Initial ED Visit Research Articles

Emergency department presentation of idiopathic intracranial hypertension

Idiopathic intracranial hypertension (IIH), or pseudotumor cerebri, is a syndrome characterized by an elevated intracranial pressure in the absence of a focal lesion, infective process, or hydrocephalus. New onset IIH may present to the emergency department in a variety of ways. To describe the etiologic associations and clinical features in this disorder, we performed a retrospective analysis of consecutive emergency department patients with new onset IIH during the calendar years 1987–1996. A total of 52 patients met all study criteria. The mean patient age was 27 ± 8.9 years; the female-to-male ratio was 7:1. An etiologic association could be identified in 85% of cases and included obesity, hypertension, drugs, endocrine, and systemic disorders. Headache was a dominant complaint in most patients ( 48 52 ) and associated with dizziness, nausea, and/or visual complaints. Fourteen patients (27%) were not diagnosed on their initial ED visit and were more likely to have atypical clinical features (71% vs. 24%; P = .004). Atypical features included paraesthesias, neck/back pain, unilateral headache, vertigo, and nystagmus. Papilledema, the ophthalmoscopic hallmark of IIH, was not detected initially in 11 patients (21%). These results suggest that IIH is a relatively uncommon neurological illness that may have a variety of causes. The emergency department diagnosis may be complicated by atypical clinical features and a lack of detectable papilledema.

Comparison of Intramuscular Triamcinolone an d Oral Pre dnisone in the Outpatient Treatment of Acute Asthma: A Ran domize d Controlle d Trial

Study objective: To determine whether a one-time dose of triamcinolone diacetate, 40 mg intramuscular (IM), given to adult patients treated in the emergency department for mild to moderate exacerbation of asthma would decrease the rate of relapse during the following week, compared with a nontapering course of oral prednisone, 40 mg/day over 5 days. Methods: A randomized, double-blind, controlled clinical trial was conducted at two university-affiliated community teaching hospitals with a combined annual census of 97,000. Patients were eligible if they were between the ages of 18 and 50 years, had an initial peak expiratory flow rate of less than 350 L/minute, and were to be discharged from the ED taking steroids. Patients were randomly assigned to receive either triamcinolone (40 mg IM) and placebo tablets or a placebo injection and prednisone (40 mg/day orally for 5 days). Patients were instructed to use a β-agonist metered-dose inhaler, to continue other routine medications, to complete symptom diary cards, and to return in 7 to 10 days for follow-up. The main outcome measure was relapse, which was defined as an unscheduled visit to a physician's office or ED for worsening or persistent symptoms within 7 days of the initial ED visit. Results: A total of 168 patients were initially enrolled; 6 patients were withdrawn for protocol violations and 8 because they could not be contacted for follow-up. A total of 154 patients were available for outcome analysis, 78 in the triamcinolone group and 76 in the prednisone group. There were no differences between the two patient groups with regard to demographics, smoking history, weight, or symptom severity. Mean initial peak flows were 244± 64 L/minute for the triamcinolone group and 245±83 L/minute for the prednisone group. Fifty percent of the study patients were current smokers. The relapse rates were 9.0% (7/78) in the triamcinolone group and 14.5% (11/76) in the prednisone group ( P=.29). The absolute difference in relapse rates was 5.5% (95%CI, -4.6% to 15.6%). There was no difference in symptom frequency or severity between the two groups during the first 5 days of outpatient treatment. Analysis between the groups stratified for smoking showed no difference in relapse rate between smokers and nonsmokers. Conclusion: A single dose of triamcinolone diacetate, 40 mg IM, produced a relapse rate similar to that of prednisone, 40 mg/day orally for 5 days, after ED treatment of mild to moderate exacerbations of asthma. Intramuscular triamcinolone would appear to be an attractive alternative when compliance with a daily oral regimen is of concern. [Schuckman H, DeJulius DP, Blanda M, Gerson LW, DeJulius AJ, Rajaratnam M: Comparison of intramuscular triamcinolone and oral prednisone in the outpatient treatment of acute asthma: A randomized controlled trial. Ann Emerg Med March 1998;31:333-338.]

Pelvic Ultrasound Performed by Emergency Physicians for the Detection of Ectopic Pregnancy in Complicated First-Trimester Pregnancies

Study objective: To determine the accuracy and application of pelvic ultrasound performed by emergency physicians in detecting ectopic pregnancy (EP) in complicated first-trimester pregnancies. Methods: We studied consecutive pelvic ultrasounds performed in all women who presented with abdominal pain or vaginal bleeding during the first trimester of pregnancy over a 6-month period. Patients with clinical evidence of incomplete abortion were not included. We compared ultrasound results with subsequent ultrasound findings by the radiology department and correlated them with follow-up diagnoses and outcomes. Results: Of the 136 eligible patients, a final diagnosis was rendered in 125; 11 were lost to follow-up. These ED ultrasound findings were recorded: established intrauterine pregnancy (IUP) with embryonic structures, 87 (70%); indeterminate scan revealing no distinct evidence of IUP or EP, 15 (12%); early intrauterine gestational sac of less than 6 weeks without embryonic structures, 12 (10%); EP, 8 (6%); blighted ovum, 2 (2%); and molar pregnancy, 1 (1%). The initial ED ultrasound determination was consistent with radiology department findings, final outcome, or both in 121 (96%) (95% confidence interval [CI], 91% to 97%). ED ultrasound accurately identified 87 pregnancies with intrauterine embryonic structures, including 5 patients with fetal demise (95% CI, 97% to 100%). Diagnosis of pregnancy location in these 87 patients effectively ruled out EP, with a negative predictive value of 100%. The sensitivity and specificity of ED ultrasound in the detection of EP were 90% and 88%, respectively. Conclusion: Pelvic ultrasonography performed by emergency physicians can be used to rule out EP and make an accurate diagnosis in most patients with complicated first-trimester pregnancies during the initial ED visit. The remaining patients at risk can be identified and a diagnosis made by means of follow-up ultrasound and serial hCG determinations. [Durham B, Lane B, Burbridge L, Balasubramaniam S: Pelvic ultrasound performed by emergency physicians for the detection of ectopic pregnancy in complicated first-trimester pregnancies. Ann Emerg Med March 1997;29:338-347.]

Rectal Bleeding in the Pediatric Emergency Department

Study objectives: To describe the presumptive diagnoses in an unselected, ambulatory, pediatric population complaining of rectal bleeding; to determine how often those diagnoses changed with follow-up; and to determine how often the bleeding represented an acutely life-threatening condition. Design: Retrospective case series. Setting: Urban, tertiary care pediatric emergency department. Participants: One hundred four patients with 109 visits with a chief complaint of blood in the stool. Interventions: None. Main results: Follow-up was available on 95 of 109 visits (87.1%), with a mean duration of 7.5 months. A specific presumptive etiology was established for 73 of 109 patients (67%) at the initial ED visit and for 74 of 95 patients (77%) at follow-up. The etiologies varied markedly by age. Four patients (4.2%; 95% confidence interval, 0.2% to 8.2%) presented with a life-threatening condition (requiring an RBC transfusion or operative intervention): intussusception (three patients) and Meckel's diverticulum (one patient). Concordance between the ED diagnosis and the follow-up diagnosis was 81%. Conclusion: A complaint of rectal bleeding is typically not life threatening in children. Emergency physicians normally are able to establish a presumptive diagnosis, which usually remains the same with follow-up. [Teach SJ, Fleisher GR: Rectal bleeding in the pediatric emergency department. Ann Emerg Med June 1994;23:1252-1258.]

Use of the emergency department for hypertension screening: A prospective study

There is controversy as to whether the emergency department is an inappropriate site for screening for hypertensive patients. The pain and apprehension associated with many ED visits have been thought to elevate blood pressure readings falsely in this setting. To resolve this question, all patients admitted to the ED of a university hospital during a one-year period were screened prospectively for hypertension. Follow-up was attempted for patients who, on admission and discharge, had systolic pressures higher than 159 mm Hg or diastolic pressures higher than 94 mm Hg. A total of 239 patients met these criteria, and follow-up was obtained in 45% of the cases. Significant hypertension (systolic greater than 159 mm Hg or diastolic greater than 94 mm Hg) was found in 35% of these patients on follow-up. Borderline hypertension (systolic, 140 to 159 mm Hg; or diastolic, 90 to 94 mm Hg) was documented in 33% of the patients. Thirty-two percent were found to be normotensive when evaluated in a follow-up visit. The number of patients experiencing pain at the time of their initial ED visit was similar among the three groups. Almost half the patients with hypertension on follow-up needed further workup or therapy. The ED can be a useful screening site for hypertension; elevated blood pressure on discharge should ensure referral for follow-up evaluation and therapy.