Stroke thrombolysis given by emergency physicians: The time is here.

Emergency Medicine core clinical privileges include administration of thrombolytic therapy for myocardial infarction and stroke. However, emergency medicine providers have created their own paradigm to rely on neurology specialty consultation to treat acute stroke patients. A 2013 study supported by the American Academy of Neurology showed an 11% shortage of neurologists at that time and projected a 19% shortage by 2025. The lack of neurologists is a worldwide problem. To help ease the shortage, teleneurology and telestroke care has been implemented by neurologists, most notably for acute ischemic stroke (AIS) patients. We present a model in which an Emergency Medicine (EM) Stroke Champion (SC); an EM physician within our Neurologic Emergency Department, directs care for acute stroke patients at our comprehensive hub and primary stroke center spoke hospitals. The SCs independently treat patients with fibrinolytic therapy and provide teleneurology to fellow emergency physicians caring for acute stroke patients at spoke hospitals. Over nineteen months the SCs received 457 phone calls for patients meeting stroke alert criteria. Sixteen patients were deemed eligible for IV alteplase with one hemorrhagic conversion (6.25%). Sixty-four patients required transfer, and this was facilitated by the SCs. The concept of emergency physician SCs providing teleneurology consultation to other fellow emergency physicians was found to be feasible and safe. This model has the potential to be generalized not to just stroke champions, but to all emergency physicians to feel both confident and comfortable treating acute stroke patients.

Acute myeloid leukemia presenting as horizontal diplopia.

Acute myeloid leukemia (AML) accounts for 16% of all leukemias in children. Prognosis in the pediatric population is better than that of older populations, with a younger age at diagnosis being a favorable prognostic factor [1]. Diplopia is a rare first presenting sign of AML. We present a 15 year old male complaining of diplopia and unilateral orbital swelling. Workup in the emergency department found normal neuroimaging but revealed a markedly elevated leukocytosis with anemia and thrombocytopenia. Peripheral smear showed increased blast cells >10%. This patient was ultimately diagnosed with AML. This case demonstrates an atypical presentation of AML and urges a thorough work up for patients presenting with unexplained diplopia.

Cardiopulmonary resuscitation causing thoracolumbar hyperextension with severe spinal cord injury: A case report.

Thoracic vertebral fractures are extremely rare complications of cardiopulmonary resuscitation (CPR). A morbidly obese 79-year-old female positive for COVID-19 suffered cardiac arrest and received CPR for 18 minutes with return of spontaneous circulation. Post cardiac arrest the patient was unable to be weaned from the ventilator and had decreased lower extremity movement. A computed tomography scan of the chest/abdomen/pelvis demonstrated a widely diastatic spinal separation at the T12/L1 intervertebral disc space with L1 spinous process fracture. The patient ultimately expired from the severe spinal cord injury combined with older age, COVID-19 pneumonia, and morbid obesity. CPR can be an important life-saving procedure, but strict attention to proper technique is of paramount importance as it can have many possible complications.

Innovations in Care Delivery of Stroke from Emergency Medical Services to the Neurointerventional Operating Room.

Acute ischemic stroke (AIS) and its care is currently one of the most dynamic and evolving illnesses across the globe. Among the most crucial factors in providing the best care to patients are the expedient delivery of thrombolytics and endovascular intervention when indicated. Here, we review our unique model of efficient care centered in our innovative Neurological Emergency Department (Neuro ED). The Neuro ED acts as our hub for EMS communication, imaging, administration of intravenous alteplase, and transition to the Neurointerventional OR. Our structure with its enabling of shortened IV alteplase delivery times and faster door-to-needle (DTN) times may serve as an international model for stroke centers.

Beware of babesiosis: A rare and severe case causing death.

Babesiosis is an infectious disease caused by protozoa of the genus Babesia which is primarily transmitted by tick vectors. Most cases are asymptomatic or only mild to moderate, but some cases may be severe causing death. A 57 year old male with no reported travel outside the country was escorted by Emergency Medical Services to our Pennsylvania hospital in July of 2018 presenting with hypoglycemia, jaundice, and hypotension. Initial assessment further revealed the patient to be severely hypothermic. Resuscitative efforts began immediately and the laboratory reported parasites observed on the patient's peripheral blood smear. The patient was admitted to the intensive care unit with severe septic shock and disseminated intravascular coagulation. The patient was ultimately transferred to a tertiary care center for exchange transfusion therapy and veno-arterial extracorporeal membrane oxygenation support, but expired 36 h after presentation. Current CDC data reflects a steady rise of tick borne disease in the United States, but as of 2016 there have been no reported cases of babesiosis in the state of Pennsylvania, let alone fatalities. Clinicians need to be aware of the risk of fulminant illness when practicing in known endemic regions.

Is There a Neurologist in the House? A Summary of the Current State of Neurovascular Rotations for Emergency Medicine Residents.

OBJECTIVES: Neurovascular and neurocritical care emergencies constitute a leading cause of morbidity/mortality. There has been great evolution in this field, including but not limited to extended time-window therapeutic interventions for acute ischemic stroke. The intent of this article is to evaluate the goals and future direction of clinical rotations in neurovascular and neurocritical care for emergency medicine (EM) residents. METHODS: A panel of 13 board-certified emergency physicians from the Society for Academic Emergency Medicine (SAEM) neurologic emergencies interest group (IG) convened in response to a call for publications-three with fellowship training/board certification in stroke and/or neurocritical care; five with advanced research degrees; three who have been authors on national practice guidelines; and six who have held clinical duties within neurology, neurosurgery, or neurocritical care. A mixed-methods analysis was performed including a review of the literature, a survey of Council of Emergency Medicine Residency Directors (CORD) residency leaders/faculty and SAEM neuro-IG members, and a consensus review by this panel of select neurology rotations provided by IG faculty. RESULTS: Thirteen articles for residency neurovascular education were identified: three studies on curriculum, three studies evaluating knowledge, and seven studies evaluating knowledge after an educational intervention. Intervention outcomes included the ability to recognize and manage acute strokes, manage intracerebral hemorrhage, calculate National Institutes of Health Stroke Scale (NIHSS), and interpret images. In the survey sent to CORD residency leaders and neuro-IG faculty, response was obtained from 48 programs. A total of 52.1% indicated having a required rotation (6.2% general neurology, 2% stroke service, 18.8% neurologic intensive care unit, 2% neurosurgery, 22.9% on a combination of services). The majority of programs with required rotations have a combination rotation (residents rotate through multiple services) and evaluations were positive. CONCLUSIONS: Variability exists in the availability of neurovascular/neurocritical care rotations for EM trainees. Dedicated clinical time in neurologic education was beneficial to participants. Given recent advancements in the field, augmentation of EM residency training in this area merits strong consideration.

ECMO used successfully in a near fatal case of opioid-induced acute respiratory distress syndrome.

Acute Respiratory Distress Syndrome (ARDS) was first recognized during the 1960s. It is a distinct type of hypoxemic respiratory failure characterized by acute abnormality of both lungs. Extracorporeal membrane oxygenation (ECMO) is being increasingly used for patients with severe ARDS refractory to otherwise conventional management. A 29year old male arrived with Emergency Medical Services (EMS) status post presumed heroin overdose. He was administered Naloxone 2mg intravenously prior to arrival in the emergency department. The patient arrived in severe respiratory distress with a pulse oximetry level of 50% and was immediately intubated. The patient's pulse oximetry level remained in the seventies despite intubation and aggressive ventilator management. The Intensive Care Unit team in conjunction with cardiothoracic surgery initiated venovenous ECMO therapy in the emergency department itself. The patient was transferred to a tertiary center for venoarterial ECMO that was continued for 6 more days. After an extensive hospitalization, the patient was ultimately transferred to an acute medical rehabilitation center. With the current opioid crisis, emergency physicians and providers need to be aware that opioids can induce severe ARDS refractory to mechanical ventilation. ECMO as a treatment option can be used safely and successfully as described in this unique patient case report.

Improved door-to-needle times and neurologic outcomes when IV tissue plasminogen activator is administered by emergency physicians with advanced neuroscience training.

BACKGROUND: The neurologic emergency department (neuro ED) at our medical center is staffed by emergency medicine physicians who have specialized neuroscience training and give intravenous (IV) tissue plasminogen activator (tPA) independently for acute ischemic stroke patients. Door-to-needle (DTN) times, discharge location, and discharge National Institute of Health Stroke Scale (NIHSS) scores were studied between the neuro ED and main emergency department (ED) with the hypothesis that all measures would be better in the neuro ED group. METHODS: This is a retrospective study evaluating DTN time, discharge outcomes, and discharge location in acute stroke patients who received IV tPA at our comprehensive stroke center. These outcome measures were compared between patients who were evaluated and treated in our neuro ED to those treated in our main ED. RESULTS: From 2012 to 2014, 67 acute stroke patients received IV tPA in our ED. Thirty-five patients were evaluated in the neuro ED, and 32, in the main ED. Average DTN times were significantly faster in the neuro ED at 35 minutes, compared to main ED DTN times of 83 minutes. Discharge NIHSS score was significantly lower, and more patients were discharged to home in the neuro ED group compared to the main ED group. CONCLUSIONS: Trained neuro ED physicians can safely give IV tPA independently for stroke patients with improved DTN times, lower discharge NIHSS, and higher likelihood of being discharged to home compared to the main ED physicians who used teleneurology consultation. This suggests utility in training emergency medicine physicians to administer tPA independently based on clinical practice guidelines.

Wax on, wax off: a rare case of catatonia.

Catatonia was first described by a German psychiatrist, Karl Kahlbaum, in 1874. It is a behavioral syndrome marked by an inability to move normally, which can occur in the context of many underlying general medical and psychiatric disorders. A wide variety of neurologic, metabolic, drug-induced, and psychiatric causes of catatonia have been reported. We present a unique case of late onset catatonia in a 56-year-old man with no prior medical or psychiatric history initially presenting with stroke-like symptoms. The patient was awake and alert, with spontaneous eye opening, but completely nonverbal and not following any commands. Specifically, the patient demonstrated stupor, catalepsy, mutism, and negativism. After extensive emergency department testing, including negative computed tomography head, negative magnetic resonance imaging brain, negative electroencephalogram, and normal laboratory results, the patient was diagnosed with new-onset bipolar disorder with depressive features presenting as catatonia. Recognizing catatonia is important because it may be caused or exacerbated by treatment of the underlying disorder. Failure to institute treatment early in the course of catatonia is associated with a poor prognosis.