Emergency department management of acute agitation in the reproductive age female and pregnancy

BACKGROUND:Agitation is a common presentation within emergent departments(EDs).Agitation during pregnancy should be treated as an obstetric emergency,as the distress may jeopardize both the patient and fetus.The safety of psychotropic medications in the reproductive age female has not been well established.This review aimed to explore a summary of general agitation recommendations with an emphasis on ED management of agitation during pregnancy.METHODS:A literature review was conducted to explore the pathophysiology of acute agitation and devise a preferred treatment plan for ED management of acute agitation in the reproductive age or pregnant female.RESULTS:While nonpharmacological management is preferred,ED visits for agitation often require medical management.Medication should be selected based on the etiology of agitation and the clinical setting to avoid major adverse effects.Adverse effects are common in pregnant females.For mild to moderate agitation in pregnancy,diphenhydramine is an effective sedating agent with minimal adverse effects.In moderate to severe agitation,high-potency typical psychotropics are preferred due to their neutral effects on hemodynamics.Haloperidol has become the most frequently utilized psychotropic for agitation during pregnancy.Second generation psychotropics are often utilized as second-line therapy,including risperidone.Benzodiazepines and ketamine have demonstrated adverse fetal outcomes.CONCLUSION:While randomized control studies cannot be ethically conducted on pregnant patients requiring sedation,animal models and epidemiologic studies have demonstrated the effects of psychotropic medication exposure in utero.As the fetal risk associated with multiple doses of psychotropic medications remains unknown,weighing the risks and benefits of each agent,while utilizing the lowest effective dose remains critical in the treatment of acute agitation within the EDs.

Trends in oxycodone and oxycodone-containing analgesics administration for back pain in emergency departments in the USA(2007–2018)

BACKGROUND:To describe trends in oxycodone and oxycodone-containing analgesic prescribing for the treatment of back pain among adults in emergency departments(EDs) in the USA from 2007 to 2018.METHODS:Data were gathered from the National Hospital Ambulatory Medical Care Survey(NHAMCS) from 2007 to 2018.The study population included individuals of all ages presenting to USA EDs.The NHAMCS reasons for visit and oxycodone drug ID codes were used to isolate patients with back pain.The main outcome was the proportion of oxycodone and oxycodone-containing analgesics prescribed for back pain in the EDs over the specified time period.RESULTS:There was a relative decrease in the overall administration of oxycodone for back pain in the EDs by 62.3% from 2007(244,000 visits) to 2018(92,000 visits).The proportion of ED patients prescribed with oxycodone-containing analgesics for back pain increased among patients aged 45 years and older(from 43.8% to 57.6%),female patients(from 54.5% to 62.0%),black patients(from 22.5% to 30.4%),and Hispanic/Latino patients(from 9.4% to 19.6%).Oxycodone/acetaminophen was most prescribed and accounted for 90.2% of all oxycodone-containing analgesics in 2007,with a decrease to 68.5% in 2018.Pure oxycodone was the second most prescribed medication,accounting for 6.1% in 2007 and 31.5% in 2018.CONCLUSION:The overall number of oxycodone-containing analgesics decreased significantly from 2007 to 2018.However,that number trended upward in 45-year-old and older,female,black,or Hispanic/Latino patients from 2007 to 2018.The total amount of pure oxycodone increased significantly from 2007 to 2008.

Quantitative assessment of the impact of a triage physician on the Accreditation Council for Graduate Medical Education resident milestones in the emergency department

The “door-to-doctor” time for patients to be seen by a physician is an increasingly studied metric.Hospitals may shorten this time by implementing a triage physician (TP).The exact role of a TP may vary across departments.TPs put in preliminary orders for lab work,imaging,and treatment,and decide treatment location for further evaluation.As the prevalence of TPs grows,its effect on resident education in academic emergency departments (EDs) remains unclear.We implemented a TP in the spring of 2016 and assessed resident physicians before and after implementation.

Factors associated with the clinical outcomes of adult cardiac and non-cardiac origin cardiac arrest in emergency departments: a nationwide retrospective cohort study from China

Cardiac arrest(CA)is one of the most common causes of death.[1-3]Despite extensive studies on the management of CA,the global survival rate in adults is only approximately 7%,and 30-day survival is even less than 2%in China.[4]Some studies have shown that CA patients of cardiac and non-cardiac origin may differ in underlying diseases,clinical manifestations,and prognosis,which leads to diff erences in terms of the pathophysiological mechanism and treatment measure.[5,6]However,little is known about the risk factors in relation to the prognosis of CA across arrest etiologies.

Development and validation of an emergency bloodstream infection score for predicting in-hospital mortality in patients with community-acquired bloodstream infections

BACKGROUND:Community-acquired bloodstream infections(CABSIs)are common in the emergency departments,and some progress to sepsis and even lead to death.However,limited information is available regarding the prediction of patients with high risk of death.METHODS:The Emergency Bloodstream Infection Score(EBS)for CABSIs was developed to visualize the output of a logistic regression model and was validated by the area under the curve(AUC).The Mortality in Emergency Department Sepsis(MEDS),Pitt Bacteremia Score(PBS),Sequential Organ Failure Assessment(SOFA),quick Sequential Organ Failure Assessment(qSOFA),Charlson Comorbidity Index(CCI),and McCabe–Jackson Comorbid Classification(MJCC)for patients with CABSIs were computed to compare them with EBS in terms of the AUC and decision curve analysis(DCA).The net reclassification improvement(NRI)index and integrated discrimination improvement(IDI)index were compared between the SOFA and EBS.RESULTS:A total of 547 patients with CABSIs were included.The AUC(0.853)of the EBS was larger than those of the MEDS,PBS,SOFA,and qSOFA(all P<0.001).The NRI index of EBS in predicting the in-hospital mortality of CABSIs patients was 0.368(P=0.04),and the IDI index was 0.079(P=0.03).DCA showed that when the threshold probability was<0.1,the net benefit of the EBS model was higher than those of the other models.CONCLUSION:The EBS prognostic models were better than the SOFA,qSOFA,MEDS,and PBS models in predicting the in-hospital mortality of patients with CABSIs.

Assessment of knowledge, attitude and practice regarding oxygen therapy at emergency departments in Riyadh in 2017: A cross-sectional study

BACKGROUND: Administering oxygen therapy(OT) has an essential role in preventing/managing hypoxemia in both acute and chronic conditions. It should be adjusted to achieve the normal oxygen saturation of 94%–98% in most cases. This study aims to evaluate knowledge, attitude and practice(KAP) of nurses, paramedics, emergency medical technicians(EMTs) and Emergency Medical Services(EMS) physicians working at emergency departments(ED) in Riyadh, Saudi Arabia. METHODS: In this cross-sectional study, a structured questionnaire was used to assess KAP related to OT of nurses, paramedics, EMTs and EMS physicians currently working at an ED of a tertiary care hospital. Knowledge and attitude were assessed using a Likert scale from 1–5, whereas practice was assessed as a yes/no categorical variable.RESULTS: A total of 444 emergency health-care workers(EHCWs) participated, of which 225(50.7%) were male, with the majority(77%) in the age group of 20–35 years. Over half of the sample were nurses(266; 59.9%). The mean score for knowledge about OT was 5.51±1.45, attitude was 26.31±3.17 and for practices 4.55±1.76. The main factors which were associated with poor KAP were workload and lack of local guidelines. The distribution of overall practice score was signifi cantly better among paramedics – nurses group and EMT – nurses group.CONCLUSION: This study demonstrates that there is a gap in EHCWs' KAP, particularly regarding when to provide OT to a patient. This gap can affect patients' safety. Extensive educational and training programs about OT are needed to raise awareness among health-care providers.

Trends in mortality of emergency departments patients in China

BACKGROUND: Emergency medical service system (EMSS) in China is becoming more important. However, studies on mortality of emergency departments (EDs) patients in tertiary hospitals and on the trends in mortality of ED patients all over China are stagnant. The objective of this study was to quantify and describe the trends in mortality of ED patients in China. METHODS: Nine tertiary teaching hospitals were selected from tertiary teaching hospitals in different regions. The annual numbers of ED visits and deaths of these hospitals in 2004, 2009 and 2014 were recorded and analyzed. Chi-square test was used to compare the mortality of the EDs’ visits. Moreover, data on the mortality of ED patients in China from 2005 to 2015 were summarized and analyzed from the China Health and Family Planning Statistical Yearbooks (2006–2016). RESULTS: From 2004 to 2014, the overall annual mortalities in EDs increased among the tertiary hospitals (P<0.001). However, the overall annual mortality in EDs all over China decreased from 0.12% in 2005 to 0.08% in 2015. And the mortalities of EDs patients in the eastern, central and western regions of China all decreased. In addition, the average mortality of EDs patients in northern China was obviously higher than that in southern China (P<0.05). CONCLUSION: The ED mortality was increased in tertiary hospitals while decreased all over China during the past decade, which may be partly caused by some critical challenges faced by China’s EMSS, such as overcrowding and long length of stay in EDs of tertiary hospitals.

Value of procalcitonin and presepsin in the diagnosis and severity stratification of sepsis and septic shock

Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection.[1,2]Septic shock,the most severe form of sepsis,is characterized by circulatory and cellular/metabolic abnormalities,and can increase mortality to>40%.[1-3]Early recognition and risk stratification of septic shock are crucial but challenging because of the heterogeneity of its presentation and progression.

Development and Validation of a Prediction Model on Adult Emergency Department Patients for Early Identification of Fulminant Myocarditis

Objective It is difficult to predict fulminant myocarditis at an early stage in the emergency department.The objective of this study was to construct and validate a simple prediction model for the early identification of fulminant myocarditis.Methods A total of 61 patients with fulminant myocarditis and 160 patients with acute myocarditis were enrolled in the training and internal validation cohorts.LASSO regression and multivariate logistic regression were selected to develop the prediction model.The selection of the model was based on overall performance and simplicity.A nomogram based on the optimal model was built,and its clinical usefulness was evaluated by decision curve analysis.The predictive model was further validated in an external validation group.Results The resulting prediction model was based on 4 factors:systolic blood pressure,troponin I,left ventricular ejection fraction,and ventricular wall motion abnormality.The Brier scores of the final model were 0.078 in the training data set and 0.061 in the internal testing data set,respectively.The C-indexes of the training data set and the testing data set were 0.952 and 0.968,respectively.Decision curve analysis showed that the nomogram model developed based on the 4 predictors above had a positive net benefit for predicting probability thresholds.In the external validation cohort,the model also showed good performance(Brier score=0.007,and C-index=0.989).Conclusion We developed and validated an early prediction model consisting of 4 clinical factors(systolic blood pressure,troponin I,left ventricular ejection fraction,and ventricular wall motion abnormality)to identify potential fulminant myocarditis patients in the emergency department.

Clinical and epidemiological features of pelvic fractures presenting to the emergency department in a tertiary health care hospital in south India:A retrospective study

Objective:To determine the clinical and epidemiological features of pelvic fracture patients presenting to the Emergency Department.Methods:This prospective observational study was conducted in a tertiary care center in south India.Causes of injury,types of pelvic fractures,the associated injuries,and outcome at the time of discharge were recorded.Results:A total of 140 patients were included in this study.Most patients were classified as type A(n=62),followed by type B(n=48)and type C(n=30).A total of 112 patients were injured due to road traffic accidents,followed by a fall from a height(n=23)and a fall from a heavy object(n=5).Most subjects had facial injuries(n=99,70.7%),followed by head injuries(n=51,36.4%).Five percent of the patients were expired,12%left against medical advice,and 83%were discharged.Conclusions:The incidence of pelvic fractures presenting to the Emergency Department is relatively high in India.Road traffic accidents are the primary cause of pelvic fractures and associated facial and head injuries.The outcomes demonstrate the need for improved prevention strategies and comprehensive management protocols to reduce mortality.

Monkeypox outbreak in the age of COVID‑19:a new global health emergency

Dear Editor,The World Health Organization recently declared monkeypox as a global emergency after reporting more than 57,000 new cases worldwide[1].Monkeypox is an orthopoxvirus similar in nature to the Variola virus,which is a causative agent for smallpox[2].Monkeypox virus presents as a unique challenge for global health and should be regarded with grave concern as the vast majority of cases are occurring in countries where the disease is not considered endemic.Furthermore,the spread of this pathogen is occurring concomitantly as the world is still engaged in a battle with the coronavirus disease 2019(COVID-19)pandemic,which has caused substantial damage to global healthcare infrastructure.If monkeypox continues its rapid spread,hospitals could be quickly overwhelmed by both COVID-19 and monkeypox cases.Now more than ever,early symptom recognition and use of all available treatments to contain monkeypox outbreaks are vital.Early precautions including early recognition of symptoms by physicians,use of currently available treatments,and promoting precautionary measures in at-risk populations may be vital in preventing hospital burden and further physician burnout.

Symptoms and comorbidities associated with abnormal levels of serum calcium,magnesium,and phosphate in the emergency department:a prospective observational study

Emergency departments(EDs)play a significant role in hospital healthcare systems.[1]According to the US Centers for Disease Control and Prevention,130 million individuals visited the ED in 2018.[2]A previous study has demonstrated that unnecessary laboratory tests did not change the management plan.[3]These actions led to ED overcrowding,causing consequences to patient outcomes.

Use of anticoagulation reversal therapy in the emergency department:a single-center real-life retrospective study

The incidence of atrial fibrillation(AF)and deep vein thrombosis/pulmonary embolism(DVT/PE)has increased in the last decades as a consequence of global aging and th refinement of diagnostic techniques;thus,the consumption o anticoagulant drugs has increased significantly.[1,2]Prescription of direct oral anticoagulants(DOACs)have overtaken thos of vitamin K antagonists(VKA)since the mid-2010s.[3]Consequently,the incidence of these drugs’side effects has also increased;the most relevant side effect in terms of morbidity and mortality is bleeding.In addition to critically ill bleeding patients,another indication of anticoagulant reversal therapy is the need for emergency surgery or for a procedure with high risk of bleeding.

Key elements and checklist of shared decisionmaking conversation on life-sustaining treatment in emergency:a multispecialty study from China

BACKGROUND:Shared decision-making(SDM)has broad application in emergencies.Most published studies have focused on SDM for a certain disease or expert opinions on future research gaps without revealing the full picture or detailed guidance for clinical practice.This study is to investigate the optimal application of SDM to guide life-sustaining treatment(LST)in emergencies.METHODS:This study was a prospective two-round Delphi consensus-seeking survey among multiple stakeholders at the China Consortium of Elite Teaching Hospitals for Residency Education.Participants were identified based on their expertise in medicine,law,administration,medical education,or patient advocacy.All individual items and questions in the questionnaire were scored using a 5-point Likert scale,with responses ranging from"very unimportant"(a score of 1)to"extremely important"(a score of 5).The percentages of the responses that had scores of 4-5on the 5-point Likert scale were calculated.A Kendall’s W coefficient was calculated to evaluate the consensus of experts.RESULTS:A two-level framework consisting of 4 domains and 22 items as well as a ready-touse checklist for the informed consent process for LST was established.An acceptable Kendall’s W coefficient was achieved.CONCLUSION:A consensus-based framework supporting SDM during LST in an emergency department can inform the implementation of guidelines for clinical interventions,research studies,medical education,and policy initiatives.

Clinical profile of medication-related emergencies among patients presenting to the emergency department:An observational study

Objective:To determine the clinical profile of patients presenting with medication-related emergencies to the Emergency Department of our institute.Methods:This was an observational study conducted between November 2018 and September 2020 at Bangalore Baptist Hospital,Karnataka.A total of 138 subjects who satisfied the inclusion criteria were included in the study.The severity of adverse drug reactions(ADR)is assessed based on the Hurwitz severity assessment scale of ADR.Glasgow coma scale at the time of presentation and source of medication were noted.The type of drug overdose,requirement of advanced airway and vasopressors,and the outcome were also assessed.Results:Among medication-related emergencies(n=138)in our study,ADR contributed to 70.3%(n=97)of the study population,and drug overdose accounted for 29.7%(n=41).One-third of the ADR occurred in patients aged above 60 years.Most patients were hemodynamically stable and did not require vasopressors,or advanced airway in both groups.Most patients had Glasgow coma scale ranging from 13-15 in both groups.Nonsteroidal anti-inflammatory drugs were the most used medicine(17/41,41.5%)and most medications were over the counter drugs(25/41,61.0%)in the drug overdose group;meanwhile in the ADR group,anti-diabetic medication was the most used medicine(34/97,35.1%)and most medications were prescribed in the ADR group(93/97,95.9%).Conclusions:Our study shows that ADR is the most common type of medication-related emergency.

Impact of an emergency department nursing intervention on continuity of care, self-care, and psychological symptoms

BACKGROUND The emergency department plays a crucial role in providing acute care to patients.Nursing interventions in this setting are essential for improving the continuity of care,enhancing patients’self-care abilities,and reducing psychological symp-toms.AIM To evaluate the effect of nursing interventions in the emergency department on these indicators in an emergency department.METHODS A retrospective analysis was conducted on 120 patients admitted to the emergency department between January 2022 and May 2023.The patients were divided into two groups:The control group(conventional nursing intervention)and the observation group(conventional nursing intervention+emergency department nursing intervention).The two groups were compared regarding continuity of care,self-care ability,psychological symptoms,and satisfaction with care.RESULTS The emergency department nursing interventions significantly improved the continuity of care,enhanced patients’self-care abilities,and reduced psycho-logical symptoms such as anxiety and depression.CONCLUSION Nursing interventions in the emergency department positively impact continuity of care,self-care,and psychological symptoms.However,it is important to acknowledge the limitations of this study,including the small number of studies,variable methodological quality,and the heterogeneity of the study population.Future research should address these limitations and further explore the effects of different types of nursing interventions in the emergency department.Additionally,efforts should be made to enhance the application and evaluation of these interventions in clinical practice.

Analysis of prognostic factors in patients with emergency sepsis

BACKGROUND Emergency sepsis is a common and serious infectious disease,and its prognosis is influenced by a number of factors.AIM To analyse the factors influencing the prognosis of patients with emergency sepsis in order to provide a basis for individualised patient treatment and care.By retrospectively analysing the clinical data collected,we conducted a comprehensive analysis of factors such as age,gender,underlying disease,etiology and site of infection,inflammatory indicators,multi-organ failure,cardiovascular function,therapeutic measures,immune status and severity of infection.METHODS Data collection:Clinical data were collected from patients diagnosed with acute sepsis,including basic information,laboratory findings,medical history and treatment options.Variable selection:Variables associated with prognosis were selected,including age,gender,underlying disease,etiology and site of infection,inflammatory indicators,multi-organ failure,cardiovascular function,treatment measures,immune status and severity of infection.Data analysis:The data collected are analysed using appropriate statistical methods such as multiple regression analysis and survival analysis.The impact of each factor on prognosis was assessed according to prognostic indicators,such as survival,length of stay and complication rates.RESULTS Descriptive statistics:Descriptive statistics were performed on the data collected from the patients,including their basic characteristics and clinical presentation.CONCLUSION Type 2 diabetes mellitus were independent factors affecting the prognosis of patients with sepsis.

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.

Prevalence of Acute Myocardial and Brain Toxicity in Emergency Department Patients Exposed to Carbon Monoxide

Introduction: Due to its severe toxicity, carbon monoxide poisoning is an emergency that leads to cardiac and brain involvement, and emergency physicians should aim to master this diagnosis. This study is intended to describe the expected prevalence of these severe toxicities in the emergency department. Materials and Methods: A retrospective cohort of consecutive patients over 16 years of age presenting with carbon monoxide poisoning to the emergency department of the Hospital Universitario Austral, Argentina, during the period from January 2018 to June 2022. The prevalence of myocardial and brain toxicity was assessed regarding percentage, continuous variables with mean and standard deviation, categorical variables with percentage and absolute frequency. Positive findings of acute neurological toxicity included seizures, syncope and coma, while cardiovascular toxicity encompassed acute myocardial infarction (MI) diagnosed by electrocardiogram or elevated troponin levels, arrhythmias, and the development of pulmonary edema/ congestive heart failure (CHF) confirmed by chest X-ray with suggestive signs or clinically compatible symptoms. Patients were followed-up for 90 days to estimate hospitalization and mortality. Results: A total of 67 patients were evaluated;44.77% of them were males with a mean age of 38.5 ± 14.97 years. The prevalence of acute myocardial toxicity was 7.46% (n: 5). Among these patients, 3 had overweight as a risk factor, and 3 showed ECG abnormalities with negative T-waves. The prevalence of acute brain toxicity was 8.9% (n: 6). In total, 37% (n: 25) of patients met the criteria for hyperbaric oxygen therapy, of which 32% (n: 8) underwent more than one session. A total of 7.46% of patients (n: 5) required hospitalization. Mortality at 90 days was 0%. Conclusion: Among the patients who presented to the emergency department, the prevalence of acute myocardial toxicity was 7.46% (n: 5), which is lower than the prevalence reported in other studies to date. The prevalence of acute brain toxicity was 8.9% (n: 6), and there are no studies describing the prevalence of acute brain toxicity in the emergency department to date. There were no fatalities in our series.

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.