Michael J. Bullard

Sensitivity of computed tomography performed within six hours of onset of headache for diagnosis of subarachnoid haemorrhage: prospective cohort study

Objective To measure the sensitivity of modern third generation computed tomography in emergency patients being evaluated for possible subarachnoid haemorrhage, especially when carried out within six hours of headache onset. Design Prospective cohort study. Setting 11 tertiary care emergency departments across Canada, 2000-9. Participants Neurologically intact adults with a new acute headache peaking in intensity within one hour of onset in whom a computed tomography was ordered by the treating physician to rule out subarachnoid haemorrhage. Main outcome measures Subarachnoid haemorrhage was defined by any of subarachnoid blood on computed tomography, xanthochromia in cerebrospinal fluid, or any red blood cells in final tube of cerebrospinal fluid collected with positive results on cerebral angiography. Results Of the 3132 patients enrolled (mean age 45.1, 2571 (82.1%) with worst headache ever), 240 had subarachnoid haemorrhage (7.7%). The sensitivity of computed tomography overall for subarachnoid haemorrhage was 92.9% (95% confidence interval 89.0% to 95.5%), the specificity was 100% (99.9% to 100%), the negative predictive value was 99.4% (99.1% to 99.6%), and the positive predictive value was 100% (98.3% to 100%). For the 953 patients scanned within six hours of headache onset, all 121 patients with subarachnoid haemorrhage were identified by computed tomography, yielding a sensitivity of 100% (97.0% to 100.0%), specificity of 100% (99.5% to 100%), negative predictive value of 100% (99.5% to 100%), and positive predictive value of 100% (96.9% to 100%). Conclusion Modern third generation computed tomography is extremely sensitive in identifying subarachnoid haemorrhage when it is carried out within six hours of headache onset and interpreted by a qualified radiologist.

High risk clinical characteristics for subarachnoid haemorrhage in patients with acute headache: prospective cohort study

Objective To identify high risk clinical characteristics for subarachnoid haemorrhage in neurologically intact patients with headache. Design Multicentre prospective cohort study over five years. Setting Six university affiliated tertiary care teaching hospitals in Canada. Data collected from November 2000 until November 2005. Participants Neurologically intact adults with a non-traumatic headache peaking within an hour. Main outcome measures Subarachnoid haemorrhage, as defined by any of subarachnoid haemorrhage on computed tomography of the head, xanthochromia in the cerebrospinal fluid, or red blood cells in the final sample of cerebrospinal fluid with positive results on angiography. Physicians completed data collection forms before investigations. Results In the 1999 patients enrolled there were 130 cases of subarachnoid haemorrhage. Mean (range) age was 43.4 (16-93), 1207 (60.4%) were women, and 1546 (78.5%) reported that it was the worst headache of their life. Thirteen of the variables collected on history and three on examination were reliable and associated with subarachnoid haemorrhage. We used recursive partitioning with different combinations of these variables to create three clinical decisions rules. All had 100% (95% confidence interval 97.1% to 100.0%) sensitivity with specificities from 28.4% to 38.8%. Use of any one of these rules would have lowered rates of investigation (computed tomography, lumbar puncture, or both) from the current 82.9% to between 63.7% and 73.5%. Conclusion Clinical characteristics can be predictive for subarachnoid haemorrhage. Practical and sensitive clinical decision rules can be used in patients with a headache peaking within an hour. Further study of these proposed decision rules, including prospective validation, could allow clinicians to be more selective and accurate when investigating patients with headache.

Early corticosteroid use in acute exacerbations of chronic airflow obstruction

To determine the benefit of early steroid use in acute exacerbations of chronic airflow obstruction in the ED, 113 patients with an average age of 66 years, acute or chronic dyspnea, an FEV1 of < 60% and FEV1/FVC ratio of < 60% were included in a randomized, double-blinded, interventional clinical trial. All patients received the same bronchodilator treatment. At 6 hours the steroid- treated group showed a 21.71 L/min improvement in PEFR (P < .05) and 0.14 L improvement in FEV1 (P < .05), while the nonsteroid group showed insignificant improvements of 5.52 L/min and 0.02 L, respectively. Of those patients receiving steroids, 22 achieved > 40% improvements in PEFR by 6 hours and 17 achieved similar results in FEV1, whereas of those not receiving steroids, 13 and 8, respectively, achieved improvements. Within 24 hours of observation in the ED, 16 patients receiving steroids were discharged and none relapsed within 2 weeks. Of those not receiving steroids, only 10 were discharged and 3 returned with exacerbations. Although early response to steroids in chronic airflow obstruction is variable, the overall medical and cost benefits justify their early use in acute exacerbations.

The Role of Triage Liaison Physicians on Mitigating Overcrowding in Emergency Departments: A Systematic Review

OBJECTIVES The objective was to examine the effectiveness of triage liaison physicians (TLPs) on mitigating the effects of emergency department (ED) overcrowding. METHODS Electronic databases (Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, Web of Science, HealthSTAR, Dissertation Abstracts, and ABI/INFORM Global), controlled trial registry websites, conference proceedings, study references, contact with experts in the field, and correspondence with authors were used to identify potentially relevant TLP studies. Intervention studies in which a TLP was used to influence ED overcrowding metrics (length of stay [LOS] in minutes, physician initial assessment [PIA], and left without being seen [LWBS]) were included in the review. Two reviewers independently conducted data extraction and assessed the citation relevance, inclusion, and study quality. For continuous outcomes, weighted mean differences (WMD) were calculated and reported with corresponding 95% confidence intervals (CIs). For dichotomous variables, individual and pooled statistics were calculated as relative risk (RR) with 95% CI. RESULTS From 14,446 potentially relevant studies, 28 were included in the systematic review. Thirteen were journal publications, 12 were abstracts, and three were Web-based articles. Most studies employed before-after designs; 23 of the 28 studies were considered of weak quality. Based on the statistical pooling of data from two randomized controlled trials (RCTs), TLP resulted in shorter ED LOS compared to nurse-led triage (WMD = -36.85 min; 95% CI = -51.11 to -22.58). One of these RCTs showed a significant reduction in the PIA associated to TLP presence (WMD = -30.00 min; 95% CI = -56.91 to -3.09); the other RCT showed no change in LWBS due to a CI that included unity (RR = 0.82; 95% CI = 0.67 to 1.00). CONCLUSIONS While the evidence summarized here suggests that to have a TLP is an effective intervention to mitigate the effects of ED overcrowding, due to the weak research methods identified, more research is required before its widespread implementation.

Acute pancreatitis following organophosphate intoxication.

BACKGROUND Acute pancreatitis as a complication of organophosphate intoxication has been infrequently addressed. Previous reports have suggested that acute pancreatitis may follow the oral ingestion of several organophosphates, including parathion, malathion, difonate, coumaphos, and diazinon, or after cutaneous exposure to dimethoate. No cases of acute pancreatitis following mevinphos (CAS 7786-34-71) poisoning have been reported to date. The possible pathogeneses of the pancreatic insult in organophosphate intoxication are excessive cholinergic stimulation of the pancreas and ductular hypertension. CASE REPORT We describe a patient presenting with painless acute pancreatitis following an intentional ingestion of large amounts of mevinphos. Serum amylase and lipase values were increased and determination of amylase isoenzymes confirmed a pancreatic origin. A computerized tomograph of the abdomen showed diffuse swelling of the pancreas. The patient was discharged after a seven week clinical course, complicated by a delayed neuropathy. CONCLUSIONS As acute pancreatitis in organophosphate intoxication may be more common than reported, serum pancreatic enzymes and appropriate imaging studies should be more liberally utilized. Early recognition and appropriate therapy for acute pancreatitis may lead to an improved prognosis.

The role of triage nurse ordering on mitigating overcrowding in emergency departments: a systematic review

OBJECTIVES The objective was to examine the effectiveness of triage nurse ordering (TNO) on mitigating the effect of emergency department (ED) overcrowding. METHODS Electronic databases (Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, SCOPUS, Web of Science, HealthSTAR, Dissertation Abstracts, ABI/INFORM Global), controlled trial registry websites, conference proceedings, study references, experts in the field, and correspondence with authors were used to identify potentially relevant studies. Interventional studies in which TNO was used to influence ED overcrowding metrics (length of stay [LOS] and physician initial assessment [PIA]) were included in the review. Two reviewers independently assessed study eligibility and methodologic quality. Mean differences were calculated and reported with corresponding 95% confidence intervals (CIs). RESULTS From more than 14,000 potentially relevant studies, 14 were included in the systematic review. Most were single-center ED studies; the overall quality was rated as weak, due to methodologic deficiencies and variable outcome reporting. TNO was associated with a 37-minute mean reduction (95% CI = -44.10 to -30.30 minutes) in the overall ED LOS in one randomized clinical trial (RCT); a 51-minute mean reduction (95% CI = -56.3 to -45.5 minutes) was observed in non-RCTs. When applied to injured subjects with suspected fractures, TNO interventions reduced ED LOS by 20 minutes (95% CI = -37.5 to -1.9 minutes) in three RCTs and by 18 minutes (95% CI = -23.2 to -13.2) in two non-RCTs. No significant reduction in PIA was observed in two RCTs. CONCLUSIONS Overall, TNO appears to be an effective intervention to reduce ED LOS, especially in injury and/or suspected fracture cases. The available evidence is limited by small numbers of studies, weak methodologic quality, and incomplete reporting. Future studies should focus on a better description of the contextual factors surrounding these interventions and exploring the impact of TNO on other indicators of productivity and satisfaction with health care delivery.

Prolonged Severe Withdrawal Symptoms After Acute-on-Chronic Baclofen Overdose

INTRODUCTION Baclofen is frequently used to treat muscle spasticity due to spinal cord injury and multiple sclerosis. Baclofen overdose can lead to coma, respiratory depression, hyporeflexia, and flaccidity. An abrupt decrease in the dose of baclofen due to surgery or a rapid tapering program may result in severe baclofen withdrawal syndrome manifesting hallucinations, delirium, seizures, and high fever. Severe baclofen withdrawal syndrome secondary to intentional overdose, however, has not received mention. CASE REPORT A 42-year-old male receiving chronic baclofen therapy, 20 mg/d, attempted suicide by ingesting at least 800 mg of baclofen. He was found in coma 2 hours postingestion with depressed respirations, areflexia, hypotonia, bradycardia, and hypotension. Treatment with intravenous fluids, atropine, dopamine, and hemodialysis was associated with restoration of consciousness within 2 days but disorientation, hallucinations, fever, delirium, hypotension, bradycardia, and coma developed during the following week. Baclofen withdrawal syndrome was not diagnosed until hospital day 9, when reinstitution of baclofen rapidly stabilized his condition. Oral overdosage of baclofen causes severe neurological and cardiovascular manifestations due to its GABA and dominant cholinergic effects. Severe baclofen withdrawal syndrome is manifest by neuropsychiatric manifestations and hemodynamic instability. Caution should be exercised after a baclofen overdose in patients receiving chronic baclofen therapy.

Consultations in the emergency department: a systematic review of the literature

Objectives: Consultation is a common and important aspect of emergency department (ED) practice which can lead to delays in patient flow. Little is known about ED consultations and this review systematically evaluated the literature on ED consultations. Methods: Comprehensive searches of MEDLINE, PUBMED, SCIRUS, Cochrane Library, Web of Science, Health Star and other databases from 1966 to 2007 were performed. The grey literature and reference lists were searched and authors were contacted to identify other eligible studies. Published and unpublished studies reporting the proportion of consultations in the ED using any type of design were considered for this review. Eligible studies were required to involve patients presenting to the ED. Studies reporting on the proportion of consultation in a specific subpopulation of patients and interventions to improve consultations were also considered for inclusion. Two reviewers independently selected studies and extracted data from included studies regarding the proportion of consultations in the ED or the patient subgroup. Individual study proportions were calculated together with 95% confidence intervals (CI). Results: From more than 15 000 pre-screened citations, 12 studies were finally included in the review. All but three of the included studies were published. Overall, four studies examined ED consultation proportions, six identified the rate of consultation for special populations of ED presentations and two examined interventions to improve consultations. Consultation varied from 20% to 40% for all patients, with lower proportions in the selected populations studied and a high rate of hospitalisation for consulted patients. Limited research on interventions to improve the ED consultation process has also been completed. Conclusions: Consultation research in the emergency setting is limited and variable; however, high consultation rates exist in some centres. This systematic review outlines the current state of the literature and suggests that further research is urgently needed.

The role of a rapid assessment zone/pod on reducing overcrowding in emergency departments: a systematic review.

Objective To evaluate the effectiveness of a rapid assessment zone (RAZ) to mitigate emergency department (ED) overcrowding. Methods Electronic databases, controlled trial registries, conference proceedings, study references, experts in the field and correspondence with authors were used to identify potentially relevant studies. Intervention studies, in which a RAZ was used to influence length of stay, physician initial assessment and patients left without being seen, were included. Mean differences were calculated and reported with corresponding 95% CIs; individual statistics are presented as RR with associated 95% CI. Results From 14 446 potentially relevant studies, four studies were included in the review. The quality of one study was appraised as moderately high; others were rated as weak. Two studies showed that a RAZ was associated with a reduction of 20 min (95% CI: −47.2 to 7.2) in the ED length of stay; in one non-randomised clinical trial (RCT), a 192 min reduction was reported (95% CI: −211.6 to −172.4). Physician initial assessment showed a reduction of 8.0 min; 95% CI: −13.8 to −2.2 in the RCT and a reduction of 33 min (95% CI: −42.3 to −23.6) and 18 min (95% CI: −22.2 to −13.8) respectively were found in two non-RCTs. There was a reduction in the risk of patient leaving without being seen (RCT: RR=0.93, 95% CI: 0.77 to 1.12; non-RCT: RR =0.68, 95% CI: 0.63 to 0.73). Conclusions Although the results are consistent, and low acuity patients seem to benefit the most from a RAZ, the available evidence to support its implementation is limited.

Comparison Between Canadian Triage and Acuity Scale and Taiwan Triage System in Emergency Departments

BACKGROUND/PURPOSE Since the implementation of National Health Insurance in Taiwan, Emergency Department (ED) volume has progressively increased, and the current triage system is insufficient and needs modification. This study compared the prioritization and resource utilization differences between the four-level Taiwan Triage System (TTS) and the standardized five-level Canadian Triage and Acuity Scale (CTAS) among ED patients. METHODS This was a prospective observational study. All adult ED patients who presented to three different medical centers during the study period were included. Patients were independently triaged by the duty triage nurse using TTS, and a single trained research nurse using CTAS with a computer support software system. Hospitalization, length of stay (LOS), and medical resource consumption were analyzed by comparing TTS and CTAS by acuity levels. RESULTS There was significant disparity in patient prioritization between TTS and CTAS among the 1851 enrolled patients. With TTS, 7.8%, 46.1%, 45.9% and 0.2% were assigned to levels 1, 2, 3, and 4, respectively. With CTAS, 3.5%, 24.4%, 44.3%, 22.4% and 5.5% were assigned to levels 1, 2, 3, 4, and 5, respectively. The hospitalization rate, LOS, and medical resource consumption differed significantly between the two triage systems and correlated better with CTAS. CONCLUSION CTAS provided better discrimination for ED patient triage, and also showed greater validity when predicting hospitalization, LOS, and medical resource consumption. An accurate five-level triage scale appeared superior in predicting patient acuity and resource utilization.