J.Stephen Huff

Clinical Policy for the Initial Approach to Adolescents and Adults Presenting to the Emergency Department With a Chief Complaint of Headache

Abstract ACEP Clinical Policies committee and the Clinical Policies SubCommittee on Headache [American College of Emergency Physicians: Clinical policy for the initial approach to adolescents and adults presenting to the emergency department with a chief complaint of headache. Ann Emerg Med June 1996;27:821-844.]

Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Seizures

This clinical policy from the American College of Emergency Physicians is the revision of a 2004 policy on critical issues in the evaluation and management of adult patients with seizures in the emergency department. A writing subcommittee reviewed the literature to derive evidence-based recommendations to help clinicians answer the following critical questions: (1) In patients with a first generalized convulsive seizure who have returned to their baseline clinical status, should antiepileptic therapy be initiated in the emergency department to prevent additional seizures? (2) In patients with a first unprovoked seizure who have returned to their baseline clinical status in the emergency department, should the patient be admitted to the hospital to prevent adverse events? (3) In patients with a known seizure disorder in which resuming their antiepileptic medication in the emergency department is deemed appropriate, does the route of administration impact recurrence of seizures? (4) In emergency department patients with generalized convulsive status epilepticus who continue to have seizures despite receiving optimal dosing of a benzodiazepine, which agent or agents should be administered next to terminate seizures? A literature search was performed, the evidence was graded, and recommendations were given based on the strength of the available data in the medical literature.

Spinal epidural hematoma associated with cocaine abuse

A 41-year-old man rapidly developed quadriparesis moments after injecting cocaine. Investigation discovered a cervical spinal epidural hematoma. This complication of cocaine abuse has not been previously reported.

Pathophysiology and definitions of seizures and status epilepticus

The pathophysiology of seizures is multifactorial and incompletely understood. Experimental work demonstrates that prolonged, abnormal, and excessive neuronal electrical activity in itself is injurious through several mechanisms independent of systemic acidosis and hypoxia. Population survival studies and laboratory investigations support the idea that brain injury and epileptogenesis result from status epilepticus. The basic distinction in seizure types is that of generalized and partial seizures. Correct classification of seizure types will aid in clinical communications and guide correct therapies. Revised definitions of generalized convulsive status epilepticus suggest making this diagnosis with as few as 5 minutes of continuous seizure activity.

Electrocardiographic ST-segment elevation: Takotsubo cardiomyopathy versus ST-segment elevation myocardial infarction--a case series.

Takotsubo cardiomyopathy, or left ventricular apical ballooning syndrome, is a newly described disorder in which patients develop anginal symptoms, often times with acute congestive heart failure, during periods of stress. The electrocardiogram demonstrates ST-segment and/or T-wave abnormalities similar to those findings seen in acute coronary events; on occasion, serum markers can be abnormal. As an extreme, acute pulmonary edema with or without cardiogenic shock can also be encountered. At cardiac catheterization, these patients are found to have abnormal left ventricular function yet normal coronary arteries. We compared 2 populations encountered in the emergency department (ED) population--Takotsubo cardiomyopathy and ST-segment elevation myocardial infarction. In the ED, features of the presentation and management were similar between the 2 groups with the exception of the presence of female sex and abnormal QT interval occurring more often in Takotsubo cardiomyopathy subgroup. These 2 cardiovascular maladies present in very similar fashion in the ED; distinction in the ED may not be possible.

Anterograde amnesia following triazolam use in two emergency physicians

Anterograde amnesia following triazolam ingestion lasting beyond the sedative-hypnotic effect of the drug has recently been reported. Two additional cases are presented involving emergency physicians.

Acute mannitol intoxication in a patient with normal renal function

A young, previously healthy patient with multiple trauma mistakenly received 400 grams of mannitol over a 3-hour period. The laboratory report of hyponatremia prompted treatment with hypertonic saline before the hyperosmolar state was recognized. The osmolal gap was 118. Mannitol intoxication in a patient without preexisting renal failure is unusual. Identification of an abnormal osmolal gap and recognition of the hyperosmolar state is discussed.

Nonurgent Commercial Air Travel After Nonhemorrhagic Cerebrovascular Accident

Nonurgent commercial air travel in patients who have experienced a nonhemorrhagic cerebrovascular accident (CVA) may occur, particularly in the elderly traveling population. A recent CVA, particularly occurring during a persons travel, presents a significant challenge to the patient, companions, family, and health care team. Specific medical recommendation, based on accumulated scientific data and interpreted by medical experts, is needed so that travel health care professionals can appropriately guide the patient. Unfortunately, such recommendations are almost entirely lacking despite the relative frequency of CVA and air travel. This article reviews the existing recommendations with conclusions based on both these limited data and rationale conjecture.

Differences in interpretation of cranial computed tomography in ED traumatic brain injury patients by expert neuroradiologists

Cranial computed tomography (CT) is generally regarded as the standard for evaluation of structural brain injury in patients with traumatic brain injury (TBI) presenting to the emergency department (ED). However, the subjective nature of the visual interpretations of CT scans and the qualitative nature of reporting may lead to poor interrater reliability. This is significant because CT positive scans include a continuum of structural injury with differences in treatment. The purpose of the present study was to evaluate the consistency of readings of head CT scans obtained within 24 hours after mild TBI in the ED, as assessed by an independent adjudication panel of 3 experienced neuroradiologists. In 80.1% of the cases, all 3 adjudicators agreed with the determination of the presence of structural injury. However, when interrater agreement was assessed with respect to the specific classification of the injury, agreement was poor, with a κ of 0.3 (0.29-0.316; confidence interval [CI] 95%). When classification was collapsed, considering only the presence or absence of hematomas, agreement among all 3 adjudicators improved to 55%, but the κ of 0.355, (0.332-0.78; CI 95%) was still only fair. The data suggest the need for improved recognition and quantification of specific structural injuries in the TBI population for better identification of patients requiring clinical intervention.

A Brain Electrical Activity Electroencephalographic-Based Biomarker of Functional Impairment in Traumatic Brain Injury: A Multi-Site Validation Trial

The potential clinical utility of a novel quantitative electroencephalographic (EEG)-based Brain Function Index (BFI) as a measure of the presence and severity of functional brain injury was studied as part of an independent prospective validation trial. The BFI was derived using quantitative EEG (QEEG) features associated with functional brain impairment reflecting current consensus on the physiology of concussive injury. Seven hundred and twenty adult patients (18-85 years of age) evaluated within 72 h of sustaining a closed head injury were enrolled at 11 U.S. emergency departments (EDs). Glasgow Coma Scale (GCS) score was 15 in 97%. Standard clinical evaluations were conducted and 5 to 10 min of EEG acquired from frontal locations. Clinical utility of the BFI was assessed for raw scores and percentile values. A multinomial logistic regression analysis demonstrated that the odds ratios (computed against controls) of the mild and moderate functionally impaired groups were significantly different from the odds ratio of the computed tomography (CT) postive (CT+, structural injury visible on CT) group (p = 0.0009 and p = 0.0026, respectively). However, no significant differences were observed between the odds ratios of the mild and moderately functionally impaired groups. Analysis of variance (ANOVA) demonstrated significant differences in BFI among normal (16.8%), mild TBI (mTBI)/concussed with mild or moderate functional impairment, (61.3%), and CT+ (21.9%) patients (p < 0.0001). Regression slopes of the odds ratios for likelihood of group membership suggest a relationship between the BFI and severity of impairment. Findings support the BFI as a quantitative marker of brain function impairment, which scaled with severity of functional impairment in mTBI patients. When integrated into the clinical assessment, the BFI has the potential to aid in early diagnosis and thereby potential to impact the sequelae of TBI by providing an objective marker that is available at the point of care, hand-held, non-invasive, and rapid to obtain.