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PJC November 2020: Neurology

The November 2020 Prehospital Journal Club meeting will be on Friday, November 27th, from 5:30 PM to 6:30 PM Mountain Time. This month’s PJC will be conducted remotely using Zoom – click the button below to register through Zoom.

A note from Dr. Dickey

Hello all,

We’re getting ready to have another journal club, this time starting with a bit of a theme. This round is (drumroll) Neurology.

I have a few thoughts on how to manage this. Start with a subsection (example: traumatic brain injury). We can review your current management and thoughts, then look through an article and do a quick review of some other literature that plays a role. This way there is some clinical focus, some evidence-based focus, and mostly we all learn from each other. Secondary benefit: less people fall asleep.

Since last time I have also been trying to think of ways that we can help boost interest and attendance. One way that makes sense is to have you set the schedule. AKA if you see an interesting article (and we can get it on PDF without violating legal restrictions) send it to us and we can review it. You can also pose clinical questions… say you had a challenging patient with a neuro concern (example: refractory seizure), send us a quick scenario and we can go through it. Please, if you choose to do either of these give us some time to prepare (ideally, a week, but a couple of days would also be reasonable on occasion).

Another thing that we are sending out this time is a quick two page prompter (included). This gives the articles, but also gives you a chance to stop and think about what you know about the topic overall (even if you didn’t get a chance to read the articles, taking five minutes to think about what you know about the topic will help).
This time: Seizures/status epilepticus, Ischemic stroke, syncope/near-syncope, and traumatic brain injury.

Looking forward to it, Sean will post the time once I stop being a slacker and get my part of the prep done.

Tyler Dickey, MD

Prompter

As always, if you have an interesting journal article from the prehospital realm, you can send the complete article to us at least a week before the next journal club for review and discussion. This will hopefully keep your interests in mind.

Seizure/Status Epilepticus

What is my current understanding and my current practice?

Randomized trial of three anticonvulsant medications for status epilepticus–2019

  • Trial that was seeking to answer what the next most appropriate antiepileptic medication would be following benzodiazepine for status epilepticus
  • Does this apply to me?
  • After reading this article, does this influence my decision-making?

Stroke

What is my current understanding and my current practice?

Stroke vision, aphasia, neglect (VAN) assessment–a novel emergent large vessel occlusion screening tool: Pilot study and comparison with current clinical severity indices–2017

  • Trial looking to see if a simplified stroke scale to look for large vessel occlusion (and thus potential for interventional management) would outperform traditional stroke assessment (NIHSS)
  • Does this apply to me?
    • Lots of options: Cincinnati stroke Scale (CPSSS), 3 Item Stroke Scale (3I-SS), Face, arm, speech test (FAST), Los Angeles Motor Scale (LAMS), LEGS, MASS, Med PACS, OPSS, RACE, ROSIER.
    • NIHSS (NIH stroke scale)- what the neurologists use
  • After reading this article, does this influence my practice?

Thrombolysis guided by perfusion imaging up to 9 hours after onset of stroke–2019

  • Trial that was trying to assess the safety of extending out thrombolytics for acute ischemic stroke
  • Does this apply to me?
  • What is my current understanding and my current practice?
    • NIMS Study
    • ECASS3 Study
    • What is the standard of care?
  • After reading this article, does this influence my decision-making?

Syncope

What is my current understanding and my current practice?

Comparison of 30 days serious adverse clinical events for elderly patients presenting to the emergency department with near syncope versus syncope–2018

  • Trial focusing on elderly patients with a goal of assessing risk for syncope and near-syncope presentations.
  • Does this apply to me?
  • After reading this article, does this influence my decision-making?

Traumatic Brain Injury

What is my current understanding and my current practice?

Prehospital triage and emergency room care and TBI–2013

  • Review article discussing TBI management
  • Does this apply to me/my patients?
  • What is my current understanding and my current practice?
  • After reading this article, does this change my practice?

Articles to be discussed (time allowing)

  • Kapur J, Elm J, Chamberlain JM, et al. Randomized trial of three anticonvulsant medications for status epilepticus. N Engl J Med. 2019;381(22):2103-2113.
  • Teleb MS, Ver Hage A, Carter J, Jayaraman MV, McTaggart RA. Stroke vision, aphasia, neglect (Van) assessment—a novel emergent large vessel occlusion screening tool: pilot study and comparison with current clinical severity indices. J NeuroIntervent Surg. 2017;9(2):122-126.
  • Ma H, Campbell BCV, Parsons MW, et al. Thrombolysis guided by perfusion imaging up to 9 hours after onset of stroke. N Engl J Med. 2019;380(19):1795-1803.
  • Bastani A, Su E, Adler DH, et al. Comparison of 30-day serious adverse clinical events for elderly patients presenting to the emergency department with near-syncope versus syncope. Annals of Emergency Medicine. 2019;73(3):274-280.
  • Chmayssani M. Prehospital triage and emergency room care in TBI. Emergency Medicine. 2014;04(01).

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PJC September 2020

The September 2020 Prehospital Journal Club meeting will be on Thursday, September 10th from 5:30 PM to 6:30 PM MST. As always, you can attend in person or online through Google Meet.

Our location information for attending in person.

Google Meet link:
https://meet.google.com/dtg-bsbc-thd

Articles to be discussed: (time allowing)

  • Baekgaard JS, Eskesen TG, Sillesen M, Rasmussen LS, Steinmetz J. Ketamine as a rapid sequence induction agent in the trauma population: A systematic review. Anesth Analg. 2019;128(3):504-510. doi:10.1213/ANE.0000000000003568
  • Elmer J, Brown F, Martin-Gill C, Guyette FX. Prevalence and Predictors of Post-Intubation Hypotension in Prehospital Trauma Care. Prehospital Emerg Care. 2020;24(4):461-469. doi:10.1080/10903127.2019.1670300
  • Lemkes JS, Janssens GN, Van Der Hoeven NW, et al. Coronary angiography after cardiac arrest without ST-segment elevation. N Engl J Med. 2019;380(15):1397-1407. doi:10.1056/NEJMoa1816897
  • Perkins GD, Ji C, Deakin CD, et al. A randomized trial of epinephrine in out-of-hospital cardiac arrest. N Engl J Med. 2018;379(8):711-721. doi:10.1056/NEJMoa1806842
  • The CRASH-3 trial collaborators. Effects of tranexamic acid on death, disability, vascular occlusive events and other morbidities in patients with acute traumatic brain injury (CRASH-3): a randomised, placebo-controlled trial. Lancet. 2019;394(10210):1713-1723. doi:10.1016/S0140-6736(19)32233-0
  • Wafaisade A, Lefering R, Bouillon B, Böhmer AB, Gäßler M, Ruppert M. Prehospital administration of tranexamic acid in trauma patients. Crit Care. 2016;20(1):1-9. doi:10.1186/s13054-016-1322-5

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The “X-waiver” — prescribing buprenorphine

The “X-waiver” (technically the DATA 2000 waiver) is a process that allows certain medical providers to prescribe buprenorphine for the treatment of opioid use disorder (OUD). The use of buprenorphine (and Suboxone, a combination of buprenorphine and naloxone) is a cornerstone of medication assisted treatment (MAT). While there is a lot of stigma and confusion surrounding the X-waiver (and even more surrounding MAT in general), the process is actually quite simple.

This lesson will discuss the X-waiver — the requirements, the application process, and what comes afterward.

Download the lesson outline, then enjoy the video!

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Compartment Syndrome

Compartment syndrome isn’t often seen in the prehospital setting, but it is a limb-threatening emergency that providers must recognize promptly. Left unchecked, compartment syndrome can even progress to rhabdomyolysis, putting the kidneys at risk of permanent damage.

This lesson will discuss compartment syndrome — the risk factors, the mechanisms, and how to treat it.

Download the lesson outline, then enjoy the video!

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Hyperthermia & Heat-Related Illness

Summer is upon us and prehospital providers are likely to see more patients suffering from heat-related illness. The most serious heat-related illness — heat stroke — has a mortality rate of up to 30%, so it’s important that we’re prepared to treat hyperthermic patients.

This lesson will discuss heat stroke — the different types, how to diagnose it, and how to treat it, including some of evidence-based patient cooling strategies.

Download the lesson outline, then enjoy the video!

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Diabetic Ketoacidosis

Did you know that in a span of just 21 years, hospital admissions for diabetic ketoacidosis (DKA) in the United States nearly doubled? As prehospital providers there’s a very good chance that we’re going to have patients who are suffering from DKA. DKA is one of those unique diseases that can be deadly if untreated, but if the patient receives proper care mortality is less than 1%.

Join us in our lesson on DKA, including the basics of cellular energy, what causes DKA, how to diagnose it, and how to treat it.

Download the lesson outline, then enjoy the video!