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ACEP Now: Vol 36 – No 01 – January 2017Figure 2: Management plan for superficial venous thrombosis of the lower extremity.
Abbreviations: DVT, deep venous thrombosis; SFJ, saphenofemoral junction; SPJ, saphenopopliteal junction.
Reprinted from Litzendorf ME, Satiani B. Superficial venous thrombosis: disease progression and evolving treatment approaches. Vascular Health and Risk Management. 2011;7:572 with permission from Dove Medical Press Ltd.
2. tPA and Intracranial Aneurysms, an Explosive Mistake?
Notwithstanding the momentum toward giving more tissue plasminogen activator (tPA) to patients with ischemic stroke, safety and patient selection are of utmost importance. Controversy remains regarding the overall safety and efficacy of this treatment. However, certain assumptions about safety have been made that are not supported by the literature. “You would have to be out of your mind to give tPA to someone with a known intracranial aneurysm” seems like a reasonable statement. However, the fact of the matter is that tPA doesn’t make aneurysmal rupture more likely, and most people will die with their intracranial aneurysm (ICA) and not from it. Of course, if the aneurysm has already ruptured or a sentinel bleed has occurred, tPA would be a really bad idea.
Goyal et al investigated this issue and noted some surprising findings.3 Knowing the numbers of patients with ICA receiving tPA would be small, they created two components for their study. The first was a multicenter, prospective, observational study of 1,398 patients with acute ischemic stroke who received IV thrombolysis and also had neuroimaging, and the second was a meta-analysis combining the data from the first component with five other studies. In the first observational trial, 3 percent of patients had unruptured ICAs. There was one known case of symptomatic intracranial hemorrhage (ICH), but it was not associated with an ICA. In phase two, the meta-analysis of 120 patients, 6.7 percent experienced symptomatic ICH, and the relative risk was not impacted by the presence or absence of unruptured ICA. Although the numbers are small, they probably always will be. When it comes to tPA and ischemic stroke, proceeding with caution is always recommended. However, the presence of an ICA should be seriously considered and, of course, the patient informed of its presence, but it is not an absolute contraindication to tPA administration.
3. Glucose: If It’s High, Treat It?
Patients frequently present to the emergency department with incidentally elevated glucose levels. The question is, do we need to react to and treat every abnormality we see? The answer, in my opinion, is no. If an elevated glucose is merely an incidental finding and not a cause or contributing factor of the presenting condition or complaint, then perhaps we should resist the temptation to treat it—just note it and move on. I think we have come full circle on asymptomatic hypertension in the emergency department. Perhaps it’s time to do the same with incidental hyperglycemia.
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