Emergency Medicine Journal最新文献

A brief systematic review was conducted to assess the effectiveness of erector spinae plane block (ESPB) as an analgesic option for adults attending the emergency department with renal colic. MEDLINE and EMBASE databases were searched, and supplementary searches undertaken using Google Scholar and PubMed Medical Subject Headings. Two randomised controlled trials, two case series, one meta-analysis and one individual case were identified. Patient details, key results and study limitations were recorded in table format. Our findings support the use of ESPB as an effective form of analgesia in renal colic for initial treatment and refractory pain. Further studies should include a cost-effectiveness analysis to evaluate the suitability of ESPB for everyday management of renal colic.

Prehn's sign describes the eradication of testicular pain on lifting the scrotum and has been proposed as a method to differentiate causes of acute testicular pain. A short systematic review was conducted to evaluate the question: in patients presenting with acute unilateral testicular pain, is a negative Prehn's sign an accurate sign for diagnosis of testicular torsion (TT)?Medline, Embase and Cochrane databases were searched using the OVID interface from inception to 26 February 2025. Following the removal of duplicates, the search strategy yielded a total of 11 papers. Study information, participant group, relevant outcomes and study weaknesses were extracted from each article.Four studies addressed the three-part question. The only study that had the full text available for review found that 33% of patients with TT had a positive Prehn's sign, which equated to an OR of 5.941 (95% CI 1.432 to 24.658). Of the three remaining retrospective cohort studies, Prehn's sign was reported to be positive in 10.5%, 37.5% and 100% of patients with TT, respectively. Therefore, the negativity of Prehn's sign ranged from 0% to 89.5% in patients with TT.The clinical bottom line is that Prehn's sign is insufficiently sensitive to rule out TT; however, its negativity increases the likelihood of a TT diagnosis.

Background: Acute limb pain in young children presenting to the emergency department (ED) can be a sign of serious pathology, with septic arthritis being the most important condition to rule out. Two clinical decision rules (CDRs) have been developed to assist with the diagnosis: Kocher's rule (which allocates points for fever, weight-bearing status, white cell count and erythrocyte sedimentation rate) and Caird's rule (which also includes C-reactive protein). This study aimed to determine (1) the diagnostic accuracy of the two rules for the identification of septic arthritis and (2) other clinical features most strongly associated with septic arthritis.

Methods: Prospective observational study of consecutive children aged <16 years with non-traumatic acute limp presenting to three EDs in Melbourne, Australia between July 2016 and September 2018. Data were prospectively collected on weight-bearing status, duration of symptoms, joint examination findings and signs of systemic disease. Structured chart reviews and telephone follow-up were used to adjudicate the presence/absence of septic arthritis. Area under the receiver operating characteristics curve (AUC) was calculated for each published CDR, and sensitivity, specificity and likelihood ratios were calculated for clinical findings.

Results: Of 583 patients presenting with atraumatic limp, 535 (91.8%) eligible patients had sufficient follow-up data. 14 (2.6%) were diagnosed with septic arthritis. Kocher's rule had an AUC of 0.72 (95% CI 0.42 to 1.00), while Caird's rule had an AUC of 0.78 (95% CI 0.52 to 1.00) for septic arthritis. Univariable analysis demonstrated strong associations between range of joint motion (unadjusted OR 13.9, 95% CI 5.0 to 38.5), signs of systemic disease (OR 20.5, 95% CI 6.2 to 67.7), hip pain (OR 3.8, 95% CI 1.2 to 11.7) and presence of fever (OR 5.1, 95% CI 1.0 to 25.1) with septic arthritis. Markedly reduced range of motion compared with the unaffected side had the highest positive likelihood ratio (12.1, 95% CI: 7.5 to 19.5), while inability to weight bear had a positive likelihood ratio of 3.85 (95% CI 2.49 to 5.95). None of the tested clinical findings had a negative likelihood ratio less than 0.3, or a positive predictive value of more than 25%.

Conclusion: Septic arthritis is a relatively uncommon diagnosis in children presenting to the ED with an acute limp. Markedly reduced range of motion and inability to weight bear appear to be the strongest predictors of septic arthritis; however, their absence is insufficient to rule out the diagnosis.

Objectives: In fall 2022, paediatric EDs (PEDs) and urgent cares (PUCs) cared for an unprecedented number of children, leading to long waits and boarding patients. This surge mimicked the adult ED/UC COVID-19 pandemic experience. Learning from published data and surge response plans, we adapted our response using rapid cycle quality improvement methodology.

Methods: A multidisciplinary PUC/PED team met to determine the current state and create interventions. After the standard seasonal surge response did not have a significant impact, we further expanded inpatient capacity, created new physical PUC space, started provider intake and transitioned PED beds to inpatient.

Results: Statistical control charts were used to monitor metrics from 4 weeks prior to the surge to when volumes returned to baseline, but improvement was seen prior to this. Our primary outcome measure, left without being seen (LWBS) rates, decreased from a peak of 40% to <5% and PUC door-to-provider time (process measure) decreased from 158 min to 106 min before the surge was over. These metrics also dropped below the prior baseline after volumes returned to normal. PED door-to-provider time (process measure) and PUC lengths of stay (LOS) (balancing measure) were maintained throughout.

Conclusions: Using rapid cycle methodology, we responded quickly to an unprecedented patient volume by innovatively increasing staffing and space. We improved LWBS rates and PUC door-to-provider time despite high volumes and large numbers of boarding patients. We created efficiencies that allowed us to maintain PUC LOS and PED door-to-provider times during the surge. This resulted in sustained improvement, and we now operate with shorter LOS and door-to-provider times than historically achieved.

Objectives: We aimed to evaluate the impact of the COVID-19 pandemic and subsequent introduction of the Victorian Virtual Emergency Department (VVED) consultation service for paramedics on paramedic-to-general practitioner (GP) referral patterns, case time burden and ambulance reattendance rates.

Methods: We conducted interrupted time series regression assessing paramedic-to-GP referrals with the following two interruptions: (1) the COVID-19 pandemic in March 2020 and (2) VVED integration in July 2022. We included ambulance patients between 2018 and 2023 across Victoria, Australia.

Results: A total 3 205 562 patients across 65 months were included; 38.7% presented in the 26 months prior to the beginning of the COVID-19 pandemic (n=1 239 975), 43.8% between March 2020 and June 2022 (n=1 403 139) and 17.6% in the 11 months after VVED implementation (n=562 448). There was no step change in paramedic-to-GP referrals associated with the COVID-19 pandemic, although a 3% relative monthly trend increase in referrals to GP occurred (incident rate ratio (IRR) 1.03, 95% CI 1.02 to 1.04). Subsequent VVED integration was associated with a -16% relative step change in referrals to GPs (IRR 0.84, 95% CI 0.74 to 0.96); however, no trend change was observed. Median case time burden increased throughout the study by 0.52 min per month (median difference 0.52 min, 95% CI 0.51 to 0.52). At the study period conclusion, EMS attendances resulting in GP referrals had a 40 min median case cycle duration, compared with 120 min for ED conveyances. Ambulance 7-day reattendance rates were similar between those referred to VVED (8.8%) vs GPs (8.7%).

Conclusions: The COVID-19 pandemic was associated with increased paramedic-to-GP referrals in lieu of ambulance conveyances. The VVED was associated with an initial decrease in paramedic-to-GP referrals; however, the trend of increasing GP referrals continued. paramedic-to-GP referrals consumed a third of the time burden associated with ambulance conveyance to ED.

A short review of the literature was conducted to compare the length of emergency department (ED) stay and hospital admission rates in patients with exacerbations of asthma or chronic obstructive pulmonary disease (COPD) treated with salbutamol via a metered dose inhaler with a spacer (MDIS) versus nebulisation. Database searches were conducted using Cochrane, EMBASE, MEDLINE and Google Scholar. Six papers met our inclusion criteria and underwent analysis. Our results suggest that delivery of salbutamol via MDIS may reduce hospital admissions and ED length of stay in this patient cohort.

Background: Acute appendicitis requires timely diagnosis. The diagnostic efficacy of tongue examination in making this diagnosis has not been established. This study investigates whether the Tongue Coating Index (TCI), a validated measure of tongue coating, can aid in diagnosing acute appendicitis.

Methods: We conducted a prospective cohort study (1 September 2018-31 December 2020) at a single Japanese hospital. Adults (≥20 years) with suspected acute appendicitis, presenting to either the emergency department or general outpatient clinic, were enrolled. Tongue images were taken at presentation; two independent examiners-unrelated to clinical care and blinded to patient data-later scored these images using the TCI. A composite reference standard (clinical findings, imaging, histopathology, follow-up) was used to confirm appendicitis. We compared the TCI's diagnostic performance with the Alvarado score and its components using C-index, area under the curve (AUC), sensitivity and specificity.

Results: Of 145 included patients, 69 (47.6%) were diagnosed with acute appendicitis. The TCI demonstrated comparable discriminative ability (C-index AUC 0.62; 95% CI, 0.53 to 0.71) to that of the Alvarado score (0.66; 95% CI, 0.57 to 0.75). Of Alvarado score components, migration of pain had an AUC of 0.63 (95% CI, 0.55 to 0.71), anorexia 0.58 (95% CI, 0.50 to 0.66) and tenderness in the right lower quadrant 0.55 (95% CI, 0.50 to 0.60). At a cut-off of 3, the TCI demonstrated high sensitivity of 96% (95% CI, 88% to 98%) but low specificity of 21% (95% CI, 13% to 32%). Conversely, at a cut-off of 10, the TCI showed increased specificity of 83% (95% CI, 73% to 90%) but reduced sensitivity of 29% (95% CI, 20% to 41%).

Conclusion: The TCI showed comparable diagnostic performance to the Alvarado score and its individual components. TCI may potentially serve as an additional non-invasive indicator for diagnosing or ruling out acute appendicitis. Further research is essential to validate its clinical utility.

Background and aims: There is growing recognition among practitioners worldwide of the benefits of practising emergency medicine in different countries and healthcare settings. A recent survey by the Royal College of Emergency Medicine found interest and experience in global health (GH) work among college members, but many struggled with barriers that limited their contribution to this work. This study aims to understand the role of GH experience by emergency care practitioners and how it interconnects with the National Health Service and UK practice.

Methods: Anonymised semistructured interviews were conducted from August to November 2022 on a purposive sample of UK emergency care practitioners who had previously undertaken GH work. Reflexive thematic analysis was used to analyse and present their experiences in this field.

Results: The three key themes from the analysis were that emergency care is a specialty well positioned to contribute to GH settings; practitioners feel this contribution confers benefits to both the individual and their healthcare system; and the current structure of UK emergency care training presents barriers to maximising the benefits of these experiences.

Conclusion: The perceived benefits of GH involvement to the emergency care and base organisation are manifold; as are the skills offered by this practitioner group. Readily accessible funding, networks, mentorship and support from training programme leadership were all identified as ways of improving the quality and frequency of meaningful GH involvement.