Author Archive for: jbeckesmay

Validation of the Ottawa Subarachnoid Hemorrhage Rule in Patients With Acute Headache

24 Sep
September 24, 2018

Background: The assessment and management of the acute onset headache from the perspective of the emergency department is a point of contention and discussion commonly faced by emergency providers.  The Ottawa Subarachnoid Hemorrhage Rule is a clinical decision making instrument that was created to help identify patients who need further workup beyond a basic history and physical exam. It does not define the extent of workup required, specifically whether or not a CT versus CT and LP are required to rule out a subarachnoid hemorrhage. In a 2010, Perry et al (1) published results from a prospective cohort study which attempted to formulate a collection of sensitive, high risk characteristics that could identify patients who require workup for subarachnoid hemorrhage. The three separate collections of high-risk features were all found to be highly sensitive (100% sensitivity with 95% CI) and so further investigation was found to be warranted. An additional prospective cohort by Perry et al (2) was designed to further assess the sensitivity, specificity, and overall applicability of these 3 decision making rules to identify patients who require subarachnoid hemorrhage workup. The initial results of this study showed one of the clinical decision making instruments to have a superior sensitivity of 98.5% (95% CI, 94.6%-99.6%). The rule was then redefined to include “thunderclap” headache and limited neck flexion on exam, and then reassessed utilizing a recursive partitioning analysis in order to obtain 100% sensitivity. The Perry et al 2017 (3) study was designed to validate the collection of high-risk characteristics this group has identified as warranting possible workup for subarachnoid hemorrhage. Read more →

Targeted Temperature Management in Out-of-Hospital Cardiac Arrest: 33°C or 36°C?

19 Jun
June 19, 2017

Background: In 2002, the New England Journal of Medicine published two studies that changed the management of post-cardiac arrest patients by showing improved outcomes in patients treated with therapeutic hypothermia (32°C-34°C) for at least 24 hours. (Bernard 2002, Hypothermia 2002).  The landscape changed again in 2013 with the publication of the Targeted Temperature Management (TTM) trial in the New England Journal, which compared post-cardiac arrest hypothermia at 32-34°C and at 36°C and found no difference in outcomes (Nielson 2013). After the publication of the TTM trial, many hospitals changed their cooling protocols to a target temperature of 36°C, however, recently it has been shown that this may pose an increased risk of fever. (Cassamento 2016). Read more →

Normalization of Vital Signs Does Not Reduce the Probability of Pulmonary Embolism

09 Feb
February 9, 2017

Background: In patients with symptoms of pulmonary embolism (PE), we often turn to vital signs, including heart rate, respiratory rate and pulse oximetry, as part of our initial impression of the patient.  Before even considering further testing, such as d-dimer or CTPA, we look first at the vital signs to form our gestalt impression of the patient.  Clinical decision making tools are utilized in one static point in time, but gestalt decision-making occurs over the course of the patient’s entire stay in the Emergency Department (ED).  Because of this, clinicians may use changes in vital signs to augment their differential diagnosis or to justify their belief that a PE work up is not necessary.  

Read more →