Round 29 (Weakness)
EM Clerkship
Zack Olson, MD ; Mike Estephan, MD ; Maddie Watts, MD
4.9 • 816 Ratings
🗓️ 1 January 2022
⏱️ 32 minutes
🧾️ Download transcript
Summary
Initial Assessment:
* Obtain Vitals and blood glucose level* Time of onset (important for tPA/TNK vs thrombectomy)* Neurologic and Cardiac Examination / NIHSS* do not delay head CT to complete NIHSS, can always finish after CT* Assess contraindications for tPA
Workup:
* Labs: CBC, CMP, Troponin, Coags, EtOH, bedside accucheck* CXR and UA (infections can cause recrudescence of prior cva)* ECG looking specifically for AFib* Stat Imaging: CT Head noncontrast, followed by CTA Head/Neck and/or CT Perfusion
Treatment:
* tPA / TNK if significant neurologic deficits are present and no contraindications exist* Thrombectomy if large vessel occlusion present without contraindications* Admission to stroke unit to…* Workup the etiology of stroke (usually carotid US, Echo /w bubble study, telemetry monitoring), * Optimize treatment of risk factors such has HLD, HTN, AFib, etc* Obtain early PT/OT/Rehab
Post-tPA Complications: Angioedema (2-5%) and Hemorrhage (2-7%)
* Have a high index of suspicion for hemorrhage – monitor for headaches, change in mental status, signs of ICP, etc* Stop tPA immediately* If concerned for hemorrhage, elevate head of bed and obtain STAT CT Head* For hemorrhage, consider TXA, Platelets, Cryoprecipitate (as recommended by the AHA, however evidence is extremely poor) and consult Neurosurgery* For Angioedema, monitor airway closely, intubate if necessary, and consider medical treatment (FFP, Antihistamines, Steroids, Epinephrine, TXA – all of which have poor evidence for benefit)
Further Reading:
MD Calc- tPA Contraindications
EMDocs – Post tPA Complications
EMRA – Post tPA Hemorrhage
Transcript
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| 0:00.0 | Hello, residents. My name is Zach Olson. I'm joined today by Mike Estefan, and thank you for downloading |
| 0:06.1 | this month's episode of the EM Clerkship podcast. This episode is sponsored by Pearson Ravitts Insurance, |
| 0:12.8 | my personal disability and life insurance agent, and today is round number 29 of the game. |
| 0:19.3 | 29. Yeah, 29. Okay. |
| 0:21.3 | A few of you have reached out to me recently because, as you may or may not be aware, |
| 0:25.8 | the ABEM, the American Board of Emergency Medicine, recently made changes to their test format. |
| 0:31.0 | So all these triple cases that we've been doing, those are gone all of a sudden. |
| 0:34.7 | And now they've replaced it with this new format called structured interviews. |
| 0:39.5 | Now, in full disclosure, I've never had to do a structured interview myself because this came |
| 0:44.4 | after I did my test. |
| 0:45.9 | But a few of these are available online. |
| 0:47.9 | I've listened to them. |
| 0:48.9 | And we're going to do our best attempt at this today to help Mike get ready for the oral boards. |
| 0:53.2 | I will say just as like kind of aside, |
| 0:55.0 | I think this is a good change for ABM to do because the triples were supposed to be checking |
| 0:59.8 | your ability to multitask. However, in the real world, multitasking is completely different |
| 1:06.6 | than these triple cases. Like, it's not, in the real world, it's not three interesting cases that, |
| 1:11.9 | you know, someone is timing out for you and spacing out for you that are all perfectly designed to be it's like not like that. It's more like you just get 10 people that all say, you know, COVID-19 as the chief complaint and one of them is a 30-year-old with a typical ACS. You know, it's like, it's more, it's just not, I never thought it was a good part of the test. |
| 1:10.9 | These structured interviews are meant to make, to demonstrate. rolled with atypical ACS. You know, it's like, it's more, it's just not, I never thought it was a good |
| 1:27.6 | part of the test. These structured interviews are meant to make, to demonstrate that the candidate can think through and not just that they've memorized like a template. Like, I need a BMP and a CBC and a light paste or whatever. It's more of, well, why do you need a BMP? And so they ask a lot of questions like that. So I think this is a good |
| 1:44.7 | change. So like the single patient cases, Mike has 15 minutes to complete one of these. This case, |
| 1:52.4 | again, created by me, they're not derived from actual ABM cases that I had. They're not real |
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