Indicaciones y rendimiento diagnóstico de la punción lumbar en urgencias

The Optimal Management of Acute Febrile Encephalopathy in the Aged Patient: A Systematic Review

The elderly comprise less than 13 percent of world population. Nonetheless, they represent nearly half of all hospitalized adults. Acute change in mental status from baseline is commonly seen among the elderly even when the main process does not involve the central nervous system. The term "geriatric syndrome" is used to capture those clinical conditions in older people that do not fit into discrete disease categories, including delirium, falls, frailty, dizziness, syncope, and urinary incontinence. Despite the growing number of elderly population, especially those who require hospitalization and the high burden of common infections accompanied by encephalopathy among them, there are several unresolved questions regarding the optimal management they deserve. The questions posed in this systematic review concern the need to rule out CNS infection in all elderly patients presented with fever and altered mental status in the routine management of febrile encephalopathy. In doing so, we sought to identify all potentially relevant articles using searches of web-based databases with no language restriction. Finally, we reviewed 93 research articles that were relevant to each part of our study. No prospective study was found to address how should AFE in the aged be optimally managed.

Lumbar punctures: use and diagnostic efficiency in emergency medical departments

Background

Lumbar punctures (LP) are regularly and effortlessly used in the emergency medical departments (EMD). LP use and efficiency have not been fully explored in the published literature.

Aims

The goal of this study was to assess in a French EMD, the frequency of use and the diagnostic efficiency of LP, the final diagnoses, and related medical practices.

Methods

We retrospectively studied all patients who underwent an LP after admission to our adult EMD in 2004 and 2005. Patients’ medical files were reviewed to collect clinical and paraclinical features. We defined efficient LP as abnormal LP, which confirmed a suspected diagnosis in an emergency setting.

Results

A total of 247 patients, representing 0.5% of all admissions, underwent an LP. LP were efficient in fewer than 15% of cases and confirmed aseptic meningitis (8.5%), bacterial meningitis (2.4%), Guillain-Barré syndromes (1.6%), subarachnoid hemorrhages (SAH, 0.4%), and carcinomatous meningitis (0.4%). The principal differential diagnoses were infections outside the central nervous system (CNS, 30%), noninfectious neurological disorders (28.7%), and benign headaches (14.2%). The main assumed LP indications were to search for CNS infection (62%) and for SAH (25%). LP efficiency decreased dramatically according to patients’ age. Brain imaging was performed in 90% of patients prior to LP. Excessive use of polymerase chain reaction to detect herpes simplex in cerebrospinal fluid was observed. The only LP complications found were postdural puncture headaches (6.1% of cases). The rate of traumatic LP was 17%.

Conclusions

Our results are in accordance with the few published surveys on this topic. LP efficiency is modest but must be considered in light of the seriousness of suspected diagnoses. However, the search for differential diagnoses should not be neglected.

Error diagnóstico en urgencias: relación con el motivo de consulta, mecanismos y trascendencia clínica

BACKGROUND AND OBJECTIVE

We intended to analyze the relation between the main symptom at hospital admission and the diagnosis mistake, assessing the reasons and clinical implications.

PATIENTS AND METHOD

We analyzed hospitalized patients from the emergency room to the medical wards. We collected: age, sex, time, main symptom at admission, diagnosis at admission and final diagnosis, days of hospitalization and mortality. We established two groups: patients with a concordant diagnosis and patients with a wrong diagnosis, and we compared the characteristics of them. In each case of a wrong diagnosis, we analyzed the reason of the mistake and the clinical consequences.

RESULTS

We found a wrong diagnosis in 42 (6.2%) cases. Fever, as main symptom at admission, had a significant higher rate of mistake than other symptoms. No differences were found in the other variables analyzed. Most frequently omitted diagnosis were infectious diseases, pulmonary embolism and heart failure. Main causes of mistake were a deficient clinical evaluation and X-ray interpretation. The mistake implied a delay in the specific treatment in 42.8% cases.

CONCLUSIONS

Diagnostic mistakes in the emergency room are more frequent in patients attending with fever. They are mostly related to deficient clinical evaluation or wrong interpretation of X-ray findings. Although these mistakes usually lead to a delay in the treatment, no increase in the days of hospitalization or mortality is observed.

[Hospital emergency rooms]

Overuse of hospital emergency rooms (HERs) is parallel to their controversy. To understand this problem, some concepts should be first clarified. In HERs, there are some intrinsic aspects which are directly related to the emergency itself and thus cannot be modified (intermittent patient flow, need to prioritize, difficulty to achieve a rapid diagnosis, influence of time on treatment, value of clinical follow up, patient's expectations, impact of HER on the overall hospital working dynamics). On the other hand, there are some extrinsic aspects which indeed are not related to HER itself but are rather historically associated with it (precarious structure, delay on admission, lack of privacy, inadequate triage of cases, lack of professionalization); these latter aspects may be potentially modified and should be reconsidered.

[Diagnostic concordance between emergency room and hospitalization in medical patients]

BACKGROUND

The purpose of this study was to know the concordance of diagnosis between emergency rooms amd hospitalization wards and to analyze the mistake index, the epidemiological characteristics and the main reasons for the mistakes.

PATIENTS AND METHOD

We analyzed hospitalized patients and used a three-level concordance: exact diagnosis (A), syndromical concordance (B) and mistake (C). We compared age, sex, time and days of hospitalization between the groups A+B and C. We also analyzed the causes of mistakes in group C.

RESULTS

We found 88.1% of patients in level A, 7.3% in level B and 4.6% in level C. There were no significant differences in the variables analyzed. Main mistakes were a deficient clinical evaluation (50%) and X-ray interpretation (28.6%).

CONCLUSIONS

Concordance of diagnoses was the rule, with less than 5% mistakes. There is no clinical or epidemiological pattern for the mistake. The most frequent cause for it was a deficient clinical evaluation.