Emerg. Care Med., Volume 1, Issue 2 (June 2024) – 9 articles

Emergency Departments (ED) play a vital role within the health system, representing the ‘front door’ to hospitals, the first point of hospital contact for patients who are undifferentiated and may be critically ill. They also serve as a safety net for the healthcare system. Together with ED overcrowding, this patient care environment is highly vulnerable to the provision of suboptimal care and breaches in patient safety. Government agencies in Australia currently collect data that are broad and administratively focused and are limited in capacity to identifying clinical quality. Clinical quality registries (CQR) help fill this gap but are often funded by not-for-profit organisations or research grants. There is no emergency care CQR in Tasmania, Australia. We propose the establishment of the Tasmanian Emergency Care Outcomes Registry (TECOR) to monitor emergency care processes and outcomes. The primary objective of TECOR is to monitor the unexpected 30-day mortality of patients who are cared for in the ED as well as 30-day safety events where emergency care was the primary contributor. The TECOR is expected to provide ongoing data on other important processes of emergency care in Tasmania such as length of stay in EDs, 28-day representation to EDs and hospital length of stay. The registry was designed to national standards and will meet the needs of the clinical community and have a positive impact on the communities it serves. Full article

Orthopedic emergencies due to fractures are one of the main reasons for surgical intervention. The distal radius is a structure prone to fractures, particularly in young people. The main objective of this study was to evaluate the success rate of methoxyflurane in the reduction in distal radius fractures that required conservative treatment. The medical records of all the patients with Frykman type I and type II distal radius fractures who underwent fracture reduction with methoxyflurane or propofol from December 2021 to January 2023 were reviewed. The success rate of distal radius fracture reduction with methoxyflurane was analyzed, and the secondary outcomes, such as the recovery time and length of stay in the orthopedic emergency department, were assessed and compared with propofol. A total of 145 patients with distal radius fractures presented to the emergency department during the study period. Seventy-five patients met our inclusion criteria. Fifty patients had a fracture reduction with methoxyflurane, while twenty patients received propofol. The median recovery time and reduction duration were 30 min and 65.5 min, respectively, resulting in a shorter period for the methoxyflurane group. Methoxyflurane was successfully used in 48 of the 82 patients undergoing Frykman type I and type II distal radius fracture reduction while improving the recovery time due to its easy self-delivery and rapid effectiveness in the patient, as well as being able to estimate the level of pain so that the amount of anesthetic needed can be estimated and adverse effects avoided. Methoxyflurane represents a great candidate for surgical interventions like the reduction in distal radius fractures. Full article

A 15-year-old girl was admitted to the Pediatric Emergency Department due to abdominal discomfort, anorexia, diarrhea, emesis, and weight loss. An inflammatory bowel disease diagnosis was suspected and a complete endoscopic investigation was deemed necessary. Initially, only colonoscopy with ileoscopy was performed, with evidence of widespread ileal ulcers, whereas a subsequent esophagogastroduodenoscopy revealed a huge trichobezoar that was further surgically removed. Trichobezoars are intraluminal conglomerates composed of ingested hair and are typically associated with underlying psychiatric disorders. Bezoars can be asymptomatic or present with various gastrointestinal symptoms, mimicking, among other conditions, inflammatory bowel disease. They may extend through the pylorus into the jejunum leading to Rapunzel Syndrome, which may cause intestinal obstruction. The treatment of trichobezoar depends on its location and volume. An endoscopic approach is possible for small-sized trichobezoars, but to avoid bezoar tail migration along the intestine, causing obstruction, conventional laparotomy is the only valid treatment for patients with Rapunzel Syndrome. Due to the increasing incidence of psychiatric disorders in pediatric age during the SARS-CoV-2 pandemic and their relationship with trichobezoars, an increase in cases of trichobezoars was observed. Thus, interdisciplinary collaboration between psychiatrists, pediatricians, and surgeons is crucial not only during the acute phase but also for long-term management and prevention of recurrence. Full article

Procedural sedation and analgesia (PSA) in the emergency department (ED) presents a crucial aspect of emergency medicine, enabling the execution of painful or distressing procedures with minimal patient discomfort. This narrative review delineates the pharmacological framework, methodologies, and clinical considerations integral to optimizing PSA, with a particular focus on pediatric and geriatric populations. Through a comprehensive review and analysis of current practices, this work evaluates the pharmacokinetics and pharmacodynamics of widely utilized sedatives and analgesics, including propofol, ketamine, dexmedetomidine, fentanyl, midazolam, etomidate, nitrous oxide, and remimazolam. Special attention is dedicated to the selection criteria based on patient-specific risk factors, procedural requirements, and the management of potential adverse effects. The manuscript also explores innovative sedation techniques and the integration of new pharmacological agents, emphasizing evidence-based approaches to enhance patient safety and outcome. The results underscore the significance of tailored sedation strategies, especially for vulnerable groups such as pediatric and geriatric patients, highlighting the need for meticulous pre-procedural assessment and monitoring to mitigate risks. The conclusions drawn advocate for a nuanced application of PSA, guided by current evidence and clinical guidelines, to improve the quality of care in emergency settings. This research reinforces the imperative for ongoing education, skill development, and the adaptation of new evidence into clinical practice to advance procedural sedation and analgesia in the ED. Full article

Emergency department physicians uncommonly associate myopericarditis with bacterial infection and, even more rarely, encounter myopericarditis caused by meningococcal infection. This case report describes a 38-year-old man who presented with chest pain, electrocardiographic changes, and cardiac biomarkers consistent with acute myopericarditis and rapidly developed central nervous system symptoms that were concerning for acute bacterial meningitis. The diagnosis of Neisseria meningitidis infection was confirmed by blood cultures. Once identified, the patient made a full recovery following a course of intravenous antibiotic therapy. This case underscores the difficulty of diagnosing this rare, but potentially life-threatening, condition in the emergency department. Full article

Introduction: Metformin, a commonly used oral antihyperglycemic drug, poses a rare risk related to the development of metformin-associated lactic acidosis (MALA). The Extracorporeal Treatments in Poisoning (EXTRIP) group recommended intermittent haemodialysis (IHD) as a primary elimination therapy in case of severe metformin poisoning. However, in haemodynamically unstable patients, our previous observations suggested that continuous venovenous haemofiltration (CVVH) might be more effective. This retrospective cohort study aimed to contribute evidence on the use of IHD and CVVH in patients with severe MALA, particularly in haemodynamically unstable patients. Methods: Data from January 2015 to December 2020 were collected from the Leuven University Hospital. Two separate search methods, based on hospital activity records and laboratory criteria, were used to identify patients with MALA. Patients diagnosed with MALA, receiving extracorporeal treatment within 24 h of admission, were included. Patients were categorized into the IHD and CVVH groups. Patient characteristics, treatment details, and outcomes were analysed. Results: Among 358,148 patient records, 35 MALA cases were identified. IHD was chosen as the initial elimination technique in 13 cases, whereas 22 patients were first commenced on CVVH. Patients treated with CVVH were sicker, had more comorbidities and had higher ventilation and vasopressor requirements. CVVH group had longer vasopressor use, longer ICU stays, and higher in-hospital mortality. Discussion: CVVH rather than IHD seems to be the preferred elimination technique in the more critically ill patients with MALA. Due to its retrospective design, this study failed to identify the superior elimination technique in terms of efficacy. Poorer outcomes in the CVVH group are likely attributed to the severity of illness rather than the inferiority of the elimination therapy. We acknowledge the diagnostic challenges regarding MALA. Using metformin assays could be beneficial in managing these patients. Conclusions: This study suggests clinicians’ preference for CVVH in severe cases of MALA with haemodynamic instability. Full article

This review compares the efficacy of video laryngoscopy (VL) with that of direct laryngoscopy (DL) in adult patients with difficult airways who require emergency intubation. Intubation and laryngoscopy are critical in emergency settings, and VL has emerged as an alternative to DL, particularly in difficult airway cases and when performed by non-experienced practitioners. VL demonstrates advantages such as a wider field of view, enhanced glottic visibility, and higher first-pass success rates, particularly in difficult airway scenarios. However, it also presents limitations, including potential view obstruction and technical complexity. While the evidence points to the advantages of VL, particularly in achieving higher first-pass success rates and minimizing adverse events in adult patients with difficult airways, the inconclusive findings from randomized trials emphasize the importance of future research in refining practices and improving patient outcomes. Full article

Background: Treatment of a flexor tendon sheath infection of the thumb usually involves prompt surgical irrigation and debridement (ID). There are few descriptions of this procedure despite the unique anatomy of the thumb flexor sheath. The aim of this study was to investigate thumb flexor sheath ID and explore the relevant anatomy. Methods: The current ID technique was performed on eight embalmed cadaveric hands. Coloured latex was injected into the sheath, and the surrounding region was dissected. Outcomes of interest were the distribution of latex, the success of the procedure, and the anatomy of the radial bursa. Results: Latex was successfully injected into all specimens, although A1 pulley stenosis caused significant resistance to flow. Latex filled the radial bursa (four specimens), reached the distal boundary of the transverse carpal ligament (three), or did not pass the A1 pulley (one); in addition, latex was found in the deep spaces of the hand and wrist (five specimens). The radial bursa was located at a median (range) of 33.2 (23.9–34.5) mm proximal to the carpometacarpal joint and at 7.8 (0–14.0) mm distal to the distal border of the pronator quadratus. Conclusion: These findings contribute to the existing body of knowledge on the anatomy of the thumb flexor sheath and radial bursa, and will help guide hand surgeons to perform thorough ID for infection. A modified surgical technique is presented, which may help further inform the treatment of pyogenic flexor tenosynovitis and other serious hand conditions. Full article

Objective: To identify the factors associated with a neurologically favourable survival of out-of-hospital cardiac arrest (OHCA) occurring in toilets. Methods: We retrospectively compared neurologically favourable 1-month survival rates and survival-related factors for 330,849 non-emergency medical service-witnessed OHCAs that occurred in toilets with those that occurred elsewhere using a nationwide database. Results: Compared to outpatient or hospital admission, OHCA was more likely to be associated with toilets (crude odds ratio [cOR] [95% confidence interval [CI]]: 2.52 [2.48–2.57]). The neurologically favourable 1-month survival rate for OHCA occurring in toilets (1.8%) was significantly lower than that in other places (2.9%) (cOR [95% CI]: 0.60 [0.53–0.68]). Bystander cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) use were minimal in toilets. Neither bystander CPR (adjusted OR [95% CI]: 1.19 [0.91–1.75]) nor AED use (adjusted OR [95% CI]: 2.05 [0.65–6.41]) was associated with improved neurologically favourable 1-month survival in toilets. Conclusions: Despite the poor neurologically favourable survival rate of OHCA in toilets, the provision of bystander CPR and AED was not associated with survival. Potential contributing factors include low rates of bystander intervention and delayed patient detection. To address this issue, focusing particular attention on unwell patients who use the toilets is crucial, and preventive approaches should be promoted. Full article