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Thank you to our speakers today — Dr. Richardson on research methods, Dr. Weingart on hypothermia, Bing with his journal club presentation (highlighted here), Abiola with trauma talk on the utility of repeat head CTs for recognizing intracranial hemorrhage, and Suzi for her M+M presentation on burn management.

Bing’s journal club presentation and discussion is summarized here — please feel free to add comments.

As for points from Abiola’s and Suzi’s talks, please see below:

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Longtime followers of this blog may recall a kerfuffle over a year ago, related to a graduating senior’s incendiary journal club discussion, in which he examined a small but well-conducted trial of using dexamethasone in benign headaches. At the Journal Club and in my online review, concluded that a one-time dose of this pretty safe medication would be of value in reducing headache recurrence, and were dismayed when an esteemed reviewer for Journal Watch brushed aside the study as too small and unstructured (her review is reprinted in the blog post comments section).

Several residents complained in the comments section, and the term “nihilism bias” was coined. Months went by, but on the night of St. Patrick’s Day, the editor-in-chief of Journal Watch and a leading figure in EM jumped into the fray and advised us that changing practice based on a single, small study is not the kind of care he teaches or wants to be subjected to.

Steroids in headache, which had been a hot topic at SAEM last year and subject of some additional trials in the interim, was addressed again in Journal Watch this week. The very same editor reviewed a new meta-analysis of dexamethasone for acute migraines (Colman, BMJ 2008 Jun 14; 336:1359) and wrote:

“…The authors conclude that when added to standard acute migraine treatment, a single parenteral dose of dexamethasone is associated with a 26%reduction in headache recurrence within 72 hours. An accompanying editorial notes that patients with diabetes should be treated with caution because of the potential for prolonged elevation of blood sugar…

Despite the limitations of a meta-analysis, these results suggest that a single dose of dexamethasone is a reasonable addition to the treatment of acute migraine episodes that has little downside for patients without contraindications to steroids. Although dexamethasone had no benefit for initial pain relief, the number needed to treat to prevent one recurrence was only 9, suggesting that treatment has significant potential to help patients remain functional and avoid repeat emergency department visits. This study tested only parenteral administration, but an oral dose might be just as effective in nonvomiting patients.”

Perhaps a lot has changed in 18 months, perhaps not so much (the Baden 2006 study that was the basis of our original journal club was the smallest in the meta-analysis, and showed the most favorability of dexamethasone), but one things for sure — you can now order a dose of dex with a clear conscience.

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 week in journal club, Matt reviewed a nice little trial submitted by a group of Texans to the Canadian Journal of Emergency Medicine. They studied IV dexamethasone in preventing benign headache recurrence (Can J Emerg Med 2006;8(6):393-400, PDF) – something I had never tried, but apparently has been bouncing around the neurology and EM literature for 20 years.

It turns out that migraines may not be simply a vascular disorder, but rather an inflammatory disease. And, as Matt pointed out, it’s very difficult to diagnose migraines; it might be simpler for us ED folk to say headaches exist on a continuum between tension and migraine, and maybe ED patients with primary headache would benefit from a steroid.

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