Objectives: The objective was to determine the incidence of subarachnoid hemorrhage (SAH) diagnosed by lumbar puncture (LP) when the head computed tomography (CT) was reported as demonstrating no subarachnoid blood.Methods: Data were obtained on patients who received LP to diagnose or exclude SAH attending six hospitals over 5 years. Subsequent investigations and outcomes were reviewed in all patients with LPs that did not exclude SAH.Results: A total of 2,248 patients were included. A total of 1,898 LPs were suitable for biochemical analysis, of which 92 (4.8%) were positive for blood, suggesting SAH; 1,507 (79.4%) were negative; and 299 (15.6%) were inconclusive. Of the 92 patients with positive cerebrospinal fluid analysis, eight patients (0.4%) had aneurysms on further imaging, and one had a carotid cavernous fistula. Conclusions:In patients presenting to the emergency department with acute severe headache, LP to diagnose or exclude SAH after negative head CT has a very low diagnostic yield, due to low prevalence of the disease and uninterpretable or inconclusive samples. A clinical decision rule may improve diagnostic yield by selecting patients requiring further evaluation with LP following nondiagnostic or normal noncontrast CT brain imaging.ACADEMIC EMERGENCY MEDICINE 2015;22:1267-1273© 2015 by the Society for Academic Emergency Medicine A cute headache is a common presentation to the emergency department (ED), accounting for around 1% to 2% of all encounters.1,2 The differential diagnosis is wide and includes potentially life-threatening conditions, such as aneurysmal subarachnoid hemorrhage (SAH). Aneurysmal SAH has an incidence of approximately six to eight per 100,000 per person-years, and prevalence of 0.4% to 6%, estimated overall to be around 2%. 3,4 There is an overall risk of rupture of 1.9%.4 SAH has a 1-month mortality of around 40% to 45%, and of those surviving the hemorrhage, around 30% will have severe disabilities. 5,6 Following the initial presentation, the risk of rebleeding is approximately 1.5% per day and 15% to 20% in the first
Our unique morning handover structure ensures patient safety, as well as the appropriate transfer of information and responsibility to all involved with the care of patients in the ED. It offers the opportunity for multiprofessional learning, encourages teamwork and improves operational processes within the ED.
A 54-year-old man presented to the emergency department with a 4-week history of right shoulder pain radiating down his arm, with some associated sensory loss. Further questioning and examination in the department revealed a classical Horner’s syndrome; miosis, partial ptosis and hemifacial anhidrosis. An initial chest X-ray was deemed to be unremarkable; however, further review by a radiologist noted asymmetrical right apical thickening. A subsequent high-resolution CT scan of the chest revealed a right-sided Pancoast tumour. This case highlights the importance of a thorough history and examination in identifying a rare cause of shoulder and/or back pain.
Objectives and BackgroundsEmergency Department (ED) handovers are arguably more complex than that which takes place in ward environments. This is because of an unpredictable patient load, compressed time-frames to meet operational and performance targets and undifferentiated and undiagnosed nature of the clinical problems. In order to ensure safe, relevant and accurate handovers in our department, we have implemented a novel multiprofessional model incorporating appropriate information exchange, learning opportunities and social interaction. In this study we investigated the effectiveness and usefulness of this new morning handover structure.MethodsA questionnaire containing 10 questions were given to staff over a 1-week period (14 to 20 March 2011). The questions included the following: (a) usefulness of multiprofessional handover (MPH) as a source of information about departmental and trust updates; (b) patient care and operational issues; (c) interprofessional education forum; and (d) comparison with previous handover experience.ResultsWe obtained data from 75 staff members comprising a mixture of the multiprofessional team (clinical lead, matron, all grades of medical staff, all grades of nursing staff, medical and nursing students, emergency pharmacist, domestic violence team, general manager, practice development team and alcohol liaison nurse). The results demonstrated that staff mostly supported the new morning handover structure. It was thought to be a very useful source of information in regards to departmental and trust updates in a multiprofessional forum (75 staff members). Staff members felt it was a forum for interprofessional education (65 staff members). Also, majority agreed that it improved patient care and operational issues within the department and trust wide (67 staff members).ConclusionsOur unique morning handover structure ensures patient safety as well as appropriate transfer of information and responsibility to all involved with the care of patients in the Emergency Department. It offers the opportunity for multiprofessional learning, encourages team work and improves the operational processes within the Emergency Department.
Although cocaine induced myopathy and myotoxicity are described in the literature, we report a rare case of cocaine induced paraspinal myositis presenting with acute sciatic symptoms. A 35-year-old man presented with acute left-sided sciatica and was discharged from the emergency department (ED). He subsequently attended ED the following day in severe pain and bilateral sciatic symptoms, but denied symptoms of neurogenic bowel/bladder disturbance. Clinical examination was limited by severe pain: focal midline lumbar tenderness was elicited on palpation, per rectal and limb examinations were within normal limits with no significant neurological deficit. He was admitted for observation and pain management. His blood tests revealed a leucocyte count of 21.5×109/L, C reactive protein of 89 mg/L and deranged renal function with creatinine of 293 μmol/L. An urgent lumbar spine MRI was arranged to rule out a discitis or epidural abscess. Lumbar MRI did not demonstrate any features of discitis but non-specific appearances of paraspinal inflammation raised the suspicion of a paraspinal myositis. Creatinekinase (CK) was found to be 66329 IU/L and a detailed history revealed he was a cocaine user. Paraspinal muscle biopsy confirmed histological features compatible with myositis. Other serological tests were negative, including anti-GBM, ANCA, ANA, Rheumatoid factor, Hep B, Hep C, myositis specific ENA, Treponema pallidum, Borrelia burgdorferi, Rickettsia, Leptospira, EBV and CMV. There was good clinical response to treatment with prednisolone 20 mg OD with an improvement in renal function, CK levels and CRP. He had resumed normal activities and return to work at 6-week follow-up. A detailed social history including substance misuse is important in patients presenting to the ED—especially in cases of severe musculoskeletal pain with no obvious localising features. Drug induced myotoxicity, although rare, can result in symptomatic patients with severe renal failure.
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