Are we done with CT/LP to rule out SAH?

The BMJ study was a shocking news in 2011 regarding Sensitivity of Modern CT scan in diagnosis of SAH within 6 hours of presentation, Click here for more Then, Storke in 2012 reported another study that showed there is “no added value of CSF analysis to detect SAH within 6 hours of patient presentation with headache”. click here for more
Neurology reported 4 days ago another study in non-academic hospitals with same setting of patient presentation within 6 hours of symptoms onset. Negative predictive value for detection of subarachnoid blood by staff radiologists working in a nonacademic hospital was 99.9% (95% confidence interval 99.3%-100.0%). Is this something that we can officially close the case? and practice safe and do not harm patient with suspicious SAH/LP/Post LP headache!

SIRS in Sepsis

SIRS criteria an immune response to infection can be diagnosed by ( 96.8<Temp>100.4, HR>90, RR>20 and 4K<WBC>12k). A new study  in 172 ICUs among 109,663 patients with infection and organ failure found that 87.9% had SIRS +Ve and 12.1% had SIRS -Ve severe sepsis. This method to define septic patient missed one in eight patients with similar findings in a high risk group. This is another reason that we should treat the patient, not the number!

 

Link to NEJM

Surviving Sepsis Campaign update

Surviving Sepsis Campaign updated its guideline regarding new evidence (ProCESS, ARISE, ProMIS). It is required to do a series of actions within first 3 hours and 6 hours of patient presentation(time of triage):

The first 3 hours:

1. Measure lactate level
2. Obtain blood cultures prior to administration of antibiotics
3. Administer broad spectrum antibiotics
4. Administer 30ml/kg crystalloid for hypotension or lactate ≥4mmol/L 

You can find more here.

Low Dose Ketamine for Analgesia

When I saw this article in Annals , I was sure that I have seen it before, but could not believe that 2 studies with almost same methods, same number of patients, and same dose of medication.

First one AJEM , Feb, 2015. Annlas of EM published Subdissociative-Dose Ketamine Versus Morphine for Analgesia. Prospective, randomized, double-blind trial, Ketamine at 0.3 mg/kg or Morphine at 0.1 mg/kg by IV push during 3 to 5 minutes. 45 patients in each group. Ketamine with dose of  0.3 mg/kg provides pain relief and also safe compare to Morphince for acute pain management in ED

Link to article

Importance of Vital Signs during Handoff

Well, I just sent an article that how important is the role of vital signs during pre-hospital or in ED assessment. Annals of EM published an article: Communication of Vital Signs at Emergency Department Handoff: Opportunities for Improvement. In a prospective observational study, authors  observed 1,163

patients sign out during 130 ED shifts. We did not communicate hypotension in 42%, and hypoxia in 74% at our sign out. Interestingly, ED overcrowding was not associated with this communication error. We need to do a better job on sign out and at least start on reminding ourselves about vital signs!

Link to article

Predictors of progress to septic shock among ED Patients

We were always told that Don’t underestimate triage or field vital signs! Now, we have a study that shows 25 % of patients presenting to ED  with sepsis will progress to septic shock within 3 days.

This is a retrospective study with  3,960 patients that had two or more SIRS criteria. Approximately 12% of septic emergency department patients develop shock within 48 hours of presentation, and more than half of these patients develop shock after the first 4 hours of emergency department arrival. Factors associated with this turnout are: 1. Female Patients 2. non-persistent hypotension 3. Bandemia (10% at least) 4. Lactate of 4 5. PMH of CAD.

 

This tells me as always how important is to send these patient to ICU instead of IMC or floor and downgrade them from ICU instead of upgrade them to ICU!

Link to article