The Downeast EM Podcast
Blood Pressure Pearls for Neuro Emergencies with Evie Marcolini

Blood Pressure Pearls for Neuro Emergencies with Evie Marcolini

January 8, 2020

We have a lot of numbers to remember when it comes to the care of the brain injured patient. From subarachnoid hemorrhage to traumatic brain injury, it can be hard to keep all the numbers straight. We sat down with neuro-intensivist Dr. Evie Marcolini to discuss blood pressure targets for these different disease processes.

Check out our post on the Down East EM blog for more

  

SUMMARY OF RECOMMENDATIONS AND ASSOCIATED LITERATURE

Subarachnoid Hemorrhage (SAH)

Systolic blood pressure (SBP) to <160 (AHA recs) [1]

Neurosurgeons/neurointensivists like it <140 to decrease rebleed risk.

Evie Pearl: SAH often happens in younger, healthy women who can tolerate a lower BP and so if you go below 140 even, and the patient tolerates it, that is ok.

 

Intracerebral Hemorrhage

SBP <180 (Atach 2) [2]

Evie Pearl: BP goal depends on baseline for patient.

 -Elderly, comorbid with baseline elevated BP aim higher (<180)

 -Younger healthy patients without pre-existing hypertension, aim lower (ex <160)

 

Acute Ischemic Stroke

TPA Candidate  <185/110 (AHA recs) [3]

Non-TPA Candidate <220

Evie Pearl 1: remember we are trying to keep BP on the higher side to perfuse the penumbra, but the larger the core infarct the higher the risk of reperfusion hemorrhage. 

Evie Pearl 2: do a neuro exam on the patient sitting up, then lie them flat and repeat the exam. If it improves, the stroke is BP dependent and you may want the patient to run on the higher side, let them lie flat, or give some gentle fluids.

 

Traumatic Brain Injury

SBP >110 age 15-49 or >70 (Brain Trauma Foundation) [4]

SBP > 100 age 50-69

Evie Pearl: These numbers are based on the fact that we do not have robust data on specific BP parameters. Newer data (Spaite paper [5]) is showing that not only is avoiding hypotension necessary, but allowing BPs to run higher (up to 130) may be of benefit. 

 

 

References

1. Connolly ES Jr, Rabinstein AA, Carhuapoma JR, Derdeyn CP, Dion J, Higashida RT, Hoh BL, Kirkness CJ, Naidech AM, Ogilvy CS, Patel AB, Thompson BG, Vespa P; American Heart Association Stroke Council; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; Council on Cardiovascular Surgery and Anesthesia; Council on Clinical Cardiology. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/american Stroke Association. Stroke. 2012 Jun;43(6):1711-37. doi: 10.1161/STR.0b013e3182587839. Epub 2012 May 3.

 

2. Qureshi AI, Palesch YY, Barsan WG, Hanley DF, Hsu CY, Martin RL, Moy CS, Silbergleit R, Steiner T, Suarez JI, Toyoda K, Wang Y, Yamamoto H, Yoon BW; ATACH-2 Trial Investigators and the Neurological Emergency Treatment Trials Network. Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage. N Engl J Med. 2016 Sep 15;375(11):1033-43. doi: 10.1056/NEJMoa1603460. Epub 2016 Jun 8.

 

3. Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, Brown M, Demaerschalk BM, Hoh B, Jauch EC, Kidwell CS, Leslie-Mazwi TM, Ovbiagele B, Scott PA, Sheth KN, Southerland AM, Summers DV, Tirschwell DL. Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2019 Dec;50(12):e344-e418. doi: 10.1161/STR.0000000000000211. Epub 2019 Oct 30.

 

4. Carney N, Totten AM, O'Reilly C, Ullman JS, Hawryluk GW, Bell MJ, Bratton SL, Chesnut R, Harris OA, Kissoon N, Rubiano AM, Shutter L, Tasker RC, Vavilala MS, Wilberger J, Wright DW, Ghajar J. Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery. 2017 Jan 1;80(1):6-15. doi: 10.1227/NEU.0000000000001432.

 

5. Spaite DW, Hu C, Bobrow BJ, Chikani V, Sherrill D, Barnhart B, Gaither JB, Denninghoff KR, Viscusi C, Mullins T, Adelson PD. Mortality and Prehospital Blood Pressure in Patients With Major Traumatic Brain Injury: Implications for the Hypotension Threshold. JAMA Surg. 2017 Apr 1;152(4):360-368. doi: 10.1001/jamasurg.2016.4686.

 

Author: Jason Hine MD

Peer Review: Jeff Holmes MD

Coding in the Community- Keeping It Real with Really Limited Resources

Coding in the Community- Keeping It Real with Really Limited Resources

December 18, 2019

Coding cardiac arrest patients is tough. There's lots to do- from getting access, to doing ultrasounds, to analyzing rhythms, the tasks really add up! This is especially true in a low-staffing, low-resource setting. In this post we review how to code someone well with limited resources.

 

Check out our post on the Down East EM blog for shownotes, references, and more.

 

Author: Jason Hine MD

Peer Reviewer: Jeff Holmes MD

Fentanyl Hysteria with Ryan Marino

Fentanyl Hysteria with Ryan Marino

December 3, 2019

In this podcast we sit down the ED toxicologist Ryan Marino to talk about this phenomenon in the media of "fentanyl hysteria"- a trend of fear-mongering, exaggerated reporting, and misinformation. 

 

Check out our post on the Down East EM blog for shownotes, references, and more.

 

Examples of Fentanyl Hysteria reporting:

San Fran Chronicle Article on Police OD

CNN Article on Deputy and EMT exposure

 

Author: Jason Hine MD

Peer Review: Jeff Holmes MD

Neuroimaging Update: The Studies and Sequences You Should Know

Neuroimaging Update: The Studies and Sequences You Should Know

November 18, 2019

The world of emergency neuroimaging is evolving and increasingly influencing time-sensitive treatment decisions. A basic understanding of the imaging studies and sequences you may be asked to obtain in the ED may help you better manage your patients. In this post, Dr. Matthew Siket reviews the four major neuroimaging modalities (CT, CTA, Perfusion, and MRI).

For the full show notes on our DownEast EM blog

https://www.downeastem.org/downeastem/2018/6/29/neuroimaging

 

References:

  1. Smith AG and Hill CR. Imaging assessment of acute ischaemic stroke: a review of radiological methods. Br J Radiol. 2018;91:1083.[Pubmed]

  2. Albers GW et al. New Engl J Med 2018;378:708-18.[Pdf]

  3. Thomalla G et al. New Engl J Med 2018; 379(7):611-22.[Pdf]

Author Matt Siket, MD and Jeff Holmes, MD

Peer Reviewed by Andrew Perron, MD

Emergency Mansplaning- Gender Equality in your ED

Emergency Mansplaning- Gender Equality in your ED

November 1, 2019

Gender equity (or in truth, inequity) in medicine has come under the spotlight with an increasing focus on a culture of fairness, improving female practitioners' access to leadership roles, and moving away from the "good ol' boys club" medicine is prone to being. 

In this guest lecture we have Dr. Kimon Ioannides talking on Mansplaining in the ED.

Check out our post on the Down East EM blog for shownotes, references, and more.

 

 

Author: Jason Hine MD and Kimon Ioannides MD

Peer Review: Jeff Holmes MD

Buprenorphine, the Opioid Epidemic, and the Emergency Provider

Buprenorphine, the Opioid Epidemic, and the Emergency Provider

October 16, 2019

Check out our post on the Down East EM blog for shownotes, references, and more.

 

The reality of America’s opioid addiction and overdose problem has reached the lay press. As overdose deaths begin to outpace car accidents as the #1 cause of accidental deaths, the Opioid Crisis has people’s attention.

How we deal with this epidemic in the Emergency Department has been a topic of hot debate, both in publication and in the Free Open Access Medical Education (FOAM) world.

To dive into these topics, we sat down with Dr. Ken Starr, an Emergency and Addiction medicine specialist, to review buprenorphine. 

 

Author: Jason Hine MD and Ken Starr MD

Peer Review: Jeff Holmes MD

Marble Mouth- Oropharyngeal Foreign Bodies in Kids

Marble Mouth- Oropharyngeal Foreign Bodies in Kids

October 1, 2019

Check out our post on the Down East EM blog for shownotes, references, and more.

In this podcast we review the complexity of the oral foreign body (FB) in kids and why this disease process is so tough to handle.

 

 

 

Other helpful links!

 
 
Making Metacognition Work for You

Making Metacognition Work for You

September 16, 2019

Check out our post on the Down East EM blog for shownotes, references, and more.

 

Metacognition is a person’s ability to understand their thought patterns and how they come to their conclusions. It is a critically imporant skill for health care providers as it has the ability to both hinder and help their medical decsion making. In this podcast episode, Dr. Samantha Wood describes the dual process theory of thinking as well as seven metacognition hacks that you can use on your next shift.

 

Author: Samantha Wood MD

Peer Reviewer:  Jeffrey A. Holmes, MD 

Toss the Tube or Scoop and Run?- Controlling the Airway in Out of Hospital Cardiac Arrest

Toss the Tube or Scoop and Run?- Controlling the Airway in Out of Hospital Cardiac Arrest

August 21, 2019

How should we handle the airway in out of hospital cardiac arrest? Just bag and go? Should we tube these guys? Maybe just toss in a supraglottic? In this podcast we review these three strategies and the recent research on the topic.

 

Article 1:

Effect of Bag-Mask Ventilation vs Endotracheal Intubation During Cardiopulmonary Resuscitation on Neurological Outcome After Out-of-Hospital Cardiorespiratory Arrest
A Randomized Clinical Trial [pubmed]

Article 2:

Effect of a Strategy of a Supraglottic Airway Device vs Tracheal Intubation During Out-of-Hospital Cardiac Arrest on Functional Outcome: The AIRWAYS-2 Randomized Clinical Trial. [pubmed]

Article 3:

Effect of a Strategy of Initial Laryngeal Tube Insertion vs Endotracheal Intubation on 72-Hour Survival in Adults With Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial. [pubmed]

 

The Glasgow-Pittsburgh Cerebral Performance Categories

Modified Rankin Scale

 

Author: Jason Hine MD and Sam Potter MD

Peer Reviewer: Jeff Holmes MD

You Down with GME? Yeah, You Know Me- Learning during residency from the residents’ perspective

You Down with GME? Yeah, You Know Me- Learning during residency from the residents’ perspective

July 21, 2019

Check out our post on the Down East EM blog for shownotes, references, and more.

 

We talk a fair bit in MedEd (that's medical education for cool people) about how to best teach medicine, but rarely sit down these trainees after they’ve been through to really get a sense of what they think. 

So we sat down with two of our graduating chief residents to ask them their parting thoughts on GME. 

 

Author: Jason Hine MD

Peer Reviewed by: Jeff Holmes MD