COMMENTARY

Three Must-Read Emergency Medicine Articles of 2016

Amal Mattu, MD

Disclosures

January 18, 2017

The past year was once again a great year for emergency medicine literature. My stack of must-read articles is taller this year than any other in recent memory.

Narrowing my selections was difficult, and I chose to avoid topics that we've covered in prior Viewpoints or in my (2015 literature review). I also specifically chose emergency medicine–relevant articles outside of mainstream emergency medicine journals that most emergency physicians already read.

I'll make the usual disclaimer that these are not necessarily the best articles from a methodologic standpoint, but they are my favorite practice-changing articles and focus on high-risk conditions. Each of them promotes simple thoughts and concepts that can be employed during your next shift and which might be lifesaving. There's no doubt that some of these will elicit controversy and argument, and that's partly the reason I've chosen them.

What were your favorite articles from 2016? Please tell us in the comments section.

Sensitivity of Early Brain Computed Tomography to Exclude Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Meta-analysis

Dubosh NM, Bellolio MF, Rabinstein AA, Edlow JA
Stroke. 2016;47:750-755

The standard of care for evaluating patients with suspected spontaneous subarachnoid hemorrhage (SAH) has for many years been CT followed by lumbar puncture (LP) if the CT is negative. However, after 23 years of clinical practice and having performed or supervised hundreds of LPs after negative CTs, I can count the number of positive LPs on a single hand. Have I been too liberal in working up patients for SAH? Or is the traditional "standard of care" too conservative in requiring LPs to be performed in so many patients?

During the past few years, more literature has suggested that we probably can safely bypass the LP in selected cases after a negative CT. Perry and colleagues[1]published a highly publicized paper in 2011 that brought this discussion to the forefront, and Dubosh and coworkers have published the latest article in this stream. After an extensive review of the literature, they concluded that the post-test probability of SAH after a negative CT is ≤ 0.2%. Several caveats are provided by the authors:

  • The CT must be performed within 6 hours of headache onset.

  • The presentation is an isolated thunderclap headache (no primary neck pain, seizure, or syncope at onset).

  • There is no meningismus, and the neurologic exam is normal.

  • The CT scanner is a modern (third-generation or newer) machine.

  • The CT is technically adequate (no significant motion artifact).

  • Thin cuts ≤ 5 mm are done through the base of the brain.

  • The hematocrit is > 30%.

  • The physician interpreting the CT is an attending-level radiologist (or has equivalent experience in reading brain CTs).

  • The radiologist should specifically examine the CT for subtle hydrocephalus, small amounts of blood in the dependent portions of the ventricles, and small amounts of isodense or hyperdense material in the basal cisterns.

  • After a negative CT, the clinician should communicate to the patient the post-test risk for SAH that persists (1-2 per 1000).

If the above criteria cannot be met, it seems safest to follow the traditional mantra of CT-LP. If the criteria are met, however, the CT-alone approach appears to be a reasonable option with sufficient supporting literature to meet the standard of care when trying to rule out SAH.

Abstract

Comments

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