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1.
Objective
Given the same pretest probability (10%) for subarachnoid hemorrhage (SAH), pulmonary embolism (PE), and acute coronary syndrome (ACS), we determined if differences exist in the risk tolerance for disease exclusion according to published guidelines given a negative test result.Methods
Published guidelines that make practice recommendations on the evaluation of ACS, PE, and SAH were sought using the National Guideline Clearinghouse in low-risk settings. Second-order Monte Carlo simulation was performed to determine point estimates and confidence intervals (CIs) for posttest probabilities assuming a pretest probability of 10%.Results
Guidelines recommend that patients with low-risk suspected ACS should undergo stress testing. For SAH, computed tomography (CT) followed by lumbar puncture (LP) is recommended without mention of pretest probability; and D-dimer testing is recommended to exclude PE in low-risk patients. Test sensitivity for thallium-201 single photon emission computed tomography (SPECT) was 89%, exercise echocardiogram was 85%, D-dimer testing was 95%, and CT/LP for SAH was 100% (as a gold standard) and CT only was 97.5%. Given a negative test result, for PE, posttest probability was 0.5% (95% CI 0.1%-0.9%); for SPECT, 1.1% (SD 0.5%-1.6%); and for exercise echocardiogram, 1.5% (95% CI 0.5%-2.5%) compared with a posttest probability of 0% for CT followed by LP for SAH. Using a CT-only approach gives a posttest probability of 0.2% (95% CI 0.2%-0.4%).Conclusions
Guidelines for suspected PE and ACS allow small but nonzero calculated risk end points in low-risk settings, whereas SAH guidelines afford no misses. Because many gold standard tests are more invasive and can have adverse effects, guideline authors should consider adopting a standard acceptable miss rate as an end point for workups with low clinical suspicion to avoid the overuse of invasive testing. 相似文献2.
Shah KH McGillicuddy D Spear J Edlow JA 《The American journal of emergency medicine》2007,25(6):608-611
Objective
The objective of this study is to determine if visual and tactile inspection of the spine is useful in the prediction of a difficult or traumatic lumbar puncture (LP).Design
This was a prospective, observational, cohort study conducted in the emergency department (ED) on patients who were undergoing an LP. Physicians prospectively completed a structured data form that included information about the patient, number of prior LPs performed, their assessment of the LP difficulty, and the number of needlesticks required. A “difficult” LP and a “traumatic” tap were defined a priori. χ2, t tests, and regression were used as appropriate; an independent statistician performed the statistical analysis.Setting
The study was conducted at an urban university teaching hospital with an annual ED census of approximately 48 000 patients between November 1, 2002, and June 1, 2003.Patients
The study population included a convenience sample of patients undergoing LP in the ED.Results
Of the 148 patients enrolled, LP was difficult in 47 (32%) patients and traumatic in 23 (16%) patients. The percentage of patients that did not have a visible spine was significantly higher in the difficult and traumatic groups (P < .05). Among patients where the physician was unable to visualize the spine, there were significantly more difficult LPs (P < .05).Conclusion
It may be possible to predict which patients will have difficult or traumatic LPs before performing the procedure. Simple bedside assessments of spine visibility and palpability may assist in planning the approach to an LP in patients. 相似文献3.
Hussein D. Kanji Andrew Neitzel Mypinder Sekhon Jessica McCallum Donald E. Griesdale 《Journal of critical care》2014
Purpose
Cervical spine (CS) injury in blunt trauma is a prevalent and devastating complication. Clearing CS injuries in obtunded patients is fraught with challenges, and no single imaging modality or algorithm is both safe and effective. Increased time in c-spine precautions is associated with greater patient morbidity including increased ventilator associated pneumonia, delirium and ulceration. We systemically reviewed the literature to assess the effectiveness of 64-slice computed tomographic (CT) scanners in clearing traumatic CS injuries.Materials and Methods
Studies were identified using MEDLINE and Embase, the references of identified studies, international experts on CS clearance and authors of primary studies. Three reviewers independently selected and extracted data from studies that reported on both CT and MRI in traumatic CS injury.Results
We included five studies involving a total of 3443 patients; however, heterogeneity and lack of sample size precluded quantitative summation of the results. Qualitative assessment showed that 64-Slice CT scan, when applied within a set protocol, performed favourably in clearing injury.Conclusions
Data suggests that using 64-slice CT scans on obtunded trauma patients with grossly intact motor function, in the context of a defined clearance protocol with interpretation by an experienced radiologist, may be sufficient to safely clear significant CS injury. A prospective study comparing MRI and 64-slice CT scan clearance in this population is necessary to corroborate these conclusions. 相似文献4.
Yves Benabu Levental Mark Suissa Daniel Rafael Glikstein 《The American journal of emergency medicine》2009
Objective
The objective of the study is to demonstrate the pitfalls in the diagnosis of cerebral venous thrombosis (CVT) especially when subarachnoid hemorrhage (SAH) is associated and discuss the diagnostic value of computed tomography (CT) imaging as well as the use of other diagnostic modalities. In addition, we will briefly summarize the pathophysiology of SAH in the setting of CVT.Methods
We reviewed 16 articles, which included 26 different case reports of SAH associated with CVT. In addition, we presented our experience with a case of SAH secondary to CVT.Results
Nonenhanced CT was able to detect SAH in 86% of cases and CVT in only 36%. Further imaging testing was necessary to further characterize the extent of the thrombosis. The location of the SAH varied, but it never involved the skull base. Risk factors for CVT development included hypercoagulable states, oral contraceptives use, history of recent fracture or surgery, family or personal history of deep vein thrombosis, smoking, and hyperlipidemia and migraines. Sixty-two percent of patients had acute onset severe headaches, 35% presented with nuchal rigidity, and 35% presented with seizures.Conclusions
Cerebral venous thrombosis must be considered in the differential diagnosis of patients presenting with a broad range of neurological presentations especially in the presence of new onset of seizures. Computed tomographic offers many clues to the diagnosis of CVT when concomitant SAH is present. These include the presence of SAH at cerebral convexities with associated basal cisterns and skull base sparing. Recognition of these subtleties will allow prompt and appropriate management and, when in doubt, encourage further investigations. 相似文献5.
Background
Citing the enhanced resolution of 64-slice computed tomography (CT), some clinicians now use CT instead of magnetic resonance imaging (MRI) to detect occult hip fracture.Objective
Our objective was to determine the incidence of occult hip fractures missed by 64-slice CT but detected by MRI.Methods
We reviewed the medical records and radiology reports of patients over age 60 years with a hip fracture (acetabular, intertrochanteric, trochanteric, femoral neck, and femoral head) during a 3-year period, January 1, 2007 through December 31, 2009. We also reviewed all hip CT and MRI scans ordered during that period. Occult fractures were those visualized on CT or MRI but with negative plain films. We compared CT and MRI findings, and calculated percentages and 95% confidence intervals (CIs).Results
Of 235 hip fractures, 211 were visible on initial plain films (90%, 95% CI 85–93%) and 24 (10%, 95% CI 6–15%) were occult. Eighteen occult fractures (7.6%, 95% CI 4.6–11.8%) were identified by CT (MRI not done), one (0.4%, 95% CI 0–2%) by MRI (CT not done), one (0.4%, 95% CI 0–2%) by both CT and MRI, and 4 patients (1.7%, 95% CI 0.5–4.3%) had a positive MRI but negative CT scan.Conclusion
Although 64-slice CT detected the majority of occult fractures, it missed four (2%) significant fractures detected by MRI. CT scan is helpful in the diagnosis of occult hip fracture, but one should not completely exclude the diagnosis based on a negative 64-slice CT scan in a patient with persistent, localized hip pain who cannot bear weight. 相似文献6.
Huang CC Huang CH Kuo HY Chan CM Chen JH Chen WL 《The American journal of emergency medicine》2012,30(5):732-736
Objective
The aim of this study was to investigate if the electrocardiographic (ECG) abnormalities assessed early in the emergency department (ED) are associated with the in-hospital mortality of the patients with spontaneous subarachnoid hemorrhage (SAH).Methods
We studied prospectively a cohort of 222 adult patients with spontaneous SAH in an ED. A 12-lead ECG was performed for these patients in the ED. The patients were stratified into nonsurvivors and survivors based on the in-hospital mortality. The clinical characteristics, heart rate, corrected QT interval (QTc) and 7 predefined morphologic abnormalities were compared between these 2 groups of patients.Results
Compared with the survivors (n = 178), the nonsurvivors (n = 44) had significantly slower heart rate (75 ± 23 vs 83 ± 16, P = .018) and more prolonged QTc (492 ± 58 vs 458 ± 40, P = .001). There were significantly higher frequency of occurrence of ECG morphologic abnormalities (66% vs 37%, P = .001) and nonspecific ST- or T-wave changes (NSSTTCs; 32% vs 12%, P = .015) in the nonsurvivors compared with those in the survivors. Multiple logistic regression model identified QTc (odds ratio, 1.0; 95% confidence interval, 1.0-1.0; P = .005) and NSSTTC (odds ratio, 3.3; 95% confidence interval, 1.0-10.7; P = .047) as the significant ECG variables associated with in-hospital mortality.Conclusions
The occurrence of NSSTTC and prolonged QTc assessed early in the ED are independently associated with the in-hospital mortality in adult patients with spontaneous SAH. 相似文献7.
Background
Handheld measurement of intraocular pressure (IOP) has been previously shown to accurately predict elevated intracranial pressure (ICP) in neurosurgical patients. Handheld tonometry may have clinical utility in the prediction of elevated ICP among a cohort of emergency department (ED) patients receiving lumbar puncture (LP).Objective
To ascertain the sensitivity and specificity of IOP for the prediction of elevated ICP in ED patients undergoing LP.Methods
In this prospective observational pilot study, all ED patients over the age of 18 years and undergoing LP in the ED for any reason were eligible to participate. Study participants had IOP measured with the Tono-Pen XL (Reichert, Inc., Depew, NY) while in the supine position before LP. OP was measured in the lateral recumbent position. Elevated IOP was defined as ≥ 20 mm Hg; elevated ICP was defined as ≥ 20 mm H2O.Results
There were 82 patients screened and 46 patients enrolled at the time of interim analysis. Of the 46 patients, 32 had a successful LP in the lateral recumbent position. There were 18/32 patients with a successful LP in the lateral recumbent position who had elevated opening pressure; 9/32 patients with a successful LP had an elevated IOP. Furthermore, 4/9 patients with elevated IOP also had an elevated opening pressure. There was only one patient who had elevated IOP, elevated ICP, and diagnostic cerebrospinal fluid (sensitivity 24%, 95% confidence interval [CI] 9–48%; specificity 63%, 95% CI 32–88%; positive predictive value 28%, 95% CI 14–47%; negative predictive value 72%, 95% CI 53–96%).Conclusions
Handheld tonometry has poor sensitivity and specificity for the prediction of increased ICP, and should not be used as a screening tool in the ED. 相似文献8.
Wiley D. Jenkins Whitney Zahnd Regina Kovach Patricia Kissinger 《The Journal of emergency medicine》2013
Background
Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) are the most commonly reported notifiable diseases in the United States, with annual reported cases exceeding 1.2 million and estimated costs exceeding $1.2 billion. Reported Emergency Department (ED) prevalence rates for CT and GC for adolescents and young adults range from 0.9% to 8.1%.Objective
Our aim was to evaluate the burden of CT/GC infection in ED patients, assess the extent of associated under- and overtreatment, and investigate mechanisms whereby ED screening can be feasible.Methods
We performed a systematic review of the time period from 1995 to 2010.Discussion
Positivity rates for ED patients are comparable with other high-risk populations, and sufficient for selected screening to be cost-effective. Unfortunately, ED patient follow-up is notoriously difficult, and clinicians frequently must choose to either delay treatment until laboratory confirmation or presumptively treat based on presenting symptoms and clinical diagnosis. This results in high rates of both undertreatment (i.e., not treating those infected) and overtreatment (i.e., treating those who are infection-free). Incorrect on-the-spot treatment decisions can result in potentially infected future partners and lack of follow-up treatment, or unnecessary treatment and personal stress associated with improper diagnosis.Conclusions
ED clinician activities are frequently symptom-driven, and screening nonsymptomatic patients presents a major barrier. Educating ED clinicians on the topics of CT/GC epidemiology, sample collection, and analysis will enable them to address the risks in their presenting populations. Collaboration with health department partners for sample analysis, cost-sharing, and patient follow-up can make routine screening feasible and enable EDs to become more important partners in intervention programs. 相似文献9.
Neeraj S. Naval Tiffany Chang Filissa Caserta Robert G. Kowalski Juan Ricardo Carhuapoma Rafael J. Tamargo 《Journal of critical care》2012
Objective
Patients with aneurysmal subarachnoid hemorrhage (aSAH) require management in centers with neurosurgical expertise necessitating emergent interhospital transfer (IHT). Our objective was to compare outcomes in aSAH IHTs to our institution with aSAH admissions from our institutional emergency department (ED).Methods
Data for consecutive patients with aSAH admitted to Johns Hopkins Medical Institutions between 1991 and 2009 were analyzed from a prospectively obtained database. We compared in-hospital mortality and functional outcomes at first clinical appointment post-aSAH (30-120 days) using dichotomized Glasgow Outcome Scale (good outcome: Glasgow Outcome Scale 4-5) in ED admissions with IHTs.Results
A total of 1134 consecutive patients with aSAH were included in analysis (ED 40.1%, IHT 59.9%). Direct ED admissions had a higher incidence of poor Hunt and Hess grade (4/5) and major medical comorbidities, with no significant differences between the 2 groups in age, intraventricular hemorrhage, and hydrocephalus. In-hospital mortality for ED admissions (14.9%) was significantly lower than that for IHTs (20.5%), with 1.8 times greater adjusted odds of survival after multivariate analysis (P = .001). Emergency department admissions had nearly 2-fold greater odds of good outcomes (odds ratio, 1.89; P < .001) after multivariate analysis.Conclusions
Our institutional ED SAH admissions had significantly better outcomes than did IHTs, suggesting that delays in optimizing care before transfer could deleteriously impact outcomes. 相似文献10.
Katherine E. Kroll Marc A. Camacho Shiva Gautam Robin B. Levenson Jonathan A. Edlow 《The Journal of emergency medicine》2014
Background
Headache is a common complaint in emergency department (ED) patients. Nearly 15% of ED headache patients will have brain computed tomography (CT) done. One frequent finding on these scans is “chronic sinusitis.” Assuming that “chronic sinusitis” is the cause of the patient's headache is a potential source of mis-diagnosis.Study Objective
We hypothesized that CT findings of chronic sinusitis occur with equal frequency in patients with atraumatic headache as in control patients with minor head injury.Methods
This is a retrospective, single-center medical record review of consecutive discharged patients who received noncontrast head CT scans in an urban ED for either minor closed head injury or atraumatic headache. Each patient's head CT radiologic report was reviewed for findings of sinusitis and classified as chronic sinusitis, indeterminate for sinusitis, air-fluid levels, or no findings of sinusitis.Results
We enrolled 500 patients (234 in the atraumatic headache group, 266 in the minor head injury group). The two groups were similar except that more women were enrolled in the atraumatic headache group. CT findings of chronic sinusitis in the atraumatic headache group (22.2%) and the minor head injury group (17.7%; difference 4.5%; 95% confidence interval of −2.5–11.6%).Conclusion
Prevalence of CT findings of sinusitis in ED patients with atraumatic headaches and mild head injury are similar. This strongly suggests that CT findings of chronic sinusitis in patients with atraumatic headache may be incidental, and are rarely the cause of a patient's acute headache. 相似文献11.
Chase M Joyce NR Carney E Salciccioli JD Vinton D Donnino MW Edlow JA 《The American journal of emergency medicine》2012,30(4):587-591
Background
Vertigo is a common emergency department (ED) complaint with benign and serious etiologies with overlapping features. Misdiagnosis of acute stroke may result in significant morbidity and mortality. Magnetic resonance imaging (MRI) is superior to computer tomography (CT) for diagnosis of acute stroke but is costly with limited availability.Objective
The aim of this study was to identify clinical characteristics associated with a cerebrovascular cause for vertigo.Methods
We performed a retrospective chart review on patients with an MRI for vertigo, with or without additional historical or physical examination findings, over 18 months. Study patients were seen in the ED for vertigo within 2 weeks of MRI. Data collected included medical history, physical findings, and imaging results. Fisher's exact test was used to identify factors associated with the primary outcome, an acute stroke.Results
There were 325 eligible patients; 131 were ED patients. Patients were 57 (±18) years, and 53% were women. There were 12 ED patients with a new stroke (9.2%). Two variables were associated with acute stroke: a presenting complaint of gait instability (odds ratio, 9.3; 95% confidence interval, 2.6-33.9) or a subtle neurologic finding (odds ratio, 8.7; 95% confidence interval, 2.3-33.1). One patient with a new stroke had a prior stroke, 3 were age >65 years, and none had coronary artery disease or dysrhythmia. Among patients with acute stroke, 5 also had head CT, and none detected the stroke.Conclusions
This study identified 2 variables associated with acute stroke that should be considered in the evaluation of ED patients with vertigo. Head CT was inadequate for diagnosing acute stroke in this patient population. 相似文献12.
Objectives
The objective of this study is to investigate the role of sympathovagal balance in predicting inhospital mortality by assessing power spectral analysis of heart rate variability (HRV) among patients with nontraumatic subarachnoid hemorrhage (SAH) in an emergency department (ED).Methods
A cohort of 132 adult patients with spontaneous SAH in an ED was prospectively enrolled. A continuous 10-minute electrocardiography for off-line power spectral analysis of the HRV was recorded. Using the inhospital mortality, the patients were classified into 2 groups: nonsurvivors (n = 38) and survivors (n = 94). The HRV measures were compared between these 2 groups of patients.Results
Having compared the various measurements, the very low–frequency component, low-frequency component, normalized low-frequency component (LF%), and low-/high-frequency component ratio (LF/HF) were significantly lower, whereas the normalized high-frequency component was significantly higher among the nonsurvivors than among the survivors. A multiple logistic regression model identified LF/HF (odds ratio, 2.16; 95% confidence interval [CI], 1.18-3.97; P = .013) and LF% (odds ratio, 0.78; 95% CI, 0.69-0.88; P < .001) as independent variables that were able to predict inhospital mortality for patients with SAH in an ED. The receiver operating characteristic area for LF/HF in predicting inhospital mortality was 0.957 (95% CI, 0.914-1.000; P < .001), and the best cutoff points was 0.8 (sensitivity, 92.1%; specificity, 90.4%).Conclusions
Power spectral analysis of the HRV is able to predict inhospital mortality for patients after SAH in an ED. A tilt in the sympathovagal balance toward depressed sympathovagal balance, as indicated by HRV analysis, might contribute to the poor outcome among these patients. 相似文献13.
Is female sex associated with ED delays to diagnosis of appendicitis in the computed tomography era?
Sarah McGann Donlan MD Mark B. Mycyk MD 《The American journal of emergency medicine》2009,27(7):856-858
Background
Historically, females had delays to definitive diagnosis of appendicitis when compared to males. In this current millennium, appendicitis is now most commonly diagnosed by computed tomography (CT) in the emergency department (ED) rather than at surgery.Objective
The aim of the study was to assess if female gender is still associated with delays to diagnosis of appendicitis in the CT era.Methods
A retrospective cohort analysis of adult patients with appendicitis at a university teaching hospital ED was conducted. Inclusion criteria was age of more than 18 years and an International Classification of Diseases, Ninth Revision (ICD-9), diagnosis of appendicitis. Patients were excluded from analysis if they were pregnant, no CT scan was obtained in the ED, or had incomplete outcome data.Results
One hundred thirty-seven patients met inclusion criteria; 65 female, 72 males. Time from triage to CT order was 138 minutes in females and 95 minutes in males (P = .0012). Time from initial physician evaluation to CT order was 45 minutes in females and 28 minutes in males (P = .0012). Nonclassic symptoms were more common in females and pelvic evaluation did not delay the CT order.Conclusion
Female gender is still associated with delays to CT acquisition and diagnosis of appendicitis. 相似文献14.
Joji Inamasu Satoru Miyatake Hideto Tomioka Masaru Suzuki Masashi Nakatsukasa Naoki Maeda Takeshi Ito Kunihiko Arai Masahiro Komura Kenichi Kase Kenji Kobayashi 《Resuscitation》2009,80(9):977-980
Aim
Aneurysmal subarachnoid haemorrhage (SAH) is a relatively common cause of out-of-hospital cardiac arrest (OHCA). Early identification of SAH-induced OHCA with the use of brain computed tomography (CT) scan obtained immediately after resuscitation may help emergency physicians make therapeutic decision as quickly as they can.Methods
During the 4-year observation period, brain CT scan was obtained prospectively in 142 witnessed non-traumatic OHCA survivors who remained haemodynamically stable after resuscitation. Demographics and clinical characteristics of SAH-induced OHCA survivors were compared with those with “negative” CT finding.Results
Brain CT scan was feasible with an average door-to-CT time of 40.0 min. SAH was found in 16.2% of the 142 OHCA survivors. Compared with 116 survivors who were negative for SAH, SAH-induced OHCA survivors were significantly more likely to be female, to have experienced a sudden headache, and trended to have achieved return of spontaneous circulation (ROSC) prior to arrival in the emergency department less frequently. Ventricular fibrillation (VF) was significantly less likely to be seen in SAH-induced than SAH-negative OHCA (OR, 0.06; 95% CI, 0.01–0.46). Similarly, Cardiac Trop-T assay was significantly less likely to be positive in SAH-induced OHCA (OR, 0.08; 95% CI, 0.01–0.61).Conclusion
Aneurysmal SAH causes OHCA more frequently than had been believed. Immediate brain CT scan may particularly be useful in excluding SAH-induced OHCA from thrombolytic trial enrollment, for whom the use of thrombolytics is contraindicated. The low VF incidence suggests that VF by itself may not be a common cause of SAH-induced OHCA. 相似文献15.
Kessler C Chen J Dill C Tyndall G Olszyk MD 《The American journal of emergency medicine》2010,28(8):947-951
Background
The Veterans Health Administration (VHA) has reformed its emergency medical services.Objectives
This study updates an overview of emergency medicine within VHA.Methods
This is a cross-sectional survey of VHA medical facilities offering emergency medical care.Results
Sixty-eight percent (95/140) of facilities had emergency departments (EDs) only, 12% (16/140) had both ED and urgent care centers (UCCs), and 16% (23/140) had only UCCs. The mean (SD) ED/UCC census was 13?371 (7664). A mean (SD) of 53% (27%) of facility admissions were admitted through ED/UCCs. The median of all ED/UCC admissions admitted to intensive care unit level care was 11% (interquartile range, 7-16). Of physicians with any board certification, 16% (209/1331) of physicians had emergency medicine board certification.Conclusions
Emergency medical care is now available at most VHA facilities. The specialty of emergency medicine has an important but minority presence within clinical emergency medical care at VHA. 相似文献16.
Objective
Accepted guidelines define when to terminate unsuccessful resuscitations. We examined whether such resuscitations last longer for transported arrests in the field compared with those occurring in the emergency department (ED).Methods
This was a retrospective study of patients who died in an urban, academic ED over 32 months starting from January 2001. Total length of resuscitation and the interval occurring in-ED were compared for arrests in the ED and transported arrests from the field.Results
A total of 132 patients met the criteria, of whom 71 (53.8%) arrested in the field. Mean overall resuscitation times were longer for arrests occurring in the field (44 minutes; 95% confidence interval [CI], 39-48) compared with those in the ED (19 minutes; 95% CI, 16-22; P < .001). Mean resuscitation intervals occurring in the ED were no different for arrests occurring in the field (16 minutes; 95% CI, 13-19) than in the ED (19 minutes; 95% CI, 16-22; P > .05).Conclusions
Unsuccessful resuscitations were longer and beyond guideline recommendations when arrests occurred in the field and were transported. The interval of resuscitation that occurred in the ED was the same whether or not prehospital resuscitation occurred. 相似文献17.
Michael D. Zwank Benjamin M. Ho David Gresback Logan H. Stuck Joshua G. Salzman Wendy R. Woster 《The American journal of emergency medicine》2014
Background
Patients with renal colic commonly present to the emergency department (ED) and are usually treated with analgesics, antiemetics and hydration. Computed tomographic (CT) scan is commonly utilized in evaluating patients with suspected renal colic.Objectives
We compared diagnosis and treatment plans before and after CT in patients with suspected renal colic with the aim to evaluate how often changes in diagnosis, treatment and disposition are made.Methods
In this prospective observational study, we enrolled a convenience sample of clinically Stable ED patients older than 17 with suspected renal colic for whom CT was planned. Exclusion criteria were: chronic kidney disease, urinary tract infection, recent CT and history of previous kidney stone. Pre-CT and Post-CT surveys were completed by the treating provider.Results
The discharge diagnosis was renal colic in 62 of 93 enrolled patients (67%). Urinalysis showed blood in 52 of these patients (84%). CT confirmed obstructing kidney or bladder stone in 50 patients. There were five cases of alternative diagnoses noted on CT scan. After CT scan, 7 patients had changes in disposition. Sixteen providers felt that CT would not change management. In these cases, CT offered no alternative diagnosis and didn't change disposition.Conclusion
CT scan didn't change management when providers did not expect it would. This indicates that providers who are confident with the diagnosis of renal colic should consider forgoing a CT scan. CT scan did occasionally find important alternative diagnoses and should be utilized when providers are considering other concerning pathology. 相似文献18.
Study objective
We sought to determine the incidence of alternative diagnosis in patients with a history of kidney stones who experience recurrent symptoms and undergo repeat computed tomography (CT) imaging at their return to the emergency department (ED).Methods
This was a retrospective chart review of ED patients at a tertiary care hospital. Inclusion criteria were all adult ED patients who received a repeat CT for renal colic, after having previously received the diagnosis of obstructive kidney stone confirmed by CT, in our ED. Patients were identified by reviewing the charts of those patients with repeat visits to the ED after January 1, 2004, in which they complained of symptoms suggestive of renal colic and received a CT scan. We determined the frequency of the same diagnosis on repeat CT scan in this population compared with the frequency of alternative diagnosis.Results
Two hundred thirty-one patients met criteria for the study. Fifty-nine percent were male. One hundred eighty-nine (81.8%) patients had no change in diagnosis as a result of a repeat renal colic CT scan. Twenty-seven (11.6%) patients received an alternative diagnosis that did not require urgent intervention, and 15 (6.5%) patients received a diagnosis that did require an urgent intervention.Conclusion
Repeat CT imaging of patients with known nephrolithiasis changed management in a minority of patients (6.5%). Knowing the frequency of alternative diagnosis in this population may help clinicians and patients balance the risks and benefits of repeat renal colic CT scans in patients with a history of kidney stones who return to the ED with similar symptoms. 相似文献19.
Venkatesh Thiruganasambandamoorthy Erik P. Hess Ekaterina Turko Jeffrey J. Perry George A. Wells Ian G. Stiell 《The Journal of emergency medicine》2013
Background
Little is known about the outcomes of adults with syncope seen in Canadian Emergency Departments (EDs).Objectives
We sought to determine the frequency, timing, and type of serious adverse outcomes occurring in these patients, and the proportion that occur outside the hospital.Methods
We conducted a health records review of syncope patients presenting to a tertiary care ED over an 18-month period. We included all patients older than 16 years of age who fulfilled the syncope definition (sudden transient loss of consciousness with spontaneous complete recovery), and excluded those with altered mental status, alcohol or illicit drug use, seizure, or trauma. We assessed for outcomes in the ED and after ED disposition. We also evaluated follow-up arrangements for patients discharged from the ED.Results
Of the total 87,508 patient visits, 505 (0.6%) were due to syncope. The mean age was 58.5 years (range 16–101 years), 70.1% arrived by ambulance, and 12.3% were admitted to the hospital. Five patients died: 2 in the ED, 1 as an inpatient, and 2 after discharge. Overall, there were 49 (9.7%) serious outcomes, with dysrhythmias being the most common (4.6%); 22 (4.4%) occurred in the ED, 15 (3.0%) in the hospital, and 12 (2.4%) outside the hospital. Eight serious outcomes occurred in patients discharged from the ED without any planned follow-up.Conclusion
Although syncope represented < 1% of all patient visits, morbidity was substantial, particularly in patients discharged from the ED. Future research should help clinicians identify syncope patients at high risk for serious outcomes. 相似文献20.
Kevin A. Kerber Lisa Schweigler Brady T. West A. Mark Fendrick Lewis B. Morgenstern 《The American journal of emergency medicine》2010