Brian Cohn

Can Anticoagulated Patients be Discharged Home Safely from the Emergency Department after Minor Head Injury

BACKGROUND Anticoagulated patients have increased risk for bleeding, and serious outcomes could occur after head injury. Controversy exists regarding the utility of head computed tomography (CT) in allowing safe discharge dispositions for anticoagulated patients suffering minor head injury. CLINICAL QUESTION What is the risk of delayed intracranial hemorrhage in anticoagulated patients with minor head injury and a normal initial head CT scan? EVIDENCE REVIEW Four observational studies were reviewed that investigated the outcomes of anticoagulated patients who presented after minor head injury. RESULTS Overall incidence of death or neurosurgical intervention ranged from 0 to 1.1% among the patients investigated. The studies did not clarify which patients were at highest risk. CONCLUSION The literature does not support mandatory admission for all anticoagulated patients after minor head injury, but further studies are needed to identify the higher-risk patients for delayed bleeding to determine appropriate management.

Are Prophylactic Antibiotics Necessary for Anterior Nasal Packing in Epistaxis

Editor’s Note: Emergency physicians must often make decisions about patient management without clear-cut data of sufficient quality to support clinical guidelines or evidence-based reviews. Topics in the Best Available Evidence section must be relevant to emergency physicians, are formally peer reviewed, and must have a sufficient literature base to draw a reasonable conclusion but not such a large literature base that a traditional “evidence-based” review, meta-analysis, or systematic review can be performed.

Can Bedside Oculomotor (HINTS) Testing Differentiate Central From Peripheral Causes of Vertigo

Editor’s Note: Emergency physicians must often make decisions about patient management without clear-cut data of sufficient quality to support clinical guidelines or evidence-based reviews. Topics in the Best Available Evidence section must be relevant to emergency physicians, are formally peer reviewed, and must have a sufficient literature base to draw a reasonable conclusion but not such a large literature base that a traditional “evidence-based” review, meta-analysis, or systematic review can be performed.

IS EMERGENCY DEPARTMENT CARDIOVERSION OF RECENT-ONSET ATRIAL FIBRILLATION SAFE AND EFFECTIVE?

BACKGROUND Atrial fibrillation (AF) is a very common dysrhythmia presenting to Emergency Departments (EDs). Controversy exists regarding the optimal clinical therapy for these patients, which typically focuses on rhythm rate-control and admission or cardioversion and discharge home. CLINICAL QUESTION Is ED cardioversion of recent-onset atrial fibrillation safe, effective, and does it result in positive meaningful patient outcomes? EVIDENCE REVIEW Five observation studies with nearly 1600 ED patients with atrial fibrillation treated with either rate-control or cardioversion were reviewed and results compiled. RESULTS Overall, ED cardioversion for recent-onset AF seems safe and effective, with success rates ranging from 85.5% to 97% in these studies. Although further research should seek to identify patients at low risk for thromboembolic complication, more rigorously assess patient satisfaction, and show cost savings, emergency physicians should feel comfortable using this approach in select patients. CONCLUSION ED cardioversion for recent-onset AF seems safe and effective.

Does Management of Diabetic Ketoacidosis with Subcutaneous Rapid-acting Insulin Reduce the Need for Intensive Care Unit Admission?

BACKGROUND In the last 20 years, rapid-acting insulin analogs have emerged on the market, including aspart and lispro, which may be efficacious in the management of diabetic ketoacidosis (DKA) when administered by non-intravenous (i.v.) routes. CLINICAL QUESTION In patients with mild-to-moderate DKA without another reason for intensive care unit (ICU) admission, is the administration of a subcutaneous (s.c.) rapid-acting insulin analog a safe and effective alternative to a continuous infusion of i.v. regular insulin, and would such a strategy eliminate the need for ICU admission? EVIDENCE REVIEW Five randomized controlled trials were identified and critically appraised. RESULTS The outcomes suggest that there is no difference in the duration of therapy required to resolve DKA with either strategy. CONCLUSION Current evidence supports DKA management with s.c. rapid-acting insulin analogs in a non-ICU setting in carefully selected patients.

Is Dexamethasone as Effective as Prednisone or Prednisolone in the Management of Pediatric Asthma Exacerbations

ATA EXTRACTION AND YNTHESIS ata were abstracted from the tudies by 1 of 4 authors and erified by a second author. bstracted data included subject haracteristics, asthma severity core, treatments, adverse effects, nd clinical outcomes. Study quality as assessed independently by 2 eviewers with the Cochrane risk f bias tool, the Jadad score, and 2 dditional items assessing for ndustry sponsorship and use of an ntention-to-treat analysis. Results ere pooled with a fixed-effects odel, and heterogeneity was ssessed with the I statistic.