European journal of emergency medicine : official journal of the European Society for Emergency Medicine
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Rigid cervical collars are known to increase intracranial pressure (ICP) in severe traumatic brain injury (TBI). Cerebral blood flow might decrease according to the Kellie Monroe doctrine. For this reason, the use of the collar in patients with severe TBI has been abandoned from several trauma protocols in the Netherlands. There is no evidence on the effect of a rigid collar on ICP in patients with mild or moderate TBI or indeed patients with no TBI. As a first step we tested the effect in healthy volunteers with normal ICPs and intact autoregulation of the brain. ⋯ We included 22 male and 23 female volunteers. In total 360 ONSD measurements were performed in these 45 volunteers. Application of a collar resulted in a significant increase in ONSD in both the left (β=0.06, 95% confidence interval: 0.05-0.07, P<0.001) and the right eye (β=0.01, 95% confidence interval: 0.00-0.02, P=0.027) CONCLUSION: Application of a rigid cervical collar significantly increases the ONSD in healthy volunteers with intact cerebral autoregulation. This suggests that ICP may increase after application of a collar. In healthy volunteers, this seems to be of minor importance. On the basis of our findings the effect of a collar on ONSD and ICP in patients with mild and moderate TBI needs to be determined.
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The recent emergence of 'non-VKA' oral anticoagulants may have led to some forgetting that vitamin K antagonists (VKA) are by far the most widely prescribed oral anticoagulants worldwide. Consequently, we decided to summarize the information available on them. This paper presents the problems facing emergency physicians confronted with patients on VKAs in 10 points, from pharmacological data to emergency management. ⋯ The INR must be measured 30 min after the infusion. Before an invasive procedure, if an INR of less than 1.5 (<1.3 in neurosurgery) is required, it can be achieved by combining prothrombin complex concentrate and vitamin K. A well-codified strategy is essential for managing patients requiring emergency invasive procedures or presenting bleeding complications.
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Multicenter Study
Applying the Ottawa subarachnoid haemorrhage rule on a cohort of emergency department patients with headache.
The Ottawa subarachnoid haemorrhage (SAH) rule suggests that alert patients older than 15 years with a severe nontraumatic headache reaching maximum intensity within 1 h and absence of high-risk variables effectively have a SAH ruled out. We aimed to determine the proportion of emergency department (ED) patients with any headache fulfilling the entry criteria for the Ottawa SAH rule. ⋯ In this descriptive observational study, the majority of ED patients presenting with a headache did not fulfil the entry criteria for the Ottawa SAH rule. Less than 5% of the patients in this cohort could have SAH excluded on the basis of the rule. More definitive studies are needed to determine an accepted benchmark for the proportion of patients receiving further work-up (computed tomographic brain) after fulfilling the entry criteria for the Ottawa SAH rule.
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Computed tomography of the kidneys, ureters and bladder is the recommended imaging modality for suspected urolithiasis. Early scanning is advised in guidelines, but there is limited published evidence to support this recommendation. ⋯ There is no evidence in this cohort that discharging patients for outpatient imaging is associated with poorer outcomes, provided that an appropriate clinical risk assessment is carried out.
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The majority of uncomplicated toddler fractures of the tibia (toddler's fractures) do not need an orthopaedic surgeon's intervention or follow-up. However, inexperienced emergency room physicians, general practitioners and orthopaedic trainees and surgeons understandably defer to a cautious approach of referral and subsequent frequent clinical and radiographic follow-up. An evidence-based pathway can help prevent this overtreatment, reduce unnecessary radiation exposure and decrease the financial burden on families and the healthcare system. ⋯ Toddler's fractures do not require routine orthopaedic surgeon assessment, intervention or follow-up. If diagnosed and managed correctly at initial presentation, patients with toddler's fractures may be discharged safely without the need for further clinician contact. We developed a toddler's fracture clinical care pathway to reduce unnecessary orthopaedic surgeon referral and clinical and radiographic follow-up, thereby decreasing radiation exposure and costs to families and the healthcare system without risking patient outcomes.