Emergency medicine clinics of North America
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The landscape of acute stroke care has changed dramatically in the last decade. Even before the approval of tissue plasminogen activator for acute stroke in 1996, organized acute stroke care was initiated at several hospitals and the pharmaceutical industry was deeply entrenched in the search for neuroprotective agents. ⋯ Despite the failures of many neuroprotective agents and the relative lack of use of tPA, the acute treatment of the stroke has gained increasing importance both at an individual and national level. This chapter reviews some of the advances in the acute treatment of stroke, future of acute stroke care and discusses the emerging role of the emergency physician in this area.
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Emerg. Med. Clin. North Am. · Aug 2002
ReviewAcute ischemic stroke: emergent evaluation and management.
This article discusses stroke, the third leading cause of death and number one cause of adult disability in the United States, inflicting a devastating physical, emotional, and financial toll on its victims and their families. The last decade has seen the emergence of new treatments for acute stroke, energizing stroke care providers and spreading a sense of optimism among them. Because effective stroke treatment is extremely time-dependent, it is paramount that emergency physicians understand and excel in their critical role at the forefront of stroke management. This article outlines the emergent evaluation and management of acute ischemic stroke, emphasizing the importance of the emergency physician in acute stroke treatment.
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The diagnosis of acute stroke remains a clinical diagnosis in the initial phases of patient evaluation. There is a differential diagnostic process to the abrupt onset of focal neurologic deficit that characterizes an acute stroke. "Is this a CNS event?" might be the initial question posed by the clinician. The stroke mimics of systemic problems such as hypoglycemia, hyperglycemia, and other encephalopathies are considered. ⋯ The standard acute neuroimaging with noncontrast CT scanning uncovers some mass lesions mimicking stroke and confirm a stroke subtype in other patients. Ischemic stroke, like other common diseases, does have uncommon manifestations. Acute stroke is considered in neurologic syndromes in which abrupt onset of symptoms figure prominently, particularly in patients with cerebrovascular risk factors.
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Infrequent causes of stroke are likely to be encountered by emergency physicians. Infrequent causes of stroke can be recalled using the ABC-IT mnemonic. Of the many infrequent causes, the five conditions more likely to be encountered are sickle cell anemia, migrainous stroke, antiphospholipid antibody syndrome, arterial dissection, and cocaine-related stroke. Consideration of the use of thrombolytic therapy in a patient with stroke from any cause lies at the forefront of treatment strategy in the emergency department.
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Although once considered unlikely, bioterrorism is now a reality in the United States since the anthrax cases began appearing in the fall of 2001. Intelligence sources indicate there are many countries and terrorist organizations that either possess biological weapons or are attempting to procure them. ⋯ The CDC category A agents represent our greatest challenge because they have the potential to cause grave harm to the medical and public health systems of a given population. Thus, it is imperative that plans be developed now to deal with the consequences of an intentional release of any one or more of these pathogens.