Volume 20

A prospective, observational study of the performance of MEWS, NEWS, SIRS and qSOFA for early risk stratification for adverse outcomes in patients with suspected infections at the emergency department

Original Articles, Volume 20, Issue 2, Pages 89-156 (2021)

Background: Many patients with suspected infection are presented to the emergency Department. Several scoring systems have been proposed to identify patients at high risk of adverse outcomes.

Methods: We compared generic early warning scores (MEWS and NEWS) to the (SIRS) criteria and quick Sequential Organ Failure Assessement (qSOFA), for early risk stratification in 1400 patients with suspected infection in the ED. The primary study end point was 30-day mortality.

Results: The AUROC of the NEWS score for predicting 30-day mortality was 0.740 (95% Confidence Interval 0.682-0.798), higher than qSOFA (AUROC of 0.689, 95% CI 0.615- 0.763), MEWS (AUROC 0.643 (95% CI 0.583-0.702) and SIRS (AUROC 0.586, 95%CI 0.521 - 0.651). The sensitivity was also highest for NEWS≥ 5 (sensitivity 75,8% specificity of 67,4%).

Conclusion: Among patients presenting to the ED with suspected infection, early risk stratification with NEWS (cut-off of ≥5) is more sensitive for prediction of mortality than qSOFA, MEWS or SIRS, with adequate specificity.

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A prospective, observational study of the performance of MEWS, NEWS, SIRS and qSOFA for early risk stratification for adverse outcomes in patients with suspected infections at the emergency department Read More

Quality: What does it mean in Acute Medicine and how do we measure it?

Clinical Reviews, Volume 20, Issue 2, Pages 89-156 (2021)

Acute Medicine is a specialty that is not defined by a single organ system and sits at the interface between primary and secondary care. In order to document improvements in the quality of care delivered a system of metrics is required.

A number of frameworks for measurements exist to quantify quality of care at the level of patients, teams and organisations, such as measures of population health, patient satisfaction and cost per patient. Measures can capture whether care is safe, effective, patient-centred, timely, efficient and equitable. Measurement in Acute Medicine is challenged by the often-transient nature of the contact between Acute Medicine clinicians and patients, the lack of diagnostic labels, a low degree of standardisation and difficulties in capturing the patient experience in the context.

In a time of increasing ecological and financial constraints, reflecting about the most appropriate metrics to document the impact of Acute Medicine is required.

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Evaluation of systemic vasoconstriction and prognosis using thermography: a systematic review

Clinical Reviews, Volume 20, Issue 2, Pages 89-156 (2021)

Purpose: This systematic review investigates whether infrared thermography (IRT) can measure systemic vasoconstriction and addresses the value of IRT in assessing circulatory deficiency and prognoses.

Methods: Design was based on the PRISMA criteria and a systematic search of 6 databases was performed.

Results: Of 3,198 records, five articles were included. Three clinical studies were identified; two found significant correlations between IRT obtained temperatures and mortality. An experimental study found an association between peripheral temperature and stroke volume. An animal study found that central-peripheral temperature differences correlated with shock index, mean arterial pressure, and disease progression.

Conclusions: Data from the most valid study suggests that central-peripheral temperature differences should be investigated further, both on its own, and integrated with other variables.

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An unusual presentation of dysarthria in a young patient, a stroke mimic

Case Reports, Volume 20, Issue 2, Pages 89-156 (2021)

Internal carotid artery dissection commonly affects younger patients. We present a case of a previously fit and well 43-year-old gentleman who presented with a sudden onset of slurring of speech, with right-sided tongue deviation and fasciculation on examination. Signs and symptoms began following participation in a home workout class. Magnetic resonance angiography revealed right-sided extracrainal internal carotid artery dissection leading to right-sided unilateral twelfth cranial nerve palsy.

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Pott’s Puffy Tumour: a rare but sinister cause of facial swelling

Case Reports, Volume 20, Issue 2, Pages 89-156 (2021)

A 27 year old female presented to the emergency department with intermittent central forehead swelling over several months associated with a headache. She was admitted under the medical team as having had a suspected allergic reaction but the diagnosis of a Pott’s Puffy Tumour was quickly made and confirmed through CT and MR imaging. This uncommon condition is related to sinusitis leading to localised abscess formation with osteomyelitis and a subsequent swollen appearance over the affected facial sinus.

This patient’s sinus abscess extended into the epidural space and caused destruction of the anterior and posterior walls of the frontal sinus. The patient was managed with intravenous antibiotics, analgesia and referral to the local ENT team for surgical intervention.

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Primary upper extremity deep vein thrombosis (effort thrombosis)

Case Reports, Volume 20, Issue 2, Pages 89-156 (2021)

Primary spontaneous upper extremity deep vein thrombosis is characterised by thrombosis within deep veins draining the upper extremity due to anatomical abnormalities of the thoracic outlet causing axillosubclavian compression and subsequent thrombosis. It is an uncommon condition that typically presents with unilateral arm swelling in a young male following vigorous upper extremity activity. The diagnosis of this condition is usually made by Doppler ultrasound, but other investigations are mandatory to exclude the secondary causes of upper extremity DVT. Different treatment options are available including anticoagulation, thrombolysis, and surgery. We report the case of a young healthy male with athletic physique who presented with pain and swelling of his dominant arm after weightlifting in the gym.

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Editorial – Evolve, Adapt, Innovate and Deliver: Acute Medicine post COVID pandemic

Editorials, Volume 20, Issue 2, Pages 89-156 (2021)

Predictions for acute care in the upcoming months are difficult. There will be challenges: there always are and that to a degree is what makes working in acute care so fulfilling. However, even the most adaptive and innovative acute care systems will toil when these challenges become overwhelming. Back in 2015, the then SAM President Mark Holland described a “perfect storm” of events that could lead to a challenging winter period. It was as predicted; but this storm continues to evolve and has not yet reached its perfected chaotic peak.

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Fatal Methaemoglobinaemia Due To Intentional Sodium Nitrite Poisoning

Case Reports, Volume 20, Issue 2, Pages 89-156 (2021)

We report a case of fatal methaemoglobinaema resulting from sodium nitrite poisoning. A 28 year old woman arrested in the emergency department following collapse. During resuscitation a venous blood gas revealed a methaemoglobin percentage of 81%. Following treatment with methylene blue, sodium bicarbonate and adrenaline, the methaemoglobin decreased. Prior to transfer to intensive care, a CT head revealed extensive hypoxic brain injury. Two days later brain death was confirmed on brainstem testing. Severe methaemoglobinaemia is rapidly fatal, with fast diagnosis and treatment associated with improved outcomes.

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