Emergency Medicine Journal最新文献

Abdominal visceral cancer pain is a challenging oncology presentation to treat in the ED. Current emergency oncologic pain management strategies focus largely on parenteral opioid administration, although ultrasound-guided regional anaesthesia has the potential to provide more targeted, superior and long-lasting analgesia without comparable adverse side effects. In particular, a continuous erector spinae plane block (ESPB) performed between T6 and L2 represents a promising analgesic tool in this patient population. Anterior spread of local anaesthetic from the erector spinae plane to the paravertebral space may anaesthetise abdominal visceral sensory afferents travelling centrally within the thoracolumbar spinal nerves and the sympathetic chain at this level, thereby directly blocking pain conduction stemming from the gastrointestinal tract. While emergency physicians are becoming well versed in single-shot nerve blocks, continuous nerve blockade with catheter placement has yet to be readily adopted. The continuous ESPB for malignancy-related abdominal pain has the potential to not only reshape established oncologic pain management paradigms but also serve as the stepping stone for emergency physician adoption of continuous nerve blocks.

Background: Sodium nitrite has become established as a method of self-harm and suicide. Toxicity occurs primarily through the formation of methaemoglobin (MetHb). In response to a coroner request, West Midlands Ambulance Service developed a prehospital methylthioninium chloride (methylene blue) capability within the specialist Hazardous Area Response Team (HART) to treat methaemoglobinaemia. A service evaluation was planned to understand the impact.

Methods: A retrospective observational series of patients, during a planned evaluation period from 1 July 2020 to 1 July 2024. All patients receiving a HART response for suspected sodium nitrite poisoning were included. A Patient Group Direction (PGD) for the treatment of methaemoglobinaemia by paramedics was produced, allowing treatment with intravenous methylthioninium chloride 1-2 mg/kg in specific circumstances. MetHb levels were assessed using handheld pulse CO-Oximeters.

Results: Nine patients were attended for suspected sodium nitrite toxicity and three were administered prehospital methylthioninium chloride under PGD indications. In addition, one patient had no evidence of toxicity, four had conditions unequivocally associated with death and one was in cardiac arrest. The patient in cardiac arrest received sodium nitrite in hospital from the HART team under verbal direction from medical staff but did not survive. Serial CO-Oximeter readings for two of the three patients who received methylthioninium chloride indicated a decrease in MetHb levels and all three survived. Consumable costs associated with the new capability were minimal. Potential improvements to the service were identified, including changes to PGD indications.

Conclusion: The limited number of cases seen in the evaluation period suggests that restricting the prehospital provision of methylthioninium chloride to specialist teams is proportionate, and it appears feasible for specialist paramedics to deliver prehospital methylthioninium chloride under PGD indications. However, prehospital use of methylthioninium chloride for the treatment of methaemoglobinaemia currently lacks sufficient evidence to support widespread adoption without further evaluation.

This practice review addresses the management of haemophilia and heritable bleeding disorders in the ED. These disorders are uncommonly encountered by the emergency physician, but prompt and appropriate management is critical to ensure good outcomes. This practice review describes the principles of emergency care for people with bleeding disorders, with an emphasis on a pragmatic clinical approach, and provides examples of challenging emergencies.

Background: In 2019, the National Health Service (NHS) England announced the implementation of same day emergency care (SDEC) in every hospital with a type 1 emergency department (ED). SDEC aims to provide timely and appropriate specialist care to patients on the same day, expediting their investigations and avoiding unnecessary hospitalisation. There is limited evidence for SDEC adoption and its effectiveness. This mixed-method study identifies and analyses SDEC implementation methods and describes subjective workforce views through both surveys and interviews.

Methods: An electronic survey was developed and distributed via email to 60 randomly selected hospitals in England with type 1 EDs. Follow-up interviews were conducted to contextualise survey responses and explore perceptions of SDEC and subjective barriers to efficiency.

Results: In total, 39 responses (including dual responses from SDEC and ED staff) were received from 34 hospitals (57%). All hospitals had an acute medical SDEC, with more limited implementation of surgical (53%) and frailty SDECs (29%). The SDECs opened on average 12 hours on weekdays and 10 hours on weekends. Referral and patient selection models varied. 79% of hospitals used their SDECs as emergency bed spaces. 85% of units assessed between 31 and 50 patients/day, with no unit admitting >10 patients/day. Although interviews were generally positive regarding SDEC efficiency, issues included differing perceptions of SDEC purpose, variability in models of patient selection, unclear referral pathways and inconsistent staffing levels.

Conclusions: Since its introduction, SDEC has been implemented and developed with great variability across England. While the introduction of the NHS SAMEDAY guidelines in 2024 may assist in mitigating these discrepancies nationally, more research is vital to identify optimal methods of service delivery and evaluation of this new healthcare system.