Afleveringen
-
Date: October 3, 2025
Reference: Doheim et al. Meta-Analysis of Randomized Controlled Trials on IV Thrombolysis in Patients With Minor Acute Ischemic Stroke. Neurology 2025
Guest Skeptic: Dr. Casey Parker is a Rural Generalist, Evidence-based medicine enthusiast and Ultrasound Nerd.
This episode was recorded live, in beautiful Broome, Australia, at the Spring Seminar on Emergency Medicine (SSEM 2025). You can get copies of the slides used in the presentation at this LINK. You can also watch the episode on YouTube.
Case: Dani is a recently retired emergency department (ED) doc who has spent the last year travelling the world, playing banjo & sharing time with family and friends. This morning, whilst eating a breakfast of eggs and ham, Dani had a sudden onset of right-hand weakness and difficulty speaking. Dani’s family called 000 (911 in North America), and she was taken to the ED within one hour. On arrival at your medium-sized rural ED, Dani is assessed by the “Stroke Team aka, you” as having mild motor weakness in the right hand and mild dysarthria. Dani is given an NIHSS score of 4. A rapid CT and CTA is quickly reported as “no acute large vessel occlusion” and “No intracranial bleed and no established cortical infarction”. You know that many centers in the city are offering intravenous tPA for patients with acute ischemic stroke. You wonder if Dani should get a dose?
Background: Minor ischemic strokes (MIS), often defined by NIHSS ≤5, are very common, with roughly half of all ischemic strokes presenting with mild deficits. Despite the mild presentation, these strokes are not always benign. About 30% of patients with initially minor stroke symptoms end up significantly disabled (unable to walk independently) at 90 days [1]. In short, a small stroke can still have a big impact on a patient’s life if it isn’t effectively treated or if it progresses.
Dr. Daniel Fatovich
There have been gallons of ink spilled in the discussion of the stroke literature, with much debate on previous SGEM episodes about the relative risks and benefits of IV thrombolytic therapy for acute strokes. Drs. Ken Milne and Danny Fatovich have earned themselves the title of “non-expert EM contrarians” when discussing the literature around acute ischemic stroke management with Neurologists all over the world.
IV thrombolysis (tissue plasminogen activator [tPA], or newer Tenecteplase [TNK]) is a well-established therapy for acute ischemic stroke based on some questionable evidence [2-6]. However, its role in mild strokes has been hotly debated. On one hand, treating early might prevent a minor stroke from evolving or causing hidden disability. On the other hand, tPA carries a risk of intracerebral hemorrhage, and many minor stroke patients recover well without aggressive intervention. Guidelines have wrestled with this nuance: current recommendations endorse tPA for mild strokes that have clearly disabling deficits, but advise against tPA for mild non-disabling strokes [7]. The core controversy is whether the potential functional benefit in MIS is worth the bleeding risk if the patient is already doing okay.
Things changed 10 years ago after Mr. CLEAN was published. It showed that endovascular interventions (EVT) for acute large vessel occlusions (LVOs) could have impressive results (NNT of 7). However, the role of IV thrombolytics for minor stroke syndromes remains unclear and controversial. Legendary (now-retired) ED Dr. Joe Lex once stated, “If I can kick the syringe outta’ your hand – then don’t give me the tPA!” Was Joe right?
Before 2019, practice varied widely. Some neurologists treated almost any stroke within the window, reasoning that “time is brain” even for mild deficits, while others were more conservative. Observational studies yielded mixed signals. Several studies suggested that thrombolysis in mild strokes improves the chance of an excellent outcome at discharge or 90 days, while others showed minimal benefit. -
Date: October 26, 2023
Reference: Jones et al. Opioid analgesia for acute low back pain and neck pain (the OPAL trial): a randomised placebo-controlled trial placebo-controlled trial. Lancet July 2023
Guest Skeptic: Dr. Sergey Motov is an Emergency Physician in the Department of Emergency Medicine, Maimonides Medical Center in New York City. He is also one of the world’s leading researchers on pain management in the emergency department, specifically the use of ketamine. His twitter handle is @PainFreeED.
Case: A 37-year-old man without a significant past medical history presents to the emergency department (ED) with a chief complaint of lower back pain that started three days prior to the ED visit after unloading a truck with furniture. He states that pain is severe (7/10 in intensity), sharp, constant, non-radiating, and is exacerbated by any movement. The patient is unable to go to work due to pain and is experiencing severe limitations in his daily activities. He denies any weakness or numbness of the lower extremities or bowel or bladder dysfunction. You perform a physical examination and note prominent tenderness to palpation at bilateral lumbar paraspinal regions with normal neuro-vascular examination. You engage the patient in shared decision making about his most likely diagnosis (muscle strain) and treatment approach such as a short course of non-steroidal anti-inflammatory drugs (Ibuprofen) and gradual physical activity as tolerated. The patient, however, believes that ibuprofen will not touch his pain and insists on receiving an opioid-containing medication.
Background: Low back pain and neck pain are extremely common conditions worldwide [1]. We have covered the issue of back pain several times on the SGEM including:
SGEM#87:Let Your Back Bone Slide (Paracetamol for Low-Back Pain)
SGEM#173: Diazepam Won’t Get Back Pain Down
SGEM#240: I Can’t Get No Satisfaction for My Chronic Non-Cancer Pain
SGEM#304: Treating Acute Low Back Pain – It’s Tricky, Tricky, Tricky
SGEM#366: Relax, Don’t Do It – Skeletal Muscle Relaxants for Low Back Pain
Back pain and neck pain are leading causes of disability on a global scale [2,3]. The substantial disability burden imposes enormous costs both directly on healthcare systems, and indirectly through productivity losses [4,5].
Not only are these conditions common and painful they are difficult to treat. Many pharmacologic treatments have been tried with limited efficacy.
Acetaminophen (Williams et al Lancet 2014)
Muscle relaxants (Friedman et al JAMA 2015)
NSAIDs (Machado et al Ann Rheum Dis 2017)
Steroids (Balakrishnamoorthy et al Emerg Med J 2014)
Benzodiazepines (Friedman et al Ann Emerg Med 2017)
Many non-pharmacologic therapies have also been tried with limited efficacy.
Cognitive Behavioral Therapy and mindfulness (Cherkin et al JAMA 2016)
Chiropractic (Paige et al JAMA 2017)
Physical therapy (Paolucci et al J Pain Research 2018)
Acupuncture (Colquhoun and Novella Anesthesia and Analgesia 2013)
One treatment modality, opioids, can be effective but comes with very real potential harms. The American College Physicians (ACP) has a 2017 policy on guidelines for treating non-radicular low back pain (Qaseem et al Annals of Int Med). Their third recommendations states:
Clinicians should only consider opioids as an option in patients who have failed the aforementioned treatments and only if the potential benefits outweigh the risks for individual patients and after a discussion of known risks and realistic benefits with patients. (Grade: weak recommendation, moderate-quality evidence)
The American College of Emergency Physicians (ACEP) has addressed the issue of opioid use in patients being discharged home after an acute episode of pain. They give a Level C Recommendations saying:
Do not routinely prescribe, or knowingly cause to be co-prescribed, a simultaneous course of opioids and benzodiazepi... -
Zijn er afleveringen die ontbreken?
