Evaluation of hand infections in the emergency department using point-of-care ultrasound

BACKGROUND:We aimed to evaluate the utility of point-of-care ultrasound(POCUS)in the assessment of hand infections that present to the emergency department(ED)and its impact on medical decision making and patient management.METHODS:We conducted a retrospective review of patients who presented to two urban academic EDs with clinical presentations concerning for skin and soft tissue infections(SSTI)of the hand between December 2015 and December 2021.Two trained POCUS fellowship physicians reviewed an ED POCUS database for POCUS examinations of the hand.We then reviewed patients’electronic health records(EHR)for demographic characteristics,history,physical examination findings,ED course,additional imaging studies,consultations,impact of POCUS on patient care and final disposition.RESULTS:We included a total of 50 cases(28 male,22 female)in the final analysis.The most common presenting symptoms and exam findings were pain(100%),swelling(90%),and erythema(74%).The most common sonographic findings were edema(76%),soft tissue swelling(78%),and fluid surrounding the tendon(57%).POCUS was used in medical decision making 68%of the time(n=34),with the use of POCUS leading to changes in management 38%of the time(n=19).POCUS use led to early antibiotic use(11/19),early consultation(10/19),and led to the performance of a required procedure(8/19).The POCUS diagnosis was consistent with the discharge diagnosis of flexor tenosynovitis 8/12 times,abscess 12/16 times,and cellulitis 14/20 times.CONCLUSION:POCUS is beneficial for evaluating of hand infections that present to the ED and can be used as an important part of medical decision making to expedite patient care.

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.

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.

Outcomes and impact of an advanced clinical ultrasound track in an emergency medicine residency

Point-of-care ultrasound(POCUS)is a core component of emergency medicine(EM)residency training used to guide medical decision making and to enhance procedural competence.[1-3]Many repetitions of POCUS exams are required to achieve competency,and it is difficult to quantify a minimum needed to achieve mastery.[4,5]For EM residents whose career goals require greater depth of knowledge and skill in POCUS,educators can consider expanded training through a professional development track.

Evaluation of disease burden and symptom scores in patients with acute atrial fi brillation in the emergency department

Atrial fibrillation(AF)is a major public health problem and poses a substantial economic burden on healthcare systems worldwide.[1-4]The emergency department(ED)serves as the first point of contact with the healthcare system and plays a key role in the management of patients with AF,which accounts for 3%-10%of all hospital admissions.[5]Treatment plans are often discussed and initiated at the ED.

Calcium carbonate-associated milk-alkali syndrome as a cause of altered mental status in the emergency department:a case report

Hypercalcemic crises as a result of milk-alkali syndrome(MAS)are an uncommon cause of altered mental status and acute renal failure in the emergency department.Although it is uncommonly reported in the emergency medicine literature,emergency physicians should be aware of this syndrome due to significant morbidity and mortality if left undiagnosed.

Simulation-based assessment for the emergency medicine milestones: a national survey of simulation experts and program directors

The focus of outcome-based education has shifted from the process of training to the end“product”of education.This has necessitated a reframing of the teaching,learning,and assessment.Therefore,in 2013,the Accreditation Council for Graduate Medical Education(ACGME)implemented the educational milestones for all accredited residencies and fellowship programs.[1]The milestones have been described as“developmentally based,specialty-specific achievements that residents are expected to demonstrate at established intervals as they progress through training.”[1]Milestones are based on the six core competencies established by the ACGME and American Board of Medical Specialties(ABMS),which consist of medical knowledge(MK),patient care(PC),interpersonal and communication skills(ICS),practice-based learning and improvement(PBLI),professionalism(PROF),and systems-based practice(SBP).[2,3]ACGME,in conjunction with the American Board of Emergency Medicine(ABEM),drafted 23 detailed subcompetencies relevant to emergency medicine(EM).[4]

Early endotracheal intubation is not associated with the rate of return of spontaneous circulation following cardiac arrest at the emergency department:an exploratory analysis

Cardiac arrest poses a significant global public health challenge,manifesting in approximately 550,000 cases annually within the United States.[1]In-hospital cardiac arrest(IHCA)is commonly attributed to airways and respiratory issues.[2]Recommendations emphasize the expertise of responders in airway management.[3]Various options exist,such as chest compression-only cardiopulmonary resuscitation(CPR),bag-mask ventilation(BMV),and advanced airways.The BMV and advanced airways are not deemed equivalent or superior based on previous evidence.[4]Achieving consistency in choosing and timing the optimal airway approach during IHCA is crucial.The current American Heart Association guidelines suggest an advanced airway strategy when endotracheal intubation(ETI)success rates are high,but the optimal time for advanced airway management remains unclear.[5]Wong et al[6]revealed that survival improved by less than 5 min with advanced airway management.According to a subgroup analysis of IHCA patients in emergency departments(EDs),early intubation was associated with a 1.5-fold greater rate of return of spontaneous circulation(ROSC)than in other locations.[7]ED patients’constant monitoring and immediate management,with readily available intubation equipment,enhance early intubation and survival rates.[6]Nonetheless,IHCA patients intubated within the first 15 min had a lower ROSC rate.

Predictors of first-pass success intubations in the emergency departments in Germany:analysis of the German Airway Registry between 2015 and 2022

In the field of airway management,there is no national registry in Germany that captures data on emergency airway management.To improve quality,one needs to know the data first.Examples include gender,age,indications for emergency airway management,level of education,the intubating department,the intubation method,and other factors that can serve as a basis for quality improvement changes.

The role of acetazolamide in critical care and emergency medicine

Acetazolamide is the commonly prescribed oral and intravenous carbonic anhydrase inhibitor;over the years,its use in clinical practice has decreased in favor of more recent drugs.However,it is a rather handy drug,which can be useful in several clinical settings when managing critically ill patients.The objective of this review is the evaluation of the most recent evidence on the use of acetazolamide in emergency medicine and critical care medicine.Furthermore,the safety profile of this drug has been evaluated.This is a narrative review on the use of acetazolamide in the main contexts in which this drug can be useful in emergency situations for patients with potential critical issues.For the timeline 1999–2024,a search was conducted on the main scientific platforms;resources of greatest relevance for the use of acetazolamide in critical care and emergency medicine were selected.The most common emergency situations in which a critically ill patient could benefit from acetazolamide therapy are acute heart failure,acute mountain sickness,post hypercapnic metabolic alkalosis,idiopathic intracranial hypertension and acute angle-closure glaucoma.In a few cases,however,randomized controlled clinical trials have been conducted.There are also other less solid indications based mostly on experience or retrospective data.Acetazolamide seems to be an overall safe drug;serious side effects are rare and can be avoided by carefully selecting the patients to be treated.Acetazolamide represents a precious resource for emergency physicians and intensivists;critical patients with different conditions can in fact benefit from it;furthermore,acetazolamide is a safe drug if administered to correctly selected patients.

Epidemiology of Hand Injuries That Presented to the Emergency Department of a Tertiary Care Facility in Suburban Mumbai, India: A Study Including 489 Patients

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.

Community emergency medicine:Benefits and challenges of screening for elder abuse in the emergency department of a developing country

As people live longer and fewer babies are born, the elderly became the fastest and largest growing population of the world, expected to increase further from 86 million in 2005 to 394 million in 2050 worldwide. Older patients represent a large bulk of the population arriving in emergency departments （EDs） all over the world.[1] They use hospitals more frequently than younger patients, have more hospital admissions from the ED and more prolonged hospital stays.[2] Elder abuse is defined as a single, or repeated, act which causes harm or distress to an older person and it can occur within any relationship where there is an expectation of trust from the elder person＇s perspective.[3,4] The ED setting is a particularly important environment being the first point of contact with formal services for the abused elderly population.[5] Careful consideration is demanded when older people attend the ED, with particular attention paid to assessment of subjective and objective data in terms of manifestations and potential indicators of abuse.

Effect of neutrophil CD64 for diagnosing sepsis in emergency department

BACKGROUND:The aim of this study is to investigate the diagnostic and prognostic value of neutrophil CD64(nCD64)as a novel biomarker in sepsis patients.METHODS:One hundred fifty-one adult patients diagnosed with sepsis and 20 age-matched healthy controls were enrolled in the study.Patients with sepsis were further subdivided into a sepsis group and a septic shock group.nCD64 expression,serum procalcitonin(PCT)level,C-reactive protein(CRP)level,and white blood cell(WBC)count were obtained for each patient,and Sequential Organ Failure Assessment(SOFA)scores were calculated.RESULTS:nCD64 expression was higher in the sepsis group with confirmed infection than in the control group.The receiver operating characteristic(ROC)curve of nCD64 was higher than those of SOFA score,PCT,CRP and WBC for diagnosing infection.The area under the curve(AUC)of nCD64 combined with SOFA score was the highest for all parameters.The AUC of nCD64 for predicting 28-day mortality in sepsis was signifi cantly higher than those of PCT,CRP,and WBC,but slightly lower than that of SOFA score.The AUC of nCD64 or PCT combined with SOFA score was signifi cantly higher than that of any single parameter for predicting 28-day mortality.CONCLUSION:nCD64 expression and SOFA score are valuable parameters for early diagnosis of infection and prognostic evaluation of sepsis patients.

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.

Emergency department diagnosis of an ovarian inguinal hernia in an 11-year-old female using point-of-care ultrasound

Dear editor,Inguinal hernias affect 5%of children and are usually defined as a protrusion of intestine or omentum through abdominal wall or inguinal canal defects.^([1])Inguinal hernias may contain structures other than bowel and unique cases have been documented since the

Role of Ultrasound Lung Comets in the Diagnosis of Acute Heart Failure in Emergency Department: A Systematic Review and Meta-analysis

Objective A new technique of transthoracic lung ultrasonography(TLS) has emerged and demonstrated promising results in acute heart failure diagnosis at an early stage. However, the diagnostic value of ultrasound lung comets(ULCs) for acute heart failure(AHF) performed in busy emergency department(ED) is uncertain. The present meta-analysis aimed to assess the diagnostic efficiency of ULCs in AHF. Methods We conducted a search on online journal databases to collect the data on TLS performed for diagnosing AHF published up to the end of July 2017. The sensitivity, specificity, positive likelihood ratio(PLR), negative likelihood ratio(NLR), and summary receiver operating characteristic(SROC) curve were calculated. The post-test probability of AHF was calculated by using Bayes analysis. Results We enrolled a total of 15 studies involving 3,309 patients. The value of sensitivity, specificity, PLR, NLR, DOR, area under the SROC curve, and Q* index was 85%, 91%, 8.94, 0.14, 67.24, 0.9587, and 0.9026, respectively. We detected significant heterogeneity among included studies, and therefore, all these results were analyzed under the random-effect model. We also explored possible sources of heterogeneity among the studies by using meta-regression analysis. Results suggest that the time interval between patient’s admission to bedside TLS examination was closely related to TLS accuracy. Conclusion This meta-analysis demonstrated that detecting ULCs is a convenient bedside tool and has high accuracy for early AHF diagnosis in ED. TLS could be recommended to be applied for early diagnosis of AHF in ED.

Utility of point-of-care musculoskeletal ultrasound in the evaluation of emergency department musculoskeletal pathology

BACKGROUND: To evaluate the utilization of point-of-care ultrasound(POCUS) for the assessment of emergency department(ED) patients with musculoskeletal symptoms and the impact of musculoskeletal POCUS on medical decision-making and patient management in the ED.METHODS: This was a retrospective review of ED patients presenting with musculoskeletal symptoms who received a POCUS over a 3.5-year period. An ED POCUS database was reviewed for musculoskeletal POCUS examinations used for medical decision-making. Electronic medical records were then reviewed for demographic characteristics, history, physical examination findings, ED course, additional imaging studies, and impact of musculoskeletal POCUS on patient management in ED. RESULTS: A total of 264 subjects(92 females, 172 males) and 292 musculoskeletal POCUS examinations were included in the fi nal analysis. Most common symptomatic sites were knee(31.8%) and ankle(16.3%). Joint effusion was the most common fi nding on musculoskeletal POCUS, noted in 33.7% of the patients, and subcutaneous edema/cobblestoning was found in 10.2% of the patients. Muscle or tendon rupture was found in 2.3% of the patients, and 1.9% of the patients had joint dislocation. Bursitis or bursa fluid was found in 3.4% of patients, and tendonitis/tendinopathy was found in 2.3%. Twenty percent of them were ultrasound-guided musculoskeletal procedures, and most of them(73.3%) were arthrocentesis. Of the included studies, all except three either changed or helped guide patient management as documented in the patients' medical records.CONCLUSION: Our study fi ndings illustrate the utility of POCUS in the evaluation of a variety of musculoskeletal pathologies in the ED.

Effect of harmless acute pancreatitis score, red cell distribution width and neutrophil/lymphocyte ratio on the mortality of patients with nontraumatic acute pancreatitis at the emergency department

BACKGROUND: Harmless acute pancreatitis score(HAPS), neutrophile/lymphocyte ratio and red blood cell distribution width(RDW) are used to determine the early prognosis of patients diagnosed with nontraumatic acute pancreatitis in the emergency department(ED).METHODS: Patients diagnosed with acute pancreatitis(K 85.9) in the ED according to the ICD10 coding during one year were included in the study. Patients with chronic pancreatitis and those who had missing data in their files were excluded from the study. Patients who did not have computed tomography(CT) in the ED were not included in the study.RESULTS: Ultimately, 322 patients were included in the study. The median age of the patients was 53.1(IQR=36–64). Of the patients, 68.1%(n=226) had etiological causes of the biliary tract. The mortality rate of these patients within the first 48 hours was 4.3%(n=14). In the logistic regression analysis performed by using Balthazar classification, HAPS score, RDW, neutrophile/lymphocyte ratio, age, diabetes mellitus and systolic blood pressure, the only independent variable in determining mortality was assigned as Balthazar classification(OR: 15; 95% CI: 3.5 to 64.4).CONCLUSIONS: HAPS, neutrophile/lymphocyte ratio and RDW were not effective in determining the mortality of nontraumatic acute pancreatitis cases within the first 48 hours. The only independent variable for determining the mortality was Balthazar classifi cation.

Accuracy of abdominal ultrasound for the diagnosis of small bowel obstruction in the emergency department

BACKGROUND： Emergency physicians frequently encounter patients with acute small bowel obstructions （SBO）. Although computed tomography （CT） imaging is the current gold standard in the assessment of patients with suspected SBO in the emergency department, a few studies have examined the use of ultrasound as an alternative imaging technique. METHODS： We evaluated the accuracy of ultrasound performed in the ED by a variety of providers （physicians with various levels of training, physician assistants） compared to CT imaging in 47 patients with suspected SBOs. RESULTS： Our data demonstrated a sensitivity of 93.8% and a specificity of 93.3% when compared to abdominal CT, and a sensitivity of 94.3% and specificity of 95.2% using a composite endpoint of abdominal CT and discharge diagnosis. CONCLUSION： Ultrasound can play an important role in the identification of small bowe obstructions in ED patients.