Grand mal seizures temporally related to cocaine use: clinical and diagnostic features.

STUDY OBJECTIVES: To determine the appropriate diagnostic workup of the emergency department patient with an uncomplicated cocaine-related grand mal seizure. DESIGN SETTING: Retrospective analysis. A city and county ED with 45,000 selected visits per year. TYPE OF PARTICIPANTS: Thirty-seven patients with acute grand mal seizure after cocaine exposure were studied. All had historical or laboratory evidence of cocaine use and no history of prior seizure disorder. INTERVENTIONS: The diagnostic workup varied among patients. Most received computed head tomography (35), whereas fewer received-ECG (18), EEG (16), and lumbar puncture (six). MEASUREMENTS AND MAIN RESULTS: Thirty-three patients with an uncomplicated cocaine-related seizure had an unremarkable series of diagnostic tests. The four patients with remarkable neurologic manifestations were compared with the remainder of patients who were without neurologic abnormalities. Comparison of groups by route of cocaine intake revealed no significant difference in the time interval to seizure (P = .761). CONCLUSION: Diagnostic workup probably is not indicated for the patient experiencing a cocaine-related generalized seizure who will recover promptly and have a normal postictal examination.

Management of acute pyelonephritis in an emergency department observation unit.

STUDY OBJECTIVES: To determine whether moderately to severely ill patients with acute pyelonephritis can be treated successfully on an outpatient basis, and whether any aspect of history, physical examination, or initial laboratory data predicts failure of outpatient therapy and the need for hospitalization. DESIGN: Retrospective chart review of all patients with a diagnosis of acute pyelonephritis seen during a three-year period. SETTING: Emergency department observation unit of an urban teaching hospital serving residents of the city and county of Denver. TYPE OF PARTICIPANTS: Women between the ages of 15 and 50 with symptoms, physical examination, and initial laboratory data consistent with a diagnosis of pyelonephritis. INTERVENTIONS: Patients received IV antibiotics, rehydration, analgesics, and antiemetics in an observation unit for up to 12 hours, when they were either admitted to the hospital or discharged home on oral antibiotics. MEASUREMENTS AND MAIN RESULTS: Sixty-three of 87 patients (72%) with acute pyelonephritis were managed successfully as outpatients, nine (22%) were hospitalized directly from the observation unit because they were considered to be too ill to go home, and five (6%) returned with persistent symptoms after ED therapy and were hospitalized. No clinical or laboratory variable predicted success or failure of ED observation unit therapy at the time of initial presentation. CONCLUSION: In selected patients, the observation unit may be used to initiate therapy for acute pyelonephritis. Those with an adequate clinical response to initial treatment may be discharged on oral antibiotic therapy with appropriate follow-up.