About Moises Gallegos, MD MPH

Editor, ALiEM
Clinical Assistant Professor of Emergency Medicine
Stanford University School of Medicine

Treating Blood Pressure in Intracranial Hemorrhage

hemorrhagic stroke equal podcast

Blood pressure control in the setting of ischemic stroke has a clearly recognized benefit in patient outcomes. The impact of blood pressure control in hemorrhagic stroke is not as well understood. The ACEP E-QUAL Network podcast, a partnership with ALiEM to promote clinical practice improvements, reviewed this topic with Dr. Latha Ganti (University of Central Florida College of Medicine). Dr. Ganti addressed the evidence behind recommended blood pressure targets and the available medications to achieve control. We present highlights from this discussion with Dr. Jason Woods.

 

What is the goal of blood pressure control in hemorrhagic stroke?

Management of blood pressure in intracranial hemorrhage (ICH) raises questions about the benefit of limiting hematoma expansion while maintaining cerebral perfusion. While it seems intuitive that hypertension should be controlled to limit hematoma expansion, patients with hemorrhagic stroke may be dependent on higher blood pressures for adequate perfusion.

Does lowering blood pressure lead to perihematomal ischemia?

ICH Adapt studies did not show evidence of decreased cerebral blood flow in perihematomal tissue and demonstrated that there is likely preservation of autoregulation which prevents ischemia [1].

Does lowering BP help prevent hematoma expansion and improve outcomes?

The risk of hematoma expansion is highest within the first couple of hours following initial bleeding. Hematoma expansion is clearly associated with worse outcomes. Scoring tools exist to estimate the risk of hematoma expansion. The “spot sign,” seen on source images from a computed tomography angiogram of the brain, suggests an area of dynamic bleeding.

  • ICH ADAPT: no difference in hematoma expansion or clinical outcome with acute blood pressure lowering [2].
  • INTERACT 2: intensive lowering of blood pressure did not result in a significant reduction in mortality or severe disability [3].
  • ATACH 2: intensive lowering of blood pressure did not improve functional outcomes but was associated with increased renal dysfunction [4].

What is the optimal systolic blood pressure (SBP) target?

AHA Guidelines 2015

  • ICH patients with SBP 150-220 mmHg, lower to 14 mmHg is safe
  • ICH patients with SBP > 220 mmHg, aggressive reduction with continuous infusion may be reasonable

So what’s the right thing to do? If data suggests that lowering may not be as beneficial, what should the target blood pressure be?

  • Target SBP 140-160 mmHg is a reasonable target

What medications are preferred for blood pressure control in ICH?

The ideal agent for blood pressure management in ICH would have a quick onset, but short duration, to allow titration.

Recommended first-line:

  • Labetalol
    • Onset < 5 min
    • Duration of effect 2-4 hr
    • IV bolus dose: 20 mg, followed by 20-80 mg every 10 min to a total dose of 300 mg.
    • Infusion dose: 0.5 mg-2 mg/min
    • Avoid in: asthma, COPD, heart failure, AV block
  • Nicardipine
    • Onset 1-2 min
    • Half-life ~ 40 min
    • Infusion dose: 0.5-1 mcg/kg/min, max 3 mcg/kg/min
  • Clevidipine
    • Onset 1-4 min
    • Duration of effect 5-15 min
    • Infusion dose: 1 mg/hr, up to 21 mg/hr, titrate by 2.5 mg/hr every 5-10 min
    • Avoid in: severe aortic stenosis, and lipid metabolism dysfunction or known allergy to eggs or soy (delivered as lipid emulsion)

Available second-line (mostly off-label, not preferred)

  • Esmolol
  • Fenoldopam
  • Hydralazine
  • Enalaprilat

Conclusions

When it comes to blood pressure: keep it simple.

  • Target SBP 140-160 mmHg
  • Top three drugs: Labetalol, Nicardipine, Clevidipine

Although labetalol has common contraindications, it is available as a bolus dose. In a clinical setting where drips may not be readily available, Labetalol can be easier to get.

Interested in more ACEP-EQUAL podcasts?

Listen to the other ACEP E-QUAL podcasts on our Soundcloud account.

References

  1. Butcher K, Jeerakathil T, Emery D, et al. The Intracerebral Haemorrhage Acutely Decreasing Arterial Pressure Trial: ICH ADAPT. Int J Stroke. 2010;5(3):227-233. PMID: 20536619
  2. Butcher KS, Jeerakathil T, Hill M, et al. The Intracerebral Hemorrhage Acutely Decreasing Arterial Pressure Trial. Stroke. 2013;44(3):620-626. PMID: 23391776
  3. Anderson CS, Heeley E, Huang Y, et al. Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage. N Engl J Med. 2013;368(25):2355-2365. PMID: 23713578
  4. Qureshi AI, Palesch YY, Barsan WG, et al. Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage. N Engl J Med. 2016;375(11):1033-1043. PMID: 27276234
By |2020-10-09T09:47:57-07:00Oct 23, 2020|Academic, Emergency Medicine, Neurology|

Anticoagulant Reversal in Hemorrhagic Stroke

anticoagulant equal podcast

Acute management of cerebrovascular accidents can be challenging enough, but questions about anticoagulant reversal in the setting of hemorrhagic stroke add another layer of complexity. The ACEP E-QUAL Network podcast, a partnership with ALiEM to promote clinical practice improvements, reviewed this topic with Dr. Joshua Goldstein (Massachusetts General Hospital, Harvard Medical School). Dr. Goldstein addressed common anticoagulants and their reversal agents, summarizing available literature to inform clinical practice. We present highlights from this discussion with Dr. Jason Woods.

 

What is the goal of anticoagulant reversal?

Since it is impossible to go back in time to prevent intracranial hemorrhage (ICH), the focus of management for hemorrhagic stroke should be to prevent further bleeding and allow brain tissue an opportunity to recover. The goal of anticoagulant reversal in patients with ICH is to decrease ongoing bleeding.

Warfarin

Warfarin is a vitamin K antagonist. Since vitamin K is required for the processing of coagulation factors II, VII, IX, and X, patients on warfarin have decreased amounts of these factors in circulation. To increase the availability of these factors, countering the effect of warfarin therapy can be two-fold:

  1. Replenish vitamin K to allow the production of new factors.
  2. Provide replacement of these factors directly.

Vitamin K supplementation will not provide immediate effect, and it may take up to 24 hours for the production of new coagulation factors. While it should be given early, patients also require factor replacement acutely.

Fresh frozen plasma (FFP) or prothrombin complex concentrate (PCC) can be given to supplement coagulation factors.

  • FFP carries each of the 4 needed factors in addition to other clotting factors.
    • The cost of FFP is low.
    • Transfusion will take some time as it will require ~ 1 L volume.
  • PCC, marketed as Kaycentra in the US, consists of concentrated Factor II, VII, IX, X, and proteins C and S.
    • The cost of PCC is higher.
    • Transfusion is quick, ~70 mL, and leads to rapid correction of INR.

Studies have shown PCC to be associated with faster INR reversal, less ICH expansion, and a non-statistical trend toward decreased mortality [1]. PCC does carry a theoretical risk of thromboembolism given the rapid correction, but no evidence exists to suggest that this is the case.

Direct Oral Anticoagulants (DOACs)

There are 2 categories of DOACs:

  1. Factor II inhibitors (e.g., dabigatran)
  2. Factor Xa inhibitors (e.g., rivaroxaban, apixaban, edoxaban)

Approach to reversal: remove the inhibitor to allow normal function of already existent Factor II or Xa

  • Time
    • Time can be thought of as a reversal agent. Most DOACs have a half-life ~12 hours. If the timing of the last dose is known and it was hours ago, there may not be much medication left to reverse.
  • Monoclonal antibodies
    • Reversal of dabigatran can be achieved with the use of a monoclonal antibody, idarucizumab, to bind up circulating inhibitor.
    • Reversal of Factor Xa inhibitors can similarly be attempted with the use of monoclonal antibody andexanet. Andexanet is notably more expensive than idarucizumab.
  • PCC
    • PCC can be used off-label to outcompete circulating inhibitor with extra coagulation factors and increase the number of functional factors.

It should be noted that there are no reliable tests for measuring DOAC activity.

Dual Antiplatelet Therapy (DAPT)

The most common agents are aspirin and Plavix (clopidogrel). The issue with patients on these antiplatelet agents is not a lack of platelets, but the presence of medication that suppresses normal platelet function. Theoretically, if one could provide extra platelets, the inhibiting agent could be saturated and the remaining platelets provide some functional activity.

The PATCH trial demonstrated, however, that platelet transfusion led to significantly worse outcomes [2]. While there is no readily available reversal agent for DAPT, platelet transfusion should be avoided. In fact, observational data suggest that patients on single antiplatelet therapy don’t fare worse and may not need reversal like those with DAPT [3].

Conclusions

Warfarin reversal

  • IV vitamin K + PCC (or FFP)

Dabigatran reversal

  • Specific agent: Idarucizumab
  • Non-specific agent: PCC

Factor Xa inhibitor reversal

  • Specific agent: Andexanet
  • Non-specific agent: PCC

Antiplatelet reversal

  • No available agent
  • Transfusion of platelets associated with worse outcomes.

Interested in more ACEP-EQUAL podcasts?

Listen to the other ACEP E-QUAL podcasts on our Soundcloud account.

References

  1. Steiner T, Poli S, Griebe M, et al. Fresh frozen plasma versus prothrombin complex concentrate in patients with intracranial haemorrhage related to vitamin K antagonists (INCH): a randomised trial. Lancet Neurol. 2016;15(6):566-573. [PMID: 27302126]
  2. Baharoglu MI, Cordonnier C, Al-Shahi Salman R, et al. Platelet transfusion versus standard care after acute stroke due to spontaneous cerebral haemorrhage associated with antiplatelet therapy (PATCH): a randomised, open-label, phase 3 trial. Lancet. 2016;387(10038):2605-2613. [PMID:27178479]
  3. Khan NI, Siddiqui FM, Goldstein JN, et al. Association Between Previous Use of Antiplatelet Therapy and Intracerebral Hemorrhage Outcomes. Stroke. 2017;48(7):1810-1817. [PMID:28596454]
By |2020-10-09T09:33:43-07:00Oct 16, 2020|Academic, Emergency Medicine, Neurology|

Physician Wellness in the COVID-19 Era | Wellness Think Tank

wellness think tank physician wellnessThe COVID-19 pandemic has changed our world in many ways, and for trainees in medicine, the new day-to-day experience of residency continues to adapt and take shape. COVID-19 has undoubtedly affected clinical experiences and educational curricula for residencies. Personal wellbeing for EM residents has become even more important with the new stressors of being on the frontlines. How has the resident experience changed in the ED? How are residents dealing personally and professionally with the new state of things? What strategies, interventions, and resources that residents are utilizing to combat burnout?

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By |2020-07-28T07:03:27-07:00Jul 31, 2020|Life, Wellness, Wellness Think Tank|

ALiEM Statement Against Racism

ALiEM Statement Against Racism

Illustration by Dr. Moises Gallegos

Academic Life in Emergency Medicine (ALiEM) stands in solidarity with emergency physicians and learners in denouncing the structural racism and acts of violence that disproportionately affect persons of color. ALiEM denounces the senseless death of George Floyd which adds to the ever-rising numbers of deaths among Black men and women. The dissemination of the now-viral video documenting Mr. Floyd’s last desperate moments has brought a renewed public awareness to a disease that has for far too long afflicted this nation. We see the injustice and disparities in healthcare that are made even more visible during the COVID-19 pandemic. ALiEM is committed to taking action against racism and discrimination and joins the American College of Emergency Physicians (ACEP), the Society for Academic Emergency Medicine (SAEM), and the American Academy of Emergency Medicine (AAEM) in urging frontline healthcare providers, educators, and leaders to promote a safe, equitable, and inclusive learning and patient care environment in emergency medicine. We support diversity in free and open access to medical education and uphold efforts to embrace our common humanity.

By |2020-06-01T16:43:29-07:00Jun 2, 2020|Public Health|

Book Club: Forget a Mentor, Find a Sponsor

Forget the Mentor, Find a Sponsor book - sponsorshipOne of the most common themes in advice for career advancement is “find a mentor.” But we are rarely told HOW to find a mentor, WHY we need mentors, or WHAT ROLE mentors are supposed to play in our careers. In addition to the lack of direction regarding mentorship, when you start to research “what is mentorship,” it becomes clear that there are several limitations to the benefits of this popularized mentor-mentee relationship. To see results, the key may be more than mentorship and the answer is likely sponsorship.

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By |2020-01-25T19:22:37-08:00Feb 7, 2020|Book Club, Incubators|

Making Heads or Tails of the Flipped Classroom: Tips and Tricks for Students

Now more than ever, medical educators are excited about the flipped classroom, defined by Bishop and Verleger as “a new pedagogical method, which employs asynchronous video lectures and practice problems as homework, and active, group-based problem-solving activities in the classroom” [1]. The premise is that students will learn basic concepts during self-study, at their own pace, and come to the classroom ready to dive into small groups and problem-based application [2].

This approach may be unfamiliar and you may find yourself asking: 

  1. Why should I care? 
    and
  2. How do I get the most out of it?

Let’s begin with the first question. Several studies looking at the flipped classroom conclude it is good for your learning. Though it may initially be perceived as extra work, once the student realizes that the work just replaces the after-class homework they used to do, students’ report a generally high satisfaction, and high engagement with the in-class activity [3-6]. The flipped classroom can make you a more effective “lifelong learner.” While assessing learning efficacy is challenging, some studies have shown improvements in analytical and problem-solving skills in students who come prepared and fully engage in the in-class activities [3,7]. 

As for the second question, to ensure that you get the best flipped classroom experience, we compiled a list of must-do steps to engage with this educational strategy successfully.

Tips and Tricks:

Prepare (yes, really)

The proverbial wisdom that “by failing to prepare, you are preparing to fail” holds true with this pedagogy. Don’t walk through the door if you haven’t done the prep work. Assigned videos and podcasts are not just “suggestions,” but rather the building blocks for your in-class time. The point of the flipped classroom is for you to do the “easy stuff” at home and the harder, application-type activities, with your educator present. It’s essential that you complete them prior to class. Think of it as doing the classwork at home, and the homework in class! By reviewing material ahead of time you will be ready to ask clarifying questions and grasp higher-level concepts, in order to make the best use of your teacher’s direct attention.

Don’t skip ahead (or you’ll end up behind)

With access to the learning material online, you may be tempted to “skip ahead” to answers. However, the course will often build on itself and part of the learning process will be to work through application problems with only the information you have at the moment. Future sessions may allow a second-look with a new lens, so staying true to the current schedule is best. Similarly, allowing yourself to fall behind and expecting to catch up later will put you at a disadvantage during the in-person sessions.

Commitment (like any good relationship)

In order to bring a complex topic to a class, there are often multiple moving parts for a flipped classroom activity. If you’re set up in a team, designate 1-2 classmates to hold the rest of your team accountable for the work that you need to get done and the deadlines that you need to complete. Rotating responsibilities part of the way through the course will allow every member to experience different roles. If you’re not working in a team, find an accountability buddy and commit to keeping each other on task and on schedule, so that you can come to your in-class sessions as prepared as you can be.

Feedback (talk to me!) 

Let’s face it, you’ve spent a lot of time searching for useful learning resources and have probably found some gems. Instructors may not have known about a great new video or podcast when the material was compiled. Let them know what you’ve found and why you think that it’s a helpful resource for your classmates. Sometimes what you’ve found will help make the next class better, or can be added as supplemental material. Remember that you appreciate high-quality feedback and your instructors aren’t much different. 

How do you get to Carnegie Hall? (Answer: practice, practice, practice) 

It may be the case that concepts being discussed during a flipped classroom setting seem far removed from clinical practice, especially in the pre-clinical years when you are fully immersed in the basic sciences. The key is practice. In the flipped classroom, the skills acquired through dedicated medical topics, learning how to navigate the vast amount of resources available, working as a team, and dissecting problem-solving challenges will help you in the clinical setting. Be intentional about the skillset you’ve acquired and apply it to past/present/future patients. 

For example, if you learned about risk stratification tools for chest pain during a class, the next time you encounter a virtual case, a standardized patient, or a real patient with chest pain you’ll know if you can apply the TIMI/HEART/Well’s/PERC scores and how to access them online. After calculating the score, you will be able to convey to your attending, admitting team, and consultants your clinical decision-making and application of evidence-based medicine. Bringing your knowledge to the bedside helps solidify the classroom learning and connect it to real live patients which will help you grow as a clinician. 

Want to learn more about the pedagogy of the flipped classroom?  And here’s a great example of curated resources for an emergency medicine intern level flipped classroom by @EMFundamentals.

What do you think? Are there other ways that you as a student have made flipped classroom successful for you? Leave us a comment below or @ALiEMFac on Twitter to let us know! 

Blog post edited and curated by:

Mark Ramzy, DO
Faculty Incubator Multimedia and Communications Editor

References

  1. Bishop, J., & Verleger, M. A. (2013). The Flipped Classroom: A Survey of the Research. In 2013 ASEE Annual Conference & Exposition. Atlanta, Georgia. 
  2. Huu Anh Vuong, Nguyen et al. Students’ Perceived Challenges of Attending a Flipped EFL Classroom in Viet Nam. Theory and Practice in Language Studies. 2018.
  3. Sait MS,et al. Advances in medical education and practice: student perceptions of the flipped classroom. Adv Med Educ Pract. Published May 2017; PMID: 28496377
  4. Young TP, et al. The Flipped Classroom: A Modality for Mixed Asynchronous and Synchronous Learning in a Residency Program. West J Emerg Med. 2014. PMID: 25493157
  5. King AM, et al. Flipping the Classroom in Graduate Medical Education: A Systematic Review. J Grad Med Educ. Feb 2019; PMID: 30805092 
  6. Smallhorn, M. The flipped classroom: A learning model to increase student engagement not academic achievement. Student Success, 2017.
  7. White PJ, et al. Student Engagement with a Flipped Classroom Teaching Design Affects Pharmacology Examination Performance in a Manner Dependent on Question Type. Am J Pharm Educ. 2017; PMID: 29302082

By |2019-11-29T18:31:31-08:00Nov 29, 2019|Academic, Incubators, Medical Education|

SAEM Clinical Image Series: Dysphagia and Dyspnea in a Well Digger

progressive pulmonary fibrosis causing dysphagia and dyspnea

[Click for larger view]

Chief Complaint: Pain with swallowing

History of Present Illness: A 43-year-old male presented to the emergency department with progressing pain upon swallowing. He described a sensation of food becoming stuck and creating a fullness in his chest. Review of symptoms was positive for dyspnea on exertion worsening over several months, but negative for cough, fevers, or weight change. He reported no medical history and had recently emigrated from Guatemala where he worked as a well digger.
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By |2019-07-28T21:32:47-07:00Jun 17, 2019|Pulmonary, SAEM Clinical Images|
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