498 Abstracts

factors, more likely to present with NSTEMI, and less likely toreceive traditional evidence-based therapies, both as inpatientsand outpatients. They also concluded that dialysis patients hadexcess mortality that was not accounted for by baseline predic-tors for outcome using the GRACE risk score.

[Ashley Menne, MD

Denver Health Medical Center, Denver, CO]

Comments: Although a retrospective study and a post hocanalysis of data collected for other reasons, this was a very largestudy and likely has generalizable validity. Although it is cer-tainly possible that there may be an uncontrolled-for confounderin the dataset, the authors did try to control for those that wouldgenerally be most obvious and, in doing so, still demonstratedthat end-stage renal disease requiring dialysis puts patients atsignificant risk for concomitant cardiac disease. Whether ornot this is causal or simply a situation where one disease is sim-ply mirroring the other cannot be determined, but the associa-tion does seem to be real and important.

, DELAYED INTRACRANIAL HEMORRHAGE AF-TER BLUNT TRAUMA: ARE PATIENTS ON PRE-INJURY ANTICOAGULANTS AND PRESCRIPTIONANTIPLATELET AGENTS AT RISK? Peck KA, Sise CB,Shackford SR, et al. J Trauma 2011;71:1600–4.

Anticoagulant therapy in trauma patients poses a significantproblem to the emergency medicine physician. There have beenmultiple studies demonstrating increased morbidity and mortal-ity in patients on anticoagulants, but there currently is no con-sensus on the treatment of anticoagulated patients with blunttrauma. The authors of this retrospective study of 500 patientsover the age of 15 years with a blunt mechanism of traumawho were admitted to a large level I trauma center on confirmedanticoagulants attempted to demonstrate that an initial negativehead computed tomography (CT) scan in conjunctionwith a nor-mal neurological examination over a 6-h observation period wassufficient to rule out significant intracranial bleeding. Patientswere included if they were taking warfarin with an internationalnormalized ratio (INR) > 1.3, clopidogrel, heparin, enoxaparin,or dipyridamole. Patients on warfarin made up 58.3% of thepopulation and those taking clopidogrel accounted for an addi-tional 24.3% of patients. Initial head CT scans were negative in85% of patients for final analysis. Of these 424 patients, themean age was 75 years, and approximately 50% of them weremale. Fall from standing was the mechanism in 84.2%, witha further 9.0% of patients being involved in a motor vehiclecrash; 35.7% of patients had loss of consciousness, and themean GCS score on presentation was 14.8 (6 0.9). The meaninjury severity score was 4.9 (6 3.7), and 10 patients hada Head Abbreviated Injury Scale Score$ 3. Of the 424 patients,only 85.4% of patients had a second head CT scan performed;4 patients had positive findings on the second head CT scan.All patients were in their 80s (ages 80, 86, 86, and 89 years)and all were on warfarin therapy (INR ranging from 1.7–3.9).Findings on head CT scan included a small tentorial subduralhemorrhage, a possible intraparenchymal hemorrhage, a smallsubarachnoid hemorrhage, and a small hematoma. Three ofthese patients were discharged home and the fourth patient

died in the hospital of unrelated cardiac causes during an ortho-pedic procedure. Fifteen patients had an interval change in theirneurologic status during their 6-h observation, and none of themhad positive findings on their second head CT scan. In an at-tempt to account for the 15% of patients who did not undergoa second CT scan, the authors queried local databases for hospi-tal readmissions and deaths and found 4 patients whowere read-mitted to a hospital within 30 days of discharge. Three of thesepatients were readmitted for medical reasons and the fourth pa-tient was admitted for neurological deterioration and was foundto have ‘‘trace intraventricular blood’’ documented on head CTscan number three, which resolved on subsequent CT scans ofthe head without intervention. The authors concluded thatwith only four positive findings on head CT scans and one read-mission for a possible missed intracranial bleed, an initialnegative head CT scan followed by a 6-h observation is suffi-cient to rule out subsequent intracranial bleeds.

[Austin Johnson, MD

Denver Health Medical Center, Denver, CO]

Comment: This article is limited mostly by its retrospectivedesign. Still, it is worth noting that although the authors suggesta 6-h observation period after head injury in these patients, noneof the patients in their cohort who had a change in their neuro-logic status during this period had any findings on their secondCT scan. Furthermore, it seems that in all of the patients who de-veloped new findings on the second CT scan, none had anysymptoms develop within 6 h, nor did any require any changein management. Clearly, a well-designed, large prospectivestudy is still necessary to determine the appropriate care for anti-coagulated trauma patients in the emergency department.

, DIAGNOSIS OF UROLITHIASIS AND RATE OFSPONTANEOUS PASSAGE DURING PREGNANCY.Burgess K, Gettman M, Rangel L, Krambeck A. J Urol2011;186:2280–4.

Computed tomography (CT) in pregnancy is avoided when-ever possible to limit fetal radiation exposure. For this reason,ultrasound is often the initial imaging modality utilized to eval-uate for urolithiasis in pregnancy. However, the sensitivity of ul-trasound for detecting urolithiasis in pregnancy is highlyvariable, ranging from 28.5% to 95.2%. As such, the accuratediagnosis of urolithiasis during pregnancy is difficult. This studyretrospectively reviewed the records of patients diagnosed withurolithiasis in pregnancy during a 12-year period (1997–2009)for confirmed stone event as well as spontaneous passage, to de-termine if the commonly held convention that most stones (ashigh as 81%) diagnosed during pregnancy will pass with conser-vative management. This study identified 112 patients with 117episodes of urolithiasis. Stones were confirmed, either by ultra-sound (n = 43), CT (n = 20), visualization of passed stone(n = 22), surgical removal (n = 1), or post-partum imaging(n = 4), equating to 90 of 117 (77%) confirmed stone events.Of those with confirmed stones, only 43 of 90 (48%) passedspontaneously. This study revealed that nearly a quarter of pa-tients diagnosed with urolithiasis during pregnancy may havebeen inappropriately diagnosed. This inappropriately high diag-nosis rate likely contributes to the misconception that most