The chest pain center in the emergency department

Despite the improvement of medical treatment for acute coronary syndromes throughout the 20th century, the authors believe that many cases of life-threatening coronary events could be avoided through early detection of CAD and the use of preventive strategies. Establishing chest pain units that are linked to the ED is one excellent strategy to risk-stratify patients with symptoms who are at risk for sustaining an AMI or having lethal arrhythmias. There is a need for more research on chest pain units to determine the value for cost and to further optimize strategies for ACI detection and screening. In EDs with high volumes of chest pain patients, or high pressures to avoid hospital admissions, a planned, systematic, and rapid approach to the treatment of AMI and the diagnosis of chest pain is a rewarding necessity.     

Pediatric trauma: Blood product transfusion characteristics in a pediatric emergency department,a single center experience

AimTo investigate clinical and laboratory data, management and outcomes of pediatric trauma patients who initially received blood product transfusions.MethodsBetween January 2011-January 2021, traumatic children who underwent blood product transfusions within 24 h of arrival at the emergency department were included. Demographics, clinical and laboratory data, Injury Severity Score (ISS), volume of transfused blood products and crystalloid boluses in 24 h were recorded. Massive transfusion (MT) was defined as transfusion of ≥40 mL/kg of all blood products in 24 h.ResultsAmong 32 cases, 8 (25.0 %) patients met the MT threshold criterion. Length of pediatric intensive care unit (PICU) stay and mechanical ventilation (MV) were longer for patients who received MT although there was no difference for age, ISS, volume of crystalloid boluses, length of hospital stay, and 30-day mortality between those who received MT or not. Volume of crystalloid boluses was higher in patients who died than those who survived but the volume of blood products was similar for two groups. An APTT value of >37.5 s was identified as a predictor of 30-day mortality (OR = 48.000, 95 % CI: 3.704-621.998, p: 0.003).ConclusionChildren who received MT had longer durations of MV and PICU stay than those who did not receive, but there was no significance for ISS, volume of crystalloid boluses, hospital stay, or mortality between two groups. Volume of crystalloid boluses was higher in patients who died than those who survived. An APTT value of >37.5 s can be used to predict 30-day mortality.     

Incidence and impact of undisclosed cocaine use in emergency department chest pain and trauma patients

Background

One of the highest rates of illicit cocaine consumption in Europe is in Spain. Our objective was to study the incidence and impact of undisclosed cocaine consumption in patients attending the emergency department (ED) for trauma or chest pain.

Methods

We analysed urine samples from consecutive patients attending the ED for trauma or chest pain to determine the presence of cocaine, cannabis, amphetamine/metaamphetamine and opioids by semiquantative tests with fluorescence polarization immunoassay (FPIA).

Results

Thirty percent of eligible patients participated. Of 75 cases, 61.3% had trauma and 38.7% chest pain; 25% presented a positive test for drugs. Cocaine was present in 13.3% and cannabis in the same proportion. No differences were found regarding positive cocaine test and chief complaint, ED or hospital stay, or additional tests. Cocaine-positive patients were significantly younger.     

Psychiatric aspects of chest pain in the emergency department

We estimate that a third of the patients who present to the ED with chest pain have a current psychiatric disorder and that psychiatric disorders among chest pain patients are associated with a high rate of ED utilization for chest pain evaluations. Physicians in the ED recognize only a small fraction of the psychiatric disorders, so appropriate treatment or referral may be infrequent. The proportion of chest pain patients with CAD who also have a psychiatric disorder may be in the range of 20% to 30%, justifying careful assessment of psychiatric disorders in CAD patients. We conclude that the psychiatric aspects of chest pain are sufficiently prevalent, clinically significant, and a contributor to unnecessarily high utilization of medical services. We call for clinical research to address these questions by outlining three areas of study that will advance our knowledge and care of the patient with chest pain.     

Patient flow in the emergency department: the chest pain patient

Prompt treatment of the chest pain patient in the emergency department (ED) is crucial. To ensure prompt treatment, identification of factors that delay flow of these patients through the department is essential. To identify factors that delay patient flow through the ED, the authors conducted a prospective study of all chest pain patients, using a time-flow analysis. Eighty-eight (36%) of 245 patients required critical unit admissions and had an average department stay of 3 1/2 hours. Flow differences were seen between critical and noncritical care patients. Three primary sources of delay were identified: critical unit bed availability, the registration process, and the role of the unit admitting resident. Additional findings confirmed the efficacy and role of the triage nurse in patient flow. Nursing and medical education and staffing needs were addressed. The use of the community's emergency medical services was examined by analyzing the disposition of patients arriving at the ED by ambulance.     

Managing recurrent nonischemic chest pain in the emergency department

Many patients who seek emergency evaluation for recurrent chest pain have had negative cardiac evaluations, sometimes including normal coronary angiograms. Despite reassurance, many of these patients return to emergency departments with complaints of chest pain. Studies have shown that one third to one half of these patients suffer from panic disorder characterized by attacks of intense fear accompanied by chest pain or discomfort, nausea, and shortness of breath. If panic disorder is identified, it can be successfully treated. This article explores the causes of recurrent nonischemic chest pain and offers treatment recommendations.     

Acute fatal chest pain: optimized procedure in emergency department

Objective

To explore the diagnostic procedure of acute fatal chest pain in emergency department (ED) in order to decrease the misdiagnosis rate and shorten the definite time to diagnosis. The ultimate aim is to rescue the patients timely and effectively.

Methods

Three hundreds and two patients (56.9±11.8 Years, 72% men) complained with acute chest pain and chest distress presenting to our ED were recruited. They were divided into two groups according to visiting time (Group I: from October 2010 to March 2011, Group II: from October 2011 to March 2012). The misdiagnosis rate, definite time for diagnosis and medical expense were analyzed. Patients of Group I were diagnosed by initial doctors who made their diagnosis according to personal experience in outpatient service or rescue room in ED. While patients of Group II were all admitted to rescue room and were diagnosed and rescued according to the acute chest pain screening flow-process diagram. Differences inter-group was compared.

Results

The misdiagnosis rate of fatal chest pain in Group I and Group II was 6.8% and 0% respectively, and there was statistic difference (P=0.000). The definite time to diagnosis was 65.3 min and 40.1 min in control and Group II respectively, the difference had statistic significance (P=0.000). And the mean cost for treatment was 787.5/124.5 ¥/$ and 905.5/143.2 ¥/$ respectively, and there was statistic difference too (P=0.012).

Conclusion

Treating emergency patients with acute chest pain according to the acute chest pain screening flow-process diagram in rescue room will decrease misdiagnosis apparently, and it can also shorten the definite time to correct diagnosis. It has a remarkable positive role in rescuing patients with acute chest pain timely and effectively.

     

Ultrasound assisted evaluation of chest pain in the emergency department

Chest pain is a commonly encountered emergency department complaint, with a broad differential including several life-threatening possible conditions. Ultrasound-assisted evaluation can potentially be used to rapidly and accurately arrive at the correct diagnosis. We propose an organized, ultrasound assisted evaluation of the patient with chest pain using a combination of ultrasound, echocardiography and clinical parameters. Basic echo techniques which can be mastered by residents in a short time are used plus standardized clinical questions and examination. Information is kept on a checklist. We hypothesize that this will result in a quicker, more accurate evaluation of chest pain in the ED leading to timely treatment and disposition of the patient, less provider anxiety, a reduction in the number of diagnostic errors, and the removal of false assumptions from the diagnostic process.     

Comprehensive quality assurance in a level II trauma center emergency department

QA is a logical, interesting, and rewarding process, from which many benefits can be derived if a positive approach is taken. The process is undoubtedly time-consuming, and staff involvement, and administrative commitment to providing required resources are critical to ensuring improvements in care.     

Violence in a pediatric emergency department: lessons learned from one experience

A multitude of forces influence the probability of violence in an emergency department, but none impact as directly as the skilled response of the emergency nurse. It is important not to overlook the availability of security and law enforcement, but it may be equally important for nurses to take appropriate steps toward preventing or solving such problems with a minimum of physical and emotional pain for all concerned. With time and practice, incidents of violence can be replaced with opportunities for growth and healing.     

Thallium myocardial scanning in the emergency department evaluation of chest pain

Chest pain is a common complaint of patients seen in the emergency department. The causes are legion, and range from the non-life threatening to the potentially catastrophic. Thallium heart scanning was done prospectively in 20 patients with a "classic" history for myocardial infarction (eight patients) or atypical chest pain and/or associated symptoms plus an abnormal ECG (12 patients) to discern a subset of patients from whom thallium scintography may be indicated in the emergency department. Although further investigation is needed, our preliminary study suggests that myocardial scanning with thallium can be a safe, fairly rapid, and useful objective parameter in the emergency department detection of suspected myocardial infarction, and in differential diagnosis of chest pain when other data such as the history, physical examination, ECG, or enzymes are inconclusive.     

Lipoprotein analysis in the evaluation of chest pain in the emergency department

Apolipoproteins were measured in a prospective blinded fashion in blood specimens from patients with chest pain in the emergency department. A definitive diagnosis for the chest pain (non-cardiac-related in 32% and angina or myocardial infarction in 68%) was available in 136 of the 162 patients originally enrolled in the study. Logistic regression and multivariate analysis failed to show any usefulness of apolipoprotein determinations in distinguishing patients with cardiac ischemia from those without it. The clinician's initial impression of the chest pain, the electrocardiogram, a history of previous angina, myocardial infarction, or peripheral atherosclerosis, and male sex were strongly associated with the final diagnosis. We conclude that, although apolipoprotein analysis has proved useful in epidemiologic studies, the most reliable indicators of ischemic pain remain the medical history, the electrocardiogram, and the clinician's overall initial impression.     

Effectiveness of pain management among trauma patients in the emergency department,a systematic review

ObjectiveTo systematically review the available data and scientific literature and to compile all evidence-related studies of the effectiveness of pain management for traumatic patients in the emergency department.MethodsThe present study was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.ResultsA total of 777 articles were retrieved, and eighteen were selected according to the inclusion criteria in this systemic review. These studies were published from 2004 to 2020 and reported from all around the world. Seventeen studies were based on pharmacological intervention, and one study was based on nonpharmacological intervention. Analgesics and methoxyflurane administration were the most adapted interventions for pain management in traumatic patients among the selected studies. Other reported interventions were fixed nitrous oxide/oxygen mixture, sufentanil, and professional practice assessment.ConclusionThis systemic review provides an overview of the effectiveness of pharmacological and nonpharmacological pain management in trauma patients in the emergency department. Analgesic treatment is an effective and ancient management strategy with drawbacks of associated side effects and intravenous administration. New strategies reported and applied by oral or nasal route administration with similar and better efficacies. However, large-scale studies are crucial for better implementation and outcome. Nonpharmacological interventions may also contribute to pain relief.     

The experience of trauma resuscitation in the emergency department: themes from seven patients.

PURPOSE: Little is known about the patients' experience of trauma resuscitation in the emergency department. Therefore, the purpose of this study was to determine (1) patients' perspectives of the experience of trauma resuscitation in the emergency department; (2) if patients have perceptions of vulnerability during trauma resuscitation in the emergency department; and (3) if there are factors that influence the patients' experience. METHODS: A qualitative study of 7 patients using interpretive phenomenology was conducted in a Level I lead trauma hospital in Ontario, Canada. Inclusion criteria included age >/=18 years; trauma code initiated in the emergency department; Glasgow Coma Scale score >/=13; Revised Trauma Score >/=10; and physically and cognitively capable of participating in an interview in English. The sample included 4 men and 3 women. One-on-one semistructured tape-recorded interviews were conducted on the in-patient Trauma Unit between day 2 and 7 after trauma resuscitation. Follow-up interviews were conducted 7 to 12 months after the initial interview. RESULTS: Four themes were revealed in the data analysis: "I remember," "I was scared," "I felt safe," and "I will be okay." The findings revealed that initial perceptions of vulnerability subsided as a sense of feeling safe became prominent. System factors, such as a clearly identifiable trauma team leader, and caring behaviors, such as touch and tone of voice, were important and contributed to the overall belief that it was a positive experience. CONCLUSION: Both system factors and nursing interventions were important in contributing to the patients' feelings of being safe during trauma resuscitation in the emergency department. The fact that pain was felt or that family was not present, for example, seemed less important to patients than the perception that they were in capable hands and believed they were "safe."