The Canadian C-spine rule for radiography in alert and stable trauma patients.

CONTEXT: High levels of variation and inefficiency exist in current clinical practice regarding use of cervical spine (C-spine) radiography in alert and stable trauma patients. OBJECTIVE: To derive a clinical decision rule that is highly sensitive for detecting acute C-spine injury and will allow emergency department (ED) physicians to be more selective in use of radiography in alert and stable trauma patients. DESIGN: Prospective cohort study conducted from October 1996 to April 1999, in which physicians evaluated patients for 20 standardized clinical findings prior to radiography. In some cases, a second physician performed independent interobserver assessments. SETTING: Ten EDs in large Canadian community and university hospitals. PATIENTS: Convenience sample of 8924 adults (mean age, 37 years) who presented to the ED with blunt trauma to the head/neck, stable vital signs, and a Glasgow Coma Scale score of 15. MAIN OUTCOME MEASURE: Clinically important C-spine injury, evaluated by plain radiography, computed tomography, and a structured follow-up telephone interview. The clinical decision rule was derived using the kappa coefficient, logistic regression analysis, and chi(2) recursive partitioning techniques. RESULTS: Among the study sample, 151 (1.7%) had important C-spine injury. The resultant model and final Canadian C-Spine Rule comprises 3 main questions: (1) is there any high-risk factor present that mandates radiography (ie, age >/=65 years, dangerous mechanism, or paresthesias in extremities)? (2) is there any low-risk factor present that allows safe assessment of range of motion (ie, simple rear-end motor vehicle collision, sitting position in ED, ambulatory at any time since injury, delayed onset of neck pain, or absence of midline C-spine tenderness)? and (3) is the patient able to actively rotate neck 45 degrees to the left and right? By cross-validation, this rule had 100% sensitivity (95% confidence interval [CI], 98%-100%) and 42.5% specificity (95% CI, 40%-44%) for identifying 151 clinically important C-spine injuries. The potential radiography ordering rate would be 58.2%. CONCLUSION: We have derived the Canadian C-Spine Rule, a highly sensitive decision rule for use of C-spine radiography in alert and stable trauma patients. If prospectively validated in other cohorts, this rule has the potential to significantly reduce practice variation and inefficiency in ED use of C-spine radiography.

Canadian CT head rule study for patients with minor head injury: methodology for phase II (validation and economic analysis).

Prospective validation on a new set of patients is an essential test of a new decision rule. However, many clinical decision rules are not prospectively assessed to determine their accuracy, reliability, clinical sensibility, or potential impact on practice. This validation process is important because many statistically derived rules or guidelines do not perform well when tested in a new population. The methodologic standards for a validation study are similar to those described in the article on phase I for derivation studies in the August 2001 issue of Annals of Emergency Medicine. The goal of phase II is to prospectively assess the accuracy, reliability, and acceptability of the decision rule in a new set of patients with minor head injury. This will determine the clinical utility of the rule and is essential if such a rule is to be widely adopted into clinical practice.

The Canadian CT Head Rule Study for patients with minor head injury: rationale, objectives, and methodology for phase I (derivation).

Head injuries are among the most common types of trauma seen in North American emergency departments, with an estimated 1 million cases seen annually. "Minor" head injury (sometimes known as "mild") is defined by a history of loss of consciousness, amnesia, or disorientation in a patient who is conscious and talking, that is, with a Glasgow Coma Scale score of 13 to 15. Although most patients with minor head injury can be discharged without sequelae after a period of observation, in a small proportion, their neurologic condition deteriorates and requires neurosurgical intervention for intracranial hematoma. The objective of the Canadian CT Head Rule Study is to develop an accurate and reliable decision rule for the use of computed tomography (CT) in patients with minor head injury. Such a decision rule would allow physicians to be more selective in their use of CT without compromising care of patients with minor head injury. This paper describes in detail the rationale, objectives, and methodology for Phase I of the study in which the decision rule was derived. [Stiell IG, Lesiuk H, Wells GA, McKnight RD, Brison R, Clement C, Eisenhauer MA, Greenberg GH, MacPhail I, Reardon M, Worthington J, Verbeek R, Rowe B, Cass D, Dreyer J, Holroyd B, Morrison L, Schull M, Laupacis A, for the Canadian CT Head and C-Spine Study Group. The Canadian CT Head Rule Study for patients with minor head injury: rationale, objectives, and methodology for phase I (derivation). Ann Emerg Med. August 2001;38:160-169.]

Dexamethasone prevents relapse after emergency department treatment of acute migraine: a randomized clinical trial.

OBJECTIVE: To determine whether the addition of intravenous dexamethasone to standard emergency department (ED) migraine therapy would decrease the incidence of severe recurrent headache 24 to 48 hours after initial treatment. METHODS: Patients aged 19 to 65 years whose headache was severe enough to require parenteral therapy and who met International Headache Society migraine criteria were eligible for this randomized, double-blind trial. The study was conducted in the ED of 2 community hospitals, 1 of which was a tertiary referral centre. Exclusion criteria included pregnancy, focal findings, fever, meningismus, allergy to the study drug, active peptic ulcer disease and diabetes mellitus. Demographic and clinical data, including headache severity, were recorded. After abortive therapy (antiemetics, intravenous nonsteroidal agents, dihydroergotamine or opioids), blinded nurses administered dexamethasone (24 mg intravenously) or placebo. Patients recorded headache severity on a Visual Analogue Scale (VAS) at time T = 0, T = 30 minutes and T = 60 minutes and at discharge. They were contacted 48 to 72 hours later and asked whether they had suffered a recurrence of their headache, categorized as class A (severe, provoking another physician visit), class B (severe, interfering with daily activity but not provoking a physician visit), class C (mild, requiring self-medication but not limiting activity) or class D (mild, requiring no treatment). RESULTS: Two of 100 patients were lost to follow-up, leaving 98 in the study sample. Placebo recipients were more likely to be female; other baseline characteristics were similar between groups. Median VAS pain score was 83 mm on ED arrival, 35 mm after initial treatment and 12 mm on discharge. At follow-up, 65 of 98 patients had suffered headache recurrence. In the placebo versus dexamethasone groups, respectively, the results were 11 versus 0 in class A, 11 versus 9 in class B, 7 versus 11 in class C and 4 versus 12 in class D. Regarding the primary outcome, 9 of 49 dexamethasone patients (18%) and 22 of 49 placebo patients (45%) had severe (classes A and B) recurrent headache (odds ratio 0.28; 95% CI, 0.11 to 0.69; p = 0 .005). CONCLUSIONS: Migraine recurrence is common after "successful" ED treatment. Inflammation may be a critical factor in migraine genesis. Intravenous dexamethasone decreases the incidence of severe recurrent headache after ED treatment and should be offered to patients thought to be at risk of recurrent headache.

A comparison of intubation success for paediatric transport team paramedics using lighted vs regular tracheal tube stylets.

We conducted a prospective randomized study of success rate and time to intubation using Trachlight and Surch-Lite lighted stylets versus a regular tracheal tube stylet, in a training setting. Participants, 18 paediatric transport paramedics, performed two intubations with each of the three devices, using an airway management trainer. There was no significant difference in mean time for intubation between the three devices. The times for external confirmation of correct tube placement were comparable using the two lighted stylets. External confirmation of the tube placement using the lighted stylets was quicker than laryngoscopic visualization. In darkness, with a nonfunctioning laryngoscope, intubations were successfully performed 100% of the time with the lighted stylet, but only 11% of the time with the regular stylet. All paramedics felt that a lighted stylet would be a useful airway management adjunct for the transport environment for complicated intubations or for use in very high or low levels of ambient light.

Intravenous vs subcutaneous naloxone for out-of-hospital management of presumed opioid overdose.

OBJECTIVE: To determine whether naloxone administered i.v. to out-of-hospital patients with suspected opioid overdose would have a more rapid therapeutic onset than naloxone given subcutaneously (s.q.). METHODS: A prospective, sequential, observational cohort study of 196 consecutive patients with suspected opioid overdose was conducted in an urban out-of-hospital setting, comparing time intervals from arrival at the patient's side to development of a respiratory rate > or =10 breaths/min, and durations of bag-valve-mask ventilation. Subjects received either naloxone 0.4 mg i.v. (n = 74) or naloxone 0.8 mg s.q. (n = 122), for respiratory depression of <10 breaths/min. RESULTS: Mean interval from crew arrival to respiratory rate > or =10 breaths/min was 9.3 +/- 4.2 min for the i.v. group vs 9.6 +/- 4.58 min for the s.q. group (95% CI of the difference -1.55, 1.00). Mean duration of bag-valve-mask ventilation was 8.1 +/- 6.0 min for the i.v. group vs 9.1 +/- 4.8 min for the s.q. group. Cost of materials for administering naloxone 0.4 mg i.v. was $12.30/patient, compared with $10.70/patient for naloxone 0.8 mg s.q. CONCLUSION: There was no clinical difference in the time interval to respiratory rate > or =10 breaths/min between naloxone 0.8 mg s.q. and naloxone 0.4 mg i.v. for the out-of-hospital management of patients with suspected opioid overdose. The slower rate of absorption via the s.q. route was offset by the delay in establishing an i.v.

Variation in ED use of computed tomography for patients with minor head injury.

STUDY OBJECTIVE: To determine the frequency of utilization, yield for brain injury, incidence of missed injury, and variation in the use of computed tomography (CT) for ED patients with minor head injury. METHODS: This retrospective health records survey was conducted over a 12-month period in the EDs at seven Canadian teaching institutions. Included in this review were adult patients who sustained acute minor head injury, defined as witnessed loss of consciousness or amnesia and a Glasgow Coma Scale score of 13 or greater. Data were collected by research assistants who were trained to select cases and abstract data in a standardized fashion according to a resource manual. Subsequently, patient eligibility was reviewed by the study coordinator and principal investigator. RESULTS: Of the 1,699 patients seen, 521 (30.7%) were referred for CT, and 418 (79.8%) of these scans were negative for any type of brain injury. Overall, 105 (6.2%) of these patients sustained acute brain injury, including 9 (.5%) with an epidural hematoma Cochran's Q test for homogeneity demonstrated significant variation between the seven centers for rate of ordering CT (P < .0001), from a low of 15.9% to a high of 70.4%. All five cases of "missed" hematoma occurred at the institutions with the highest and third highest rates of CT use. After controlling for possible differences in case severity and patient characteristics at each hospital, logistic regression analysis revealed that five of seven hospitals were significantly associated with the use of CT (respected odds ratios [OR], .4, .5, .5, 3.2, and 4.7). Three of the centers (two with the highest ordering rates) showed significant heterogeneity in the ordering of CT among their attending staff physicians, from a low of 6.5% to a high of 80.0%. CONCLUSION: There was considerable variation among institutions and individual physicians in the ordering of CT for patients with minor head injury. Although emergency physicians were selective when ordering CT, the yield of radiography was very low at all hospitals. None of the cases of "missed" intracranial hematoma came from the lowest ordering institutions, indicating that patients may be managed safely with a selective approach to CT use. These findings suggest great potential for more standardized and efficient use of CT of the head, possibly through the use of a clinical decision rule.

Variation in emergency department use of cervical spine radiography for alert, stable trauma patients.

OBJECTIVE: To, assess the emergency department use of cervical spine radiography for alert, stable adult trauma patients in terms of utilization, yield for injury and variation in practices among hospitals and physicians. DESIGN: Retrospective survey of health records. SETTING: Emergency departments of 6 teaching and 2 community hospitals in Ontario and British Columbia. PATIENTS: Consecutive alert, stable adult trauma patients seen with potential cervical spine injury between July 1, 1994, and June 30, 1995. MAIN OUTCOME MEASURES: Total number of eligible patients, referral for cervical spine radiography (overall, by hospital and by physician), presence of cervical spine injury, patient characteristics and hospitals associated with use of radiography. RESULTS: Of 6855 eligible patients, cervical spine radiography was ordered for 3979 (58.0%). Only 60 (0.9%) patients were found to have an acute cervical spine injury (fracture, dislocation or ligamentous instability); 98.5% of the radiographic films were negative for any significant abnormality. The demographic and clinical characteristics of the patients were similar across the 8 hospitals, and no cervical spine injuries were missed. Significant variation was found among the 8 hospitals in the rate of ordering radiography (p < 0.0001), from a low of 37.0% to a high of 72.5%. After possible differences in case severity and patient characteristics at each hospital were controlled for, logistic regression analysis revealed that 6 of the hospitals were significantly associated with the use of radiography. At 7 hospitals, there was significant variation in the rate of ordering radiography among the attending emergency physicians (p < 0.05), from a low of 15.6% to a high of 91.5%. CONCLUSIONS: Despite considerable variation among institutions and individual physicians in the ordering of cervical spine radiography for alert, stable trauma patients with similar characteristics, no cervical spine injuries were missed. The number of radiographic films showing signs of abnormality was extremely low at all hospitals. The findings suggest that cervical spine radiography could be used more efficiently, possibly with the help of a clinical decision rule.

Acute gastric dilatation as a relatively late complication of tetraplegia due to very high cervical cord injury.

Patients sustaining an injury to the cervical spine at C3/4 level, with extensive cord damage, are difficult to manage. The injury is associated with a high mortality. The respiratory complications, including those associated with tracheostomy and intermittent-positive-pressure ventilation, are well recognised. The initial ileus and its management is also well documented. This report describes the development of acute gastric dilatation occurring 4 weeks after injury. The condition is particularly serious as many complications may have been overcome by this time resulting in a false sense of security. Two case histories are described. It is suggested that to a variable degree this complication probably occurs frequently in these patients. The aetiology of the acute gastric dilatation is discussed and recommendations are made (based on experience with one of the cases described), which may reasonably be expected to minimise the development and progress of the condition.

Comparison of diazepam and flurazepam in the treatment of insomnia in general practice.

In a double-blind crossover study in general practice, flurazepam was shown to be significantly better (p less than 0.001) than diazepam in treating sleep disturbance. Fewer patients reported side-effects on flurazepam.

Depression in family practice.

Few physicians on graduation realize the prevalence of depressive illness, or are capable of diagnosing other than the more severe cases. The author summarizes the manner in which these patients present. This is based on a theory of etiology which is related to specific stress, in predisposed people, resulting in a disturbance in function of the brain - probably the diencephalon. A brief outline of management and sources for further reading are also presented.