1. ED TIA Patient Case Presentation Transient Ischemic Attack Patient Update: The Optimal Management of Emergency Department Patients With Suspected Cerebral Ischemia

2. ED TIA Patient Case Presentation Case Presentation and Audience Response Questions

3. ED TIA Patient Case Presentation Edward P. Sloan, MD Andy Jagoda, MD FERNE Executive Board Members

4. ED TIA Patient Case Presentation A 62 year-old professor has an apparent stroke while teaching at the local community college. EMS is called, and contact to the local EMS base station occurs within 15 minutes of the onset of symptoms. The gentleman has some slurred speech, blurry vision, and is unable to purposefully move his R hand. He arrives at the closest comprehensive ED within 30 minutes of the time of symptom onset, at which time his symptoms have resolved.

5. ED TIA Patient Case Presentation ED TIA Patient Diagnosis Do you identify patients as having a TIA only if there is a history of a clear neurological deficit, or do you also consider dizziness or vertigo as being possible TIAs? 1. I only diagnose TIAs when there is a clear deficit. 2. I also define TIAs in patients with dizziness or vertigo.

6. ED TIA Patient Case Presentation ED TIA Patient Neuroimaging How do you neuroimage patients with suspected cerebral ischemia and TIA? 1. I neuroimage TIA patients with noncontrast CT. 2. I neuroimage TIA patients with MR imaging. 3. I do not routinely neuroimage TIA patients.

7. ED TIA Patient Case Presentation Carotid Doppler Utilization Do you utilize carotid artery Doppler examination in the ED for suspected TIA patients? 1. I routinely utilize carotid artery Doppler. 2. I often utilize carotid artery Doppler. 3. I sometimes utilize carotid artery Doppler. 4. I never utilize carotid artery Doppler.

8. ED TIA Patient Case Presentation ED TIA Patient Treatment Do you treat your ED recurrent TIA patients who are on daily low dose aspirin with any other therapies acutely? 1. I routinely treat these ED TIA patients with another Rx. 2. I often treat these ED TIA patients with another Rx. 3. I sometimes treat these ED TIA patients with another Rx. 4. I only rarely treat these ED TIA patients with another Rx.

9. ED TIA Patient Case Presentation ED TIA Patient Therapies What therapy do you use in addition to or instead of daily low dose aspirin if there for an ED recurrent TIA patient? 1. ASA-Dipyridamole 2. Clopidigrel. 3. Heparin or LMW heparin. 4. Other.

10. ED TIA Patient Case Presentation Atrial Fibrillation Rx Do you treat your TIA patients who are in atrial fibrillation with heparin or LMW heparin if they are not anti-coagulated? 1. I routinely treat these ED TIA patients with heparin. 2. I often treat these ED TIA patients with heparin. 3. I sometimes treat these ED TIA patients with heparin. 4. I only rarely treat these ED TIA patients with heparin.

11. ED TIA Patient Case Presentation Short Term Stroke Risk It is suggested that the short term stroke risk for ED TIA patients with suspected ischemia is quite high (such that hospital admission is virtually mandatory). Do you agree with this statement? 1. I agree that the short term stroke risk is high. 2. I don’t believe that the short term stroke risk is high. 3. I am uncertain about the short term stroke risk. 4. I do not let this risk influence my disposition strategies.

12. ED TIA Patient Case Presentation TIA Risk Assessment Tool Use Do you routinely use risk assessment tools when deciding disposition in your ED TIA patients? 1. I routinely use risk assessment tools. 2. I often use risk assessment tools. 3. I sometimes use risk assessment tools. 4. I never use risk assessment tools.

13. ED TIA Patient Case Presentation ED TIA Patient Hospital Admission Do you admit to the hospital your ED TIA patients with suspected ischemia? 1. I routinely admit my ED TIA patients to the hospital. 2. I often admit my ED TIA patients to the hospital. 3. I sometimes admit my ED TIA patients to the hospital. 4. I only rarely admit my ED TIA patients to the hospital.

14. ED TIA Patient Case Presentation ED Rapid Dx or OBS Protocol Do you work in an ED that utilizes a rapid evaluation protocol or an observation unit for TIA patients so that disposition home is possible? 1. Yes, we use a rapid rule out protocol in our ED. 2. Yes, we have an observation unit protocol for these patients. 3. No, we do not have these resources in my principal ED.

15. ED TIA Patient Case Presentation 48 Hour Neurology Follow-up Can you routinely arrange for neurologist follow-up within 48 hours for you ED TIA patients who are discharged home? 1. Yes 2. No 3. I never send ED patients home, and so do not need this referral.

16. ED TIA Patient Case Presentation ED TIA Patient Home Disposition I would be comfortable sending a patient home who has a negative complete TIA evaluation (neurological exam, lab, cardiac, neuroimaging, carotid) and good support and follow-up. Do you agree with this statement? 1. I agree without reservation. 2. I agree but have concerns with this approach. 3. Although it makes sense, I tend to disagree with this statement. 4. I fully disagree with this statement.

17. ED TIA Patient Case Presentation Future ED Practice Change I believe that over time we will send more ED TIA patients home once we confirm the safety of ED-based complete evaluations. Do you agree with this statement? 1. I agree that ED TIA disposition will change. 2. I agree that ED TIA disposition will change as more MRI neuroimaging data is obtained. 3. I do not believe practice will change because of persistent safety concerns. 4. I do not believe practice will change because of persistent medico-legal risks.

18. ED TIA Patient Case Presentation Questions? www.ferne.org Questions? www.ferne.org <andy.jagoda@mssm.edu> ferne_clindec_2008_tia_case_ars_questions_062508_final