Emergency Department Observation of Children with Minor Head Injury Reduces Use of Computed Tomography
But does not impair identification of clinically important traumatic brain injuries
In a secondary analysis of data from the Pediatric Emergency Care Applied Research Network, researchers evaluated whether observing children (age, less than 18 years) with minor head injury before deciding whether to obtain a head computed tomography (CT) scan affects use of CT and diagnosis of traumatic brain injury (TBI). Data on duration of observation were not collected.
Of 40,113 patients (median age, 5.6 years), 5433 (14%) were observed. Observed patients were significantly less likely to undergo CT than patients who were not observed (31% vs. 35%). After adjustment for clinical covariates, the likelihood of CT scanning remained lower for patients who were observed (adjusted odds ratio, 0.53). Rates of clinically important TBI (defined as intracranial injury resulting in death, neurosurgical intervention, intubation for more than 24 hours, or hospital admission for 2 or more nights) were similar between groups (0.75% and 0.87%, respectively).
The authors conclude that observing intermediate-risk patients would result in approximately 39 fewer CT scans per 1000 children who present to the emergency department with blunt head trauma; intermediate-risk children were defined as those with normal mental status and no evidence of skull fracture and at least one of the following: loss of consciousness, severe mechanism of injury, vomiting, not acting normally per parents (children less than 2 years), or severe headache (children above 2 years).
Comment: The lack of data on duration of observation makes practical application of these findings difficult. However, neurologically normal children with a history of loss of consciousness, transient vomiting, or headache can be observed before deciding about CT. Children with persistent symptoms or any sign of clinical deterioration should undergo immediate CT.
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Katherine Bakes, MD
Published in Journal Watch Emergency Medicine May 27, 2011
Citation(s): Nigrovic LE et al. The effect of observation on cranial computed tomography utilization for children after blunt head trauma. Pediatrics 2011 Jun; 127:1067.
2011年5月27日 星期五
2011年5月20日 星期五
視神經超音波可以評估腦壓
Optic Nerve Ultrasound Predicts Elevated Intracranial Pressure
In a small meta-analysis, ultrasound measurement of optic nerve sheath diameter had a sensitivity of 90% for predicting elevated ICP.
Bedside emergency department ocular ultrasound is increasingly used to detect retinal detachment, but does it also have other uses? Researchers performed a meta-analysis of six prospective studies (231 patients) in which researchers compared intracranial pressure (ICP) monitoring and ultrasound measurement of optic nerve sheath diameter (ONSD) in consecutive adult patients with suspected elevated ICP. ONSD was measured 3 mm behind the globe; ICP and ONSD measurements were performed within 1 hour of each other.
The pooled sensitivity for ONSD detection of elevated ICP was 90% and the pooled specificity was 85%. The pooled diagnostic odds ratio was 51, meaning that patients with elevated ICP were 51 times more likely to have a positive ONSD test than those without elevated ICP.
Comment: With a 90% sensitivity for ruling out elevated intracranial pressure, bedside ultrasound measurement of optic nerve sheath diameter shows promise as a new tool to guide decision making, including prioritizing patients for diagnostic studies and determining whether computed tomography is needed before an unstable polytrauma patient is taken to the operating room.
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Kristi L. Koenig, MD, FACEP
Published in Journal Watch Emergency Medicine May 20, 2011
Citation(s): Dubourg J et al. Ultrasonography of optic nerve sheath diameter for detection of raised intracranial pressure: A systematic review and meta-analysis. Intensive Care Med 2011 Apr 20; [e-pub ahead of print]. (http://dx.doi.org/10.1007/s00134-011-2224-2)
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【實際做法】
http://emj.bmj.com/content/26/9/630.full.pdf
In a small meta-analysis, ultrasound measurement of optic nerve sheath diameter had a sensitivity of 90% for predicting elevated ICP.
Bedside emergency department ocular ultrasound is increasingly used to detect retinal detachment, but does it also have other uses? Researchers performed a meta-analysis of six prospective studies (231 patients) in which researchers compared intracranial pressure (ICP) monitoring and ultrasound measurement of optic nerve sheath diameter (ONSD) in consecutive adult patients with suspected elevated ICP. ONSD was measured 3 mm behind the globe; ICP and ONSD measurements were performed within 1 hour of each other.
The pooled sensitivity for ONSD detection of elevated ICP was 90% and the pooled specificity was 85%. The pooled diagnostic odds ratio was 51, meaning that patients with elevated ICP were 51 times more likely to have a positive ONSD test than those without elevated ICP.
Comment: With a 90% sensitivity for ruling out elevated intracranial pressure, bedside ultrasound measurement of optic nerve sheath diameter shows promise as a new tool to guide decision making, including prioritizing patients for diagnostic studies and determining whether computed tomography is needed before an unstable polytrauma patient is taken to the operating room.
—
Kristi L. Koenig, MD, FACEP
Published in Journal Watch Emergency Medicine May 20, 2011
Citation(s): Dubourg J et al. Ultrasonography of optic nerve sheath diameter for detection of raised intracranial pressure: A systematic review and meta-analysis. Intensive Care Med 2011 Apr 20; [e-pub ahead of print]. (http://dx.doi.org/10.1007/s00134-011-2224-2)
---
【實際做法】
http://emj.bmj.com/content/26/9/630.full.pdf
2011年5月6日 星期五
外傷急救新觀念：術中血壓不必keep太高！
Hypotensive Resuscitation in Trauma Patients Lessens Transfusion Needs
Also reduces incidence of postoperative coagulopathy and associated death.
The authors report an interim analysis of the first prospective randomized trial of intraoperative hypotensive resuscitation in patients. At a single level I trauma center, 90 patients with at least one episode of in-hospital systolic blood pressure ≤90 mm Hg who were undergoing laparotomy or thoracotomy for blunt (6 patients) or penetrating (84) trauma were randomized at entry to the operating room to have their mean arterial pressure (MAP) maintained at a target minimum of 50 mm Hg (low MAP) or 65 mm Hg (high MAP). Methods of achieving target levels were at the discretion of the anesthesiologist. MAPs that rose above the target were not lowered.
The low-MAP group received a significantly smaller amount of blood products (packed red blood cells, fresh frozen plasma, platelets) than the high-MAP group (1594 mL vs. 2898 mL) and had significantly lower mortality within 24 hours of admission to the intensive care unit (2.3% vs. 17.4%) and significantly lower mortality due to coagulopathy-associated postoperative hemorrhage (0 of 6 vs. 7 of 10). Mortality at 30 days did not differ significantly between the two groups (23% and 28%, respectively).
Comment: This interim analysis suggests that maintaining a low MAP during intraoperative resuscitation in seriously ill trauma patients is safe, reduces use of blood products, and decreases the incidence of postoperative coagulopathy and the related consequence of death. If these promising findings hold in the final analysis, similar approaches should be undertaken in the field and the emergency department.
—
John A. Marx, MD, FAAEM
Published in Journal Watch Emergency Medicine May 6, 2011
Citation(s): Morrison CA et al. Hypotensive resuscitation strategy reduces transfusion requirements and severe postoperative coagulopathy in trauma patients with hemorrhagic shock: Preliminary results of a randomized controlled trial. J Trauma 2011 Mar; 70:652.
Also reduces incidence of postoperative coagulopathy and associated death.
The authors report an interim analysis of the first prospective randomized trial of intraoperative hypotensive resuscitation in patients. At a single level I trauma center, 90 patients with at least one episode of in-hospital systolic blood pressure ≤90 mm Hg who were undergoing laparotomy or thoracotomy for blunt (6 patients) or penetrating (84) trauma were randomized at entry to the operating room to have their mean arterial pressure (MAP) maintained at a target minimum of 50 mm Hg (low MAP) or 65 mm Hg (high MAP). Methods of achieving target levels were at the discretion of the anesthesiologist. MAPs that rose above the target were not lowered.
The low-MAP group received a significantly smaller amount of blood products (packed red blood cells, fresh frozen plasma, platelets) than the high-MAP group (1594 mL vs. 2898 mL) and had significantly lower mortality within 24 hours of admission to the intensive care unit (2.3% vs. 17.4%) and significantly lower mortality due to coagulopathy-associated postoperative hemorrhage (0 of 6 vs. 7 of 10). Mortality at 30 days did not differ significantly between the two groups (23% and 28%, respectively).
Comment: This interim analysis suggests that maintaining a low MAP during intraoperative resuscitation in seriously ill trauma patients is safe, reduces use of blood products, and decreases the incidence of postoperative coagulopathy and the related consequence of death. If these promising findings hold in the final analysis, similar approaches should be undertaken in the field and the emergency department.
—
John A. Marx, MD, FAAEM
Published in Journal Watch Emergency Medicine May 6, 2011
Citation(s): Morrison CA et al. Hypotensive resuscitation strategy reduces transfusion requirements and severe postoperative coagulopathy in trauma patients with hemorrhagic shock: Preliminary results of a randomized controlled trial. J Trauma 2011 Mar; 70:652.
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