Sinai EM Journal Club

At our last Journal Club, Tom presented a 2005 paper from JEM on new CT scanners in the evaluation of SAH. The paper was called Subarachnoid Hemorrhage Diagnosis By Computed Tomography and Lumbar Puncture: Are Fifth Generation CT Scanners Better at Identifying SAH? by Boesiger and Shiber, and it appears in Journal of Emergency Medicine (2005: Vol. 29, No. 1 pp23-27).

The article is motivated by the fact that 1% of headache patients in the ED have SAH. Most are traumatic, but those that aren’t are usually from Circle-of-Willis aneurysm ruptures, which often kill or disable otherwise healthy people. EM physicians hate that sort of unsettling risk, and the situation is further complicated by the 20-50% of SAHers who present with a sentinel bleed. So there’s a real opportunity to help some potentially moribund patients —  but if you ask most interns, they’ll say they’re shoving too many needles into the backs of people who probably just needed some exedrin.

Maybe we can change our practice, based on recent upgrades in CT scanner technology. These authors were the first to look at the new scanners with an eye toward sensitivity in SAH diagnosis. More below…

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This month in Journal Club, we continued our theme of prognostication papers as Corey reviewed two recent ones from Latha G. Stead’s group at Mayo.  One paper ran last year and is called “Initial Emergency Department Blood Pressure as Predictor of Survival After Acute Ischemic Stroke” (Neurology 2005, 65:1179:1183). The second paper is called “Impact of Acute Blood Pressure Variability on Ischemic Stroke Outcome” (Neurology 2006:66:1878-1881).

This is something I frankly hadn’t spent much time thinking about — all the emphasis in stroke guidelines and tPA admin has been about getting BP down into a safe range, not worrying about whose BP is too low. But the big result from the first paper was that a diastolic of < 70 mmHg, a systolic less than 155, or an MAP of less than 100 mmHg was associated with higher mortality at 90 days than those with higher BPs (even after adjusting for age, gender, NIHSS score, etc). The worst relative risk (RR) was for a diastolic less than 70; RR = 2.2 in that case, which the authors find is actually worse than the RR of having a diastolic over 105 (RR=1.9… How about that).    Read more »

Oh yes, Conference Journal Club will be a duel this week, featuring two chiefs – nearing retirement, holding back nothing, fighting for their honor and their patients' cortex… Heads will roll.

Marc's paper is available here — it's a classic, the NINDS trial from 1995 (NEJM 333:1581-1587), predating Marc's arrival at Sinai (which historians believe occurred sometime during Clinton's second term). Many of the interns were still in high school in 1995, but otherwise, pretty much nothing has changed in medicine.

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