Emergency medicine journal : EMJ
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Recent evidence suggests that presenting GCS may be higher in older rather than younger patients for an equivalent anatomical severity of traumatic brain injury (TBI). The aim of this study was to confirm these observations using a national trauma database and to test explanatory hypotheses. ⋯ For an equivalent severity of intracranial injury, presenting GCS is higher in older patients than in the young. This observation is unlikely to be explained by differences in mechanism of injury or types of intracranial injury between the two groups.
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Management of isolated calf deep vein thrombosis is an area of significant international debate and variable clinical practice. Both therapeutic anticoagulation and conservative management carry risk. As clinical care of suspected and confirmed venous thromboembolic disease increasingly becomes the remit of emergency medicine, complex decisions are left to practising clinicians at the front door. ⋯ Estimates of haemorrhagic risk are based on robust data from large prospective management studies of venous thromboembolic disease; the risks of untreated calf deep vein thrombosis are based on small cohorts and therefore less exact. Pending further trial evidence, these risks should be discussed with patients openly, in the context of personal preference and shared decision-making. Anticoagulation may maximally benefit those patients with extensive and/or symptomatic disease or those with higher risk for complication (unprovoked, cancer-associated or pregnancy).
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To identify studies describing the accuracy of prehospital sepsis identification and to summarise results of studies of prehospital management of patients with sepsis, severe sepsis or septic shock. ⋯ The evidence suggests that identification of sepsis in the prehospital setting by EMS providers is carried out with varied success, depending on the strategy used; however, high-quality studies are lacking. Relying on provider impression alone had poor sensitivity, but some moderate-quality evidence supporting structured screening for sepsis with vital signs criteria demonstrated modest sensitivity and specificity. Additional research to improve diagnostic accuracy and explore improvements in EMS management is needed.
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A short cut review was carried out to establish whether prehospital blood transfusion in the trauma patient with active haemorrhage can reduce mortality. 11 directly relevant papers were found using the reported search strategy. Of these two presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. It is concluded that prehospital blood transfusion may reduce short-term mortality in these patients, but that the evidence level is low and further definitive randomised controlled trials are needed to prove benefit.
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Long-term oral anticoagulant (OAC) therapy is used for the treatment and prevention of thrombosis and thromboembolism. As OAC use is so widespread, emergency physicians are likely to encounter patients on anticoagulant therapy in the emergency department (ED) on a regular basis, either for the same reasons as the population in general or as a result of the increased bleeding risk that OAC use entails. ⋯ However, the INR does not give an accurate evaluation of coagulation status with NOACs, and alternative tests are therefore needed for use in emergency settings. This paper discusses what information the INR provides for a patient taking warfarin and which coagulation tests can guide the physician when treating patients on one of the NOACs, as well as other differences in emergency anticoagulation management.