Patient anxiety in the accident and emergency department

• ? Structured interviews were carried out with a sample of 96 patients to identify the sources of anxiety for patients in the accident and emergency (A & E) department.
• ? Only two patients reported that they were not at all anxious about any aspect of being in A & E. The average number of anxieties reported was 69.
• ? The most frequently reported anxieties were ‘not being able to carry on your usual activities’, ‘not knowing what will happen to you in the department’, ‘having to undergo an uncomfortable procedure’, ‘feeling pain’ and ‘not knowing what is wrong’.
• ? The findings indicate that patients were as concerned with psychological and social aspects associated with admission as they were about psysical factors.
• ? The authors suggest that it is essential for nurses in A & E to assess patients holistically and consider their psychological state and social circumstances as well as their physical condition. There is also a need for closer links to be developed between accident and emergency departments and other community health agencies and for more emphasis to be placed on referral to other bodies.

     

An evaluation of physiological parameters of stress in the emergency department

Seven physiological parameters previously used in stress research were studied to determine which would be able to quantitate levels of stress and study interventions in the emergency department setting. Eighteen emergency medicine personnel were prospectively studied. Sequential measurements of heart rate, respiratory rate, systolic blood pressure, diastolic blood pressure, skin temperature, serum norepinephrine, and serum epinephrine were recorded during multiple shifts in the emergency department. These parameters were assessed in repeated measures analysis of variance models with the subject's stress score of the shift and a calculated stress score of the shift. Respiratory rate demonstrated a significant association with the score of the shift over time within subjects (P = .0228). Skin temperature showed a significant trend over time (P = .0001) and in relation to how stressful the subject perceived the shift to be (P = .0006). A significant association was detected between epinephrine change over the shift and the subject's perception of the stress of the shift (P = .0217), and the stress score of the shift (P = .0009). Sequential serum epinephrine appears to be an objective measure of both perceived stressfulness of a shift and objective stress scoring of the shift. Respiratory rate changes and skin temperature changes over a shift may also be useful to measure stress in individuals in this setting.     

Midazolam use in the emergency department

Midazolam is the first water-soluble benzodiazepine. As with other benzodiazepines it has amnestic, sedative, hypnotic, anxiolytic, and anticonvulsant properties. Midazolam is about two to four times more potent than diazepam. Midazolam has been extensively used for a variety of outpatient procedures, but there has been no documentation of its safety in emergency department patients. The authors retrospectively reviewed all patients receiving midazolam during a 2-year period at the University of Cincinnati Center for Emergency Care. The study population consisted of 389 patients (men 56%; women 44%) with an average age of 33.3 years. Midazolam was used intravenously for sedation before a wide variety of painful procedures and for agitation control. The average dose was 3.86 mg, with a range of 0.5 mg to 20.0 mg. The majority of patients (79.2%) received narcotics or sedative/hypnotic agents in addition to midazolam. There was an overall complication rate of 1.0%. Two patients (0.5%) developed clinically significant respiratory depression after midazolam use. Both patients had also received fentanyl citrate and the respiratory depression was reversed with naloxone. Two patients (0.5%) receiving several other drugs developed short periods of hypotension. There were no apparent long term sequelae. The authors conclude that midazolam can be safely used in the emergency department setting. Careful dosing and titration to the desired clinical effects is mandatory. Patients should be closely monitored to maximize safety.     

Midazolam use in the emergency department

Midazolam is a new imidazobenzodiazepine derivative that is two to three times as potent as diazepam, is water-soluble, has a rapid onset and short duration of action, and produces a profound amnestic effect. These properties make it an extremely useful drug for outpatient sedation. We performed retrospective review of midazolam use in a general emergency department over a one-year period. Midazolam was used in 120 patients, 71 men and 49 women, with an average age of 46 years. The average dose given was 3.4 mg, with a range of 1 to 10 mg. In 69 of the cases (57%) other drugs were administered, most commonly an opiate. There were only four adverse reactions. One patient developed urinary retention, one patient vomited, and two patients were somnolent for a prolonged period of time. There were no serious cardiovascular or respiratory problems. We conclude that midazolam is a safe drug to use in the emergency department. Close monitoring of the patient and the availability of airway support equipment are mandatory.     

An evaluation of tympanic thermometry in a paediatric emergency department

Background and objectives

The consequences of missing fever in children can be grave. Body temperature is commonly recorded at the axilla but accuracy is a problem. This study aimed to evaluate the accuracy of a tympanic thermometer in the paediatric emergency setting.

Method

In a total of 106 infants, the body temperature was measured in the daytime with an infrared tympanic thermometer, and at the axilla with an electronic thermometer and at the rectum (gold standard for measurement of body temperature). Fever was defined as a rectal temperature of 38.0 °C or greater, axillary temperature of 37.5 °C or greater, and tympanic temperature of 37.6 °C or greater. The temperature readings at the three sites were compared statistically.

Results

There was a greater correlation of the tympanic measurement with the rectal measurement than the axillary with the rectal in both febrile and afebrile infants. The mean difference between the tympanic and rectal measurements was lower than that between the axillary and rectal measurements in both groups of infants (tympanic 0.38 °C and 0.42 °C, and axillary 1.11 °C and 1.58 °C, respectively). Tympanic measurements had a sensitivity of 76% whereas axillary measurements had a sensitivity of only 24% with rectal temperatures of 38–38.9 °C.

Conclusion

Tympanic thermometry is more accurate than measurement of tempeature with an electronic axillary thermometer. It is also quick and safe, and thus it is recommended in the paediatric emergency setting.     

Pain assessment instruments for use in the emergency department

Each patient's pain experience is uniquely his or her own. Standardized pain assessment methodologies and procedures provide a window to this experience and constitute a necessary first step to our understanding of pain, in both clinical and research settings. All too often, emergency department pain assessment is cursory--performed more to satisfy regulatory requirements than to guide our therapies or evaluate our practices. This article provides information on a number of assessment techniques that are appropriate for clinical and research use. Their use should inform our practice and lead to continuous improvements in our management of pain.     

Adnexal mass evaluation in the emergency department

Female patients who have stable vital signs presenting to the emergency department with abdominopelvic pain and an adnexal mass can be extremely difficult to manage. However, by performing a rapid problem-oriented history and physical with emphasis on the age of patient, menstrual history, and pelvic exam, a detailed differential diagnosis can be compiled. With the addition of a complete blood count and HCG, if appropriate, and a CA-125 for your consultant, additional information can be obtained while a ultrasound examination is being performed. With the above information, consultation and disposition should be readily accomplished.     

An evaluation of the nurse practitioner role in a major rural emergency department

The purpose of this pilot study was to investigate whether nurse practitioners are able to provide a level of primary health service applicable to remote/isolated settings in wound management and treatment of blunt limb trauma. It was hypothesized that there would be no significant difference in the quality of care, or the level of client satisfaction, provided by the medical officers and the nurse practitioners in the study. Two groups participated in the study, nurse practitioners and medical officers. The study used a randomized trial design. Data were collected using quantitative and qualitative methods. Two hundred and thirty-two clients participated in the study. Of this number 63 were supervised cases in the pilot trial. In the randomized trial participants were distributed between nurse practitioners and medical officers (n = 169), of which 91 were randomized to medical officers and 78 to nurse practitioners. Telephone interviews were conducted to evaluate client satisfaction. The majority of study participants were surveyed for client satisfaction (n = 132). This represents approximately 78% of the randomized sample and multivariate analysis was carried out on the data. Study results indicate that there were no significant differences between the two groups in relation to client satisfaction. Very positive outcomes of treatment were consistent across groups in the study. The study also found that there was strong support for the role of the nurse practitioner in the rural emergency setting. Recommendations include further research to measure the efficacy of nurse practitioners utilizing the selected competencies in remote/isolated settings.     

急诊患者家属焦虑程度的调查分析及护理

对２２２例急诊患者家属应用状态焦虑量表进行心理调查和评定。结果显示：急诊患者家属焦虑明显高于正常人，重症急诊患者家属的焦虑程度显著高于一般急诊患者家属。家属的焦虑程度与其性别、年龄、职业、文化程度及角色有关；女性显著高于男性，离退休人员高于其它人员；相关与回归处理发现，患者家属的焦虑程度与其年龄呈正相关，与其文化程度呈负相关。通过此次调查，了解到急诊患者家属的基本焦虑情况，并针对具体情况提出了适当的护理措施，以降低患者家属的焦虑程度，使其提供更高的社会支持，有利于患者的治疗和护理。     

Ketamine: Its use in the emergency department

Ketamine has been known to the medical world for over 30 years, yet is not widely used to its full potential. It is often considered to be a ‘third world’ drug only. In light of a recent increase in interest in its use in the developed world, this review is for emergency physicians to use as a quick reference.     

急诊科新护士焦虑状况的调查分析

目的 调查分析急诊科新护士的焦虑状况,为护理管理提供参考依据.方法 采用Zung焦虑自评量表(self-rating anxiety scale,SAS)及自行设计的问卷,对厦门市2家三甲综合医院的32名急诊科新护士(经过转科来院工作时间不足2年的护士)的焦虑状况及相关因素进行了测评. 结果急诊科新护士的SAS总分均值与常模(中国正常人群)SAS均分比较有显著差异.急诊科新护士中,大专和本科学历SAS均分无显著差异,不同工作年限的急诊科新护士SAS均分有显著差异.结论 急诊科新护士的焦虑情况较严重,建议护理管理者应重视新护士的心理健康和加强培养新护士的心理素质等,缓解急诊科新护士的焦虑心理.     

An evaluation of clinical predictors to determine need for rectal temperature measurement in the emergency department

A cross-sectional study was conducted in an urban emergency department to determine if predictive variables existed that would identify a patient who would be afebrile by oral temperature measurement and febrile by rectal temperature measurement. This study included 366 patients. Five variables studied achieved statistical significance by univariant analysis: mouth breathing (P = .002), respiratory rate (P = .001), supplemental oxygen (P = .009), pulse (P = .0001), and supplemental oxygen via mask (P = .01). Placing these variables in a logistic regression model left two variables that significantly explained the variance of the model: pulse (odds-risk ratio, 1.032/increase in pulse of 1 from 0; 95% confidence interval, 1.020 to 1.039) and mouth breathing (odds-risk ratio, 2.113; 95% confidence interval, 1.41 to 3.43). There was poor linear correlation between oral and rectal temperatures (r = 0.2). If a patient has an unexplained tachycardia and/or is breathing by mouth and is afebrile orally, a rectal temperature measurement should be obtained to determine if fever exists. The results of this study suggest that good linear correlation does not exist between oral and rectal temperature measurements.     

An evidence-based narrative review of the emergency department evaluation and management of rhabdomyolysis

Background

Rhabdomyolysis is a medical condition caused by muscle breakdown leading to potential renal damage. This can result in significant morbidity and mortality if not rapidly identified and treated.