Neurological diagnoses in the emergency room: differences between younger and older patients

Article Arq Neuropsiquiatr 2011;69(2-A):212-516 Neurological diagnoses in the emergency room Differences between younger and older patients Marcos C. Lange, Vera L. Braatz, Carolina Tomiyoshi, Felipe M. Nóvak, Artur F. Fernandes, Laura N. Zamproni, Élcio J. Piovesan, Edison M. Nóvak, Helio A.G. Teive, Lineu C. Werneck ABSTRACT Neurological diseases are prevalent in the emergency room (ER). The aim of this study was to compare the neurological diagnoses between younger and older patients evaluated in the ER of a tertiary care hospital. Method: Patients admitted to the ER who required neurological evaluation in the first 24 hours were separated into two groups based on age, ≤50 years old and >50 years old. Results: Cerebrovascular disease (59.6% vs. 21.8%, p<0.01) was most frequent in the >50 years old group. Seizures (8.1% vs. 18.6%, p<0.01) and primary headache (3.7% vs. 11.4%, p<0.01) were most frequent in the ≤50 years old group. Conclusion: The current study demonstrated that these three neurological diagnoses represented the majority of the neurological evaluations in the ER. National guidelines for ER teams that treat these prevalent disorders must be included in clinical practice and training. Key words: nervous-system disease, stroke, headache, seizures, emergency medical services, health services epidemiology. Diagnósticos neurológicos na sala de emergência: diferenças entre pacientes jovens e idosos RESUMO Doenças neurológicas são prevalentes na sala de emergência (SE). O objetivo deste estudo é comparar a ocorrência de diagnósticos neurológicos entre pacientes jovens e idosos atendidos na SE de um hospital terciário. Método: Pacientes admitidos na SE que necessitaram avaliação neurológica nas primeiras 24 horas após a admissão foram separados em dois grupos baseados na idade, ≤50 anos de idade e >50 anos de idade. Resultados: Doença cerebrovascular foi o diagnóstico mais comum nos pacientes >50 anos (59,6% vs. 21,8%, p<0,01). Convulsões (8,1% vs. 18,6%, p<0,01) e cefaléias primárias (3,7% vs. 114%, p<0,01) foram mais frequentes no grupo ≤50 anos. Conclusão: O presente estudo demonstrou que esses três diagnósticos neurológicos representam a maioria das avaliações neurológicas na SE. Diretrizes nacionais para os profissionais emergencistas que tratam estas doenças devem ser incluídos na prática clínica e no treinamento médico. Palavras-chave: doença do sistema nervoso, AVC, cefaléia, convulsões, serviço médico de emergência, epidemiologia em serviços de saúde. Correspondence Marcos Christiano Lange Hospital de Clínicas Serviço de Neurologia Rua General Carneiro 181 / 4º andar 80060-900 Curitiba PR - Brasil E-mail: Received 10 May 2010 Received in final form 17 August 2010 Accepted 24 August 2010 212 In recent years, with technological improvement and new methods of therapeutic management, emergency medicine has become an important medical specialty. Patients evaluated in the emergency room (ER) could have life-threat- ening diseases that must be identified immediately to begin the correct treatment and improve patient prognosis. Neurological disorders are a common reason for admission to the ER and are associated with high morbidity and mortality, Neurology Division, Internal Medicine Department, Hospital de Clínicas, Universidade Federal do Paraná, Curitiba PR, Brazil. Arq Neuropsiquiatr 2011;69(2-A) increasing public-health costs1. From 8% to 15% of all patients admitted to the ER in general hospitals require assessment by a neurologist2. Generally, cerebrovascular disease (CVD), headache and epilepsy accounted for almost half of all acute admissions related to neurological diseases3, and elderly patients had the highest incidence of neurological symptoms during ER evaluation2. In Brazil, there is little information available on the characteristics of the neurological consultation that takes place in the ER. The aim of this study was to evaluate the clinical profile and short-term follow-up of patients admitted to the ER of a university hospital and to compare young and old patients in an attempt to identify different patterns. METHOD A retrospective review of the data bank from the Emergency Neurology Unit of the Neurology Division of the Hospital de Clínicas at the Universidade Federal do Paraná (HC-UFPR) was done. The ER of the HC-UFPR is a tertiary care, nontrauma reference unit, exclusively dedicated to public-health assistance. The clinical neurological staff of the hospital is on call 24 hours a day, 7 days a week. The study was approved by the Local Ethics Committee of the institution. All patients admitted to the ER of the HC-UFPR who required neurological assessment from February 2007 to January 2008 were evaluated. Inclusion criteria for the study were patients older than 14 years with acute neurological symptoms, evaluated by the ER staff and by the hospital neurologist in the 24 hours following admission. Exclusion criteria were nonemergency patients and patients without data on the medical registers to confirm the patient’s diagnosis and outcome. The data evaluated were gender, age, main diagnosis and outcome (discharge or hospital admission and death). Only deaths that occurred in the first 72 hours after ER admission were considered to be related. All patients were submitted to a neurological clinical evaluation and when necessary, laboratory and neurological complementary analyses were performed for determining the final diagnosis, including brain computed tomography, brain magnetic resonance imaging, digital arteriography, cerebrospinal fluid analysis, electroencephalography or electromyography with nerve conduction study that was based on the clinical neurological findings. Patients with previous neurological diseases were included when they presented acute complications or a recent worsening of symptoms. The main diagnoses were categorized into the following disease groups: [A] CVD, confirmed based on brain imaging that was distinct from arterial and venous, hemorrhagic Emergency room: neurological diagnoses Lange et al. and ischemic stroke conditions. This diagnosis was concluded only for patients with symptom onset within the last 24 hours; [B] A diagnosis of epilepsy was considered when the patient presented with a previous history of seizures and was admitted because of convulsive symptoms within the last 6 hours; or if the patient presented with first-ever seizures within the past 24 hours without secondary findings after clinical, neurological and complementary evaluation, excluding a secondary seizure; [C] Primary headache was considered when the patient presented with a previous history of primary headache with symptoms worsening within the past 24 hours; or if clinical, neurological and complementary evaluation excluded secondary causes for the symptoms in a patient without a previous headache history; [D] Neurological symptoms secondary to clinical condition (SCC) were considered when the neurological symptoms were rel (...truncated)