Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What blood pressure goals do you typically target for patients in the immediate post thrombectomy period?
There aren't excellent data to guide this decision. In general, I make a patient-specific decision. For all patients (both tPA treated and otherwise), I target <180/100. If they're TICI 0-1, I usually keep to that. With TICI 2a, I usually lower to <160 and with 2b/3 I usually lower to <140. The guid...
What antithrombotic regimen do you recommend prior to and in anticipation of CEA for patients with symptomatic carotid stenosis?
Dual antiplatelet therapy with aspirin and clopidogrel
Do you typically recommend platelet transfusions in patients with spontaneous ICH?
Enthusiasm for platelet transfusion for spontaneous intracerebral hemorrhage among patients on antiplatelet therapy has been dampened by the results of the PATCH study. The small 190-patient randomized study demonstrated worse outcomes for those assigned to platelet transfusion. While the serious ad...
Do you typically recommend four factor prothrombin complex concentrate versus fresh frozen plasma for INR correction in patients with vitamin K antagonist associated spontaneous ICH?
Great question! Despite the lack of large randomized controlled trials, PCCs achieve faster reversal of the INR level than FFPs do, and thus I favor using PCCs with Vitamin K as a first line agent for Vitamin K antagonist related ICH.
Do you typically recommend CT angiogram and CT venogram to assess for patients with lobar spontaneous ICH?
For lobar hemorrhages I routinely obtain CTA (head/neck) & MRI (brain with contrast). On MRI, GRE/SWI sequences are good to look for micro-hemorrhage/amyloid-type of pathology. I only get MRA if patient has an elevated creatinine/CKD or anaphylaxis reaction to iodinated contrast. In my opinion, CTA ...
For a patient with high suspicion for NMDA receptor encephalitis, is there a role for giving rituximab along with methylprednisolone & IVIG (all three together) while the CSF anti-NMDAR antibodies are still pending?
The answer to this question was reported in Graus et al., PMID 26906964.
Do you routinely obtain an EEG in patients who are admitted with traumatic intra-cerebral hemorrhage?
We routinely obtain cEEG monitoring on all moderate (GCS 9-12) and severe (GCS 3-8) TBIs at our institution, regardless of their intracranial pathology. It is estimated that in this patient population, the frequency of sub-clinical seizures is around 20-25% and can be associated with elevated ICP, w...
How do you manage acute exacerbations of trigeminal neuralgia?
I do not have personal experience treating TN exacerbations in the ED. What is generally recommended under those circumstances is intravenous phenytoin. Schnell et al. recently published it in The Journal of Headache and Face Pain (Schnell et al., PMID 32981076). They published the results of a retr...
Would you recommend short-term dual antiplatelet therapy for a patient who received tPA, and is otherwise eligible for dual antiplatelet therapy per POINT or SAMMPRIS trial?
I would agree. tPA is not a contraindication to the later prescription of dual antiplatelet therapy. I do not see a definite answer to the question of 21 days versus 90 days, the CHANCE trial (Wang et al., PMID 23803136) supports 21 days and the POINT trial (Johnston et al., PMID 29766750) 90 days. ...
What is your practice for the timing of resumption of oral anticoagulation after ICH?
These are great questions and no good answers (therefore the question). In the near future, well-designed prospective studies and clinical trials will settle the uncertainties.Timing of resumption of anticoagulation has been addressed in modeling studies of risks of recurrent bleeding and thromboemb...