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  Background: Up to 20% of CVAs involve posterior circulation Most commonly missed Posterior strokes not well identified on the usual screening tools Anatomy:     Symtoms: dizziness off balance sensation vision is blurry, oscillating or jumping bilateral leg weakness and / or numbness hemiparesis with motion disturbances on non-hemiparetic side facial symptoms Signs: ataxia (finger to nose / heel to shin / truncal) ataxia when standing (Romberg) or walking locked-in syndrome nystagmus bilateral horizontal gaze palsy internuclear ophthalmoplegia: vertical and rotatory nystagmus visual field defects Vertebral Artery Dissection: sudden rotational force minor trauma, childbirth, sexual intercourse, coughing, sneezing, Chiropractic high velocity manipulation 60%-90% alsoRead More →

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Ketamine is being used with increasing frequency in the prehospital setting for sedation of the agitated patient. Ketamine received some bad press in the summer of 2018 which resulted in putting the prehospital study of the use of ketamine in agitated patients on hold in Minneanapolis, MN. With increased use, we wanted to provide a succint review of ketamine and its use specifically for sedation. This is different than using ketamine for analgesia, which we will discuss in an upcoming episode.  Ketamine Fast Facts:  Developed as an anesthetic Dissociative agent Both amnestic and analgesic properties Administer IM, IV, IO, IN Dose: 1-2 mg/kg IV/IO; 4-5Read More →

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Epinephrine has been a mainstay in cardiac arrest treatment since the early days of resuscitation. When I first learned advanced cardiac life support, epinephrine was administered to “every pulseless individual,” or so the mnemonic went to help remind the importance of this first line pharmacologic agent. On the positive side, epinephrine increases ATP production by releasing stored glucose, which in theory provides energy for the myocardium to contract during the low flow state of cardiac arrest. Epinephrine also constricts the arterioles and increases coronary artery filling pressures, increasing blood flow to the myocardium. Epinephrine is not without downsides, however. The arterioles supplying the brain areRead More →

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    Identifying an ST-elevation MI in patients who have a Left bundle branch block can be very challenging to the clinician. There are changes in the precordial ST and T waves that can make it very difficult in the setting of chest pain to figure out if the patient is or is not having an MI. This has been recognized for several decades back to the time when we were trying to figure out which patients should undergo primary coronary angioplasty. Some of the dogma regarding the “inability” to identify an MI in the setting of a left bundle comes from these early studiesRead More →

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   C-Spine, C-Spine Run, Part 1 In this inaugural episode of the Medical Director Minute Podcast, we examine selective spinal immobilization / spinal motion restriction (SMR) guidelines to examine the literature behind most of these protocols. In recent years, there has been a movement to limit use of long spine boards, a former staple of EMS. While the use of spine boards for immobilization (aka, spinal motion restriction or SMR), there are some valid uses for spine boards as you can see in this youtube video (no, that’s not me in the video…). The two sets of guidelines most of these protocols are based onRead More →

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  C-Spine, C-spine Run Part 2 In part 1 of this two-part series, we discussed the basis for selective spinal immobilization or the process of deciding to fully immobilize, partially immobilize or not immobilize a patient. We discussed the NEXUS and Canadian c-spine rules that are the basis for these protocols, with the majority using NEXUS as it is easier to use. For an in depth discussion of these rules, please either listen to or check out the show notes for that episode. Application: Now that we have discussed these rules, how do we apply this information to our patients? In order to accurately applyRead More →