Should ultrasound guidance be used for central venous catheterisation in the emergency department?

In September 2002, the National Institute of Clinical Excellence (NICE) issued guidelines for England and Wales suggesting that ultrasound guidance should be used for all electives, and should be considered for most emergency, central venous catheterisations.1 These guidelines propose a major change of practice for most clinicians practising in UK Emergency Departments. There are also resource and training implications. In this paper we systematically review the literature to establish what evidence exists for the routine use of ultrasound guidance in the placement of central venous catheters in adult patients attending the Emergency Department, and provide an overview of the practical elements of this procedure.     

Should a benzodiazepine antagonist be used in unconscious patients presenting to the emergency department?

Patients in coma with suspected drug poisoning are commonly encountered in the emergency department. Benzodiazepines are one of the most commonly used drugs in self-poisoning. Flumazenil, a benzodiazepine antagonist has been suggested as a diagnostic and treatment tool in suspected poisoning of unclear cause, but caution is required due to potential side effects. No systemic review of this literature has been done on this topic. OBJECTIVES: The aim of this study is to examine if flumazenil should be used in patients with coma from suspected drug poisoning. SEARCH STRATEGY: Randomised controlled trials were identified from the Cochrane Library, Pubmed and EMBASE. Bibliographies from included studies, known reviews and texts were searched. Content experts were contacted. SELECTION CRITERIA: Randomised controlled trials were eligible for inclusion. Studies were included if patients who presented with altered mental state from suspected drug poisoning were treated with intravenous flumazenil as compared to placebo. DATA COLLECTION AND ANALYSIS: Data were extracted and methodological quality was assessed independently by two reviewers. MAIN RESULTS: Seven randomised controlled trials were included. A total of 466 patients were involved. Flumazenil was found to reverse coma from suspected drug poisoning with a relative benefit of 4.45 (95% CI 2.65, 7.45). In terms of major side effects, there was no statistical difference between flumazenil and placebo (RR 2.86, 95% CI 0.12-69.32). However, in terms of minor side effects, flumazenil was associated with a higher incidence of anxiety (RR 2.84, 95% CI 1.28-6.30) and other side effects (RR 3.73, 95% CI 2.078-6.73). There was no difference in the incidence of vomiting (RR 4.28, 95% CI 0.95-19.35). CONCLUSION: Current evidence shows that flumazenil may be effective in the reversal of coma in patients presenting to the emergency department with coma from suspected drug poisoning.     

Should etomidate be the induction agent of choice for rapid sequence intubation in the emergency department?

The ideal induction agent for emergency airway management should be rapidly acting, permit optimum intubating conditions, and be devoid of significant side effects. This review was performed to ascertain whether etomidate should be the induction agent of choice for rapid sequence intubation (RSI) in the emergency department, specifically examining its pharmacology, haemodynamic profile, and adrenocortical effects. A search of Medline (1966-2002), Embase (1980-2002), the Cochrane controlled trials register, and CINAHL was performed. In addition, the major emergency medicine and anaesthesia journals were hand searched for relevant material. Altogether 144 papers were identified of which 16 were relevant. Most studies were observational studies or retrospective reviews with only one double blind randomised controlled trial and one un-blinded randomised controlled trial. Appraisal of the available evidence suggests that etomidate is an effective induction agent for emergency department RSI; it has a rapid onset of anaesthesia and results in haemodynamic stability, even in hypovolaemic patients or those with limited cardiac reserve. Important questions regarding the medium to long term effects on adrenocortical function (even after a single dose) remain unanswered.     

Can emergency department triage nurses predict patients' dispositions?

Early recognition of inpatient bed requirements might be helpful in expediting the admission process through the emergency department (ED). With this in mind, we asked whether ED triage nurses could accurately predict patients' in-hospital dispositions. A prediction was recorded for 521 ED patients, of whom 107 (20.5%) were ultimately admitted to the hospital. Nurses correctly anticipated 66 of 107 hospital admissions (sensitivity = 61.7%, PPV = 61.7%). With respect to predicting specific levels of inpatient care, nurses correctly anticipated 17 of 45 floor admissions (sensitivity = 37.8%, PPV = 34.7%), 14 of 33 step-down/monitored unit admissions (sensitivity = 42.4%, PPV = 48.3%), and 12 of 24 intensive care unit admissions (sensitivity = 50.0%, PPV = 66.7%). Lacking in sensitivity and positive predictive value, particularly with regard to specific levels of inpatient care, triage nurses' predictions may have limited potential to expedite the admission process.     

Can patients with non-convulsive seizure be identified in the emergency department?

BACKGROUND: Non-convulsive seizure (NCS) is an underdiagnosed, potentially treatable emergency with significant mortality and morbidity. The objective of this study is to examine the characteristics of patients with NCS presenting with altered mental status (AMS) and diagnosed with electroencephalography (EEG), to identify the factors that could increase the pre-test probability of NCS.     

Acute stent thrombosis: Should preventative measures start in the emergency department?

Stent thrombosis is a potentially life threatening condition caused by several factors or a combination factors, such as resistance to platelet agents and type of anticoagulation used as well as stent types. We report a case of acute thrombosis and discuss potential areas of intervention with literature review.     

Should freestanding emergency departments be considered in Australia?

The concept of freestanding EDs is a popular operational model of emergency care in the USA. This model has been described as an emergency physician-created innovative solution in resolving ongoing overcrowding issues in EDs. A decentralised community-based emergency care model may be a solution to meet the increasing demand for emergency and unscheduled acute care in Australia. It may also help to reduce the number of acute hospital admissions through EDs. The aim of freestanding EDs should be to manage and discharge a cohort of patients, mainly in Australasian Triage Scale 3 and 4 categories, currently seen in hospital-based EDs. This article briefly examines the potential merits and issues if this concept is considered in Australia. It also provides an early proposed model for such EDs.     

Is routine pregnancy test necessary in women of reproductive age admitted to the emergency department?

BACKGROUND:

This study aimed to determine the necessity of pregnancy test in women of reproductive age admitted to emergency department (ED) in routine practice.

METHODS:

We retrospectively reviewed the records of patients who presented to the ED between January 1, 2006 and December 31, 2010 and received a pregnancy test.

RESULTS:

The median age of 1 586 patients enrolled into the study was 27 years. Of these patients, 19.55% had a positive result of pregnancy test. The most common complaint at admission was abdominal pain in 60.15% of the patients, and pregnancy test was prescribed. 15.83% of the patients with abdominal pain had a positive result of pregnancy test. Of the patients, 30.64% had nausea-vomiting at admission, and 11.52% had a positive result of pregnancy test. When other complaints were considered, the most commonly observed complaints were non-specific symptoms such as dizziness, malaise and respiratory problems. Of the patients, 70.93% were not remembering the date of last menstruation, and 9.51% showed a positive result of pregnancy test. Urinary tract infection (UTI) was commonly diagnosed with an incidence of 17.65%, which was followed by non-specific abdominal pain (NSAP) (16.77%) and gastrointestinal disorders such as gastritis and peptic ulcer (6.87%). Of the patients, 88.40% were discharged from ED, and 11.60% were hospitalized.

CONCLUSION:

Pregnancy test should be given to women of reproductive age as a routine practice in ED in developing countries like Turkey.KEY WORDS: Female, Emergency Medical Services, Pregnancy, Reproduction     

How accurate is weight estimation in the emergency department?

Objective: To determine the accuracy of medical staff, nursing staff and patients for estimating weight in an ED population. Methods: This is a prospective, observational study. Medical staff, nursing staff and patients were asked to estimate patient weight that was then measured. The main outcome was average per cent error in weight estimation for each group. Results: Average per cent error in estimates was 3.9% for patients (95% CI 3.6–4.1%), 7.7% (95% CI 7.2–8.2%) for nurses and 11% (95% CI 10.2–11.7%) for physicians. Ninety‐one per cent of patients (95% CI 90–93%), 78% of nurses (95% CI 75–80%) and 59% of physicians (95% CI 56–63%) made weight estimates accurate to within 10% of actual weight. Conclusion: Patients are generally accurate in estimating their true weight and health care workers showed only moderate accuracy. Where possible, drug dose calculations should be based on measured weight and if this is not possible, patient estimate of weight should be sought. Health care worker estimation should be used only when this is not possible.