Comparación de la regla canadiense y los criterios de New Orleans en el traumatismo craneal leve en un hospital español / Comparison of the Canadian CT head rule and the New Orleans criteria in patients with minor head injury in a Spanish hospital

Fundamento y objetivo: Comparar 2 escalas para la valoración de pacientes con traumatismo craneoencefálico (TCE) leve, la regla canadiense (EC) y los criterios de New Orleans (NO), de acuerdo a su precisión diagnóstica, en pacientes que acuden a un servicio de urgencias hospitalario, así como determinar los valores predictivos más importantes. Método: Estudio transversal realizado en un hospital de primer nivel en el periodo de enero del 2011 a enero del 2013. Se incluyeron los pacientes con criterios de TCE leve. A todos los pacientes se les realizó una tomografía computarizada (TC) de cráneo como parte del protocolo interno y se completó con la EC y los criterios de NO. Consideramos como variable principal la presencia de lesiones traumáticas en el TC, y como variables secundarias la intervención neuroquirúrgica y el síndrome posconmocional. Se compararon la sensibilidad, especificidad, los valores predictivos y el índice de validez (IV) de la EC y de los criterios de NO en el subgrupo de pacientes con una puntuación en la escala de coma de Glasgow (GCS) de 15 puntos. Resultados: Se evaluaron un total de 217 pacientes, de los que 197 presentaban una puntuación en la GCS de 15 puntos. Ambas escalas mostraban un 100% de sensibilidad cuando se presentaba una lesión importante en el TC, la EC 100% (IC 95%: 97,4-100%) y los criterios de NO 100% (IC 95%: 97,4-100%), pero la EC consiguió mayores valores de especificidad 25,3% (IC 95%: 18,6-32%), valor predictivo positivo (VPP) e IV. Las 2 escalas mostraron un 100% de sensibilidad en relación con la intervención neuroquirúrgica, y la EC con criterios de alto riesgo consiguió, claramente, una mayor especificidad, VPP e IV de 55,2 (IC 95%: 8,3-62,2%) vs. 7,6 (IC 95%: 3,8-11,5%) de NO. Con respecto al síndrome posconmocional, los criterios de NO mostraron mayor sensibilidad 100% (IC 95%: 96,2-100%) y valores predictivos, aunque menor especificidad e IV comparado con la EC 76,9% (IC 95%: 50,2-100%). Conclusiones: Nuestro estudio demuestra la alta sensibilidad de la EC y de los criterios de NO en pacientes con TCE leve tanto para detectar una lesión clínica importante en el TC como la necesidad de una intervención neuroquirúrgica, así como una mejor especificidad de la EC comparada con los criterios de NO. Se recomienda la adopción de reglas de predicción clínica, en especial de la EC, para la solicitud de un TC de cráneo en pacientes con TCE leve (AU)

Background and objective: To compare two scales for assessment of patients with mild head injury. The Canadian CT Head Rule (CCHR) and New Orleans Criteria (NOC) according to their diagnostic accuracy in patients attending an emergency department, and to determine the most important predictive values. Method: Cross-sectional study in a first-level Hospital in the period of January 2011 to January 2013. Patients with mild head injury criteria were included. All the patients underwent a computed tomography (CT) of the head as part of internal protocol and the CCHR and NOC criteria were recorded for each patient. We consider the main variable the presence of traumatic lesions on CT and, as secondary variables, neurosurgical intervention and post-concussion syndrome. Sensitivity, specificity, predictive values and validity index (VI) of the CCHR and the NO criteria in the subgroup of patients with a Glasgow Coma Scale (GCS) score of 15 points were compared. Results: A total of 217 patients, of whom 197 had a GCS score of 15 points were evaluated. Both rules showed 100% sensitivity when a significant injury was presented in the CT, the CCHR 100% (95% CI: 97.4%-100%) and the NO criteria 100% (95% CI: 97.4%-100%); but the CCHR achieved higher values of specificity 25.3% (95% CI: 18.6%-32%), positive predictive value (PPV) and VI. The two rules showed a 100% sensitivity regarding neurosurgical intervention; however the CCHR with high-risk criteria showed better specificity, PPV and VI 55.2 (95% CI: 8.3%-62.2%) compared to the NO criteria 7.6 (95% CI: 3.8%-11.5%). With regard to post-concussion syndrome criteria NO criteria showed better sensitivity 100% (95% CI: 96.2%-100%) and predictive values, but lower specificity and VI compared with the CCHR 76.9% (95% CI: 50.2%-100%). Conclusions: Our study demonstrates the high sensitivity of the CCHR and the NO criteria in patients with mild head injury, both to detect a significant clinical lesion on CT or the need for neurosurgical intervention and better specificity of CCHR compared with NO criteria. The adoption of clinical prediction rules, especially the CCHR, to request a CT scan in patients with mild head injury should be recommended in the emergency department (AU)

Comparison of the Canadian CT head rule and the New Orleans criteria in patients with minor head injury in a Spanish hospital. / Comparación de la regla canadiense y los criterios de New Orleans en el traumatismo craneal leve en un hospital español.

BACKGROUND AND OBJECTIVE: To compare two scales for assessment of patients with mild head injury. The Canadian CT Head Rule (CCHR) and New Orleans Criteria (NOC) according to their diagnostic accuracy in patients attending an emergency department, and to determine the most important predictive values. METHOD: Cross-sectional study in a first-level Hospital in the period of January 2011 to January 2013. Patients with mild head injury criteria were included. All the patients underwent a computed tomography (CT) of the head as part of internal protocol and the CCHR and NOC criteria were recorded for each patient. We consider the main variable the presence of traumatic lesions on CT and, as secondary variables, neurosurgical intervention and post-concussion syndrome. Sensitivity, specificity, predictive values and validity index (VI) of the CCHR and the NO criteria in the subgroup of patients with a Glasgow Coma Scale (GCS) score of 15 points were compared. RESULTS: A total of 217 patients, of whom 197 had a GCS score of 15 points were evaluated. Both rules showed 100% sensitivity when a significant injury was presented in the CT, the CCHR 100% (95% CI: 97.4%-100%) and the NO criteria 100% (95% CI: 97.4%-100%); but the CCHR achieved higher values of specificity 25.3% (95% CI: 18.6%-32%), positive predictive value (PPV) and VI. The two rules showed a 100% sensitivity regarding neurosurgical intervention; however the CCHR with high-risk criteria showed better specificity, PPV and VI 55.2 (95% CI: 8.3%-62.2%) compared to the NO criteria 7.6 (95% CI: 3.8%-11.5%). With regard to post-concussion syndrome criteria NO criteria showed better sensitivity 100% (95% CI: 96.2%-100%) and predictive values, but lower specificity and VI compared with the CCHR 76.9% (95% CI: 50.2%-100%). CONCLUSIONS: Our study demonstrates the high sensitivity of the CCHR and the NO criteria in patients with mild head injury, both to detect a significant clinical lesion on CT or the need for neurosurgical intervention and better specificity of CCHR compared with NO criteria. The adoption of clinical prediction rules, especially the CCHR, to request a CT scan in patients with mild head injury should be recommended in the emergency department.

Ictus talámico secundario a disección vertebral tras la práctica de yoga / Thalamic stroke secondary to vertebral dissection after doing yoga

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Intervención en el servicio de urgencias para lograr un inicio y seguimiento adecuados de la anticoagulació en pacientes con fibrilación auricular / Emergency department training on the appropriate prescription of anticoagulants in atrial fibrillation and on patient follow-up after discharge

Objetivos: Evaluar el resultado de una intervención formativa realizada en el servicio de urgencias (SU), en cuanto a la correcta prescripción y uso de un protocolo de anticoagulación en pacientes con fibrilación auricular (FA) y su posterior seguimiento. Método: Estudio cuasi-experimental con un grupo de control no equivalente, pre/post intervención formativa. Se seleccionaron dos grupos de pacientes (pre y postintervención) mediante muestreo consecutivo, mayores de 18 años, que se presentaron en el SU con FA identificada en el ECG y con criterios de anticoagulación según la estratificación de riesgo de la escala CHA2DS2-VASc 􀀀 2. El resultado primario fue la proporción de pacientes anticoagulados al alta del SU. El resultado secundario fue la proporción de pacientes anticoagulados al mes del alta del SU. Resultados: Se incluyeron 184 pacientes (86 preintervención, 98 postintervención). La intervención aumentó de manera significativa el comienzo de la anticoagulación [preintervención 32 (37%) vs postintervención 95 (97%);p < 0,001] y el seguimiento al mes de comenzar el tratamiento [preintervención 26 (30%) vs postintervención 91(93%); p < 0,001]. Conclusiones: Una intervención formativa en el SU es efectiva para implementar los protocolos adaptados a las guías de práctica clínica de la anticoagulación (AU)

Objectives: The main objective was to evaluate the effect of an emergency department training intervention on the use of a protocol for prescribing anticoagulant therapy in atrial fibrillation and on following patients after discharge. Methods: Quasi-experimental pre-post study of a training intervention; the control patients were not matched but were selected consecutively before and after the intervention. All patients were over the age of 18 years, had atrialfibrillation identified by electrocardiogram, and indications for anticoagulant therapy, specifically a score of 2 or more on the CHADS2-DS2-VASc scale (cardiac failure, hypertension, age >75 years, diabetes, stroke [doubled], vascular disease, age 65-74 years, sex). The primary outcome was percentage of patients on anticoagulant therapy on discharge from the department. The secondary outcome was the percentage of patients on therapy 1 month after discharge. Results: A total of 184 patients (86 before the intervention and 98 afterwards) were included. Training significantly increased the prescription of anticoagulants in the department (before the intervention, 32 patients [37%] vs 95[97%] afterwards; P<.001). In the preintervention period, 26 patients (30% were on anticoagulants 1 month later; in the postintervention period, 26 (30%) were still on therapy (P<.001). Conclusions: This study shows that emergency staff training is effective for implementing protocols based on anticoagulant therapy guidelines (AU)

[Emergency department training on the appropriate prescription of anticoagulants in atrial fibrillation and on patient follow-up after discharge]. / Intervención en el servicio de urgencias para lograr un inicio y seguimiento adecuados de la anticoagulación en pacientes con fibrilación auricular.

OBJECTIVES: The main objective was to evaluate the effect of an emergency department training intervention on the use of a protocol for prescribing anticoagulant therapy in atrial fibrillation and on following patients after discharge. MATERIAL AND METHODS: Quasi-experimental pre-post study of a training intervention; the control patients were not matched but were selected consecutively before and after the intervention. All patients were over the age of 18 years, had atrial fibrillation identified by electrocardiogram, and indications for anticoagulant therapy, specifically a score of 2 or more on the CHADS2-DS2-VASc scale (cardiac failure, hypertension, age >75 years, diabetes, stroke [doubled], vascular disease, age 65-74 years, sex). The primary outcome was percentage of patients on anticoagulant therapy on discharge from the department. The secondary outcome was the percentage of patients on therapy 1 month after discharge. RESULTS: A total of 184 patients (86 before the intervention and 98 afterwards) were included. Training significantly increased the prescription of anticoagulants in the department (before the intervention, 32 patients [37%] vs 95 [97%] afterwards; P<.001). In the preintervention period, 26 patients (30% were on anticoagulants 1 month later; in the postintervention period, 26 (30%) were still on therapy (P<.001). CONCLUSION: This study shows that emergency staff training is effective for implementing protocols based on anticoagulant therapy guidelines.

OBJETIVO: Evaluar el resultado de una intervención formativa realizada en el servicio de urgencias (SU), en cuanto a la correcta prescripción y uso de un protocolo de anticoagulación en pacientes con fibrilación auricular (FA) y su posterior seguimiento. METODO: Estudio cuasi-experimental con un grupo de control no equivalente, pre/post intervención formativa. Se seleccionaron dos grupos de pacientes (pre y postintervención) mediante muestreo consecutivo, mayores de 18 años, que se presentaron en el SU con FA identificada en el ECG y con criterios de anticoagulación según la estratificación de riesgo de la escala CHA2DS2-VASc 2. El resultado primario fue la proporción de pacientes anticoagulados al alta del SU. El resultado secundario fue la proporción de pacientes anticoagulados al mes del alta del SU. RESULTADOS: Se incluyeron 184 pacientes (86 preintervención, 98 postintervención). La intervención aumentó de manera significativa el comienzo de la anticoagulación [preintervención 32 (37%) vs postintervención 95 (97%); p < 0,001] y el seguimiento al mes de comenzar el tratamiento [preintervención 26 (30%) vs postintervención 91 (93%); p < 0,001]. CONCLUSIONES: Una intervención formativa en el SU es efectiva para implementar los protocolos adaptados a las guías de práctica clínica de la anticoagulación.