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What Is a Mini Stroke? The Silent Symptoms of a Transient Ischemic Attack

Reprinted from HealthiNation

Learning you’ve had a transient ischemic attack (TIA) might feel like a relief. It’s only a “mini stroke,” and it doesn’t cause permanent damage. In some cases, you may not have even experienced noticeable symptoms.

“Since TIAs don’t result in stroke [and] don’t result in a permanent blockage of the brain, many times people say, ‘Well why do I really care?’” says Carolyn Brockington, MD, a neurologist at Mount Sinai Hospital.

But the truth is that having a mini stroke does not mean you’ve dodged a bullet or you’re off the hook. If anything, a TIA is a warning sign of being at risk for a stroke in the future.

What Is a TIA?

To understand what TIAs mean for your health, it helps to know what they actually are.

TIAs are caused by the same factors that cause an actual ischemic stroke: a blood clot blocking the blood flow to the brain.

What sets a mini stroke apart from a full-blown ischemic stroke is that word transient—meaning “temporary.” During a TIA, blood flow to the brain stops for a only brief period, according to the National Stroke Association. The blockage can mimic symptoms of stroke, but it doesn’t usually cause long-term brain damage.

TIA symptoms may be less severe and noticeable, so you might confuse them for a random headache or dizzy spell. The trademark feature is that they happen suddenly and only last for a short period of time, according to Dr. Brockington.

A common story from people who have had a TIA is that they are walking normally, and “all of a sudden they feel their right leg’s dragging, and maybe their arm’s a little weak on one side,” says Dr. Brockington. “Then a few minutes later it’s gone.”

What It Means to Have a TIA

“TIAs serve as warning signs,” says Dr. Brockington. “Many times, people who will ultimately develop a stroke have had small TIAs along the way.”

In fact, the American Stroke Association (ASA) refers to TIAs not as “mini strokes,” but as “warning strokes.” About a third of people who experience a TIA end up having a more serious stroke within a year, according to the ASA.

Having a TIA is serious, but it could still play a positive role in managing your health. Just like with a full-blown stroke, a TIA may be caused by hypertension, high cholesterol, or smoking.

“That’s the opportunity to figure out when or why something is happening in the brain,” says Dr. Brockington.

If you have a TIA, your doctor can run tests to pinpoint the problem, such as issues with the blood, blood vessels, or heart. For example, if your doctor sees that your blood pressure is too high, he or she may help you treat high blood pressure to lower your risk of having a more serious stroke.

Your doctor may recommend lifestyle changes for a healthy heart or prescribe medications, such as blood thinners, to help prevent future stroke.

If you think you may have had a so-called mini stroke, keep this in mind: “Just because the symptoms went away doesn’t mean there’s not a problem,” says Dr. Brockington. “Could it happen again? Certainly, if we don’t identify the real reason why it occurred.”

The Most Dangerous Mistake You Can Make If You’re Having a Stroke

 Stroke symptoms can be vague: feeling weak, numb, having blurry vision. Someone having a stroke might not feel quite right, but they might not necessarily suspect or know they’re having a stroke. It’s important to recognize these signs as potential stroke symptoms, and take them seriously by calling 911—*not* going to the doctor or hospital on your own to have them checked out.

The Dangers of Driving During a Stroke

It doesn’t matter how severe (or not severe) your potential stroke symptoms are: Driving is considered off-limits. Here’s why:

“Stroke can worsen over time,” says Carolyn Brockington, MD, a neurologist at The Mount Sinai Hospital. “If you start off with mild symptoms, there’s no way of knowing whether they’re going to get more severe.”

Even with mild stroke symptoms, your driving may be impaired. Common stroke symptoms include lack of coordination, confusion, weakness in the arms or legs, and trouble seeing in one or both eyes, according to the National Institute of Neurological Disorders and Stroke (NINDS). Each of those can impact the ability to drive safely, similar to driving while intoxicated.

Getting into a car accident will not only put you at risk for further injury, but it will postpone the start of treatment for your stroke. When it comes to avoid brain damage from stroke, every minute counts. Starting treatment as soon as possible after the onset of stroke symptoms can help prevent disability caused by stroke, according to NINDS.

That doesn’t mean the passenger seat is the answer, either. Don’t have a friend or bystander (or even an Uber driver) take you to the ER.

What to Do if You’re Having a Stroke

“You really need to call 911 in order to be taken to the emergency room that’s closest to you,” says Dr. Brockington.

Ambulances save you time in more ways than one. They literally get through traffic faster, get treatment for stroke started sooner, and can ensure doctors who specifically treat stroke are ready for your arrival to the hospital, according to the Centers for Disease Control and Prevention (CDC).

In the ambulance, EMS professionals can begin your treatment by monitoring your vitals, noting your symptoms, and taking down your medical history—saving you precious time once you reach the hospital.

“When people have strokes, many times their blood pressure is very high,” says Dr. Brockington. EMS professionals can give medicine to lower BP and make sure you’re getting enough oxygen.

EMS professionals can also help figure out what type of stroke you’re having, says Dr. Brockington, which is important to know for treatment. They can notify the ER so doctors are prepared with equipment and medication to begin treatment ASAP.

Unfortunately, while the risks of driving yourself to the hospital during a stroke are well documented, one in three stroke patients do not call an ambulance, according to the CDC.

“We know that a stroke occurs from not enough blood getting to the brain in a period of time,” says Dr. Brockington. “We want to try to limit the degree of damage to the brain. The people who come in right away … and are treated faster, usually do better in terms of recovery.”

“The best advice I can give someone who thinks they might be having a stroke is to call 9-1-1,” says Dr. Brockington. “Time is brain. The longer they wait, the more likely it is that the brain may be irreversibly damaged.

From HealthiNation.com

Stroke Information & Resource Guide


Last updated: December 27, 2020

Original Source:

https://www.acls.net/stroke-information-and-resources


A stroke is a serious and sometimes life-threatening condition. It is a leading cause of disability and the fourth leading cause of death among Americans. Until recently, if you were to experience a stroke, supportive care was all that was available. But now, stroke management has progressed to a point where a stroke can be stopped in its path.

There are treatments available that can prevent or limit disability caused by a stroke as well as saving many lives. The success of such treatments is dependent upon how much time has passed since the symptoms appeared. Therefore, the early recognition of a stroke by the patient or their family is of the utmost importance. This article will attempt to give you the information you need to recognize a stroke and respond accordingly.

What is a stroke?

There are blood vessels that are dedicated to providing each and every region of the brain with the nutrients and oxygen that it needs to function. Over the years, a plaque from cholesterol and other lipid substances can start to build up in the blood vessels causing them to narrow, and if that plaque ruptures producing damage to the vessel wall, the body tries to heal it. Clot-forming molecules will reach the site and clot off the vessel. Once the blood vessel is closed, there is no blood flow to the tissue beyond the blockage. Sometimes, the clot will dislodge, travel in the blood, and block a smaller vessel downstream. Without oxygen and nutrition, the tissue beyond the blockage will begin to die.

A stroke due to such an underlying mechanism is referred to as ischemic, and the severity of it will depend upon the location of the blood clot. This is the predominant form of stroke, at least 8 out of every 10 cases of stroke are ischemic strokes.

Another less frequent type of stroke occurs when a blood vessel ruptures and causes bleeding into or around the brain. This type of stroke is called a hemorrhagic stroke. Although not impossible to treat, this type of stroke tends to be more serious and difficult to handle.

Review the healthcare provider algorithm for a response to a stroke which includes the Cincinnati Prehospital Stroke Scale and take our online quiz for stroke response.

Additional resources

What is a stroke?

Definition of stroke

What is a hemorrhagic stroke?

Why me? Causes of stroke

Stroke risk is increased by the same factors that increase the risk of suffering a heart attack; smoking, obesity, diabetes, hypertension, sedentarism, and high cholesterol, all contribute to the risk of stroke. Anything that you can do to eliminate or change these risk factors will decrease your chances of having a stroke. There can be a genetic component to stroke risk, as well as drug-related factors.

An important note is that the hemorrhagic stroke can often appear without any kind of risk associated, as it is a stroke that can appear due to an aneurysm or congenital issues.

Stroke prevention

Lifestyle tips to prevent stroke

9 Ways to prevent a stroke

Recognizing a stroke by signs and symptoms

Since the medical management of a stroke varies depending on the length of time since symptoms first appeared, and due to the fact that this will affect prognosis, prompt recognition of a stroke is extremely important.

Keep in mind that stroke symptoms usually start quite suddenly and get worse over time. You may be sitting at a table and suddenly be unable to hold your coffee cup or get your words out correctly. Signs and symptoms of stroke include sudden onset of weakness on one side of the body and slurred speech or dysarthria, meaning, the inability to make your words come outright. A sudden change in the way you walk or feeling that one leg is not “acting right” can be a sign of stroke. Some patients also notice changes in their ability to see. Loss of balance is another common sign of stroke. Patients who have blood around their brain may complain that “they have the worst headache of their life”.

A useful acronym to recognize and respond to stroke is FAST:

  • Face
    • Drooping of one side of the face. Ask the person to smile and note if it is uneven. 
  • Arms
    • Weakness or numbness in one arm. Ask the person to lift both arms. Does one extremity drift downward or is the person unable to lift it? 
  • Speech
    • Difficulty in speech, is it slurred? Ask the person to repeat a phrase and note any changes in speech. 
  • Time
    • If any of these symptoms are present, it’s time to call 911 immediately. Also, take note of the time since symptoms onset, which will be required by doctors to decide on appropriate treatment. 

In the case of a hemorrhagic stroke, the symptoms appear in a more abrupt way and vary from the ischemic one, the headache is the first thing to appear, it consists of a very severe pain which makes the patient feel like “his head is gonna explode”, then the rest of the symptoms start to appear.

Nausea and vomiting are common along with dizziness and a very stiff neck, usually accompanied by confusion and even seizures, this set of symptoms are called “meningeal syndrome” due to the inflammation of the meninges (a set of membranes that cover the brain and spinal cord), thanks to severe and sudden hemorrhage in the brain.

It is important to remember though, that the only and best way to ascertain the type of stroke along with the adequate treatment for it, is through imaging studies, such as, a CT scan or an MRI, this last one uses magnets and radio waves in order to create pictures of the organs and structures of the body. These tests can detect changes or damage to the brain tissue. All of this is done in the confines of a medical center, so it’s important to take note that we have to act fast in order for adequate treatment to be given.

Warning signs of stroke

Signs and symptoms of stroke

Women and stroke

Hemorrhagic stroke overview

I’m having a stroke! What should I do?

It is imperative that you get help and get to a hospital  AS SOON AS POSSIBLE following the onset of symptoms of a stroke. Treatment for stroke is very time-dependent. A clot-busting medication can be given to clear the clot from the vessel, but only if you are at the hospital within 3 hours (4.5 hours for some patients) of onset of symptoms.Call 911 immediately. Do not wait for relatives to arrive. Do not wait while you pack clothing for the hospital or wait for your family to return a call. The amount of damage done by the stroke is subject to how long the blood vessel remains blocked. Keep in mind that time is brain. For every minute you delay getting medical attention, more brain tissue is being damaged.

If you are calling help for a friend or family member, after dialing 911, you should attempt to determine the time since symptoms began. If you arrived at your family member’s house and found them having symptoms, it may be advantageous to phone a neighbor that may have seen them. You are attempting to figure out the time that the patient was “last known well”. This could be a telephone conversation, a neighbor who saw them getting their mail earlier in the day, or the report of someone who was with them when their symptoms began. This is important because the clot-busting medication can only be given within a certain timeframe.

It is also important to note that in the case of a hemorrhagic stroke since this type of stroke does not derive from pressures from a clot or a plaque, utmost care must be taken if the patient was taking any form of clot-busting medication since these kinds of treatments generally worsen the stroke itself.

What should I do if I am having a stroke?

Response to Stroke

What to expect when the ambulance arrives

The paramedics and EMTs will focus on two things: making sure that your vital signs are stable and transporting you quickly and efficiently to a stroke center that is capable of treating you.

Don’t be surprised if EMS encourages you to go to a hospital other than the one that you would prefer. There are certain hospitals that are classified as Stroke Centers at different levels. Comprehensive stroke centers (usually the larger teaching hospitals) are capable of not only giving clot-busting medication but are also able to perform procedures quickly to remove the clot and restore your blood flow.

If you are transported to a hospital that is not a stroke center, valuable time will be wasted while they complete their assessment and diagnostic testing and then transfer you to an appropriate stroke center for treatment. Transporting you directly to the closest stroke center available can save precious time. Most EMS have protocols in place for this purpose.

Comprehensive stroke center

Find a certified stroke center near you.

What treatments are available for stroke?

Since ischemic stroke is the most common type of stroke, its treatment is the one described here. At the end of this section, you will find links to articles on stroke management which include treatment of hemorrhagic stroke. Remember, for any type of emergency treatment, the earlier it’s begun, the better the results.

Clot-busting medication: tPA is a clot-busting medication that has been used for many years to treat strokes, heart attacks, and pulmonary embolisms (clots in the blood vessels of the lungs). It is given intravenously and dissolves the clot to restore blood flow. It is, however, not without complications: tPA can cause bleeding in the brain and other parts of the body. So, you will be assessed to make sure that you are not at high risk of bleeding. For example, if you recently had a major injury, surgery, or internal bleeding, it would be too dangerous to administer a clot-busting medication for your stroke. Clot-busting medication cannot be administered if more than 3 hours (4.5 hours in some cases) have elapsed since symptom onset. After such time the risks outweigh benefits. That is why it is important to know when symptoms began. The time that your symptoms began is the time when the blood vessel became occluded.

Percutaneous interventions: just like with a heart attack there are procedures to place a catheter directly into a vessel that feeds the brain and removes the clot that is blocking it. A catheter is placed through the groin and threaded up to the blood vessel that has been blocked. The clot can then be dissolved by directly delivering clot-busting medication or it can be physically removed with the help of a tiny device at the end of the catheter.

The treatment of a hemorrhagic stroke varies from the ischemic one. Due to the fact that a hemorrhagic stroke appears more suddenly and even without previous risks associated (hypertension in the case of an ischemic stroke) the time to act when presented with a hemorrhagic stroke must be faster.

Anticonvulsants due to the high risk of seizures related to a hemorrhagic stroke, different forms of anticonvulsants are administered, which can then be extended for weeks or even months until the risk is lowered.

Antihypertensive agents and diuretics since most hemorrhagic strokes derive from sudden high blood pressure, a drug that lowers said blood pressure needs to be administered along with another one that helps the intracranial/meningeal pressure, this kind of treatment is often given with care due to the risks associated with them and with the stroke itself.

Surgical procedures The main objective of a surgical procedure to treat a hemorrhagic stroke is to drain the blood from the meninges, alleviating the pressure done on said areas and helping with the onset of symptoms derived from it.

The gold standard of stroke treatment

Time is brain - Treatment for stroke

How is stroke treated?

Stopping stroke in its tracks

Stroke treatment

Treating stroke

Hemorrhagic stroke

Hemorrhagic stroke treatment

How is a stroke treated?

This page is written by  on Jul 3, 2016.

 This page is last reviewed and updated by  on Jul 6, 2020.

Choking and the Heimlich Maneuver

Last updated: December 26, 2020

Choking is a life threatening situation that occurs whenever a foreign object lodges in the throat or windpipe. This can cause blockage to the oxygen flow to the brain. Choking a real medical emergency that requires fast and appropriate action by the closest available person. Choking can cause potential death if not acted upon immediately.

Causes of choking

While choking occurs most often among infants and children, choking among adults is not uncommon. [1] According to Injury Facts 2017, choking is the fourth leading cause of unintentional injury death. Of the 5,051 people who died from choking in 2015, 2,848 were older than 74. 

These are the common reasons for choking:

  • When a foreign matter ends up in the trachea and becomes stuck as the airway narrows, choking occurs. Food or other foreign matter is supposed to go on another path when swallowed. As swallowing occurs, the epiglottis covers the trachea to prevent the swallowed object from entering the airway. However, when swallowing happens while talking or laughing, the object may go down the wrong pipe hence getting stuck in the airway.
  • Normal swallowing may be deterred by alcohol consumption or drug intake.
  • When food is not chewed properly or when swallowing too much food, large chunks of food may become lodged in the throat.
  • Certain illnesses may cause choking such as Parkinson’s disease may also cause some difficulty in swallowing and this can be a potential cause for choking.

Choking hazards for infants and toddlers

Infants and toddlers are still learning how to chew and swallow properly. This means that they are more prone to choking. Parents must supervise closely when an infant or toddler is eating. They also tend to put anything they touch in their mouth so they must be watched at all times. According to the CDC, the following food are potential hazards to infants and children[2]:

  • Cooked or raw whole corn kernels 
  • Uncut cherry or grape tomatoes
  • Pieces of hard raw fruit or vegetables
  • Whole pieces of canned fruit
  • Uncut grapes, berries, cherries, or melon balls
  • Uncooked dry fruit such as raisins
  • Whole or chopped nuts and nut butters such as peanut butter
  • Tough or large chunks of meat
  • Hot dogs, meat sticks, or sausages
  • Fish with bones
  • Large chunks of cheese, especially string cheese
  • Cookies or granola bars
  • Potato or corn chips, pretzels, or similar snack foods
  • Crackers or breads with seeds, nut pieces, or whole grain kernels
  • Whole kernels of cooked rice, barley, wheat, or other grains
  • Hard candy, jelly beans, caramels, gum drops, or gummy candies
  • Chewing gum
  • Marshmallows

Choking symptoms

Most of the time, choking victims will have difficulty in speaking so it is important to know the symptoms of potential choking just in case one is around someone who might be a victim. The following are the known symptoms of choking:

  • Coughing hard
  • Gagging
  • Throat clutching
  • Panicking signals while unable to speak
  • Chest beating
  • Inability to speak
  • Turning pale or blue
  • Losing consciousness

Prevention

It is difficult to know when choking will occur however, certain practices can be put in place to prevent this from happening. 

  1. Eat and chew with enough pacing. 
  2. Avoid talking or laughing while eating.
  3. Avoid alcohol before eating.
  4. For infants and toddlers, always supervise them while eating. 
  5. Make sure that a child’s area is free from objects that can be easily fit in the child's mouth.
  6. When an infant is just beginning solid food intake, cut up the infant’s food into smaller pieces.
  7. For someone with choking prone illness, meals should always be facilitated.

The heimlich maneuver

Named after the American surgeon Henry Heimlich, the Heimlich maneuver is a well known emergency procedure that is recommended for someone who is choking. This can be learned even by a non-medical professional. Most of the time, choking needs immediate intervention and waiting for a medical professional for help may endanger the life of the victim. The Heimlich maneuver is a series of under-the-diaphragm abdominal thrusts. These thrusts are intended to lift the diaphragm, forcing air from the lungs to produce an artificial cough. The cough will force air through the trachea, pushing the object blocking the airway out to the mouth. Abdominal thrusts must be strong enough to force air from the lungs but not too strong as to damage any internal organs or the victim’s ribs.

Before performing the procedure, make sure to call emergency medical help if you are alone with the victim or have someone else call otherwise. To perform the Heimlich maneuver [3]:

  1. Reach around the person's waist.
  2. Position one clenched fist above the navel and below the rib cage.
  3. Grasp your fist with your other hand. Pull the clenched fist sharply and directly backward and upward under the rib cage 6 to 10 times quickly.
  4. If the person is obese or in late pregnancy, give chest compressions.
  5. Continue uninterrupted until the obstruction is relieved or advanced life support is available. In either case, the person should be examined by a healthcare provider as soon as possible.

When helping an infant or toddler, extra precaution is needed. Before performing thrusts, try doing at least five firm blows on the child’s back. If the child responds with a cry or cough, this is a good sign. Continue giving back blows until the child coughs out the cause of the choking. If the child is still unresponsive, place the child facing upwards on your lap with the head in a lower position than the whole body. Perform chest thrusts using two fingers on the center of the breastbone just below the nipples. The thrust must be enough to compress the child’s chest a third to a half of its depth.

Continue doing the Heimlich maneuver until the obstruction is cleared or medical assistance arrives.

Link can be found at the following url:

https://www.acls.net/choking-and-the-heimlich-maneuver.htm

References: 

  1. https://www.nsc.org/home-safety/safety-topics/choking-suffocation
  2. https://www.cdc.gov/nutrition/InfantandToddlerNutrition/foods-and-drinks/choking-hazards.html
  3. https://www.hopkinsmedicine.org/health/wellness-and-prevention/choking-and-the-heimlich-maneuver

 This page is written by  on Oct 7, 2020.

THE SERIOUSNESS OF A COPPERHEAD ENVENOMATION

YOU THINK YOU KNOW ABOUT COPPERHEAD ENVENOMATIONS? THINK AGAIN.

This article is credited to: 

Wild Snakes: Education And Discussion

Please visit their website for more information about snakes. Follow them on Facebook

Let me begin by saying I’m ethnocentric, and this article refers to the copperheads found in the United States. I’m not talking about the Australian copperheads of the Austrelaps genus.

Taxonomy is always changing, which is sometimes a necessary nuisance and other times nothing more than a testament to pride, greed, and obstinance. By the time I finish typing this, copperhead taxonomy may have changed again. When I first got into toxicology, there was one species of copperhead (Agkistrodon contortrix) with five subspecies (contortrix, mokasen, laticinctus, pictigaster, and phaeogaster). Now people tend to think them as two species: A. contortrix (Eastern copperhead) and A. laticinctus (Broad-banded copperhead).

A. contortrix © Lisa Powers/Froghaven Farm

I don’t think there is enough envenomation literature out there that distinguishes the different species and subspecies, so I’m going to talk about them generally.

Copperheads account for the plurality, and maybe the majority, of venomous bites in the United States. From 2012 through 2016, there were 9,247 copperhead bites reported to the American Association of Poison Control Centers. In comparison, there were 1,234 bites from cottonmouths, 4,912 rattlesnake bites, and 400 coralsnake bites. I don’t have the #s for unknown native pit vipers or exotics immediately available, and time is of the essence, so you’ll have to learn to live with the disappointment of not knowing.

Of course, many bites go unreported to U.S. poison centers, so we don’t know the real #s for the various type of snakes. But presumably the relative frequencies would be preserved.

Nonetheless, lots of bites. But because there are soooo many physicians out there, most have treated very few, if any, envenomations. And yet this does not stop them from perpetuating nonsense when it comes to copperhead envenomations.

IS A COPPERHEAD BITE A BIG DEAL?

Far too frequently I hear people minimize the significance of copperhead bites. Physicians – and lay people – will state that they’re “no big deal”.

That may be true, depending on how you define “big deal”. Copperhead envenomations are not going to keep the earth from spinning on its axis. They won’t change the way northerners mispronounce the word “pecan”. And they won’t stop the Golden State Warriors from dominating the NBA for the foreseeable future. (Mind you, I’m not happy about this. I’m just realistic. Go Rockets!!!!)

A. contortrix © Lisa Powers/Froghaven Farm

If you equate “big deal” with death, then it is sorta true that copperhead envenomations are not THAT big of a deal. Death is pretty rare. But, I would like to point out, there have been fatal copperhead envenomations. Hells bells, there was a death in 2014 and another in 2015. In that same span, there were 10 deaths from rattlesnakes. There were no reported deaths from coralsnakes or water moccasins (cottonmouths) in those years. This is in the U.S., I should specify…. Again, I’m ethnocentric. And on a time crunch because I really want to watch the last two episodes of Stranger Things season 2.

Related:  Snake Bites & Misinformation

Finally, if you define “big deal” as having the ability to ruin your day and significantly affect your life for the next few weeks, and possibly months and years, copperhead envenomations ARE a big deal. And it makes me apoplectic that some healthcare providers minimize the significance of copperhead bites, especially when patients are exhibiting severe signs and symptoms right in front of them.

In the same National Poison Data System data from the AAPCC, 2.13% of copperhead envenomations resulted in death or major effects, defined as signs that were life-threatening or resulted in significant residual disability or disfigurement. This is not nearly as much as the 8.84% of rattlesnake bites with death or major effects, but it’s more than 1.94% of water moccasin (cottonmouth) bites. I’m not sure if 2.13% vs. 1.94% is a statistically significant difference, but it does make me wonder why most people make a big deal about water moccasins (which they should) but disregard copperheads (which they should not do).

In a study of untreated copperhead bites in North Carolina, there was follow up for 7 patients with mild bites (which they defined as tissue injury limited to the immediate bite site without systemic manifestations) and 8 patients with moderate bites (defined as extension of local tissue effects to a major joint proximal to the bite site +/- systemic manifestations such as nausea or abnormal coagulation studies without clinical bleeding). The median length of disability for these patients was 42 days (range 5 – 365 days). I’d say 42 days of disability is pretty significant.

Annually, I treat ~ 50 bites at the bedside and ~ 50 bites over the phone or computer as a snakebite consultant. Copperheads account for approximately 65% of all of snake envenomations, Let me tell you, I’ve seen some pretty impressive bites. About 20% of confirmed copperhead bites would be considered “severe” because of local findings and/or systemic involvement, typically in the form of hematotoxicity, including coagulopathy, hypofibrinogenemia, and/or thrombocytopenia. While I have your attention, I want to reiterate “confirmed” copperheads, which has nothing to do with their religious training. I think too many studies are weakened by inexact species identification. I list the species as “unknown” unless the snake has been positively identified in person or via photograph of the actual “herp perp”. In my follow up clinic I have also seen patients who went untreated elsewhere, and there are a lot (gaggles, maybe even herds, clutches, or colonies) of folks with permanent effects, even months after the bite.

This article is credited to: 

Wild Snakes: Education And Discussion

Please visit their website for more information about snakes. Follow them on Facebook

DOES A PATIENT REALLY NEED ANTIVENOM IF BITTEN BY A COPPERHEAD?

Okay, so I have demonstrated that copperhead envenomations can be bad. Why is that important? I’m glad I asked. It’s important because we can (and, as I am about to argue, should) do something about them.

At the time of this writing (September 2018), there is one antivenom that is FDA-approved for the treatment of all North American pit vipers. Crotalidae Polyvalent Immune Fab (ovine), better known as CroFab®. In the initial studies in the mid-1990s, back when the drug was known as CroTab, copperheads were not included. So, until recently, there was no documented evidence of efficacy against copperhead bites.

However, in 2017, Gerardo et al (and, like Paul Simon sang, “you can call me al” because I’m one of the co-authors), published the first double-blind, placebo-controlled, randomized clinical trial of CroFab in mild and moderate copperhead bites. And we found a few important things:

75% of patients who were treated with antivenom were back at baseline by 31 days, whereas it took 57 days for 75% of untreated patients to return to baseline. At 14 days post-bite, patients who were treated with antivenom had a clinically and statistically significantly better performance on the patient-specific functional scale. They were better on performing tasks they identified as important in their lives
Nobody treated with antivenom required opioids after 21 days, whereas it took 90 days for the untreated group to be opioid-free. In this age of widespread opioid abuse, misuse, and dependence, I think that’s yuuuge.

A more recent sub-analysis of the data by Anderson et al (I’m still al) demonstrated that early treatment with antivenom (defined as within 5.47 hours of envenomation) resulted in better outcomes than late treatment:

Patients in the early treatment group had a median time of 17 days to full recovery; the untreated group took an average of 28 days.

TREAT AN ENVENOMATION LIKE YOU WOULD TREAT A FIRE.

This makes complete sense. I often compare envenomations to fires. If you treat early and aggressively, before the fire (bite) spreads, you can extinguish it with fewer resources and less resultant damage than if you wait for it to spread. If you treat after the fire (bite) has spread, there is more damage and you use more resources, only to get a less complete response.

In the unified treatment algorithm for the management of crotaline snakebite in the U.S. by Lavonas et al, treatment (for pit vipers in general) was recommended by the panel for systemic toxicity or when local effects crossed one major joint. Some panelists even recommended treating finger bites that did not have extension past a major joint if there was any significant injury. I totally agree! If you see there’s evidence of a more-than-minimal envenomation, you treat. Yet in some places (I’m looking at you, my adopted Lone Star State) many physicians who treat snakebites wait until the local damage has spread across two joints. This baffles me. This dithering results in more injury and less likelihood that the recovery will be complete.


SO WHY THE RELUCTANCE TO TREAT?

Well, a lot of times it’s because of ignorance. Doctors may be unaware that copperheads can cause serious injury. They may not realize that antivenom is effective against copperhead bites. Maybe providers have concerns about the safety of antivenom. All drugs have the potential for adverse events, right?! However, CroFab does have an excellent safety profile. In a meta-analysis by Schaeffer et al in 2012, there was an 8% incidence of acute adverse reactions. More recently, Kleinschmidt et al found an 2.3% incidence of acute adverse reactions. In the pediatric population the incidence skyrocketed all the way to 2.7%. Heck, standing between me and a kolache is more dangerous!

The last common argument for withholding treatment is that most people recover, eventually, and antivenom is expensive. I agree it’s not cheap. But neither is a permanent disability. Even a prolonged absence from work can be financially devastating. I think it’s better to treat the patient liberally and then help him or her find a way to pay for treatment if needed than to withhold/delay treatment and miss that opportunity to do the most good.

Too many people want to separate copperheads from other native pit vipers. Rather than focus on the species, I recommend looking at the patient. If he or she has a more-than-minimal pit viper bite, treat it aggressively, irrespective of the species. You only have one chance to make a first impression, and you have only one opportunity to treat before things get hinky.


WHAT TO DO IN THE UNFORTUNATE EVENT OF A BITE?

  1. Go to the hospital, and read these beforehand so you’re prepared: Snakebite pre-hospital management and Snakebite in Hospital (Pit vipers) and Snakebite in Hospital (Coralsnakes).
  2. Reach out to us at the National Snakebite Support Group for access to snakebite experts.

This article is credited to: 

Wild Snakes: Education And Discussion

Please visit their website for more information about snakes. Follow them on Facebook

 Spencer Greene, MD 09/12/2018

About 

Spencer Greene, MD, MS, FACEP, FACMT is the Director of Medical Toxicology and an Assistant Professor in the Henry J.N. Taub Department of Emergency Medicine at Baylor College of Medicine. He directs the only medical toxicology service in Houston. Clinical interests include salicylates, anticonvulsant toxicity, physostigmine, alcohol withdrawal, and envenomations, and he consults on more than 100 bites and stings annually, including snakebites, spider bites, asp envenomations, and jellyfish stings. He serves as a consulting toxicologist for the Southeast Texas Poison Center and has directed the annual Houston Venom Conference since its creation in 2013. He was also the course director for the American College of Medical Toxicology's Natural Toxins Academy.https://wsed.org/

Tips for Icing Injuries Safely and Effectively


As an instructor, you already know that first aid guidelines include applying ice to an injured body part, such as a bone, joint or muscle injury. However, questions that often arise in class are:

  • What type of ice is best?
  • What shouldn’t be used?
  • How long should ice be applied?

Here are some facts to remember when applying ice to an injury:

“Frozen water” ice is best: Several studies show that crushed ice, shaved ice, and ice cubes are the most effective at cooling the body. Instant ice packs are not as effective at cooling the body, and often do not last as long as frozen water ice.

Frozen vegetables: A makeshift ice bag of frozen peas can also be effective in a pinch, as peas have a high water content and the bag can conform to any body part. However, frozen peas may warm up more quickly than ice and not provide as much of a therapeutic effect.

Be careful with instant ice packs: The temperature of Instant ice packs, which become cold via a chemical reaction, can vary greatly. Some instant ice packs can become too cold initially, which can damage the skin. Others may not become cold enough, or stay cold long enough to have a meaningful effect on an injury.

Use a wet barrier: If a barrier is used between the skin and ice, it should be wet. This helps the cold application penetrate deeper into body tissue.

Do not ice continuously: NSC First Aid programs recommend icing an injured body part for 20 minutes (or 10 minutes if icing produces discomfort), remove for 30 minutes, then reapply. The “more is better” approach should not be used when icing an injury. Continuous icing can potentially cause tissue and nerve damage, and some studies show that it may actually have the reverse effect by increasing swelling.

RESCUE BREATHS: ARE THEY GONE OR NOT?


By guest blogger Bill Rowe, Director of Content Development

I still remember the day when the 2010 CPR and ECC guidelines were released and the primary message from the news media was that rescue breaths were eliminated from CPR. Headlines screamed, broadcasters announced with great fanfare, and sound bites ruled… rescue breaths were gone!

But it really wasn’t that simple.

First, let’s clear up the main point. For people that become trained lay providers of CPR, rescue breaths are still a critical part of their ability to perform CPR. They are still part of standardized layperson training.

Let me see if I can help clear things up.

First, some related anatomy. There are two main ways that cardiac arrest occurs. The most common is sudden cardiac arrest.  As its name implies, sudden cardiac arrest happens abruptly, and mostly to adults, when the electrical system of the heart short-circuits, the mechanical pumping action stops, and forward blood and oxygen flow ceases. A victim of SCA usually collapses and becomes unresponsive. Normal breathing stops, except for occasional non-productive agonal gasps. This is the most common form of treatable cardiac arrest. Immediate CPR to buy time for early defibrillation provides the best chance for survival.

When sudden cardiac arrest occurs, uncirculated oxygen remains in the bloodstream. Research has shown that doing chest compressions, without rescue breaths, can circulate that oxygen and be as effective in doing it as traditional compression/rescue breath CPR for the first few minutes.

This is where the idea of eliminating rescue breaths got started. Other contributing influences included the potential for giving rescue breaths to be unpleasant, such as after injury or vomiting, and there is more detail in learning how to do them, including keeping the tongue from blocking the airway and making an airtight seal when blowing.

Getting rid of rescue breaths for sudden cardiac arrest looked like a reasonable concept.      

However, the other common path to cardiac arrest is secondary cardiac arrest, when there is an initial airway or breathing problem that prevents oxygen from entering the body. The lack of available oxygen will progressively weaken and slow the heart rate down until the heart stops. Secondary cardiac arrest occurs from things such as drowning, opioid overdose, and suffocation. This is the most common way cardiac arrest occurs in children.

Different from sudden cardiac arrest, an essential part of the treatment for secondary cardiac arrest is providing effective rescue breaths. Getting oxygen into the body and circulated to heart tissue will stimulate the heart to beat faster and become stronger. An improving heart and the resulting oxygen to the brain can stimulate the breathing effort.

So, getting rid of rescue breaths can make CPR a whole lot easier for treating the problem of sudden cardiac arrest, but will not help someone survive a secondary cardiac arrest. How should we train lay providers in CPR?

The correct answer is that we can do both kinds of training, depending on the person being trained.

Nothing has changed in traditional standardized CPR provider training. Students learn and practice both chest compressions and rescue breaths to be able to manage both sudden and secondary cardiac arrests. If a person has the time, this is the recommended training to take.

But what about all of those who are not able to take traditional training? Keeping in mind that sudden cardiac arrest is much more likely than secondary cardiac arrest, what about a simpler approach for the masses that can be learned in minutes with little or no practice?

In 2010, the CPR guidelines were updated with the concept of compression-only CPR as a separate option for untrained bystanders. This was based on the concept that, for at least a few minutes, chest compressions alone could circulate the remaining oxygen in the bloodstream of a victim of sudden cardiac arrest. Evidence showed that, in this circumstance, compression-only CPR was just as effective as traditional CPR with compressions and breaths.

Learning compression-only CPR is easy. If a person collapses in front of you, put the heels of both hands on the center of the person’s chest and push. Push repetitively, push fast, push hard, and don’t stop until an AED is attached and analyzing.  Awareness in compression-only CPR can be accomplished through things such as public service announcements, posters on walls, lunch-time talks, and short half-time presentations at sporting events.

So, rescue breaths were not eliminated for trained lay CPR providers, just for the much shorter and broader awareness of compression-only CPR.

As an authorized instructor of our core ASHI and MEDIC First Aid training programs, you are a critical conduit to students in clarifying the difference between traditional and compression-only CPR, and the limitation of compression-only CPR training.

We should remain committed to providing hands-on skills training to as many people as possible in both compressions and rescue breaths. We should provide awareness training in compression-only CPR when we can, but always encouraging those participating to go further and learn more.

All the First Aid Stuff That's Changed Since You First Learned It


When was the last time you took a first aid class? The ‘80s? ‘90s? Like everything in the medical field, first aid is constantly evolving, and what you may have learned to do as a first responder 10 years ago could be completely wrong today. Let’s take a look at some of the biggest changes over the last few years.

To help sort through all this medical knowledge, we talked with Jordan Ourada, EMS Liaison at HealthONE, who walked us through the most common procedures right now. He was also quick to point out that the research is constantly evolving, so if you’re in a position that demands it, keeping up with your first aid training is a must. Oddly, some of these standards have gone in and out of vogue over the years, so depending on when you learned basic first aid, some of your knowledge may still be up to date.

CPR Has Changed Completely


Cardiopulmonary resuscitation (CPR) was first introduced in 1960. Back then, the typical procedure was known as the ABCs: airway, breathing, chest compressions. You started with opening the airway to try and resuscitate the victim by giving them quick breaths through the mouth, then moved onto pumping on the chest to get the heart beating again. Depending on when you learned CPR, you may have also learned to put pressure on the patient’s windpipe to decrease the amount of air that entered the stomach. Back in 2010, this procedure completely changed.

Now, the recommended method is CAB: chest compressions, airway, breathing. One cycle of CPR includes 30 compressions, followed by two rescue breaths lasting about one second. The order changed because researchers found that the chest compressions are the most important part, and in a lot cases, the breaths are unnecessary. This type of CPR is best for drowning victims and people who collapse with breathing problems.

In fact, a “hands only CPR” or “compression only CPR” is now recommended for most emergencies we come across as bystanders (unless it’s a drowning victim or people who collapse with breathing problems. Regular CPR is still best in those cases). Ourada points out that in some cases, the breathing can actually do more harm than good and compression only CPR is recommended:

The American Heart Association is constantly studying and reviewing the most effective way to save a life in out of hospital cardiac arrest. While in the past it was common practice to do mouth to mouth resuscitation, it has been found that not only does that not help, it can make things worse by filling the belly with air making it more difficult to do effective chest compressions. It also increases the likelihood of the patient vomiting in your face which—let’s face it—is gross in addition to being hazardous to the health of rescuers. It is now recommended that the most effective way to resuscitate someone in cardiac arrest is consistent, deep and fast chest compressions without interruption.

Which is all to say, if you cannot give breaths, you should simply continue chest compressions at a rate of around 100 per minute (which is about the same as the song “Staying Alive”, as you may have heard) until help arrives or the person shows obvious signs of life-like breathing. It’s also worth noting that since CPR research is constantly evolving, it’s recommended that you take a CPR course every two to three years to keep up to date.

Applying Tourniquets Is Useful (Again)


Depending on when you took a first aid class, you either learned to apply tourniquets above bleeding wounds or learned expressly not to ever use one. Likewise, if you’ve ever watched any action movie ever, you just assume a tourniquet is appropriate for just about any kind of injury. However, studies published in the likes of the Journal of Trauma and this one in the Journal of Special Operations Medicine show the rate of complications is pretty low. Ourada explains:

Tourniquets were popular many years ago, then went out of vogue for a long time due to the risk of limb damage and compartment syndrome. In the last few years however, after extensive use and study by the military in the wars in the Middle East, tourniquets are back in a big way and have been found to be the most beneficial way to stop serious arterial (squirting) bleeding in limbs. You do want to be aware of how long it is on the limb as it does cause damage, but that takes a long time and ideally the injured person is on their way to a trauma center in that time.

So, when should you use a tourniquet? They’re best used to limit severe external bleeding on limbs. Before you apply a tourniquet, you should attempt to control open bleeding by applying direct pressure to the bleeding site until it stops. If it doesn’t slow down within about 15 minutes, then it’s time to use a tourniquet (and no, you don’t need to elevate the limb, that was also debunked). To properly apply a tourniquet, place it two to four inches away from the wound site, between the wound and the trunk of the body. Then, tighten it in a knot around the limb until the bleeding stops. Many first aid kits have tourniquets you can use that make the process a lot easier.

While tourniquets are back in vogue, it’s still only recommended you use them with proper training, so if you missed that in your first aid class, it’s worth heading back.

Don’t Induce Vomiting without Calling Poison Control


If you took a first aid class prior to 2010, there’s a reasonable chance you learned to induce vomiting when someone ingests a foreign, possibly toxic substance. It was so popular that people were told to keep ipecac around in the house just in case. It turns out this is a terrible idea.

The reasoning is pretty simple. In most cases, common treatments for when someone ingests toxic substances, (treatments like milk, activated charcoal, and ipecac), are unhelpful, and in some cases, harmful. Ourada says that depending on what the victim swallowed, inducing vomiting can do more harm coming back up than it did going down, so it’s always best to refer to the experts instead of going with some universal treatment plan.

Regardless of whether a first aid teacher may have told you, you should alwayscall Poison Control (1-800-222-1222) before doing anything at all.

Don’t Store Bare Severed Digits In Ice


When you lose a digit, say a finger or toe, the old advice said your best bet to get it reattached was to put the digit on ice and make your way to the hospital as soon as possible. While that’s partially true, and makes for a great scene in a movie, it’s not the whole story. Putting it directly on ice is a bad idea.

When you place an amputated digit directly on ice, you risk damaging it. Ourada explains:

Do not throw the digit straight on the rocks because that can freeze and damage the skin and vessels. It’s best to wrap the amputated part in cloth or paper towels and then put in a cooler or a cup of ice to keep it cool. Avoid direct ice contact and avoid placing it in liquid and water logging it. Get to a trauma center as soon as possible.

Once you get to a trauma center, they can reattach the digit provided it’s still in good shape. If things go well, the victim will regain use of it completely.

Similarly, if someone loses a tooth, the previous recommendation was to simply get to a dentist as soon as possible with the tooth in hand. Now, it’s recommended you store the tooth in Hank’s Balanced Salt Solution, propolis, egg white, coconut water, Ricetral, or whole milk. If none of these are available, you can also store the tooth in the victim’s own saliva until they can get to a dentist.

Never Put Something In a Seizure Victim’s Mouth


You may have heard that when you witness someone having a seizure, you should place an object between their teeth for them to bite down on so they don’t swallow or bite off their tongue. If your first aid knowledge is really old, you maybe also learned to restrain the victim. Both of these are incredibly wrong. Sticking something in a seizure victim’s mouth can cause them to choke, and restraining them can lead to broken bones or other injuries.03:03

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Seizures are tough to watch, because you can’t really do anything. The best you can do is clear the area and try to make the victim as comfortable as possible. Ourada’s suggestions are pretty simple:

Old wisdom says to place something in the victim’s mouth, like a wooden spoon, to keep them from biting their tongue. This is not recommended as you can do damage by trying to force something into their mouth, and it also creates a choking hazard. The best thing to do if you see someone seizing is to help lower them to the ground if they are not already there and try to put something soft under their head so they don’t strike their head on the ground while seizing.

Beyond that, the CDC adds that while your first reaction might be to offer water to a victim as soon as they stop seizing, you should always wait until they’re full alert before doing so.


Heat Exhaustion or Heat Stroke?

Safe at Home - Guide to First Aid and Safety for Kids

One of the most important functions that parents must do is protect your children at home and away from home.

Unfortunately, keeping your children safe at home is a very difficult task. In the course of a normal day, children, regardless of the age, are exposed to a number of potential dangers. These dangers could result in cuts, bruises and scrapes to more serious medical problems such as broken bones, allergic reaction and head injuries.

While it is not expected that parents will be able to treat all medical emergencies, it is very important to know what you should do if it happens at your house. The first step is to assess the extent of the injury. If it is a simple cut or skinned knee, cleaning the wound and bandaging it to keep it clean and dry may be all that is needed. However, if your child has sustained a serious burn or is in a great deal of pain, at trip to the emergency room or a call for an ambulance may be needed.

Medical care should only be done by a trained professional. However, by assessing the situation you may be able to provide some basic first care. To help parents provide proper care and to keep children safe at home, we have provided a selection of resources that you can use. But, remember if you are unsure of the extent of injuries, you must contact a medical emergency service or if they are mobile enough without pain, a visit to your local emergency facility.

Basic Disaster Supplies Kit

Why You Should Learn Compression-Only CPR

Learn CPR: You Can Do It!

Mayo Clinic: First Aid

Kids Health: First Aid & Safety

MedlinePlus: First Aid Tips

Boy Scouts of America: First Aid and Safety

Wilderness First Aid Basics

First Aid Fact Sheets

CPR Facts and Stats

WebMD: First Aid and Emergencies

Injuries & First Aid

First Aider's Guide to Alcohol

Broken Bones / Dislocations for Broken Bones

First Aid-Fractures

Emergencies and First Aid

First Aid & Safety

Basic First Aid: What to Do

First Aid Booklet

Common First Aid Accidents

First Aid Book for Kids

Child and Baby First Aid Tips

CPR on Kids

First Aid Kits

First Aid Kit Essentials

First Aid Tips to Teach Children

What You Need In A Family First Aid Kit

First Aid Measures Kids Should Practice

Credits to Emily’s List Girl Scout Emily who recommended that we add this page