TIA - Inpt vs. Outpt Management?

[Re3iRtH]

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Hey all,
Was just doing the World CCS cases, came across a TIA, while my
basic management was correct: Exam, CT head, aspirin, counseling,
d/c home, echo, carotid doppler etc.
Their explanation was to transfer patient to ward to do the same
management. Now, I already had my 2 blocks of EM as a TY, and it
seemed like every patient with a TIA with no gross medical issues that are
horribly managed, was monitored for a couple of hours and sent home, to
f/u the Echo and Doppler with PCM.
Thoughts?

 

[haresh]

Hey all,
Was just doing the World CCS cases, came across a TIA, while my
basic management was correct: Exam, CT head, aspirin, counseling,
d/c home, echo, carotid doppler etc.
Their explanation was to transfer patient to ward to do the same
management. Now, I already had my 2 blocks of EM as a TY, and it
seemed like every patient with a TIA with no gross medical issues that are
horribly managed, was monitored for a couple of hours and sent home, to
f/u the Echo and Doppler with PCM.
Thoughts?

best explanation from the web :

Whether or not TIA's get admitted or not is not really the issue, and no published guideline makes a specific recommendation in this regard. The issue is the timeliness of their TIA work-up. For example, if a hospital can get Carotid dopplers performed on a TIA patient in the ED, and they are normal, and the EKG does not show Afib, and the patients does not exhibit Afib while monitored in the ED, it is probably reasonable to start or advance that patient's anti-platelet therapy, arrange for a prompt outpatient echocardiogram, and discharge the patient from the ED. Many hospitals just admit the patient, because they cannot perform such an expedited work-up out of the ED. If you discharge the patient home without this initial work-up and the patient has a stroke before their work-up is performed, even if their stroke was not preventable, the care provider will be at high medicolegal risk."

So, on exam we can actually complete all the work on day 1. However, exam will not penalize you if you keep the patient for one extra day. Moreover, the risk of stroke in next 24 hours in the TIA patient is about 10% ...TIA is a warning. So you will be safe if you just admit and get all work up mentioned above, start anti-platelet and discharge 24 hours later ( this is applicable if neurological signs resolved completely).

If neuro signs are still significant or progressing, you must start tpa with in 3 to 4.5 hours if patient presented with in 3 hrs of onset of symptoms. However, the error-filled UW software reports results for emergency investigations in the ER much later than the usual report times used in USMLE exam Primum software ...this can alter your approach and can delay the Emergency management substracting your score. Be aware of the guidelines and practice the cases on Primum.

 

[Knicks]

best explanation from the web :

Whether or not TIA’s get admitted or not is not really the issue, and no published guideline makes a specific recommendation in this regard. The issue is the timeliness of their TIA work-up. For example, if a hospital can get Carotid dopplers performed on a TIA patient in the ED, and they are normal, and the EKG does not show Afib, and the patients does not exhibit Afib while monitored in the ED, it is probably reasonable to start or advance that patient’s anti-platelet therapy, arrange for a prompt outpatient echocardiogram, and discharge the patient from the ED. Many hospitals just admit the patient, because they cannot perform such an expedited work-up out of the ED. If you discharge the patient home without this initial work-up and the patient has a stroke before their work-up is performed, even if their stroke was not preventable, the care provider will be at high medicolegal risk."

So, on exam we can actually complete all the work on day 1. However, exam will not penalize you if you keep the patient for one extra day. Moreover, the risk of stroke in next 24 hours in the TIA patient is about 10% ...TIA is a warning. So you will be safe if you just admit and get all work up mentioned above, start anti-platelet and discharge 24 hours later ( this is applicable if neurological signs resolved completely).

If neuro signs are still significant or progressing, you must start tpa with in 3 to 4.5 hours if patient presented with in 3 hrs of onset of symptoms. However, the error-filled UW software reports results for emergency investigations in the ER much later than the usual report times used in USMLE exam Primum software ...this can alter your approach and can delay the Emergency management substracting your score. Be aware of the guidelines and practice the cases on Primum.

damn! time and time again I keep reading things like this. I don't want UW to affect my score like that.

What's the best way to overcome this???

 

[OveractiveBrain]

damn! time and time again I keep reading things like this. I don't want UW to affect my score like that.

What's the best way to overcome this???

The explanation is be conservative. if you've diagnosed "stroke" or "tia" you bring them in. Thats what you just learned. It has nothing to do with haresh's crap talk. The OP was using his PERONSAL TRAINING EXPERIENCE to answer a question that has RIGID RIGHT ANSWERS. He got the answer "wrong" on the test (should admit stroke/tia) because he did what he would have done in real life.

I disagree with it, and think TIAs should come in, but Im no ER physician. Honestly, I think the test wants you to assign "meh, this is no big deal" (home) vs "hey, this could be a problem" (wards) vs "holy crap! this guys gonna die!" (icu). I think we can all agree that Stroke is at least "could be a problem."

However, if you DID all the things you were supposed to (Carotids, Echo, CT, MRI, ASA) and didn't admit, youd probably have a small ding, rather than a gross violation, and would still succeed the case

However, this point of contention has nothing to do with the software and everything to do with differences in clinical practice.

And Knicks, You "keep reading" the "same thing" from the SAME PERSON (Haresh) who cannot get over this 3 -4.5 hour window deal. He blames his continued failure on one nuance of CSS software. You aren't going to tPA a TIA. The OP was asking about this particular experience. For the test, its best to bring them in for Obs = Inpatient

 

[Knicks]

^^ True. Good point(s).

 

[haresh]

The explanation is be conservative. if you've diagnosed "stroke" or "tia" you bring them in. Thats what you just learned. It has nothing to do with haresh's crap talk. The OP was using his PERONSAL TRAINING EXPERIENCE to answer a question that has RIGID RIGHT ANSWERS. He got the answer "wrong" on the test (should admit stroke/tia) because he did what he would have done in real life.

I disagree with it, and think TIAs should come in, but Im no ER physician. Honestly, I think the test wants you to assign "meh, this is no big deal" (home) vs "hey, this could be a problem" (wards) vs "holy crap! this guys gonna die!" (icu). I think we can all agree that Stroke is at least "could be a problem."

However, if you DID all the things you were supposed to (Carotids, Echo, CT, MRI, ASA) and didn't admit, youd probably have a small ding, rather than a gross violation, and would still succeed the case

However, this point of contention has nothing to do with the software and everything to do with differences in clinical practice.

And Knicks, You "keep reading" the "same thing" from the SAME PERSON (Haresh) who cannot get over this 3 -4.5 hour window deal. He blames his continued failure on one nuance of CSS software. You aren't going to tPA a TIA. The OP was asking about this particular experience. For the test, its best to bring them in for Obs = Inpatient

And I keep hearing the same talk from UW promoter "overactivebrain" who is obviously overactive in significantly supporting the errors on UW. People , use your common sense . Visit other forums and see what they are talking about these dangerous errors on UW. It is not my own opinion. Use your own brain and try to do a case properly on that ******ed software in designated time to manage a case. And Mr.Overactive, by God's grace and with the help of other respected courses; I have improved my CCS knowledge much more than what i gained from UW. So I think I am certainly better off than you with respect to guidelines. Anyway, it is disgusting to argue with this agents who are getting paid to cheat others. These people are obviously getting paid for promoting uw and this is the solo reason why these people are on this forum for the last three years...can there be any other motive? Unlike overactive said it is not one "nuance" on UW , it is several of them ( uw surgeons do not accept patients, false guidelines, violating the simulated times, total neglect of simulated time concept in ccs, no description of what is scored most on ccs, no details on what must not be missed in a case and many moreeee)...read other posts and problems encountered by other people on this forum.

I will be happy to discuss any CCS case challenges that you "real exam takers" are facing . Such discussion will be fruitful rather than repeatedly supporting and endorsing a commercial, selfish, error-filled usmleworld ccs.

 

[haresh]

^^ True. Good point(s).

the overactive guy said you do not tpa a TIA ...true but....
this "overactive" guy needs to understand that in presence of persistent neuro deficits, TIA can not be defined as "TIA" until 24 hours have elapsed. In other words, you will not know if it was TIA or CVA until 24 hrs of observation if neuro signs are persistently abnormal. If neuro signs completely resolved in front of your eyes soon after presentation, you can call it a tIA and do work up and send them home. But if some one has progressive neurological deficits, you do not sit in the ER and debate whether it is TIA or CVA until 24 hours. You want a CT scan stat. You act based on clinical progression and tpa it as soon as possible !!! Use clinical judgement...something that UW does not teach you.

My God, "overactive" ...no wonder you are living on promotion kickbacks because I can not see you practicing on your own as a physician!

 

[OveractiveBrain]

the overactive guy said you do not tpa a TIA ...true but....
this "overactive" guy needs to understand that in presence of persistent neuro deficits, TIA can not be defined as "TIA" until 24 hours have elapsed. In other words, you will not know if it was TIA or CVA until 24 hrs of observation if neuro signs are persistently abnormal. If neuro signs completely resolved in front of your eyes soon after presentation, you can call it a tIA and do work up and send them home. But if some one has progressive neurological deficits, you do not sit in the ER and debate whether it is TIA or CVA until 24 hours. You want a CT scan stat. You act based on clinical progression and tpa it as soon as possible !!! Use clinical judgement...something that UW does not teach you.

My God, "overactive" ...no wonder you are living on promotion kickbacks because I can not see you practicing on your own as a physician!