Editor’s note: The Hong Kong Journal of Emergency Medicine has partnered with a small group of selected journals of international emergency medicine societies to share from each a highlighted research study, as selected monthly by their editors. Our goals are to increase awareness of our readership to research developments in the international emergency medicine literature, promote collaboration among the selected international emergency medicine journals, and support the improvement of emergency medicine world-wide, as described in the WAME statement at http://www.wame.org/about/policy-statements#Promoting%20Global%20Health. Abstracts are reproduced as published in the respective participating journals and are not peer reviewed or edited by the Hong Kong Journal of Emergency Medicine.
Annals of Emergency Medicine
(The print version of this article has been scheduled for July 2021)
The NSW Pathology Atlas of Variation: part II—the association of variation in emergency department laboratory with outcomes for patients presenting with chest pain
Nasir Wabe, PhD, Craig Scowen, MSc, Alex Eigenstetter, BSc, Robert Lindeman, PhD, Andrew Georgiou, PhD
Study objective: Laboratory test use varies across emergency departments (EDs), yet little is known about the effect of this variation on outcomes. The aim of this study is twofold: to stratify EDs into clusters based on similar test use and to determine whether the clusters differ in patient operational outcomes among patients presenting to EDs with undifferentiated chest pain.
Methods: We conducted a retrospective cohort study of 222,788 patients presenting with undifferentiated chest pain at 44 EDs across New South Wales, Australia, from January 2017 to September 2018. The operational outcomes measured in this study included ED length of stay, hospital admission, the Emergency Treatment Performance target, and 7- and 15-day all-cause and same-cause ED revisit rates. We performed a hierarchical cluster analysis to identify ED clusters and mixed-effects models to determine the association between the clusters and the operational outcomes.
Results: Two ED clusters, moderate users (18 EDs) and high users (26 EDs), were identified. After adjustment for confounders, the median ED length of stay was greater by 15.7% (equivalent to 33.4 min) in high versus moderate users (95% confidence interval, 6.62–25.52 min), and high users were less likely to achieve the Emergency Treatment Performance target versus moderate users (odds ratio, 0.66; 95% confidence interval, 0.50–0.86). There were no significant differences between the users in hospital admission and ED revisit rates.
Conclusion: Our findings suggest that reducing test use may reduce ED length of stay and improve the chance of achieving the Emergency Treatment Performance target.
Correspondence
Corresponding Author
How to cite this article:
Wabe, N, Scowen, C, Eigenstetter, A, et al. The NSW Pathology Atlas of Variation: part II—the association of variation in emergency department laboratory with outcomes for patients presenting with chest pain. Ann Emerg Med 2021. doi:10.1016/j.annemergmed.2021.01.006
JULY 2021:
Perception of level of knowledge, skills, and safety before and after training to perform videolaryngoscopy with the Intubox barrier system for airway management in patients with COVID-19
Adández Martínez MG, Leal Costa C, García López JA, Torres Ganfornina M, Ramos Morcillo AJ, García Palenciano C, Díaz Agea JL
Cited: Adández Martínez MG, Leal Costa C, García López JA, et al. Perception of level of knowledge, skills, and safety before and after training to perform videolaryngoscopy with the Intubox barrier system for airway management in patients with COVID-19. Emergencias 2021; 33: 93–99.
http://emergencias.portalsemes.org/descargar/grado-de-percepcin-sobre-el-conocimiento-las-habilidades-y-la-seguridad-antes-y-despus-de-un-programa-de-entrenamiento-con-videolaringoscopia-y-mecanismo-de-proteccin-intubox-en-el-manejo-de-la-va-area-de-pacientes-con-covid19/
Objectives: The main objective was to describe physicians’ perception of their knowledge, skill, and safety before and after training to perform videolaryngoscopy while using the Intubox barrier system when managing the airway of a patient with coronavirus 2019 disease (COVID-19). The secondary objective was to assess the safety afforded by the barrier by means of visually evaluating particle dispersion during intubation.
Methods: Single-arm clinical simulation trial. The participants were physicians who received training in both a low-fidelity and a high-fidelity simulation zone. The participants assessed their knowledge, skill, and safety when using the Intubox before and after training using a specially designed and validated questionnaire. Droplet contamination was estimated visually.
Results: Twenty-seven physicians with a mean (SD) age of 40 (10.8) years participated; 63% were women. They perceived their knowledge, skill, and safety to be significantly higher after training. Droplet contamination was seen to decrease when airway management maneuvers were done with the barrier in place.
Conclusion: After simulation training, the emergency physicians judged their knowledge, skill, and safety to be greater when they used the barrier during airway management in patients with COVID-19. The combined use of a laryngoscope and the Intubox barrier resulted in less particle dispersion during intubation.
Keywords: training, simulation, airway management, safety, COVID-19
EMJ July 2021
Non-invasive assessment of fluid responsiveness to guide fluid therapy in patients with sepsis in the emergency department: a prospective cohort study
Koopmans NK, Stolmeijer R, Sijtsma BC, van Beest PA, Boerma CE, Veeger NJ, Ter Avest E
doi:10.1136/emermed-2020-209771
Background: Little is known about optimal fluid therapy for patients with sepsis without shock who present to the emergency department (ED). In this study, we aimed to quantify the effect of a fluid challenge on non-invasively measured Cardiac Index (CI) in patients presenting with sepsis without shock.
Methods: In a prospective cohort study, CI, stroke volume (SV), and systemic vascular resistance (SVR) were measured non-invasively in 30 patients presenting with sepsis without shock to the ED of a large teaching hospital in the Netherlands between May 2018 and March 2019 using the ClearSight system. After baseline measurements were performed, a passive leg raise (PLR) was done to simulate a fluid bolus. Measurements were then repeated 30, 60, 90, and 120 s after PLR. Finally, a standardized 500 mL NaCl 0.9% intravenous bolus was administered after which final measurements were done. Fluid responsiveness was defined as >15% increase in CI after a standardized fluid challenge.
Measurements and main results: Seven (23%) out of 30 patients demonstrated a >15% increase in CI after PLR and after a 500-mL fluid bolus. Fluid responders had a higher estimated glomerular filtration rate (eGFR) (64 (44–78) vs 37 (23–47), p = 0.009) but otherwise similar patient and treatment characteristics as non-responders. Baseline measurements of cardiac output (CO), CI, SV, and SVR were unrelated to PLR fluid responsiveness. The change in CI after PLR was strongly positively correlated to the change in CI after a 500-mL NaCl 0.9% fluid bolus (r = 0.88, p < 0.001).
Conclusion: The results of this study demonstrate that in patients with sepsis in the absence of shock, three out of four patients do not demonstrate a clinically relevant increase in CI after a standardized fluid challenge. Non-invasive CO monitoring in combination with a PLR test has the potential to identify patients who might benefit from fluid resuscitation and may contribute to a better tailored treatment of these patients.
Keywords: bacterial, clinical management, infectious diseases, non-invasive, treatment
African Journal of Emergency Medicine
The official journal of the African Federation for Emergency Medicine, the Emergency Medicine Association of Tanzania, the Emergency Medicine Society of South Africa, the Egyptian Society of Emergency Medicine, the Libyan Emergency Medicine Association, the Ethiopian Society of Emergency Medicine Professionals, the Sudanese Emergency Medicine Society, the Society of Emergency Medicine Practitioners of Nigeria, and the Rwanda Emergency Care Association
From the pandemic’s front lines: a social responsibility initiative to develop an international free online emergency medicine course for medical students
Cevik AA, Cakal ED, Kwan J
Cevik AA, Cakal ED and Kwan J. From the pandemic’s front lines: A social responsibility initiative to develop an international free online emergency medicine course for medical students. Afr J Emerg Med 2021; 11(1): 1–2.
doi:10.1016/j.afjem.2020.11.005
The COVID-19 pandemic has disrupted medical education and forced medical schools to shift to remote teaching. However, in many institutions, this shift was complicated by the lack of previous experience and resources as well as the decreased educational time and effort due to increased clinical load. In April 2020, the International Emergency Medicine (iEM) Education Project embarked upon a social responsibility initiative to ease and facilitate this transition for emergency medicine clerkships. A 4-week open online emergency medicine core content course for medical students covering 11 lessons and 37 topics was created. This course contains a total of 25 hours of content, 66 chapters curated from the free iEM Education Project 2018 eBook and Society of Academic Emergency Medicine curriculum website, and 131 videos granted freely by the commercial medical education resources provider, Lecturio. In the first 24 h, the website was visited 3127 times from 57 countries in 6 continents. While online teaching is not a substitute for in-person clinical teaching, such initiatives can provide resources to clinical teachers who are overwhelmed with clinical duties and an opportunity for medical students from low-resource settings to continue their training safely during the pandemic.
Reproduced with permission
Annals of Emergency Medicine
(The print version of this article has been scheduled for August 2021)
A prospective study of intramuscular droperidol or olanzapine for acute agitation in the emergency department: a natural experiment due to drug shortages
Jon B Cole, MD, Jamie L Stang, BS, Paige A DeVries, BS, Marc L Martel, MD, James R Miner, MD, Brian E Driver, MD
Study objective: Intramuscular medications are commonly used to treat agitation in the emergency department (ED). The purpose of this study is to compare intramuscular droperidol and olanzapine for treating agitation.
Methods: This was a prospective observational study of ED patients receiving intramuscular droperidol or olanzapine for acute agitation. The treating physician determined the medication and dose; however, over time, drug shortages made either olanzapine (July to September 2019) or droperidol (November 2019 to March 2020) unavailable, creating a natural experiment. The primary outcome was time to adequate sedation, assessed by the Altered Mental Status Scale (AMSS), defined as time to AMSS score less than or equal to 0.
Results: We analyzed 1257 patients (median age, 42 years; 73% men); 538 received droperidol (median dose 5 mg) and 719 received olanzapine (median dose 10 mg). The majority of patients (1,086; 86%) had agitation owing to alcohol intoxication. Time to adequate sedation was 16 min (interquartile range, 10–30 min) for droperidol and 17.5 min (interquartile range, 10–30 min) for olanzapine (absolute difference, −0.7 min; 95% confidence interval, −2.1 to 0.5 min). Adjusted Cox proportional hazard model analysis revealed no difference between groups in time to sedation (hazard ratio for adequate sedation for droperidol compared with olanzapine, 1.12; 95% confidence interval, 1.00–1.25). Patients receiving olanzapine were more likely to receive additional medications for sedation (droperidol, 17%; olanzapine, 24%; absolute difference, −8% (95% confidence interval, −12% to −3%)). We observed no difference between drugs regarding adverse effects except for extrapyramidal adverse effects, which were more common with droperidol (n = 6; 1%) than olanzapine (n = 1; 0.1%).
Conclusion: We found no difference in time to adequate sedation between intramuscular droperidol and olanzapine.
Correspondence
Corresponding Author
How to cite this article:
Cole JB, Stang JL, DeVires PA, et al. A prospective study of intramuscular droperidol or olanzapine for acute agitation in the emergency department: a natural experiment due to drug shortages. Ann Emerg Med 2021. https://doi.org/10.1016/j.annemergmed.2021.01.005
AUGUST 2021:
Factors associated with death due to trauma in patients with a Glasgow Coma Scale score of 3 and bilateral fixed dilated pupils
Chico-Fernández M, Barea-Mendoza JA, Servià-Goixart L, Ormazabal-Zabala T, Quintana-Díaz M, González-Robledo J, Iglesias-Santiago A, Sánchez-Arguiano MJ, Pérez-Bárcena J, Llompart-Pou JA
Cited: Chico-Fernández M, Barea-Mendoza JA, Servià-Goixart L, et al. Factors associated with death due to trauma in patients with a Glasgow Coma Scale score of 3 and bilateral fixed dilated pupils. Emergencias 2021; 33: 121–127.
http://emergencias.portalsemes.org/descargar/factores-asociados-con-la-mortalidad-en-pacientes-traumticos-con-puntuacin-de-3-en-la-escala-de-coma-de-glasgow-y-midriasis-bilateral-arreactiva/
Objectives: To compare patients with a Glasgow Coma Scale (GCS) score of 3 stratified according to pupillary reaction and to explore factors associated with in-hospital death in those with bilateral fixed dilated pupils.
Methods: Prospective, observational, multicenter study. We included all patients with trauma and a GCS score of 3 admitted to the intensive care unit from March 2015 to December 2019. Factors associated with in-hospital mortality in the patients with bilateral dilated pupils were explored using multiple regression analysis.
Results: Of the 933 patients included, 454 (48.7%) had responsive pupils, 201 (21.5%) had a single fixed dilated pupil, and 278 (29.8%) had bilateral dilation. Hospital mortality was high in all three groups: 32.5% in those with normal responsive pupils, 54.6% in those with a single unreactive pupil, and 91.0% in those with bilateral dilation. Factors significantly associated with in-hospital death were age, a score of 3 or more on the Abbreviated Injury Scale for the head, and shock or refractory shock. Type I or II diffuse lesions and evacuated mass lesions were protective in patients with a GCS score of 3 and bilateral dilated pupils. Twelve (46.1%) of the 26 patients with bilateral dilated pupils and a GCS score of 3 had a GCS score of 14 or 15 on discharge from the hospital.
Conclusions: The in-hospital mortality was 91% in this study of trauma patients with a GCS score of 3 and bilateral dilated pupils. Factors significantly associated with in-hospital death were age, a score of 3 or more on the Abbreviated Injury Scale for the head, and shock or refractory shock. Type I or II diffuse lesions and evacuated mass lesions were protective in patients with a GCS score of 3 and bilateral dilated pupils.
Keywords: wounds and injuries, severe, head injury, Glasgow Coma Scale, mydriasis, bilateral, survival
African Journal of Emergency Medicine
The official journal of the African Federation for Emergency Medicine, the Emergency Medicine Association of Tanzania, the Emergency Medicine Society of South Africa, the Egyptian Society of Emergency Medicine, the Libyan Emergency Medicine Association, the Ethiopian Society of Emergency Medicine Professionals, the Sudanese Emergency Medicine Society, the Society of Emergency Medicine Practitioners of Nigeria, and the Rwanda Emergency Care Association
An electronic survey of preferred podcast format and content requirements among trainee emergency medicine specialists in four Southern African universities
Ekambaram K, Lamprecht H, Lalloo V, Caruso N, Engelbrecht A, Jooste W
Ekambaram K, Lamprecht H, Lalloo V, et al. An electronic survey of preferred podcast format and content requirements among trainee emergency medicine specialists in four Southern African universities. Afr J Emerg Med 2021; 11(1): 3–9.
doi:10.1016/j.afjem.2020.10.014
Introduction: Global usage of educational emergency medicine (EM) podcasts is popular and ever-increasing. This study aims to explore the desired content, format, and delivery characteristics of a potential educational, context-specific Southern African EM podcast, by investigating current podcast usages, trends, and preferences among Southern African EM registrars of varying seniority.
Methods: We developed an electronic survey—using a combination of existing literature, context-specific specialist-training guidance, and input from local experts—exploring preferred podcast characteristics among EM registrars from four Southern African universities.
Results: The study’s response rate was 75%, with 24 of the 39 respondents being junior registrars. Ninety-four percent of respondents used EM podcasts as an educational medium: 64% predominantly using podcasts to supplement a personal EM study program. The primary mode of accessing podcasts was via personal mobile devices (84%). In addition, respondents preferred a shorter podcast duration (5–15 min), favored multimedia podcasts (56%), and showed an apparent aversion toward recorded faculty lectures (5%). Eighty-two percent of respondents preferred context-specific podcast content, with popular topics including toxicology (95%), cardiovascular emergencies (79%), and medico-legal matters (74%). Just-in-Time learning proved an unpopular learning strategy in our study population, despite its substantial educational value.
Conclusion: Podcast usage proved to be near-ubiquitous among the studied Southern African EM registrars. Quintessentially, future context-specific podcast design should cater for mobile device use, shorter duration podcasts, more video content, context-specific topics, and content optimized for both Just-in-Time learning.
Reproduced with permission
