Emergency Medicine Journal最新文献

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.

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.

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.