Authors: Rob Hirst, Chris Connolly, Becky Maxwell, Andy Neill, Dave McCreary / Codes: / Published: 03/04/2023
Clinical Question
- can we use a lactate level to tell if someone’s tLOC was a seizure.
Paper Title
- Utility of serum lactate on differential diagnosis of seizure-like activity: A systematic review and meta-analysis
Author
- Patel, Seizure: European Journal of Epilepsy
Background
- most of the time diagnosis of seizure is easy. It happens in front of us in the ED or a witness saw it and can describe it. IN that scenario we know what we’re dealing with. But then we have everything else. The person found unconscious on the street who recovers. Was that a seizure or what was the cause.
- it’s also clear that immediately after a generalised seiziure lactate levels are typically raised. it’s not unusual to find lactates in the high teens in the immediately post ictal state.
- so can we use the lactate level to tell is there’s been a seizure?
Methods
- this is a SRMA. This should include a focussed question with a detailed search of the extant literature in the hope of collating all the data and sytnthesising it into some usable clinical answer.
- they used the PRISMA guidance and registered with PROSPERO in advance.
Results
- 180 weaned down to 8
- 5 retrosepctive and 3 prospective.
- they graded the studies with a structured tool and they were largely of medium quality
- 1400 pts overall of whoom 900 had had a generalised seizure
- using the data they come up with somewhere in the range of a lactate of 2.5 as a somewhat discriminatory tool. But overall they found those with seizures had a mean difference in lactate of somewhere in the 5 range.
- interestingly they did not find any big difference between those who had generalised seizures and those suffering from the unfortunately named acronym PNES (psychogenic nonepileptiform seizures)
Thoughts
- in some ways we all knew this and indeed probably use it in clinical practice already. though it’s nice to see something in print
- on the other hand the big issue with all SRMA is the quality of data going in. HEre they were largely chart review type studies mostly with dubious gold standards. How exactly do you prove the person had a seizure?
- the timing is the other key point. lactate seems to clear very quickly in these folk. if you’re making your assessment 3 hrs after the episode then who knows what value it might have so i’d be very careful about excluding seizures on the basis of this.
- finally even if you do conclude it wasn’t a generalised seizure there’s still a lot of work left to do in terms of could this be partial seizures or other forms of tLOC.
- the other classic test i always hear about is prolactin. there’s a whole bunch of work around prolactin rises post seizure but it is not something i have access to.
Clinical Question
- do you resuscitate better with your buddies? or at least with people you know?
Title
- Effect of Increased Interprofessional Familiarity on Team Performance, Communication, and Psychological Safety on Inpatient Medical Teams
Author
- Christiana A. Iyasere JAMA Internal Medicine
Background
- I always felt one of the most stressful times during training was the change over week. not only were you dealing with new hospitals and new systems but there was also this crowd of new people and personalities. And it took time to find your place, who to trust and who was an idiot and who wasn’t (though most of the time it was clear i was the idiot!). There’s been lots of resus situations i’ve reflected on that have either gone well or badly and have been impacted by the team dynamics of the people involved.
- so if i knew them all well would it help?
Methods
- From Harvard in the states
- this is an RCT of the trainees. And just for context, MGH has 1100 beds and 200 trainees just on the general medicine side of things.
- as with most internships, they move around the wards and teams. But for this tral they randomised 15 inters to stay 4 months on one floor and the others to do the usual random movements.
- outcomes here were mainly human factor types ones but also some patient focussed outcomes.
- they used some ward based simulations which were videod and analysed and rated. they also had an independant observer follow them round to see if communication was good. they also surveyed the interns on their own experience of it
Results
- overall the intervention group who stayed in the same place seemed to do better. there were lots of interesting ones but one that could my eye was the intervention group at one point were paged 60 times vs 90 times in the usual group. there were lots of little results like this
- there was no difference in things like patient mortality but that is hardly surprising.