We were treated to 4 great presentations today, including some original research from Dr Robin Clouston. This months presenters included Dr Paul Vanhoutte, Dr Joanna Middleton, Dr Robin Clouston PGY2 and Dr Reid Sadoway PGY1.
Delirium in the Emergency Department
Dr Paul Vanhoutte
Acute Confusional State
- Delirium
- Dementia
- Amnesia
Delirium
- Disturbance of consciousness
- Change in cognition – (dementia has a more insidious onset)
- Short period of time
- Clinical evidence
Dementia
Investigations
Risk Factors
Some Stats
Confusion Assessment Method (CAMS)
- Acute onset and fluctuating course
- Inattention/distractibility
- Disorganised thinking
- Alteration
Delirium if 1 and 2 with either 3 or 4
Management
Medication
Restraints?
O2 in all (careful if COPD)
Check blood sugar
A discussion on the use restraint followed
Maybe necessary in some circumstances
But should be closely observed
Enables diagnosis of cause and initial treatment
ACEP Guidelines on pharmacoligic treatment
- Undifferentiated agitation: monotherapy with lorazepam/midazolam, droperidol or haliperidol
- Agitation and psychosis: atypical or typical antipsychotic
- Agitated and violent: combo therapy
- Coma cocktail: Thiamine, dextrose, naloxone
- Glucagon IM if no IV access for hypoglycemia
- Treat underlying cause
Take Home Message
- Need to differentiate ACS into Delirium vs Dementia vs Psychiatry
- Big list of triggering differential diagnosis
- High mortality
- Majority will require early stabilisation and admission
- Some maybe appropriately discharged e.g those from NH or with good family
Diagnostic Utility of CRP in the ED
Dr Joanna Middleton
Should we be using it?
How should we use it?
Discussion Point 1
Nurses have noticed that its use has increased in last 2 years
?Change in practice, ?Switch from ESR to CRP
Is CRP the new D-DIMER?
History
An interesting historical outline – see attached pdf of presentation
Discovered in 1930
Used in the 50’s and 60’s extensively
Then lost favour
Resurgence in the 1990’s
Will it loose favour again?
Mechanism
Injury/illness stimulus (Tissue Injury)
IL-6 produced and stimulates liver production of CRP
Takes 4-6 hrs to appear in blood
Exponential rise
Peaks at 48-73hrs
Short hallf life
Levels drop quickly
Therefore good for following disease
What is Normal
Median – 0.8
90th – 3
99th – 10
Horizon: < 4.9
Most published literature has a CRP cut off of 10
Numerous causes of CRP elevation
Cannot differentiate viral from bacterial
Obseity elevate CRP
Class 1 obesity – 11% > 10
Take Home Points
Point #1 for EM CRP levels are not reliable in the first 12 hours after a stimulus…
Point #2: Serial measurements are much more useful than an isolated result
Point # 3 Healthy patients should have a CRP <2-3
Point #4: Much of the published literature used a CRP cut-off of 10…
POINT #5: LOTS OF THINGS ELEVATE CRP – Anything that causes tissue/cell damage
Point #6: CRP cannot differentiate between viral and bacterial unless…
Point # 7: CRP >100 is probably a bacterial infection
Point # 8: JUST ABOUT ANYTHING CAN ELEVATE CRP
Point #9: STEROIDS SCREW UP CRP LEVELS – So do some Auto-immune disease
Point #10 – Joanna’s Rule: If your patient in the ED has a CRP <0.3*…. Then there is probably nothing wrong with them – provided they have had symptoms for > 24hrs (excluding point 9)
See the pdf attached to this post for an analysis of CRP performance in specific conditions
Bottom Line
Maybe helpful in differentiating neonates with serious infection, but requires serial testing.
Maybe helpful in combination with WBC and PMN ratio for ruling out adult appendicitis if they present with pain > 24hrs
Safety in the Emergency Department
Local research: Comparison of ED Crowding Scores
Dr Robin Clouston iFMEM PGY2
Dr Robin Clouston presented her research on ED Safety and Crowding.
The primary goal is to determine which of the six ED Crowding tools and five single variables studied is the best tool to measure the intensity of ED crowding, as compared to the outcome variable of physician rating, measured by Visual Analogue Scale (VAS). i.e. Which ED crowding tool produces a score most closely correlated with the physician VAS?
A secondary goal will be to determine which tool is the best correlated with early emergency department crowding, defined in this study as detection of crowding up to four hours before recognized by clinicians via the Visual Analogue Scale.
Key Results
Of the six formal crowding tools, the DEC ED Saturation Score had the best predictive value with sensitivity of 76.2% and specificity of 64.3%.
For predictions of current safety: the NEDOCS score had the best combined sensitivity and specificity at 80% each,
Single variable with the highest predictive value of safety at time 0 was the “# patients in beds/waiting”
For prediction of safety in 2 hours: again the NEDOCS score most predictive, with sensitivity = 92.7% and specificity=89.5%.
Burns – ED Assessment and Management – Literature Review
Dr Reid Sadoway PGY1