All the amazing RACC literature for September 2023
Search Results for: TXA
EM Nerd-The Case of the Missing Comparator
Since the publication of NINDS, a large number of registry based observational studies have been used for the weaponization of tPA in the clinical setting. Initially utilized to justify the use of tPA outside the controlled setting of a clinical trial, and later used to support the profitable indication creep we have observed in the […]
EMCrit – RACC Lit Update 2021-12-22
All the Resus and Acute Crit Care Goodness in 10 minutes
The Man with the Twisted Lip
As an Emergency Medicine doctor we are trained to function in varying degrees of uncertainty. We work in a world of risk of benefits vs harms. When the benefit to harm ratio reaches a threshold for action we are taught to do so swiftly and decisively. Given this, […]
PulmCrit- Should we monitor fibrinogen during full- & half-dose PE thrombolysis?
No high-quality evidence exists on fibrinogen monitoring in PE. Most practitioners don’t check fibrinogen levels for patients getting TPA for PE. This is a bit paradoxical, because fibrinogen is usually monitored in patients receiving catheter-directed thrombolysis – a procedure involving lower doses of TPA with a markedly lower risk of intracranial hemorrhage.
PulmCrit – Heparin resistance in COVID & implications for DVT prophylaxis
background: what is heparin resistance? Heparin works by binding to antithrombin III and thereby activating antithrombin III, an endogenous anticoagulant which inhibits clotting factors (especially Xa). Heparin + Anti-thrombin III → [Heparin-Antithrombin-III complex] → Inhibition of Xa activity Heparin resistance refers to situations where unusually large doses of heparin are required to achieve anticoagulation. This […]
NeuroEMCrit – Time is Brain – Acute Ischemic Stroke Part I: Vascular Syndromes and Thrombolysis
All things Ischemic Stroke – Part 1
The Case of the Non-inferior Inferiority Continues
Low-Dose tPA
EM Nerd-Behind the Veil of Science
On March 26th 2018, the New York Times published an article by Gina Kolata, For Many Strokes, There’s an Effective Treatment. Why Aren’t Some Doctors Offering It?, examining the efficacy of tPA in acute ischemic stroke. The article was dismissive and misleading. In response, I sent a letter to the editor which I fear […]
Thrombotic microangiopathies (including TTP, ST-HUS, and C-HUS)
CONTENTS Thrombotic Microangiopathy(TMA) Definition of TMA Causes of TMA Investigating the cause of TMA Initial empiric therapy for TMA Thrombotic thrombocytopenic purpura (TTP) Epidemiology of acquired TTP Clinical presentation of TTP Initial treatment of acquired TTP Shiga-Toxin mediated Hemolytic Uremic Syndrome (ST-HUS) Epidemiology & presentation of ST-HUS Diagnosis of ST-HUS Treatment of ST-HUS Complement-mediated Hemolytic […]
A Secondary Examination of The Adventure of the Cardboard Box
In November of 1995 stroke care as we know it drastically and permanently changed. With the publication of NINDS-2 the NEJM ushered in the interventional era of acute ischemic stroke (1). No longer were we powerless in our management of these patients. Finally we could offer them more than an aspirin to chew on, a […]
The Case of the Magician’s Sleight
Since the earliest trials examining the efficacy of tPA for acute ischemic stroke there has been a tendency to play it fast and loose with the scientific method. The results of the landmark NINDS-2 trial (1), a moderate sized RCT, with a tenuously positive primary outcome (Fragility Index of 3), were never validated. The results […]
PulmCrit: What is the fragility index of the NINDS trial?
Medicine continues to be plagued by poorly reproducible studies. The storyline is familiar. First, a very positive study is released in a major medical journal, with great fanfare. This leads to widespread changes in practice. Decades later, it becomes clear that the study was incorrect. Recently a new tool was developed to help understand the reproducibility of clinical studies: the fragility index. This post will analyze the NINDS trial from the perspective of its fragility index.
EMCrit 218 – Physostigmine with Bryan Hayes
Physostigmine for Anticholinergic toxicity
EMCrit Wee – MOPETT Trial
A new trial on half-dose thrombolysis for PE for sub-massive PE
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