Page 204 - TNFlipTest

ER24 Emergency Medicine
Approach to Common ED Presentations
Toronto Notes 2019
WhichPatientscanSafelyUndergoLumbarPunctureWithout Screening CT?
N Engl J Med 2001;345:1727-33 Purpose:Toinvestigatewhethertheabsenceofcertain
clinical features at baseline may be used to identify adults with suspected meningitis who were unlikely to have abnormal computed tomography (CT) findings. Methods:Adultswithsuspectedmeningitisseeninthe Emergency Department were prospectively studied. Data
for the following baseline characteristics was collected: sociodemographic characteristics, co-existing conditions (basedonCharlsoncomorbidityindex),presence/absence
of immunocompromised state, clinical features, neurological abnormalities, laboratory results and management decisions. CT was performed, and results were interpreted in duplicate by staff radiologists and neuroradiologists unaware of the patients’ clinical findings.
Results: 301 adults with suspected meningitis were included, of which 235 underwent CT head scans prior to a lumbar puncture. Baseline clinical findings associated with an abnormal CT head finding were: age of at least 60 years, immunocompromised state, history of central nervous system disease, and history of seizure within 1 wk prior to presentation, and several neurological abnormalities (abnormal level of consciousness, inability to answer two consecutive questions or follow two consecutive commands, gaze palsy, abnormal visual fields, facial palsy, arm drift, leg drift, and abnormal language (e.g., aphasia). None
of these features were present at baseline in 96 of 235 (41%) patients who underwent CT scanning. The CT head scan was normal in 93 of these 96 patients (negative predictive value 97%). Conclusion: In adults with suspected meningitis, clinical features may identify those unlikely to have abnormal CT scan findings.
Parenteral Dexamethasone for Preventing Recurrence of Acute Severe Migraine Headache
BMJ 2008;336(7657):1359
Purpose: To examine effectiveness of parenteral corticosteroids for relief of acute sevaere migraine headache and prevention of recurrent headaches.
Methods: Meta-analysis of RCTs comparing corticosteroids (alone or in combination with standard abortive therapy) to placebo or any other standard treatment for acute migraine in adults.
Results: Seven RCTs met eligibility criteria, all of which used standard abortive therapy and subsequently compared single dose parenteral dexamethasone to placebo. All trials examined pain relief and recurrence of headache within 72 hr. While dexamethasone and placebo were comparable for acute pain reduction (mean difference 0.37, 95% CI -0.20 to 0.94) and side effect profiles, dexamethasone provided lower recurrence rates (relative risk 0.75, 0.60 to 0.90; number needed to treat 9). Conclusion: Single dose parenteral dexamethasone with standard abortive therapy is associated with a 26% relative reduction in headache recurrence within 72 h.
CT Head within 6 h is 100% Sensitive for Diagnosis of Subarachnoid Hemorrhage (SAH)
BMJ 2012;343(d4277)
Purpose: To measure the sensitivity of CT in emergency patients being evaluated for possible SAH, particularly when carried out within 6 h of headache onset.
Methods: A prospective multicentre cohort study was conducted in 11 tertiary care emergency departments across Canada to measure the sensitivity of CT head in the evaluation of ED patients for SAH. Neurologically intact adults who presented with new onset non-traumatic headache reaching maximum intensity in less than one hour who had head CT as part of their diagnostic workup to rule out SAH were considered eligible. Patients were deemed positive for SAH if there was subarachnoid blood on CT, xanthochromia in the CSF or red blood cells in the final tube of CSF collected. Some patients with normal results on CT received LPs at the discretion of the treating physician. Unless patients had a negative result on LP or a definitive cause for the headache identified through neuroimaging patients were followed for six mo to ascertain their outcome. Primary outcome was CT results interpreted by a staff radiologist.
Results: 3,132 patients were enrolled (mean age 45.1 yr, 2,571 (82.1%) reporting worst headache ever). Overall sensitivity of
CT for detecting subarachnoid hemorrhage was 92.9% (95%
CI 89.0% to 95.5%), specificity was 100% (99.9% to 100%), negative predictive value was 99.4% (99.1% to 99.6%) and positive predictive value was 100% (98.3% to 100%). For patients scanned within 6 h of symptom onset (n=953), sensitivity was 100% (97.0% to 100.0%), specificity was 100% (99.5% to 100%), negative predictive value was 100% (99.5% to 100%) and positive predictive value was 100% (96.9% to 100%)..
Conclusion: CT is highly sensitive in identifying subarachnoid hemorrhage when it is carried out within 6 h of headache and interpreted by a qualified radiologist.
■ increased ICP
◆ worse in morning, when supine or bending down, with cough or valsalva ◆ physical exam: neurological deficits, cranial nerve palsies, papilledema
◆ diagnosis: CT head
◆ management: consult neurosurgery
■ meningitis (see Infectious Diseases, ID18)
◆ flu-like symptoms (fever, N/V, malaise), meningeal signs, petechial rash
◆ altered LOC and confusion
◆ rule out increased ICP; if CT head and mental status normal, if no neurological signs and no
papilledema, then do LP for diagnosis
◆ treatment: early empiric antibiotics ± acyclovir, steroid therapy
■ temporal arteritis (causes significant morbidity, blindness) (see Ophthalmology, OP35)
◆ vasculitis of large and mid-sized arteries, gender 3:1 F:M, most commonly age >70 yr
◆ headache, scalp tenderness, jaw claudication, arthralgia, myalgia, fever, malaise or weight loss
◆ temporal artery tender on palpation, relative afferent pupillary defect (RAPD), optic disc edema
on fundoscopy
◆ labs: elevated ESR, CRP
◆ temporal artery biopsy is gold standard for diagnosis
◆ associated with polymyalgia rheumatica
◆ treatment: high-dose steroids immediately if suspected, no need to hold treatment until
pathology results
Disposition
• admission:ifunderlyingdiagnosisiscriticaloremergent,ifthereareabnormalneurologicalfindings, if patient is elderly or immunocompromised (atypical presentation), or if pain is refractory to oral medications
• discharge:assessforriskofnarcoticmisuse;mostpatientscanbedischargedwithappropriateanalgesia and follow-up with their family physician; instruct patients to return for fever, vomiting, neurologic changes, or increasing pain
Joint and Back Pain
JOINT PAIN (see Rheumatology, RH3)
• ruleoutlifethreateningcauses:septicjoint(seeOrthopedics,OR11)
History and Physical Exam
• history:recenttrauma,druguse(anticoagulants,glucocorticoids)
• associated symptoms: fever, constitutional symptoms, skin lesions, conjunctivitis, urethritis
• patternsofjointinvolvement:polyarticularvs.monoarticular,symmetricvs.asymmetric
• inflammatorysymptoms:morningstiffness≥30min,pain/stiffnessthateasewithactivity,mid-day
fatigue, soft tissue swelling
• non-inflammatorysymptoms:morningstiffness<30min,stiffnessshort-livedafterinactivity,
increasing pain with activity
• assess for pain with ROM, localized joint pain, effusion, erythema, warmth, swelling, inability to bear
weight, fever; may indicate presence of septic joint
Investigations
• bloodwork:CBC,ESR,CRP,WBC,INR/PTT,bloodcultures,urate
• jointx-ray±contralateraljointforcomparison
• bedside U/S to identify effusion
• testjointaspiratefor:culture,WBC,polynuclearcells,glucose,Gramstain,crystals
Management
• septicjoint:empiricIVantibiotics±jointdecompressionanddrainage
• crystallinesynovitis:NSAIDsathighdose,colchicinewithinfirst24h,corticosteroids
■ do not use allopurinol, as it may worsen acute attack
• acutepolyarthritis:NSAIDs,analgesics(acetaminophen±opioids),localorsystemiccorticosteroids • osteoarthritis: NSAIDs, acetaminophen
• soft tissue pain: allow healing with enforced rest ± immobilization
■ non-pharmacologic treatment: local heat or cold, electrical stimulation, massage
■ pharmacologic: oral analgesics, NSAIDs, muscle relaxants, corticosteroid injections, topical agents
BACK PAIN (see Family Medicine, FM37)
• ruleoutextraspinalemergencies:aorticdissection,AAA,PE,MI,retroperitonealbleed,pancreatitis
• ruleoutspinalemergencies:osteomyelitis,caudaequina,epiduralabscessorhematoma,spinalfracture
History and Physical Exam
• evaluateriskforfracture(osteoporosis,age),infection(IVdruguser,recentspinalintervention, immunosuppression), cancer, vascular causes (cardiac risk factors)
• typicalmusculoskeletalbackpainismoderate,worsewithmovementorcoughwithnovisceral symptoms
• assessvitalsigns,performprecordial,abdominal,andneurologicexaminationoflowerextremities