M A N U S C R I P T A C C E P T E D ACCEPTED MANUSCRIPTAbbreviations: CI = confidence interval, CNS = central nervous system, Cr = creatinine, CVS = cardiovascular system, ED = emergency department, FiO2 = fraction inspired oxygen, GCS = Glascow coma score, GIT = gastrointestinal system, HAEM = haematological system, HR = hazard ratio, ICU = intensive care unit, IQR = inter-quartile range, NA = noradrenaline, OR = odds ratio, PaO2 = arterial oxygen partial pressure (mmHg), RA = room air, RESP = respiratory system, RR = relative risk, SBP = systolic blood pressure, SD = standard deviation, SIRS = systemic inflammatory response syndrome, SOFA = sequential organ function assessment, SpO2 = oximetry saturation, UO = urine output. M A N U S C R I P T A C C E P T E D ACCEPTED MANUSCRIPT ABSTRACTObjective: A proposed revision of sepsis definitions has abandoned SIRS, defined organ dysfunction as an increase in total SOFA score of ≥2, and conceived "qSOFA" as a bedside indicator of organ dysfunction. We aimed to (1) determine the prognostic impact of SIRS, (2) compare diagnostic accuracy of SIRS and qSOFA for organ dysfunction, and (3) compare standard (Sepsis-2) and revised (Sepsis-3) definitions for organ dysfunction in emergency department patients with infection.Methods: Consecutive ED patients admitted with presumed infection were prospectively enrolled over three years. Observational data were collected sufficient to calculate SIRS, qSOFA, SOFA, comorbidity and mortality.Results: 8871 patients were enrolled, 4176 (47.1%) with SIRS. SIRS was associated with increased risk of organ dysfunction (RR 3.5), and mortality in patients without organ dysfunction (OR 3.2). SIRS and qSOFA showed similar discrimination for organ dysfunction (AUROC 0.72 vs 0.73). qSOFA was specific but poorly sensitive for organ dysfunction (96.1%, 29.7% respectively). Mortality for patients with organ dysfunction was similar for Sepsis-2 and Sepsis-3 (12.5%, 11.4%) although 29% of patients with Sepsis-3 organ dysfunction did not meet Sepsis-2 criteria. Increasing number of Sepsis-2 organ dysfunctions was associated with greater mortality.Conclusions: SIRS was associated with organ dysfunction and mortality, and abandoning the concept appears premature. Although qSOFA≥2 showed high specificity, poor sensitivity may limit utility as a bedside screen. Although mortality for organ dysfunction was comparable between Sepsis-2 and Sepsis-3, more prognostic and clinical information is conveyed using Sepsis-2 regarding number of organ dysfunctions. The SOFA score may require recalibration.
BackgroundPatients with infections account for a significant proportion of Emergency Department (ED) workload, with many hospital patients admitted with severe sepsis initially investigated and resuscitated in the ED. The aim of this registry is to systematically collect quality observational clinical and microbiological data regarding emergency patients admitted with infection, in order to explore in detail the microbiological profile of these patients, and to provide the foundation for a significant programme of prospective observational studies and further clinical research.Methods/designED patients admitted with infection will be identified through daily review of the computerised database of ED admissions, and clinical information such as site of infection, physiological status in the ED, and components of management abstracted from patients' charts. This information will be supplemented by further data regarding results of investigations, microbiological isolates, and length of stay (LOS) from hospital electronic databases. Outcome measures will be hospital and intensive care unit (ICU) LOS, and mortality endpoints derived from a national death registry.DiscussionThis database will provide substantial insights into the characteristics, microbiological profile, and outcomes of emergency patients admitted with infections. It will become the nidus for a programme of research into compliance with evidence-based guidelines, optimisation of empiric antimicrobial regimens, validation of clinical decision rules and identification of outcome determinants. The detailed observational data obtained will provide a solid baseline to inform the design of further controlled trials planned to optimise treatment and outcomes for emergency patients admitted with infections.
The National Emergency X-ray Utilisation Study (NEXUS) criteria and the Canadian cervical spine rules are validated clinical decision-making tools used to facilitate selective cervical spine (C-spine) radiography. The NEXUS criteria are frequently used, as the Canadian cervical spine rules have been noted to be difficult to learn, remember and implement. We present a series of significant C-spine injury in three elderly patients who would not have warranted C-spine imaging using the NEXUS criteria. Each patient was mobile and fully orientated after the injury. There was no midline tenderness, neurological deficit, distracting injury or alcohol/drug involvement. Plain film imaging was initially performed as each patient had a reduced range of movement. Significant odontoid peg injury was confirmed on subsequent computed tomography/MRI imaging for all patients. Despite previous validation studies of the NEXUS criteria in the elderly population, we would urge caution in using the NEXUS criteria alone in determining radiography of the C-spine in the elderly.
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