RESUMO
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.
Assuntos
Serviço Hospitalar de Emergência/tendências , Doadores de Tecidos/psicologia , Obtenção de Tecidos e Órgãos/métodos , Serviço Hospitalar de Emergência/organização & administração , Serviço Hospitalar de Emergência/estatística & dados numéricos , Humanos , Doadores de Tecidos/estatística & dados numéricos , Doadores de Tecidos/provisão & distribuição , Obtenção de Tecidos e Órgãos/estatística & dados numéricos , Reino Unido , Recursos HumanosRESUMO
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.
Assuntos
Injúria Renal Aguda/diagnóstico , Injúria Renal Aguda/terapia , Cuidados Críticos/métodos , Serviço Hospitalar de Emergência , Idoso , Comorbidade , Consenso , Gastroenteropatias/complicações , Humanos , Masculino , Guias de Prática Clínica como AssuntoRESUMO
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.
Assuntos
Bacteriemia/sangue , Serviço Hospitalar de Emergência , Contagem de Linfócitos , Neutrófilos/citologia , Adulto , Idoso , Bacteriemia/diagnóstico , Biomarcadores/sangue , Proteína C-Reativa/análise , Diagnóstico Precoce , Feminino , Humanos , Contagem de Leucócitos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Curva ROC , Estudos Retrospectivos , Sensibilidade e EspecificidadeRESUMO
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.
Assuntos
Serviço Hospitalar de Emergência , Ressuscitação/métodos , Choque Hemorrágico/terapia , Ferimentos e Lesões/terapia , Transtornos da Coagulação Sanguínea/diagnóstico , Transtornos da Coagulação Sanguínea/terapia , Transfusão de Sangue , Cuidados Críticos , Humanos , Masculino , Pessoa de Meia-Idade , Choque Hemorrágico/diagnóstico , Choque Hemorrágico/prevenção & controle , Tromboelastografia/métodos , Ferimentos e Lesões/complicaçõesRESUMO
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.
Assuntos
Cuidados Críticos , Serviço Hospitalar de Emergência , Doença Pulmonar Obstrutiva Crônica/terapia , Respiração Artificial , Insuficiência Respiratória/terapia , Idoso , Feminino , Humanos , Doença Pulmonar Obstrutiva Crônica/complicações , Insuficiência Respiratória/diagnóstico , Insuficiência Respiratória/etiologiaAssuntos
Serviço Hospitalar de Emergência/organização & administração , Mortalidade Hospitalar/tendências , Sepse/mortalidade , Sepse/terapia , Diagnóstico Precoce , Medicina de Emergência/organização & administração , Medicina Baseada em Evidências , Promoção da Saúde/organização & administração , Humanos , Cooperação Internacional , Guias de Prática Clínica como Assunto , Avaliação de Programas e Projetos de Saúde , Sepse/diagnóstico , Choque Séptico/diagnóstico , Choque Séptico/mortalidade , Choque Séptico/terapia , Análise de Sobrevida , Reino UnidoRESUMO
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.