MP25: The role of advanced imaging in the management of benign headaches in the emergency department: a systematic review

R. Lepage; L. Krebs; S.W. Kirkland; C. Alexiu; S. Campbell; B.H. Rowe

doi:10.1017/cem.2017.191

MP25: The role of advanced imaging in the management of benign headaches in the emergency department: a systematic review

CJEM ◽

10.1017/cem.2017.191 ◽

2017 ◽

Vol 19 (S1) ◽

pp. S73 ◽

Cited By ~ 1

Author(s):

R. Lepage ◽

L. Krebs ◽

S.W. Kirkland ◽

C. Alexiu ◽

S. Campbell ◽

...

Keyword(s):

Systematic Review ◽

Emergency Department ◽

Ct Scans ◽

Secondary Headache ◽

Advanced Imaging ◽

Ct Utilization ◽

Weighted Median ◽

Ct Head ◽

Study Population ◽

Headache Patients

Introduction: Headache is a common emergency department (ED) presentation. Benign (i.e., non-pathological) headaches are particularly common, including exacerbations of chronic migraine, tension, and cluster headache. Several studies have reported concerns over the frequent use of advanced imaging, specifically computed tomography (CT), in the ED management of benign or primary headache presentations. This systematic review examined the proportion of adult ED benign headache presentations who receive a CT(head). Methods: Eight bibliographic databases and the grey literature were searched. All studies reporting the proportion of benign headache patients receiving a CT(head) in the ED were eligible for inclusion. Studies which included a secondary headache population of 15% of their total study population or less where eligible for inclusion. Two reviewers independently assessed study inclusion and completed quality assessment and data extraction. Weighted medians were calculated for the primary and secondary outcomes, as appropriate. Results: The search returned 2,444 unique citations, of which 20 met the inclusion criteria (21 patient groups were analyzed). The majority of the studies were descriptive in nature and conducted in North America. The reported proportion of benign headache patients receiving a CT(head) varied considerably (range: 2.06-67.21%); with a weighted median of 30.0% (interquartile range: 30.0, 30.0). Studies published in 2000 or later (18/21 groups) were found to have a higher weighted median percentage compared to those published pre-2000 (p=0.016). Neither the country of origin nor the proportion of patients with secondary headache included within the study population had a significant effect on CT utilization. Of the three studies which reported the discharge diagnosis of all patients, sub-arachnoid hemorrhage was discovered in 2/241 (0.83%) of CT scans. Conclusion: Considerable variation in CT utilization for benign headache ED presentations exists and estimates indicate that more than a quarter of patients receive a CT(head). Overall, these CT scans rarely identify significant pathology, suggesting imaging may be safely reduced. Further research is required to identify interventions which can safely and effectively reduce unnecessary imaging among headache presentations.

Download Full-text

P015: Implementing the Canadian CT Head Rule in a community emergency department

CJEM ◽

10.1017/cem.2016.191 ◽

2016 ◽

Vol 18 (S1) ◽

pp. S83-S83

Author(s):

G. Bock ◽

R. Setrak ◽

S. Freeman

Keyword(s):

Emergency Department ◽

Demographic Data ◽

Ct Scans ◽

P Value ◽

Relative Reduction ◽

Exclusion Criteria ◽

Head Ct ◽

Preliminary Results ◽

Ct Head ◽

Significant Injury

Introduction: The Canadian CT Head Rule (‘the rule’) is widely used across the country and its use is specifically recommended by Choosing Wisely Canada. Studies in Canadian hospitals have shown appropriate declines in CT scans when decision tools have been made readily available and useable at the point of care. Research into the implementation of the Canadian CT Head Rule in particular has shown that barriers to its use include an inability to accurately recall each criteria and forgetting to attempt to apply the rule altogether. In an attempt to provide our clinicians with effective access to the rule, we modified CT requisitions and order procedures to facilitate the use of the rule for every head CT in our emergency department (ED). Methods: A quality improvement (QI) approach was used to pilot, implement, and evaluate the modified CT requisition at our hospital. Several Plan-Do-Study-Act cycles involving stakeholders in the hospital resulted in iterative changes to the requisition leading to the implemented version. The new requisition required physicians to indicate which rules or exclusion criteria were met and this was made mandatory for all head CTs ordered. Demographic data was collected on all patients presenting to the ED on age, gender, CTAS level, disposition, and length of stay. Data on which exclusion criteria were appropriate, the rules met leading to CT scans, whether each requisition was used appropriately, and whether there was a significant injury found was collected for each patient receiving a head CT after implementation. Results: In our primary outcome (% of ED visits receiving a head CT), preliminary results have demonstrated a relative reduction in head CT ordering of 10.9%. Our study at completion is powered to detect a ~10% relative change in ordering behaviour, and a Chi square of the data to date yields a P-value of 0.0147. There are no significant differences in visit volume or any of the demographics collected to date. Final results including analysis are anticipated in March, 2016. Conclusion: Preliminary results on this simple, no-cost intervention are very promising. The reduction in head CTs ordered suggests that with mandated access to an easy-to-use, well validated decision tool, ED physicians have been able to confidently defer scans that have a very low risk of having any significant injury present, reducing cost, radiation exposure, and perhaps time in department.

Download Full-text

Reduction of paediatric head CT utilisation at a rural general hospital emergency department

BMJ Quality & Safety ◽

10.1136/bmjqs-2019-010322 ◽

2020 ◽

Vol 29 (11) ◽

pp. 912-920

Author(s):

Jeffrey Paul Louie ◽

Joseph Alfano ◽

Thuy Nguyen-Tran ◽

Hai Nguyen-Tran ◽

Ryan Shanley ◽

...

Keyword(s):

Emergency Department ◽

Head Injury ◽

Rural Community ◽

Emergency Departments ◽

Control Charts ◽

Intervention Period ◽

Head Ct ◽

Pediatric Injury ◽

Ct Utilization ◽

Ct Head

BackgroundBlunt head injury is a common pediatric injury and often evaluated in general emergency departments. It estimated that 50% of children will undergo a head computed tomography (CT), often unnecessarily exposing the child to ionizing radiation. Pediatric academic centers have shown quality improvement (QI) measures can reduce head CT rates within their emergency departments. We aimed to reduce head CT utilization at a rural community emergency department.MethodsChildren presenting with a complaint of blunt head injury and were evaluated with or without a head CT. Head CT rate was the primary outcome. We developed a series of interventions and presented these to the general emergency department over the duration of the study. The pre and intervention data was analysed with control charts.ResultsThe preintervention and intervention groups consisted of 576 children: 237 patients with a median age of 8.0 years and 339 patients with a median age of 9.00 years (p=0.54), respectively. The preintervention HCT rate was 41.8% (95% CI 35.6% to 48.1%) and the postintervention rate was 27.7% (95% CI 23.3% to 32.7%), a decrease of 14.1% (95% CI 6.2% to 21.9%, p=0.0004). During the intervention period, there was a decrease in HCT rate of one per month (OR 0.96, 95% CI 0.92 to 1.00, p=0.07). The initial series of interventions demonstrated an incremental decrease in HCT rates corresponding with a special cause variation.ConclusionThe series of interventions dispersed over the intervention period was an effective methodology and successfully reduced HCT utilisation among children with blunt head injury at a rural community emergency department.

Download Full-text

Effect of a preauthorization policy on the utilization rate of after-hours emergency department neuroradiology computed tomography

CJEM ◽

10.2310/8000.2012.120597 ◽

2013 ◽

Vol 15 (03) ◽

pp. 161-166 ◽

Cited By ~ 1

Author(s):

Deljit Dhanoa ◽

Kirsteen Rennie Burton ◽

Lyne Noël de Tilly ◽

Ravi J. Menezes

Keyword(s):

Computed Tomography ◽

Emergency Department ◽

Control Group ◽

Head Group ◽

Ct Utilization ◽

Noncontrast Ct ◽

Ct Head ◽

After Hours ◽

The Impact ◽

Ct Studies

ABSTRACTObjective:To evaluate the impact of an emergency department (ED) automatic preauthorization policy on after-hours utilization of neuroradiology computed tomography (CT).Methods:All CT studies of the head with contrast facial bones, orbits, spine, and neck requested through the ED and performed between January 1, 2004, and December 31, 2010, were reviewed. The preauthorization policy was instituted on February 25, 2008. A control group of noncontrast CT head studies was used for comparison. Pre- and postpolicy implementation utilization rates were compared between the control group of noncontrast CT head studies and the study group neuroradiology CT studies.Results:During the study period, 408,501 ED patient visits occurred and 20,703 neuroradiology CT studies were carried out. The pre- and postimplementation groups of noncontrast CT head scans totalled 7,474 and 6,094, respectively, whereas the pre- and postimplementation groups of all other neuroradiology CT studies totalled 3,833 and 3,302, respectively. The CT utilization between the two groups did not differ significantly: the noncontrast head group pre- and postpolicy implementation increased by 0.31 to 3.41%, whereas the utilization of all other neuroradiology CT studies increased by 0.22 to 1.84% (pvalue = 0.061 for a difference between groups).Conclusion:Implementation of an automatic preauthorization policy for after-hours neuroradiology CT studies did not result in a statistically significant increase in CT utilization. This suggests that concerns regarding the negative effects of such policiesmay be unfounded, and further research in this area is warranted.

Download Full-text

Triage bei Kopfschmerz in der Hausarztpraxis: Wann einweisen?

DMW - Deutsche Medizinische Wochenschrift ◽

10.1055/a-0759-8052 ◽

2019 ◽

Vol 144 (10) ◽

pp. 651-658

Author(s):

Solveig Carmienke ◽

Dagny Holle-Lee

Keyword(s):

Primary Care ◽

Emergency Department ◽

General Practitioner ◽

Hospital Care ◽

Secondary Headache ◽

Red Flags ◽

Secondary Headaches ◽

Specialist Treatment ◽

Yellow Flags ◽

Headache Patients

AbstractHeadache is one of patients’ most common reasons to consult their general practitioner and covers about 2 – 5 % of the consultations in primary care. Often, the general practitioner is the first to be contacted by patients with headache. Mostly, headaches are primary and only 2 % of the patients have secondary headaches. The distinction between primary and secondary headache is the most important step in the management of patients with headache in primary care. Therefore, this article shows important elements of anamnesis and examination of headache patients in primary care. Furthermore, this article focuses on identification of red flags and yellow flags in the consultation of patients with headache and suggests recommendations for referral to emergency department, hospital care or specialist treatment.

Download Full-text

The Value of Cranial CT Imaging in Patients With Headache at the Emergency Department

Frontiers in Neurology ◽

10.3389/fneur.2021.663353 ◽

2021 ◽

Vol 12 ◽

Author(s):

Cynthia M. C. Lemmens ◽

M. Christien van der Linden ◽

Korné Jellema

Keyword(s):

Emergency Department ◽

Diagnostic Imaging ◽

Ct Imaging ◽

Secondary Headache ◽

Headache Disorders ◽

Focal Neurological Deficit ◽

Cranial Ct ◽

Imaging Results ◽

Headache Onset ◽

Headache Patients

Background: Headache is among the most prevalent complaints in patients presenting to the emergency department (ED). Clinicians are faced with the difficult task to differentiate primary (benign) from secondary headache disorders, since no international guidelines currently exist of clinical indicators for neuroimaging in headache patients.Methods: We performed a retrospective review of 501 patients who presented at the ED with headache as a primary complaint between April 2018 and December 2018. Primary outcomes included the amount of diagnostic imaging, the different conclusions provided by diagnostic imaging, and the clinical factors associated with abnormal imaging results.Results: About half of the patients were diagnosed with a primary headache disorder. Cranial CT imaging at the ED was performed regularly (61% of the patients) and led to the diagnosis of underlying pathology in 1 in 7.6 patients. In a multivariate model, factors significantly associated with abnormal cranial CT results were age 50 years or older, presentation within 1 h after headache onset, clinical history of aphasia, and focal neurological deficit at examination.Conclusions: As separate clinical characteristics have limited value in detecting severe underlying headache disorders, cranial imaging is regularly performed in the ED. Clinical prediction model tools applied to headache patients may identify patients at risk of intracranial pathology prior to diagnostic imaging and reduce cranial imaging in the future.

Download Full-text

A74 INCREASING RATES OF CT IMAGING IN THE EMERGENCY DEPARTMENT AMONG PATIENTS WITH INFLAMMATORY BOWEL DISEASE

Journal of the Canadian Association of Gastroenterology ◽

10.1093/jcag/gwab002.072 ◽

2021 ◽

Vol 4 (Supplement_1) ◽

pp. 40-41

Author(s):

R Kandel ◽

M Merlano ◽

P Tan ◽

G Brar ◽

J D McCurdy

Keyword(s):

Inflammatory Bowel Disease ◽

Emergency Department ◽

Bowel Disease ◽

Imaging Finding ◽

Ct Imaging ◽

Ct Scans ◽

Steady Increase ◽

Abdominal Ct ◽

Ct Utilization ◽

Inflammatory Bowel

Abstract Background Computed tomography (CT) imaging of the abdomen is often performed in the emergency department (ED) to exclude urgent pathology in patients with Inflammatory Bowel Disease (IBD). However, concerns over excessive radiation exposure from repeated use have led to expert consensus guidelines advising against CT imaging unless there is suspicion of complications (obstruction, perforation, abscess) or a non-IBD cause for symptoms. Aims Our study aimed to determine trends in abdominal CT utilization and findings among patients with IBD in the ED. Methods We performed a retrospective cohort study between 01/01/2009 and 31/12/2018 at a single academic center. We identified ED encounters for adults (age ≥17 years) with a pre-existing diagnosis of IBD from our institutional database and determined the proportion resulting in an abdominal CT scan within 72 hours of presentation. IBD subtypes were classified based on ICD-10 claims: K50.90* for Crohn’s disease (CD), K51.90* for Ulcerative colitis (UC) and IBD undifferentiated (IBDU) for patients with both claims. A time trend analysis was performed using a generalized linear model that assumed a Poisson distribution. CT scans were classified according to the dominant imaging finding. For this part we excluded studies performed within 1-month of surgery or those re-assessing a known abscess or malignancy. Results A total of 14783 encounters were identified. Among these encounters 3000 CT scans were performed: 2000 for patients with CD (21.9%), 652 for UC (16.5%) and 348 for IBDU (20.4%). The rates of CT utilization significantly increased by 2.7% (95% CI, 1.2–4.3; p=0.0004) in patients with CD, by 4.2% (95% CI, 1.7–6.7; p=0.0009) in patients with UC and by 6.3% in patients with IBDU (95% CI, 2.5–10.0; p=0.0011). Among the eligible CT scans performed for CD, the following dominant findings were reported: normal (25%), inflammation (23%), obstruction (23%), penetrating (18%) and unrelated to IBD (8.6%). In contrast, the following findings for patients with UC were reported: normal (20%), inflammation (39%), obstructive (19%), penetrating (8%) and unrelated to IBD (15%). Conclusions In this single center study, a steady increase in CT utilization in the ED was observed in patients with IBD. Interestingly, only a small proportion of the CT scans demonstrated urgent findings. Future studies are required to determine the factors that contribute to the ongoing increase in CT utilization in this patient population. Funding Agencies None

Download Full-text

Using Ketamine and Propofol for Procedural Sedation of Adults in the Emergency Department: A Systematic Review and Meta-Analysis

Advanced Pharmaceutical Bulletin ◽

10.15171/apb.2019.002 ◽

2019 ◽

Vol 9 (1) ◽

pp. 5-11 ◽

Cited By ~ 9

Author(s):

Morteza Ghojazadeh ◽

Sarvin Sanaie ◽

Seyed Pouya Paknezhad ◽

Sahba-Sadat Faghih ◽

Hassan Soleimanpour

Keyword(s):

Systematic Review ◽

Emergency Department ◽

Adverse Effects ◽

Randomized Clinical Trials ◽

Meta Analysis ◽

Procedural Sedation ◽

Beneficial Effects ◽

Advantages And Disadvantages ◽

Significant Difference ◽

Study Population

Purpose: Ketamine-propofol combination (ketofol) is being used to provide a safe and effective procedural sedation (PS) in emergency department (ED) and may theoretically have beneficial effects since using lower doses of each drug may result in a reduction of the adverse events of both agents while maintaining optimal conditions for performing procedures. This systematic review was conducted to evaluate the efficacy, advantages and disadvantages of these two drugs for PS. Methods: The PRISMA statement was used for this systematic review. We searched the databases of PubMed, Scopus, ProQuest, Medline (Ovid) from 1990 to August 2017 for randomized clinical trials (RCTs) in which the study population aged ≥18 and was referred to ED. Full-texts of the studies performed in adults that were published in English were reviewed for inclusion. Both authors independently evaluated all studies. Five articles were eligible for the meta-analysis based on their common outcomes. Results: The total number of subjects was 1250, of which 635 were treated with propofol and 615 were treated with ketofol. Although two of the five studies showed a better quality of sedation with ketofol, the other three did not find any significant difference between propofol and ketofol. This systematic review found a lower incidence of respiratory adverse effects in ketofol group than propofol group. Conclusion: Ketamine/propofol mixture (ketofol) has less respiratory adverse effects than propofol alone in ED procedural sedation.

Download Full-text

LO15: The incidence of intracranial bleeding following a fall on level ground in geriatric patients

CJEM ◽

10.1017/cem.2019.58 ◽

2019 ◽

Vol 21 (S1) ◽

pp. S12

Author(s):

K. de Wit ◽

Z. Merali ◽

Y. Kagoma ◽

É. Mercier

Keyword(s):

Systematic Review ◽

Emergency Department ◽

Random Effects ◽

Geriatric Patients ◽

Meta Analysis ◽

Intracranial Bleeding ◽

Point Estimate ◽

Mesh Terms ◽

Neurosurgical Patients ◽

Ct Head

Introduction: Falls are a common presentation to the emergency department among geriatric patients. The incidence of intracranial bleeding following a fall is unclear and approach to ordering a CT head scan is not standardized. The aim of this systematic review and meta-analysis was to establish the incidence of intracranial bleeding after a fall in geriatric patients. Methods: The systematic review was registered in PROSPERO. Two authors independently searched Medline and EMBASE (OVID interface) from conception till 20th June 2018. The search combined multiple MESH terms and text words for [falls], [elderly] and [brain injury]. The search was repeated in Google Scholar and recent conference abstracts were reviewed. Studies were included if > 80% of the included patients were > 65 years who presented to the emergency department after a fall on level ground. We excluded studies enrolling select populations (for example trauma team activation, neurosurgical patients or only anticoagulated patients). There were no language restrictions. The random effects model was used to perform a meta-analysis on the incidence of intracranial bleeding in geriatric patients after a fall on level ground. Results: From the 7,043 titles and abstracts, 175 full articles were reviewed and 7 studies, including 6758 patients, were included in the analysis. 2/7 studies were prospective. The studies varied in their inclusion criteria with 3/7 studies only including patients with normal neurological testing. Most retrospective studies included patients if they had a CT head scan. Neither prospective study imaged all patients but both followed the patients for a delayed diagnosis of intracranial bleeding. Risk of bias was moderate or high for the majority of studies. The random effects pooled incidence of intracranial bleeding was 5.2% (95% CI 2.8 – 8.2%), I2 96%. Conclusion: Around 1 in 20 geriatric patients who present to the emergency department after a fall have intracranial bleeding. This point estimate can be used to calculate sample size requirements for future studies on intracranial bleeding in this population.

Download Full-text