True Emergency Research Articles

The front-line general surgery consultant as a new model of emergency care

Introduction Emergency general surgery services in England are undergoing rapid structural change with the aim of improving care. In our centre, the key issues identified were high numbers of admissions, inappropriate referrals, prolonged waiting times, delayed senior input and poor patient satisfaction. A new model was launched in January 2015 to address these issues: the surgical triage unit (STU). This study assesses the success of the new service. Methods All emergency general surgical admissions during a five-month period before introduction of the STU were compared with those of a comparable five-month period after its introduction. Process, clinical and patient experience outcomes were assessed to identify improvement. Results Attendance fell from 3,304 patients in the 2014 cohort to 2,830 in the 2015 cohort. During the 2015 study period, 279 more patients were discharged on the same day. Resource requirement fell by 2,635 bed days (23%). The number of true surgical emergencies remained consistent. Rates for reattendance (7.8% for 2014 vs 8.1% for 2015) and readmission (5.7% for 2014 vs 5.7% for 2015) showed no significant difference. Patient experience data demonstrated a significant improvement in both net promoter score (64.1 vs 82.2) and number of complaints (34 vs 5). Clinical outcomes for low risk procedures remained similar. Emergency laparotomy in-hospital mortality fell (11.4% vs 10.3%) despite preoperative risk stratification suggesting a risk burden that was significantly higher than the national average. Conclusions This novel model of emergency general surgery provision has improved clinical efficiency, patient satisfaction and outcomes. We encourage other units to consider similar programmes of service improvement.

Topical Ophthalmic Formulation of Trichostatin A and SurR9-C84A for Quick Recovery Post-alkali Burn of Corneal Haze.

Alkali burn injury is a true ocular emergency of the conjunctiva and cornea that requires immediate precision. Lack of an immediate therapy can lead to a substantial damage in the ocular surface and anterior segment further causing visual impairment and disfigurement. We explored the regenerative capability of dominant negative survivin protein (SurR9-C84A) and histone deacetylase inhibitor trichostatin-A (TSA) in vivo, in a rat alkali burn model. A topical insult in rat eyes with NaOH led to degradation of the conjunctival and corneal epithelium. The integrity of the conjunctival and corneal tissue was increased by TSA and SurR9-C84A by improving the clathrin and claudin expressions. Wound healing was initiated by an increase in TGF-beta-1 and, increased endogenous survivin which inhibited apoptosis post-TSA and SurR9-C84A treatments. Protein expressions of fibronectin and alpha-integrin 5 were found to increase promoting corneal integrity. The cytokine analysis confirmed increased expressions of IL-1beta, IL-6, IL-12, IL-13, IFN-gamma, TNF-alpha, GMCSF, Rantes, and MMP-2 in injured cornea, which were found to be significantly downregulated by the combined treatment of SurR9-C84A and TSA. The ocular and systemic pharmacokinetic (PK) parameters were measured post-topical ocular administration of TSA and SurR9-C84A. The SurR9-C84A and TSA sustained relatively longer in the cornea, conjunctiva, and aqueous humor than in the tear fluid and plasma. Our results confirmed that a combination of TSA with SurR9-C8A worked in synergy and showed a promising healing and anti-inflammatory effect in a very short time against alkali burn. Therefore, a combination of TSA and SurR9-C84A can fulfill the need for an immediate response to wound healing in alkali burnt cornea. We also synthesized ultra-small chitosan nanoparticles (USC-NPs) targeted with alpha-SMA antibodies that can be used for delivery of TSA and SurR9-C84A specifically to the ocular burn site.

Magnetic Resonance Imaging of Musculoskeletal Emergencies

Musculoskeletal trauma and infections are commonly encountered in the emergency department. Magnetic resonance imaging (MRI) is rarely employed in true emergencies and most musculoskeletal studies can be deferred to the outpatient setting. This article seeks to address the urgent conditions in which MRI can play a role in diagnosis, management, and treatment. This article outlines MRI's role in the evaluation of posterolateral corner injuries and other soft-tissue pathologies such as rhabdomyolysis, diabetic myonecrosis, septic arthritis, cellulitis, necrotizing fasciitis, and compartment syndrome.

Effect of Immediate Implementing A Standardized Nursing Care, on Outcomes of patients With Acute Angle Closure Glaucoma

Background: Acute angle closure glaucoma (AACG) is a true medical emergency. Glaucoma is the second leading cause of blindness worldwide. Aim: To assess the effect of immediate implementing standardized nursing care on outcomes of patients' with AACG. Methods: Quasi-experimental research design was used to conduct this study. The sample size calculated about 40 cases for each group include in the study. Data was collected using two tools Tool (1):- Patient assessment sheet. Tool (II):- Manifestations Assessment sheet. Results: There was a statistically significant difference before and immediately after implementing a standardized nursing care on patients outcomes with AACG regarding intra ocular pressure (P-value10.806, 0.124, 0.147), visual acuity and pain score among the studied groups p-value (0.002, 0.023, and 0.001) respectively. 65.0% of the studied groups had satisfactory level of knowledge regarding visual acuity, intra ocular pressure (IOP), and pain score characteristics. Conclusion Implementing a standardized nursing care had a positive effect on outcomes of patients' with AACG. Recommendations: Screening all people aged 40 years or more for symptoms &signs of glaucoma. Health education programs about standardized nursing care rules for patients' with AACG.

Urgent Care as Intermediary Care: How Inbound and Outbound Transport Can Enhance Care of Community-Based Pediatric Emergencies

With increasing options for acute care outside the medical home, high-functioning freestanding pediatric urgent care centers (UCCs) have become epicenters for intermediary care: alternate destinations for acutely ill or injured children with serious but not imminent life-threatening problems. Pediatric UCCs may be an optimal site to treat low acuity emergency medical services (EMS) patients, to triage true pediatric emergencies, and to develop universal transfer protocols to transition children to hospitals for higher levels of acute or subspecialty care. As a large percentage of visits to pediatric emergency departments (EDs) are urgencies rather than emergencies, there is a growing role for a community-based solution for intermediate-level conditions. Improved access, defined transfer protocols, community triage, and EMS paramedicine are all examples of trends in pediatric urgent care to improve public health, efficiency of care, and provide general cost savings for acutely ill or injured children. This article discusses the current state and future direction of transportation of pediatric patients to and from UCCs and the potential impact on a health system.

Surgical Considerations in Total Anomalous Pulmonary Venous Connection

Total anomalous pulmonary venous connection (TAPVC) is predominantly a neonatal congenital cardiac diagnosis in which the pulmonary veins fail to return to the left atrium. The presence or absence of obstruction defines the clinical presentation, and in the setting of obstructed pulmonary veins, this diagnosis represents a true surgical emergency. Improvements in perioperative care and refinement of surgical techniques continue to allow for improved survival and decreased morbidity. A description of the surgical anatomy and key concepts in the perioperative and surgical management of TAPVC are presented in this review.

Blunt scrotal trauma resulting in unilateral ruptured testicle

We present a case of testicular rupture after blunt scrotal trauma requiring surgical exploration and repair with salvage of the injured testicle. Testicular rupture is a true urological emergency and early diagnosis and surgical exploration maximized testicular salvage. Ultrasonography proves useful in evaluating the scrotal contents and allowing for early diagnosis of testicular injury.

Reasons to seek periodontal treatment in a libyan community

Background: Periodontitis is a persistent bacterial infection characterized by the progressive destruction of the tooth-supporting structures and can lead to tooth loss. By triggering inflammatory reactions, periodontitis can detrimentally affect systemic health. Periodontitis is a prevalent disease in developed countries like the USA, whereas none is known about its prevalence or the motivations to ask for periodontal treatment in Libya. Aim of the Study: The aim of this study is to understand and analyze the motivation factors to seek periodontal care in the Libyan community; we recorded the chief complaints (CCs) of Libyan patients seeking periodontal treatment in a dental clinic. To the best of our knowledge, this is the first attempt to gather data regarding periodontal disease and the associated CCs in the Libyan community. Materials and Methods: A total of 121 (20–80 years) Libyan patients with periodontitis who sought periodontal care in a private polyclinic were examined. Their CCs were recorded and grouped into true periodontal CC, emergency, esthetic, or referral based. Results: Most of the patients had moderate-to-severe chronic periodontitis. The examiner recorded 170 CCs. They were divided into 14 different CC groups. The most popular CC (32%) was “I was told that I have gum disease,” which is not a true periodontal CC. The second (31%) was “my gum bleeds when I brush my teeth,” which represents a true periodontal CC. Pain constituted only 3% of the patients' complaints. Other true periodontal CCs reported in descending order were: teeth mobility, recession, gum enlargement, bad odor, tooth sensitivity, and gum discoloration. All together constituted 20%. The rest presented for checkup and “cleaning” (9%) or were referred before commencing orthodontic treatment (4%) or implant placement (1%). Conclusion: The major motivation factor to seek periodontal care was found to be the information given to the patient that they had periodontal problems. This emphasizes the crucial role of health-care providers in determining patients with periodontal diseases and raises the awareness level of this silent disease among the Libyan population.

Post-Operative Delirium in Elderly People Diagnostic and Management Issues of Post-Operative Delirium in Elderly People.

Hippocrates a Greek physician commonly known as the Father of Medicine was the first to describe delirium, 'phrenitis', differencing it from other disorders such as melancholia and mania. Since then, it still remains a clinical problem which is not yet resolved.Postoperative delirium is a common medical problem that occurs preferentially in surgical patients aged 65 years and older. It is a true medical emergency that requires immediate professional attention and treatment. Faced by health professionals and especially nurses it is often undetected, misdiagnosed, and under-treated as a complication by them during clinical care.Delaying diagnosis relates to increased mortality and morbidity and affects deleteriously the elderly patients outcome, predisposing higher postoperative complications, prolonged hospital stay, malnutrition, immobility or bed confinement, higher health care costs, possible transfers to nursing homes and there is even higher death rates within 30 days, 6 months and 1 year.There is a knowledge deficit of the predisposing and causative factors of postoperative delirium occurrence, evaluation and assessment of cognitive status and health professionals, especially nurses need to receive the necessary training and education to provide quality care for the elderly with postoperative delirium.As postoperative delirium is frequent in the geriatric patients, it is obvious that we are facing a new challenge to find the right combination for the management and treatment for optimal therapeutic outcomes.

Facial Trauma in Sports.

Injuries resulting from facial trauma are common in all sports. Athlete-to-athlete contact, falls, and blows from equipment account for the majority of these events. Appropriate knowledge of basic science, relevant anatomy, and clinical skills is required to provide the correct medical care. While true medical emergencies are infrequent, a prompt accurate diagnosis is essential in developing targeted management and return to play options.

Geriatric Otolaryngologic Emergencies at a Teaching Hospital in Taiwan

Summary Background Many diseases are more common in older people than in younger people, and it may be more difficult to make a diagnosis because older patients often have nonspecific symptoms. The purpose of this study was to analyze the geriatric patients treated in an otolaryngology emergency room at a Taiwanese teaching hospital over a 5-year period. Methods A retrospective review was performed on patients older than 18 years of age who presented in otolaryngology emergency rooms from January 2010 to December 2014. A total of 4101 patients were enrolled in this study. Patients aged older than 65 years of age were defined as the elderly group. The retrieved data incvluded age, gender, clinical presentations, and treatment modalities for further analysis. Results A total of 502 patients (12.2%) were included in the elderly group. There were 287 males and 215 females ranging from 65 to 100 years of age with mean age of 75.7 ± 7.6. The most common need was pharyngolaryngology ( n = 274; 54.6%) followed by otology ( n = 128; 25.5%), rhinology ( n = 77; 15.3%), and head and neck surgery ( n = 23; 4.6%). Acute upper respiratory tract infection was the most frequent diagnosis. Foreign bodies were mostly found in the throat followed by the ears. Most patients with epistaxis sustained anterior nasal septum bleeding. More than 65% of the patients (335/502; 66.7%) were true emergencies. Conclusions The non-emergent disease, acute upper respiratory tract infection was the most frequent diagnosis. Although geriatric patients had a variety of medical conditions, most can be managed with a conservative treatment strategy.

Eliminate now: seven critical actions required to accelerate elimination of Plasmodium falciparum malaria in the Greater Mekong Subregion.

The emergence in 2009 of Plasmodium falciparum parasites resistant to the primary therapies currently in use (artemisinin-based combination therapy, ACT) in Southeast Asia threatens to set back decades of global progress in malaria control and elimination. Progress to date through multiple sets of initiatives and partners to contain or eliminate these parasites has been hampered due to a wide range of organizational, financial, and health systems-level challenges. In this commentary, a set of seven specific and concrete actions are proposed to directly address these issues and to accelerate P. falciparum elimination within the Greater Mekong Subregion to avert a wider public health crisis. These actions are specifically needed to elevate the situation and response mechanisms to those of a true emergency; to address systems-level challenges with personnel limitations and stock-outs of key commodities; and to restructure the response mechanisms to be well-aligned with the required outcomes. Consideration of these issues is especially pressing with planning meetings for renewal of the Regional Artemisinin-resistance Initiative (RAI) framework slated for late 2016 and into 2017, but these suggestions are also relevant for malaria programmes globally.

Successful treatment of annular rupture during transcatheter aortic valve implantation

Annular rupture presents arare but potentially fatal complication of transcatheter aortic valve implantation (TAVI). Although it can be subtle and subclinical in presentation, most severe forms present with hemodynamic instability and represent true emergencies requiring amore invasive treatment, even conventional surgery. We present acase of successful treatment of annular rupture by left ventricular outflow tract patch and surgical aortic valve replacement.

Case report-ovarian torsion in a child: a painful twist in the tale

Ovarian torsion in children is a rare cause of acute abdominal pain and is a true surgical emergency. The clinical presentation closely resembles other pathologies such as urinary tract infections, gastroenteritis and more common surgical emergencies such as appendicitis. We present a case of previously healthy 6 year old female child who presented with abdominal pain, intermittent fever and vomiting. Ultrasonography of the abdomen and pelvis revealed features suggestive of ovarian torsion for which Subacute Laparoscopic Oophorectomy was performed. The authors would like to sensitize readers to the possibility of ovarian torsion in the paediatric populace and reiterate that timely diagnosis and management can prevent catastrophic sequelae.

Anaphylaxis in the Cardiac Cath Lab: A True Emergency

Anaphylaxis in the Cardiac Cath Lab: A True Emergency

Scrotum incarceration with nine galvanized iron rings: An unusual case report

In this case report we describe the case of a 36-year-old male who presented to the emergency department with a grossly swollen scrotum. Nine galvanized iron rings were placed around his scrotum for the enhancement of his sexual performance. Attempts to remove them with lubricants, ring cutters, pliers, and orthopedic bone cutters were unsuccessful. Finally, they were removed with a hydraulic bolt cutter borrowed from the fire department. Genital incarceration or strangulation represents a true urological emergency. Removal of such devices can be challenging for emergency physicians and often requires resourcefulness and a multidisciplinary approach.

Dermatological emergencies: one-year data analysis of 8,620 patients from the largest Portuguese tertiary teaching hospital.

Skin conditions frequently lead to emergency department (ED) visits. While most are benign in course, some will present as true dermatological urgencies/emergencies, requiring admission. To present data on skin diseases most frequently found in the ED, and those most frequently requiring admission at the largest Portuguese tertiary teaching hospital, and to explore an association between epidemiological variables and frequency of diagnoses within this context. A retrospective study was conducted on all patients examined during 2012 for dermatology emergency consultation (DEC) at the Hospital de Santa Maria, Lisbon, Portugal. Association between epidemiological variables (gender and age of patients, and season of the year) and frequency of diagnoses was investigated. In total, 8,620 patients were examined by a dermatologist in the ED, constituting 3.9% of all ED visits in our centre. Overall, 333 diagnoses were made, the most frequent of which was eczema not-otherwise-specified (9.4%). However, infectious and parasitic diseases constituted the leading motive for DEC (31.5%). Only 264 patients were admitted, with 65 diagnoses leading to admission. Nine diagnoses alone led to 60% of all admissions. Infectious and parasitic diseases constituted the leading cause of admission (34.7%). An association between frequency of diagnoses and gender, age, and season was identified. Despite the variety of dermatological pathologies, only a limited group of diseases was responsible for most of the true dermatological emergencies. Therefore, in the absence of a readily available dermatologist, knowledge of these entities, as well as demographic and environmental data, may help to improve the management of these patients.

Evidence Is Important: Safety Considerations for Emergency Catheter Cricothyroidotomy.

Evidence Is Important: Safety Considerations for Emergency Catheter Cricothyroidotomy.

Superficial Dorsal Venous Rupture of the Penis: False Penile Fracture That Needs to be Treated as a True Urologic Emergency

A 38-year-old man with history of repaired penile fracture presented with rapid detumescence, penile pain, and ecchymosis during vaginal sexual intercourse concerning for recurrent fracture. Surgical exploration revealed ruptured superficial dorsal vein of the penis, which was subsequently ligated. Patients with traumatic penile vascular injuries often present with clinical features indistinguishable from a true penile fracture. Gradual detumescence and an absence of characteristic popping sound may indicate a vascular injury but they cannot safely rule out a true penile fracture. Both true and false penile fractures require emergent surgical exploration and repair to prevent long-term complications.

Giant cell arteritis: ophthalmic manifestations of a systemic disease.

Giant cell arteritis (GCA) is a systemic granulomatous vasculitis, primarily affecting medium-large arteries. It has a predilection for the aorta and its major branches, including the carotid and vertebral arteries. Ophthalmic artery involvement frequently leads to irreversible visual loss, and therefore GCA is one of the few true ophthalmic emergencies. GCA, although classified as a large vessel vasculitis, is known to affect smaller-sized vessels, resulting in a multiplicity of signs in the eye, some of which are often missed. We set out to highlight some of the less frequently observed clinical signs, which may provide clues to clinically diagnosing GCA in patients presenting with non-classical features and inconclusive inflammatory markers. We review the literature and describe the diverse ocular features and some of the systemic findings that can be associated with GCA. Although the most common ocular manifestation of GCA is anterior ischaemic optic neuropathy, the clinical presentation of GCA can vary dramatically. In the absence of obvious ocular involvement, more subtle ophthalmic signs of anterior segment ischaemia, such as hypotony and anisocoria, may be present at the time of initial clinical examination. There are no specific biomarkers for disease to date; therefore, pertinent history and clinical examination can guide towards diagnosis in the acute setting. The diagnostic process is not always straightforward, yet appropriate and prompt diagnosis is critical to enable timely intervention and prevent significant morbidity.