Acute ischemic stroke therapy.

Acute ischemic stroke is a medical emergency that requires rapid evaluation and treatment. Prehospital and emergency department care can be streamlined to meet those goals. Intravenous rt-PA therapy improves outcome in selected patients with ischemic stroke if given within 3 hours of stroke onset, but offers no benefit beyond that time window. Intra-arterial thrombolytic therapy and intravenous defibrogenating agents may also be beneficial in selected patients. Newer thrombolytic agents such as aspirin and heparin in acute ischemic stroke treatment have been clarified by recent trials.

Supporting emergency medicine research: developing the infrastructure.

The long-term goals of developing research within the specialty of emergency medicine (EM) include the following: 1) to continue to improve the quality and quantity of EM research in order to ultimately improve emergency patient care; 2) to maximize the research potential of emergency health care professionals in order to develop new emergency research talent and enthusiasm; and 3) to establish the academic research credentials of the specialty of EM in order to become competitive for federal research funding, and further improve emergency patient care. This article addresses the process by which the infrastructure for EM research can be developed at academic medical centers and provides recommendations. The roles of the academic chair, research director, senior researcher, and departmental faculty are discussed.

Supporting emergency medicine research: developing the infrastructure.

The long-term goals of developing research within the specialty of emergency medicine include the following: (1) to continue to improve the quality and quantity of emergency patient care; (2) to maximize the research potential of emergency health care professionals to develop new emergency research talent and enthusiasm; and (3) to establish the academic research credentials of the specialty of emergency medicine to become competitive for federal research funding, and further improve emergency patient care. This article addresses the process by which the infrastructure for emergency medicine research can be developed at academic medical centers and provides recommendations. The roles of the academic chair, research director, senior researcher, and departmental faculty are discussed.

Research directions in emergency medicine.

The goal of emergency medicine is to improve health while preventing and treating disease and illness in patients seeking emergency medical care. Improvements in emergency medical care and the delivery of this care can be achieved through credible and meaningful research efforts. Improved delivery of emergency medical care through research requires careful planning and the wise use of limited resources. To achieve this goal, emergency medicine must provide appropriate training of young investigators and attract support for their work. Promotion of multidisciplinary research teams will help the specialty fulfill its goals. The result will be the improvement of emergency medical care which will benefit not only the patients emergency physicians serve but also, ultimately, the nation's health.

The ABCs of measuring intracerebral hemorrhage volumes.

BACKGROUND AND PURPOSE: Hemorrhage volume is a powerful predictor of 30-day mortality after spontaneous intracerebral hemorrhage (ICH). We compared a bedside method of measuring CT ICH volume with measurements made by computer-assisted planimetric image analysis. METHODS: The formula ABC/2 was used, where A is the greatest hemorrhage diameter by CT, B is the diameter 90 degrees to A, and C is the approximate number of CT slices with hemorrhage multiplied by the slice thickness. RESULTS: The ICH volumes for 118 patients were evaluated in a mean of 38 seconds and correlated with planimetric measurements (R2 = 9.6). Interrater and intrarater reliability were excellent, with an intraclass correlation of .99 for both. CONCLUSIONS: We conclude that ICH volume can be accurately estimated in less than 1 minute with the simple formula ABC/2.

Spontaneously resolving cervical epidural hematoma presenting with hemiparesis.

Cervical epidural hematoma is an uncommon cause of neck pain. It may occur spontaneously or after trauma and has also become associated with many underlying conditions. Most patients present with paraparesis or tetraparesis. We describe the case of a healthy 60-year-old woman in whom a spontaneous cervical epidural hematoma developed while she was swimming. She presented with transient hemiparesis and recovered without surgery. This case is unusual with respect to the patient's neurologic presentation and her spontaneous recovery without neurologic sequelae.

Urgent therapy for acute stroke. Effects of a stroke trial on untreated patients.

BACKGROUND AND PURPOSE: As part of the recruitment efforts for the National Institutes of Health Tissue Plasminogen Activator Pilot Study, public education and awareness campaigns were conducted to encourage early hospital arrival. We evaluated the change in arrival times during the course of the study for all stroke patients, including those who were not entered into study. METHODS: Data were gathered on all patients presenting within 24 hours of stroke onset to all of the study hospitals. Coincident with the start of the study, educational and promotional programs, which stressed signs and symptoms of stroke and the need to call 911, were presented to physicians, paramedical personnel, and the public. The study was divided into four quartiles to analyze differences in time to hospital arrival and use of 911. RESULTS: Of 2099 patients screened, time data were available on 1116. During the course of the study, the mean time from symptom onset to hospital arrival declined significantly (3.2 hours versus 1.5 hours). Patients arrived for treatment sooner at community hospitals than at university/teaching hospitals. The use of 911 increased from 39% in the first quartile of the study to 60% in the fourth quartile. This was a consistent finding in all study sites. Increased use of 911 was seen almost exclusively in patients with nonhemorrhagic stroke. CONCLUSIONS: Times from stroke onset to hospital arrival decreased significantly during the course of the National Institutes of Health Tissue Plasminogen Activator Pilot Study. Significantly increased use of 911 was the likely major explanation for the shortened arrival times. The decrease in arrival times may be a consequence of the public and professional education programs conducted at all study sites.

Role of emergency medicine residency programs in determining emergency medicine career choice among medical students.

STUDY OBJECTIVE: To characterize the role of emergency medicine residency programs in determining emergency medicine career choice among medical students. DESIGN: Observational, cross-sectional, descriptive study. Information on student career choice was obtained through a targeted query of the National Resident Matching Program data base, simultaneously stratified by specialty and school, and adjusted for class size. PARTICIPANTS: All accredited emergency medicine residency programs and four-year allopathic medical schools. RESULTS: Fifty-two schools (42%) had a closely affiliated emergency medicine residency program, ie, one based primarily at the institution's main teaching hospital(s). This configuration was associated with a 70% increase in the median proportion of students choosing emergency medicine as a career when compared to the 73 schools with no closely affiliated emergency medicine residency (5.1% vs 3.0%, P < .0001). When institutions were stratified by overall commitment to emergency medicine, the median proportion of students choosing emergency medicine as a career was 2.9% for institutions with a minimal commitment to emergency medicine (neither an academic department of emergency medicine nor a closely affiliated emergency medicine residency), 4.1% for institutions with a moderate commitment to emergency medicine (either a department of emergency medicine or an emergency medicine residency, but not both), and 5.7% for institutions with a substantial commitment to emergency medicine (a department of emergency medicine and an emergency medicine residency) (P < .0001). When institutional commitment to emergency medicine was examined in a simple multivariate model, only the presence of an emergency medicine residency was associated independently with student career choice (P < .001). CONCLUSION: An emergency medicine residency program that is closely affiliated with a medical school is strongly and independently associated with a quantitatively and statistically significant increase in the proportion of students from that school who choose a career in emergency medicine. These data support the proposition that, if emergency medicine is to meet national manpower shortage needs by attracting students to the specialty, it must establish residency programs within the primary teaching hospital(s) of medical schools. Such a configuration does not currently exist in the majority of schools.

Current status of academic emergency medicine within academic medicine in the United States.

OBJECTIVE: To characterize the status of emergency medicine within U.S. academic medical centers. METHODS: All accredited emergency medicine residency programs and all four-year allopathic medical schools in the United States were identified. Institutions were defined as academic medical centers based upon NIH research grant funding. These institutions were ranked using five measures of academic stature: a survey of medical school deans, a survey of internal medicine residency directors, level of research funding, characteristics of the student body, and an unweighted composite variable reflecting overall academic stature. The relationship between institutional academic stature and an empiric scale of institutional affiliation with emergency medicine was assessed. RESULTS: Sixty-two institutions were designated academic medical centers. These medical schools captured 90% of all NIH grant monies awarded in fiscal year 1990. Twenty-six of 87 emergency medicine residency programs (30%) were closely affiliated with one of these medical schools. Within academic medical centers, the presence of a residency or an academic department of emergency medicine was inversely associated with the medical school deans' ranking (p < 0.005), research rank (p < 0.001), and composite academic rank (p < 0.001). CONCLUSION: The majority of emergency medicine residency programs (70%) are not closely affiliated with institutions receiving the bulk (90%) of NIH resources for research. Within the institutions receiving the majority of NIH funding, there is a quantitatively and statistically significant inverse association of institutional emergency medicine affiliation and institutional academic rank.

Time of hospital presentation in patients with acute stroke.

BACKGROUND: Stroke is a leading cause of death and disability in the United States. Although new treatments are being studied, most must be given early in the course of stroke to be effective. This study was performed to identify factors associated with early hospital arrival in patients with stroke. METHODS: As part of the National Institute of Neurologic Disorders and Stroke Tissue-Type Plasminogen Activator Pilot Study, information from patients, patients' families, or, most commonly, the medical record was gathered on all patients presenting to the hospital within 24 hours of the onset of stroke. A total of 14 hospitals participated. Three were university hospitals, and 11 were community hospitals with and without university affiliation. The main outcome measure was the time from stroke onset to hospital arrival. RESULTS: Of 2099 patients screened, adequate time data were available in 1159. Thirty-nine percent presented to the hospital 90 minutes or less after symptom onset and 59% within 3 hours. Early hospital arrival after stroke was greatly influenced by the type of first medical contact and, to a lesser degree, by the patient's location at the time of the stroke and the time of the day at which the stroke occurred. Hospital arrival was fastest in patients using 911 as their first medical contact (mean, 155 minutes; median, 84 minutes) vs their personal physician (mean, 379 minutes; median, 270 minutes; P < .0001) or a study hospital (mean, 333 minutes; median, 212 minutes; P < .0001). Time from symptom onset to arrival was longer for patients having the stroke at night compared with patients having a stroke in the morning (P < .05), in the afternoon (P < .01), or in the evening (P < .0001). Time to hospital arrival was significantly longer for patients having the stroke at home than for patients having the stroke at work (P < .01) or in an unknown place (P < .05). Gender, age, race, and presence of brain hemorrhage had no significant effect. CONCLUSIONS: As many as 50% of patients with stroke arrive at the hospital within 3 hours of symptom onset. Our data indicate that strategies to increase the use of 911 systems may have a high yield with regard to recruitment into urgent treatment protocols for stroke.

Safety assessment of high-dose narcotic analgesia for emergency department procedures.

STUDY OBJECTIVE: To evaluate the safety of high-dose IV narcotics in patients requiring analgesia for painful emergency department procedures. DESIGN: Prospective multicenter clinical trial. SETTING: Five adult urban EDs. METHODS AND MEASUREMENTS: All patients received IV meperidine (1.5 to 3.0 mg/kg) titrated to analgesia followed by a painful procedure. Vital signs and alertness scale were recorded at regular intervals, and patients were observed for four hours. Adverse events were monitored and documented. Comparisons between baseline and postanalgesia intervals were made with a repeated measures ANOVA (Dunnett's test). RESULTS: Although statistically significant changes in vital signs and alertness scale occurred, they were not clinically significant. Opiate reversal with naloxone was not needed in any patient, and no significant respiratory or circulatory compromise occurred. CONCLUSION: This study of 72 patients demonstrates that high-dose narcotic analgesia is appropriate, well tolerated, and safe when used in selected patients before painful procedures in the ED. Narcotic antagonists and resuscitation equipment nonetheless should be available to maximize safety.

High-dose intravenous naloxone for the treatment of acute ischemic stroke.

To evaluate the safety and possible efficacy of high-dose naloxone for the treatment of acute cerebral ischemia, 38 patients received a loading dose of 160 mg/m2 over 15 minutes followed by a 24-hour infusion at the rate of 80 mg/m2/hr. Nausea and/or vomiting were common side effects. Naloxone was discontinued in seven patients (because of hypotension in one, bradycardia and hypotension in two, myoclonus in one, focal seizures in two, and hypertension in one); all seven patients responded to treatment and no permanent sequelae to naloxone were noted. Twelve of the 38 patients showed early neurologic improvement (by completion of the naloxone loading dose). However, there was no correlation between such a loading dose response and clinical outcome at 3 months. Our experience suggests that naloxone is safe at the dose used, but data for efficacy are inconclusive.

Use of high dose naloxone in acute stroke: possible side-effects.

The effects of high dose naloxone in humans have not been studied extensively. We treated 36 patients who had acute ischemic cerebral infarction with high doses of naloxone to evaluate potential efficacy and toxicity. All patients were treated with a 160-mg/m2 (4-mg/kg) loading dose followed by 80 mg/m2.h (2 mg/kg.h) x 24 h. There were no statistically significant changes in group mean arterial pressure, respiratory rate, or heart rate in response to the loading dose or infusion, although clinically significant changes did occur in four patients. Twenty-three patients had adverse reactions possibly related to naloxone, the most common of which were nausea (n = 20), bradycardia and/or hypotension (n = 3), myoclonus (n = 1), and hypertension (n = 1). Seven patients had naloxone discontinued for possible adverse reactions. All adverse reactions abated with discontinuation of naloxone and/or pharmacologic therapy when indicated. No deaths were attributable to naloxone treatment. High dose naloxone appears to be well tolerated in the majority of elderly patients with acute cerebral infarction.

Measurements of acute cerebral infarction: a clinical examination scale.

We designed a 15-item neurologic examination stroke scale for use in acute stroke therapy trials. In a study of 24 stroke patients, interrater reliability for the scale was found to be high (mean kappa = 0.69), and test-retest reliability was also high (mean kappa = 0.66-0.77). Test-retest reliability did not differ significantly among a neurologist, a neurology house officer, a neurology nurse, or an emergency department nurse. The stroke scale validity was assessed by comparing the scale scores obtained prospectively on 65 acute stroke patients to the patients' infarction size as measured by computed tomography scan at 1 week and to the patients' clinical outcome as determined at 3 months. These correlations (scale-lesion size r = 0.68, scale-outcome r = 0.79) suggested acceptable examination and scale validity. Of the 15 test items, the most interrater reliable item (pupillary response) had low validity. Less reliable items such as upper or lower extremity motor function were more valid. We discuss methods for improving the reliability and validity of brief examination scales to be used in stroke therapy trials.