The COVID-19 pandemic has shed light on the ongoing pandemic of racial injustice. In the context of these twin pandemics, emergency medicine organizations are declaring that “Racism is a Public ...Health Crisis.” Accordingly, we are challenging emergency clinicians to respond to this emergency and commit to being antiracist. This courageous journey begins with naming racism and continues with actions addressing the intersection of racism and social determinants of health that result in health inequities. Therefore, we present a social-ecological framework that structures the intentional actions that emergency medicine must implement at the individual, organizational, community, and policy levels to actively respond to this emergency and be antiracist.
Bronchiolitis accounts for a considerable number of Emergency Department (ED) visits by infants each year and is the leading cause of respiratory infection in children 2 years of age and younger. ...Suctioning remains one of the main supportive treatments, but suctioning practices of nasal aspiration and deep suctioning vary among practitioners in bronchiolitis management. Our objective was to explore associations between suction type and respiratory distress, oxygen saturation, and markers of respiratory compromise such as airway escalation, disposition, ED length of stay (LOS), and outpatient outcomes.
This was a prospective observational study on infants (aged 2–23 months) in a pediatric ED with bronchiolitis from September 2022 to April 2023. Infants with tracheostomies, muscular weakness, and non-invasive positive pressure ventilation were excluded. Infants were grouped into nasal aspiration, deep suctioning, or combination groups. Mean differences in respiratory scores (primary outcome) and oxygen saturation were measured at three timepoints: pre-suction, 30 and 60 min post-suction. Escalation to airway adjuncts, disposition, and ED LOS were also recorded. Discharged families were contacted for phone call interviews.
Of 121 enrolled infants (nasal aspiration n = 31, deep suctioning n = 68, combination n = 22), 48% (n = 58) were discharged, and 90% (n = 52) completed the study call. There was no interaction between suction type and timepoint (p = 0.63) and no effect between suction type and respiratory score (p = 0.38). However, timepoint did have an effect on respiratory score between 0 and 30 min post-suction (p = 0.01) and between 0 and 60 min post-suction (p < 0.001). Admitted infants received more deep suctioning or a combination of suctioning compared to those discharged (p = 0.005). Suction type had no effect on oxygen saturation, airway adjunct escalation, length of stay, or outpatient outcomes (p > 0.11).
There was no difference in respiratory scores or outpatient outcomes between suction types. Deep suctioning may not be needed in all infants with bronchiolitis.
•Bronchiolitis accounts for many pediatric ED visits each year.•Bronchiolitis is the leading cause of respiratory infection in children under age 2.•Supportive care including suctioning remains the primary management.•Nasal aspiration and deep suctioning reduce respiratory distress in bronchiolitis.•Deep suctioning may not be needed in all infants with bronchiolitis.
Intravenous fluids and vasopressor agents are commonly used in early resuscitation of patients with sepsis, but comparative data for prioritizing their delivery are limited.
In an unblinded ...superiority trial conducted at 60 U.S. centers, we randomly assigned patients to either a restrictive fluid strategy (prioritizing vasopressors and lower intravenous fluid volumes) or a liberal fluid strategy (prioritizing higher volumes of intravenous fluids before vasopressor use) for a 24-hour period. Randomization occurred within 4 hours after a patient met the criteria for sepsis-induced hypotension refractory to initial treatment with 1 to 3 liters of intravenous fluid. We hypothesized that all-cause mortality before discharge home by day 90 (primary outcome) would be lower with a restrictive fluid strategy than with a liberal fluid strategy. Safety was also assessed.
A total of 1563 patients were enrolled, with 782 assigned to the restrictive fluid group and 781 to the liberal fluid group. Resuscitation therapies that were administered during the 24-hour protocol period differed between the two groups; less intravenous fluid was administered in the restrictive fluid group than in the liberal fluid group (difference of medians, -2134 ml; 95% confidence interval CI, -2318 to -1949), whereas the restrictive fluid group had earlier, more prevalent, and longer duration of vasopressor use. Death from any cause before discharge home by day 90 occurred in 109 patients (14.0%) in the restrictive fluid group and in 116 patients (14.9%) in the liberal fluid group (estimated difference, -0.9 percentage points; 95% CI, -4.4 to 2.6; P = 0.61); 5 patients in the restrictive fluid group and 4 patients in the liberal fluid group had their data censored (lost to follow-up). The number of reported serious adverse events was similar in the two groups.
Among patients with sepsis-induced hypotension, the restrictive fluid strategy that was used in this trial did not result in significantly lower (or higher) mortality before discharge home by day 90 than the liberal fluid strategy. (Funded by the National Heart, Lung, and Blood Institute; CLOVERS ClinicalTrials.gov number, NCT03434028.).
This case report presents the diagnostic difficulties encountered by a 96-year-old woman with osteoporosis who experienced acute chest pain following minor trauma, eventually diagnosed with a sternal ...fracture. It highlights the nuanced presentation and diagnostic challenges associated with sternal fractures in older patients. Despite the prevalent use of chest radiography and computed tomography in acute trauma assessments, this case emphasizes their limitations, as both modalities initially failed to detect the sternal fracture. The successful identification of the fracture using ultrasound (US) underscores the utility of this modality in detecting subtle yet clinically significant injuries. This report advocates for a high index of suspicion for sternal fractures in older patients presenting with chest pain after minor trauma and suggests that US is a valuable, less invasive diagnostic tool. By illuminating the potential for minor trauma to cause major injury and the critical role of US in diagnosis, this case provides valuable insights into the management of sternal fractures in the geriatric population, urging clinicians to consider atypical presentations in diagnostic evaluations.This case report presents the diagnostic difficulties encountered by a 96-year-old woman with osteoporosis who experienced acute chest pain following minor trauma, eventually diagnosed with a sternal fracture. It highlights the nuanced presentation and diagnostic challenges associated with sternal fractures in older patients. Despite the prevalent use of chest radiography and computed tomography in acute trauma assessments, this case emphasizes their limitations, as both modalities initially failed to detect the sternal fracture. The successful identification of the fracture using ultrasound (US) underscores the utility of this modality in detecting subtle yet clinically significant injuries. This report advocates for a high index of suspicion for sternal fractures in older patients presenting with chest pain after minor trauma and suggests that US is a valuable, less invasive diagnostic tool. By illuminating the potential for minor trauma to cause major injury and the critical role of US in diagnosis, this case provides valuable insights into the management of sternal fractures in the geriatric population, urging clinicians to consider atypical presentations in diagnostic evaluations.
The coronavirus disease 2019 (COVID-19) pandemic has significantly impacted various aspects of healthcare services, including emergency care services. Healthcare staff face mental issues and physical ...exertion when caring for patients potentially infected with COVID-19. Understanding the experiences and perspectives of emergency department (ED) healthcare staff during the COVID-19 pandemic is essential to inform evidence-based interventions and strategies to mitigate the impact on emergency care services. This study aims to investigate the experiences of ED healthcare staff regarding emergency care services during the COVID-19 pandemic, thus providing valuable insights into the challenges faced.INTRODUCTIONThe coronavirus disease 2019 (COVID-19) pandemic has significantly impacted various aspects of healthcare services, including emergency care services. Healthcare staff face mental issues and physical exertion when caring for patients potentially infected with COVID-19. Understanding the experiences and perspectives of emergency department (ED) healthcare staff during the COVID-19 pandemic is essential to inform evidence-based interventions and strategies to mitigate the impact on emergency care services. This study aims to investigate the experiences of ED healthcare staff regarding emergency care services during the COVID-19 pandemic, thus providing valuable insights into the challenges faced.This study utilized a cross-sectional study design. Data were collected from 256 ED healthcare staff working in nine different hospitals located in Turkey between November 15, 2021, and December 30, 2021. Data were analyzed using descriptive statistics.MATERIALS AND METHODSThis study utilized a cross-sectional study design. Data were collected from 256 ED healthcare staff working in nine different hospitals located in Turkey between November 15, 2021, and December 30, 2021. Data were analyzed using descriptive statistics.A total of 256 participants were included in the study. Of the participants, 58.6% were nurses, 19.5% were ED doctors, and 21.9% were emergency medical technicians. In addition, 67.2% of the participants were infected with COVID-19, and almost all of them (94.1%) were psychologically affected by the pandemic process. It was found that 85.2% of ED healthcare staff felt excluded by society due to being healthcare staff and 71.9% had to be separated from their families. Nurses were separated from their families at the highest rate (78%) during this period.RESULTSA total of 256 participants were included in the study. Of the participants, 58.6% were nurses, 19.5% were ED doctors, and 21.9% were emergency medical technicians. In addition, 67.2% of the participants were infected with COVID-19, and almost all of them (94.1%) were psychologically affected by the pandemic process. It was found that 85.2% of ED healthcare staff felt excluded by society due to being healthcare staff and 71.9% had to be separated from their families. Nurses were separated from their families at the highest rate (78%) during this period.More than half of the ED healthcare staff had problems accessing protective equipment and were separated from their families during the pandemic due to the risk of COVID-19 transmission. Although the number of ED visits decreased because of restrictions at the beginning of the pandemic, ED visits increased again with the abolition of restrictions.CONCLUSIONMore than half of the ED healthcare staff had problems accessing protective equipment and were separated from their families during the pandemic due to the risk of COVID-19 transmission. Although the number of ED visits decreased because of restrictions at the beginning of the pandemic, ED visits increased again with the abolition of restrictions.
Deep brain stimulation (DBS) has emerged as an important therapeutic option for several movement disorders; however, the management of acute complications, such as acute subdural hematoma (ASDH), ...remains challenging. This is the case of a 71-year-old woman with Parkinson's disease who developed ASDH 12 years after bilateral DBS placement. On admission with altered consciousness, imaging revealed significant displacement of the DBS electrodes because of the hematoma. Emergent craniotomy with endoscopic evacuation was performed with preservation of the DBS system. Postoperatively, complete evacuation of the hematoma was confirmed, and the patient experienced significant clinical improvement. ASDH causes significant electrode displacement in patients undergoing DBS. After hematoma evacuation, the electrodes were observed to return to their proper position, and the patient exhibited a favorable clinical response to stimulation. To preserve the DBS electrodes, endoscopic hematoma evacuation via a small craniotomy may be useful.Deep brain stimulation (DBS) has emerged as an important therapeutic option for several movement disorders; however, the management of acute complications, such as acute subdural hematoma (ASDH), remains challenging. This is the case of a 71-year-old woman with Parkinson's disease who developed ASDH 12 years after bilateral DBS placement. On admission with altered consciousness, imaging revealed significant displacement of the DBS electrodes because of the hematoma. Emergent craniotomy with endoscopic evacuation was performed with preservation of the DBS system. Postoperatively, complete evacuation of the hematoma was confirmed, and the patient experienced significant clinical improvement. ASDH causes significant electrode displacement in patients undergoing DBS. After hematoma evacuation, the electrodes were observed to return to their proper position, and the patient exhibited a favorable clinical response to stimulation. To preserve the DBS electrodes, endoscopic hematoma evacuation via a small craniotomy may be useful.
Cytoreduction in leukostasis can be achieved using leukapheresis. We report a case of chronic myeloid leukemia (CML) identified by a persistent erection, which was successfully treated using the ...Spectra Optia®︎ apheresis system. A 29-year-old male presented with an erection for 12 hours without identified triggers and no improvement despite penile corpus cavernosum puncture. His white blood cell count was 458,930/μL. A diagnosis of CML-induced persistent erection with secondary hyperleukocytosis was established. Following an emergency bilateral penile corpus cavernosum incision (distal shunting), he received hydroxyurea and febuxostat. Persistent erection resolved after leukapheresis for two consecutive days. Rapid leukocyte count reduction can effectively address leukostasis in CML without major complications.Cytoreduction in leukostasis can be achieved using leukapheresis. We report a case of chronic myeloid leukemia (CML) identified by a persistent erection, which was successfully treated using the Spectra Optia®︎ apheresis system. A 29-year-old male presented with an erection for 12 hours without identified triggers and no improvement despite penile corpus cavernosum puncture. His white blood cell count was 458,930/μL. A diagnosis of CML-induced persistent erection with secondary hyperleukocytosis was established. Following an emergency bilateral penile corpus cavernosum incision (distal shunting), he received hydroxyurea and febuxostat. Persistent erection resolved after leukapheresis for two consecutive days. Rapid leukocyte count reduction can effectively address leukostasis in CML without major complications.
The Verbal Numerical Rating Scale is the most commonly used self-report measure of pain intensity. It is unclear how the validity and reliability of the scale scores vary across children’s ages. We ...aimed to determine the validity and reliability of the scale for children presenting to the emergency department across a comprehensive spectrum of age.
This was a cross-sectional study of children aged 4 to 17 years. Children self-reported their pain intensity, using the Verbal Numerical Rating Scale and Faces Pain Scale–Revised at 2 serial assessments. We evaluated convergent validity (strong validity defined as correlation coefficient ≥0.60), agreement (difference between concurrent Verbal Numerical Rating Scale and Faces Pain Scale–Revised scores), known-groups validity (difference in score between children with painful versus nonpainful conditions), responsivity (decrease in score after analgesic administration), and reliability (test-retest at 2 serial assessments) in the total sample and subgroups based on age.
We enrolled 760 children; 27 did not understand the Verbal Numerical Rating Scale and were removed. Of the remainder, Pearson correlations were strong to very strong (0.62 to 0.96) in all years of age except 4 and 5 years, and agreement was strong for children aged 8 and older. Known-groups validity and responsivity were strong in all years of age. Reliability was strong in all age subgroups, including each year of age from 4 to 7 years.
Convergent validity, known-groups validity, responsivity, and reliability of the Verbal Numerical Rating Scale were strong for children aged 6 to 17 years. Convergent validity was not strong for children aged 4 and 5 years. Our findings support the use of the Verbal Numerical Rating Scale for most children aged 6 years and older, but not for those aged 4 and 5 years.
Objectives
We aimed to synthesize the available evidence on the demographics, prevalence, clinical characteristics, and evidence‐based management of homeless persons in the emergency department (ED). ...Where appropriate, we highlight knowledge gaps and suggest directions for future research.
Methods
We conducted a systematic literature search following databases: PubMed, Ovid, and Google Scholar for articles published between January 1, 1990, and December 31, 2016. We supplemented this search by cross‐referencing bibliographies of the retrieved publications. Peer‐reviewed studies written in English and conducted in the United States that examined homelessness within the ED setting were included. We used a qualitative approach to synthesize the existing literature.
Results
Twenty‐eight studies were identified that met the inclusion criteria. Based on our study objectives and the available literature, we grouped articles examining homeless populations in the ED into four broad categories: 1) prevalence and sociodemographic characteristics of homeless ED visits, 2) ED utilization by homeless adults, 3) clinical characteristics of homeless ED visits, and 4) medical education and evidence‐based management of homeless ED patients.
Conclusion
Homelessness may be underrecognized in the ED setting. Homeless ED patients have distinct care needs and patterns of ED utilization that are unmet by the current disease‐oriented and episodic models of emergency medicine. More research is needed to determine the prevalence and characteristics of homelessness in the ED and to develop evidence‐based treatment strategies in caring for this vulnerable population.
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