Subarachnoid haemorrhage rules in the decision for acute CT of the head: external validation in a UK cohort.

BACKGROUND: The Ottawa subarachnoid haemorrhage (SAH) rule and the Emerald SAH rule are clinical decision tools to aid in the decision for computed tomography (CT) of the head in patients attending an emergency department (ED) with acute non-traumatic headache. The objective of this study was to analyse the performance of these rules in a contemporary UK cohort. METHODS: We performed a retrospective external validation study. Patients undergoing CT of the head for the evaluation and treatment of non-traumatic headaches over a 6-month period in the ED at two tertiary centres were assessed. Each patient's Ottawa rule and Emerald rule were calculated and compared with their final diagnosis. RESULTS: The cohort consisted of 366 patients and there were 16 cases of SAH (based on CT findings or the presence of xanthochromia in cerebrospinal fluid). The Ottawa rule identified 288 patients requiring CT of the head. The sensitivity of the Ottawa rule was 100% (95% confidence interval (CI) 71-100%) and the specificity was 22% (95% CI 18-27%). The Emerald rule identified 267 patients who required CT, and achieved a sensitivity of 81% (95% CI 54-96%) and a specificity of 27% (95% CI 23-32%). CONCLUSIONS: The Ottawa SAH rule correctly identified all patients with SAH in this contemporary cohort. The Emerald rule did not perform as well in this cohort and is unsuitable for clinical use. The Ottawa rule is a useful tool to aid in the decision for CT of the head in patients presenting with acute non-traumatic headache to the ED.

Diagnostic peritoneal lavage and ultrasonography for blunt abdominal trauma: attitudes and training of current general surgical trainees.

OBJECTIVE: It has been suggested that diagnostic peritoneal lavage is now obsolete in UK hospitals with access to either skilled ultrasonography or emergency physician or surgeon-performed focused abdominal sonography in trauma. Diagnostic peritoneal lavage continues to be advocated and taught on Advanced Trauma Life Support courses. The aim of this study was to evaluate the experiences and attitudes of general-surgery trainees in one UK training region towards diagnostic peritoneal lavage and focused abdominal sonography in trauma in managing blunt abdominal trauma. METHODS: An anonymous postal piloted questionnaire was sent to all 66 general surgery specialist trainees in one UK training region between January and March 2005. RESULTS: Out of 40 replies to the questionnaire (response rate 61%), 53% and 38% of surgical trainees had either never performed or never observed a diagnostic peritoneal lavage during their training. Thirteen trainees (33%) felt diagnostic peritoneal lavage to be obsolete and would never contemplate using it; 15 trainees (37%) might consider using diagnostic peritoneal lavage if computed tomography or ultrasonography were unavailable. Ten trainees (25%) felt that diagnostic peritoneal lavage had been superseded by computed tomography. Only 12 trainees (30%) had worked in a UK hospital with access to facilities for focused abdominal sonography in trauma and only seven trainees (18%) had received any training or experience in focused abdominal sonography in trauma. CONCLUSIONS: Surgical trainees in one UK training region lack skills in both diagnostic peritoneal lavage and focused abdominal sonography in trauma for managing blunt abdominal trauma and are therefore reliant upon the availability of prompt, skilled radiological assistance or emergency physician-provided focused abdominal sonography in trauma.