2008 CAEP/ACMU Scientific Abstracts - Plenary Presentations: 1-4

2008 Scientific Abstracts

CJEM 2008;10(3):255-295

Abstracts: 1-4, 5-24, 25-43, 44-73, 74-103, 104-131

Plenary presentations

The Grant Innes Research Paper*

1 A MULTICENTRE randomized controlled trial of nebulized epinephrine and dexamethasone in outpatients with bronchiolitis

Plint AC, Johnson DW, Patel H, Wiebe N, Correll R, Brant R, Mitton C, Gouin S, Bhatt M, Joubert G, Black K, Turner T, Whitehouse S, Klassen TP; the Pediatric Emergency Research Canada (PERC). Departments of Pediatrics and Emergency Medicine, University of Ottawa, Ottawa, ON

Introduction: Bronchiolitis is the most common disease of the lower respiratory tract in the first year of life. Hospital admissions have almost doubled over the last 10–15 years in North America. The objective of this study was to determine if the treatment of infants with bronchiolitis presenting to the emergency department (ED) with nebulized epinephrine (epi), oral dexamethasone (dex) or both results in a reduction in hospital admissions. Methods: Infants, 6 weeks to 12 months, presenting with bronchiolitis to 8 Canadian pediatric EDs were enrolled in a double-blind, placebo-controlled 2-factor RCT. Infants were randomized to treatment with 1) epi and dex, 2) epi plus placebo, 3) nebulized placebo plus dex and 4) nebulized placebo plus oral placebo. The primary outcome measure was hospital admission up to 7 days after enrolment. Results: Eighthundred subjects were enrolled. Study groups were similarin age, sex, RSV status, baseline clinical score, length of symptoms and atopy history. The epi/dex groups were significantly less likely to be admitted by day 7 than the placebo group, but neither the dex nor epi alone groups showed any significant reduction in admission compared with placebo.

The number needed to treat with epi/dex to prevent 1 admission within 7 days of the initial visit is 11.4. The epi and epi/dex group showed a significant improvement in clinical score and heart rate over the first hour of the study when compared with placebo, while the dex group did not. Conclusion: In this largest RCT of bronchiolitis treatment, neither dex nor epi alone lowered hospitalization rates, but combined therapy with epinephrine and dexamethasone reduced hospital admissions by 30%. Eleven infants would need to be treated with this combination to prevent 1 hospitalization.Keywords: bronchiolitis, dexamethasone, nebulized epinephrine

*The Grant Innes Research Paper and Presentation is an award created in honour of Dr. Grant Innes, Founding Editor-in-Chief of the Canadian Journal of Emergency Medicine (CJEM).

The Grant Innes Research Paper and Presentation will be awarded to the top ranked abstract submitted to the annual CAEP research abstract competition. The recipient of this award will have their abstract published in CJEM as the Grant Innes Research Paper and they will present the abstract at the research plenary at the CAEP annual conference. A plaque and cash prize will awarded to the recipient at the plenary presentation.

2 MULTICENTRE prospective validation of the Canadian C-Spine Rule by ED triage nurses

Stiell IG, Clement C, O’Connor A, Davies B, Leclair C, Sheehan P, Clavet T, Beland C, Mackenzie T, Daigle S, Scollan MA, Rattle N, Moore M, Tessier J, O’Donohue K. University of Ottawa, Ottawa, ON

Introduction: The Canadian C-Spine Rule (CCR) for c-spine imaging was derived, validated and implemented by physicians in 3 large studies (n = 29 031). We believe ED nurses could also use the CCR to clinically clear the c-spine and rapidly remove immobilization. This study prospectively evaluated the accuracy, reliability and acceptability of the CCR when used by nurses. Methods: This prospective cohort study was conducted in 6 EDs (2 teaching and 4 community) and involved alert and stable adult trauma patients who presented with neck pain or on a backboard. We provided standardized 2-hour training to 203 ED triage nurses. Nurses assessed patients by the CCR, including neck tenderness and range of motion, reapplied immobilization, and completed a data form. Some patients were examined by a second RN. Analyses included sensitivity, specificity and kappa coefficient, with 95% CIs. Results: The 3400 patients enrolled over 32 months had these characteristics: mean age 41.4 (range 16–100), female 53.6%, ambulance arrival 74.4%, clinically important c-spine injury (CICI) 1.2%, c-spine treatment 1.1%, admission 8.0%. The CCR classified patients for 38 CICI cases with sensitivity 100.0% (95% CI 91%–100%), specificity 43.0% (95% CI 42%–45%) and would have only required immobilization for 53.6%. Early in the study, nurses misclassified 3 patients with CICI despite obvious high-risk factors. No patients suffered sequelae and retraining efforts led to no further missed cases. Overall, nursing interpretation had sensitivity for CICI of 92.1% (95% 78%–97%) and had 92.5% agreement with the adjudicated CCR interpretation. Nurses had good interobserver agreement (n = 474) for CCR interpretation with a kappa of 0.79 (0.73–0.85). Nurses rated theoretical discomfort in applying the CCR in only 4.9% of cases. Conclusion: We found ED nursing use of the CCR to be accurate, reliable and acceptable. Widespread implementation by triage nurses would prevent prolonged and uncomfortable immobilization for many stable trauma patients. Keywords: implementation, Canadian C-Spine Rule, triage nurses

3 ISOLATED recurrent vomiting rarely predicts brain injury in children with blunt minor head injury

Osmond MH, Klassen TP, Stiell IG, Correll R; the CATCH Study Group. Department of Pediatrics, University of Ottawa, Ottawa, ON

Introduction: Recurrent vomiting is a frequent indication for ordering a cranial CT scan in children with head injury. It is unknown whether isolated recurrent vomiting is predictive of traumatic brain injury (TBI) in children with minor head injury. Methods: We carried out this prospective cohort study in 10 Canadian pediatric teaching hospital EDs and enrolled consecutive children (0–16 yr) who presented with blunt head trauma, a Glasgow Coma Scale (GCS) score of 13–15 and documented loss of consciousness, amnesia, disorientation, recurrent vomiting (2 distinct episodes at least 15 min apart) or irritability. We evaluated the association of recurrent vomiting with TBI seen by CT in those patients with no other signs or symptoms of brain injury (isolated vomiting). Results: Of the 3867 children with minor head injury, 161 (4.2%) had TBI on CT and 24 (0.6%) required neurological intervention. Of the 1634 (42.3%) children who had recurrent vomiting, 89 (5.4%, 95% CI 4.4%–6.7%) had TBI on CT versus 72 of 2233 (3.2%, 95% CI 2.6%–4.0%) without recurrent vomiting (difference 2.2%, 95% CI 0.09%–3.6%). Neurological intervention occurred in 16 of 1634 (1.0%, 95%CI 0.6%–1.6%) children with recurrent vomiting. 226 out of 3867 (5.8%) children had isolated recurrent vomiting (mean age 2.6, SD 2.0, 72.1% ≤ 3 yr). Compared with all enrolled children, those with isolated recurrent vomiting were younger (mean age 2.6 v. 9.6 yr, p < 0.001). For those with isolated recurrent vomiting (i.e., without any other symptoms or signs of brain injury), 2 of 226 (0.9%, 95% CI 0.2%–3.2%) had TBI on CT and none (95% CI 0.0%–1.7%) had brain injury that required neurological intervention.Conclusion: Isolated recurrent vomiting following blunt head injury occurs more commonly in young children and is rarely predictive of TBI on CT or brain injury requiring neurological intervention. Cranial CT scans should be decreased in this population as they are rarely positive for TBI. Keywords: pediatric head trauma, clinical decision rule, CT scanning

4 PARENTERAL dexamethasone for preventing recurrent migraine headaches: a systematic review of the literature

Colman I, Friedman BW, Brown MD, Innes GD, Grafstein E, Roberts TR, Rowe BH. School of Public Health and Department of Emergency Medicine, University of Alberta, Edmonton, AB; St. Paul Hospital, University of British Columbia, Vancouver, BC

Introduction: Acute migraine headaches are common emergency department (ED) presentations and numerous treatment agents are used. These agents are generally effective; however, migraine relapses often occur. This systematic review examined the effectiveness of parenteral corticosteroids for pain relief and prevention of recurrence in acute migraine. Methods: Searches of MEDLINE, EMBASE, LILACS, the Cochrane trials register and CINAHL were conducted; conference proceedings, clinical practice guidelines, contacts with industry and author correspondence were also completed. Included studies were randomized controlled trials in which corticosteroids (alone or in combination with abortive therapy) were compared to placebo or any other standard therapy for treatment of acute migraine attacks in adults. Relevance, inclusion and study quality were assessed independently by 2 reviewers. Weighted mean differences (WMD) and relative risks (RR) were calculated and reported with corresponding 95% confidence intervals (CIs). Results: From 666 potentially relevant abstracts, 7 studies met the inclusion criteria. All included trials employed regular abortive therapy and subsequently compared single-dose parenteral dexamethasone (DEX) to placebo, examining pain relief and headache recurrence within 72 hours. DEX and placebo provided similar pain reduction (WMD 0.37, 95% CI –0.20 to 0.94). DEX was, however, more effective than placebo in reducing rates of recurrent migraine (RR 0.74, 95% CI 0.60–0.90). Side effect profiles were similar between DEX and placebo groups.Conclusion: When added to standard abortive migraine therapy, single-dose parenteral dexamethasone is associated with a 26% relative reduction in recurrent headache (number needed to treat: 9) occurring within 72 hours. Further research is required to determine whether specific patient subgroups are more likely to benefit from this treatment. Keywords: migraine, dexamethasone, migraine relapse, systematic review

Abstracts: 1-4, 5-24, 25-43, 44-73, 74-103, 104-131