David R. Vinson

Immediate and Delayed Traumatic Intracranial Hemorrhage in Patients With Head Trauma and Preinjury Warfarin or Clopidogrel Use

STUDY OBJECTIVE Patients receiving warfarin or clopidogrel are considered at increased risk for traumatic intracranial hemorrhage after blunt head trauma. The prevalence of immediate traumatic intracranial hemorrhage and the cumulative incidence of delayed traumatic intracranial hemorrhage in these patients, however, are unknown. The objective of this study is to address these gaps in knowledge. METHODS A prospective, observational study at 2 trauma centers and 4 community hospitals enrolled emergency department (ED) patients with blunt head trauma and preinjury warfarin or clopidogrel use from April 2009 through January 2011. Patients were followed for 2 weeks. The prevalence of immediate traumatic intracranial hemorrhage and the cumulative incidence of delayed traumatic intracranial hemorrhage were calculated from patients who received initial cranial computed tomography (CT) in the ED. Delayed traumatic intracranial hemorrhage was defined as traumatic intracranial hemorrhage within 2 weeks after an initially normal CT scan result and in the absence of repeated head trauma. RESULTS A total of 1,064 patients were enrolled (768 warfarin patients [72.2%] and 296 clopidogrel patients [27.8%]). There were 364 patients (34.2%) from Level I or II trauma centers and 700 patients (65.8%) from community hospitals. One thousand patients received a cranial CT scan in the ED. Both warfarin and clopidogrel groups had similar demographic and clinical characteristics, although concomitant aspirin use was more prevalent among patients receiving clopidogrel. The prevalence of immediate traumatic intracranial hemorrhage was higher in patients receiving clopidogrel (33/276, 12.0%; 95% confidence interval [CI] 8.4% to 16.4%) than patients receiving warfarin (37/724, 5.1%; 95% CI 3.6% to 7.0%), relative risk 2.31 (95% CI 1.48 to 3.63). Delayed traumatic intracranial hemorrhage was identified in 4 of 687 (0.6%; 95% CI 0.2% to 1.5%) patients receiving warfarin and 0 of 243 (0%; 95% CI 0% to 1.5%) patients receiving clopidogrel. CONCLUSION Although there may be unmeasured confounders that limit intergroup comparison, patients receiving clopidogrel have a significantly higher prevalence of immediate traumatic intracranial hemorrhage compared with patients receiving warfarin. Delayed traumatic intracranial hemorrhage is rare and occurred only in patients receiving warfarin. Discharging patients receiving anticoagulant or antiplatelet medications from the ED after a normal cranial CT scan result is reasonable, but appropriate instructions are required because delayed traumatic intracranial hemorrhage may occur.

Implications of the Failure to Identify High-Risk Electrocardiogram Findings for the Quality of Care of Patients With Acute Myocardial Infarction Results of the Emergency Department Quality in Myocardial Infarction (EDQMI) Study

Background— The impact of misinterpretation of the ECG in patients with acute myocardial infarction (AMI) in the emergency department (ED) setting is not well known. Our goal was to assess the prevalence of the failure to identify high-risk ECG findings in ED patients with AMI and to determine whether this failure is associated with lower-quality care. Methods and Results— In a retrospective cohort study of consecutive patients presenting to 5 EDs in California and Colorado from July 1, 2000, through June 30, 2002, with confirmed AMI (n=1684), we determined the frequency of the failure by the treating provider to identify significant ST-segment depressions, ST-segment elevations, or T-wave inversions on the presenting ECG. In multivariable models, we assessed the relationship between missed high-risk ECG findings and evidence-based therapy in the ED after adjustment for patient characteristics and site of care. High-risk ECG findings were not documented in 201 patients (12%). The failure to identify high-risk findings was independently associated with a higher odds of not receiving treatment among ideal candidates for aspirin (odds ratio [OR], 2.13; 95% confidence interval [CI], 1.51 to 2.94), β-blockers (OR, 1.85; 95% CI, 1.14 to 3.03), and reperfusion therapy (OR, 7.69; 95% CI, 3.57 to 16.67). Among patients with missed high-risk ECG findings, in-hospital mortality was 7.9% compared with 4.9% among those without missed findings (P=0.1). Conclusions— The failure to identify high-risk ECG findings in patients with AMI results in lower-quality care in the ED. Systematic processes to improve ECG interpretation may have important implications for patient treatment and outcomes.

Epiploic appendagitis: a new diagnosis for the emergency physician. Two case reports and a review.

Two cases of epiploic appendagitis are presented. One was mistaken for acute appendicitis, the other for acute diverticulitis. In both cases, the correct diagnosis was made in the operating suite. With the aid of contemporary imaging modalities, however, the diagnosis of epiploic appendagitis need no longer hinge on the pathologic specimen but may be established by the emergency physician. As this disorder recently has been demonstrated to be predominantly self-limited, laparotomy no longer is considered necessary. Conservative management has been shown to be safe. The anatomy, pathophysiology, clinical presentation, radiologic evaluation, and emergency management of epiploic appendagitis are reviewed.

Informing the design of clinical decision support services for evaluation of children with minor blunt head trauma in the emergency department

Integration of clinical decision support services (CDSS) into electronic health records (EHRs) may be integral to widespread dissemination and use of clinical prediction rules in the emergency department (ED). However, the best way to design such services to maximize their usefulness in such a complex setting is poorly understood. We conducted a multi-site cross-sectional qualitative study whose aim was to describe the sociotechnical environment in the ED to inform the design of a CDSS intervention to implement the Pediatric Emergency Care Applied Research Network (PECARN) clinical prediction rules for children with minor blunt head trauma. Informed by a sociotechnical model consisting of eight dimensions, we conducted focus groups, individual interviews and workflow observations in 11 EDs, of which 5 were located in academic medical centers and 6 were in community hospitals. A total of 126 ED clinicians, information technology specialists, and administrators participated. We clustered data into 19 categories of sociotechnical factors through a process of thematic analysis and subsequently organized the categories into a sociotechnical matrix consisting of three high-level sociotechnical dimensions (workflow and communication, organizational factors, human factors) and three themes (interdisciplinary assessment processes, clinical practices related to prediction rules, EHR as a decision support tool). Design challenges that emerged from the analysis included the need to use structured data fields to support data capture and re-use while maintaining efficient care processes, supporting interdisciplinary communication, and facilitating family-clinician interaction for decision-making.

Can selected patients with newly diagnosed pulmonary embolism be safely treated without hospitalization? A systematic review

STUDY OBJECTIVE Omitting inpatient therapy for emergency department patients with newly diagnosed pulmonary embolism occurs infrequently in the United States. We seek to describe the safety of initial outpatient management of these patients and their demographics, comorbidities, risk stratification, treatment, and outcomes. METHODS We identified studies from searches of MEDLINE, EMBASE, and other databases from inception through March 22, 2012. We supplemented this with a search of conference proceedings and consultation with experts. We selected prospective studies of adults with acute, symptomatic, objectively confirmed pulmonary embolism who were discharged home without hospitalization. All contributing studies explicitly defined inclusion and exclusion criteria plus objectively confirmed outcome measures: recurrent thromboembolism, major hemorrhage, and mortality. Two investigators independently identified eligible studies and extracted data. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria to assess study quality. RESULTS From 2,286 screened titles/abstracts, we selected 8 studies with a total of 777 patients. Seven observational studies were rated low in quality. The one randomized controlled trial was higher in quality, used stricter inclusion criteria, and found that 90-day outcomes for outpatient management were not inferior to inpatient care. Among the 7 studies that reported 90-day outcome measures, the overall incidence of venous thromboembolic-related and hemorrhage-related mortality was very low: 0 of 741 (upper 95% confidence limit 0.62%). CONCLUSION The data on exclusive outpatient management of acute symptomatic pulmonary embolism are limited, but the existing evidence supports the feasibility and safety of this approach in carefully selected low-risk patients.

Carisoprodol-Induced Myoclonic Encephalopathy

CASE REPORT A 39-year-old man ingested 35 g carisoprodol. He developed agitation, tachycardia, myoclonus, and coma. The blood carisoprodol was 71 micrograms/mL; the meprobamate was 26 micrograms/mL. DISCUSSION Carisoprodol overdose is thought to induce simple central nervous system depression. This case demonstrates a severe overdose with symptoms more consistent with myoclonic encephalopathy. A review of cases presenting to the San Francisco Division of the California Poison Control System during 1997 suggests that carisoprodol is more commonly associated with agitation and bizarre movement disorders than the current literature suggests. The pharmacology and potential mechanisms of toxicity are discussed. CONCLUSION Agitation, hypertonia, and a myoclonic encephalopathy may be seen with significant carisoprodol intoxication.

Missed opportunities for reperfusion therapy for ST-segment elevation myocardial infarction: Results of the Emergency Department Quality in Myocardial Infarction (EDQMI) study

BACKGROUND Although it is known that reperfusion therapy for ST-elevation myocardial infarction (STEMI) is underused, the reasons for the failure to provide this potentially life-saving treatment are not well described. METHODS In a cohort of 2215 consecutive patients presenting with acute myocardial infarction to 5 emergency departments in Colorado and California between 2000 and 2002, patients with ischemic symptoms and ST-segment elevation on electrocardiogram without documented guideline-based contraindications to therapy were identified as eligible reperfusion candidates. Multivariable logistic models were constructed to identify factors associated with the failure to receive reperfusion. The emergency department records of patients not receiving reperfusion were reviewed to categorize the reasons therapy was not provided. RESULTS Of 460 eligible patients, 102 (22%) did not receive reperfusion therapy. Patient factors associated with failure to receive reperfusion therapy included older age, peripheral vascular disease, and absence of chest pain; patients seen by both resident and attending physicians were more likely to receive treatment than those seen by an attending alone. In cases where reperfusion was not provided, ST-segment elevation was not identified in 34% (n = 35), left bundle-branch block was not considered as an indication in 13% (n = 13), there was documentation of a reason for withholding therapy not supported by guidelines in 34% (n = 35), and there was no documentation of reasons for withholding reperfusion in 19% (n = 19). CONCLUSIONS Initiatives to improve electrocardiogram interpretation and evidence-based patient selection may reduce gaps in the delivery of reperfusion therapy to eligible candidates and thereby potentially improve STEMI outcomes.

SLOW INFUSION FOR THE PREVENTION OF AKATHISIA INDUCED BY PROCHLORPERAZINE: A RANDOMIZED CONTROLLED TRIAL

The utility of intravenous prochlorperazine (PCZ) in the treatment of nausea, vomiting, and headache may be limited by the akathisia that occurs frequently with the recommended 2-min infusion rate. We tested the hypothesis that decreasing the rate of PCZ infusion to 15 min reduces the incidence of akathisia at 1 hour. This double-blinded, randomized, controlled trial was conducted in the Emergency Department of an academic tertiary-care medical center with an annual census of 95,000 emergency patient visits. We enrolled a convenience sample of adult patients who received 10 mg i.v. PCZ for the treatment of nausea, vomiting, or headache. Subjects were randomized to receive either a 2-min infusion of PCZ (10 mg) followed by a 15-min infusion of saline, or a 2-min infusion of saline followed by a 15-min infusion of prochlorperazine. The incidence of akathisia at 1 hour was measured by using explicit diagnostic criteria. One hundred sixty patients were randomly enrolled into two groups, which were comparable with respect to age, gender, weight, and complaint. Akathisia developed in 31 of 84 patients (36.9%) who received the 2-min infusion of PCZ and in 18 of 76 patients (23.7%) who received the 15-min infusion of PCZ (p = 0.07), a 36% (95% CI, -5% to 61%) relative reduction. The delta from pre-infusion to postinfusion scores between the two groups was not significant (p = 0.19). We conclude that slowing the rate of PCZ infusion does not decrease akathisia.

Current management of migraine in US emergency departments: An analysis of the National Hospital Ambulatory Medical Care Survey

Background Published data from 1998 revealed that most patients treated for migraine in an emergency department received opioids. Over the intervening years, a large body of evidence has emerged demonstrating the efficacy and safety of non-opioid alternatives. Expert opinion during these years has cautioned against use of opioids for migraine. Our objectives were to compare current frequency of use of various medications for acute migraine in US emergency departments with use of these same medications in 1998 and to identify factors independently associated with opioid use. Methods We analyzed National Hospital Ambulatory Medical Care Survey data from 2010, the most current dataset available. The National Hospital Ambulatory Medical Care Survey is a public dataset collected and distributed by the Centers for Disease Control and Prevention. It is a multi-stage probability sample from randomly selected emergency departments across the country, designed to be representative of all US emergency department visits. We included in our analysis all patients with the ICD9 emergency department discharge diagnosis of migraine. We tabulated frequency of use of specific medications in 2010 and compared these results with the 1998 data. Using a logistic regression model, into which all of the following variables were entered, we explored the independent association between any opioid use in 2010 and sex, age, race/ethnicity, geographic region, type of hospital, triage pain score and history of emergency department use within the previous 12 months. Results In 2010, there were 1.2 (95% confidence interval 0.9, 1.4) million migraine visits to US emergency departments. Including opioid-containing oral analgesic combinations, opioids were administered in 59% of visits (95% confidence interval 51, 67). The most commonly used parenteral agent, hydromorphone, was used in 25% (95% confidence interval 19, 33) of visits in 2010 versus less than 1% (95% confidence interval 0, 3) in 1998. Conversely, use of meperidine had decreased markedly over the same timeframe. In 2010, it was used in just 7% (95% confidence interval 4, 12) of visits compared to 37% (95% confidence interval 29, 45) in 1998. Metoclopramide, the most commonly used anti-dopaminergic, was administered in 17% (95% confidence interval 12, 23) of visits in 2010 and 3% (95% confidence interval 1, 6) of visits in 1998. Use of any triptan was relatively uncommon in 2010 (7% (95% confidence interval 4, 11) of visits) and in 1998 (10% (95% confidence interval 6, 15) of visits). Of the predictor variables listed above, only emergency department use within the previous 12 months was associated with opioid administration (adjusted odds ratio: 2.87 (95% confidence interval 1.03, 7.97)). Conclusions In spite of recommendations to the contrary, opioids are still used in more than half of all emergency department visits for migraine. Though use of meperidine has decreased markedly between 1998 and 2010, it has largely been replaced by hydromorphone. Opioid use in migraine visits is independently associated with prior visits to the same emergency department in the previous 12 months.

Risk of Traumatic Intracranial Hemorrhage in Patients with Head Injury and Preinjury Warfarin or Clopidogrel Use

OBJECTIVES Appropriate use of cranial computed tomography (CT) scanning in patients with mild blunt head trauma and preinjury anticoagulant or antiplatelet use is unknown. The objectives of this study were: 1) to identify risk factors for immediate traumatic intracranial hemorrhage (tICH) in patients with mild head trauma and preinjury warfarin or clopidogrel use and 2) to derive a clinical prediction rule to identify patients at low risk for immediate tICH. METHODS This was a prospective, observational study at two trauma centers and four community hospitals that enrolled adult emergency department (ED) patients with mild blunt head trauma (initial ED Glasgow Coma Scale [GCS] score 13 to 15) and preinjury warfarin or clopidogrel use. The primary outcome measure was immediate tICH, defined as the presence of ICH or contusion on the initial cranial CT. Risk for immediate tICH was analyzed in 11 independent predictor variables. Clinical prediction rules were derived with both binary recursive partitioning and multivariable logistic regression. RESULTS A total of 982 patients with a mean (± standard deviation [SD]) age of 75.4 (±12.6) years were included in the analysis. Sixty patients (6.1%; 95% confidence interval [CI] = 4.7% to 7.8%) had immediate tICH. History of vomiting (relative risk [RR] = 3.53; 95% CI = 1.80 to 6.94), abnormal mental status (RR = 2.85; 95% CI = 1.65 to 4.92), clopidogrel use (RR = 2.52; 95% CI = 1.55 to 4.10), and headache (RR = 1.81; 95% CI = 1.11 to 2.96) were associated with an increased risk for immediate tICH. Both binary recursive partitioning and multivariable logistic regression were unable to derive a clinical prediction model that identified a subset of patients at low risk for immediate tICH. CONCLUSIONS While several risk factors for immediate tICH were identified, the authors were unable to identify a subset of patients with mild head trauma and preinjury warfarin or clopidogrel use who are at low risk for immediate tICH. Thus, the recommendation is for urgent and liberal cranial CT imaging in this patient population, even in the absence of clinical findings.