Search

Background Since the COVID-19 pandemic has occurred, nations showed their unpreparedness to deal with a mass casualty incident of this proportion and severity, which resulted in a tremendous number of deaths even among healthcare workers. The World Society of Emergency Surgery conceived this position paper with the purpose of providing evidence-based recommendations for the management of emergency surgical patients under COVID-19 pandemic for the safety of the patient and healthcare workers. Method A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRISMA-P) through the MEDLINE (PubMed), Embase and SCOPUS databases. Synthesis of evidence, statements and recommendations were developed in accordance with the GRADE methodology. Results Given the limitation of the evidence, the current document represents an effort to join selected high-quality articles and experts’ opinion. Conclusions The aim of this position paper is to provide an exhaustive guidelines to perform emergency surgery in a safe and protected environment for surgical patients and for healthcare workers under COVID-19 and to offer the best management of COVID-19 patients needing for an emergency surgical treatment. We recommend screening for COVID-19 infection at the emergency department all acute surgical patients who are waiting for hospital admission and urgent surgery. The screening work-up provides a RT-PCR nasopharyngeal swab test and a baseline (non-contrast) chest CT or a chest X-ray or a lungs US, depending on skills and availability. If the COVID-19 screening is not completed we recommend keeping the patient in isolation until RT-PCR swab test result is not available, and to manage him/she such as an overt COVID patient. The management of COVID-19 surgical patients is multidisciplinary. If an immediate surgical procedure is mandatory, whether laparoscopic or via open approach, we recommend doing every effort to protect the operating room staff for the safety of the patient.

[Abstract] The accepted use of left ventricular assist device (LVAD) technology as a good alternative for the treatment of patients with advanced heart failure together with the improved survival of the LVAD-supported patients on the device and the scarcity of donor hearts has significantly increased the population of LVAD-supported patients. The expected and non-expected device-related and patient-device interaction complications impose a significant burden on the medical system exceeding the capacity of the LVAD implanting centres. The ageing of the LVAD-supported patients, mainly those supported with the 'destination therapy' indication, increases the risk for those patients to experience comorbidities common in the older population. The probability of an LVAD-supported patient presenting with medical emergency to a local emergency department, internal, or surgical ward of a non-LVAD implanting centre is increasing. The purpose of this trilogy is to supply the immediate tools needed by the non-LVAD specialized physician: ambulance clinicians, emergency ward physicians, general cardiologists, internists, anaesthesiologists, and surgeons, to comply with the medical needs of this fast-growing population of LVAD-supported patients. The different issues discussed will follow the patient's pathway from the ambulance to the emergency department and from the emergency department to the internal or surgical wards and eventually to the discharge home from the hospital back to the general practitioner. In this first part of the trilogy on the management of LVAD-supported patients for the non-LVAD specialist healthcare provider, after the introduction on the assist devices technology in general, definitions and structured approach to the assessment of the LVAD-supported patient in the ambulance and emergency department is presented including cardiopulmonary resuscitation for LVAD-supported patients.

[Abstract] The improvement in left ventricular assist device (LVAD) technology and scarcity of donor hearts have increased dramatically the population of the LVAD-supported patients and the probability of those patients to present to the emergency department with expected and non-expected device-related and patient-device interaction complications. The ageing of the LVAD-supported patients, mainly those supported with the 'destination therapy' indication, increases the risk for those patients to suffer from other co-morbidities common in the older population. In this second part of the trilogy on the management of LVAD-supported patients for the non-LVAD specialist healthcare provider, definitions and structured approach to the LVAD-supported patient presenting to the emergency department with bleeding, neurological event, pump thrombosis, chest pain, syncope, and other events are presented. The very challenging issue of declaring death in an LVAD-supported patient, as the circulation is artificially preserved by the device despite no other signs of life, is also discussed in detail.

In light of the accumulating evidence on the negative predictive value of soluble urokinase plasminogen activator receptor (suPAR), a group of experts from the fields of intensive care medicine, emergency medicine, internal medicine and infectious diseases frame a position statement on the role of suPAR in the screening of patients admitted to the emergency department. The statement is framed taking into consideration existing publications and our own research experience. The main content of this statement is that sUPAR is a non-specific marker associated with a high negative predictive value for unfavourable outcomes; levels < 4 ng/ml indicate that it is safe to discharge the patient, whereas levels > 6 ng/ml are an alarming sign of risk for unfavourable outcomes. However, the suPAR levels should always be interpreted in light of the patient's history.

For many patients, notably among elderly nursing home residents, no plans about end-of-life decisions and palliative care are made. Consequently, when these patients experience life-threatening events, decisions to withhold or withdraw life-support raise major challenges for emergency healthcare professionals. Emergency department premises are not designed for providing the psychological and technical components of end-of-life care. The continuous inflow of large numbers of patients leaves little time for detailed assessments, and emergency department staff often lack training in end-of-life issues. For prehospital medical teams (in France, the physician-staffed mobile emergency and intensive care units known as SMURs), implementing treatment withholding and withdrawal decisions that may have been made before the acute event is not the main focus. The challenge lies in circumventing the apparent contradiction between the need to make immediate decisions and the requirement to set up a complex treatment project that may lead to treatment withholding and/or withdrawal. Laws and recommendations are of little assistance for making treatment withholding and withdrawal decisions in the emergency setting. The French Intensive Care Society (Société de Réanimation de Langue Française, SRLF) and French Society of Emergency Medicine (Société Française de Médecine d’Urgence, SFMU) tasked a panel of emergency physicians and intensivists with developing a document to serve both as a position paper on life-support withholding and withdrawal in the emergency setting and as a guide for professionals providing emergency care. The task force based its work on the available legislation and recommendations and on a review of published studies.

OBJECTIVE We hypothesized that a paper documentation and discharge bundle can expedite patient care during an influenza-related surge. METHODS Retrospective cohort study of low-acuity patients younger than 21 years surging into a pediatric emergency department between January and March 2018 with influenza-like illness. Patient visits documented using a paper bundle were compared with those documented in the electronic medical record on the same date of visit. The primary outcome of interest was time from physician evaluation to discharge for patient visits documented using the paper bundle compared with those documented in the electronic medical record. Secondary outcome was difference in return visits within 72 hours. We identified patient and visit level factors associated with emergency department length of stay. RESULTS A total of 1591 patient visits were included, 1187 documented in the electronic health record and 404 documented using the paper bundle. Patient visits documented using the paper bundle had a 21% shortened median time from physician evaluation to discharge (41 minutes; interquartile range, 27-62.8 minutes) as compared with patient visits documented in the electronic health record (52 minutes; interquartile range, 35-61 minutes; P < 0.001). There was no difference in return visits (odds ratio, 0.7; 95% confidence interval, 0.2, 2.2). CONCLUSIONS Implementation of paper charting during an influenza-related surge was associated with shorter physician to discharge times when compared with patient visits documented in the electronic health record. A paper bundle may improve patient throughput and decrease emergency department overcrowding during influenza or coronavirus disease-related surge.

Objective There are different clinical approaches for traumatic tympanic membrane perforation in the pediatric age group. The purpose of this study was to compare spontaneous recovery and the paper patch procedure and to analyze the factors that play a role in recovery. Materials and methods Pediatric patients who were admitted to the Emergency Department between January 2014 and June 2019 due to traumatic tympanic membrane perforation were investigated. Among these patients, medical records of cases followed by the otorhinolaryngology clinic for spontaneous closure or paper patch procedure were retrospectively examined. Medical records of a total number of 71 patients aged 2-16 years (33 females, 38 males) were analyzed. Results The overall closure rate was 89.75% (64/71). Although there was no difference between the groups of small- and medium-size perforations in terms of closure rates, the closure rate in large perforations was 90.9% in the paper patch group and 63.6% in the spontaneous closure group, and the difference between these two groups was statistically significant (p < 0.05). Additionally, the closure rate in the paper patch group (91.6%) was found to be significantly higher than that in the spontaneous closure group (58.3%) in the presence of a perforation contacting the malleus (p > 0.05). Conclusion Both procedures can be employed in pediatric cases of traumatic tympanic membrane perforation with high success rates. However, in case of a large perforation or a perforation contacting the malleus that is detected in the Emergency Department, it is necessary to refer the patients to the otorhinolaryngology clinic immediately for paper patch procedure instead of following up the patients for spontaneous closure.

This paper provides an update on the European Society of Cardiology task force report on the management of chest pain. Its main purpose is to provide an update on the decision algorithms and diagnostic pathways to be used in the emergency department for the assessment and triage of patients with chest pain symptoms suggestive of acute coronary syndromes.

Older adults account for 25% of all emergency department (ED) patient encounters. One in five Americans will be 65 or older by 2030. In response to this need, geriatric emergency medicine (GEM) has developed into a robust area of academic and clinical interest, with extensive evidence-based research and guidelines, including clear undergraduate and postgraduate GEM competencies. Despite these developments, GEM content remains underrepresented in curricula and licensing examinations. The complex reasons for these deficits include a perception that care of older adults is not a core emergency medicine (EM) competency, a disjunction between traditional definitions of expertise and the GEM perspective, and lack of curricular capacity. This White Paper, prepared on behalf of the Academy of Geriatric Emergency Medicine, describes the state of GEM education, identifies the challenges it faces, and reviews innovations, including research presented at the 2018 Society for Academic Emergency Medicine (SAEM) Annual Scientific Meeting. The authors propose a number of recommendations. These include recognizing GEM as a core educational priority in EM, enhancing academic support for GEM clinician-educators, using social learning and practical problem solving to teach GEM concepts, emphasizing a whole-person multisystem approach to care of older adults, and identifying ageist attitudes as a hurdle to safe and effective GEM care.

Approximately 10% of patients resuscitated from out-of-hospital cardiac arrest (OHCA) survive to hospital discharge. Improved management to improve outcomes are required, and it is proposed that such patients should be preferentially treated in cardiac arrest centres (CACs). The minimum requirements of therapy modalities for the CAC are 24/7 availability of an on-site coronary angiography laboratory, an emergency department, an intensive care unit, imaging facilities, such as echocardiography, computed tomography, and magnetic resonance imaging, and a protocol outlining transfer of selected patients to CACs with additional resources (OHCA hub hospitals). These hub hospitals are regularly treating a high volume of patients and offer further treatment modalities. This consensus document describes the aims, the minimal requirements for therapeutic modalities and expertise, and the structure, of a CAC. It represents a consensus among the major European medical associations and societies involved in the treatment of OHCA patients.

The 2019 novel coronavirus acute respiratory epidemic is creating a stressed situation in all the health systems of the affected countries. Emergency medical systems and specifically the emergency departments as the front line of the health systems are suffering from overload and severe working conditions, the risk of contagion and transmission of the health professionals adds a substantial burden to their daily work. Under the perspective of European Society For Emergency Medicine, the recommendations provided by the health authorities are reviewed focus on the emergency department's activity. ispartof: EUROPEAN JOURNAL OF EMERGENCY MEDICINE vol:27 issue:3 pages:174-177 ispartof: location:England status: published

Background Pain is one of the most common reasons patients present to the emergency department (ED). Emergency physicians should be aware of the numerous opioid and nonopioid alternatives available for the treatment of pain. Objectives To provide expert consensus guidelines for the safe and effective treatment of acute pain in the ED. Methods Multiple independent literature searches using PubMed were performed regarding treatment of acute pain. A multidisciplinary panel of experts in Pharmacology and Emergency Medicine reviewed and discussed the literature to develop consensus guidelines. Recommendations The guidelines provide resources for the safe use of opioids in the ED as well as pharmacological and nonpharmacological alternatives to opioid analgesia. Care should be tailored to the patient based on their specific acute painful condition and underlying risk factors and comorbidities. Conclusions Analgesia in the ED should be provided in the most safe and judicious manner, with the goals of relieving acute pain while decreasing the risk of complications and opioid dependence.

Adult congenital heart disease (ACHD) patients represent a growing population with increasing use of acute emergency department (ED) care. Providing comprehensive ED care necessitates an understanding of the most common clinical scenarios to improve morbidity and mortality in this population. The aim of this position document is to provide a consensus regarding the management of the most common clinical scenarios of ACHD patients presenting to the ED.

Heart failure is a global public health challenge frequently presenting to the emergency department. After initial stabilization and management, one of the most important decisions is to determine which patients can be safely discharged and which require hospitalization. This is a complex decision that depends on numerous subjective factors, including both the severity of the patient's underlying condition and an estimate of the acuity of the presentation. An emergency department observation period may help select the correct option. Ideally, during an observation period, risk stratification should be carried out using parameters specifically designed for use in the emergency department. Unfortunately, there is little objective literature to guide this disposition decision. An objective and reliable definition of low-risk characteristics to identify early discharge candidates is needed. Benchmarking outcomes in patients discharged from the emergency department without hospitalization could aid this process. Biomarker determinations, although undoubtedly useful in establishing diagnosis and predicting longer-term prognosis, require prospective validation for emergency department disposition guidance. The challenge of identifying emergency department acute heart failure discharge candidates will only be overcome by future multidisciplinary research defining the current knowledge gaps and identifying potential solutions.

The evaluation of patients who have experienced a fall has been an integral part of geriatric emergency care. All physicians who engage in the care of the geriatric population in acute settings need to familiarize themselves with the current literature on this topic. However, it can be challenging to navigate the large body of literature on this topic. The purpose of this article is to identify and summarize the key studies that can be helpful for faculty interested in an evidence-based fall evaluation. The authors compiled a list of key papers on emergency department (ED) based upon a structured literature search supplemented with suggestions by key informants and an open call on social media; 32 studies on ED evaluation were identified. Our authorship group then engaged in a modified Delphi technique to develop consensus on the most important studies about fall evaluation for emergency physicians. This process eventually resulted in the selection of the top five articles on fall evaluation. Additionally, we summarize these studies with regard to their relevance to emergency medicine (EM) trainees and junior faculty. Evaluation of older patients with a history of falls is a challenging but crucial component of EM training. We believe our review will be educational for junior and senior EM faculty to better understand these patients' care and to design an evidence-based practice.

Background: Presentation of sepsis is dependent on synthesis of varied clinical information, making identification of septic patients challenging. Common practice is to identify sepsis through a manual screening tool, which may miss opportunities for early sepsis detection. Electronic screening efforts requiring additional documentation by providers may not integrate easily into provider workflow. Objectives: To develop an automated sepsis risk screening tool in the electronic health record that would accurately identify patients at risk for sepsis without requiring additional documentation. Methods: Criteria in the manual screening tool were mapped to standard documentation routinely entered in the electronic health record (Epic Systems, Corp.). Data elements were scored electronically at arrival and every 15 minutes during their encounter from the medical history, medication record, vital signs, and physical assessment (Fig. 1). Scores that exceeded a predefined sepsis risk threshold triggered a Best Practice Advisory, which alerted bedside staff to perform sepsis huddles and consider appropriate interventions. Statistical comparison of the automated tool to the manual process was completed by two-tail paired t test. Results: In an 8-week testing period, the automated sepsis risk screening tool identified 100% of patients flagged by the manual process (N = 29) (Table 1). The electronic tool identified sepsis patients, on average, 68 minutes earlier. This was statistically significant (P < 0.001). Conclusions/Implications: The automated sepsis risk screening tool is as accurate as a validated manual process and alerted bedside clinicians earlier. Deployment has potential to improve timely sepsis detection and management of patients without requiring additional documentation by provider.

Primary care services in or alongside emergency\ud departments look and function differently and are\ud described using inconsistent terminology. Research to\ud determine effectiveness of these models is hampered by\ud outdated classification systems, limiting the opportunity\ud for data synthesis to draw conclusions and inform\ud decision-making and policy. We used findings from a\ud literature review, a national survey of Type 1 emergency\ud departments in England and Wales, staff interviews,\ud other routine data sources and discussions from\ud two stakeholder events to inform the taxonomy. We\ud categorised the forms inside or outside the emergency\ud department: inside primary care services may be\ud integrated with emergency department patient flow or\ud may run parallel to that activity; outside services may be\ud offered on site or off site. We then describe a conceptual\ud spectrum of integration: identifying constructs that\ud influence how the services function—from being closer\ud to an emergency medicine service or to usual primary\ud care. This taxonomy provides a basis for future evaluation\ud of service models that will comprise the evidence base\ud to inform policy-making in this domain. Commissioners\ud and service providers can consider these constructs in\ud characterising and designing services depending on local\ud circumstances and context.

Occult caustic ingestion in the pediatric population is a challenging diagnosis to make in the emergency department. Failure to suspect and diagnose a caustic ingestion can lead to potentially life-changing comorbidities. Historically, the diagnosis of caustic ingestion has been clinical without any suitable diagnostic tools to aid in the suspicion of occult cases. In this case, we describe a novel use of ophthalmic pH paper to diagnose caustic ingestion in a three-year-old.

An update of the first position paper on ipecac syrup from 1997 was published by the American Academy of Clinical Toxicology and the European Association of Poison Centres and Clinical Toxicologists in 2004. The aims of this paper are to briefly summarize the content of the 2004 Position Paper and to present any new data.A systematic review of the literature from the year 2003 forward.The literature search yielded a limited number of meaningful articles, and there remains no convincing evidence from clinical studies that ipecac improves the outcome of poisoned patients. Furthermore, the availability of ipecac is rapidly diminishing.The routine administration of ipecac at the site of ingestion or in the emergency department should definitely be avoided. Ipecac may delay the administration or reduce the effectiveness of activated charcoal, oral antidotes, and whole bowel irrigation. There is not sufficient evidence to warrant any change in the previous ipecac position papers. There are, however, insufficient data to support or exclude ipecac administration soon after ingestion of some specific poisons in rare situations.

The 2014 outbreak of Ebola Virus Disease (EVD) in West Africa has presented a significant public health crisis to the international health community and challenged US emergency departments to prepare for patients with a disease of exceeding rarity in developed nations. With the presentation of patients with Ebola to US acute care facilities, ethical questions have been raised in both the press and medical literature as to how US emergency departments, emergency physicians, emergency nurses and other stakeholders in the healthcare system should approach the current epidemic and its potential for spread in the domestic environment. To address these concerns, the American College of Emergency Physicians, the Emergency Nurses Association and the Society for Academic Emergency Medicine developed this joint position paper to provide guidance to US emergency physicians, emergency nurses and other stakeholders in the healthcare system on how to approach the ethical dilemmas posed by the outbreak of EVD. This paper will address areas of immediate and potential ethical concern to US emergency departments in how they approach preparation for and management of potential patients with EVD.