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Moussa BS, Abd Elatiff ZM, Kamal Eldin Elhadary GM. Survey study of the etiology of non-traumatic altered consciousness in the Emergency Department at Suez Canal University Hospital in Egypt. World J Clin Cases 2023; 11:1310-1317. [PMID: 36926139 PMCID: PMC10013117 DOI: 10.12998/wjcc.v11.i6.1310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 01/06/2023] [Accepted: 02/03/2023] [Indexed: 02/23/2023] Open
Abstract
BACKGROUND Disorders of consciousness including coma in non-trauma patients can be caused by a wide variety of pathologies affecting the central nervous system. They represent a frequent challenge in emergency medicine and are combined with a very high in-hospital mortality. Hence, early treatment of these patients is vital and increases the likelihood of a good outcome.
AIM To identify the causes of altered consciousness presentation to the Emergency Department at Suez Canal University Hospital.
METHODS This was a descriptive cross-sectional study conducted on 87 patients with acute non-traumatic disturbed level of consciousness (DLOC) at the Emergency Department.
RESULTS The mean age of the studied patients was 60.5 ± 13.6 years. Among them, 60% were males and 40% were females. The most common cause of acute non-traumatic DLOC was systemic infection, such as sepsis and septic shock (25.3%), followed by respiratory causes (24.1%) and neurological causes (18.4%).
CONCLUSION The most common cause of acute non-traumatic DLOC was systemic infections followed by respiratory and neurological causes.
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Affiliation(s)
- Bassant S Moussa
- Emergency Medicine Department, Suez Canal University, Faculty of Medicine, Ismailia 41522, Egypt
| | - Zeinab M Abd Elatiff
- Emergency Medicine Department, Suez Canal University, Faculty of Medicine, Ismailia 41522, Egypt
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2
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Kim ISY, Balogun OO, Prescott BR, Saglam H, Olson DM, Speir K, Stutzman SE, Schneider N, Aguilera V, Lussier BL, Smirnakis SM, Dupuis J, Mian A, Greer DM, Ong CJ. Quantitative pupillometry and radiographic markers of intracranial midline shift: A pilot study. Front Neurol 2022; 13:1046548. [PMID: 36561299 PMCID: PMC9763295 DOI: 10.3389/fneur.2022.1046548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 10/20/2022] [Indexed: 12/12/2022] Open
Abstract
Background Asymmetric pupil reactivity or size can be early clinical indicators of midbrain compression due to supratentorial ischemic stroke or primary intraparenchymal hemorrhage (IPH). Radiographic midline shift is associated with worse functional outcomes and life-saving interventions. Better understanding of quantitative pupil characteristics would be a non-invasive, safe, and cost-effective way to improve identification of life-threatening mass effect and resource utilization of emergent radiographic imaging. We aimed to better characterize the association between midline shift at various anatomic levels and quantitative pupil characteristics. Methods We conducted a multicenter retrospective study of brain CT images within 75 min of a quantitative pupil observation from patients admitted to Neuro-ICUs between 2016 and 2020 with large (>1/3 of the middle cerebral artery territory) acute supratentorial ischemic stroke or primary IPH > 30 mm3. For each image, we measured midline shift at the septum pellucidum (MLS-SP), pineal gland shift (PGS), the ratio of the ipsilateral to contralateral midbrain width (IMW/CMW), and other exploratory markers of radiographic shift/compression. Pupil reactivity was measured using an automated infrared pupillometer (NeurOptics®, Inc.), specifically the proprietary algorithm for Neurological Pupil Index® (NPi). We used rank-normalization and linear mixed-effects models, stratified by diagnosis and hemorrhagic conversion, to test associations of radiographic markers of shift and asymmetric pupil reactivity (Diff NPi), adjusting for age, lesion volume, Glasgow Coma Scale, and osmotic medications. Results Of 53 patients with 74 CT images, 26 (49.1%) were female, and median age was 67 years. MLS-SP and PGS were greater in patients with IPH, compared to patients with ischemic stroke (6.2 v. 4.0 mm, 5.6 v. 3.4 mm, respectively). We found no significant associations between pupil reactivity and the radiographic markers of shift when adjusting for confounders. However, we found potentially relevant relationships between MLS-SP and Diff NPi in our IPH cohort (β = 0.11, SE 0.04, P = 0.01), and PGS and Diff NPi in the ischemic stroke cohort (β = 0.16, SE 0.09, P = 0.07). Conclusion We found the relationship between midline shift and asymmetric pupil reactivity may differ between IPH and ischemic stroke. Our study may serve as necessary preliminary data to guide further prospective investigation into how clinical manifestations of radiographic midline shift differ by diagnosis and proximity to the midbrain.
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Affiliation(s)
- Ivy So Yeon Kim
- Boston University School of Medicine, Boston, MA, United States,Boston Medical Center, Boston, MA, United States,Mass General Brigham, Boston, MA, United States
| | - Oluwafemi O. Balogun
- Boston University School of Medicine, Boston, MA, United States,Boston Medical Center, Boston, MA, United States,Mass General Brigham, Boston, MA, United States
| | - Brenton R. Prescott
- Boston University School of Medicine, Boston, MA, United States,Boston Medical Center, Boston, MA, United States,Mass General Brigham, Boston, MA, United States
| | - Hanife Saglam
- Mass General Brigham, Boston, MA, United States,Harvard Medical School, Boston, MA, United States
| | - DaiWai M. Olson
- University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Kinley Speir
- University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Sonja E. Stutzman
- University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Nathan Schneider
- University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Veronica Aguilera
- University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Bethany L. Lussier
- University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Stelios M. Smirnakis
- Mass General Brigham, Boston, MA, United States,Jamaica Plain Veterans Administration Medical Center, Boston, MA, United States
| | - Josée Dupuis
- Boston University School of Public Health, Boston, MA, United States,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
| | - Asim Mian
- Boston University School of Medicine, Boston, MA, United States,Boston Medical Center, Boston, MA, United States
| | - David M. Greer
- Boston University School of Medicine, Boston, MA, United States,Boston Medical Center, Boston, MA, United States
| | - Charlene J. Ong
- Boston University School of Medicine, Boston, MA, United States,Boston Medical Center, Boston, MA, United States,Mass General Brigham, Boston, MA, United States,Harvard Medical School, Boston, MA, United States,*Correspondence: Charlene J. Ong
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Lee JS, Cha YS, Yeon S, Kim TY, Lee Y, Choi JG, Cha KC, Lee KH, Kim H. Changes in Diagnosis of Poisoning in Patients in the Emergency Room Using Systematic Toxicological Analysis with the National Forensic Service. J Korean Med Sci 2021; 36:e118. [PMID: 33975395 PMCID: PMC8111044 DOI: 10.3346/jkms.2021.36.e118] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 03/18/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND It is difficult to diagnose patients with poisoning and determine the causative agent in the emergency room. Usually, the diagnosis of such patients is based on their medical history and physical examination findings. We aimed to confirm clinical diagnoses using systematic toxicological analysis (STA) and investigate changes in the diagnosis of poisoning. METHODS The Intoxication Analysis Service was launched in June 2017 at our hospital with the National Forensic Service to diagnose intoxication and identify toxic substances by conducting STA. Data were collected and compared between two time periods: before and after the initiation of the project, i.e., from June 2014 to May 2017 and from June 2017 to May 2020. RESULTS A total of 492 and 588 patients were enrolled before and after the service, respectively. Among the 588 after-service patients, 446 underwent STA. Among the 492 before-service patients, 69.9% were diagnosed clinically, whereas the causative agent could not be identified in 35 patients. After starting the service, a diagnosis was confirmed in 84.4% of patients by performing a hospital-available toxicological analysis or STA. Among patients diagnosed with poisoning by toxins identified based on history taking, only 83.6% matched the STA results, whereas 8.4% did not report any toxin, including known substances. The substance that the emergency physician suspected after a physical examination was accurate in 49.3% of cases, and 12% of cases were not actually poisoned. In 13.4% of patients who visited the emergency room owing to poisoning of unknown cause, poisoning could be excluded after STA. Poisoning was determined to be the cause of altered mental status in 31.5% of patients for whom the cause could not be determined in the emergency room. CONCLUSION A diagnosis may change depending on the STA results of intoxicated patients. Therefore, appropriate STA can increase the accuracy of diagnosis and help in making treatment decisions.
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Affiliation(s)
- Je Seop Lee
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Yong Sung Cha
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Seonghoon Yeon
- Drug and Forensic Toxicology Division, National Forensic Service, Wonju, Korea
| | - Tae Youn Kim
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Yoonsuk Lee
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jin Geul Choi
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Kyoung Chul Cha
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Kang Hyun Lee
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Hyun Kim
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea.
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4
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Lutz M, Möckel M, Lindner T, Ploner CJ, Braun M, Schmidt WU. The accuracy of initial diagnoses in coma: an observational study in 835 patients with non-traumatic disorder of consciousness. Scand J Trauma Resusc Emerg Med 2021; 29:15. [PMID: 33436034 PMCID: PMC7805149 DOI: 10.1186/s13049-020-00822-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 12/13/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Management of patients with coma of unknown etiology (CUE) is a major challenge in most emergency departments (EDs). CUE is associated with a high mortality and a wide variety of pathologies that require differential therapies. A suspected diagnosis issued by pre-hospital emergency care providers often drives the first approach to these patients. We aim to determine the accuracy and value of the initial diagnostic hypothesis in patients with CUE. METHODS Consecutive ED patients presenting with CUE were prospectively enrolled. We obtained the suspected diagnoses or working hypotheses from standardized reports given by prehospital emergency care providers, both paramedics and emergency physicians. Suspected and final diagnoses were classified into I) acute primary brain lesions, II) primary brain pathologies without acute lesions and III) pathologies that affected the brain secondarily. We compared suspected and final diagnosis with percent agreement and Cohen's Kappa including sub-group analyses for paramedics and physicians. Furthermore, we tested the value of suspected and final diagnoses as predictors for mortality with binary logistic regression models. RESULTS Overall, suspected and final diagnoses matched in 62% of 835 enrolled patients. Cohen's Kappa showed a value of κ = .415 (95% CI .361-.469, p < .005). There was no relevant difference in diagnostic accuracy between paramedics and physicians. Suspected diagnoses did not significantly interact with in-hospital mortality (e.g., suspected class I: OR .982, 95% CI .518-1.836) while final diagnoses interacted strongly (e.g., final class I: OR 5.425, 95% CI 3.409-8.633). CONCLUSION In cases of CUE, the suspected diagnosis is unreliable, regardless of different pre-hospital care providers' qualifications. It is not an appropriate decision-making tool as it neither sufficiently predicts the final diagnosis nor detects the especially critical comatose patient. To avoid the risk of mistriage and unnecessarily delayed therapy, we advocate for a standardized diagnostic work-up for all CUE patients that should be triggered by the emergency symptom alone and not by any suspected diagnosis.
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Affiliation(s)
- Maximilian Lutz
- Department of Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Martin Möckel
- Department of Emergency Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Tobias Lindner
- Department of Emergency Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Christoph J Ploner
- Department of Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Mischa Braun
- Department of Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany.,Center for Stroke Research, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Wolf Ulrich Schmidt
- Department of Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany. .,Center for Stroke Research, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany.
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5
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Luttrull MD, Boulter DJ, Kirsch CFE, Aulino JM, Broder JS, Chakraborty S, Choudhri AF, Ducruet AF, Kendi AT, Lee RK, Liebeskind DS, Mack W, Moritani T, Roca RP, Shah LM, Sharma A, Shih RY, Symko SC, Bykowski J. ACR Appropriateness Criteria ® Acute Mental Status Change, Delirium, and New Onset Psychosis. J Am Coll Radiol 2020; 16:S26-S37. [PMID: 31054753 DOI: 10.1016/j.jacr.2019.02.024] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 02/08/2019] [Indexed: 11/30/2022]
Abstract
Acute changes in mental status represent a broad collection of symptoms used to describe disorders in mentation and level of arousal, including the more narrowly defined diagnoses of delirium and psychosis. A wide range of precipitating factors may be responsible for symptom onset including infection, intoxication, and metabolic disorders. Neurologic causes that may be detected on neuroimaging include stroke, traumatic brain injury, nonconvulsive seizure, central nervous system infection, tumors, hydrocephalus, and inflammatory disorders. Not infrequently, two or more precipitating factors may be found. Neuroimaging with CT or MRI is usually appropriate if the clinical suspicion for an acute neurological cause is high, where the cause of symptoms is not found on initial assessment, and for patients whose symptoms do not respond appropriately to management. There was disagreement regarding the appropriateness of neuroimaging in cases where a suspected, nonneurologic cause is found on initial assessment. Neuroimaging with CT is usually appropriate for patients presenting with delirium, although the yield may be low in the absence of trauma or a focal neurological deficit. Neuroimaging with CT or MRI may be appropriate in the evaluation of new onset psychosis, although the yield may be low in the absence of a neurologic deficit. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | | | - Daniel J Boulter
- Research Author, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Claudia F E Kirsch
- Panel Chair, Northwell Health, Zucker Hofstra School of Medicine at Northwell, Manhasset, New York
| | | | - Joshua S Broder
- Duke University School of Medicine, Durham, North Carolina; American College of Emergency Physicians
| | - Santanu Chakraborty
- Ottawa Hospital Research Institute and the Department of Radiology, The University of Ottawa, Ottawa, Ontario, Canada
| | - Asim F Choudhri
- Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Andrew F Ducruet
- Barrow Neurological Institute, Phoenix, Arizona; neurosurgical consultant
| | | | - Ryan K Lee
- Einstein Healthcare Network, Philadelphia, Pennsylvania
| | - David S Liebeskind
- University of California Los Angeles, Los Angeles, California; American Academy of Neurology
| | - William Mack
- University of Southern California, Los Angeles, California; neurosurgical consultant
| | | | - Robert P Roca
- Sheppard Pratt Health System, Towson, Maryland; American Psychiatric Association
| | | | - Aseem Sharma
- Mallinckrodt Institute of Radiology, Saint Louis, Missouri
| | - Robert Y Shih
- Walter Reed National Military Medical Center, Bethesda, Maryland
| | | | - Julie Bykowski
- Specialty Chair, UC San Diego Health Center, San Diego, California
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6
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[Rapid increase of patients with dementia in emergency medical facilities]. Nihon Ronen Igakkai Zasshi 2019; 56:6-14. [PMID: 30760685 DOI: 10.3143/geriatrics.56.6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
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Braun M, Ploner CJ, Lindner T, Möckel M, Schmidt WU. [Coma in the emergency room]. DER NERVENARZT 2018; 88:607-615. [PMID: 28424823 DOI: 10.1007/s00115-017-0329-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Coma of unknown origin (CUO) is a frequent unspecific emergency symptom associated with a high mortality. A fast diagnostic work-up is essential given the wide spectrum of underlying diagnoses that are made up of approximately 50% primary central nervous system (CNS) pathologies and approximately 50% extracerebral, almost exclusively internal medical causes. Despite the high mortality associated with this symptom, there are currently no generally accepted management guidelines for adult patients presenting with CUO. We propose an interdisciplinary standard operating procedure (SOP) for patients with acute CUO as has been established in our maximum care hospital. The SOP is triggered by simple triage criteria that are sufficient to identify CUO patients before arrival in hospital. The in-hospital response team is led by a neurologist. Collaboration with nursing staff, internal medicine, anesthesiology, neurosurgery and trauma surgery is organized along structured pathways that include standardized laboratory tests, including cerebrospinal fluid (CSF), toxicology, computed tomography (CT) and CT angiography imaging (CTA). Our data suggest that neurologists and internists need to be placed at the beginning of the diagnostic work-up. Imaging should not just be carried out depending on the clinical syndrome because sensitivity, specificity and inter-rater reliability of the latter are not sufficient and because in many cases, multiple pathologies can be detected that could each explain CUO alone. Clinical examination, imaging and laboratory testing should be regarded as components of an integrative diagnostic approach and the final aetiological classification should only be made after the diagnostic work-up is complete.
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Affiliation(s)
- M Braun
- Klinik für Neurologie, Charité-Universitätsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Deutschland.,Centrum für Schlaganfallforschung (CSB), Berlin, Deutschland
| | - C J Ploner
- Klinik für Neurologie, Charité-Universitätsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Deutschland.
| | - T Lindner
- Arbeitsbereich Notfallmedizin/Rettungsstellen, Charité-Universitätsmedizin Berlin, Campus Virchow Klinikum und Campus Charité Mitte, Berlin, Deutschland
| | - M Möckel
- Arbeitsbereich Notfallmedizin/Rettungsstellen, Charité-Universitätsmedizin Berlin, Campus Virchow Klinikum und Campus Charité Mitte, Berlin, Deutschland
| | - W U Schmidt
- Klinik für Neurologie, Charité-Universitätsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Deutschland.,Centrum für Schlaganfallforschung (CSB), Berlin, Deutschland
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Development of a Prediction Model for Diagnosis of Acute Poisoning in Patients with Altered Mental Status and Absent History of Alcohol/Drug Ingestion. J Emerg Med 2017; 53:680-684. [PMID: 28886979 DOI: 10.1016/j.jemermed.2017.06.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 05/14/2017] [Accepted: 06/28/2017] [Indexed: 11/20/2022]
Abstract
BACKGROUND Diagnosis of acute poisoning in patients with altered mental status and absent history is a challenging diagnostic problem in clinical practice. OBJECTIVE The aims of the study were to develop a simple clinical tool to stratify risk of acute poisoning in patients with altered mental states and no history of alcohol/drug ingestion, and develop a prediction model using initial observations from which a simple risk score could be derived. METHODS The study was carried out on non-trauma patients aged 15 years and older admitted with altered mental states and no history of alcohol or drug ingestion. Univariate analysis and logistic regression were carried out and a score was derived and validated. RESULTS There were 607 patients included, with mean age of 60.3 years and 54% were male. The regression model performed moderately well on both the training and validation sets with areas under the receiver operating characteristic curve of 0.834 and 0.844, respectively. The risk score correlated with the regression model (R2 = 0.969). At cutoff thresholds of 20% for the model and 2 for the score, sensitivity and specificity of the regression model (67.6% and 85.6%) and the score (67.6% and 85.4%) were moderate, while positive predictive values were low (43.4%) and negative predictive values were high (94.2%) for both the regression model and the score. CONCLUSIONS A prediction model with a derived risk score was developed with a high negative predictive value and may have potential in assessing risk of poisoning in altered mental status and may have value in a prehospital environment or at triage.
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Altered Mental Status in ICU Patients: Diagnostic Yield of Noncontrast Head CT for Abnormal and Communicable Findings. Crit Care Med 2017; 44:e1180-e1185. [PMID: 27488219 DOI: 10.1097/ccm.0000000000002005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To evaluate the diagnostic yield of noncontrast head CT for acute communicable findings in ICU patients specifically scanned for altered mental status. DESIGN Retrospective observational cohort study. SETTING University Hospital Neuroscience, Medical, and Surgical ICUs. PATIENTS ICU patients with new-onset altered mental status. INTERVENTION Noncontrast head CT. MEASUREMENTS AND MAIN RESULTS Reports on head CTs from two university hospitals performed for the sole indication of altered mental status in ICU patients between July 2011 and June 2013 were reviewed for 1) acute (new or worsening) hemorrhage, 2) mass effect/herniation, 3) infarction, and 4) hydrocephalus. Subgroup analyses of positive findings were performed by 1) ICU group type, 2) age, and 3) race. A total of 2,486 head CTs were performed in 1,357 patients whose age ranged from 14 to 116 years (median, 59; mean, 57.6 ± 16). Acute communicable findings in at least one of four categories were present in 22.8% (566/2,486) of examinations, with hydrocephalus being most common (11.5% [286/2,486]). The frequency of any acute communicable findings in neuroscience, medical, and surgical ICUs was 28.6% (471/1,648), 9.8% (43/440), and 13.1% (52/398), respectively. Neuroscience ICU head CTs had significantly higher rates of acute communicable findings in all categories, except for acute infarction, compared with the other two ICUs (p < 0.001). Acute hydrocephalus (13.6% vs 7.4%; p < 0.001) and mass effect (6.7% vs 4.3%; p = 0.01) were more common in patients less than 65 years. For other acute categories, no significant difference was noted by age. There was no significant difference in the likelihood of a positive examination by race. CONCLUSIONS Almost one in four head CTs in a university ICU patient population performed for primary indication of altered mental status yields abnormal communicable findings. In this patient population, utilization management barriers to examination ordering should be minimized.
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Jung YH, Jeong DK, Lee JW, Moon HJ, Choi JH, Song JH. The Significance of Clinical Examination for Brain Lesion Differentiation of Patients with Head Trauma after Alcohol Intoxication. JOURNAL OF TRAUMA AND INJURY 2016. [DOI: 10.20408/jti.2016.29.4.99] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Yoon Hyun Jung
- Department of Emergency Medicine, College of Medicine, Soonchunhyang University, Cheonan, Korea
| | - Dong Kil Jeong
- Department of Emergency Medicine, College of Medicine, Soonchunhyang University, Cheonan, Korea
| | - Jung Won Lee
- Department of Emergency Medicine, College of Medicine, Soonchunhyang University, Cheonan, Korea
| | - Hyung Jun Moon
- Department of Emergency Medicine, College of Medicine, Soonchunhyang University, Cheonan, Korea
| | - Jae Hyung Choi
- Department of Emergency Medicine, College of Medicine, Soonchunhyang University, Cheonan, Korea
| | - Jun Hwan Song
- Department of Pediatrics, College of Medicine, Soonchunhyang University, Cheonan, Korea
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Botwinick I, Johnson JH, Safadjou S, Cohen-Levy W, Reddy SH, McNelis J, Teperman SH, Stone ME. Geriatric nursing home falls: A single institution cross-sectional study. Arch Gerontol Geriatr 2016; 63:43-8. [DOI: 10.1016/j.archger.2015.12.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2015] [Revised: 11/14/2015] [Accepted: 12/02/2015] [Indexed: 10/22/2022]
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Abstract
Because coma has many causes, physicians must develop a structured, algorithmic approach to diagnose and treat reversible causes rapidly. The three main mechanisms of coma are structural brain lesions, diffuse neuronal dysfunction, and, rarely, psychiatric causes. The first priority is to stabilise the patient by treatment of life-threatening conditions, then to use the history, physical examination, and laboratory findings to identify structural causes and diagnose treatable disorders. Some patients have a clear diagnosis. In those who do not, the first decision is whether brain imaging is needed. Imaging should be done in post-traumatic coma or when structural brain lesions are probable or possible causes. Patients who do not undergo imaging should be reassessed regularly. If CT is non-diagnostic, a checklist should be used use to indicate whether advanced imaging is needed or evidence is present of a treatable poisoning or infection, seizures including non-convulsive status epilepticus, endocrinopathy, or thiamine deficiency.
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Affiliation(s)
- Jonathan A Edlow
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Rochester, MN, USA.
| | | | - Stephen J Traub
- Department of Emergency Medicine, Mayo Clinic, Scottsdale, AZ, USA
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13
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Wasserman EB, Shah MN, Jones CMC, Cushman JT, Caterino JM, Bazarian JJ, Gillespie SM, Cheng JD, Dozier A. Identification of a neurologic scale that optimizes EMS detection of older adult traumatic brain injury patients who require transport to a trauma center. PREHOSP EMERG CARE 2014; 19:202-12. [PMID: 25290953 DOI: 10.3109/10903127.2014.959225] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVE We sought to identify a scale or components of a scale that optimize detection of older adult traumatic brain injury (TBI) patients who require transport to a trauma center, regardless of mechanism. METHODS We assembled a consensus panel consisting of nine experts in geriatric emergency medicine, prehospital medicine, trauma surgery, geriatric medicine, and TBI, as well as prehospital providers, to evaluate the existing scales used to identify TBI. We reviewed the relevant literature and solicited group feedback to create a list of candidate scales and criteria for evaluation. Using the nominal group technique, scales were evaluated by the expert panel through an iterative process until consensus was achieved. RESULTS We identified 15 scales for evaluation. The panel's criteria for rating the scales included ease of administration, prehospital familiarity with scale components, feasibility of use with older adults, time to administer, and strength of evidence for their performance in the prehospital setting. After review and discussion of aggregated ratings, the panel identified the Simplified Motor Scale, GCS-Motor Component, and AVPU (alert, voice, pain, unresponsive) as the strongest scales, but determined that none meet all EMS provider and patient needs due to poor usability and lack of supportive evidence. The panel proposed that a dichotomized decision scheme that includes domains of the top-rated scales -level of alertness (alert vs. not alert) and motor function (obeys commands vs. does not obey) -may be more effective in identifying older adult TBI patients who require transport to a trauma center in the prehospital setting. CONCLUSIONS Existing scales to identify TBI are inadequate to detect older adult TBI patients who require transport to a trauma center. A new algorithm, derived from elements of previously established scales, has the potential to guide prehospital providers in improving the triage of older adult TBI patients, but needs further evaluation prior to use.
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Zehtabchi S, Abdel Baki SG, Omurtag A, Sinert R, Chari G, Roodsari GS, Weedon J, Fenton AA, Grant AC. Effect of microEEG on clinical management and outcomes of emergency department patients with altered mental status: a randomized controlled trial. Acad Emerg Med 2014; 21:283-91. [PMID: 24628753 DOI: 10.1111/acem.12324] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Revised: 09/19/2013] [Accepted: 09/20/2013] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Altered mental status (AMS) is a common presentation in the emergency department (ED). A previous study revealed 78% electroencephalogram (EEG) abnormalities, including nonconvulsive seizure (NCS; 5%), in ED patients with AMS. The objective of this study was to assess the impact of EEG on clinical management and outcomes of ED patients with AMS. METHODS This was a randomized controlled trial at two urban teaching hospitals. Adult patients (≥18 years old) with AMS were included. Excluded patients had immediately correctable AMS (e.g., hypoglycemia) or were admitted before enrollment. Patients were randomized to routine care (control) or routine care plus EEG (intervention). Research assistants used a scalp electrode set with a miniature, wireless EEG device (microEEG) to record standard 30-minute EEGs at presentation, and results were reported to the ED attending physician by an off-site epileptologist within 30 minutes. Primary outcomes included changes in ED management (differential diagnosis, diagnostic work-up, and treatment plan from enrollment to disposition) as determined by surveying the treating physicians. Secondary outcomes were length of ED and hospital stay, intensive care unit (ICU) requirement, and in-hospital mortality. RESULTS A total of 149 patients were enrolled (76 control and 73 intervention). Patients in the two groups were comparable at baseline. EEG in the intervention group revealed abnormal findings in 93% (95% confidence interval [CI] = 85% to 97%), including NCS in 5% (95% CI = 2% to 13%). Using microEEG was associated with change in diagnostic work-up in 49% (95% CI = 38% to 60%) of cases and therapeutic plan in 42% (95% CI = 31% to 53%) of cases immediately after the release of EEG results. Changes in probabilities of differential diagnoses and the secondary outcomes were not statistically significant between the groups. CONCLUSIONS An EEG can be obtained in the ED with minimal resources and can affect clinical management of AMS patients.
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Affiliation(s)
- Shahriar Zehtabchi
- The Department of Emergency Medicine; State University of New York; Downstate Medical Center; Brooklyn NY
| | | | | | - Richard Sinert
- The Department of Emergency Medicine; State University of New York; Downstate Medical Center; Brooklyn NY
| | - Geetha Chari
- The Department of Neurology; State University of New York; Downstate Medical Center; Brooklyn NY
| | - Gholamreza S. Roodsari
- The Department of Emergency Medicine; State University of New York; Downstate Medical Center; Brooklyn NY
| | - Jeremy Weedon
- The Scientific Computing Center; State University of New York; Downstate Medical Center; Brooklyn NY
| | - André A. Fenton
- The Department of Physiology and Pharmacology; State University of New York; Downstate Medical Center; Brooklyn NY
- The Center for Neural Science; New York University; New York NY
| | - Arthur C. Grant
- The Department of Neurology; State University of New York; Downstate Medical Center; Brooklyn NY
- The Department of Physiology and Pharmacology; State University of New York; Downstate Medical Center; Brooklyn NY
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