Emergency Medicine Journal最新文献

Introduction: Tension pneumothorax in children, although infrequently encountered, requires management with a high level of confidence and skill from the attending physician. Despite this, recommendations on location and needle length for needle thoracostomy (NT) in paediatric patients are not well-established. We therefore aimed to (1) identify how age, sex and body anthropometry affect chest wall thickness (CWT) at common NT landmarks and (2) determine the adequacy of needle lengths used.

Methods: A retrospective review was undertaken of chest CT scans performed on children aged 0-17 years at KK Women's and Children's Hospital in Singapore. Patients were categorised as infants (<1 year old), children (1-9 years old) and adolescents (10-17 years old). Bilateral CWT at the second intercostal space (ICS) mid-clavicular line (MCL) and fourth ICS mid-axillary line (MAL) were measured radiographically. Adequacy of needle length is defined as CWT < needle length in >95% of cases.

Results: 588 CT scans (192 infants, 224 children, 172 adolescents) were reviewed. Mean CWT at the second ICS MCL was 12.61 mm (SD±4.14 mm), 15.62 mm (SD±4.88 mm) and 26.64 mm (SD±11.48 mm) for infants, children and adolescents, respectively. Mean CWT at the fourth ICS MAL is 14.95 mm (SD±5.25 mm), 16.49 mm (SD±5.89 mm) and 28.20 mm (SD±11.53 mm) for infants, children and adolescents, respectively. Adequate needle length was 25 mm, 32 mm and 50 mm for infants, children and adolescents, respectively, when inserted at the second ICS MCL.

Conclusion: In a Singaporean population, mean CWT at the second ICS MCL is thinner than mean CWT at the fourth ICS MAL for all age, sex, weight-for-length and body mass index categories. For successful NT at the second ICS MCL, a 25 mm needle is recommended for infants, 32 mm for children and 50 mm for adolescents.

Background: Hip fracture pain is severe and is commonly managed with intravenous opioids that cause adverse effects in older adults. Although the use of regional anaesthesia is increasing, high-quality evidence remains limited, with insufficient randomised controlled trial (RCT) evaluating the effectiveness of the pericapsular nerve group (PENG) block in the emergency department (ED). This study aimed to compare the analgesic efficacy of ultrasound-guided PENG block with intravenous morphine for acute hip fracture pain in older adults presenting to the ED.

Methods: This open label, 1:1 parallel RCT using software-generated randomisation compared PENG block versus intravenous morphine (0.1 mg/kg) in patients aged ≥65 years who presented to the ED with femoral head, intertrochanteric, subtrochanteric and neck fractures with acute moderate-to-severe pain, defined as ≥5 on an 11-point Verbal Numeric Rating Scale (VNRS). The primary outcome was improvement in the VNRS score at 30 min. The secondary outcomes included the need for rescue therapy (intravenous fentanyl 0.5 µg/kg) and the incidence of adverse events. RESULTS: A total of 34 patients were included in the final analysis, with 17 patients in each group. At 30 min, the median reduction in pain score was greater in the PENG block group than in the intravenous morphine group (-6 (IQR-6 to -5) vs -3 (IQR -5 to -2); p=0.001). Generalised estimating equation analysis accounting for repeated measures demonstrated that the PENG block was associated with a significantly more pronounced reduction in pain over time than intravenous morphine (adjusted β = -1.55; 95% CI -2.63 to -0.47; p=0.005). Rescue analgesia was required in 5.9% of patients receiving intravenous morphine, whereas no patients in the PENG block group required rescue therapy.

Conclusion: PENG block is a highly effective and safe alternative to intravenous morphine for managing acute hip fracture pain, particularly in older adults.

Background: Out-of-hospital cardiac arrest (OHCA) shows marked geographic variability. Socio-economic deprivation may contribute to this variability, but evidence from mixed urban-rural regions remains limited. We aimed to identify spatial clusters of OHCA incidence in northern France and to assess whether these clusters were associated with deprivation, care processes and outcomes.

Methods: We conducted a retrospective, population-based cohort study using data from the French National Out-of-Hospital Cardiac Arrest Registry for all OHCAs managed by mobile intensive care units between 1 July 2015 and 30 June 2016 in Nord-Pas-de-Calais. Age-adjusted and sex-adjusted standardised incidence ratios were smoothed with a Besag-York-Mollié Bayesian model. Spatial scan statistics identified incidence clusters. Cluster-level socioeconomic indicators, care processes and outcomes were compared RESULTS: Incidence was mapped across 1541 municipalities. Among 2867 OHCAs, mean annual OHCA incidence was 68.8 per 100 000 inhabitants (range <0.5 to >1.5 across municipalities). Two high-incidence clusters (relative risk between 1.61 and 1.68) and three low-incidence clusters (relative risk between 0.48 and 0.66) were detected. High-incidence clusters displayed greater deprivation and lower median income. Bystander basic life support was less frequent (26.7%) and 12-month survival lowest (1.4%) in the most deprived cluster.

Conclusions: Pronounced spatial inequality in OHCA burden exists within northern France. Municipalities with higher deprivation experience disproportionately higher incidence and poorer long-term survival. Targeted cardiopulmonary resuscitation training and strategic automated external defibrillator deployment should prioritise these vulnerable communities.

Background: Emergency department (ED) intubations are high-risk procedures with wide variability in training and governance. Although emergency physicians (EPs) in Ireland are trained to intubate, structured airway governance within EDs is not well described. This quality improvement project aimed to develop and evaluate a sustainable airway governance framework in a large Irish ED.

Methods: Using the model for improvement, sequential interventions were implemented between May 2024 and October 2025. Interventions evolved across cycles and included appointment of an emergency medicine (EM) airway lead, Emergency Medicine Airway Registry Ireland (EMARI)-linked QR code data capture, standardised checklists and airway equipment, video laryngoscopy with recording, daily intubation drills, competency-based sign-off and structured multidisciplinary teaching with feedback (Airways, Biscuits, Caffeine). Primary outcome measures were first-pass success (FPS) and complication rates.

Results: Across 156 intubations in 154 patients, EPs were primary intubators in 82.7%. Overall mean FPS was 91.7% and complication rate was 12.3%. Performance metrics were maintained within predefined safety targets (>90% FPS, <15% complications) across all four Plan-Do-Study-Act (PDSA) cycles, despite staff turnover and progressive introduction of interventions. Following implementation of daily drills, senior airway supervision and competency sign-off (PDSA cycle 2), FPS remained consistently above target and complication rates remained low through subsequent cycles. EMARI data capture reached 99.4%, and video capture increased over time to 72%.

Conclusions: A structured airway governance programme combining leadership, checklist standardisation, simulation and continuous feedback was associated with maintenance of FPS>90% with low complication rates over successive PDSA cycles. This pragmatic, replicable framework supports establishment of national EM airway governance standards to maintain procedural competency and patient safety and is replicable in international EDs with similar pre-existing airway management practices.

Objectives: Acute behavioural disturbance (ABD), formally known as excited delirium, is an under-recognised clinical picture often characterised by abnormal physiology and extreme agitation. The condition is potentially dangerous for both patients and practitioners, particularly in the prehospital setting. Our objective was to systematically review the evidence for management of ABD within the prehospital environment.

Methods: A systematic literature search (PROSPERO CRD42023447238) of PubMed, Cochrane trials, Cochrane reviews, Embase, Web of Knowledge, Google Scholar and MEDLINE was performed from inception until February 2025. Any study that examined the management of ABD prehospitally was included. Randomised controlled trials, observational cohort studies and case series that were written in English were included. Methodological quality of included studies was interpreted using the ROBINS-I (Risk Of Bias In Non-randomised Studies - of Interventions) and GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach.

Results: From 6091 studies, 42 were included; none were high quality and 6 were moderate quality. Ketamine demonstrated the most effective sedation (range 79-98% of all patients included achieving adequate sedation as defined in the studies), although doses and methods of administration varied significantly. Midazolam generally showed a higher number of side effects than other drugs studied. Droperidol was not found to have a higher mortality than others, and no effect was seen on the QT interval.

Conclusions: Ketamine was found to be the most studied drug for treatment of ABD in the prehospital setting and is likely the most effective method of sedation at a dose of 5 mg/kg intramuscularly. Midazolam appears to have a higher risk of side effects, particularly respiratory-related, in comparison to other sedative agents. Conclusions are limited by the quality of evidence currently available and additional research is required to establish the most effective mode of administration and dose for this population group, as well as better definition of the presenting condition and outcome measures.

Prospero registration number: CRD42023447238.

Background: Ambulance personnel are routinely exposed to emotionally demanding and high-stress situations, making adequate support initiatives crucial for their mental health. Previous research suggests that ambulance workers' subjective experience of perceived support is more strongly associated with mental health outcomes than measures of specific types of support. However, the relationship between specific types of received support and the overall perception of receiving support remains unclear. This study investigates how different types of support and the overall amount of support types used are associated with perceived support among ambulance personnel.

Methods: In this cross-sectional study of 389 ambulance personnel, regression analyses were applied to examine the associations between six types of received support and perceived support. We adjusted for covariables and support outside work. Additionally, a generalised linear model was used to assess the association between the total number of support types used and perceived support.

Results: This study demonstrates that four specific types of received support (debriefing/defusing, formal peer support, informal managerial support and informal collegial support) were significantly positively associated with perceived support among ambulance personnel (debriefing/defusing: B=2.44, SE=0.77, t=2.80, 95% CI 0.90 to 3.90; formal peer support: B=2.35, SE=1.19, t=1.83, 95% CI 0.02 to 4.67; informal managerial support: B=2.08, SE=0.80, t=2.54, 95% CI 0.48 to 3.59; informal collegial support: B=4.21, SE=1.90, t=2.87, 95% CI 0.47 to 7.83). Additionally, the number of support types used was associated with higher levels of perceived support.

Conclusion: These findings highlight the need for a multifaceted support strategy, focusing on both specific support types as well as availability of several parallel support initiatives, in organisational prevention strategies.

Background: Falls represent 10% of emergency department (ED) visits in older patients. Identification of those at risk for future falls is important to allow for preventive interventions. The aim of the study was to investigate the accuracy of a new algorithm, based on an adaptation of the World Falls Guidelines (WFG) for falls prevention and management, to identify patients at high risk of recurrent falls in a cohort of older patients with fall-related visits to the ED.

Methods: The FALL-ER registry is a prospective, observational, multipurpose cohort including consecutive, community-dwelling patients age ≥65 years, attending the ED of five Spanish hospitals after a fall during 52 randomly selected days between 2014 and 2015. Variables necessary to operationalise the algorithm or a proxy when necessary were recorded. The primary outcome was a new fall within 6 months after the index visit. Survival and logistic regression analyses were conducted.

Results: The cohort included 1241 patients (median age 80 years (IQR 73-85), 69.1% female). The algorithm allowed the classification of 1039 patients (88.7%) as high risk, 39 (3.3%) as intermediate risk and 93 (7.9%) as low risk of future falls. Overall, there were 134 patients (11.4%) who met the outcome and experienced a new fall within 6 months after the index ED visit. The cumulative probability of suffering a new fall was 13% (95% CI 10.8% to 15.1%), 17% (95% CI 4.8% to 29.1%) and 8.5% (95% CI 2.4% to 14.6%) in the high-risk, intermediate-risk and low-risk groups, respectively, without significant differences between groups (log-rank=0.422). Being classified as high risk had a sensitivity of 90% (95% CI 85% to 95%) and a specificity of 11% (95% CI 10% to 13%) for new falls.

Conclusions: A new fall-risk screening tool, based on the WFG algorithm, had poor discriminatory capacity in our ED cohort to predict new falls within 6 months of the index fall.

Background: Prompt diagnosis of subarachnoid haemorrhage (SAH) is crucial to prevent life-threatening complications. However, timely SAH diagnosis is not uniformly achieved. This work aims to identify and analyse patient-reported reasons contributing to delayed SAH diagnosis.

Methods: We prospectively interviewed all patients with delayed SAH diagnosis at Wessex Neurological Centre, UK, between 1 May 2018 and 30 April 2021. Interviews were structured detailing symptom onset, healthcare consultations and reasons for delays. Content analysis was used to develop a coding scheme, and statistical analysis was performed using analysis of variance, χ2 and Fisher's exact tests.

Results: Of 550 cases of spontaneous SAH, 106 (19.3%) diagnoses were delayed.85/106 (80.2%) patients did not seek immediate medical attention (15.5% of all SAH). The most common reasons were 'waiting to see if symptoms would settle' (18/85, 3.3% of all SAH) and 'headaches not severe enough' (15/85, 2.7% of all SAH).48/106 (45.3%) reported diagnostic delays after seeking care (8.7% of all SAH), attributable to either misdiagnosis (36/48, 6.5% of all SAH) or errors in diagnostic testing (12/48, 2.2% of all SAH).Patients who did not seek immediate medical attention were more likely to experience diagnostic delays after seeking care (OR 9.77, 95% CI 4.97 to 19.49, p<0.001). Among patients presenting late, diagnostic delays after seeking care occurred more frequently in Glasgow Coma Scale (GCS) 15 patients compared with GCS <15 (OR 5.3, 95% CI 1.4 to 19.5, p=0.011). 49/85 (57.6%) patients who delayed seeking care, and 21/36 (58.3%) misdiagnosed patients reported clinical thunderclap headache.

Conclusion: Prospective patient interviews capture data missed by retrospective chart review. This work has therefore identified important sources of delay in seeking care following the onset of SAH. Patients with delayed presentation were more likely to experience healthcare errors. These insights may help inform clinician awareness and public health initiatives aimed at earlier diagnosis.

Aim: Resident doctors in their 3rd year of emergency medicine training in the UK face multiple challenges, leading to very high levels of burnout and exodus from the training programme. The North West School of Emergency Medicine trialled reflective practice (Balint) groups to try and help this. This involves regular small group meetings focusing on case-based reflections on the emotional aspects of practice. We aimed to explore the impact of Balint groups on emergency medicine resident doctors.

Methods: Qualitative study involving semistructured interviews with resident doctors in their 3rd year of training (ST3) in the UK. Participants included those who had undertaken Balint group sessions, ST3s who did not participate, and Balint group facilitators. Interviews were recorded, transcribed and analysed using reflexive thematic analysis.

Findings: 12 participants were included between September 2023 and May 2024. They reported Balint groups to be a hugely positive part of their training. Participants developed a psychological toolkit and a supportive community to help manage the emotional and stress-related aspects of emergency medicine. This led to improved job satisfaction, which participants believed would enhance retention. Participants felt their ability to manage the emotional needs and challenges of their patients had improved. The groups were feasible to run but required planning and communication to facilitate release from clinical work.

Conclusion: Balint groups for ST3 emergency medicine resident doctors are feasible. Clinicians report benefits for themselves and perceived benefits for their patients. This supports continuing and developing the programme locally and piloting similar programmes in other professional groups and localities.

Background: Burnout is a widely recognised occupational phenomenon, with emergency department (ED) healthcare workers globally facing a heightened risk. Despite this, data on the burden of burnout among ED healthcare workers, especially in low-resource settings, are limited. Our study sought to establish the prevalence and factors associated with burnout and workplace stressors among ED healthcare workers in Uganda.

Methods: An online-based survey was conducted among ED professionals across four private and public hospitals. Burnout was assessed using the Maslach Burnout Inventory-Human Services Survey tool. Data were analysed using univariable and multivariable logistic regression analyses.

Results: Data from 82 participants were analysed (response rate of 88%), with approximately equal numbers of males and females, just over half providing care to both adult and paediatric patients and 61% working in public facilities. Overall, 9.7% of participants met the criteria for burnout. In total, 48.7% (n=40) reported high emotional exhaustion, 21.9% (n=18) reported high depersonalisation and 35.4% (n=29) reported low personal accomplishment. At least 80% of participants identified key ED stressors including work-related fatigue, patients' financial problems, work overload, equipment shortages and challenges in balancing professional and personal responsibilities. After adjusting for covariates such as overload of health professional literature needed to be read, patients' financial problems, educational issues, lack of sufficient clinical skills and ED violence, burnout was positively associated with poor communication with colleagues in the ED (adjusted OR (AOR) 9.90; 95% CI 1.60 to 61.17; p=0.014) and with caring for the old and terminally ill patients (AOR 7.54; 95% CI 1.38 to 41.29; p=0.020). These associations were consistent with the high depersonalisation domain of burnout.

Conclusion: Burnout, particularly in the emotional exhaustion domain, is notably prevalent among ED healthcare workers in Uganda. There is a pressing need for context-specific interventions aimed at improving early recognition of burnout and addressing persistent ED stressors. Such measures are essential to enhance ED healthcare workers' well-being, and ultimately improve in-hospital emergency care in Uganda.