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WORLD HOSPITAL DIRECTORY
Emergency Medicine Medical Emergency Medicine Journal current issue
<p><I>‘Free vapes given to smokers at hospitals could help thousands quit, study suggests.’ And ‘Calls for free vapes to be handed out in emergency departments.’</I></p> <p>These were the headlines describing this month’s Editor’s Choice, the Cessation of Smoking Trial in the Emergency Department (COSTED), when it was published on-line in March. Of course COSTED wasn’t <I>just</I> about vapes. This randomised, controlled study conducted by Pope and colleagues at 6 UK emergency departments (ED) recruited patients attending for any reason who smoked daily. Intervention patients received 15 min of face-to-face smoking cessation counselling in the ED, an e-cigarette starter kit and instructions, and referral to a local NHS smoking cessation service. Controls received written information about a local NHS stop smoking service but were not directly referred. The headlines tell the tale (more abstinence in the intervention group), but the study sparked some other questions for us. Is it a good...
<sec><st>Background</st>
<p>Supporting people to quit smoking is one of the most powerful interventions to improve health. The Emergency Department (ED) represents a potentially valuable opportunity to deliver a smoking cessation intervention if it is sufficiently resourced. The objective of this trial was to determine whether an opportunistic ED-based smoking cessation intervention can help people to quit smoking.</p>
</sec>
<sec><st>Methods</st>
<p>In this multicentre, parallel-group, randomised controlled superiority trial conducted between January and August 2022, adults who smoked daily and attended one of six UK EDs were randomised to intervention (brief advice, e-cigarette starter kit and referral to stop smoking services) or control (written information on stop smoking services). The primary outcome was biochemically validated abstinence at 6 months.</p>
</sec>
<sec><st>Results</st>
<p>An intention-to-treat analysis included 972 of 1443 people screened for inclusion (484 in the intervention group, 488 in the control group). Of 975 participants randomised, 3 were subsequently excluded, 17 withdrew and 287 were lost to follow-up. The 6-month biochemically-verified abstinence rate was 7.2% in the intervention group and 4.1% in the control group (relative risk 1.76; 95% CI 1.03 to 3.01; p=0.038). Self-reported 7-day abstinence at 6 months was 23.3% in the intervention group and 12.9% in the control group (relative risk 1.80; 95% CI 1.36 to 2.38; p<0.001). No serious adverse events related to taking part in the trial were reported.</p>
</sec>
<sec><st>Conclusions</st>
<p>An opportunistic smoking cessation intervention comprising brief advice, an e-cigarette starter kit and referral to stop smoking services is effective for sustained smoking abstinence with few reported adverse events.</p>
</sec>
<sec><st>Trial registration number</st>
<p> <A HREF="NCT04854616">NCT04854616</A>.</p>
</sec>
<p>Since electronic cigarettes (e-cigarettes) first appeared in the tobacco product marketplace over a decade ago, they have been evaluated as another tool for promoting successful smoking cessation. The randomised controlled trial by Pope <I>et al</I> reported in this issue of the <I>Emergency Medicine Journal,</I> adds to a growing literature on the use of e-cigarettes as a smoking cessation intervention, providing evidence in a novel, pragmatic setting—emergency departments (EDs).<cross-ref type="bib" refid="R1">1</cross-ref> A 2024 Cochrane review reported high-certainty evidence for their effectiveness, primarily from randomised controlled trials, showing that nicotine e-cigarettes are more effective in helping smokers to quit than nicotine replacement therapy (NRT), a cessation modality approved by the US Food and Drug Administration.<cross-ref type="bib" refid="R2">2</cross-ref> Although the evidence is increasingly compelling, its generalisability to other healthcare settings is uncertain.</p> <p>This study is a step toward addressing that uncertainty about how e-cigarettes could be used to promote smoking cessation among...
<p>Smoking cessation is currently topical with recent government announcements regarding restricting the sale of disposable vapes and a consultation on raising the legal age of buying tobacco from 18 years, so that anyone born after a certain year will never be able to buy cigarettes legally. This edition of the EMJ contains a randomised controlled multicentre trial of smoking cessation initiated in the emergency department (ED).<cross-ref type="bib" refid="R1">1</cross-ref> The intervention group received brief smoking cessation advice as well as provision of an e-cigarette starter kit and referral to the local stop smoking services, while the control group received advice on how to self-refer to the local stop smoking service. The 6-month follow-up results showed a statistically significant greater chance of self-reported abstinence from smoking for the previous 7 days in the intervention group compared with the control group. The intervention was delivered by dedicated smoking cessation advisors based in the...
<sec><st>Background</st>
<p>Addressing increasing patient demand and improving ED patient flow is a key ambition for NHS England. Delivering general practitioner (GP) services in or alongside EDs (GP-ED) was advocated in 2017 for this reason, supported by £100 million (US$130 million) of capital funding. Current evidence shows no overall improvement in addressing demand and reducing waiting times, but considerable variation in how different service models operate, subject to local context.</p>
</sec>
<sec><st>Methods</st>
<p>We conducted mixed-methods analysis using inductive and deductive approaches for qualitative (observations, interviews) and quantitative data (time series analyses of attendances, reattendances, hospital admissions, length of stay) based on previous research using a purposive sample of 13 GP-ED service models (3 inside-integrated, 4 inside-parallel service, 3 outside-onsite and 3 with no GPs) in England and Wales. We used realist methodology to understand the relationship between contexts, mechanisms and outcomes to develop programme theories about how and why different GP-ED service models work.</p>
</sec>
<sec><st>Results</st>
<p>GP-ED service models are complex, with variation in scope and scale of the service, influenced by individual, departmental and external factors. Quantitative data were of variable quality: overall, no reduction in attendances and waiting times, a mixed picture for hospital admissions and length of hospital stay. Our programme theories describe how the GP-ED service models operate: inside the ED, integrated with patient flow and general ED demand, with a wider GP role than usual primary care; outside the ED, addressing primary care demand with an experienced streaming nurse facilitating the ‘right patients’ are streamed to the GP; or within the ED as a parallel service with most variability in the level of integration and GP role.</p>
</sec>
<sec><st>Conclusion</st>
<p>GP-ED services are complex . Our programme theories inform recommendations on how services could be modified in particular contexts to address local demand, or whether alternative healthcare services should be considered.</p>
</sec>
<sec id="s1"><st>Clinical introduction</st> <p>A previously healthy 46-year-old man experienced acute mid-calf pain while playing paddle tennis. He treated himself with non-steroidal anti-inflammatory drugs and local cold application, and took a rest. One week later, he consulted the ED due to persistent pain and swelling in the area. Examination revealed tenderness to palpation of the medial belly of the gastrocnemius muscle. A point-of-care ultrasound was performed (<cross-ref type="fig" refid="F1">figure 1</cross-ref>).</p> </sec> <sec id="s2"><st>Question</st> <p>What is the most likely diagnosis?</p> <p><l type="letterupper"><li><p>Morel-Lavallée lesion</p> </li><li> <p>Pyomyositis</p> </li><li> <p>Complicated Baker’s cyst</p> </li><li> <p>‘Tennis leg’ injury</p> </li></l></p></sec> <sec id="s3"><st>Answer: D</st> <p>Rupture of the medial portion of the medial gastrocnemius muscle, commonly known as ‘tennis leg’, often occurs during sports such as tennis or paddle tennis, typically resulting from sudden knee extension and plantar flexion.<cross-ref type="bib" refid="R1">1</cross-ref></p> <p>On ultrasound, this injury presents as an anechoic collection located between the fascia of the medial gastrocnemius and...
<p>In this edition of the <I>Emergency Medicine Journal</I>, Dr Cooper and her colleagues explore the facilitators and barriers to the effectiveness of different general practitioner service models in or alongside EDs (GP-ED).<cross-ref type="bib" refid="R1">1</cross-ref> The availability of these services in the UK expanded in response to a 2017 budget commitment of £100 million to enhance A&E services including the colocation of on-site GP services.<cross-ref type="bib" refid="R2">2</cross-ref> The authors observed that the demand for ED services is influenced by a range of individual, department and wider system factors, but that colocated GP/ED service models did not reduce attendances and waiting times and had a mixed impact on hospital admissions and length of hospital stay.<cross-ref type="bib" refid="R1">1</cross-ref></p> <p>The findings are not surprising, as they align with international experience.<cross-ref type="bib" refid="R3">3–5</cross-ref><cross-ref type="bib" refid="R4"></cross-ref><cross-ref type="bib" refid="R5"></cross-ref> Specifically, Ramlakhan <I>et al</I><cross-ref type="bib" refid="R3">3</cross-ref> found little evidence to support the implementation of colocated urgent care...
<sec><st>Background</st>
<p>Tools to increase the turnaround speed and accuracy of imaging reports could positively influence ED logistics. The Caire ICH is an artificial intelligence (AI) software developed for ED physicians to recognise intracranial haemorrhages (ICHs) on non-contrast enhanced cranial CT scans to manage the clinical care of these patients in a timelier fashion.</p>
</sec>
<sec><st>Methods</st>
<p>A dataset of 532 non-contrast cranial CT scans was reviewed by five board-certified emergency physicians (EPs) with an average of 14.8 years of practice experience. The scans were labelled in random order for the presence or absence of an ICH. If an ICH was detected, the reader further labelled all subtypes present (ie, epidural, subdural, subarachnoid, intraparenchymal and/or intraventricular haemorrhage). After a washout period, the five EPs reviewed again the scans individually with the assistance of Caire ICH. The mean accuracy of the EP readings with AI assistance was compared with the mean accuracy of three general radiologists reading the films individually. The final diagnosis (ie, ground truth) was adjudicated by a consensus of the radiologists after their individual readings.</p>
</sec>
<sec><st>Results</st>
<p>Mean EP reader accuracy significantly increased by 6.20% (95% CI for the difference 5.10%–7.29%; p=0.0092) when using Caire ICH to detect an ICH. Mean accuracy of the EP cohort in detecting an ICH using Caire ICH was found to be more accurate than the radiologist cohort prior to discussion; this difference, however, was not statistically significant.</p>
</sec>
<sec><st>Conclusion</st>
<p>The Caire ICH software significantly improved the accuracy and sensitivity of detecting an ICH by the EP to a level comparable to general radiologists. Further prospective research with larger numbers will be needed to understand the impact of Caire ICH on ED logistics and patient outcomes.</p>
</sec>
<sec id="s1"><st>Clinical introduction</st> <p>A 57-year-old man presented acutely with involuntary movements of his left hand. He had hypertension, chronic kidney disease and chronic obstructive pulmonary disease. These movements were best described as sudden, recurrent and arrhythmic loss of tone and power of the left wrist and fingers (<cross-ref type="fig" refid="V1">video 1</cross-ref>). They were most prominent when extending the left wrist, but were absent when the arms were at rest and were not elsewhere. There were no additional neurological deficits. Serum urea, ammonia, sodium, potassium, calcium, magnesium, phosphate and glucose levels were normal. His haematological profile, infective markers and thyroid function were unremarkable.</p> </sec> <sec id="s2"><st>Question</st> <p>Which best describes his involuntary movements?</p> <p><l type="letterupper"><li><p>Focal tremors</p> </li><li> <p>Focal dystonia</p> </li><li> <p>Unilateral athetosis</p> </li><li> <p>Unilateral asterixis</p> </li></l></p></sec> <sec id="s3"><st>Answer: D</st> <p>While the other options also involve involuntary movements, their individual characteristics are incongruent with the patient’s signs: (A) tremors are rhythmic oscillations...
<sec><st>Background</st>
<p>Management of acute kidney injury (AKI) in the ED can be difficult due to uncertainty regarding the aetiology. This study investigated the diagnostic value of venous system ultrasound for determining the aetiological subtypes of AKI in the ED.</p>
</sec>
<sec><st>Methods</st>
<p>This multidisciplinary prospective cohort study was conducted in a single academic ED over the course of a year. Adult patients with AKI were evaluated using the venous excess ultrasound (VExUS) score, which is a four-step ultrasound protocol. The protocol begins with the inferior vena cava (IVC) measurement and examines organ flow patterns, including portal, hepatic and renal veins in the presence of dilated IVC. The AKI subtypes (hypovolaemia, cardiorenal, systemic vasodilatation and renal) were adjudicated by nephrologists and emergency physicians, considering data that became available during the hospitalisation. We determined the diagnostic test characteristics of VExUS for identifying each of the four AKI aetiological subtypes.</p>
</sec>
<sec><st>Results</st>
<p>150 patients with AKI were included in the study. Hypovolaemia was the most frequent finally adjudicated cause of AKI (66%), followed by cardiorenal (18%), systemic vasodilatation (8.7%) and renal (7.3%). In diagnosing the cardiorenal subtype, the area under the curve (AUC) for VExUS grade >0 was 0.819, with 77.8% sensitivity and 80.5% specificity, and the AUC for IVC maximum diameter >20.4 mm was 0.865, with 74.1% sensitivity and 86.2% specificity. For the hypovolaemia subtype, the AUC for VExUS grade ≤0 was 0.711, with 83.8% sensitivity and 56.9% specificity, and the AUC for IVC maximum diameter ≤16.8 mm was 0.736, with 73.7% sensitivity and 68.6% specificity. None of the parameters achieved adequate test characteristics for renal and systemic vasodilatation subtypes.</p>
</sec>
<sec><st>Conclusion</st>
<p>The VExUS score has good diagnostic accuracy for cardiorenal AKI and fair accuracy for hypovolaemic AKI but cannot identify renal and systemic vasodilatation subtypes. It should not therefore be used in isolation to determine the cause of AKI in the ED.</p>
</sec>
<sec><st>Trial registration number</st>
<p> <A HREF="NCT04948710">NCT04948710</A>.</p>
</sec>
<p>Reviewing and acting on diagnostic reports is a professional obligation.<cross-ref type="bib" refid="R1">1</cross-ref> This includes X-ray of the chest (CXR) reports which recommend follow-up imaging and only become available after the patient has been discharged. Emergency departments (EDs) are required to have safe systems in place to manage radiology reports.<cross-ref type="bib" refid="R2">2</cross-ref> It is not known how many repeat CXRs are indicated or if repeat CXRs yield clinically significant findings. This study sought to determine how often a follow-up CXR altered patient management.</p> <p>This single-centre study took place in an ED with approximately 53 000 annual presentations. All CXRs are reviewed for acute findings and actioned during the ED visit by the attending emergency medicine clinicians. Radiology reports typically only become available after the patient has been discharged. Previously, our ED forwarded these reports to the patient’s general practitioner (GP). The local GP committee raised concerns that patients would not necessarily...
<sec><st>Objective</st>
<p>We sought to validate the clinical performance of a rapid assessment pathway incorporating the Siemens Atellica IM high sensitivity cardiac troponin I (hs-cTnI) assay in patients presenting to the emergency department (ED) with suspected acute myocardial infarction (AMI).</p>
</sec>
<sec><st>Methods</st>
<p>This was a multicentre prospective observational study of adult ED patients presenting to five Australian hospitals between November 2020 and September 2021. Participants included those with symptoms of suspected AMI (without ST-segment elevation MI on presentation ECG). The Siemen’s Atellica IM hs-cTnI laboratory-based assay was used to measure troponin concentrations at admission and after 2–3 hours and cardiologists adjudicated final diagnoses. The HighSTEACS diagnostic algorithm was evaluated, incorporating hs-cTnI concentrations at presentation and absolute changes within the first 2 to 3 hours. The primary outcome was index AMI, including type 1 or 2 non-ST segment elevation MI (NSTEMI) or ST-elevation MI (STEMI) following presentation. 30-day major adverse cardiac outcomes (including AMI, urgent revascularisation or cardiac death) were also reported. The trial was registered with the Australian and New Zealand Clinical Trials Registry.</p>
</sec>
<sec><st>Results</st>
<p>1994 patients were included. The average age was 56.2 years (SD<I>=</I>15.6), and 44.9% were women. 118 (5.9%) patients had confirmed index AMI. The 2-hour algorithm defined 61.3% of patients as low risk. Sensitivity was 99.1% (94.0%–99.9%) and negative predictive value was 99.9% (99.3%–100%). 24.4% of patients were deemed intermediate risk. When applying the parameters for high risk, 252 (14.3%) were identified, with a specificity of 91.5% (88.7%–93.6%) and a PPV of 42.0% (35.6–48.7%).</p>
</sec>
<sec><st>Conclusions</st>
<p>A 2-hour algorithm based on the HighSTEACS strategy using the Siemens Atellica IM hs-cTnI laboratory-based assay enables safe and efficient risk assessment of emergency patients with suspected AMI.</p>
</sec>
<sec><st>Trial registration number</st>
<p>ACTRN12621000053820.</p>
</sec>
<p>In the ED, laboratory high-sensitivity cardiac troponin (hs-cTn) tests facilitate ‘rule-out’ of myocardial infarction (MI).<cross-ref type="bib" refid="R1">1</cross-ref> Contemporary point-of-care (POC) troponin tests have inferior analytical sensitivity,<cross-ref type="bib" refid="R2">2</cross-ref> preventing rapid ‘rule-out’ strategies in near-patient settings. The new Siemens Atellica VTLi POC test meets hs-cTn criteria.<cross-ref type="bib" refid="R3">3</cross-ref></p> <p>Between June and September 2022, adult ED patients (≥16 years) with symptoms suspicious for MI and no ST-segment elevation on ECG were eligible for inclusion if staff trained on the POC instrument were available. Simultaneously, blood was taken for near-patient testing with the VTLi POC hs-cTnI assay (limit of detection (LOD) of 1.2 ng/L, sex-specific 99th percentile upper reference limits (URLs) of 18 ng/L (female) and 27 ng/L (male), and an optimised ‘rule-out’ threshold of <4 ng/L)<cross-ref type="bib" refid="R3">3</cross-ref> and for laboratory testing with the Abbott Alinity hs-cTnI assay (LOD of 1.6 ng/L, URLs of 16 ng/L (female) and 34 ng/L (male), and an optimised ‘rule-out’ threshold of <5 ng/L),<cross-ref...
<p>High-sensitivity troponin (hsTn) is used with ECG and clinical evaluation to stratify patients attending ED as low risk for acute myocardial infarctions (AMI). Diagnostic pathways incorporate a single test threshold for stratification with these assays. The Siemens Atellica VTLi Point-Of-Care-hsTnI assay (POC-hsTnI) has an 8 min turn-around which may expedite decision-making. Although a single-test low-risk (‘rule-out’) threshold for this assay has been reported,<cross-ref type="bib" refid="R1">1</cross-ref> it was desirable to determine a threshold specifically for New Zealand ED settings and intended end-users.</p> <p>From 3 November 2022 to 28 May 2023, hsTnI was measured by POC-hsTnI and laboratory (Beckman Coulter DXI800) assays from one venous blood draw into a single lithium heparin tube. The whole-blood limit of detection (LoD) of the POC-hsTnI is 1.6 ng/L, and the 10% and 20% coefficient of variations (CVs) are 8.9 ng/L and 3.7 ng/L.<cross-ref type="bib" refid="R2">2 3</cross-ref><cross-ref type="bib" refid="R3"></cross-ref> The Beckman assay plasma LoD and 20%...
<p>Intra-abdominal infections are the second most common source of severe sepsis and successful treatment relies on early intervention and appropriate resources.<cross-ref type="bib" refid="R1">1–3</cross-ref><cross-ref type="bib" refid="R2"></cross-ref><cross-ref type="bib" refid="R3"></cross-ref> The COVID-19 pandemic has disrupted the global healthcare system as evidenced by a national study in England showing reduced admissions and higher 90-day mortality for common acute surgical conditions.<cross-ref type="bib" refid="R4">4 5</cross-ref><cross-ref type="bib" refid="R5"></cross-ref> We examined intra-abdominal infection-related mortality trends from 1999 to 2021, which encompasses the COVID-19 pandemic.</p> <p>Using the National Vital Statistics System (NVSS) database (1999–2021), which registers more than 99% of deaths in the USA, we obtained decedents with intra-abdominal infection, defined as deaths related to acute cholecystitis, acute appendicitis, <I>Clostridioides difficile</I> colitis, diverticulitis or pyelonephritis (multiple causes were possible). Age-standardised mortality rates (ASMR) per 100 000 population were calculated using the 2010 US Census as the standard population. Joinpoint Regression Program (V.4.9.0.0) was performed to evaluate ASMR trends...
<p>Cannabinoid hyperemesis syndrome (CHS) is an episodic syndrome of cyclic vomiting in the context of the prolonged use of cannabis. The Royal College of Emergency Medicine Toxicology Special Interest Group has produced guidance to support emergency medicine clinicians with the recognition and treatment of people experiencing CHS.</p>
<p>Considerations regarding recognition, investigation and communication are discussed, and recommendations regarding treatment options (which include haloperidol and capsaicin) are made. There is a focus on making recommendations on the best available evidence.</p>
<sec id="s1"><st>Clinical introduction</st> <p>A healthy 16-year-old boy presented with a 3-day history of odynophagia. This occurred after a football struck his anterior chest and neck region. The odynophagia radiated to the retrosternal area. Dysphagia, dyspnoea and fever were not noted. His only abnormal vital sign was an RR of 24 beats per minute. His neck appeared normal, and his voice exhibited clarity and normal pitch without hoarseness or stridor. The chest radiogram (CXR) was normal. Lateral view neck radiography was performed (<cross-ref type="fig" refid="F1">figure 1</cross-ref>).</p> </sec> <sec id="s2"><st>Question</st> <p>What is the most likely diagnosis?</p> <p><l type="letterupper"><li><p>Hyoid bone fracture</p> </li><li> <p>Retropharyngeal haematoma</p> </li><li> <p>Pneumomediastinum</p> </li><li> <p>Oesophagus rupture</p> </li></l></p></sec> <sec id="s3"><st>Answer: C</st> <p>The lateral neck radiograph revealed prevertebral soft-tissue radiolucent tracking, indicative of free air (<cross-ref type="fig" refid="F2">figure 2</cross-ref>).</p> <p>In collision sports, pneumomediastinum occurs rarely, primarily attributed to the Macklin effect. This involves alveolar rupture, causing air dissection along the bronchovascular...
<p>Royal College of Emergency Medicine (RCEM) Best Practice Guidelines are produced by a variety of special interest groups or convened expert advisory groups which sit under the umbrella of the College’s Quality in Emergency Care Committee (QECC).<cross-ref type="bib" refid="R1">1</cross-ref> They are produced to bridge the gap between systematically derived evidence-based recommendations and the need for emergency clinicians to provide quality care and advice to patients, or to respond to evolving trends.</p> <p>Unlike National Institute for Health and Care Excellence (NICE) guidelines, which are costly to produce, incorporate calls for evidence, formal evidence searches and economic evaluation, and take significant periods of time to produce, RCEM guidance is produced by volunteer members. The RCEM working groups and committees are often required to produce guidance at pace, making recommendations where only limited evidence exists or on the basis of expert opinion.</p> <p>These guidelines go through a peer-review process (being circulated both...
<p>This month’s update comes from the Emergency Department at Northern General Hospital, Sheffield. We used a multimodal search strategy, drawing on free open-access medical education resources and literature searches. We identified the five most interesting and relevant papers (decided by consensus) and highlight the main findings, key limitations and clinical bottom line for each paper.</p> <p><l type="unord"><li><p>Worth a peek—interesting, but not yet ready for prime time.</p> </li><li> <p>Head turner—new concepts.</p> </li><li> <p>Game changer—this paper could/should change practice.</p> </li></l></p> <sec id="s1"><st>A non-inferiority randomised controlled trial comparing nebulised ketamine to intravenous morphine for older adults in the emergency department with acute musculoskeletal pain. Kampan <I>et al</I></st><sec id="s1-1"><st>Topic: Analgesia</st><sec id="s1-1-1"><st>Outcome rating: Head turner</st> <p>Inadequate management of acute pain in older adults contributes to adverse outcomes including decline in mobility, cognition and mood. Effective analgesia is important but must consider the physiological changes associated with ageing that affects pharmacokinetics. Although opioids are effective,...
<p>Editor’s note: EMJ has partnered with the journals of multiple international emergency medicine societies to share from each a highlighted research study, as selected by their editors. This edition will feature an abstract from each publication.</p>
<p>A short cut review of the literature was carried out to examine the evidence supporting antithrombotic treatment and/or endovascular therapy to reduce mortality and/or prevent future stroke following blunt cerebrovascular injury (BCVI). Five papers were identified as suitable for inclusion using the reported search strategy. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of the best papers are tabulated. It is concluded that in patients with BCVI confirmed by CT angiography, there is limited evidence to support screening for, or treating BCVI. In confirmed BCVI where the risk of stroke is felt to outweigh the risk of bleeding, antiplatelet therapy appears to be as effective as therapeutic anticoagulation.</p>
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