Patients In Emergency Setting Research Articles

Clinical Characteristics and Treatment Responses of Patients in Delirious Mania: A Case Series

BACKGROUND: Delirious mania (DM) is a severe psychiatric condition having rapid onset of delirium, mania, and psychosis. It is an emergency condition as it has acute onset and is characterized by extreme hyperactivity. Catatonic signs may also be present. Very few cases have been reported from India, hence making it imperative to study its clinical characteristics and possible treatment, which can help in providing care to such patients in emergency settings. CLINICAL CASES DESCRIPTION: This paper describes four cases with a diagnosis of DM — demography, clinical features, investigations, treatment. All the patients had an acute onset and rapid progression of symptoms, with clinical symptoms of talkativeness, increased psychomotor activity, decreased need for sleep, aggressive and violent behavior, increased libido, increased appetite with delusion of grandiosity, disorientation to time/place/person, impaired memory of recent events, impaired attention with fluctuating course, negativism, echolalia, and echopraxia. CONCLUSION: There is a high likelihood of misdiagnosing DM in the absence of diagnostic guidelines. There should be an active search for the underlying aetiology in all cases of DM. Atypical antipsychotics and mood stabilizers may be used to treat less severe forms of DM. Modified electric convulsive treatment and intravenous benzodiazepines elicit a good response.

The RELIEF feasibility trial: topical lidocaine patches in older adults with rib fractures

BackgroundLidocaine patches, applied over rib fractures, may reduce pulmonary complications in older patients. Known barriers to recruiting older patients in emergency settings necessitate a feasibility trial. We aimed to establish...

The predictive value of the Kampala Trauma Score (KTS) in the outcome of multi-traumatic patients compared to the estimated Injury Severity Score (eISS)

PurposeThe classification of trauma patients in emergency settings is a constant challenge for physicians. However, the Injury Severity Score (ISS) is widely used in developed countries, it may be difficult to perform it in low- and middle-income countries (LMIC). As a result, the ISS was calculated using an estimated methodology that has been described and validated in a high-income country previously. In addition, a simple scoring tool called the Kampala Trauma Score (KTS) was developed recently. The aim of this study was to compare the diagnostic accuracy of KTS and estimated ISS (eISS) in order to achieve a valid and efficient scoring system in our resource-limited setting.MethodsWe conducted a cross-sectional study between December 2020 and March 2021 among the multi-trauma patients who presented at the emergency department of Imam Reza hospital, Tabriz, Iran. After obtaining informed consent, all data including age, sex, mechanism of injury, GCS, KTS, eISS, final outcome (including death, morbidity, or discharge), and length of hospital stay were collected and entered into SPSS version 27.0 and analyzed.Results381 multi-trauma patients participated in the study. The area under the curve for prediction of mortality (AUC) for KTS was 0.923 (95%CI: 0.888–0.958) and for eISS was 0.910 (95% CI: 0.877–0.944). For the mortality, comparing the AUCs by the Delong test, the difference between areas was not statistically significant (p value = 0.356). The diagnostic odds ratio (DOR) for the prediction of mortality KTS and eISS were 28.27 and 32.00, respectively.ConclusionIn our study population, the KTS has similar accuracy in predicting the mortality of multi-trauma patients compared to the eISS.

75. The Association of Intravenous Nitrates Dosing Regimens on Blood Pressure Reduction and ICU Admission Rates among Acute Hypertensive Heart Failure Patients in Emergency Settings: A Systematic Review, Meta Analysis, and Meta-Regression

75. The Association of Intravenous Nitrates Dosing Regimens on Blood Pressure Reduction and ICU Admission Rates among Acute Hypertensive Heart Failure Patients in Emergency Settings: A Systematic Review, Meta Analysis, and Meta-Regression

10. The Association of Intravenous Nitrates Dosing Regimens on Blood Pressure Reduction and ICU Admission Rates among Acute Hypertensive Heart Failure Patients in Emergency Settings: A Systematic Review, Meta Analysis, and Meta-Regression

10. The Association of Intravenous Nitrates Dosing Regimens on Blood Pressure Reduction and ICU Admission Rates among Acute Hypertensive Heart Failure Patients in Emergency Settings: A Systematic Review, Meta Analysis, and Meta-Regression

Treatment-seeking threshold and accessibility of psychiatric outpatient services in Switzerland: the relationship with stigma and self-esteem.

Perceived stigmatization and low self-esteem are linked to poorer mental health outcomes, but their impact on treatment-seeking thresholds and the importance of outpatient service location remain unclear. The study included 525 outpatients of the University Psychiatric Clinic (UPK) Basel, Switzerland, of whom 346 were treated at inner city services and 179 at services located on the main site of the UPK at the outer city limits. Perceived discrimination and devaluation (PDD), self-esteem (SE), treatment-seeking threshold (TST), and accessibility were measured via a self-reported questionnaire. The PDD consisted of 12 items evaluating beliefs about the level of stigma towards individuals with mental illness in the general population on a 5-point Likert scale. SE, TST and accessibility were assessed through single-item 7-point Likert scales. PDD and SE were positively correlated (p < 0.001), suggesting that lower perceived stigma was linked to higher self-esteem, and were not associated with TST. The relationship between PDD and SE remained consistent after controlling for age, gender, and nationality. Age was negatively correlated with TST (p = 0.022), while gender did not significantly influence any of the variables. There was little variation regarding PDD, with emergencies at the site of the psychiatric clinic and substance use disorder (SUD) patients reporting higher levels of stigmatization. Emergency patients and those with SUD and personality disorder reported the lowest SE ratings. TST showed a broad range and was highest for emergency services and transcultural psychiatry patients. Differences in accessibility were mainly linked to the location, with outpatient service users in the inner city reporting better accessibility (p < 0.001) and higher SE (p = 0.009). In comparison to patients using services with planned contacts only, patients in emergency settings differed by higher TST (p = 0.018) and better ratings of accessibility (p = 0.004). In conclusion, there was a relevant amount of stigmatization, impaired self-esteem, and, for some outpatient services, high thresholds to seek treatment. Future research should explore other factors influencing TST. The findings highlight the need to address stigmatization and accessibility when planning mental health services.

On-Arrival Lumbar Epidural Analgesia for Lower Limb Trauma Pain in Emergency Care: A Superiority Randomized Controlled Trial.

Lower limb trauma in emergency settings often leads to pain management challenges. Traditional methods, primarily non-steroidal anti-inflammatory drugs (NSAIDs) and opioids, have limitations. This study explores the efficacy of epidural analgesia in emergency for lower limb trauma patients (ELETRA) as an alternative for managing pain in lower limb trauma patients upon arrival in emergency care. This study primarily focuses on determining ELETRA's effectiveness in reducing pain for patients with lower limb trauma upon arrival. It also aims to evaluate ELETRA's influence on decreasing stress and shortening hospital stays compared to traditional pain management approaches. This study was executed as a prospective, parallel-design, randomized controlled trial in the emergency department of a tertiary care teaching hospital. The interventions were performed in a dedicated induction room adjacent to the emergency operating theater. The trial was registered in the Clinical Trial Registry of India with registration number CTRI/2022/08/044699 dated 16/08/2022.Participants were 18- to 50-year-old patients with lower limb injuries, classified under American Society of Anesthesiologists (ASA) class 1 or 2. Participants were randomized into two groups: one receiving ELETRA and the other standard pain control treatment. The effectiveness of pain relief was measured through a visual analogscale (VAS), and hemodynamic parameters, adverse effects, levels of acute phase reactants, and stress hormones were also measured along with patient satisfaction. The study enrolled 356 participants with lower limb injuries. After excluding participants lost following the intervention, data from 157 individuals in Group A and 160 in Group B were analyzed. Group A's success rate for analgesia (VAS < 2) was 92.35% (n = 145), significantly higher than Group B's 75.62% (n = 121) (p < 0.001). The commonest side effect was hypotension (5.73%) inGroup Aand nauseainGroup B (7.5%). C-reactive protein (CRP) levels rose to 104.71 ± 8.99 mg/dL in Group A and 192.58 ± 9.23 mg/dL in Group B; the difference was statistically significant. Serum cortisol levels were also higher in Group B (67.18 ± 9.21) compared to Group A (44.72 ± 6.14) at one week. Group B had a longer hospital stay, averaging 12.24 ± 4.81 days, against Group A's 10.19 ± 4.91 days. ELETRA is a safe and effective alternative for pain management in lower limb trauma patients in emergency settings. It reduces pain, improves patient satisfaction, and has a favorable impact on stress responses.

Assessing Reverse Shock Index as a Survival Predictor for Trauma Patients in Emergency Settings: A Retrospective Observational Study

ntroduction: Identifying trauma patients with shock is crucial, as early intervention and prompt treatment improve patient prognosis and survival. To address this, the ratio of Systolic Blood Pressure (SBP) and Heart Rate (HR), known as the Reverse Shock Index (RSI), is measured. Aim: To evaluate the effectiveness of RSI calculation in assessing prognosis. Materials and Methods: This was a retrospective observational study in which data were retrospectively collected on trauma patients treated in the Emergency Room (ER) at Dhiraj Hospital, Sumandeep Vidyapeeth Deemed to be University, Vadodara, Gujarat, India, from January 2021 to December 2022. Patients involved in road traffic accidents, fall from a height of ≥6 m, assault, and machinery injuries were included. Upon arrival, vital signs such as HR, SBP, Respiratory Rate (RR), Glasgow Coma Scale (GCS), associated injuries, and in-hospital mortality were documented. Any resuscitative procedures required, such as Cardiopulmonary Resuscitation (CPR), intubation, oxygen therapy, chest tube insertion, and blood transfusion, were also recorded. The RSI was calculated for all trauma patients and divided into two groups (RSI &lt;1 and RSI ≥1). The t-test was performed with a 95% Confidence Interval (CI). Results: Out of 363 patients, data from 320 patients were included. Among them, 55 patients (17.2%) had RSI &lt;1, and 265 patients (82.8%) had RSI ≥1. Patients with RSI &lt;1 exhibited lower GCS scores, tachypnoea (RR &gt;29), or bradypnoea (RR &lt;10), along with higher mortality rates. These patients also required resuscitative interventions. Those with RSI &lt;1 experienced more head injuries, thoracic trauma, and maxillofacial injuries (p&lt;0.001). Conclusion: The RSI &lt;1 in trauma patients demonstrated significantly higher predictive accuracy for adverse outcomes, serving as a primary tool for early intervention and aggressive care in the ER.

A DNA aptamer-based assay for the detection of soluble ST2, a prognostic biomarker for monitoring heart failure

Heart failure (HF) is emerging as a leading cause of death worldwide. Estimation of BNP levels is a routine diagnosis in these patients. However, in patients having high body-mass index (BMI), renal disease or in geriatric patients, BNP level is reported to be noisy and leads to incongruous conclusion. Thus, for better risk stratification among heart failure patients, it is imperative to look for a superior biomarker. In recent times, sST2 has shown promise as a biomarker. Identifying such biomarkers in peripheral blood of HF patients, need an affine and selective molecular recognition element. Thus, in the current study an aptamer (sS9_P) against sST2 was identified from an aptamer library. Systematic Evolution of Ligands through Exponential enrichment (SELEX) derived aptamer evinced role of its primer binding domains in maintaining its selectivity. This aptamer candidate demonstrated dissociation constant (Kd) in low nanomolar range, and the Limit of Detection (LOD) was ~4 ng. Circular dichroism confirms the formation of complex stem-loop like structure. The well characterized sS9_P aptamer was used in an Aptamer Linked Immobilized Sorbent Assay (ALISA) to detect sST2 level in patients' serum (n = 99). Aptamer sS9_P has shown significant discrimination to differentiate HF patients and healthy volunteers with a reasonable specificity (~83 %) with a modest sensitivity of ~64 %. While sST-2 antibody has shown poor specificity of ~44% but good sensitivity (~87%). The insight obtained from this study indicates that a combination of aptamer and antibody-based assay can be used to design a point-of-care assay for the rapid detection of HF patients in emergency settings.

Acute cholecystitis: Which flow-chart for the most appropriate management?

Acute cholecystitis (AC) is a very common disease in clinical practice. Laparoscopic cholecystectomy remains the gold standard treatment for AC, however due to aging population, the increased prevalence of multiple comorbidities and the extensive use of anticoagulants, surgical procedures may be too risky when dealing with patients in emergency settings. In these subsets of patients, a mini-invasive management may be an effective option, both as a definitive treatment or as bridge-to-surgery. In this paper, several non-operative treatments are described and their benefits and drawbacks are highlighted. Percutaneous gallbladder drainage (PT-GBD) is one of the most common and widespread techniques. It is easy to perform and has a good cost/benefit ratio. Endoscopic transpapillary gallbladder drainage (ETGBD) is a challenging procedure that is usually performed in high volume centers by expert endoscopists, and it has a specific indication for selected cases. EUS-guided drainage (EUS-GBD) is still not widely available, but it is an effective procedure that could have several advantages, especially in rate of reinterventions. All these treatment options should be considered together in a stepwise approach and addressed to patients after an accurate case-by-case evaluation in a multidisciplinary discussion. In this review, we provide a possible flowchart in order to optimize treatments, resource and provide to patients a tailored approach.

A review of ultrasound for the diagnosis of acute appendicitis in adults

Acute appendicitis is one of the most common surgical emergencies globally, with a lifetime incidence of 8.6% in men and 6.7% in women. While acute appendicitis should be managed promptly to reduce the morbidity associated with perforated appendicitis, morbidity from negative appendicectomy is similar to morbidity from uncomplicated appendicitis. Computer tomography is widely used to aid in the diagnosis of acute appendicitis, however, is costly, often has a slow turn around time, and is associated with exposure to ionising radiation. In contrast, ultrasound is cheap, widely available, requires minimal patient preparation, and does not require exposure to ionising radiation. Ultrasonography is becoming increasingly used for adult patients in emergency settings. The literature has estimated the sensitivity of ultrasound for acute appendicitis in adult patients as between 39-96.4%. The sensitivity and specificity of ultrasound for the diagnosis of acute appendicitis is significantly increased when the appendix is visualised. In cases of a non visualised appendix, indirect ultrasound signs can improve the sensitivity to 93.9% and specificity to 85.7%. The variation in sensitivity and specificity for ultrasound in the diagnosis of acute appendicitis in adults may be due to multiple factors. Ultrasonographer experience, a retrocaecal appendix and obesity have all been described. Given the availability, cost and potential to reduce the rate of negative appendicectomy, ultrasound should be considered as the first line imaging modality for adult patients presenting with suspected AA.

Abstract 167: Nasal Sensor Capnographic Differences In Major Traumatic Brain Injury Patients Receiving Non-rebreather Mask Versus Nasal Cannula Oxygen Delivery

Background: The advent of highly sensitive End-Tidal CO2 (ETCO2) sensors allows effective monitoring of intubated patients in EMS. Previous work has explored the use of ETCO2 monitoring in non-intubated patients with sensors placed in the nares. However, little is known about the effect of passive O2 delivery [nasal cannula (NC) or high-flow, non-rebreather mask (NRB)] on ETCO2 measurement. Objective: To compare ETCO2 measurements in non-intubated Traumatic Brain Injury (TBI) patients receiving O2 via NC vs. NRB in the field. Methods: A subset of cases from the EPIC EMS TBI Study (NIH-1R01NS071049) were evaluated (4/13-4/18). Non-intubated cases from 5 EMS agencies providing monitor data, including continuous ETCO2. Start and end segments were excluded to remove artifact from initiation (“ramp-up”) or termination of monitoring. Statistics: Wilcoxon rank-sum test, two-sample t-test, and Chi-squared test were used as appropriate. Linear regression compared continuous variables in adjusted analyses (α = 0.05). Results: Included were 151 cases [median age: 52 (range: 9-91; 66% male)]. Of those, 62 (41%) received NCO2 and 89 (59%) via NRB. Patient-level mean ETCO2 was slightly lower in the NC group (mean = 26.9 mmHg; SD 6.7) compared to NRB (mean 30.2; SD 8.1; p=0.007). Differences in the mean were: Unadjusted: 3.3 (95% CI 0.9-5.7); Adjusted 2.7 (0.2-5.2). There were no significant differences in means of the patient-level lowest or highest recorded values. Conclusion: While there was a statistically lower ETCO2 in the NC versus NRB-oxygenated patients, it was around 3 mmHg and, thus, not clinically significant. This is surprising since: 1) the O2 flow rates and 2) the open-air (NC) versus mask (NRB) delivery methods are so dramatically different. Future study is needed to identify the clinical implications of using noninvasive ETCO2 measurement as a tool for monitoring ventilatory status and changes in non-intubated TBI (and other) patients in emergency settings.

Development of the PREDS score to predict in-hospital mortality of patients with Ebola virus disease under advanced supportive care: Results from the EVISTA cohort in the Democratic Republic of the Congo.

SummaryBackgroundAs mortality remains high for patients with Ebola virus disease (EVD) despite new treatment options, the ability to level up the provided supportive care and to predict the risk of death is of major importance. This analysis of the EVISTA cohort aims to describe advanced supportive care provided to EVD patients in the Democratic Republic of the Congo (DRC) and to develop a simple risk score for predicting in-hospital death, called PREDS.MethodsIn this prospective cohort (NCT04815175), patients were recruited during the 10th EVD outbreak in the DRC across three Ebola Treatment Centers (ETCs). Demographic, clinical, biological, virological and treatment data were collected. We evaluated factors known to affect the risk of in-hospital death and applied univariate and multivariate Cox proportional-hazards analyses to derive the risk score in a training dataset. We validated the score in an internal-validation dataset, applying C-statistics as a measure of discrimination.FindingsBetween August 1st 2018 and December 31th 2019, 711 patients were enrolled in the study. Regarding supportive care, patients received vasopressive drug (n = 111), blood transfusion (n = 101), oxygen therapy (n = 250) and cardio-pulmonary ultrasound (n = 15). Overall, 323 (45%) patients died before day 28. Six independent prognostic factors were identified (ALT, creatinine, modified NEWS2 score, viral load, age and symptom duration). The final score range from 0 to 13 points, with a good concordance (C = 86.24%) and calibration with the Hosmer-Lemeshow test (p = 0.12).InterpretationThe implementation of advanced supportive care is possible for EVD patients in emergency settings. PREDS is a simple, accurate tool that could help in orienting early advanced care for at-risk patients after external validation.FundingThis study was funded by ALIMA.

Are there differences in cardiothoracic surgery performed by trainees versus fully trained surgeons?

We sought to assess the safety of training in cardiothoracic surgery comparing outcomes of cases performed by trainees versus fully trained surgeons. EmBase, Scopus, PubMed, and OVID MEDLINE were searched in August 2021 independently by two authors. A third author arbitrated decisions to resolve disagreements. Inclusion criteria were articles on cardiothoracic surgery reporting on outcomes for trainees. Studies were assessed for appropriateness as per CBEM criteria. Eight hundred and ninety-two results were obtained, 27 represented best evidence (2-meta-analyses, 1-RCT, and 24 retrospective cohort studies). In all 474,160 operative outcomes were assessed for 434,535 coronary artery bypass grafting(CABG) (431,329 on-pump vs. 3206 off-pump), 3090 AVR, 1740 MVR/repair, 26,433 mixed, 3565 congenital, and 4797 thoracic procedures. In all398,058 cases were performed by trainees and 75,943 by consultants. One hundred fifty-nine cases were indeterminate. There were no statistically significant differences in the patients' preoperative risk scores. All studies excluded extreme high-risk patients in emergency setting, patients with poor left ventricular function, and reoperation cases that were undertaken by consultants. There were no differences in cardiopulmonary bypassand clamp times for CABG. Times for valve replacement and repair cases were longer for trainees. There were no differences in the postoperative outcomes including perioperative myocardial infarction, resternotomy for bleeding, stroke, renal failure, intensive therapy unitlength of stay, and total length of stay. One study reported no differences on angiographic graft patency at 1 year. There were no differences in in-hospital or midterm mortality out to 5-years. Trainees can perform cardiothoracic surgery in dedicated high-volume units with outcomes comparable to those of fully trained surgeons.

Radiographic patterns on Chest X-ray as a supporting imaging tool in triaging of suspected Corona Virus Disease (COVID) patients.

Objective:To evaluate the radiographic patterns on Chest X-Ray (CXR) in accordance with Modified Brixia Scoring as supporting imaging tool in triaging of Corona Virus Disease (COVID-19) pneumonia.Methods:In this cross-sectional study, chest radiographs of suspected COVID patients at emergency triage, Lady Reading Hospital (LRH) from April 18th to July 22nd 2020 were evaluated for patterns of COVID pneumonia and scored in accordance with modified Brixia score. Each zone was categorized as score of “one” for interstitial pattern, “two” for mixed interstitial /alveolar pattern and “three” for alveolar pattern. Radiographic patterns consistent with COVID pneumonia or patients having strong clinical suspicion were advised Polymerase Chain Reaction (PCR) tests.Results:Total of 2,225 individuals were screened for patterns of COVID-19 pneumonia on chest radiograph. Out of these 1465(65.8%) had normal chest radiograph and 760(34.2%) had abnormal findings. Out of the total, 648 suspected COVID patients were selected for PCR. The radiographic patterns ranged from mixed interstitial/alveolar pattern in 261(40.3%) patients, alveolar pattern in 231(35.6%), interstitial pattern in 87(13.4%), pleural effusion in 12(1.9%), other findings in 5(0.8%) while 52(8%) suspected Covid patients had normal radiographs. The PCR was positive in 326(50.3%), negative in 100(15.4%) and inconclusive in 60(9.3%) while 162(25%) were lost to follow up. Amongst the 52 suspected Covid patients having normal chest radiographs, 10 were positive on PCR, 21 negative, seven suspected and two inconclusive, while 12 were lost to follow up.Conclusion:Chest radiograph is used for triaging of suspected COVID pneumonia patients in emergency settings. It assesses the severity of disease according to modified Brixia scoring for treatment plan.

Short Communication: Opportunities and Challenges for Early Person-Centered Care for Older Patients in Emergency Settings.

The provision of person-centered care (PCC) for older adults in emergency settings is important. This short communication explores the complexity of providing comprehensive PCC for older adults in emergency settings, based on a synthesis of existing literature and empirical data from a small-scale case study on the potential of improving patient engagement in a Danish emergency department (ED). Our findings highlight overall positive attitudes towards PCC, as patient engagement is perceived as important and feasible during the waiting hours that older patients experience. However, the key challenges include barriers in organizational structures and cross-sectoral care coordination. We conclude that staff education, optimized care coordination across sectors, and increased involvement of geriatric nurses may enhance the provision of PCC for older, complex adults in EDs. We further conclude that future research into the feasibility and effects of structured approaches for providing PCC in EDs is needed, including exploration of organizational models for PCC.

Predicting Imaging Outcomes in Acute Stroke Therapy—Comparison of Magnetic Resonance Imaging and Computed Tomography

Abstract Background Imaging of acute stroke patients in emergency settings is critical for treatment decisions. Most commonly, CT with CTA is used worldwide for acute stroke. However, MRI may be advantageous in certain settings. With advancements in endovascular clot retrieval techniques, there is a need to identify and use the best possible imaging for the diagnosis and outcome prediction of hyperacute stroke. Methods This mixed retrospective and prospective observational study was conducted over 2 years in patients who underwent reperfusion therapies. Patients were included in this study if they had a baseline as well as follow-up noncontrast CT and diffusion-weighted imaging (DWI) MRI. We compared them for estimating final infarct size and outcomes after reperfusion therapy. Results A total of 86 patients were included in the study. Baseline DWI found new infarcts in 33 patients compared to baseline CT. Sensitivity and specificity of CT and DWI in predicting the final infarct size was 75.3% and 76.9% and 97.2% and 92.3%, respectively. A positive correlation of 51.2% and 84.4% was noted between b-CT Alberta stroke programme early CT score (ASPECTS) and b-DWI with 72 hours DWI ASPECTS, respectively (p &lt; 0.001). The positive predictive value of CT was 94.8% and DWI was 98.6%. None of the patients had reversible hyperintensities in the follow-up DWI. Conclusion MRI is more sensitive and specific than noncontrast CT in predicting final infarct volume. It predicts final outcomes better and could be an alternative if available in acute stroke settings.

Intraosseous versus intravenous access while wearing personal protective equipment: a meta-analysis in the era of COVID-19.

Obtaining vascular access is one of the key procedures performed in patients in emergency settings. The study was conducted as a meta‑analysis and a systematic review and aimed to address the following question: which intravascular access method should be used in patients with COVID‑19 when wearing full personal protective equipment (PPE)? We performed a systematic search of PubMed, EMBASE, and CENTRAL databases for randomized controlled trials that compared intravascular access methods used by operators wearing full level C PPE. We evaluated procedure duration and the success rate of intraosseous and peripheral intravenous accesses. Eight randomized controlled trials were included in quantitative synthesis. The use of PPE during intravascular access procedures had an impact on procedure duration in the case of intraosseous access (mean difference [MD], 11.69; 95% CI, 6.47-16.92; P <0.001), as well as reduced the success rate of intraosseous access by 0.8% and intravenous access by 10.1%. Under PPE conditions, intraosseous access, compared with peripheral intravenous access, offered a shorter procedure time (MD, -41.43; 95% CI, -62.36 to -24.47; P <0.001). This comprehensive meta‑analysis suggested that the use of PPE significantly extends the duration of intravascular procedures. However, under PPE conditions, operators were able to obtain intraosseous access in a shorter time and with a higher success rate than in the case of intravenous access.

Approaching acute pain in emergency settings: European Society for Emergency Medicine (EUSEM) guidelines-part 1: assessment.

Pain management is a vital component of patient care, particularly in the emergency setting. Pain can hinder the opportunities to treat and manage pain-causing conditions and remains one of the primary reasons patients seek emergency medical care, yet despite this, pain often remains under-acknowledged, under-assessed and undertreated. Despite the importance of effective management of acute pain, there are currently no well-defined emergency medicine guidelines at a European level to support healthcare professionals in achieving this goal. The European Society for Emergency Medicine (EUSEM) identified this as a significant unmet requirement, for improving day-to-day patient management and for providing guidance to trainees and non-emergency medicine physicians. Under the auspices of EUSEM, a programme-the European Pain Initiative-was launched with the aim of providing information, advice and guidance on pain management in pre-hospital and emergency department settings. Search terms were developed to search MEDLINE, Cochrane database, Google Scholar and EMBASE online databases to return English language articles published in the last 10years. A working package of reference materials was evaluated against inclusion and exclusion criteria and levels of evidence ascribed. A short survey was developed by the European Pain Initiative Steering Committee for completion by EUSEM members to evaluate actual clinical practice. A working document of > 800 publications was identified for further review and evaluation against agreed criteria. Some further publications were included by the Steering Committee to explore older literature for long-established analgesics, or newly emergent literature that was considered important for inclusion but was identified as the guideline development was underway. This article provides the methodology used to inform the guidelines, including survey results of EUSEM members on assessment and treatment of acute pain. A companion manuscript in this issue presents an evidence-based review and recommendations for individualised evaluation of acute pain in patients in emergency settings.

Challenges in anaesthesia and pain management for burn injuries.

Burn-injured patients provide unique challenges to those providing anaesthesia and pain management. This review aims to update both the regular burn anaesthetist and the anaesthetist only occasionally involved with burn patients in emergency settings. It addresses some aspects of care that are perhaps contentious in terms of airway management, fluid resuscitation, transfusion practices and pharmacology. Recognition of pain management failures and the lack of mechanism-specific analgesics are discussed along with the opioid crisis as it relates to burns and nonpharmacological methods in the management of distressed patients.