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Post-lumbar puncture headaches: Experience in 501 consecutive procedures
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Editor’s Comment: The controlled circumstances of this study such as the NPO status, and the time frame involved preclude the use of such a protocol in the emergency department in most situations. However, the use of ketamine for sedation in the emergency department is clearly safe and efficacious. Whether oral or intramuscular administration is most appropriate deserves further study.
0 THE ROLE OF ABDOMINAL X-RAYS IN THE DIAGNOSIS AND MANAGEMENT OF INTUSSUSCEPTION. Smith D, Bonadio W, Losek J. Pediatric Emergency Care. 1992;8(6):325-27. This study was undertaken to determine the clinical sensitivity and specificity of abdominal radiographs in identifying patients with intussusception for the pediatric emergency department setting. Three groups of patients were selected for comparison, forty two “clinical” controls, forty two “normal” controls and forty two patients who had a discharge diagnosis of intussusception. The patients were aged from 3 months to 36 months and presented to Children’s Hospital of Wisconsin over an 18 month period. The control groups were matched for age and sex. The “clinical” group presented with symptoms compatible with intussusception. All patients received supine and upright abdominal radiographs. The films were randomized, blinded and then interpreted by each of six full-time pediatric emergency physicians, with no clinical information. These physicians then identified patients for whom they would proceed to barium enema. The mean sensitivity was 80.5% and the mean specificity was 58%. The authors concluded that based on the sensitivity, which is comparable to that associated with signs and symptoms, the plain films should be utilized as an adjunct when evaluating the patient with [Maureen Campbell, DO] suspected intussusception. Editor’s Comment: Most studies report a 35-40% positive finding rate on abdominal radiographs for intussusception. Where the diagnosis is seriously considered, it would be more expedient to proceed directly to barium enema.
0 USES AND TECHNIQUE OF PEDIATRIC LUMBAR PUNCTURE. Ward E, Gushurst CA. AJDC. 1992;146: 1160-1165. The authors reviewed the recent literature pertaining to lumbar puncture and summarized various aspects related to indications, contraindications, technique and analysis. They reviewed only pediatric literature and did not include neonates. The authors recommended lumbar puncture in all children under one year of age with suspected bacteremia. Repeat lumbar puncture was recommended in the case of clinical deterioration, development of neurologic findings, or to confirm the diagnosis of aseptic meningitis. The authors also advocated lumbar puncture for children under one year with cellulitis anywhere on the body which
The Journal of Emergency Medicine
is suspected to be H. influenzae type B, especially if it involves the face. The authors did not advocate routine lumbar punctures in the evaluation of first simple febrile seizures unless the child was under one year. Contraindications included infection over the puncture site, an untreated clotting abnormality, preexisting spinal cord compression or trauma, and elevated increased intracranial pressure. Numerous complications of lumbar puncture have been reported in the literature and these are elucidated further. With regard to technique, there was no difference in traumatic or dry lumbar punctures with various needle types, but stylets reduce the risk of epidermoid tumor formation. A clear hubbed needle may be easier to use as there is less weight and cerebrospinal fluid (CSF) is easier to visualize. When interpreting traumatic lumbar punctures, gram stain, CSF glucose, and observed-to-expected WBC ratio were helpful, while calculations based on the peripheral WBC count were not. [Suzanne Chilton, MD] Editor’s Comment: Of note is that antibiotic therapy prior to lumbar puncture did not change CSF characteristics such that the diagnosis of meningitis could not be made.
Cl POST-LUMBAR PUNCTURE HEADACHES: EXPERIENCE IN 501 CONSECUTIVE PROCEDURES. Kuntz, HM et al. Neurology. 1992;42:1884-1887. This study was performed to ascertain the frequency and risk factors for post-lumbar puncture headache (LPHA). The authors described the experience of all patients referred to the outpatient lumbar puncture (LP) service at the Mayo Clinic Rochester and the Mayo Clinic Scottsdale. Post LPHA was defined as a headache (HA) that improved or disappeared with recumbency, and occurred on one or more of the seven follow-up days after LP. Information collected on all patients included demographic data, presence of HA prior to LP, opening and closing pressures, amount of CSF removed, position of patient during and after LP, and the duration of recumbency after LP. All but 16 of the 501 LP’s were performed with a 20-gauge needle. The rest were done using a 22gauge needle. The authors found that 183 patients (36.5%) reported headache on one or more of the 7 days following LP. Females (43%) were more likely to experience LPHA than males (29%). Patients who reported HA prior to LP were more likely to report LPHA. Those with low body mass index had increased incidence of LPHA. Patients who were supine (36%) after the procedure were less likely to have LPHA than those who were prone (49010).Opening and closing pressures, number of cells in the CSF, amount of CSF removed, and the experience of the lumbar puncturist were not associated with increased risk of LPHA. [Daniel J. Safranek] Editor’s Comment: Unfortunately, there were too few patients in the 22 gauge needle group to ascertain if using a smaller needle would result in fewer LPHA.
Editor’s Comment: The controlled circumstances of this study such as the NPO status, and the time frame involved preclude the use of such a protocol in the emergency department in most situations. However, the use of ketamine for sedation in the emergency department is clearly safe and efficacious. Whether oral or intramuscular administration is most appropriate deserves further study.
0 THE ROLE OF ABDOMINAL X-RAYS IN THE DIAGNOSIS AND MANAGEMENT OF INTUSSUSCEPTION. Smith D, Bonadio W, Losek J. Pediatric Emergency Care. 1992;8(6):325-27. This study was undertaken to determine the clinical sensitivity and specificity of abdominal radiographs in identifying patients with intussusception for the pediatric emergency department setting. Three groups of patients were selected for comparison, forty two “clinical” controls, forty two “normal” controls and forty two patients who had a discharge diagnosis of intussusception. The patients were aged from 3 months to 36 months and presented to Children’s Hospital of Wisconsin over an 18 month period. The control groups were matched for age and sex. The “clinical” group presented with symptoms compatible with intussusception. All patients received supine and upright abdominal radiographs. The films were randomized, blinded and then interpreted by each of six full-time pediatric emergency physicians, with no clinical information. These physicians then identified patients for whom they would proceed to barium enema. The mean sensitivity was 80.5% and the mean specificity was 58%. The authors concluded that based on the sensitivity, which is comparable to that associated with signs and symptoms, the plain films should be utilized as an adjunct when evaluating the patient with [Maureen Campbell, DO] suspected intussusception. Editor’s Comment: Most studies report a 35-40% positive finding rate on abdominal radiographs for intussusception. Where the diagnosis is seriously considered, it would be more expedient to proceed directly to barium enema.
0 USES AND TECHNIQUE OF PEDIATRIC LUMBAR PUNCTURE. Ward E, Gushurst CA. AJDC. 1992;146: 1160-1165. The authors reviewed the recent literature pertaining to lumbar puncture and summarized various aspects related to indications, contraindications, technique and analysis. They reviewed only pediatric literature and did not include neonates. The authors recommended lumbar puncture in all children under one year of age with suspected bacteremia. Repeat lumbar puncture was recommended in the case of clinical deterioration, development of neurologic findings, or to confirm the diagnosis of aseptic meningitis. The authors also advocated lumbar puncture for children under one year with cellulitis anywhere on the body which
The Journal of Emergency Medicine
is suspected to be H. influenzae type B, especially if it involves the face. The authors did not advocate routine lumbar punctures in the evaluation of first simple febrile seizures unless the child was under one year. Contraindications included infection over the puncture site, an untreated clotting abnormality, preexisting spinal cord compression or trauma, and elevated increased intracranial pressure. Numerous complications of lumbar puncture have been reported in the literature and these are elucidated further. With regard to technique, there was no difference in traumatic or dry lumbar punctures with various needle types, but stylets reduce the risk of epidermoid tumor formation. A clear hubbed needle may be easier to use as there is less weight and cerebrospinal fluid (CSF) is easier to visualize. When interpreting traumatic lumbar punctures, gram stain, CSF glucose, and observed-to-expected WBC ratio were helpful, while calculations based on the peripheral WBC count were not. [Suzanne Chilton, MD] Editor’s Comment: Of note is that antibiotic therapy prior to lumbar puncture did not change CSF characteristics such that the diagnosis of meningitis could not be made.
Cl POST-LUMBAR PUNCTURE HEADACHES: EXPERIENCE IN 501 CONSECUTIVE PROCEDURES. Kuntz, HM et al. Neurology. 1992;42:1884-1887. This study was performed to ascertain the frequency and risk factors for post-lumbar puncture headache (LPHA). The authors described the experience of all patients referred to the outpatient lumbar puncture (LP) service at the Mayo Clinic Rochester and the Mayo Clinic Scottsdale. Post LPHA was defined as a headache (HA) that improved or disappeared with recumbency, and occurred on one or more of the seven follow-up days after LP. Information collected on all patients included demographic data, presence of HA prior to LP, opening and closing pressures, amount of CSF removed, position of patient during and after LP, and the duration of recumbency after LP. All but 16 of the 501 LP’s were performed with a 20-gauge needle. The rest were done using a 22gauge needle. The authors found that 183 patients (36.5%) reported headache on one or more of the 7 days following LP. Females (43%) were more likely to experience LPHA than males (29%). Patients who reported HA prior to LP were more likely to report LPHA. Those with low body mass index had increased incidence of LPHA. Patients who were supine (36%) after the procedure were less likely to have LPHA than those who were prone (49010).Opening and closing pressures, number of cells in the CSF, amount of CSF removed, and the experience of the lumbar puncturist were not associated with increased risk of LPHA. [Daniel J. Safranek] Editor’s Comment: Unfortunately, there were too few patients in the 22 gauge needle group to ascertain if using a smaller needle would result in fewer LPHA.