CJEM Articles: corticosteroids

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  • Changing the process of care and practice in acute asthma in the emergency department: experience with an asthma care map in a regional hospital
    September 2007 9 5
    Ambikaipakan Senthilselvan, Brian H. Rowe, Carol H. Spooner, Duncan Mackey, Harris Lari, Leslie Tyler, Marlene Myles, Sandra Blitz

    Introduction: Despite the frequency of acute asthma in the emergency department (ED) and the availability of guidelines, significant practice variation exists. Asthma care maps (ACMs) may standardize treatment. This study examined the use of an ACM to determine its effects on patient management in a regional hospital.

    Methods: Patients aged 2 to 65 years who presented to the ED with a primary diagnosis of acute asthma were enrolled in a prospective study that took place 5 months before (pre) and 5 months after (post) ACM implementation. Research assistants using a standardized questionnaire abstracted data through direct patient interviews and then followed up at 2 weeks with a standardized telephone interview.

    Results: Overall, 71 pre patients and 70 post patients were enrolled. Characteristics in both groups were similar. The care map was used in 100% of the cases during the post period. The mean length of stay in the ED for the pre, compared with the post period, was similar (2 h 14 min v. 2 h 25 min; p = 0.60), as were admission rates (11% v. 9%; p = 0.59). Systemic corticosteroid use was similar (62% v. 57%; p = 0.56); however, the total number of β-agonists (2 v. 4 treatments; p = 0.002) and anticholinergics (1 v. 2 treatments; p < 0.001) administered in the ED was higher during the post period. Prescriptions for oral (73% v. 60%; p = 0.15) and inhaled (78% v. 78%; p = 0.98) corticosteroids at discharge remained the same. Relapse rates at follow-up were unchanged (29% v. 34%; p = 0.52).

    Conclusion: This study provides evidence that implementation of an ACM increased acute bronchodilator use; however, prescribing preventive medications did not increase. Further research is required to evaluate other strategies to improve asthma care by emergency physicians.

  • Dexamethasone prevents relapse after emergency department treatment of acute migraine: a randomized clinical trial
    April 1999 1 1
    Cathy Metcalfe, Edward C. Dillon, Grant D. Innes, Iain MacPhail, Min Gao

    Objective: To determine whether the addition of intravenous dexamethasone to standard emergency department (ED) migraine therapy would decrease the incidence of severe recurrent headache 24 to 48 hours after initial treatment.
    Methods: Patients aged 19 to 65 years whose headache was severe enough to require parenteral therapy and who met International Headache Society migraine criteria were eligible for this randomized, double- blind trial. The study was conducted in the ED of 2 community hospitals, 1 of which was a tertiary referral centre. Exclusion criteria included pregnancy, focal findings, fever, meningismus, allergy to the study drug, active peptic ulcer disease and diabetes mellitus. Demographic and clinical data, including headache severity, were recorded. After abortive therapy (antiemetics, intravenous nonsteroidal agents, dihydroergotamine or opioids), blinded nurses administered dexamethasone (24 mg intravenously) or placebo. Patients recorded headache severity on a Visual Analogue Scale (VAS) at time T = 0, T = 30 minutes and T = 60 minutes and at discharge. They were contacted 48 to 72 hours later and asked whether they had suffered a recurrence of their headache, categorized as class A (severe, provoking another physician visit), class B (severe, interfering with daily activity but not provoking a physician visit), class C (mild, requiring self-medication but not limiting activity) or class D (mild, requiring no treatment).
    Results: Two of 100 patients were lost to follow-up, leaving 98 in the study sample. Placebo recipients were more likely to be female; other baseline characteristics were similar between groups. Median VAS pain score was 83 mm on ED arrival, 35 mm after initial treatment and 12 mm on discharge. At followup, 65 of 98 patients had suffered headache recurrence. In the placebo versus dexamethasone groups, respectively, the results were 11 versus 0 in class A, 11 versus 9 in class B, 7 versus 11 in class C and 4 versus 12 in class D. Regarding the primary outcome, 9 of 49 dexamethasone patients (18%) and 22 of 49 placebo patients (45%) had severe (classes A and B) recurrent headache (odds ratio 0.28; 95% CI, 0.11 to 0.69; p = 0 .005).
    Conclusions: Migraine recurrence is common after “successful” ED treatment. Inflammation may be a critical factor in migraine genesis. Intravenous dexamethasone decreases the incidence of severe recurrent headache after ED treatment and should be offered to patients thought to be at risk of recurrent headache.