Dx of Meningitis - CT before LP

25M college student p/w worst headache of his life, fevers, chills, painful & stiff neck. PMH epilepsy. Off meds. Hasn't had a seizure in 10 years. No other significant past medical. Tachy, febrile, tachypnic, normal O2 sat. Positive nuchal rigidity on exam. Oriented, follows commands, no motor or gaze palsy. WBCs 14. Does he need a head CT before LP?

Click here for a JAMA Rational Clinical Exam piece on bedside dx of acute meningitis (can you trust Kernig and Brudzinski?), the study that established the CT before LP rules, and some useful cards from ALiEM's PV series to enhance your bedside recall of these rules.

tPA for the Management of Acute Ischemic Stroke - FreeOAM vs. {industry funded} Guidelines

In noon conference today, the presenting resident reviewed the AHA/ASA March 2013 guidelines on management of acute ischemic stroke. It was a good overview of the guidelines, but there wasn't a lot of room for debate on the evidence for and against tPA in this scenario. Luckily I've been privy to the tPA in acute stroke debate in the #FOAMed community.

Mini FOAMed Lit Review on the use of tPA for the management of acute ischemic stroke:

1. Emergency Med Lit of Note were out of the gate quick early this year to question the integrity of the ACEP guidelines on this topic.
2. theNNT convinced me with their thorough evidence based review. Their "red light" made it clear to me what the answer is on this topic. 
3. Recently LiTFL posted a two part series on this topic by Michelle Johnston. She left the final decision on the validity of tPA use for this indication to the reader, but her analysis is thorough and presents a strong case to exercise caution when considering tPA. 
4. Just this morning ALiEM's Todd Seigel posted a review focused primarily on the NINDS study, AHA, & ACEP guidelines. His post stands in contrast to the other FOAM contributions to this debate, and Graham Walker of theNNT & MDCalc was quick to point out this contrast. 

But can FOAMed stand up to 3 major organizations (AHA, ASA & ACEP) all arguing strongly for use of tPA in select patient groups?

Thankfully, there's at least one organization that has stood strong & reasonable. The AAEM have put out statements, commentaries, educational material, & letters all asking for an injection of evidence-based, calmly considered, carefully weighed thought, skepticism, debate, and further investigation on this topic. 

Despite some guidelines, it can at least be said, tPA for the management of acute ischemic stroke is not the standard of care.

Headache & Weakness

Case (What's the diagnosis, how do you know, and what is your management strategy?):

A 25-year-old female presented to the emergency department complaining of flashing lights in her right eye that started one hour earlier while watching a home movie. The patient reported that while trying to read, she was unable to discern the words but could understand words spoken to her. She also felt disoriented and thought that she was slurring her words. Following the onset of numbness in her lips, she noted weakness in her right leg. A bilateral parietal headache occurred shortly after the symptoms began. She denied any history of headaches and had no other medical problems. She was not pregnant and was not taking any medications. She denied use of illicit drugs or alcohol. Her family medical history was negative for migraine headaches. She was afebrile, with blood pressure 152/76, heart rate 96, respiratory rate 24, and oxygen saturation 100%. On physical examination, she had ptosis of her right eye and decreased sensation around the right side of her mouth. A right homonymous hemianopsia was present. Her right lower extremity muscle strength was 4/5 compared to 5/5 on left lower extremity. She ambulated well but had difficulty turning around to return to bed, stating she felt disoriented. Her headache was persistent during the examination but she had no photophobia. Complete blood count and electrolytes were within normal limits. Her urine drug screen was negative. There were no acute findings on head CT without contrast. Within 2 hours, her symptoms and headache completely resolved. In a young female with no prior medical history, what could this be?


Click here for the source of this case, the answers to the case, and a good review on management of this illness.

Improving Outcomes in Acute Stroke

Two articles on management strategies in Acute Stroke and their affect on outcomes:

Processes in Acute Stroke, JAMA, 2010
Mannitol in Acute Stroke, Cochrane, 2009

After reading, should be able to answer the following questions:

What processes of care improve outcomes in acute stroke? (3)
Is mannitol indicated in the treatment of brain edema in the setting of acute stroke?


Bonus:

Read this:

Preventing VTE in Stroke, 2005

What may be the number one cause of mortality in the acute period post-stroke?


Answers