Dual antiplatelet therapy (DAPT) improves outcomes in patients with high-risk TIA or minor ischemic stroke

In patients with minor ischemic stroke or high-risk TIA, those who received a combination of clopidogrel and aspirin had a lower risk of major ischemic events but a higher risk of major haemorrhage at 90 days than those who received aspirin alone. However, the relative reduction in recurrent stroke occurred almost entirely during the first week, whereas bleeding events (most of which were not intracranial) were distributed fairly evenly throughout 90-day follow-up. Thus, it appears that one can maximize benefit and minimize harm by confining DAPT to just a few weeks 

Oxygen therapy for acutely ill medical patients: a clinical practice guideline

What you need to know

  • It is a longstanding cultural norm to provide supplemental oxygen to sick patients regardless of their blood oxygen saturation
  • A recent systematic review and meta-analysis has shown that too much supplemental oxygen increases mortality for medical patients in the hospital
  • For patients receiving oxygen therapy, aim for peripheral capillary oxygen saturation (SpO2) of ≤ 96% (strong recommendation)
  • For patients with acute myocardial infarction or stroke, do not initiate oxygen therapy in patients with SpO2 ≥ 90% (for ≥ 93% strong recommendation, for 90-92% weak recommendation)
  • A target SpO2 range of 90-94% seems reasonable for most patients and 88-92% for patients at risk of hypercapnic respiratory failure; use the minimum amount of oxygen necessary

Dizziness…the good and the ugly…

The differential diagnosis of vertigo can be broken into peripheral and central causes. It is imperative the Emergency Physician consider central causes of vertigo.

 

Signs/ Symptoms Differentiating Peripheral and Central Vertigo

Peripheral Central
Onset Sudden or Insidious Sudden
Severity of Vertigo Intense Spinning Ill-defined, may be severe or less intense
Prodromal Dizziness Occurs in up to 25%, often single episode Occurs in up to 25%, recurrent episodes suggest TIA’s
Intolerant of head movements/Dix-Hallpike Maneuver Yes Varies, but often intolerant
Associated Nausea/Diaphoresis Frequent Variable, but often frequent
Auditory Symptoms Points to peripheral causes May be present
Proportionality of Symptoms Usually proportional Often disproportionate
Headache/Neck Pain Unusual More likely
CNS signs/symptoms Absent Usually present
Head Impulse Test Abnormal Often normal
Nystagmus Horizontal Vertical/direction-changing
HINTS Testing Negative Abnormal in at least 1 out of 3 tests

TIA (Transient Ischaemic Attack)

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  • TIA is defined as a brief episode of neurologic dysfunction with no permanent infarction.
  • Head CT noncontrast is not reliable for acute ischemia, but it can find alternative conditions necessitating management. MRI with DWI displays greater diagnostic ability.
  • Risk scores that predict future stroke are not reliable when used alone.
  • Patients are typically admitted for inpatient management due to this risk of future stroke.

 

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Acute Visual Loss in the ED

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  1. History including specific eye involvement, sudden vs. chronic loss, pain, redness and discharge, trauma, other symptoms, and medication use are vital.
  2. Physicians should be comfortable completing an appropriate history and physical examination including general inspection, visual acuity, pupils, EOMs, visual fields, fluorescein, lids, IOP, slit lamp, and US.
  3. Emergent consultation is required for acute angle closure glaucoma, retinal detachment, CRAO, open globe, endophthalmitis, chemical burn, infectious keratitis, and giant cell arteritis.
  4. Urgent referral is needed for uveitis, vitreous hemorrhage, acute maculopathy, CRVO, and optic neuritis.
  5. Keep in mind other etiologies of vision loss including ischemia, stroke, toxin, infection, and functional.

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TIA

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Cornerstones of treatment for TIA revolve around reducing the risk of future events with blood pressure control, lipid control, and antiplatelet agents. Blood pressure should be maintained at 140/90 with a thiazide diuretic and/or an ACE inhibitor. Statins should be given to keep LDL of under 100mg/dL or 70mg/dL in high risk patients. Niacin or gemfibrozil are recommended to maintain HDL above 40mg/dL. Antiplatelet agents include aspirin with or without dipyridamole, or clopidogrel alone.

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