CJEM Articles: stroke
Displaying 1-3 of 3 results
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March
2010
12
2
Aikta Verma, David J. Gladstone, Jiming Fang, Jordan Chenkin, Richard Verbeek, Sandra E. Black
Objective: Prehospital Code Stroke triage has the potential to overwhelm stroke centres by falsely identifying patients as eli gible for fibrinolysis. We sought to determine whether online medical control (whereby paramedics contact the medical control physician before a Code Stroke triage is assigned) reduced the proportion of false-positive Code Stroke patients.
Methods: Following the introduction of a protocol for prehospi tal Code Stroke triage in an urban centre, online medical control alternated with off-line medical control (whereby paramedics implement Code Stroke triage independently) over 4 discreet intervals. We reviewed data for patients triaged to 3 regional stroke centres to compare the proportion of false-positive Code Stroke patients during online versus off-line medical control. We predefined false positives as patients triaged as Code Stroke who had symptoms discovered on awakening, were last seen in their usual state of health greater than 2 hours before assess ment or had a final diagnosis other than stroke.
Results: The proportion of false positives was lower during online medical control (31% v. 42%, p = 0.003). This was explained by a lower proportion of patients whose symptoms were discovered on awakening (8% v. 14%, p < 0.001) and who were last seen in their usual state of health greater than 2 hours before assessment (22% v. 32%, p = 0.005). A final diagnosis of stroke was similar in the 2 groups (77% v. 79%, p = 0.39), as was the proportion of patients receiving fibrinol ysis (35% v. 33%, p = 0.72). Eighteen percent of patients were denied Code Stroke triage during online control, most com monly because of the time of symptom onset.
Conclusion: Online medical control is associated with a reduced proportion of false-positive Code Stroke triage.
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September
2007
9
5
Joe Nemeth
When a patient presents to the emergency department with a neurologic deficit and a cerebrovascular event is included in the differential diagnosis, the classic recommendation is to examine the carotid artery and assess for the presence of a bruit. The diagnostic yield and utility of this practice has seldom been called into question. This critical appraisal will review the practice of listening for a carotid artery bruit (CAB) in suspected stroke patients and analyze its clinical utility, including the sensitivity and specificity of a CAB for detecting a significant lesion and the potential impact a CAB may have on the investigation and disposition of such patients.
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September
2006
8
5
Dean R. Chittock, Juan J. Ronco, Vinay K. Dhingra, William R. Henderson
Objectives: To clarify the benefits, risks and timing of glucose control and intensive insulin therapy in several groups, specifically the neurologic, cardiac and septic populations of patients, commonly seen in the emergency department.
Methods: Electronic search of MEDLINE (1966-2005; once with PubMed and once with Ovid) and Embase (1980-2005) using the terms insulin and glucose combined with emergency medicine, intensive care, cardiology and emergency department.
Results: There is considerable controversy in the literature surrounding the use of strict glucose control in cardiac, neurologic and septic patients. Much of this literature is non-randomized, and the timing of therapy is poorly investigated.
Conclusions: Hyperglycemia is associated with adverse outcomes in acutely ill neurologic, cardiac and septic patients, but it remains unclear whether this is a causative association. Glucose control and intensive insulin therapy may be useful in some patient subgroups; however, controlled trials of aggressive glycemic control have provided insufficient evidence to justify subjecting patients to the real risks of iatrogenic hypoglycemia. We recommend a cautious approach to the control of glucose levels in acutely ill emergency department patients, with a target glucose of below 8 to 9 mmol/L.
