tPA Lawsuits Airway Management Elevate Head of Bed 30 Degrees NPO - - PDF document

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2/19/2014 Basic Stroke Care tPA Lawsuits Airway Management Elevate Head of Bed 30 Degrees NPO Bedrails Up Fever Control Blood Sugar Control ASA 160-325mg PO (if no blood on CT) Reverse Anticoagulants tPA NOT given tPA given DVT Prophylaxis

SLIDE 1

2/19/2014 1

Basic Stroke Care

Airway Management Elevate Head of Bed 30 Degrees NPO Bedrails Up Fever Control Blood Sugar Control ASA 160-325mg PO (if no blood on CT) Reverse Anticoagulants DVT Prophylaxis (ward)

tPA NOT given tPA given

Liang B, et al. Annals of EM (2008) Thiess D, et al. Neurol Clin (2010)

tPA Lawsuits

ACEP/AAN Policy 2013

Level A recommendations. In order to improve functional outcomes, IV tPA should be offered to acute ischemic stroke patients who meet National Institute

f Neurological Disorders and Stroke (NINDS) inclusion/exclusion criteria and can

be treated within 3 hours after symptom onset.* Level B recommendations. In order to improve functional outcomes, IV tPA should be considered in acute ischemic stroke patients who meet European Cooperative Acute Stroke Study (ECASS) III inclusion/exclusion criteria and can be treated between 3 to 4.5 hours after symptom onset.* * The effectiveness of tPA has been less well established in institutions without the systems in place to safely administer the medication. Note: Within any time window, once the decision is made to administer IV tPA, the patient should be treated as rapidly as possible. As of this writing, tPA for acute ischemic stroke in the 3- to 4.5-hour window is not FDA approved.

SLIDE 2

2/19/2014 2

Vertigo

2014

Stuart Swadron MD FRCPC FAAEM FACEP

University of Southern California Los Angeles County/USC Medical Center

Not Missing Something BAD

Dizziness Dizziness

SLIDE 3

2/19/2014 3

Dizziness Dizziness

Vertigo Vertigo

Lightheadedness Lightheadedness Dysequilibrium Dysequilibrium Dysequilibrium Dysequilibrium

Dizziness Dizziness

Vertigo Vertigo

Lightheadedness Lightheadedness Dysequilibrium Dysequilibrium

Dizziness Dizziness

Vertigo Vertigo

Lightheadedness Lightheadedness

SLIDE 4

2/19/2014 4

8 3 4 5 6 6 7 9 10 Cerebellum

Central Peripheral

Tinnitis Hearing Loss

8 3 4 5 6 6 7 9 10 Cerebellum

Central Peripheral

12 The 5 D’s and Crossed Findings

Dizziness (vertigo) Dysphagia Diploplia Dysmetria Dysarthria Long tract findings

Any of these = CENTRAL = BAD

(motor/sensory)

Walk

SLIDE 5

2/19/2014 5

SLIDE 6

2/19/2014 6

Vertigo

2014

1. Make sure that it’s isolated

31,000 patients Discharged with diagnosis of vertigo or dizziness Stroke in only 1 in 500 in the first month

ACUTE VESTIBULAR SYNDROME

BPPV CEREBELLAR STROKE

Viral Otolith debris Vascular

Gradual onset < 1 minute episodes Sudden onset

Positive Head Impulse test Positive Dix-Hallpike test Negative Head Impulse test

Suppression meds Corticosteroids Epley maneuver Admission ASA

Isolated Vertigo

SLIDE 7

2/19/2014 7

Delayed onset Fatiguable Decreases with fixation Nystagmus in Peripheral Vertigo

QuickTime™ and a decompressor are needed to see this picture. ACUTE VESTIBULAR SYNDROME

BPPV CEREBELLAR STROKE

Viral Otolith debris Vascular

Gradual onset < 1 minute episodes Sudden onset

Positive Head Impulse test Positive Dix-Hallpike test Negative Head Impulse test

Suppression meds Corticosteroids Epley maneuver Admission ASA

Isolated Vertigo

The Head Impulse Test

Negative (normal) Positive

SLIDE 8

2/19/2014 8

Negative (normal) Head Impulse Test