International Journal of Emergency Medicine - Latest Articles

Non-traumatic splenic rupture in a patient on oral anticoagulation

Marije de Kubber — 2013-05-21T00:00:00Z

Background: Splenic injury is normally associated with trauma, but spontaneous splenic rupture has been described in various systemic diseases.Case presentationA 56-year-old male on oral anticoagulation presented to the emergency department with epigastric pain, nausea, and left upper quadrant tenderness. There was no history of trauma. Contrast-enhanced CT imaging revealed a large subcapsular haematoma of the spleen. Oral anticoagulation was antagonised with vitamin K and the patient was discharged in good condition after 3 days of clinical observation. Conclusion: Non-traumatic splenic rupture is a rare complication of oral anticoagulation.

Evaluation of ambulance offload delay at a university hospital emergency department

Derek Cooney — 2013-05-10T00:00:00Z

Background: Ambulance offload delay (AOD) has been recognized by the National Association of EMS Physicians (NAEMSP) as an important quality marker. AOD is the time between arrival of a patient by EMS and the time that the EMS crew has given report and moved the patient off of the EMS stretcher, allowing the EMS crew to begin the process of returning to service. The AOD represents a potential delay in patient care and a delay in the availability of an EMS crew and their ambulance for response to emergencies. This pilot study was designed to assess the AOD at a university hospital utilizing direct observation by trained research assistants.FindingsA convenience sample of 483 patients was observed during a 12-month period. Data were analyzed to determine the AOD overall and for four groups of National Emergency Department Overcrowding Scale (NEDOCS) score ranges. The AOD ranged from 0 min to 157 min with a median of 11 min. When data were grouped by NEDOCS score, there was a statistically significant difference in median AOD between the groups (p < 0.001), indicating the relationship between ED crowding and AOD. Conclusion: The median AOD was considered significant and raised concerns related to patient care and EMS system resource availability. The NEDOCS score had a positive correlation with AOD and should be further investigated as a potential marker for determining diversion status or for destination decision-making by EMS personnel.

INR reduction after prothrombin complex concentrate (Co-fact©) administration: comparison of INR outcomes in different patient categories at the emergency department

Floris Roodheuvel — 2013-05-10T00:00:00Z

Background: Co-fact©, prothrombin complex concentrate, is used for restoring the international normalized ratio (INR) in patients on vitamin K antagonists (VKA) presenting with acute bleeding. In this prospective cohort study, we evaluated whether adequate INR values were reached in ED patients using the Sanquin (Federation of Dutch Thrombosis Services) treatment protocol. Methods: We evaluated this protocol for two target INR groups: group 1, target INR ≤ 1.5 (for life-threatening bleeding/immediate intervention); group 2, target INR 1.6-2.1 (in cases of a minor urgent surgery or serious overdosing of anticoagulant). We specifically wanted to identify both under- and over-treated patients. Reversing VKA anticoagulation therapy to unnecessarily low INR values may involve thrombotic risks. Apart from this risk, the patient is also administered an excess amount of the drug. This means unnecessary costs and may present problems with restoring an anticoagulated state at a later time. Results: In our cohort, the Sanquin dosing protocol was followed for 45/60 patients. It appeared that out of the 41 patients in group 1 (target INR ≤ 1.5), 35 (85%) achieved the goal INR. This occurred more often than for the 19 patients in group 2 (target INR 1.6–2.1), where only 6 (32%) achieved the goal INR. Using the protocol resulted in a positive trend toward better INR reversal in group 1.In group 2, no relation between using the protocol and achieving the desired INR value was detected. Physicians ignoring the proposed dose of Co-fact© prescribed significantly less Co-fact© (even when correcting for patient weight). It appeared that patients in group 1 had a significantly lower baseline INR than patients in group 2. Group 2 patients, on the other hand, had a baseline INR > 7.5 in 53% of the cases. Conclusion: In our cohort, for most patients in INR group 2 treated with Co-fact©, the achieved INR value was outside the desired range of 1.6-2.1. The supra-therapeutic range of baseline INR in group 2 may have contributed to the different kind of bleeding witnessed in this patient group.Our results support the idea that treatment of patients on vitamin K antagonists with Co-fact© could benefit from a slightly different approach, taking into account the INR value to which the patient needs to be reversed.

National survey of pediatric services available in US emergency departments

Ashley Sullivan — 2013-04-24T00:00:00Z

Background: Children account for nearly 20% of all US emergency department (ED) visits, yet previous national surveys found that many EDs lack specialized pediatric care. In response, a 2001 joint policy statement recommended resources needed by EDs for effective pediatric emergency care delivery. We sought to update and enhance previous estimates of pediatric services available in US EDs. Methods: We administered a telephone survey to a 5% random sample (n = 279) of all US EDs from the 2007 National Emergency Department Inventory-USA. The survey collected data on local capabilities (including typical management of three clinical scenarios) and prevalence of a coordinator for pediatric emergency care. We used descriptive statistics to summarize data. Multivariable logistic regression was used to examine the association between survey respondent and ED characteristics as well as the presence of a coordinator for pediatric emergency medicine. Results: Data were collected from 238 hospitals (85% response rate). A minority of hospitals had pediatric departments (36%) or intensive care units (12%). The median annual number of ED visits by children was 3,870 (interquartile range 1,500–8,800). Ten percent of hospitals had a separate pediatric ED; only 17% had a designated pediatric emergency care coordinator. Significant positive predictors of a coordinator were an ED pediatric visit volume of ≥1 patient per hour and urban location. Most EDs treated only mild-to-moderate cases of childhood bronchiolitis and asthma exacerbation (77% and 65%, respectively). Less than half (48%) of the hospitals reported the ability to surgically manage a child with acute appendicitis. Conclusion: We found little change in pediatric emergency services compared to earlier estimates. Our study results suggest a continued need for improvements to ensure access to emergency care for children.

Increased incidence of hypotension in elderly patients who underwent emergency airway management: an analysis of a multi-centre prospective observational study

Kohei Hasegawa — 2013-04-24T00:00:00Z

Background: Although the number of elderly increases disproportionately throughout the industrialised nations and intubation-related cardiovascular compromise is associated with hospital mortality, no emergency medicine literature has reported the direction and magnitude of effect of advanced age on post-intubation hypotension. We seek to determine whether advanced age is associated with an increased rate of hypotension at airway management in emergency departments (EDs). Methods: We conducted an analysis of a multi-centre prospective observational study of 13 Japanese EDs from April 2010 to March 2012. Inclusion criteria were all adult non-cardiac-arrest patients who underwent emergency intubation. We excluded patients in whom airway management was performed for shock or status asthmaticus as the principal indication. Patients were divided into two groups defined a priori: age ≥ 65 years old (elderly group) and age < 65 years old (younger group). The primary outcome measure was post-intubation hypotension in the ED. Results: During the 24-month period, 4,043 subjects required emergency airway management at 13 EDs. Among these, the database recorded 3,872 intubations (capture rate 96%). Of 1,903 eligible patients, 975 patients were age ≥ 65 years (51%) and 928 patients were age < 65 years (49%). The elderly group had a significantly higher rate of post-intubation hypotension compared with the younger group [3% vs. 1%; unadjusted OR 2.7 (95% CI, 1.3–5.6); P = 0.005]. In a model controlling for potential confounders (sex, principal indication, method, medication used to intubate, multiple intubation attempts), advanced age had an adjusted OR for post-intubation hypotension of 2.6 (95% CI, 1.3–5.6; P = 0.01). Conclusions: In this large multi-centre study of ED patients who underwent emergent airway management, we found that elderly patients have a significantly higher risk of post-intubation hypotension. These data provide implications for the education and practice of ED airway management that may lead to better clinical outcomes and improved patient safety.

Emergency departments in The Netherlands: is there a difference in emergency departments with and without emergency physicians? a cross-sectional web-based survey

Wendy Thijssen — 2013-04-15T00:00:00Z

Background: There is a growing interest in emergency departments (EDs) and the development of emergency medicine in The Netherlands. In the last decade several policy reports have stated that the quality of emergency care should be improved and that emergency physicians (EPs) play a large role in the quality improvement. The Netherlands Society of Emergency Physicians (NVSHA) has developed an emergency medicine training program, which has been nationally recognized since 2009. Nevertheless, not all EDs are staffed with EPs yet. This study aimed to explore differences between Dutch EDs with EPs and those without EPs. Methods: A cross-sectional web-based survey was performed on data over the year 2008 or 2009 in all 105 Dutch hospitals with an emergency department. We documented which ED-specific courses were attended by physicians working in the ED (list of 3 courses) and which clinical audit activities were implemented (list of 6 activities). The choice of courses and clinical audits was based on those mentioned in published quality reports and in national debates on emergency care. We compared EDs with and without EPs. The final analysis was based on a linear regression analysis, controlling for ED size and having an EP training program. We considered P < 0.05 significant. Results: Our survey’s response rate was 67%. EPs worked significantly more often in larger EDs. The linear regression analysis shows that the total number of courses attended by physicians was on average 0.51 higher (P = 0.000) in EDs with EPs than in EDs without EPs, and the total number of implemented clinical audits was on average 0.49 higher (P = 0.008). After controlling for potential confounders, the effect of both the composite number of courses attended (P = 0.001) and the composite number of implemented clinical activities (P = 0.032) remained significant. Conclusion: This study shows that EPs are significantly more present in larger EDs and in EDs where there is more continuing professional education and where there are more clinical audit activities. Our findings suggest that the presence of emergency physicians is positively associated with the quality of emergency care, but prospective research is required to examine causality.

Experience with the core curricular elements for international emergency medicine fellowships

David Beran — 2013-04-15T00:00:00Z

Background: The number of international emergency medicine (IEM) fellowships available in the US has grown dramatically since the inception of subspecialty training in 1994 Bayram et al. (Acad Emerg Med 17:748–757, 2010). These fellowships vary according to their curricular structure, intensity of fellow exposure and requirements for program completion. The variety of fellowship structures may have negative connotations for graduates from its fellowships and reflect upon the translatability of their skill sets.The recent article “Core Curricular Elements for International Emergency Medicine Fellowships” Alagappan and Holliman (Emerg Med Clin 23(1):1–10, 2005) was designed as a curricular development tool and enumerates seven foci within the broad field of IEM.ObjectivesThe authors of this article describe their experience using this curriculum development tool. Individual experiences in each of the seven categories described in the “Core Curricular Elements” article were identified and undertaken within the typical 2-year training period.DiscussionA curricular structure is described that integrates exposure to all seven areas along with the Master’s of Public Health (MPH) degree, the clinical component and the academic component thematic to existing fellowships. Benefits of this curriculum include increased exposure to multiple areas of IEM, potential for greater standardization and increased translatability of skill set. Disadvantages include superficial exposure to areas of IEM and potentially decreased travel time. Conclusion: The result is a plausible curriculum where fellows would gain exposure to more areas of IEM than they may have otherwise while still earning their MPH, working clinical shifts and carrying out academic fellowship requirements. The authors conclude that this structure allows fellowships to continue drawing on their strengths, provides a more well-rounded fellowship experience and increases structure without requiring standardization.

Outcome predictors of uncomplicated sepsis

Ewoud ter Avest — 2013-04-08T00:00:00Z

Background: The development of sepsis risk prediction models and treatment guidelines has largely been based on patients presenting in the emergency department (ED) with severe sepsis or septic shock. Therefore, in this study we investigated which patient characteristics might identify patients with an adverse outcome in a heterogeneous group of patients presenting with uncomplicated sepsis to the emergency department (ED).FindingsWe performed a retrospective cohort analysis of all ED patients presenting with uncomplicated sepsis in a large teaching hospital during a 3-month period. During this period, 70 patients fulfilled the criteria of uncomplicated sepsis. Eight died in the hospital. Non-survivors were characterized by a higher abbreviated Mortality in Emergency Department Sepsis (MEDS) score (7.2 ± 3.4 vs. 4.8 ± 2.9, p = 0.03) and a lower Hb (6.6 ± 1.2 vs. 7.7 ± 1.4, p = 0.03), and they used beta-blockers more often (75% vs. 19%, p < 0.01). Conclusions: Non-survivors of uncomplicated sepsis had on average a higher abbreviated MEDS score, a lower hemoglobin (Hb) and more often used β-blockers compared to survivors. Early identification of these factors might contribute to optimization of sepsis treatment for this patient category and thereby prevent disease progression to severe sepsis or septic shock.

Practical use, effects and complications of prehospital treatment of acute cardiogenic pulmonary oedema using the Boussignac CPAP system

Eva Spijker — 2013-04-08T00:00:00Z

Background: Early use of continuous positive airway pressure (CPAP) has been shown to be beneficial within the setting of acute cardiogenic pulmonary edema (ACPE). The Boussignac CPAP system (BCPAP) was therefore introduced into the protocols of emergency medical services (EMS) in a large urban region. This study evaluates the implementation, practical use and complications of this prehospital treatment. Methods: This was a retrospective case series study. The study was carried out in a period shortly after the implementation of the BCPAP system on all EMS ambulances in the The Hague region. According to protocol, diagnosis of ACPE in the prehospital setting was left to the discretion of the EMS paramedics and the facial mask was applied immediately after the diagnosis had been made. Patients were selected through hospital registration and diagnostic criteria for ACPE. Only those patients showing evident clinical signs of ACPE were included. Patient characteristics, physiologic variables, clinical outcomes and complications were collected from EMS transport reports and hospital records. Results: Between 1 June 2008 and 30 April 2009 a total of 180 patients were admitted for ACPE. Of these, 76 (42%) had evident clinical signs of ACPE upon presentation and were included. Three patients were transferred and in 14 cases data were missing. Out of the remaining 59 patients, 16 (27%) received BCPAP. In 43 (73%) cases the mask was not applied. For 7 out of 43 cases that were eligible for BCPAP treatment but did not receive the facial mask, an explanation was found in the EMS transport record. No complications were recorded pertaining to using the BCPAP system. Conclusions: A significant portion of patients with clinical signs of acute cardiogenic pulmonary edema in the prehospital setting is not treated according to protocol using BCPAP. Based on the small group of patients that actually received BCPAP treatment, the facial mask seems feasible and effective for the treatment of acute cardiogenic pulmonary edema in the prehospital setting.

Non-invasive vagus nerve stimulation for the treatment of acute asthma exacerbations--results from an initial case series

Elmin Steyn — 2013-03-19T00:00:00Z

A prospective multicentre clinical study was initiated to evaluate the safety and potential clinical benefit of non-invasive vagus nerve stimulation (nVNS) for the treatment of bronchoconstriction exacerbations in asthmatics. Due to slow enrolment and design changes of the device, the study was prematurely terminated after enrolment of four eligible patients. Three of the four patients were considered treatment successes based on improvement in FEV1, improvement in VAS dyspnoea scoring, and the absence of device-related adverse events.Trial RegistrationClinicalTrials.gov Identifier: NCT01385306