Objective The COVID-19 pandemic might have adversely affected outcomes of patients in emergency departments (EDs). The aim of this study is to evaluate the impact of the COVID-19 pandemic on in patients admitted through the emergency department.
Methods This study is a single-center, retrospective, observational cohort study. We compared the prognosis of patients admitted through the ED before the COVID-19 pandemic (November 2018 to June 2019) and after COVID-19 (November 2020 to June 2021). The primary outcome was in-hospital mortality. Multivariable logistic regression analysis was performed to determine whether the COVID-19 pandemic was independently associated with patient prognosis.
Results The number of patients admitted through the ED before and after COVID-19 was 5,333 and 4,625, respectively. The mean ED length of stay before and after COVID-19 was 401 and 442 minutes, respectively (P<0.001). The number of in-hospital deaths before and after COVID-19 were 269 (5.0%) and 322 (7.0%), respectively (P<0.001). Multivariable logistic regression analysis showed that the COVID-19 period was significantly associated with higher in-hospital mortality (adjusted odds ratio, 1.37; 95% confidence interval, 1.12–1.67; P=0.002).
Conclusion In the COVID-19 period, in-hospital mortality increased compared to that before COVID-19 among hospitalized ED patients.
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Objective This study was conducted to evaluate the association between changes in repeated brain computed tomography (CT) findings and the optic nerve sheath diameter (ONSD) determined by ocular ultrasonography in patients with moderate blunt traumatic brain injury (TBI).
Methods This cross-sectional study was performed on patients with moderate blunt TBI (Glasgow Coma Scale, 9–12) who were referred to the emergency department during a 1-year period. Initially, all patients underwent a brain CT scan and primary ocular ultrasonography. Patients who were candidates for a second brain CT scan under observation in the emergency department also underwent a second ocular ultrasound. The primary outcome was the progression of brain lesions on repeated brain CT scans. Logistic regression and the area under receiver operating characteristic curve (AUC) were used.
Results Overall, 204 patients with a mean age of 43±13.4 years were enrolled in the study. The study detected expanding changes in brain CT scans from 29 patients (14.2%). The progression of lesion on CT scan were significantly associated with changes in the Glasgow Coma Scale. In the second brain CT scan, there were significant associations between the progression of lesion on CT scan and the increased size of the ONSD measured on both axial and coronal sections (odds ratio, 17.3–47.5; AUC, 0.88–0.93).
Conclusion Among patients with moderate TBI, an increase in ONSD on ocular ultrasound seems to be an appropriate criterion for repeating a brain CT scan to select a suitable therapeutic intervention.
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Objective We evaluated the utility of the Korean Modified Early Warning Score (KMEWS), which combines the Modified Early Warning Score (MEWS) and the Korean Triage and Acuity Scale (KTAS), as a triage tool to screen for infection in patients who visit the emergency department.
Methods We retrospectively reviewed data extracted from electronic medical records. Patients aged ≥18 years with an infection who were admitted to the hospital via the emergency department between January 2018 and December 2019 were eligible for inclusion. The KMEWS score was calculated as the sum of the KTAS level and the MEWS score. We generated receiver operating characteristic curves and determined the area under the receiver operating characteristic curve (AUC) for the KMEWS, KTAS, MEWS, and Mortality in Emergency Department Sepsis (MEDS) scales. The primary outcome was septic shock, and secondary outcomes were intensive care unit admission and in-hospital mortality.
Results The AUC values (95% confidence interval) for predicting septic shock were as follows: KMEWS, 0.910 (0.902–0.918); MEWS, 0.896 (0.887–0.904); KTAS score, 0.809 (0.798–0.819); and MEDS, 0.927 (0.919–0.934). The AUC values (95% confidence interval) for predicting in-hospital mortality were as follows: KMEWS, 0.752 (0.740–0.764); MEWS, 0.717 (0.704–0.729); KTAS score, 0.764 (0.752–0.776); and MEDS, 0.844 (0.834–0.854). The AUC values (95% confidence interval) for predicting intensive care unit admission were as follows: KMEWS, 0.826 (0.816–0.837); MEWS, 0.782 (0.770–0.793); KTAS score, 0.821 (0.810–0.831); and MEDS, 0.839 (0.829–0.849).
Conclusion The KMEWS, which is a combination of the MEWS and the KTAS scores, might be a useful triage tool in emergency department patients who present with infection, particularly for predicting septic shock.
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Vaso-occlusive crisis (VOC) in sickle cell disease can cause severe pain and requires a thoughtful approach to analgesia. Considering the heightened awareness of the harm associated with opioids, an exploration of safer and more effective alternatives is overdue. Ketamine may play a role in supplementing or replacing opioid analgesia for patients in VOC. Studies on the use of ketamine for VOC are sparse, though increasing. In this review, we summarize the literature on subdissociative ketamine use for VOC to offer providers insight into the most effective and safe dosing regimens for sickle cell disease patients. Overall, the studies discussed in this review show decreased opioid use when subdissociative ketamine is provided as an adjunct and resolution of pain for most patients when subdissociative ketamine is used as the sole form of analgesia in VOC. Most studies examined intravenous delivery, and successful outcomes were established for both adult and pediatric patients in multiple clinical settings, including in the emergency department. Although more research is needed, it is clear from the published data that subdissociative ketamine may provide an efficacious addition to the clinician’s toolbox for managing VOC.
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Clin Exp Emerg Med 2022;9(3):198-206. Published online September 20, 2022
Objective Hip fractures are associated with significant morbidity and mortality. Ultrasound-guided peripheral nerve blocks are a safe method to manage pain and decrease opioid usage. The pericapsular nerve group (PENG) block is a novel, potentially superior block because of its motor-sparing effects. Through training, simulation, and supervision, we aim to determine whether it is feasible to perform the PENG block in the emergency department.
Methods Phase 1 consisted of emergency physicians attending a workshop to demonstrate ultrasound proficiency, anatomical understanding, and procedural competency using a low-fidelity model. Phase 2 consisted of a prospective, observational, feasibility study of 10 patients with hip fractures. Pain scores, side effects, and opioid usage data were collected.
Results The median pain score at time 0 (time of block) was 9 (interquartile range [IQR], 6.5–9). The median pain score at 30 minutes was 4 (IQR, 2.0–6.8) and 3.5 (IQR, 1.0–4.8) at 4 hours. All 10 patients required narcotics prior to the initiation of the PENG block with a median dosage of 6.25 morphine milligram equivalents (MME; IQR, 4.25–7.38 MME). After the PENG block, only 30% of the patients required further narcotics with a median dosage of 0 MME (IQR, 0–0.6 MME) until operative fixation.
Conclusion In this feasibility study, PENG blocks were safely administered by trained emergency physicians under supervision. We demonstrated data suggesting a trend of pain relief and decreased opiate requirements, and further investigation is necessary to measure efficacy.
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Objective We aimed to investigate the characteristics of frequent emergency department (ED) users in Korea.
Methods We analyzed the Korea Health Panel Study data of a sampled population from the 2005 Population Census of Korea data, and adults (age ≥18 years) who visited the ED at least once a year between 2014 and 2017 were included in the study. People who visited three or more times a year were classified as frequent users. We compared demographic, socioeconomic, and health-related factors between nonfrequent and frequent users. We used a multivariable logistic regression analysis to determine factors related to frequent ED visits. We also compared the characteristics of ED use in both nonfrequent and frequent users.
Results A total of 5,090 panels were included, comprising 6,853 visits. Frequent users were 333 (6.5% of all panels), and their ED visits were 1,364 (19.9% of all ED visits). In the multivariable regression analysis, medical aid coverage (adjusted odds ratio [aOR] of the National Health Service coverage, 0.55; 95% confidence interval [CI], 0.40–0.75), unemployment (aOR of employment, 0.72; 95% CI, 0.56–0.91), prior ward admission in a year (aOR, 2.14; 95% CI, 1.67–2.75), and frequent outpatient department use (aOR, 1.72; 95% CI, 1.35–2.20) were associated with frequent use. Moreover, frequent users visited the ED of public hospitals more often than than nonfrequent users (19.2% vs. 9.8%). Medical problems rather than injury/poisoning were the more common reasons for visiting the ED (84.5% vs. 71.2%).
Conclusion We found that frequent ED users were likely to be those with socioeconomic disadvantage or with high demand for medical service. Based on this study, further studies on interventions to reduce frequent ED use are required for better ED services.
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Objective The national health systems are currently facing the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. We assessed the efficacy of outpatient management for patients with SARS-CoV-2 related pneumonia at risk of progression after discharge from the emergency department.
Methods This was a single-center prospective study. We enrolled patients with confirmed SARS-CoV-2 pneumonia, without hypoxemic respiratory failure, and at least one of the following: age ≥65 years or the presence of relevant comorbidities or pneumonia extension >25% on high resolution computed tomography. Patients with pneumonia extension >50% were excluded. An ambulatory visit was performed after at least 48 hours, when patients were either discharged, admitted, or deferred for a further visit. As a control, we evaluated a comparable historical cohort of hospitalized patients.
Results A total of 84 patients were enrolled (51 male patients; mean age, 62.8 years). Two-thirds of the patients had at least one comorbidity and 41.6% had a lung involvement >25% on high resolution computed tomography; the mean duration of symptoms was 8.0±3.0 days, and the mean PaO2/FiO2 ratio was 357.5±38.6. At the end of the follow-up period, 69 patients had been discharged, and 15 were hospitalized (mean stay of 6 days). Older age and higher National Early Warning Score 2 were significant predictors of hospitalization at the first follow-up visit. One hospitalized patient died of septic shock. In the control group, the mean hospital stay was 8 days.
Conclusion Adopting a “discharge and early revaluation” strategy appears to be safe, feasible, and may optimize hospital resources during the SARS-CoV-2 pandemic.
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Objective Coronavirus disease 2019 (COVID-19) has notably altered the emergency department isolation protocol, imposing stricter requirements on probable infectious disease patients that enter the department. This has caused adverse effects, such as an increased rate of leave without being seen (LWBS). This study describes the effect of fever/respiratory symptoms as the main cause of isolation regarding LWBS after the COVID-19 pandemic.
Methods We retrospectively analyzed emergency department visits before (March to July 2019) and after (March to July 2020) the COVID-19 pandemic. Patients were grouped based on existing fever or respiratory symptoms, with the LWBS rate as the primary outcome. Logistic regression analysis was used to identify the risk factors of LWBS. Logistic regression was performed using interaction terminology (fever/respiratory symptom patient [FRP]×post–COVID-19) to determine the interaction between patients with FRPs and the COVID-19 pandemic period.
Results A total of 60,290 patients were included (34,492 in the pre–COVID-19, and 25,298 in the post–COVID-19 group). The proportion of FRPs decreased significantly after the pandemic (P<0.001), while the LWBS rate in FRPs significantly increased from 2.8% to 19.2% (P<0.001). Both FRPs (odds ratio, 1.76; 95% confidence interval, 1.59–1.84 (P<0.001) and the COVID-19 period (odds ratio, 2.29; 95% confidence interval, 2.15–2.44; P<0.001) were significantly associated with increased LWBS. Additionally, there was a significant interaction between the incidence of LWBS in FRPs and the COVID-19 pandemic period (P<0.001).
Conclusion The LWBS rate has increased in FRPs after the COVID-19 pandemic; additionally, the effect observed was disproportionate compared with that of nonfever/respiratory symptom patients.
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Objective As the use of electric scooters increased in Italy in the last years, we aimed to estimate the burden of accidents caused by this micro-mobility vehicle and identify characteristics, severity, and type of injuries.
Methods We conducted a case series analysis of news reports about electric scooter crashes occurring in Italy from January 1, 2019 to September 30, 2020. Events were included when a road traffic accident involved an electric scooter and caused damages or injuries to the driver or others.
Results We identified 96 road accidents involving electric scooters in Italy. The mean age of patients was 30 ± 16 years, and 79% (n = 71/90) were male. Of the 96 patients, only two (2%) were driving an electric scooter with a helmet, and three (3%) were driving while intoxicated. In 68% (n = 62/94) of cases, the incident was caused by a collision with another vehicle or a pedestrian, and 30% (n = 18/96) were transported with life-threatening injuries to the emergency department. In 15% (n = 14/96), the emergency medical service physician was dispatched to the scene. Head trauma was the most common injury (60%, n = 32/53). Patients who had life-threatening conditions were more likely to have head trauma than those who did not (82% [n = 9/11] vs. 55% [n = 23/42], P = 0.10). Polytrauma was significantly more common in patients with life-threatening conditions than in patients with no life-threatening conditions (36% [n = 4/11] vs. 5% [n = 2/42], P < 0.01). Fifteen percent of patients (n = 12/81) were admitted to the intensive care unit; only one death was reported.
Conclusion Road traffic accidents involving electric scooters often result in serious injuries, including head trauma and polytrauma, necessitating the involvement of an emergency medical service physician and intensive care unit admission in a non-negligible percentage of instances.
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Objective Among the pediatric population with minor head trauma, it is difficult to determine an indication for the usage of brain computerized tomography (CT). Our study aims to compare the efficiency of the most commonly used clinical decision rules: the Pediatric Emergency Care Applied Research Network (PECARN) and Canadian Assessment of Tomography for Childhood Head Injury 2 (CATCH2).
Methods This retrospective study investigated whether the PECARN and CATCH2 rules were applicable to Korean children with minor head trauma for reducing the use of brain CT imaging, while detecting intracranial pathology.
Results Overall, 251 patients (0–5 years old) admitted to emergency rooms within 24 hours of injury were included between August 2015 to August 2018. The performance results are as follows: the PECARN and CATCH2 rules had a sensitivity of 80.00% (51.91%–95.67%) and 100% (78.20%–100.00%) with a specificity of 28.39% (22.73%–34.60%) and 15.25% (10.92%–20.49%), respectively; the negative predictive values were 98.58% and 100%, respectively. Overall, the CATCH2 rule was more successful than the PECARN rule in detecting intracranial pathology; however, there was no significant difference between them. Furthermore, the PECARN and CATCH2 rules lowered the rate of head CT imaging in our study group.
Conclusion Both the rules significantly lowered the rate of indicated brain CT. However, since the CATCH2 rule had higher sensitivity and negative predictive value than the PECARN rule, it is more appropriate to be used in emergency rooms for detecting intracranial pathology in children with minor head trauma.
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