A Simple Protocol Avoids Unnecessary Invasive Procedures, Emergency Care

Main Category: Public Health
Article Date: 19 May 2006 - 4:00 PDT

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When a patient comes to the emergency room with a severe headache, this may be a sign of a Subarachnoid Hemorrhage (SAH), an extremely serious condition caused by a bleeding brain aneurysm. On the other hand, there may be less threatening explanations for the pain. Until now, there has been no way to rule out the more serious condition and a series of tests involving some risk to the patient would have had to be done.

In a paper presented at the 2006 Society for Academic Emergency Medicine Annual Meeting, May 18-21, 2006 in San Francisco, a group of Canadian researchers reported on their investigation of a protocol which could minimize invasive testing. In a study conducted at 6 university Emergency Departments involving nearly 2000 patients, 80% underwent head computed tomography (CT), 45% received lumbar puncture (LP, i.e. a spinal tap), 83% had either CT and/or LP, and 6.4% had a final diagnosis of SAH.

By using 4 simple clinical observations, the authors were able to predict whether a patient was at high risk for SAH. For example, of those who arrived by ambulance, 57% were later diagnosed with SAH, while only 17% of those who arrived by ambulance did not have SAH. Vomiting was a symptom in 58% of the patients with SAH and only in 26% of those without SAH. A diastolic blood pressure >=100mmHg or age >=45 were also strong predictors of SAH.

By using these simple observations, the authors developed a clinical rule that any patient showing 1 or more of these symptoms would then be a candidate for further investigation, via CT and/or LP. This rule would identify all the patients with SAH, while reducing the investigation rate to 66%.

According to Jeffrey Perry, MD, "While we do not recommend an immediate change in management until after a validation study is complete, this study will have a tremendous impact on patient care. It will improve our ability to determine which patients require investigations for their headache and which ones just need pain control without costly and invasive testing."

The presentation is "A Clinical Decision Rule to Safely Rule-Out Subarachnoid Hemorrhage in Acute Headache Patients in the Emergency Department" by Jeffrey J Perry MD. Dr. Perry's co-authors are Ian G Stiell MD, George A Wells PhD, Melodie Mortensen RN, Marco Sivilotti MD, Michael Bullard MD, Cheryl Symington RN, Howard Lesiuk MD, Jacques S Lee MD, Mary A Eisenhauer MD, Lorne Wiesenfeld MD, and Joseph Caytak MD. Dr. Perry is an emergency medicine physician at The Ottawa Hospital, a scientist at the Ottawa Health Research Institute, and an assistant professor at the University of Ottawa.

This paper will be presented at the 2006 SAEM Annual Meeting, May 18-21, 2006, San Francisco, CA on Thursday, May 18, in the Plenary Session beginning at 8:00 AM in Salon 9 of the San Francisco Marriott. Abstracts of the papers presented are published in the May issue of the official journal of the SAEM, Academic Emergency Medicine.

About The Society for Academic Emergency Medicine
saem.org

The Society for Academic Emergency Medicine (SAEM) is a national non-profit organization of over 6,000 academic emergency physicians, emergency medicine residents and medical students. SAEM's mission is to improve patient care by advancing research and education in emergency medicine. SAEM's vision is to promote ready access to quality emergency care for all patients, to advance emergency medicine as an academic and clinical discipline, and to maintain the highest professional standards as clinicians, teachers, and researchers. The SAEM Annual Meeting attracts approximately 2,000 medical students, residents and academic emergency physicians. It provides the largest forum for the presentation of original research in the specialty of Emergency Medicine.

About Academic Emergency Medicine
aemj.org

The SAEM's official journal, Academic Emergency Medicine, is published by Elsevier. Established in 1994, Academic Emergency Medicine is a monthly peer-reviewed journal that publishes material relevant to the practice, education, and investigation of emergency medicine, and reaches a wide audience of emergency care practitioners and educators. Each issue contains a broad range of topics relevant to the improvement of emergency, urgent or critical care of the acutely ill or injured patient. Regular features include original research, preliminary reports, education & practice and annotated literature.

About Elsevier
elsevier.com

Elsevier is a world-leading publisher of scientific, technical and medical information products and services. Working in partnership with the global science and health communities, Elsevier's 7,000 employees in over 70 offices worldwide publish more than 2,000 journals and 1,900 new books per year, in addition to offering a suite of innovative electronic products, such as ScienceDirect (sciencedirect.com), MD Consult (mdconsult.com), Scopus (info.scopus.com), bibliographic databases, and online reference works.