Christiane Vorwerk

Prediction of mortality in adult emergency department patients with sepsis

Objectives: To determine the efficacy of the abbreviated Mortality in Emergency Department Sepsis (MEDS) score, the Modified Early Warning (MEW) score and near-patient-test (NPT) lactate levels in predicting 28-day mortality in adult emergency department (ED) patients with sepsis. Methods: A retrospective cohort study of adult ED patients with sepsis admitted to hospital was conducted in a large urban teaching and a district general hospital. Data were collected during four time periods between 1 January 2006 and 31 January 2007. Inclusion criteria were age ⩾16 years and an ED diagnosis of sepsis. Primary outcome for all patients was 28-day mortality. Patients were preassigned to risk groups according to their abbreviated MEDS score, MEW score and NPT lactate. Results: 307 ED patients with sepsis were included in the study. Among these there were 72 deaths (23%). Mortality rates for the low-, moderate- and high-risk groups of the abbreviated MEDS score were 1/63 (1.6%), 48/205 (23.4%) and 23/39 (59.0%) patients. The MEDS score for low-risk patients was 98.6% (95% CI 92.5% to 99.9%) sensitive and 26.5% (95% CI 21.0% to 32.6%) specific and for high-risk patients it was 31.9% (95% CI 21.4% to 44.0%) sensitive and 93.2% (95% CI 89.2% to 96.1%) specific for death within 28 days. Mortality rates for the low- and high-risk MEW score were 20/159 (12.6%) and 52/148 (35.1%) patients. The MEW score for high-risk patients was 72.2% (95% CI 60.4% to 82.1%) sensitive and 59.2% (95% CI 52.6% to 65.5%) specific for mortality. An NPT lactate level of ⩾4 mmol/l was 49.1% (95% CI 35.1% to 63.2%) sensitive and 74.3% (95% CI 64.8% to 82.3%) specific for 28-day mortality. Conclusion: These results demonstrate the efficacy of the abbreviated MEDS score, the MEW score and NPT venous lactate levels in predicting 28-day mortality in ED patients with sepsis. The abbreviated MEDS score was found to be the best performing risk assessment model which, with prospective validation, may aid early clinical decision-making in ED patients with sepsis and might affect the outcome from sepsis.

The prognostic value of tissue oxygen saturation in emergency department patients with severe sepsis or septic shock

Objectives To determine the derangement of muscle tissue oxygen saturation (StO2) in the early phase of emergency department (ED) sepsis management and its relationship to 30-day mortality in patients with severe sepsis or septic shock. Methods A prospective cohort study conducted in the ED of a university hospital. Patients were included if they had a clinical diagnosis of severe sepsis or septic shock. Thenar muscle tissue StO2 on arrival in the ED and its change with usual ED sepsis management was measured using near-infrared spectroscopy. A follow-up measurement was obtained after 24 h of treatment. All patients were followed for 30 days. Results 49 patients were included, of which 24 (49%) died. There was no difference in mean StO2 on arrival in the ED between survivors and non-survivors (72% vs 72%; p=0.97). Following ED treatment the mean StO2 of survivors improved significantly to 78% (p<0.05) while StO2 remained persistently low in non-survivors (p=0.94). Persistently low StO2 (<75%) despite initial resuscitative treatment was associated with a twofold increase in mortality (RR of death 2.1%; 95% CI 1.2% to 3.5%). Conclusion Patients with severe sepsis/septic shock have abnormal muscle tissue StO2 upon arrival in the ED. Inability to normalise StO2 with ED sepsis management is associated with a poor outcome. The role of StO2 as an early prognostic and potential therapeutic biomarker in severe sepsis or septic shock warrants further exploration.

Prediction of severe bacterial infection in children with an emergency department diagnosis of infection

Objective To determine the relationship between near-patient-test (NPT) lactate, white blood cell count (WBC) and C-reactive protein (CRP) and severe bacterial infection (SBI) in children presenting to the emergency department (ED) with infection. Methods An observational cohort study was undertaken in a paediatric emergency department of a large urban teaching hospital. Data were collected from January 2007 until December 2007. Inclusion criteria were age <16 years, blood test including NPT lactate obtained in the ED and infection-related ED diagnosis. Patients were pre-assigned to risk groups according to their NPT lactate, WBC and CRP. Results 506 children were included in the study, of which 42 (8.3%) had SBI. NPT lactate, WBC and CRP were significantly higher in the SBI cohort. High-risk NPT lactate (≥4 mmol/l) had a sensitivity of 38.1% (95% CI 23.6% to 54.4%) and a specificity of 89.7% (95% CI 86.5% to 92.3%); high-risk WBC (<5 or ≥15×109/l) had a sensitivity of 51.2% (95% CI 35.1% to 67.1%) and a specificity of 73.8% (95% CI 69.4% to 77.8%); and high-risk CRP (≥50 mg/l) had a sensitivity of 36.8% (95% CI 21.8% to 54.1%) and a specificity of 83.6% (95% CI 79.4% to 87.2%) for SBI. All three high-risk markers combined yielded a sensitivity of 5.3% (95% CI 1.5% to 17.3%) and a specificity of 99.2% (95% CI 97.6% to 99.7%) for SBI. Conclusion The data from our study suggest that NPT lactate provides early diagnostic information about the risk of SBI in children presenting to the ED with a suspected infection. Combining NPT lactate with WBC and CRP resulted in a promising rule-in-tool for SBI in children in the ED which, with prospective validation, has the potential to aid early identification of SBI in children.

Thoracic electrical bioimpedance: a tool to determine cardiac versus non-cardiac causes of acute dyspnoea in the emergency department

Objectives To determine whether cardiohaemodynamic parameters, using non-invasive thoracic electrical bioimpedance (TEB), can differentiate between cardiac and non-cardiac causes of acute breathlessness in adult emergency department (ED) patients. Methods A prospective cohort study of adult patients who presented with acute breathlessness to the ED of a large urban teaching hospital. Study patients had their cardiohaemodynamic parameters measured, using a TEB device. The patient’s hospital discharge diagnosis was used as the definitive diagnosis to determine whether the underlying cause of acute dyspnoea was cardiac or non-cardiac related. The definitive diagnosis was compared with the TEB data and the ED physician’s diagnosis. Results 52 patients were recruited into the study, of whom 51 had complete TEB data and were included in the analysis. There were statistically significant differences in cardiac output (6.2 vs 7.9, p<0.001), cardiac index (CI; 3.1 vs 4.4, p<0.001), systemic vascular resistance (1227 vs 933, p=0.002) and systemic vascular resistance index (2403 vs 1681, p<0.001) between the cardiac and non-cardiac cohort. CI was found to be an excellent discriminator (receiver operating characteristics area under the curve 0.906). The optimal diagnostic criterion for CI to distinguish between cardiac and non-cardiac dyspnoea was 3.2 l/min per square metre or less (positive likelihood ratio 7.9; negative likelihood ratio 0.14). Conclusion This study demonstrated that non-invasive TEB cardiohaemodynamic parameters can differentiate between cardiac and non-cardiac-related causes of dyspnoea in ED patients presenting with acute breathlessness. A large-scale trial is required to determine if TEB-derived cardiohaemodynamic information can aid ED clinicians in their early clinical decision-making and improve the care and outcome of patients with dyspnoea.

Use of helium-oxygen mixtures in the treatment of croup: a systematic review

Objective: To determine the effect of helium-oxygen inhalation on relieving symptoms and distress in children with croup as measured by the croup score, and to identify areas of uncertainty for future research. Methods: Systematic review of prospective randomised and non-randomised controlled trials of children with the clinical diagnosis of croup, comparing the effect of helium-oxygen mixtures with placebo or any active treatment. Outcome measures were change in croup score, physiological parameters, hospital admission rates, need for intubation and adverse events. All records as identified by a systematic search strategy were assessed independently by two reviewers. Results: Two trials were identified for inclusion assessing the effect of helium-oxygen inhalation in children with croup in an emergency department. In one trial the control group received humidified oxygen and in the other nebulised epinephrine. An improvement in the mean croup score over time was seen in the control and intervention groups of both trials, with no significant difference between the groups. Significant methodological and clinical heterogeneity in the design of the trials precluded a meaningful meta-analysis. Conclusion: At present there is no evidence to support the use of helium-oxygen therapy in children with croup. Methodologically well-designed and adequately powered randomised controlled trials are needed to determine whether helium-oxygen inhalation as part of the initial treatment in croup alters outcome.

In an emergency - call the clinical librarian!

This paper reviews the role of the clinical librarian in the emergency department.

BET 1: HELIOX IN CROUP

Report by Christiane Vorwerk , Specialist Registrar in Emergency Medicine Search checked by Tim Coats , Consultant in Emergency Medicine Institution: Emergency Department, Leicester Royal Infirmary, Leicester, UK #### Three-part question In [children with croup] is [heliox] effective in [relieving symptoms and reducing croup score]? View this table: Table 1 Relevant papers #### CLINICAL SCENARIO A 2½-year-old girl is brought to the emergency department in respiratory distress. Her father tells you that he noticed a barking cough throughout the night and that her breathing was becoming noisier. On examination the child is …

Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 1: Heliox in croup.

Report by Christiane Vorwerk , Specialist Registrar in Emergency Medicine Search checked by Tim Coats , Consultant in Emergency Medicine Institution: Emergency Department, Leicester Royal Infirmary, Leicester, UK #### Three-part question In [children with croup] is [heliox] effective in [relieving symptoms and reducing croup score]? View this table: Table 1 Relevant papers #### CLINICAL SCENARIO A 2½-year-old girl is brought to the emergency department in respiratory distress. Her father tells you that he noticed a barking cough throughout the night and that her breathing was becoming noisier. On examination the child is …

MEWS: predicts hospital admission and mortality in emergency department patients

The paper by Burch et al 1 on the modified early warning (MEW) score predicting hospital admission and inhospital mortality is both interesting and topical. I agree with the authors that the MEW score, a risk assessment tool now widely used in UK emergency departments (ED) to facilitate the early identification of high-risk patients, is a good predictor of inhospital mortality.2 I also share the authors’ concerns that there are limitations to using the MEW score and that the MEW …

Survey of neonatal resuscitation equipment in emergency departments in the UK

Objective All emergency departments (EDs) should be adequately equipped and prepared to deal with unexpected neonatal deliveries and resuscitation. A study was undertaken to determine what neonatal resuscitation equipment is available in EDs in the UK and to formulate recommendations for improvement. Methods A prospective telephone survey of all UK EDs was conducted between November 2008 and February 2009 to determine the type of neonatal resuscitation equipment available as recommended in the fourth edition of the APLS guidelines. Results 169 EDs were identified, 137 (81%) of which successfully completed the survey. The majority of EDs followed APLS recommendations for provision of neonatal resuscitation equipment. There was a particularly good availability of basic airway equipment (99%), but 11% did not have a source of warmth, 5% lacked advanced airway equipment and 31% had no equipment for obtaining umbilical access. A Resuscitaire was present in 47% of EDs surveyed. Conclusion There is a good level of provision of neonatal resuscitation equipment in UK EDs, although certain areas need to be addressed. There is a particular need for improving the provision of warming and advanced airway equipment. The authors consider that it is not necessary to have a neonatal Resuscitaire in the ED provided other equipment is readily available. The findings of this survey prompt the recommendation that all EDs should review their neonatal resuscitation equipment in accordance with APLS guidance, and ensure that staff have immediate access to this equipment and are comfortable with its use.