On the Horizon: Propofol for Migraines

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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By Zlatan Coralic, PharmD|2016-11-11T18:37:24-08:00May 25, 2013|Neurology, Tox & Medications|

PV Card: Contraindications to Thrombolytics in Stroke

This Paucis Verbis (PV) card is an updated version of the PV card on Contraindications to Thrombolytics for CVA from September 10, 2010, based on the Stroke 2013 AHA/ASA new guidelines that were just published.¹ Some changes include…

There is new mention of new anticoagulants in the market with additional absolute exclusion criteria.
A blood glucose < 50 mg/dL has been upgraded from a relative exclusion to an absolute exclusion criteria. There is no more mention of glucose > 400 mg/dL as an exclusion criteria.
Seizure at onset of presentation has moved from an absolute to a relative risk.
Post-AMI pericarditis is no longer a relative exclusion criteria.

PV Card: Contraindications for Thrombolytics in Stroke

Adapted from [1]
Go to ALiEM (PV) Cards for more resources.

Reference

Jauch E, Saver J, Adams H, et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013;44(3):870-947. [PubMed]

By Michelle Lin, MD|2021-10-06T19:58:38-07:00May 23, 2013|ALiEM Cards, Neurology, Tox & Medications|

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

A 57-year-old male (75 kg) 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 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?

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By Bryan D. Hayes, PharmD, DABAT, FAACT, FASHP|2020-02-16T14:45:12-08:00Apr 16, 2013|Neurology, Tox & Medications, Tricks of the Trade|

PV card: Bell’s Palsy Treatment

Bell’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.

“Because of the possibility of a modest increase in recovery, patients might be offered antivirals (in addition to steroids) (Level C). Patients offered antivirals should be counseled that a benefit from antivirals has not been established, and, if there is a benefit, it is likely that it is modest at best”²
UpToDate: “For the subgroup of patients with severe facial palsy at presentation, defined as House-Brackmann grade IV or higher, we suggest early combined therapy with prednisone (60 to 80 mg per day) plus valacyclovir (1000 mg three times daily) for one week rather than glucocorticoids alone (Grade 2B).”
“The authors conclude that although a strong recommendation for adding antiviral agents to corticosteroids to further improve the recovery of patients with severe Bell palsy is precluded by the lack of robust evidence, it should be discussed with the patient.”³
“Antiviral agents, when administered with corticosteroids, may be associated with additional benefit.”⁴

PV Card: Treatment of Bell’s Palsy

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Adapted from [1, 2, 4]
Go to ALiEM (PV) Cards for more resources.

Thanks to Dr. Kristin Berona (UCSF-SFGH EM resident) for the idea and notes!

References

Lockhart P, Daly F, Pitkethly M, Comerford N, Sullivan F. Antiviral treatment for Bell’s palsy (idiopathic facial paralysis). Cochrane Database Syst Rev. 2009;(4):CD001869. [PubMed]
Gronseth G, Paduga R, American A. Evidence-based guideline update: steroids and antivirals for Bell palsy: report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology. 2012;79(22):2209-2213. [PubMed]
van der, Rovers M, de R, van der. A small effect of adding antiviral agents in treating patients with severe Bell palsy. Otolaryngol Head Neck Surg. 2012;146(3):353-357. [PubMed]
de A, Al K, Guyatt G, et al. Combined corticosteroid and antiviral treatment for Bell palsy: a systematic review and meta-analysis. JAMA. 2009;302(9):985-993. [PubMed]

By Michelle Lin, MD|2021-10-08T09:23:49-07:00Feb 21, 2013|ALiEM Cards, Neurology|

P-video: How to remember the GCS scoring

In this inaugural P-video, Dr. Jeremy Faust gives us a quick way to remember how keep the maximum subscores of the Glasgow Coma Scale (GCS) straight. There’s verbal, motor, and eyes. Which has a max score of 4, 5, and 6?

By Jeremy Faust, MD|2016-10-26T17:05:06-07:00Jan 2, 2013|Neurology, P-videos|

Bottom 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.

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By Michelle Lin, MD|2016-11-11T18:42:23-08:00Jan 1, 2013|Neurology, Radiology|

Bottom 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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By Michelle Lin, MD|2016-11-11T18:42:29-08:00Jan 1, 2013|Neurology|

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