Steroids for migraine headaches: a randomized double-blind, two-armed, placebo-controlled trial.

BACKGROUND: Recurrence of migraine headache after treatment in the emergency department (ED) is common. Conflicting evidence exists regarding the utility of steroids in preventing migraine headache recurrence at 24-48 h. OBJECTIVE: To determine if steroids decrease the headache recurrence in patients treated for migraine headaches in the ED. METHODS: Double-blind placebo-controlled, two-tailed randomized trial. Patients aged >17 years with a moderately severe migraine headache diagnosed by treating Emergency Physician were approached for participation. Enrollees received either dexamethasone (10 mg i.v.) if intravenous access was utilized or prednisone (40 mg by mouth × 2 days) if no intravenous access was obtained. Each medication was matched with an identical-appearing placebo. Patients were contacted 24-72 h after the ED visit to assess headache recurrence. RESULTS: A total of 181 patients were enrolled. Eight were lost to follow-up, 6 in the dexamethasone group and 2 in the prednisone arm. Participants had a mean age of 37 years (±10 years), with 86% female. Eighty-six percent met the International Headache Society Criteria for migraine headache. Of the 173 patients with completed follow-up, 20/91 (22%) (95% confidence interval [CI] 13.5-30.5) in the steroid arm and 26/82 (32%) (95% CI 21.9-42.1) in the placebo arm had recurrent headaches (p = 0.21). CONCLUSION: We did not find a statistically significant decrease in headache recurrence in patients treated with steroids for migraine headaches.

Can nurses appropriately interpret the Ottawa Ankle Rule?

The objective of this study was to determine if ED triage nurses could appropriately interpret the Ottawa Ankle Rules (OAR). We conducted a prospective, observational trial of a clinical decision rule in a suburban ED on a convenience sample of ED patients, aged >17 years with acute ankle injuries. Nurses and EPs were trained in the appropriate use of the OAR. Nurses and physicians recorded their initial blinded patient assessments on standardized data collection instruments that included the OAR. X-rays were ordered without specific discretion to OAR by nurses or physicians. Sensitivity, specificity, negative predictive value, and positive predictive value were calculated as appropriate; kappa (k) values were calculated to assess interobserver agreement (IOA). One hundred three patients enrolled: mean age 37 +/- 16 years; 67% female; 27 had fractures. IOA between nurses and physicians was moderate for overall interpretation of OAR (kappa = 0.44). IOA (kappa) for each criterion varied from (1) moderate for fifth metatarsal pain (0.56), posterior malleolar pain (0.44), medial malleolar pain (0.40), and weight bearing with foot pain (0.48); to (2) fair for weight bearing with ankle pain (0.32) and navicular pain (0.21). Sensitivity of the nurse's interpretation of OAR for fracture was 92%, specificity 36%, negative predictive value 90%, and positive predictive value 32%. Sensitivity of the EP's utilization of the OAR for fracture was 92%, specificity 47% with a negative predictive value 94%, and a positive predictive value 38%. Nurses showed only a moderate ability to interpret the overall OAR for ordering of x-rays. Nurses' understanding of the individual criterion were variable.

Can emergency department triage nurses appropriately utilize the Ottawa Knee Rules to order radiographs?-An implementation trial.

OBJECTIVE: To determine whether triage nurses can successfully interpret the Ottawa Knee Rule (OKR) and order knee radiographs according to the OKR. METHODS: This was a prospective implementation trial of a clinical decision rule, set in a suburban, community emergency department (ED), evaluating a convenience sample of ED patients aged > 17 years with acute knee injuries. Patients were excluded for altered mental status, distracting injuries, and knee lacerations. Triage nurses and attending emergency physicians (EPs) were trained in appropriate use of the OKR. The triage nurses evaluated eligible patients and radiographs were ordered according to their interpretation of the OKR. EPs who were initially blinded to the triage assessments also evaluated the patients. EPs could add an x-ray order if, according to their assessment of the OKR, one was indicated and a radiograph had not been ordered by the nurse. Nurses and EPs recorded their blinded assessments on standardized data collection instruments. Kappa values were calculated to assess interobserver agreement (IOA) between nurses and EPs; sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) were calculated as appropriate. RESULTS: One hundred three patients were enrolled; 53% were female; 10 fractures were identified (9.7%). The IOAs between the nurses and EPs for each of the criteria were moderate to almost perfect: age-0.94; fibular head tenderness-0.4; isolated patellar tenderness-0.68; inability to bend knee to 90 degrees-0.73; inability to bear weight-0.76. The IOA was moderate (0.52) for the overall interpretation of the OKR by nurses and EPs. Sensitivity of nurse interpretation of the OKR for fracture was 70%, specificity 33%, NPV 91%, PPV 10%. Sensitivity of EP interpretation of the OKR for fracture was 100%, specificity 25%, NPV 100%, PPV 13%. CONCLUSIONS: Triage nurses showed fair to good ability to appropriately apply the OKR to pre-order knee radiographs.