Comparing 11 early warning scores and three shock indices in early sepsis prediction in the emergency department

BACKGROUND:This study aimed to evaluate the discriminatory performance of 11 vital sign-based early warning scores(EWSs)and three shock indices in early sepsis prediction in the emergency department(ED).METHODS:We performed a retrospective study on consecutive adult patients with an infection over 3 months in a public ED in Hong Kong.The primary outcome was sepsis(Sepsis-3 definition)within 48 h of ED presentation.Using c-statistics and the DeLong test,we compared 11 EWSs,including the National Early Warning Score 2(NEWS2),Modified Early Warning Score,and Worthing Physiological Scoring System(WPS),etc.,and three shock indices(the shock index[SI],modified shock index[MSI],and diastolic shock index[DSI]),with Systemic Inflammatory Response Syndrome(SIRS)and quick Sequential Organ Failure Assessment(qSOFA)in predicting the primary outcome,intensive care unit admission,and mortality at different time points.RESULTS:We analyzed 601 patients,of whom 166(27.6%)developed sepsis.NEWS2 had the highest point estimate(area under the receiver operating characteristic curve[AUROC]0.75,95%CI 0.70-0.79)and was significantly better than SIRS,qSOFA,other EWSs and shock indices,except WPS,at predicting the primary outcome.However,the pooled sensitivity and specificity of NEWS2≥5 for the prediction of sepsis were 0.45(95%CI 0.37-0.52)and 0.88(95%CI 0.85-0.91),respectively.The discriminatory performance of all EWSs and shock indices declined when used to predict mortality at a more remote time point.CONCLUSION:NEWS2 compared favorably with other EWSs and shock indices in early sepsis prediction but its low sensitivity at the usual cut-off point requires further modification for sepsis screening.

Prediction of sepsis within 24 hours at the triage stage in emergency departments using machine learning

BACKGROUND:Sepsis is one of the main causes of mortality in intensive care units(ICUs).Early prediction is critical for reducing injury.As approximately 36%of sepsis occur within 24 h after emergency department(ED)admission in Medical Information Mart for Intensive Care(MIMIC-IV),a prediction system for the ED triage stage would be helpful.Previous methods such as the quick Sequential Organ Failure Assessment(qSOFA)are more suitable for screening than for prediction in the ED,and we aimed to fi nd a light-weight,convenient prediction method through machine learning.METHODS:We accessed the MIMIC-IV for sepsis patient data in the EDs.Our dataset comprised demographic information,vital signs,and synthetic features.Extreme Gradient Boosting(XGBoost)was used to predict the risk of developing sepsis within 24 h after ED admission.Additionally,SHapley Additive exPlanations(SHAP)was employed to provide a comprehensive interpretation of the model's results.Ten percent of the patients were randomly selected as the testing set,while the remaining patients were used for training with 10-fold cross-validation.RESULTS:For 10-fold cross-validation on 14,957 samples,we reached an accuracy of 84.1%±0.3%and an area under the receiver operating characteristic(ROC)curve of 0.92±0.02.The model achieved similar performance on the testing set of 1,662 patients.SHAP values showed that the fi ve most important features were acuity,arrival transportation,age,shock index,and respiratory rate.CONCLUSION:Machine learning models such as XGBoost may be used for sepsis prediction using only a small amount of data conveniently collected in the ED triage stage.This may help reduce workload in the ED and warn medical workers against the risk of sepsis in advance.

Urinary Tract Infection in Pediatric Emergency Department of Mohamed VI Hospital in Marrakech: Epidemiological Profile and Antibiotic Resistance

Background: Urinary tract infection (UTI) is one of the most frequent bacterial infections in pediatrics. The aim of our work was to establish the epidemiological and bacteriological profile of UTIs in children and then to study the sensitivity of the bacterial strains isolated to antibiotics. Materials and methods: This is a retrospective descriptive study over 3 years (2019-2022), including all cytobacteriological examination of urine (CBEU), performed in children aged 3 months to 14 years, admitted and treated for UTI, in the pediatric emergency department of Mohamed VI University Hospital. Results: A total of 239 children were included in our study. The mean age was 26 months. The sex ratio was 1.08. Escherichia coli was the most isolated bacterial strain in 79% of samples. The tested strains showed a high level of sensitivity to susceptibility rate toward amikacin (91%) and ciprofloxacin (100%) and whereas the level of resistance was high to the most current recommended antibiotics, mainly beta-lactams. Management was based, in severe forms of pyelonephritis, dual antibiotic therapy based on Third-generation cephalosporins combined with gentamycin. Favorable outcome was noted in 94% of children. Conclusion: Awareness-raising on the proper use of antibiotics, issuing national recommendations for the treatment of urinary tract infections in order to standardize therapeutic regimens is strongly recommended. Effective control of these infections requires a global prevention strategy that implies close collaboration between epidemiologists, clinicians, bacteriologists, hygienists and the health care team.

Diagnostic accuracy of the tongue blade test combined with clinical signs to detect maxillary and mandibular fractures in the emergency department

BACKGROUND: To evaluate the diagnostic accuracy of clinical signs combined with the tongue blade test(TBT) to detect maxillary and mandibular fractures.METHODS: A cross-sectional study enrolled patients with maxillary and mandibular injuries in the emergency department. Physical examination and the TBT were performed, followed by radiological imaging(facial X-ray or computed tomography [CT]). The diagnostic accuracy was calculated for individuals and a combination of clinical findings at predicting maxillary and mandibular fractures.RESULTS: A total of 98 patients were identified, of whom 31.6% had maxillary fractures and9.2% had mandibular fractures. The combination of malocclusion, tenderness on palpation and swelling with positive TBT had 100% specificity to detect maxillary and mandibular fractures. In the absence of malocclusion, the combination of tenderness on palpation and swelling with positive TBT produced a specificity of 97.8% for maxillary fracture and a specificity of 96.2% for mandibular fracture. A clinical decision tool consisting of malocclusion, tenderness on palpation, swelling and TBT revealed a specificity of 100% and a positive predictive value of 100%.CONCLUSION: The clinical decision tool is potentially useful to rule out mandibular fractures,thus preventing unnecessary radiation exposure.

Survey study of the etiology of non-traumatic altered consciousness in the Emergency Department at Suez Canal University Hospital in Egypt

BACKGROUND Disorders of consciousness including coma in non-trauma patients can be caused by a wide variety of pathologies affecting the central nervous system.They represent a frequent challenge in emergency medicine and are combined with a very high in-hospital mortality.Hence,early treatment of these patients is vital and increases the likelihood of a good outcome.AIM To identify the causes of altered consciousness presentation to the Emergency Department at Suez Canal University Hospital.METHODS This was a descriptive cross-sectional study conducted on 87 patients with acute non-traumatic disturbed level of consciousness(DLOC)at the Emergency Department.RESULTS The mean age of the studied patients was 60.5±13.6 years.Among them,60%were males and 40%were females.The most common cause of acute non-traumatic DLOC was systemic infection,such as sepsis and septic shock(25.3%),followed by respiratory causes(24.1%)and neurological causes(18.4%).CONCLUSION The most common cause of acute non-traumatic DLOC was systemic infections followed by respiratory and neurological causes.

The Definition of Non-Urgent Visits to the Emergency Department and Validation of Criteria for Referrals

Background: The centers of disease control and prevention define a non-urgent Emergency Department (NU-ED) visit as a medical condition requiring treatment within more than 24 hours. These visits constitute one of the main reasons for emergency department (ED) overcrowding, which greatly affects healthcare workers’ wellbeing, health costs, patients’ satisfaction and treatment outcomes. Currently, there is no solid definition of non-urgent emergency visits, which is the first step towards dealing and potentially solving this issue. Having that, the aim of the current study is to define and validate the criteria for NU-ED visits in Israel. Methods: This qualitative study included twelve senior physicians and nurses working in Emergency Department and/or Health Maintenance Organizations (HMOs) across Israel. The study was performed using in-depth, semi-structured, open-ended interviews. Qualitative data analysis was performed by conventional content analysis. Results: The urgency of medical visits was defined based on these two questions: 1) Does the medical condition require an immediate treatment? 2) Is the emergency department the only place that can provide the required treatment at a certain timepoint? We found that non-urgent visits mostly occur during the nights and weekends, when medical treatments are not available in the HMOs. Visitors for non-urgent cases mostly complained about minor injuries or chronic conditions, fever, abdominal or chest pain. Most visits occurred based on referral from the family physician or the nurse from the call center. Participants reported a lack of awareness and knowledge about the roles of the EDs and the available options in the HMOs, which seem unable to provide patients with appropriate treatments. The usage of triage scales seems to ensure that patients are being treated based on the clinical urgency of their condition. Medical cases that score above 3 can be defined as non-urgent visits. Therefore, implementation of these scales in the community and their use in decision making of referrals to emergency department might greatly reduce non-urgent visits. Conclusions: Participants defined urgent ED visits as medical situations that need to be treated immediately, while there are no available treatment options in the HMOs. Participants identified many reasons behind NU referrals to the ED, mainly, low awareness about the role of ED, low availability of certain tests in the HMOs, and inability to provide adequate treatment in the community.

Acute Fevers in the Medical Unit of the Medical-Surgical Emergency Department of the Donka National Hospital

Introduction: Fever is a high core temperature ≥ 37.5°C in the morning and 37.8°C in the evening. It is acute when it evolves from 0 to 20 days. Very common in clinical practice, the etiological diagnosis, particularly in developing and tropical countries, is often a challenge for clinicians due to their diversity and the limited availability of diagnostic tools. There is a wide spectrum of etiological diagnoses including infectious causes and non-infectious causes. The aim of this study was to investigate the etiology of fevers acute at the medical unit in the medico-surgical emergency department of the Donka National Hospital. Methods: This was a descriptive cross-sectional study lasting 03 months (January 01, 2022 to March 31, 2022). We included in this study all patients seen in the medical unit, whose age ≥ 18 years, without distinction of sex, from any origin, with an axillary temperature ≥ 37.5°C in the morning and 37.8°C in the evening, evolving from 0 to 20 days, hospitalized or followed on an outpatient basis, and having given verbal consent. Results: Of a total of 1087 patients seen, 466 had an acute fever. The mean age was 40.04 ± 18.91 years (18 and 96 years). The female sex (58.15%) was predominant with a sex ratio of 0.72. Malaria (50.86%) was the main diagnosis. The treatment consisted of compressed paracetamol (59.01%), arthemether + lumefantrine (50.85%). Conclusion: The incidence of acute fevers is high in the medical unit of the medico-surgical emergency department of the Donka National Hospital. Malaria was the main pathology. Treatment was etiological and symptomatic. This high incidence could be explained by the fact that Guinea is an endemic malaria zone. A study taking into account other etiological factors would be of great interest.

The impact of prehospital blood sampling on the emergency department process of patients with chest pain:a pragmatic non-randomized controlled trial

BACKGROUND:In patients with chest pain who arrive at the emergency department(ED)by ambulance,venous access is frequently established prehospital,and could be utilized to sample blood.Prehospital blood sampling may save time in the diagnostic process.In this study,the association of prehospital blood draw with blood sample arrival times,troponin turnaround times,and ED length of stay(LOS),number of blood sample mix-ups and blood sample quality were assessed.METHODS:The study was conducted from October 1,2019 to February 29,2020.In patients who were transported to the ED with acute chest pain with low suspicion for acute coronary syndrome(ACS),outcomes were compared between cases,in whom prehospital blood draw was performed,and controls,in whom blood was drawn at the ED.Regression analyses were used to assess the association of prehospital blood draw with the time intervals.RESULTS:Prehospital blood draw was performed in 100 patients.In 406 patients,blood draw was performed at the ED.Prehospital blood draw was independently associated with shorter blood sample arrival times,shorter troponin turnaround times and decreased LOS(P<0.001).No differences in the number of blood sample mix-ups and quality were observed(P>0.05).CONCLUSION:For patients with acute chest pain with low suspicion for ACS,prehospital blood sampling is associated with shorter time intervals,while there were no significant differences between the two groups in the validity of the blood samples.

The effect of prophylactic antibiotics in acute upper gastrointestinal bleeding patients in the emergency department

BACKGROUND: Currently, prophylactic antibiotics are recommended only for cirrhotic patients with acute upper gastrointestinal bleeding(AUGIB);however, the benefit for other AUGIB patients remains undetermined. We aimed to compare the clinical outcomes between patients with AUGIB with and without prophylactic antibiotics to identify the population that requires this therapy.METHODS: Patients with AUGIB admitted between 1st January 2019 and 31st December 2021 in the Emergency Department of Peking Union Medical College Hospital were enrolled. Patients were divided into the antibiotic and non-antibiotic groups. The primary outcome was in-hospital mortality, and the secondary outcome was the onset of new infection. The risk factors for mortality and infection were analyzed, and stratification analysis of prophylactic antibiotics was performed. Continuous data were analyzed using the t-test or nonparametric rank sum test, and categorical data were analyzed using the Chi-square test or Fisher's exact test. Indicators with significant differences between the groups were included for logistic regression analysis. A P-value <0.05 was considered statistically significant. RESULTS: A total of 392 individuals were included, among them, 281 patients received prophylactic antibiotics, and 111 patients did not receive prophylactic antibiotics. The mortality rates were significantly lower in the antibiotic group than in the non-antibiotics group(6.41% vs. 17.12%, P=0.001). The risk factors for infection were varicose veins(P=0.045) and endotracheal intubation(P=0.005) in the prophylactic antibiotic group, and endoscopic treatment(P=0.010) in the non-prophylactic antibiotic group. Stratified analyses showed that patients with age ≥ 65 years, endotracheal intubation, endoscopic treatment, and AUGIB of variceal etiologies benefited from prophylactic antibiotics.CONCLUSION: AUGIB patients may benefit from prophylactic antibiotics to decrease mortality, especially those aged ≥ 65 years and those with endotracheal intubation, endoscopic treatment, and variceal etiologies.

Application effect of phloroglucinol injection in elderly patients with spastic abdominal pain in emergency department

BACKGROUND Although norepinephrine injection is commonly used in emergency situations,it is associated with risks for elderly patients with spasmodic liver pain.This study explores the safety and effectiveness of mebendazole injection,an alternative treatment option,for the emergency management of spasmodic abdominal pain,while minimizing adverse reactions,in elderly patients.AIM To explore the development of norepinephrine injection and the adverse reactions of this drug in emergency elderly patients with spasmodic liver pain.METHODS The control group consisted of 56 elderly patients visiting our hospital from January 2021 to December 2021.After hospital admission,the control group was intravenously administered tolopin.The experimental group consisted of 56 emergency patients with spasmodic abdominal pain who visited our hospital until June 2022.After hospital admission,the experimental group was intravenously administered toloxazole.The two groups were treated for 3 d.The disappearance of clinical symptoms was observed before and after the treatment,and the difference in adverse reactions between the two groups was compared.RESULTS The pain of the wife,fire,diarrhea,drowning,and surrounding time disappeared in the experimental group.No statistical difference was observed between the experimental and control groups in visual pain analog scale(VAS)scores before and after the treatment(P>0.05).The VAS scores of abdominal pain severity after 0.5 h,1.0 h,and after 6.0 h of treatment were significantly lower for the experimental group than for the control group.After the treatment,the therapeutic effect in the experimental group was higher and statistically significant than that in the control group(P<0.05).The probability of adverse reactions before the treatment was lower in the experimental group than in the control group.CONCLUSION During emergency,mebendazole injection exhibited a good therapeutic value when used for the clinical treatment of elderly patients with spasmodic stomach pain.It accelerated the disappearance of clinical symptoms such as stomach pain,reduced the stomach weight,and improved clinical activity.Reducing and promoting the frequency of high treatment safety with mebendazole injection is worthwhile.

Improving the approach to non-cardiac syncope in the emergency department observation unit

Syncope is a rather frequent condition,responsible for1.0%–1.5%of emergency department (ED) visits.[1]Even if the development of clinical guidelines has improved the ED management of syncope,[2]the hospitalization rate is still very high (up to 50%),especially compared with the incidence of short-term adverse events,which is11%globally,but decreases to less than 4%when events already diagnosed in the ED are excluded,[1]meaning that most patients will not benefit from admission.

Post Antibiotic Grade IV Anaphylaxis: A Case Report from the Emergency Department of Chu Donka

Anaphylaxis is a serious systemic reaction that is part of the general pattern of potentially fatal hypersensitivity reactions requiring immediate management. We report the case of a patient presenting to emergency with signs of malaria and pneumonia who was diagnosed with grade 4 anaphylaxis following antibiotic injection in the emergency department. The patient was 30 years old, with no previous history of anaphylaxis, and presented to the emergency department with fever, dry cough, headache and dizziness associated with prostration. Physical examination showed stable hemodynamics (BP = 110/80 mmHg, HR = 95 p/min,) and respiratory function with SpO2 = 98%, HR = 22 c/min and crepitus rales at the base of the lungs. The laboratory work-up carried out in the emergency department revealed a biological inflammatory syndrome associated with hyperleukocytosis of 11,260/mm3, a positive thick drop with GE(+) dp = 1183 T/microlitre;blood glucose = 0.83 g/l;Covid 19 RDT = (negative). A diagnosis of malaria and pneumonia was made and antibiotic therapy (ceftriaxone) and artesunate were indicated. During the injection of ceftriaxone 1 g, the patient became agitated, followed by cardiorespiratory arrest, confirming the diagnosis of stage 4 anaphylaxis. Treatment consisted of stopping the ceftriaxone injection, external cardiac massage and ventilation, intravenous adrenaline and vascular filling, which enabled the patient to recover and stabilize. The diagnosis of anaphylaxis is clinical. Early administration of adrenaline is the mainstay of treatment.

Prevalence of Metabolic Syndrome in the Medical-Surgical Emergency Department of the Donka National Hospital

Introduction: The metabolic syndrome (MS) corresponds to the coexistence of several metabolic disorders including three (3) factors out of five (5) in the same individual. These five (5) major criteria are central or abdominal obesity, hypertriglyceridemia, low High-Density Lipoprotein cholesterol (HDLc), hyperglycemia, and elevated blood pressure. It has been the subject of various definitions over the past 10 years. It is a clinical-biological entity recognized by the World Health Organization (WHO) in 1998, the National Cholesterol Education Program-Adult Treatment Panel III (NCEP-ATP III) in 2001, the International Diabetes Federation (IDF) in 2005, then the IDF Harmonization Consensus in 2009. The objective of this study was to determine the prevalence of metabolic syndrome in the medico-surgical emergency department of the Donka national hospital. Methods: This was a descriptive study, data collection took place from February 5 to July 5, 2022 and, covering all patients aged 16 and over, without distinction of sex, origin received in consultation in the medical unit in the emergency department of Donka and having agreed to participate in the study. Anthropometric, clinical and biological data were recorded. Results: We recruited 107 patients whose age ranged from 20 to 94 years with a mean age of 58.92 ± 13.78 years. The prevalence of metabolic syndrome in our study population was 6.30% with a female predominance of 73.83%. The most frequent components of the metabolic syndrome were abdominal obesity (100%) followed by hyperglycemia (85.98%) and hypertension (85.05%). Among the complications related to the metabolic syndrome, diabetes was found with (46.73%), hypertension (43.93%) and stroke (16.93%). Conclusion: Our results show a significant prevalence of the metabolic syndrome and its main complications, which were diabetes, hypertension and stroke. These data justify early detection and treatment strategies.

An academic emergency department:residents' perspective

BACKGROUND:Since demographic changes have contributed to the growth of emergency medicine,a highly populous nation such as India needs to give physicians associated due credit and recognition.The management of knowledge source must also be conducted with due care as the work environment is completely different from that of any other clinicians.METHODS:The data were collected by direct interaction with residents of the department.Additional information was gathered by observation.The data were verified for validity.RESULTS:This study was to bring out the benefits of proactive decisions that could further enhance the emergency department.But such decisions did not always result in positive responses and improved morale.When such decisions were retracted as it causes misalignment with the existing system.An academic emergency department was expected and physicians should enrich their knowledge about emergency medicine.CONCLUSIONS:The problems faced by emergency department might be similar but the way in which one tackles the situation would be different.Decision making in this hospital may not be the best but it would've been the optimum one given the conditions available.

Lean techniques for the improvement of patients' flow in emergency department

BACKGROUND: Emergency departments(EDs) face problems with overcrowding, access block, cost containment, and increasing demand from patients. In order to resolve these problems, there is rising interest to an approach called "lean" management. This study aims to(1) evaluate the current patient flow in ED,(2) to identify and eliminate the non-valued added process, and(3) to modify the existing process.METHODS: It was a quantitative, pre- and post-lean design study with a series of lean management work implemented to improve the admission and blood result waiting time. These included structured re-design process, priority admission triage(PAT) program, enhanced communication with medical department, and use of new high sensitivity troponin-T(hsTnT) blood test. Triage waiting time, consultation waiting time, blood result time, admission waiting time, total processing time and ED length of stay were compared.RESULTS: Among all the processes carried out in ED, the most time consuming processes were to wait for an admission bed(38.24 minutes; SD 66.35) and blood testing result(mean 52.73 minutes, SD 24.03). The triage waiting time and end waiting time for consultation were significantly decreased. The admission waiting time of emergency medical ward(EMW) was significantly decreased from 54.76 minutes to 24.45 minutes after implementation of PAT program(P<0.05).CONCLUSION: The application of lean management can improve the patient flow in ED. Acquiescence to the principle of lean is crucial to enhance high quality emergency care and patient satisfaction.

Utilization of the Accident & Emergency Departments by Chinese elderly in Hong Kong

BACKGROUND: The epidemiological data on elderly patients attending Accident and Emergency Departments(AEDs) in Hong Kong is lacking. The study aimed to examine the epidemiology of geriatric patient visits to AEDs in Hong Kong, including demographic data and predictors of life-saving interventions(LSI) and admission.METHODS: A retrospective cross-sectional study of geriatric patients older than 64 years old attending three AEDs during the year 2012, with a sample of 1 200 patient visits recruited. The data were retrieved from the medical records of the respective hospitals. Descriptive characteristics of the visits were provided. Multivariate logistic regression was performed to evaluate the predictors of LSI and hospital admission.RESULTS: The mean age of the patients was 79.1 years. Totally 49.7% of the patients were male. "Diseases of the respiratory system" was the commonest diagnosis in AEDs as well as that required admission. The admission rate was 56.8%. Logistic regression demonstrated that dependent activity of daily living(ADL), arrival by ambulance, and the higher number of co-morbidities were predictors of LSI, while advanced age, dependent ADL, institutionalized patients, arrival by ambulance, and higher number of co-morbidities were predictors of hospital admission.CONCLUSIONS: Ageing population is creating an imminent burden on the emergency service in Hong Kong. Previously unavailable epidemiological information about geriatric attendance to AEDs was described. This forms the basis for development of future studies concerning the medical services on this specific group of patients.

Availability and quality of procedural sedation and analgesia in emergency departments without emergency physicians: A national survey in the Netherlands

BACKGROUND: Emergency physicians have been successful in implementing procedural sedation and analgesia(PSA) to treat emergency department(ED) patients who need to undergo painful procedures.However, 25% of the EDs in the Netherlands are not staffed by emergency physicians.The aim of this study was to investigate PSA availability and quality in EDs without emergency physicians.METHODS: We performed an exploratory cross-sectional study amongst ED nurses and physicians in all 13 EDs without emergency physicians in the Netherlands.Data were gathered using a standardized questionnaire.RESULTS: The response rate was 34.3%(148/432).Of the respondents, 84/148(56.8%) provided adult PSA and 30/148(20.3%) provided paediatric PSA.Main reasons for not providing PSA were insufficient numbers of trained staff to support PSA in the ED and insufficient training and exposure.The providers agreed significantly stronger when reflecting their PSA competencies in adults compared to paediatric patients.CONCLUSION: The key to improve pain management in the ED-setting may lay in investing in continuous training of ED health care professionals and/or acquiring professionals who are both qualified in PSA and available in the ED.

Evaluating the management of anaphylaxis in US emergency departments:Guidelines vs.practice

BACKGROUND:Anaphylaxis is characterized by acute episodes of potentially life-threatening symptoms that are often treated in the emergency setting.Current guidelines recommend:1) quick diagnosis using standard criteria;2) first-line treatment with epinephrine;and 3) discharge with a prescription for an epinephrine auto-injector,written instructions regarding long-term management,and a referral(preferably,allergy) for follow-up.However,studies suggest low concordance with guideline recommendations by emergency medicine(EM) providers.The study aimed to evaluate how emergency departments(EDs) in the United States(US) manage anaphylaxis in relation to guideline recommendations.METHODS:This was an online anonymous survey of a random sample of EM health providers in US EDs.RESULTS:Data analysis included 207 EM providers.For respondent EDs,approximately 9%reported using agreed-upon clinical criteria to diagnose anaphylaxis;42%reported administering epinephrine in the ED for most anaphylaxis episodes;and <50%provided patients with a prescription for an epinephrine auto-injector and/or an allergist referral on discharge.Most provided some written materials,and follow-up with a primary care clinician was recommended.CONCLUSIONS:This is the first cross-sectional survey to provide "real-world" data showing that practice in US EDs is discordant with current guideline recommendations for the diagnosis,treatment,and follow-up of patients with anaphylaxis.The primary gaps are low(or no) utilization of standard criteria for defining anaphylaxis and inconsistent use of epinephrine.Prospective research is recommended.

The presenting and prescribing patterns of migraine in an Australian emergency department: A descriptive exploratory study

BACKGROUND: Migraine is a common neurological condition that frequently presents to the emergency department(ED). Many medications are available to treat migraine. This study aims to characterize the demographics of patients who present to a large metropolitan ED with migraine, and to identify the medications used in treating this condition.METHODS: This study is a retrospective database interrogation of clinical records, used to collect quantitative data on patient demographics and medication prescriptions in the ED.RESULTS: A total of 2 228 patients were identified as being treated for migraine over a 10-year period. The proportion of the ED population presenting with migraine steadily increased in this time. Females(71%) more commonly presented to the ED with migraine than males. The migraine population was signifi cantly younger(M=37.05, SD=13.23) than the whole ED population(M=46.17 SD=20.50)(P<0.001). A variety of medications were used in the treatment of migraine in the ED. Simple analgesics such as paracetamol and ibuprofen, anti-emetics and intravenous(IV) fluids with phenothiazine additives were commonly used. Over 20% of patients were prescribed oral or parenteral opiates(42 of 194 initial medication prescriptions, and 64 of 292 as required medication prescriptions). Triptans were very rarely used.CONCLUSION: Migraine is an increasingly common presentation to the ED. People presenting to the ED with migraine are more likely to be younger and female than the general ED population. Peak presentations for migraines occurred in January and February. The medications that are prescribed in the ED for migraine is varied and are not always in line with current evidence for the treatment of migraine. The excessive reliance on opiates and lack of the use of triptans denotes a signifi cant variation from published guidelines.

Infected aortic and iliac aneurysms:Clinical manifestations in the emergency departments of two hospitals in southern Taiwan,China

BACKGROUND: Accurate diagnosis of infected aortic and iliac aneurysms is often delayed, hampering timely treatment and potentially resulting in a fatal consequence. The aim of this study was to discover useful clinical features that can help physicians to identify these patients.METHODS: We reviewed the discharge notes from two hospitals and identifi ed all patients who had a diagnosis of infected aneurysms of the thoracoabdominal aorta and iliac arteries between July 2009 and December 2013. Eighteen patients, aged from 41 to 93, were reviewed. Only 6 patients were diagnosed accurately in their fi rst visit to our ED.RESULTS: Most patients had at least one underlying illness, and it took 1 to 30(9.9±6.5) days for physicians to diagnose their infected aneurysm. Localized pain and fever were the two most commonly presented symptoms. The majority(92%) of isolated microorganisms were gram-negative bacilli, including Salmonella spp, Klebsiella pneumoniae, and Escherichia coli. Two of the 3 patients who underwent non-operative therapy died, and all of the patients who underwent a combination of medical and operative therapies survived.CONCLUSION: We suggest that physicians liberally use computed tomography scans on patients with unknown causes of pain and inflammatory processes. A combination of surgical and medical treatments is indicated for all patients with infected aortic and iliac aneurysms.