How to recognise an LV thrombus when you see one: a review of cardiac point-of-care ultrasound
Case presentation A 47-year-old man presents to the ED with shortness of breath and chest pain. The shortness of breath has been progressively worsening in the setting of running out of his medications 3 days prior, while the chest pain started after smoking methamphetamines the day prior to presentation. He denies any fevers, new cough, sputum production or sick contacts. He has a 20-year history of daily methamphetamine use. His medical history is notable for heart failure with a reduced ejection fraction (HFrEF) of 20%, type 2 diabetes, coronary artery disease (CAD), untreated deep vein thrombosis and depression. His pr...
Source: Emergency Medicine Journal - October 21, 2022 Category: Emergency Medicine Authors: Tam, E., Graglia, S. Tags: Sono case series Source Type: research
Wrist deformity following falling down
Clinical introduction A 8-year-old girl presented to our emergency department with a painful deformity of her left wrist following falling onto her outstretched hand. The physical examination showed ecchymosis, swelling, and left wris deformity with radial deviation and ulna apex (figure 1). Sensation and capillary refill time on the left distal limb were normal. Left wrist radiograph was obtained (figure 2A). Following closed reduction under sedation, the fluoroscopic radiograph showed persistent deformity with unacceptable alignment (figure 2B). Question Which of the following is the most appropriate management? Attempt ...
Source: Emergency Medicine Journal - October 21, 2022 Category: Emergency Medicine Authors: Lee, C.-Y., Lu, C.-C. Tags: Open access, EMJ Image Challenge Source Type: research
Point-of-care testing with high-sensitivity cardiac troponin assays: the challenges and opportunities
Methods to improve the safety, accuracy and efficiency of assessment of patients with suspected acute coronary symptoms have occupied decades of study and have supported significant changes in clinical practice. Much of the progress is reliant on results of laboratory-based high-sensitivity cardiac troponin assays that can detect low concentrations with high precision. Until recently, point-of-care (POC) platforms were unable to perform with similar analytical precision as laboratory-based assays, and recommendations for their use in accelerated assessment strategies for patients with suspected acute coronary syndrome has ...
Source: Emergency Medicine Journal - October 21, 2022 Category: Emergency Medicine Authors: Cullen, L., Collinson, P. O., Giannitsis, E. Tags: Open access Practice review Source Type: research
Starting anticoagulation for atrial fibrillation in the emergency department safely
Atrial fibrillation (AF) is a common morbidity, which is increasing in prevalence.1 AF predisposes patients to stroke while anticoagulation therapy reduces the stroke risk in this population. The proportion of patients with AF receiving oral anticoagulation is one of the pan-Canadian quality indicators set by the Canadian Cardiovascular Society.2 Our review of local ED practice identified that only 17% of patients with AF eligible for anticoagulation were being prescribed an anticoagulant.3 We implemented a simple ED pathway for initiating anticoagulation in patients with AF in four EDs. The pathway was available for emerg...
Source: Emergency Medicine Journal - October 21, 2022 Category: Emergency Medicine Authors: Kirwan, C., Ramsden, S., Carter, J., Tong, X. C., Huang, J., Clayton, N., McArthur, R., Kibria, A., de Wit, K. Tags: Research letter Source Type: research
Why so hypoxic?
Clinical introduction A 35-year-old man presented to the emergency department with a 7-day history of cough and dyspnoea. At triage, his oxygen saturation was 69% on room air. His blood pressure and heart rate were normal. He has a history of congenital hypoventilation syndrome and pulmonary hypertension (PH). His chest radiograph is shown in figure 1. Question Which of the following is the correct diagnosis? Dilated cardiomyopathy. Pericardial effusion. Large Hiatus Hernia. Ascending aortic dissection. Answer: (B) Pericardial effusion The X-ray demonstrates an enlarged cardiac shadow, large enough to occupy a significant ...
Source: Emergency Medicine Journal - October 21, 2022 Category: Emergency Medicine Authors: Byrne, C., Slattery, M., Ui Bhroin, S. Tags: EMJ Image Challenge Source Type: research
Monocyte chemoattractant protein-1 is not predictive of cardiac events in patients with non-low-risk chest pain
Conclusion
MCP-1 is not predictive of 90-day MACE in patients with non-low-risk chest pain. (Source: Emergency Medicine Journal)
Source: Emergency Medicine Journal - October 21, 2022 Category: Emergency Medicine Authors: Ashburn, N. P., Snavely, A. C., Allen, B. R., Christenson, R. H., Herrington, D. M., Hiestand, B. C., Miller, C. D., Stopyra, J. P., Mahler, S. A. Tags: Original research Source Type: research
Potential impact of a novel pathway for suspected myocardial infarction utilising a new high-sensitivity cardiac troponin I assay
Conclusion
The novel pathway using the Access hsTnI assay has an acceptably low 30-day MACE rate. (Source: Emergency Medicine Journal)
Source: Emergency Medicine Journal - October 21, 2022 Category: Emergency Medicine Authors: Meek, R., Cullen, L., Lu, Z. X., Nasis, A., Kuhn, L., Sorace, L. Tags: Original research Source Type: research
Emergency physicians experience of stress during resuscitation and strategies for mitigating the effects of stress on performance
Conclusions
Stress is commonly experienced by EPs during resuscitation and can impact decision-making and procedural performance. This study identifies the most common sources of stress during a resuscitation as well as the strategies that EPs use to mitigate the effects of stress on their performance. These findings may contribute to the development of tailored stress management training for critical care clinicians. (Source: Emergency Medicine Journal)
Source: Emergency Medicine Journal - October 21, 2022 Category: Emergency Medicine Authors: Groombridge, C. J., Maini, A., Ayton, D., Soh, S.-E., Walsham, N., Kim, Y., Smit, D. V., Fitzgerald, M. Tags: Original research Source Type: research
Differences in the thermal properties and surface temperature of prehospital antihypothermia devices: an in vitro study
Conclusion
At 20°C, HPMK and Ready-Heat-II increased fluid temperature in the model, while the other devices decreased heat loss. At 8°C, none of the tested devices increased the temperature. However, active heating devices prevented heat loss slightly better than passive methods. A protective insulation layer should be used with all active heating blankets. (Source: Emergency Medicine Journal)
Source: Emergency Medicine Journal - October 21, 2022 Category: Emergency Medicine Authors: Dvir, E., Epstein, D., Berzon, B., Raz, A., Lehavi, A. Tags: Original research Source Type: research
A handy point-of-care ultrasound
Clinical introduction A 69-year-old woman attended the ED with pain and swelling of her right wrist. She presented 1 day after a coronary angiogram in which her right radial artery had been catheterised. Following the procedure, her wrist was sore but she was managing the pain at home until suddenly, while straining to pass a bowel motion, she felt a ‘pop’ and noticed immediate swelling and bruising of her hand (figure 1). She attended the ED where she underwent clinical examination and a point-of-care ultrasound (figure 2). Question Which of the following is the most likely diagnosis? Postprocedural infection ...
Source: Emergency Medicine Journal - October 21, 2022 Category: Emergency Medicine Authors: Ui Bhroin, S., Jamal, A., Lim, N. Tags: EMJ Image Challenge Source Type: research
Temperature measurement of babies born in the pre-hospital setting: analysis of ambulance service data and qualitative interviews with paramedics
Conclusions
This study demonstrates a lack of neonatal temperature measurement by paramedics in the South West following BBA, and highlights barriers and facilitators that could serve as a basis for developing an intervention to improve neonatal temperature measurement. (Source: Emergency Medicine Journal)
Source: Emergency Medicine Journal - October 21, 2022 Category: Emergency Medicine Authors: Goodwin, L., Voss, S., McClelland, G., Beach, E., Bedson, A., Black, S., Deave, T., Miller, N., Taylor, H., Benger, J. Tags: Original research Source Type: research
Management of patients presenting to the emergency department with sudden onset severe headache: systematic review of diagnostic accuracy studies
Conclusion
The Ottawa SAH Rule rules out further investigation in only a small proportion of patients. CT undertaken within 6 hours (with expertise of a neuroradiologist or radiologist who routinely interprets brain images) is highly accurate and likely to be sufficient to rule out SAH; CT beyond 6 hours is much less sensitive. The CT–LP pathway is highly sensitive for detecting SAH and some alternative diagnoses, although LP results in some false positive results. (Source: Emergency Medicine Journal)
Source: Emergency Medicine Journal - October 21, 2022 Category: Emergency Medicine Authors: Walton, M., Hodgson, R., Eastwood, A., Harden, M., Storey, J., Hassan, T., Randall, M. S., Hassan, A., Williams, J., Wade, R. Tags: Open access Systematic review Source Type: research
Sensitivity of modern multislice CT for subarachnoid haemorrhage at incremental timepoints after headache onset: a 10-year analysis
Conclusion
These data suggest that it may be possible to extend the timeframe from headache onset within which modern MSCT can be used to rule out aneurysmal SAH. (Source: Emergency Medicine Journal)
Source: Emergency Medicine Journal - October 21, 2022 Category: Emergency Medicine Authors: Vincent, A., Pearson, S., Pickering, J. W., Weaver, J., Toney, L., Hamill, L., Hurrell, M., Than, M. Tags: Original research Source Type: research
Thunderclap headache syndrome presenting to the emergency department: an international multicentre observational cohort study
Conclusions
Thunderclap headache presenting to the ED appears be associated with higher risk for serious intracranial pathology, including SAH, although most patients with this type of headache had a benign cause. Neuroimaging rates did not align with international guidelines, suggesting potential need for further work on standardisation. (Source: Emergency Medicine Journal)
Source: Emergency Medicine Journal - October 21, 2022 Category: Emergency Medicine Authors: Roberts, T., Horner, D. E., Chu, K., Than, M., Kelly, A.-M., Klim, S., Kinnear, F., Keijzers, G., Karamercan, M. A., Wijeratne, T., Kamona, S., Kuan, W. S., Graham, C. A., Body, R., Laribi, S., on behalf of the HEAD study investigators Tags: Original research Source Type: research
New NHS Prehospital Major Incident Triage Tool: from MIMMS to MITT
This article describes the output from this review, the changes being undertaken to UK major incident triage and the introduction of the new NHS Major Incident Triage Tool from the Spring of 2023. (Source: Emergency Medicine Journal)
Source: Emergency Medicine Journal - October 21, 2022 Category: Emergency Medicine Authors: Vassallo, J., Moran, C. G., Cowburn, P., Smith, J. Tags: Editor's choice Concepts Source Type: research
