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Journal: International journal of emergency medicine


BACKGROUND: A high index of suspicion is required to make this diagnosis of constrictive pericarditis (CP) in patients presenting with cirrhosis and volume overload, as they can otherwise go misdiagnosed for years. METHODS: Case report. FINDINGS: A 51 year-old man with a history of presumed alcoholic cirrhosis presented to the emergency department with anasarca. Abdominal ultrasound with Doppler demonstrated a nodular cirrhotic liver, but no evidence of portal hypertension or ascites. The chest x-ray, however, was significant for a right-sided pleural effusion and pericardial calcification, suggestive of (CP). Transthoracic echocardiogram and ECG-gated computerized tomography scan of the chest without IV contrast confirmed the diagnosis. The patient was referred to thoracic surgery for definitive pericardiectomy. CONCLUSION: The diagnosis of CP is often neglected by admitting physicians, who usually attribute the symptoms to another disease process. Although a multimodality approach is necessary for the diagnosis of CP, this case highlights the utility of chest x-ray, a relatively non-invasive and inexpensive test, in expediting the diagnosis.

Concepts: Heart failure, Echocardiography, Medical imaging, Cirrhosis, Ascites, Pleural effusion, Hepatorenal syndrome, Wilson's disease


BACKGROUND: Mental health related presentations are common in Australian emergency departments (EDs). We sought to better understand ED staff knowledge and levels of confidence in treating people with mental health related problems using qualitative methods. METHODS: This was a qualitative learning needs analysis of Australian emergency doctors and nurses regarding the assessment and management of mental health presentations. Participants were selected for semi-structured telephone interview using criterion-based sampling. Recruitment was via the Australasian College for Emergency Medicine and College of Emergency Nursing Australasia membership databases. Interviews were audio-recorded and transcribed verbatim. Thematic framework analysis was used to identify perceived knowledge gaps and levels of confidence among participants in assessing and managing patients attending EDs with mental health presentations. RESULTS: Thirty-six staff comprising 20 doctors and 16 nurses consented to participate. Data saturation was achieved for four major areas where knowledge gaps were reported. These were: assessment (risk assessment and assessment of mental status), management (psychotherapeutic skills, ongoing management, medication management and behaviour management), training (curriculum and rotations), and application of mental health legislation. Participants' confidence in assessing mental health patients was affected by environmental, staff, and patient related factors. Clinicians were keen to learn more about evidence based practice to provide better care for this patient group. Areas where clinicians felt the least confident were in the effective assessment and management of high risk behaviours, providing continuity of care, managing people with dual diagnosis, prescribing and effectively managing medications, assessing and managing child and adolescent mental health, and balancing the caseload in ED. CONCLUSION: Participants were most concerned about knowledge gaps in risk assessment, particularly for self-harming patients, violent and aggressive patients and their management, and distinguishing psychiatric from physical illness. Staff confidence was enhanced by better availability of skilled psychiatric support staff to assist in clinical decision-making for complex cases and via the provision of a safe ED environment. Strategies to enhance the care of patients with mental health presentations in Australian emergency departments should address these gaps in knowledge and confidence.

Concepts: Psychology, Hospital, Risk, Illness, Educational psychology, Risk management, Urgent care, Psychiatry


BACKGROUND: The mortality rate of patients complicated with sepsis-associated organ failure remains high in spite of intensive care treatment. The purpose of this study was to define the duration of systemic inflammatory response syndrome (SIRS) before organ failure (DSOF) and determine the value of DSOF as a prognostic factor in septic patients. METHODS: This retrospective cohort study was conducted in an 11-bed medical and surgical intensive care unit (ICU) in a university hospital. The primary endpoint was in-hospital mortality of the septic patients. RESULTS: One hundred ten septic patients with organ failure and/or shock were enrolled in this study. The in-hospital mortality rate was 36.9%. The median DSOF was 28.5 h. As a metric variable, DSOF was a statistically significant prognostic factor according to univariate analysis (survivor: 74.7 +/- 9.6 h, non-survivor: 58.8 +/- 16.5 h, p = 0.015). On the basis of the ROC curve, we defined an optimal cutoff of 24 h, with which we divided the patients as follows: group 1 (n = 50) comprised patients with a DSOF <=24 h, and group 2 (n = 60) contained patients with a DSOF >24 h. There were statistically significant differences in the in-hospital mortality rate between the two groups (52.0% vs. 25.0%, p = 0.004). Furthermore, by multivariate analysis, DSOF <=24 h (odds ratio: 5.89, 95% confidence interval: 1.46-23.8, p = 0.013) was a significant independent prognostic factor. CONCLUSION: DSOF may be a useful prognostic factor for severe sepsis.

Concepts: Inflammation, Cohort study, Statistics, Systemic inflammatory response syndrome, Intensive care medicine, Multivariate statistics, Septic shock, Sepsis


 The objective of this paper is to evaluate the response times and outcome of patients in two groups of patients attended by permanently (PS) and temporarily stationed ambulances (TS) (fluid deployment).


Pre-hospital laryngoscopic endotracheal intubation (ETI) is potentially a life-saving procedure but is a technique difficult to acquire. This study aimed to obtain a recommendation for the number of times ETI should be practiced by constructing the learning curve for endotracheal intubation by paramedics, as well as to report the change in the frequency of complications possibly associated with intubation over the training period.

Concepts: Endotracheal tube, Learning, Intubation, Emergency medical services, Learning curve, Paramedic, Emergency medical technician, National Registry of Emergency Medical Technicians


Angioedema is a common presentation in the emergency department (ED). Airway angioedema can be fatal; therefore, prompt diagnosis and correct treatment are vital.

Concepts: Medical terms, Medical diagnosis, Differential diagnosis, Dublin


Innovative methods for delivering healthcare via the use of technology are rapidly growing. Despite the passage of the Affordable Care Act, emergency department visits have continued to rise nationally. Healthcare systems must devise solutions to face these increasing volumes and also deliver high quality care. In response to the changing healthcare landscape, New York Presbyterian Hospital has implemented a comprehensive enterprise wide digital health portfolio which includes the first mobile stroke treatment unit on the east coast and the first emergency department-based digital emergency care program in New York City.

Concepts: Health care, Medicine, Healthcare, Health insurance, Health, Urgent care, New York City, Massachusetts


Pain is among the most commonly treated symptoms in the emergency department, and opioids are commonly prescribed from the emergency department to treat moderate to severe pain. Prescription drug monitoring programs (PDMP) can be used to assist physicians identify individuals at increased risk to misuse or abuse opioids. While the use of the PDMP has been shown useful among clinicians, in the past, utilization of the PDMP has been less than optimal. The objective of this study was to assess the current utilization and perceptions of the prescription drug monitoring program among emergency medicine providers in Florida.

Concepts: Pharmacology, Hospital, Drugs, Opioid, Pain, Urgent care, Suffering


The safe and effective administration of fluids and medications during the management of medical emergencies in children depends on an appropriately determined dose, based on body weight. Weight can often not be measured in these circumstances and a convenient, quick and accurate method of weight estimation is required. Most methods in current use are not accurate enough, but the newer length-based, habitus-modified (two-dimensional) systems have shown significantly higher accuracy. This meta-analysis evaluated the accuracy of weight estimation systems in children. Articles were screened for inclusion into two study arms: to determine an appropriate accuracy target for weight estimation systems; and to evaluate the accuracy of existing systems using standard meta-analysis techniques. There was no evidence found to support any specific goal of accuracy. Based on the findings of this study, a proposed minimum accuracy of 70% of estimations within 10% of actual weight (PW10 > 70%), and 95% within 20% of actual weight (PW20 > 95%) should be demonstrated by a weight estimation system before being considered to be accurate. In the meta-analysis, the two-dimensional systems performed best. The Mercy method (PW10 70.9%, PW20 95.3%), the PAWPER tape (PW10 78.0%, PW20 96.6%) and parental estimates (PW10 69.8%, PW20 87.1%) were the most accurate systems investigated, with the Broselow tape (PW10 55.6%, PW20 81.2%) achieving a lesser accuracy. Age-based estimates achieved a very low accuracy. Age- and length-based systems had a substantial difference in over- and underestimation of weight in high-income and low- and middle-income populations. A benchmark for minimum accuracy is recommended for weight estimation studies and a PW10 > 70% with PW20 > 95% is suggested. The Mercy method, the PAWPER tape and parental estimates were the most accurate weight estimation systems followed by length-based and age-based systems. The use of age-based formulas should be abandoned because of their poor accuracy.

Concepts: Estimator, Evidence-based medicine, Systematic review, Measurement, Accuracy and precision, Meta-analysis, Estimation, Morality


In order to enhance patient safety during resuscitation of critically ill patients, we need to optimize team communication and enhance team situational awareness but little is known about resuscitation team communication patterns. The objective of this study is to understand how teams communicate during resuscitation; specifically to assess for a shared mental model (organized understanding of a team’s relationships) and information needs.

Concepts: Psychology, Understanding, Illness, Cognition, Educational psychology, Knowledge, Nonviolent Communication, The A-Team