Could this be measles?

Infection with the measles virus causes an unpleasant disease with many potentially serious complications. It is predominantly a childhood illness but can affect any age. Measles is extraordinarily contagious, but immunisation with measles containing vaccine provides comprehensive protection. An international programme of universal immunisation from the mid-1980s has been very effective; measles was declared eliminated in the USA nearly two decades ago and became a rarity in other countries with high rates of vaccine uptake. Until recently, this was a forgotten disease in high-income countries, but paediatricians, emergency and primary care physicians worldwide are now encountering measles with increased frequency. Attributed to international travel and pockets of vaccine hesitancy locally, new outbreaks of measles have been recorded in many regions thought to have been free of the disease. Because it was previously so uncommon, measles presents a diagnostic challenge and an unrecognised case may cause infection to spread among communities. The present article presents a case of confirmed measles infection and discusses the epidemiology, clinical features, investigation, management and prevention of measles.

Could this be whooping cough?

Whooping cough is a notifiable bacterial respiratory infection caused by Bordetella pertussis It may produce serious disease, especially in immunocompromised individuals and very young children. The number of reported cases increases in the winter months and the incidence peaks every 4-5 years. However, this periodicity is variable and is inconsistent between different geographical regions. Bordetella pertussis infection (BPI) may be underdiagnosed because of its seasonality and the fact that clinical features may be indistinguishable from other respiratory disorders in the paediatric ED setting. Treatment with antibiotics reduces the period of infectivity but may not shorten the illness. This review discusses the epidemiology of the disease, its clinical features, diagnosis, treatment and the disposition of patients with BPI.

Critical care in the Emergency Department: organ donation.

Organ transplantation is associated with improved outcomes for some patients with end-stage organ failure; however, the number of patients awaiting a transplant exceeds the available organs. Recently, an extended role has been proposed for EDs in the recognition and management of potential donors. The present review presents an illustrative case report and considers current transplantation practice in the UK. Ethical and legal considerations, the classification of deceased donors and future developments promising greater numbers of organs are discussed.

Critical care in the emergency department: acute kidney injury.

Acute kidney injury (AKI) is common among emergency department patients admitted to hospital. There is evidence of inadequate management of the condition leading to adverse outcomes. We present an illustrative case of AKI complicating a gastrointestinal disorder in an older adult. We discuss the clinical presentation, assessment and management of AKI with reference to recent consensus guidelines on classification and treatment.

Neutrophil to lymphocyte count ratio as an early indicator of blood stream infection in the emergency department.

OBJECTIVES: Early identification of patients with blood stream infection (BSI), especially bacteraemia, is important as prompt treatment improves outcome. The initial stages of severe infection may be characterised by increased numbers of neutrophils in the peripheral blood and depression of the lymphocyte count (LC). The neutrophil to LC ratio (NLCR) has previously been compared with conventional tests, such as C-reactive protein (CRP) and white cell count (WCC), and has been proposed as a useful marker in the timely diagnosis of bacteraemia. METHODS: Data on consecutive adult patients presenting to the emergency department with pyrexial illness during the study period, November 2009 to October 2010, were analysed. The main outcome measure was positive blood cultures (bacteraemia). Sensitivity, specificity, positive and negative predictive values and likelihood ratios were determined for NLCR, CRP, WCC, neutrophil count and LC. RESULTS: 1954 patients met the inclusion criteria. Blood cultures were positive in 270 patients, hence the prevalence of bacteraemia was 13.8%. With the exception of WCC, there were significant differences in the mean value for each marker between bacteraemic and non-bacteraemic patients (p<0.001). The area under the receiver operating characteristic curve was highest for NLCR (0.72; 95% CI 0.69 to 0.75) and LC (0.71; 0.68 to 0.74) and lowest for WCC (0.54; 0.40 to 0.57). The sensitivity and specificity of NLCR for predicting bacteraemia were 70% (64% to 75%) and 57% (55% to 60%), respectively. Positive and negative predictive values for NLCR were 0.20 (0.18 to 0.23) and 0.92 (0.91 to 0.94), respectively. The positive likelihood ratio was 1.63 (1.48 to 1.79) and the negative likelihood ratio was 0.53 (0.44 to 0.64). CONCLUSIONS: Although NLCR outperforms conventional markers of infection, it is insufficient in itself to guide clinical management of patients with suspected BSI, and it offers no advantage over LC. However, it may offer some diagnostic utility when taken into account as part of the overall assessment.

Critical care in emergency department: massive haemorrhage in trauma.

Inadequate resuscitation of major haemorrhage is an important cause of avoidable death in severely injured patients. Early recognition of blood loss, control of bleeding and restoration of circulating volume are critical to the management of trauma shock, and transfusion of blood components is a key intervention. Vital signs may be inadequate to determine the need for transfusion, and resuscitation regimens targeting vital signs may be harmful in the context of uncontrolled bleeding. This article addresses current concepts in haemostatic resuscitation. Recent guidelines on the diagnosis and treatment of coagulopathy in major trauma, and the role of component and adjuvant therapies, are considered. Finally, the potential role of thromboelastography and rotational thromboelastometry are discussed.

Towards evidence-based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 4: Prognostic value of B-type natriuretic peptides (BNP and NT-proBNP) in community-acquired pneumonia.

A short cut review was carried out to establish the prognostic value of B-type natriuretic peptides (BNP and NT-proBNP) in community acquired pneumonia (CAP). Three cohort studies were directly relevant to the question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. The clinical bottom line was that B-type natriuretic peptides have prognostic value in CAP but further prospective studies were needed to assess their application in clinical practice.

Critical care in the emergency department: acute respiratory failure.

Acute respiratory failure (ARF) is a frequent emergency department (ED) presentation. The definition and common causes of ARF are discussed in this article and ED management of the condition is discussed, using an illustrative case report. The paper considers the role of B-type natriuretic peptide in diagnosis and non-invasive ventilation (NIV) in treatment. Intensive care unit admission denial is common in ARF, although the evidence base is lacking. Finally, the decision-making process is described when a patient with ARF fails to improve with NIV.

Influence of a previous neck sprain on recovery after whiplash injury.

The impact of a previous neck sprain on recovery from whiplash injury is unknown as published studies have produced conflicting results. This article reviews the literature on the prognosis of a second whiplash injury, distinguishing between previous injuries with and without complete recovery. The best available evidence suggests that a previous injury with incomplete recovery represents an adverse prognostic indicator. However, where there has been complete recovery, the prior injury does not influence the prognosis.