CJEM Articles: Jeffrey J. Perry
Displaying 1-6 of 6 results
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May
2010
12
3
Catherine M. Clement, Cheryl Symington, Christian Vaillancourt, David Birnie, Garth Dickinson, Ian G. Stiell, Jeffrey J. Perry, Martin S. Green
Objective: There is no consensus on the optimal management of recent-onset episodes of atrial fibrillation or flutter. The approach to these conditions is particularly relevant in the current era of emergency department (ED) overcrowding. We sought to examine the effectiveness and safety of the Ottawa Aggressive Protocol to perform rapid cardioversion and discharge patients with these arrhythmias.
Methods: This cohort study enrolled consecutive patient visits to an adult university hospital ED for recent-onset atrial fibrillation or flutter managed with the Ottawa Aggressive Protocol. The protocol includes intravenous chemical cardioversion, electrical cardioversion if necessary and discharge home from the ED.
Results: A total of 660 patient visits were included, 95.2% involving atrial fibrillation and 4.9% involving atrial flutter. The mean age of patients enrolled was 64.5 years. In total, 96.8% were discharged home and, of those, 93.3% were in sinus rhythm. All patients were initially administered intravenous procainamide, with a 58.3% conversion rate. A total of 243 patients underwent subsequent electrical cardioversion with a 91.7% success rate. Adverse events occurred in 7.6% of cases: hypotension 6.7%, bradycardia 0.3% and 7-day relapse 8.6%. There were no cases of torsades de pointes, stroke or death. The median lengths of stay in the ED were as follows: 4.9 hours overall, 3.9 hours for those undergoing conversion with procainamide and 6.5 hours for those requiring electrical conversion.
Conclusion: This is the largest study to date to evaluate the Ottawa Aggressive Protocol, a unique approach to cardioversion for ED patients with recent-onset episodes of atrial fibrillation and flutter. Our data demonstrate that the Ottawa Aggressive Protocol is effective, safe and rapid, and has the potential to significantly reduce hospital admissions and expedite ED care.
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March
2010
12
2
Erik P. Hess, George A. Wells, Ian G. Stiell, Jeffrey J. Perry, Pam Ladouceur
Objective: We derived a clinical decision rule to determine which emergency department (ED) patients with chest pain and possible acute coronary syndrome (ACS) require chest radiography.
Methods: We prospectively enrolled patients over 24 years of age with a primary complaint of chest pain and possible ACS over a 6 month period. Emergency physicians completed standardized clinical assessments and ordered chest radiographs as appropriate. Two blinded investigators independently classified chest radiographs as "normal," "abnormal not requiring intervention" and "abnormal requiring intervention," based on review of the radiology report and the medical record. The primary outcome was abnormality of chest radiographs requiring acute intervention. Analyses included interrater reliability assessment (with κ statistics), univariate analyses and recursive partitioning.
Results: We enrolled 529 patients during the study period between Jul. 1, 2007, and Dec. 31, 2007. Patients had a mean age of 59.9 years, 60.3% were male, 4.0% had a history of con gestive heart failure and 21.9% had a history of acute myocardial infarction. Only 2.1% (95% confidence interval [CI] 1.1%-3.8%) of patients had radiographic abnormality of the chest requiring acute intervention. The κ statistic for chest radiograph classification was 0.81 (95% CI 0.66-0.95). We derived the following rule: patients can forgo chest radiography if they have no history of congestive heart failure, no history of smoking and no abnormalities on lung auscultation. The rule was 100% sensitive (95% CI 32.0%-40.4%) and 36.1% specific (95% CI 32.0%-40.4%).
Conclusion: This rule has potential to reduce health care costs and enhance ED patient flow. It requires validation in an independent patient population before introduction into clinical practice.
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March
2010
12
2
Erik P. Hess, George A. Wells, Ian G. Stiell, Jeffrey J. Perry, Pam Ladouceur
Objective: We derived a clinical decision rule to determine which emergency department (ED) patients with chest pain and possible acute coronary syndrome (ACS) require chest radiography.
Methods: We prospectively enrolled patients over 24 years of age with a primary complaint of chest pain and possible ACS over a 6 month period. Emergency physicians completed standardized clinical assessments and ordered chest radiographs as appropri ate. Two blinded investigators independently classified chest radi ographs as "normal," "abnormal not requiring intervention" and "abnormal requiring intervention," based on review of the radiol ogy report and the medical record. The primary outcome was abnormality of chest radiographs requiring acute intervention. Analyses included interrater reliability assessment (with κ statistics), univariate analyses and recursive partitioning.
Results: We enrolled 529 patients during the study period between Jul. 1, 2007, and Dec. 31, 2007. Patients had a mean age of 59.9 years, 60.3% were male, 4.0% had a history of con gestive heart failure and 21.9% had a history of acute myocardial infarction. Only 2.1% (95% confidence interval [CI] 1.1%-3.8%) of patients had radiographic abnormality of the chest requiring acute intervention. The κ statistic for chest radiograph classification was 0.81 (95% CI 0.66-0.95). We derived the following rule: patients can forgo chest radiography if they have no history of congestive heart failure, no history of smoking and no abnormalities on lung auscultation. The rule was 100% sensitive (95% CI 32.0%-40.4%) and 36.1% specific (95% CI 32.0%-40.4%). Conclusion: This rule has potential to reduce health care costs and enhance ED patient flow. It requires validation in an independent patient population before introduction into clinical practice.
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November
2009
11
6
Anne-Maree Kelly, Catherine M. Clement, Debra Eagles, Ian G. Stiell, Jamie Brehaut, Jeffrey J. Perry, Suzanne Mason
Objective: Patients with acute headache often undergo com puted tomography (CT) followed by a lumbar puncture to rule out subarachnoid hemorrhage. Our international study exam ined current practice, the perceived need for a clinical deci sion rule for acute headache and the required sensitivity for such a rule.
Methods: We approached 2100 emergency physicians from 4 countries (Australia, Canada, the United Kingdom and the United States) to participate in our survey by sampling the membership of their emergency associations. We used a modified Dillman technique with 3-5 notifications and a prenotification letter employing a combination of electronic mail and postal mail. Physicians were questioned about neu rologically intact patients who presented with headache. Analysis included both descriptive statistics for the entire sample and stratification by country.
Results: The total response rate was 54.7% (1149/2100). Respondents were primarily male (75.5%), with a mean age of 42.5 years and a mean 12.3 years of emergency depart ment (ED) experience. Of the physicians who responded, 49.5% thought all acute headache patients should be investi gated with CT and 57.4% felt CT should always be followed by lumbar puncture. Of the respondents, 95.7% reported they would consider using a clinical decision rule for patients with acute headache to rule out subarachnoid hemorrhage. Respondents deemed the median sensitivity required by such a rule to be 99% (interquartile range 98%-99%). Approxi mately 1 in 5 physicians suggested that 100% sensitivity was required.
Conclusion: Emergency physicians report that they would welcome a clinical decision rule for headache that would determine which patients require costly or invasive tests to rule out subarachnoid hemorrhage. The required sensitivity of such a rule was realistic. These results will inform and inspire the development of clinical decision rules for acute headache in the ED.
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November
2004
6
6
Amy C. Plint, Jeffrey J. Perry, Jennifer L.Y. Tsang
Objectives: The objective of this study was to evaluate the utility of circumferential casting in the emergency department (ED), orthopedic follow-up visits, and radiographic follow-up in the management of children with wrist buckle fractures.
Methods: We performed a retrospective medical record review of all children < 18 years of age who presented to our tertiary care children's hospital between July 1, 2000, and June 30, 2001, and were diagnosed with a fracture of the wrist, radius or ulna. Based on the radiology reports, we identified buckle fractures of the distal radius, the distal ulna, or both bones. We excluded children who had other types of fractures.
Results: We identified 840 children with fractures of the wrist, radius, or ulna. Of these, 309 met our inclusion criteria. The median age of our study cohort was 9.2 years. Emergency physicians immobilized 269 of these fractures in circumferential casts; of these, 30 (11%) had cast complications. Of the 276 subjects who had orthopedic follow-up visits and radiographs, 184 (67%) had multiple visits and 127 (46%) had multiple radiographs performed. No subjects had fracture displacement identified on follow-up.
Conclusions: Orthopedic follow-up visits and radiographic follow-up may have minimal utility in the treatment of pediatric wrist buckle fractures. ED casting may pose more risk than benefit for these children. Splinting in the ED with primary care follow-up appears to be a reasonable management strategy for these fractures. A prospective study comparing ED splinting and casting for pediatric wrist buckle fractures is needed.
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September
2002
4
5
Alena Spacek, George Wells, Ian Stiell, Jeffrey J. Perry
Objectives: This study evaluated the incidence of subarachnoid hemorrhage (SAH) and the use of computed tomography (CT) and lumbar puncture (LP) in a cohort of emergency department (ED) patients with acute headache.
Methods: Health records from a tertiary care ED were used to identify all patients over 15 years of age who presented with headache over a 10-month period. Patients were excluded if they had been referred with confirmed SAH or if they had recurrent headache, head trauma, decreased level of consciousness or new neurologic deficits. Outcome measures included ED diagnosis, use of CT or LP, and ED length of stay. Analysis included descriptive statistics, 95% confidence intervals (CIs) and analysis of variance for length of stay.
Results: The mean age of the 891 patients was 41.9 years. Ten (1.1%) of the patients had SAH, 313 (35.1%) underwent CT, and 85 (9.5%) underwent LP. Only 9 (2.9%) of the CT scans and 2 (2.4%) of the LPs were positive for SAH. Of the 296 patients with normal CT results, 232 (78.4%) did not undergo subsequent LP. The mean length of stay was 4.0 hours (95% CI, 3.8-4.1) if no diagnostic testing was performed, 5.0 hours (95% CI, 4.7-5.4) if CT was performed and 7.1 hours (95% CI, 6.3-7.9) if LP was performed (p = 0.001).
Conclusions: Diagnostic testing was associated with substantially prolonged lengths of stay. CT and LP had low diagnostic yields, which suggests the need for a clinical decision rule to rule out SAH in ED patients with acute headache.
