CAEP/ACMU 2000 Scientific Abstracts: 61-64

CAEP Abstracts

CJEM 2001;2(3):169-187

061 When the Clinical Impression is "Deep Vein Thrombosis vs. Cellulitis": Do Patient Characteristics Predict the Duplex Diagnosis?
Rabuka CE, Azoulay LY, Kahn SR. McGill University Health Centre, Montreal, Que.

OBJECTIVES: 1) To determine the proportion of patients who had a final diagnosis of deep vein thrombosis (DVT), cellulitis, or both among emergency department (ED) patients in whom the initial clinical impression was "DVT versus (vs.) cellulitis" and who underwent duplex scanning. 2) To determine which baseline clinical parameters, if any, predicted the final diagnosis.
METHODS: Baseline demographic, historical, physical exam, and laboratory variables were collected in a chart review of ED patients with the diagnosis of cellulitis vs. DVT, leading to referral for duplex scan. Patients with positive and negative duplex studies were compared on these variables using the Student t-test or the Chi-square test. RESULTS: Of 109 patients, 19 had a positive duplex scan (17.4%), 2 of who were treated for both DVT and cellulitis. Comparing patients with positive vs. negative duplex scan: 5.3% vs. 14.4% had constitutional symptoms; 0% vs. 12.2% had rigors (p = 0.056); 26.3% vs. 4.4% had recent surgery; 0% vs. 7.8% had distinct margins of erythema (p < 0.01); 15.8% vs. 3.3% had varicose veins; 5.3% vs. 18.9% were currently on antibiotics; 15.8% vs. 26.7% had diabetes; 31.6% vs.16.7% had peripheral vascular disease; and 50% vs. 21.4% had an elevated WBC. CONCLUSION: There are differences in a number of baseline characteristics of "DVT vs. cellulitis" patients with positive vs. negative duplex scans, some of which were statistically significant despite the limited sample size.
Key words: deep vein thrombosis, cellulitis, diagnosis

062 Predicting Severe Obstruction from Urinary Calculi Using Pain Scales.
Papa L, Stiell I, Lee J, Wells G, Mahoney J. Clinical Epidemiology Unit, University of Ottawa, Ottawa.

OBJECTIVES: Pain may be an important predictor of disease severity in patients with urinary calculi. This study prospectively assessed pain as a predictor of severe obstruction due to renal colic.
METHODS: Consecutive patients with suspected renal colic were assessed prospectively at 2 teaching hospital EDs based on acute flank pain and hematuria. A 10 cm visual analogue scale (VAS) was used to assess patients' pain on arrival and at discharge from the ED. Severe obstruction was defined by the following IVP (intravenous pyelogram) criteria: i) urine extravasation, or ii) prolonged dense nephrogram with delayed filling of the ureter >15 minutes, or iii) delayed ureteral filling below the stone longer than 2 hours. Severe obstruction suggested the need for imaging in the ED. Appropriate univariate analyses with 95% CIs were performed. RESULTS: From January to September 1999, 447 patients with suspected renal colic were identified. A total of 333 patients (75%) had an IVP done (84% within 24 hours of presentation). Severe obstruction was identified in 62 (19%) of all IVPs. Arrival VAS pain scores (mean +/­ SD) were significantly higher (p = 0.002) in patients with severe obstruction (8.5 +/­2 cm) than those without severe obstruction (6.9 ± 3.2). Discharge VAS scores were also significantly greater (p = 0.027) in those with severe obstruction (2.5 ± 2.4 cm) than those without (0.9 ± 1.8 cm). Emergency physicians correctly estimated the likelihood of severe obstruction in only 28% of cases. CONCLUSION: Physicians are unable to predict severe obstruction in the ED. Pain on arrival and at discharge from the ED are significant indicators of severe obstruction and therefore the need for urgent imaging. If we could derive a clinical decision rule, using tools such as pain scales, to identify those patients who will have severe obstruction from their calculi, we could be more accurate with imaging in the ED.
Key words: renal colic, pain severity, visual analog scale

063 Incidence of Akathisia from Intravenous Metoclopramide for Migraine Headache.
Seviour CM, Harrison DW, Abu-Laban RB. Vancouver General Hospital, Vancouver, BC.

OBJECTIVES: Akathisia is a distressing side effect of metoclopramide, a drug commonly used to treat migraine headachse. We sought to determine the incidence of metoclopramide-induced akathisia (MIA) as this information is required before evaluating preventative interventions.
METHODS: A prospective study was carried out at a tertiary ED from January 1997 to January 1998. Adults treated with 10 mg of IV metoclopramide for migraine headache were eligible. Patients without exclusions completed questionnaires before and 30 minutes after therapy, blinded to the true purpose of the study. The questionnaires contained a 10-cm visual analogue scale (VAS) of headache severity and a series of Likert scale symptom questions. Nested within these "distractions" were the three subjective questions from the Prince Henry Hospital Akathisia Rating Scale. An increase of two or more in the summed score of the nested questions was considered diagnostic of MIA. RESULTS: 92 of 104 patients studied recorded full responses. Scores for virtually every distraction question decreased or remained unchanged after therapy. Within this strong improvement trend were 11 patients who had a diagnostic increase in their akathisia score (12.0%; 95% CI, 6.1%­20.4%). Many of these cases had increases in 2 or all 3 of the nested questions. Mean VAS scores for headache severity decreased significantly after therapy (8.3 cm before vs. 3.1 cm after, p < 0.0001) and 83% of respondents reported they would accept metoclopramide again. CONCLUSIONS: This study demonstrates that the incidence of MIA is significant and that metoclopramide is an effective therapy for migraine headache. Further research on measures to prevent or reduce MIA is warranted.
Key words: headache, migraine, metoclopramide, akathisia

064 Access to Firearms and Other Weapons and Threats of Domestic Violence in a Northern Emergency Department.
Rowe BH, Cox JE, Carter MH, Sahai VS, Bretzlaff-Michaud JA, Bota GW. University of Alberta, Edmonton, Alta.

OBJECTIVES: Weapon use in domestic violence (DV) increases the risk of serious injury, disability, and mortality. Little is known about the access to household weapons and the threat these pose to women. This study examines access to firearms and threats using weapons in women visiting a northern Canadian ED.
METHODS: A prospective cross-sectional study was performed in which a random sample of consenting women (age >16) were interviewed in private during their ED stay by dedicated female research nurses. Within the 52-question survey, specific items focussed on household firearms and other weapons.
RESULTS: 983 (80%) of 1223 eligible patients consented; 177 (18%) reported having a firearm in their present dwelling. Overall, 153 (16%) women had previously been threatened with a weapon; more women (123 [13%]) had been threatened using weapons (e.g., knives, tools, etc) other than guns (p = 0.002). Threats with other weapons were strongly associated with firearm threats (p < 0.001). However, firearms were generally stored safely: unloaded (166 [93%]), in locked storage (144 [79%]), and separated from ammunition (122 [71%]). Weapon-related threats were most strongly associated with previous injury from a partner during pregnancy (p < 0.001), any previous injury by a partner (p < 0.001), and respondent alcohol use (p = 0.05).
CONCLUSIONS: Firearm ownership and threats with weapons (including firearms) were common in this patient sample. Any weapon threat(s) must be considered a serious issue for both patients and health care workers, since injury is closely associated with partner violent action.
Key words: domestic violence, firearms