@IM_Crit_

#foamed #foamcc #meded #Medsky #emimcc

When managing patients with ischemic #stroke, can we please adopt a single BP target? Currently, BP should be <185/110 mmHg prior to thrombolysis & <180/105 after, which feels unnecessarily complicated. Wouldn't it be simpler to use one target, such as <180/100 mmHg, for both?

Updated the acute ischemic stroke chapter based on 2026 ASA/AHA guidelines

Chapter focuses on supportive care (*not* who gets lysis/EVT)

This has not changed very much

Top blue numbered section is designed to be used as a checklist when you settle these pts into ICU

emcrit.org/ibcc/ais/ #EMIMCC

Efficacy and safety of minocycline in patients with acute ischaemic stroke (EMPHASIS): a multicentre, double-blind, randomised controlled trial Minocycline therapy initiated within 72 h of acute ischaemic stroke provided a significant functional outcome benefit compared with placebo at 90 days, without safety concerns. Future studies are need...

#Minocycline therapy initiated within 72 h of acute ischemic #stroke provided a significant functional outcome benefit compared with placebo at 90 days

#foamed #foamcc #meded #Medsky #emimcc

@pulmcrit.bsky.social has to update the chapter!

www.thelancet.com/journals/lan...

Preventing these closures would cost around $6 billion annually, 0.1% of total national healthcare spending, the report states

#medsky

309 hospitals are at immediate closure risk due to the severity of their financial challenges. In 10 states, 50% or more of rural hospitals are at risk. Facilities with the greatest risk of closure have exhausted financial reserves and carry more debt than assets

Not good:

734 rural hospitals across the US, which represent one-third of all rural facilities nationwide, are at risk of closing due to severe financial problems, according to the Center for Healthcare Quality and Payment Reform’s most recent analysis

www.beckershospitalreview.com/finance/734-...

#foamed #foamcc #meded #Medsky #emimcc #stroke

Key points for TNK administration:

Do not exceed 25 mg

Initiate treatment as soon as possible after symptom onset

Follow institutional stroke protocols and imaging requirements prior to administration

TNK is administered in a weight-based fashion:

TNK offers several practical and clinical advantages:

Single 5-sec iv bolus (no infusion pump required)
Reduced medication preparation time
Lower risk of dosing and infusion errors
Rapid door-to-needle times
Particularly useful in drip-and-ship and resource-limited settings

TNK is a genetically modified tissue plasminogen activator (tPA) with:

Greater fibrin specificity
Longer plasma t1/2
Resistance to plasminogen activator inhibitor-1

These properties allow TNK to be administered as a single iv bolus, unlike tPA, which requires bolus + infusion

AIS is a medical emergency in which rapid restoration of cerebral blood flow is critical to limit irreversible neuronal injury ("time is brain"). Intravenous thrombolysis remains a cornerstone of treatment for eligible patients presenting early after symptom onset

The (2026) Guidelines for the Early Management of Patients With Acute Ischemic Stroke (AIS) were just published

When managing a patient with AIS, what do you use for thrombolysis?

Alteplase (tPA)

Tenecteplase (TNK)

The new 2026 AHA/ASA stroke guidelines include this table 👇 for the management of thrombolytic-induced angioedema.

There is NO discussion or any additional text about this topic.

I find this to be insufficient, not evidence-based, and potentially confusing... #1/2 #EMIMCC

ICU Secrets:

Although tachypnea is a concerning clinical finding, it is important to note that respiratory rate alone does not reliably reflect the degree of respiratory effort

#foamed #foamcc #meded #medsky #emimcc

Kudos to the authors!

#foamed #foamcc #meded #Medsky #idsky #emimcc

Good to remember that CAP is associated with:
1. ⬆️ short- & long-term risk of cardiovascular disease (myocardial infarction, stroke, or fatal coronary disease) in the first 30 d & up to 1 y
2. other long-term adverse health outcomes such as cognitive impairment & functional decline

The review states: "there is conflicting evidence on the mortality benefit of glucocorticoid treatment in patients with CAP admitted to the ICU"
My bias: I put more faith on the CAPECOD study than the REMAP-CAP; a CAP patient sick enough to get an ICU bed will also get steroids (no questions asked)!

I fact-checked the claim 👆 that "beta-lactam or beta-lactamase inhibitors may be better than cephalosporins in the ICU setting". I didn't see evidence for that in the referenced (#43) meta-analysis (which focused on "outpatient pneumonia")

Regarding the antibiotic management, there is emphasis on the use of macrolides, especially for severe CAP (not just for CAP due to atypical bugs...)

There are many different tests for determining etiology in CAP patients

It's worth remembering that urine Streptococcus & Legionella antigen tests are only ~75% sensitive... I see this often...

Also: a negative COVID or influenza test is not 100% trustworthy!

Caution: chest radiography (CXR) can miss a lot of lung consolidations detected by chest CT and lung US

An etiologic agent is not identified in >50% of CAP cases. Streptococcus pneumoniae is the most common bacterial pathogen. A respiratory virus is identified in 30-40% of cases. In 6-10% of CAP cases with identified etiology, both a bacterium & a virus are detected

And age of course!

In a prospective population-based cohort study of ~7,500 adults hospitalized for CAP in Louisville, Kentucky, the median age was 68 years

The in-hospital mortality rate was 6.5% & the 30-day mortality rate was 13.0%! Comparable to acute coronary syndrome...

In a systematic review of 29 studies, CAP risk factors with the highest adjusted odds ratios included poor nutritional status, immunosuppressive therapy, dental or periodontal disease, smoking, functional impairment, COPD/asthma, previous CAP, steroids & proton pump inhibitors

Nice review (and a refresher) on community-acquired pneumonia (CAP):

In the United States, CAP is estimated to be responsible for 1.2 million emergency department visits & 41,210 deaths annually

Thank you for coming to my TED Talk!

#FOAMed #FOAMcc #MedEd #EMBound #medsky #emimcc

Forget it. I will try to do my best without #LLMs:

Let's try #chatGPT4o: