Registrar teaching 10th May 2013

Emergency Neurology Updates

1. Sensitivity of computed tomography performed within six hours of onset of headache for diagnosis of subarachnoid haemorrhage: prospective cohort study.
Perry JJ, Stiell IG, Sivilotti ML, et al. BMJ. 2011 Jul 18;343:d4277Take home points: Non-contrast CTB performed within six hours of headache onset can be considered “rule out” test for subarachnoid haemorrhage, without performing an LP

2. Do children with blunt head trauma and normal cranial computed tomography scan results require hospitalization for neurologic observation?TBI Study Group for the Pediatric Emergency Care Applied Research Network (PECARN). Ann Emerg Med. 2011 Oct;58(4):315Take home points: Kids with minor HI and a normal CTB are safe to discharge home

3. Immediate and delayed traumatic intracranial hemorrhage in patients with head trauma and pre-injury warfarin or clopidogrel use.Clinical Research in Emergency Services and Treatment (CREST) Network. Ann Emerg Med. 2012 Jun;59(6):460-8Take home points: IC bleed is at common in patients taking clopidogrel alone. Delayed ICH is rare in patients taking warfarin or clopidogrel.

4. Management of minor head injury in patients receiving oral anticoagulant therapy: a prospective study of a 24-hour observation protocol.Menditto VG, Lucci M, Polonara S, Pomponio G, Gabrielli A. Ann Emerg Med. 2012 Jun;59(6):451-5Take home points: 6% incidence of delayed ICH in warfarinised patients 24 hrs after an initial normal CTB

5. An analysis of predictive markers for intracranial haemorrhage in warfarinised head injury patients
Authors: Rendell, S et al. Emerg Med J. 2013 Jan;30(1):28-31.
Take home points: Up to 15% of warfarinised patients have an abnormal CTB after head trauma. A subtherapeutic INR is not protective or predictive.

6. The benefits and harms of intravenous thrombolysis with recombinant tissue plasminogen activator within 6 h of acute ischaemic stroke [IST-3]: a randomised controlled trialThe IST-3 collaborative group. Lancet. 2012 Jun 23;379(9834):2352

Take home points: You need to read this one and come to your own conclusions. The following editorials may help clarify your viewpoint:

• The Lancet, Volume 380, Issue 9847 p 1053, 22 September 2012
• Emergency Medicine Australasia (2012) 24, 473–476
• Emergency Medicine Australasia (2012) 24, 477–479

Central venous catheters, CVP, and fluid responsiveness

The five components of the ‘bundle’ that aim to reduce catheter-related blood stream infection are:

• Hand Hygiene
• Maximal Barrier Precautions Upon Insertion
• Chlorhexidine Skin Antisepsis
• Optimal Catheter Site Selection, with Avoidance of the Femoral Vein for Central Venous Access in Adult Patients
• Daily Review of Line Necessity with Prompt Removal of Unnecessary Lines

Further information is here.

Fluid responsiveness

The failure of CVP to predict fluid responsiveness is nicely demonstrated in this landmark study.

A recent summary of methods of predicting fluid responsiveness is here.