We thank Dr Gyan and colleagues for their thoughtful critique of our paper and welcome the opportunity to clarify the intended interpretation of our findings.
We acknowledge that there are a number of limitations to this service evaluation highlighted in your letter, which are also addressed in the paper itself.
Lumbar puncture in patients with acute severe headache – Response to letter Read More
We read with interest the service evaluation by Voase and colleagues examining the diagnostic yield of lumbar puncture (LP) in patients presenting with acute severe headache1. The authors address an important subject in a time of increasingly sensitive neuroimaging and evolving management pathways for suspected subarachnoid haemorrhage (SAH). We would, however, urge caution in interpreting the findings presented.
Lumbar puncture in patients with acute severe headache Read More
Issue 4 of the Acute Medicine Journal (AMJ) reports an interesting exchange between the authors of a service evaluation investigating the prevalence of subarachnoid haemorrhage (SAH) in patients undergoing a lumbar puncture (LP)1, and readership colleagues evaluating its merit, in light of the current evidence base and clinical recommendations2. This discourse highlights the two phases of scientific peer review, which operates as the quality control mechanism for academic publishing.
Subarachnoid haemorrhage (SAH) is a potentially life-threatening cause of acute severe headache. This service evaluation aimed to investigate the prevalence of SAH in patients referred to acute medicine with acute severe headache who underwent a lumbar puncture (LP) at a tertiary teaching hospital, over a four-year period. Of the 677 samples analysed for CSF bilirubin, 619 were negative (91.5%), 48 indeterminate (7%), and 10 classified as positive (1.5%). Only one patient (0.1%) was diagnosed with an aneurysmal SAH and underwent intervention. Therefore, the diagnostic yield of an LP to exclude SAH in this setting is extremely low. This service evaluation challenges the dogma that LP is necessary in all patients with acute severe headache.
The traditional procedure of identifying anatomical landmarks when performing lumbar punctures can lead to a failure rate of 19%.
The Society of Hospital Medicine have published a statement, recommending use of ultrasound (US) guidance for all adult lumbar punctures (LP).
A recent meta-analysis found several advantages of point of care US guided LP: higher success rate and diminished pain.
US assisted LP is easy to learn, integrating ultrasound guided LP into Acute Medicine curriculum, could lead to better patient outcome.
Ultrasound for Lumbar Punctures – An Invaluable tool for the Acute Physician Read More
Abstract
Most junior doctors learn common practical procedures, like lumbar puncture, on the job. This usually involves unstructured observation, demonstration and then supervised practice. Thus, most doctors have learned to perform a lumbar puncture without studying the theory of the procedure in any detail. The result is that patients experience less than optimal care, and more complications than necessary. This article first outlines some educational principles with regard to teaching and learning practical procedures and then describes the theory of diagnostic lumbar puncture.
Abstract
Aims:
• Evaluate the use of lumbar puncture (LP) in the Acute Medical Department of a typical urban district general hospital.
• Increase the proportion performed on appropriate patients.
Methodology: An observational, single-centre, retrospective examination of patients undergoing LP at Solihull Hospital over four consecutive months. Discussion of findings and LP indications with the Acute Medicine Department. Re-audit over four months.
Results: Total LPs performed fell by 65%. The proportion performed on patients presenting with red flags rose by 19% (p=0.0098). The proportion that yielded positive findings rose by 33% (p<0.0001). 72% of patients with red flags had negative LP. Conclusions: Awareness of indications and observation of practice reduces total LPs performed and increases the proportion performed on appropriate patients.
Lumbar Punctures in the Acute Medicine Department: indications and evaluation of use Read More
Abstract
A 49 year old man presented with rapid onset paraparesis, evidence of lower motor neurone features and sensory impairment following a respiratory tract infection. Initially he was treated with intravenous immunoglobulins for suspected Guillain-Barré syndrome (GBS). Subsequent cerebrospinal fluid (CSF) analysis identified unexpectedly high protein levels (attributable to Froin’s syndrome1) and magnetic resonance imaging (MRI) was highly suggestive of leptomeningeal carcinomatosis and cerebral metastases secondary to disseminated malignant melanoma. The disease progressed with rapid deterioration despite high dose corticosteroids and the patient died 12 days after admission.
This case brings several key points to the attention of the acute physician, in particular the need to give serious consideration to the differential diagnosis of cancer in a patient presenting with lower limb weakness.
Melanomatous Leptomeningeal Carcinomatosis masquerading as Guillain-Barré Syndrome Read More
Abstract
Over the last decade, new protein-conjugate vaccines against Haemophilus influenzae type b (Hib) and Neisseria meningitidis serogroup C (MenC) have had a dramatic effect on the epidemiology of childhood meningitis in the United Kingdom. Amongst adults, bacterial meningitis remains an important cause of preventable morbidity and mortality. Clinicians need to remain vigilant for the possibility of this infection. The identification of the one patient with meningitis out of many with trivial viral infections remains a difficult task. Even once the diagnosis is made clinically, the subsequent investigation and management of the patient remains controversial, with strong opinions often influenced by one or two adverse experiences. Potential improvements in the way we identify and manage meningitis patients have been identified in recent years. This review will focus on those areas relevant to the emergency care specialist. Meningitis in the immunocompromised patient often has a different clinical and epidemiological pattern and is beyond the scope of this review.
The Emergency Management of Adult Bacterial Meningitis Read More
Abstract
Sudden severe headache is a cardinal feature of subarachnoid haemorrhage (SAH) and other potentially life threatening neurological conditions. Early diagnosis and management improves the outcome of SAH. In general practice, benign thunderclap headache vastly outnumbers SAH as a cause of sudden headache. Thunderclap headache is a diagnosis of exclusion and all patients admitted with a first presentation of a severe headache lasting more than one hour should be investigated with a CT and lumbar puncture. It must be borne in mind that these investigations may miss diagnoses such as venous sinus thrombosis and Magnetic Resonance Angiography (MRA) should be performed if clinical suspicion remains high.