International Journal of Emergency Medicine最新文献

Background: Emergency department (ED) crowding is a growing concern worldwide and associated with negative effects. In 2013, 68% of Dutch ED-managers experienced crowding on several days of the week. This resulted into the introduction in phases of an ambulance diversion dashboard, in order to influence ED input. Increasing numbers of Dutch EDs have implemented this dashboard, visualizing regional ambulance diversions by means of a traffic light.

Methods: This is a descriptive study of a nationwide online survey of Dutch EDs, conducted between January and October 2023. It included both qualitative and quantitative questions. The outcomes and analysis are derived from descriptive data of respondents' experience of crowding as well as their usage and perceived effectiveness of the ambulance diversions dashboard.

Results: At the time of the survey, 62 of 82 Dutch EDs (75.6%) actually used the dashboard, of which 56 EDs responded (90.3% response rate). 69.7% Of ED managers experienced ED crowding more than three times a week. Of the respondents using the dashboard, 52.8% reported it only occasionally alleviates ED inflow. The purported reasons are the limited number of patients affected by the red light (ambulance diversion) and the presence of regional crowding. The effects of the orange light (impending ambulance diversion) on ED input differ greatly among hospitals, mostly due to their own internal agreements. In accordance, many respondents (53.6%) expressed dissatisfaction with the resources available to them to alleviate crowding.

Conclusion: After conducting a national survey, ED crowding is reported as a persisting nationwide problem with its prevalence largely unchanged since the introduction of the ambulance diversion dashboard. Most hospitals reported having insufficient resources to alleviate it. The effects of the ambulance diversion dashboard to decrease crowding are apparently limited because it affects a small portion of total ED presentations and because of the influence of regional crowding. The main function of the orange light is to increase ED throughput and output rather than reducing ED input.

Background: Timely emergency medical services (EMS) are particularly important among trauma patients, as inefficient EMS systems can result in potentially avoidable death before reaching a hospital. The Dhulikhel Hospital Dispatch Center coordinates and monitors a growing network of ambulances, including seven Type B ambulances staffed with a trained prehospital care provider and medical equipment. This study evaluates the prehospital care and outcomes of trauma patients transported by Type B ambulances to Dhulikhel Hospital's Emergency Department, as monitored by the Dispatch Center.

Methods: Data were collected via a retrospective chart review of Dispatch Center records, including patient demographics, injury mechanisms, prehospital care, and outcomes. Patients were included if they experienced physical trauma and were transported by a Type B ambulance to Dhulikhel Hospital's Emergency Department between 2019 and 2023.

Results: Between 2019 and 2023, 224 trauma patients were transported to the hospital and received prehospital care services from Type B ambulances monitored by the Dispatch Center. Most patients were male (59%), and nearly half were aged 18-44 (49%). The median total transport time for Dhulikhel Hospital-owned Type B ambulances was 40 min. Type B ambulances reached patients across 24 municipalities (88% in Kavrepalanchowk and Sindupalchowk districts). Falls (55%) and road traffic accidents (30%) were the most common injury mechanisms, followed by physical assault (7%). Falls were significantly associated with female, pediatric, and geriatric patients (p < 0.05), while road traffic accidents predominated among males, particularly in adults aged 25-34 years (p < 0.05). Approximately one-third of patients admitted to the hospital after evaluation in the emergency department experienced multiple injuries, and the most prevalent diagnosis of admitted cases were extremity fractures (52%).

Conclusion: Trauma cases accounted for 15% (227/1541) of all patients who received transport and prehospital care services from a Type B ambulance monitored by the Dispatch Center between 2019 and 2023. This study demonstrates the critical role of Type B ambulances and an integrated dispatch center in advancing timely and efficient prehospital care for trauma patients in Nepal.

Purpose: Here we describe a patient admitted for a stroke that was unexpectedly correlated with subclinical infective endocarditis attributable to a rarely opportunistic pathogen, Abiotrophia defectiva.

Case report: A 75-year-old man presented with a stroke. Transesophageal echocardiography suggested vegetation on all aortic valve cusps, despite the absence of clinical or laboratory signs of infection. Surprisingly, three sets of blood cultures collected without fever were positive for A. defectiva. Although the patient did not exhibit classic signs of infection during hospitalization, the severity of the valve condition necessitated replacement with a bioprosthesis.

Conclusions: This clinical case underscores the importance of investigating the infective origin of endocarditis, even in the absence of clinical or laboratory evidence. Physicians should maintain a high level of suspicion, especially in patients with highly suggestive anamnestic characteristics.

Background: Globally, most children seek emergency care at general rather than specialized pediatric emergency departments. There remains significant variation in the provision of pediatric emergency care, particularly in resource-constrained settings. The objective of this study is to pilot a self-assessment tool to evaluate pediatric emergency care capabilities in low- and middle-income country (LMIC) hospitals on the African Continent.

Methods: This was a prospective cross-sectional descriptive study using a convenience sample of sub-Saharan African hospitals. The assessment tool was developed by operationalizing the technical contents of existing standards and guidelines from international bodies including the World Health Organization and International Federation of Emergency Medicine. The pilot was conducted at emergency departments located across different regions on the African continent. Descriptive statistics were used to evaluate different domains of pediatric emergency care capabilities including pediatric triage, protocols, staffing, training, equipment, consumables, and medicines.

Results: Sixteen hospitals with emergency departments completed the assessment tool (participation rate of 76%). The hospitals were in nine different countries across four regions of sub-Saharan Africa. National/academic hospitals comprised 56.3% of the participating hospitals. The majority, 44%, of these hospitals saw pediatric patient volumes of 2,000-4,999 patients per year. Dedicated pediatric triage spaces and resuscitation spaces were available at 37.5% and 56.3%, respectively. Formal pediatric resuscitation guidelines were used at 62.5%. Doctors on the self-assessment teams came from primarily pediatrics and general practitioner training backgrounds (both 68.8%). Basic respiratory and airway support equipment (e.g. oxygen, bag-valve mask devices) were available in all participating hospitals, whereas advanced airway equipment (e.g. pediatric intubation equipment) was available in 37.5% of hospitals. Most medicines from the World Health Organization Essential Medicines list were available at participating hospitals.

Conclusions: To date, this is the first assessment tool dedicated to the comprehensive evaluation of pediatric emergency care in LMICs. This pilot provides a first approach to evaluate pediatric emergency healthcare capabilities in the hospital setting with future directions to improve the tool based on qualitative feedback.

Introduction: Psychiatric emergency departments (EDs) in France have been under pressure from several factors, exacerbated by the COVID-19 pandemic. The pandemic led to an increase in psychiatric disorders, particularly anxiety and depression, with younger people and women being most affected. The aim of this study was to provide a comprehensive description of the trends in the number of visits to the largest psychiatric emergency department in France, with a particular focus on the period preceding and following the advent of COVID-19 pandemic.

Methods: This retrospective study analyzed data from 69,764 visits to the Centre Psychiatrique d'Orientation et d'Accueil (CPOA) in Paris from 2016 to 2023. Patient data, including demographics, reasons for visit, and diagnoses, were collected and analyzed to identify trends over this period.

Results: The study observed a 28.5% increase in ED visits from 2016 to 2023. The increase was primarily driven by mood and anxiety disorders, which showed increases of 38.6% and 75.4%, respectively. The average age of patients decreased, reflecting a younger population increasingly affected by psychiatric problems. Interestingly, despite the increase in ED visits, hospital admissions decreased by 11.9%, with a notable decrease in involuntary commitment.

Discussion: The findings highlight a paradox where increased psychiatric ED visits are not accompanied by an increase in hospital admissions. This suggests a shift toward outpatient care due to systemic factors, including reduced hospital bed availability and challenges in accessing timely outpatient services. This study underscores the need to strengthen outpatient mental health services to effectively manage the growing demand. Further research, especially multicenter studies, is recommended to validate these findings and inform policy changes.

Background: Adenomyosis, typically associated with heavy menstrual bleeding and pelvic pain, is rarely linked to neurological complications. This case presents a rare instance of ischemic stroke in a young patient with adenomyosis and vascular abnormalities, underscoring the role of anemia, hypercoagulability, and vascular factors as potential contributors to cerebral infarction.

Case presentation: We describe a 41-year-old female with a history of adenomyosis who presented with right-sided hemianopia and dizziness following severe menstrual bleeding. Imaging revealed multiple acute cerebral infarctions and diffuse narrowing of the left internal carotid artery, suggesting an underlying vascular pathology. Thrombelastography revealed a hypercoagulable state, raising questions about the contributions of systemic and vascular factors in the context of adenomyosis.

Conclusion: This case highlights the need for a multidisciplinary approach in young patients with atypical risk factors. The findings underscore the importance of considering gynecological, vascular, and coagulation abnormalities in the evaluation of cerebrovascular events, offering new insights into diagnostic and therapeutic strategies.

Background: Angiotensin-converting enzyme inhibitors (ACEI) are the most common cause of drug-induced angioedema in the United States. Our primary objective was to provide descriptive evidence regarding emergency department (ED) disposition of ACEI-induced angioedema patients. Our secondary objective was to evaluate unique patterns in those with ACEI-induced angioedema at a tertiary referral center, including demographics, details of those requiring intubation, length of inpatient stay, and allergy documentation.

Methods: This was a retrospective study evaluating all cases of ACEI-induced angioedema at a large, regional academic medical center. We performed a medical record review to identify patients with ACEI-induced angioedema who presented to the ED from January 1, 2016, to December 31, 2022. A structured data abstraction process was utilized to select patients of interest, followed by descriptive statistics, chi-square tests and odds ratios for categorical data, and Kruskal Wallis tests for continuous data.

Results: A total of 637 unique patient encounters met potential inclusion. After a substantial, standardized review, 94 patients met inclusion. During the study period, there were 94 patients presenting to the ED who were diagnosed as having angioedema secondary to an ACEI (90 patients) or angiotensin receptor blocker (ARB) (4 patients). Overall, 53 patients (56.38%) improved during their ED stay, and of those, 32 patients (60.38%) were discharged home. None of the 12 patients that worsened were sent home from the ED. Those who were discharged from the ED with a median stay of 4 h had no increased risk of return to the ED versus those who were admitted. The only treatment found to have statistical association with disposition was intramuscular epinephrine. Only 13 of 43 ED discharged patients (23.64%) had their ACEI/ARB documented in their allergy listings compared to 42 of 51 patients (76.36%) of admitted patients, odds ratio of failure to document was 0.0929 (95% CI, 0.0352 to 0.24512). Only one patient out of the total 94 returned to the ED due to recurrent angioedema symptoms during our study period and was subsequently discharged.

Conclusion: Our results indicated that at a large, tertiary care referral center, patients with ACEI-angioedema who did not exhibit severe symptoms were safely discharged home with low risk of early return visit to the ED. Severe symptoms were found to be any throat symptoms, voice change, drooling, worsening swelling, or complaints of dyspnea. Further, among those admitted, patients in our study had a short inpatient stay and were safely discharged with no documented early return visit to the ED.

Background: Penetrating cardiac trauma is an entity with high pre and intrahospital mortality due to complications such as cardiac tamponade and massive hemothorax. A ventricular septal defect (VSD) occurs in 1-5% of cases and can present early or late. The management strategy for VSD resulting from penetrating cardiac trauma is uncertain.

Case presentation: A 19-year-old man was admitted in cardiorespiratory arrest after a precordial stab wound. Cardiopulmonary resuscitation was initiated achieving return of spontaneous circulation. eFAST evaluation revealed cardiac tamponade, he was taken to emergency left thoracotomy finding a perforation of the free wall of the left ventricle and a tear of the upper lobe of the left lung that were sutured. The patient was discharged and six days later was readmitted with fever and dyspnea. During treatment for a surgical site infection a new-onset pansystolic murmur was found: A transthoracic echocardiogram revealed a 13-mm VSD with left-to-right shunt. A multidisciplinary team recommended percutaneous closure of the defect which was successfully performed without complications.

Conclusions: Traumatic VSD is a rare complication of penetrating cardiac trauma. A thorough clinical and echocardiographic evaluation is essential for its diagnosis and characterization. Symptomatic septal defects, those 10 mm or larger, with Qp: Qs greater than 1.5, or causing complications such as pulmonary hypertension or valvular involvement, are usually closed to prevent progression of heart failure. Management of traumatic VSD has traditionally been surgical. However, a percutaneous intervention is a viable alternative in selected stable patients. Unlike ischemic VSD, early intervention after patient stabilization generally yields favorable outcomes.

Background: Chest pain is a common reason patients are admitted to the hospital. The most clinically significant cases are those in which the pain is due to an immediate life-threatening condition, such as acute aortic dissection (AAD). A prompt and correct diagnosis is crucial to patient survival. This case report of a patient who presented with chest pain confirms the appropriateness of urgent imaging tests e.g. POCUS when AAD is suspected in high-risk patients, regardless of the results of additional laboratory tests such as the D-dimer (DD) assay.

Case report: A 72-year-old female patient was brought by the emergency medical team to the emergency room due to fainting without loss of consciousness and severe chest pain. Owing to worsening hypotonia and recurrent chest pain, a thoracic computed tomography (CT scan) was performed and subsequently revealed aortic dissection within the ascending segment with bleeding into the pericardial sac. The results of previously ordered laboratory tests, including the DD assay, were unremarkable and were obtained only after the thoracic CT scan had been acquired. Despite prompt medical intervention, the patient died.

Conclusion: Vigilance is required when diagnosing chest pain in high-risk patients who are suspected of having AAD. The case presented in this report confirms the importance of a thorough history and physical examination as well as prompt diagnostic imaging e.g. POCUS or CT scan. Dedicated laboratory tests such as the DD assay, while often helpful, may fail to reveal remarkable abnormalities in time for medical intervention.