Emergency Department Management Research Articles

Temporal assessment of emergency response and rescue capability for hybrid hydrogen-gasoline fueling stations based on dynamic scenario construction

In the event of a fire or explosion at a hybrid hydrogen-gasoline fueling station, the consequences can be significantly more severe compared to a traditional refueling station or hydrogen refueling station. It is imperative to establish an effective assessment model specific to the hybrid station to prevent and mitigate such accidents. This paper introduces a temporal dynamic assessment model designed to evaluate the emergency response and rescue capabilities of hybrid hydrogen-gasoline fueling stations. The model is grounded in dynamic scenario construction and utilizes information-driven theory. This innovative approach allows for evaluations of the risk evolution process at different stages of an accident. The proposed assessment model combines the Temporal Weighted Average (TOWA) and Temporal Weighted Geometric Average (TOWGA) operators to integrate assessment values across different stages including the initial disaster assessment, emergency action plans, effectiveness feedback, and emergency response adjustment. This integration yields a comprehensive dynamic assessment value for the emergency response and rescue capabilities of the hybrid hydrogen-gasoline fueling station. Based on the dynamic assessment of a previously occurring accident, the specialized emergency management department performed most effectively during the incident response stage, achieving a commendable assessment value of 3.184. Following closely was the government emergency response department, with assessment values of 2.865 and 2.277. This study offers a novel analytical perspective for emergency management in hybrid hydrogen-gasoline fueling stations by incorporating the findings of both dynamic and static assessments.

Multiple Sclerosis: An Emergency Medicine-Focused Narrative Review

BackgroundMultiple sclerosis (MS) is a rare but serious condition associated with significant morbidity. ObjectiveThis review provides a focused assessment of MS for emergency clinicians, including the presentation, evaluation, and emergency department (ED) management based on current evidence. DiscussionMS is an autoimmune disorder targeting the central nervous system (CNS), characterized by clinical relapses and radiological lesions disseminated in time and location. Patients with MS most commonly present with long tract signs (e.g., myelopathy, asymmetric spastic paraplegia, urinary dysfunction, Lhermitte's sign), optic neuritis, or brainstem syndromes (bilateral internuclear ophthalmoplegia). Cortical syndromes or multifocal presentations are less common. Radiologically isolated syndrome and clinically isolated syndrome (CIS) may or may not progress to chronic forms of MS, including relapsing remitting MS, primary progressive MS, and secondary progressive MS. The foundation of outpatient management involves disease-modifying therapy, which is typically initiated with the first signs of disease onset. Management of CIS and acute flares of MS in the ED includes corticosteroid therapy, ideally after diagnostic testing with imaging and lumbar puncture for cerebrospinal fluid analysis. Emergency clinicians should evaluate whether patients with MS are presenting with new-onset debilitating neurological symptoms to avoid unnecessary testing and admissions, but failure to appropriately diagnose CIS or MS flare is associated with increased morbidity. ConclusionsAn understanding of MS can assist emergency clinicians in better diagnosing and managing this neurologically devastating disease.

The HF-ABCDE + FG approach in heart failure: a simplified decision-making algorithm for management in emergency department.

The HF-ABCDE + FG approach in heart failure: a simplified decision-making algorithm for management in emergency department.

Code De-Escalation: Decreasing restraint use during agitation management in a community hospital emergency department

IntroductionRestraint use in the emergency department (ED) can pose significant risks to patients and health care workers. We evaluate the effectiveness of Code De-escalation– a standardized, team-based approach for management and assessment of threatening behaviors– in reducing physical restraint use and workplace violence in a community ED. MethodsA retrospective observational study of a pathway on physical restraint use among patients placed on an involuntary psychiatric hold in a community ED. This pathway includes a built-in step for the team members to systematically assess perceptions of threats from the patient behavior and threats perceived by the patient. Our primary outcome was the change in the rate of physical restraint use among patients on an involuntary psychiatric hold. Our secondary outcome was the change in the rate of workplace violence events involving all ED encounters. We evaluated our outcomes by comparing all encounters in a ten-month period before and after implementation, and compared our results to rates at neighboring community hospitals within the same hospital network. ResultsPre intervention there were 434 ED encounters involving a psychiatric hold, post-intervention there were 535. We observed a significant decrease in physical restraint use, from 7.4% to 3.7% (ARR 0.028 [95% CI 0.002–0.055], p < 0.05). This was not seen at the control sites. ConclusionsA standardized de-escalation algorithm can be effective in helping ED's decrease their use of physical restraints in management of psychiatric patients experiencing agitation.

Assessing the Awareness of EVTM Practices Among Emergency Medicine Physicians in Turkey

Background: Trauma is the leading cause of death in those aged 1–44 years; nearly half of these fatalities are due to bleeding. As resuscitative endovascular balloon occlusion of the aorta (REBOA) and other endovascular resuscitation and trauma management (EVTM) methods became known in Turkey, they started to arouse interest. The main objective of this study is to reveal the impressions of emergency medicine (EM) doctors about EVTM and REBOA application possibilities, and the secondary objective is to determine the issues that are limiting their spread. Methods: We conducted a 22-question cross-sectional survey via e-mail between 1 January and 1 April 2020. The questions were formulated to be closed-ended, semi-closed-ended, and open-ended. The evaluation questions utilized 3- and 5-point Likert scales and Yes/No questions. EM specialists, residents, consultants, and physicians working as emergency department (ED) directors in Turkey were included. EM specialists working in units other than EDs and specialists from other branches were excluded. Results: Among the 512 people contacted for this study, 132 agreed to participate. The numbers of participants that were aware of REBOA and EVTM were 114 and 99, respectively. Participants thought that femoral vascular access, extracorporeal membrane oxygenation (ECMO), and REBOA were more applicable in EDs (median 4, 4, and 4.5, respectively; interquartile range 1–5). Participants considered lack of knowledge and skills and lack of equipment as barriers to REBOA (median 5 and 5, respectively). Conclusions: To disseminate EVTM practices in Turkey, projects should be conducted primarily to address lack of knowledge, skills, and equipment.

Metformin-Associated Lactic Acidosis-Is This on Your Radar?

Background: Metformin is a biguanide hyperglycemic agent used to manage non–insulin-dependent diabetes mellitus. Adverse reactions include mainly mild gastrointestinal adverse effects, but severe complications, such as metformin-associated lactic acidosis (MALA) can occur. Metformin is excreted renally and, therefore, not recommended in patients with renal impairment. The reported incidence of MALA is 3 cases per 100,000 patient-years. Case ReportA 79-year-old woman with a complex medical history, including end-stage renal disease on dialysis and type 2 diabetes, presented to the emergency department (ED) for altered mental status. Prior to arrival, she was found to be hypoglycemic. Her laboratory results were significant for creatinine of 6.56 mg/dL and an anion gap of 52 mmol/L. The venous blood gas revealed a venous pH of 6.857 [reference range (7.32–7.43)], pCO2 of 15.9 mm Hg (40.6–60 mm Hg), HCO3 of 2.7 mmol/L (21–30 mmol/L), lactate of 27 mmol/L (0.5–2 mmol/L), and ammonia of 233 µmol/L. The patient was dialyzed emergently in the ED; repeat laboratory test results showed blood urea nitrogen of 10 mg/dL, creatinine of 1.65 mg/dL, carbon dioxide of 26 mmol/L, and anion gap of 13 mmol/L. The repeat ammonia was 16 µmol/L. The patient's metabolic encephalopathy resolved, and she was discharged home on hospital day 3. Why Should an Emergency Physician Be Aware of This?MALA has a high mortality rate (36%). Laboratory markers have not been found to be a reliable predictor of mortality. Sodium bicarbonate is controversial, but a pH < 7.15 indicates consideration of its use. A pH < 7.1 and a lactate level > 20 mmol/L indicate the need for emergent hemodialysis. Prompt recognition and management in the ED with early hemodialysis can result in good patient outcomes, with a return to their baseline function despite severe laboratory findings.

Factor First: An Assessment of Emergency Department Care of Patients with Hemophilia

Background: With the establishment of hemophilia treatment centres (HTCs) and home infusion programs for factor replacement therapy, emergency department use among patients with hemophilia occurs less frequently, with patients often presenting for significant bleeding events only. As a result, the management of patients with hemophilia can represent a challenge to emergency department (ED) physicians and staff. Both delays in diagnosis of a bleeding event, and timely administration of hemostatic therapy have been associated with patient morbidity and mortality. The World Federation of Hemophilia, in addition to other organizations, emphasize the importance of timely receipt of clotting factor replacement therapy, providing treatment at the time a bleed is suspected. If a patient with hemophilia is registered with a HTC, they often carry a wallet card, or have a formalized treatment plan, outlining their diagnosis and emergency treatment of bleeding recommendations to ensure timely access to hemostatic therapy. The aim of this study was to describe ED management of patients with hemophilia at a single Canadian HTC, with a focus on use of individualized emergency bleeding management protocols, and time to receipt of hemostatic therapy within the ED. Methods: Adult patients with hemophilia A or B (FVIII or FIX ≤40%), of any severity, followed at the Southern Alberta Rare Blood and Bleeding Disorders Comprehensive Care Program, were identified for inclusion. ED health utilization and ED encounter management data for each of the four hospital sites in Calgary, AB was obtained from the electronic health record for the cohort, through to 2022. Results: A total of 191 patients with hemophilia A and B were identified for study inclusion. 153 patients with hemophilia A (mild 64.7%; moderate 5.9%; severe 28.8%) and 38 patients with hemophilia B (mild 44.7%; moderate 36.8%; severe 18.4%). Males comprised 77.5% of the patient cohort. A total of 393 ED visits occurred over the study period. Less than a third of ED visits were associated with receipt of hemostatic therapy (either desmopressin or clotting factor concentrate). The median time from triage to ordering of hemostatic therapy was 2.9 hrs (IQR 2.3-3.2), and median time from triage to administration of hemostatic therapy was 4.2 hrs (IQR 3.1-4.2). For ED visits due to suspected bleeds, the proportion of patients who received either coagulation factor replacement or desmopressin within two hours of ED triage is depicted in Figure 1. Time to receipt of hemostatic therapy did not significantly differ whether desmopressin or clotting factor concentrate was administered. The number of ED visits in which the individualized emergency bleeding management protocol was accessed is depicted in Figure 2. Among those accessed in 2022, the proportion of protocols that were updated within the last 365 days was 86.8%. Less than 20% of ED visits were associated with a hematology consultation. Conclusions: Increasing utilization of individualized emergency bleeding management protocols for patients with hemophilia was observed; however, significant delays in timely receipt of hemostatic therapy remains, with infrequent involvement of hematology in consultation. Time to receipt of potentially life-saving hemostatic therapy for our cohort falls outside of hemophilia care standards. This data provides a better understanding of the experience of patients with hemophilia in the ED and provides an opportunity to define further quality improvement interventions to ensure quality care metrics in this population are met.

Slow on the Draw-ED Management of Elevated BP in Older Adults.

The purpose of this study is to review data surrounding the emergency department management of elevated blood pressure in older adults, including the management of hypertensive crisis andoutpatient management of markedly elevated blood pressure. Acute lowering of blood pressure in older adults with markedly elevated blood pressure may lead to serious complications without improvements in hospital length of stay, return visits, or mortality. Older adults presenting with elevated blood pressures without evidence of end-organ damage should be referred for outpatient management of their blood pressure. Treatment of hypertensive emergency should follow standard guidelines with additional considerations for aging physiology. Acute lowering of elevated blood pressure in older adults without evidence of end-organ damage has the potential for harm. If the emergency physician opts to acutely treat, they should consider the increased risk of side effects in older adults and avoid Beers list medications including short-acting nifedipine and clonidine.

Physicians’ Perceptions of Clinical Decision Support to Treat Patients With Heart Failure in the ED

Clinical decision support (CDS) could help emergency department (ED) physicians treat patients with heart failure (HF) by estimating risk, collating relevant history, and assisting with medication prescribing if physicians' perspectives inform its design and implementation. To evaluate CDS usability and workflow integration in the hands of ED physician end users who use it in clinical practice. This mixed-methods qualitative study administered semistructured interviews to ED physicians from 2 community EDs of Kaiser Permanente Northern California in 2023. The interview guide, based on the Usability Heuristics for User Interface Design and the Sociotechnical Environment models, yielded themes used to construct an electronic survey instrument sent to all ED physicians. Main outcomes were physicians' perceptions of using CDS to complement clinical decision-making, usability, and integration into ED clinical workflow. Seven key informant physicians (5 [71.4%] female, median [IQR] 15.0 [9.5-15.0] years in practice) were interviewed and survey responses from 51 physicians (23 [45.1%] female, median [IQR] 14.0 [9.5-17.0] years in practice) were received from EDs piloting the CDS intervention. Response rate was 67.1% (51 of 76). Physicians suggested changes to CDS accessibility, functionality, and workflow integration. Most agreed that CDS would improve patient care and fewer than half of physicians expressed hesitation about their capacity to consistently comply with its recommendations, citing workload concerns. Physicians preferred a passive prompt that encouraged, but did not mandate, interaction with the CDS. In this qualitative study of physicians who were using a novel CDS intervention to assist with ED management of patients with acute HF, several opportunities were identified to improve usability as well as several key barriers and facilitators to CDS implementation.

Pediatric Burns: A Systematic Review and Meta-Analysis on Epidemiology, Gender Distribution, Risk Factors, Management, and Outcomes in Emergency Departments.

Pediatric burns pose a significant public health concern, ranking as the fifth most common nonfatal injury globally. This review consolidates data on the epidemiology, outcomes, and management of pediatric burns presenting to emergency departments. A systematic review was conducted across multiple databases, yielding 22 articles from 1992 to 2020. Utilizing the methodological index for non-randomized studies (MINORS) instrument, non-comparative studies scored from 2 to 11 with an average of 6.87, while comparative studies ranged from 12 to 16, averaging 13.67. The review included a total of 828,538 pediatric patients who were evaluated in the systematic review. Predominantly male victims ranged from 53% to 83%. The youngest victims were aged between 0 to 4 years. Burn etiology was largely attributed to scalds. A majority suffered from second-degree burns, with some studies reporting up to 89%. Limited data on total body surface area (TBSA) were documented, with only 2.5% requiring hospitalization. Common interventions included immediate resuscitation and skin grafting. Essential areas for future research are identified, including household risks, pre-treatment decisions, and the significant role of family dynamics in burn injury recovery. Pediatric burns remain a considerable concern, particularly among males and in household environments. The data underline the imperative for prevention strategies and optimized emergency care to positively influence outcomes for burn victims. Future research areas range from evaluating pre-treatment decisions to assessing community awareness regarding burn first aid.

National Survey on the Emergency Department Management of Febrile Infants 29 to 60 Days Old With an Abnormal Urinalysis.

Recent clinical practice guidelines recommend that decisions regarding lumbar puncture (LP) for febrile infants older than 28 days should no longer be based on urinalysis results, but rather independently determined by inflammatory markers and sometimes guided by shared decision-making (SDM). This study sought to assess management decisions for febrile infants aged 29 to 60 days with an abnormal urinalysis. A scenario-based survey was sent to emergency department physicians at all 15 Canadian tertiary pediatric centers. Participants were asked questions regarding management decisions when presented with a well-appearing febrile infant in the second month of life with either an abnormal or normal urinalysis. Response rate was 50.2% (n = 116/231). Overall, few respondents would perform an LP based on either an abnormal or normal urinalysis alone (10.3% and 6.0%, respectively). However, regression analysis demonstrated that decisions regarding LP were influenced by urinalysis results ( P < 0.001), with respondents more likely to defer to inflammatory marker results for infants with a normal urinalysis result (57.8%) compared with those with an abnormal urinalysis (28.4%). Hospitalization (62.1%) and empiric antibiotic treatment by intravenous route (87.9%) were both frequent for low-risk infants with an abnormal urinalysis. Nearly half of respondents reported rarely (<25% of encounters) engaging families in SDM regarding LP decisions. Knowledge translation initiatives reflecting current evidence should target use of inflammatory markers rather than urinalysis results to guide decisions regarding LP. Efforts emphasizing outpatient management with oral antibiotics and SDM for low-risk infants with an abnormal urinalysis could also further align management with current evidence and guidelines.

Common Complications and Cardiopulmonary Resuscitation in Patients with Left Ventricular Assist Devices: A Narrative Review.

Heart failure remains a major global burden regarding patients' morbidity and mortality and health system organization, logistics, and costs. Despite continual advances in pharmacological and resynchronization device therapy, it is currently well accepted that heart transplantation and mechanical circulatory support represent a cornerstone in the management of advanced forms of this disease, with the latter becoming an increasingly accepted treatment modality due to the ongoing shortage of available donor hearts in an ever-increasing pool of patients. Mechanical circulatory support strategies have seen tremendous advances in recent years, especially in terms of pump technology improvements, indication for use, surgical techniques for device implantation, exchange and explantation, and postoperative patient management, but not in the field of treatment of critically ill patients and those undergoing cardiac arrest. This contemporary review aims to summarize the collected knowledge of this topic with an emphasis on complications in patients with left ventricular assist devices, their treatment, and establishing a clear-cut algorithm and the latest recommendations regarding out-of-hospital or emergency department management of cardiac arrest in this patient population.

Assessment of knowledge gaps in STEMI management among intern doctors in moroccan emergency department: a descriptive analytical study

Abstract Introduction Acute coronary syndrome (ACS) remains a significant public health issue in Morocco despite progress in management and prevention. ACS includes ST-segment elevation myocardial infarction (STEMI), a life-threatening condition that requires prompt diagnosis and treatment. Intern doctors working in emergency department are critical in managing STEMI, but there is limited information on their knowledge and practice of this condition. Purpose This study aimed to assess the knowledge gaps in STEMI management among intern doctors working in emergency department in Morocco. Methods This study employed a descriptive analytical design to assess the knowledge gaps in STEMI management among 141 intern doctors working in emergency department in Morocco who were selected through convenience sampling. Data were collected using an online questionnaire consisting of 15 questions on diagnostic criteria, treatment options, and interpretation of three electrocardiograms (ECGs): one typical and two atypical. Descriptive statistical analysis was performed to summarize the data and calculate the percentages of correct answers for each question, and the data were analyzed using Microsoft Excel. Results 96.45% of the intern doctors had good theoretical knowledge of typical and atypical clinical presentation. However, only 52.48% knew the typical electrocardiographic presentation, and only 9.22% knew the revised atypical presentations. Regarding hospital management, 99.30% knew the superiority of angioplasty within 120 minutes, but only 29.08% knew the time limit for its implementation in symptomatic patients. In addition, 55.32% knew the contraindications of thrombolysis, 67.38% knew the essential elements of the loading dose, but only 18.44% knew the exact loading dose in elderly subjects and those with renal insufficiency. For complications, most physicians (85.82%) knew the complications of this pathology, 64.53% knew how to manage associated hypertensive emergencies, and 26.95% knew how to manage associated acute pulmonary edema. For clinical cases, 68.79% were able to identify the typical ECG of ST elevation in the extensive anterior territory. However, only 14.18% identified the two atypical electrocardiograms. Conclusion In conclusion, this study highlights the significant knowledge gaps in STEMI management among intern doctors working in emergency department in Morocco. While intern doctors had good theoretical knowledge of STEMI management, they struggled to apply this knowledge in practice, particularly when it came to interpreting ECGs and implementing time-sensitive treatments. These findings emphasize the urgent need for targeted training on STEMI management in emergency department, especially for young physicians who may lack experience in this area. By addressing these knowledge gaps, we can improve the management of STEMI and ultimately reduce the morbidity and mortality associated with ACS.

Standardized Clinical Pathways Improve Management of Vaso-Occlusive Episodes in the Pediatric Emergency Department

Introduction: Pain secondary to vaso-occlusive episodes (VOE) is one of the most common and debilitating complications of sickle cell disease (SCD). Although there are guidelines for pain management, these are often not well-followed. Pain management is entrenched in subjectivity and susceptible to implicit bias. Research has shown that clinical pathways improve care for patients which is especially important in vulnerable populations such as pediatric patients with SCD. Following a quality improvement project at our institution that resulted in significantly improved inpatient care for pediatric patients with SCD, the goal of this project was to create an accessible clinical pathway with multidisciplinary input to streamline management of VOE in the emergency department (ED) and assure equitable care for all. We aimed to improve time to analgesics, increase the percent of patients receiving pain medications within 30 minutes, and increase intranasal fentanyl and patient-controlled anesthesia (PCA) utilization in the pediatric ED. Methods: The care signature clinical pathway was created using a multidisciplinary approach with individuals representing the department of pediatric hematology-oncology, pediatric emergency, anesthesiology, pharmacy, and nurse management. The pathway was developed based on updated American Society of Hematology guidelines for pain management in pediatric VOE. The pathway became available for use via electronic medical record on July 12 th, 2022. Outcome measures regarding pain management were evaluated for one year prior to pathway publication and compared to outcomes one year after publication. Patients with a primary or secondary diagnosis of SCD presenting to the Yale pediatric ED with vaso-occlusive pain were included. Results: A total of 214 ED visits were evaluated. The pre-pathway cohort included 108 encounters from July 1 st, 2021 to June 30 th, 2022 and the post-pathway cohort included 106 ED encounters from August 1 st, 2022 to July 21 st, 2023. During the first year post implementation, a provider utilized the clinical pathway a total of 534 times (121 individuals) with an average of 1 time per day. An analgesic was ordered for 63 (58.3%) patients and administered for 31 (28.7%) patients within 30 minutes of arrival in the pre-pathway cohort. An analgesic was ordered for 73 (68.9%) and administered for 32 (30.2%) patients within 30 minutes of arrival in the post-pathway cohort. Comparing pre- and post-pathway cohorts, the median time to pain medication order was 22 vs 17 minutes and pain medication administration was 42 vs 40 minutes respectively. Intranasal fentanyl was used for 2 (1.9%) patients in the pre-pathway cohort and 12 (11.3%) patients in the post-pathway cohort. A total of 0 (0%) hydromorphone PCAs were administered in the ED in the pre-pathway cohort compared to 4 (3.8%) hydromorphone PCA administered in the ED in the post-pathway cohort. Conclusion: Standardizing pain management using a clinical pathway has shown improvement in ED management of VOE in the first year post implementation with increased utilization of intranasal fentanyl and PCAs. Our goal of increased percentage of patients receiving pain medication within 30 minutes and decreased time to first analgesic was not achieved, however this is an ongoing project and with education in implementation of the clinical pathway we hope to continue to see long term progress. Additionally, in the future, we plan to expand use of this pathway to additional sites within our health care system.

NATIONWIDE DEMOGRAPHIC DISPARITIES IN UNITED STATES EMERGENCY DEPARTMENT VISITS IN PATIENTS WITH RHEGMATOGENOUS RETINAL DETACHMENT.

Within the evolving landscape of healthcare in the United States (US), delineating the demographic nuances and financial implications of emergent conditions, such as rhegmatogenous retinal detachment (RRD), is paramount. This study seeks to analyze the demographic and hospital billing amount/cost of service disparities in RRD visits to emergency departments (EDs) nationwide. We conducted a retrospective, cross-sectional, population-based study using International Classification of Diseases, 10th revision , and Current Procedural Terminology codes in the 2016 to 2019 Nationwide Emergency Department Sample databases to identify RRD visits. The analysis included demographics, hospital billing amount, and cost of service of RRD ED management. A total of 12,492 RRD encounters were identified with men constituting 64% and a prominent age group being 50 to 64 years (49.3%). Most patients (90%) were managed in metropolitan teaching hospitals, predominantly in the southern U.S. region (56.1%). Private insurance covered 45% of patients. Same-day RRD repair odds increased in November and December. Whites had a higher likelihood for same-day treatment. Hospital billing amount rose from $23,600 in 2016 to $30,354 in 2019, with stable mean total cost of service. Rhegmatogenous retinal detachment ED visit incidence did not show seasonal variation ( P = 0.819). Most patients with RRD in U.S, EDs were middle-aged men, with Whites more likely to receive same-day repair. There was no sex bias observed in same-day repair decision-making. Although hospital billing amount increased over the study period, total cost of service remained stable. The incidence of RRD ED visits showed no seasonal variation.

Initial Evaluation and Management of Patients Presenting with Acute Chest Pain in the Emergency Department.

To review the initial evaluation of chest pain in the emergency department (ED), with a focus on coronary artery disease (CAD) and acute coronary syndromes (ACS), using consensus statements from major cardiovascular disease organizations. Major cardiovascular organizations have released consensus statements on this topic, notably the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain and the 2022 ACC Expert Consensus Decision Pathway on the Evaluation and Disposition of Acute Chest Pain in the Emergency Department. Also, recent studies have evaluated the use of high sensitivity troponin (hs-cTn) to safely rule out myocardial infarction (MI), with the development of rule-out pathways designed to be utilized in the ED. This review highlights the comprehensive differential diagnoses of chest pain in the ED and urgent management of these etiologies, with a focus on cardiovascular etiologies. There exist a few rule-out pathways recommended by major cardiovascular organizations, notably the high-STEACS and the ESC 0/1 and 0/2 pathways that can safely and quickly discharge patients with low risk of MI.

A National Study of Expedited Partner Therapy Use in Emergency Departments: A Survey of Medical Director Knowledge, Attitudes, and Practices.

Emergency departments (EDs) are the primary source of health care for many patients diagnosed with sexually transmitted infections (STIs). Expedited partner therapy (EPT), treating the partner of patients with STIs, is an evidence-based practice for patients who might not otherwise seek care. Little is known about the use of EPT in the ED. In a national survey, we describe ED medical directors' knowledge, attitudes, and practices of EPT. A cross-sectional survey of medical directors from academic EDs was conducted from July to September 2020 using the Academy of Academic Administrators of Emergency Medicine Benchmarking Group. Primary outcomes were EPT awareness, support, and use. The survey also examined barriers and facilitators. Forty-eight of 70 medical directors (69%) responded. Seventy-three percent were aware of EPT, but fewer knew how to prescribe it (38%), and only 19% of EDs had implemented EPT. Seventy-nine percent supported EPT and were more likely to if they were aware of EPT (89% vs. 54%; P = 0.01). Of nonimplementers, 41% thought EPT was feasible, and 56% thought departmental support would be likely. Emergency department directors were most concerned about legal liability, but a large proportion (44%) viewed preventing sequelae of untreated STIs as "extremely important." Emergency department medical directors expressed strong support for EPT and reasonable levels of feasibility for implementation but low utilization. Our findings highlight the need to identify mechanisms for EPT implementation in EDs.

Emergency Management of Multiple Maxillofacial Trauma Patients with Head Injury: A Case Report

Trauma to the face has the potential to be life-threatening and cause facial deformities. Head injuries are usually a more severe consequence of such incidents and must be addressed earlier. Here we present a case of a 24year old male patient with history fell from motorcycle three hours before the patient was admitted to the hospital, the patient fell with the mechanism of his face hitting the asphalt first. He was diagnosed with panfacial fracture of facial bones and mild head injury. Emergency treatment need to be done for his general condition improvement, transfusion of red blood cell, admister of elecltrolyte, oxygenation and observation of consciousness, primary suture of laceration, placing erich bar wire for maxilla mandible, placing skin traction was done in the emergency room. The patient then was scheduled for open reduction internal fixation of the facial fracture after the condition was optimal enough. Maintaining the airway and limiting bleeding are fundamental concepts in the emergency department's management of maxillofacial trauma.

Incidence, Management, and Hospital Costs of Orthopaedic Injuries of E-Scooter Riders in Western Australia.

The use of electric scooters (e-scooters) is increasing in Australia and internationally. The increasing availability of e-scooters has led to a rise in the number of injuries, with most patients sustaining orthopaedic injuries. This retrospective case series describes the incidence, management, and hospital costs of the orthopaedic injuries, which presented to the emergency department (ED) of the major trauma center in Western Australia. Data on demographics, ED dispatch destination, management, follow-up clinics, and hospital costs were collected between 2017 and 2022. Since June 2020, there have been 61 e-scooter crashes, which resulted in orthopaedic injuries, with more than half of the crashes occurring after the introduction of regional e-scooter sharing schemes. Thirty-two patients (52%) were admitted to the hospital. The most common orthopaedic fracture was to the upper limb (44%), followed by the lower limb (41%) and the axial skeleton (15%). Fourteen (23%) patients sustained more than one fracture. Twenty-two patients (36%) required operative management. The median number of outpatient clinic attendances per patient was 3 (interquartile range (IQR): 1-5), with inpatients requiring twice the number of clinics as compared to those discharged from the ED. The median cost per presentation was AU$5880.60 (IQR: AU$1283.10-AU$21,150.90) with inpatient costs exceeding those discharged from the ED. The range of the total costs was AU$413.80 to AU$100,239.80. The rise in the accessibility of e-scooters in Western Australia has led to a rise in ED presentations with orthopaedic injuries. Considering the recent implementation of e-scooter sharing schemes in metropolitan areas, ongoing surveillance of e-scooter injuries by clinicians and policy makers is warranted to inform harm minimization strategies.

Clinical Presentation and Emergency Department Management Checkpoints of Acute Aortic Syndromes during the First Two Waves of the COVID-19 Pandemic.

The COVID-19 pandemic has deeply affected the activity and patient flows of Emergency Departments (EDs), and concern for the worsening outcome of cardiovascular emergencies has been raised. However, the impact of COVID-19 on all subtypes of acute aortic syndromes (AASs) has not been evaluated so far. Cases of AASs managed in the ED of three hub hospitals in a large area of Northern Italy were retrospectively analyzed, comparing those registered during the pandemic (March 2020 to May 2021) with corresponding pre-COVID-19 periods. A total of 124 patients with AAS were managed during the COVID-19 period vs. 118 pre-COVID-19 (p = 0.70), despite a -34.6% change in ED visits. Posterior chest pain at presentation was the only clinical variable with a different prevalence (46.0% vs. 32.2%, p = 0.03). Surgery and endovascular treatment rates were unchanged. Time intervals influenced by patient transfer to the hub center were longer during the COVID-19 period and longest during high viral circulation periods. Ninety-day mortality was unchanged, with a higher mortality trend during the pandemic surges. In conclusion, ED presentation and care of AASs were marginally affected by COVID-19, but efforts are needed to preserve efficient patient transfer to specialized centers and prevent mortality, especially during pandemic peaks.