International study of emergency department care for pediatric traumatic brain injury and the role of CT scanning

Objects: Our objective was to investigate the use of CT and its relationship to head injury severity and age. Method: The multi-center group International Study of Head Injury Project (ISHIP) serves as the administrative body for research design, data collection and analysis. This is a nonrandomized prospective study of longitudinal outcomes following examination and care in emergency department in five different countries. The subjects of our study were 4,690 children from birth to 15 years of age, all of whom were systematically evaluated. Each child was medically evaluated and categorized as to injury severity, mechanism of injury and findings on X-ray and CT scan. Follow-up interview and assessment was completed for comparison with the presenting clinical state. Results: CT scans were performed for674 (14.3%) of the children: 438 scans were normal and 236 were abnormal (P<0.001). Of the children with abnormal CT scans, 23.3% had mild head injuries, 42.7% had moderate injuries, and 33.8% had severe injuries, as determined by the GCS. By age, 10.5% of the positive CTs were in children aged 0–2 years, 56.3% in 3- to 9-year-olds, and 33% in 10- to 15-year-olds; only in 2% of cases were both CT and X-ray positive. Conclusions: The majority of children did not need significant medical intervention. Physicians ordered X-ray investigations more frequently than CT scanning. The use of X-ray to decide whether or not CT is ne- cessary is not warranted. The implications of positive CTs in mild or moderate injuries were most noteworthy, as were age-related interactions with positive CT findings. Received: 23 June 2000     

Computed tomography (CT) scan findings in children with seizures only

One hundred and fifteen children with seizures only were studied with Computed Tomography (CT) scan at King Khalid University Hospital (KKUH), Riyadh, Saudi Arabia. Eighty percent of the children had normal CT scan; 8.7% showed cerebral atrophy and in only 11.3% was there a specific abnormality; such as infarction, porencephalic cysts, and arachnoid cysts. These specific type of abnormalities belong to partial and combined types of seizures and were treated medically. Fifty-seven cases of generalized type of seizures showed only 6 cases of abnormal CT scan and that is only brain atrophy. Based on these findings, we believe that CT scan should not be a part of the routine investigations of children with seizures only, especially those of generalized type.     

Early computed tomographic scanning after resection of brain tumors in children

Enhanced and non-enhanced computed tomography (CT) brain scans were performed within 72 h of surgery on 21 children in whom brain tumors had been resected totally or subtotally, and scans were repeated at varying intervals thereafter. Biopsies of the resection margins were performed in 12 patients at the end of the surgical procedure. The immediate CT scan showed enhancement in the resection margin in 13 of the 21 patients and in 9 of the 13, the enhancement disappeared on follow-up scans. There was discordance between the results of immediate CT scan examination and the biopsies of the resection margins in 7 of the 12 cases. The advantages and disadvantages of an immediate postoperative scan versus a more delayed CT scan are discussed.     

Suicide attempters in the emergency department before hospitalization in a psychiatric ward

PURPOSE. The study aims to compare the current suicidal risk of mood disorder patients who had just attempted suicide, as compared with those who had not attempted suicide, admitted to an emergency department (ED), and then hospitalized in a psychiatric unit. METHOD. One hundred sixty‐one mood disorder patients admitted to the ED were studied. A total of 22.4% of the participants were admitted for a suicide attempt. Patients were assessed for psychopathology and diagnosis. FINDINGS. Suicide attempters were nearly 12 times more likely to report ongoing suicidal ideation during the psychiatric evaluation in the ED than nonattempters. Men and women did not differ for current and previous suicide attempts or for ongoing suicidal ideation. PRACTICAL IMPLICATIONS. It is important to conduct a suicide risk assessment when individuals are admitted to an ED.     

Safety issues and concerns for the neurological patient in the emergency department

Introduction  Patient safety in our medical system has been an increasing national concern. Neurological patient safety in the emergency department (ED) has not been studied. The purpose of this article is thus to describe the issues relevant to neurological patient safety in the ED, review the current status of the literature, identify specific patient populations at risk, and suggest applicable solutions. Methods  Medline and PubMed literature review of key words associated with patient safety, neurological diseases, and EDs. Results  Little data can be found on overall neurological patient safety in the ED, however data for specific neurological emergencies including subarachnoid hemorrhage, stroke, status epilepticus, and head and spine trauma does exist and is reviewed. Conclusions  Limitations in ED education and access to neurological expertise may place some patients at risk. Recommendations for improving neurological patient safety in the EDs are suggested and include a discussion on barriers to implementation.     

Influence of psychiatric comorbidities in migraineurs in the emergency department

Objective

To examine how psychiatric comorbidities in migraineurs in the emergency department (ED) affect healthcare utilization and treatment tendencies.

Method

This is a cross-sectional analysis of 2872 patients who visited our ED over a 10-year period and were given a principal diagnosis of migraine.

Results

Compared to migraineurs without a psychiatric comorbidity, migraineurs with a psychiatric comorbidity had about three times more ED visits, six times more inpatient hospital stays and four times more outpatient visits. Migraineurs with psychiatric comorbidities received narcotics in the ED more often than migraineurs without psychiatric comorbidities (P<0.0001). In addition, migraineurs with psychiatric disorders were more likely to have a computed tomography scan of the head [Risk Ratio (RR) 1.42 (95% confidence interval (CI)=1.28–1.56, P<0.001)] or a magnetic resonance image of the brain [RR 1.53 (95% CI=1.33–1.76, P<0.001)] than patients without a psychiatric disorder when visiting our hospital center.

Conclusions

Migraineurs with psychiatric comorbidity who visit the ED have different healthcare utilization tendencies than migraineurs without psychiatric comorbidity who visit the ED. This is seen in the frequency of ED visits, outpatient visits and inpatient stays, in the medications administered to them and in the radiology tests they undergo.     

HIPDM single photon emission computed tomography brain imaging in partial onset secondarily generalized tonic-clonic seizures

HIPDM-Single photon emission computed tomography brain imaging was performed during interictal and ictal stages in three patients with complex partial seizures and secondarily generalized tonic-clonic seizures. In all three patients, interictal studies demonstrated decreased regional cerebral perfusion (rCP) and ictal studies showed increased rCP in the epileptogenic region. The demonstration of focal hyperperfusion by SPECT performed during secondarily generalized tonic-clonic seizures suggests that rCP in the epileptic focus remains higher than in other cerebral regions during immediate postictal stages, even in secondarily generalized seizures.     

Results of computed tomography in "neurologically normal" children after initial onset of seizures

A combined retrospective and prospective study assessed the results of computed tomographic (CT) scans in infants and children without neurologic deficit who presented with initial onset of seizures. Of 101 pediatric patients, 81 had afebrile seizures and 20 had complicated febrile seizures (i.e., focal, multiple, or prolonged). Seven children (7%), 6 with afebrile and 1 with a febrile seizure, had CT abnormalities. Four patients (4%) required further diagnostic workup including angiography and/or surgery. Children with afebrile focal seizures were more likely to have an abnormality than those with afebrile generalized seizures without focal components (13% and 4.9%, respectively). This study demonstrated a lower percentage of overall CT abnormalities, yet a similar percentage of "therapeutically important" abnormalities, in neurologically normal children with new onset of seizures when compared to previous reports of children with chronic seizures. Although an abnormal CT was more likely to be associated with an abnormal electroencephalogram, a normal result did not eliminate the possibility of an abnormal CT.     

Risk stratification of non-traumatic headache in the emergency department

Objective   To determine the diagnostic accuracy of an algorithm structured in four clinical scenarios to discriminate benign primary headaches from serious secondary non-traumatic headaches (NTH) in the emergency department (ED). Background   NTH is usually a benign symptom but can occasionally result in serious outcome making the disposition of patients with NTH difficult in the ED. Design and methods   Consecutive adults patients referring to 8 EDs of the Emilia-Romagna region in Italy for NTH as the chief complaint were recruited in the study for a 30-day period. ED physicians attributed to each patient one of the four clinical scenarios (1, 2 and 3 identifying serious secondary headaches and scenario 4 identifying benign primary headaches) or an undetermined scenario when none of the four scenarios applied. Reference standards of the study were the head CT scan and a follow-up telephone interview after three months by the ED admission. Results   The test was administered to 256 out of 302 (85 %) eligible patients. The analysis (scenario 1,2,3 vs scenario 4) was based on 180 patients who completed the follow-up showing a sensitivity of 100 % (95 % confidence interval, 81 % to 100 %) and a specificity of 64 % (56 % to 71 %). The likelihood ratio for a positive test was 2.67 (2.15 to 3.31) and the likelihood ratio for a negative test was 0.04 (0.003 to 0.64). Conclusions   An algorithm based on four clinical scenarios can be administered to the majority of patients presenting to the ED with the chief complaint of NTH. The algorithm showed a good accuracy in identifying patients with non-life threatening causes of headache and could be used as a risk stratification tool to improve clinical decision- making. Further studies are required to validate this diagnostic algorithm. On behalf of the Multidisciplinary Group for Non-Traumatic Headache in Emergency Department: Bologna Maggiore (Massimo Annicchiarico, Tommaso Sacquegna), Bologna S. Orsola (Giuseppe Rè, Rita Rinaldi), Forlì (Alberto Vandelli, Walter Neri), Lugo (Mario Ravaglia, Piero De Carolis), Imola (Tiziano Lenzi, Vittoria Mussuto), Modena Policlinico (Pietro Martella, Jessica Mandrioli), Modena Estense (Mario Cavalli, Francesco Nonino), Parma (Mario Cavazza, Gian Camillo Manzoni), Piacenza (Cristina Maestri, Fabiola Magnifico), Ravenna (Maria Pazzaglia, Pietro Querzani), Reggio Emilia (Anna Maria Ferrari, Giovanni Ferrarini)     

The role of gap junctions in seizures

Electrotonic synaptic communication between neurons via gap junctions (gjs) is increasingly recognized as an important synchronizing mechanism in the brain. At the same time, the biology of central nervous system (CNS) gjs is being unravelled. The pathogenesis of the abnormal neuronal synchrony underlying seizures, formerly thought to be based mainly on chemical synaptic transmission, now includes a role for gap junctional communication. This concept has been strengthened by evidence from several in vitro seizure models, in which pharmacological manipulations of gap junctional communication predictably affect the generation of seizures: blockers diminishing seizures and enhancers increasing the seizures. Evidence for interneurons, coupled in part by gjs, generating synchronous neural network activity including seizures, is presented. Also neuromodelling studies, which have enhanced our ability to understand the functional role that gap junctional communication plays in the generation and maintenance of neural synchrony and seizures, are presented. Gap junctional communication appears to be a promising target for the development of future anticonvulsant therapy.     

False positive diagnosis of subarachnoid haemorrhage on computed tomography scan

Five cases are presented in which subarachnoid haemorrhage (SAH) was diagnosed by clinicians and/or radiologists on computed tomography (CT) scan. No macroscopic SAH was present on neuropathologic examination. In retrospect it was considered that the neurologic signs and the neuropathologic features close to the time of CT scan were in keeping with the patients being brain dead, i.e. had no cerebral blood flow at the time of the scans. On review of the CT scans it was considered the hyperdense material seen in the subarachnoid space must have been blood in congested subarachnoid blood vessels. The cases demonstrate that if a patient presents comatose and CT scan shows cerebral oedema then the presence of high attenuation material in the subarachnoid space should not necessarily be considered to represent SAH. The value of seeking radiological opinion is highlighted but even then diagnosis may be difficult.     

The role of computed tomography (CT) in the diagnosis of neurocysticercosis

With the introduction of computed tomography (CT), the diagnosis of cysticercosis of the central nervous system (CNS) has been considerably improved. This is very important, especially for the countries in which the disease is still endemic. Plain skull radiographs or invasive procedures such as pneumography, ventriculography, and cerebral angiography can be used, but now CT has become the examination of choice because it is a safe, noninvasive, and accurate method thus making the other procedures unnecessary. In the present paper, 8,676 CT scans are reviewed from which 710 are selected patients with neurocysticercosis. CT has provided the diagnosis with greater precision than before. Its localization in the series was as follows: parenchymal, 473 patients, 65.2%; meningeal, 125 patients, 18.3%; mixed, 96 cases, 14%; intraventricular, 16 cases, 2.5%.     

Epileptic seizures in the emergency room: clinical and electroencephalographic findings associated with brain perfusion patterns on computed tomography

Journal of Neurology - Diagnosis of epileptic seizures, particularly regarding status epilepticus (SE), may be challenging in an emergency room setting. The aim of the study was to study the...     

The value of the use of plasma B-type natriuretic peptide among acute ischemic stroke patients in a Chinese emergency department

Objective

To determine the value of the use of plasma B-type natriuretic peptide (BNP) among acute ischemic stroke patients in a Chinese emergency department (ED).

Materials and methods

In our ED, the emergency physicians prospectively assessed consecutive adult patients with acute phase of ischemic stroke and measured plasma BNP by Biosite Triage^®BNP POCT platform on admission, then followed up these patients. And the stroke neurologists evaluated patients’ functional outcome at hospital discharge, and also made discharge diagnosis and stroke etiologic subtypes according to TOAST criteria: large-artery atherosclerosis (LAA), cardioembolism (CE), small-artery occlusion (SAO), stroke of other determined etiology (SOE) and stroke of other undetermined etiology (SUE).

Results

In this study, 142 of 238 acute ischemic stroke patients met the study criteria [mean age 70.84 ± 11.48 years, 74 (52.11%) female]. Of the 142 patients, 35.92% were diagnosed with LAA at discharge, 25.35% with CE, 27.46% with SAO, 11.27% with SOE or SUE. Age, previous cardiac disease, atrial fibrillation, the length of hospital stays, SSS score on admission ≤ 25 and mRS ≥ 3 or death at discharge were all significantly higher in the CE patients compared to other subtypes (p < 0.01). And the mean BNP concentration was significantly higher in the CE group than in other three subtypes (p < 0.001). The optimal cut-off concentration, sensitivity and specificity of the plasma BNP concentration suitable to distinguish CE from non-CE were 66.50 pg/ml, 75.0% and 88.7%, respectively.

Conclusions

Plasma BNP level is significantly higher in CE patients than in other TOAST subtypes, and by using Biosite Triage^®BNP POCT platform, emergency physicians should strongly consider CE subtype with the plasma BNP level of over 66.50 pg/ml. However, the single BNP biomarker panel cannot be used to confidently rule out or identify stroke subtypes as a diagnosis and must be taken in context with clinical assessment and judgment before making management decisions in the ED.     

A study of computed tomography scan and magnetic resonance imaging findings in pseudohypoparathyroidism

We report three children with pseudohypoparathyroidism aged 13-16 years who presented with seizures and tetany. CT scan revealed striatopallidal calcification in two. MRI revealed wide-spread involvement showing T1 hyperintensity in striatopallidodentate distribution in all three and midbrain in one patient. T2 and FLAIR images were normal. T1 hyperintensity could represent early stage of calcification in whom MRI is more sensitive.     

Frequency of alternative to restraints and seclusion and uses of agitation reduction techniques in the emergency department

INTRODUCTION: The use of restraints to manage patients in the emergency department (ED) is controversial. The Joint Commission on Accreditation of Healthcare Organization (JCAHO) and numerous advocacy groups have pushed for the use of alternatives to restraints. The need to protect the patients' rights while also reducing the risks they may pose to themselves, other patients, and medical staff is difficult to balance. The purpose of this study was to assess which agitation reduction techniques, if any, are used prior to restraints in the ED as recommended by the JCAHO. The second purpose was to determine the reasons for differing levels of usage and/or compliance with the JCAHO recommendations. METHODS: A survey tool was developed to include the new restraint and seclusion standards from Joint JCAHO. It was sent to a random sample of the EDs from a randomized list of hospitals in the United States and to all psychiatric EDs from the American Association for Emergency Psychiatrists (AAEP). A mailed survey allowed for institutions to review their yearly census for the information to questions. The survey included questions on the use of agitation reduction techniques, what are those methods, what methods are most effective for ED doctors, has staff received training in how and when to use those methods, and reasons why they do or do not use them in the ED. The study was IRB approved as exempt. RESULTS: A 40% response rate was obtained overall (391 out of 960). The majority, 70%, of general ED have no psychiatric unit vs. 87% of specialized EDs having a unit attached. The overwhelming majority of both, at 90% to 98%, do use alternatives to restraints prior to restraints. When restraints are used, 30% used physical and 30% used physical and chemical restraints combined. A management protocol is in place at 90% of the institutions to use alternative first and 76% of the staff is educated on the use of alternative methods. The methods in order of popularity are verbal interventions at 84%, one-to-one at 79%, decrease in stimulation at 74%, and food or drink at 69%. The rating of the effectiveness of those methods is low, with the following percentages feeling that the respective techniques were effective: one-to-one, less than 48%; verbal intervention, 36%; decreasing stimulation, 15%; and food or drink, 18%. However, 61% feel that chemical restraints were effective. DISCUSSION: The majority of respondents have training on alternatives to restraints. They do use alternatives to restraints, with one-to-one, food or drink, and verbal interventions being the most frequently used. These are seen as not very effective. The use of physical and/or a combination of physical and chemical restraints is used by 60% of respondents due to the perceived high level of effectiveness.     

Emergency department visits by children with and without autism spectrum disorder: An initial comparison evaluating multiple outcome measures at one urban children's hospital

Hospitals everywhere, especially children's hospitals, attempt to give exceptional care to all of their patients regardless of race, religion, socio-economic class, or intellectual ability. We evaluated data collected in the emergency department of a children's hospital, comparing duration of visit in minutes, chief complaint upon arrival to the emergency department, mode of arrival to the emergency department, method of obtaining patient history, demographic information, medications prescribed, medical testing, laboratory testing, diagnosis at discharge, billing code(s) used by the hospital per visit, and the type of insurance billed for services for patients with and without autism spectrum disorder. Results showed no differences were found between the presenting complaint provided by the caretaker upon entering the emergency department and the medical diagnosis for which the patient was actually treated within the emergency department. The tests also showed that there was a significant association between the categories of presenting complaints and whether or not the patient had autism spectrum disorder. The arrival mode to the emergency department was not significantly different between those with and without autism spectrum disorder. There was no significant difference existing between the two groups regarding cost of medical services provided and no significant difference existed between the two groups for the number of laboratory tests, medical tests, or total tests conducted, as well as no significant difference was found between the two groups was found in the length of hospital stay.