EM Reflections – October 2019

Thanks to Dr Joanna Middleton for leading the discussions this month

Edited by Dr David Lewis 

Discussion Topics

  1. Subarachnoid Hemorrhage

    • Misdiagnosis of SAH is not infrequent and usually results from common errors
      • Failure to appreciate the spectrum of clinical presentations associated with SAH
      • Failure to obtain a head CT or to understand its limitations in the diagnosis of SAH
  2. Spontaneous Bacterial Peritonitis

    • Like peritonitis but different…
    • Early iv albumin in selected case reduces mortality

Subarachnoid Hemorrhage

Headache is one of the most common reasons for presentation to the emergency department (ED), seen in up to 2% of patients. Most are benign, but it is imperative to understand and discern the life-threatening causes of headache when they present. Headache caused by a subarachnoid hemorrhage (SAH) from a ruptured aneurysm is one of the most deadly, with a median case-fatality of 27–44%. Fortunately, it is also rare, comprising only 1% of all headaches presenting to the ED

Approach to the Diagnosis and Management of Subarachnoid Hemorrhage


Missed Diagnosis

Missed Diagnosis of Subarachnoid Hemorrhage in the Emergency Department

Over 3 years there were 1603 patients hospitalized with a diagnosis of nontraumatic SAH; 1507 (94.0%) of these were admitted through the ED. Of the 176 EDs in the province, 147 (83.5%) admitted at least 1 patient with SAH, ranging from 1 to 49 per ED. Of these, 38 (25.9%) were in small hospitals, 93 (63.3%) in community hospitals, and 16 (10.9%) in teaching hospitals. With the exception of age, triage level, and hospital type, persons with missed SAH did not differ from those initially diagnosed with SAH.

A total of 150 (10.0%; 95% CI, 8.5 to 11.6) patients had an ED visit in the 14 days preceding their SAH admission. SAH was missed on a prior ED visit in 81 (5.4%; 95% CI, 4.3 to 6.6) cases.

The majority of missed cases were diagnosed with “migraine” or “headache” at the prior related visit


Spontaneous Bacterial Peritonitis

…spontaneous bacterial peritonitish

similar but more subtle

The signs and symptoms of SBP are subtle compared with those seen in patients with bacterial peritonitis in the absence of ascites – By separating the visceral from the parietal peritoneal surfaces, ascites prevents the development of a rigid abdomen


Fever = >37.8

Who to test?

In addition, patients with ascites admitted to the hospital for other reasons should also undergo paracentesis to look for evidence of SBP. A low clinical suspicion for SBP does not obviate the need for testing

E.coli ~50%


Intravenous Albumin?

It is estimated that 12-25% of patients with ascites in the ED will have spontaneous bacterial peritonitis (SBP) but the classic triad of fever, abdominal pain, and worsening ascites is often absent (Borzio 2001)(Runyon 1988). With a mortality rate approaching 40%, rapid diagnosis and evidence-based treatment is critical in the management of patients presenting with SBP (Salerno 2013).

The 2012 AASLD Guidelines, based largely on the trial by Sort, et al., recommend that patients with ascitic fluid PMN counts greater than or equal to 250 cells/mm3 and clinical suspicion of SBP, who also have a serum creatinine >1 mg/dL, blood urea nitrogen >30 mg/dL, or total bilirubin >4 mg/dL should receive IV albumin (1.5 g/kg) within 6 hours of detection and 1.0 g/kg on day 3. (Class IIa, Level B)

Should You Give Albumin in Spontaneous Bacterial Peritonitis (SBP)?



Further Reading

Spontaneous Bacterial Peritonitis


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