Week eight of Virtual Conference is upon us. Much thanks to last weeks’ lecturers for a fantastic job, including our guest lecturers. This week we feature lectures from Drs Silver, Pavelka and Willis, with a guest lecture from Dr Christine Stehman MD (https://medicine.iu.edu/faculty/15132/stehman-christine) on wellness in the times of COVID -19, and Journal Club lead by Dr MacDonald.
This month’s journal club features 3 stroke articles. The EXTEND IA I trial, the EXTEND IA II trial (1-4), and the SKIP trial
One of the issues with using lytics for acute thrombotic stroke management is the fact that there is both limited data to guide clinicians on the dose of thrombolytics as well as the fact that there is limited evidence that it does not improve outcomes (Phan 2017, Rai 2018) (3,4). There is also the question of thrombolytic selection and dosing – alteplase or tenecteplase. Alteplase literature is most prominent but tenecteplase (TNK) literature is scarce. These studies attempted to evaluate the use of TNK in thrombotic stroke for thrombolysis and addressed dosage. Additionally, there is question of whether thrombolysis systemically should even occur when there is endovascular therapy available (clot aspiration/thrombectomy/intra-arterial lysis/stenting. (5)
EXTEND IA – this trial evaluated the proposed question – In patients with ischemic stroke who undergo thrombectomy is tenecteplase non-inferior to alteplase in establishing reperfusion? (2) REBELEM has a great review (here) regarding this paper. The conclusion? Tenecteplase results in improved perfusion after thrombectomy compared to alteplase but only in patients that undergo endovascular intervention. Additionally, the rates of reperfusion prior to thrombectomy were low in both groups (22% in telecteplase vs 10% in alteplase group). There are no differences in clinically significant outcomes.(1,2)
EXTEND IA part II – Does higher dose tenecteplase (0.40 mg/kg) result in improved cerebral reperfusion when administered prior to endovascular therapy in LVO (large vessel occlusion) ischemic stroke? (3,4) REBELEM review (here) Conclusion – Among patients with large vessel occlusion ischemic stroke, a dose of 0.40mg/kg, compared with 0.25mg/kg, of tenecteplase did not significantly improve cerebral reperfusion prior to endovascular thrombectomy. The findings suggest that the 0.40-mg/kg dose of tenecteplase does not confer an advantage over the 0.25-mg/kg dose in patients with large vessel occlusion ischemic stroke in whom endovascular thrombectomy is planned.
SKIP – Randomized study of endovascular therapy with versus without intravenous tissue plasminogen activator in acute stroke with ICA and M1 occlusion – A prospective, multicenter, randomized trial to determine if endovascular therapy (EVT) is as effective as bridging therapy with EVT and intravenous thrombolysis (IVT) in acute ischemic stroke.(5,6) AHA review (here). Conclusions – Rate of favorable outcome at 90 days between two groups was not significantly different. However, intracerebral hemorrhages of direct EVT was significantly fewer than bridging therapy (both thrombolysis and EVT). In a Japanese stroke population this trial did not show the noninferiority of direct EVT to bridging therapy with respect to favorable outcomes. (6)
Read the reviews provided by the link and also refer to Dr MacDonald’s email. Stay tuned for journal club for more dissection of these studies.
Prior to the COVID era, we conducted Chief Resident and Resident Leaders elections – the Chiefs were announced in early March prior to this website being formed – thus I thought it would be pertinent to announce and give kudos on here in light of the recent selections for leadership positions finalized this week. Congratulations again to next Academic Year’s Chiefs Dr Scarborough, Dr Blustein, Dr K. Smith, and Dr Magee.
This week we completed elections for Resident Leader roles – Resident Chair of ED Quality Improvement (Drs Soliman and Brewer – Co-Chairs), Resident Chair of Trauma Quality Improvement (Drs Hardy and Willis – Co-Chairs), Resident Chair of Recruitment and Advocacy (Drs Vo and Rice – Co-chairs). Looking forward to working with you all!
It’s National Womens Health week, and also recently Mother’s day! So just wanted to show support for Womens Health, Mothers everywhere, and also give a shoutout to Women in Healthcare. Thank you for all you do! We can’t do it without you!
Here is an interesting piece on Schizophrenia courtesy of ThoughtCatalog. https://thoughtcatalog.com/lorenzo-jensen-iii/2017/10/37-schizophrenic-people-describe-the-terrifying-voices-they-hear/ It is accounts of people living with schizophrenia talking about the auditory hallucinations that they have that constantly affect their lives and everyone around them. It is quite an eye-opening read.
Dr Pavelka will be giving a lecture this week on schizophrenia and will be conducting an interesting exercise. We thought it would be a good idea to also give the option to do this asynchronously if you are interested.
First – get some headphones and plug them in. Navigate to this website https://www.proprofs.com/quiz-school/story.php?title=mjc0odeynglgxd and enter in the email firstname.lastname@example.org when prompted. Then navigate to this video on auditory hallucinations, start it in the background, listen to the audio while you complete the quiz:
The audio and time to complete the quiz is about 3 minutes. It is an interesting exercise designed to give you an insight into daily life of people experiencing auditory hallucinations.
Here is an interesing EMDOCS article about pearls and pitfalls of psych medications in the ED.
Lets talk about Lithium. Lithium is typically prescribed for treating and preventing mania and depression seen in bipolar disorder, augmenting an established antidepressant regimen, and demonstrating anti-suicidal effects. It also has numerous toxic side effects(7).
Here is what you need to know about lithium toxicity: The therapeutic window for lithium is narrow, with 0.6- 1.2 mEq/L generally being the acceptable upper limit of normal (7).
Acute ingestions/toxicity –> nausea, vomiting and diarrhea. Late findings –> Neuro symptoms of tremor, ataxia and confusion due to distribution into the CNS.
Chronic toxicity –> typically demonstrates neurologic symptoms early, such as progression of an existing tremor, hyperreflexia, clonus, ataxia, altered mental states, seizures, or encephalopathy. (7)
Systemic manifestations of chronic lithium use may lead to renal dysfunction including nephrogenic diabetes insipidus or tubulointerstitial nephropathy. Thyroid dysfunction, mainly hypothyroidism, can occur. In pregnancy, lithium may lead to multiple fetal impairments including Ebstein’s anomaly, hypothyroidism, and neurotoxic sequela previously discussed. (7)
Be careful when drawing a lithium level – Serum level may be falsely elevated if placed in a green top tube due to the heparin lithium interaction. (8)
Treatment –> start with IVF. Consider hemodialysis. Indications for HD include:
- Kidney function impaired and the [Li+] level is >4.0 mEq/L OR [Li+].>5.0 mEq/L (without other factors) (8)
- Clinical deterioration
- Progressive neuro symptoms such as decreased level of consciousness, seizures, or life-threatening dysrhythmias irrespective of [Li+] serum level (8)
- Baseline renal failure and/or a possible contraindication to aggressive fluid resuscitation (CHF, etc) (8)
Thats it for now! see you at virtual conference.
- Campbell BCV et al. Tenecteplase versus Alteplase before Thrombectomy for Ischemic Stroke. NEJM; 378(17): 1573-1582. PMID: 29694815
- Anand Swaminathan, “Tenecteplase versus Alteplase before Endovascular Therapy for Ischemic Stroke (EXTEND-IA TNK)”, REBEL EM blog, June 4, 2018. Available at: https://rebelem.com/tenecteplase-versus-alteplase-before-endovascular-therapy-for-ischemic-stroke-extend-ia-tnk/.
- Campbell BCV et al. Effect of intravenous tenecteplase dose on cerebral repercussion before thrombectomy in patient with large vessel occlusion ischemic stroke: The EXTEND-IA TNK Part 2 Randomized Clinical Trial. JAMA 2020. PMID: 32078683
- Anand Swaminathan, “EXTEND-IA TNK Part II – What Dose of Tenecteplase is the Right Dose?”, REBEL EM blog, March 23, 2020. Available at: https://rebelem.com/extend-ia-tnk-part-ii-what-dose-of-tenecteplase-is-the-right-dose/.
- The randomized study of endovascular therapy with versus without intravenous tissue plasminogen activator in acute stroke with ICA and M1 occlusion (SKIP study). Int J Stroke. 2019 Oct;14(7):752-755.
K. Holmes DO FACEP