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Emergency Medicine Journal
Journal Prestige (SJR): 0.912
Citation Impact (citeScore): 1
Number of Followers: 53  
  Hybrid Journal Hybrid journal (It can contain Open Access articles)
ISSN (Print) 1472-0205 - ISSN (Online) 1472-0213
Published by BMJ Publishing Group Homepage  [68 journals]
  • Highlights from this issue
    • Authors: Maconochie; I. K.
      Pages: 403 - 403
      Abstract: Do EPs change their clinical behaviour in the hallway encounters or when a companion is present' A cross-sectional survey and the commentary by Jacky Hanson and Kirsten Walthall Privacy is a key element in the process of undertaking a consultation with a patient, as it allows due care and attention to paid to the patient’s condition and to their concerns. This survey (see page 406) was conducted at the 2015 American College of Emergency Physicians Scientific Assembly, by inviting practising ED physicians into a booth at this meeting; participants were asked to consider 22 items to determine if seeing patients in the corridor (‘hallway encounters’) had any impact on practice including any delay or diagnostic failure, and if yes, then to provide greater detail about the associated problems encountered. Within this survey, physicians were also asked if the presence of a companion altered the nature of the consultation with the patient....
      Keywords: EMJ Primary survey
      PubDate: 2018-06-21T08:00:01-07:00
      DOI: 10.1136/emermed-2018-207856
      Issue No: Vol. 35, No. 7 (2018)
  • Effects of hallway/corridor and companions on clinical encounters: a
           possible explanation
    • Authors: Hanson, J; Walthall, K.
      Pages: 404 - 405
      Abstract: All emergency medicine practitioners will have experienced the results of increased demand and exit block on our EDs. Crowded departments have made practising hallway/corridor-based medicine a daily occurrence. We already know that length of stay in hospital and mortality rates increase with crowding and that working in these conditions1 suggests patients are receiving substandard management. Certainly, there is the loss of privacy which all healthcare systems have gone to great lengths to protect and on which much of our medical teaching is premised. Stoklosa et al2 describe two distinct non-private clinical encounters, one where the patient was seen and assessed in a hallway and the other when the patient was seen along with a companion. Both which are said to impinge on the physician’s assessment of the patient. At closer reading, the premise of the survey is to determine if the assessing physician believes that...
      PubDate: 2018-06-21T08:00:01-07:00
      DOI: 10.1136/emermed-2018-207467
      Issue No: Vol. 35, No. 7 (2018)
  • Do EPs change their clinical behaviour in the hallway or when a companion
           is present' A cross-sectional survey
    • Authors: Stoklosa, H; Scannell, M, Ma, Z, Rosner, B, Hughes, A, Bohan, J. S.
      Pages: 406 - 411
      Abstract: ObjectivesOur aim was to determine whether emergency physicians (EPs) felt their standard patient evaluation practice was modified by two non-private clinical encounters: hallway encounters and encounters during which a companion was present.MethodsWe administered an iteratively developed cross-sectional survey at an annual national professional meeting. We used logistic regression to compare relationships among non-private clinical encounters and predictors of interest.Results409 EPs completed the survey. EPs deviated from standard history-taking when practising in a hallway location (78%) and when patients had a companion (84%). EPs altered their standard physical exam when practising in a hallway location (90%) and when patients had a companion (77%). EPs with at least a decade of experience were less likely to alter history-taking in the hallway (OR 0.55, 95% CI 0.31 to 0.99). Clinicians who frequently evaluated patients in the hallway reported delays or diagnostic error-related to altered history-taking (OR 2.34, 95% CI 1.33 to 4.11). The genitourinary system was the most common organ system linked to a delay or diagnostic error. Modifications in history-taking were linked to delays or failure to diagnose suicidal ideation or self-harm (25%), intimate partner violence (40%), child abuse (12%), human trafficking (8%), substance abuse (47%) and elder abuse (17%).ConclusionsOur study suggests that alterations in EP usual practice occurs when the doctor–patient dyad is disrupted by evaluation in a hallway or presence of a companion. Furthermore, these disruptions are associated with delays in care and failure to diagnosis medical, social and psychiatric conditions.
      Keywords: Editor's choice
      PubDate: 2018-06-21T08:00:01-07:00
      DOI: 10.1136/emermed-2017-207119
      Issue No: Vol. 35, No. 7 (2018)
  • Essential medicines for emergency care in Africa
    • Authors: Broccoli, M. C; Pigoga, J. L, Nyirenda, M, Wallis, L, Calvello Hynes, E. J.
      Pages: 412 - 419
      Abstract: ObjectivesEssential medicines lists (EMLs) are efficient means to ensure access to safe and effective medications. The WHO has led this initiative, generating a biannual EML since 1977. Nearly all countries have implemented national EMLs based on the WHO EML. Although EMLs have given careful consideration to many public health priorities, they have yet to comprehensively address the importance of medicines for treating acute illness and injury.MethodsWe undertook a multistep consensus process to establish an EML for emergency care in Africa. After a review of existing literature and international EMLs, we generated a candidate list for emergency care. This list was reviewed by expert clinicians who ranked the medicines for overall inclusion and strength of recommendation. These medications and recommendations were then evaluated by an expert group. Medications that reached consensus in both the online survey and expert review were included in a draft emergency care EML, which underwent a final inperson consensus process.ResultsThe final emergency care EML included 213 medicines, 25 of which are not in the 2017 WHO EML, but were deemed essential for clinical practice by regional emergency providers. The final EML has associated recommendations of desirable or essential and is subdivided by facility level. Thirty-nine medicines were recommended for basic facilities, an additional 96 for intermediate facilities (eg, district hospitals) and an additional 78 for advanced facilities (eg, tertiary centres).ConclusionThe 25 novel medications not currently on the WHO EML should be considered by planners when making rational formularies for developing emergency care systems. It is our hope that these resource-stratified lists will allow for easier implementation and will be a useful tool for practical expansion of emergency care delivery in Africa.
      PubDate: 2018-06-21T08:00:01-07:00
      DOI: 10.1136/emermed-2017-207396
      Issue No: Vol. 35, No. 7 (2018)
  • Lower extremity pain and numbness
    • Authors: Pettit; N. R.
      Pages: 419 - 433
      Abstract: Clinical introductionA 45-year-old man with no past medical history presents with bilateral lower extremity pain and perineal numbness after walking 10–15 min. The pain starts in his bilateral buttocks and radiates down into his thigh and into his toes. He has no back pain, fever, difficulty urinating or stooling, incontinence or trauma. Social history is positive for smoking. Physical examination was only remarkable for non-dopplerable lower extremity pulses, and he was unable to ambulate down the ED hallway without becoming symptomatic. Ultrasound of his abdominal aorta (figure 1) was performed.Figure 1Transverse view of distal abdominal aorta, just proximal to the bifurcation. (A) The aorta without Doppler. (B) The same image with Doppler mode activated.QuestionWhat is the most likely diagnosis based on the image'A. Lumbar stenosisB. Abdominal aortic aneurysmC. Aortic thrombusD. Aortic dissection
      Keywords: EMJ Image Challenge
      PubDate: 2018-06-21T08:00:01-07:00
      DOI: 10.1136/emermed-2017-207248
      Issue No: Vol. 35, No. 7 (2018)
  • Risk stratifying chest pain patients in the emergency department using
           HEART, GRACE and TIMI scores, with a single contemporary troponin result,
           to predict major adverse cardiac events
    • Authors: Reaney, P. D. W; Elliott, H. I, Noman, A, Cooper, J. G.
      Pages: 420 - 427
      Abstract: BackgroundThe majority of patients presenting to the ED with cardiac sounding chest pain have a non-diagnostic ECG and the problem of differentiating those suffering an acute coronary syndrome from those without is familiar to all ED clinical staff. To stratify risk in these patients, specific scores have been developed. Recent work has focused on incorporating newer high-sensitivity cardiac troponin (hs-cTn) assays; however, issues regarding performance and availability of these assays remain.AimProspectively compare HEART, Global Registry of Acute Coronary Events (GRACE) and Thrombolysis in Myocardial Infarction (TIMI) scores, using a single contemporary cTn at admission, to predict a major adverse cardiac event (MACE) at 30 days.MethodProspective observational cohort study performed in a UK tertiary hospital in patients with suspected cardiac chest pain and no significant ST elevation on initial ECG. Data collection took place 2 December 2014 to 8 February 2016. The treating clinician recorded risk score data real time and a single contemporary cTn taken at presentation was used in score calculation. The primary endpoint was 30-day MACE. C-statistic was determined for each score and diagnostic characteristics of high-risk and low-risk cut-offs were calculated.Results189/1000 patients in the study developed a 30-day MACE. The c-statistic of HEART for 30-day MACE (0.87 (95% CI 0.84 to 0.90)) was higher than TIMI (0.78 (95% CI 0.74 to 0.81)) and GRACE (0.74 (95% CI 0.70 to 0.78)).HEART score ≤3 identified low-risk patients with sensitivity 99.5% (95% CI 97.1% to 99.9%) and negative predictive value (NPV) 99.6% (95% CI 97.3% to 99.9%) exceeding TIMI 0 (sensitivity 97.4% (95% CI 93.9% to 99.1%) and NPV 97.8% (95% CI 94.8% to 99.1%)) and GRACE score 0–55 (sensitivity 95.2% (95% CI 91.1% to 97.8%) and NPV 95.8% (95% CI 92.2% to 97.7%)).ConclusionHEART outperformed both TIMI and GRACE in overall discriminative capacity for 30-day MACE. Using a single contemporary cTn at presentation, a HEART score of ≤3 demonstrated sensitivity and NPV of ≥99.5% for 30-day MACE. These results reach the threshold for a safe discharge strategy but should be interpreted thoughtfully in light of other work.
      PubDate: 2018-06-21T08:00:01-07:00
      DOI: 10.1136/emermed-2017-207172
      Issue No: Vol. 35, No. 7 (2018)
  • End-tidal carbon dioxide output in manual cardiopulmonary resuscitation
           versus active compression-decompression device during prehospital quality
           controlled resuscitation: a case series study
    • Authors: Setälä, P. A; Virkkunen, I. T, Kämäräinen, A. J, Huhtala, H. S. A, Virta, J. S, Yli-Hankala, A. M, Hoppu, S. E.
      Pages: 428 - 432
      Abstract: BackgroundActive compression–decompression (ACD) devices have enhanced end-tidal carbon dioxide (ETCO2) output in experimental cardiopulmonary resuscitation (CPR) studies. However, the results in out-of-hospital cardiac arrest (OHCA) patients have shown inconsistent outcomes, and earlier studies lacked quality control of CPR attempts. We compared manual CPR with ACD-CPR by measuring ETCO2 output using an audiovisual feedback defibrillator to ensure continuous high quality resuscitation attempts.Methods10 witnessed OHCAs were resuscitated, rotating a 2 min cycle with manual CPR and a 2 min cycle of ACD-CPR. Patients were intubated and the ventilation rate was held constant during CPR. CPR quality parameters and ETCO2 values were collected continuously with the defibrillator. Differences in ETCO2 output between manual CPR and ACD-CPR were analysed using a linear mixed model where ETCO2 output produced by a summary of the 2 min cycles was included as the dependent variable, the patient as a random factor and method as a fixed effect. These comparisons were made within each OHCA case to minimise confounding factors between the cases.ResultsMean length of the CPR episodes was 37 (SD 8) min. Mean compression depth was 76 (SD 1.3) mm versus 71 (SD1.0) mm, and mean compression rate was 100 per min (SD 6.7) versus 105 per min (SD 4.9) between ACD-CPR and manual CPR, respectively. For ETCO2 output, the interaction between the method and the patient was significant (P
      PubDate: 2018-06-21T08:00:01-07:00
      DOI: 10.1136/emermed-2017-207103
      Issue No: Vol. 35, No. 7 (2018)
  • Paediatric traumatic cardiac arrest: a Delphi study to establish consensus
           on definition and management
    • Authors: Rickard; A. C., Vassallo, J., Nutbeam, T., Lyttle, M. D., Maconochie, I. K., Enki, D. G., Smith, J. E., on behalf of PERUKI (Paediatric Emergency Research in the UK Ireland)
      Pages: 434 - 439
      Abstract: AimsPaediatric traumatic cardiac arrest (TCA) is associated with low survival and poor outcomes. The mechanisms that underlie TCA are different from medical cardiac arrest; the approach to treatment of TCA may therefore also need to differ to optimise outcomes. The aim of this study was to explore the opinion of subject matter experts regarding the diagnosis and treatment of paediatric TCA, and to reach consensus on how best to manage this group of patients.MethodsAn online Delphi study was conducted over three rounds, with the aim of achieving consensus (defined as 70% agreement) on statements related to the diagnosis and management of paediatric TCA. Participants were invited from paediatric and adult emergency medicine, paediatric anaesthetics, paediatric ICU and paediatric surgery, as well as Paediatric Major Trauma Centre leads and representatives from the Resuscitation Council UK. Statements were informed by literature reviews and were based on elements of APLS resuscitation algorithms as well as some concepts used in the management of adult TCA; they ranged from confirmation of cardiac arrest to the indications for thoracotomy.Results73 experts completed all three rounds between June and November 2016. Consensus was reached on 14 statements regarding the diagnosis and management of paediatric TCA; oxygenation and ventilatory support, along with rapid volume replacement with warmed blood, improve survival. The duration of cardiac arrest and the lack of a response to intervention, along with cardiac standstill on ultrasound, help to guide the decision to terminate resuscitation.ConclusionThis study has given a consensus-based framework to guide protocol development in the management of paediatric TCA, though further work is required in other key areas including its acceptability to clinicians.
      PubDate: 2018-06-21T08:00:01-07:00
      DOI: 10.1136/emermed-2017-207226
      Issue No: Vol. 35, No. 7 (2018)
  • Senior doctor triage (SDT), a qualitative study of clinicians views on
           senior doctors involvement in triage and early assessment of emergency
    • Authors: Abdulwahid, M. A; Turner, J, Mason, S. M.
      Pages: 440 - 446
      Abstract: IntroductionDespite the focus during the last decade on introducing interventions such as senior doctor initial assessment or senior doctor triage (SDT) to reduce emergency department (ED) crowding, there has been little attempt to identify the views of emergency healthcare professionals on such interventions. The aim of this study was to gain an understanding of SDT from the perspective of emergency hospital staff. A secondary aim of this study was to develop a definition of SDT based on the interview findings and the available literature on this process.MethodsQualitative semi-structured telephone interviews were conducted with participants of different backgrounds including senior doctors, nurses, paramedics and ED managers. Textual data were analysed using a template analysis approach.Results27 participants from 13 EDs across England were interviewed. SDT was viewed as a safety mechanism and a measure to control patient flow. The most prominent positive aspect was the ability to initiate early investigations and treatment. Various shortcomings of SDT were described such as the lack of standardisation of the process and its cost implications. Participants identified a number of barriers to this process including insufficient resources and exit block, and called for solutions focused on these issues. A proposed definition of an ‘ideal’ SDT was developed where it is described as a systematic brief assessment of patients arriving at the ED by a senior doctor-led team, which takes place in a dedicated unit. The aim of this assessment is to facilitate early investigation and management of patients, early patient disposition and guide junior staff to deliver safe and high-quality clinical care.ConclusionThis is the first national study to explore the opinions of various emergency and managerial staff on the SDT model. It revealed variable interpretations of this model and what it can and cannot offer. This has led to a standard definition of the SDT process, which can be useful for clinicians and researchers in emergency care.
      PubDate: 2018-06-21T08:00:01-07:00
      DOI: 10.1136/emermed-2017-207219
      Issue No: Vol. 35, No. 7 (2018)
  • Emergency department overcrowding: a survey among European neurotrauma
    • Authors: Velt, K. B; Cnossen, M, Rood, P. P. M, Steyerberg, E. W, Polinder, S, Lingsma, H. F, the CENTER-TBI investigators
      Pages: 447 - 448
      Abstract: BackgroundED overcrowding is an increasing problem worldwide that may negatively affect quality of care and patient outcomes. We aimed to study ED overcrowding across European centres.MethodsQuestionnaires on structure and process of care, including crowding, were distributed to 68 centres participating in a large European study on traumatic brain injury (Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury).ResultsOf the 65 centres included in the analysis, 32 (49%) indicated that overcrowding was a frequent problem and 28 (43%) reported that patients were placed in hallways ‘multiple times a day’; 27 (41%) stated that multiple times a day, there was no bed available when a patient needed to be admitted. Ambulance diversion rarely occurred in the participating centres.ConclusionSimilar to reports from other parts of the world, ED crowding appears to be a considerable problem in Europe. More research is needed to determine effective ways to reduce overcrowding.
      PubDate: 2018-06-21T08:00:01-07:00
      DOI: 10.1136/emermed-2017-206796
      Issue No: Vol. 35, No. 7 (2018)
  • Prehospital haemostatic dressings for trauma: a systematic review
    • Authors: Boulton, A. J; Lewis, C. T, Naumann, D. N, Midwinter, M. J.
      Pages: 449 - 457
      Abstract: BackgroundHaemorrhage is a major cause of mortality and morbidity following both military and civilian trauma. Haemostatic dressings may offer effective haemorrhage control as part of prehospital treatment.AimTo conduct a systematic review of the clinical literature to assess the prehospital use of haemostatic dressings in controlling traumatic haemorrhage, and determine whether any haemostatic dressings are clinically superior.MethodsMEDLINE and EMBASE databases were searched using predetermined criteria. The reference lists of all returned review articles were screened for eligible studies. Two authors independently undertook the search, performed data extraction, and risk of bias and Grading of Recommendations, Assessment, Development and Evaluation quality assessments. Meta-analysis could not be undertaken due to study and clinical heterogeneity.ResultsOur search yielded 470 studies, of which 17 met eligibility criteria, and included 809 patients (469 military and 340 civilian). There were 15 observational studies, 1 case report and 1 randomised controlled trial. Indications for prehospital haemostatic dressing use, wound location, mechanism of injury, and source of bleeding were variable. Seven different haemostatic dressings were reported with QuikClot Combat Gauze being the most frequently applied (420 applications). Cessation of bleeding ranged from 67% to 100%, with a median of 90.5%. Adverse events were only reported with QuikClot granules, resulting in burns. No adverse events were reported with QuikClot Combat Gauze use in three studies. Seven of the 17 studies did not report safety data. All studies were at risk of bias and assessed of ‘very low’ to ‘moderate’ quality.ConclusionsHaemostatic dressings offer effective prehospital treatment for traumatic haemorrhage. QuikClot Combat Gauze may be justified as the optimal agent due to the volume of clinical data and its safety profile, but there is a lack of high-quality clinical evidence, and randomised controlled trials are warranted.Level of evidenceSystematic review, level IV.
      PubDate: 2018-06-21T08:00:01-07:00
      DOI: 10.1136/emermed-2018-207523
      Issue No: Vol. 35, No. 7 (2018)
  • Abstracts from international Emergency Medicine journals
    • Pages: 458 - 459
      Abstract: Editor’s note: EMJ has partnered with the journals of multiple international emergency medicine societies to share from each a highlighted research study, as selected by their editors. This edition will feature an abstract from each publication.
      PubDate: 2018-06-21T08:00:01-07:00
      DOI: 10.1136/emermed-2018-207851
      Issue No: Vol. 35, No. 7 (2018)
  • Sex differences in mortality among critically ill children in Pakistan
    • Authors: Campbell; M.
      Pages: 460 - 460
      Abstract: I read with interest the article on the outcomes of critically ill children in Pakistan.1 There are two surprising findings that the authors did not discuss. First, only 37% of the attending children were female. Second, 59% of all deaths were female. One can calculate the male death rate (8.2%) and the female death rate (20.1%). This means that the relative risk of dying for girls presenting as triage category 1 is 2.44 (2.23–2.76, p
      Keywords: Epidemiology
      PubDate: 2018-06-21T08:00:01-07:00
      DOI: 10.1136/emermed-2018-207512
      Issue No: Vol. 35, No. 7 (2018)
School of Mathematical and Computer Sciences
Heriot-Watt University
Edinburgh, EH14 4AS, UK
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