Is Platelet Transfusion Effective in Patients Taking Antiplatelet Agents Who Suffer an Intracranial Hemorrhage?

BACKGROUND: Patients taking antiplatelet agents (APAs) with intracranial hemorrhage (ICH) may be treated with platelet transfusion. OBJECTIVES: We conducted a systematic review of the use of platelet transfusion in the management of APA-related ICH. METHODS: We searched the Cochrane, Medline, Embase, and CINAHL databases. Included studies were randomized, case-controlled, or cohort studies comparing outcomes in adult patients with APA-related ICH who received or did not receive platelet transfusion. Study quality was measured using appropriate scores. The primary outcome of interest was in-hospital mortality rate. Secondary outcomes included rates of craniotomy, neurological, medical, or radiological deterioration; mean length of hospital stay, delayed mortality, and functional status at discharge. We reported proportions, medians with interquartile ranges, and pooled odds ratios with their 95% confidence intervals. p values < 0.05 were considered statistically significant. RESULTS: There were no randomized controlled trials. Seven retrospective cohort studies (four traumatic, three primary ICH) were included. For APA-related traumatic ICH, the pooled odds ratio (OR) for in-hospital mortality with platelet transfusion was 1.77 (95% confidence interval [CI] 1.00-3.13). There were no statistically significant differences for secondary outcomes except for proportion with medical decline (6/44 vs. 2/64; p = 0.006). For APA-related primary ICH, the pooled OR for in-hospital mortality with platelet transfusion was 0.49 (95% CI 0.24-0.98). There were no statistically significant differences for most secondary outcomes between the two groups. These studies had important methodological limitations. CONCLUSIONS: The evidence for platelet transfusion in APA-related ICH was inconclusive due to methodological limitations.

Identifying predictors of an abnormal computed tomographic scan among patients with a head injury and a Glasgow Coma Scale of 15.

AIM: The aim of this study was to determine the proportions of patients with a head injury and a Glasgow Coma Scale of 15 with an abnormal computed tomographic (CT) head scan and to explore its predictors. METHODS: We conducted a retrospective study on adult patients with such injuries. Patients were risk stratified to undergo a head CT and subsequently discharged or admitted to a neurosurgical (NS) intensive care unit (ICU)/high-dependency (HD) NS or general ward (GW) and observation ward [Emergency Diagnostic and Therapeutic Centre (EDTC)]. The primary outcomes were proportions of abnormal CT results and NS interventions. The secondary outcomes included rates of disposition status, and the distribution and predictors of abnormal CT results. Data were analysed using descriptive statistics. We identified predictors of an abnormal head CT using logistic regression and reported their odds ratios (ORs) and 95% confidence intervals. RESULTS: We reviewed 2038 complete records. A total of 1088 scans were performed; 115 (10.6%) were abnormal. There were 962 (47.2%) discharges and 1076 (52.8%) admissions; six (0.6%) required NS interventions and ICU/HD admission. The proportions of GW admissions (n=1070) were as follows: EDTC 78.0%; NS 18.0%; and medical 4.0%. The proportions of abnormal CT results among these disposition statuses were as follows: NS ICU/HD 6/6 (100%); EDTC 59/835 (7.1%); NS GW 47/188 (25.0%); and medical GW 3/33 (9.1%). We identified three predictors, namely, vomiting [OR 2.23 (1.39-3.58)]; loss of consciousness [OR 1.56 (1.03-2.36)]; and amnesia [OR 2.08 (1.30-3.31)]. CONCLUSION: Abnormal CT and NS interventions were infrequent in patients with a head injury and a Glasgow Coma Scale of 15. We identified three predictors of abnormal head CTs.

Are butyrophenones effective for the treatment of primary headache in the emergency department?

OBJECTIVES: Butyrophenones have been reported to provide effective migraine relief in the emergency department (ED). We conducted a systematic review of the evidence for their use in the ED. DATA SOURCE: We searched the Cochrane, Medline, Embase, and CINAHL databases. STUDY SELECTION: Included studies were randomized trials of a parenteral butyrophenone (droperidol, haloperidol) versus placebo or a comparator in migraine or benign headache with results available in English. Study quality was determined using the Jadad score. Six articles were included. DATA EXTRACTION: Primary outcomes were subjective or objective headache relief (>50% improvement in visual analogue scale scores). Secondary outcomes included side effects. We reported pooled odds ratios (ORs) with their 95% confidence intervals (CIs) for subjective or objective headache relief for butyrophenones versus placebo or comparator agents. DATA SYNTHESIS: Three studies reported subjective headache relief with a butyrophenone versus placebo or meperidine in migraine. Two studies reported objective headache relief with droperidol versus prochlorperazine, whereas one study compared droperidol versus olanzapine in benign headache. The pooled OR for subjective headache relief was 8.08 (95% CI 1.54-42.30) for a butyrophenone versus placebo, whereas it was 1.50 (95% CI 0.33-6.77) for droperidol versus meperidine in migraine. The pooled OR for objective headache relief was 2.96 (95% CI 1.36-6.43) for droperidol versus prochlorperazine in benign headache. Rates of side effects were 10 to 45%; akathesia and sedation were the most common. CONCLUSIONS: Butyrophenones are effective for the relief of migraine or benign headache. However, adverse effects make it difficult to recommend butyrophenones above agents with similar effectiveness and fewer problems.

Identifying risk factors for an abnormal computed tomographic scan of the head among patients with altered mental status in the Emergency Department.

AIMS: The aims of our study are to evaluate the use of computed tomographic scan of the head (CT-head) in patients with altered mental status (AMS) presenting to the Emergency Department (ED) and to identify clinical features associated with an abnormal CT-head result. METHODS: In this prospective observational study, we recruited consecutive adult patients with undifferentiated AMS and no major trauma at a busy urban ED over 11 months. Demographical, clinical, radiological and laboratory data were collected prospectively. The primary outcome measure was an abnormal CT-head result. Secondary outcome measures were the distribution of aetiologies of AMS with age, mortality rate and length of hospital stay. Logistic regression was applied to identify variables associated with an abnormal CT-head result. RESULTS: Nine hundred and sixty-seven patients were recruited. The rate of CT-head use in the ED was 41%, with 45% of the scans being abnormal. We identified eight clinical factors associated with an abnormal CT-head result. Odds ratios (95% confidence intervals) for diastolic blood pressure greater than 80 mmHg, focal weakness, Glasgow Coma Score less than 15, antiplatelet use, upgoing plantar response, presence of headache, anticoagulant use and dilated pupils were 1.016 (1.003-1.029), 1.816 (1.063-3.103), 1.899 (1.113-3.242), 2.203 (1.146-4.234), 2.680 (1.623-4.427), 3.369 (1.449-7.830), 3.589 (1.253-10.283) and 5.212 (1.153-23.558), respectively. CONCLUSION: Our study identified important risk factors for an abnormal CT-head result which can be used in future research to establish a guideline for rational ordering of the test in AMS patients.

Prospective study of patients with altered mental status: clinical features and outcome.

AIMS: Patients with altered mental status (AMS) present commonly to the Emergency Department (ED). The aim of this prospective study is to identify the various clinical features of this diverse group of patients and trace their outcomes. This will allow clinicians to be aware of the natural history of the symptom complex and the difficulties in managing them. METHODS: In this prospective observational study, we recruited patients aged 18 and above diagnosed with AMS at Tan Tock Seng Hospital ED from December 2006 to October 2007. This is an urban ED. Demographic, clinical, radiology, laboratory data, final diagnosis and length of stay were collected from their entry into the ED till discharge or demise using the ED's and inpatient electronic records. RESULTS: From December 2006 to October 2007, 967 patients with a mean age of 66.5 years diagnosed with AMS were recruited into our study. The total number of CT scans done during the study period was 674, of which 246 (37%) were abnormal and 428 (63%) were normal. The mean hospital length of stay was 11.6 days. Patients with abnormal CT results stayed longer than those whose results were normal (median of 9 days versus median of 6 days). The three most common causes of AMS in our study population were of neurological (34.4%), infectious (18.3%) and metabolic (12%) aetiologies. Overall, 106 (11%) patients died during hospitalisation; 36 (33.9%) and 39 (36.8%) deaths were attributed to ischaemic stroke and haemorrhagic stroke, respectively. CONCLUSIONS: AMS remains a symptom complex that carries a significant length of hospital stay and mortality. The most common causes of AMS are those that require timely intervention and are highly treatable. This study will provide insight into proper allocation of resources to manage this group of patients, from triaging to investigations and treatment at the ED and inpatient levels.