Emergency Medicine Journal最新文献

Acute hyperkalaemia is a potentially life-threatening electrolyte disturbance frequently encountered in emergency departments. Timely recognition and appropriate treatment are critical to prevent serious complications such as cardiac arrhythmias and death. This narrative review summarises current evidence-based and guideline-based recommendations for the emergency management of hyperkalaemia, with a focus on practical challenges and frequently encountered clinical uncertainties. A selective literature search was conducted using PubMed, EMBASE and major international guidelines, emphasising clinical studies performed in emergency departments or acute care settings.Key treatment principles include therapy with intravenous calcium salts, primarily indicated in patients with ECG changes or serum potassium levels ≥6.5 mmol/L. Insulin-glucose therapy remains a cornerstone of transcellular potassium shifting but carries a considerable risk of subsequent hypoglycaemia, particularly in non-diabetic patients with low baseline glucose levels. Inhaled beta-agonists such as salbutamol provide an effective and synergistic potassium-lowering effect and are recommended in combination with insulin. The use of sodium bicarbonate remains uncertain and its indication appears limited to patients with severe comorbid conditions and metabolic acidosis. Diuretics may support potassium elimination in patients with volume overload, although prospective evidence in ED populations is lacking. Sodium polystyrene sulfonate is no longer recommended due to questionable efficacy and risk of gastrointestinal adverse events. Newer potassium binders, including sodium zirconium cyclosilicate and patiromer, show promise in recent studies but require further validation in acute care settings. Haemodialysis remains the definitive option in refractory cases or patients with end-stage renal disease.

Objectives: To evaluate the diagnostic accuracy of presepsin and procalcitonin (PCT) for sepsis and septic shock (Sepsis-3) in the emergency department (ED) based on the Sepsis-3 definition, where early diagnosis remains challenging due to the lack of rapid and reliable diagnostic methods.

Methods: This multicentre prospective cohort study recruited adults from eight EDs in Thailand between October 2020 and June 2022. Patients with suspected infection or those who met the quick Sequential Organ Failure Assessment criteria were enrolled. Admission blood samples were analysed for presepsin, PCT, lactate and blood culture, with follow-up presepsin and PCT measurements performed on days 3 and 7, and follow-up for 30-day mortality. Sepsis diagnosis was adjudicated with reference to the Sepsis-3 criteria and blood culture result. Diagnostic accuracy metrics, including the area under the receiver operating characteristics curve (AUROCs), sensitivity, specificity and predictive values of presepsin and PCT were evaluated.

Results: Of 668 included participants, 438 (65.6%) were diagnosed with sepsis and 58 (8.7%) with septic shock. Presepsin levels were significantly higher in patients with Sepsis-3 than in patients without sepsis at ED admission and decreased over time. Presepsin exhibited a slightly higher AUROC for predicting sepsis (AUROC 0.63 (95% CI 0.59 to 0.67)) and septic shock (AUROC 0.73 (95% CI 0.66 to 0.80)) compared with PCT (AUROC for sepsis 0.62, 95% CI 0.58 to 0.66 and septic shock 0.72, 95% CI 0.65 to 0.78). Elevated presepsin and PCT levels were associated with increased mortality within 30 days (OR 2.61, 95% CI 1.73 to 3.92 and OR of 1.62, 95% CI 1.09 to 2.42 consequently).

Conclusions: Presepsin showed slightly higher diagnostic accuracy than PCT, but overall diagnostic accuracy was modest. When interpreted together with clinical assessment and routine tests, presepsin may assist early risk stratification and support, rather than replace, clinical judgement in decisions such as resuscitation or antibiotic initiation.

Background: Emergency department (ED) utilisation and delays are a major public health concern internationally, with increased mortality with ED delays and overcrowding. The study aimed to assess how the population characteristics of ED catchment areas are associated with ED use and delays to admission or discharge, and how catchment presentation rates are associated with ED delays.

Methods: A cross-sectional study of presentations and delays to all 27 Scottish EDs for December 2023-February 2024. Catchment areas were defined for every ED in Scotland and population demographics for each, as Scottish Index of Multiple Deprivation (SIMD) and 8-fold Urban-Rural Classification (UR8). ED performance metrics for the study period were extracted from routinely reported data. Robust regression assessed the associations between catchment area demographics and ED delays, with negative binomial regression analysis of the association between catchment area demographics and presentation rates for the local population, reported as incidence rate ratio (IRR).

Results: For each decile lower (more deprived) in median SIMD, monthly attendances increased by 10% (IRR 1.10, 95% CI 1.10 to 1.11). For each step more rural in the median UR8 of a catchment, the percentage of patients experiencing a delay to admission or discharge of over 4 hours reduced by 5.3% (95% CI 4.9% to 5.7%), and each step more deprived in median SIMD decile of a catchment area was associated with 4.8% more delays beyond 4 hours (95% CI 3.0 to 6.8%). There was no association between presentation rates and delay to admission or discharge.

Conclusion: EDs with more deprived catchment areas have higher presentation rates and greater delays in care. More rural EDs have fewer delays, which may mitigate some of the effects of geographical isolation in the provision of more timely care. In isolation, ED presentation rates are not associated with delays to care, adding to evidence that overall attendances are less important than other factors contributing to ED delays. Policymakers should consider the allocation of resources to best promote health equity.

Introduction: Emergency department (ED) crowding is an international concern. It results in care being delivered in non-standard treatment spaces including corridors, termed escalation areas in the UK. Limited data suggest their use is widespread. This study aimed to establish the prevalence of UK escalation area use at a national level.

Methods: A prospective cross-sectional point prevalence study was carried out in 165 UK EDs over five snapshots in March 2025 selected to represent a range of expected ED activity. The primary outcome was the proportion of patients receiving care in escalation areas. Secondary outcomes were the number of patients awaiting an inpatient bed, ED occupancy and resuscitation capacity. The presence of paediatric patients and those with mental health presentations in escalation areas is also reported.

Results: Across the five snapshots, 17.7% (n=10 042) of ED patients were receiving care in escalation areas. At each snapshot there were more patients awaiting an inpatient bed than patients in escalation areas. The percentage of escalation area patients in non-clinical areas such as corridors ranged from 54.5% to 61.1%. ED occupancy (patients per cubicle space) ranged from 1.0 (IQR 0.7-1.4) to 2.4 (IQR 1.8-3.1). There was no available resuscitation cubicle at 10.5% (n=17/162) to 26.2% (n=43/164) of sites. Paediatric and mental health patients were receiving care in escalation areas across all time points.

Conclusion: Almost one in five ED patients was experiencing escalation area care during the five snapshots. National guidance states escalation area use is not acceptable; this research demonstrates it is routine. This study supports the hypothesis that, to address ED escalation area care, the focus should be on facilitating the flow of patients who require an inpatient bed out of the ED. Further research should consider the effect of escalation area care on patient level outcomes and the effectiveness of interventions to reduce ED crowding.

Background: Since December 2022, the National Health Service (NHS) has experienced large-scale strikes by staff. The NHS cancels approximately 12 million elective care appointments each year, and around 1 million elective appointments were cancelled due to strikes between 2022 and 2024. During strikes, emergency care is prioritised, and it has been claimed that emergency departments (EDs) run 'better than usual'. The aim of this study was to investigate changes in patient flow into hospitals through the ED during the strike periods.

Methods: Cox proportional hazards modelling was applied to data from two different EDs in the north-west of England to model time between patient arrival at the ED and their subsequent admission. Systematic (linear temporal trend, yearly seasonality, daily seasonality, weekends, ED 'heat') and patient/presentation-level factors (urgency, service referred to, patient age, ethnicity and gender) were controlled for. The impact of different striking professions on patient time to admission was investigated using HRs, where a higher HR indicated faster admission.

Results: Over the analysis period, we observed 61 separate strike days: 40 junior doctor strike days, 11 nursing days, 10 consultant days and 7 ambulance days. Junior doctor and consultant strikes coincided on 4 days. For the type 1 ED, median time to see a clinician was similar on strike and non-strike days (median 2 hours 27 min on strike days (IQR: 1 hour 2 min to 4 hours 53 min), 2 hours 27 min on non-strike days (IQR: 1 hour 5 min to 5 hours 14 min)). Patients were admitted through the ED more quickly on both the junior doctor and consultant strike days compared with non-strike days (HRs: 1.12, 1.28, both p≤0.001). This increased flow was only seen while consultants were striking in the type 2 smaller ED.

Conclusions: These findings suggest that the improved patient flow observed on strike days could be driven by the additional inpatient capacity created through the postponement of elective care. This result indicates that NHS hospital systems could potentially be adjusted to enhance turnaround times and reduce ED crowding.

Background: Radiation exposure, transition delays and costs associated with unnecessary imaging in children have stimulated research into clinical decision rules and other interventions to reduce imaging in the emergency department (ED). The objective of this systematic review is to examine the effectiveness of implementing interventions to reduce imaging in children with upper/lower extremity injuries in the ED.

Methods: Seven databases and the grey literature were searched up to May 2024. Comparative studies assessing interventions to reduce imaging in children with upper/lower extremity injuries implemented in the ED were eligible. Two independent reviewers screened for study eligibility, quality assessment and data extraction, with disagreements settled via third-party adjudication. Changes in imaging are reported as ORs with 95% CIs, using a random effects model.

Results: From 9387 citations, eight unique studies enrolling 7793 children were included with the majority using a before-after design. Potential concerns for bias were documented due to a lack of reporting of key quality domains. Decision rules for ankle injuries successfully reduced radiography (OR=0.11; 95% CI 0.07 to 0.16, I²=38%). A decision rule for wrist injuries reduced imaging (OR=0.06; 95% CI 0.03 to 0.11); however, eight injuries were missed. Two studies implementing clinical guidelines reported decreases in radiographs per patient (p<0.001). One trial reported increased imaging in children assessed by triage nurses using an established clinical decision rule (OR=5.44; 95% CI 2.96 to 10.02), with 16 missed injuries identified.

Conclusions: Guidelines incorporating clinical decision rules, particularly decision rules for ankle injuries, can reduce radiography for children with extremity injuries in the ED. Further investigations are warranted to identify other extremity injuries, the components of the intervention and the most efficient clinicians to target.

Prospero registration number: CRD42016042875.