1. “Six Publications That Influence Neurological Emergency Patient Resuscitation in 2010”

2. Ponte Vedra Beach, FL June 24, 2010 2010 Clinical Decision Making in Emergency Medicine Ponte Vedra Beach, FL June 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

3. Edward P. Sloan, MD, MPH FACEP Professor Department of Emergency Medicine University of Illinois College of Medicine Chicago, IL

4. Attending Physician Emergency Medicine University of Illinois Hospital Swedish American Belvidere Hospital Chicago, IL

5. Disclosures FERNE Chairman and President FERNE Chairman and President FERNE advisory board for The Medicine Company in May 2007 FERNE advisory board for The Medicine Company in May 2007 Dr. Sloan has been approved to study PCC (Beriplex) through an industry contract with the University of Illinois at Chicago. Dr. Sloan has been approved to study PCC (Beriplex) through an industry contract with the University of Illinois at Chicago.

6. Thank You Clinical Decisions in EM Consortium Clinical Decisions in EM Consortium Well assembled staff Well assembled staff FERNE staff FERNE staff

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

8. Learning Objectives Assess relevant medical literature to neurological emergency resuscitation. Assess relevant medical literature to neurological emergency resuscitation. Establish how ED clinical practice might change with recent publications. Establish how ED clinical practice might change with recent publications.

9. Learning Objectives Discuss the implications of changes on ED patient outcomes & resource use. Discuss the implications of changes on ED patient outcomes & resource use. Review guidelines that may impact decision making when resuscitating patients with acute neurological emergencies. Review guidelines that may impact decision making when resuscitating patients with acute neurological emergencies.

10. Case Presentations Acute ischemic stroke: tPA at the 4.5 hour time point? Acute ischemic stroke: tPA at the 4.5 hour time point? Status epilepticus: therapy after benzodiazepines and phenytoins? Status epilepticus: therapy after benzodiazepines and phenytoins? Hypothermic resuscitation s/p cardiac arrest: standard of care? Hypothermic resuscitation s/p cardiac arrest: standard of care?

11. Case Presentations Transient ischemic attack: outpatient ED management? Transient ischemic attack: outpatient ED management? ICH in coagulopathic patients: INR reversal strategies? ICH in coagulopathic patients: INR reversal strategies? Severe hypertension and ICH: aggressive continuous infusion Rx? Severe hypertension and ICH: aggressive continuous infusion Rx?

12. Acute Ischemic Stroke Case Presentation 62 year old patient with HTN history presents with acute middle cerebral artery distribution stroke at four hours. 62 year old patient with HTN history presents with acute middle cerebral artery distribution stroke at four hours. Key Clinical Question Should IV tPA be given at or beyond the 4.5 hour window? Should IV tPA be given at or beyond the 4.5 hour window?

14. Acute Ischemic Stroke IV tPA should not be given at or beyond the 4.5 hour window because of increased ICH risk and loss of potential benefit at and beyond this 270 minute time point. IV tPA should not be given at or beyond the 4.5 hour window because of increased ICH risk and loss of potential benefit at and beyond this 270 minute time point. IV tPA should be given as quickly as possible, since benefit is related to the speed with which it can be given. IV tPA should be given as quickly as possible, since benefit is related to the speed with which it can be given.

15. Acute Ischemic Stroke TimeOR NNTP TimeOR NNTP 0-90 min2.55 4.5.0001 0-90 min2.55 4.5.0001 91-180 min1.64 9.0.0119 91-180 min1.64 9.0.0119 181-270 min1.3414.1.0054 181-270 min1.3414.1.0054 271-360 min1.2221.4.1057 271-360 min1.2221.4.1057 0-360 min1.4012.6.0001 0-360 min1.4012.6.0001 Other therapies for thrombus lysis or clot removal should be considered near or at the 270 minute (4.5 hour) IV tPA time limit. Other therapies for thrombus lysis or clot removal should be considered near or at the 270 minute (4.5 hour) IV tPA time limit.

16. Status Epilepticus Case Presentation 37 year old patient with seizure, SE history presents with SE that is refractory to ED benzodiazepine and phenytoin therapy. 37 year old patient with seizure, SE history presents with SE that is refractory to ED benzodiazepine and phenytoin therapy. Key Clinical Question What is the best next Rx that offers the best chance for this refractory SE to be terminated? What is the best next Rx that offers the best chance for this refractory SE to be terminated?

17. Status Epilepticus The therapies that offer the best chance for terminating GCSE that is refractory to benzodiazepines & phenytoins Rx include anesthetic doses of barbiturates, midazolam, or propofol. The therapies that offer the best chance for terminating GCSE that is refractory to benzodiazepines & phenytoins Rx include anesthetic doses of barbiturates, midazolam, or propofol.

18. Status Epilepticus Ketamine: an alternative in hypotensive refractory SE patients. Ketamine: an alternative in hypotensive refractory SE patients. Rx such as IV valproic acid or IV levetiracetam: may be effective in terminating complex partial SE, buy not likely to effectively Rx refractory GCSE. Rx such as IV valproic acid or IV levetiracetam: may be effective in terminating complex partial SE, buy not likely to effectively Rx refractory GCSE.

19. Hypothermic Resus s/p Cardiac Arrest Case Presentation 59 year old patient sustains a cardiac arrest and is defibrillated out of ventricular fibrillation in a sinus rhythm with pulses. 59 year old patient sustains a cardiac arrest and is defibrillated out of ventricular fibrillation in a sinus rhythm with pulses. Key Clinical Question Is it SOC to implement hypothermic resuscitation in order to maximize neurological outcome? Is it SOC to implement hypothermic resuscitation in order to maximize neurological outcome?

20. Hypothermic Resus s/p Cardiac Arrest It is the standard of care to implement cooling methods in cardiac arrest patients who survive the initial resuscitation in order to maximize the chance for a good neurological outcome. It is the standard of care to implement cooling methods in cardiac arrest patients who survive the initial resuscitation in order to maximize the chance for a good neurological outcome. “The data from the studies reviewed by the Cochrane Collaboration supports the current best medical practice as recommended by the International Resuscitation Guidelines.” “The data from the studies reviewed by the Cochrane Collaboration supports the current best medical practice as recommended by the International Resuscitation Guidelines.”

21. Hypothermic Resus s/p Cardiac Arrest Cooling should take place in the ED following a successful resuscitation from Vfib using whatever means are necessary to reduce core temperature. Cooling should take place in the ED following a successful resuscitation from Vfib using whatever means are necessary to reduce core temperature. Definitive protocols for hypothermia resuscitation patients need to be implemented in the critical care units so that sustained hypothermia can be provided and complications minimized after ED resuscitation. Definitive protocols for hypothermia resuscitation patients need to be implemented in the critical care units so that sustained hypothermia can be provided and complications minimized after ED resuscitation.

22. Transient Ischemic Attack Case Presentation 71 year old patient with DM, HTN presents with loss of the use of R hand, unsteady gait, and poor vision for 20 minutes. The CT scan is negative and the current neurological exam is normal. 71 year old patient with DM, HTN presents with loss of the use of R hand, unsteady gait, and poor vision for 20 minutes. The CT scan is negative and the current neurological exam is normal. Key Clinical Question Can an outpatient ED observation strategy for easily identified ED TIA patients provide outcomes comparable to those of similar TIA patients admitted to the hospital? Can an outpatient ED observation strategy for easily identified ED TIA patients provide outcomes comparable to those of similar TIA patients admitted to the hospital?

24. Transient Ischemic Attack An outpatient ED observation strategy can be utilized in way that provides comparable patient outcomes to patients who are admitted to the hospital for the evaluation of their TIA. An outpatient ED observation strategy can be utilized in way that provides comparable patient outcomes to patients who are admitted to the hospital for the evaluation of their TIA. The ABCD2 score was best predictive of patients at risk for recurrent TIAs or major strokes. Patients with a low ABCD2 score are more likely to have a recurrent TIA, and those with a high ABCD2 score are at greatest risk for a subsequent moderate or severe stroke. The ABCD2 score was best predictive of patients at risk for recurrent TIAs or major strokes. Patients with a low ABCD2 score are more likely to have a recurrent TIA, and those with a high ABCD2 score are at greatest risk for a subsequent moderate or severe stroke.

25. Transient Ischemic Attack Patients with an ABCD2 score of 0-3 are at the lowest risk for a stroke within 7 days. Patients with an ABCD2 score of 0-3 are at the lowest risk for a stroke within 7 days. The diagnostic evaluation of ED TIA patients can be performed in an observation unit with outcomes comparable to ED TIA patients who are admitted for their subsequent care. This accelerated ED protocol care can be provided more quickly and at less cost than routine hospital care. The diagnostic evaluation of ED TIA patients can be performed in an observation unit with outcomes comparable to ED TIA patients who are admitted for their subsequent care. This accelerated ED protocol care can be provided more quickly and at less cost than routine hospital care.

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

27. ICH in Coagulopathic Pts Case Presentation 80 year old patient with atrial fibrillation hx on Coumadin presents with headache, vomiting, and altered mental status. The CT shows an acute cerebral hemorrhage. 80 year old patient with atrial fibrillation hx on Coumadin presents with headache, vomiting, and altered mental status. The CT shows an acute cerebral hemorrhage. Key Clinical Question What is the best way to reverse the elevated INR to minimize the adverse effects of this coagulopathic state? What is the best way to reverse the elevated INR to minimize the adverse effects of this coagulopathic state?

28. ICH in Coagulopathic Pts The best way to reverse an elevated INR in order to maximize outcome in the setting of INH may include the use of PCC and point of care INR testing. The best way to reverse an elevated INR in order to maximize outcome in the setting of INH may include the use of PCC and point of care INR testing. Although this is not the current standard of care in the US, it may become more common as more use of PCC occurs. Although this is not the current standard of care in the US, it may become more common as more use of PCC occurs.

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

30. Severe HTN & ICH Case Presentation 48 year old pt with HTN, CRF/dialysis history presents with coma and a BP of 240/142. The CT shows an acute ICH. 48 year old pt with HTN, CRF/dialysis history presents with coma and a BP of 240/142. The CT shows an acute ICH. Key Clinical Question Is the aggressive use of a continuous infusion anti-hypertensive therapy the best way to reduce BP to minimize the CNS end organ damage from uncontrolled severe HTN? Is the aggressive use of a continuous infusion anti-hypertensive therapy the best way to reduce BP to minimize the CNS end organ damage from uncontrolled severe HTN?

32. Severe HTN & ICH Although the use of a continuous infusion anti-hypertensive therapy may reduce blood pressure most quickly and consistently in the setting of uncontrolled severe hypertension and ICH, it is not clear that this approach is mandatory. Although the use of a continuous infusion anti-hypertensive therapy may reduce blood pressure most quickly and consistently in the setting of uncontrolled severe hypertension and ICH, it is not clear that this approach is mandatory.

33. Severe HTN & ICH Aggressive SBP and MAP reductions in hypertensive ICH patients have not yet been demonstrated to have a consistent beneficial effect or improved patient outcomes. Aggressive SBP and MAP reductions in hypertensive ICH patients have not yet been demonstrated to have a consistent beneficial effect or improved patient outcomes.

34. Severe HTN & ICH If benefit is derived from aggressive BP reduction, it will likely be correlated with reduced hematoma growth, reduced perihematomal edema, less frequent occurrences of neurological deterioration, and improved clinical outcomes as measured by mRS at 90 days and beyond. If benefit is derived from aggressive BP reduction, it will likely be correlated with reduced hematoma growth, reduced perihematomal edema, less frequent occurrences of neurological deterioration, and improved clinical outcomes as measured by mRS at 90 days and beyond.

35. Conclusions 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

36. Questions? edsloan@uic.edu 312 317 4996 www.ferne.org ferne_clindec_2010_sloan_six_neuro_papers_062510 8/9/2015 5:05 PM