June 2023 Pick of the Month

Humans Are Not Socks

In this month’s AEM POTM, Head computed tomography findings in geriatric emergency department patients with delirium, altered mental status, and confusion: A systematic review, Liu et al. examine the utility of the head CT examination in patients with acute delirium. This systematic review with meta-analysis provides several teaching points that can shift the decision-making for acutely confused patients away from normative behavior (“I need to order the CT scan because the hospitalist will want it”) toward evidence-based diagnostic hypothesis generation.

Toward this goal, the work has several important points, but two salient findings stand out. First, the categorical presence of anticoagulation did not increase risk of a positive finding on head CT. In current practice, sometimes it seems every patient who is “taking thinners” requires a head CT. Hence the point of the meme below. Second, the article forwards the shocking finding that examining the patient has diagnostic value. The odds ratio for a positive head CT was 110 (95% confidence interval [CI] 30.5– 340.1) for patients with a focal neurological finding on physical examination.

Thus, today on shift, this article can help with deciding priority of the head CT in patients with acute delirium: presence of a focal neurological defect equates to high priority (i.e., stroke alert), whereas no focal defect supports the decision to not activate the stroke team. By extension, this systematic review with meta-analysis raises the research question of what set of criteria (which will clearly include no new neurological deficit) can predict a low probability of a significant finding on head CT?

Jeffrey A. Kline, MD

Editor-in-Chief

Source: gomerblog.com

Source: Kirsty Challen, BSc, MBChB, MRes, PhD, Lancashire Teaching Hospitals | AEM Editor of Infographics