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 safet...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.展开更多
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 gather...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.展开更多
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 depar...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.展开更多
Background: Hand injuries are very common and responsible for a significant number of emergency department (ED) visits, most of which are not to hand specialists [1]. The functionality and outcome of hand injuries can...Background: Hand injuries are very common and responsible for a significant number of emergency department (ED) visits, most of which are not to hand specialists [1]. The functionality and outcome of hand injuries can vary significantly depending on the mechanism and pattern of injuries, which is why it is imperative for emergency physicians to recognize the complexities, and the potential repercussion of missed injuries in such cases. Objective: The aim of this study is to provide epidemiological information on hand injuries and their patterns. The objective is 1) to assess whether most hand injuries are superficial (simple), or involve underlying deeper structures (complex) and 2) to assess whether most hand injuries presented to the emergency department were managed by the emergency physician or plastic/orthopaedic surgeon. Methods: This retrospective single-centre observational study conducted at an emergency department in a tertiary care hospital in Mumbai, India collected data from hand trauma patients using a standardized documentation form. Demographic data, trauma-related data, and disposition plans were analysed. Results: A total of 489 cases sustained hand injuries over a period of one year. The patients were predominantly males in the 20 - 30 year age group and injuries were mainly sustained over the right hand. Most of the injuries were sustained at home (42%). The most common mechanism (34%) was sharp object injury (including needle-stick and other sharps in hospital), followed by blunt injury (30%). Among grievous hand injuries, door jamb was a mechanism noted in 11% of patients, accounting for 50% of all crush injuries. Lacerations were the most common pattern (24.7%) noticed, followed closely by fractures (23.3%). Digits II - IV were injured most commonly (54%), followed by carpals (14%) and the thumb (10%). Nearly 80% of the hand injuries were managed by emergency physicians alone, with 61% of cases involving superficial structures. Though 14% of the cases required plastic surgery intervention, the initial evaluation of all these patients was performed by the emergency physician. Conclusions: Our study highlights the burden of hand injuries on the emergency physician, as well as the odds of missed injuries, directly indicating the necessity of a thorough anatomical knowledge of the structures of the hand, and in turn, a proper physical examination. A dedicated registry for hand trauma would help quantify the mechanism and pattern of injuries, and formulate preventive strategies.展开更多
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...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.展开更多
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 mo...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.展开更多
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...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.展开更多
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 abnor...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.展开更多
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...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.展开更多
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 ...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.展开更多
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,...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.展开更多
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...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.展开更多
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...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.展开更多
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 consump...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.展开更多
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 20...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.展开更多
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 criteri...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.展开更多
BACKGROUND: Communication failure in prehospital emergency medicine can affect patient safety as it does in other areas of medicine as well. We analyzed the database of the critical incident reporting system for preho...BACKGROUND: Communication failure in prehospital emergency medicine can affect patient safety as it does in other areas of medicine as well. We analyzed the database of the critical incident reporting system for prehospital emergency medicine in Germany retrospectively regarding communication errors.METHODS: Experts of prehospital emergency medicine and risk management screened the database for verbal communication failure, non-verbal communication failure and missing communication at all.RESULTS: Between 2005 and 2015, 845 reports were analyzed, of which 247 reports were considered to be related to communication failure. An arbitrary classifi cation resulted in six different kinds: 1) no acknowledgement of a suggestion; 2) medication error; 3) miscommunication with dispatcher; 4) utterance heard/understood improperly; 5) missing information transfer between two persons; and 6) other communication failure.CONCLUSION: Communication defi cits can lead to critical incidents in prehospital emergency medicine and are a very important aspect in patient safety.展开更多
BACKGROUND: We compare educational environments(i.e. physical, emotional and intellectual experiences) of emergency medicine(EM) residents training in the United States of America(USA) and Saudi Arabia(SA).METHODS: A ...BACKGROUND: We compare educational environments(i.e. physical, emotional and intellectual experiences) of emergency medicine(EM) residents training in the United States of America(USA) and Saudi Arabia(SA).METHODS: A cross-sectional survey study was conducted using an adapted version of the validated Postgraduate Hospital Educational Environment Measure(PHEEM) survey instrument from April 2015 through June 2016 to compare educational environments in all emergency medicine residency programs in SA and three selected programs in the USA with a history of training Saudi physicians. Overall scores were compared across programs, and for subscales(autonomy, teaching, and social Support), using chi-squared, t-tests, and analysis of variance.RESULTS: A total of 219 surveys were returned for 260 residents across six programs(3 SA, 3 USA), with a response rate of 84%. Program-specific response rates varied from 79%–100%. All six residencies were qualitatively rated as "more positive than negative but room for improvement". Quantitative PHEEM scores for the USA programs were significantly higher: 118.7 compared to 109.9 for SA, P=0.001. In subscales, perceptions of social support were not different between the two countries(P=0.243); however, role autonomy(P<0.001) and teaching(P=0.005) were better in USA programs. There were no significant differences by post-graduate training year.CONCLUSION: EM residents in all three emergency medicine residency programs in SA and the three USA programs studied perceive their training as high quality in general, but with room for improvements. USA residency programs scored higher in overall quality. This was driven by more favorable perceptions of role autonomy and teaching. Understanding how residents perceive their programs may help drive targeted quality improvement efforts.展开更多
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 clinica...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.展开更多
BACKGROUND:A long length of stay(LOS) in the emergency department(ED) associated with overcrowding has been found to adversely affect the quality of ED care.The objective of this study is to determine whether patients...BACKGROUND:A long length of stay(LOS) in the emergency department(ED) associated with overcrowding has been found to adversely affect the quality of ED care.The objective of this study is to determine whether patients who speak a language other than English at home have a longer LOS in EDs compared to those whose speak only English at home.METHODS:A secondary data analysis of a Queensland state-wide hospital EDs dataset(Emergency Department Information System) was conducted for the period,1 January 2008 to 31 December 2010.RESULTS:The interpreter requirement was the highest among Vietnamese speakers(23.1%)followed by Chinese(19.8%) and Arabic speakers(18.7%).There were significant differences in the distributions of the departure statuses among the language groups(Chi-squared=3236.88,P<0.001).Compared with English speakers,the Beta coefficient for the LOS in the EDs measured in minutes was among Vietnamese,26.3(95%Cl:22.1-30.5);Arabic,10.3(95%Cl:7.3-13.2);Spanish,9.4(95%CI:7.1-11.7);Chinese,8.6(95%Cl:2.6-14.6);Hindi,4.0(95%Cl:2.2-5.7);Italian,3.5(95%Cl:1.6-5.4);and German,2.7(95%Cl:1.0-4.4).The final regression model explained 17%of the variability in LOS.CONCLUSION:There is a close relationship between the language spoken at home and the LOS at EDs,indicating that language could be an important predictor of prolonged LOS in EDs and improving language services might reduce LOS and ease overcrowding in EDs in Queensland's public hospitals.展开更多
文摘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.
文摘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.
文摘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.
文摘Background: Hand injuries are very common and responsible for a significant number of emergency department (ED) visits, most of which are not to hand specialists [1]. The functionality and outcome of hand injuries can vary significantly depending on the mechanism and pattern of injuries, which is why it is imperative for emergency physicians to recognize the complexities, and the potential repercussion of missed injuries in such cases. Objective: The aim of this study is to provide epidemiological information on hand injuries and their patterns. The objective is 1) to assess whether most hand injuries are superficial (simple), or involve underlying deeper structures (complex) and 2) to assess whether most hand injuries presented to the emergency department were managed by the emergency physician or plastic/orthopaedic surgeon. Methods: This retrospective single-centre observational study conducted at an emergency department in a tertiary care hospital in Mumbai, India collected data from hand trauma patients using a standardized documentation form. Demographic data, trauma-related data, and disposition plans were analysed. Results: A total of 489 cases sustained hand injuries over a period of one year. The patients were predominantly males in the 20 - 30 year age group and injuries were mainly sustained over the right hand. Most of the injuries were sustained at home (42%). The most common mechanism (34%) was sharp object injury (including needle-stick and other sharps in hospital), followed by blunt injury (30%). Among grievous hand injuries, door jamb was a mechanism noted in 11% of patients, accounting for 50% of all crush injuries. Lacerations were the most common pattern (24.7%) noticed, followed closely by fractures (23.3%). Digits II - IV were injured most commonly (54%), followed by carpals (14%) and the thumb (10%). Nearly 80% of the hand injuries were managed by emergency physicians alone, with 61% of cases involving superficial structures. Though 14% of the cases required plastic surgery intervention, the initial evaluation of all these patients was performed by the emergency physician. Conclusions: Our study highlights the burden of hand injuries on the emergency physician, as well as the odds of missed injuries, directly indicating the necessity of a thorough anatomical knowledge of the structures of the hand, and in turn, a proper physical examination. A dedicated registry for hand trauma would help quantify the mechanism and pattern of injuries, and formulate preventive strategies.
基金supported by the Doctoral Scientific Research Foundation of the First Affiliated Hospital of USTC(RC2021023)Key Research and Development Plan of Anhui Province(S2022e07020194).
文摘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.
文摘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.
基金supported by National Key R&D Program of China(2017YFC0908700,2017YFC0908703,2018FY100600)Taishan Scholar Climbing Program of Shandong Province(tspd20181220)+5 种基金Taishan Young Scholar Program of Shandong Province(tsqn20161065)Fundamental Research Funds of Shandong University(2014QLKY04)National Natural Science Foundation of China(81601717,81571934,81570401,81772036,81671952)China Postdoctoral Science Foundation(2016M602149)the Natural Science Foundation of Shandong Province(BS2014YY032)the Key R&D Program of Shandong Province(2017G006013,2016GSF201235,2016ZDJS07A14,2018GSF118003)
文摘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.
基金supported by the National Natural Science Foundation of China(no.82374069)the Beijing Municipal Administration of Hospitals’Youth Program(no.QML20170105)the Beijing Municipal Administration of Hospitals Clinical Medicine Development of Special Funding Support“Yangfan”Project(no.ZYLX201802)。
文摘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.
文摘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.
文摘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.
文摘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.
文摘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.
基金supported by the China Medical BoardOpen Competition Program(20-378)Peking University Third Hospital Fund for Returned Scholars(BYSYLXHG2020004)+1 种基金JX was supported by the Peking Union Medical College Fund for Informatization of Postgraduate Courses(2021YXX001)YLZ was supported by the Sichuan University Graduate Education Reform Project(GSSCU2021046)。
文摘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.
文摘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.
文摘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.
基金supported in part by an unrestricted educational grant from Mylan Specialty Pharmaceuticals(Basking Ridge,NJ)
文摘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.
文摘BACKGROUND: Communication failure in prehospital emergency medicine can affect patient safety as it does in other areas of medicine as well. We analyzed the database of the critical incident reporting system for prehospital emergency medicine in Germany retrospectively regarding communication errors.METHODS: Experts of prehospital emergency medicine and risk management screened the database for verbal communication failure, non-verbal communication failure and missing communication at all.RESULTS: Between 2005 and 2015, 845 reports were analyzed, of which 247 reports were considered to be related to communication failure. An arbitrary classifi cation resulted in six different kinds: 1) no acknowledgement of a suggestion; 2) medication error; 3) miscommunication with dispatcher; 4) utterance heard/understood improperly; 5) missing information transfer between two persons; and 6) other communication failure.CONCLUSION: Communication defi cits can lead to critical incidents in prehospital emergency medicine and are a very important aspect in patient safety.
文摘BACKGROUND: We compare educational environments(i.e. physical, emotional and intellectual experiences) of emergency medicine(EM) residents training in the United States of America(USA) and Saudi Arabia(SA).METHODS: A cross-sectional survey study was conducted using an adapted version of the validated Postgraduate Hospital Educational Environment Measure(PHEEM) survey instrument from April 2015 through June 2016 to compare educational environments in all emergency medicine residency programs in SA and three selected programs in the USA with a history of training Saudi physicians. Overall scores were compared across programs, and for subscales(autonomy, teaching, and social Support), using chi-squared, t-tests, and analysis of variance.RESULTS: A total of 219 surveys were returned for 260 residents across six programs(3 SA, 3 USA), with a response rate of 84%. Program-specific response rates varied from 79%–100%. All six residencies were qualitatively rated as "more positive than negative but room for improvement". Quantitative PHEEM scores for the USA programs were significantly higher: 118.7 compared to 109.9 for SA, P=0.001. In subscales, perceptions of social support were not different between the two countries(P=0.243); however, role autonomy(P<0.001) and teaching(P=0.005) were better in USA programs. There were no significant differences by post-graduate training year.CONCLUSION: EM residents in all three emergency medicine residency programs in SA and the three USA programs studied perceive their training as high quality in general, but with room for improvements. USA residency programs scored higher in overall quality. This was driven by more favorable perceptions of role autonomy and teaching. Understanding how residents perceive their programs may help drive targeted quality improvement efforts.
文摘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.
文摘BACKGROUND:A long length of stay(LOS) in the emergency department(ED) associated with overcrowding has been found to adversely affect the quality of ED care.The objective of this study is to determine whether patients who speak a language other than English at home have a longer LOS in EDs compared to those whose speak only English at home.METHODS:A secondary data analysis of a Queensland state-wide hospital EDs dataset(Emergency Department Information System) was conducted for the period,1 January 2008 to 31 December 2010.RESULTS:The interpreter requirement was the highest among Vietnamese speakers(23.1%)followed by Chinese(19.8%) and Arabic speakers(18.7%).There were significant differences in the distributions of the departure statuses among the language groups(Chi-squared=3236.88,P<0.001).Compared with English speakers,the Beta coefficient for the LOS in the EDs measured in minutes was among Vietnamese,26.3(95%Cl:22.1-30.5);Arabic,10.3(95%Cl:7.3-13.2);Spanish,9.4(95%CI:7.1-11.7);Chinese,8.6(95%Cl:2.6-14.6);Hindi,4.0(95%Cl:2.2-5.7);Italian,3.5(95%Cl:1.6-5.4);and German,2.7(95%Cl:1.0-4.4).The final regression model explained 17%of the variability in LOS.CONCLUSION:There is a close relationship between the language spoken at home and the LOS at EDs,indicating that language could be an important predictor of prolonged LOS in EDs and improving language services might reduce LOS and ease overcrowding in EDs in Queensland's public hospitals.