- Email: [email protected]
311 Transient Ischemic Attack “Bouncebacks”: Emergency Department Discharges Who Return as Admissions Within Seven Days
Research Forum Abstracts Results: The answers provided by both groups of emergency physicians will be compared to the gold standard interpretations of the two Epileptologists, and the sensitivity and inter-rater agreement (kappa) will be determined. Conclusion: If successful, the real-time interpretation of EEGs in the ED by emergency physicians may lead to more prompt diagnosis of NCS in patients presenting with altered mental status, allowing for earlier initiation of appropriate therapy and improved patient outcomes.
309
Predictors of Neurosurgical Interventions in Low Risk Patients With Isolated Traumatic Subarachnoid Hemorrhage
Sawas A, Huang E, Vosswinkle J, McCormack JE, Thode HC, Jr., Singer AJ/Stony Brook University, Stony Brook, NY
Study Objectives: Patients with isolated traumatic subarachnoid hemorrhage (tSAH) are often transferred to regional trauma centers for possible neurosurgical interventions (NSI). However, NSI are rarely needed, especially in patients with mild traumatic brain injuries. We explored the association between clinical characteristics and need for NSI in patients with tSAH and a Glascow Coma Score (GCS) of 15 and attempted to derive a decision rule to identify patients at very low risk of NSI in whom inter-facility transfers would be unnecessary. Methods: Study Design: Retrospective review of regional trauma registry (20012014). Setting: Suburban county serving a population of 1.5 million with 11 local hospitals and one academic level 1 trauma center. Patients: Isolated tSAH (ICD 9 codes 852.0-852.1). Measures and Potential Predictors of NSI: Demographic and clinical characteristics. Outcomes: Death, mechanical ventilation or need for NSI (intracranial pressure [ICP] monitoring, ventriculostomy or craniotomy). Data Analysis: Univariate analysis, (chi-square test) and logistic regression were used to determine the association between predictors and outcomes. Results: There were1008 cases identified. Mean age (SD) was 62 (25) and 48% were male. Mechanism of injury included falls (70%), MVC (15%), and assaults (6%). Comorbidities included bleeding disorders (17%), diabetes (18%), and hypertension (52%). Mean (SD) ISS was 10.3 (2.3), highest abbreviated injury scale (AIS) was 3 for 98% of cases, 2 for 1% and 4 or 5 for 1%. 385 (38%) patients were admitted to the ICU and 22 (2%) were mechanically ventilated. Mortality was 2% and only 8 (0.8%) patients required NSI. Mechanical ventilation and NSI were more likely to occur with an increase in AIS (AOR 6.6, 95% CI 2.5-17.0) and with the presence of a bleeding disorder (AOR 2.7 95% CI 1.2-6.0). This model was poorly predictive, with a sensitivity of 3.4% and specificity 100%. Area under the curve was 0.63 (95% CI 0.52-0.75). A second multivariate model found hypertension related to NSI (P ¼ .046) with 88% sensitivity, 48% specificity, 1.3% PPV and 99.8% NPV. Conclusion: The need for neurosurgical intervention in low risk patients (GCS 15) with isolated tSAH is rare and is associated with hypertension. Due to small sample size we were unable to derive a specific model for predicting neurosurgical interventions in these patients.
310
Prospective Double-Blinded Randomized Field-Based Clinical Trial of Metoclopramide and Ibuprofen for the Treatment of Acute Mountain Sickness
Irons HR, Salas RN, Bhai S, Harris NS/Massachusetts General Hospital, Boston, MA; Brigham and Women’s Hospital, Boston, MA
Study Objectives: Acute mountain sickness (AMS) is very common, afflicting 50-80% of high altitude travelers and can be debilitating. AMS is defined as headache combined with nausea, vomiting, fatigue, weakness, lightheadedness, and/or difficulty sleeping that occurs as a result of rapid exposure to high altitude. While acetazolamide is effective at aiding acclimatization and improving AMS, it is not without side effects and time to symptom relief may be delayed. Recent studies have shown some promise for the use of ibuprofen in AMS. There are similarities between AMS and migraine headaches with nausea being a commonly associated symptom. The antiemetic metoclopramide has been well studied and is commonly administered for treatment of migraine headaches in emergency departments across the US. We hypothesized that metoclopramide and ibuprofen may be effective alternative treatment options for both the headache and nausea of acute mountain sickness. Methods: We performed a prospective, double-blinded, randomized, field-based clinical trial of metoclopramide and ibuprofen for the treatment of acute mountain
S112 Annals of Emergency Medicine
sickness. Enrollment was during the climbing season March-May 2013 and 2015 along the usual approach to Mount Everest in Nepal. Subjects were recruited from tea houses in the villages of Pheriche (4280m) and Dingboche (4358m), the Himalayan Rescue Association clinic in Pheriche, and posted signage. Eligibility criteria were recent increase in altitude over 1000 vertical feet in the last 24 hours and presence of headache plus at least one other symptom required for diagnosis of AMS (including nausea, vomiting, fatigue, weakness, lightheadedness or difficulty sleeping). Patients with severe AMS, HACE, or HAPE were excluded. Subjects were randomized to either 10 mg metoclopramide or 400 mg ibuprofen. Subjects and investigators were blinded to the treatment group. Subjects were assessed by vital signs, Lake Louise Score, and a Visual Analog Scale for headache and nausea severity immediately prior to ingestion of study medication, and then serially at 30, 60, and 120 minutes following medication ingestion. Results were analyzed by univariate comparisons and logistic regression with P < .05 considered significant. Results: Analysis of demographic data revealed no statistically significant differences between metoclopramide and ibuprofen groups with respect to age, sex, nights spent at altitude, previous use of medication for altitude illness, altitude of birth, or altitude of residence. Groups did not differ significantly in initial Lake Louise Score, heart rate, or oxygen saturation. Both metoclopramide and ibuprofen were effective in significantly reducing headache severity compared to initial headache over the 2-hour course of the study. Metoclopramide had the additional benefit of reducing nausea to a greater degree than ibuprofen, although both medications reduced overall symptoms of AMS. Conclusion: Both metoclopramide and ibuprofen were effective at reducing AMS symptoms including headache and nausea. Metoclopramide had the additional benefit of reducing nausea to a greater degree than ibuprofen. Therefore, metoclopramide may be an effective alternative treatment option in acute mountain sickness especially for those patients who additionally report nausea.
311
Transient Ischemic Attack “Bouncebacks”: Emergency Department Discharges Who Return as Admissions Within Seven Days
Brennan JJ, Vilke GM, Hsia RY, Chan TC, Killeen JP, Huang J, Castillo EM/University of California, San Diego, CA; University of California, San Francisco, CA
Study Objectives: Patients who are seen with transient cerebral ischemia, also known as transient ischemic attack (TIA), are often discharged from the emergency department (ED) with no complications. However, because this can indicate a sentinel event, there is an important subset of patients that subsequently return to the ED and are admitted for inpatient care. The purpose of this study is to identify and describe patients discharged from an ED with a primary diagnosis of TIA who are admitted within seven days of the discharge to potentially isolate factors that might be used for predicting poorer outcomes. Methods: This was a multi-center retrospective longitudinal cohort study of all hospital ED visits in California in 2011 using non-public data from 324 licensed nonmilitary acute care hospitals in the state of California. Visits without a valid patient identifier and patients under that age of 18 years or who expired were excluded. A TIA index ED discharge was defined as a primary diagnosis of a Transient Cerebral Ischemia (ICD9 code 435.9). The seven-day post ED discharge admission rates were calculated and the admission diagnosis related groupings (DRGs) were reported. Logistic regression was used to assess independent associations between demographic characteristics (age, sex, race/ethnicity) and payer between those who were discharged from the ED and returned within seven days and those who did not return in that period. Results: During the 12-month study period, 9,199 patients were discharged from an ED with 9,523 visits diagnosed as TIA. A total of 331 (3.6%) were admitted within the seven-day follow-up period. The majority of patients who returned were greater than 75 years of age (54.1%), female (54.1%), non-Hispanic white (71.6%) and had Medicare as their primary payer (73.4%). The most common admitting DRGs were intracranial hemorrhage or cerebral infarction (31.7%) followed by transient ischemia (17.5%). In the logistic regression model, patients with private insurance were less likely to be admitted within seven days (OR 0.6, 95% CI¼0.43, 0.86, P ¼ .005) compared those without private insurance. There were no other differences between demographic characteristics. Conclusion: In this study of all 324 non-military licensed EDs in California, patients who were discharged from an ED with a TIA diagnosis and then were admitted within seven days were identified. A large proportion of these patients had been admitted for potentially serious conditions.
Volume 66, no. 4s : October 2015
309
Predictors of Neurosurgical Interventions in Low Risk Patients With Isolated Traumatic Subarachnoid Hemorrhage
Sawas A, Huang E, Vosswinkle J, McCormack JE, Thode HC, Jr., Singer AJ/Stony Brook University, Stony Brook, NY
Study Objectives: Patients with isolated traumatic subarachnoid hemorrhage (tSAH) are often transferred to regional trauma centers for possible neurosurgical interventions (NSI). However, NSI are rarely needed, especially in patients with mild traumatic brain injuries. We explored the association between clinical characteristics and need for NSI in patients with tSAH and a Glascow Coma Score (GCS) of 15 and attempted to derive a decision rule to identify patients at very low risk of NSI in whom inter-facility transfers would be unnecessary. Methods: Study Design: Retrospective review of regional trauma registry (20012014). Setting: Suburban county serving a population of 1.5 million with 11 local hospitals and one academic level 1 trauma center. Patients: Isolated tSAH (ICD 9 codes 852.0-852.1). Measures and Potential Predictors of NSI: Demographic and clinical characteristics. Outcomes: Death, mechanical ventilation or need for NSI (intracranial pressure [ICP] monitoring, ventriculostomy or craniotomy). Data Analysis: Univariate analysis, (chi-square test) and logistic regression were used to determine the association between predictors and outcomes. Results: There were1008 cases identified. Mean age (SD) was 62 (25) and 48% were male. Mechanism of injury included falls (70%), MVC (15%), and assaults (6%). Comorbidities included bleeding disorders (17%), diabetes (18%), and hypertension (52%). Mean (SD) ISS was 10.3 (2.3), highest abbreviated injury scale (AIS) was 3 for 98% of cases, 2 for 1% and 4 or 5 for 1%. 385 (38%) patients were admitted to the ICU and 22 (2%) were mechanically ventilated. Mortality was 2% and only 8 (0.8%) patients required NSI. Mechanical ventilation and NSI were more likely to occur with an increase in AIS (AOR 6.6, 95% CI 2.5-17.0) and with the presence of a bleeding disorder (AOR 2.7 95% CI 1.2-6.0). This model was poorly predictive, with a sensitivity of 3.4% and specificity 100%. Area under the curve was 0.63 (95% CI 0.52-0.75). A second multivariate model found hypertension related to NSI (P ¼ .046) with 88% sensitivity, 48% specificity, 1.3% PPV and 99.8% NPV. Conclusion: The need for neurosurgical intervention in low risk patients (GCS 15) with isolated tSAH is rare and is associated with hypertension. Due to small sample size we were unable to derive a specific model for predicting neurosurgical interventions in these patients.
310
Prospective Double-Blinded Randomized Field-Based Clinical Trial of Metoclopramide and Ibuprofen for the Treatment of Acute Mountain Sickness
Irons HR, Salas RN, Bhai S, Harris NS/Massachusetts General Hospital, Boston, MA; Brigham and Women’s Hospital, Boston, MA
Study Objectives: Acute mountain sickness (AMS) is very common, afflicting 50-80% of high altitude travelers and can be debilitating. AMS is defined as headache combined with nausea, vomiting, fatigue, weakness, lightheadedness, and/or difficulty sleeping that occurs as a result of rapid exposure to high altitude. While acetazolamide is effective at aiding acclimatization and improving AMS, it is not without side effects and time to symptom relief may be delayed. Recent studies have shown some promise for the use of ibuprofen in AMS. There are similarities between AMS and migraine headaches with nausea being a commonly associated symptom. The antiemetic metoclopramide has been well studied and is commonly administered for treatment of migraine headaches in emergency departments across the US. We hypothesized that metoclopramide and ibuprofen may be effective alternative treatment options for both the headache and nausea of acute mountain sickness. Methods: We performed a prospective, double-blinded, randomized, field-based clinical trial of metoclopramide and ibuprofen for the treatment of acute mountain
S112 Annals of Emergency Medicine
sickness. Enrollment was during the climbing season March-May 2013 and 2015 along the usual approach to Mount Everest in Nepal. Subjects were recruited from tea houses in the villages of Pheriche (4280m) and Dingboche (4358m), the Himalayan Rescue Association clinic in Pheriche, and posted signage. Eligibility criteria were recent increase in altitude over 1000 vertical feet in the last 24 hours and presence of headache plus at least one other symptom required for diagnosis of AMS (including nausea, vomiting, fatigue, weakness, lightheadedness or difficulty sleeping). Patients with severe AMS, HACE, or HAPE were excluded. Subjects were randomized to either 10 mg metoclopramide or 400 mg ibuprofen. Subjects and investigators were blinded to the treatment group. Subjects were assessed by vital signs, Lake Louise Score, and a Visual Analog Scale for headache and nausea severity immediately prior to ingestion of study medication, and then serially at 30, 60, and 120 minutes following medication ingestion. Results were analyzed by univariate comparisons and logistic regression with P < .05 considered significant. Results: Analysis of demographic data revealed no statistically significant differences between metoclopramide and ibuprofen groups with respect to age, sex, nights spent at altitude, previous use of medication for altitude illness, altitude of birth, or altitude of residence. Groups did not differ significantly in initial Lake Louise Score, heart rate, or oxygen saturation. Both metoclopramide and ibuprofen were effective in significantly reducing headache severity compared to initial headache over the 2-hour course of the study. Metoclopramide had the additional benefit of reducing nausea to a greater degree than ibuprofen, although both medications reduced overall symptoms of AMS. Conclusion: Both metoclopramide and ibuprofen were effective at reducing AMS symptoms including headache and nausea. Metoclopramide had the additional benefit of reducing nausea to a greater degree than ibuprofen. Therefore, metoclopramide may be an effective alternative treatment option in acute mountain sickness especially for those patients who additionally report nausea.
311
Transient Ischemic Attack “Bouncebacks”: Emergency Department Discharges Who Return as Admissions Within Seven Days
Brennan JJ, Vilke GM, Hsia RY, Chan TC, Killeen JP, Huang J, Castillo EM/University of California, San Diego, CA; University of California, San Francisco, CA
Study Objectives: Patients who are seen with transient cerebral ischemia, also known as transient ischemic attack (TIA), are often discharged from the emergency department (ED) with no complications. However, because this can indicate a sentinel event, there is an important subset of patients that subsequently return to the ED and are admitted for inpatient care. The purpose of this study is to identify and describe patients discharged from an ED with a primary diagnosis of TIA who are admitted within seven days of the discharge to potentially isolate factors that might be used for predicting poorer outcomes. Methods: This was a multi-center retrospective longitudinal cohort study of all hospital ED visits in California in 2011 using non-public data from 324 licensed nonmilitary acute care hospitals in the state of California. Visits without a valid patient identifier and patients under that age of 18 years or who expired were excluded. A TIA index ED discharge was defined as a primary diagnosis of a Transient Cerebral Ischemia (ICD9 code 435.9). The seven-day post ED discharge admission rates were calculated and the admission diagnosis related groupings (DRGs) were reported. Logistic regression was used to assess independent associations between demographic characteristics (age, sex, race/ethnicity) and payer between those who were discharged from the ED and returned within seven days and those who did not return in that period. Results: During the 12-month study period, 9,199 patients were discharged from an ED with 9,523 visits diagnosed as TIA. A total of 331 (3.6%) were admitted within the seven-day follow-up period. The majority of patients who returned were greater than 75 years of age (54.1%), female (54.1%), non-Hispanic white (71.6%) and had Medicare as their primary payer (73.4%). The most common admitting DRGs were intracranial hemorrhage or cerebral infarction (31.7%) followed by transient ischemia (17.5%). In the logistic regression model, patients with private insurance were less likely to be admitted within seven days (OR 0.6, 95% CI¼0.43, 0.86, P ¼ .005) compared those without private insurance. There were no other differences between demographic characteristics. Conclusion: In this study of all 324 non-military licensed EDs in California, patients who were discharged from an ED with a TIA diagnosis and then were admitted within seven days were identified. A large proportion of these patients had been admitted for potentially serious conditions.
Volume 66, no. 4s : October 2015