Volume 17

Screening instruments for identification of vulnerable older adults at the emergency department: a critical appraisal

Original Articles, Volume 17, Issue 3, Pages 117 – 172 (2018)

Abstract

Background: Early detection of vulnerable older adults at the emergency department (ED) and implementation of targeted interventions to prevent functional decline may lead to better patient outcomes.

Objective: To assess the level of agreement between four frequently used screening instruments: ISAR-HP, VMS, InterRAI ED Screener and APOP.

Methods: Observational prospective cohort study in patients ≥ 70 years attending Dutch ED.

Results: The prevalence of vulnerability ranged from 19% (APOP) to 45% (ISAR-HP). Overall there was a moderate agreement between the screening instruments (Fleiss Kappa of 0.42 (p<0.001)). Conclusion: Depending on the screening instrument used, either only a small percentage or almost as many as half of the presenting patients will be eligible for targeted interventions, leading to large dissimilarities in working processes, resources and costs.

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A case of Osmotic demyelination syndrome despite normal rate of Sodium correction with good recovery

Case Reports, Volume 17, Issue 3, Pages 117 – 172 (2018)

The Osmotic demyelination syndrome (ODS) primarily occurs with rapid correction of severe hyponatraemia that has been present for more than two or three days. Some patients are, however at risk and can develop ODS at higher sodium concentration and lower rates of correction. A case of Osmotic demyelination Syndrome which developed despite an ‘optimal’ rate of correction of serum Sodium with good clinical outcome is described. The risk factors that contribute to development of ODS and strategies to prevent this complication are discussed, along with recommendations on how to manage this condition in hospital inpatients.

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Times are A-Changin’: self-poisoning and ICU admissions in the northern part of the Netherlands

Original Articles, Volume 17, Issue 3, Pages 117 – 172 (2018)

Introduction: We noticed that fewer patients with self-poisoning were transferred from the ED to the Intensive Care Unit (ICU) than previously. To objectify this, we evaluated ED and ICU admissions in two time periods.

Methods: The number of admissions was collected during 1994-1998 and 2010-2014. As a sample survey, full records of patients with an intoxication from January 2010 till December 2010 were studied.

Results: From 2010-2014 26 patients/year were admitted from the ED to the ICU; from 1994-1998 51 patients/year (p=0.0001). In 2010, 270 patients presented to our ED; 31 were admitted to the ICU; 1 patient died. Time spent in the ED was 236 min for patients who went home, 290 min for patients who went to a nursing ward and 185 minutes for patients transferred to the ICU.

Conclusion: We found indeed fewer ICU admissions in recent years. Changing work routines - a longer observation period in the ED, causing a workload shift from the ICU to the ED, more than changing patient or drug characteristics, may be the cause for this development.

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Abnormal cardiac conduction in a septic patient: incidental finding or cause for concern?

Picture Quiz - Answers, Volume 17, Issue 2, Pages 57 – 116 (2018)

The initial ECG (figure 1A) demonstrates a regularly irregular rhythm at approximately 80bpm. There is a profound first-degree atrioventricular(AV) block with a PR interval of over 400ms. There is monomorphic ventricular ectopy in a right bundle branch pattern. The baseline QRS complexes are narrow.

Abnormal cardiac conduction in a septic patient: incidental finding or cause for concern? Read More

Assessment of Fluid responsiveness in the Acute Medical Patient and the Role of Echocardiography

Review Articles, Volume 17, Issue 2, Pages 57 – 116 (2018)

Both hyper and hypovolaemia have been associated with poor outcomes. Assessment of fluid responsiveness is challenging in the acute medical patient, due to time constraints, limited evidence and quite often the lack of accurate assessment tools on the Acute Medicine Unit (AMU). This article explains how focused echo assessment is quick and easy to use for this purpose on the acute medical take and highlights key principles to bear in mind when assessing for hypovolaemia and whether to administer fluid therapy. The increasing familiarity with focused echo such as Focused Intensive Care Echocardiography (FICE) and Point Of Care Ultrasound (POCUS) makes extension of these skill sets to assess for fluid responsiveness a relatively straightforward next step for acute physicians.

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Iliofemoral deep vein thrombosis and the problem of post-thrombotic syndrome

Review Articles, Volume 17, Issue 2, Pages 57 – 116 (2018)

Deep vein thrombosis (DVT) is an important cause of short-term mortality and long-term morbidity. Among the different presentations of DVT, thrombus in the iliofemoral veins may be considered the severest form. Although anticoagulation is the mainstay of the management of iliofemoral thrombosis, despite adequate anticoagulant treatment, complications including post-thrombotic syndrome is not uncommon. The latter is often overlooked but can cause considerable morbidity to the affected individuals. Preventing this condition remains a challenge but recent clinical trials of catheter directed thrombolysis and elasticated compression stockings provide some advance in this context. In this article, with the aid of a clinical case, we review the particular considerations to take into account when managing patients with an iliofemoral DVT.

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Abnormal cardiac conduction in a septic patient: incidental finding or cause for concern?

Picture Quiz, Volume 17, Issue 2, Pages 57 – 116 (2018)

A 64-year-old male presents to the emergency department in acute respiratory distress. He gives a limited history of progressive shortness of breath of one week’s duration and several episodes of sudden unexplained syncope. There was no history of chest pain, palpitations or localising symptoms of infection. He takes no regular medications.

Abnormal cardiac conduction in a septic patient: incidental finding or cause for concern? Read More

Successful intravenous lipid emulsion therapy: Olanzapine intoxication

Case Reports, Volume 17, Issue 2, Pages 57 – 116 (2018)

Abstract

Olanzapine is an antipsychotic drug used in psychiatric diseases. At high doses it exhibits cardiovascular and neurological sideeffects in particular. Lipid emulsion therapy for the removal of medication from plasma in high-dose lipophilic drug use has recently become very widespread. In the light of current literature, this report discusses the successful treatment of a patient within 4 hrs of olanzapine overdose as an attempted suicide, who presented with agitation and clouded consciousness

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