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Previously all subarachnoid hemorrhage (SAH) patients were admitted, whereas now patients with angiography may be discharged.
To survey neurosurgeons to determine current practice and what constitutes a clinically significant subarachnoid hemorrhage.
We surveyed all neurosurgeons listed in the Canadian Medical Directory. We used a modified Dillman technique with up to five mailed surveys plus a pre-notification letter. Neurosurgeons rated the significance of 13 scenarios of subarachnoid hemorrhage. Scenarios varied from aneurysmal subarachnoid hemorrhage to patients with isolated xanthochromia in cerebrospinal fluid. Each scenario was rated for clinical significance using a 5-point scale [1(always) to 5(never)].
Of the 224 surveyed, 115 neurosurgeons responded. Scenarios with aneurysms requiring intervention, arteriovenous malformations, death or any surgical intervention all had median responses of 1 (IQR 1, 1). Scenarios having xanthochromia and few red blood cells in cerebrospinal fluid with negative computerized tomogram (CT) and angiography had median responses of 3 (IQR 1, 4). Scenarios with perimesencephalic pattern on CT with negative angiography had median of 3 (IQR 2, 4). Scenarios where patient is discharged from the emergency department had median of 4 (IQR 3, 5).
Subarachnoid hemorrhages due to aneurysms or arteriovenous malformations causing death or requiring surgical intervention are always clinically significant. Other types of nonaneurysmal subarachnoid hemorrhages had inconsistent ratings for clinical significance. These survey results highlight the need for further discussions to standardize the diagnosis of what constitutes a clinically significant subarachnoid hemorrhage and what care should be afforded to these patients.
There are currently no widely used guidelines to determine which older patients with acute respiratory conditions require hospital admission. This study assessed the need for clinical decision rules to help determine whether hospital admission is required for patients over 50 years for three common respiratory conditions: chronic obstructive pulmonary disease (COPD), heart failure (HF), and community-acquired pneumonia (CAP).
Emergency physicians (EPs) from the United States, Canada, and Australasia.
A random sample of EPs from the United States, Canada, and Australasia.
A modified Dillman technique with a prenotification letter and up to three postal surveys.
EP opinions regarding the need for and willingness to use clinical decision rules for emergency department (ED) patients over 50 years with COPD, HF, or CAP to predict hospital admission. We assessed the required sensitivity of each rule for return ED visit or death within 14 days.
A total of 801 responses from 1,493 surveys were received, with response rates of 55%, 60%, and 46% for Australasia, Canada, and the United States, respectively. Over 90% of EPs reported that they would consider using clinical decision rules for HF, CAP, and COPD. The median required sensitivity for death within 14 days was 97 to 98% for all conditions.
EPs are likely to adopt highly sensitive clinical decision rules to predict the need for hospital admission for patients over 50 years with COPD, HF, or CAP.
Multiple studies have demonstrated low rates of antithrombotic use, low neuroimaging rates, and high subsequent risk of stroke at 90 days following an emergency department (ED) diagnosis of transient ischemic attack (TIA). This study assessed the use of antithrombotic medications, neuroimaging, and subsequent 90-day stroke rate for patients in a more recent cohort of ED patients discharged home with TIA.
We conducted a 1-year historical cohort study of all patients discharged with a TIA at a tertiary care ED (census 60,000 visits/year), which was one of the four sites participating in one of the aforementioned studies. Data were extracted from paper and electronic records onto standardized data extraction forms. Clinical findings, medications, and tests were recorded.
A total of 211 patients were enrolled in the study. The patients had the following characteristics: the mean age was 71.2 years (SD 13.8 years), 56.9% were female, 53.1% had a history of hypertension, 26.5% had a history of ischemic heart disease, and 17.1% had a previous stroke. The most frequent neurologic deficit was unilateral weakness (53.6%), and most deficits lasted for more than 60 minutes (71.6%). Antithrombotic medications were used for 96.7% of patients at ED discharge. Neuroimaging was conducted in 94.3% of patients while in the ED. Our cohort had a 90-day stroke rate of 1.9%.
This study established that most TIA patients receive neuroimaging in the ED and are started on or maintained on antithrombotic agents. Clinicians are encouraged to ensure that electrocardiography is done routinely and to involve Neurology in follow-up care.
There is no consensus on the optimal management of recent-onset episodes of atrial fibrillation or flutter. The approach to these conditions is particularly relevant in the current era of emergency department (ED) overcrowding. We sought to examine the effectiveness and safety of the Ottawa Aggressive Protocol to perform rapid cardioversion and discharge patients with these arrhythmias.
This cohort study enrolled consecutive patient visits to an adult university hospital ED for recent-onset atrial fibrillation or flutter managed with the Ottawa Aggressive Protocol. The protocol includes intravenous chemical cardioversion, electrical cardioversion if necessary and discharge home from the ED.
A total of 660 patient visits were included, 95.2% involving atrial fibrillation and 4.9% involving atrial flutter. The mean age of patients enrolled was 64.5 years. In total, 96.8% were discharged home and, of those, 93.3% were in sinus rhythm. All patients were initially administered intravenous procaïnamide, with a 58.3% conversion rate. A total of 243 patients underwent subsequent electrical cardioversion with a 91.7% success rate. Adverse events occurred in 7.6% of cases: hypotension 6.7%, bradycardia 0.3% and 7-day relapse 8.6%. There were no cases of torsades de pointes, stroke or death. The median lengths of stay in the ED were as follows: 4.9 hours overall, 3.9 hours for those undergoing conversion with procaïnamide and 6.5 hours for those requiring electrical conversion.
This is the largest study to date to evaluate the Ottawa Aggressive Protocol, a unique approach to cardioversion for ED patients with recent-onset episodes of atrial fibrillation and flutter. Our data demonstrate that the Ottawa Aggressive Protocol is effective, safe and rapid, and has the potential to significantly reduce hospital admissions and expedite ED care.
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