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25 05, 2013

On the Horizon: Propofol for Migraines

2016-11-11T18:37:24+00:00

propofol

Propofol for the treatment of migraines in the ED might be on the horizon. This will possibly be a new practice in emergency medicine, although it has been known for some time. Propofol, when given at procedural sedation doses, seems to miraculously terminate migraines refractory to usual treatment. Patients awake with minimal to no headache and may be discharged from the ED much quicker than traditional treatment with possibly less side effects. The proposed mechanism of action is described in below papers, but in short,  propofol seems to “reboot” the brain and terminate the migraine.

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16 04, 2013

Trick of the Trade: Rapid Oral Phenytoin Loading in the ED

A 57 y/o, 75 kg male presents to the ED after a witnessed seizure. He describes a history of seizure disorder and is prescribed phenytoin, but recently ran out. A level is sent and, not surprisingly, results as < 3 mcg/mL (negative). After a complete ED workup, the decision is made to ‘load’ him with phenytoin 1 gm and discharge him with a prescription to resume phenytoin. An IV was not placed.

Can you rapidly load him orally?

21 02, 2013

PV card: Bell’s Palsy Treatment

2019-02-19T18:20:53+00:00

Bells PalsyBell’s Palsy is an idiopathic unilateral facial nerve paralysis.

Since the 2009 Cochrane review1 showing that antivirals added no benefit to corticosteroids in Bell’s Palsy, I stopped prescribing them. The NNT.com site has concluded the same. Looking at the literature a little more, the recommendations are a little murkier. Some groups are still advocating for antivirals for severe cases, because there may be a very small but questionably positive benefit.

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1 01, 2013

MIA 2012: Backes D, et al. Time-dependent test characteristics of head computed tomography in patients suspected of nontraumatic subarachnoid hemorrhage. Stroke. 2012 Aug;43(8):2115-9

2016-11-11T18:42:23+00:00

ich_mca_berry_aneurysmBottom Line 1

  • 100% sensitive and specific if < 6 hours from headache onset
  •  90% sensitive if after 6 hours

A noncontrast head CT can effectively rule out atraumatic subarachnoid hemorrhage (aSAH) in patients who present with acute headache within six hours after ictus. Those who present outside this time window or present atypically for SAH (ie neck pain) require further workup, including a lumbar puncture.

1 01, 2013

MIA 2012: IST-3 collaborative group et al. The benefits and harms of intravenous thrombolysis with recombinant tissue plasminogen activator within 6 h of acute ischaemic stroke (the third international stroke trial [IST-3]): a randomised controlled trial. Lancet. 2012 Jun 23;379(9834):2352-63.

2016-11-11T18:42:29+00:00

Screen Shot 2013-06-01 at 7.22.47 AMBottom Line 1

Giving tPA to stroke patients within 6 hrs of symptom onset does not improve mortality or independence at 6 months.  However, patients might be a little “less disabled” while they are alive. Maybe.

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