suckstobeme

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So last night I had a pt that had a new headache that I ended up CT'ing and by the time they got back from CT the meds I gave her kicked in and her headache was gone and I just d/c'ed her. But that made me think. She takes ASA and Plavix for CAD with stents; what if I needed to do an LP. Is her taking ASA and Plavix a contraindication to LP? What about just ASA?
 
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deleted65604

CONTRAINDICATIONS FOR SPINAL PUNCTURE

Spinal puncture is absolutely contraindicated in the presence of infection in the tissues near the puncture site.[39][130] Spinal puncture is relatively contraindicated in the presence of increased ICP from a space-occupying lesion. Caution is particularly advised when lateralizing signs (hemiparesis) or signs of uncal herniation (unilateral third nerve palsy with altered level of consciousness) are present. In such cases, a tentorial or cerebellar pressure cone may be precipitated or aggravated by the spinal puncture. Cardiorespiratory collapse, stupor, seizures, and sudden death may occur when pressure is reduced in the spinal canal.[26]

The risk of herniation seems to be particularly pronounced in patients with brain abscess.[13][107] Brain abscesses frequently occur as expanding intracranial lesions with headache, mental disturbances, and focal neurologic signs rather than as infectious processes with signs of meningeal irritation. In 75% of cases, a primary source of chronic suppuration is present. Common predisposing causes of brain abscess include craniofacial trauma, craniocerebral trauma, penetrating injuries with bone fragments in brain, transmitted foreign objects or large animal bites of infant skulls, postneurosurgical procedures, cardiovascular disorders with right to left shunts, bacterial endocarditis, gram-negative sepsis in neonates, dental infections, chronic sinusitis, otitis, mastoiditis, chronic abdominal pulmonary or pelvic infections, bacterial meningitis, and immunosuppression. Infarcted brain tissue may develop abscesses in the presence of sepsis because of a compromised blood-brain barrier.[114] Although the CSF is usually abnormal (elevated pressure, elevated white blood cell count, and elevated protein concentration), spinal puncture in patients with a known, or highly probable, abscess is contraindicated in most cases. In one study by Samson and Clark, 5 of 22 patients exhibited signs of midbrain compression within 2 hours of lumbar puncture.[107] Evidence of herniation markedly reduces the patient's chances for survival.

Brain abscess may spontaneously rupture into the ventricular system producing ventriculitis and meningitis. If the history suggests possible brain abscess, CT can rapidly diagnose and localize the lesion.[144] Because the appearance of brain abscesses on CT is similar to that of neoplastic and vascular lesions, false-positive reports of brain abscess may be encountered.[102]

Lumbar puncture can cause trauma to the dural or arachnoid vessels, which may result in minor hemorrhage into the CSF. This generally is of little consequence. However, the number of patients with hemophilia and human immunodeficiency virus (HIV) infection who require lumbar puncture has increased in the past decade. Spinal epidural hematomas may occur in some subpopulations of patients undergoing lumbar puncture. Individuals most at risk are those with some sort of bleeding diathesis, including those on anticoagulant therapy or those with abnormal clotting mechanisms, especially thrombocytopenia. Edelson and colleagues reviewed more than 100 cases of spinal epidural hematoma; approximately one third were associated with anticoagulant therapy.[29] Most articles describe isolated cases.[29][71][104][112] Spinal subdural hematomas after lumbar puncture are even more rare than epidural hematomas.[25][30]

When a patient is anticoagulated or has a coagulopathy, the tap should be performed by experienced clinicians, who are less likely to traumatize the dura. The patient should be carefully followed for progressive back pain, lower extremity motor and sensory deficits, and sphincter impairment after the procedure. Complaints of motor weakness, sensory loss, or incontinence after lumbar puncture should be thoroughly investigated. Lumbar puncture may be performed in the presence of a coagulation defect if the procedure is expected to provide essential information, such as in the diagnosis of meningitis. In cases of severe thrombocytopenia, the infusion of platelets before the lumbar puncture may be desirable.

The infusion of clotting factors in the hemophiliac patient and normalization of the prothrombin time with fresh frozen plasma in the anticoagulated patient are desirable if the clinical situation permits such delay before performing a lumbar puncture. Because as many as 90% of patients with severe hemophilia are seropositive for HIV, the issue of performing a lumbar puncture in patients with coagulopathies is an increasingly common phenomenon. Silverman and colleagues have demonstrated the safety of lumbar puncture in patients with hemophilia A or B who had their deficit clotting factor replaced before the procedure. In their series of 33 patients (30 with <1% normal factor level) who underwent a total of 52 spinal taps after specific factor replacement, no serious procedure-related complications were identified.[120] Their protocol was to attain an immediate postinfusion factor level between 5% and 100%. Use of additional factor replacement after lumbar puncture is of unknown value.

Howard and colleagues reported on 5223 lumbar punctures done in 958 children with newly diagnosed acute lymphoblastic leukemia.[56] Of these lumbar punctures, 29 were performed with platelet counts of 10 × 109/L or less, 170 with platelet counts of 11 - 20 × 109/L, and 742 with platelet counts of 21 - 50 × 109/L. No serious complications were reported. The overall rate of traumatic taps was 10.5%, but these were not associated with adverse sequelae. They concluded that in children with acute lymphoblastic leukemia, prophylactic platelet transfusion for lumbar puncture is not required if the platelet count is greater than 10 × 109/L. The number of patients with platelet counts of 10 × 109/L or less was too small to reach any conclusion about this group of patients.

If the history and physical examination suggest a treatable illness, such as meningitis or subarachnoid hemorrhage, the clinician may perform a spinal puncture after careful consideration of the entire clinical picture. In all cases, the study should be undertaken after careful thought regarding how the results will assist in patient evaluation and treatment. It is unlikely that the spinal puncture will beneficially alter management in the presence of a neoplasm, a cranial hematoma, an abscess, a completed nonembolic infarction, or cranial trauma.

References

13. Brewer NS, MacCarty CS, Wellman WE: Brain abscess: A review of recent experience. Ann Intern Med 1975; 82:571.

25. Domenicucci M, Ramieri A, Ciappetta P, et al: Nontraumatic acute spinal subdural hematoma. J Neurosurg 1999; 91:65.

26. Duffy GP: Lumbar puncture in the presence of raised intracranial pressure. Br Med J 1969; 1:407.

29. Edelson RN, Chernik NL, Posner JB: Spinal subdural hematomas complicating lumbar puncture. Arch Neurol 1974; 31:134.

30. Egede LE, Moses H, Wang H: Spinal subdural hematoma: A rare complication of lumbar puncture. MD Med J 1999; 48:15.

39. Fishman RA: Cerebrospinal Fluid in diseases of the nervous system, Philadelphia, WB Saunders, 1980.

56. Howard SC, Gajjar A, Ribeiro RC, et al: Safety of lumbar puncture for children with acute lymphoblastic leukemia and thrombocytopenia. JAMA 2000; 284:2222.

71. Laglia AG, Eisenberg RL, Weinstein PR, et al: Spinal epidural hematoma after lumbar puncture in liver disease. Ann Intern Med 1978; 88:515.

102. Rotheram Jr EB, Kessler LA: Use of computerized tomography in nonsurgical management of brain abscess. Arch Neurol 1979; 36:25.

104. Ruff RL, Dougherty JL: Evaluation of acute cerebral ischemia for anticoagulant therapy: Computed tomography or lumbar puncture. Neurology 1981; 31:736.

107. Samson DS, Clark K: A current review of brain abscess. Am J Med 1973; 54:201.

112. Senelick RC, Norwood CW, Cohen GH: "Painless" spinal epidural hematoma during anticoagulant therapy. Neurology 1976; 26:213.

114. Seydoux C, Francioli P: Bacterial brain abscesses: Factors influencing mortality and sequelae. Clin Infect Dis 1992; 15:394

120. Silverman R, Kwiatkowski T, Bernstein S, et al: Safety of lumbar puncture in patients with hemophilia. Ann Emerg Med 1993; 22:1739.

130. Tourtellotte WW, Shorr RJ: Cerebrospinal fluid. In: Youmans JP, ed. Neurological Surgery, vol 1. Philadelphia: WB Saunders; 1982:423.

144. Zimmerman RA, Bilaniuk LT, Shipkin PM, et al: Evolution of cerebral abscess: Correlation of clinical features with computed tomography: A case report. Neurology 1977; 27:14.
 
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deleted65604

I think all of your questions should have been answered in the above excerpt from Robert's: Clinical Procedures in Emergency Medicine (From MDConsult).

The short answer is no, ASA and plavix are not contraindications. Plavix might make me more likely to be very detailed about the potential complications when I'm getting consent from the patient (I usually get just verbal consent, unless the patient is anticoagulated, then I would get written consent). When I was on neurosurgery, I had a patient who developed a spinal epidural hematoma after an epidural for hip surgery. They ended up taking him to surgery to evacuate the hematoma as he was having motor weakness and numbness from cord compression (hematoma had tracked superiorly and was involving the spinal cord, not just the cauda equina).

Look at how low the platelet count was in some of those leukemia patients above. Many with platelet counts less than 10 with no adverse outcomes.

I would not give platelets prior to LP in a patient on ASA or plavix. I would just describe the known complication of epidural hematoma and the symptoms to return for evaluation to the ER.

It is an extremely safe procedure, compared to a lot of the stuff that is done in medicine. Compare the small risk of hematoma after LP in a patient on plavix to the risk of bleeding out in a cardiac patient who is on ASA, plavix, and sometimes integrelin, or reopro, who the cardiac surgeon has to take to surgery. Those people remove their heart, stop blood flow to it, then put microscopic sutures in to numerous tiny anastomoses, and then shock the heart into beating again and hope they don't spring a leak and bleed to death.
 
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I had a patient with lupus cerebritis in whom I had to place a central line (and did a subclavian); I did the subclavian because I'm most experienced with it, and it had the most benefits. However, I did wonder why the site seemed "gooey" after I'd accessed the vessel. Found out after that this pt got daily Lovenox. As she was intermittently actively seizing (and had not abated with IM benzodiazepines), it was "**** or get off the pot" time. Fortunately, as I was the "more skilled provider", I like to think that that is why I was successful.
 

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I'm more interested in why you thought it was OK to send them home just because their headache was gone.
 

docB

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I'm more interested in why you thought it was OK to send them home just because their headache was gone.
Point taken. I usually don't do a CT unless I'm planning on doing the LP before I'm convinced. However I do frequently get roped into dcing patient who had a neg CT and no LP because my PAs do it that way. They do that because the older EPs do it that way. So when I get into that situation I document that the history is not cw SAH by noting there was no sudden onset, no exertional corelation, totaly normal exam, no risk factors, etc. and let them go. I agree that if you were worried enough to CT you should be thinking LP but sometimes I try to explain it away in the note.

I also do think that if their pain is relieved by stuff like compazine, imitrex, phenergan and so on I'm less worried. If they've had 8 of Dilaudid the "pain free" thing isn't as impressive.
 

Seaglass

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I also do think that if their pain is relieved by stuff like compazine, imitrex, phenergan and so on I'm less worried. If they've had 8 of Dilaudid the "pain free" thing isn't as impressive.

I've sen SAH pain, ICH pain, brain met pain, skull fx pain, all kinds of pain go away with the headache cocktail, so the fact that the pain resolves doesn't really change my initial impression much.
 

WilcoWorld

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I've seen very experienced docs come down on both sides of the pain-resolved HA issue, and I'll admit that I've yet to make up my mind. Until I do I'll keep tapping.

However, I have also been frustrated by DocB's situation where you get sign out on a patient with "Needs LP" written on the chart (which I think is a lame sign-out in the 1st place) then you go to see the patient & you never would have LP'd the patient. Like a 3 year old kid with a triage temp of 38.0 (36.9 after antipyretics) who is running around the room playing, or a 32 yo female who says that this headache is like every other migraine she's had, that she said it was the worst headache of her life because EVERY migraine is the worst of her life, and that she was simply out of her home meds, but now that you treated her she feels fine thankyouverymuch, but please go harpooning in her adipose laden back because that last doc sure did scare her so.

arrrg
 

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Fortunately, I've never had an in-house sign out as horrible as that ("Needs LP"). Anecdotally, I did hear of a former hospitalist writing an order for "STAT intubation" and then walking away. Obviously, a huge outlier so I'm not dissing hospitalists here.

I have had, on multiple occasions, pts sent from a local urgent care after being told they need a CT and LP. After 2 minutes with the patient, I realize they don't need either.

I just have a very detailed discussion with the patient about why I don't think those tests are necessary and what the potential risks of the tests themselves are. I haven't had one yet who was persistent in their desire for the test. I'm not sure what I'll do when I come across one who is.

Take care,
Jeff
 

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Oh, and you can add me to the "I don't consider pain relief as a diagnostic sign" club. I advise all my SAH r/o patients to undergo the LP even after a negative CT and pain relief.

I don't get my feelings hurt if they decline the LP, though. To be honest, I might decline it as well if I were in their shoes.

Take care,
Jeff
 

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Regarding epidural hematomas, I had a young lady with numbness in her legs after an epidural block for c-section. MRI negative. Just something else to think about...

I'm with most everyone else here, get a CT, you get a LP. I tell them risks/benefits and def tell them that their headache can come back and get worse after the LP. If they refuse, they prob didnt need it in the first place, but I document all over the chart, pt informed.... If they still want it, then easy to do (unless you have a ummm healthy eater :D)
 
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Regarding epidural hematomas, I had a young lady with numbness in her legs after an epidural block for c-section. MRI negative. Just something else to think about...

I'm just trying to get the point you're making. Or are you just joking? All women have numbness in their legs after c-section. :) Did the patient have an epidural hematoma or not? if the MRI was negative, then she didn't have an epidural hematoma. Can you clarify?
 

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I rarely LP unless there is a very classic story. I CT for numerous reasons, not just subarachnoid hemorrhage. There are other things that occur that can be detected with CT.

Where I trained, our neurology and neurosurgery attendings quoted their own studies that demonstrated extremely low likelihood of missed SAH by CT using newer generation CT's.
 
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southerndoc

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Without doing the work to find it there was also a well done recent study showing the miss rate is about the same even with newer scanners. Your point about CT being good for other causes of HA is certainly true.

I found a reference but it's not the one I was thinking of: http://www.ncbi.nlm.nih.gov/pubmed/...nel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum
Plus given the fact that a study demonstrated that detection of xanthrochromia was "less than ideal" (more like abysmal) without photospectric analysis, it pretty much means I could flip a coin to see if the patient had a SAH with a negative CT.
 

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Plus given the fact that a study demonstrated that detection of xanthrochromia was "less than ideal" (more like abysmal) without photospectric analysis, it pretty much means I could flip a coin to see if the patient had a SAH with a negative CT.

Yeah xanthochromia is useless in the US as like 1% of hospitals use the spect for it, the rest of us in the real world get visual which is fitty-fitty.

Q
 

WilcoWorld

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Plus given the fact that a study demonstrated that detection of xanthrochromia was "less than ideal" (more like abysmal) without photospectric analysis, it pretty much means I could flip a coin to see if the patient had a SAH with a negative CT.

So what's your r/o SAH algorithm (starting with HA as Chief Complaint)?
 

southerndoc

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So what's your r/o SAH algorithm (starting with HA as Chief Complaint)?
Usually non-contrast CT followed by either MRA or CT angiogram of the Circle of Willis. If it's in the middle of a night shift, I will ask the patient if they want to wait (rarely do they ever do this) or I will arrange for one to be done the following morning and will allow the patient to go home and have the scan done as an outpatient (which I have arranged and will follow the results of and call the patient with the results).

If I am strongly suspicious, then I will not discharge the patient.
 
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deleted65604

SAH is one of those crappy medicolegal issues that each doctor needs to find their own threshold for working up. A normal CT within a few hours of onset of headache, that completely goes away, is most likely not a SAH. I think it is reasonable and the right thing to do, to discuss the risks of SAH with the patient. If you put it to the patient, "Look, I'm 99% sure that this isn't a SAH. However, there is a very small chance that I could be wrong. To be completely sure, I need to do a lumbar puncture. The most common side effect that results from a lumbar puncture is a severe headache that might end up requiring a blood patch."

In the end, yes, you are basically trying to talk the patient out of getting a lumbar puncture, and getting them out the door. If you communicate explicitly about the risks, thoroughly document in the chart that you recommended a lumbar puncture to completely rule it out and the patient refused, I think you are doing what is right for the patient, not just practicing defensive medicine at the expense of the patient.

Don't get me wrong, I love to do lumbar punctures. In fact, I was known in residency as Dr. Jara-Tap-Bacoa, because the nurses thought I did too many. (I was also called Kool-aid by one nurse, for what the CSF on my taps tended to look like)
 
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We do CT and CTA for HA les than 24 hours old, CT and tap if longer than 24 hours.

Wow. I'm surprised at the CT/CTA approach. I envision a scene like this in a courtroom:

Lawyer: "Seaglass, what is your standard reference text in EM?"

Seaglass: "Well, as my colleagues have pointed out thus far, I am a very skilled, conscientious and well-read physician. As a result, I am familiar with Rosen, Tintinalli, and Harwood-Nuss -- as well as peer-reviewed online references such as Up-to-Date and emedicine.com -- and frequently refer to any and ALL of them so as to do my best to reflect best practice from a consensus of the best minds in emergency medicine as I strive to meet "standard of care".

Lawyer: "Very good, sir. Now point to the page in any ONE of the above text books, and or a document from one of the online sources, that says a SAH can be ruled out with CT/CTA without offering or considering LP..."

Seaglass: "err..... do you want the keys to my house now, or ....."

Ok, Ok, I jest.

But I think you're always iron clad if you do the non-con, and then explain to the patient the benefit/risk of LP and let them decide. I document the conversation and the patient's decision every time. I do it objectively. If they want me to "decide", I refuse (to decide), but gently, and use body language and tone to sort of guide them. I wouldn't go so far as to make them sign an AMA if I thought they really needed an LP (I rarely have them refuse when I think they really need it and I phrase it the right way) but my documentation will carefully document that we had a conversation about risk/reward and the patient is of sound mind, etc. and refused.

Maybe you could get enough docs to be on the stand with you and say that CT/CTA is an equivalent standard of care (shrug). I personally would have NO PROBLEM attesting to the fact in a courtroom that you have a very small likelihood of missing one with this approach. But lawyers are shifty F *& & ers and my approach works for me. I present it only as another option, not a critical review of your practice.
 

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This is a protocol we have decided on in conjuntion with our neurosurgeons and is only for acute onset headache when sensitivity for HA by CT is at its greatest. No doubt there is a lot of risk in management of SAH regardless of how you do it but I'm pretty comfortable with this.
 

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We do CT and CTA for HA les than 24 hours old, CT and tap if longer than 24 hours.

While CT for SAH within 24 hours is the best it gets, the yield is far from ironclad and LP is still warranted. CTA does not provide a demonstrable improvement in outcomes because while it may show you a berry aneurysm that did not show up on a non-contrast CT, it does not give you the critical piece of information: does the patient have a subarachnoid hemorrhage or not? A 2mm berry aneurysm without a SAH will be managed with surveillance, while the same aneurysm in the setting of an LP-proven SAH will prompt acute management.
 
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late to this party, but I do the LP. Doesnt take that long, tolerated well if good local anesthesia provided, provides key info you can't get with another study. In this respect, one of my favorite things to do - gives you a tangible answer most of the time.
 

Seaglass

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Traumatic taps are common. Certainly a negative tap in a patient is great but what do you do when the RBC count is 20, 15? There is no cut off established to make it a "negative tap." In our protocol if you run into an aneurysm on the CT neurosurg is consulted and they can decide if they want to LP or not.

Overall I agree with most of what is said here, I certainly still tap a lot of people (our protocol is only for people with HA <24 hours from onset). Just offering up another option. I know ours is not the only major medical center in NC that employs this approach.
 

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Traumatic taps are common. Certainly a negative tap in a patient is great but what do you do when the RBC count is 20, 15? There is no cut off established to make it a "negative tap." In our protocol if you run into an aneurysm on the CT neurosurg is consulted and they can decide if they want to LP or not.

Overall I agree with most of what is said here, I certainly still tap a lot of people (our protocol is only for people with HA <24 hours from onset). Just offering up another option. I know ours is not the only major medical center in NC that employs this approach.

I think there's two issues here. The first is "does this patient REALLY have a SAH". I would be comfortable using your approach of CT/CTA within the first 24h, too. I believe that the risks of missing an SAH are small.

But the second issue is liability. If you got unlucky and missed the SAH with your CT/CTA approach, I think you could be vulnerable in court. If you got unlucky and missed a SAH in the context of a traumatic tap, however, I think it's easier to defend in court. In other words, I think you'll have an easier time lining up your peers to say on the stand that there is no consensus about how many RBCs constitutes a traumatic tap vs. SAH than you will lining up your peers to say that one can attempt to definitively exclude a SAH without doing an LP (which of course is a problematic statement in and of itself, because even that is probably not 100% fool proof!)

Again, I agree with you clinically. My comfort level with the legal issues is just different. Two contrasting opinions, neither one should be taken as gospel.

Not sure which institutions in NC you're referring to... UNC and Duke both follow the LP approach. Don't know 'bout ECU
 

Emedpa

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I rarely LP unless there is a very classic story. I CT for numerous reasons, not just subarachnoid hemorrhage. There are other things that occur that can be detected with CT.

Where I trained, our neurology and neurosurgery attendings quoted their own studies that demonstrated extremely low likelihood of missed SAH by CT using newer generation CT's.

This is my approach as well. the last time I picked up a sah by lp with neg ct the consultant wanted mri and then decided the sah was "too small to be clinically significant" and he sent the pt home.....
 

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In my opinion there are many indications to order a head CT without doing a reflexive LP. However, I agree that pain relief after medication administration is not a valid reason to forgo LP. If a patient is fully alleviated with tylenol or motrin... I'll buy that. But once you've given narcotics, you should have already made up your mind about CT/LP.

50% of the time I will order a head CT without LP for HA's. My indication is usually r/o Mass/Tumor or SDH.

Examples:

1) Constant HA lasting over 1 wk (not worst of life)

2) Chronic Recurrent HA's who have never had imaging before (not worst of life)

3) ER bouncebacks for HA without signs/symtoms suggestive of SAH, Meningititis, Pseudotumor

4) Elderly patients or Dialysis patients with mild subacute HA to r/o SDH
 

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When I was just a volunteer in an ER in Brooklyn NY over 12 years ago the docs used to do an LP, then spin it down in the ED. They then would look at the cells under a microscope and look for old RBC's (shrunken/ruptured) vs. new RBC's. If they were old (relatively) it represented a bleed and not a traumatic tap. I've never heard of that since that time. Anyone know if this is still done anywhere?
 

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When I was just a volunteer in an ER in Brooklyn NY over 12 years ago the docs used to do an LP, then spin it down in the ED. They then would look at the cells under a microscope and look for old RBC's (shrunken/ruptured) vs. new RBC's. If they were old (relatively) it represented a bleed and not a traumatic tap. I've never heard of that since that time. Anyone know if this is still done anywhere?
What you are describing sounds like looking for xanthochromia. Am I missing something here because this is the accepted standard for detecting SAH with LP's.
 

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I know it's the way it's done in the lab, but has anyone done it themselves in the ED any longer?
 

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I know it's the way it's done in the lab, but has anyone done it themselves in the ED any longer?
No, it's not allowed by the Joint Commission. Most places have trouble keeping the guiaic cards in the ER without a big stink by the lab. No way would my lab allow me to keep a centrifuge and microscope in the ER.
 
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No, it's not allowed by the Joint Commission. Most places have trouble keeping the guiaic cards in the ER without a big stink by the lab. No way would my lab allow me to keep a centrifuge and microscope in the ER.

We have microscope competency exams to use the microscope in the ED. One guy has kept up on it. (And it is JCAHO mandated.)
 
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  6. Your reply has occurred very quickly after a previous reply and likely does not add anything to the thread.
  7. This thread is locked.