we run a rapid rule out pathway for alert patients
with ?SAH
CT, good access, done within an hour or so up till
around 10pm - then difficult to get on fully conscious
patient
LP at least 12 hours post onset. We use 25G whitacre
needles though my attempts to convert the general
medics to them have largely failed ("theyre too
bendy"). Certainly takes a while to get the hang of
them but the reward is a much lower incidence of post
LP headache.
We can do this ourselves as we have an obs ward.
CSF analysed by spectrophotometry (again, not
avaliable in the night)
No bed rest unless symptoms dictate.
We invited GPs to send us these patients, but still
only get 2-3 a week: Talking to the GPs, I think
there's a significant number whob don't get
investigated
Steve Meek
RUH Bath
--- Katherine Henderson <[log in to unmask]> wrote:
> One of the problems with headache/A&E LPs seems to
> me to be the timing of
> the LP. For ?SAH we usually organise the CT. If it
> is negative my
> understanding is that the timing of the LP is a bit
> unclear but probably
> should be at least 12 hours post onset of symptoms.
> This often is beyond the
> A&E 'window'. Does anyone work to any specific rule
> re this?
>
> Katherine Henderson
> A&E Homerton and RLH
>
>
> ----- Original Message -----
> From: "Slade, Mark" <[log in to unmask]>
> To: <[log in to unmask]>
> Sent: Tuesday, January 02, 2001 12:15 PM
> Subject: Re: TIA
>
>
> > Actually there's no evidence that LP patients need
> to rest after the
> > procedure - just common practice.
> >
> > Mark Slade
> > General Medicine consultant
> > Oxford
> >
> > -----Original Message-----
> > From: Simon Carley
> [mailto:[log in to unmask]]
> > Sent: 02 January 2001 10:26
> > To: [log in to unmask]
> > Subject: Re: TIA
> >
> >
> > We have a CDU in Manchester, although its
> effectiveness is usually
> > compromised by being full of medical patients
> waiting for beds for hours
> and
> > hours.
> >
> > There are a number of conditions that are suitable
> for rule in / rule out
> > strategies within 6 hours (our working time scale
> for CDU type patients).
> >
> > We rule out myocardial infaction in all low and
> moderate risk chest pain
> > patients with a 6 hour strategy
> > DVT investigation and management is done within
> the A+E department.
> > A pleuritic chest pain protocol is soon to start.
> > Many OD's can be managed within a 6 hour window.
> > There are clearly many others as well.
> >
> > Headache is my own interest and tends to fall down
> a little if an LP is
> > required as these patients are advised to rest for
> a period beyond our
> > working window.
> >
> > The protocols are designed as evidence based rule
> in/ rule out. There is
> > still a huge amount of work to do on the
> protocols.
> >
> > TIA is not really the same as unstable angina,
> although there is the
> > description of "stutttering TIA's", which is an
> increase in frequency of
> > TIA's, or multiple events that is more in keeping
> with cerebral unstable
> > angina.
> >
> > There is little reason why a single TIA event
> cannot be investigated as an
> > out patient. With appropriate support from
> services such as the vascular
> > labs then the initial TIA work up could be
> completed fairly rapidly in
> A+E.
> > Other investigations as an out patient with follow
> up in a stroke clinic.
> > Such a system operated successfully in a hospital
> I previously worked in.
> >
> > Simon Carley
> > SpR in Emergency Medicine
> > Manchester Royal Infirmary
> > England
> > [log in to unmask]
> > Evidence based Emergency Medicine
> > http://www.bestbets.org
> >
> > ----- Original Message -----
> > From: Adrian Kerner <[log in to unmask]>
> > To: <[log in to unmask]>
> > Sent: Monday, January 01, 2001 8:43 PM
> > Subject: Re: TIA
> >
> >
> > > I know how I would like my mum managed!
> > >
> > > TIA is the equivalent of cerebral unstable
> angina. Surely it should
> > mandate
> > > admission - at very least to arrange/perform
> duplex etc and assess the
> > need
> > > for surgical intervention.
> > >
> > > These patients could be assessed by 'us' in a
> 'Clinical Decision Unit'.
> > > Such a CDU is being set up at St James in Leeds.
> > >
> > > It will be interesting to see the effect of such
> a 'unit' on the number
> of
> > > carotid endarterectomy performed, before and
> after opening!
> > >
> > > Other problems to be dealt with on the CDU will
> include
> > >
> > > Pleuritic chestpain
> > > Swollen legs
> > > Headache.
> > >
> > > Has anyone on the list any experience of a CDU?
> > >
> > > Regards
> > >
> > > Adrian Kerner
> > > SpR
> > > A&E St. James Leeds
> > >
> >
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