Clinical and experimental emergency medicine
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This meta-analysis aimed to establish the role of standardized emergency department (ED) observation protocols in the management of syncopal patients as an alternative to ordinary admission. A systematic electronic literature search was performed to identify randomized controlled trials or observational studies evaluating syncopal patients managed in ED observation units. Data regarding mean length of stay, rate of etiological diagnosis, admission rate, and incidence of short-term serious outcomes were extracted. ⋯ Pooled analysis of the outcomes showed a mean stay of 28.2 hours, an etiological diagnosis rate of 67.3%, an admission rate of 18.5%, and a very low incidence of short-term serious outcomes (2.8%). Due to elevated diagnostic yield and low incidence of short-term adverse events, ED observation units-based management strategy seems ideal for patients with syncope. Nevertheless, further research is needed to identify criteria for selecting patients to be managed with this approach, define evaluation protocols, and confirm the safety of this strategy.
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The diagnosis or exclusion of pulmonary embolism (PE) remains challenging for emergency physicians. Symptoms can be vague or non-existent, and the clinical presentation shares features with many other common diagnoses. Diagnostic testing is complicated, as biomarkers, like the D-dimer, are frequently false positive, and imaging, like computed tomography pulmonary angiography, carries risks of radiation and contrast dye exposure. ⋯ However, the spectrum of PE severity varies widely, so emergency physicians must be able to risk-stratify patients to ensure the appropriate disposition. Finally, PE response teams have been developed to facilitate rapid access to advanced therapies (e.g., catheter directed thrombolysis) for patients with high-risk PE. This review will discuss the clinical challenges of PE diagnosis, risk stratification and treatment that emergency physicians face every day.
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Emergency departments (ED) face significant challenges in delivering high quality and timely patient care on an ever-present background of increasing patient numbers and limited hospital resources. A mismatch between patient demand and the ED's capacity to deliver care often leads to poor patient flow and departmental crowding. These are associated with reduction in the quality of the care delivered and poor patient outcomes. ⋯ The use of doctor triage, rapid assessment, streaming and the co-location of a primary care clinician in the ED have all been shown to improve patient flow. In addition, when used effectively point of care testing has been shown to reduce patient time in the ED. Patient flow and departmental crowding can be improved by implementing new patterns of working and introducing new technologies such as point of care testing in the ED.
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Acute dizziness/vertigo is among the most common causes for visiting the emergency department. The traditional approach to dizziness starts with categorizing dizziness into four types: vertigo, presyncope, disequilibrium, and nonspecific dizziness. However, a recently proposed approach begins with classifying dizziness/vertigo as acute prolonged spontaneous dizziness/vertigo, recurrent spontaneous dizziness/vertigo, recurrent positional vertigo, or chronic persistent dizziness and imbalance. ⋯ Isolated positional vertigo is usually caused by benign paroxysmal positional vertigo, which can be treated at the bedside. In recent years, marked progress has occurred in the evaluation/management of acute dizziness/vertigo. However, even with developments in imaging technology, the diagnosis of acute dizziness/vertigo largely relies on bedside examination.
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Increased awareness of the signs and symptoms of sepsis and an emphasis on the importance of early treatment have helped to improve survival rates from this serious and frequent condition in recent years. With no specific, effective anti-sepsis therapies available, management focuses on early source control with adequate and appropriate antibiotics and removal of any source of infection, rapid resuscitation, hemodynamic stabilization and organ support. Use of dedicated teams to care for patients with sepsis can help optimize early management.