Major Radiologic and Clinical Outcomes of Total Spine MRI Performed in the Emergency Department at a Major Academic Medical Center.

BACKGROUND AND PURPOSE: Total spine MRIs are requested by the emergency department when focused imaging can not be ordered on the basis of history or clinical findings. However, their efficacy is not known. We assessed the following: 1) major radiologic and clinical outcomes of total spine MR imaging performed by the emergency department, and 2) whether the presence of a high-risk clinical profile and/or neurologic findings impacts the clinical outcomes. MATERIALS AND METHODS: Total spine MRIs requested by the emergency department during a 28-month period were evaluated for major radiologic (cord compression, cauda equina compression, and other significant findings) and major clinical outcomes (hospital admission during the visit followed by an operation, radiation therapy, or intravenous antibiotics or steroids). Associations between a high-risk clinical profile (cancer, infection, coagulopathy) and/or the presence of neurologic findings and outcomes were assessed. RESULTS: After we excluded trauma or nondiagnostic studies, 321/2047 (15.7%) MRIs ordered during study period were total spine MR imaging; 117/321 (36.4%) had major radiologic and 60/321 (18.6%) had major clinical outcomes (34/60 in <24 hours); and 58/117(49.6%) with major radiologic outcome were treated compared with 2/205 (1.0%) without (OR = 99, P < .001). The presence of both a high-risk clinical profile and neurologic findings concurrently in a patient (142/321) increased the likelihood of major clinical outcomes during the same visit (OR = 3.1, P < .001) and in <24-hours (OR = 2.6, P = .01) compared with those with either a high-risk clinical profile or neurologic findings alone (179/321). CONCLUSIONS: Total spine MR imaging ordered by our emergency department has a high radiologic and significant clinical yield. When a high-risk clinical profile and neurologic findings are both present in a patient, they should be prioritized for emergent total spine MR imaging, given the increased likelihood of clinical impact.

Emergency department consultations for patients with neurological emergencies.

BACKGROUND: The spectrum of neurological emergencies that front-line physicians encounter is diverse. Appropriate assessment and neurological consultation is essential to good patient outcomes because many of these conditions depend on the rapid initiation of proper therapy. METHODS: In this retrospective study, we reviewed patients for whom the emergency physician elected to consult a neurologist to categorize the types of complaints, resources utilized, patient disposition and final diagnoses. RESULTS: Of the 500 patients analyzed in our study, the most common chief complaints were focal weakness (22%), headache (18.2%), dizziness or vertigo (16%), and seizure (14.2%). The most common reasons for neurological consultation were specific symptom (70.6%), concern for a specific diagnosis (17.4%), specific radiologic finding (9.2%), and ambiguity in the diagnosis (2.8%). Overall stroke accounted for 18.6% of the cases in our study. Non-contrast brain computed tomography was the most common imaging study (72.2%), and 37.0% of patients received advanced neuroimaging. The presentation of patients varied as 47% presented without having been seen by another healthcare professional, 24% were referred to the emergency department (ED) following by some other outpatient provider for evaluation, and 29% were transferred from another ED. CONCLUSIONS: Patients with neurological emergencies are common and consume a disproportionate amount of resources in the ED. Emergency physician training must target the modern evaluation of patients with a large variety of neurological emergencies and place special emphasis on the evaluation of patients with weakness, seizures, headache, and dizziness.

Migraine: diagnosis and pharmacologic treatment in emergency department.

Acute headache is a common chief complaint in the Emergency Department (ED), accounting for up to 4% of all ED visits. Migraine is a common, chronic, at times incapacitating disorder, characterized by attacks of severe headache, autonomic nervous system dysfunction, and in some patients, an aura characterized by various neurologic symptoms. It is the most common cause of severe, recurring headaches. Although most headaches in the ED are benign, one should be vigilant in searching for "red flags", which may represent dangerous conditions. In addition to properly identifying important secondary causes of headache, the goal of acute therapy is to provide rapid, complete, and sustained relief of pain and associated symptoms without generating significant adverse effects. In many patients, migraine responds well to simple treatment at the time of an attack. In patients with substantial disability, it is appropriate to prescribe a triptan early in the course of treatment, in keeping with a stratified approach to care.

Headache in United States emergency departments: demographics, work-up and frequency of pathological diagnoses.

Headache is a common complaint in the emergency department (ED). In order to examine headache work-ups and diagnoses across the USA, we queried a representative sample of adult ED visits (the National Hospital Ambulatory Medical Care Survey) for the years 1992-2001. Headache accounted for 2.1 million ED visits per year (2.2% of visits). Of the 14% of patients who underwent neuroimaging, 5.5% received a pathological diagnosis. Of the 2% of patients who underwent lumbar puncture, 11% received a pathological diagnosis. On multivariable analysis, a decreased rate of imaging was noted for patients without private insurance [odds ratio (OR) 0.61, confidence interval (CI) 0.44, 0.86] and for those presenting off-hours (OR 0.55, CI 0.39, 0.77). Patients over 50 were more likely to receive a pathological diagnosis (OR 3.3, CI 1.2, 9.3). In conclusion, clinicians should ensure that appropriate work-ups are performed regardless of presentation time or insurance status, and be vigilant in the evaluation of older patients.

Emergency department management of pulmonary embolism.

There are several points that bear repetition. First, consider the diagnosis of PE in all patients presenting with chest pain, dyspnea, syncope, oxygen desaturation, or unexplained hypotension. Evaluate these patients in a rational manner. At any individual hospital, develop algorithms with consultants so that when one is faced with a patient with a PE, the flow of both diagnostics and therapeutics flows smoothly and rapidly. Consider the concept of risk stratification, and remember that not all patients with PE are created equal. In particular, be on the same page with all consultants regarding the use of right heart echocardiography, both for its potential diagnostic capabilities and for its ability to identify patients who could be at greater risk for bad outcomes.

Rectus sheath hematoma.

We describe 3 patients with rectus sheath hematoma presenting to the emergency department. Prompt consideration of this uncommon cause of abdominal pain may prevent more expensive and invasive diagnostic tests and, in some cases, unnecessary hospitalization and laparotomy.

Lyme disease and related tick-borne illnesses.

Our knowledge of Lyme disease, currently the most common vector-borne illness in North America, has expanded over the past decade. The causative spirochete, Borrelia burgdorferi, is transmitted by the bite of an infected Ixodes tick. Infection usually results in erythema migrans and can spread hematogenously to skin, heart, nervous system, joints, and other organs. Prompt recognition and treatment with antibiotics usually leads to rapid improvement and markedly reduces subsequent manifestation. Unrecognized and untreated Lyme disease can cause late arthritic and neurologic syndromes that are more difficult to treat and that may not respond to antibiotics. Other tick-borne illnesses can be fatal if not treated.