This workshop covers critical emergency medicine scenarios: for pulmonary embolism, clinicians must use age-adjusted D-dimer cutoffs (age × 10 for patients over 50) and recognize that stable patients with right ventricular dysfunction may deteriorate despite normal blood pressure; for stroke, the therapeutic window is biological rather than chronological, meaning thrombolysis can be considered up to 9 hours if tissue viability is confirmed through advanced neuroimaging, and patients with large vessel occlusions should be referred for mechanical thrombectomy within 24 hours.
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Workshop Emergências 2026 - Atualizações em AVC e TEPAñadido:
Hello everyone. My name is Jessica. Currently, I am a first-year cardiology resident at IMIP here in Pernambuco, and this course was a game-changer for me; it was fundamental. At the time I was doing my residency in internal medicine in Sergipe, and he helped me a lot in my daily clinical practice, and the theoretical foundation helped me to achieve my [music] spot in my cardiology residency today. The knowledge I gained from the course, I'm able to apply here in my cardiology residency. And that was very important, right? Because through extremely didactic classes, very, very relaxed so that you can follow the line of reasoning, very dynamic, very well articulated, I certainly recommend it. So, my rating is 10 out of 10. Thanks. [music] My name is Eduardo Ramos, I am a doctor, I work in Minas Gerais, excellent course. We received very high-quality lessons there, and quite adequate support [music] as well. And it's a course that added a lot to me, above all, the course gave me a great deal of confidence to do what needed to be done. So it's an excellent course. I recommend it to all doctors, to everyone who works shifts there.
It's a course that's worth the investment.
Hello, my name is Rodrigo, I am a [musician] doctor specializing in family and community medicine and also in traffic medicine. The course taught me a lot about dealing with various problems in clinical practice related to cardiology issues, giving us more confidence and peace of mind when attending to seriously ill patients, both in primary care, where I work with families, and in emergency rooms, where I provide urgent and emergency care. I highly recommend the course.
Excellent course, very didactic.
Hello, my name is Víor. I am a cardiology resident physician at Hospital São Paulo. This course has significantly contributed to my daily experience in cardiology, both during my residency and on- call shifts. The lessons are focused and the question bank is very comprehensive, allowing you to practice for music exams without sacrificing a solid theoretical foundation. Furthermore, I felt more prepared to discuss clinical cases and recent articles with colleagues and supervisors, which greatly contributed to my professional development. [music] Another point that caught my attention was the intuitive platform, the affordable price, and the exchange of experiences through the WhatsApp group, which made everything more dynamic and direct.
My name is Alexandre, I'm a cardiologist here in Rio de Janeiro, and I wanted to tell you that this electrocardiogram course on the platform is sensational. It made me remember a lot of these things, and I'm using it in practice now, so I think it's really worth it for its practicality, right? The cost-benefit ratio is very good, isn't it? And the [music] teacher's performances are suspended, right, man? It's fierce. That's it. I hope you enjoy [the music] as much as I am enjoying it. Big hug to everyone.
Hey guys. My name is Bruno Danda.
This year, 2020, finally brought me the coveted title of specialist from the Brazilian Society of Cardiology.
As we know, the TEC exam is very difficult to manage on your own, especially when it comes to setting a schedule and sticking to it.
Therefore, it is of fundamental importance to have the support and guidance of a team that focuses primarily on the TEC exam.
Why do I say this? Because it's necessary for us to study in a focused way to take the test. Through Instagram, Telegram, and WhatsApp groups. The team gave me all the support I needed to clear up any doubts. and to approach the exam feeling confident, secure in the knowledge he had acquired. So, I want to express my gratitude here for the support, especially from the editor-in-chief, Dr. Bruno Ferraz, who was there for me whenever I needed him, guiding me on what I should focus on when studying for the technical exam. My name is David, I am a medical clinic resident. I wanted to talk a little bit about the course here. So the course is very practical. It really addresses the everyday cardiovascular energies that will appear for you.
So I highly recommend the course. If you are truly afraid of attending to a cardiac emergency patient, you can take the course, and I guarantee you will leave well-prepared to treat them. Thanks.
Good morning, colleagues. I wanted to share this with you. [music] I am Italian, I am a doctor in Italy. I thought this course was very well done. Yes, the topics are comprehensive, up-to-date, and very well explained. Ah, I found it, I found this course very good for my clinical practice, for day-to-day work. Well, I'm finishing college, the emergency master's degree, so I thought this course would be good for my training. Oh, I've already signed up for an echocardiography course on the same platform. So, thank you very much, Bruno Ferraz and colleagues, and keep up the good work.
[music] Cartology questions, team, thank you very much. Excellent course, very good study platform.
In the thematic questions, it breaks down each issue, showing that it is indeed possible to pass the exam by perfectly understanding the content and applying it to our daily practice. Thank you all very much.
Hey everyone. Well, I wanted to thank the staff at Questões [música] em Cardiologia, Professor Bruno, Professor Ivio, and everyone else, who helped me a lot and were fundamental in my passing the society's certification exam. So, I wanted to leave this note as a thank you [music] to the Cardiology Issues course and I recommend it to anyone who wants to either update their knowledge or face this challenge that is the tech exam. Big hug and thank you again.
My name is Márcia, this year was my second year taking the PEC [music] exam, and choosing the cardiology questions was crucial to my passing. I am very grateful to Dr. Bruno, Dr. Udmila, Dr. Gabriel, and the entire team. So I am very grateful to the cardiology questions that provided me with this preparation, not only in theoretical content, but also in the mental aspect of how to approach an exam.
Hi everyone, just stopping by to say say thank you.
Goodnight. Good evening everyone.
Welcome to another broadcast of Questions in Cardiology. For those who don't know me, I'm Bruno Ferraz, editor-in- chief of the Cardiology Issues page.
I'm here with Professor Ludmila as well, who is responsible for the PE and Stroke modules in our course. That's why I extended that invitation to her. She's always up-to-date on these extremely important topics, she works in emergency situations, and she has a lot of experience in emergencies, so we can discuss these important issues.
Good evening, Ludmila, how are you? Good evening, Bruno. How's it going, everyone?
Okay, guys, let's continue with our workshop. I'm here, and I'll also take this opportunity to ask a few questions. I noticed that several students had questions.
We can't answer everyone 's questions via WhatsApp.
To access everything, you need to join the group in the course through the Minds platform. For those of you who have n't already, the link to register on the Mind platform is in the video description. You have to watch the class on the platform, and when you finish watching the class, you have to check in to confirm that you watched the class, which will then unlock the test. The test has 10 questions; the minimum passing grade is seven. If you don't get a seven, you won't be able to start the next test. The next test will open today at 9:30, which is about the time we'll finish this class, okay? It's important to follow this process so you can get your certificate, okay everyone? Regarding the e-book, we'll send it password-protected; we'll release the password today during class, okay? So just stay tuned to the class and we'll reveal the password to you, no problem at all, okay everyone? So, uh, just to recap the first night, yesterday we did one, for those who didn't watch yesterday, I invite you to watch it, the class is available on the platform. I invite everyone to watch yesterday's class; it was a class on chest pain, and we covered several details of the chest pain guidelines. Well, it's a very complex case, where most of the students who were here killed the patient. So, to show you that it's important to know the details of cardiac emergencies, and today we're going to look at some very complex cases as well, okay? And I want to know who's in the chat, right? This includes those who are already our students, those who are not yet our students, and those who want to become our students, okay?
So, I want to know who's in the chat, who's already our student, and where you're watching our broadcast from today. Gr is asking: "What about those who didn't take yesterday's test?", what do they do? You can take the test until Sunday. You can take the test until Sunday, no problem at all. You can do it today, you can do it tomorrow, you can do all three, okay? And the test started like this. Several people took the test, several people managed to take the test, okay? So, if you couldn't open the test, it's because there was some problem and you didn't watch the class on the platform. You have to watch the class on the platform. Beauty? So, there are people here from Belém do Pará, São Paulo, Santos, okay? Angola. So, we have people from all over the world watching our broadcast today. Here it is. Lucia said she managed to do it yesterday, right?
Oh, Miguel is one of our students, a student in our course. Thank you, Miguel.
Awesome, guys!
Guilherme is asking which platform, the Mes platform, where we respect our courses. It's in the video description. Registration is free, just sign up.
The link is in the video description, okay? We also sent this by email.
Beauty?
Awesome, guys! So, let's start our broadcast, okay? Let's begin our broadcast. Let me pass by here.
Awesome, guys! As you know, there are people from London. Wow, there are people from London watching our live stream today. Very cool.
Let's go. Very chic.
Okay, come on, everyone. So today we're going to talk about two diagnoses that always come up during the emergency room shift. Yesterday's diagnosis was also crucial. We talked about chest pain. Anyone who works the emergency room knows that chest pain is a common problem on every shift. Today we're going to talk about pulmonary embolism and stroke, which also come up every shift.
You need to understand these entities, okay? And tomorrow we're going to talk about atrial fibrillation and ACS. Obviously everyone needs to know the new ACLS, right? These two guidelines came out this year, okay? These TEP ABC guidelines are from 2026, they came out at the beginning of the year, okay? And there's some really cool content for you in our e-book. So we'll reveal the e-book password during the lesson.
So stay tuned because we're going to reveal the e-book password, okay? So let's start with a few initial questions, first by telling a true story, okay? Well, this story happened to me, it must have been about 5 years ago. Well, I don't know if you all know, but I'm also an endocardiographer, right? I work at a large private hospital here in Rio de Janeiro, and I also work at the university.
I was, uh, I was on duty, doing weekend rounds, and then suddenly the colleague who does rounds on the floor said: "Bruno, Bruno, help me, help me." Here we had a patient who had been admitted for a routine procedure. The patient had benign prostatic hyperplasia (BPH), and he was admitted for a catheter replacement. Point.
The patient had already been discharged. High quality.
When the patient changed clothes to leave, when he got up, he had an episode of acute dysnea, turned purple, fell onto the bed [clearing his throat], lay down on the bed again, right? And then they called me, right?
He said, "Bruno, come here, because since I also do ultrasounds, help me out here. See if you can do a quick ultrasound here so we can figure out the diagnosis." And there was an ultrasound machine nearby. I grabbed the ultrasound machine, and right then and there I did the subcostal window; the right ventricle was stationary. I said, "Well, the diagnosis has been made." The patient experienced sudden antipinaia. With the right ventricle (RV) stopped, the diagnosis is pulmonary embolism (PE), right? showing how important it is when you have the right tools, know how to use them, and develop the proper reasoning, you make the right decision and the fastest decision possible. Even though people got the diagnosis very quickly, right?
We recommended thrombolysis, and at the moment we were administering the thrombolysis to this patient, the patient stopped breathing. And when this patient stops working, it's extremely difficult to remove them, because thrombolysis can't reach the thrombus; we ca n't dissolve the thrombus. It's even debatable whether or not we should perform thrombolysis on a patient who has stopped breathing due to pulmonary embolism, right? But in this scenario, the patient is immobile, so there's no harm to be done, right? So we tried, we tried, we still performed thrombolysis, but the patient didn't recover, showing the severity of an apparently normal patient, a patient ready for discharge, and the patient develops such a severe condition that he dies because of it, okay? So, we can't be careless when it comes to preventing pulmonary embolism, right?
So we have to be very aware of this risk. Alright, guys? So, here's the first question of the night. Where do you most often make mistakes in your reasoning about pulmonary embolism ( PE) during your shift? You suspect it too late, you don't usually think about PE, you end up ordering dedimer from everyone and end up confused by the result. You are unsure when to administer thrombolysis and when to use your anticoagulant, or you don't know when to refer for catheterization or treat clinically. What are your thoughts on this matter? I'm going to put the question here and you're going to answer with the numbers, okay?
Just a minute.
I thought it was already configured yesterday. It did n't stay. He was. It's there.
So let's go. You can answer, guys.
Place it up here. You can answer, guys. What do you do in this scenario? Answer 1, 2, 3 or qu or six.
What is the main difficulty you face when dealing with patients with pulmonary embolism ( PE) during your shift?
One important thing, guys, there's no point in sending messages. Some people are sending messages via WhatsApp. The instructions are clear. The instructions were given in the WhatsApp group.
Guys, you need to register on the platform. The link is in the video description, okay? The link is in the video description. Just sign up, watch the class, and take the test, okay? It's not difficult.
Several colleagues have already succeeded. Just follow the correct steps, okay?
So, look, I'm seeing here that most of it is pretty divided, right? Most people are unsure when to administer thrombolytics and when to administer anticoagulants, right? And some colleagues suspect something very late, right? So this is the main difficulty that colleagues face when they identify a patient with pulmonary embolism during their shift. Alright, guys? So let's continue here.
So let's begin with our first clinical case. First clinical lesson: don't fall for fake news, okay?
It's a patient who arrives at the emergency room at 2 PM. It's an elderly woman who is brought in by her son. She is a 78- year-old woman, a suspected diabetic with osteoporosis, with no history of thrombosis, and she comes to you with a complaint of mild dyspnea with less exertion for the past 5 days, which worsened today. So she thought it was to raise her blood pressure, took her antihypertensive medication, and came to the emergency room. The patient arrives with a blood pressure of 132/78, a heart rate of 96, a respiratory rate of 18, and an oxygen saturation of 95. She is afebrile, without edema, without calf pain, and has a normal physical examination. And I ask you, what is the pre-test probability for this patient? Would you order dedimer for this patient? So, this is my first question here, I'm going to put the poll back on the screen, okay?
Well, in this case, the els is probably low, probably low, okay?
Without classic signs, what is their behavior? First, order a dedimer test; if negative, rule out PE and investigate other causes.
Two, I'm not ordering the dedimer, the probability is very low, I'll investigate and see if it's pneumonia. Three, I ask for edimer, but I anticipate that one dose may be due to other causes.
And in the fourth year, I'll go straight to the year of tomography without any finger-pointing. Comment below, guys, comment in the chat what you would do with this patient. You 're on duty there, you have to make a decision, right? That's how it is, this patient arrives at the emergency room every day. Every day. Every day. Anyone who works shifts knows that this grandma always shows up for her shift. So, I want to know what you would do in this scenario. Tell me about it. Just type in the chat.
It's to find out what you guys were talking about in this chat. Most are going with two, don't ask for dextrose, very low probability, investigate and pneumonia.
Is there any chance this sick person is tetep? It does exist, right? The patient is tired, right? It could be PEEP, it could be, right? That's not our first hypothesis. Would n't dedimer be a good option for us, at least to rule out PE?
What do you think? Leave a comment below. Leave a comment below.
So, most people are going in pairs, huh?
Most people go in pairs. A significant majority in the case of two. In second place is number three, which asks for dedio, but anticipates that, being elderly, he may be driven by other causes, right?
Beauty. That's awesome! Let's begin our discussion.
It was requested that dedimer be requested, right? Dedimer was requested. The dedimer came back at 720, and the hospital's reference value was 500.
Cordwells were calculated, and the result was zero, indicating a low probability, but the dedimer came back at 720, above the cutoff point. Now I'll move on to the next question. You order a CT angiography for this patient.
So let's go, let's come back here. I'm going to reset our poll here and we'll show it again.
Yes, if the amount is above 500, the protocol dictates an investigation. Two, no, the Els is low, probably the dedimer is elevated for another reason. Three, it depends. I need to calculate the age-adjusted cutoff point. And four, I'm requesting other tests to decide and an X-ray. Comment below, guys, what would you do? You guys are on duty, right? And it has to be defined, it has to be defined.
Oh, IT Caroline said that negative dimer doesn't rule out PE. It doesn't rule it out. Are you sure about that?
It will be?
Gustavão did very well. It is impossible to apply the perqu rule. Gustav is our student. Gustavão knows everything.
Let's see who's winning now? Number four is winning. I request further tests.
Eccardiogram, radiographs. Number four is winning by a landslide now.
Some [clearing throat] colleagues scored one, it's tied at two, right? Okay, let's see, let's see then. Let's begin our discussion of this topic here.
Ludmila, tell us about it.
I can have a patient with 500 dedimer, a grandmother, do I value her or not? Tell us what happened. Well, in this latest guideline, we incorporated many scores, right? It's a very comprehensive guideline, but it has changed a lot compared to the guidelines of European and American society, okay? Well, even in the previous guideline, the ESC guideline, there was already a recommendation to adjust the didimer according to the age group. Why? Because we know there is a linear relationship, meaning that the dedimer is directly proportional to age. So we can't assume that a 100-year-old patient will have the same cutoff value, even if the lab provides 500 as the upper limit, it won't be the same as a 20-year-old patient. So how do you adjust it? So there's an age-adjusted dimer (D10) that was validated in the latest American Heart Association (AHAR) guideline, but which had already been recommended in the previous ESC guideline as well.
Specifically, for the population over 50 years of age, you have to take the person's age and multiply it by 10. It's easy to understand, because usually the cutoff point for D10 is 500, so it's age times 10. So, up to 50 years, 50 x 10 equals 500. Therefore, above 50 years, if it's 60 years, then a D10 of up to 600 is considered normal because it 's adjusted for age. This is important because dedimer is a good screening test, right? So, the goal of us requesting dedimer is... And we assess whether the patient has a low or intermediate probability, because when you think, "Man, I do n't think it's a PE, it doesn't look like a PE," you're going to order a test to confirm or rule it out. Do you think it 's not PE?
The patient's demeanor, of course we ca n't base it solely on demeanor, but we have to observe it, apply the scores there, it's Geneva, Wels, and so on. But if you think that pulmonary embolism is not the main hypothesis and you calculate, you use a pre-test calculator which is, for example, the ELS or Geneva calculator and you see that it is a lower or intermediate probability, you will order a test to rule it out.
So, in a patient with low or intermediate probability, a negative dedimer does indeed have exclusionary power; it has a high negative predictive value. In other words, the fact that it comes back negative gives you the assurance that you can release the patient, because in principle, PE is not the primary diagnostic hypothesis. But there's a problem, right?
We know that the dedimer test is very sensitive; it's a good screening test.
So we joke that sneezing increases the dedimer, and pneumonia itself can increase the dedimer. We saw that COVID-19 caused an elevation in dedimer levels, right? There came a time when adjustments were made according to the dimer, empirical anticoagulation was performed, and so on. But we know that there are several confounding factors.
The patient who is hospitalized, the patient who has neoplasia, especially metastatic neoplasia, pregnancy, PPER (post-exposure prophylaxis), there are several confounding factors.
So we adjust the dimer for age, but we need to know that a positive dimer doesn't necessarily mean a PE (pronounced pulmonary embolism). That's why we routinely need to get a confirmatory test.
But before we start asking for a CT scan and, in quotes, condemning several people to undergo an exam that, in principle, involves radiation, there's a theoretical risk of contrast-induced nephrotoxicity, it's a less readily available exam, and the patient could have an allergic reaction, right? Those are potential risks, right? So, in order to avoid performing these unnecessary tests, there are some other criteria, right? So, one very interesting incorporation of this dichotomy was something that was already being discussed in emergency medicine, which is the score perk, right?
So, PERK is an abbreviation for pulmonary embolism brew out, right? So, it's a rule for you to exclude PE. So, that patient who scores negatively on all eight points—no one needs to know exactly what those are, okay? That patient who scores negatively on those eight Corperk points, okay? At first glance, it seems like it shouldn't be a case of PE (pulmonary embolism). So, this patient who has a low probability, and you evaluate the SCOPER score, this patient, by chance, because she is over 50 years old, she would no longer be scoring negative, she would have a point there where she wouldn't be a " no," okay? So, with this patient, we couldn't, so to speak, afford not to order dedimer. Overall, in the low to intermediate probability scenario, we'll be using dedimer. But if you apply this scorpion test to a patient who you don't think has pulmonary embolism, there's a way, the way we say low scorpion test, low Geneva test, and we apply this scorpion test, patient with low probability, negative scorpion test, in principle you are authorized not to order the dedimer test. Given that PE is not their primary diagnostic hypothesis. This patient would score at least one point.
So, in that case, we would need to resort to dedimer. The patient has an intermediate probability of pulmonary embolism, but that's not the primary diagnostic hypothesis yet.
The biggest benefit of you asking would be because it has a higher chance of being a pulmonary embolism, okay? Well, this is a test to filter out which patients need or don't need a CT scan. That patient has a high probability, we just have to think about it: are you sure it's a pulmonary embolism? Do you want to order a test to rule out or to confirm? Do you want to order a highly specific test? A highly specific test is a confirmatory test, which in the case of PE, the problem isn't in the parenchyma, it's a problem in the vasculature; there's the formation of a thrombus that obstructs it. So the preferred examination isn't a CT scan, okay? Be careful, everyone. Oh, she had a CT scan, and it was normal.
It's a CT scan with contrast. This is not just any CT scan with contrast, or angiotomography; it's a vascular study. You perform the contrast and there's a filling defect, documenting that you have a material that is classically a thrombus, right? An organic material that obstructs circulation, okay? So that's the motto, right? Remember that a high probability is a confirmatory test, okay? As we mentioned, the diuretic is adjusted for the age range, so up to that age range, up to 750, you don't need to order diuretic because it's age-appropriate, okay?
And besides that, okay? He also made use of another algorithm, which was also validated in this guideline, which is the EARS algorithm, okay? It's the EARs algorithm, it's another calculator that aims to adjust the cutoff point for the dedimer according to the pre-test probability, okay? So he takes into consideration whether the patient has signs and symptoms of DVT, okay?
Given that DVT and PE are part of the same disease spectrum, which is VTE, right?
Venous thromboembolism, if the patient has thrombosis and if the patient has a clinical picture more likely to be pulmonary embolism, okay? It's that patient who has a certain appearance that you think doesn't suggest a PE, meaning one who doesn't score high, doesn't have motility, doesn't have signs of DVT, PE isn't the primary diagnostic hypothesis, you tolerate a dedimer adjusted for that probability of up to 1000, okay? Let's say the patient is 80 years old, the cutoff point would be 800. In theory, you would have to order a CT scan. But now, in this patient, if you do this other risk calculator, and it does n't score at all, up to 1000 is considered normal, okay? Now, what about that patient who scored one more high dedimer value above 500? Why? Because between 500 and 1000 we say it's like a gray zone within a gray area, right? Many patients will have elevated dimer levels, even when adjusted for their age range, and you're avoiding unnecessary anesthesia. So there have been a lot of changes, right? So, this perk was also incorporated, along with the validation of the age-adjusted DEDIM and a flowchart based on the EARS protocol, okay? So, dedimer, what is it and what is it used for? As we've already said, this is a patient with a low to intermediate probability, okay?
It's not a confirmatory test; it increases in several situations. It won't detect a filling defect in the pulmonary circulation, okay? Classically, the cutoff point is 500, but in the population over 50 years old, we need to adjust for age range, and the rule is clear: you multiply the age by 10, so 80 years is 80 x 10, meaning that up to 800 is considered normal, adjusted for age, okay? That's the name of the study, adus PA, right?
The study that was done to validate the application of the age-adjusted digital designation is precisely what this study aimed to do. And when we're not going to ask, when the patient has a certain way about them, what exactly is that "way about them," folks? It's not subjective. You used a pre-clinical pre-test probability assessment calculator, right? It's the Scords Geneva.
If the probability is high, you don't want to rule out PE, you want to confirm it.
So you ask for a confirmatory exam, which is usually a CT scan, okay? Okay? But eventually we can also make use of scintigraphy, okay? But usually, before a CT scan of the pulmonary arteries in the chest, the protocol for pulmonary embolism (PE) is followed, okay? Well, we don't do the dimer test in theory; if this patient eventually had a negative finger, it wouldn't be possible to rule out a pathology, okay? And remember the false positives in the elderly, that's why we adjust for those over 50 years old; a patient with pneumonia may have an enlarged finger. So, if you ask for a finger for some reason and the patient has pneumonia, okay? If the image doesn't show a pulmonary infarction, then there's no flipped classroom approach, so proceed with pneumonia treatment, okay? Neoplasia, especially metastatic neoplasia, pregnancy, postpartum period, post-surgery, heart disease itself, stroke, right? Situations where you have an increase in prothrombotic activity, right? That's traumatic, isn't it? Well, the fact that the patient has a positive finger test doesn't mean he has a pulmonary embolism, right?
It is a marker there of fibrin degradation.
Good one, Ludmila. So let's move on now. Are there any remaining questions, are there any doubts here, guys? I saw that London for Everyone asked: "But can I order an angiotomography for this case?" Not with this patient, right?
Because if the patient has it, when we do the new dedimer cut for him, he's [clearing his throat] within a normal range, right? An elderly patient, right? The finger is elevated, but when we use the age-based cutoff point, it 's not elevated. So it's falsely elevated, right? That's exactly what we were explaining here, okay?
So, in this case, it doesn't make much sense for us to order a CT scan for this patient, okay?
Let's move on to our next case. Did anyone have any questions about this? If so, please comment in the chat and we'll try to answer them. Beauty? But did you like this first case? Did you learn anything? Did you know that? Were you already familiar with this issue of dedimer? Do you use dedimer a lot in your clinical practice, in the emergency room? Leave a comment in the chat so we can see how your practice goes and if we've added anything new to your knowledge. Beauty? Okay guys, let's move on to case two. Case two is the case where that help changes everything. So, let's start here. This is a patient who was admitted for medical treatment. The patient has been with us for 4 hours already.
He is a 55-year-old man who traveled by car for 12 hours to visit his family. Moderate dyspnea at 12 o'clock, right-sided pleuritic pain, and mild hemoptysis. Oh, what Ludmiro said, oh, it already has that strong smell, oh. A patient with prolonged mobility, spinal pain, pleuritic pain, hemoptysis, looks and feels like they have a pulmonary embolism, right? He arrives with a blood pressure of 104 over 68, an elevated heart rate of 112, a respiratory rate of 22, and an oxygen saturation of 91% in ambient air. And we do the cord tests on this patient, seven points, high probability.
So, as we've already discussed, we're not going to go into that area again, but this is a patient who needs to go for a CT scan, right?
I think we don't have much doubt about that. This is a high- probability patient. So here we're going to show you the CT scan. I'm going to grab my little pen here.
No felt-tip pen, I'll show you how to do it with my laser sharpener, okay? But first I have to take it off, I have to pause it first. Hold on a minute. Can you see this here? Oh here, oh, oh, oh, oh, oh, oh, oh.
I paused, I paused. Oh, look at the big one! Can you see the blood clot here?
Oh, I'm going to get my laser pointer.
See the blood clot here?
Look at that huge bump! Look at that crash!
See? Here I have a chest CT angiography. Here I have the pulmonary branch, the ascending branch here, the descending branch, and we have the pulmonary branches. So there's a bump, a filling defect here, [rumbling] right at the fork.
Then a huge thrombus, a huge thrombus. So it's a significant PE (pulmonary embolism) in this case, right? So here we see that the thrombus extends, right? And it's a very interesting detail that we also often see in tomography. I'll pause here to show you. Oh, here, look. And I returned.
Let me show you right here at the very end. Oh, I can already see from the CT scan that it's serious. Hey guys, look at the size of the VD! Look at V here, poor thing, all squeezed in, all squeezed in. The big VD and the tight V. So, with that CT scan, I already had a significant understanding. I have a very high VDV ratio here, right? The VD is huge here, it's compressing my VR, okay? So I can already imagine it's a pretty serious situation, right? But as a student of medical issues and cardiology, he knows how to perform echocardiograms. So, he knows how to perform an echocardiogram; he takes the trachoma and then immediately performs the echocardiogram. And what will he think? You'll find it here, look. I want to know, does anyone know the name of that sign? Write in the comments if you know the name of this symbol. I want to see who can guess the name of this sign. First person to guess correctly. Oh, there are people talking here. Tricia is asking why the VD is so big? Why is VD so big?
Why is VD so big? Why did VD grow? Guys, when God created our hearts, he also created a muscular VR headset because I need muscles to pump it up. The VD doesn't need muscle. VD needs to be lenient because I have variations in blood glucose levels. VD doesn't have much muscle.
VD is tiny because it needs to adapt to the soft tissue. If you drink 2 liters of water, it needs to adapt to that 2 liters of water. If you receive a 2L intravenous infusion, he needs to adapt to that. His right ventricle (RV) needs to be able to adapt to the blood volume. Not V. The V needs to have the strength to pump.
So, since his right ventricle is very malleable, when I have an overload, I have a pulmonary embolism, I have a thrombus lodged in the lung, what happens? It overloads the whole system, it clogs everything up, VD grows, okay? VD is growing.
Gustavo, Gustavo got McConnel right again. Ingrid also got McConnel's signal right. Valeria got it right, but she wrote it wrong. Carolina also put Marcell on the show, I don't know if he's being cheated on, but poor Mac, right? This is the famous McConnell sign. What is McConnel's sign? I have apical hypercontractility and asynesia of the basal portions, which is very typical of pulmonary embolism. I see it here, look. Here I have my V, left atrium, right atrium, right ventricle. Look how big it's gotten! Usually his V is quite small, right? It looks tiny here. And I even have right atrium overload here. Two right cavities are overloaded, okay? So I have severe PE. I have a severe pulmonary embolism. But what was our patient's blood pressure like? It was good, wasn't it? The patient's blood pressure was good, right? So many people might think: "Oh, it's fine, the pressure is good." Right? And that 's the echocardiogram report. And we also have the information, look, the patient has an elevated troponin of 80, ultra- sensitive troponin, okay? And a BNP. And here the troponin cutoff point is nine, okay? And the BNP was also elevated at 680, patient not in shock.
So you're on duty, and this patient comes to you. I want to know what you would do in a situation like this, okay? So, guys, I want to know what you would do when faced with a patient like this.
Full anticoagulation, await clinical evolution, and thrombolysis only if decompensation occurs.
Two, immediate systemic thrombolysis, because right ventricular dysfunction justifies the risk. Three, referral for catheter-directed thrombolysis or percutaneous thrombectomy. And four, anticoagulation plus ICU with rigorous monitoring and multidisciplinary decision-making.
Comment below, guys, comment in the chat what you would do. You're on duty, are you dealing with a patient like this? A very common patient, right, Ludmila?
It's the day-to-day, tough decisions, right? Like yesterday, yesterday is there with me, intern is a disease that, when in doubt, think of PE, right? As Bruno mentioned, the presentation could be a cardiac arrest, it could be dyspnea, it could be a condition already progressing with respiratory issues, it could be a case of shock, right? It could be anything, right? Just think about it, you have to consider the possibility of pulmonary embolism, especially since it's a very serious condition, and if you eat a fly, you know, what happens to the patient? The patient dies, dies well, the skin is at a non-shockable pace, right, classic, it's a cause, it's not there, right?
No one goes straight to full anticoagulation, waits for clinical evolution, and only deals with thrombosis if decompensation occurs.
Nobody's going for that, nobody marked option one, nobody liked option one.
Just because I said it, someone will mark it from here, look, it'll be a few seconds, someone will mark option one. Just because I said it, I didn't say that was the answer, okay, guys?
Just pointing out that most people are going with number three, right?
Catheter-directed thrombolysis or percutaneous thrombectomy. That's it. Let's wait a little longer for the staff to respond.
Let's see what people here think. Awesome!
Mostly three and four.
I think the real question here is between three and four, right? What would be the best strategy, right? But with the number three gaining a certain degree of advantage, right? Okay, let's begin our discussion.
So, let's begin our discussion here regarding this clinical case.
Come on, Ludmila. The first thing we need to do is classify this patient, right? AND. And this new guideline brought new things for us. Tell us about the latest news regarding the guideline classification.
Wow, there were so many new things, right? My God in heaven. So, remember that the old guidelines, right, from the European Society, from the American Heart Association, basically divided PE into three large groups, right?
So, high-risk PE, right? What is high risk? High risk of death, right? The patient arrives with hemodynamic stability, right? It classically presents with hypotension and signs of hypoperfusion, okay?
What people used to call massive PE, which is a term we don't use anymore. Low-risk PE, okay?
Which is the case for most people, right? And it's an intermediate risk, okay? That's not high risk, right? An intermediate risk that can be low-intermediate or high-intermediate, based on the presence or absence of right ventricular dysfunction and markers of injury, such as troponin, myocardial injury, right?
Whether it's NT for BNP or BNP. So, it was basically these three large groups, okay? And the indication for thrombolysis was basically for patients who already had instability, which is a high- risk pulmonary embolism.
So, in this latest American Heart guideline, instead of having three classifications, there were actually four, right? Because the intermediate risk was subdivided. He's now sub-classified it into five types, right? So, category A, category B, C, D, and E. And gradually, as you increase the distance from the letter, the letter gets bigger, okay? That's why he puts it in colors, right? He puts it on in red, right? Because there is an increased risk of morbidity, mortality, and death as your condition worsens and you move up in category, okay? It's a disease that we know isn't static; it 's dynamic. So the patient's condition can worsen when moving from one category to another, okay?
Precisely in accordance with the clinical evolution. So, category A, what we can eventually see, is actually the classic diagnosis from the radiologist, right? It's that patient who went, for example, to have a screening CT scan, okay? He has a neoplasm, he's undergoing staging, he even uses this example in the guideline, okay? I don't know, maybe a lung cancer. I went to have a CT scan with contrast, I didn't go for an angel CT scan, but by chance, when they administered the contrast, they saw that there was a filling defect in the pulmonary artery segment. It's a subsegmental PE, it's a subclinical PE, the patient is asymptomatic, it's an incidentaloma, meaning the patient didn't have this diagnosis, they have no complaints, they didn't actively present with those complaints, they underwent a complementary exam or the patient had coronary angiography, okay?
Because he was stratifying one, he was asymptomatic at that moment. You discovered a pulmonary embolism there; it was an incidental finding, okay? Category B refers to patients seeking medical attention, whether they're in the emergency room, the ICU, the semi-intensive care unit, or a general ward—in short, those who have symptoms, okay? But he has a low clinical severity score; he doesn't show signs of significant repercussions.
C, the one that's symptomatic, but scores higher, right? So, C is that patient who, for example, has the foot, right? Nowadays, we have various scoring systems. This guideline also brought about five or six scores. So, classically we had the PES, which is an abbreviation for pulmonary embolism severity index, that is, an index of severity of pulmonary embolism, okay?
Nobody needs to know this by heart, but we need to know when to apply it, okay? And according to the PES, a higher PES, right, above 85 points, or a modified PES greater than or equal to one, there is an increased risk of mortality, okay?
Well, this is a patient who is already in a more critical condition.
Category D refers to patients with imminent cardiopulmonary failure, a pre-shock state, patients who begin to show signs of hypoperfusion, compensated shock, patients who experienced transient hypotension that resolved, and the extreme case, patients who are either in cardiac arrest or experiencing extracardiac obstructive shock.
Oh, remember, like Bruno said, right? Well, the patient with PE, he/she has the pathophysiology of PE with severity, okay? Yes, it's precisely the dysfunction of the right ventricle (RV). That's why, in a patient who arrives with hypotension, in a differential diagnosis of shock, we might use an echocardiogram, a POCOS protocol, or a RUSH protocol, for example.
What do we need to evaluate? differential diagnosis of shock. So, a patient in shock has hypotension, shows signs of impaired perfusion, and a subcostal ultrasound was performed, okay? And he saw that VD is greater than VE, so VD should be less than 0.9. If the right ventricle (RV) is larger than the left ventricle (LV), then there's a displacement of the septum into the left ventricle, right? The patient has evident right ventricular dysfunction. What causes acute right ventricular dilation along with a condition of potency? It's called PE (pulmonary embolism) because pulmonary circulation is a low- resistance circulation. So the VD isn't used to dealing with pressure overload. He is acutely unable to hypertrophy. So what does he do?
Dilata. It dilates and causes dysfunction. This leads to a death spiral. So, a patient suspected of having a pulmonary embolism who is unstable must have right ventricular dysfunction. If he doesn't have right ventricular dysfunction, pulmonary embolism doesn't justify the instability. If he needs to assess whether he has sepsis, then ultrasound, including P of Care, is very helpful in the differential diagnosis, right? You'll see if the veto is hyperdynamic, if the patient has, say, anechoic fluid, or tamponade, which isn't the focus of this lesson, but to remember that echocardiography is a very important bedside examination, especially in unstable patients, because it allows you to make a differential diagnosis.
In fact, it doesn't score much in the guideline, but in other guidelines, since 2019, the ESC guideline already points out that in a patient who is unstable, for whom you cannot perform an angio-CT scan due to instability or unavailability, in the absence of contraindications, you are authorized to perform thrombolysis, in a patient who has a high probability of PE, presents with a suspected high-risk PE, that is, is unstable or dynamically unstable and has, in principle, impaired RV function. You can even administer thrombolysis to this patient. Awesome!
And here's a really cool detail that's important to mention because many people don't know it.
Do you know why patients with pulmonary embolism die? The patient with PE dies because the right ventricle becomes so swollen that it compresses the left ventricle, and the ventricle stops lying down, okay? That's why the patient dies. I've already seen images of seriously ill patients like that, with their condition progressing severely; it was on CT scan. The patient, I've seen a CT scan that showed the garden was collapsing.
And then the signs of severity are when you see a lot of contrast and it's trapped in the vena cava, because the contrast agent can't reach it.
Exactly. Contrast reflux into the cava. It's a sign of severity that we also find in CT scans.
So that's what the patient dies from, right?
So, let's dry down the more serious categories a little, Ludmila, now category C, which you already mentioned.
So we have category C, which is the symptomatic patient, but there's already a sign of greater severity, okay?
But there's no clear clinical deterioration, okay? So now C is subdivided into three categories, okay? Well, B is B1, B2, C is a bit trickier because it 's C1, C2, C3, and D1 and D2, okay? Well, C refers to the patient who has a higher PEZ score, and has other scores, okay, that he uses, like the BOVA score, for example, news, news that we use for sepsis, okay? Well, he even uses the shock index, right? It's a ratio you can see at the bedside, which is the proportion between heart rate and systolic pressure. Well, in a patient who has a normal right ventricle (RV), whether ideally determined by echocardiography or even by CT scan parameters, as Bruno mentioned, the RV-LV ratio is classically up to 9. The RV must be smaller than the LV. The VE is a bigger camera, okay? If your VD is equal to or greater than 1.2, especially if it's above 1.2, that's a criterion that likely indicates your VD is very dilated, very dysfunctional.
Biomarkers, as we've already discussed, include troponin and BNP, or NT for BNP, okay? If the patient has one or the other, then it's C2, okay? Well, if the patient has both abnormalities, that is, he has right ventricular dysfunction, okay? Yes, it's documented, and he has an altered biomarker, okay? Whenever there is right ventricular dysfunction, remember that old concept from the classification, even older, which was submassive pulmonary embolism, right? It's the patient who isn't unstable, but has right ventricular dysfunction, which, as Bruno said, is the pathophysiology of severe pulmonary embolism, right? It develops into extracardiac obstructive shock, okay? Remember that this patient, right, from category C, starting from C, we have to activate the pulmonary embolism rapid response team, which is the PERTIME, okay? What is pertime? It's like a hard team, you know, for decisions involving potentially seriously ill patients. So you're going to call on the emergency physician, the intensivist, the pulmonologist, a vascular surgeon, the interventional cardiologist, the cardiologist, the radiologist, the pneumologist. There are several specialties that share the common goal of making a more appropriate decision and not leaving the decision of whether or not to perform reperfusion treatment, which is thrombolysis, or mechanically thrombectomy, to just one person, okay? Awesome!
It's important to remember that in this patient, it's important to measure lactate levels, okay? Lactate was very important in this guideline and is sometimes an initial parameter for indicating poor perfusion.
So lactate is important in these patients, right? Because they might already be reaching that stage, right, Ludmila? Yes, he's sometimes in a state of compensated shock, he has normal lactate levels. And lactate is a test that we collect in a blood gas analysis, a test that is inexpensive, readily available, and quick.
Imagine you're treating a hypertensive patient, the one he mentions here, a patient who is hypertensive, uncontrolled, with refractory resistance hypertension, who has a higher baseline blood pressure. If the patient falls, if the fall is greater than 40 mm, right? Eh, or the patient he has has elevated lactate. What does elevated lactate mean? Anaerobic metabolism. Initially, an anaerobic environment. There's a shock, is n't there? A shock that's sometimes hidden, right? An imbalance between DO2, oxygen supply, and oxygen consumption. This shows it at the micro level, right? In that case, the microvascular microemergency, lactate is a parameter that we use in sepsis and also in cardiogenic shock, and now also in a more consolidated way in extracardiac obstructive shock, which is pulmonary embolism, right? So, give that patient who's showing early signs of organ failure, it's practically a pre-shock, okay? Remember that he even mentions expansion with liters, remember that there is a reverse body high effect, we can't just start rapidly opening the IV in a patient with pulmonary embolism, precisely because the right ventricle, with increased pressure, dilates and distends, shifting the interventricular septum into the left ventricular cavity. The V, as Bruno said, becomes too small. If you increase the volume of fluid, you reject more enduscripts, which means you create that classic " death spiral" that we always talk about in our courses, where the patient reduces left ventricular output secondary to an increase in right ventricular volume. So, be careful when adding volume. Ah, okay, I'll start the IV drip slowly, I'll take it easy. If it's a very heavy pulmonary embolism, a reverse Borei effect, it will worsen the instability, and the patient could die, okay?
We've already talked about D, E is for patients who are already in shock, right? That classification called Sky, which is a classification we use for cardiogenic shock, right? Well, then we have E1 and E2. E1 refers to someone with recurrent or persistent hypotension, who has classic shock, and you'll need to administer vasopressors, okay? Dobutoxone, an inotropic substance, or possibly milrinone levos emendama, is a substance that increases contractility, okay? Eh, the sweeping anthem, finally. And E2 is that patient who stopped remembering, as Bruno mentioned in the first case, right? The patient in the first case was a patient undergoing cardiac arrest.
There's even a protocol called " casa," which is a protocol where we perform bedside ultrasounds in the context of cardiac arrest, so we can make a differential diagnosis, because eventually pulmonary embolism, especially in hospitalized patients, has to be a possibility to consider, right? It is one of the major causes of death in hospitals.
And now I'm going to talk about the indications for thrombolysis, right? What scenario do I need to consider when performing thrombolysis, and what precautions do we need to take in the case of thrombolysis?
So, you want me to speak now, Bruno?
Talk to yourself.
Ah, okay. Excellent. So, remember that when we have a decision regarding thrombolysis, besides knowing the indication, we always need to remember the contraindications, okay? The contraindications are basically very similar to those of Ave and acute CMCA, right? So, remember the head, right?
right? So, neoplasm of the central nervous system, whether primary or metastatic, a primary hemorrhage, imagine, the person has already bled spontaneously in the central nervous system. If you take a medication that can systemically lyse fibrin, what can you promote? It's secondary bleeding, okay? A patient who has had hemorrhagic stroke at any point in their life, or ischemic stroke in the last 3 months, okay? Patient with recent, significant traumatic brain injury, recent gastrointestinal bleeding, okay? These are situations that are contraindications, right?
When do we have initial indications that he has documented things properly? From the moment he subdivided it into more classes in that guideline, it somewhat alleviated that doubt, whether to do it or not.
Therefore, category E is indisputable. The patient is in obstructive shock, he's in cardiac arrest, okay? This patient has to do it. Now you're going to consider the patient who is at risk of shock, deteriorating shock, compensated shock, has elevated lactate, signs of impaired perfusion, reduced urine output, and is tachycardic, okay? Well, we shouldn't be using it routinely, okay? Well, category A is because the patient is stable and asymptomatic, category B is mildly symptomatic, and then C1 and C2, okay? Because studies show that even though C has more symptoms and is more severe, it has a higher risk, a higher risk, okay? This patient doesn't simultaneously score on right ventricular dysfunction and elevation markers of injury, right?
And for some patients, we have to consider catheter-guided thrombolysis, which was the scenario for this particular patient.
So, what happens then? Nowadays we have the option of doing it through a procedure, through hemodynamics, right?
So, the pulmonary artery is then cordoned off, okay? And the fibrinolytic is infused locally, with a reduced dose of RTPA, because you're creating a mixed effect, right? You would have an advantage by taking a lower dose of Uteplasa, instead of 100 mg over 2 hours. So you administer a lower dose, and the alteplase will basically be acting inside the pulmonary artery, okay? And that thing over there helps improve VD performance, okay?
So that's reasonable, right? So the better the level of evidence, right? The green one in the guideline, right? So, category E1, right? That patient who is critical, who is in frank shock, we can consider that patient who is deteriorating in stages D1 and D2, okay?
Remember that if the patient has an increased risk of bleeding, we prefer local thrombolysis over systemic thrombolysis, not that systemic thrombolysis is contraindicated, but the patient is very elderly, more fragile, right? Because there is an increased risk of intracranial bleeding in the older population. And what about categories C2 and C3, okay? That is precisely the patient who has right ventricular dysfunction and who has at least one marker there, whether it's isolated right ventricular dysfunction or elevated troponin or BNP or both, in the case of C3, in principle the studies are still ongoing because it's actually something that is newer, it's from the last few years, right?
That's all we know about this group, right? C2 and C3. And when we perform both thrombolysis and thrombectomy, what we add for our patient is improved DVD function.
It's a reduction in pulmonary hypertension, right?
So, we work with surrogate outcomes, right? We don't have any studies showing a benefit in reducing mortality, do we? What we end up finding is improvement in surrogate endpoints, such as right ventricular dysfunction and pulmonary hypertension, right? So, and it probably has some degree of benefit, right?
But it's a little more difficult for us to weigh that benefit. And a patient with that type of VD, I would consider it, you know, a therapy that has a low complication rate, right?
So I believe the benefit would be interesting for these patients, right?
Priscila brought up a good question here. What is the time window for thrombolysis and thrombectomy?
So, look, it's different from what happens in a heart attack, right? In a heart attack, we know because there are no collateral vessels, it's a single vessel, a small vessel, right? So, typically we do it in up to 12 hours, right? Well, the issue of thrombolysis, that's already changed, I think since, I don't know, 2007, right?
We consider up to 14 days, right? You can extend thrombolysis until you believe symptoms have started, and also consider thrombectomy. But do we know what?
The biggest benefit is that we're doing it early, because the blood clot is still fresh, right? An organized thrombus adheres more firmly to the vessel, making it more difficult to achieve the benefit of reperfusion, whether chemically or mechanically.
And Priscila, Priscila, you were so involved, thank you for your participation, Priscila. In cases where thrombectomy is unavailable, which might be the case we're discussing now, right? Is thrombolysis indicated? Look, the great benefit of thrombolysis itself, as we were saying here, is in patients who have right ventricular dysfunction, okay? Well, in a patient who initially presents with more evident clinical deterioration, an extracardiac obstructive shock, which is not the case with this patient, even though he has parameters of right ventricular dysfunction, markers of injury, okay? This patient needs to be closely monitored so that we can assess when their condition deteriorates and then begin treatment. Why?
Because thrombolytic treatment, while beneficial for critically ill patients, carries a risk of bleeding, especially central nervous system bleeding, we know it does. So, from a literary point of view, okay?
Thrombolysis is really indicated in patient E, right? And in D. D is deteriorating. The patient who shows no signs of deterioration, who is in category C, right?
Well, for this patient, initially, we're going to administer standard treatment, clinical treatment, and activate the pertime system so that this rapid response team can make a joint decision and assess whether the patient eventually progresses to stage D, worsens clinically, because this patient is a dynamic patient, and then yes, we're administering reperfusion treatment. Awesome!
So that's what was discussed, right, this classification, this patient of ours in the discussion, category C, right, and for him it would be quite pertinent for the evaluation of his case. He needs to be given anticoagulants, right? And remember that we generally use low molecular weight heparin, right? But always think of it this way: when the patient is getting much worse, sometimes it's better to have the patient under control and administer unfractionated paroxysmal nori, because you have reversed metabolism and it has a shorter half-life, okay? So you have to consider that possibility as well, okay? And this is a patient that you definitely have to consider for both thrombolysis and mechanical catheterization, okay? This is the patient in our clinical case. Any questions, guys? So this is a summary, okay? What do we have to do? Any questions in this case? Are you guys enjoying the discussion? I was just looking at it now, and very few people liked this video. This is absurd, guys. Let's just drop a like button, okay? It's important, if you 're not subscribed to our channel, subscribe now, okay? Top-notch content for you.
Subscribe to our channel. I want to increase the number of subscribers. We've already surpassed 40,000 subscribers. I want to get to 50, 60, and let's go, okay?
Beauty?
So let's move on to our next case.
Now let's discuss the ABC cases.
We've concluded our discussion on PE, right? Let's now discuss case ABC, case number three, which is a case without words, literally.
Literally. So, the patient arrives at the emergency room, and the family calls for assistance at 10:22. She is a 71- year-old woman with a history of atrial fibrillation while using apxaban; her last dose was yesterday at dinner.
The person complaining since 9:30 is having trouble speaking properly, right? She tries to speak, but the words won't come out, no weakness in her limbs, no falling. Blood pressure 158 over 94, irregular heart rate 82, she has atrial fibrillation, right?
Saturation 97. Neurological. The child's expression phase understands commands, but they cannot name objects. No myoplegia, no ataxia, no dysphagia, no stagmus.
In the three-point game, he only gained points with the facsimile. Window, 52 minutes. And now I ask you, are you on duty? Do you have to act in front of this patient? Do you recommend thrombolysis? So let's open our poll. Are you guys enjoying these polls? So you think participating is adding value?
Are these polls proving to be fun? Leave a comment below. So, in that case, in the 3rd stage, FA was only performed using apxanaban. The dose was given last night, it's morning, a 52-minute window, you thrombolyze this patient.
No, not at all, the risk of bleeding is low, but the benefit outweighs the risk. Yes, two would cause a disabling deficit independent of the other; in three, it depends. We need to know how many hours ago she took the pixaban. And four, I'm waiting for a CT scan and MRI before deciding. Hey everyone, are you on duty? The decision is yours. Write it in the comments, write it down. I want to see what you guys would do on your shift. This also seems like a very common clinical case, does n't it, Ludmila?
These are tough decisions, aren't they?
Exactly.
Working on-call without AVE is also difficult.
Suspected bird strike. Initial suspicion of a bird strike threat. Most of the time it's just the beginning of a suspected threat, right? AND. Hey guys, what would you do? Most people are going for number four, right? Waiting for CT scan and MRI before deciding.
Oh, people even want pictures.
Remember that Sprite commercial?
Image is nothing, thirst is everything.
Obey your thirst.
No one would think of performing thrombolysis on this woman who isn't speaking, who is speechless.
14% scored two, considered the deficit disabling and thought of it as a stroke, but most are waiting for the image.
Most of them are in the picture.
Alright, let's begin our discussion.
Come on, let's go, then. Let me move on to the next slide.
Come on, Ludmila. So, initially, a disabling deficit is different from a high Net current deficit, right?
He scored that very well. This last guideline is also part of our course, right? We're going to do a complete review of the latest American Heart Association guideline, which was released, if I'm not mistaken, I think it was in March, right? March or January of 2026, okay?
So, classically, the decision to chemically open the vessel with thrombolytics is for a patient who has a condition that no one needs to know by heart, but we need to know that whenever a patient arrives in an acute scenario, with a focal deficit of sudden, abrupt onset, we have to consider that it is an acute neurovascular syndrome, whether it's a stroke, ischemic or hemorrhagic. So, the Na HSS scale in Portuguese doesn't matter, okay? It's a scale that scores, you know, from zero to 40-something. So basically you go there to check it out at the time and then you apply. The higher this scale, the more points it has, because it has a greater deficit, that is, more functional loss, meaning that neuron is more compromised, either because it bled or because blood didn't reach it, because it's an ischemic stroke, okay? So, classically, the indication for thrombolysis is a patient who had a Na level equal to C, okay? So, he had a significant deficit.
Well, what he pointed out in that last guideline is to relativize. What does relativizing mean? He doesn't set a cutoff point in NA. He wants to know the following: regardless of the originator, for example, the patient is, I don't know, a surgeon, uh, and he has paresis, the patient is a pianist or a phase, I have amorosis. From a functional standpoint, according to that scale, he'll score less than five, but that's disabling for the patient, okay? Why do we perform thrombolysis, right?
We perform thrombolysis to improve the patient's functionality, the patient's ranking, which is a modified scale, okay? And we want to reintegrate this patient into the community with the least possible deficit, so that they can have years of work, etc., and a good quality of life, okay? So, aphasia, right? The patient has a motor phasia, right, to compress Broca's area, a compressive phasia, okay? a maurose, paresis in the dominant hand. This is considered a disabling deficit.
In that situation, okay? Yes, we will always consider the possibility of thrombolysis, of course, respecting the presence of contraindications, okay?
So, every time we throw the ball, we have to spike it, right? To cut to the chase, is the patient a candidate? The first question we ask is: is the patient a candidate?
So, if he is a candidate for thrombolysis, then he meets the same contraindications, okay? So, there was hemorrhage, which is a life-threatening condition, there was ischemic stroke in the last 3 months, SAH, as we already discussed in the context of PE, okay? Well, in that situation, yes, we'll remember, in this specific case, that the patient, due to anticoagulation because of a flu-like illness, uses a Doak, right? So, full anticoagulation, use of Doak, full dose in the last 48 hours, okay?
Initially, it is a contraindication to the trombone. It's important to remember that when we perform thrombolysis, we don't base it solely on clinical evaluation, right? So every time a patient arrives with a suspected case of hypoglycemia, the first test we do is a capillary blood glucose test, because hypoglycemia is a stroke mimic, right? It mimics a stroke; hypoglycemia can lead to deficits.
Then we'll do a CT scan. If the CT scan shows no bleeding, it doesn't necessarily indicate ischemic injury. We actually don't want the CT scan to show any abnormalities. From a normal CT scan, a patient with a functional deficit, a focal deficit, is an ischemic stroke until proven otherwise, okay? Remember that in patients who have contraindications for thrombolysis for any reason, and who have lesions in large vessels, then yes, it's important to perform a vascular study, right? An angulation of the skull and cervical vessels, okay? Internal carotid artery injury, middle cerebral artery injury, M1 branch, possibly M2 branch, and currently the inclusion in this latest guideline of basilar occlusion, which is responsible for irrigating the posterior fascia, as an indication for performing mechanical opening within 24 hours. Of course, the benefit varies later on; we know the benefit is a little smaller, but you can avoid opening that jar for up to 24 hours. And he even mentions in the guideline that if a patient has an occlusion of large vessels and is not a candidate for thrombectomy due to unavailability, you can even consider thrombolysis, but that's a topic for another day, as it 's more complex.
Exactly. I see there are a lot of people here in the chat, and they're nervous about the image, right? And there's an important image issue involved, right? Yeah, in that guideline, right? The guideline talks a lot about that. We'll talk about that later, but the image should n't delay the course of action. The image is solely for the purpose of ruling out bleeding.
That.
Point.
She cannot delay the conduct. Sometimes you want to, oh, let's do the angel thing here now, let's do it. She can't get in the way, right? So here, as we've already discussed, this issue of Nate's paradox, right? When to use it and when to ignore it, okay? And here's where the issue of decision heuristics comes in, right? Right, which is important, is the question of defining what constitutes a disabling deficit, right? So, regardless of the Nat deficit, we will indeed consider immediate thrombolysis, okay? And here, look, that's precisely the window, right, the immediate window from 0 to 4:30, right? And taking the image he provides is the only image strictly necessary to rule out hemorrhage.
Point. You can't waste time on images. The image needs to be sent as quickly as possible. There are even protocols that sometimes consider the use of thrombolytics in the radiology department's scanning room. She just had a CT scan and there's nothing wrong.
You have to open the jar as quickly as possible, right? Because you have time, right? And the time frame here is much shorter, isn't it, than what happens in a heart attack? So it's important to keep that concept in mind, right, Ludmila? That's just like Bruno said, right? Just as we have "time" as muscle in the heart, here "time is brain," right? So our window of opportunity, in quotes here, is 4 hours, and it's worth remembering that this refers to the last time the patient was seen in good condition. This is a concept that we'll apply later, which is the wake-up stroke, right? It's the moment when the stroke was last seen without a focal deficit, okay? And as he said, the preferred examination is indeed a non-contrast CT scan of the head. It's a quick, quick exam, okay? We shouldn't delay the thrombolytic infusion, which is the treatment of choice for opening the vessel, for chemical reperfusion of the vessel, by performing what he calls advanced neuroimaging, okay? What is advanced neuroimaging? Study of vases, angel TC, okay? Or even resonance imaging or perfusion studies, such as perfusion tomography. Awesome!
So, uh, the latest details about this case, right, which are important, right? What can and cannot stop thrombolysis, right? That's important information, okay? Remember this: when you look at the table, the guideline, it's about contraindications to thrombolysis, okay? Well, contraindications to thrombolysis, we 'll see, are the extremes of glycemia, because both hypoglycemia and hyperglycemia can be stroke mimics, right, imitating a stroke, but from the moment you've done reperfusion, infused glucose, administered insulin, and the patient remains symptomatic, it's not a metabolic deficit, it's not a metabolic dysfunction, and there's no vascular issue, okay?
Blood pressure, you know, you have to be careful, right?
Typically in ischemic stroke, we do what we call permissive hypertension, right? Why? Well, the patient has ischemia, we have, I always like to use this avocado example, right? So, we have an avocado there, we have the seed, which is the core, okay? That's the area that's already dead, right? And then there's that area we use, which is the avocado pulp itself, the shaded area. What is the twilight area? That area that's like a bermed myocardium, central nervous system. You have a lower metabolism there because less blood is reaching the body; it adapts to the reduced metabolism. This leads to a focal deficit, a neuronal dysfunction, okay? And when you administer thrombolytics, you want to reperfuse that region that's functioning poorly, that's metabolically inactive, but not completely dead. So, when you're doing stricter blood pressure control, right?
So, typically, in patients who are not candidates for thrombolysis, we maintain a blood pressure of around 220/120; we tolerate this hypertension, okay? Why?
Because if we sharply lower the pressure, if we lower the mean arterial pressure, we will decrease the cerebral perfusion pressure and consequently, because there is a direct relationship between them, right? You will worsen the ischemia in the penumbra areas, and the penumbra will turn into a dead area, which is the cor, and that's what we don't want to happen. As for the father, oh, but you ask, but my God, Mila, but I'm going to do the thrombolysis, it wasn't 220, calm down. When you perform thrombolysis, you are treating the blood vessel by opening it. So, no matter how much you lower the mean arterial pressure, you will be reperfusing that vessel and consequently you can lower the pressure, also because there is a theoretical risk of bleeding in the central nervous system, of hemorrhagic stroke.
That's why, in order to start thrombolytic treatment, we need to have a systolic blood pressure of less than or equal to 185, and a diastolic blood pressure of 110. And during the infusion, we lower the mercury pressure by 5 mmHg from that point. So it's 180 during the infusion, below 105 so we can maintain the thrombolytic, okay? We don't base our decisions on supplementary tests, okay? Love, the patient, oh no, I use a common NR equal to 1.7, it can't be. Well, I'm full of thrombocytopenia, I think it's thrombocytopenia, but that's an exception. So, we don't delay treatment based on additional tests, okay? That 's basically it. Awesome!
Any questions about this case three, guys? So, are you enjoying this? Any questions about this? That's a good case, right? It's an everyday occurrence, right? Case of the day. Awesome!
Priscila asked a question that we're going to answer in this next case, okay, Priscila? Just wait a moment, we'll respond to this next case. Awesome!
Moniquinha is here today. I want to understand the lesson. Didn't you understand yesterday? That makes sense. If you didn't understand it yesterday, you can watch it again. You can watch it again. They're asking, but what would the answer be? The answer would be, we take an image of the patient to rule out a quick image, and the patient then goes for thrombectomy, right?
Great, awesome!
So let's move on to case four, shall we? It's never too late.
You're facing a patient who's in the emergency room at 5:30 PM, no, 3:30 PM, okay? That post-lunch feeling, you had a late lunch that day, the coffee isn't having any effect anymore, is it? You're feeling that post-prandial sleepiness, right? That general malaise, and a family member arrives bringing you a patient, a 68-year-old man, not currently undergoing treatment but with no history of atrial fibrillation, and he woke up today with weakness in his left arm.
This morning, at 9:30 AM, remember, it's 3:30 PM now, he woke up at 9:30 AM, the whole family was at work, so the patient only arrived at the ER at 3:30 PM. On arrival, blood pressure was 168/98, heart rate was a regular 78, and oxygen saturation was 98%; on follow-up, moderate left myoplegia and mild dysarthria were present; evolution window was 6 hours.
And then you say, family, oh no, it went past the window, can't we recommend thrombolysis?
But could this indicate thrombolysis? Patient there in the network, 8, 6 hours of pain-free window here. What are we going to do with this patient? Let's go back to our poll. I want to know what you would do. Are you on duty? This shift is hectic, everyone here is bringing bad luck today. So, firstly, I explain that the window of opportunity has passed and treatment is only with preventive anticoagulation.
Two, I request a perfusion CT scan or DW FLIR MRI to assess ischemic penumbra. Remember that you're in the most prestigious hospital on Earth, you have everything, okay? Refer directly for mechanical thrombectomy, within a 24- hour window, or start heparin and wait for spontaneous improvement. What would you do?
You are in the most top-notch hospital on the face of the earth. You can do whatever you want with the patients, okay? What would you do in this scenario? It went past the window, what am I going to do?
Initiate paratrin, anticoagulant, directly to mechanical thrombectomy.
Lucas is saying, actually you don't know the window of opportunity because the patient woke up with a deficit. You have a point, Lucas, so what would you do with this patient?
And then, most requested perfusion CT or RMDW FLIR to assess the ischemic penumbra. Now I want to hear honestly from everyone present in this live stream. Who among you has already requested that CT scan or that MRI?
You're asking for it here, right?
Stirring up trouble, huh, Bruno? Are they asking for something here? They never asked for anything in their lives.
Gustavão is there, and he's getting spoiled with so many good tests available for clinical cases. But Gustavão, let me tell you something. Here's a tip from the bottom of my heart. Because I see a lot of colleagues saying things like: "Oh, because where I work they don't have that.
Get out of that place. You have to evolve.
If you're in a place that doesn't offer you the resources to practice quality medicine, leave.
Go to a place where you have adequate working conditions, where you can offer the best to your patient. If you stay in a place where you can't grow, you can't evolve, you'll stagnate your whole life. So, always think about that. If I 'm in a place that I think isn't good, doesn't have, doesn't offer growth, right? Think about leaving that place. I need to go to a better hospital.
Always think about growing, always think about working in the best hospital possible, okay? Great, life advice. That's awesome.
Let's go.
Then José said: "You said history is top-notch." It really is top-notch, is n't it?
Then Jackson said that the neurologist asks for it, right? Better than the neurologist who asks for that.
Better teaching, better advice.
Exactly that, guys.
Okay, everyone? That's important.
Always try to evolve. Never be someone who is constantly bothered by the situation you are in. Always try to improve. Great!
So, most went to number two, 83% requested a perfusion CT scan or DW FLIR MRI to evaluate ischemic penumbra. So let's discuss this case.
They requested the extended window image, right? The DW FLIR showed a small infarct in the right internal capsule, and the FLIR showed no sign of established infarction, positive MMET, viable penumbra identified, wakeup criteria met.
So, in this case, thrombolysis is indicated, right, Ludmila? I 'm going to talk a little about these radiological terms that everyone is afraid of, okay? So, in a very summarized way, what is this MRI that we evaluated? What we call a mismatch, that is, it didn't match, it didn't go together, right? So, unlike what many people think, this MRI, this sequence of two images on the MRI for the This ischemic stroke sequence isn't lengthy, it lasts about 5 or 10 minutes, it's quick, because we know that the major limitation of MRI is that sometimes the patient is more critical, the patient is on a ventilator, they can't undergo this exam. This sequence is a quick sequence, okay? And what is its objective? We know that when a patient has a stroke, they have two areas, an ischemic stroke, which is the objective of this lesson. We have the core area, which is the central area, the core area, the center that is dead, it's that hot zone of the trauma, the one with the greatest area of pfusion, which is already necrotic. And we have the penumbra area, which is like the peel of an avocado, that part we eat, which is the area you want to improve with thrombolytic infusion, okay? This diffusion sequence is interesting because of the stroke diffusion. Why? Because when you have ischemia, an infarction, diffusion is altered early on, around The first is 30 minutes.
The FLIR, however, takes 4 hours to show an alteration.
So, if the patient has a MISMAT, meaning an altered diffusion indicating ischemic injury, and a normal FLIR, this means they have less than 4.5 hours of deficit. If the patient has less than 4.5 hours of deficit, theoretically, this is the therapeutic window we usually use for patients indicated for thrombolysis, right? And it's what we use in wake-up stroke, right?
So, for a patient with an indeterminate window, classically, the patient was alone at home, the patient fell asleep, you don't know if the stroke started when they lay down or immediately before they woke up.
So, to avoid condemning the patient to not undergoing interventional reperfusion treatment, we resort to advanced neuroimaging.
Perfusion tomography is less readily available; you make a ratio between the colored area and the area of... penumbra. In practice, we end up using MRI more.
[laughs] So, these are the studies, right, the Wakeup study, which was the initial study, then we have Diffuse, okay?
Remember that it's the wake-up stroke, that's why it 's called wake-up stroke, right? For a waking stroke, we do diffusion MRI, okay? And with these other studies, the Diffuse study, okay? We can consider thrombectomy within 24 hours in a patient who has an alteration in perfusion, okay?
So this is our paradigm shift, right? A paradigm shift from time to tissue, right? Time is very important when we don't have this information, right? So, when I have an early window, right? I know the beginning of the deficit, I know exactly when the deficit started, so we can use this data, but when we don't know this issue of the deficit, right? I have to look for this information on tissue viability. These are the methods we have to help. We're trying to identify if a patient might be eligible for thrombolysis or even thrombectomy in this scenario, right?
So that's precisely the idea, as Ludmila said, to rescue the avocado, as she mentioned, right? So I want to save my penumbra area, right? That's the main idea, to look for this disproportion, which would be Mismet. So the idea is precisely to look for this information, right?
The issue of diffusion resonance, right, as Ludmila mentioned, it's all here, all this information is here. And the idea is precisely to identify if I have viable tissue, tissue capable of being saved, okay? And there are some interesting data as well, right, which is, for example, what happens, especially when we think about endovascular treatment, in some scenarios, when I have occlusion of large vessels, right? So this was something new, right, Ludmila?
Yes, it also changed a lot. We know that some studies already showed that you can have benefits there in up to 24 Okay, so what did he change a little bit in terms of paradigm? When we evaluate thrombolysis, thrombectomy, there's a classification called ASPECTS, okay? ASPECTS is like a score that the radiologist gives to certain sections of the anterior circulation. And basically, a normal ASPECTS score would be 10. That's for a patient who doesn't have any ischemic changes. As they lose points because they have an alteration on the CT scan, okay? Their ASPECTS score decreases, okay? So, in this latest guideline, he made some adjustments according to ASPEX, okay? And he also included PASPEX, which is the ASPECT score.
So, basically, a patient with a higher ASPECTS score is one who, in principle, has a CT scan close to normal, okay? So, that patient who has a practically normal CT scan, and who has a high Na, okay? In other words, they have a lot of functional deficit and a modified functional ranking scale, which is the MRS, okay?
Showing that he has a previous functionality of zero to one, you can consider thrombectomy within 24 hours, okay? That is, you did an angiogram, okay? It showed that there is an occlusion of large vessels. By the way, internal carotid, middle cerebral artery, M1 branch, M2, proximal branches, M2 when it is a dominant branch, okay? This patient will be transferred to some location or, if he is in a service that has this availability, he undergoes mechanical reperfusion treatment, okay?
In this latest guideline, he also incorporated other things, right? Uh, such as the classification of posterior circulation, right? So, a patient who has a basilar artery obstruction, okay? It was already done empirically in studies, but now as a formal recommendation as well, the patient with posterior fossa obstruction can also be a candidate for thrombectomy within 24 hours. And remember that posterior fossa obstruction is deceptive, okay? It can present clinically with a patient with central vertigo. We use that HINT maneuver, right, which It's an acronym, for us to make the differential diagnosis between central and peripheral vertigo, but eventually the patient may present with a coma, sudden tetraplegia, okay? Precisely because it's affecting the posterior circulation, okay? And the patient with a posterior fossa stroke, okay? Uh, when they have a clinical worsening, because sometimes they are limping, this patient also benefits from having a thrombectomy within 24 hours.
[snoring] Great. Great. So that's the final algorithm, right?
A lot of things, right, folks? That's the guideline.
So, less than 4 hours, the image we take is a non-contrast CT scan, okay? Uh, if the patient has a capacitance deficit, you will subject them to thrombolysis, okay? Uh, there was also the inclusion here, in addition to autoplase, of the possibility of tenecteplase, if the patient has proximal vessel lesions, okay? Uh, you You can also perform mechanical thrombectomy, okay? If the patient doesn't have proximal vessel injury, no, but in principle it's thrombosis. Now, if the patient has a delta between 4:30 and 9, which was the case with this patient, right? So the patient arrives with up to 9 hours, so you can't just say: "Oh, it hasn't been more than 4 and a half hours, I can't thrombolyze." It 's not like that anymore. Nowadays, with these more advanced studies, right? Down fuse, up to 9 hours you can do an extended thrombosis window. Why? Because we can evaluate precisely in perfusion studies, tissue studies, as Professor Bruno said, to evaluate the proportion between the dead area, the core area, and the ischemic penumbra area. If you have a penumbra that is worth rescuing, we will indeed subject this patient to thrombolytic treatment, okay? Or even a thrombectomy, which he puts here in LVO, which is In English, for a stroke, between 6 and 24 hours, you would do advanced neuroimaging, okay? In this population here, okay? If you have large vessel lesions, okay? We can also consider thrombectomy as a higher level of evidence, because the patient has a lot of deficit, usually the patient has had symptoms for a long time, okay? And thrombectomy would be a treatment of choice in this population.
Great. So, guys, I hope everyone enjoyed the class, right? So, now the final closing of this stroke module. I'm going to tell you the password now, okay? For our e-book, okay? And here, guys, I want to know what you thought of today's class, right?
If you liked it, write it in the comments, okay? Tomorrow will also be a very practical session, because tomorrow is AF and SLS, right? News about AF, SLS. So you can't miss it.
If you're enjoying the class now, you have to be present. Tomorrow, and tomorrow there's a special surprise for those who stay until the end, okay? So, I want you all to be there tomorrow, okay? And that's how we like to teach you, bringing everything that's practical and in a very objective way, precisely in the clinical case, because here we're going to explain it to you in the clinical case, in the clinical case. So, how to bring it from a practical point of view, we know that there are situations that appear in our daily lives, we're in practice, we experience this, right? Dmila is an emergency coordinator, she's worked in emergency for a long time, she works in intensive cardiology, so I encounter these cases all the time, all the time, all the time, okay? So we have to pass on the experience to you.
I'm part of the guidelines, I wrote, I helped write the chest pain guidelines. So we have the authority to pass this subject on to you, okay? So, the four traps that we taught you today, first, the elevated and elderly finger. You can't fall into this trap of... Elevated finger in the elderly.
Second, stable PE with compromised RV.
Be careful. It's important to check a patient who sometimes seems stable, but I have to monitor troponin, BNP, and RV, right? This patient may have a poor outcome. Third, stroke with low sodium without thrombolysis, right?
I have to consider the possibility, if the patient has contraindications for thrombolysis, refer for thrombectomy. And finally, in some stroke scenarios, in addition to the 4:AS3, I can offer thrombolysis to my patient if I have the methods indicated for that situation, okay? So, which of these four stroke traps do you feel capable of acting on if it appears during your shift? Comment below, guys, what you think you'll do differently now when you get to your shift, comment in our chat, our last poll of the day, okay?
Meanwhile, I'll read the comments if any questions have arisen here, okay? Great. Thank you. Oh, London for everyone, look. Score greater than six. The patient easily meets this criterion, as it presents on the eighth. Perfect. Exactly that. Very good. Edson did a great job. Lucas is a fan of Professor Ludmila. She has fans, huh? Top-notch class, a class to be applied in everyday life. Anderson, I have a question here. A negative CT scan rules out PE. What is the sensitivity for peripheral vessels?
Very good question.
Yes, Lud, go ahead.
What happens? The CT angiography has a high sensitivity, 90-something, okay? But we know that subsegmental PE has a higher capacity, it has more false negatives. But what is the repercussion of this? He even mentions this in older guidelines, right? Uh, nowadays, with more modern CT scanners, we can diagnose peripheral vessels, but if it's a very small PE, it may not be detected by CT angiography, and you won't do a pulmonary angiography for that reason. Why? It's based on the assumption that if it's a Very subsegmental PE, which you can't diagnose with CT scans, okay? You wouldn't need to use another method. Why? Because it's a PE that, in principle, doesn't have clinical repercussions, okay? But this is an exception, subsegmental PE, okay? Older CT scanners don't have the capacity to make the diagnosis, that is, to show that there is a filling defect, but it's eventually that type A PE, which is even controversial depending on the situation, anticoagulation, right? It's the patient who is asymptomatic, right? So, subsegmental PE, the capacity of CT scans is lower, okay? But with more modern images you can make the diagnosis.
Great. People are asking, I haven't said that yet.
Calm down, guys. I haven't said that yet. A colleague is asking here, regarding the test. The test is available, it will be released, it should have just been released at 9:30. It's available on the Mind platform. If you haven't registered, you can find it in the description of this video. Okay, you can register, right? But you have to take the first test first, don't you? You can't start with test two, you have to take test one.
Test two is only released after you take test one. And just like test three, it's already available on the platform.
Tomorrow's test will only be released tomorrow night, okay? It's only on the platform and only those who get more than 70% on all three tests will get the certificate.
Those who watched the class will get a perfect score, easy peasy. Just pay attention. And the PDF password, you can open the PDF and look for the answer in the PDF. Remember that you have 30 minutes to take the test, right? You can look for the PDF password. And today's PDF password is " cardiológicas" (without accents and all lowercase). Cardiológicas, right? Cardiológicas. The test will be available to take until Sunday.
So, if you want to take your time later, if you want to rewatch this class later, no problem at all. No problem at all. Is that okay? You can take them all at once. You can do it.
All at once, no problem at all. Good night. Some notary support without on the web? I didn't understand anything you said. My Spanish is very weak, isn't it?
He wants me to write. I think he, I don't know if he's asking for the password or if he wants something translated.
To say that today Vasco won against Barracas Central from Argentina. So, today Vasco won against an Argentinian team, okay? Will the classes be available until Sunday? Yes, they will be available until Sunday, okay? Okay?
So you can watch as many times as you want. Okay, everyone? So, I've released the password for you, okay? Here are three lessons. Dedimer is not used without age adjustment. Pulmonary embolism without shock can be serious, and in stroke, the window is biological, not chronological.
Here's the workshop platform, okay? So, the answers are here in the class, just watch and you'll get them right. And tomorrow I want to see all of you here, FA, ACS. And a surprise for those who stayed these three nights. A Maria Montenegro didn't find the tests, and you didn't look for them because they're on the platform anymore. You sign up, log in, and you 'll see it; it says "tests" there. So there's no difficulty, just look for them there. Lots of people found them. A lot of people found them. Okay, everyone.
Ludmila, thank you for being here. I think it was a very good discussion, and let's go together, guys. Everyone, it's a pleasure to narrate in your presence. Much peace in your hearts. As you already know, my body will leave, but my heart remains for you. Whoever is asking for the password for ebook one has to watch lesson one. No, nobody gives the ebook password to them. Watch lesson one, okay, Víor? Go watch lesson one, it's there, okay? Thanks, Lud. A hug.
Good night, everyone. Bye, then?
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