Vertigo

Vertigo is a very difficult topic. Although typically the diagnosis is split into central vs peripheral, it's probably better to think of it as
- investigate now
- investigate later
- No investigations needed.


Peripheral does not equal benign -> eg acoustic neuroma
Central does not equal life threatening -> migraine. Central rarely occurs in isolation, is less intense than peripheral, not possitional, hearing loss and tinnitus are rare and nystagmus is not inhibited by ocular fixation.It normally persists for more than 48 hours. Mild nausea and vomiting.

There are a few great flow charts, and lots of things to think about to work out what the cause is.

1. How long does it last for?
Seconds (psychogenic), Less than 1 min (BPPV), Minutes (Vascular/Ischaemic), Hours
(Meniere's or vestibular migraine), Hours to days (vestibular neuronitis, central causes, MS), Recurrent with headaches (Vestibular migraines).

2. Is it central or peripheral?

3. Dix - Hallpike to see if it's BPPV (peripheral cause)
Don't do it if there's any neck pathology that would make the procedure harmful - like arthritis. If patient dizzy on turning over in bed, BPPV is possible.

Patient in middle of bed. Looks towards one end of bed. Quickly lie flat.
Then over and up to the other side of the couch
Look for nystagmus
Nystagmus is diagnostic.

5. Treat the BPPV with Epley manueuvere:
Lie patient down
Head over couch
Look to side
Quickly turn head to other side - look for nystagmus. Stay there for 30 - 6o sec
Prepare to look at the floor - keep head still and roll onto side
Quickly look at floor
Stay for 30 - 60 seconds
Then sit up and put head down to keep looking at the floor

6. If it's central, HINTs
HI – Head impulse test: This test is a test of the patient vestibulo-occular reflex
Ask patient to look at a fixed target. Rapidly rotate head and look at eyes. A patient with an intact vestibulo-occular reflects will be able to maintain their gaze on the fixed target. The patient who has a defect with one of the vestibules will not be able to maintain gaze and as the head is rotated the eyes will rotate with the head away from the target, after a brief pause will then saccade back to the target. This can be subtle and some people have suggested that it can help
to use a phone with a slow motion app to capture the eye movements.

N - Nystagmus: Nystagmus mixed in peripheral, horizontal in central.
Peripheral vertigo decreases with fixation. Central vertigo persists with fixation.
Peripheral fatigues, central doesn't.
Horizontal, unidirectional never vertical in peripheral vertigo. Any direction for central vertigo.
In peripheral nystagmus resolves within 48 hours, and in central persists beyond 48 hours.


TS- Test of skew: Cerebellum and midbrain are required to allow the eyes to maintain fixed on their target during binocular vision. Cover each eye in turn and when an eye is uncovered looking for vertical deviation of the uncovered eye suggesting the presence of a central lesion.

7. Central Causes
Need ongoing referral and investigation. MRI in the first 48 hours misses 10 - 30% Posterior Circulation Strokes.

8. Treatment
Betahistine is for Meniere's disease only. Seak secondary care advice before starting.

9. Other Investigations
Arrhythmias are rarely the cause of dizziness, but it's worth having a look just incase.
ECG Abnormalities suggestive of arrhythmic syncope
Bifascicular block
Prolonged QRS
Mobitz 1
Brady <50bmp
Sinus pause >3sec
Pre-excited QRS
Long QT
RBBB with ST elevation (Brugada)

10. Look for red flag features
Headache 40% posterior circulation stroke
Gait ataxia May be only non‑vertiginous manifestation of cerebellar stroke
Hyperacute onset Suggests vascular origin
Vertigo and hearing loss AICA or urgent ENT problem
Prolonged symptoms (greater than 4 days) Floor of fourth ventricle problem
Symptoms on valsalva Perilymphatic fistula

References
https://vertigoed.wordpress.com/
http://www.londonscn.nhs.uk/wp-content/uploads/2016/04/neuro-adult-with-dizzy-spells-edu-videos-042016.pdf
http://www.rcemlearning.co.uk/modules/vertigo-will-it-make-your-head-spin/ 

Sepsis

So Sepsis confuses me. There's loads of guidelines we're supposed to follow (some with out of date evidence) and it's not as simple as it could be. I've tried to simplify it... but might easily have misinterpreted something!

Sepsis = life threatening organ dysfunction due to dysregulated host response to infection. “SOFA” helps define and “prove” organ dysfunction. 

CEM and Surviving Sepsis Criteria define with SIRS
Need at least two of:
Temp > 38.3   Temp <36
WCC >12 or WCC <4
HR >90 RR >20
AMS BM >7.7

Patients with at least two SIRS criteria and suspected infective source should have the sepsis six delivered ASAP (within three hours of time of presentation according to surviving sepsis, within an hour if severe sepsis according to RCEM and most trusts).  Surviving sepsis state within six hours of presentation we need vasopressors, re-assessment and re-check of the lactate.

Septic Shock – need vasopressors to keep MAP >65, lactate >2 despite fluid resuscitation. Sepsis 6 – 30mg/ kg for hypotension or lactate >4.

SOFA Scores
New studies have shown that SIRS is non specific and should no longer used for sepsis prognosis. They instead suggest a “SOFA (sepsis related organ failure assessment)” score where a changing score of > 2 = mortality of 10%.
 The Qsofa is a quick bedside alternative, and >2 factors + suspected infection should make you think of sepsis:
"BAT" BP <100
          AMS
                        Tachypnoea RR >22
This has not made its way into national guidelines yet.

RCEM Guidelines 
Screen for sepsis using “SIRS criteria”
Sepsis risk stratify. Start sepsis six immediately if any one of:
• SBP <90mmHg or >40mmHg fall from baseline
• MAP <65mmHg
• Heart rate >130 per minute*
• New need for supplemental oxygen to maintain saturations >90% and bilateral infiltrates.
• Respiratory rate >25 per minute*
• AVPU = V, P or U*
• PaO2 / FiO2 ratio <300 (mmHg) or <39.9 (kPa)
• Lactate >2.0mmol/L
• Creatinine >176.8µmol/L
• INR >1.5
• aPTT >60s
• Platelet count <100 x109/L
• Bilirubin >34.2µmol
• Urine output <0.5mL/kg for two consecutive hours

Uncomplicated Sepsis: Decide whether to initiate sepsis six or not, >ST4 review within an hour, hourly obs, repeat lactate in two hours.

Red Flag Sepsis: HR > 130, AVPU less than A, RR >25
If blood results not confirmatory for severe sepsis, senior to review.

Red Flag or Severe: Severe sepsis is no longer in the Sepsis definitions but is in the RCEM guideline. Sepsis six ASAP, but within 60 minutes. >ST4 review. Obs 30minly.  Repeat lactate.

Septic Shock: As above. Inform EM Consultant. Refer to outreach.  Persisting hypotension requiring vasopressors to maintain MAP. Blood lactate >2mmol/L despite adequate volume resuscitation.

NICE Guidelines – July 2016
High risk of sepsis: in <1 year and >75 (or very frail). Immunosuppressed – by drugs or disease. Surgery in past six weeks. Breach of skin integrity. IV drug user. Indwelling lines or catheters. Pregnant or <6 weeks post partum.

Risk stratification for 12years and older – history. Respiratory (>25 or >40% FiO2 to keep sats >92% = high. Moderate = RR 21 – 24). BP (High = <90 or >40 below normal. Mod =91 – 100mmg Hg.). Circ (High = HR >130 bpm, anuric 18 hours, <0.5ml/hour if catheterised. Mod = HR 91 – 130 or new arrhythmia. Anuric 12 – 18 hours. 0.5 – 1ml / kg). Temp (Mod = temp <36). Skin (High = mottled or ashen, cyanosis, non blanching rash. Mod = Skin signs of infection).

There is a different stratification for children <5, and aged 5 – 11.

If >1 high risk criteria, senior clinical decision maker to review. Tests for glucose, lactate, cultures, FBC, CRP, U&E, creatinine, clotting. Antibiotics. Discuss with a Consultant. If septic shock, IV fluids stat, and refer to critical care. If lactate 2-4, give IV fluid bolus within an hour. Lactate <2, consider IV fluids. Monitor every 30minly. Consultant to r/v if failure to respond.

CEM Standards – severe sepsis and septic shock
Observe temp, PR, RR, BP, Mental status, BM on arrival.
Senior EM review within an hour
High flow O2 before leaving ED
Lactate, blood cultures
20mls/ kg fluid – 75% within an hour of arrival, 100% before leaving ED. Antibiotics – 50% within an hour, 100% before leaving ED.
Urine output measured before leaving the ED.

Trials
EGDT: Rivers. Found mortality benefit for EGDT.
ProCESS: Looked at protocol resus vs. usual car in septic shock. More ICU admissions in EGDT group. No difference otherwise.
ARISE: Australia. No advantage of EGDT.
PromMISe: UK based. No advantage over EGDT, which also increases costs.

Some theories: busted!
• Activated protein C - doesn't work
• Steroids - don't work, may be a small role only.
• Intensive insulin therapy - was based on harm from hyperglycaemia now used as moderate therapy only.

CRP
C reactive protein (CRP) is a protein produced by the liver in response to triggers from macrophages and adipose cells, which binds to the surface of dead or dying cells to activate the complement system.
CRP will rise within 2 hours of inflammation onset and peak at 48hrs. A normal level of CRP is not truly known.

References and Resources
http://www.rcem.ac.uk/Shop-Floor/Clinical%20Standards/Sepsis
http://www.heftemcast.co.uk/sepsis-in-the-ed/
http://www.heftemcast.co.uk/sepsis-smaccback/
http://www.frca.co.uk/article.aspx?articleid=100855
http://stemlynsblog.org/early-goal-directed-therapy-dead-st-emlyns/
http://www.survivingsepsis.org/SiteCollectionDocuments/SSC_Bundle.pdf http://stemlynsblog.org/the-promise-study-egdt-rip/
http://stemlynsblog.org/surviving-sepsis-update/
http://foam4gp.com/2015/07/23/foam4gp-map-my-esr-is-bigger-than-your-crp-or-do-we-care-not/