Academic emergency medicine : official journal of the Society for Academic Emergency Medicine
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Review Comparative Study
Can computed tomography angiography of the brain replace lumbar puncture in the evaluation of acute-onset headache after a negative noncontrast cranial computed tomography scan?
The primary goal of evaluation for acute-onset headache is to exclude aneurysmal subarachnoid hemorrhage (SAH). Noncontrast cranial computed tomography (CT), followed by lumbar puncture (LP) if the CT is negative, is the current standard of care. Computed tomography angiography (CTA) of the brain has become more available and more sensitive for the detection of cerebral aneurysms. This study addresses the role of CT/CTA versus CT/LP in the diagnostic workup of acute-onset headache. ⋯ CT followed by CTA can exclude SAH with a greater than 99% posttest probability. In ED patients complaining of acute-onset headache without significant SAH risk factors, CT/CTA may offer a less invasive and more specific diagnostic paradigm. If one chooses to offer LP after CT/CTA, informed consent for LP should put the pretest risk of a missed aneurysmal SAH at less than 1%.
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Patients frequently present to the emergency department (ED) with headache. Those with sudden severe headache are often evaluated for spontaneous subarachnoid hemorrhage (SAH) with noncontrast cranial computed tomography (CT) followed by lumbar puncture (LP). The authors postulated that in patients without neurologic symptoms or signs, physicians could forgo noncontrast cranial CT and proceed directly to LP. The authors sought to define the safety of this option by having senior neuroradiologists rereview all cranial CTs in a group of such patients for evidence of brain herniation or midline shift. ⋯ Awake and alert patients with a normal neurologic examination and SAH may have brain herniation and/or midline shift. Therefore, cranial CT should be obtained before LP in all patients with suspected SAH.
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Comparative Study
Tissue oxygenation does not predict central venous oxygenation in emergency department patients with severe sepsis and septic shock.
This study sought to determine whether tissue oxygenation (StO(2)) could be used as a surrogate for central venous oxygenation (ScVO(2)) in early goal-directed therapy (EGDT). ⋯ Correlation between StO(2) and ScVO(2) was fair. The two measures trend in the same direction, but clinical use of StO(2) in lieu of ScVO(2) is unsubstantiated due to large and systematic biases. However, these biases may reflect real physiologic states. Further research may investigate if these measures could be used in concert as prognostic indicators.
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Multicenter Study Comparative Study
Prospective multicenter study of bronchiolitis: predictors of an unscheduled visit after discharge from the emergency department.
There is little evidence about which children with bronchiolitis will have worsened disease after discharge from the emergency department (ED). The objective of this study was to determine predictors of post-ED unscheduled visits. ⋯ In this study of children age younger than 2 years with bronchiolitis, one of six children had unscheduled visits within 2 weeks of ED discharge. The three predictors of unscheduled visits were age under 2 months, male sex, and previous hospitalization.