Emergency Department Research Articles

Ultrasound-Guided Nerve Blocks for Flexor Tenosynovitis

Performing an ultrasound-guided nerve block (UGNB) is now common practice in many emergency departments (EDs) and is considered a core skill according to the American College of Emergency Physicians (ACEP). Nerve blocks are mostly utilized for fractures and laceration repairs, however, these blocks have many other applications. We present a case of utilizing an ulnar UGNB in a patient with flexor tenosynovitis and a history of intravenous drug use (IVDU) when parental opiates proved to be ineffective.

Health Care Service Utilization Among People with HIV, Chronic Pain, and Depression: Utilization and Cost Outcomes from the HIV-PASS Study.

In the United States (U.S.), 90% of annual health care expenditures are devoted to people with chronic physical and mental health conditions. For people with HIV (PWH), two common, chronic comorbidities are pain and depression. This report assesses the impact of a brief psychotherapy intervention for PWH and comorbid chronic pain and depression on health care service utilization. Data from the HIV Pain and Sadness Study (HIV-PASS) randomized trial were used. Electronic health records were reviewed to tabulate use of the following services: (a) outpatient rehabilitation; (b) outpatient psychiatric; and (c) hospital-based (e.g., emergency department). Estimated average marginal effects were analyzed to determine how many times a participant accessed the service and the charge at each event. The sample consisted of 187 adults recruited from three U.S. sites. Individuals randomized to the three-month, seven session HIV-PASS intervention had average charges for hospital-based services that were significantly less during the post-treatment phase (months 4-12; 95%CI: -$16,612, -$131; p =.046) than those randomized to the comparison condition. On average, comparison condition participants were charged $8,371 more for hospital services in the 8-month period following intervention. No significant differences between treatment conditions were observed in use of outpatient rehabilitation, outpatient psychiatric services, or hospital-based care. Consistent with predictions, lower health care charges among those randomized to the HIV-PASS behavioral intervention were incurred for hospital services, indicating that a brief behavioral intervention could lead to decreased use of more emergent and expensive care services among persons with HIV, depression, and chronic pain.

Correlation of Point of Care Ultrasound (POCUS) Guided Pupillary Assessment Parameter with Glasgow Coma Scale in Patients with Altered Mental Status– A Cross Sectional Study

Background: Earlier studies have proved deteriorating Glasgow Coma Scale (GCS) as a marker of raised intracranial pressure (ICP). Low GCS is associated with abnormal pupillary parameters. Currently, many studies have proved that ultrasound provides a feasible and objective assessment of pupillary light reflex. However, literature is lacking to evaluate objective pupillary parameters to predict GCS of the patients by point of care ultrasound (POCUS). Materials and methods: In this prospective, cross-sectional study, 200 patients were recruited in the emergency department. The inclusion criteria were patients older than 18 years with acute presentation of altered mental status. Exclusion criteria were patients who had partial globe rupture or dementia. The patients underwent a B-mode POCUS-guided evaluation at rest and after light stimulation. Statistical analysis of relationship between pupillary assessment parameters and GCS was performed using Spearman's Rank correlation coefficient, Kruskal-Wallis equality-of-populations rank test, and area under the receiver operating characteristic. Results: The study consisted of 200 (42 female, 158 male) patients with mean (± standard deviation) of age and GCS of 43.56 ± 16.50 years and 5.54 ± 3.00, respectively. Majority of non-reactive pupils had a GCS Score of 3-8 (74 cases, 97.37%). The Pupillary diameter (PD) and PD variation showed statistically significant agreement with pupil reactivity to light stimulation and GCS, with Spearman's correlation coefficient ranging from 0.28 to 0.33 for PD, and -0.55 to -0.50 (p-value <0.05) for PD variation, respectively. PD variation rate (PDVR) is the percentage change in the magnitude of constriction of PD on light stimulation. PDVR of >19.68% had a sensitivity of 86.96% (95% CI: 82.04 - 91.88%) and specificity of 64.97% (95% CI: 58.00 - 71.94%) to detect GCS>8. Conclusion: PD variation and PDVR measured by POCUS has significant correlation with GCS >8. The study showed good sensitivity and low specificity of PDVR on light stimulation to detect GCS >8.

Hemorrhagic stroke code the transition to comprehensive stroke code

As recommended by the working group of vascular and interventional neurology of the Colombian Association of Neurology (ACN), stroke is defined as a neurological emergency characterized by a sudden neurological deficit potentially of arterial origin. Upon confirmation via neuroimaging, the diagnosis is rendered as cerebral infarction (CI) or hemorrhage, either intracerebral (ICH) or subarachnoid (SAH). Additionally, it can be of venous origin, such as cerebral venous thrombosis (CVT). The stroke code is currently widely recognized as a time-is-brain strategy that seeks to meet strict time goals for treating ischemic stroke (iS), which have substantially improved the outcomes of stroke patients. However, this has not been the case for hemorrhagic stroke (hS), which, given the conditions, is also admitted through the emergency department and clearly benefits from having a standardized protocol of care and time goals, like iS, to improve patient outcomes. The strategy recommended by the ACN for the early identification of a stroke is CORRE+. This acronym was created by neurologist Luis Roa and is designed to facilitate the identification of both ischemic and hemorrhagic strokes of anterior or posterior circulation. It comprises the following criteria: C: twisted face and/or worst headache, O: eye sudden alteration of vision, R: rapid weakness of an arm and/or leg, R: rare when speaking, E: altered balance + emergencies attend. The acronym is intended to be used by the general community and in different extra- and intra-hospital scenarios for immediate consultation.

Study: More inpatient beds needed to tackle youth MH crisis

Given a pediatric mental health crisis that continues to worsen, children increasingly have prolonged emergency department (ED) visits while awaiting mental health care; however, those long waits have been partially attributed to inadequate availability of pediatric inpatient psychiatric beds, according to a study published last month in JAMA Pediatrics.

Rare Cause of Pediatric Abdominal Pain Diagnosed on Point of Care Ultrasound (POCUS)

An 11-year-old postmenarchal female presented to the pediatric emergency department (ED) with 2 days of periumbilical and right lower abdominal pain. Radiology-performed ultrasound (RADUS) did not visualize the appendix, and there was a plan for surgical consultation to decide between serial abdominal exams versus computed tomography (CT) scan. While awaiting consultation and to help further narrow the differential diagnosis, the emergency provider performed a point of care ultrasound (POCUS) of the urinary tract. This revealed several anomalies including a solitary left kidney with hydronephrosis, and a well-circumscribed, fluid-filled structure with mixed echogenicity posterior to the bladder and inferior to the uterus. Given these findings on POCUS, further imaging was pursued, including a RADUS of the pelvis followed by a magnetic resonance imaging (MRI) of the abdomen. Further imaging ultimately diagnosed a bicornuate uterus, septate vagina with hematocolpos and solitary left kidney consistent with Obstructed Hemivagina and Ipsilateral Renal Anomaly (OHVIRA) syndrome. This case is an illustration of how POCUS is an invaluable tool to narrow the differential diagnosis and guide advanced imaging or consultation for both common and rare causes of pediatric abdominal pain.

Piloting a Diagnostic Foot and Ankle Fracture Sonographic Algorithm with Rural and Adolescent Patients

Background: Foot and ankle injuries are a common presenting complaint to the Emergency Department (ED) and are often assessed with plain radiography. Rural environments may not have access to radiography mandating the referral or transfer patients to regional centers for definitive diagnosis. The Ottawa Foot and Ankle Rules (OFAR) is a clinical decision rule that can assist in ruling out fractures. Point of care ultrasound (POCUS) can augment this decision rule. The objective of this study was to assess both the feasibility and test characteristics of a previously described POCUS augmented clinical assessment, OFAR-POCUS, for adolescent and adult patients with foot and ankle pain in a rural environment. Methods: This was a prospective cohort study from June to August 2022 including patients with chief complaint of foot or ankle injury presenting to a rural clinic. Patients were included if they had positive finding(s) on the OFAR Test and required radiographic imaging. Patients were excluded if they did not consent, speak English, were unable to be scanned, had obvious joint deformities, had altered mental status, were not physiologically stable, had other injuries preventing sonography, were pregnant, or had previous injury with internal fixation, osteomyelitis, or rheumatoid arthritis. POCUS was performed before transport for radiography. POCUS examiners were POCUS novices who underwent a one and a half to two-hour, standardized foot and ankle POCUS training session. All POCUS studies were reviewed by two emergency medicine ultrasound fellowship trained faculty for quality assurance. Standard test characteristics were calculated for bedside clinician and expert POCUS interpretations compared to the radiographic control. Results: Thirteen POCUS examiners performed exams on 20 patients included in analysis; four patients had fractures on radiograph (20%). The bedside clinician POCUS interpretation had sensitivity (SN) = 100% (95% Cl, 40%-100%), specificity (SP) =94% (95% Cl, 70%-100%), and negative likelihood ratio (-LR) = 16.00 (95% Cl, 2.40-106.73). Expert POCUS interpretation had SN=75% (95% Cl, 19%-99%), SP=75% (95% Cl, 48%-93%), and -LR=0.33 (95% Cl, 0.06-1.86). Conclusion: A POCUS enhanced clinical strategy for clinically significant foot and ankle fractures in adolescent and adult patients in a rural setting is feasible. Larger studies are required to further characterize test characteristics and use of foot and ankle POCUS where plain radiography is unavailable.

Evaluating a Lung Abscess in a Pediatric Patient using Point-of-Care Ultrasound (POCUS)

Application of ultrasound to evaluate pediatric respiratory disease in the emergency department setting is rapidly growing, particularly as we often weigh the risks of exposure to radiation with other readily available imaging modalities in the acute care setting. In this case report, we describe how point of care ultrasound (POCUS) was utilized by emergency providers to characterize a lung abscess diagnosed in a pediatric patient. We also compare the ultrasound findings to other imaging studies.

Safety and accuracy of the computer interpretation of normal ECGs at triage.

ECGs performed at ED triage are mandatorily assessed by an emergency physician contributing to task interruptions, decreased quality of care and increased error risk. Recent literature suggests that a triage ECG interpreted as normal by the ECG machine software correlates with benign interpretation from attending cardiologists.Ambiguity persists regarding the safety of the normal computerized ECG interpretation and whether real-timephysician review is needed. In this prospective cohort study, we evaluated the GE Marquette 12SL ECG software's clinical accuracy for normal triage ECGs. We compared machine interpretation, ED physicians' real-time interpretation and management as well as cardiologists systematic but delayed review of the ECGs to establish diagnostic accuracy and safety of a normal software interpretation. Additional data were collected from the emergency department patient tracking system and charts to determine patient outcomes when machine normal interpretation differed from ED physicians and cardiologists' analysis. Between November 16th 2020 and November 19th 2021, we collected 1220 machine-normal ECGs performed at Charles-Le Moyne Hospital ED triage. 1051 ECGs were eligible for inclusion. ED physicians agreed with the machine for 1028 normal diagnoses (97.8% IC (0.95): 96.7-98.5) and cardiologists agreed with the machine for 1037 ECGs (98.7% IC (0.95) 97.8-99.2). Relevant changes in ED management were recorded in three patients (0.29% IC (0.95): 0.1-0.8) whose ECGs were read as normal by the software: two emergent referrals to the catheterization lab and one emergent transfer to the resuscitation bay with next day coronarography. A normal ECG interpretation from the GE Marquette 12SL ECG software at ED triage has a very high accuracy and a very low probability of clinically relevant change in patient outcome and ED trajectory.

Visualizing the Real Time Reduction of Pulled Elbow Using Point of Care Ultrasound (POCUS)

POCUS is a useful tool for correctly identifying pulled elbow. We believe that clinicians working in Pediatric Emergency Departments should be encouraged to embrace using it in cases which are less straightforward – either due to an atypical history or based on examination findings. This will serve to not only increase safety and improve the patient journey, but also to improve the clinician’s confidence in their practice. This is the first ever documented instance where the reduction of pulled elbow has been demonstrated in real time using POCUS.

Ultrasound-Guided Nerve Blocks Have the Potential to Reduce Racial and Ethnic Disparities in Emergency Department Pain Management

Ultrasound-Guided Nerve Blocks Have the Potential to Reduce Racial and Ethnic Disparities in Emergency Department Pain Management

A Case Series of Foreignbody Oesophagus and its Management at Tertiary Care Hospital

Objectives: To study the role of clinical examination as well as radiological investigations to rule out oesophageal foreign bodies as well as its plan of management.  Methodology: In total 10 patients with foreign body oesophagus came to Emergency department and ENT OPD in GGH, Anantapuram were prospectively analysed. The study period was from january 2023 to june 2023.A detailed clinical examination and radiological investigations done.  Results: There was male preponderance with children younger than 10 years compromising 50% of the patients. Upper oesophagus 80% was the favoured site for foreign body lodgement. were coins (60%) ,bones of chicken and meat(30%) gold chain (10%). There were no mortality or no major complications in this study group.  Conclusion: The complications due to oesophageal foreinbodies can be prevented by the early identification as well as referring the patients helps in proper management.The treatment of foreign body of oesophagus with the help of rigid esopaghoscopy was an effective ,safe and reliable procedure.

Prenatal homelessness, food insecurity, and unemployment and adverse infant outcomes in a California cohort, 2007-2020.

Characterize the relationship between infant outcomes and prenatal homelessness, food insecurity and unemployment. California live births between 22- and 44-weeks' gestation comprised 6,089,327 pregnancies (2007-2020). Data were collected from linked Vital Statistics and hospital discharge records. Prenatal homelessness, food insecurity, and unemployment were classified as health-related social needs (HRSN) using International Classification of Disease codes in delivery records. Risk ratios for preterm birth, low birthweight, small for gestational age, neonatal intensive care unit admission, emergency department admission, rehospitalization, and death were estimated using log-linear Poisson regression adjusted for birthing person race, payer, and education. 65.7 per 100,000 births had HRSN. These infants had a higher risk of preterm birth (aRR 2.7), low birthweight (aRR 2.7), SGA (aRR 1.5), NICU admission (aRR 3.5), and death (aRR 3.0). HRSN increase the risk of infant morbidity and mortality but remain underreported in administrative records, making definitive conclusions difficult.

Co-use of cannabis and alcohol among adults and the burden of traumatic brain injury from fall-related events

ABSTRACT Background Co-use of cannabis and alcohol is an emerging trend that can exacerbate injury outcomes. While research has focused on younger age groups, there is a need to examine consequences associated with co-use among adults populations. Falls represent a leading cause of injury among older adults. Coupled with substance use, injuries associated with falls may be more severe. Objectives To examine the burden of fall-related head injury among adults who co-use cannabis and alcohol. Methods Emergency department data from the 2019–2022 National Electronic Injury Surveillance System were analyzed for fall-related head injuries associated with co-use of cannabis and alcohol among middle-aged and older adults aged 55–75. Results An annualized estimate of 545,276 fall-related injuries occurred. Patients who presented with co-use of cannabis and alcohol had the highest prevalence of TBI (PR 1.75; 95% CI 1.25–2.25) and CMF injuries (PR 1.70; 95% CI 1.38–2.03) when contrasted to the alcohol-only or cannabis-only groups. Conclusions Results highlight the burden of co-use of cannabis and alcohol on fall-related head injuries. Healthcare providers, policymakers, patients, and caregivers should be aware of these risks and prioritize targeted interventions to mitigate the impact on the health and safety of older individuals.

Annual Clinical and Economic Burden of Medically Attended Lower Respiratory Tract Illnesses Due to Respiratory Syncytial Virus among US Infants Aged

We developed a model to project the expected annual clinical and economic burden of medically attended lower respiratory tract illnesses due to respiratory syncytial virus (RSV-LRTI) among US infants aged <12 months by combining information on population size, disease rates, mortality rates, and unit costs. Among the 3.7 million US infants aged <12 months each year, a total of 592,700 cases of RSV-LRTI (hospitalizations: 48,499; emergency department visits: 144,599; outpatient clinic visits: 399,602) were projected to occur, yielding total annual costs of $1.6 billion. The annual burden of RSV-LRTI among US infants is considerable, especially among those aged <3 months, who account for 43% of total costs.

Analysis of the Application of Emergency Severity Index Toward Patient Triage Response Time In the Emergency Department: Literature Review

Introduction: Triage is the process of determining the condition of patients at risk of death, potential disability, and worsening patient conditions. Response time is crucial in treating patients quickly and accurately. Objective This literature study aims to analyze the application of the Emergency Severity Index (ESI) Triage to the Triage Response Time in the Emergency Department. Methods: This research employs a literature review study with an analytic method approach that meets the inclusion and exclusion criteria. The search for articles or journals utilizes keywords and Boolean operators to refine the search and select relevant literature. The keywords used include ESI, Triage, Response time," and "Emergency Department. Results: The study reveals the effectiveness of utilizing the Emergency Severity Index (ESI) Triage on Triage Response Time in the Emergency Department. . Conclusion The speed at which nurses respond and determine patient triage can be enhanced through the use of ESI (Emergency Severity Index). To support this, nurses must possess knowledge and skills related to the ESI to minimize the mortality rate of patients.

Are there differences in low-acuity emergency department visits between culturally and linguistically diverse migrants and people with English-speaking background: a population-based linkage study of adults over 45

BackgroundGrowing numbers of avoidable low-acuity visits to emergency departments (ED) are a major health policy concern globally and are thought to contribute to ED crowding. This study explores the differences...

Association between behavioral parameters of men in psychiatric emergency department video recording and subsequent violence in the psychiatric ward.

Violence risk is a major challenge among acute psychiatric inpatients. The study aimed to predict violent behavior risk in an acute psychiatric ward using video recordings from the emergency department. 69 videos of the emergency department recording the first ten minutes following patients' arrivals were included. Psychiatrists watched the videos, completed relevant Brief Psychiatric Rating Scale items and answered intuitive questions about each patient's risk of violence. Demographic and clinical data were also collected. Motoric mannerisms as rated in the BPRS significantly differed between violent and non-violent patients (p < 0.05). Additionally, we found a significant correlation between intuitive prediction of violence and actual violence (p = 0.008). Violent behavior was predicted in 42.1% of the cases by the intuitive evaluation compared to 11.5% mistakenly evaluated patients. Logistic regression revealed that the intuitive question and the BPRS items regarding tension and motoric mannerism created a successful model for predicting violence with 88.2% sensitivity and 72.5% specificity. We sought to define the factors that most accurately predict violence in the acute psychiatric ward, based solely on behavior in the emergency department. Intuitive impressions of clinicians and motoric mannerisms should be considered when evaluating patients for potential violent behavior.

Epidemiological and clinical management aspects related to urinary tract infections diagnosed in the emergency department in elderly patients in Spain: Results of the EDEN-36 study

To estimate the incidence of urinary tract infections (UTI) in elderly patients in Spanish emergency departments (ED), the need for hospitalization, diagnostic confirmation in hospitalized patients, adverse events and the predictive capacity of several biomarkers. In this a posteriori substudy of a generic study of reasons for ED visits in elderly patients, we included patients aged ≥65 years seen in 52 Spanish EDs for 1 week, selecting those diagnosed with UTI. As adverse events, in-hospital and 30-day mortality and combined adverse event (death or hospitalization) at 30 days post-discharge were collected. Relative risks (RR) were calculated. The predictive capacity of 10 variables and 6 biomarkers was investigated. A total of 25,375 patients were included, 1058 with UTI (annual incidence: 24.7 per 1000 inhabitants aged ≥65 years and year, 95%CI: 24.5-24.9). A total of 36.5% were hospitalized, and in 80% the diagnosis of UTI was confirmed at discharge. Overall 30-day mortality was 5.4% and in-hospital mortality was 3.4%. Functional dependence was associated with both events (RR:2.91;1.18-7.17 and RR:12.61;1.47-108.11, respectively), as was having a CRP greater than 100 mg/L (RR:2.24;1.17-4.30 and RR:3.21;1.37-7.51, respectively). The combined post-high event occurred in 10.6%, and was associated with functional dependence (RR:2.05;1.04-4.06). CRP and hemoglobin had significant value in predicting 30-day post-discharge mortality or hospitalization. UTI is a frequent diagnosis in elderly patients consulting in the ED. Functional dependence is the best factor associated with adverse events. The biomarkers analyzed do not have a good predictive capacity.

Addressing heatwave impacts on hospital admissions in an Italian region.

This study explores the dynamic of emergency department (ED) access during heat waves. Given the importance of avoiding overcrowding and long waits in an ED, it is important to explore all the possible determinants of ED inflows. We shed some light on the impact that heat waves have on this dynamic, via a quantitative analysis of the number of ED visits in the Campania region of Italy during the summers between 2016 and 2019. Aggregating individual-level data, we examine the relationship between extreme heat events and number of ED visits, controlling for social, demographic and economic characteristics. Our findings, obtained through Random Effects Poisson and fractional probit estimations, show that heat waves above 39 perceived degrees Celsius significantly increase the number of ED visits, revealing the impact that heat waves have on ED utilization in Campania. Insights for local public health strategies and emergency preparedness initiatives are discussed.