Life-Threatening Conditions That Walk:
A Clinician’s ReviewThis section is compiled by Frank M. Painter, D.C.
Send all comments or additions to: Frankp@chiro.org
David J. Schimp, DC, DACNB, DAAPM
Clinician and Associate Professor
Texas Chiropractic CollegeDr. Schimp describes the six most common undiagnosed life-threatening conditions
encountered by chiropractors.
ABSTRACT
Chiropractors are hybrid physicians with a broad skill set. DCs need the diagnostic acumen of orthopedists and neurologists, a fine manual therapist’s hands, a psychologist’s insights, and the capacity to instantly respond to the unexpected. As front-line health care professionals, we may find ourselves serving as ER physicians. When a previously undiagnosed life-threatening condition shows up, we must recognize the problem and triage the patient appropriately. This article will review the six most common undiagnosed life-threatening conditions encountered by chiropractors.
Keywords: cancer, abdominal aortic aneurysm, deep-vein thrombosis, pulmonary embolism, venous thromboembolism, stroke, cerebrovascular accident, subdural hematoma, myocardial infarction, red flag assessment, life-threatening conditions, chiropractor, chiropractic physicianINTRODUCTION
Daniel, et al., have identified the six most common life-threatening conditions that a chiropractic physician is likely to encounter in clinical practice. [1] The goal of this article is to translate the current evidence-based knowledge of these conditions into a quick-scan diagnostic and management reference for cancer, abdominal aortic aneurysm, venous thromboembolism, stroke, myocardial infarction, and subdural hematoma.
I. CANCER
Routine screening tests for the early detection of cancer save lives, but these tests are not without risk when applied indiscriminately. The potential for harm associated with routine screening includesa) false positives leading to unnecessary invasive testing,
b) stress and anxiety over test results,
c) financial issues, and
d) utilization costs [e.g., occupying an imaging device when someone else needs it more].Although early detection may be desirable, it does not always mean that the patient will have a better clinical outcome. The following recommendations were adopted by the U.S. Preventive Services Task Force (USPSTF) and reflect best practices based on current knowledge. The guidelines can be viewed online, downloaded in a PDF format, or accessed through a mobile device using the Electronic Preventive Services Selector (ePSS) application.
For a complete review of these guidelines, visit
http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/index.html
Figure 1 – Most Common Fatal CancersAdult Male Population
1. Lung
2. Prostate
3. Colon
Adult Female Population
1. Lung
2. Breast
3. Colon
Lung Cancer
A history of smoking is the major risk factor for lung cancer. Insufficient evidence exists to recommend routine screening because of the risk for significant harms associated with a high rate of false positives. Screening should, however, be considered for symptomatic, high-risk patients (i.e., smoking history, passive exposure to tobacco, chronic obstructive pulmonary disease, idiopathic pulmonary fibrosis, and environmental or occupational hazardous exposure). (See Figure 2) Low-dose computerized tomography, chest x-ray, or sputum cytology can detect cancer at earlier stages, but the USPSTF report states that data are insufficient to determine if early detection reduces mortality.
Figure 2 – Lung Cancer Screening
USPSTF does not recommend routine screening.
Consider screening a symptomatic high-risk population:1. New-onset cough that doesn’t resolve, or
2. Hemoptysis (coughing blood), or
3. Chronic cough that doesn’t go away, or
4. Constant chest pain, or
5. Swelling of the neck and face, or
6. Shortness of breath and wheezing, or
7. Unexplained weight loss, anorexia, or fatigue
Prostate Cancer
Routine prostate-specific antigen (PSA) screening for prostate cancer is not recommended by the USPSTF. Some organizations continue to recommend PSA screening. The decision to screen should be patient centered. The informed patient should be allowed to make an autonomous decision based on the natural history of the disease and the potential for harm or benefit. PSA should be performed with a digital rectal exam.
For additional information about routine PSA testing, visit
http://www.thennt.com/nnt/psa-test-to-screen-for-prostate-cancer.
Figure 3 – Prostate Cancer Screening
USPSTF does not recommend routine screening.
Pre-screening considerations:1. Family history of prostate cancer before 65
2. Non-tender, non-pitting lower-extremity edema
3. Hematuria
4. Bone pain
5. Obesity
Prostate Cancer
Breast Cancer
The USPSTF recommends biennial screening mammography in women 50-74. The recommendation to routinely screen women who are between 40 and 49 is less strong. Screening in this population should be a patient-centered, autonomous decision based on the individual’s situation and values. Women with a family history of breast cancer may choose to learn more about the relative value of genetic testing to assess their personal risk. Screening through breast self-examination does not reduce breast cancer mortality. Health care providers should promote and support breast-feeding, which decreases breast and ovarian cancer risk.
The recommendation for routine mammography screening may be less than absolute. In his book In Hippocrates’ Shadow, David Newman, MD, suggests that screening mammography is an industry that does not reduce mortality from breast cancer.
Interested readers can learn more about this perspective by visiting
http://www.thennt.com/nnt/screening-mammography-for-reducing-deaths.
Figure 4 – Breast Cancer Screening
USPSTF recommends routine mammography screening in women 50-74.
Consider screening in a high-risk population:1. Family history
2. Breast tenderness or lump
3. Change in breast or nipple appearance
4. Clear or bloody nipple dischargeNote: The USPSTF recommends cytology screening (Pap smear) for cervical cancer in women 21-65. Ovarian screening is not recommended. See USPSTF guidelines.
Colorectal Cancer
The major risk factors for colorectal cancer are advanced age, family history, and African-American race. Colorectal cancer screening is recommended annually for adults 50-75 using high-sensitivity fecal occult blood testing. These screening guidelines are not applicable to individuals with a personal history of cancer or adenomatous polyps. The USPSTF does not recommend regular dosing of aspirin or non-steroidal anti-inflammatory drugs (NSAIDs) prophylactically for the prevention of colorectal cancer.
Figure 5 – Colorectal Cancer Screening
USPSTF recommends screening for adults 50-75.1. High-sensitivity fecal occult blood testing (FOBT) annually
2. Sigmoidoscopy every 5 years with FOBT every 3 years
3. Colonoscopy every 10 yearsSymptoms of advanced disease:
1. A change in bowel habits
2. Perception of incomplete bowel evacuation
3. Rectal bleeding or dark stool
4. Abdominal pain
5. Weakness, fatigue, weight lossNote: Sigmoidoscopy and colonoscopy carry complication risk.
Figure 6 – Clinical Red Flags for Cancer1. New-onset seizure (rule out intracranial pathology)
2. Loss of appetite or unexplained weight loss
3. Night sweats, fever, chills
4. Nocturnal pain
5. Non-pitting, non-tender lower-extremity edema
II. ABDOMINAL AORTIC ANEURYSM
Abdominal aortic aneurysms are often clinically silent. It is estimated that roughly 1.5 million Americans unknowingly harbor an aortic aneurysm. Routine screening of individuals at high risk is recommended because rupture can be catastrophic.
A supplemental web-based patient resource may be found by visiting
http://aoutreach.org.
Routine screening using abdominal ultrasonography is recommended for men 65-75 who have smoked 100 cigarettes or more in their lifetime. Ultrasound screening is performed one time. Follow-up testing is only required if an aneurysm is identified on screening evaluation. Aneurysms less than 5 cm should be reassessed for expansion at 6-month intervals. Aneurysms more than 5 cm require immediate surgical consideration.
Insufficient evidence exists to recommend routine screening for men 65-75 who have not smoked or who have a lifetime smoking history of less than 100 cigarettes. Women do not require routine screening. Abdominal palpation is not an adequate screening tool.
Figure 7 – Abdominal Aortic Aneurysm Screening [1, 2]
USPSTF recommends ultrasonographic screening:1. Men 65-75 with smoking history
Signs/symptoms of aortic dissection
1. Back or abdominal pain with a tearing or ripping sensation
2. Migrating pain (may include leg pain)
3. Sudden chest pain
4. Neurological deficit
5. Diastolic murmur
6. Pulse deficit (absence of palpable pulse waves in a peripheral artery for one or more heartbeats)
7. Hypotension (systolic <90mmHg)
8. Tachycardia (>100bpm)
9. Diaphoresis (profuse sweating, usually sudden and spontaneous)
10. Periumbilical or flank ecchymosis
11. Lower-extremity cyanosis
III. VENOUS THROMBOEMBOLISM
This section is adapted from: Schimp D,
The leg to worry about: A systematic approach to the differential diagnosis of vascular disease, radiculopathy and entrapment neuropathy, Part I.
J Amer Chiropr Assoc 2012 Sept-Oct;49(5):13-21.
The term venous thromboembolism (VTE) encompasses both deep-vein thrombosis and pulmonary emboli. Thrombi that develop in the deep veins are worrisome because of the risk for subsequent pulmonary embolism. [5-7] Risk factors include increased age, estrogenic medications (combined oral contraceptive use, hormone therapy, tamoxifen), hyperhomocysteinemia, congestive heart failure, underlying malignancy, smoking, recent childbirth, recent surgery, obesity, prolonged bed rest or inactivity during travel, and a history of heart disease. [8, 9]
The Wells’ Clinical Prediction Rules for deep-vein thrombosis10 is a decision tool that stratifies patients as low, medium, or high risk. Figure 8 identifies risk factors for deep-vein thrombosis, and Figure 9 identifies risks for pulmonary embolism according to these rules.
Figure 8 – Deep-Vein Thrombosis Risk Factors [10]1. Active cancer
2. Paralysis or immobilization of the lower extremity
3. Bedridden for more than 3 days or surgery within 4 weeks
4. Localized tenderness along distribution of deep veins
5. Entire leg swollen
6. Unilateral calf swelling of greater than 3 cm (below tibial tuberosity)
7. Unilateral pitting edema
8. Collateral superficial veins
9. Paralysis/paresis, recent plaster immobilization
10. Previous history of deep-vein thrombosisFigure 9 – Pulmonary Embolism Risk Factors [11, 12]
1. Clinical signs of deep-vein thrombosis (DVT)
2. Heart rate >100bpm
3. Immobilization for more than 3 days or surgery within 4 weeks
4. Previous diagnosis of DVT or pulmonary embolism
5. Hemoptysis
6. Malignancy with treatment within 6 monthsNote: Pleuritic chest pain is worse with inspiration.
Considered alone, the classic symptoms of deep-vein thrombosis like swelling, pain, and discoloration have a low predictive value. This is also true of classic findings like Homan’s sign, edema, tenderness, and warmth. A combination of these features, together with the clinician’s gestalt (gut feeling), can be useful to stratify patients as low, medium, or high risk for pulmonary emboli. Stratification is meant to reduce the number of unnecessary and invasive tests by recognizing low-risk patients who are more likely to be harmed by than to receive benefit from further testing. The Wells’ Clinical Prediction Rules for deep-vein thrombosis (DVT) and pulmonary embolism (PE) are validated clinical decision tools that can be applied with a high level of confidence. The PERC rule (Pulmonary Embolism Rule-out Criteria) is another useful tool with negative predictive value (i.e., PERC-negative patients are low risk and do not require further investigation). Decision tools make an important contribution to evidence-based care and can be rapidly employed in the clinical setting. One web-based portal to these clinical prediction rules (Wells’ and PERC) is www.mdcalc.com.
This paragraph elaborates on a proposed algorithmic approach to the patient with suspected venous thromboembolism in Figure 10. Patients who are suspected of venous thromboembolism but have a Wells’ Pulmonary Embolism (PE) Risk Score that is less than 2 are at low risk and may not benefit from additional testing. If the Wells’ PE Risk Score is greater than 2 but no greater than 4, the patient is at moderate risk and the D-dimer serological assay is utilized for further stratification prior to imaging. The D-dimer is a fibrin degradation product and is a measure of blood clotting activity. It has very good sensitivity, but its specificity is poor. This means that a negative test is highly predictive of the absence of disease but a positive test does not establish the diagnosis. If the D-dimer is positive, unavailable (or in patients who are stratified as high risk using the Wells’ PE risk score [i.e., Wells’ score 5 or greater]), venous ultrasound or CT angiogram examinations are used to confirm the suspicion of venous thromboembolism and establish the diagnosis. Patients with a unilateral swollen leg, dyspnea (shortness of breath), pleuritic chest pain (i.e., sharp, stabbing chest pain with inspiration), hemoptysis, and tachycardia (>100 bpm) who are suspected of having a pulmonary emboli will be triaged immediately to CT angiogram or other advanced imaging procedures.
IV. STROKE
Cerebrovascular accidents are classified as either hemorrhagic or ischemic. Intracranial hemorrhage accounts for the minority of stroke presentations and is most often caused by hypertension or rupture of an aneurysm. Atherothrombosis and emboli are responsible for ischemic stroke (infarction). Both stroke subtypes are medical emergencies, but a prompt response to the latter and early administration of Tissue Plasminogen Activator (tPA) may favor a better outcome. The Cincinnati Pre-hospital Stroke Scale uses the acronym F-A-S-T to identify patients with stroke (see Figure 11).
Figure 11 – Stroke Risk Factors (FAST) [13]1. Facial weakness (lower)
2. Arm drift (pronator drift)
3. Speech abnormal (dysarthria)
4. Time (urgent medical referral tPA)
5. Sudden-onset “worst headache” of life
6. Leg weakness on Mingazzini test
7. Decreased ability to perform finger- or arm-rolling testNote: Mingazzini test identifies proximal hip girdle weakness suggesting a pyramidal system lesion (stroke). The patient is supine and instructed to hold a position of 90-degree knee and thigh flexion. Subtle weakness may be observed on the involved side as the weaker limb drops.
Note: The finger- or arm-rolling tests suggest a pyramidal system lesion (stroke) when the patient is unable to “twiddle” or roll the thumbs or forearms in a symmetrical fashion (i.e., the uninvolved side circles around the involved arm while the latter is seen to move at a slower rate or not at all).
Transient ischemic attack (TIA) warns of impending stroke and requires immediate medical investigation. Hallmarks of TIA are identified in Figure 12. The USPSTF does not recommend the routine use of carotid artery screening for carotid artery stenosis. The risk associated with a false-positive test outweighs the potential benefit of screening. Ultrasonic duplex imaging to detect carotid artery stenosis is not advised – the recommendation not to screen should be emphasized in individuals who are asymptomatic. Medical screening and intervention is warranted in patients who have experienced symptoms consistent with TIA. These patients will most likely be advised to undergo carotid ultrasonographic imaging and transthoracic echocardiograph.
Figure 12 – Risk Factors for Transient Ischemic Attack1. Sudden onset and resolution (duration minutes to hours)
2. Negative clinical findings
a. Anesthesia over large body region (not paresthesia)
b. Loss of motor function (large region of involvement)
3. Repeating history of short-lived neurological events
4. Hypertension
5. Hypercholesterolemia
6. Smoking
7. Male gender
8. Advanced ageApproximately 20% of all strokes involve the territory of the vertebrobasilar arterial system that supplies the brainstem and cerebellum. Stroke in this region is most often the result of arterial dissection and can present as new-onset, spontaneous, and sustained neck pain, headache, or dizziness. In a patient whose continuous dizziness lasts 24 hours or longer (acute vestibular syndrome), stroke must be differentiated from vestibular neuronitis. Diffusion-weighted MRI is inadequate to definitely rule out posterior fossa stroke in the first 72 hours. An easy-to-perform bedside evaluation known as HINTS is highly sensitive to acute posterior fossa stroke in patients with acute vestibular syndrome during the first 24-48 hours. [14]
The HINTS evaluation is a three-stage test:HI = head impulse
N = nystagmus
TS = test of skewThe HINTS evaluation steps should be performed in this order.
1) Observation for spontaneous or gaze-shifting or vertical nystagmus
2) Observation for skew deviation of the eyes – ocular misalignment or strabismus in the vertical plane. If vertical strabismus is not obvious on direct observation, perform the cover/uncover test (occlude central vision/fixation of one eye and uncover). If a shift or correction saccade is observed when the eye is uncovered, the test is positive and suggests a central disorder.
3) The head-impulse test is a variation on the vestibulo-ocular reflex. The patient fixes his/her gaze on the examiner’s nose. The examiner then passively rotates the patient’s head introducing 10-20 degrees of rotation. In an unpredictable fashion, the examiner quickly “thrusts” the head back to neutral while observing the eyes for saccadic movements. The eyes should remain focused. In the patient with acute vestibular syndrome (continuous vertigo of 24 hours or longer), the absence of saccadic eye movements or ocular “catch-up” corrections during the head-impulse test suggests a central etiology (posterior inferior cerebellar artery [PICA] involvement/cervical artery dissection). The presence of a normal head-impulse test demonstrates preservation of the neural circuitry between the vestibular nuclei and the extra-ocular nuclei. The vestibular nuclei are often preserved in a PICA-territory stroke.To observe videos of the HINTS evaluation, see
http://content.lib.utah.edu/cdm/ref/collection/ehsl-dent/id/6
Despite the potential value of this test, utilization in a clinical setting may be challenging, particularly in the acute stages of disease.
Figure 13 – Abnormal HINTS Evaluation for Stroke = INFARCTImpulse (head) test
Normal
___
Fast phase nystagmus
Alternating (gaze shifting)
___
Refixation
Cover
Test
___Other stroke risk factors in the dizzy patient:
1. Abrupt onset
2. Disproportionately severe
a. Dizziness
b. Nausea
3. Multiple prodromal episodes
4. Sudden hearing loss
5. Craniocervical pain
6. Vascular risk factors
V. MYOCARDIAL INFARCTION
Heart disease is a major cause of mortality worldwide, but it remains difficult to predict who will suffer a cardiac event. Contemporary clinical guidelines and prediction rules to evaluate a patient with chest pain require medical testing and technical knowledge beyond the scope of this article. Parameters of low-risk chest pain for patients presenting to an emergency room have been suggested (source: http://www.thennt.com/risk/low-risk-chest-pain-over-age-40) and provide useful insights to gauge relative risk for a serious outcome. [15-19] The information at the above web link is useful because it empowers clinicians to provide critical knowledge that will enable patients to make informed choices regarding the nature/extent of health care they receive during a cardiac examination.
Tools that assess cardiovascular risk factors are available. The Framingham Cardiac Risk assessment tool allows clinicians to evaluate the 10-year risk of cardiovascular heart disease based on age, total cholesterol, HDL cholesterol, systolic blood pressure, diastolic blood pressure, diabetes, and smoking history. DCs interested in providing patients with wellness care may learn more by visiting http://www.mdcalc.com/framingham-coronary-heart-disease-risk-score.
Figure 14 identifies common presenting symptoms that suggest the need for medical referral for possible myocardial infarction.
Figure 14 – Signs or symptoms of myocardial Infarction1. Chest pain on exertion (or at rest)
2. Intense, unremitting retrosternal chest pain
3. Radiation to neck, shoulder, ulnar aspect left arm
4. Substernal pressure, squeezing, aching, burning, sharpness
5. Sense of indigestion
6. Tachycardia
7. Hypertension
8. Tachypnea
9. Wheezing, frothy sputum
10. FeverNote: Administration of aspirin when heart attack is suspected is estimated to save 1 life for every 42 people (http://www.thennt.com/nnt/aspirin-for-major-heart-attack/). [20]
The USPSTF recommends prophylactic aspirin for men 45-79 and women 55-79.
VI. SUBDURAL HEMATOMA
DCs frequently encounter patients after minor head injury. Validated decision tools are available that help predict the patient at risk for a serious outcome. Two of several clinical decision tools will be discussed here.
The Canadian CT Head Rule identifies 5 high-risk factors and can be applied to children over 16 and adults. If any one factor is present, urgent non-contrast CT imaging of the head is warranted. The Canadian CT Head Rule has a sensitivity of 100% for a neurosurgical lesion. The 5 high-risk factors are in Figure 15. Patients who present with obvious neurological signs following a minor head injury should be immediately triaged to imaging.
Figure 15 – Canadian CT Head Rule (high-risk factors) [21, 22]1. Glasgow coma scale score < 15 2 hours after the injury
2. Suspected skull fracture (bleeding or clear fluid from nose, ear)
3. Skull fracture palpable (depressed skull fracture)
4. Age over 65
5. Vomiting, more than 2 episodesNote: Glasgow Coma Scale (GCS) score of 15=normal cognition, orientation. If a patient is stable 6 hours after an injury, the risk of a serious outcome is 20% of the original risk.
The Pediatric Emergency Care Applied Research Network identifies children with minor head injury who may have a clinically important brain injury requiring a neurosurgical intervention with 100% sensitivity. This landmark study evaluated the outcome of more than 42,000 children following minor head injury and identified high-risk parameters. One of the most important aspects of this study is the identification of children who are at very low risk for a clinically important brain injury. Children who are classified as low risk should not receive CT imaging of the head because the radiation risk for developing a fatal cancer is approximately three times as great as the risk of the disease itself. [22]
This important article and a user-friendly algorithm to stratify risk is available at
http://www.pecarn.org/documents/Kuppermann_2009_The-Lancet.pdf
Figure 16 – PECARN – Children at Low Risk Following Head Injury [23]High-risk factors
1. Depressed GCS14
2. Altered mental status
3. Palpable skull fracture
4. Occipital, parietal, temporal scalp hematoma
5. Loss of consciousness >5seconds
6. Severe mechanism of injury
7. Not acting normally
8. History of vomiting
9. Severe headache
CONCLUSION
The purpose of this article has been to provide a contemporary review of the six most common undiagnosed life-threatening conditions that a DC is likely to encounter and to provide diagnostic decision tools, resources, and access links.
Prompt recognition and appropriate triage of these conditions may save a life.
Dr. Schimp is an attending clinician and associate professor at Texas Chiropractic College.
REFERENCES
Dwain M Daniel, Harrison Ndetan, Ronald L Rupert and Dniel Martinez, Self-reported recognition of undiagnosed life threatening conditions in chiropractic practice: a random survey. Chiropractic & Manual Therapies 2012, 20:21.doi: 10.1186/2045-709X-20-21.
Klompas M.
Does this patient have an acute thoracic aortic dissection?
JAMA. 2002 May 1;287 (17):2262-72. PubMed PMID: 11980527.Tapson VF.
Advances in the diagnosis and treatment of acute pulmonary embolism.
F1000 Med Rep 2012;4:9.Abunasser J, Tejada JP, Foley RJ.
The diagnosis and management of pulmonary embolism.
Conn Med. 2012 Jan;76(1):5-14.Wong P, Baglin T.
Epidemiology, risk factors and sequelae of venous thromboembolism.
Phlebology. 2012:27 Suppl 2:2-11.Van Langevelde K, et al.
Broadening the factor V Leiden paradox: pulmonary embolism and deep-vein thrombosis as two sides of the spectrum.
Blood 2012 April 10 [Epub].Ramzi D, Leeper K.
DVT and Pulmonary Embolism: Part I. Diagnosis.
Am Fam Physician. 2004 Jun 15;69(12):2829-2836.Wong P, Baglin T.
Epidemiology, risk factors and sequelae of venous thromboembolism.
Phlebology. 2012:27 Suppl 2:2-11.Ramzi D, Leeper K.
DVT and Pulmonary Embolism: Part I. Diagnosis.
Am Fam Physician. 2004 Jun 15;69(12):2829-2836.Wells PS, Anderson DR, et al.
Value of assessment of pretest probability of deep-vein thrombosis in clinical management.
Lancet 1997;350:1796.Wells PS, Anderson DR, Rodger M, Stiell I, Dreyer JF, Barnes D, Forgive M, Kovacs G, Ward J, Kovacs MJ.
Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and d-dimer.
Ann Intern Med. 2001 Jul 17;135(2):98-107. PubMed PMID:11453709.Wolf SJ, McCubbin TR, Feldhaus KM, Faragher JP, Adcock DM.
Prospective validation of Wells Criteria in the evaluation of patients with suspected pulmonary embolism.
Ann Emerg Med. 2004 Nov;44(5):503-10. PubMed PMID: 15520710.Kothari RU, Pancioli A, Liu T, Brott T, Broderick J.
Cincinnati Prehospital Stroke Scale: reproducibility and validity.
Ann Emerg Med (April 1999) 33(4);373-8 PMID: 10092713.Jorge C Kattah, MD; Arun V Talkad, MD; David Z Wang, DO, Yu-Hsiang Hsieh, PhD, MS; David E Newman-Toker, MD, PhD;
HINTS to diagnose stroke in the acute vestibular syndrome three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging.
Stroke 2009, 40:3504-3510. doi: 10.1161/STROKEAHA.109.551234.Hollander JE, et al.
Coronary computed tomographic angiography for rapid discharge of low-risk patients with potential acute coronary syndromes.
Ann Emerg Med. 2009; 53:295-304.Goldstein JA, et al.
A randomized controlled trial of multi-slice coronary computed tomography for evaluation of acute chest pain.
Am Coll Cardiol. 2007;49:863-871Marsan, et al.
Evaluation of a clinical decision rule for young adult patients with chest pain.
Acad Emerg Med. 2005; 12(1): 24-31 (n=593).Walker, et al.
Characteristics and outcomes of young adults who present to the emergency department with chest pain.
Acad Emerg Med. 2001; 8(7): 703-708 (n=312).Lee TH, et al.
Long-term survival of emergency department patients with acute chest pain.
Am J Cardiol. 1992;69:145–51 (n=333).Randomized trial of intravenous streptokinase, oral aspirin, both, or neither among 17187 cases of suspected acute myocardial infarction.
Lancet. 1988 Aug 13;2(8607):349-60.Stiell IG, Wells GA, Vandemheen K, Clement C, Lesiuk H, Laupacis A, McKnight RD, Verbeek R, Brison R, Cass D, Eisenhauer ME, Greenberg G, Worthington J.
The Canadian CT head rule for patients with minor head injury.
Lancet. 2001 May 5;357(9266):1391-6. PubMed PMID: 11356436.Stiell IG, Clement CM, Rowe BH, Schull MJ, Brison R, Cass D, Eisenhauer MA, McKnight RD, Bandiera G, Holroyd B, Lee JS, Dreyer J, Worthington JR, Reardon M, Greenberg G, Lesiuk H, MacPhail I, Wells GA.
Comparison of the Canadian CT head rule and the New Orleans Criteria in patients with minor head injury.
JAMA. 2005 Sep 28;294(12):1511-8. PubMed PMID: 16189364.Kuppermann N, et al.
Pediatric emergency care applied research network (PECARN). Identification of children at very low risk of clinically important brain injuries after head trauma: a prospective cohort study.
Lancet. 2009 Oct 3;374(9696):1160-70. Epub 2009 Sep 14. PubMed PMID: 19758692
Return to STROKE AND CHIROPRACTIC
Since 12-12-2014
| Home Page | Visit Our Sponsors | Become a Sponsor |
Please read our DISCLAIMER |