache, hx on Coumadin presents with headache, vomiting, and altered mental status. The vomiting, and altered mental status. The CT shows an acute cerebral hemorrhage.CT shows an acute cerebral hemorrhage.

Key Clinical QuestionKey Clinical Question• What is the best way to reverse the What is the best way to reverse the

elevated INR to minimize the adverse elevated INR to minimize the adverse effects of this coagulopathic state?effects of this coagulopathic state?

ICH in Coagulopathic PtsICH in Coagulopathic Pts• The best way to reverse an elevated INR The best way to reverse an elevated INR

in order to maximize outcome in the in order to maximize outcome in the setting of INH may include the use of setting of INH may include the use of PCC and point of care INR testing.PCC and point of care INR testing.

• Although this is not the current standard Although this is not the current standard of care in the US, it may become more of care in the US, it may become more common as more use of PCC occurs.common as more use of PCC occurs.

ICH in Coagulopathic PtsICH in Coagulopathic Pts• Thrombotic events, especially cardiac Thrombotic events, especially cardiac

events, were noted in the FAST trial of events, were noted in the FAST trial of ICH patients, which utilized rFVIIa. ICH patients, which utilized rFVIIa. Although it is not clear that similar Although it is not clear that similar thromboembolic events will occur with thromboembolic events will occur with the use of PCC, there must be the use of PCC, there must be monitoring for these potential monitoring for these potential complications, especially cardiac events, complications, especially cardiac events, when reversing OAC in the setting of when reversing OAC in the setting of ICH.ICH.

Severe HTN & ICHSevere HTN & ICHCase Presentation Case Presentation • 48 year old pt with HTN, CRF/dialysis 48 year old pt with HTN, CRF/dialysis

history presents with coma and a BP of history presents with coma and a BP of 240/142. The CT shows an acute ICH.240/142. The CT shows an acute ICH.

Key Clinical QuestionKey Clinical Question• Is the aggressive use of a continuous Is the aggressive use of a continuous

infusion anti-hypertensive therapy the infusion anti-hypertensive therapy the best way to reduce BP to minimize the best way to reduce BP to minimize the CNS end organ damage from uncontrolled CNS end organ damage from uncontrolled severe HTN?severe HTN?

Severe HTN & ICHSevere HTN & ICH• Although the use of a continuous Although the use of a continuous

infusion anti-hypertensive therapy may infusion anti-hypertensive therapy may reduce blood pressure most quickly and reduce blood pressure most quickly and consistently in the setting of consistently in the setting of uncontrolled severe hypertension and uncontrolled severe hypertension and ICH, it is not clear that this approach is ICH, it is not clear that this approach is mandatory.mandatory.

Severe HTN & ICHSevere HTN & ICH• Aggressive SBP and MAP reductions in Aggressive SBP and MAP reductions in

hypertensive ICH patients have not yet hypertensive ICH patients have not yet been demonstrated to have a consistent been demonstrated to have a consistent beneficial effect or improved patient beneficial effect or improved patient outcomes.outcomes.

Severe HTN & ICHSevere HTN & ICH• If benefit is derived from aggressive BP If benefit is derived from aggressive BP

reduction, it will likely be correlated with reduction, it will likely be correlated with reduced hematoma growth, reduced reduced hematoma growth, reduced perihematomal edema, less frequent perihematomal edema, less frequent occurrences of neurological occurrences of neurological deterioration, and improved clinical deterioration, and improved clinical outcomes as measured by mRS at 90 outcomes as measured by mRS at 90 days and beyond.days and beyond.

ConclusionsConclusions• Acute neuroresuscitation critical

• Treatment options are known

• Literature provides useful info

• Pt outcomes can be optimized

• Reasonable standard of care

• Enhances practice of Emergency Medicine

Questions?Questions?edsloan@uic.edu312 317 4996

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