Open Access Emergency Medicine最新文献

Introduction: Aggression in the Emergency Department (ED) remains an ongoing issue, described as reaching epidemic proportions, with an impact on staff recruitment, retention, and ability to provide quality care. Most literature has focused on the definition (or lack of) core concepts, efforts to quantify the phenomenon or provide an epidemiological profile. Relatively little offers evidence-based interventions or evaluations of the same.

Aim: To identify the range of suggested practices and the evidence base for currently recommended actions relating to the management of the aggressive Emergency Department patient.

Methods: A meta-synthesis of existing reviews of violence and aggression in the acute health-care setting, including management of the aggressive patient, was undertaken. This provided the context for critical consideration of the management of this patient group in the ED and implications for clinical practice.

Results: An initial outline of issues was followed by a systematic search and 15 reviews were further assessed. Commonly identified interventions are grouped around educational, interpersonal, environmental, and physical responses. These actions can be focused in terms of overall responses to the wider issues of violence and aggression, targeted at the pre-event, event, or post-event phase in terms of strategies; however, there is a very limited evidence base to show the effectiveness of strategies suggested.

Clinical implications: The lack of evidence-based intervention strategies leaves clinicians in a difficult situation, often enacting practices based on anecdote rather than evidence. Local solutions to local problems are occurring in a pragmatic manner, but there needs to be clarification and integration of workable processes for evaluating and disseminating best practice.

Conclusion: There is limited evidence reporting on interventional studies, in addition to identification of the need for high quality longitudinal and evaluation studies to determine the efficacy of those responses that have been identified.

Since its introduction in 1985 with Ciaglia, percutaneous tracheostomy (PT) was contraindicated in emergency settings and obesity. However, several case series in the last 20 years have documented the use of PT in life-threatening airway emergencies. We present a case of severe acute airway obstruction in a 66-year-old woman successfully treated with a placement of an awake PT. The woman's glottic obstruction was caused by a recurrent laryngeal neoplasia and revealed by nasoendoscopy. This acute condition required a serious effort from the patient to oxygenate and therefore prevented orotracheal intubation as well as the use of any supraglottic device and/or sedation. Blood aspiration after a first attempt to make a quick access to the tracheal lumen with an emergency cricothyroidotomy, and difficulties in the exact identification of tumor infiltration, led us to perform an awake tracheostomy. Due to elevated risk of airway bleeding, we started with a surgical approach to better identify anatomical structures. After the correct inter-tracheal ring space identification, sudden worsening of clinical symptoms required that we complete the procedure quickly with the aid of a Ciaglia Blue Rhino™-Cook (CBR) tracheostomy kit. At the tracheostomy tube placement, the patient quickly resolved her dyspnea and physiological breathing was restored.